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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7500
} | Medical Text: Admission Date: [**2134-11-18**] Discharge Date: [**2134-12-10**]
Date of Birth: [**2081-9-26**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Spehenoid [**Doctor First Name 362**] mass
Major Surgical or Invasive Procedure:
[**2134-11-19**]: Right pterional craniotomy for tumor resection
History of Present Illness:
Patient is a 53M s/p fall at home(reportedly tripped on trash),
down for approximately 12hrs. EMS arrived, and he was found to
be disoriented. He was apparently able to walk to the ambulance
of his own volition, but became obtunded, tachycardic and
hypoxic en route to the hospital. He was intubated at that
time. Head CT was done, which revealed a significantly sized
right fronto-parietal mass, and he was then transferred to [**Hospital1 18**]
for definitive neurosurgical care.
Past Medical History:
HTN, DM, GOUT, OSA, Class III Obestiy
Social History:
Unmarried, resides at home alone. Per brother(who resides in
OH), he was laid off approximately two years ago(previously
workes as a security operations manager for [**Company **]). He reports
since that time, he has had subtle personality changes. Within
the last six months, had become progressively socially recluse,
to the point of neglecting self care. His parents are
alive(residing in FL-mother with dementia, father w/ [**Name2 (NI) **] IV
Renal CA), a sister(who also resides in FL), and
brother([**Name (NI) **])-whom resides in OH.
Family History:
Non-contributory.
Physical Exam:
On Admission:
98.9 BP: 116/66 HR: 99 R: 14 O2Sats: 97% on
AC/100%/600/14/10
Gen: Intubated, sedated, NAD, grossly obese
HEENT: Pupils: ERRLA, [**2-28**] b/l. +Corneal
Neck: Supple.
Lungs: bibasilar coarse crackles
Cardiac: RRR no M/G/R
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated/sedated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally.
Motor: withdraws to noxious stimuli x4, L symmetric to R
Sensation: Unable to assess
Reflexes: B T Br Pa Ac
Right 2+
Left 2+
Toes downgoing bilaterally
Exam on Discharge:
Alert, oriented to person, place, month and year. Face is
symmetric, tongue is midline. Full strength and power throughout
upper and lower extremities. Cognition is somewhat impaired, and
intermittant expressive confusion. Wound is clean dry and
intact; sutures/staples have been removed
Pertinent Results:
Labs on Admission:
[**2134-11-18**] 07:00PM BLOOD WBC-13.6* RBC-4.80 Hgb-14.8 Hct-44.1
MCV-92 MCH-30.9 MCHC-33.6 RDW-14.7 Plt Ct-251
[**2134-11-18**] 07:00PM BLOOD Neuts-89.0* Lymphs-2.9* Monos-5.9 Eos-2.0
Baso-0.4
[**2134-11-18**] 07:00PM BLOOD PT-12.7 PTT-28.8 INR(PT)-1.1
[**2134-11-18**] 07:00PM BLOOD Glucose-122* UreaN-34* Creat-1.5* Na-149*
K-4.5 Cl-105 HCO3-33* AnGap-16
[**2134-11-19**] 03:05AM BLOOD ALT-18 AST-18 AlkPhos-82 TotBili-0.7
[**2134-11-18**] 07:00PM BLOOD CK(CPK)-95
[**2134-11-18**] 07:00PM BLOOD CK-MB-5 cTropnT-0.05*
[**2134-11-18**] 07:00PM BLOOD Calcium-9.3 Mg-2.4
Labs on Discharge:
[**2134-12-10**] 01:40AM BLOOD WBC-5.7 RBC-3.78* Hgb-11.4* Hct-34.2*
MCV-91 MCH-30.2 MCHC-33.3 RDW-15.7* Plt Ct-235
[**2134-12-9**] 02:02AM BLOOD PT-12.5 PTT-32.1 INR(PT)-1.1
[**2134-12-9**] 10:24PM BLOOD Glucose-129* UreaN-11 Creat-0.7 Na-146*
K-3.8 Cl-99 HCO3-42* AnGap-9
Imaging:
CTA of Head: significantly sized sphenoid [**Doctor First Name 362**] mass extending up
to the right fronto parietal region. Measure approx 8cm in
diameter. approx 1.5cm of subfalcineherniation.
CT Head(post-op): showing appropriate resection and
decompression.
Head CT [**11-28**]: area of hypodenisity within the right MCA
distribution. Again noted are expected post-surgical changes.
Head CTA/P [**12-2**]:
1. There is no evidence of acute hemorrhagic transformation.
2. Status post craniotomy. Persistent hypodensity in the right
frontal and
temporal lobes, unchanged. Mass effect upon the ipsilateral
cerebral peduncle with midline shift, is slightly decreased in
size when compared to prior study.
3. Perfusion study demonstrates decreased cerebral blood volume
in the right MCA territory with increased MTT, consistent with
prior right MCA infarct.
Brief Hospital Course:
The patient was admitted to the ICU for Q1 hour neuro checks. He
remained intubated and was on dilantin and decadron. He was able
to withdraw all 4 extremities to noxious stimuli. The patient
was morbidly obese and was unable to undergo an MRI because he
was over the weight limit. His CT scan revealed a 7.5 x 5.3 cm
mass in the right middle and anterior cranial fossa with midline
shift and uncal and subfalcine herniation. The patient was taken
to the operating room on [**2134-11-19**] and underwent a right
craniotomy for tumor resection. The procedure was technically
difficult due to the large size of the mass and the proximity of
the MCA. However, the tumor was able to be decompressed well
with no complications. The patient remained intubated and was
brought directly to CT for a post-op scan. It revealed expected
post-operative fluid within the resection cavity, decompression,
and decreased midline shift. The patient then returned to the
ICU.
His exam improved and he was able to follow commands when the
sedation was turned off. He was started on a decadron taper. His
dilantin levels were monitored and adjustments made as
indicated. The patient was extubated on [**11-23**] in the afternoon
without incident. It was further noted that his serum sodium
levels were becoming more elevated(153), so he was started on
100cc of free water q6h. This was successfully treating his
hypernatremia. On [**11-24**], he was transferred to the stepdown
unit. The sodium continued to improve. PT and OT worked with the
patient to get him OOB to chair. The patient's brother brought
in a list of home medications and these were added on [**11-26**].
Additionally a psych consult was obtained to determine if the
patient was competent to make his own decisions and to give his
brother permission to assist him with his affairs.
On [**11-27**] the patient was noted to be more obtunded and then
began to have respiratory distress he was immediately
transferred to ICU. He was found to have a hypercarbic acidosis.
Further imaging showed a RLL consolidation and a right mca
hypodensity. He continued to move all extremities with more
spontaneously movement on the right. Attempts to wean the vent
were successful, and he transferred to the neurosurgical
stepdown unit after extubation. LENIS and CTA ruled out DVT/PE.
Perfusion studies were performed for hypodensity on CT. This
showed decreased cerebral blood volume in the right MCA
territory with increased MTT, consistent with prior right MCA
infarct.
He was without neurologic deline but he continued to have
cognitive impairment. He was seen by psychiatry who felt that he
would benefit from inpatient cognitive rehab.
On [**12-8**], he was found to be significantly lethargic, and
minimally following commmands in comparision to previous days. A
blood gas was obtained and he was found to be hypercarbic
acidosis. An urgent Pulmonary and medicine consult was obtained.
He was transferred to the ICU for further pulmonary managment.
After further titration of his non-invasive support, his
acidosis was corrected, and mental status improved. Pulmonary
made significant recommendations as to the subsequent treatment
of his pulmonary management. He was screened and accepted for
disposition to [**Hospital1 **], and this was carried out on [**2134-12-10**]
Medications on Admission:
Atenolol
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 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. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze/ desaturation.
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
9. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed) as needed for foley insertion.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Enalapril Maleate 10 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
17. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for sbp>190.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Sphenoid [**Doctor First Name 362**] mass - Atypical meningioma (Who Grade II)
Sleep Apnea
Hypercarbic respiratory failure
Urinary tract infection
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been prescribed Keppra for anti-seizure medicine,
take it as prescribed until you are seen in neurosurgery follow
up.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? 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.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2134-12-27**]
at 4pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will need a CT with contrast of the brain prior to this
appointment, as you are unable to have an MRI.
You Also have an appointment with your PCP(Dr. [**Last Name (STitle) **] on [**2-8**], [**2135**] at 1:45pm. He is located at [**Hospital3 **] at
[**Location (un) 84395**] call [**Telephone/Fax (1) 250**] if you
require additional directions, or need to change the date and
time of this approintment.
Completed by:[**2134-12-10**]
ICD9 Codes: 486, 2760, 2762, 5990, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7501
} | Medical Text: Admission Date: [**2103-7-3**] Discharge Date: [**2103-7-12**]
Service: MEDICINE
Allergies:
Allopurinol
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
hypotension, LLE pain
Major Surgical or Invasive Procedure:
Right groin line placement
Right radial artery line placement
History of Present Illness:
Pt is a legally blind [**Age over 90 **] y/o F with PMH significant for CHF,
infra-renal AAA s/p endovascular repair with chronic leak, and
peripheral vascular disease with chronic bilateral LE skin
tears, presented to the [**Hospital1 18**] on [**7-3**] with hypotension and a
3-day hx of worsening LLE pain. She was seen by her VNA (helps
manage her chronic skin tears) who found patient hypotensive.
Patient also reports LE pain was throbbing and sharp diffuse
throughout her entire leg. On presentation, she denies any chest
pain/SOB/palpitations, fevers/chills (although frequently cold),
nausea/vomiting. She reported chronic diarrhea, decreased
appetite and chronic skin tears worse in the lower extremities
bilaterally.
.
Per patient's nephew (very involved in her care): Pt. has been
hypotensive over the last week accompanied with weakness and
confusion. Also, pt's PCP discontinued her [**Name9 (PRE) **] 80 mg on
[**2103-6-27**] for these episodes of hypotension and weakness, but
increased her furosemide to 40 mg [**Hospital1 **]. Her nephew voiced concern
about pt's very poor PO intable, ability to take medications on
her own and perform ADLs.
.
In the ED, initial vs were: T 97.4 P 61 BP 91/48 R 20 O2 sat.
SBPs were in the 90-100s range. On exam she is a frail, elderly
woman and LLE warm, erythematous w/ appearance of cellulitis.
Cannot palpate pulses, but easy to doppler. Patient was given
vanc/zosyn/clinda. Access 20G in R antecub. Got 1500cc of fluid
total. Reported guiac positive stool in the ED. Vitals prior to
transfer 96.7 56 101/83 13 96% on 4L NC.
.
On arrival in the MICU, her VS were T:94.8 (rectal) BP: 95/42
P:64 R: 18 O2: 94% on 3L NC and she complained of pain in her LE
extremities worse in her left, chills, oriented to self, place
and date but had somewhat of tangential speech. She was bolused
500cc twice with unresponsive MAPs and with difficult central
access via SC or IJ, an A-line was placed and phenylepherine
(stopped at 6AM on [**7-5**]) given for 24 hours and was gradually
weaned off. She was found to grow 4000 GNR on urine cultures
resistant to b-lactams on speciation. There were no other
impressive sources of infection although a CT abd and
gallbladder U/S had evidence of chronic cholecystitis. LE films
was neg for gas or fluid collections. She was worked up with a
CT abd, hand was gradually weaned of pressors with 250cc
boluses. Her labs were neg for bands.
Past Medical History:
1. CHF (EF 45%, though likely an overestimate given severe MR)
2. CAD (last cath in [**2096**] with complete occlusion of ramus
intermedius, moderate disease elsewhere)
3. Decreased vision R eye, now legally blind
4. PVD - s/p arthrectomy and B/L superficial femoral artery PTCA
5. Severe mitral regurgitation
6. Depression
7. Hysterectomy
8. Endoscopic aortic aneurysm repair [**11-28**]
9. Chronic kidney disease (baseline Cr 1.4)
Social History:
Born in [**Location (un) 669**] MA but currently lives in [**Location **] Corner alone.
She has a home VNA and someone to help clean her house. Her
nephew who lives in [**State 2748**] visits weekly to check on her
and brings her groceries. Has no family in [**Location (un) 86**] (twin sister
and two older siblings passed away). Retired from advertising
and currently spends her days listening to the television.
Ambulates with a scooter but nephew has expressed concern about
patient's inability to ambulate well around her home in addition
to inconsistently taking her medication.
- Tobacco: remote history, discontinued over 35 years ago
- Alcohol: 6oz of Vermouth every evening (per patient's nephew).
Patient states drinks occassionally).
.
Family History:
Twin sister-died from liver cancer at age 43
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:94.8 (rectal) BP: 95/42 P:64 R: 18 O2: 94% on 3L NC
General: Alert, oriented, no acute distress
HEENT: Sclara are cloudy, reactive pupils 3-->2 mm. Dry mucuos
membranes. Oropharynx clear without lesions or ulcers.
Neck: supple, JVP to level of mandible at 30 degrees
Lungs: Poor inspiratory effort without rales.
CV: Regular rate with occassional PVC's, 2/6 systolic murmur. No
rubs, gallops
Abdomen: protuberant abdomen with linear midline scar. Soft,
non-tender, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. Tympanic to percussion
GU: foley with clear urine
Ext: B/L lower extremity erythema with erosions and ulcerations.
TTP. Dopplerable pulses.
Neuro: AOX3 but tangeintal speech. Sluggish but MAE. Can move
toes and hands
.
DISCHARGE PHYSICAL EXAM:
Vitals: Tc:97.2, BP:138/69(90-130/50-60) HR:74(60-80), R:20
O2:95% on 2L. I/O: 8h (100/200, 24h (2380/1300)
General: Elderly female lying comfortable in bed, oriented to
self and place not date, no acute distress
HEENT: Sclera translucent, mucous membranes dry, poor dentition
with many missing dention, oropharynx clear
Neck: supple, JVP not assessed, no LAD
Lungs: Clear to auscultation bilaterally, decreased breath
sounds on the right base and mild crackles in the left base
CV: Regular rate with extra heart sounds, 2/6 systolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, midline abd scar, dependent
edema and skin breaks in the lower abdomen/inguinal area (better
than yesterday).
Ext: Warm, well perfused, 2+ edema with several ulcerations of
different depths. pulses not palpated
Pertinent Results:
Admision Labs
=================
[**2103-7-3**] 06:31PM LACTATE-2.3*
[**2103-7-3**] 02:09PM URINE HOURS-RANDOM
[**2103-7-3**] 02:09PM URINE GR HOLD-HOLD
[**2103-7-3**] 02:09PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2103-7-3**] 02:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-LG
[**2103-7-3**] 02:09PM URINE RBC-<1 WBC-20* BACTERIA-MOD YEAST-NONE
EPI-<1 TRANS EPI-<1
[**2103-7-3**] 02:09PM URINE MUCOUS-RARE
[**2103-7-3**] 01:32PM LACTATE-2.6*
[**2103-7-3**] 01:20PM UREA N-45* CREAT-1.5* SODIUM-126*
POTASSIUM-4.3 CHLORIDE-91* TOTAL CO2-22 ANION GAP-17
[**2103-7-3**] 01:20PM ALT(SGPT)-16 AST(SGOT)-29 LD(LDH)-203
CK(CPK)-63 ALK PHOS-151* TOT BILI-1.9* DIR BILI-1.5* INDIR
BIL-0.4
[**2103-7-3**] 01:20PM LIPASE-15
[**2103-7-3**] 01:20PM CK-MB-11* MB INDX-17.5* cTropnT-0.02*
[**2103-7-3**] 01:20PM ALBUMIN-3.5
[**2103-7-3**] 01:20PM WBC-8.3 RBC-3.51* HGB-11.9* HCT-35.4*
MCV-101* MCH-33.9* MCHC-33.6 RDW-18.2*
[**2103-7-3**] 01:20PM NEUTS-75* BANDS-8* LYMPHS-9* MONOS-4 EOS-0
BASOS-0 ATYPS-1* METAS-3* MYELOS-0
[**2103-7-3**] 01:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-1+
[**2103-7-3**] 01:20PM PLT SMR-NORMAL PLT COUNT-151
[**2103-7-3**] 01:20PM PT-19.2* PTT-36.7* INR(PT)-1.7*
[**2103-7-6**] 06:15AM BLOOD WBC-6.2 RBC-3.49* Hgb-11.3* Hct-36.3
MCV-104* MCH-32.4* MCHC-31.1 RDW-19.0* Plt Ct-118*
[**2103-7-7**] 07:00AM BLOOD WBC-6.3 RBC-3.96* Hgb-12.6 Hct-41.3
MCV-104* MCH-31.8 MCHC-30.5* RDW-18.9* Plt Ct-134*
[**2103-7-8**] 06:30AM BLOOD WBC-6.8 RBC-3.45* Hgb-11.6* Hct-37.3
MCV-108* MCH-33.8* MCHC-31.2 RDW-18.6* Plt Ct-125*
[**2103-7-9**] 06:35AM BLOOD WBC-6.8 RBC-3.63* Hgb-11.8* Hct-37.7
MCV-104* MCH-32.4* MCHC-31.3 RDW-18.5* Plt Ct-126*
[**2103-7-10**] 07:17AM BLOOD WBC-6.8 RBC-3.61* Hgb-11.7* Hct-37.3
MCV-103* MCH-32.3* MCHC-31.3 RDW-18.4* Plt Ct-123*
[**2103-7-11**] 05:21AM BLOOD WBC-7.4 RBC-3.33* Hgb-11.2* Hct-34.8*
MCV-105* MCH-33.8* MCHC-32.3 RDW-18.2* Plt Ct-168
[**2103-7-12**] 05:30AM BLOOD WBC-7.6 RBC-3.24* Hgb-10.9* Hct-34.0*
MCV-105* MCH-33.5* MCHC-32.0 RDW-18.3* Plt Ct-201
[**2103-7-6**] 06:15AM BLOOD Neuts-79.8* Lymphs-15.6* Monos-2.4
Eos-1.9 Baso-0.3
[**2103-7-7**] 07:00AM BLOOD Neuts-76.0* Lymphs-17.5* Monos-4.1
Eos-2.1 Baso-0.3
[**2103-7-8**] 06:30AM BLOOD Neuts-72.1* Lymphs-20.8 Monos-4.1 Eos-2.5
Baso-0.4
[**2103-7-10**] 07:17AM BLOOD Neuts-74.5* Lymphs-21.9 Monos-2.6 Eos-0.8
Baso-0.2
[**2103-7-6**] 06:15AM BLOOD Plt Ct-118*
[**2103-7-7**] 07:00AM BLOOD Plt Ct-134*
[**2103-7-8**] 06:30AM BLOOD Plt Ct-125*
[**2103-7-9**] 06:35AM BLOOD Plt Ct-126*
[**2103-7-10**] 07:17AM BLOOD Plt Ct-123*
[**2103-7-11**] 05:21AM BLOOD Plt Ct-168
[**2103-7-12**] 05:30AM BLOOD Plt Ct-201
[**2103-7-8**] 03:33PM BLOOD Glucose-114* UreaN-22* Creat-1.1 Na-142
K-4.4 Cl-113* HCO3-18* AnGap-15
[**2103-7-9**] 06:35AM BLOOD Glucose-105* UreaN-20 Creat-1.0 Na-144
K-4.0 Cl-112* HCO3-19* AnGap-17
[**2103-7-10**] 03:45PM BLOOD Na-140 K-4.3 Cl-109*
[**2103-7-11**] 05:27PM BLOOD Na-140 K-4.2 Cl-108
[**2103-7-12**] 05:30AM BLOOD Glucose-96 UreaN-22* Creat-0.9 Na-140
K-4.1 Cl-108 HCO3-23 AnGap-13
[**2103-7-7**] 07:00AM BLOOD ALT-15 AST-22 AlkPhos-154* TotBili-1.1
[**2103-7-8**] 06:30AM BLOOD ALT-13 AST-25 AlkPhos-137* TotBili-1.1
[**2103-7-10**] 07:17AM BLOOD ALT-14 AST-23 LD(LDH)-258* AlkPhos-134*
TotBili-1.4
[**2103-7-9**] 06:35AM BLOOD Albumin-2.8* Calcium-8.5 Phos-2.8 Mg-2.0
[**2103-7-10**] 03:45PM BLOOD Mg-1.9
[**2103-7-11**] 05:21AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.6
[**2103-7-12**] 05:30AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.1
[**2103-7-4**] 12:55AM BLOOD Lactate-3.2*
[**2103-7-4**] 10:37AM BLOOD Lactate-1.9
[**2103-7-7**] 08:18PM BLOOD Lactate-1.8
Brief Hospital Course:
.
#Septic Shock: Patient presented with hypotension, as well as
bandemia and hypothermia to 35C. She was admitted to the ICU.
Her blood pressure was refractory to IV fluids and she was
started on vasopressors to maintain a MAP> 60 through a left
femoral line. Her blood pressure medications (isosorbide
mononitrate, metoprolol, lasix ) were held due to hypotension.
She was started on broad spectrum antibiotics that included
Vanc/Cefepime/Flagyl. Her blood culture from admission grew
Acinetobacter Baumannii. Her antibiotics were changed to
meropenem on [**2103-7-5**]. She was weaned of vasopressors by ICU
day three and was transferred out to the medicine floor where
she remained hemodynamically stable with systolic blood
pressures ranging from 90s to 120s.
#Acinetobacter bacteremia: Her blood culture from admission grew
Acinetobacter Baumannii. The infectious disease service was
consulted. The source was likely urinary as urine culture on
admission was dirty (although culture not obtained until after
antibiotics initiated). A skin source was also considered given
multiple skin tears in her lower extremities. She was started on
meropenem on [**2103-7-5**] with plan to complete a fourteen day
course (finishing [**2103-7-18**]). She will need blood cultures drawn
after completion of antibiotics to verify eradication of
infection.
.
#Acute on chronic systolic heart failue: An echocardiogram
showed an ejection fraction of 30-35% with a 2+ mitral
regurgitation, new as compared to a study in [**11/2102**] which
showed an ejection fraction of 45%. She developed a new oxygen
requirement. Exam and chest imaging were consistent with volume
overload (2-3L nasal cannula). This likely occurred due to
aggressive IVF resuscitation in the ICU. She was started on
lasix 10-20IV boluses for goal diuresis of 500cc daily. She has
achieved that goal with a regimen of 20IV lasix twice daily.
This at times has been limited by borderline blood pressures
with systolics in the 90s. At discharge she is satting 95% on
2L nasal cannula breathing comfortably at 16 resps per minute.
She still appears volume overloaded with crackles at bases and
significant lower extremity edema at her upper thighs. Would
recommend further diuresis with lasix 20IV [**Hospital1 **] with goal
negative of 500cc daily. She was given a dose of 20IV this
morning at 11AM. Would check electrolytes twice daily and
replete as has had brief runs (up to 8 beats) of SVT with LBBB
conduction noted on telemetry. Her home metoprolol succinate
(100mg daily) was changed to 6.25mg TID during the
hospitalization, which her blood pressure tolerates well.
Isosorbide has been held during diuresis. She has a foley
catheter for urine monitoring and also has lower extremity
breakdown that could potentially be a nidus for infection.
.
#Lower extremity Skin tears: This is a chronic problem although
per her nephew her legs looked significantly worse of late.
Ultra-sound of the legs were negative for deep venous
thrombosis. Wound care was consulted and recommended: 1.
Pressure Redistribution - Atmos Air 2. Cleanse bilateral groins
and perineum with Aloe Vesta foam cleanser daily. Pat dry 3.
Apply Critic aid clear to bilateral groins daily. Place Kerlix
in between skin fold to separate skin and wick moisture. [**Month (only) 116**]
re-apply skin barrier ointment after each 3rd cleansing. 4.
Apply Crit aid clear antifungal to perineum daily. 5. Reposition
q2 hours. 6. OOB to chair on chair cushion for 2 hr at a time.
7. Waffle to bilateral feet. Float heels. 8. Apply Aloe Vesta
ointment to intact dry skin daily. 9. Continue with wound care
to BLE's traumatic skin tears
for planning. 10. Patient is not safe at home alone, MSW and
Case Management
for planning. Her wounds were improved at discharge.
.
#Coagulopathy: Her PTT/PT were elevated on admission (INR of
1.9) thought to be due to malnutrition or possibly chronic liver
disease. She was given vitamin K 10mg PO for three days and her
INR trended down to 1.4 at discharge.
.
#Gallstones: She was found to have gallstones but no evidence of
acute cholecystitis on abdominal imaging (CT and ultrasound).
.
#Chronic Kidney Disease: Her creatinine on admission ranged from
1.5-1.1 and on discharge it was 0.9. All nephrotoxins were
avoided and her medications were renally dosed.
.
#Diarrhea: She reports loose stools at home and etiology is
unclear especially since CT of the abdomen showed well formed
stools but there was no evidence of inflammation or enteritis. C
diff toxin was negative. There was some concern for overflow
encoparesis and stool impaction. She was put on a bowel regimen
and this stabilized over the hospital stay.
.
#Aneursym: CTA showed her aneursym was stable w/ type 3 endoleak
with unchanged aneurysmal sac diameter and no evidence of any
free fluid suggestive of blood.
.
#CAD: No symptoms of active ischemia. Her isosorbide was held in
the setting of hypotension from sepsis and then active diuresis.
was stable and she was continued on her pravastatin and aspirin.
.
#Code status: per patient and her nephew she would want to be
DNR but ok to intubate.
Medications on Admission:
Furosemide 40mg [**Hospital1 **]
Metoprolol Succinate 100mg daily
ASA 81mg daily
Pravastatin 10mg daily
Sertraline 50mg daily
Omeprazole 20mg daily
Ferrous sulfate 325mg daily
Vit D3 1000 daily
Multivitamin daily
Imiquimod 5% cream
Isorbide mononitrate 30mg daily
Discharge Medications:
1. meropenem 500 mg Recon Soln Sig: One (1) Intravenous every
twelve (12) hours for 6 days: last day to complete 14 day course
will be [**2103-7-18**].
Disp:*12 * Refills:*0*
2. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY
(Daily) as needed for apply to leg ulcers.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for Pain/Fever.
11. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO TID (3
times a day).
Disp:*10 Tablet(s)* Refills:*2*
12. Meropenem 500 mg IV Q12H
Day 1 = [**2103-7-5**]
13. Outpatient Lab Work
check Chem-7 twice daily while diuresing with IV lasix
14. lasix 20IV twice daily; hold for SBP<90
15. telemetry
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Primary Diagnosis:
-Septic Shock
-Pulmonary Edema
.
2. Secondary Diagnosis:
-CHF (EF 45%, though likely an overestimate given severe MR)
-CAD (last cath in [**2096**] with complete occlusion of ramus
intermedius, moderate disease elsewhere)
-Decreased vision R eye, now legally blind
-PVD - s/p arthrectomy and B/L superficial femoral artery PTCA
-Severe mitral regurgitation
-Depression
-Hysterectomy
-Endoscopic aortic aneurysm repair [**11-28**]
-Chronic kidney disease (baseline Cr 1.4)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at the [**Hospital1 18**] when you were
recently admitted for low blood pressures and found to have
bacteria growing in your blood. You were first stabilized in
the intensive care unit and then you were transferred to the
medicine floor where your blood pressures continued to be
stable. You were treated with antibiotics for you infection. You
will need to contine to take antibiotics while at rehab until
[**7-18**].
.
Over your hospital stay, you required oxygen to maintain your
oxygen saturation at normal levels. The decline in your
pulmonary function was thought to be from a combination of fluid
in your lungs and decreased lung volumes. You were give some
lasix to reduce the fluid in your lungs and that is something
you will have to continue at rehab.
.
We changed the dressings on your leg ulcers daily and they were
improved your hospital stay.
.
Followup Instructions:
You should follow-up with the scheduled appointments below:
Department: VASCULAR SURGERY
When: THURSDAY [**2103-9-6**] at 2:45 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2103-9-20**] at 12:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
ICD9 Codes: 0389, 2761, 5990, 4280, 4240, 4439, 311, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7502
} | Medical Text: Admission Date: [**2185-6-15**] Discharge Date: [**2185-7-2**]
Date of Birth: [**2116-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
ACDF C5-7
Posterior laminectomy and fusion C5-T1
History of Present Illness:
Mr. [**Known lastname 431**] is a 68 year-old man with hx of alcohol abuse,
pancreatic insufficiency, DM, and HTN who was admitted on
[**2185-6-15**] to Ortho-Spine after falling from a 12-foot ladder while
intoxicated. MRI spine at [**Hospital **] Hospital revealed unstable
right C7 facet fracture and C6/7 disc herniation. He was
transferred to [**Hospital1 18**] for further management.
Past Medical History:
DM
HTN
Prostate cancer s/p prostatectomy
Alcohol abuse
Pancreatic insufficiency
Social History:
Lives with wife. [**Name (NI) **] history of tobacco or drug abuse. According
to wife, pt began drinking heavily at age 60 when diagnosed with
prostate cancer. He has been intermittently sober since then. He
has recently been drinking 0.5-1 pint vodka. He often goes
through withdrawal at home which manifests as tremors and
anxiety. He once had hallucinations, but there is no history of
seizures.
Family History:
N/C
Physical Exam:
Vitals: T 98.3 BP 140/80 HR 67 RR 18 O2 sat 96%RA
General: alert and oriented to person but not place or time,
agitated and delirious
CV: RRR, no murmurs/rubs/gallops
Resp: CTAB, no wheezes/crackles/rhonchi
GI: Abd soft NT/ND, bowel sounds present
Extremities: BUE- 4/5 strength at deltoid and biceps, [**5-4**]
triceps, wrist flexion/extension, finger flexion/extension and
intrinics; sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**],
reflexes symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
On admission:
[**2185-6-15**] 06:58PM BLOOD WBC-5.8 RBC-3.47* Hgb-10.5* Hct-32.0*
MCV-92 MCH-30.4 MCHC-33.0 RDW-16.7* Plt Ct-128*
[**2185-6-15**] 06:58PM BLOOD Neuts-89.9* Lymphs-6.1* Monos-3.2 Eos-0.7
Baso-0.1
[**2185-6-15**] 06:58PM BLOOD Plt Ct-128*
[**2185-6-15**] 07:41PM BLOOD PT-11.7 PTT-23.0 INR(PT)-1.0
[**2185-6-18**] 01:45PM BLOOD Fibrino-505*
[**2185-6-15**] 06:58PM BLOOD Glucose-129* UreaN-22* Creat-1.2 Na-139
K-5.2* Cl-103 HCO3-20* AnGap-21*
[**2185-6-16**] 06:50AM BLOOD Calcium-7.6* Phos-3.2 Mg-1.2*
[**2185-6-16**] 06:39PM BLOOD Type-ART Temp-37.1 Rates-/40 Tidal V-600
FiO2-40 pO2-155* pCO2-41 pH-7.34* calTCO2-23 Base XS--3
Intubat-INTUBATED Vent-CONTROLLED
[**2185-6-18**] 02:04PM BLOOD Glucose-166* Lactate-0.9 Na-132* K-3.9
Cl-97*
[**2185-6-16**] 06:39PM BLOOD Hgb-9.8* calcHCT-29
[**2185-6-16**] 11:34PM BLOOD freeCa-1.04*
.
On discharge:
[**2185-7-1**] 04:09PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2185-7-1**] 12:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-19
Bnzodzp-NEG
.
[**2185-6-29**] and [**2185-6-26**] BLOOD CULTURE-pending
[**2185-6-29**] Ucx neg
[**2185-6-24**] & [**2185-6-26**] ucx neg
[**2185-7-1**] 06:10AM BLOOD WBC-5.7 RBC-3.01* Hgb-8.7* Hct-26.7*
MCV-89 MCH-28.8 MCHC-32.5 RDW-16.1* Plt Ct-484*
[**2185-7-1**] 06:10AM BLOOD Plt Ct-484*
[**2185-7-1**] 06:10AM BLOOD Glucose-261* UreaN-8 Creat-0.9 Na-140
K-3.9 Cl-105 HCO3-25 AnGap-14
[**2185-7-1**] 06:10AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8
[**2185-7-1**] 12:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-19
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2185-7-2**] 07:35AM BLOOD WBC-5.4 RBC-2.94* Hgb-8.2* Hct-25.7*
MCV-88 MCH-28.0 MCHC-32.0 RDW-16.3* Plt Ct-522*
[**2185-7-2**] 07:35AM BLOOD Glucose-206* UreaN-14 Creat-0.8 Na-137
K-4.1 Cl-101 HCO3-27 AnGap-13
[**2185-7-2**] 07:35AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.8
.
CT C-Spine w/o contrast [**2185-6-15**]:
IMPRESSION: Fracture of right superior articulating facet of C7
with anterior subluxation of C6 inferior facet. C6-C7 disc space
widening, concerning for ligamentous injury; posterior
osteophyte disc complex at C5-C6 that narrows the canal;
Recommend MRI to further assess.
.
MR [**First Name (Titles) 11598**] [**Last Name (Titles) 1093**] w/o contrast [**2185-6-16**]:
IMPRESSION:
1. Disruption of the anterior and posterior longitudinal
ligaments and the ligamentum flavum at the level of C6/7, with
adjacent soft tissue
abnormalities, compatible with highly unstable extension-type
fracture injury.
2. Right C7 facet fracture with impaction of the C6 inferior
facet into the fracture site. This has not significantly changed
since the CT examination from the prior day.
3. Acute C6/7 posterior disc herniation resulting in moderate
stenosis of the spinal canal at this level. Signal abnormalities
within the cord are
suggestive of contusion. No hematoma is seen.
.
C-SPINE (PORTABLE); SPINAL FLUORO [**2185-6-16**]:
IMPRESSION: There is an anterior plate at the C5 through C7
levels with
normal alignment at this time.
.
Portable CXR [**2185-6-16**]:
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Tip of the endotracheal tube is substantially above the upper
margin of the clavicles, at least 9 cm above the carina, 6 cm
above optimal placement. Subsequent chest radiograph, 6:05 a.m.
on [**6-17**] available at the time of this review showed no change
in this malposition.
Lungs are low in volume but aside from mild left basal
atelectasis, clear. Heart size normal. No pleural abnormality.
.
ECG [**2185-6-21**]:
Sinus rhythm. Consider left atrial abnormality. Left anterior
fascicular block. Delayed R wave progression is non-specific but
clinical correlation is suggested. No previous tracing available
for comparison.
.
CT Head w/o contrast [**2185-6-23**]:
IMPRESSION:
1. No acute hemorrhage or fracture is detected.
2. Fluid in the paranasal sinuses, may be secondary to recent
intubation/surgery.
.
Right Elbow Xray [**2185-6-23**]:
IMPRESSION:
1. Slight irregularity at the radial head suspicious for an
occult fracture. Small joint effusion.
2. Enthesopathy at medial and lateral epicondyles of distal
humerus and
triceps insertion on the olecranon.
.
Portable CXR [**2185-6-18**]:
FINDINGS: Endotracheal tube is in a proximal location, 9.5 cm
above the
carina. New nasogastric tube terminates within the stomach with
side port
near the GE junction. Dr. [**Last Name (STitle) 85028**] has been paged with these
results. Exam is otherwise remarkable for worsening atelectasis
at the left lung base, with no other relevant short interval
changes.
.
Portable CXR [**2185-6-26**]:
FINDINGS: The feeding tube has been removed. The lungs are
grossly clear
without focal consolidation. Hardware within the lower cervical
spine is
seen.
.
OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION [**2185-6-28**]:
EVALUATION:
An oral and pharyngeal swallowing videofluoroscopy was performed
today in collaboration with Radiology. Nectar-thick liquid
(tspn, cup) and pureed consistency barium (1 tspn only) were
administered. Results follow:
.
ORAL PHASE:
Oral phase was most remarkable for moderately reduced bolus
control resulting in premature spillover of nectar thick liquid
to the valleculae and airway before the swallow. Mild-moderate
tongue weakness (specifically base of tongue) contributed to
pharyngeal residue. Oral transit time for individual swallows
was WNL.
.
PHARYNGEAL PHASE:
Swallow was initiated in a timely manner, however pt presented
with severely reduced hyolaryngeal excursion, moderately reduced
laryngeal valve closure, and near absent epiglottic deflection.
Pt had at least moderately reduced bolus propulsion and apparent
edema near the level of the UES (in line with new cervical
spinal
hardware). Deficits in combination with oral phase deficits
resulted in moderate to severe vallecular and pyriform sinus
residue after [**5-5**] swallows per bolus.
.
ASPIRATION/PENETRATION:
Pt demonstrated penetration before and during the swallow which
resulted in aspiration after the swallow with both nectar thick
liquids and purees. Pt had spontaneous throat clear which
temporarily would improve the amount of aspiration or
penetration, however it did not fully clear and thus the
material
would be re-aspirated. Cued cough was also ineffective at fully
eliminating aspirated material.
.
TREATMENT TECHNIQUES:
Pt benefits partially but not fully from spontaneous repeat
swallows (5-6 per bite/sip) and cued swallow-cough-swallow
maneuver. There is no strategy, however, which eliminates
aspiration or pharyngeal residue.
.
SUMMARY:
Pt, currently POD #[**8-9**] from anterior and posterior cervical
spinal surgeries with hardware, demonstrates severe
oropharyngeal
dysphagia as described above most notable for reduced movement
of
the pharyngeal swallow mechanism and swelling at the level of
the
cervical hardware. Deficits result in significant pharyngeal
residue and aspiration across all consistencies assessed. Based
on the results of today's evaluation, he does not appear safe
for
PO intake and should remain fully NPO at this time including no
Dobbhoff today. Given the length of time pt will require to
recover from his current deficits and his propensity to self-d/c
NGTs despite our efforts otherwise, MD team may wish to consider
longer term means of nutritional support such as PEG. If we can
be of further assistance with discussion regarding plan of care,
please contact us. Otherwise, we will f/u in approximately 1
week's time for reassessment, if he remains at this facility.
Alternatively, pt could have swallow f/u in a rehab setting.
.
RECOMMENDATIONS:
1. NPO, no ice chips, no oral meds
2. Q4 oral care while NPO.
3. Support non-oral means of nutrition, hydration, and
medication
4. Consider longer term means of non-oral nutrition.
5. Repeat swallowing evaluation in 1 week's time.
Page/reconsult
if we can be of further assistance prior to that f/u.
6. Pt will benefit from intensive swallow therapy and
cognitive-linguistic dx/tx in a rehab setting upon d/c.
.
NG tube placement [**2185-6-30**]:
IMPRESSION: Successful placement of a nasointestinal tube into
the
post-pyloric position. The tube is ready to use.
.
Ct head [**2185-6-29**] non contrast:
There is no acute hemorrhage, edema, mass effect or acute major
vascular
territorial infarction. Global, predominantly central
parenchymal atrophy is likely age-related. Periventricular white
matter hypodensities are most likely the sequelae of chronic
small vessel ischemic disease. There is minimal fluid in ethmoid
air cells and frontal sinuses, bilaterally. The remainder of the
paranasal sinuses and mastoid air cells appear clear. Surgical
clips and post-surgical changes are noted in the scalp overlying
the left occipital bone.
IMPRESSION: No acute intracranial abnormality.
.
CXR [**2185-6-29**]:
FINDINGS: Small retrocardiac opacity, could be atelectasis.
There is no
pneumonia. There is no pleural effusion, or pneumothorax. Hilar,
mediastinal, and cardiac silhouette are within normal limits.
There is mild
rightward scoliosis in the thoracic spine. Anterior posterior
cervical fusion at the lower C-spine.
IMPRESSION:
1. No pneumonia.
2. Small retrocardiac opacity, could be atelectasis.
Brief Hospital Course:
Mr. [**Known lastname 431**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2185-6-15**] and taken to the Operating Room for a cervical fusion
through an anterior approach C5-7. Please refer to the dictated
operative note for further details. The surgery was without
complication and the patient was transferred to the PACU in
stable condition. TEDs/pnemoboots were used for postoperative
DVT prophylaxis. Intravenous antibiotics were given per standard
protocol. Initial postop pain was controlled with a PCA.
Post-operatively he was noticed to be confused and withdrawing
from alcohol. He was transfered to the T/SICU for further
management. On HD#3 he returned to the operating room for a
scheduled posterior cervical fusion as part of a staged 2-part
procedure. Please refer to the dictated operative note for
further details. The second surgery was also without
complication and the patient returned to the T/SICU intubated.
.
He was subsequently extubated without difficulty but failed a
speech and swallow likely secondary to soft tissue swelling from
his surgeries. A Dobhoff was placed and he was given tubefeeds.
His further withdrawal symptoms were managed with ativan and
valium. He pulled out his Dobhoff tube on [**6-21**]. He was
transfered to the medical service for further management.
.
On the medical service, he failed a second speech and swallow
evaluation on [**6-22**] and another Dobhoff tube was placed on [**6-23**].
We started him on thiamine and a multivitamin and continued his
folate. It was felt that his altered mental status was largely
due to delirium and not alcohol or benzodiazepine withdrawal,
and we thus sought to minimize use of narcotics and
benzodiazepines.
.
On [**6-23**], Mr. [**Known lastname 431**] [**Last Name (Titles) 18095**] an unfortunate fall to the floor
as he was getting out of his chair. He had a CT scan of his head
and complete spine, which showed no acute intracranial process
and no fractures. An x-ray of his right elbow showed a tiny
non-displaced fracture of his radial head. His right arm was put
in a sling, and on discahrge was recommended for full [**Last Name (un) **] of
motion, non weight bearing, and sling for comfort.
Subsequently, he was kept with a 1:1 sitter until his transfer
to an outside hospital.
.
The patient had several aspiration events associated with a
brief desaturation and occasional fever. The differential for
these fevers included aspiration pneumonitis vs. neuroleptic
malignant syndrome. His CXRs did not demonstrate a
consolidation and making pneumonia less likely although he
certainally is at risk for developing a true aspiration PNA.
All psych meds were stopped due to concern of NMS and he
remained afebrile without leukocytosis throughout rest of
hospital stay. While at [**Hospital 26260**] hospital these psych meds
should be restarted soon after arrival. He was re-evaluated by
Speech and Swallow on [**6-27**] and again failed a bedside speech and
swallow exam. On [**6-28**] he underwent a video swallow study that
showed mild-moderate tongue weakness, near absent epiglottic
deflection, and edema near the level of the UES in line with new
cervical spinal hardware. These defects resulted in aspiration
with both nectar thick liquids and purees. Based on these
results, it was recommended that patient be kept NPO without
oral meds. A dobhoff was placed for nutrition but he pulled it
out the same day before it could be utilized for tube feeds.
The next day, another dobhoff was attempted and patient was kept
on restraints so as not to pull it out. Tube feeds were started
on [**6-30**].
.
Given that he does not tolerate [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube well, a more
long-term means of non-oral nutrition should be pursued,
possibly with a PEG tube. We discussed the issue of the PEG
tube with the patient and his wife on [**6-28**]. However, his wife
expressed her desire for the patient to be transferred to [**Hospital 85029**] Center to be under the care of his primary care
physician. [**Name10 (NameIs) **] patient should continue this discussion on a
means for long-term nutrition at his outside hospital. If he is
discharged to a rehab facility without a PEG tube in place, he
should continue to be kept NPO until re-evaluation one week
later with a repeat swallow study. He should receive intensive
swallow therapy and cognitive-linguistic treatment in a rehab
setting. He should also receive q4h oral care while NPO. He
also had episodes of oxygen desaturations to the high 80s that
improved to the high 90s with both oxygen via nasal cannula and
with suctioning of oral secretions. By discharge, his oxygen
saturation was stable in the mid to high 90s on room air.
Please note: blood cultures were still pending on discharge.
.
Of note, patient continued to show signs of sun-downing until
the 2 days before transfer. Delirium persisted despite the fact
that he was ostensibly taken off all possible sedatives,
including benzos and his psychiatric medications. Patient
periodically agitated, often requiring restraints. He was
combative off restraints and received one dose of 5mg zyprexa IM
which did not alleviate symptoms. Psych consult was obtained to
evaluate and recommended starting 1mg haldol standing and 1mg
qhs prn on [**6-30**]. QTC was mildly prolonged to 455 and thus he was
changed to liquid haldol. His psych meds were so far in the
hospitalization but citalopram was started at low dose and
should be titrated up. Patient's mental status improved after
the haldol; he was alert and oriented x 3 the next morning [**7-1**].
CXR, UA, and blood cx were unremarkable. TSH, B12, folate, and
RPR were checked as part of delirium work up and were pending on
discharge.
.
However, throughout the day, he became more somnolent and
lethargic, out of proportion to the amount of haloperidol he was
receiving. A urine toxicology returned on [**7-1**] positive for
benzos in the urine which had been discontinued since [**6-23**]. It
is unclear why he had benzos in the urine at that time. Blood
toxicology was negative.
Of note Mrs. [**Known lastname 431**] was updated daily by several members of the
medical team including Dr. [**Last Name (STitle) **] (attending), Dr. [**Last Name (STitle) 3315**] (pgy3),
and Dr. [**Last Name (STitle) **] (pgy1). She repeatedly expressed concern that we
were not caring for her husband well. [**Name2 (NI) **] was transferred to
[**Hospital 26260**] Hospital on [**2185-7-2**] per the wishes of his wife.
Medications on Admission:
Lantus 12 units
Metformin 500 mg [**Hospital1 **]
Lisinopril 30 mg qam
Nifedipine 30 mg qam
Simvastatin 10 mg pm
Pancrease 10 mg TID
Clonazepam 0.5 mg qid
Citalopram 40 mg qam
Albuterol NEB
Prilosec 20 mg pm
Chromium 500 mcg
Fenugreek 600 mg [**Hospital1 **]/meals
Discharge Medications:
1. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Lisinopril 20 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Folic Acid 1 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 QHS (once a day (at bedtime)).
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Insulin
per attached sliding sclae
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
15. Haloperidol Lactate 2 mg/mL Concentrate Sig: o.5 PO BID (2
times a day).
16. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
17. Ondansetron 4 mg IV Q6H:PRN nausea
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis: C7 superior facet fracture and C6 perched
right inferior facet with C6-7 disc injury, delirium, ?NMS,
failed speech and swallow
Secondary diagnoses: Diabetes mellitus type 2, hypertension,
alcohol abuse, pancreatic insufficiency, history of prostate
cancer s/p prostatectomy
Discharge Condition:
Discharge Instructions:
You were admitted after falling off a ladder and fracturing a
cervical vertebra (a part of your spine). Our surgeons performed
anterior and posterior fusion of your cervical spine. You
[**Hospital1 18095**] a fall while you were in the hospital. CT scans of
your head and spine showed no acute bleeding in your head and no
disruption of your spine. An elbow x-ray showed a tiny
nondisplaced fracture of your right radius (one of the bones in
your forearm), and you were given a sling. It was not possible
to tell the age of that fracture.
.
You were very confused at the hospital and psychiatry was
consulted. You are now on haldol. Your confusion is getting
better.
.
You also showed symptoms of alcohol withdrawal which was treated
with medications. You should abstain from alcohol in the future.
You also had some confusion due to sedating medications which
slowly improved. You had some fevers that were thought to be due
to neuroleptic malignant syndrome (in which patients develop
high temperatures due to psychiatric medications) or aspiration
pneumonia. However, your chest x ray was clear, making
pneumonia less likely. Your fevers resolved when your
psychiatric medications were stopped, your psych medications
will be restarted after transfer to your new hospital but they
may be restarted slowly. We started your citalopram at a low
dose on [**2185-7-1**].
.
You had persistent difficulty with swallowing, as shown by
several swallowing tests in the hospital. As a result of your
swallowing difficulties, you like aspirated while in the
hospital. We tried to give you nutrition through a tube that
goes through your nose into your stomach but you pulled it out
several times. You will likely need a more long-term source of
nutrition such as a PEG tube, which is a tube that goes into
your stomach and attaches to the outside. You will be
transferred to an outside hospital as you and your family
requested. There, this issue of the feeding tube should be
addressed further. For now you have a tube through your nose.
.
Post op instructions from our surgeons:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy: 2-3 times a day you should go
for a walk for 15-30 minutes as part of your recovery. You can
walk as much as you can tolerate. Limit any kind of lifting.
-Brace: You have been given a collar. This is to be worn for
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications once you
are taking things by mouth. No NSAIDs (ibuprofen, aleve).
-Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
.
We will send the doctors at your [**Name5 (PTitle) **] hospital a list of your
medications on transfer.
Followup Instructions:
Please schedule a follow-up appointment with Dr. [**Last Name (STitle) 363**] in 10
days at ([**Telephone/Fax (1) 11061**].
Completed by:[**2185-8-11**]
ICD9 Codes: 5849, 4019, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7503
} | Medical Text: Admission Date: [**2165-8-20**] Discharge Date: [**2165-8-22**]
Service: MEDICINE
Allergies:
Digoxin
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
hpi:86 yo female with non-ischemic CM, EF 10-20%, severe MR,
asthma who was admitted [**8-20**] with right facial droop. CT and MRI
negative for CVA. On hospital day#2 developed acute onset soba
dn increased rr and hr. Lasix had been held in the am due to low
bp. Denied CP, though was not mentating well and unable to
answer questions reliably. Stat cxr showed worsening chf. ABG
showed 7.25/46/235 on nrb. Pt received 80 and then 40 mg IV
lasix with no response. 1 mg IV morphine given. EKG showed ST
with baseline LBBB. Pt transferred to CCU for presumed CHF
exacerbation.
Social History:
lives at facility, no EtOH or tob, retired real estate broker
Family History:
No DM, CAD, HTN, cancer
86 yo F with EF 10-20%, 4+ MR [**Name13 (STitle) **] to the CCU with acute
tachy/hypoxia.
1) Respiratory distress--Ddx: CHF +/- aspiration PNA. By CXR,
history, CHF likely a component. However, pt showed no response
to another lasix 120 mg IV as well as lasix drip. Also, per
nursing staff, pt had not been mentating well and had had
difficulty taking PO and may have aspirated. O/N pt developed a
fever over empiric levo/flagyl. Though the pt satted well and
had improved abg's on NRB and then high flow mask, the
underlying pathophysiology--her CHF and likely pna--did not
appear improved.
2) Poor cardiac output--The has had a hx of declining mentation
over the past few weeks that has fallen precipitously leading to
this admit. Also, during this admit, the pt's Cr has elevated
significantly and her urine output has fallen. This is likely
due to worsening cardiac out-put. It is unclear what the
precipitating event was that led to the acute decompensation of
her cardiac output. O/N her CO was unresponsive to dobutamine
and her BP was worsening by its effects.
3) Low [**Name (NI) 49810**] pt's BP worsening with the dobutamine. During the
administration of the dopamine, she was found to have a temp to
103. The pt's BP did not recover despite the dobutamine being
stopped and levophed being administered and escalated to the
maximum dose. The pt was felt to be septic.
4) Code status: [**Name (NI) 49811**] pt's cardiogenic shock exacerbated by
an apparent underlying septic shock was discussed with the
family. The pt's family had been updated as to Ms. [**Known lastname 49812**]
condition throughout the night. With no improvement in pt's MAPs
despite escalating doses of levophed, the felt including son
(hcp) felt goals of care should be to make pt [**Name (NI) 3225**].
5) Communication Son [**Name (NI) 382**]: Dr. [**First Name4 (NamePattern1) **] [**Known lastname **] [**Telephone/Fax (1) 49813**] (c),
[**Telephone/Fax (1) 49814**] (h)
Past Medical History:
1. PE
2. hypertension
3. hypothyroidism
4. asthma
4. nonischemic CHF with EF <20%
5. dementia
6. depression
6. CRF baseline 1.3-1.5
Social History:
Social History:
lives at facility, no EtOH or tob, retired real estate broker
Family History:
Family History:
No DM, CAD, HTN, cancer
Physical Exam:
PE: 101 rr20 bp 103/60 hr88
Gen: opens eyes to name, o/wnon-responsive
skin: no lesions
heent: pupils sluggishly reactive to light, mmd
heart: rrr no mrg
lungs: diffuse rales on post and ant exam
abd: soft/nt/nd +BS
ext: non edema , PT pulss intact
neuro: unable to assess
Pertinent Results:
[**2165-8-20**] 11:40PM GLUCOSE-133* UREA N-42* CREAT-1.6* SODIUM-136
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-13
[**2165-8-20**] 11:30PM URINE HOURS-RANDOM
[**2165-8-20**] 11:30PM URINE GR HOLD-HOLD
[**2165-8-20**] 11:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2165-8-20**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2165-8-20**] 06:52PM GLUCOSE-163* LACTATE-2.0 NA+-133* K+-4.6
CL--96* TCO2-27
[**2165-8-20**] 06:45PM UREA N-43* CREAT-1.9*
[**2165-8-20**] 06:45PM CK(CPK)-31
[**2165-8-20**] 06:45PM TSH-11*
[**2165-8-20**] 06:45PM T4-7.2
[**2165-8-19**] 04:40AM PLT COUNT-179
[**2165-8-19**] 12:35PM PT-16.1* PTT-35.2* INR(PT)-1.8
[**2165-8-20**] 06:45PM PT-14.7* PTT-32.9 INR(PT)-1.5
Brief Hospital Course:
A/P: The pt is an 86 yo F with EF 10-20%, 4+ MR transferred to
the CCU with acute tachycardia/hypoxia.
1) Respiratory distress??????On admission the pt??????s differential
diagnosis was: CHF +/- aspiration PNA. By CXR, and the patient??????s
history, CHF was a likely a component to her presentation.
However, the pt showed no response to a bolus of lasix IV as
well as lasix drip. Also, per nursing staff, the pt had not been
mentating well and had had difficulty taking PO and may have
aspirated. O/N pt developed a fever over empiric levo/flagyl.
Though the pt satted well and had improved abg's on NRB, then
high flow mask, the underlying pathophysiology--her CHF and low
cardiac output as well as her likely pna--did not appear
improved. By [**2165-8-21**] the pt had made little urine out-put and ,
thus, appeared to remain volume overloaded pulmonary-wise. Per
Dr. [**Last Name (STitle) **] and the cardiology fellow, low dose peripheral
dobutamine was atarted in hopes of improving cardiac output.
However, the urine output remained low and the pt??????s BP dropped
to around 60/30. The pt??????s temp spiked as well to around 103 F.
Thus, the picture was complicated by sepsis.
2) Poor cardiac output??????Before admission the pt had a hx of
declining mentation over the past few weeks that has fallen
precipitously leading to this admit. Also, during this admit,
the pt's Cr has elevated significantly and her urine output has
fallen. This was likely due to worsening cardiac out-put. It is
unclear what the precipitating event was that led to the acute
decompensation of her cardiac output. On [**8-21**] her CO was
unresponsive to dobutamine and her BP was worsening by its
effects. This likely led to the pulmonary effects described
above.
3) Low [**Name (NI) 49810**] pt's BP worsened with the dobutamine. During the
administration of the dopamine, she was found to have a temp to
103. The pt's BP did not recover despite the dobutamine being
stopped and levophed being administered and escalated to the
maximum dose. Eventually levophed was added with minimal
effect. The pt was deemed to be septic.
4) Code status: [**Name (NI) 49811**] pt's cardiogenic shock exacerbated by
an apparent underlying septic shock was discussed with the
family. The pt's family was updated as to her condition
throughout her admission. With no improvement in the pt's MAPs
despite escalating doses of levophed, the pt??????s son, Dr. [**Name (NI) **]
[**Name (NI) **] (hcp) felt the goals of care should be to make the pt [**Name (NI) 3225**].
Eventually, the patient died on [**2165-8-22**] and was declared dead
by Dr. [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1726**].
5) Communication throughout admission: the pt??????s son [**Name (NI) 382**]: Dr.
[**First Name4 (NamePattern1) **] [**Known lastname **] [**Telephone/Fax (1) 49813**] (c), [**Telephone/Fax (1) 49814**] (h)
Discharge Medications:
n/a
Discharge Disposition:
Expired
Facility:
Pt expired on [**2165-8-22**]
Discharge Diagnosis:
n/a
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 0389, 486, 5849, 5990, 4280, 4240, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7504
} | Medical Text: Admission Date: [**2204-4-8**] Discharge Date: [**2204-4-13**]
Date of Birth: [**2137-7-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
feeling unwell
Major Surgical or Invasive Procedure:
Right Internal Jugular Line placement
History of Present Illness:
66 yo m with DM, h/o CAD s/p CABG with PCI in '[**99**], severe PVD,
CKD, and s/p Vfib arrest who presents with 1 day of vague
symptoms. He reports that he started feeling unwell yesterday
afternoon with nausea, lightheadedness, and some shortness of
breath. He denies chest pain or pressure, palpitations,
vomiting, sweating. He was noted to be altered by his wife with
concern re: difficulty speaking, perhaps a left sided facial
droop and possible left hemianopsia, but limited evidence for
this. The patient denies having any difficultly speaking or
visual changes, but says that he was confused and seeing things
that weren't there. His wife reported to the neurologist that
he never had a facial droop.
.
He reports chronic DOE, no CP at rest or with exercise, +
claudication (calf pain) with ambulating 2 blocks, denies
orthopnea, sleeps on 4 pillows at night. + PND. He reports LE
edema at baseline. He lost 10 lbs over past 3 months, which he
attributes to diet and exercise.
He initially went to an OSH, where CT head was negative. He was
found to have new [**Last Name (un) **] and elevated cardiac enzymes. He was
hypotensive at OSH to SBP 80s, started on peripheral dopamine
and sent to the ED.
In the ED, initial vs were: 98.9 86 94/45 on dopamine 20 95%.
He was also reporting worsening of chronic low back pain. His
exam was notable for [**3-11**] murmur, benign abdomen, rectal was
guaiac neg. A bedside U/S in the ED was neg for pericardial
effusion. Cardiology consult was requested for stat ECHO in ED,
to look for new WMA, but was not performed. EKG was not felt to
be markedly changed from baseline. There was some concern for
aortic aneurysm given back pain so he had a CT torso w/o
contrast, which was negative for aneurysm. Vascular was
consulted and felt aortic dissection was unlikely. Neurology
was consulted for concern re: TIA and they did not feel he had a
primary neurologic process. Due to persistent hypotension, a
RIJ was placed and he was started on levofed. He was not given
any antibiotics as he was afebrile without e/o infection. VS
prior to transfer were 79 93/36 on levofed 0.12mcg, 18 99% on
3L.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
Severe CAD s/p CABG in [**2196**] and PCI in [**2199**]
CKD (Baseline Cr = 2.6)
S/p VF arrest on a treadmill test in [**2196**]
Bilateral SFA stenting with re-stenosis and arthectomy
(+) ABI and claudication (worse on L)
[**4-11**] - left common femoral to below-knee popliteal artery
bypass with non reversed right saphenous vein
Social History:
Lives with wife, immigrated from Caribbean approximately 40
years ago. Retired construction worker.
-Tobacco history: Denies
-ETOH: Denies
-Illicit drugs: Denies
Family History:
Mother died of stroke at age 45. Father with diabetes and
hypertension and died at age 70. Two brothers with coronary
artery disease, one died [**2200**] at age 59 from MI.
Physical Exam:
Admission Exam:
Vitals: 79 93/36 on levofed 0.12mcg, 18 99% on 3L
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear
Neck: CVL in right IJ (CVP 21), supple, difficult to assess JVP
on left, no LAD
Lungs: bilat rales at bases.
CV: Regular rate and rhythm, distant heart sounds, normal S1 +
S2, 2/6 SEM at RUSB, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: cool extremities, unable to palpate DP or PT pulses, trace
non-pitting edema.
NEURO: CN 2-12 intact, MAE, sensation grossly intact.
Disharge Exam:
General: Alert, oriented x3, answering questions appropriately,
no acute distress
HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear
Neck: CVL in right IJ (CVP 21), supple, difficult to assess JVP
on left, no LAD
Lungs: bilat rales at bases.
CV: Regular rate and rhythm, distant heart sounds, normal S1 +
S2, 2/6 SEM at RUSB, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: cool extremities, unable to palpate DP or PT pulses, trace
non-pitting edema.
NEURO: CN 2-12 intact, MAE, sensation grossly intact.
Pertinent Results:
Admission Labs:
[**2204-4-8**] 04:00AM BLOOD WBC-8.3 RBC-4.82 Hgb-12.6* Hct-38.4*
MCV-80* MCH-26.1* MCHC-32.7 RDW-14.9 Plt Ct-271#
[**2204-4-8**] 04:00AM BLOOD PT-22.5* PTT-27.2 INR(PT)-2.1*
[**2204-4-8**] 04:00AM BLOOD Glucose-135* UreaN-66* Creat-5.0*# Na-137
K-4.0 Cl-107 HCO3-20* AnGap-14
[**2204-4-8**] 04:00AM BLOOD ALT-150* AST-59* LD(LDH)-250 AlkPhos-109
TotBili-0.2
Cardiac Markers:
[**2204-4-8**] 04:00AM BLOOD cTropnT-0.39*
[**2204-4-8**] 07:15AM BLOOD CK-MB-16* MB Indx-6.6*
[**2204-4-8**] 07:15AM BLOOD cTropnT-0.44*
[**2204-4-8**] 04:34PM BLOOD CK-MB-19* MB Indx-6.7* cTropnT-0.56*
[**2204-4-9**] 01:34AM BLOOD CK-MB-14* MB Indx-5.5 cTropnT-0.50*
[**2204-4-9**] 06:19AM BLOOD CK-MB-12* MB Indx-5.0 cTropnT-0.53*
[**2204-4-9**] 05:30PM BLOOD CK-MB-9 cTropnT-0.71*
[**2204-4-8**] 04:59AM BLOOD Lactate-1.3 K-4.0
[**2204-4-8**] 07:32AM BLOOD Lactate-1.0
Imaging:
carotid series: [**2204-4-9**]
1. Less than 40% stenosis of the right internal carotid artery.
2. 40-59% stenosis of the left internal carotid artery.
3. Reversal of flow in the right vertebral artery, suggestive of
subclavian steal.
Echo: [**2204-4-9**]
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed (LVEF= 25-30 %) with
global hypokinesis and apical akinesis. A left ventricular
mass/thrombus cannot be excluded. There is no ventricular septal
defect. with severe global free wall hypokinesis. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. No mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion
CT abdomen/ pelvis: [**2204-4-8**]
1. normal caliber thoracic and abdominal aorta. no hematoma
detected.
Dissection cannot be detected due to lack of IV contrast.
2. Unusually large appendix (12 mm diameter) but no secondary
signs of
appendicitis. This may represent a mucocele, and elective
resection should be considered.
3. Hyperdense right renal mass may represent a hemorrhagic cyst,
but this is incompletely evaluated with this technique. This can
be further assesed with ultrasound.
4. No acute intrathoracic, intraabdominal, or intrapelvic
process seen.
5. Enlarged pretracheal lymph node.
Discharge Labs:
CBC: WBC-7.8 RBC-5.01 Hgb-12.7* Hct-38.0* MCV-76* MCH-25.4*
MCHC-33.4 RDW-14.4 Plt Ct-221 PT-19.4* PTT-72.0* INR(PT)-1.8*
Glucose-140* UreaN-102* Creat-3.8*# Na-140 K-3.7 Cl-103 HCO3-24
AnGap-17
ALT-50* AST-21 AlkPhos-94 TotBili-0.2
Calcium-8.8 Phos-3.7 Mg-2.2
Brief Hospital Course:
66 yo m with DM, h/o CAD s/p CABG with PCI in '[**99**], severe PVD,
CKD, and s/p Vfib arrest who presents with 1 day of vague
symptoms found to have hypotension, [**Last Name (un) **] and elevated CE.
# Shock/Hypotension: On arrival to the ED, patient's exam was
most consistent with cardiogenic shock, with a prior known EF
25-30%. He had no evidence of sepsis or hypovolemia on exam. His
hypotension was likely triggered by new administration of
minoxidil causing hypotension and stress leading to stress and
demand ischemia. Home BP medications were held, and he was
started on levophed with a goal MAP of 55-60. On admission to
the MICU, an a-line was placed for monitoring of his blood
pressures. Overnight in the MICU he required increasing doses of
levophed to maintain blood pressure. His CE were trended,
showing elevation of troponin and mild elevation in CK in
setting of acute kidney injury and demand ischemia. Repeat Echo
showed stable EF of 25-30%, RV free wall hypokinesis and apical
akinesis. The patient was transferred to the CCU for further
management of cardiogenic shock. Levophed was transitioned to
dopamine and patient was started on lasix gtt for diuresis with
good result. Dopamine was weaned off on [**2204-4-11**]. Throughout
hospitalization, patient was maintained on therapeutic INR with
coumadin or with therapeutic PTT with heparin gtt given history
of recently diagnosed LV thrombus. In setting of renal failure,
patient was started on carvedilol on [**2204-4-11**] and was not
restarted on atenolol. As an outpatient, the patient should be
restarted on [**Last Name (un) **] and spironolactone as tolerated by BP and
recovery of kidney function.
Of note, noninvasive blood pressures were difficult to monitor
on patient secondary to severe PVD. Carotid dopplers showed
possible subclavian steal on right, so BP should be monitored on
left.
# Coronaries: Upon admission serial EKG showed nonspecific ST
changes in the lateral leads, that were initially concerning for
ACS. Cardiac enzymes were trended, showing elevation of
troponin to 0.95 with only mild CK elevation in the setting of
worsened renal failure (see below) and cardiogenic shock.
Patient continued on ASA, plavix and atorvostatin through
duration of hospitalization. Atenolol was held secondary to
renal failure and hypotension, and was later transitioned to
carvedilol once cardiogenic shock had resolved. Carvedilol dose
uptitrated to 25mg [**Hospital1 **] by time of discharge but other
anti-hypertensives were held since BP had been so low at
presentation and had not yet rebounded to previously elevated
levels.
# Acute Kidney Injury on chronic kidney disease: Patient
admitted with oliguric renal failure with Cr elevated to 5.0
from baseline of 2.6. Likely etiology secondary to ATN in the
setting of his ongoing hypotension and poor forward flow. Renal
was consulted for help with management given his possible need
for catheterization and severe renal dysfunction. Kidney
function improved with initiation of dopamine and lasix gtt.
Home [**Last Name (un) **] and atenolol were held given worsened renal function.
Renal function was trended daily with creatinine peaking at 6.5.
On discharge had improved to 3.8 and was trending in the right
direction but will be rechecked on Monday at Dr.[**Name (NI) 5452**] office.
# Altered mental status/reported neurologic changes: Presented
with vague neurologic complaints of confusion, dysarthria, and
facial droop which had resolved by presentation to the ED.
Initially the patient was noted to have some waxing - [**Doctor Last Name 688**]
mental status thought to be secondary to toxic metabolic
encephalopathy from azotemia and cerbral hypoperfusion from
hypotension. Neurologic exam was nonfocal and mental status
improved through hospital course. Neurology was consulted and
felt that initial presentation was consistent with a TIA. For
secondary prevention, risk factor management was optimized and
patient constinued on strict control of hypercholesterolemia,
hypertension, and on antiplatelet agents. HA1C was found to be
10.6. Patient contined on coumadin to prevent embolic stroke
from known LV thrombus although this was held for a couple days
during hospitalization while there was concern that proceedure
might be needed as below.
# Known LV thrombus: Pt with history of LV thrombus documented
on prior TTE. Had been on warfarin as an outpatient but this was
held for a couple days as inpatient as concern that patient
would need additional invasive proceedures. Placed on heparin
gtt to cover while INR subtherapeutic. Warfarin was restarted 2
days prior to D/c and INR climbing but only up to 1.8 on day of
D/c so pt administered one sub-cutaneous dose of 80mg enoxaparin
on day of discharge and given script for one additional dose of
80mg enoxaparin the next day. Pharmacy was contact[**Name (NI) **] to confirm
that dosing should be 80mg daily for therapeutic
anti-coagulation in setting of improving renal failure.
# Transaminitis: New this admission, likely secondary to poor
forward flow given his presentation of hypotension. Trended
through hospital course and noted to be downtrending.
# Diabetes: Type II on insulin, on 75/25 [**Hospital1 **] [**First Name8 (NamePattern2) **] [**Last Name (un) 387**]
recommendations. Home regimen was held upon admission given
poor PO intake and patient transitioned to glargine + ISS.
Insulin regimen was adjusted to maintain blood sugars in
100-200. Ultimately put on NPH (70/30) regimen of 15 units in AM
and 15 units in PM with ISS to cover. Discharged on this
regimen.
# Incidental CT findings - noted incidentally on CT A/p. Large
appendix (12 mm diameter) but no secondary signs of
appendicitis, enlarged pretracheal lymph node and hyperdense
right renal mass that may represent a hemorrhagic cyst requires
outpatient surgical follow-up.
Medications on Admission:
-hydralazine??
Minoxidil
Coumadin
-Lipitor 80 mg Tab 1 Tablet(s) by mouth DAILY (Daily)
-Plavix 75 mg Tab 1 Tablet(s) by mouth DAILY (Daily)
# Humalog Mix 75-25 100 unit/mL (75-25) Susp, Sub-Q Inj 1
Insulin(s) once a day As [**First Name8 (NamePattern2) **] [**Last Name (un) 387**] DM
-Benicar 20 mg Tab 2 Tablet(s) by mouth qd ()
-Aspirin 325 mg Tab 1 Tablet(s) by mouth DAILY (Daily)
-Atenolol 100 mg Tab 1 Tablet(s) by mouth once a day
-Isosorbide Mononitrate SR 30 mg 24 hr Tab 2 Tablet(s) by mouth
DAILY (Daily)
-Spironolactone 25 mg Tab 2 Tablet(s) by mouth three times a day
-Folic Acid 1 mg Tab 1 Tablet(s) by mouth DAILY (Daily)
-hydralazine 50 mg Tab Oral 1 Tablet(s) Three times daily
-Coumadin 5 mg Tab Oral 1 Tablet(s) Once Daily
-gabapentin 100 mg Tab Oral 1 Tablet(s) Three times daily
-minoxidil 10 mg Tab Oral 1 Tablet(s) Once Daily -started few
days ago by Dr. [**Last Name (STitle) **]
[**Name (STitle) 46090**] 20 mg Tab Oral 1 Tablet(s) Once Daily
-Pletal 100 mg Tab Oral 1 Tablet(s) Twice Daily
cilostazol
-aldactone 50mg TID
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Fifteen (15) Units Subcutaneous twice a day.
Disp:*900 Units* Refills:*2*
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
8. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 1 doses: Please take dose at 3pm
on Sat, [**4-14**].
Disp:*1 syringe* Refills:*0*
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. insulin aspart 100 unit/mL Solution Sig: One (1) syringe
Subcutaneous four times a day: Take your blood sugars before
each meal and administer additional insulin according to
attached sliding scale:.
Disp:*900 units* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1) Hypotension
2) Acute renal failure
Secondary Diagnosis:
1) Diabetes
2) Systolic Heart Failure
3) Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **], you were admitted to the hospital with low blood
pressure and worsened kidney function. You initially were sent
to the cardiac ICU where medications were used to support your
blood pressure. You had a cat-scan of your abdomen to see if
there was something obstructing your kidenys. You received
contrast with this CT and medications after the CT to protect
your kineys from the contrast. Your warfarin was stopped for a
couple days because we thought you might need additional
proceedures with high risk of bleeding. We also stopped many of
your blood pressure medications because you had such a low blood
pressure initially. Your kidney function has improved and should
continue to improve and your blood pressure has come back up so
we have restarted some blood pressure medications. Your INR is
currently slightly less than 2 even though we have restarted
your warfarin so you will get a shot of lovenox today and give
yourself 1 shot of lovenox tomorrow to make sure your blood is
thin enough until you are seen in clinic on Monday. While you
were in the hospital there was also initially some concern that
you had a stroke. The neurologic service came to see you and
said you did not have a stroke but may have experienced what we
call a TIA with no residual symptoms.
You will follow up with Dr. [**Last Name (STitle) **] in clinic on Monday where you
will have your INR and electrolytes checked.
The following changes were made to your medications:
- Start carvedilol 25mg by mouth twice each day for blood
pressure
- Increase home furosemide to 80mg by mouth once each day for
fluid
- Start enoxaparin 80mg sub-cutaneously for 1 day (only take
this medication on Saturday, then stop)
- Your insulin coverage was changed to NPH 70/30 taking 15 units
in the morning and 15 units in the evening with a sliding scale
to cover your meal time insulin (see attached sheet)
- Continue your home Atorvastatin, warfarin, plavix, aspirin,
folic acid
- Stop all your other home medications for now until further
instructed by Dr. [**Last Name (STitle) **]: stop minoxidil, hydralazine, isosorbide
mononitrate, spironolactone, cilostazol, atenolol, benicar, your
former sliding scale.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Please give yourself your enoxaparin shot on
Saturday as mentioned above. Please make sure to check your
blood sugars before each meal and give yourself the additional
insulin as instructed by the attached insulin slidding scale.
Followup Instructions:
You have a follow-up appointment scheduled on Monday [**2204-4-16**] with Dr. [**Last Name (STitle) **]. You will have your INR and electrolytes
checked at this visit.
You also have a follow-up appointment scheduled with your PCP
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 11139**] on Thursday [**4-26**] at 12:30pm. At this
appointment you should discuss the findings of your CT scan
described below.
** While you were hospitalized, you received a CT scan of your
abdomen and pelvis to make sure there was no damage to your
kidneys. While your kidneys looked fine there were the following
findings which should be discussed with your PCP at next visit.
1. Unusually large appendix (12 mm diameter) but no secondary
signs of appendicitis. This may represent a mucocele, and
elective resection should be considered.
2. Hyperdense right renal mass may represent a hemorrhagic cyst,
but this is incompletely evaluated with this technique. This can
be further assesed with ultrasound.
3. Enlarged pretracheal lymph node.
ICD9 Codes: 5845, 4280, 4439, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7505
} | Medical Text: Admission Date: [**2183-10-14**] Discharge Date: [**2183-10-18**]
Date of Birth: [**2128-10-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
VT arrest
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Patient is a 55 yo M with PMHx of CABG [**2175**], PCI [**2180**] who
presented to [**Hospital1 **] on [**10-13**] with increasing back pain and
chest pressure. Back pain was described as sharp x 30 min,
improved with nitroglycerin. Patient was otherwise asymptomatic.
He was admitted with chest pain for ROMI and possible stress
test [**10-14**] (CTA was negative). However at approx 10 PM he was
found face down in his room after his roommate called out. He
was initially breathing with shallow breaths, but then became
apneic and pulseless. Code blue was called and CPR initiated.
Patient was found to have Ventricular tachycardia and patient
was shocked per ACLS protocol. As well, patient was loaded with
amiodarone 300 mg and intubated for airway protection (though no
report of respiratory distress). Patient was briefly transferred
to the ICU at [**Location (un) 620**], but quickly transported to [**Hospital1 18**]. Per
report after intubating food particles were suctioned from the
ET tube.
Patient was then directly sent to the cath lab. There he was
found to have a total occlusion of his SVG-OM2 graft, this was
dilated and stented x2. Right heart catherization was done that
showed elevated pulmonary pressures and an elevated PCWP to
approx 40. IV lasix was administered. A 40 cm balloon pump was
placed and patient was transported to the CCU.
.
Review of systems not possible as patient is intubated and
sedated. As OSH, review of systems was positive only for chest
pain, back pain and lower extremity edema
Past Medical History:
Hypertension
Hyperlipidemia
CAD
Social History:
Social history is significant for current tobacco use. There is
no history of alcohol abuse.
Family History:
There is significant family history of premature coronary artery
disease with several male relatives having [**Name2 (NI) **] in their 40s, 50s
with the youngest occurring at age 25-26.
Physical Exam:
VS: T 99, BP 82/50, HR 89, RR 20, O2 100% on AC volume
controlled 600 x 20 FiO2 60% PEEP 5
Gen: WDWN middle aged male intubated and sedated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVD
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. Difficult to assess secondary
to balloon pump
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND,
Ext: No c/c/e. No femoral bruits (difficult to assess with
balloon pump).
Skin: No stasis dermatitis, ulcers, purpuric chest/neck
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 0 DP,
PT 1+
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2183-10-14**] 10:54PM WBC-8.0 RBC-2.75* HGB-9.3* HCT-26.7* MCV-97
MCH-33.9* MCHC-35.0 RDW-13.2
[**2183-10-14**] 08:27PM CK-MB-83* MB INDX-0.9 cTropnT-3.12*
[**2183-10-14**] 05:34AM CK-MB-242* MB INDX-5.7
.
cardiac Cath [**2183-10-14**]
COMMENTS:
1. Coronary angiography of this right dominant system revealed
three
vessel coronary artery disease. The LMCA had a 50% ostial
stenosis.
The LAD had a 50% proximal stenosis. The LCx system had a 100%
occluded
OM2. The RCA was diffusely diseased with an 80% ostial stenosis
and a
60% proximal stenosis.
2. Arterial conduit bypass angiography revealed a widely patent
LIMA-->LAD with retrograde filling. The radial graft to the
R-PDA had a
40% proximal stenosis. The SVG-->OM2 was totally occluded.
3. Resting hemodynamics revealed markedly elevated right and
left heart
filling pressures, with RVEDP of 31 mm Hg and mean PCWP of 40 mm
Hg.
Pulmonary arterial pressures were elevated with PASP of 58 mmHg.
There
was systemic arterial hypotension with aortic SBP of 78 mm Hg.
Cardiac
index was depressed at 1.34 L/min/m2.
4. Successful stenting of proximal and distal SVG-OM graft with
3.5x28mm
Vision BMS and 2.5x28mm Minivision BMS respectively in setting
of ACS.
5. Insertion of IABP for cardiogenic shock
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2 Occluded SVG-->OM2.
3. Cardiogenic shock.
4. Succesful Stenting of SVG-OM2
5. Intraaortic ballon pump placement.
.
ECHO [**2183-10-14**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate regional left ventricular systolic
dysfunction with inferolateral akinesis, inferior hypokinesis,
apical hypokinesis/akinesis. No apical thrombus identified.
Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
Brief Hospital Course:
55 yo M with CAD s/p CABG, PCI who presents after VFib/tach
arrest with total occlusion of his SVG s/p PCI.
.
V fib/tach arrest: Likely caused by ischemia and thus possibly
reversible. Was revascularized in cath lab and now without
further episodes. Was loaded on amiodarone IV on gtt overnight,
and then turned off.
.
Cardiogenic shock: Secondary to STEMI and CAD as patient had
totally occluded SVG. Cardiac index low at 1.34. IABP placed to
support blood pressure and coronary artery filling. Briefly on
phenylephrine for hypotension. Patient on heparin, plavix,
aspirin, add beta blocker. Patient was eventually weaned off
IABP as his blood pressure tolerated. BBlocker was added. He was
transitioned to coumadin from heparin, and will be maintained on
this for apical akinesis.
.
Fluid overload: patient with increased PCWP and right sided
pressures. Possible that patient received excessive fluids prior
to transfer. As well patient with poor forward flow. diuresed as
blood pressure tolerated. Euvolemic on dc.
.
Aspiration event: Patient with suctioned food particles. Patient
with mild fever and leukocytosis. possible stress response, but
given hypotension, treated empirically with antibiotics for
aspiration pneumonia. CXR without signs of infiltrate. treated
intially with Vanc/zosyn, no signs of infection, so this was
discontinued.
.
Respiratory status: patient intubated on OSH before transferred.
STable from respiratory status, and was weaned off vent on HD 2.
.
Anemia: likely in the setting of blood loss due to
catherizations and acute stress, stable on discharge.
.
Acidosis: improved after improvement in vent settings. [**Month (only) 116**] have
metabolic acidosis after hypoxic insult.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days: You should take this medication until
until [**10-24**].
4. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed): Use only when with chest
pain. 1 tablet every 5 minutes, for a maximum of 3 doses in 15
minutes. .
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
6. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day: take along with
the 50 mg tablet.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: ST elevation MI
.
Secondary:
Aspiration Pneumonia
Hypertension
Tobacco dependence
Discharge Condition:
Stable
Discharge Instructions:
You were initially admitted to the hospital with chest pain.
While you were in the hospital you had a cardiac arrest
requiring defibrillation. The most likely reason this occurred
was because you had an acute heart attack. You were taken to
the catheterizartion lab where we found that one of your
bypasses had clotted off. This was likely the reason why you had
a cardiac arrest.
.
The following medications were changed during your
hospitalization:
Your Crestor was discontinued due to elevated levels of enzyme
involved in muscle breakdown from your cardiac arrest. You
should follow up with your cardiologist and restart a lipid
lowering [**Doctor Last Name 360**] at his discretion.
You were also started on plavix for the maintenance of your
stent. You were also started toprol xl and lisinopril. Note
that your aspirin dose has also been increased for
cardioprotective effect. You have also been started on a
nicotine patch. You are being treated for a pneumonitis
following an aspiration event secondary to yoru cardiac arrest
with levoflox.
Please take all of your medications as directed.
Lastly you were started on a blood thinner called coumadin for
your decreased heart function. For which you will need frequent
blood checks.
.
If you have any of the following symptoms, you should return to
the ED or see your PCP:
[**Name10 (NameIs) **] pain, difficulty breathing, lightheadedness, loss of
consciousness or any other serious concerns.
Followup Instructions:
We have scheduled an appointment for you with your cardiologist
Dr. [**Last Name (STitle) 3321**] on [**10-30**] at 3pm.
You should follow up with your primary care doctor, Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 17753**] to have your INR (coumadin level) monitored. Dr. [**Name (NI) 42449**] office will call you with an appointment within the
next 1 week. If you do not hear from his office, it is
important that you schedule an appointment with him to have your
INR checked within the next week.
.
You were also noted to have blood tinged sputum. It is
important that you follow up with your primary care doctor for a
full work up.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2183-10-26**]
ICD9 Codes: 4275, 5070, 2851, 2762, 5849, 4280, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7506
} | Medical Text: Admission Date: [**2137-5-12**] Discharge Date: [**2137-6-3**]
Date of Birth: [**2104-3-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p rollover MVC
Major Surgical or Invasive Procedure:
ORIF zygoma, orbital floor, maxilla
Right radial fracture ORIF
Tracheostomy and G tube placement
Chest tube placement
Bolt placement
History of Present Illness:
25 yo male s/p MVC rollover, unresponsive at scene, +ETOH.
Failed attempts to intubate on the scene. Temporary airway
placed and pt brought to ED.
Past Medical History:
none
Social History:
+ ETOH
Family History:
NC
Physical Exam:
97.8 58 100/50 100%
Fast neg
DPL neg
GCS 3
multiple facial lacs, with full thickness lac on lower lip; fork
shaped chin lac; unstable mid-face; epistaxis, facial swelling,
CTAB, deformity left clavicle
RRR
Abd soft, bruising around abdomen
pelvis stable
Ext cool, mottled, superficial lacs +LLE
Pertinent Results:
CT abd/pel: 1) Grade 4 AAST liver laceration involving segments
5, 6, 7, and 8 of the liver, with evidence of active bleeding.
2) Laceration of upper pole of right kidney.
3) Large right-sided pneumothorax.
4) Left apical pneumothorax.
5) Right first posterior rib fractures.
6) Bilateral medial clavicular fractures.
7) Fracture through posterior acetabulum.
CT head: multiple facial fractures in maxilla and orbit; complex
numerous mandibular fractures
Right forearm fracture
CT head: No cervical spine fracture or malalignment is evident.
There is extensive soft tissue swelling in the neck, especially
on the left. Findings were discussed with Dr. [**Last Name (STitle) **]. At this
time (8 a.m.), he reports that the patient has a right
hemiparesis. No evidence of acute intracranial hemorrhage or
edema; There are no skull fractures, but there are numerous
facial fractures.
[**2137-5-12**] 06:03PM LACTATE-3.1*
[**2137-5-12**] 01:48PM UREA N-11 CREAT-1.1 SODIUM-145 POTASSIUM-4.0
CHLORIDE-109* TOTAL CO2-28 ANION GAP-12
[**2137-5-12**] 01:48PM HCT-40.6
[**2137-5-12**] 01:48PM PT-13.6 PTT-25.7 INR(PT)-1.2
[**2137-5-12**] 08:10AM GLUCOSE-114* UREA N-10 CREAT-1.1 SODIUM-147*
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-26 ANION GAP-18
[**2137-5-12**] 08:10AM CALCIUM-7.1* PHOSPHATE-4.3 MAGNESIUM-1.5*
[**2137-5-12**] 08:10AM OSMOLAL-322*
[**2137-5-12**] 08:10AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2137-5-12**] 08:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2137-5-12**] 05:20AM ALT(SGPT)-396* AST(SGOT)-355* CK(CPK)-625*
ALK PHOS-57 AMYLASE-231* TOT BILI-0.7
[**2137-5-12**] 05:20AM LIPASE-155*
[**2137-5-12**] 05:20AM CK-MB-21* MB INDX-3.4 cTropnT-0.30*
[**2137-5-12**] 05:20AM ETHANOL-134*
[**2137-5-12**] 04:00AM WBC-21.7* RBC-3.93* HGB-12.1* HCT-34.4*
MCV-87 MCH-30.8 MCHC-35.2* RDW-13.6
[**2137-5-12**] 02:29AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2137-5-12**] 02:29AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2137-5-12**] 02:20AM ASA-NEG ETHANOL-229* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**5-19**]: Sputum: 1+ GNR
[**5-17**]: Sputum 1+ GNR
[**5-20**]: Blood Cx: GPC [**3-6**] coag neg
[**5-18**]: CSP 1+ PMNs/coag neg staph
[**5-17**]: JP: 3+ PMNs
[**5-19**]: cdiff neg
[**5-23**]: urine cx: neg
[**5-26**]: sputum: GNR 2+, GPC in prs 1+; resp cx GNR
Brief Hospital Course:
Pt arrived in trauma bay with GCS of 3. Multiple attempts to
intubate pt failed. LMA placed until pt brought to OR for trach.
No scans were initially performed on patient due to hemodynamic
instability. Pt brought immediately to OR for exploratory
laparotomy, BOLT, and trach. See results section for list of
traumatic injuries. CT chest showed large PTX for which a chest
tube was placed in the right apex. Pt underwent multiple
surgeries spanning 2 days. Exploratory lap negative for
significant findings. Pt tolerated the surgeries well. However,
the post operative course was complicated by O2 desaturation in
the PACU down to the low 80's. Xray did not show changes in
pneumothorax. Pt placed on NRB with adequate improvement of O2
sat. ICU stay complicated by + sputum cultures for GNR and high
fevers. Started on 3 antibiotic regimen therapy x 7 days and
improved. Pt improved on the floor, satting well on trach mask.
Floor stay complicated by delirium/altered mental status from
?etiology. White count was elevated. Patient remained afebrile,
urine negative. Sputum cultures positive for GPC and GNR on [**5-26**]
and started on Zosyn and Vanc. White count improved. Mental
status seemed to improve with decrease of ativan use and
antibiotics for presumed PNA (aspiration vs CAP). Pt was able to
sit without sitter, and plans made to discharge to rehab for
further care.
Medications on Admission:
none
Discharge Medications:
1. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) application to wounds Topical every six (6) hours.
Disp:*2 months* Refills:*0*
2. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1)
Ophthalmic five times a day.
Disp:*2 months* Refills:*0*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
every 4-6 hours as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-8**]
hours as needed.
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 1-2 MLs
PO Q4H (every 4 hours) as needed.
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
10. Morphine Sulfate 8 mg/mL Syringe Sig: One (1) Injection Q4H
(every 4 hours) as needed for breakthrough pain.
11. H2O2 Sig: One (1) twice a day: Please give H2O2 rinses
for oral hygiene.
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Chlorhexidine Gluconate 0.12 % Liquid Sig: One (1) ML Mucous
membrane [**Hospital1 **] (2 times a day).
14. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
15. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
17. medications
Regular Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-50 [**2-3**] amp D50 [**2-3**] amp D50 [**2-3**] amp D50 [**2-3**] amp D50
51-120 0 0 0 0
121-140 2 2 2 2
141-160 4 4 4 4
161-180 6 6 6 6
181-200 8 8 8 8
201-220 10 10 10 10
221-240 12 12 12 12
241-260 14 14 14 14
261-280 16 16 16 16
[**Telephone/Fax (2) 61306**] 18 18
> 301 Notify M.D.
18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1) Grade 4 AAST liver laceration involving segments 5, 6, 7, and
8 of the liver, with evidence of active bleeding.
2) Laceration of upper pole of right kidney.
3) Large right-sided pneumothorax.
4) Left apical pneumothorax.
5) Right first posterior rib fractures.
6) Bilateral medial clavicular fractures.
7) Fracture through posterior acetabulum.
8) multiple facial fractures in maxilla and orbit; complex
numerous mandibular fractures
9) Right forearm fracture
10) There is extensive soft tissue swelling in the neck,
especially on the left.
Discharge Condition:
stable
Discharge Instructions:
1. Take all the medications as directed
2. Continue oral care with peridex and Peroxide rinses
3. Please take out the staples of head on [**Last Name (LF) 766**], [**2137-6-3**].
4. You need your antibiotics through your picc line daily.
5. Continue with physical therapy at the rehab
6. Continue using your eye drops
Followup Instructions:
1. Please follow up with oralmaxilofacial surgery clinic in
2.5-3 weeks by calling [**Telephone/Fax (1) 14288**] for an appointment. Ask for
the surgery resident on-call
2. Please call the plastic surgery clinic by calling
[**Telephone/Fax (1) 17687**] to schedule an appointment for any Friday in the
next 2-3 months if you have any cosmetic issues from your
surgery
3. You also should follow up with your primary care doctor in
the next few weeks. If you don't have one, you can call
[**Telephone/Fax (1) 250**] to schedule an appointment with physicians at the
[**Company 191**] here at [**Hospital1 18**].
4. You should also call the trauma clinic to schedule an
appointment by calling [**Telephone/Fax (1) 61307**] to schedule an appointment
in the next 10-14 days.
ICD9 Codes: 5185, 2851, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7507
} | Medical Text: Admission Date: [**2200-10-20**] Discharge Date: [**2200-10-24**]
Date of Birth: [**2146-4-28**] Sex: M
Service: MEDICINE
Allergies:
spironolactone
Attending:[**Last Name (un) 11974**]
Chief Complaint:
s/p VT ablation
Major Surgical or Invasive Procedure:
Ablation of ventricluar ectopic automaticity focus
History of Present Illness:
54 year old man with HTN, HLD, CAD with h/o anterior MI s/p DES
to LAD ([**7-/2198**]), systolic CHF NYHA Class III(EF 30-35% from TTE
[**5-/2200**]), h/o sustained VT s/p BIV ICD (BIV pacing turned off
[**5-/2200**]), and COPD requiring 2L at day and night. Recent device
interrogation revealed 23 episodes of NSVT lasting between 1 and
5 seconds. There were 11 logs of SVT by the device with episodes
lasting between 9 seconds and 2 minutes and 42 seconds. He had
one episode of pace terminated monomorphic VT that fell in the
VF zone but has never had an ICD shock. Due to his underlying
heart failure and COPD, Dr. [**Last Name (STitle) 23246**] does not feel that he is a
candidate for antiarrhythmic medication given COPD and has
referred him for VT ablation.
.
In the last several months the patient reports frequent episodes
of pre-syncope and palpitations with the sensation that "my
heart's going to come right out of my chest." These episodes
occur multiple times per day and last for 10-15 minutes at a
time. He reports having associated chest tightness and a feeling
that he is starved for air. He also describes multiple episodes
of feeling like he is going to pass out but denies any frank
syncope. These episodes are unrelated to activity. Occasional
diaphoresis, no PND, no Orthopnea.
.
In EP Lab tandem heart inserted prior to VT ablation for
prophylactic support. Were able to recreate NSVT not sustained
VT -> successful ablation -> extubated, tandem heart removed;
- 21F venous sheath on R, 8F arterial sheath on R, 15F arterial
sheath on L, 7F and 9F venous sheaths on L;
- Bed rest till 10pm
- 4L positive; goal 2L negative by midnight; got 40 IV lasix in
lab
- full dose aspirin
.
On arrival to the CCU, HR 90, 120/75, SpO2 98 on 100% facemask.
.
REVIEW OF SYSTEMS: Pt difficult historian.
On review of systems denies recent illness, does confirm
pre-syncopal episodes for about 6 months, worse recently and
palpitations.
.
Cardiac review of systems is notable for some mild chest pain
with episodes, sometimes diaphoresis, both symptoms resolve on
own. No orthopnea or PND.
Past Medical History:
- Hypertension
- Hyperlipidemia
- CAD s/p anterior wall MI [**7-/2198**] treated with a DES to the LAD
- Systolic CHF (LVEF 30-35% or 10-15%? unclear)
- Sustained ventricular tachycardia- [**2199-11-2**]; [**2200-3-5**]
- S/p BIV -ICD implant [**11/2199**] at [**Hospital6 **]; BIV
pacing
turned off [**5-15**]?
- Underlying bifasicular block
- Severe COPD on 2L home day and nightO2; referred to [**Hospital1 2025**] for
consideration of heart lung transplant, turned down on basis of
lacking social supports (heavy smoker, poor social support)
- Was evaluated by [**Hospital1 2025**] for heart/lung tx and declined due to
poor social support
Social History:
Single, lives alone. No children. Disabled. Quit smoking [**3-7**]
years ago, previously smoked 1.5 ppd for 39 years.
- Former heavy drinker
Family History:
Adopted
Physical Exam:
Wt 90 kg
Ht 72 inches
.
VS: 97.8, 80/54, 75, 99% on facemask
GENERAL: Caucasian man, looks stated age, with facemask laying
flat and complaining of back pain.
HEENT: EOMI, Sclera anicteric. MMM.
NECK: JVP difficult to appreciate given large habitus, seems to
be to angle of jaw?
CARDIAC: +S1+S2 but distant heart sounds, difficult to hear.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. Hypoacive BS.
EXTREMITIES: Warm, Right radial aline, left PIV, groin bandages
clean/dry.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Dopplerable b/l LE
Pertinent Results:
[**2200-10-20**] 07:10AM PT-10.9 INR(PT)-1.0
[**2200-10-20**] 07:10AM PLT COUNT-340
[**2200-10-20**] 07:10AM WBC-10.6 RBC-5.17 HGB-13.8* HCT-44.7 MCV-86
MCH-26.7* MCHC-30.9* RDW-16.8*
[**2200-10-20**] 07:10AM estGFR-Using this
[**2200-10-20**] 07:10AM GLUCOSE-95 UREA N-15 CREAT-0.9 SODIUM-142
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-38* ANION GAP-11
[**2200-10-20**] 07:44AM freeCa-1.13
[**2200-10-20**] 07:44AM HGB-13.0* calcHCT-39
[**2200-10-20**] 07:44AM GLUCOSE-95 LACTATE-0.6 NA+-140 K+-3.8 CL--92*
[**2200-10-20**] 07:44AM TYPE-ART PO2-203* PCO2-73* PH-7.35 TOTAL
CO2-42* BASE XS-11
[**2200-10-20**] 10:03AM TYPE-ART PO2-339* PCO2-56* PH-7.40 TOTAL
CO2-36* BASE XS-8 INTUBATED-INTUBATED VENT-CONTROLLED
[**2200-10-20**] 01:44PM freeCa-1.00*
[**2200-10-20**] 01:44PM HGB-9.7* calcHCT-29 O2 SAT-99
[**2200-10-20**] 01:44PM GLUCOSE-99 LACTATE-0.8 NA+-138 K+-3.4 CL--102
[**2200-10-20**] 01:44PM TYPE-ART PO2-350* PCO2-54* PH-7.40 TOTAL
CO2-35* BASE XS-7
[**2200-10-20**] 07:56PM PLT COUNT-244
[**2200-10-20**] 07:56PM WBC-13.3* RBC-3.69*# HGB-9.9*# HCT-31.8*#
MCV-86 MCH-26.7* MCHC-31.0 RDW-17.0*
[**2200-10-20**] 07:56PM ALBUMIN-3.4* CALCIUM-7.8* PHOSPHATE-3.4
MAGNESIUM-1.7
[**2200-10-20**] 07:56PM GLUCOSE-123* UREA N-15 CREAT-0.7 SODIUM-144
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-34* ANION GAP-10
[**2200-10-20**] 09:30PM HCT-30.8*
.
EKG: 80-90bpm, sinus, LAD, PR < .2, QRS > .12, RBBB, LAFB, Q in
V3,V4, II, III, aVF (old inferior septal MI)
.
STRESS MIBI ([**2200-5-7**]): Large fixed severe defect, almost total
anterior septum and apex. RV enlarged. EF 23%.
.
TTE ([**2200-5-27**]): EF 30-35% with apex, septum, and distal anterior
wall akinetic; remainder of LV hypokinetic. Mildly dilated right
ventricle with normal function.
.
TTE at [**Hospital1 112**] ([**2199-11-29**]): LV function severely reduced with
regional variability. LVEF 25-30%. Mild generalized RV systolic
dysfunction. No evidence of pericardial effusion or tamponade.
Brief Hospital Course:
54 year old man h/o anterior MI in [**2199-7-3**] and with BIV-ICD
since [**2199-12-3**], found to have multiple episodes of VT and NSVT
on device interrogation and also symptomatic of
presyncope/palpitation, referred to [**Hospital1 18**] for ablation of
Ventricluar ectopic automaticity focus. Now s/p Ventricular
ablation.
.
# Ventricular Tachycardia - Ablation performed on [**10-20**]. Post
ablation patient was in sinus rhythm with occasional PVCs. VT
was Found on device interrogation which prompted his admission.
On ROS pt endorsed palpitation and pre-syncope. Of note, patient
is a poor Amiodarone candidate given severe COPD. On discharge
pt denied palpitations, pre-syncope.
.
# Acute blood loss - Post procedure pt developed severe
abdominal pain and low back pain, with a Hct that was 29, down
from 44 on admission. A Non-Con CT Abd/Pelvis showed small
perinephric hematoma with no extravasation, but some tracking
into the pelvis. His HCT was monitored serially and had a HCT
nadir of 24.3. On [**10-23**], his abdominal pain acutely woresened
after transfusion of 1U PRBCs, repeat CT at that time did not
show enlargement of the hematoma. His abdominal pain resolved
after he had a BM. He recieved a second unit of PRBCs and his
HCT increased to 27.3 and he was discharged home in stable
condition. His back and and abdominal pain resolved prior to
discharge.
# Ischemic Cadiomyopathy with sCHF EF 30-35%: volume status was
overloaded on admission, on 40mg PO Lasix daily at home.
Received 3L IVF during ablation, followed by 40mg IV Lasix. Dry
Weight 97kg, currently 90kg. He was gently diuresed during
admission until his O2 requirement decreased to his baseline of
2L, and he was not objectively overloaded on exam. Metop
succinate 25 mg was started which is half of his home dose and
was increased back to 50mg prior to discharge. In addition, the
following medications were continued: Aspirin 81mg (lower dose
than when he came in [**3-6**] acute blood loss), furosemide, and
rosuvastatin.
.
# Chronic COPD with 2L requirement at home day and night -
currently on facemask SaO2 99%, no wheezing, and moving air
well. He was diuresed as mentioned above and weaned to his home
O2 requirement of 2L. In addition, his combivent was continued
q6h during this hospital admission.
.
# CAD - asymptomatic currently. AMI in [**2198-7-3**] DES to LAD in
[**2198**]. Rosuvastatin 10, Metop succinate 50 mg, Plavix 75, ASA 81.
His cardiologist notes intolerant to Lisinopril, can consider
[**Last Name (un) **] as an outpatient.
.
TRANSITIONAL
- Pt was placed on medications based on list from his primary
cardiologist prior to discharge.
- CHECK HCT in 1 Week
- consider starting [**Last Name (un) **] [**3-6**] ACE intolerance (per Cardiologist)
as an outpatient
- consider f/u scan to make sure RP bleed resolved on own, and
consider this etiology if patient continues to complain of
abdominal/back pain
- DNR/Ok to intubate
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PCP.
1. Clopidogrel 75 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
hold for sbp < 100, hr < 55
4. Pantoprazole 40 mg PO Q24H
5. Rosuvastatin Calcium 10 mg PO DAILY
6. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
7. Aspirin 162 mg PO DAILY
8. ALPRAZolam 1 mg PO QID:PRN anxiety
hold for rr< 12
9. Albuterol-Ipratropium 2 PUFF IH Q6H wheezing/sob
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
11. Nitroglycerin SL 0.4 mg SL PRN chest pain, inform HO
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Albuterol-Ipratropium 2 PUFF IH Q6H wheezing/sob
3. Aspirin 81 mg PO DAILY
4. ALPRAZolam 1 mg PO QID:PRN anxiety
hold for rr< 12
5. Clopidogrel 75 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
hold for sbp < 100, hr < 55
8. Nitroglycerin SL 0.4 mg SL PRN chest pain, inform HO
9. Pantoprazole 40 mg PO Q24H
10. Rosuvastatin Calcium 10 mg PO DAILY
11. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 112187**],
You were admitted to [**Hospital1 18**] to fix the irregular beating in your
heart. The procedure was done without complications on [**10-20**].
After the procedure you had several episodes of abdominal pain.
We performed a CT scan which showed a small amount of blood in
your abdomen, but not a concerning amount. We monitored your lab
results, which were not concerning and stable. Your vital signs
were stable and normal during the duration of your stay.
We have made an appointment for you with Dr. [**Last Name (STitle) **], who
performed the procedure.
Followup Instructions:
PCP
Primary care Appointment: [**Last Name (LF) 766**], [**10-27**] at 1:30pm
With:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 112188**],MD
Location: HILLTOP FAMILY PRACTICE
Address: [**Location (un) **], SOMERSWORTH,[**Numeric Identifier 112189**]
Phone: [**Telephone/Fax (1) 87160**]
.
CARDS:
Department: CARDIAC SERVICES
When: FRIDAY [**2200-11-7**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
Completed by:[**2200-10-26**]
ICD9 Codes: 4271, 412, 496, 2851, 4019, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7508
} | Medical Text: Admission Date: [**2148-3-24**] Discharge Date: [**2148-4-4**]
Date of Birth: [**2074-7-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 y/o F with hx of asthma, HTN, DM, HL and obesity presents
today with acute onset shortness of breath. For the last week or
so, she had been having some worsening dyspnea, cough,
productive sputum and wheezing. She thought she was having an
asthma attack. Her last one was a few years ago, and she has had
a hx of intubations with attacks in the past. She has had low
grade fevers at home. No chest pain, hemoptysis. No dizziness,
fainting. She did have some nausea yesterday, but no vomiting.
No abdominal pain. No diarrhea or constipation. She lives at
home with her granddaughter and her two great grandbabies, but
they are not sick that she knows of. No other sick contacts. She
did receive her flu shot this year and her pneumonia shot a few
years ago.
.
In the ED, intial vitals were T 99.4, P 111, BP 160/60, and 89%
on NRB. She received ipratroprium and albuterol nebs. She
received levofloxacin, ceftriaxone and methlyprednisone. On
transfer, is 93% on NRB. Has not been febrile in the ED.
.
On arrival to the floor, she is febrile, satting in the 90s on
6L NC. She is comfortable and talking in full sentences, but
tired. She still feels wheezy.
Past Medical History:
PMH:
HTN
DM
Asthma
Seasonal allergies
Hypercholesterolemia
B Cataracts
Obesity
.
PSH:
[**2147-12-14**] Right shoulder reverse total arthroplasty (recent)
- was in rehab until early [**Month (only) 1096**] from this surgery
Vitrectomy
TAHBSO
Social History:
Non smoker now. Quit > 20 years back. No etoh use or illicit
drug use. Lives with granddaughter. Daughter died 7 years ago
from cancer.
Family History:
non contributory
Physical Exam:
EXAM AT ADMISSION:
GEN: pleasant, mild respiratory distress, tachypneic
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: severe bilateral wheezes, poor air movement
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
EXAM AT DISCHARGE:
Vitals (1145am): 98.9 128/70 80 20 95% on 2L
Gen: NAD. Alert and oriented x3. Mood and affect appropriate.
Pleasant and cooperative. Sitting in bed, speaking in complete
sentences.
HEENT: EOMI. MMM, oropharynx non-erythematous, no lesions.
Neck: Supple. No carotid bruits noted, no increased JVP noted.
CV: RRR. Normal S1, S2. No murmurs, rubs, or gallops.
Pulm: Respiration unlabored, no accessory muscle use. clear
inspiratory breaths with mild expiratory wheezes in posterior
lung fields
Abd: Obese. BS present. Soft, NT, ND.
Ext: WWP, no cyanosis or clubbing. Distal pulses radial 2+. mild
lower extremity edema
Skin: No rashes, ecchymoses, or other lesions noted.
Neuro/Psych: CNs II-XII intact. Coordination grossly intact.
Pertinent Results:
Hematology:
[**2148-3-24**] 01:55AM BLOOD WBC-4.8# RBC-4.22 Hgb-11.9* Hct-37.4
MCV-89 MCH-28.1 MCHC-31.8 RDW-13.3 Plt Ct-278
[**2148-3-26**] 03:39AM BLOOD WBC-14.6* RBC-4.05* Hgb-11.4* Hct-36.1
MCV-89 MCH-28.1 MCHC-31.5 RDW-13.3 Plt Ct-281
[**2148-3-29**] 01:49AM BLOOD WBC-16.5* RBC-3.90* Hgb-10.9* Hct-34.3*
MCV-88 MCH-27.9 MCHC-31.8 RDW-13.1 Plt Ct-301
[**2148-4-3**] 05:28AM BLOOD WBC-19.4* RBC-3.86* Hgb-10.6* Hct-33.9*
MCV-88 MCH-27.4 MCHC-31.3 RDW-14.4 Plt Ct-343
[**2148-4-2**] 03:23AM BLOOD WBC-20.7* RBC-3.94* Hgb-10.9* Hct-34.5*
MCV-88 MCH-27.6 MCHC-31.5 RDW-13.9 Plt Ct-362
Differential:
[**2148-3-24**] 01:55AM BLOOD Neuts-86* Bands-6* Lymphs-6* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2148-3-30**] 06:00AM BLOOD Neuts-49* Bands-1 Lymphs-24 Monos-14*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-10* NRBC-2*
[**2148-4-2**] 03:23AM BLOOD Neuts-58 Bands-3 Lymphs-28 Monos-9 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-2*
Coags:
[**2148-3-28**] 04:12AM BLOOD PT-11.8 PTT-27.4 INR(PT)-1.0
Chemistry:
[**2148-3-24**] 01:55AM BLOOD Glucose-189* UreaN-27* Creat-0.9 Na-139
K-5.3* Cl-104 HCO3-27 AnGap-13
[**2148-4-3**] 05:28AM BLOOD Glucose-105* UreaN-19 Creat-0.7 Na-139
K-3.2* Cl-99 HCO3-34* AnGap-9
[**2148-3-24**] 01:55AM BLOOD cTropnT-<0.01
[**2148-3-24**] 07:18PM BLOOD CK-MB-4 cTropnT-<0.01
[**2148-4-3**] 05:28AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.1
Culture Data:
[**2148-3-24**] 1:55 am BLOOD CULTURE
**FINAL REPORT [**2148-3-26**]**
Blood Culture, Routine (Final [**2148-3-26**]):
STREPTOCOCCUS PNEUMONIAE. FINAL SENSITIVITIES.
Note: For treatment of meningitis, penicillin G MIC
breakpoints
are <=0.06 ug/ml (S) and >=0.12 ug/ml (R).
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R).
For treatment with oral penicillin, the MIC break
points are
<=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE-----------<=0.06 S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- 1 S
PENICILLIN G---------- 0.12 I
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2148-3-24**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final [**2148-3-24**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2148-3-30**] 12:25 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
.
.
IMAGING:
[**3-24**] Chest X-ray:
IMPRESSION: Moderate interstitial/alveolar pulmonary edema.
Recommend
conventional chest radiographs after treatment to look for
possible right lung nodule.
.
[**3-25**] CT Chest:
IMPRESSION:
1. Multifocal parenchymal consolidation most compatible with
multifocal
pneumonia most severe within the left lower lobe and right upper
lobe.
2. Cardiomegaly with extensive atherosclerotic calcification
involving the
coronary arteries.
.
Echo:
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Regional left ventricular wall
motion is normal. The aortic valve leaflets (3) are mildly
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
At least mild mitral regurgitation. Mild pulmonary artery
systolic hypertension.
Brief Hospital Course:
73 year old female with a history of HTN, DM and asthma who
presented to hospital with acute onset shortness of breath in
background of one week of worsening dyspnea, cough, productive
sputum and wheezing, initially admitted to the MICU found to
have multifocal pnuemonia and CHF exacerbation.
.
# Shortness of breath/Pneumonia:
The patient was found to have a multifocal pneumonia on CT chest
which is likely causing the asthma exacerbation. She was
initilly admitted to the ICU due to high oxygen requirement. An
ECHO failed to reveal vegetations, making septic emboli a less
likely cause of any pulmonary signs or symptoms. She was
initially on vanco, cefepime and azithro, but narrowed to
ceftriaxone when culture data returned. Strep pneumoniae found
in blood cultures was sensitive to ceftriaxone, and she will
need 2 weeks of total antibiotics (last day [**2148-4-8**]).
Unfortunately, the patient's sputum culture was contaminated,
and thus unrevealing. She was treated wtih steroids on
admission, which were stopped when she was found to be
bacteremic, but because of continued wheezing and poor
respiratory improvement, steroids were restarted with a plan for
7 days of high dose steroids followed by a slow taper to treat
possible concomittant asthma exacerbation. The patient also had
acute pulmonary edema in the setting of hypertension and
tachycardia. As for her dCHF, she was initially on a nitro gtt
in the ED for hypertension and presumed dCHF exaccerbation. Her
breathing improved with BP improvement and treatment for S.
Pneumo pneumonia. Due to continued hypoxia after adequate
antibiotic coverage, repeat Chest CT was ordered - this was
negative for PE and showed interval improvement in her
pneumonia. Based on these results and clinical improvement,
patient was transferred to the floor for further management.
Once transferred to the floor, her oxygen was weaned to 1-2L,
requiring intermittant diuresis while on antibiotics. She
remained afebrile. Ceftriaxone is to be continued for 2 weeks
total course (last day [**2148-4-8**]).
.
# Steptococcus pneumoniae bacteremia: Presumed secondary to her
S. pneumoniae pneumonia. She was given IV ceftriaxone with a
plan for two weeks of treatment, as above. PICC placed prior to
discharge. Of note, ortho evaluated her recent shoulder
prosthesis (from [**2147**]) and did not think the joint was seeded in
the setting of her bacteremia. Serial cultures were negative.
LAST DAY OF Antibiotics: [**2148-4-8**] (2 week course). Of
note: She had one set of positive cultures from [**3-30**] that grew
coagulase negative staphylococcus (started vancomycin pending
final result). This was felt to be contaminant and vancomycin
was discontinued. At time of discharge she had blood cultures
from [**4-2**] and [**4-3**] that were pending with no growth to date.
These should be followed-up after discharge.
.
# Leukocytosis: Was initially presumed to be due to PNA and
becteremia. Was downtrending and then began to trend up again.
Could be secondary to steroid administration however, c. diff
was considered, but unlikely given lack of diarrhea. Pt was
afebrile and having normal bowel movements so was discharged to
Rehab with repeat CBC in 1 week to ensure that WBC trending
down.
.
# Diastolic CHF: Mildly fluid overloaded on clinical admission
exam, likely contributing to respiratory distress, as her
dyspnea improved following furosemide PRN. She was
intermittently treated with IV lasix as needed to keep her I/O
balance negative. She was restarted on her home lasix dose and
discharged to rehab for further follow up.
.
# DM: Initially continued home insulin regimen, however, due to
steroids, insulin dosing was increased. Additionally, an
insulin sliding scale was used to help control her hyperglycemia
secondary to steroids. As steroids are tapered, insulin regimen
can likely be tapered down to home regimen.
.
# Hypertension: Amlodipine 10mg PO daily and lisinopril 20mg PO
daily were used to control hypertension while in the hospital.
Home atenolol was changed to metoprolol for better heart rate
control.
.
# Tachycardia: Sinus tachycardia on EKGs, started metoprolol as
above.
.
# Code: full
Medications on Admission:
Albuterol PRN
Flovent 2 puffs QID
Atrovent 2 puffs daily
Amlodipine 5 mg daily
Atenolol 50 mg daily
Moexipril 15 mg [**Hospital1 **]
Lasix 40 mg daily
Atorva 10 mg daily
Insulin NPH 23 in AM, 12 in PM; regular 12 in AM, 8 in PM
ASA 325 mg daily
Omega 3 fatty acid tab daily
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
3. atorvastatin 20 mg Tablet Sig: 0.5 Tablet PO once a day.
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2)
Inhalation twice a day.
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every six (6) hours.
7. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: take with meals.
8. Humulin N 100 unit/mL Suspension Sig: Thirty Eight (38) units
Subcutaneous in the am.
9. Humulin N 100 unit/mL Suspension Sig: Twelve (12) units
Subcutaneous in the pm.
10. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every six (6)
hours as needed for shortness of breath or wheezing.
12. ceftriaxone 2 gram Piggyback Sig: One (1) Intravenous every
twenty-four(24) hours for 5 days: Last Dose [**2148-4-8**].
13. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Humalog 100 unit/mL Solution Sig: 0-12 units Subcutaneous
four times a day: per sliding scale.
15. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day:
PREDNISONE TAPER:
30 mg x 3 days, 20 mg x 5 days, 10 mg x 5 days then stop.
16. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
19. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnosis:
-Pneumonia
-Asthma exacerbation
.
-Secondary Diagnoses:
-Diastolic CHF
-Pneumococcal bacteremia
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:
Ms. [**Known lastname 98446**],
You were admitted to the hospital because of trouble breathing.
It was due to a combination of pneumonia, worsening asthma, and
some mild diastolic heart failure resulting in extra fluid in
your lungs. We treated you with antibiotics, steroids and lasix
(the "water pill"). You were also found to have bacteria in
your blood stream, likely related to the pneumonia. The
antibiotics helped this as well, and you had no other bacteria
in your blood stream after the first day. You are doing much
better and will be discharged to Rehab to facilitate your
improvement.
.
The following medication were started:
Ceftriaxone 2gm intravenously for 24HRS for 5 days (total
treatment 2 weeks).
Prednisone 10-30 mg per taper listed in medication list
.
The following medications were changed:
-Amlodipine 5 mg daily --> increased to 10 mg Daily
-Atenolol 50 mg daily --> metoprolol 75mg by mouth Three times a
day
-Moexipril 15 mg [**Hospital1 **] --> lisinopril 20 mg daily
-Insulin dosing increased while on steroids
.
Please take your other medications as prescribed
Followup Instructions:
Please follow up with your primary care doctor:
Department: [**Hospital3 249**]
When: FRIDAY [**2148-4-12**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], 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
Department: ORTHOPEDICS
When: WEDNESDAY [**2148-4-10**] at 10:45 AM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2148-4-10**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 7907, 2760, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7509
} | Medical Text: Admission Date: [**2175-8-8**] Discharge Date: [**2175-8-17**]
Date of Birth: [**2132-3-23**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**Known firstname 30**]
Chief Complaint:
Fever of 103 on HD, abd pain, N/V
Major Surgical or Invasive Procedure:
ERCP on [**2175-8-8**] with stent placement
ET Intubation on [**2175-8-8**]
ERCP on [**2175-8-14**] with stent placement
Extubation on [**2175-8-14**]
Hemodialysis
Central venous catheter - RIJ
Arterial line
Echocardiogram
History of Present Illness:
This is a 43 yo man transferred from MICU [**Location (un) 2452**] for ERCP in the
setting of presumed biliary sepsis. Patient was transferred on
[**2175-8-7**] from [**Hospital3 **] ED with fever found at HD [**2175-8-7**] to
103. He reports symptoms started the evening of [**8-6**] with sharp
abdominal pain, nausea, vomitting, and diarrhea. At HD he was
febrile with rigors to temp of 103. He had blood cultures and
was given vanco/ceftazidime and sent to [**Hospital3 **]. At
[**Hospital3 3583**] he was given benedryl 25mg iv, reglan 10mg iv,
morphine 6mg iv, zosyn 2.25gm iv. He had an abdomen/pelvis CT
that preliminarily showed gall bladder hypodensity without signs
of acute cholecysitis. He was transferred here for ERCP given
elevated amylase, lipase and transaminases. AT [**Hospital1 18**] ED he was
given 3L IVF for SBP 77-111 with HR 100's with Tm 101.5. He was
given tylenol 1gm. He was admitted to MICU [**Location (un) 2452**] overnight
where a right IJ central line was placed and he received 2L NS,
IV vancomycin and zosyn. Patient was transferred to the [**Hospital Unit Name 153**] for
planned ERCP intervention on the [**Hospital Ward Name **].
Past Medical History:
CAD s/p stent [**1-6**] at [**Hospital1 2177**] in the setting of pna
HTN
gout: no active symptoms for several years, does not take ppx
ESRD on HD x9 years, ? [**12-31**] post-strep infection as a child?, on
M/W/F schedule, last HD [**8-7**], at Forsinius in [**Location (un) 3320**] where he
reportedly normally gets 5kg removed
OSA on CPAP, pressure 17mmHg?, but is unable to tolerate at home
Social History:
Lives with children (age 19, 22), denies past or current
tobacco, drinks etoh only on special occaisions (less than
once/month) but drank more heavily prior to HD, occaisional MJ
but no IVDU or cocaine.
Family History:
Father with hypertension, mother with DM, sibs healthy, children
healthy.
Physical Exam:
VS: T 99.5 HR 101 BP 117/75 RR 28 Sat 93% on 4L NC
Gen: NAD, obese man, speaking in full sentances, mild labored
breathing, drowsy but arousable, witnessed apnic episodes while
sleeping
HEENT: PERRL, OP clear, MM dry, mild scleral icterus
Neck: Supple, Right IJ in place, no LAD
CV: Reg, Tachy, III/VI SEM best at RUSB, heard throughout, no
r/g
Resp: Decreased BS at both bases with scattered rales R base
Abdomen: Obese, distended but soft, NT, no obvious masses but
very protuberant, white striae, no fluid wave, tympanic to
percussion throughout, unable to palpate liver or spleen; no
periumbilical ecchymosis
Ext: 1+ PE to thigh bilaterally; 2+ DP's B, left UE fistula
+palpable thrill
Neuro: A&Ox3, CN II-XII intact, strength 5/5 B UE/LE, sensation
intact to light touch
Skin: no rashes, lesions or ecchymoses
.
Pertinent Results:
[**2175-8-8**] 10:22PM TYPE-ART TEMP-38.2 RATES-20/1 TIDAL VOL-700
PEEP-5 O2-60 PO2-79* PCO2-41 PH-7.42 TOTAL CO2-28 BASE XS-1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2175-8-8**] 10:22PM LACTATE-1.2
[**2175-8-8**] 10:22PM O2 SAT-95
[**2175-8-8**] 08:56PM TYPE-ART TEMP-38.2 RATES-[**10-30**] TIDAL VOL-700
PEEP-5 O2-60 PO2-86 PCO2-63* PH-7.28* TOTAL CO2-31* BASE XS-0
INTUBATED-INTUBATED VENT-CONTROLLED
[**2175-8-8**] 08:56PM LACTATE-0.9
[**2175-8-8**] 08:56PM freeCa-1.03*
[**2175-8-8**] 08:49PM GLUCOSE-101 UREA N-45* CREAT-10.1* SODIUM-140
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-27 ANION GAP-20
[**2175-8-8**] 08:49PM CK(CPK)-534*
[**2175-8-8**] 08:49PM CK-MB-5 cTropnT-0.29*
[**2175-8-8**] 08:49PM CALCIUM-7.6* PHOSPHATE-5.9* MAGNESIUM-2.1
[**2175-8-8**] 02:22PM TYPE-MIX PO2-44* PCO2-54* PH-7.39 TOTAL
CO2-34* BASE XS-5
[**2175-8-8**] 02:22PM LACTATE-1.4
[**2175-8-8**] 01:55PM GLUCOSE-125* UREA N-38* CREAT-9.1* SODIUM-139
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-30 ANION GAP-17
[**2175-8-8**] 01:55PM ALT(SGPT)-70* AST(SGOT)-50* LD(LDH)-198 ALK
PHOS-200* AMYLASE-241* TOT BILI-4.5*
[**2175-8-8**] 01:55PM LIPASE-236*
[**2175-8-8**] 01:55PM ALBUMIN-3.5 CALCIUM-7.8* PHOSPHATE-5.1*
MAGNESIUM-2.1
[**2175-8-8**] 01:55PM WBC-6.9 RBC-3.60* HGB-11.2* HCT-33.2* MCV-92
MCH-31.2 MCHC-33.8 RDW-14.2
[**2175-8-8**] 01:55PM NEUTS-92.5* LYMPHS-3.1* MONOS-4.0 EOS-0.2
BASOS-0.2
[**2175-8-8**] 01:55PM PLT COUNT-179
[**2175-8-8**] 01:21PM LACTATE-1.7
[**2175-8-8**] 04:10AM GLUCOSE-127* UREA N-32* CREAT-8.8* SODIUM-140
POTASSIUM-4.8 CHLORIDE-92* TOTAL CO2-32 ANION GAP-21*
[**2175-8-8**] 04:10AM ALT(SGPT)-87* AST(SGOT)-66* CK(CPK)-80 ALK
PHOS-213* AMYLASE-376* TOT BILI-3.7* DIR BILI-2.3* INDIR BIL-1.4
[**2175-8-8**] 04:10AM LIPASE-459*
[**2175-8-8**] 04:10AM CK-MB-NotDone cTropnT-0.21*
[**2175-8-8**] 04:10AM ALBUMIN-3.9 CALCIUM-7.6* PHOSPHATE-4.4
MAGNESIUM-1.2*
[**2175-8-8**] 04:10AM TRIGLYCER-236*
[**2175-8-8**] 04:10AM CORTISOL-34.3*
[**2175-8-8**] 04:10AM VANCO-10.4
[**2175-8-8**] 04:10AM ASA-NEG ACETMNPHN-7.0 bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2175-8-8**] 04:10AM WBC-10.3 RBC-3.63* HGB-11.2* HCT-32.5* MCV-90
MCH-30.9 MCHC-34.4 RDW-14.7
[**2175-8-8**] 04:10AM NEUTS-94* BANDS-4 LYMPHS-1* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2175-8-8**] 04:10AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2175-8-8**] 04:10AM PLT COUNT-240
[**2175-8-8**] 04:10AM PT-15.5* PTT-28.7 INR(PT)-1.4*
[**2175-8-8**] ERCP FINDINGS: The common bile duct was adequately
opacified with contrast medium after the cannulation of the
biliary duct. No apparent extrahepatic or intrahepatic biliary
duct dilatation or irregularity is seen. No filling defects
consistent with stones were noted. As per report, in subsequent
images, biliary stent was successfully placed. IMPRESSION:
Successful placement of biliary stent.
[**2175-8-9**] Transthoracic Echo: The left atrium is moderately
dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 70%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity
imaging are consistent with Grade II (moderate) LV diastolic
dysfunction. 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 ascending
aorta is moderately dilated. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
[**2175-8-14**] ERCP FINDINGS: Comparison is made with CT from [**8-12**], [**2174**] and prior ERCP from [**2175-8-8**]. There is
removal of a plastic stent. A retrograde cholangiogram shows
multiple filling defects, some of which likely represent stones,
within otherwise normal- appearing biliary tree. A biliary stent
was then placed.
Brief Hospital Course:
#Hypotension/Sepsis: On admission, patient met SIRS criteria
with fever, tachypnea, tachycardia and lactate of 2.5 consistent
with sepsis. Infectious source was likely biliary tract vs. HD
line infection, however also considered was pulmonary source w/
new O2 requirements although more likely from capillary
leak/CHF. Patient has remained fluid responsive intially without
need for pressors. The underlying infection was treated with IV
vancomycin/unasyn/gentamycin for synergy until cultures at OSH
grew enterobacter at which point only zosyn was continued with
appropriate coverage. The patients lactate level, fevers and WBC
were trended and returned to [**Location 213**]. Zosyn was switched to
Ciprofloxacin after the patient developed a drug rash.
.
#Mechanical ventilation: Patient came to the ICU intubated s/p
ERCP, on a propofol drip. Initially he was hypotensive which was
treated with IV fluids and discontinued propofol, switching to
fentanyl/versed for sedation. Shortly thereafter the patient
became restless, agitated and continued to be hypotensive. He
was given 10mg vecuronium and paralyzed for arterial line
placement and foley placement. His labile blood pressures also
exacerbated his already fluid-overloaded state, making it
difficult to wean off the vent. The initiation of hemodialysis
effectively controlled his BP and fluid status, and on day 7,
after his second ERCP, he was extubated and started on CPAP
overnight.
.
# Gallstone Pancreatitis: On admission the patient had elevated
LFTs, pancreatic enzymes, bilirubin and alk phos. His levels
slowly trended down post-ERCP except bilirubin and AP, which
continued to rise. The patient experienced intermittent
epigastric discomfort which prompted a RUQ US, which showed a
fatty liver but the common bile duct non-well visualised. CT
scan of abdomen showed no intrahepatic biliary dilatation,
cholelithiasis, and a subtle hypodensity in pancreatic head.
Hepatology and ERCP were consulted prompting a second-look ERCP,
which showed sludge drainage in the major papilla, stent
migrated to major papilla and several stones in the cystic duct.
The stent was replaced, antibiotics were continued, and the
patient's enzymes and bilirubin were trended.
.
# ESRD: Initially the nephrology service felt HD was not
appropriate early during admission, in setting of patient
becoming hypertensive to 200s with volume resusitation for
pancreatitis. Beta-blockers were started however the patient did
not respond and O2 sats started trending down with worsening
acidemia and low PaO2. The following day HD was initiated with
good response in blood pressure. The patient received HD
throughout his course, with the day before D/c the final time.
.
# Hypoxia: Suspected capillary leak in the setting of sepsis vs.
CHF as pt with known CAD. The patient was weaned off his O2
requirement prior to discharge.
.
# Drug Rash: Patient developed a diffuse petticheal/macular rash
on his chest and legs which was pruritic. Dermatology was
consulted who felt consistent with a drug rash. Offending [**Doctor Last Name 360**]
was felt to be Zosyn. [**Doctor Last Name **] was discontinued and rash improved.
He will continue hydoxyzine, sarna and fluocinonide.
.
# CAD: An echo was performed to rule out endocarditis as a cause
of fever. This showed extensive calcification of cardiac
skeleton, mild calcific aortic stenosis, and no definite
vegetations . His ECG had some ischemic changes of unclear
duration, and the patient had no active symptoms. Cardiac
enzymes were stably elevated on admission and, in the setting of
ESRD, this was unlikely to be acute event. His aspirin and
plavix were continued and the patient remained on telemetry for
the duration of his stay.
.
# OSA: Witnessed apneic episodes while asleep. Known history of
OSA on CPAP as outpatient but has not been tolerating of recent.
Once patient was extubated he was started on CPAP overnight.
.
# Anemia: Normocytic with normal RDW. Unclear baseline. [**Month (only) 116**] be
low related to ESRD (not on epo as outpatient that we know of).
D. bili not consistent with hemolysis. Hematocrit was trended
and continued to improve with HD and management. Renal recs: use
epo during HD.
.
Medications on Admission:
fish oil daily
sensipar 120mg daily
ativan 0.5mg prn (rare)
percocet prn (rare)
nifedipineER 90 daily (last [**8-7**])
minoxidil-dose unable to verify but pt states rx for 2 tabs and
only takes 1
renagel 2400mg tid ac
phoslo 1334mg (?) tid ac
simvastatin 20mg daily
plavix 75mg daily
aspirin 325mg daily
toprolXL 50mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
Disp:*1 tube* Refills:*0*
6. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: Take this at least one hour before you take Renagel.
Disp:*5 Tablet(s)* Refills:*0*
7. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for itching: Only take this as long as
your rash is itching.
Disp:*21 Tablet(s)* Refills:*0*
8. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for rash for 12 days: Only use while you
have the rash.
Disp:*1 tube* Refills:*0*
9. Cinacalcet 30 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
11. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Biliary Sepsis
Gallstone Pancreatitis
Secondary Diagnoses:
ESRD with hemodialysis
CAD
Drug rash
OSA
HTN
Anemia
Discharge Condition:
Good, tolerating regular diet, ambulating with walker for
deconditioning, able to climb a flight of stairs, no oxygen
requirement, VSS
Discharge Instructions:
You were seen and treated at the hopital for a blockage in the
area of your gallbladder, which caused you to become infected.
You were treated with intravenous fluids, antibiotics and ERCP
(Endoscopic Retrograde Cholangiopancreatography) twice. A small
tube called a stent was placed near your gallbladder so that it
will drain bile into your intestine.
Please take the antibiotics (Ciprofloxacin) until it is
finished. You may also use the skin cream for your rash as long
as you need it. You may take all of your home medications, and
none of the dosages were changed.
Call your doctor or come to the Emergency Department right away
if any of the following problems develop:
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow again.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 100.4 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please make an appointment to follow up with your PCP:
[**Name10 (NameIs) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 80088**] in the next week or two to further
evaluate your response to treatment.
You will also need to follow-up with the Gastroenterology team
to have a repeat ERCP 6 weeks with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please
call his office at ([**Telephone/Fax (1) 2306**] M-F 8:30am-4:30pm.
The Dermatologists would also like you to make an appointment
for some areas of skin that require follow-up. You may call
their office at ([**Telephone/Fax (1) 8132**] to schedule the appointment.
Completed by:[**2175-8-17**]
ICD9 Codes: 5856, 2749, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7510
} | Medical Text: Admission Date: [**2135-10-31**] Discharge Date: [**2135-11-7**]
Date of Birth: [**2078-5-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
chills, hypoxic episode, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
57 yo M with h/o metastatic prostate cancer presents after
episode of chills and acute SOB. Patient was dx with prostate
cancer 5 yrs ago on routine screening. He had recurrence about 1
year ago, now with known liver and bone met's. Of note, he
started an estrogen based chemotherapy (Estramustine) on Wed. of
last week with concurrent coumadin for possible hypercoagulable
state.
.
Patient had been at baseline prior to 1 day PTA when he
describes first feeling very cold and then developing severe SOB
after walking to bathroom. He attempted to get into bed, but
legs gave out and he fell onto floor. No LOC. Denies chest pain,
fever, leg pain, N/V/D. + leg swelling few weeks ago, but none
recently. Denies any cough or hemoptysis. He has had nosebleeds
with clots when he blows his nose. Also had hemorrhoidal
bleeding 1 month ago and was admitted for endoscopy.
.
Called EMS and was noted to be hypoxic to 80s on RA, tachy to
150s initially. EMS gave him 40mg IV lasix en route for ? flash
pulmonary edema as he was on lasix at home.
.
In the ED, initial VS:97, 153, 112/68, 100% NRB. Shortly
thereafter spiked to 104 . Noted to have a lactate to 4.2.
Initial CXR was unimpressive, CTA was a suboptimal study but no
large central PE. Recieved levofloxacin/zosyn, 1.5L NS, Zofran
x1 and one unit of platelets. Noted to have guaiac positive red
stool in ED and one episode of hemoptysis. Groin central line
was placed. Given obstructive pattern on LFTs, got non-con CT
abd with no obvious obstruction, only a multinodular liver.
.
Transferred to ICU, transfused 2 units PRBC given low hct, HCT
went up 2 points only and has remained stable.
On interview in the MICU, patient endorses sharp R subcostal
pain this AM, but states that it occurs when he misses his
neurontin and it has not recurred since. He currently denies any
SOB or CP, is comfortable on room air.
Past Medical History:
Hypertension
gout
right shoulder fracture,
history of chlamydia and gonorrhea
prostate CA with mets to bone, liver and spine, status post
prostatectomy with Lupron injection
umbilical hernia
status post arthroscopy of the knee.
hemorrhoidectomy, with hx of anal fissures
Recent lower GIB with negative [**Last Name (un) **] and EGD
Depression/Anxiety
Social History:
lives with wife, has children and step-children. Had twice
weekly VNA. No tobacco or EtOH.
Family History:
sister with [**Name2 (NI) 499**] CA
Physical Exam:
GEN: obese, NAD
HEENT: MMM, JVP not visible due to body habitus
CV: tachy, no m/r/g
PULM: CTAB
AB: positive BS, NT/ND, no HSM
EXT: 1+ non-pitting pedal edema to shins
NEURO: CN II-XII intact (q/o L facial droop but resolves with
smiling), strength 5/5 throughout, sensation intact, reflexes 1+
throughout.
Pertinent Results:
CBC:
8.5
7.6 >---< 31
25.9
NEUTS-71* BANDS-9* LYMPHS-7* MONOS-4 EOS-0 BASOS-0 ATYPS-2*
METAS-3* MYELOS-3* PROMYELO-1* NUC RBCS-23*
HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-NORMAL
MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL
OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
.
CHEM:
138 | 106 | 21 / 141
4.6 | 16 | 0.8 \
ALBUMIN-2.8* CALCIUM-9.1 PHOSPHATE-2.7 MAGNESIUM-2.0
.
COAGS:
PT-21.4* PTT-30.3 INR(PT)-2.0*
.
LFTS:
ALT(SGPT)-74* AST(SGOT)-261* LD(LDH)-4440* CK(CPK)-447* ALK
PHOS-1129* TOT BILI-5.1*
LIPASE-64*
.
TOX SCREEN:
SERUM: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
URINE: bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
.
CE:
[**2135-10-31**] 09:20PM cTropnT-0.03*, CK-MB-3
.
fibrinogen 873
retic count 2.0
ferritin >[**2125**]
haptoglobin 169
TRF 148
TIBC 192
.
PSA 223.8
.
ABG:
TYPE-ART TEMP-37.6 RATES-/21 O2-15 PO2-234* PCO2-25* PH-7.46*
TOTAL CO2-18* BASE XS--3 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP
.
UA
URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2
.
MICRO:
URINE CX- NEG
.
BLOOD CX:
[**10-31**]: 1 bottle growing MSSA
repeat daily blood cx neg
.
urine Legionella neg
influenza swab neg
.
ECG: Probable sinus tachycardia. ST-T wave changes are
non-specific.
.
IMAGING:
Portable CXR: 1. Low lung volumes which accentuate the
bronchovascular markings.
2. Widened mediastinum, which could in part be due to low lung
volumes and AP technique. However, if clinical concern for acute
aortic syndrome, recommend chest CTA for further evaluation.
3. Hilar prominence may be due to vascular engorgement.
4. Subtle opacities in both lung fields may be due to edema,
infection and/or metastases.
5. Bilateral, right greater than left pleural thickening versus
less likely effusions.
Chest CTA [**2135-10-31**]:
1. Suboptimal evaluation for pulmonary embolus, as above,
although no large, central embolus identified.
2. Extensive osseous metastatic disease due to prostate cancer.
3. Central interstitial thickening in upper lobes may be due to
pulmonary
edema, but given fever, also consider infectious source. Due to
history of
malignancy, malignant component is also possible. Recommend
follow-up to
resolution.
.
CTA chest [**2135-11-2**]
1. No evidence of central pulmonary embolism or aortic
dissection, but
limited study due to timing of contrast and motion.
2. New peripancreatic fat stranding. Clinical correlation for
acute
pancreatitis is recommended.
3. Pulmonary edema vs atypical pneumonia, slightly improved.
Multiple
pulmonary nodular opacities are incompletely evaluated on the
background of ground-glass opacity and a followup chest CT after
the acute pulmonary process resolves is recommended on an
outpatient.
4. 1.6-cm mediastinal lymph node, which may also be reassessed
at the time
of follow up CT.
5. Stable extensive osseous metastasis.
.
ECHO
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF 60-70%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
CT AB/PELV
1. No evidence of colitis or acute abdominal process.
2. Cirrhosis.
3. Left base small effusion/atelectasis. Upper lobe interstitial
changes; see chest CT.
4. Extensive osseous prostate metastases; e.g. vertebral body
destruction.
.
RUQ U/S:
Innumerable echogenic masses throughout the liver without
biliary
ductal dilatation. This is an unusual pattern for metastatic
prostate cancer, and if appropriate, biopsy can be considered.
.
LENIS
No deep venous thrombosis identified in the lower extremities
bilaterally. Of note, the right common femoral vein was not
interrogated due to overlying dressing.
.
HEAD CT
1. No evidence of hemorrhage, edema or mass effect.
2. No acute fractures are identified.
3. Soft tissue swelling is noted over the left parieto-occipital
region.
.
.
.
DISCHARGE LABS:
LFTS:
.
COAGS:
.
vancomycin trough [**11-6**]: 18.5
Brief Hospital Course:
57 yo M with metastatic prostate cancer (bone, liver mets)
presents with episode of hypoxia and tachycardia, fever after
starting estrogen-based therapy.
.
#. HYPOXIA/TACHYCARDIA/FEVER: Patient's initial presentation
with acute dyspnea, hypoxia and tachycardia concerning for PE,
especially in setting of pro-coagulable state on
estrogen-chemotherapy. Patient had been started on coumadin [**2-20**]
days prior, and also INR was 2/0 on presentation, it may have
been subtherapeutic when his decompensation began. Patient
underwent CTA which was non-diagnostic due to respiration
artifact and poor contrast timing. There was no e/o RV strain on
EKG or TTE. LENIS were negative for DVT. Patient was admitted to
MICU, where he was treated empirically for PE with heparin gtt.
Infection was also on the differential given high fever to 104
after presentation to the ED and CT chest showed upper lobe
infiltrates. Patient was started on broad spectrum antibiotics
(vancomycin, cefepime, levaquin) to cover for healthcare
associated PNA, since his last hospital admission was less than
1 month prior.
He was ruled out for flu. Legionella antigen was negative.
In the MICU, patient improved on this treatment regimen, and he
had stable 02 sat on room air.
.
Patient will need repeat chest CT once infection resolves ([**2-21**]
weeks) to rule out underlying malignancy.
.
Patient was transferred to medical floor after stabilization.
Heme-onc was consulted and recommended repeat CTA to rule out
PE, since this diagnosis would be a contraindication for
estramustine therapy. Patient's primary oncologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 23509**], was also contact[**Name (NI) **] and remained involved in our
treatment plan.
Repeat CTA showed no PE. Heparin gtt was stopped and patient was
restarted on home dose coumadin. However, INR became
supratherapeutic, likely because of interaction with levaquin,
and coumadin was held, vitamin K given. Dr.[**Name (NI) 24775**] plan is
to start patient on therapeutic dose Lovenox when he reinitiates
estramustine (likely after 10 days antibiotics). Patient was
placed on prophylactic dose Lovenox once INR normalized.
.
Patient had one positive blood cx, with MSSA, and all repeat
blood cx were negative. He will therefore be treated with a HAP
course (10 days of vancomycin and cefepime, 5 days of Levaquin)
with 4 additional days of vancomycin for bacteremia (14 days
total). PICC was placed. Patient remained afebrile after
receiving initial abx on HD# 1.
.
#. ANEMIA: Admission Hct 25.9 from prior 28. Had h/o LGIB 1
month ago with neg [**Last Name (un) **]. Guiaic positive in ED and started on IV
PPI. Had intermittent hemorrhoidal bleeding and
epistaxis/hemoptysis [**12-20**] anticoagulation and thrombocytopenia.
No evidence of significant GI bleeding. Received 3 total units
PRBC and Hct remained stable. No e/o hemolysis. Likely [**12-20**]
baseline anemia due to bone marrow replacement by cancer, with
minimal acute bleeding.
.
#. HYPOTENSION: Patient was hypotensive in ED, but stabilized
with antibiotics and fluids. He remained normotensive and
stable, lactate trended down. Patient received stress dose
steroids for since he was on a chronic dexamethasone regimen at
home. After HD#2, his home dose of dexamethason 1 mg TID was
resumed.
.
#. Thrombocytopenia: Most likely etiology is bone marrow
replacement by malignancy in addition to past XRT/chemo. Patient
was transfused platelets for count <50 and minor bleeding.
.
#. PROSTATE CA: Patient has prostate cancer with met's to liver,
bone. Dr. [**Last Name (STitle) 23509**] was contact[**Name (NI) **] and agreed with holding
estramutine during acute illness and infection. Our heme/onc was
also consulted. PSA was 223. Home dexamethasone was continued.
Patient had signs of worsening widespread disease, including
worsening LFTs elevation, tachycardia, and decreased alertness.
.
#. TRANSAMINITIS: LFTs increased likely [**12-20**] met's, although
there were no hepatitis serologies in our system so these were
repeated. Results pending at transfer.
.
#. LOWER EXTREMITY EDEMA: Patient developed LE edema on HD# 2,
likely due to high dose steroids and fluid resusitation. Patient
was continued on home dose Lasix and tapered to home dose
dexamethasone. Patient had no evidence of CHF on TTE, and
patient appeared otherwise euvolemic.
.
#. TACHYCARDIA: Patient remained tachycardic 100-120s despite
adequate hydration and no other signs of uncontrolled infection.
Tachycardia was attributed to underlying malignancy, since
heart rate seemed to increase with increase in LFT's, indicative
of worsening disease. Telemetry and EKGs showed sinus
tachycardia. He also had one episode atrial tachycardia vs.
AVNRT on [**11-6**], which lasted <3 seconds and was asymptomatic and
did not recur so was not treated.
.
#. Depression/anxiety: Patient became extremely fatigued and
remained largely inactive. His alertness level seemed to
decrease in days prior to discharge. Unclear if this was due to
worsening underlying illness vs. depression. Con't Wellbutrin
and clonazepam
.
*Patient was transferred to [**Hospital6 **] per request of
family, with his primary oncologist Dr. [**Last Name (STitle) 27542**] as the
accepting physician.
Medications on Admission:
Celebrex 200mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Coumadin 3mg PO daily
Clonazepam 0.5mg PO BID
Dexamethasone 1mg TID
Estramustine 140mg TID
Fentanyl patch 75mcg/hr q72, last changed [**10-31**]
Hydromorphone 4mg PO BID PRN
Lasix 20mg PO as needed daily
Neurontin 400mg PO TID
Omeprazole 20mg PO BID
Senna 2 Tabs [**Hospital1 **]
Wellbutrin 100mg TID
Lupron 22.5 q3mon, last [**2135-7-13**]
Taxotere 20mg, last infustion [**2135-10-19**]
Zometa 4mg, last shot [**2135-9-27**]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
11. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours).
12. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
13. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
14. Cefepime 2 gram Recon Soln Sig: Two (2) g Injection Q12H
(every 12 hours) for 2 days: end date [**11-9**].
15. Vancomycin 500 mg Recon Soln Sig: 1250 (1250) g Intravenous
Q 12H (Every 12 Hours) for 6 days: end date [**11-13**].
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
primary:
healthcare associated pneumonia
prostate cancer
.
secondary:
thrombocytopenia (low platelets)
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
It was a pleasure taking care of you. You were admitted for
difficulty breathing and fevers. You were found to have
pneumonia. You underwent tests for blood clots, and you did not
have a blood clot. You were treated with intravenous antibiotics
and a PICC line was placed so you can continue these antibiotics
at rehab.
Your coumadin was stopped at the recommendation of Dr.
[**Last Name (STitle) 23509**], and you will start a different bloodthinner (Lovenox)
when you restart your estramustine chemotherapy.
You received blood and platelet transfusions since you had small
amounts of bleeding.
.
There following changes were made to your medications:
- You should have infusions of vancomycin and cefepime through
the PICC line.
- You should take Lasix every other day until you are evaluated
by a doctor.
Followup Instructions:
Dr. [**Last Name (STitle) 23509**] will see you at [**Hospital1 **].
ICD9 Codes: 486, 2762, 7907, 2851, 5119, 5180, 5715, 4019, 2749, 2875, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7511
} | Medical Text: Admission Date: [**2139-9-16**] Discharge Date: [**2139-9-23**]
Date of Birth: Sex: M
Service: CCU/MEDICINE
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: This is an 83 year old male with
cardiac risk factors, his age, hyperlipidemia, with no known
coronary artery disease, who experienced progressive
substernal chest pain on [**2139-9-15**], around 11:30 p.m. The
chest pain was six out of ten. It did not radiate. It was
not associated with shortness of breath or palpitations. He
did have diaphoresis and nausea. He took Aspirin without
relief.
The patient went to the [**Hospital6 1129**]
Emergency Department where he was transferred to [**Hospital1 346**] as the [**Hospital1 2025**] Catheterization
Laboratory was very busy. At [**Hospital1 2025**], he was found to have an
acute ST segment elevation myocardial infarction with 3.0 to
5.[**Street Address(2) 2811**] elevation in leads V1 through V5.
He was placed on Heparin, Nitroglycerin. and Integrilin drips
prior to transfer and given Aspirin and a beta blocker. He
was not given thrombolytic therapy. The patient remained
with three to five out of ten chest pain despite the above
drips upon arrival to [**Hospital1 69**]
Catheterization Laboratory. His systolic blood pressure at
the time was in the low 90s.
In the Catheterization Laboratory, he presented alert,
hypotensive, and briefly placed on Dopamine which was stopped
secondary to tachycardia. His pulmonary capillary wedge
pressure was 27, left ventricular end diastolic pressure was
24. His cardiac output was 2.64 and his cardiac index was
1.6. Left ventriculogram was not obtained. He was placed on
an intra-aortic balloon pump Intracath.
The left main coronary artery was normal as were the left
circumflex and the right coronary artery. The left anterior
descending had a 99% proximal occlusion with TIMI 1 flow,
that was stented (3.0 by 23 millimeter) to a poststent 0%
residual with TIMI 3 flow to the left anterior descending and
major diagonal.
His catheterization course was complicated by intermittent
atrial fibrillation and hypotension requiring an intra-aortic
balloon pump. He was transferred to the CCU following his
catheterization for further monitoring.
PAST MEDICAL HISTORY:
1. Hyperlipidemia.
2. Kidney stones.
3. Status post cataract surgery.
4. Glaucoma.
5. Left hernia repair 44 years ago.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: None.
PHYSICAL EXAMINATION: On presentation, vital signs were
stable. Heart rate was 110 to 120, blood pressure 93/53,
sinus rate. In general, he was in no apparent distress,
pleasant and talkative. His oropharynx was clear without
lesions or exudates. His sclera were anicteric. His jugular
venous pressure measured 8.0 centimeters. He had no carotid
bruits. His lungs were clear to auscultation without
crackles, without wheezes. His heart rate was regular rate
and rhythm with S1 and S2 appreciated and S3. His abdomen
was soft, nontender, nondistended with no organomegaly and
normoactive bowel sounds. Extremities were without edema
with 1+ dorsalis pedis pulses bilaterally.
SOCIAL HISTORY: No tobacco use and no alcohol use, no drug
use. He is a former vice president of commercial loan
division of a bank.
LABORATORY DATA: White blood cell count was 9.7, hematocrit
33.7, platelet count 190,000. Sodium 140, potassium 4.1,
blood urea nitrogen 16, creatinine 0.8, glucose 148.
Arterial blood gases on four liters nasal cannula was pH
7.48/27/127.
His electrocardiogram at [**Hospital6 1129**] was
normal sinus at 65 beats per minute with left axis deviation
and 2.0 to 5.[**Street Address(2) 2811**] elevations in V1 through V6, I
and aVL. His QRS was 125 ms. His electrocardiogram post
catheterization showed atrial fibrillation at a rate of 110,
left axis deviation, QRS complex 120 ms, and resolution of ST
elevations and T wave inversions in aVL.
HOSPITAL COURSE: This is an 83 year old male status post
acute anterior myocardial infarction with proximal left
anterior descending stent to 0% residual flow. His
catheterization course was complicated by hypotension
requiring an intra-aortic balloon pump and atrial
fibrillation.
1. Cardiac - ischemia - His peak CK was 6655, peak cardiac
index was 10.1. The patient was maintained on Aspirin,
Plavix and Lipitor following his catheterization as well as
completed a course of Heparin and Integrilin. He remained
chest pain free for the duration of his admission. He had no
further dynamic electrocardiographic changes and his lipid
panel was measured with a total cholesterol of 165,
triglycerides of 78, HDL 33, LDL 116.
Pump - On hospital day number two, his intra-aortic balloon
pump was affectively weaned. An echocardiogram was obtained
on [**2139-9-16**], which demonstrated an ejection fraction of 20 to
30%, 1+ mitral regurgitation, 2+ tricuspid regurgitation,
akinesis of all but the basal segments of the anterior septum
and anterior free wall, also extensive apical akinesis but no
mass or thrombus seen. He had moderate hypokinesis of the
lateral wall and severe hypokinesis of the inferior septum.
The patient was not anticoagulated for his apical akinesis
secondary to bleeding. Please see sections below in
genitourinary and gastrointestinal.
Rhythm - His post catheterization course was complicated by
atrial fibrillation which was self limited. He had several
runs of nonsustained ventricular tachycardia, the longest of
which was approximately 28 beats in the first 72 hours
following his catheterization. He was given Amiodarone for
those first 72 hours. Subsequent to the discontinuation of
Amiodarone, the patient was in sinus rhythm without further
ectopy.
The patient also underwent a signal averaged
electrocardiogram which was positive. The patient was
informed about the possibility of potentially needing an AICD
given his reduced ejection fraction. Further discussion in
this regard will be deferred to his primary cardiologist at
the [**Hospital6 1129**].
2. Genitourinary - The patient had hematuria in the setting
of Integrilin and Heparin anticoagulation. The urology
service was consulted and a three way Foley catheter was
placed with continuous irrigation to resolution of hematuria.
A CT scan was obtained to further workup etiologies of said
hematuria. The scan demonstrated a suspicious bladder mass
along the right wall of the bladder which is questionably
consistent with inflammation versus a clot versus a tumor.
The patient also was noted to have bilateral renal stones and
bladder stones as well that appear to be asymptomatic at the
time of this admission. The urology service recommended
outpatient follow-up with potential cystoscopy.
3. Gastrointestinal - On [**2139-9-18**], the patient had one
episode of melena. He was maintained on intravenous Protonix
and his stools were followed until resolution of melena and
stable hematocrit. The episode was in the setting of
anticoagulation but will require further outpatient workup.
The patient was also seen by physical therapy during this
admission and noted to be at his baseline function upon
discharge.
4. Code Status - Full code.
MEDICATIONS ON DISCHARGE:
1. Atenolol 12.5 mg p.o. once daily.
2. Protonix 40 mg p.o. once daily.
3. Zestril 2.5 mg p.o. once daily.
4. Lipitor 10 mg p.o. once daily.
5. Aspirin 325 mg p.o. once daily.
6. Plavix 75 mg p.o. once daily, [**2139-9-23**], is day seven of a
thirty day course.
7. Sublingual Nitroglycerin p.r.n. chest pain.
The patient will have visiting nurse this week for medication
teaching.
FOLLOW-UP: The patient will be followed up by his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at his Deacon [**Doctor Last Name **] office
on [**2139-9-29**], at 4:00 p.m.. Follow-up issues will include
following up his heme positive stool and potential
gastrointestinal workup as an outpatient.
The patient will also need cardiology follow-up as per Dr.
[**Last Name (STitle) 44551**] office. The patient expressed wishes to be seen at
[**Hospital6 1129**] as it is near his home. In
terms of cardiology follow-up, the issue of considering an
AICD in a patient with a reduced ejection fraction should be
addressed. Also, anticoagulation was held this admission in
the setting of hematuria and melena, but will need to be
addressed in view of the patient's apical hypokinesis.
Urology follow-up as the patient has resolved hematuria but a
suspicious bladder mass that will need further evaluation
with a potential cystoscopy. He also has bilateral renal
stones and bladder stones that are currently asymptomatic but
possibly may be amenable to lithotripsy in the future. Dr.
[**First Name4 (NamePattern1) 717**] [**Last Name (NamePattern1) 44552**] office, [**Telephone/Fax (1) 44553**], will contact the
patient on [**2139-9-23**], for follow-up.
The patient can choose to use her services at [**Hospital1 346**] or follow-up urology as per his
primary care physician's choice. Also of note, the patient
had urine cytology sent prior to discharge and those results
will be followed up by Dr. [**Last Name (STitle) **] and faxed to the Dr.
[**Last Name (STitle) 44551**] office.
DISCHARGE DIAGNOSIS: Acute anterior ST elevation myocardial
infarction, status post percutaneous transluminal coronary
angioplasty.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 17844**]
MEDQUIST36
D: [**2139-9-23**] 18:46
T: [**2139-9-23**] 19:00
JOB#: [**Job Number 44554**]
ICD9 Codes: 4240, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7512
} | Medical Text: Admission Date: [**2145-11-16**] Discharge Date: [**2145-12-2**]
Service: MEDICINE, [**Location (un) 259**] FIRM
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
female with a history of diverticular bleeding, coronary
artery disease, atrial valve replacement on Coumadin, who
presented with passing clots per rectum for three days. The
patient had been having bright red blood per rectum two weeks
prior to admission, but this had worsened over several days
prior to admission.
She denied fever, chills, nausea, vomiting. No chest pain.
No shortness of breath. No recent antibiotic use. Her
baseline hematocrit is 38-41. She denied taking Coumadin the
night before admission.
In the Emergency Room, she was noted to have continued bright
red blood per rectum measuring approximately 300-400 cc. Her
hematocrit on arrival was 37.9; four hours after arrival was
37.0.
In the Emergency Room, she was given 1 L of intravenous
fluids but no FFP or Vitamin K. She was hemodynamically
stable and transferred to the floor. Incidentally she had an
appointment scheduled for the day after admission with Dr.
[**Last Name (STitle) 15505**] for her hemorrhoids.
PAST MEDICAL HISTORY: 1. Sigmoid diverticulosis seen on
colonoscopy in [**2144-7-2**]. 2. Atrial fibrillation. 3.
Status post atrial valve replacement, St. Jude's valve. 4.
Coronary artery disease. 5. Hypertension. 6. Diabetes
mellitus type 2. 7. Chronic obstructive pulmonary disease.
8. Congestive heart failure. 9. Status post appendectomy.
10. Status post partial thyroidectomy. 11. Status post
oophorectomy. 12. Hypercholesterolemia.
MEDICATIONS ON ADMISSION: Coumadin 2.5 mg p.o. q.d.,
Glyburide 10 mg p.o. b.i.d., Lopressor 37.5 mg p.o. t.i.d.,
Lasix 40 mg p.o. b.i.d., Captopril 25 mg p.o. t.i.d.,
Glucophage 500 mg p.o. b.i.d., Serevent 2 puffs b.i.d.,
Zantac 100 mg p.o. b.i.d., Digoxin 0.125 mg p.o. q.d.,
Combivent MDI 2 puffs b.i.d., Lipitor 10 mg p.o. q.d.
ALLERGIES: PENICILLIN CAUSES A RASH.
SOCIAL HISTORY: She lives alone. Her daughter is supportive
and lives in the area. She has a 20 pack-year tobacco
history and quit many years ago. No alcohol history.
PHYSICAL EXAMINATION: Vital signs: On admission temperature
was 98.7??????, blood pressure 140/80, heart rate in the 100-110s
and irregular, respirations 16, oxygen saturation 95% on room
air. General: The patient was pleasant and in no acute
distress. HEENT: Mucous membranes slightly dry. Oropharynx
clear. Pulmonary: Bibasilar rales. No wheeze. Otherwise
clear. Cardiovascular: Irregular rate. Loud S2. There was
a 1 out of 6 systolic murmur heard at the apex and the left
upper sternal border. Abdomen: Soft, nontender,
nondistended. Positive bowel sounds. Extremities: There
was 1+ edema. Neurological: The patient was alert and
oriented times three. Grossly intact.
LABORATORY DATA: On admission white blood cells 6.9,
hematocrit 37.9, platelet count 172; CHEM7 with a sodium of
131, potassium 4.2, chloride 90, bicarb 29, BUN 15,
creatinine 0.7, glucose 390; INR 5.6; digoxin level 0.6.
Electrocardiogram showed atrial fibrillation with a rate of
100, right bundle branch block, poor R-wave progression.
There were no significant changes compared to
electrocardiogram performed on [**2145-2-28**].
IMPRESSION: This is a 77-year-old female with a history of
diverticulosis, coronary artery disease, St. [**Male First Name (un) 1525**] AVR, who
presented with bright red blood per rectum in the setting of
an increased INR.
HOSPITAL COURSE: The patient was originally admitted to the
General Medicine Floor but continued to pass clots and bright
red blood per rectum. A repeat hematocrit was checked, and
this was 30. Her heart rate increased to the 160s, and while
she with good mental status, it was felt that she was at
hight risk for becoming hemodynamically unstable; therefore,
she was transferred to the Medical Intensive Care Unit.
1. Gastrointestinal: Given the patient's history of
diverticulosis, as well as hemorrhoids, it was felt that
these were the two most likely sources of her
gastrointestinal bleed.
Tagged red cell scans were performed, and neither of these
were diagnostic. The Gastrointestinal Service was consulted.
A colonoscopy was recommended to visualize the possible
source of the GI bleed, and because the patient became
anxious and went into respiratory distress during the bowel
prep for this procedure, it was not reattempted. In the end
it was felt that since the patient had colonoscopy only one
year ago that had documented the diverticular disease, it was
felt that a repeat colonoscopy would be poor yield unless she
were to actively rebleed.
In fact, she did not rebleed following her transfer to the
Medical Intensive Care Unit, and the only further treatment
instituted was Anusol HC topically to her perianal area for
her hemorrhoids. The patient was treated with protime pump
inhibitor while on the Medical Intensive Care Unit, and we
returned her to Zantac following discharge.
Cardiovascular: It was very difficult to control the
patient's rapid ventricular response to her atrial
fibrillation during her hospitalization. In the Medical
Intensive Care Unit, increasing doses of Lopressor were
administered up to 75 mg p.o. q.i.d. plus supplemental
Lopressor given intravenously. Unfortunately this seemed to
incite a mild flare of her chronic obstructive pulmonary
disease as described below under pulmonary. Therefore, she
was weaned off of Lopressor and started on a Diltiazem drip.
The Diltiazem drip was weaned, and p.o. Cardizem was
instituted for total p.o. dose of Cardizem 90 mg p.o. q.i.d.,
and following discharge, this was changed to Cardizem CD 360
mg p.o. q.d. Her rate was well controlled with this dose and
ranged from 75 to 90.
We continued the patient's Digoxin and Lipitor. She was
admitted on Captopril 25 mg p.o. t.i.d., but this was
decreased to 12.5 mg p.o. t.i.d. given that her blood
pressure was also well controlled with her Cardizem.
3. Infectious disease: The patient was found to have mild
pneumonia. This was treated with Levofloxacin 500 mg p.o.
q.d. for a 14-day course. The last day of her Levofloxacin
dose should be [**2145-12-5**]. The patient also had a
urinary tract infection which was found to be Enterococcus
susceptible to Levofloxacin; therefore, Levofloxacin treated
both her pneumonia, as well as her urinary tract infection.
4. Hematology: The patient's goal INR is 2.5-3.5 given her
atrial valve replacement with a St. Jude's valve, as well as
her atrial fibrillation. She was admitted supratherapeutic
with an INR of 5.8. The patient was given FFP, as well as
Vitamin K to reverse the INR. Several units of blood were
transfused given the patient's low hematocrit and documented
coronary artery disease, as well as congestive heart failure.
When the patient was transferred from the Medical Intensive
Care Unit to the General Medicine Floor, she was
subtherapeutic on her Coumadin, so we treated her with
Lovenox 80 mg subcue b.i.d. This should be continued until
her INR reaches 2.5. On the patient's home dose of Coumadin,
which was 2.5 mg p.o. q.d., the patient's INR stalled at 2.3;
therefore, we increased her Coumadin dose to 3.0 mg q.Monday,
Wednesday, and Friday, and 2.5 mg q.Tuesday, Thursday,
Saturday, and Sunday. This should be continued until her INR
is therapeutic between 2.5 and 3.5, and when this is
achieved, her Lovenox can be discontinued.
5. Pulmonary: As mentioned during the patient's preparation
for colonoscopy, she experience acute respiratory distress.
It was actually unclear exactly why this occurred, but it
could have been secondary to anxiety and underlying
pneumonia, as well as possible contribution from her
underlying chronic obstructive pulmonary disease. She
required intubation for several days, following which she was
extubated successfully without complications. She was then
treated with nebulized Albuterol and Atrovent and later
weaned off of these and treated with her regular metered dose
inhalers.
As mentioned, the patient had a pneumonia that was treated
with Levofloxacin successfully.
6. Fluids, electrolytes, and nutrition: The patient
received TPN while she was intubated on the Medical Intensive
Care Unit. When she was extubated, she had a little bit of
difficulty swallowing, so we consulted the Speech and Swallow
Service which helped us in performing a video swallow study.
This was normal, and the patient did well with liquids and
solids. Her diet should be advanced as tolerated.
7. Endocrine: The patient had good glucose control with
Glyburide, Glucophage, and regular Insulin sliding scale.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Discharged to rehabilitation facility at
[**Hospital **] Rehabilitation.
DISCHARGE MEDICATIONS: Cardizem CD 360 mg p.o. q.d., Lipitor
10 mg p.o. q.d., Serevent MDI 2 puffs b.i.d., Combivent MDI 2
puffs b.i.d., Zantac 150 mg p.o. b.i.d., Digoxin 0.125 mg
p.o. q.d., Glucophage 500 mg p.o. b.i.d., Glyburide 10 mg
p.o. b.i.d., Captopril 12.5 mg p.o. b.i.d., Coumadin 3.0 mg
q.Monday, Wednesday, Friday, 2.5 mg q.Tuesday, Thursday,
Saturday, Sunday, once the patient's INR reaches 2.5, this
should probably be decreased to 2.5 mg p.o. q.d., her goal
INR is 2.5-3.5, this should be followed closely while she is
an outpatient, Lovenox 80 mg subcue b.i.d. until her INR is
therapeutic, Levofloxacin 500 mg p.o. q.d. until [**12-5**],
Anusol HC topically to perianal area t.i.d. to q.i.d. p.r.n.
DISCHARGE INSTRUCTIONS: Her diet should include thick
liquids and solids, and she should advance to full solids as
tolerated. The reason she is having some difficulties
swallowing is that she is status post intubation.
FOLLOW-UP: She should follow-up with her primary care
physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
DISCHARGE DIAGNOSIS:
1. Lower gastrointestinal bleed, probably diverticular plus
hemorrhoidal.
2. Pneumonia.
3. Chronic obstructive pulmonary disease flare.
4. Urinary tract infection.
5. Atrial fibrillation with rapid ventricular response.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1019**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2145-12-1**] 16:02
T: [**2145-12-1**] 19:00
JOB#: [**Job Number 24986**]
ICD9 Codes: 486, 5990, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7513
} | Medical Text: Admission Date: [**2129-3-18**] Discharge Date: [**2129-3-26**]
Date of Birth: [**2076-12-31**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
[**3-19**]: Right superficial bronchial artery embolized with
embospheres and 4 coils. Rt inferior bronchial artery embolized
with PVAs. Angioseal deployed.
[**3-20**]: Had another episode of bleeding which required DL ETT
placement. Bronch showed active bleeding from same site of
emoblization. Patient hemodynamically stable but did not respond
to 1U PRBC. No further intervention.
Intubation
History of Present Illness:
This is a 52 year old male with PMH of morbid obesity with
resultant lymphedema, depression, Afib on Coumadin, OSA on CPAP,
and h/o LLL pulmonary hemorrhage secondary to an AVM requiring
rigid bronchoscopy and APC to cauterize area of bleeding
presenting for further evaluation of repeat hemoptysis. He
reportedly coughed up some bright red blood at home this evening
and was initially stable upon arrival to the ED until he was
witnessed coughing up a pint and a half of blood. Of note, he
developed a UTI about a week ago and received ceftriaxone
followed by a po cephalosporin, which likely interfered with his
Coumadin levels.
In the ED, initial VS were: 98, 130, 128/75, 16, 97%
Non-Rebreather. He arrived with normal mental status and a
patent airway, but began coughing in the ED which was productive
of bright red blood. Over the next couple minutes, the
significant bleeding continued and he was intubated for airway
protection him. Before intubation, he was noted to have about
200-300 mL of bright red bloody hemoptysis. Peripheral IV access
was obtained and 4 units of FFP were given in addition to 10mg
of IV vitamin K since his INR was supratherapeutic at 6.1 on
Coumadin. Interventional radiology, interventional pulmonology,
and cardiothoracic surgery were consulted in the ED. After
intubation, the ventilator kept alarming due to elevated
pressures likely secondary to blood clot obstruction. He
therefore required manual bagging to maintain his sats and his
resistance improved once placed in the left lateral decub
position to a point where he could be placed back on the vent.
Of note his HR was consistently in the 130s probably from Afib
RVR.
.
On arrival to the MICU, he could not be placed on the ventilator
due to the high resistance in his airways from the blood and
clots in his lungs. He required manual bagging at times to
maintain his sats as well as paralysis with cisatracurium. A
central line was placed in his right IJ to continue infusion of
blood products. A bedside flexible bronchoscopy revealed massive
hemoptysis and clotting of his bilateral bronchi. IP was
contact[**Name (NI) **] and the patient was immediately taken to the OR for
rigid bronchoscopy in an attempt to clean out the clots and find
the site of bleeding in order to cauterize it.
.
Review of systems:
unable to obtain
Past Medical History:
- hemoptysis ([**2123**]) - IP LLL
- major depression
- obstructive sleep apnea: on CPAP at home
- morbid obesity
- lymphedema
- psoriasis
- atrial fibrillation s/p cardioversion in [**4-/2128**]
- dilated cardiomyopathy (EF 35-40%)
Social History:
Has not left his house in >1 year due to
depression and now worsening obesity; lives with his sister.
Formerly smoked 1 ppd up until 5 yrs ago. Was a binge drinker in
his 20s, but no longer drinks. Distant marijuana and intranasal
cocaine use. Denies IVDU.
Family History:
Father with 2 [**Name2 (NI) **] in his 50s but still living in
his 70s currently. Mother with schizophrenia.
Physical Exam:
Admission physical exam:
Vitals: T: afebrile, BP: 100s-110s/60s-70s, P: 110s, R: 22, O2:
99% RA
General: intubated/sedated, bloody secretions in ET tube
requiring
HEENT: Sclera anicteric, MMM, ET tube in place, PERRL
Neck: supple
CV: Irregularly irregular, tachycardic
Lungs: Diminished breath sounds bilaterally
Abdomen: soft, large pannus, non-tender, bowel sounds present
GU: Foley in place
Ext: warm, well perfused, bilateral lower extremity lymphedema
and venous stasis changes
Neuro: intubated/sedated
Pertinent Results:
[**2129-3-18**] 09:33PM BLOOD WBC-7.2 RBC-4.24* Hgb-13.4* Hct-38.8*
MCV-92 MCH-31.6 MCHC-34.5 RDW-13.0 Plt Ct-269#
[**2129-3-19**] 10:50AM BLOOD WBC-17.5* RBC-3.53* Hgb-11.5* Hct-32.4*
MCV-92 MCH-32.5* MCHC-35.4* RDW-13.4 Plt Ct-257
[**2129-3-20**] 02:20PM BLOOD Hct-28.9*
[**2129-3-18**] 09:33PM BLOOD PT-61.1* PTT-51.4* INR(PT)-6.1*
[**2129-3-19**] 06:27AM BLOOD PT-16.0* PTT-31.6 INR(PT)-1.5*
[**2129-3-20**] 03:56AM BLOOD PT-14.3* PTT-29.5 INR(PT)-1.3*
[**2129-3-18**] 09:33PM BLOOD Glucose-140* UreaN-12 Creat-0.9 Na-139
K-4.1 Cl-103 HCO3-26 AnGap-14
[**2129-3-20**] 03:56AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-142
K-3.9 Cl-106 HCO3-29 AnGap-11
Brochial angiogram ([**2129-3-19**]): Two arteries of possible bleed
in the right lung from the right superior and Preliminary
Reportinferior bronchial arteries which were successfully
embolized with
Preliminary ReportEmbospheres, PVAs and four coils.
CT head [**3-23**]:
IMPRESSION: Compared to study of [**2129-3-14**], there are new regions
of subtle
hypodensity involving both the [**Doctor Last Name 352**] and white matter in the
right temporal, right occipital, and left parieto-occipital
regions. These are suspicious for cytotoxic edema related to
acute embolic infarction. Recommend MR [**First Name (Titles) 151**] [**Last Name (Titles) **] of the brain for
better evaluation.
.
Echo [**3-23**]:
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. There is mild
right ventricular dilatation and global free wall hypokinesis.
No pathologic valvular abnormality seen. Pulmonary artery
systolic pressure could not be determined.
.
Bilateral LENIs [**3-22**]:
IMPRESSION:
No evidence of deep venous thrombosis in visualized portions of
bilateral
lower extremities. Suboptimal exam due to patient's body
habitus.
.
CTA chest [**2128-3-20**]:
IMPRESSION:
1. Multiple bilateral segmental and subsegmental lower lung
pulmonary emboli.
2. Bilateral peribronchovascular opacifications consistent with
provided
history of pulmonary hemorrhage or edema.
3. Dual channel endotracheal, distal chamber ends in left main
bronchus,
proximal channel ends in distal trachea. No apparent means of
right bronchial
obturation.
4. Possible right retrohilar hematoma.
Brief Hospital Course:
This is a 52 year old male with PMH of morbid obesity with
resultant lymphedema, depression, dilated cardiomyopathy with an
EF=35-40%, Afib on Coumadin, OSA on CPAP, and h/o LLL pulmonary
hemorrhage secondary to an AVM requiring rigid bronchoscopy and
APC to cauterize area of bleeding presenting for further
evaluation of repeat hemoptysis.
#. Hemoptysis/respiratory failure. He presented to the ED with
massive hemoptysis requiring intubation for airway protection
and ventilatory support to maintain his sats. Flexible
bronchoscopy on admission in MICU showed fresh hemorrhage in
right lung. He was taken to OR for rigid bronchoscopy whose
course was complicated by persistent hypoxia and hypotension. He
was taken to IR suite where they embolized superior bronchial
artery embospheres and 4 coils while right inferior bronchial
artery was embolized with PVAs. Coagulopathy was reversed with 8
units of FFP and vitamin K while coumadin was stopped and given
3 units of PRBC.
On [**2129-3-20**] he was noted to have opacification of the right
lung. IP's bronchoscopy showed fresh bleeding. He was given 1
unit of PrBC. Double lumen ET tube was placed and plan is to
take him for rigid bronchoscopy tomorrow.
After some brief progress was made at lowering the patient's
oxygenation requirements, the patient had increasing oxygen
requirements that resulted in a CTA chest, which ended up
showing bilateral pulmonary embolism. In addition, the patient's
chest X-ray suggested some left infiltrate and he was started on
treatment for ventilator-associated pneumonia. It was also noted
at this time that his pupils were not as responsive, though he
was sedated so a neurological exam was not fully possible. A
head CT was obtained that showed three areas concerning for
embolic stroke. The patient's respiratory status showed no
improvement and by [**3-24**], he was back to requiring pressors. The
family was brought in for a series of discussions, during which
the patient's poor progress and prognosis were discussed, along
with the damage to three organ systems (lungs, heart, brain).
The patient's father and health care proxy decided to make the
patient [**Name (NI) 9036**] Measures Only. Fifteen minutes after the pressor
was stopped, the patient died.
#. Atrial fibrillation with RVR. Patient has h/o of Afib at
home on warfarin and metoprolol as well as sotalol for
rate/rhythm control. Coumadin held while INR reversed as above.
Sotalol and metoprolol held. The patient was restarted on his
sotalol following his embolization and spent more than two days
in sinus rhythm following spontaneous conversion, which also
allowed his blood pressure to recover. His then went back to
atrial fibrillation and required pressors to support his blood
pressure. A Cardiology consult was called and recommendations
made, but these recommendations were superceded by the patient's
deteriorating clinical status and decision to be made [**Name (NI) 9036**]
Measures Only.
#. Dilated cardiomyopathy. Most recent ECHO in [**2-/2129**] shows
biatrial enlargement, mild symmetric left ventricular
hypertrophy, and normal left and right ventricular function with
normal valvular function. ASA, lisinopril and Lasix are held in
setting of massive hemoptysis.
# Likely embolic stroke: CT head showed three areas of
hypodensity, most likely to be secondary to embolic stroke per
radiology. Given that patient has AVM, it is possible the AVM
was the source of paradoxical emboli. LENIs negative. Patient
was made [**Year (4 digits) **] measures only.
Medications on Admission:
-ammonium lactate 12 % Lotion Apply to affected area twice a day
-clobetasol 0.05 % Cream Apply to affected area twice a day
-furosemide 40 mg by mouth once a day
-lisinopril 2.5 mg by mouth once a day
-lorazepam 0.5-1 mg by mouth twice a day as needed for anxiety
-metoprolol tartrate 12.5 mg by mouth three times a day
-polyethylene glycol 3350 17 gram by mouth daily as needed for
constipation
-sotalol 120 mg by mouth twice a day
-trazodone 25 mg by mouth at bedtime
-venlafaxine 225 mg Tablet Extended Rel 24 hr by mouth once a
day
-warfarin 2.5 mg Tablet 1.5 Tablet(s) by mouth once a day as
directed Fridays 5mg
-aspirin 81 mg by mouth once a day
-cholecalciferol 2,000 unit by mouth once a day
-cod liver oil by mouth once a day
-docusate sodium 100 mg by mouth twice a day
-fish oil-dha-epa 1,200 mg-144 mg Capsule by mouth once a day
-multivitamin with minerals by mouth daily
-sennosides 8.6 mg; 2 tablets by mouth daily
Discharge Medications:
None. Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
ICD9 Codes: 5990, 2762, 4280, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7514
} | Medical Text: Admission Date: [**2180-7-23**] Discharge Date: [**2180-8-14**]
Date of Birth: [**2113-2-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**7-21**] emergent tracheal intubation
[**7-27**] rigid bronch/stenosis dilation/ETT advancement
[**8-1**] balloon dilation of trachea
[**8-3**] extubated
[**8-7**] tracheal resection
bronchoscopy
History of Present Illness:
67-year-old woman who presented to an
outside hospital on [**2180-7-14**] with shortness of breath, stridor
and wheezing, and after extensive workup, was found to have
subglottic stenosis. Her history dates back to [**5-/2180**] when she
was found down in [**Male First Name (un) 1056**] and diagnosed with a large
myocardial infarction. She was intubated for four days,
subsequently extubated and reintubated several hours later due
to
respiratory distress. She was eventually extubated, discharged
to home where she then flew on to [**Last Name (LF) 6185**], [**First Name3 (LF) 108**], where she
underwent a coronary artery bypass grafting. Her surgery was
uneventful and she was extubated without difficulty but
subsequently developed progressive dyspnea and wheezing and was
admitted on [**2180-7-14**] and found to have moderate-to-severe
post-intubation tracheal stenosis commencing approximately 3 cm
below the vocal cords. While waiting transfer to a tertiary
care
medical center, she developed an episode of bradycardia and
required intubation, however, the endotracheal tube was unable
be
advanced beyond the stenosis. Her endotracheal tube was changed
to 6.5, but again it could not be advanced beyond the area of
stenosis. She was subsequently transferred to the [**Hospital1 346**] for further management by the airway
service.
Past Medical History:
Significant for coronary artery disease
status post myocardial infarction in [**5-/2180**], status post
coronary
artery bypass grafting x3 in [**Location (un) 6185**], hypertension,
hypercholesterolemia, and type 2 diabetes.
Social History:
She is married, has children, no history of
tobacco use or alcohol use.
Physical Exam:
On Admission:
Vitals: 100.7F, HR 79, BP 142/72, RR 16 100%
Gen - intubated, sedated
HEENT - PERRL, EOMI B/L
Neck - supple, no adenopathy
CV - RRR, nl s1, s2
Pul - rhonchi b/l
Abd - soft, NT, ND, +BS
Ext - no c/c/e
Pertinent Results:
On admission:
[**2180-7-23**] 08:30PM WBC-6.2 RBC-2.98* HGB-8.2* HCT-24.4* MCV-82
MCH-27.4 MCHC-33.5 RDW-16.3*
[**2180-7-23**] 08:30PM PLT COUNT-76*
[**2180-7-23**] 08:30PM PT-11.8 PTT-25.7 INR(PT)-1.0
[**2180-7-23**] 08:30PM GLUCOSE-128* UREA N-24* CREAT-0.4 SODIUM-145
POTASSIUM-3.2* CHLORIDE-109* TOTAL CO2-32 ANION GAP-7*
[**2180-7-23**] 08:30PM ALT(SGPT)-23 AST(SGOT)-21 LD(LDH)-253*
CK(CPK)-29 ALK PHOS-44 TOT BILI-0.4
[**2180-7-23**] 08:30PM CK-MB-NotDone cTropnT-0.01
[**2180-7-23**] 08:30PM ALBUMIN-2.5* CALCIUM-7.7* PHOSPHATE-1.6*
MAGNESIUM-2.1
[**2180-7-23**] 10:16PM TYPE-ART TEMP-38.2 RATES-/16 TIDAL VOL-466
O2-40 PO2-209* PCO2-49* PH-7.46* TOTAL CO2-36* BASE XS-10
INTUBATED-INTUBATED VENT-SPONTANEOU
At Discharge:
[**2180-8-13**] 05:37AM BLOOD WBC-5.5 RBC-3.06* Hgb-9.1* Hct-26.0*
MCV-85 MCH-29.8 MCHC-35.0 RDW-15.8* Plt Ct-357
[**2180-8-14**] 05:40AM BLOOD PT-31.8* PTT-45.1* INR(PT)-3.4*
CXR [**8-8**]:
IMPRESSION: The post-surgical drain is again demonstrated with
its tip
overlying the upper mediastinum. The heart size and mediastinal
contours are unremarkable. The left lower lobe discoid
atelectasis is unchanged. The right lung and upper portion of
the left lung are unremarkable.
CT HEAD W/O CONTRAST [**2180-8-10**] 8:25 AM
Reason: ? acute bleed
IMPRESSION: 1) No acute intracranial hemorrhage or major
vascular territorial infarct identified. 2) Absence of the
septum pellucidum, likely congenital in origin.
CT TRACHEA [**2180-7-28**]
IMPRESSION:
1. Focal segment of tracheal stenosis involving the subglottic
and upper
intrathoracic trachea.
2. Nonspecific mild ground-glass opacity in the medial aspect of
the superior
segment of the right lower lobe, which could be secondary to
aspiration.
3. Small bilateral pleural effusions, unchanged
Brief Hospital Course:
Pt was transferred to [**Hospital1 18**] on [**7-23**] from an OSH for management
of her tracheal stenosis likely secondary to intubation. She
was admitted to the MICU service, intubated and sedated. On
admission she was started on levofloxacin and flagyl for empiric
coverage against a possible pneumonia, for which she was being
treated with zosyn and ceftriaxone at her OSH. For her tracheal
stenosis she was started on solumedrol and given nebs.
Bronchoscopy on [**7-24**] showed severe tracheal stenosis 5mm in
diamter and 2.5cm in length.
On [**7-25**] Ms [**Known lastname **] was found to be HIT positive and was therefore
started on an argatroban drip. At that time she was seen by
cardiology for pre-operative clearance. Although she had had
recent CABG, the cardiologists felt that she had no current high
risk prognostic features and therefore cleared her for surgery.
She was also seen by Dr. [**Last Name (STitle) 952**] at that time who planned to do a
tracheal resection 8 days later. Tube feeds through her OG tube
were started at that time to optimize pre-op nutrition. Pt.
also began having runs of SVT at this time requiring IV
lopressor 15-20mg.
On [**7-27**] she was underwent rigid bronch and tracheal dilation
without incident. Pt had TTE done as well which showed:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity size and systolic function (LVEF>55%). Regional
left ventricular wall motion is normal.
3. The aortic valve leaflets (3) are mildly thickened.
4. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
She was planned for surgery on [**7-31**] for a tracheal resection,
although her runs of SVT continued. Bronchial washings at this
time were negative for malignancy.
Pt contiued to have SVT with non-specific ST changes on [**7-31**],
and therefore the surgery was postponed. Cardiac enzymes were
negative. On [**8-1**] she went to the OR for rigid bronch and
balloon dilation of trachea to 14mm without complications. No
stent was placed at that time. For details please see OP note.
On [**8-2**] pt was extubated without difficulty and was seen by
speech and swallow who felt she was aspirating with thin liquids
and recommended nectar thick liquids and ground solids. On [**8-3**]
her abx were stopped after a total of 11 days (14 days of all
abx's including OSH). She continued to have episodes of narrow
complex SVT.
On [**8-4**] she was transfered out of the MICU onto the regular
floor in stable condition onto the thoracic surgery service.
She was cleared by swallow for a regular diet and thin liquids
and her tube feeds were stopped. Tracheal resection was planned
for [**8-7**]. CT of trachea on [**8-4**] confirmed subglottic stenosis.
on [**8-7**] she was made NPO after midnight and her argatroban drip
was held 4 hours prior to the procedure. The procedure went
without incident and she was transfered to the CSRU extubated in
stable condition. Post-operatively her argatroban drip was
restarted at her stable pre-op dose of 5.75. She was transfered
out of the unit on POD 1 and was given 5mg coumadin in order to
stop the argatroban. She was cleared by speech and swallow for
a regular diet.
On POD 2 pt became supratherapeutic on her coumadin. Her coags
on [**8-9**] were as follows: PT - 49, PTT - 90, INR - 5.3. The
argatroban was decreased to 5.0 at that time and she was given
only 2.5 of coumadin. In addition, her metoprolol was decreased
to 12.5 [**Hospital1 **] from 25 [**Hospital1 **] for hypotension into the low 90's/50s.
On the morning of POD3 pt was noted to be hypoglycemic and was
given 1amp of D50. However she continued to be lethargic and
began having a short run of narrow complex SVT. This resolved
with 15mg IV lopressor and her PO dose was placed back to 25
[**Hospital1 **]. When pt got up to ambulate, physical therapy noted
right-sided weakness. Pt was sent for a head CT which was
negative for an intracranial bleed and was seen by neurology.
The right-sided weakness resolved later that day. Her coags
were noted to be PT 98, PTT 100, and INR of 18.3 However these
were drawn from the same PICC line as the argatroban was being
given. Regardless, the argatroban was stopped and she recieved
on coumadin that night.
On POD4 pt had another run of SVT and her metoprolol was changed
to toprol xl 50mg qday per cardiology. Her strength improved
after daily and on POD7 she was cleared by physical therapy to
go home without services. Her coags on [**8-14**] (the day of
discharge) were PT 32, PTT 45, and INR 3.4. She was sent home
on 1 day of coumadin at 1mg followed by 2 days of 0.5mg. Her
INR will be followed by Dr. [**Last Name (STitle) **] until she returns to [**State 108**]
and she will follow up with Dr. [**Last Name (STitle) **] on [**8-17**] at which
point her coumadin dose will be readdressed.
Medications on Admission:
[**Last Name (un) 24116**], enalapril 5', imdur 30', lipitor 10', coreg 6.25", plavix
75', toprol 50', zofran prn
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
Disp:*500 ml* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Disp:*30 Tablet(s)* Refills:*0*
11. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
INR [**2180-8-15**]
[**Hospital Ward Name 23**] Clinical Center Lab
13. Outpatient Lab Work
INR [**8-17**]
[**Hospital Ward Name 23**] Clinical Center Lab
14. One Touch Ultra Test Strip Sig: One (1) strip Miscell.
four times a day: check glucose 3-4 times daily.
Disp:*1 box* Refills:*2*
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 8-12 Puffs
Inhalation Q4-6H (every 4 to 6 hours) as needed.
Disp:*1 1* Refills:*1*
16. Albuterol 90 mcg/Actuation Aerosol Sig: 8-12 Puffs
Inhalation Q4-6H (every 4 to 6 hours) as needed.
Disp:*1 1* Refills:*1*
17. Coumadin 2 mg Tablet Sig: One (1) Tablet PO AS directed: as
directed.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
tracheal stenosis, Coronary artery disease s/p MI and Coronary
artery bypass graftx 3 in [**5-/2180**], hypertension,
hypercholesterolemia, Diabetes Mellitus type 2, HEparin induced
thrombocytopenia +.
Discharge Condition:
good
Discharge Instructions:
CAll Dr.[**Name (NI) 14680**] office Interventional Pulmonary/Dr. [**Last Name (STitle) 17224**]
Thoracic Surgery office for: fever, shortness of breath, chest
pain.
TAke medications as stated on discharte instructions. 2 sets of
prescriptions provided- one month for now, 2 nd set for [**State 108**]
use.
NO lifting more than 5-7lbs.
YOu may shower. Wipe incision dry after showering. Let white
strips on incision fall off.
REgular walking as in hospital.
Go to [**Hospital Ward Name 23**] Clinical Center Lab for Blood draw Tuesday-[**2180-8-15**],
and Thursday-[**2180-8-17**]. Appointment [**8-17**] 9:30am w/ Thoracic
surgery Clinic- [**Hospital Ward Name 23**] clinical center, [**Location (un) **].
Take Coumadin 1mg tonight- [**2180-8-14**] ONLY.
Dr.[**Name (NI) 14680**] office will call to let you know what dose of
coumadin to take after blood draw.- on Tuesday and Wednesday,
then again on Thursday. through the weekend until seen by
following MD [**First Name8 (NamePattern2) **] [**Last Name (Titles) 6185**].
Be sure to eat well, add supplements as needed as taken in
hospital.
Followup Instructions:
Appointment [**2180-8-17**]-Thursday @9:30am with Dr
[**Last Name (STitle) **], [**First Name3 (LF) 1092**] Surgery Clinic, [**Hospital Ward Name 23**] Clinical
Center-[**Location (un) **], [**Hospital Ward Name 516**], [**Hospital1 18**]- [**Location (un) **], [**Location (un) 86**],
MA.
CAll [**Telephone/Fax (1) 170**] for any questions regarding this appointment
Completed by:[**2180-8-16**]
ICD9 Codes: 412, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7515
} | Medical Text: Admission Date: [**2115-7-20**] Discharge Date: [**2115-8-1**]
Date of Birth: [**2048-7-14**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy and esophageal biopsy
Blood transfusions
Esophageal Ultrasound
History of Present Illness:
Pt is a 66 yo M with a h/o CAD (s/p CABG x 3 [**10-30**] and ICD
placement [**2-28**]), MVR, A.fib, HTN who presented to the ED w/
hematemesis. After the CABG in [**10-30**]' the patient noted a
lump in his throat. The sensation was persistent and he felt as
if his throat was closing. Over the next several months the pt
also began noting increase in belching and small amounts of
regurgitation. While eating he would bring up white frothy
contents. Recently, he noted an increase need to chew his
foods. He denies any difficulty swallowing liquids. On [**7-15**]
his [**Month/Year (2) 263**] was found to be subtherapeutic 1.4, so his coumadin was
increased from 1mg to 2mg and started on Lovenox 40mg QD. On
[**7-19**] his [**Month/Year (2) 263**] was 4.7, both coumadin and lovenox were stopped.
Later that day he had some coffee ground emesis and worsening
dysphagia. The following day he had grossly bloody emesis and
had noted dark stools for 2 days. He denies any recent weight
loss, abd pain, CP, F/C. No NSAID use.
In the ED he was given Vit. K and started on heparin drip. He
was hemodynamically stable. Given 1LNS and 1 unit PRBC's. A
gastric lavage was positive for blood. GI and Cardiology were
consulted. An EGD was performed which showed a 8 mm stricture
at the GE junction, with salmon colored mucosa, and a
frond-like/vilous non bleeding mass of malignant appearance.
The scope could not be passed the GE junction. He is
transferred to the floor to await biopsy results and further
plans. He is currently hemodynamically stable and on heparin
drip for anti-coagulation.
Past Medical History:
CABG x 3 ([**10-30**])
MVR
s/p ICD placement ([**2-28**])
A.fib
HTN
Hypothyroidism
Social History:
Denies ant T/A/D use. Lives with wife, has three children.
retired from [**Company 20830**]
Family History:
Denies any h/o cancer, CAD. Parents died when he was young,
unsure of causes.
Physical Exam:
PE T 98.9 BP 112/60 HR 68 RR 18 O2sats 100% RA
Gen: Pt sitting in chair, A&O times 3, NAD
HEENT: mmm, anicteric, clear OP, PERRL, EOMI
Neck: + EJ IV, no supraclavicular nodes, no JVD
Cardiac: RRR, + mechanical valve click, +S1/S2
Resp: crackles at the bases bilaterally, good air movement
Abd: Soft, NT, ND, +BS
Ext: no edema, 2+ DP, PT pulses bilaterally
Neuro: motor/sensory function grossly intact
Pertinent Results:
[**2115-7-20**] 01:30PM WBC-9.2# RBC-3.11*# HGB-9.7*# HCT-28.2*#
MCV-91 MCH-31.1 MCHC-34.3 RDW-15.5 NEUTS-81.4* LYMPHS-13.7*
MONOS-3.9 EOS-0.6 BASOS-0.4 PLT COUNT-219
[**2115-7-20**] 01:30PM PT-19.1* PTT-34.0 [**Month/Day/Year 263**](PT)-2.4
[**2115-7-20**] 01:30PM GLUCOSE-104 UREA N-50* CREAT-1.4* SODIUM-144
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-24 ANION GAP-16
EGD
Findings:
Esophagus:
Lumen: An 8mm stricture was seen in the gastro-esophageal
junction. The scope did not traverse the lesion.
Mucosa: A salmon colored mucosa distributed in a localized
pattern, suggestive of Barrett's Esophagus was seen.
Protruding Lesions A frond-like/villous non-bleeding mass of
malignant appearance was found at the gastro-esophageal
junction. The scope could not traverse the lesion and the
examination was interrupted.
Stomach:Other Unable to visualize extent of mass or the stomach
fundus/body due to GE junction stricture.
Duodenum: Not examined
Impressions: Stricture of the gastro-esophageal junction
Barrett's esophagus
Mass in the gastro-esophageal junction
ECHO [**2115-2-6**]
Conclusions
1. The left atrium is mildly dilated.
2. Overall left ventricular systolic function is moderately
depressed. Anterior, septal and apical hypokinesis is present.
EF 35-45%
3. The aortic valve leaflets (3) are mildly thickened.
4. A bileaflet mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet motion and
transvalvular gradients.
Cardiac Cath [**2114-11-21**]
FINAL DIAGNOSIS:
1. Three vessel and left main coronary artery disease.
2. Mild-moderate mitral regurgitation.
3. Severe global systolic and mild diastolic left ventricular
dysfunction.
COMMENTS:
1. Selective angiography of this right-dominant system revealed
three-vessel and LMCA disease. LMCA distal 40-50%. The LAD had
severe ostial and proximal diffuse diseased and was totally
occluded after D1. The distal LAD filled via left-to- left and
right-to-left collaterals. D1 70% stenosis at its ostium. LCX
had a 40% stenosis at the origin of a large OM1. The OM1 branch
had serial 70% lesions proximally. The RCA mid-vessel tubular
60% stenosis and a 70% stenosis just before the RPDA.
2. The LVEDP was 16 mmHg.
3. Left ventriculography revealed an ejection fraction of 29%.
There was anterobasal hypokinesis, anterolateral akinesis,
apical
dyskinesis/akinesis, inferior and posterobasal hypokinesis.
There was
mild to moderate ([**12-28**]+) mitral regurgitation.
Labs on Discharge:
[**2115-7-31**] 06:05AM BLOOD WBC-6.3 RBC-4.02* Hgb-12.6* Hct-37.2*
MCV-92 MCH-31.3 MCHC-33.9 RDW-14.2 Plt Ct-235
[**2115-7-20**] 01:30PM BLOOD Neuts-81.4* Lymphs-13.7* Monos-3.9
Eos-0.6 Baso-0.4
[**2115-8-1**] 06:10AM BLOOD PT-24.9* PTT-99.8* [**Month/Day/Year 263**](PT)-4.1
[**2115-8-1**] 06:10AM BLOOD Creat-1.4*
[**2115-7-31**] 06:05AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.1
Brief Hospital Course:
1.[**Name (NI) 54040**] Pt was initially admitted to the MICU. His blood
pressure was stable but on the low side for him, around
100/70's. His aspirin, coumadin, BB, ACEI, diuretic were all
held and he was given fluids. In the MICU [**Name (NI) 263**] was elevated so
it was reversed with Vit. K. He was given 2 units packed RBC's
(crit was 28.2) and his Hct remained stable without further
bleeding. Also started on PPI IV. He went for on EGD which
showed a 8mm stricture at the GE junction w/ non bleeding mass
of malignant appearance. Biopsy came back positive for
adenocarcinoma. For the remainder of the hospital he had no
bleeding and his HCT was stable.
2.Esophageal adenocarcinoma- Pt was diagnosed with
adenocarcinoma after EGD with biopsy. An esophageal ultrasound
showed that his stage was T2 with possible involvement of lymph
nodes. A CT scan did not show any evidence of metastases.
Several services including surgery, oncology, radiation oncology
were consulted. Follow up appointments as an outpatient include
Radiation oncology, thoracic oncology, and PET scan.
3. [**Name (NI) 54041**] Pt with MVR in [**10-30**]. He needed to be on
anticoagulation but because of the bleeding his [**Date Range 263**] was
reversed. After the EGD he was started on heparin and the PTT
was maintained between 60-80 as per cardiology recommendations.
After the EUS he was able to be transitioned to coumadin in
anticipation of discharge. Goal [**Date Range 263**] was 2.5-3.5 given the MVR.
It took several days to get Mr. [**Known lastname **] [**Last Name (Titles) 263**] therapeutic. Patient
was drinking boost in hospital which has vitmain k. On discharge
[**Last Name (Titles) 263**] 4.1 and patient is to see anticoagulation nurse in the am
after discharge.
4.HTN- Mr. [**Known lastname 48753**] blood pressure meds were initially held because
of bleeding and low BP. After he was stabilized and not
bleeding his blood pressure was monitored. The beta blocker was
added once his BP returned to the 120's/80's and slowly
increased to his normal dose of metoprolol 25 mg [**Hospital1 **].
5. CAD- Aspirin was held secondary to the bleeding. Continued
the statin. Beta blocker as above.
6. Pulmonary- On CT the patient was found to have evidence of
interstitial pneumonitis. He did have occasional crackles at the
bases but had O2 sats in the high 90's. PFT's were done which
exhibited a restrictive picture. Pulmonary was consulted they
felt he had IPF, however treatment was not warranted at this
time secondary to his need for cancer treatment. It was advised
that he follow up with pulmonology during his cancer therapy and
have regular PFT's.
7. Hypothyroidism- Continued his levothyroxine dose from home.
8. Rise in creatinine- Pt with creatinine to 1.4 at times during
hospitalization. Could be secondary to poor po and fluid intake.
Could be worked up as outpatient if though indicated.
9.PPx: Patient was on PPI and heparin until his coumadin was
therapeutic (morning of discharge)
Medications on Admission:
Levothyroxine 100mcg QD, Atenolol 25 mg QD, Lisinopril 20mg QD,
HCTZ 25mg QD, Zocor5mg QD, Coumadin 1mg QD
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*15 Tablet(s)* Refills:*0*
2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*15 Tablet(s)* Refills:*0*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Warfarin Sodium 1 mg Tablet Sig: as directed Tablet PO HS (at
bedtime): No coumadin tonight, repeat [**Hospital1 263**] [**2115-8-2**], further
medication adjustments [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 32624**] ([**Telephone/Fax (1) 54042**].
Disp:*30 Tablet(s)* Refills:*0*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
Check Basic metabolic profile and communicate results to Dr.
[**Last Name (STitle) 54043**].
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal adenocarcinoma
Upper gastrointestinal bleeding
Anemia,acute blood loss
Elevated creatinine
Anticoagulation for mitral valve replacement
Barrett's esophagus
Coronary Artery Disease
Discharge Condition:
Stable, hematocrit stabilized, [**Last Name (STitle) 263**] 4.1 with followup [**Hospital 191**]
[**Hospital3 **].
Discharge Instructions:
1)Have your [**Hospital3 263**] checked on [**2115-8-2**] and results to be communicated
to [**Company 191**] Anticoagulation service, your coumadin will be adjusted
based on these results by [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 32624**] ([**Telephone/Fax (1) 54042**].
2) You will need a repeat chemistry next week to check for
resolution of your creatinine, results to be followed by your
primary care physician. [**Last Name (NamePattern4) **]. [**Last Name (STitle) 54043**].
3) Your PET scan is schedule for [**2115-8-2**] at 1pm located in the
[**Hospital Ward Name 23**] center, [**Location (un) **]. Instructions for the procedure--
-No strenous exercise before the procedure
-You may take in only water for 6 hours before the scan, no food
or other liquids.
-
4) [**Known firstname **] [**Last Name (NamePattern1) 54044**] ([**2115**] will contact you regarding your
appointment in the Thoracic Oncology Group, if you do not
receive a call by [**2115-8-5**] please call the number above to confirm
this appointment time.
5) Radiation Oncology appointment today, [**2115-8-1**], at 3pm at the
[**Hospital Ward Name 23**] building, [**Location (un) 442**]
Followup Instructions:
Radiation oncology, Thoracic Oncology, and PET scan appointments
listed above.
Prior appointments include:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2115-12-16**] 2:00
Provider: [**First Name11 (Name Pattern1) 610**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2115-12-16**] 2:30
ICD9 Codes: 5789, 2851, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7516
} | Medical Text: Admission Date: [**2199-9-2**] Discharge Date: [**2199-10-2**]
Date of Birth: [**2132-7-30**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Erythromycin Base / Demerol
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Abdominal pain, nausea/vomiting
Major Surgical or Invasive Procedure:
[**2199-9-20**]: Removal of tunneled catheter and placement of Hickman
catheter
History of Present Illness:
67F with multiple medical problems, including fibromyalgia, MRSA
osteomyelitis of L2-3, and a history of recurrent SBOs. She
reports increasing abdominal pain since the day prior to
admission, with waves of cramping. She has had PO intolerance
and emesis and dry heaves on day of admission as well. She
reports no flatus, but diarrhea for the past few days. All
these symptoms are typical of her prior episodes of SBO -- her
husband reports that this will be her 89th episode, typically
averaging [**1-29**] hospitalizations per year. This attack to them,
seem less severe than her prior episodes. She denies chest
pain, fevers/chills, or sick contacts.
Past Medical History:
L2-L3 osteomyelitis and discitis
Psoas abscess
Left Upper Extremity Thrombosis
Spinal Stenosis
Multiple admissions for partial small bowel obstruction
h/o ovarian CA diagnosed 23 years ago, s/p abdominal XRT
Chronic abdominal pain
Low back pain
Fibromyalgia
Hypothyroidism
GERD
Hypercholesterolemia
Depression
Radiation enteritis
Elevated creatinine
Cardiomyopathy EF 50%, [**12-28**]+ MR ([**5-31**])
Fe deficiency anemia
Past Surgical History:
TAH/BSO
Exploratory laparotomy with lysis of adhesions
Appendectomy
Laminectomy and Spinal Fusion L4-L5
Social History:
Married. Denies tobacco or alcohol use. Previously worked as a
registered nurse in an outpatient medical practice.
Family History:
Cancer, heart disease in several family members
Physical Exam:
Tc 98.5, HR 84, BP 188/97, RR 20, O2sat 100%
Genl: NAD
CV: RRR
Resp: CTA-B
Abd: soft, tender to LLQ, RLQ, no tap tenderness, no reboud, no
guarding, non-distended
Extr: no c/c/e
Pertinent Results:
[**2199-9-2**] 05:45PM GLUCOSE-87 UREA N-13 CREAT-1.1 SODIUM-139
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16
[**2199-9-2**] 05:45PM estGFR-Using this
[**2199-9-2**] 05:45PM ALT(SGPT)-7 ALK PHOS-68 TOT BILI-0.2
[**2199-9-2**] 05:45PM LIPASE-30
[**2199-9-2**] 05:45PM ALBUMIN-3.6 CALCIUM-8.9
[**2199-9-2**] 05:45PM WBC-10.7 RBC-3.25* HGB-8.8* HCT-28.0* MCV-86
MCH-27.1 MCHC-31.5 RDW-16.5*
[**2199-9-2**] 05:45PM NEUTS-65.6 LYMPHS-27.5 MONOS-5.7 EOS-0.8
BASOS-0.5
[**2199-9-2**] 05:45PM PLT COUNT-579*
[**2199-9-14**] 05:23AM BLOOD WBC-6.2# RBC-2.60* Hgb-7.2* Hct-22.1*
MCV-85 MCH-27.8 MCHC-32.7 RDW-16.1* Plt Ct-477*
[**2199-9-15**] 07:00AM BLOOD WBC-7.6 RBC-2.73* Hgb-7.5* Hct-23.2*
MCV-85 MCH-27.5 MCHC-32.3 RDW-16.3* Plt Ct-485*
[**2199-9-16**] 04:39AM BLOOD WBC-8.9 RBC-2.77* Hgb-7.7* Hct-23.6*
MCV-85 MCH-27.6 MCHC-32.4 RDW-16.2* Plt Ct-536*
[**2199-9-21**] 04:17AM BLOOD WBC-12.3* RBC-2.44* Hgb-7.0* Hct-21.1*
MCV-86 MCH-28.8 MCHC-33.3 RDW-16.1* Plt Ct-446*
[**2199-9-21**] 09:24PM BLOOD WBC-12.1* RBC-3.63*# Hgb-10.4*#
Hct-31.2*# MCV-86 MCH-28.6 MCHC-33.2 RDW-16.3* Plt Ct-398
[**2199-9-22**] 05:06AM BLOOD WBC-15.8* RBC-3.62* Hgb-10.6* Hct-30.9*
MCV-85 MCH-29.4 MCHC-34.4 RDW-16.5* Plt Ct-418
[**2199-9-28**] 05:57PM BLOOD WBC-11.8* RBC-3.12* Hgb-9.0* Hct-27.2*
MCV-87 MCH-28.7 MCHC-32.9 RDW-16.3* Plt Ct-492*
[**2199-9-29**] 05:04AM BLOOD WBC-10.8 RBC-3.18* Hgb-8.9* Hct-26.9*
MCV-85 MCH-28.1 MCHC-33.2 RDW-16.1* Plt Ct-509*
[**2199-10-2**] 04:05AM BLOOD WBC-8.4 RBC-3.03* Hgb-8.6* Hct-26.2*
MCV-87 MCH-28.3 MCHC-32.6 RDW-16.2* Plt Ct-520*
[**2199-9-18**] 04:48AM BLOOD PT-13.7* PTT-44.7* INR(PT)-1.2*
[**2199-9-22**] 05:06AM BLOOD ESR-15
[**2199-9-9**] 04:50PM BLOOD ESR-60*
[**2199-9-2**] 05:45PM BLOOD Glucose-87 UreaN-13 Creat-1.1 Na-139
K-3.5 Cl-104 HCO3-23 AnGap-16
[**2199-9-3**] 05:20AM BLOOD Glucose-99 UreaN-10 Creat-1.0 Na-140
K-3.6 Cl-107 HCO3-21* AnGap-16
[**2199-9-3**] 06:06PM BLOOD K-4.8
[**2199-9-14**] 05:23AM BLOOD Glucose-102 UreaN-5* Creat-1.2* Na-136
K-3.3 Cl-105 HCO3-22 AnGap-12
[**2199-9-15**] 07:00AM BLOOD Glucose-105 UreaN-4* Na-135 K-3.1* Cl-105
HCO3-20* AnGap-13
[**2199-9-16**] 04:39AM BLOOD UreaN-4* Creat-1.2* Na-137 K-3.7 Cl-106
HCO3-20* AnGap-15
[**2199-9-24**] 04:26AM BLOOD Glucose-105 UreaN-11 Creat-1.3* Na-130*
K-4.2 Cl-100 HCO3-21* AnGap-13
[**2199-9-25**] 04:06AM BLOOD Glucose-109* UreaN-11 Creat-1.4* Na-129*
K-4.5 Cl-98 HCO3-21* AnGap-15
[**2199-9-26**] 11:18AM BLOOD Glucose-86 UreaN-14 Creat-1.5* Na-131*
K-5.2* Cl-103 HCO3-18* AnGap-15
[**2199-9-26**] 11:42PM BLOOD Glucose-90 UreaN-12 Creat-1.5* Na-130*
K-4.6 Cl-100 HCO3-19* AnGap-16
[**2199-9-27**] 05:30AM BLOOD Glucose-79 UreaN-13 Creat-1.6* Na-130*
K-4.5 Cl-99 HCO3-20* AnGap-16
[**2199-9-28**] 05:12AM BLOOD Glucose-54* UreaN-17 Creat-1.5* Na-129*
K-4.4 Cl-100 HCO3-15* AnGap-18
[**2199-9-28**] 05:57PM BLOOD Glucose-103 UreaN-24* Creat-2.0* Na-129*
K-4.2 Cl-100 HCO3-16* AnGap-17
[**2199-9-29**] 05:04AM BLOOD Glucose-101 UreaN-24* Creat-2.0* Na-128*
K-4.0 Cl-100 HCO3-16* AnGap-16
[**2199-9-30**] 05:26AM BLOOD Glucose-82 UreaN-19 Creat-2.0* Na-129*
K-4.0 Cl-102 HCO3-17* AnGap-14
[**2199-10-1**] 07:59AM BLOOD Glucose-98 UreaN-18 Creat-1.8* Na-135
K-3.6 Cl-105 HCO3-18* AnGap-16
[**2199-10-2**] 04:05AM BLOOD Glucose-92 UreaN-17 Creat-1.6* Na-135
K-4.1 Cl-108 HCO3-19* AnGap-12
[**2199-10-2**] 04:05AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.8
[**2199-9-13**] 02:25AM BLOOD TSH-28*
[**2199-9-16**] 06:45PM BLOOD Prolact-58*
[**2199-9-15**] 07:00AM BLOOD Free T4-1.5
[**2199-9-22**] 05:06AM BLOOD CRP-1.3
[**2199-9-9**] 04:50PM BLOOD CRP-2.6
[**2199-9-15**] 07:00AM BLOOD Vanco-21.1*
[**2199-9-9**] 08:09PM BLOOD Vanco-20.1*
[**2199-9-16**] 01:08PM BLOOD tTG-IgA-3
[**2199-9-13**] 02:50AM BLOOD Type-ART pO2-92 pCO2-27* pH-7.46*
calTCO2-20* Base XS--2
[**2199-9-12**] 07:09PM BLOOD Type-ART pO2-104 pCO2-30* pH-7.42
calTCO2-20* Base XS--3
[**2199-9-13**] 02:36AM BLOOD Lactate-1.1
[**2199-9-13**] 02:50AM BLOOD Lactate-0.9
[**2199-9-13**] 02:50AM BLOOD freeCa-1.13
Brief Hospital Course:
# Gastrointestinal
The patient was admitted to the hospital for partial small bowel
obstruction. Patient initially refused a NGT and foley
catheter. She was maintained NPO and started on maintenance
fluid. She underwent serial examinations with improvement in
her abdominal pain. In the emergency department, she had a KUB
performed:
HISTORY: 67-year-old female with history of small bowel
obstructions, now
with similar symptoms. Evaluate for obstruction.
COMPARISON: CT [**2199-5-23**].
ABDOMEN, SUPINE AND LEFT LATERAL DECUBITUS: Spinal fusion
hardware is noted
at L4-L5. There are gas-filled loops of small bowel, with
several bowel loops
borderline in size, similar to the prior study. Though there is
a relative
paucity of bowel gas in the colon, air is evident in the rectum.
No free air
or pneumatosis is identified.
IMPRESSION: Borderline dilated small bowel loops, which can be
seen with an
ileus, though an early and/or partial small bowel obstruction
cannot be
excluded.
Patient was started on pain control with Dilaudid. Patient had
persistent diarrhea during her hospitalization and had at least
8 C. Difficile samples sent to the laboratory, all of which have
returned negative.
The GI service was consulted for persistent diarrhea. They
initially recommended stool cultures (negative), a clear liquid
diet, and observation for clinical improvement. The patient was
later ordered for an MR enterography, however, her diarrhea
improved prior to obtaining the study.
An Anti-transglutaminase was sent to evaluate for Celiac disease
and was in the normal range.
Disease
The patient
# Infectiouswas maintained on her home dose of Vancomycin for
her previous MRSA bacteremia and MRSA L2-L3 osteomyelitis. The
Infectious Disease service was consulted on [**2199-9-4**] and followed
her for several weeks. Patient had been on vancomycin since
[**2199-5-24**]. ID recommended continuing vancomycin.
On [**2199-9-12**], the patient was found to have a urinary tract
infection. she was started on Ciprofloxacin, though this was
changed to Bactrim as cipro can lower the seizure threshold.
The sensitivities returned on the urine culture, and was
resistant to Bactrim. Ultimately, she completed her treatment
for UTI with macrobid. There was no further dysuria, frequency,
or urgency.
On HD # 20, her vancomycin was discontinued and she was started
on Bactrim DS for her discitis This was discontinued after 3
days due to worsening renal function. Infectious disease did
not feel as though additional antibiotics were necessary for the
discitis.
On HD # 11, blood cultures were sent and returned with [**Female First Name (un) 564**]
Parapsilosis. Unfortunately, the sensitivities showed that the
[**Female First Name (un) **] was resistant to fluconazole and oral therapy was not
available. The patient was started on Micafungin 100mg IV daily
on [**2199-9-16**]. ID recommended last dose of Micafungin on [**2199-9-28**].
Micafungin was discontinued prior to discharge.
On [**2199-9-20**], the patient was brought to the operating room to
have her existing tunnelled catheter removed due to the fungemia
and a new Hickman catheter was placed without incident.
Due to the fungemia, the patient had an Ophthalmology consult
and was evaluated. They found no evidence of fungal
endophthalmitis. .
She also had a TTE performed:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**12-28**]+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is high normal. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2199-5-27**],
left ventricular systolic function is less dynamic and increased
PCWP is now suggested.
# Renal
on [**2199-9-24**] the patient was noted to have hyponatremia with a
sodium of 130. She had a nadir of 129. She further was noted
to have worsening of her creatinine (baseline 1.0-1.2). As the
creatinine continued to elevate, nephrology was consulted.
Nephrology recommended discontinuation of the bactrim as this
was likely contributing to her worsening creatinine level.
Further, the hyponatremia was attributed to SIADH likely
secondary to the patient's opiate use. Her opiate use was
curtailed and her free fluid was limited and her hyponatremia
resolved.
Renal service also made recommendations regarding the patient's
labile blood pressures. She had intermittent periods where her
systolic blood pressure was 220s with diastolics in the 110s.
She was being treated with IV lopressor and ultimately with IV
hydralazine. She was started on metoprolol by mouth and this
was titrated to effect. Renal recommended the discontinuation
of all IV blood pressure medications as they were likely causing
relative hypotension and hypoperfusion of her kidneys. She was
maintained on Coreg and started on amlodipine 2.5 mg PO daily.
If her blood pressure is not well controlled, we would recommend
increasing her amlodipine to 5 mg PO daily.
The patient's urine output was low on occasion and she did
require small boluses of IVF. The IVF likely worsened her
hyponatremia, however. In her extended care facility, she
should be encouraged to drink fluids. If she does require a
fluid bolus, would recommend a 500ml bolus given over 5 hours.
Her creatinine peaked at 2.0 and has continued to trend down.
Her most recent creatinine was 1.6 on [**2199-10-2**]. Her sodium and
creatinine should be monitored in her extended care facility.
# Hematology
The patient was maintained on Lovenox 60mg SC BID for her recent
LUE DVT (~[**2199-5-27**]). During the admission, she complained of
RUE numbness and tingling and had a negative duplex ultrasound
performed. After her Hickman line placement on [**2199-9-20**], she was
noted to have oozing around the insertion site. Shortly
thereafter, her lovenox was discontinued for several days.
After the oozing resolved, she was restarted on Lovenox, but at
a prophylactic dose only.
On [**2199-9-21**], the patient was noted to have a hematocrit of 21.1
due to blood loss on top of anemia of chronic disease and she
was transfused 2units of pRBCs with appropriate increase in
hematocrit.
# Neurologic
On HD # 10, a trigger was called as the patient was exhibiting
seizure like behavior. Nursing staff and the patient's husband
report [**Name2 (NI) 97262**] but rhythmic contractions and relaxations of
her upper extremities. This reportedly lasted for two minutes
at which point she appeared to have a blank stare and was
non-verbal. Two minutes later her confusion cleared. She
showed no evidence of tongue laceration or incontinence.
At that time she obtained a head CT:
HISTORY: 67-year-old female with small-bowel obstruction, now
with tonic-
clonic seizure. Here to assess for intracranial process.
COMPARISON: CT head, most recently of [**2199-8-3**].
TECHNIQUE: MDCT axial imaging was performed through the brain
before and
after administration of 90 mL of IV Optiray 350.
CT HEAD BEFORE AND AFTER IV CONTRAST: No evidence of acute
intracranial
hemorrhage, edema, mass effect, hydrocephalus, or large vascular
territory
infarction is seen. Periventricular white matter hypodensities
are mild,
likely due to chronic microangiopathic ischemic change. After
administration
of gadolinium, no abnormally enhancing mass is seen. Vascular
calcifications
are noted along the dominant right vertebral artery, as well as
the carotid
siphons. While the current study is not tailored towards the
study of such,
there is apparent normal enhancement of the vessels of the
circle of [**Location (un) 431**].
There is also normal enhancement of the venous sinuses. The soft
tissues,
orbits, and skull appear unremarkable. The mastoid air cells and
middle ear
cavities are normally aerated. Minimal layering fluid or mucosal
thickening
is noted along the sphenoid sinus, which was not present on
[**2199-8-3**].
IMPRESSION: No evidence of acute intracranial process nor
abnormal enhancing
mass seen. If there remains concern for subtle process, MRI
would be
recommended for more sensitive evaluation
While down at CT, the patient reportedly exhibited further
seizure activity and she received Ativan. She was transferred
to the Trauma-Surgery ICU where she had a Neurology evaluation.
Neurology commented on how the postictal period was remarkably
short and atypical for a tonic-clonic seizure. They recommended
a 24 hour EEG with video as well as a lumbar puncture. The
patient continues to refuse lumbar puncture.
EEG on [**2199-9-14**]:
FINDINGS:
ROUTINE SAMPLING: Showed a 9 Hz predominant biposterior rhythm
in the
most awake parts of this recording. There were no areas of
prominent
focal slowing or epileptiform features seen.
SLEEP: The patient progressed from wakefulness to sleep with no
additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm.
SPIKE DETECTION PROGRAMS: Showed no clear epileptiform features.
SEIZURE DETECTION PROGRAMS: There were eight entries in this
file for
muscle and movement artifacts, rhythmic alpha activity but no
ongoing
seizure activity.
PUSHBUTTON ACTIVATIONS: There were none.
IMPRESSION: This telemetry captured no pushbutton activations
and no
interictal epileptiform activity. The background activity was
normal.
EEG [**2199-9-15**]:
FINDINGS:
ROUTINE SAMPLING: Showed a 9 Hz predominant biposterior rhythm
in
wakefulness. There were no areas of prominent focal slowing or
epileptiform features seen.
SLEEP: The patient progressed from wakefulness to sleep with no
additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm.
SPIKE DETECTION PROGRAMS: There were no entries in this file.
SEIZURE DETECTION PROGRAMS: There were three entries in this
file for
movement and muscle artifacts. There was no ongoing seizure
activity
seen.
PUSHBUTTON ACTIVATIONS: There were none.
IMPRESSION: This telemetry captured no pushbutton activations
and no
ictal or interictal epileptiform activity. The background
activity was
normal.
An MRI/MRA of the brain was ordered, however, the patient was
not able to comply with the study for several days. The study
was obtained on [**2199-9-19**]:
HISTORY: 67-year-old female patient with osteomyelitis and
discitis. Patient
with mental status changes and new onset seizures.
TECHNIQUE: MRI of the head was performed with and without IV
contrast and MRA
of the brain was also performed.
COMPARISON: CT scan dated [**2199-9-12**]. No previous MRI.
FINDINGS:
MRI BRAIN:
There are nonspecific non-enhancing T2/FLAIR hyperintense foci
within the
bilateral centra semiovale and periventricular regions likely
representing
chronic small vessel ischemic changes in a patient of this age.
There is an
ill-defined focus of FLAIR-hyperintensity, with no enhancement,
within the
medial inferior right cerebellar hemisphere/lateral vermis, with
no evidence
for restricted diffusion likely representing chronic infarction.
There is
moderate diffuse parenchymal volume loss with associated
proportionate
prominence of the ventricles and sulci, likely reflecting
age-related volume
loss.
There is no evidence of acute infarction, hemorrhage, abnormal
enhancement, or
hydrocephalus. No mesial temporal sclerosis, cortical dysplasia
or heterotopia
is seen. The visualized major vascular flow voids are normal.
Orbital
structures are unremarkable. There is mucosal thickening of the
bilateral
ethmoid air cells and a mucus-retention cyst in the right
sphenoid sinus.
Otherwise, the remainder of the paranasal sinuses as well as
mastoid air cells
are clear.
MRA BRAIN:
ANTERIOR CIRCULATION: The bilateral MCAs and ACAs are
unremarkable without
evidence for aneurysm (greater than 3 mm), AVM, or stenosis.
Incidental note
is made of fenestration at the ACA-ACom complex, a normal
variant.
POSTERIOR CIRCULATION: Bilateral PCAs and basilar artery are
unremarkable.
The right vertebral artery is dominant. The left vertebral
artery is
non-dominant and becomes more diminutive, just distal to the
takeoff of the
left PICA, also a normal variant. There is no evidence for
aneurysm (greater
than 3 mm), AVM, or stenosis.
IMPRESSION:
1. No acute infarction or hemorrhage, and no pathologic focus of
enhancement.
2. Right inferior cerebellar/lateral vermian chronic infarction,
and likely
mild chronic small vessel infarction in a patient of this age.
3. Fenestration of the ACom complex, a normal variant. No
significant
neurovascular abnormality identified.
After this extensive workup, it was ddecided that the patient
had pseudoseizures rather than a true seizure disorder and that
anticonvulsants were not required.
During the hospitalization, the patient had waxing and [**Doctor Last Name 688**]
mentals status. She reportedly was seen talking to her finger
and calling out for her mother (who is deceased) on multiple
occasions. Psychiatry was consulted for her abnormal behavior.
Psychiatry recommended antidepressant -- sertraline begin at 50
mg qd, after
4 days increase to 100 mg daily. Further, they recommended that
the patient would benefit from outpt psychiatry or therapy.
# Musculoskeletal
The patient was evaluated by Orthopaedics/Spine due to her
recent L2-L3 osteomyelitis. A L spine MRI was obtained:
LUMBAR SPINE MRI.
HISTORY: 67-year-old female presents with history of lumbar
osteomyelitis.
COMPARISON: Prior lumbar spine MRIs, [**2191-4-11**] through [**2199-7-24**].
FINDINGS: The patient was unable to tolerate the examination,
only a sagittal
T2 sequence was acquired. The configuration of the lumbar spine
appears
similar, with marked abnormality of the disc space at L2-L3 with
an associated
fluid cleft. Fusion is noted just inferior to this. There is
likely at least
moderate narrowing of the spinal canal at the L3 level. There is
slightly
increased prevertebral soft tissue, displacing the aorta
anteriorly. This may
relate to progressive inflammatory change, though is
incompletely evaluated.
Again noted is a kyphotic deformity at T10 associated with the
disc protrusion
and associated osteophytes.
IMPRESSION: Incomplete examination demonstrates grossly similar
appearance to
the previous MRI from [**7-24**] on limited sagittal T2 seqeunce.
Complete
study to be performed when pt. is co-operative for complete
assessment.
Severe central canal stenosis with possible compression on the
cauda at L2-3
and L3-4 levels, incompletely assessed.
A repeat lumbar spine MRI is recommended as an outpatient if
clinically indicated.
Medications on Admission:
1. Carvedilol 3.125 mg PO BID
2. Lisinopril 10 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
5. Cholecalciferol 1000u PO DAILY
6. Sertraline 100 mg PO DAILY
7. Alendronate 70 mg PO QSUN
8. Lorazepam 0.5 mg PO Q6H as needed for anxiety.
9. Senna 8.6 mg
10. Fentanyl 100 mcg/hr Patch Q72H
11. Calcium Carbonate 500 mg PO QID
12. Levothyroxine 150 mcg PO DAILY
13. Zoloft 100mg PO DAILY
14. Vicodin 5/500mg 1-2 tabs QID prn pain
15. Lovenox 1mg/kg [**Hospital1 **]
16. Vancomycin 500mg IV daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed for pain for 10 days.
10. Simvastatin 40 mg PO daily
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Tunneled Access Line (e.g. Hickman), heparin dependent: Flush
with 10 mL Normal saline followed by Heparin as above daily and
PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 33039**] - heathwood
Discharge Diagnosis:
partial small bowel obstruction
hyponatremia
acute renal failure
fungemia
pseudoseizures
depression
Discharge Condition:
stable, afebrile
Discharge Instructions:
You were evaluated and treated for a partial small bowel
obstructions. You had a lengthy hospitalization with multiple
other treatments.
Please adhere to a renal diet. You are encouraged to drink
fluids.
Please call your primary care physician or return to the
emergency department for any of the following:
* Fever greater than 101
* Severe abdominal pain
* Persistent nausea/vomiting
* confusion
* seizure activity
* any new or concerning symptom
Followup Instructions:
Please make an appointment to see Dr. [**Last Name (STitle) **] in 2 weeks. His
office number is ([**Telephone/Fax (1) 39326**]. You should also schedule an
appointment to see your regular physician.
You should also follow up with the Infectious Disease clinic in
[**1-30**] weeks. Their telephone number is [**Telephone/Fax (1) 457**].
Completed by:[**2199-10-2**]
ICD9 Codes: 5849, 4254, 2930, 4019, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7517
} | Medical Text: Admission Date: [**2146-1-22**] Discharge Date: [**2146-2-7**]
Date of Birth: [**2067-7-11**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Percodan / Percocet / Codeine / Talwin / Demerol /
Valium / Aspirin
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy with lysis of adhesions.
History of Present Illness:
This is a 78 y/o female admitted on after 1 1/2 days of
abdominal pain, right groin pain, and N/V. EMS was called for
respiratory distress and hypotension and she was intubated in
the ED. On arrival, she was volue resuscitated and started on
pressors. Her initial physical exam revealed focal peritoneal
signs in the RLQ. A CT was done showing complete small-bowel
obstruction, with transition point at the level of the ileocecal
valve.
Past Medical History:
# Aortic stenosis - valve area 1.1 on [**2144-4-3**]
# CHF (EF of 60%)
# atrial fibrillation - on warfarin
# s/p femur fx [**8-17**]
# s/p R BKD [**2144-10-28**]
# COPD
# Rheumatoid arthritis - on prednisone
# RA/SLE/positive [**Doctor First Name **] antibody - in remission
# osteoporosis
# venous stasis
# peripheral neuropathy
# h/o Clostridium difficile in the past
# spinal stenosis
# SBO
Social History:
lives alone in home, able to do ADL's, has [**Name (NI) 269**], PT, home aid at
home. +tob hx, quit 40 years ago, no ETOH, no drugs
Family History:
arthritis, mother - liver cancer, father - CVA
Physical Exam:
Intubated, awake, in moderate distess
CV: irregularly irregular, tachycaardic
Chest: breath sounds course bilat and diminished at left
Abd: soft, obese, minimally distended and tympanitis. Localized
tenderness to the RLQ with guarding, no rebound.
Ext: mild cyanosisof left toes, +edema
Pertinent Results:
[**2146-1-22**] 02:50PM BLOOD WBC-23.4*# RBC-3.84* Hgb-12.6 Hct-37.6
MCV-98 MCH-32.9* MCHC-33.6 RDW-14.1 Plt Ct-338
[**2146-1-25**] 03:48AM BLOOD WBC-18.0* RBC-3.25* Hgb-10.5* Hct-31.9*
MCV-98 MCH-32.2* MCHC-32.8 RDW-14.1 Plt Ct-302
[**2146-1-31**] 07:20AM BLOOD WBC-15.3* RBC-3.23* Hgb-10.6* Hct-31.7*
MCV-98 MCH-32.7* MCHC-33.3 RDW-14.2 Plt Ct-369
[**2146-1-31**] 07:20AM BLOOD PT-15.1* PTT-41.5* INR(PT)-1.3*
[**2146-1-31**] 07:20AM BLOOD Glucose-74 UreaN-25* Creat-0.8 Na-138
K-3.6 Cl-99 HCO3-31 AnGap-12
[**2146-1-22**] 02:50PM BLOOD ALT-14 AST-23 AlkPhos-47 Amylase-80
TotBili-0.9
[**2146-1-25**] 03:48AM BLOOD ALT-15 AST-21 LD(LDH)-242 AlkPhos-44
Amylase-98 TotBili-0.6
[**2146-1-25**] 03:48AM BLOOD Lipase-47
[**2146-1-31**] 07:20AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.1
.
CT PELVIS W/CONTRAST [**2146-1-22**] 3:48 PM
IMPRESSION:
1. Complete small-bowel obstruction, with transition point at
the level of the ileocecal valve. Taking into account the recent
hernia reduction, it is unclear whether these findings could
represent slow passage of fecalized small bowel contents into
the cecum following the hernia reduction.
2. No sign of incarcerated hernia. Fluid-filled hernia sac seen
in the right inguinal region. This may be related to recent
reduction of the inguinal hernia.
3. Right lower lobe atelectasis, and a few nodular areas of
right lower lobe opacity which could represent aspiration, less
likely an infectious process.
4. Extensive thoracolumbar spine degenerative change, and
multiple vertebral body compression fractures as described
above.
.
Cardiology Report ECG Study Date of [**2146-1-22**] 2:43:36 PM
Atrial fibrillation with a rapid ventricular response. Extensive
ST-T wave
changes which are likely due to rate or myocardial ischemia.
Compared to the
previous tracing of [**2145-12-22**] the rate has increased
significantly and there are
now diffuse ST-T wave changes. Clinical correlation is
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
113 0 76 360/452 0 47 -155
.
CHEST (PORTABLE AP) [**2146-1-30**] 4:15 AM
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman s/p LOA for obstruction w/ elevated WBC
COMPARISON: [**2146-1-26**].
FINDINGS: The NGT, left CVL and ETT have been removed. Large
retrocardiac density with air-fluid level was consistent with
hiatal hernia. Adjacent atelectasis is seen. There are no new
focal consolidations and the pulmonary [**Month/Day/Year 1106**] markings appear
normal. There is stable cardiomegaly.
IMPRESSION: No new consolidations.
Brief Hospital Course:
This is a 78 year old female with 1 1/2 days of abdominal pain,
right groin pain, and
N/V. EMS was called for respiratory distress and she was
intubated in the ED. She had peritoneal signs on exam and a SBO
was found on CT and the pt went to the OR for ex-lap + LOA.
CV: She received beta blockers when appropriate for rate
control. She continued in A-fib. When appropriate, her Coumadin
was restarted.
Her cardiologist recommended IV Lasix for 24-48 hours to assist
with diuresis and then to resume her home PO dose. She responded
well to the IV Lasix.
Resp: She was intubated and comfortable. As she improved
clinically, she was weaned to extubate. She was extubated on
[**2146-1-26**]. She had CXR at time of discharge to assess volume
status and she was not fluid overloaded.
Abd/GI: She was NPO with IVF and a NGT. She had a Dobhoff
placed, but it remained in the stomach. She was started on
trophic tubefeeds. She was seen by speech and swallow and
cleared for a PO diet. Her NGT was removed, Dobhoff removed, and
her diet was advanced along.
Her incision was C/D/I, with a small amount of redness along the
incision.
Renal: Her BUN/Cr were monitored and stable. She had good urine
output and her volume status was watched closely. She received
occasional fluid bolus for hypovolemia. As she continued to
improved, she was started back on Lasix for diuresis due to her
CHF.
ID: She was started on broad coverage ABX, including Vanco,
Zosyn, and Flagyl. Her antibiotics were tailored and she grew
E.coli from her urine and completed a 7 day course of Meropenum.
The patient's daughter was concerned about recurrent [**Name (NI) 14870**] and
was requesting prophylactic ABX.
Atrial Fibrillation: She continued in A-fib with a controlled
rate. She was started back on her Coumadin.
PT: It was recommended that she be discharged to a rehab
facility for further strength and stability training.
Medications on Admission:
Prednisone 10', warfarin 3', gabapentin 400''', lisinopril 10',
lasix 40''', metop 50'SR, ibandronate 150 q month, morphine
15q6h prn, omeprazole 20'
Discharge Medications:
1. Prednisone 10 mg 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 once a day.
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): 1 DROP RIGHT EYE HS .
6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours): DROP RIGHT EYE Q8H .
7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): 1 DROP RIGHT EYE [**Hospital1 **] .
8. Warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Monitor INR.
9. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Warfarin 6 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Please dose daily and adjust accordingly.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Right groin pain,
Palpable hernia (nonreducible)
Small Bowel Obstruction
Respiratory distress
CHF
Sepsis
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily and work towards daily
ambulation.
* No heavy lifting (>[**10-26**] lbs) until your follow up
appointment.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 6347**]
to schedule an appointment.
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2146-3-15**] 1:00
Provider: [**Name10 (NameIs) 2352**] ECHO Phone:[**Telephone/Fax (1) 15347**] Date/Time:[**2146-4-8**]
2:30
Completed by:[**2146-2-7**]
ICD9 Codes: 0389, 5990, 4280, 4241, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7518
} | Medical Text: Admission Date: [**2159-5-3**] Discharge Date: [**2159-5-7**]
Date of Birth: [**2084-7-29**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18051**]
Chief Complaint:
malignant ascites
Major Surgical or Invasive Procedure:
Bilateral salpingo-oophorectomy,
omentectomy, total abdominal hysterectomy, radical dissection
for debulking.
History of Present Illness:
74 P0 referred for ascites. Presented with vague GI sxs and
constipation. Colonscopy wnl. US demonstrated large ascites
that contained malignant cells on paracentesis. CT previously
negative. Nl [**Last Name (un) 3907**]. Nl renal US. Elevated CA125 and CA [**73**]-9
Past Medical History:
OB: nulliparous
Gyn: nl [**Last Name (un) 3907**], nl pap, last period [**2134**]
PMH: HA, asthma, spastic colon, scoliosis
PSH: back [**Doctor First Name **], cosmetic
Social History:
quit tobacco, occasional alcohol
Family History:
paternal first cousin with breast ca
no ovarian, colon, endometrial
Physical Exam:
Initial exam notable for:
No LAD
Abdomen distedned with ascites, no masses
nl vulva, vagian, cervix
Biman limited no masses
nl rectum/cul-de-sac
Pertinent Results:
[**2159-5-6**] 06:20AM BLOOD WBC-12.0* RBC-3.68* Hgb-10.0* Hct-30.8*
MCV-84 MCH-27.2 MCHC-32.5 RDW-12.0 Plt Ct-529*
[**2159-5-6**] 06:20AM BLOOD UreaN-5* Creat-0.4 K-4.3
[**2159-5-6**] 06:20AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.1
Brief Hospital Course:
The patient was admitted to the SICU following her procedure on
[**5-3**]. Her surgery was complicated by laryngeal edema and
intraoperative hypertension requiring ICU admission. Otherwise
the surgery was uncomplicated - see operative report for
details. Her ICU course was unremarkable, she was extubated and
transferred to the floor on post op day 1 without complication.
The remainder of her post operative course was uncomplicated.
She advanced to regular diet without difficulty. On day of
discharge she was voiding and ambulating without assitance. Her
pain was well controlled with oral medication.
Medications on Admission:
flovent, atrovent
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*50 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
adenocarcinoma
Discharge Condition:
good. stable
Discharge Instructions:
no heavy lifting, no exercise, nothing in vagina 6wks
no driving 2 weeks
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/GYN NON-PPS CC8 Where: [**Hospital 4054**] OBSTETRICS & GYNECOLOGY Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2159-5-28**] 1:45
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5777**] Call to schedule
appointment
ICD9 Codes: 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7519
} | Medical Text: Admission Date: [**2129-6-14**] Discharge Date: [**2129-6-17**]
Date of Birth: [**2062-12-17**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
L Knee Pain
Major Surgical or Invasive Procedure:
L TKA
History of Present Illness:
The patient is a 66 yo M with long-standing history of L knee
pain, limited ROM and difficulties with activities of daily
living. The patient has met the clinical and radiographic
indications for joint arthroplasty and wished to proceed with
the above procedure. Prior to admission the patient has been
feeling well with no recent illness, no shortness of breath, no
chest pain and has been cleared medically for the surgical
procedure.
Patient has a history of tracheomalacia and OSA - all
precautions have been discussed with the anesthesia team and the
patient will be monitored closely post-operatively for apneic
episodes.
Past Medical History:
DM II, HTN, hyperlipidemia, obesity, OSA/tracheomalacia, BPH,
GERD
Social History:
non contrib
Family History:
non contrib
Physical Exam:
Afebrile VSS, A/Ox3
LCTA bilaterally
RRR
ABD soft, NTND, +BS
BLE fully NVI distally with 2+ DP pulses and full strength
throughout
Painful and limited ROM of L knee
Pertinent Results:
[**2129-6-16**] 07:45AM BLOOD WBC-9.3 RBC-3.53* Hgb-10.3* Hct-29.3*
MCV-83 MCH-29.2 MCHC-35.1* RDW-13.7 Plt Ct-161
[**2129-6-15**] 02:30AM BLOOD WBC-9.7 RBC-4.18* Hgb-12.0* Hct-34.5*
MCV-83 MCH-28.7 MCHC-34.7 RDW-13.6 Plt Ct-188
[**2129-6-17**] 06:55AM BLOOD Plt Ct-163
[**2129-6-16**] 07:45AM BLOOD Plt Ct-161
[**2129-6-15**] 02:30AM BLOOD Plt Ct-188
[**2129-6-15**] 02:30AM BLOOD Glucose-192* UreaN-18 Creat-0.9 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
[**2129-6-15**] 02:30AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.5*
Brief Hospital Course:
The patient was admitted on [**2129-6-14**] and taken to the operating
room by Dr. [**Last Name (STitle) **] where the patient underwent left knee total
joint arthroplasty. The procedure was well tolerated there were
no complications. Please see the separately dictated operative
report for details regarding the surgery. The patient was
subsequently transferred to the post-anesthesia care unit in
stable condition and transferred to the ICU later that day for
close monitoring of his oxygen status.
Overnight, the patient was placed on a ketamine drip for pain
control dictated by the acute pain service. The patient did not
tolerate CPAP but had O2 saturations in the high 90's on shovel
mask. IV antibiotics were continued for 24 hours postoperatively
for prophylaxis. Lovenox was started the morning of POD#1 for
DVT prophylaxis. The patient was placed in a CPM machine with
range of motion set at 0-45 degrees of flexion up to 90 degrees
as tolerated.
On postoperative day 1, the drain and foley were removed without
incident. The patient was transferred to the floor in stable
condition with continuous O2 sat, telemetry, and the ketamine
drip.
On postoperative day 2, the ketamine was d/c'd and the patient
was placed on low dose oxycodone. The surgical dressing was also
removed, and the surgical incision was found to be clean, dry,
and intact without erythema nor purulent drainage.
During the hospital course the patient was seen daily by
physical therapy. Labs were checked both post-operatively and
throughout the hospital course and repleted accordingly. The
patient was tolerating regular diet and otherwise feeling well.
Prior to discharge the patient was afebrile with stable vital
signs. Hematocrit was stable and pain was adequately controlled
on a PO regimen. The operative extremity was neurovascularly
intact and the wound was benign.
The patient was discharged to inpatient rehabilitation in a
stable condition
Medications on Admission:
lipitor, lisinopril, metoprolol, ranitidine, mvt, calan,
metformin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 3 weeks.
3. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed.
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Verapamil 240 mg Tablet Sustained Release Sig: 0.5 Tablet
Sustained Release PO Q24H (every 24 hours).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
15. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
L Knee OA
Discharge Condition:
Stable
Discharge Instructions:
Please seek medical attention if you have any nausea, vomiting,
fever greater than 101.5, chest pain, shortness of breath,
increased pain/redness/drainage from your incision site,
numbness/tingling, or any other concerning symptoms.
Take all medications as prescribed and resume home medications,
please take a stool softener if taking narcotic pain
medications, please taper down pain medication use as tolerated.
No driving nor operating heavy machinery while using narcotic
pain medications. You should take iron supplementation to boost
your blood count for 4 weeks. Ferrous sulfate 325mg once a day.
ANTICOAGULATION: Take lovenox injections (40mg) once a day x 3
weeks and then take aspirin 325 mg twice a day x 3 weeks. [**Month (only) 116**]
discontinue all blood thinners 6 weeks post-operatively.
WOUND CARE: Keep your incision clean and dry. Okay to shower
after POD#5 but do not tub-bath or submerge your incision.
Please place a dry sterile dressing to the wound each day if
there is drainage, leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed by VNA on POD 14. IF going to rehab,
then rehab can remove staples @ 2 weeks.
ACTIVITY: Weight bearing as tolerated to operative leg, CPM
machine advance as tolerated. No strenuous exercise or heavy
lifting until follow up appointment, at least.
VNA (after home): Home PT/OT, dressing changes as instructed,
and wound checks, staple removal on POD 14.
Physical Therapy:
WBAT, CPM advance as tolerated, no prolonged bedrest, ambulation
encouraged
Treatments Frequency:
Staples to be D/C'd POD14
Followup Instructions:
You have a follow-up appointment with Dr. [**Last Name (STitle) **] office in one
month. Please call to confirm/schedule your appointment.
Completed by:[**2129-6-17**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7520
} | Medical Text: Admission Date: [**2199-2-7**] Discharge Date: [**2199-2-25**]
Date of Birth: [**2116-5-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2199-2-8**] Aortic Valve Replacement(21mm Pericardial), Two Vessel
Coronary Artery Bypass Grafting(left internal mammary to left
anterior descending artery, vein graft to ramus), and Aortic
Endarterectomy.
History of Present Illness:
Mr. [**Known lastname 61512**] is a 82 year old gentleman with symptomatic
coronary artery disease and aortic stenosis. In [**2198-7-3**],
Dr. [**Last Name (STitle) **] deemed him to be too high risk for surgery due to
extensive aortic calcification. He subequently underwent aortic
valvuloplasty in [**2198-10-3**]. Due to recurrent symptoms, he
underwent repeat cardiac cathterization in [**2199-1-2**] which
revealed left main disease with an instent restenosis of ramus.
Given his severe aortic stenosis and left main lesion, he was
deemed too high risk for percutaneous intervention. He was
subquently referred to Dr. [**First Name (STitle) **] for off pump CABG, with the
possibility of aortic valve replacement. After extensive
discussion with the patient and his family, he agreed to proceed
with high risk surgery.
Past Medical History:
Severe Aortic Stenosis, s/p aortic valvuloplasty [**2198-10-3**]
Coronary Artery Disease, s/p BMS to Ramus in [**2196**]
History of TIA [**2196**]
ESRD requiring hemodialysis
Pulmonary Hypertension
Chronic Diastolic Congestive Heart Failure
Hypertension
Dyslipidemia
Type II Diabetes Mellitus
Anemia
History of Bladder Calculi
Renal Osteodystrophy
Social History:
Lives with: wife
Occupation: retired
Tobacco: denies
ETOH: social
Family History:
No family history of early MI or sudden cardiac death
Physical Exam:
Admission Physical Exam:
Pulse: 85 Resp: 18 O2 sat: 100%RA
B/P Right: Left: 144/76
Height: 5'5" Weight: 64kg
General: Elderly male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [] Murmur III/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact [X]
Left Upper Arm Fistula
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right:- Left:-
Pertinent Results:
Admits Labs:
[**2199-2-7**] WBC-7.2 RBC-4.52* Hgb-10.5* Hct-32.0* Plt Ct-117*
[**2199-2-7**] PT-12.7 PTT-25.3 INR(PT)-1.1
[**2199-2-7**] Glucose-187* UreaN-33* Creat-4.8*# Na-136 K-4.0 Cl-91*
HCO3-33*
[**2199-2-7**] ALT-22 AST-21 LD(LDH)-252* AlkPhos-57 Amylase-118*
TotBili-0.6
[**2199-2-7**] Lipase-53
[**2199-2-8**] Albumin-2.5*
[**2199-2-7**] %HbA1c-6.5*
.
[**2199-2-8**] Intraop TEE:
PRE-CPB:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic root and
ascending aorta have focal calcifications. There are simple
atheroma in the descending thoracic aorta. No thoracic aortic
dissection is seen. A guidewire is seen in the descending aorta
during femoral cannulation.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is
seen.
The mitral valve leaflets are mildly thickened. There is
significant mitral annular calcification. There is prolapse of
the anterior mitral leaflet with a posteriorly directly MR jet
with coanda effect. At least moderate (2+) mitral regurgitation
is seen.
POST-CPB:
A bioprosthetic valve is present in the aortic position. The
leaflets appear to move normally. The peak gradient across the
aortic valve is 29mmHg, the mean gradient is 12mmHg. There is a
small paravalvular leak which improved with protamine
administration.
LV systolic function appeared severely depressed immediately
after separation from bypass and slowly improved with
administration of inotropes. Estimated EF after chest closure is
30-35%.
The MR remains an eccentric jet with coanda effect. There is
moderate to severe MR. There is no evidence of aortic
dissection.
.
[**2199-2-15**] Postop Portable TTE:
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50%). The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. A bioprosthetic aortic valve prosthesis
is present. The mitral valve leaflets are mildly thickened. An
eccentric, posteriorly directed jet of Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
Due to the eccentric nature of the regurgitant jet, its severity
may be significantly underestimated (Coanda effect). The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
.
Brief Hospital Course:
Mr. [**Known lastname 61512**] was admitted and underwent routine preadmission
testing and hemodialysis. On [**2199-2-8**] he was taken to the
operating room and underwent Aortic Valve Replacement(21mm
Pericardial)/Two Vessel Coronary Artery Bypass Grafting(left
internal mammary to left anterior descending artery, vein graft
to ramus), and Aortic Endarterectomy. Cardiopulmonary Bypass
time= 245 minutes. Cross Clamp time=180 minutes. Please see
operative note for surgical details. He tolerated the procedure
well and was transferred to the CVICU intubated and sedated on
multiple pressors and inotropy to optimize cardiac function.
Renal continued to follow postoperatively for his ESRD/dialysis
needs. Mr.[**Known lastname 61512**] was kept intubated to protect his airway
while maintaining stable hemodynamics until POD# 5. Pressors and
inotropy were weaned off. Beta-blockers/Statin/Aspirin and
diuresis was initiated. Postoperative atrial fibrillation was
treated with Amiodarone and beta-blocker. Prolonged conversion
pauses and tachy-brady syndrome became apparant.
Electrophysiology was consulted and a temporary transvenous wire
was placed. Beta-blockade and Amio were held to allow for
recovery. Per EP these agents were slowly reintroduced and
tolerated. Transvenous pacing wire was discontinued on [**2-19**].
Ultimately a permanent pacemaker was deemed unnecessary.
Anticoagulation was initiated with Coumadin secondary to
paroxysmal atrial fibrillation. Supratherapeutic INR was treated
with holding anticoagulation, reversal with vitamin K and fresh
frozen plasma, and gentle dosing with Coumadin was resumed. All
lines and drains were discontinued in a timely fashion.
Antibiotics for Clostridium Difficile was initiated. A Midline
was placed for access. Speech and swallow was consulted for
swallowing evaluation. POD# 11 he was transferred to the step
down unit for further monitoring. Physical Therapy was consulted
for evaluation of strength and mobility. Hemodialysis was
conducted per Renal. He continued to progress and on POD# 17 he
was cleared for discharge to [**Hospital **] [**Hospital **] Rehabilitation at [**Doctor Last Name 1263**]
for further progress in strength, mobility, and daily
activities. Dr.[**Last Name (STitle) 85178**] to follow Coumadin dosing/INR once Mr
[**Known lastname 61512**] has been discharged from rehab. All follow up
appointments were advised.Target INR 2.0-2.5 for A Fib.
Medications on Admission:
RENAL CAPS - 1 mg Capsule - 1 Capsule(s) by mouth every morning
LABETALOL - 200 mg Tablet - 1 Tablet(s) by mouth every evening
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth at night
VALSARTAN [DIOVAN] - 160 mg Tablet - 1 Tablet(s) by mouth every
morning (held on dialysis days)
ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth every
morning
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Coumadin 1 mg Tablet Sig: Dose for goal INR of 2.0-2.5
Tablets PO once a day: dose today 1 mg only;all further dosing
per rehab provider;Goal INR is 2.0-2.5 for atrial fibrillation.
10. Insulin sliding Scale and Daily Dose
Please see attached sliding scale and daily insulin dose.
11. telemetry
please keep on telemetry
12. vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 8 days: dosing through [**3-5**]; for a 2 week course.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] @ [**Hospital **] HOSPITAL
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p AVR and CABG
Heavily Calcified Aorta
End Stage Renal Disease, requires Hemodialysis
Pulmonary Hypertension
Chronic Diastolic Congestive Heart Failure
Hypertension
Dyslipidemia
Type II Diabetes Mellitus
Anemia
Postop Sick Sinus Syndrome
postop C. difficile
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. 1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please resume hemodialysis on Tuesday/Thursday/Saturday
Schedule.
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**
**VNA to draw daily INR and call/fax results to [**Hospital 197**] Clinic
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2199-3-18**]
1:00
Cardiologist: Dr. [**Last Name (STitle) 85179**] # [**Telephone/Fax (1) 7164**], appointment arranged
for [**2199-3-5**] at 9am.
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 36361**] in [**5-7**] weeks
Dr.[**Last Name (STitle) 85179**] to follow INR/Coumadin dosing via [**Hospital 197**] Clinic
**once discharged from rehab.
[**Hospital 197**] Clinic # [**Telephone/Fax (1) 85180**]
daily labs: PT/INR for Coumadin ?????? indication: Paroxysmal Atrial
Fibrillation
Goal INR 2-2.5
Please Fax- [**Telephone/Fax (1) 7165**] Coumadin doses/INR levels to the
[**Hospital 197**] Clinic upon discharge
Results to phone fax [**Telephone/Fax (1) 7165**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2199-2-25**]
ICD9 Codes: 5856, 9971, 4241, 4280, 4168, 2724, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7521
} | Medical Text: Admission Date: [**2142-12-27**] Discharge Date: [**2143-1-1**]
Date of Birth: [**2086-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**12-27**] MVR (25/33 ON-X mechanical valve)
History of Present Illness:
55 yo M with long history of myxomatous MV and chronic MR.
Serial echos showed increased LA/LV dimensions and and severe MR
and normal EF. Referred for surgery.
Past Medical History:
MR/MVP, Migraines, Ankylosing spondylitis, GI bleed (10 years
ago), Hyperlipidemia, HTN, B hernia repair
Social History:
works as architect
quit tobacco 27 years ago
no etoh
Family History:
mother with MVR @ age 70
father with MI/CVA @ age 87
Physical Exam:
NAD HR 70 RR 12 BP 118/70
NAD
Lungs CTAB
Heart RRR 3/6 Systolic
Abdomen benign
Extrem no edema, warm
Superficial BLE aricosities
Pertinent Results:
[**2143-1-1**] 08:20AM BLOOD WBC-10.4 RBC-4.26* Hgb-13.0* Hct-36.3*
MCV-85 MCH-30.4 MCHC-35.7* RDW-14.0 Plt Ct-385
[**2142-12-30**] 08:05AM BLOOD WBC-13.8* RBC-4.31* Hgb-13.0* Hct-37.5*
MCV-87 MCH-30.1 MCHC-34.6 RDW-13.9 Plt Ct-327#
[**2143-1-1**] 08:20AM BLOOD Plt Ct-385
[**2143-1-1**] 08:20AM BLOOD PT-30.7* PTT-52.6* INR(PT)-3.2*
[**2142-12-31**] 07:35AM BLOOD PT-21.9* INR(PT)-2.1*
[**2142-12-30**] 08:05AM BLOOD PT-20.8* PTT-33.7 INR(PT)-2.0*
[**2142-12-29**] 07:10AM BLOOD PT-19.4* INR(PT)-1.9*
[**2142-12-28**] 09:03AM BLOOD PT-14.4* PTT-27.8 INR(PT)-1.3*
[**2143-1-1**] 08:20AM BLOOD Glucose-102 UreaN-25* Creat-0.7 Na-134
K-4.3 Cl-96 HCO3-30 AnGap-12
CHEST (PA & LAT) [**2142-12-31**] 9:16 AM
CHEST (PA & LAT)
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
56 year old man s/p mvr
REASON FOR THIS EXAMINATION:
r/o inf, eff
HISTORY: 56-year-old male status post mitral valve replacement.
Evaluate for infection, effusion.
COMPARISON: [**2142-12-12**].
CHEST, PA AND LATERAL: Retrosternal gas and a small air-fluid
level are seen on the lateral view, probably related to recent
sternotomy. The left basilar atelectasis has improved. However,
there is a persistent small left pleural effusion. There is also
a probable small right pleural effusion. The lung fields are
clear. Cardiomediastinal contours are normal. Sternotomy wires
and artificial mitral valve are unchanged.
IMPRESSION:
1. Retrosternal gas and air-fluid level, probably related to
recent sternotomy.
2. Persistent small left pleural effusion and probable small
right pleural effusion.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 3887**]TTE
(Complete) Done [**2142-12-27**] at 4:01:56 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Outpatient DOB: [**2086-7-17**]
Age (years): 56 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Left ventricular function. Mitral valve disease.
Mitral valve prolapse. Preoperative assessment.
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2142-12-27**] at 16:01 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: Echo Lab
Contrast: None Tech Quality: Adequate
Tape #: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD or PFO by 2D, color
Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Moderately dilated LV cavity. [Intrinsic LV
systolic function likely depressed given the severity of
valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
to moderate ([**1-30**]+) AR. Eccentric AR jet directed toward the
anterior mitral leaflet.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
Moderate/severe MVP. Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
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.
Brief Hospital Course:
He was taken to the operating room on [**12-27**] where he underwent a
mechanical MVR. He was transferred to the ICU in stable
condition. He was extubated later that day. He was transferred
to the floor on POD #1. He was started on coumadin for his
mechanical mitral valve. He had some atrial fibrillation for
which his beta blocker was increased and he converted to sinus
rhythm. He did well postoperatively. He awaited a therapeutic
INR and was ready for discharge on POD #5. Dr. [**Last Name (STitle) 3888**] (Spoke
to [**Doctor First Name **] at his office) will follow his coumadin.
Medications on Admission:
Remicade Q6W, Folate 1mg QD, Methotrexate 10mg QW, Univasc 15mg
QD, Zantac 150 QD, Lipitor 10mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 81 QD, MVI 1 QD Vit E
1000 IU QD, Fish oil 1000mg QD, Fioricet 50-325-40 1-2PRN,
Celebrex 100mg QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*60 Tablet(s)* Refills:*0*
6. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Check
INR [**1-3**] with results to Dr. [**Last Name (STitle) 3888**].
Disp:*30 Tablet(s)* Refills:*0*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Multi-Vitamin HP/Minerals Capsule Sig: One (1) Capsule PO
once a day.
10. Vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
11. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
12. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Packet(s)* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
MR/MVP, Migraines, Ankylosing spondylitis, GI bleed (10 years
ago), Hyperlipidemia, HTN, B hernia repair
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 or driving until follow up with
surgeon.
Coumadin to be followed by Dr. [**Last Name (STitle) 3888**]. Have INR checked [**1-3**]
with results called to Dr. [**Last Name (STitle) 3888**]. Goal INR 2.5-3.5 for
mechanical mitral valve.
Followup Instructions:
Dr. [**Last Name (STitle) 3888**] 2 weeks
Dr. [**Last Name (STitle) 914**] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Already scheduled appointments:
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD (Rheumatologist) Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2143-4-22**] 5:00
Completed by:[**2143-1-1**]
ICD9 Codes: 4240, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7522
} | Medical Text: Admission Date: [**2130-12-5**] Discharge Date: [**2130-12-19**]
Date of Birth: [**2056-4-5**] Sex: F
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 1557**] is a 74 year-old
female with a history of ulcerative colitis, and primary
sclerosing cholangitis resulting in cirrhosis of the liver who
presented to the hospital for liver transplantation. Her most
recent hospital admission had been in [**2130-10-15**] for
cholangitis. The patient currently denies any fevers or
chills, nausea, vomiting, diarrhea, or constipation. She also
denies any changes in her bowel habits, weight loss or cough.
She denies any rhinorrhea, sore throat, earaches, shortness of
breath, chest pain, bright red blood per rectum, dysuria,
vaginal infections or rashes.
PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. Primary sclerosing cholangitis resulting in cirrhosis.
3. Hepatitis B.
4. Cholangitis.
5. Anemia.
6. Anxiety disorder.
7. Status post total abdominal hysterectomy.
MEDICATIONS ON ADMISSION:
1. Ursodiol.
2. Asacol.
3. Folic acid.
4. Levaquin.
5. Flagyl.
6. Lopresor.
7. Tums.
8. Multivitamin.
9. Lasix.
ALLERGIES: Penicillin, which causes rash and swelling and
Azulfidine, which causes a fever.
SOCIAL HISTORY: The patient denies any alcohol, tobacco or
drugs.
PHYSICAL EXAMINATION ON ADMISSION: The patient was found to
have a temperature of 98.4 degrees Fahrenheit with a heart
rate of 80 and a blood pressure of 112/68. She was in no
acute distress and alert and oriented. Her pupils are equal,
round and reactive to light and accommodation. Her
extraocular movements intact. She was found to have some
scleral icterus and her mucous membranes are moist. Her neck
was supple with no lymphadenopathy. Heart showed a regular
rate and rhythm with a grade 2 out of 6 systolic ejection
murmur. Her lungs were clear to auscultation bilaterally
with no crackles, wheezes or rales. Her abdomen was soft,
nontender and mildly distended with an evident umbilical
hernia. She had a well healed infraumbilical midline
surgical scar. Her extremities were warm and well perfuse
with 2+ palpable radial and pedal pulses. Her skin was
notable for being jaundiced.
PERTINENT STUDIES: Her electrocardiogram showed normal sinus
rhythm and her chest x-ray was unremarkable and her lung
fields were clear. Her hematocrit at the time of admission
was 43.6. Her ALT was 91, AST 249, alkaline phosphatase 670,
and her total bilirubin was 10.5.
HOSPITAL COURSE: Mrs. [**Known lastname 1557**] was taken to the Operating Room
on [**2130-12-5**] where she underwent orthotopic liver
transplant along with Roux-en-Y hepaticojejunostomy. Please
refer to the dictated operative note for full details of this
procedure. She tolerated the procedure well and was
transferred in stable condition to the Surgical Intensive
Care Unit. She remained intubated on the night of the
operative day with a slow ventilator wean being started. She
was started on Mycophenolate, Cyclosporin in Solu-Medrol.
Her liver function tests began to trend downward. She was
seen in consultation by the Infectious Disease and [**Hospital **]
Clinic consult services for management of her postoperative
antibiotics and her postoperative blood sugars. She was
extubated on postoperative day number two, which she
tolerated well and without incident. She was also transfused
3 units of fresh frozen platelets to help correct her
coagulopathy. She was subsequently started on total
parenteral nutrition so that she would be able to maintain
her nutritional balance during the postoperative period. On
postoperative day number three she was doing quite well and
deemed stable and ready for transfer to the regular floor
from the Intensive Care Unit. On postoperative day number
four the patient was started on tube feeds via nasal jejunal
tube. The patient continued to improve, increasing strength
and mobility and continuing to show downward trends in her
liver function enzymes. Her total bilirubin at the time had
decreased to 2.3. She was transfused 2 units of packed red
blood cells on postoperative day number seven for a
hematocrit of 25.8 to which she appropriately responded. She
continued to improve and gain strength while on the floor.
Her nutritional status continued to improve her and
hematocrit remained stable. She began to slowly redevelop
her appetite. She tolerated oral intake without any
difficulty, and tube feeds were cycled to be overnight, which
she tolerated well. Her liver function tests continued to
improve and by postoperative day number twelve her total
bilirubin was 1.1. Her hematocrit remained stable at that
time at 36%. She was actively diuresed at that time using
Lasix to which she responded well and appropriately. One of
her [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains was removed at that time as well.
On postoperative day number fourteen she was deemed stable
and ready for discharge to home. It was planned that she
would be discharged home with visiting nurses so that they
would be able to assist her in the rather immediate
postoperative period.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home with visiting nurses.
DISCHARGE DIAGNOSES:
1. Status post orthotopic liver transplant on [**2130-12-5**].
2. Primary sclerosing cholangitis resulting in cirrhosis.
3. Ulcerative colitis.
4. Hepatitis B.
5. Chronic anemia.
6. Status post umbilical hernia repair.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg po q.d.
2. Calcium carbonate 500 mg po q.i.d.
3. Mycophenolate mofetil 1000 mg po b.i.d.
4. Valgancyclovir 450 mg po q day.
5. Prednisone 15 mg po q.d.
6. Neoral 100 mg po b.i.d.
7. Percocet one to two tablets po q 6 hours prn for pain.
8. Protonix 40 mg po q 12 hours.
FOLLOW UP: Follow up was scheduled for the following week
with the transplant center and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**First Name3 (LF) 13689**]
MEDQUIST36
D: [**2131-4-20**] 09:21
T: [**2131-4-20**] 10:04
JOB#: [**Job Number 103603**] & [**Numeric Identifier 103604**]
ICD9 Codes: 5715, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7523
} | Medical Text: Admission Date: [**2185-4-20**] Discharge Date: [**2185-4-23**]
Date of Birth: [**2131-3-30**] Sex: M
Service: MEDICINE
Allergies:
Benadryl Allergy / Ambisome / Flomax
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 year old man with h/o AML s/p allo cord transplant (now day
+516) complicated by chronic GVHD with arthritis, BOOP, who
presented to the BMT floor from clinic with worsening renal
function(2.3) and hyperkalemia, and worsening odynophagia on
[**2185-4-20**].
On arrival to the BMT floor, as he was transitioning into the
bed, he became mom[**Name (NI) 11711**] unresponsive to verbal stimuli and
physical stimuli. No jerking movements or incontience were
noted. A code blue was called. On arrival of the code team, BP
124/80, Hr 70s, satting 100% on 5L NC. He was responsive to
verbal stimuli and answering questions appropriately. He does
not recall only seconds of the entire episode; wife notes that
his eyes were closed. 1 amp of D50, 10units regular insulin, and
abuterol nebs were given for known hyperkalemia. An EKG was
obtained which showed isolated peaked T waves. CXR showed no
interval change when accounted for technique from prior in the
day. During this time, he did experience a headache that was
located in the forhead, temples and described as a pressure /
squeeze that he has experienced with prior tension headaches.
He was then transferred to the [**Hospital Unit Name 153**] for further cardiac
monitoring. During this time, he was also noted to have some
tremors in hands and legs, but this was not associated with any
loss of consciousness or loss of consciousness. These episodes
will occur for only seconds at a time and tend to occur when he
is holding objects in his hands / intention tremor. He has not
had formal workup for this, but there was no clear etiology to
this tremor (which has been present intermittently over the past
2 years) to date.
His wife also relays the presence of intermittent episodes of
unresponsiveness over the past x2 years ago at a frequency of
1-2x per week lasting only seconds at a time. This has not been
formally evaluated to date.
Past Medical History:
Past Medical History (taken from previous notes)
1) AML, M5b diagnosed 07/[**2182**].
- Received induction chemotherapy with 7 + 3(ARA-C and
idarubicin)-[**2182-7-23**] until [**2182-8-22**]. The patient achieved a
CR after this therapy.
- High-dose ARA-C x 2 cycles from [**2182-8-28**] until [**2182-9-27**].
- Pt found to have relapsing dz and reinduced with Mitoxantrone
and Ara-C [**Date range (1) 39624**]. Pt was found to have relapsing dz on
bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted
between [**Date range (1) 39625**] for Mitoxantrone, Etopiside and Cytarabine.
- s/p myeloablative sequential unrelated double cord blood
transplant, now D+334. Day 100 bone marrow biopsy showed no
siagnostic morphologic features of involvement by acute
leukemia, with cytogenetics revealing karyotype 46XX, consistent
with that of female donor.
2) hepatic insufficiency due to secondary hemochromatosis and
steatosis
3) Aspergillosis of the sinus/nares on voriconazole.
4) Bacillary angiomatosis
5) Acute appendicitis deep into his nadir during transplant that
was successfully treated with daptomycin, meropenem, levofloxain
and metronidazole
6) Incidental HHV6 IgG-positive, without disease
7) Hx of post chemo-induced cardiomyopathy; TTE [**6-19**] with
preserved EF.
8) Sarcoid - diagnosed in [**2172**], received intermittent steroids
9) GERD
10) HTN
11) Hypercholesterolemia
12) s/p cholecystectomy in [**6-/2180**] complicated by sinus
tract to the abdominal wall
13) Hepatic and splenic microabscesses/candidiasis ([**8-/2182**])
14) BOOP requiring extended ICU/hospital course in [**3-/2184**] and
home oxygen
15) Peripheral neuropathy
Social History:
Formerly worked as auto mechanic, now disabled econdary to AML
and GVHD. Lives with wife, teenage son. Past tobacco use, but
non currently.
Family History:
Father- CAD s/p CABG. Type II Diabetes
Mother- Type [**Name (NI) **] Diabetes.
Multiple paternal uncles with heart disease.
2 siblings in good health.
Physical Exam:
GENERAL: Middle-aged, Cushingoid, overweight man in NAD
HEENT: EOMI, PERRLA, mucous membranes moist, no cervical LAD, no
JVD, neck supple w/out tenderness
CARDIAC: RRR no m/g/r, S1, S2 nl
CHEST: kyphotic
LUNG: few bilateral crackles at bases, no wheezes, rhonchi
ABDOMEN: obese, soft, NT, ND, unable to appreciate HSM [**2-14**] body
habitus, no rebound or guarding
EXT: warm, + bilateral 2+ pitting edema to knees, DP+
bilaterally, no cyanosis - L elbow medial epicondyle tenderness
w/ effusion, no joint erythema or effusion
NEURO: CNII-XII intact, motor symmetric strength, hyperesthetic
sensation bilateral LE/feet, no evidence of toe nail erythema
DERM: ecchymoses on abdomen [**2-14**] insulin, no other lesions.
Psych: Mood liabile, affect appropriate, intermittently tearing
up to labs draws, movement to ICU
Pertinent Results:
CBC:
[**2185-4-20**] 11:11AM BLOOD WBC-5.3 RBC-2.84* Hgb-9.3* Hct-29.3*
MCV-103* MCH-32.7* MCHC-31.7 RDW-15.2 Plt Ct-101*
[**2185-4-23**] 06:10AM BLOOD WBC-2.5* RBC-2.79* Hgb-9.2* Hct-29.1*
MCV-104* MCH-33.1* MCHC-31.7 RDW-15.3 Plt Ct-88*
[**2185-4-20**] 11:11AM BLOOD Neuts-84.9* Lymphs-4.7* Monos-7.5 Eos-2.9
Baso-0
[**2185-4-23**] 06:10AM BLOOD Neuts-70.4* Lymphs-11.9* Monos-13.8*
Eos-3.7 Baso-0.2
Chemistries:
[**2185-4-20**] 11:11AM BLOOD Glucose-156* UreaN-91* Creat-2.3* Na-137
K-5.5* Cl-103 HCO3-22 AnGap-18
[**2185-4-20**] 07:49PM BLOOD Glucose-108* UreaN-74* Creat-2.1* Na-136
K-4.8 Cl-126* HCO3-18* AnGap--3*
[**2185-4-21**] 04:18AM BLOOD Glucose-112* UreaN-83* Creat-2.2* Na-137
K-5.7* Cl-108 HCO3-23 AnGap-12
[**2185-4-21**] 08:18AM BLOOD Na-139 K-6.8* Cl-109*
[**2185-4-21**] 08:18AM BLOOD Na-142 K-5.6* Cl-110*
[**2185-4-21**] 02:12PM BLOOD Na-140 K-5.7* Cl-108
[**2185-4-22**] 05:14AM BLOOD Glucose-88 UreaN-72* Creat-2.0* Na-142
K-4.8 Cl-108 HCO3-24 AnGap-15
[**2185-4-23**] 06:10AM BLOOD Glucose-88 UreaN-61* Creat-1.9* Na-142
K-4.0 Cl-108 HCO3-26 AnGap-12
LFTs:
[**2185-4-20**] 11:11AM BLOOD ALT-35 AST-28 LD(LDH)-246 AlkPhos-189*
TotBili-0.2
[**2185-4-21**] 04:18AM BLOOD ALT-33 AST-27 CK(CPK)-17* AlkPhos-168*
TotBili-0.1
Cardiac Enzymes:
[**2185-4-20**] 06:29PM BLOOD CK-MB-3 cTropnT-<0.01
[**2185-4-21**] 04:18AM BLOOD CK-MB-3 cTropnT-<0.01
[**2185-4-20**] 11:11AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.6
[**2185-4-23**] 06:10AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.2
Antibody Titers:
[**2185-4-20**] 11:11AM BLOOD IgG-412* IgA-54* IgM-17*
ABG:
[**2185-4-20**] 06:30PM BLOOD Type-ART pO2-134* pCO2-39 pH-7.38
calTCO2-24 Base XS--1 Intubat-NOT INTUBA
[**2185-4-20**] 06:30PM BLOOD Glucose-442* Lactate-1.7 Na-132* K-6.5*
Cl-100
[**2185-4-20**] 06:30PM BLOOD freeCa-1.13
Blood and urine cultures from [**4-20**] negative.
Head CT ([**4-21**]):
IMPRESSION: No acute intracranial hemorrhage. Paranasal sinus
disease in the left maxillary and sphenoid sinus, as described
above.
CXR: ([**4-21**]) :
FINDINGS: Allowing for differences in technique there has been
no interval
change in appearance of the chest since the recent study with no
acute
cardiopulmonary abnormality identified.
Brief Hospital Course:
Summary of Hospital Course: 53 year old man with h/o AML s/p
allo cord transplant (day +516 on admission) complicated by
chronic GVHD with arthritis, BOOP, who now presents to clinic
with acute on chronic renal failure. Hospital course complicated
by syncopal episode the day of admission resulting in Code Blue
and hyperkalemia, requiring brief ICU admission.
#Syncope: Patient had syncopal episode the day of admission,
where he was unresponsive for ~1 minute while lying flat.
Unclear etiology, possible due to orthostatic hypotension (noted
to have orthostatic physiology in the ICU and on the floor) vs
arrythmia vs seizure activity. Of note, (per wife), patient has
had many of these episodes recently (~2 years, ~1-2 episodes per
week). Patient denied any heralding symptoms and was not
post-ictal afterwards, but was noted to have a resting tremor in
the MICU. His history of tremor is not consistent wtih seizure
activity. It appears to be an intention tremor that gets worse
when holding on to objects and is low in amplitude while high in
frequency, bilateral and not associated with change in
consciousness or incontinence.
Noted to be hyperkalemic during the code, given amp D50 and 10 U
insulin peri-code and kayexalate in the ICU, with drop in
potassium down to 4.0 on discharge. Neurology consulted on
patient who recommended EEG and possible midodrine or fluorinef
support. Held patient's lisinopril, but continued him on his
carvedilol 12.5 mg PO BID as this was recently decreased in the
setting of light headedness/dizziness by his cardiologist on
[**3-21**], although informed him not to take the medication if he had
any pre-syncopal symptoms. Medication can be decreased at the
discretion of his cardiologist. Patient had no further syncopal
episodes or events on telemetry in the ICU or on the floor.
Neurology was consulted who recommended an EEG, possible blood
pressure support with midodrine or fluorinef, at the discretion
of the patient's outpatient oncologist and nephrologist. Was
noted to not have any telemetry events or syncopal events while
ambulating, with appropriate increase in pulse and blood
pressure. and requested to be discharged with outpatient syncope
work-up. Outpatient TTE, EEG, carotid U/S, and holter monitering
were arranged prior to discharge.
#Acute on chronic renal failure: Noted to have mildly elevated
Cre to 2.3 in clinic the day of admission. Creatine has
fluctuated over the past two years, with several episodes of
acute renal failure while hospitalized. Followed by nephrology
as an outpatient. Per outpatient notes, etiology of CKD thought
to be [**2-14**] ATN that has not resolved, medication effect in the
setting of bactrim, voriconazole, lisinopril, or AIN. Less
likely due to AML infiltration of kidneys (very rare) or
chemotherapy. Unlikely progressive glomerular disease given
patient only has scant proteinuria. Patient has refused renal
biopsy in the past. Baseline Cre has been 1.4-2.0 over the past
few months. Lisinopril was held. Cellcept was decreased to
[**Telephone/Fax (3) 39636**] as GFR was ~30. Oral fluid intake encouraged. Renal
failure resolved to baseline creatinine (1.9) on discharge.
Renal did not have chance to formally consult on patient since
he requested discharge, but stated informally that they had no
further recommendations as an inpatient since he was refusing
renal biopsy, and he could be accommodated very soon in renal
clinic with his current outpatient nephrologist.
#Congestive Heart Failure: Euvolemic to mildly hypervolemic on
exam. Requested TTE as outpatient. Continued home meds including
aspirin, beta-blocker. Held ACEI due to hyperkalemia.
#AML: allo SCT +519 days. counts stable. continued prophylactic
medications. Arranged to follow up with outpatient oncologist.
#Epigastric discomfort: Gastritis, likely in setting of
prednisone. Patient has tried and failed Nexium, reporting it
has not helped his gastritis for 3 months. Relieved with
protonix, which was added to med list on discharge. Can obtain
prior authorization from PCP [**Name Initial (PRE) 5564**].
Medications on Admission:
-Acyclovir 400 [**Hospital1 **]
-Carvedilol 12.5 [**Hospital1 **]
-Cyanocobalamin 1000mcg IM 1xmonth
-Nexium 20mg PO BID
-Furosemide 40mg PO BID
-Gabapentin 300 cap 3caps tid
-Insulin Novolog 4xday, sliding scale
-Glargine 10u qhs
-Lisinopril 5mg daily
-Montelukast 10mg PO daily
-Morphine 15mg PO q6-8 hrs prn pain
-MMF 500mg TID
-Nitro 0.3mg tab SL
-zofran 4-8mg q8 hrs prn nausea
-Oxycodone SR 10mg PO BID
-Prednisone 20mg daily
-Bactrim 800-160 MWF
-Voriconazole 200mg tab, 1.5 tab q12h
-AA Magnesium Sulfate OTC 1tab daily
-Vit C 500mg tab daily
-Aspirin 81 mg tab Enteric coated
-Cal Carb 1000mg tab [**Hospital1 **]
-Vit D3 400u daily
-Hexavitamin 1 tab daily
-Miconazole 2% powder to affected areas [**Hospital1 **]
-Thiamine 50mg PO daily
-Docusate 100mg PO BID
-Senna 1 tab [**Hospital1 **] prn
Discharge Medications:
1. Acyclovir 200 mg Capsule [**Hospital1 **]: Two (2) Capsule PO Q12H (every
12 hours).
2. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO three times
a day.
3. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Prednisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
9. Oxycodone 10 mg Tablet Sustained Release 12 hr [**Hospital1 **]: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
10. Morphine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO every 6-8 hours
as needed for pain.
11. Voriconazole 200 mg Tablet [**Hospital1 **]: 1.5 Tablets PO Q12H (every
12 hours).
12. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: Two (2)
Tablet, Chewable PO BID (2 times a day).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO every twenty-four(24)
hours.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
14. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Thiamine HCl 100 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
16. Nitroglycerin 0.3 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
17. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
18. Carvedilol 12.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a
day: HOLD if patient loses consciousness or has systolic blood
pressure less than 100.
19. Hexavitamin Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
20. Vitamin D-3 400 unit Tablet [**Hospital1 **]: One (1) Tablet PO once a
day.
21. Vitamin C 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
22. Insulin Aspart 100 unit/mL Solution [**Hospital1 **]: One (1) as directed
Subcutaneous four times a day: per sliding scale.
23. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: One (1) syringe
Subcutaneous at bedtime: 10 Units at bedtime.
24. Zofran 4 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every eight (8) hours
as needed for nausea.
25. Mycophenolate Mofetil 250 mg Capsule [**Hospital1 **]: Two (2) Capsule PO
BID (2 times a day).
26. Mycophenolate Mofetil 250 mg Capsule [**Hospital1 **]: One (1) Capsule PO
DAILY (Daily): please administer at noon .
Discharge Disposition:
Home
Discharge Diagnosis:
1' Diagnosis
Acute on Chronic Renal Failure
Hyperkalemia
Syncope
2' Diagnosis
Congestive Heart Failure
Hypertension
Acute Myelogenous Leukemia
Discharge Condition:
afebrile, hemodynamically stable, without syncopal episode x48
hours
Discharge Instructions:
You were admitted with a diagnosis of acute on chronic renal
failure, high potassium levels, and syncope. Your kidney
function resolved back to it's baseline, and your potassium
levels normalized with some kayexalate. We wanted to run some
lab tests to evaluate the reason for your syncope, but you felt
well and wanted to go home and have the testing done as an
outpatient.
Please take your medications as directed
- Please hold your lisinopril as this medication can cause
elevated potassium levels. Please restart at the discretion of
your PCP or cardiologist.
- Your Cellcept was decreased as noted on the medication list.
- We started you on protonix for your heart burn in place of the
Nexium. You may need prior authorization from your primary care
physician or oncologist for this medications.
Please return to the hospital if you have fever > 100.4, any
further fainting episodes, chest pain, palpitations, or any
other symptoms not listed here concerning enough to warrant
physician [**Name Initial (PRE) 2742**].
Followup Instructions:
Provider: [**Name Initial (NameIs) 455**] 5-HEM ONC 7F [**Name Initial (NameIs) **]/ONCOLOGY-7F
Date/Time:[**2185-4-25**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2185-4-25**] 2:00
Provider: [**Name10 (NameIs) 3310**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-7F
Date/Time:[**2185-4-25**] 2:00
with your cardiologist as an outpatient. The phone number is
[**Telephone/Fax (1) 62**].
with renal as an outpatient. Please call ([**Telephone/Fax (1) 773**] to make
an appointment.
to get your trans-thoracic echocardiogram, your carotid
ultrasound, your holter monitoring, and your EEG. They have all
been ordered and your outpatient oncologist should follow up on
the results.
- Please call [**Telephone/Fax (1) 327**] to schedule your carotid ultrasound.
- Please call [**Telephone/Fax (1) 62**] to schedule your trans-thoracic
ultrasound.
- Please call [**Telephone/Fax (1) 3104**] to schedule your holter monitoring.
- Please call [**Telephone/Fax (1) 5285**] to schedule your EEG.
Completed by:[**2185-4-25**]
ICD9 Codes: 5849, 2767, 5859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7524
} | Medical Text: Admission Date: [**2109-3-9**] Discharge Date: [**2109-3-9**]
Service: MICU
HISTORY OF PRESENT ILLNESS: This is an 84-year-old gentleman
sent from [**Hospital3 **] with advanced Parkinson
disease who developed acute respiratory distress and was
found to have a low oxygen saturation at rehabilitation.
Vital signs at rehabilitation were a heart rate of 72, blood
pressure was 140/60, respiratory rate was 24, and temperature
was 100.2.
In the Emergency Department, the patient received Lasix
secondary to rales, and a head computed tomography was
ordered for a change in mental status. Antibiotics were also
given for a question of aspiration pneumonia. The patient
was started on levofloxacin and Flagyl.
In the Emergency Department, the patient suddenly became
hypotensive and hypoxic requiring intubation and a dopamine
drip.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Advanced Parkinson disease.
2. Status post left pallidotomy in [**2102-2-20**].
3. Upper gastrointestinal bleed in [**2107-4-22**].
4. Constipation.
5. Benign prostatic hypertrophy; status post transurethral
resection of prostate in [**2090**].
6. Left rotator cuff tear.
7. Left distal radius fracture.
8. Low back pain.
9. Weight loss.
10. Anemia.
ALLERGIES: The patient is allergic to ADVIL and VALPROATE.
MEDICATIONS ON ADMISSION: Medications at the nursing home
consisted of Tylenol, calcium, vitamin D, Sinemet, Cardizem,
Imdur, Mirapex, Seroquel, Senna, Sorbitol, and Neurontin.
SOCIAL HISTORY: The patient is a holocaust survivor. He is
married with children in the area.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 98.2, heart rate was 114, blood
pressure was 94/26, respiratory rate was 26, and oxygen
saturation was 100% on 100% FIO2. In general, he was a thin
cachectic elderly white male responsive only to noxious
stimuli. Head, eyes, ears, nose, and throat examination
revealed pupils were equal, round, and reactive to light and
accommodation. Sclerae were anicteric. The oropharynx was
dry. Neck examination revealed there was no jugular venous
distention. No lymphadenopathy. The neck was supple. The
chest had poor inspiratory effort but clear to auscultation
otherwise. Heart examination revealed normal first heart
sounds and second heart sounds. A 2/6 systolic murmur. The
abdomen was soft and nontender. No hepatosplenomegaly.
There was a right easily reducible inguinal hernia.
Extremities were warm with good bilateral pulses and with no
edema. Neurologic examination revealed pupils were 3 mm and
reactive. The patient moved all extremities but was unable
to cooperate with examination.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed a white blood cell count was 4.5,
hematocrit was 32.8, and platelets were 423. Partial
thromboplastin time was 27.3 and INR was 1.3. Sodium was
138, potassium was 4.5, chloride was 99, bicarbonate was 20,
blood urea nitrogen was 69, creatinine was 2.1, and blood
glucose was 84. Creatine kinase was 199. Troponin was less
than 0.3. His blood gas once intubated was 7.07, PCO2 was
61, and a PO2 was 170; and this was on 100% FIO2.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram showed a
normal sinus rhythm at 90 with no acute ischemic changes.
A chest x-ray showed diffuse bilateral infiltrates which was
later read as metastatic disease.
A head computed tomography showed no acute process but had
old left-sided burr holes.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for his respiratory failure and shock.
While in the Intensive Care Unit, the patient remained
intubated and was continued on his levofloxacin and Flagyl
with the addition of ceftriaxone for a question of aspiration
pneumonia and sepsis. The patient became increasingly
hypotensive requiring vasopressin, dopamine, and
norepinephrine drips. The patient remained persistently
acidemic.
The patient's condition continued to decline. At
approximately 7 p.m. on the day of admission, the patient
went into asystole and received cardiopulmonary
resuscitation, atropine, and epinephrine with a transient
return of his heart rate and blood pressure; however, this
once again deteriorated and the patient again went into
asystole. He was continued with cardiopulmonary
resuscitation, atropine, and epinephrine without a response.
The patient expired at [**2045**], and family members were
notified. The case was declined by Medical Examiner, and the
family opted not to have an autopsy performed.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 13577**]
MEDQUIST36
D: [**2109-3-10**] 01:03
T: [**2109-3-12**] 18:14
JOB#: [**Job Number 97474**]
ICD9 Codes: 5070, 5849, 0389, 2762, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7525
} | Medical Text: Admission Date: [**2153-8-12**] Discharge Date: [**2153-8-15**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 77 year-old
woman status post three vessel coronary artery bypass graft
who presented to outside hospital on [**2153-8-12**] after awakening
from sleep with 7 out of 10 substernal chest pain associated
with nausea and diaphoresis. No electrocardiogram changes
were noted and cardiac enzymes were cycled and remained flat.
The patient was then transferred to [**Hospital1 190**] for cardiac catheterization. Upon arrival the
patient was denying any chest pain, shortness of breath,
nausea or diaphoresis. However, overnight on [**8-12**] the
patient developed one episode of crushing 10/10 chest pain
worse ever associated with shortness of breath. The pain was
resolved with two sublingual nitroglycerin tabs. At the time
the patient's blood pressure was elevated to 190/70 and an
electrocardiogram showed lateral ST depressions. Cardiac
catheterization was performed the following morning. Cardiac
catheterization showed reocclusion of a saphenous vein graft
to obtuse marginal graft, which was stented. The native
obtuse marginal was attempted to be stented also, but had no
reflow. The patient subsequently developed chest pain and
electrocardiogram changes while in the catheterization
laboratory, which improved with nitroglycerin, 2 liters
intravenous fluid bolus and an intraaortic balloon pump was
placed. Once stabilized a Swan was floated, which
demonstrated a PA diastolic pressure of 38. The patient was
then aggressively diuresed and transferred to the Coronary
Care Unit Service.
PAST CARDIAC HISTORY: 1. Three vessel coronary artery
bypass graft in [**2143**] with left internal mammary coronary
artery to left anterior descending coronary artery, saphenous
vein graft to right coronary artery, saphenous vein graft to
obtuse marginal. 2. Percutaneous intervention with a stent
to the right coronary artery in [**2149**]. 3. Catheterization
[**2151-7-15**], which showed saphenous vein graft to obtuse
marginal take off with no intervention taken place. 4.
Catheterization [**2151-10-15**], saphenous vein graft to
obtuse marginal roto with no reflow and TIMI two reflow. 5.
TTE in [**2151-8-14**] left ventricular hypertrophy with global
hypokinesis and severely decreased systolic function, mild
AS. 6. Persantine MIBI [**2151-5-15**] moderate anterior mild
lateral ischemia.
PAST MEDICAL HISTORY: Coronary artery disease, diabetes,
hyperlipidemia, hypertension, anterior lateral myocardial
infarction in [**2151-10-15**].
PAST SURGICAL HISTORY: 1. Coronary artery bypass graft in
[**2143**]. 2. Right CEA. 3. Cholecystectomy.
SOCIAL HISTORY: No alcohol or tobacco use. Lives with
daughter and granddaughter in [**Name (NI) 1411**].
FAMILY HISTORY: Significant for a father who died of an
myocardial infarction at age 68 and a mother who died of
heart disease at age 80.
PHYSICAL EXAMINATION ON TRANSFER TO CCU: Temperature 97.6.
Blood pressure 112/36. Heart rate 83. Respirations 17.
SAO2 98% on 3 liters nasal cannula. Intraaortic balloon pump
one to one, heart rate 89 (NSR). General, no acute distress.
The patient is somnolent, but answers questions
appropriately. HEENT oropharynx clear. Mucous membranes are
moist. Jugulovenous pressure 6 to 8 cm. Neck supple. Chest
is clear to auscultation anteriorly (the patient is lying
flat due to intraaortic balloon pump). Cardiovascular
regular rate. Normal S1 and S2. [**3-21**] holosystolic murmur
best heard at right upper sternal border, which radiates to
the apex. Abdomen soft, nontender, nondistended.
Normoactive bowel sounds. Extremities right groin site
without oozing or hematoma. 2+ pedal pulses bilaterally.
Skin warm and dry.
LABORATORY VALUES: White blood cell count 7.5, hemoglobin
12, hematocrit 35, platelets 234, sodium 131, potassium 4.1,
chloride 96, bicarb 29, BUN 15, creatinine .9, glucose 212.
PTT 87, INR 1.2, total cholesterol 187, HDL 45, LDL 107,
triglycerides 168. Electrocardiogram done after
catheterization showed normal sinus rhythm, heart rate 88,
normal axis, Q wave in 3, which was old, .5 ST elevation in
3, .5 ST depression in V6.
IMPRESSION: The patient is a 72 year-old female with
coronary artery disease status post coronary artery bypass
graft with subsequent graft failure with intervention on
saphenous vein graft to obtuse marginal and with attempt to
fix native obtuse marginal lesion. Presentation consistent
with unstable angina, but without cardiac enzyme bump.
HOSPITAL COURSE: 1. Cardiovascular: A: Coronary artery
disease, following the catheterization the patient was
started on aspirin, Plavix and Integrilin, which was
continued for approximately 24 hours. The intraaortic
balloon pump, which was placed in the catheterization
laboratory due to hypotension was continued until the
following morning where it was slowly weaned and
discontinued. Cardiac enzymes were cycled and peaked with a
CK of 237, CKMB 15 and index of 6.3 on [**8-14**] at 1:00 in the
morning.
B: Congestive heart failure, the patient with known systolic
dysfunction who was transiently hypotensive in the
catheterization laboratory, which responded well to 2 liters
of intravenous fluid. Pulmonary artery diastolic pressure
was elevated indicating the patient had received adequate
amount of fluid and Lasix intravenous was administered with
greater then 2 liters of output and prompt improvement of the
patient's symptoms. The patient had no symptoms of volume
overload for the remainder of the hospital course.
C: Rhythm and rate: Normal sinus rhythm was monitored on
telemetry throughout the course of her hospitalization, which
showed no ectopy or arrhythmias.
2. Pulmonary: The patient had no active issues. Oxygen
saturations remained in high 90s throughout the hospital
course.
3. Renal: the patient's creatinine remained within normal
limits throughout hospital course.
4. Hematology: The patient initially was with a hematocrit
of 35 dropped as low as 30.0 believed to be dilutional from
the fluid received within the catheterization laboratory. No
sites of bleeding were noted. Good hemostasis was achieved
at the groin site. After catheterization the sheath was
pulled.
5. Endocrine: The patient is on Metformin as an outpatient,
which was held for two days due to risk of complications in
the pericatheterization period and Metformin was restarted on
the day of discharge. The patient was maintained on a
regular insulin sliding scale throughout her hospital course.
6. Cardiac rehabilitation: The patient was evaluated in
house by physical therapy and found be back to baseline
condition and deemed safe for discharge to home.
CONDITION ON DISCHARGE: Improved and stable.
DISCHARGE DIAGNOSES:
1. Hypertension.
2. Unstable angina.
3. Status post catheterization with stent placement.
4. Diabetes.
5. Hyperlipidemia.
DISCHARGE MEDICATIONS: The patient is to resume regular
outpatient medications, which include Toprol XL 50 mg po
b.i.d., Norvasc 10 q.d., Quinapril 20 q.d., Imdur 60 b.i.d.,
Prevacid 30 b.i.d., Niacin 50 q.d., Plavix 75 q.d., enteric
coated aspirin 325 q.d., Metformin 500 b.i.d.
FOLLOW UP: The patient is to follow up with her primary
cardiologist Dr. [**Last Name (STitle) 23392**] in one to two weeks. The patient is
to schedule an appointment.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2153-8-16**] 15:27
T: [**2153-8-17**] 07:38
JOB#: [**Job Number 23393**]
ICD9 Codes: 4111, 4240, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7526
} | Medical Text: Admission Date: [**2172-11-30**] Discharge Date: [**2172-12-22**]
Date of Birth: [**2097-11-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
s/p mechcanical [**2097**] w/ right clavicular fracture and
right rib fractures [**2-18**] and right hemothorax
Major Surgical or Invasive Procedure:
Trach, Peg, IVC filter
History of Present Illness:
75 yo F s/p mechcanical fall transferred from [**Hospital **] hospital
w/ right clavical frcature and right rib fractures [**2-18**], right
hemothorax.
Past Medical History:
Diverticulitis, osteoarthritis, osteoporosis, hypothyroidism,
hyperchol, Afib (post-op in 04, resolved), depression, shingles,
L Foot post-herpetc neuralgia
Family History:
non- contributory
Physical Exam:
general; well appareing female w/ trach and passey muir valve in
place
HEENT: trach in place, speaks clearly w/ passey muir.
COR: RRR S1, S2
chest: CTA bilat
abd: Soft, NT, ND, +BS. peg tube in place.
extrem: no c/c/e
neuro: intact.
Pertinent Results:
CXR [**2172-12-20**]
IMPRESSION:
Persistent airspace opacity involving both lungs. Small
right-sided pleural effusion. The findings represent pulmonary
edema and are unchanged. Pneumonia is not excluded. Right-sided
rib fractures, unchanged.
ECHO [**2172-12-14**]
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Transmitral Doppler and tissue velocity
imaging are consistent with normal LV diastolic function. 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. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Normal biventricular function. Mild mitral
regurgitation.
[**2172-12-5**] 5:00 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2172-12-8**]**
GRAM STAIN (Final [**2172-12-5**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2172-12-8**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. MODERATE GROWTH.
swallow eval [**2172-12-21**]
SUMMARY / IMPRESSION:
The pt did not have any overt signs of aspiration and can
continue on the current regular diet with thin liquids. She will
benefit from wearing the PMV during POs, but noted she has been
tolerating POs without the PMV in place. She can swallow her
pills whole with water. She reported her intake has been limited
b/c she fatigues, so she may continue to need small amounts of
tube feeds until she can take in more by mouth .
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 7, wfl.
RECOMMENDATIONS:
1. Continue on current PO diet of thin liquids and regular
solids.
2. Pills whole with thin liquids.
3. Pt will benefit from wearing the PMV throughout the day,
including when taking Pos.
These recommendations were shared with the patient, nurse and
medical team.
____________________________________
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.S., CCC-SLP
Pager #[**Numeric Identifier 2622**]
Brief Hospital Course:
Pt was admitted to the SICU [**2172-11-30**] for resp compromise d/t rib
fractures, clavicular fractures.
Neuro: awake, alert on arrival. head CT neg for acute process.
Sedated after intubation. Presently wake conversant and approp.
Resp: Required intubation on HD#3 after failing BIPAP and CPAP
support.
Failure to wean from the vent d/t ARDS and required trach and
peg on [**2172-12-9**].
Weaned from vent. Trach down sized [**2172-12-20**]. Passey muir valve
placed and [**Last Name (un) 1815**] well.
CTA was done to r/o PE which was neg. IVC filter was placed
prophlactically given relative risk on [**2172-12-13**].
Right hemothorax was drained and a chest tube was placed for
continued drainage and PTX. Chest tube was removed [**2172-12-10**]
after resolution of PTX and fluid collection drained.
COR: approp tachy initially controlled w/ betablockaide.
TEE nl w/ EF 60%
intermittant lasix diuresis and pressor requirement.
OF note, during removal of arterial line - line cut and slipped
into artery. plastics consulted and line tip retrived w/adeq
profusion.
Nutrition: Dobhoff placed for nutritional support and then peg
tube placed. currently [**Last Name (un) 1815**] TF and reg diet after being seen by
speech and swallow pathology. Can wean from tube feed after
approp po nutrition established.
Heme/ID: Transfused PRBCs for HCT 23.1 w/ approp stabilzation
of HCT- presumed source of loss - right hemothorax.
Cipro was started prophlactically and d/c'd after neg culture
data. Pt spiked on HD #8 pan cultured and started on broad
spectrum IVAB for suspected VAP- vanco, cipro, ceftaz.
sputum [**12-6**]- staph coag postive- sensitive to vanco. cipro
cetaz d/c'd and completed vanco course.
Pain:An epidural was placed for pain control, PCA and toradol
were added.
Now on metadone w/ good coverage.
Rehab: working w/ PT to return to baseline level of functioning.
Medications on Admission:
Atenolol 25', ASA 325, Zoloft 200, lipitor 10, levoxyl 100 mcg,
MVI, Calcium 600", glycolax 17
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mgs PO Q6H
(every 6 hours) as needed for pain.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
RHCI - [**Hospital **] Hospital of [**Location (un) **] and Islands
Discharge Diagnosis:
s/p fall w/ right clavical fx, right rib fractures [**2-18**] , right
hemothorax
Discharge Condition:
deconditioned
[**Last Name (un) 1815**] Passey Muir valve and tube feeds.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you develop chest
pain, shortness of breath, fever, chills, or if you have issues
with your feeding tube.
If you feeding tube falls out, have it replaced immediately or
if the sutures break, tape the tube securely in place until it
can be resutured.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2173-1-5**]
at 10am on the [**Hospital Ward Name **], [**Hospital Ward Name 121**] building [**Hospital1 **] one Chest
disease center. plaese arrive 45 minutes prior to your
appointment and report ot the [**Hospital Ward Name **] clinical center [**Location (un) **] rdaiology for a CXR.
Completed by:[**2172-12-28**]
ICD9 Codes: 2851, 2720, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7527
} | Medical Text: Admission Date: [**2141-4-11**] Discharge Date: [**2141-4-18**]
Date of Birth: [**2063-3-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
T6 burst fracture
Major Surgical or Invasive Procedure:
[**2141-4-11**]: T3-T9 posterior instrumented fusion
History of Present Illness:
78 y/o female with PMHx Parkinsons disease, COPD on home O2 2L,
4.2cm thoracic aortic aneurysm, CHF, depression,
hypercholesterolemia, hx L5-S1 discectomy, R TKA years ago,
peripheral neuropathy who is POD #3 s/p T3-T9 arthrodesis and
instrumentation. The patient has had multiple visits to OSH EDs
for low back pain starting in mid [**Month (only) **] and was initially
treated with rehabilitation. At the rehab facility, she
developed progressive weakness of her lower extremity and bowel
and bladder incontinence. She was transfered back to the ED of
[**Hospital **] hospital where CXR done showed burst fracture of T6 with
retropulsed fragment causing narrowing of the canal in that
area. She was then transfered to [**Hospital1 **] on [**2141-4-11**]. There was
marked blood loss in surgery but she was hemodynamically stable
the entire long surgery. She was transfused 2 PBRCs for oozing
from surgical site. (No hct drop). She self extubated the
morning after surgery. Ortho felt that surgery was done too
late. She has intact sensation but toes are upgoing B/L, and
she is now paralyzed from waist down.
.
Other complicating factors since she has been in the TICU
include UTI, A fib, and hypoxia. She is being treated with
Augmentin for the UTI. The patient had an episode of Afib last
night (first known episode). This was thought to be secondary
to overdiuresis. The patient's heart rate never got above
105bpm. The ICU team gave intermittent lopressor 5 mg IV, then
started lopressor 12.5 mg tid PO. Currently more hypoxic than
baseline felt to be [**2-21**] to volume overload (on 4L). She
diuresed 1L to 20 IV lasix. She received an IVC filter today
prophylactically (no DVTs). The patient was to be called out of
the unit yesterday, however had an episode of hypotension,
unclear etiology, possibly not correlating non-invasive to
invasive monitoring. Hypotension has resolved and the patient
is being transferred to medicine for continued care.
.
On transfer vs were 97.2 82 103/56 17 98% on 3L. Patient
complains of some back pain, but is otherwise feeling well.
Very frustrated about her current situation. Feels bloated and
gassy as well.
Past Medical History:
1) S/p reduction of fracture dislocation T5-6 and T6-7,
posterior arthrodesis T3-4, T4-5, T5-6, T6-7, T7-8 and T8-9,
posterior instrumentation T3 to T9, and arthroplasty in same
region.
2) Parkinsons disease
3) COPD on home O2
4) 4.2cm thoracic aortic aneurysm
5) Depression
6) hypercholesterol
7) hx L5-S1 discectomy
8) R TKA years ago
9) peripheral neuropathy
10) CHF
Social History:
Was at [**Hospital 5682**] Rehab for a week prior to this admission, but
was previously living at [**Location (un) 583**] [**Hospital3 400**]. Denies any
current tobacco or ETOH use. Smoked for 35 yrs and quit [**2126**].
Son [**Name (NI) **] lives in the [**Location (un) **] area and is quite involved in the
care of the mother.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
Vitals - 97.2, 82, 103/56, 17, 98% on 3L.
GEN: elderly female, lying still, in mild discomfort
HEENT: EOMI, PERRLA, MMM, no LAD, neck supple
CV: S1S2, RRR, no m/r/g
RESP: CTA b/l, no w/r/r
ABD: soft, distended, NT, + BS, no guarding/rebound
GU: catheter in place
Back: dressing dry and intact
SKIN : no rash, no ulceration, no erythema in decubiti
NEURO: CNII-XII grossly intact, 5/5 strength in UE, 0/5 strength
in LE's. Sensation intact in LE's.
Pertinent Results:
CT C/T/L spine ([**2141-4-11**])
IMPRESSION:
1. Severe compression fracture of T6 vertebral body with
retropulsion causing narrowing of the spinal canal.
2. Bilateral sixth rib fractures at the costovertebral
junctions.
3. Right sacral fracture. Recommend a pelvis CT to assess for
associated fractures. This was discussed with Dr. [**First Name (STitle) **] in the
MICU at 8:50 am on [**2141-4-11**].
4. Lumbar spondylosis with moderate multilevel neural foraminal
narrowing. Grade I anterolisthesis at L3-4 is likely related to
facet arthropathy. Grade I anterolisthesis at L5-S1 secondary to
bilateral L5 pars defects.
5. Left renal cystic lesion is incompletely evaluated. If there
are no previous studies to confirm its stability, then further
characterization with an ultrasound is suggested.
.
MRI T-spine ([**2141-4-10**])
IMPRESSION: Burst fracture at T6 with greater than 50% loss of
height and involvement of the anterior, middle and posterior
columns as well as retropulsion and spinal canal compromise.
.
CBC
[**2141-4-15**] 05:45AM BLOOD WBC-7.8 RBC-3.02* Hgb-8.7* Hct-26.6*
MCV-88 MCH-28.7 MCHC-32.6 RDW-16.2* Plt Ct-304
[**2141-4-14**] 01:48AM BLOOD WBC-9.1 RBC-3.21* Hgb-8.8* Hct-27.7*
MCV-86 MCH-27.3 MCHC-31.7 RDW-15.3 Plt Ct-218
[**2141-4-13**] 01:53PM BLOOD WBC-10.9 RBC-3.58* Hgb-9.7* Hct-30.6*
MCV-86 MCH-27.0 MCHC-31.6 RDW-15.6* Plt Ct-235
[**2141-4-13**] 02:44AM BLOOD WBC-9.3 RBC-3.38* Hgb-9.6* Hct-29.5*
MCV-87 MCH-28.5 MCHC-32.6 RDW-16.0* Plt Ct-246
[**2141-4-12**] 03:04AM BLOOD WBC-9.4 RBC-3.35* Hgb-9.7* Hct-29.1*
MCV-87 MCH-28.8 MCHC-33.2 RDW-16.3* Plt Ct-260
[**2141-4-11**] 10:50PM BLOOD WBC-9.1 RBC-3.71* Hgb-10.3* Hct-32.4*
MCV-87 MCH-27.7 MCHC-31.7 RDW-16.0* Plt Ct-285
[**2141-4-11**] 10:13AM BLOOD WBC-10.9 RBC-3.87* Hgb-10.3* Hct-33.1*
MCV-86 MCH-26.7* MCHC-31.2 RDW-15.9* Plt Ct-296
[**2141-4-10**] 05:25PM BLOOD WBC-11.1* RBC-4.26 Hgb-11.7* Hct-36.7
MCV-86 MCH-27.6 MCHC-31.9 RDW-15.8* Plt Ct-299
.
Coag
[**2141-4-15**] 05:45AM BLOOD PT-11.0 PTT-28.4 INR(PT)-0.9
[**2141-4-13**] 02:44AM BLOOD PT-10.5 PTT-25.9 INR(PT)-0.9
[**2141-4-11**] 10:50PM BLOOD PT-11.2 PTT-23.1 INR(PT)-0.9
[**2141-4-11**] 08:00PM BLOOD PT-11.4 PTT-22.0 INR(PT)-0.9
[**2141-4-11**] 05:10PM BLOOD PT-11.2 PTT-23.4 INR(PT)-0.9
[**2141-4-11**] 12:10PM BLOOD PT-10.6 PTT-23.3 INR(PT)-0.9
.
Chemistry
[**2141-4-15**] 05:45AM BLOOD Glucose-91 UreaN-9 Creat-0.4 Na-143 K-3.7
Cl-105 HCO3-32 AnGap-10
[**2141-4-14**] 01:48AM BLOOD Glucose-92 UreaN-12 Creat-0.4 Na-140
K-4.2 Cl-103 HCO3-35* AnGap-6*
[**2141-4-13**] 01:53PM BLOOD Glucose-139* UreaN-10 Creat-0.5 Na-141
K-4.0 Cl-101 HCO3-34* AnGap-10
[**2141-4-13**] 02:44AM BLOOD Glucose-122* UreaN-11 Creat-0.5 Na-141
K-3.6 Cl-104 HCO3-30 AnGap-11
[**2141-4-12**] 03:04AM BLOOD Glucose-133* UreaN-21* Creat-0.6 Na-142
K-4.0 Cl-108 HCO3-28 AnGap-10
[**2141-4-11**] 10:50PM BLOOD Glucose-124* Creat-0.7 Na-143 K-4.1
Cl-108 HCO3-28 AnGap-11
[**2141-4-11**] 10:13AM BLOOD Glucose-106* UreaN-21* Creat-0.6 Na-143
K-4.2 Cl-105 HCO3-29 AnGap-13
[**2141-4-10**] 05:25PM BLOOD Glucose-119* UreaN-19 Creat-0.9 Na-142
K-4.1 Cl-97 HCO3-36* AnGap-13
[**2141-4-14**] 01:48AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
[**2141-4-13**] 02:44AM BLOOD Calcium-8.1* Phos-3.8 Mg-1.9
[**2141-4-12**] 03:04AM BLOOD Albumin-2.9* Calcium-8.4 Phos-4.3 Mg-1.9
[**2141-4-11**] 10:50PM BLOOD Calcium-9.5 Phos-4.4 Mg-2.0
[**2141-4-11**] 10:13AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.3
Brief Hospital Course:
This is a 78 year old female with PMH of Parkinson's, COPD, CHF,
h/o L5-S1 discectomy presents with progressive LE weakness and
bowel and bladder incontinence, found to have a nontraumatic T6
burst fracture with retropulsed fragment. Now s/p T3-T9
arthrodesis but with paralysis of bilateral lower extremities.
.
#. T6 burst fracture - nontraumatic compression fracture now s/p
emergent T5-7 posterior decompression and T3-9 fusion on
[**2141-4-11**]. Patient is now paralyzed from the waist down,
although sensation in her legs remains intact. She seems to not
have sensation of her abdomen and has developed some abrasions
there, likely from her scratching the area. Uncertain what
precipitated the fracture, T6 vertebral body was sent to
pathology to evaluate for pathologic fracture and only showed
fragments of trabecular bone with focal remodelling and
fibrocartilage with degenerative changes. Ortho does not
recommend bracing her spine following this procedure. Patient
has pain well managed with oxycodone 5 mg q6h standing.
.
#. Anemia - Patient had significant blood loss during surgical
procedure and also oozing from wound. She was transfused 2
units of pRBCs, but was never documented to have a drop in
hematocrit. No current signs of bleeding and hematocrit has
remained stable around 27.
.
#. Neurogenic bladder - PM&R recommends d/c foley catheter and
start intermittent catheterization every 4-6 hours. However,
having to reposition her legs for straight cath every 4-6 hours
is very painful for patient, and so foley was left in for the
time being. Foley can be discontinued in rehab.
.
#. Neurogenic bowel - Patient was started on an aggressive bowel
regimen of colace, senna, bisacodyl suppository, miralax, and
lactulose. During this admission, patient was also given enemas
to help with passing bowel movements. On discharge, patient's
abdomen still remains distended. She should get enemas as
needed to ensure that she has a bowel movement everyday.
.
#. UTI - urine culture shows E.coli sensitive to Augmentin.
Patient was started on Augmentin on [**4-12**] for a planned 7 day
course for treatment of UTI.
.
#. Decubitus ulcer prophylaxis - patient was turned q2hrs for
prevention of decubitus ulcer formation.
.
#. DVT prophylaxis - had an IVC filter placed on [**4-13**]
prophylactically. PM&R recommends anticoagulation with Lovenox
30 mg [**Hospital1 **] for 12 weeks despite having IVC filter placed as
patient has just had orthopedic surgery.
.
# Stress ulcer prophylaxis - Patient was started on a PPI while
in perioperative period. Can be discontinued 4 weeks out from
surgery.
.
#. Parkinson's - patient was continued on sinemet, requip, and
comtan
.
#. Depression - patient was continued on Cymbalta and Remeron
.
#. COPD - patient uses 2L of O2 at home at baseline. Patient
was continued on spiriva, ipratropium, albuterol
Medications on Admission:
Sinemet 25/100 one tab PO BID (0530 and 1030)
Sinemet 25/100 PO 0.5 tabs [**Hospital1 **] (1400 and 1900)
Sinemet CR 25/100 one tab QID (0530, 0730, 1400, 1900)
Comtan 200mg PO one tab FIVE Times per day (0530, 0730, 1030,
1400, 1900)
Requip 8 mg, 2 tabs daily
Furosemide 40mh\g PO daily
MOM 30ml PRN
Dulcolox PR PRN
Tylenol 650 mg Q6 PRN
Fleets EAnema PRNSimvastatin 40mg daily
Cymbalta 60mg daily
ASA 81 mg daily
KCL 10 Meq daily
Clonazepam 0.5 mg [**Hospital1 **]:PRN
MVI one tab daily
Prilosec 20mg [**Hospital1 **]
Remeron 15mg qHS
Naprosyn 500mg [**Hospital1 **]:PRN
Vicodin one tab [**Hospital1 **]:PRN
Spiriva 18mcg daily
Flovent 110mg 2 puffs daily
Albuterol IH 1 puff Q4 PRN
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Albuterol Sulfate 5 mg/mL Solution for Nebulization Sig: One
(1) nebulizer Inhalation every four (4) hours as needed for
shortness of breath, wheezing.
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day): Take at 05:30AM, 07:30AM, 2:00PM, 7:00PM .
7. Carbidopa-Levodopa 25-100 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): take at 2PM and 7PM.
8. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day): take at 5:30AM and 10:30AM.
9. Entacapone 200 mg Tablet Sig: One (1) Tablet PO FIVE TIMES
PER DAY ().
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
14. Ropinirole 1 mg Tablet Sig: Sixteen (16) Tablet PO QAM (once
a day (in the morning)).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness breath.
16. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
18. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours) for 12 weeks.
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
20. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): please hold for oversedation or RR<10. Patient may
refuse
.
21. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
22. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
23. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
24. Calcium Carbonate 1,000 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
25. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
26. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
27. Lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for anxiety.
28. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
Flaccid paralysis
T6 burst fracture
.
Secondary Diagnosis:
1) S/p reduction of fracture dislocation T5-6 and T6-7,
posterior arthrodesis T3-4, T4-5, T5-6, T6-7, T7-8 and T8-9,
posterior instrumentation T3 to T9, and arthroplasty in same
region.
2) Parkinsons disease
3) COPD on home O2
4) 4.2cm thoracic aortic aneurysm
5) Depression
6) hypercholesterol
7) hx L5-S1 discectomy
8) R TKA years ago
9) peripheral neuropathy
10) CHF
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Bedbound
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
leg weakness and inability to hold urine and stool. You were
found to have a T6 fracture for which you had spine surgery and
had your T3-T9 vertebrae were fused. Unfortunately even after
the surgery, you have not been able to move your legs. You are
being discharged to a rehabilitation facility to see if there is
a chance at regaining some motor function in your legs.
.
Your new medication list has been forwarded to [**Hospital3 **]
center.
Followup Instructions:
Please keep all of your outpatient follow-up appointments listed
below:
.
1. Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 711**], NP at your primary
care doctor's office on [**4-28**] at 2PM.
.
2. Department: ORTHOPEDICS
When: MONDAY [**2141-5-1**] at 9:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
3. Department: SPINE CENTER
When: MONDAY [**2141-5-1**] at 9:20 AM
With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3736**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
o At this follow-up visit your incision will be checked and
baseline X-rays and questions will be answered.
ICD9 Codes: 5990, 2851, 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7528
} | Medical Text: Admission Date: [**2177-3-10**] Discharge Date: [**2177-3-12**]
Date of Birth: [**2122-3-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Pericardial effusion.
Major Surgical or Invasive Procedure:
Pericardiocentesis and pericardial drain placement.
History of Present Illness:
The patient is a 52-year old female with a history of metastatic
breast cancer, s/p lt. mastectomy now enrolled in clinical trial
"05-395" (lapatinib monotherapy 1500 mg), who noted lt. arm
swelling [**2-28**]. Doppler neg for clot, but CT (routine, restaging)
revealed pericardial effusion. Echo [**3-3**] revealed: small to
moderate sized circumferential pericardial effusion, most
prominently inferolateral to the left ventricle and around the
right atrium, but ~1cm anterior to the right ventricle. There is
mild right ventricular diastolic collapse consistent with
increased pericardial pressure/early tamponade physiology.
.
[**3-5**]: Compared with the prior study (images reviewed) of
[**2177-3-3**], the pericardial effusion appears similar to slightly
larger. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology.
.
[**3-7**]: There is subtle RV diastolic compression without collapse
(no overt tamponade). Compared with the prior study (images
reviewed) of [**2177-3-5**], there is slightly less pericardial fluid
anteriorly. Otherwise no change.
.
A pericardial drain was placed with return of approximately 250
cc of serosanginous fluid and normalization of right heart
pressures. She is admitted to the CCU for further monitoring.
Past Medical History:
ONCOLOGY HISTORY: She was initially diagnosed in [**2164**] with a 3.5
cm infiltrating ductal carcinoma, lymph node positive, LVI
positive, ER positive. She is status post left mastectomy with
reconstruction, CAF followed by tamoxifen. She recurred in
[**7-/2169**], with metastasis to her left supraclavicular node and
lung. Biopsy documented HER-2/neu over expression by
immunohistochemistry. ER positive. She was treated with Arimidex
for six months, which was followed by Taxol and Herceptin. She
was then treated with high-dose chemo and Herceptin followed by
transplant as part of the clinical trial. This chemo included
thiotepa, [**Doctor Last Name **], and Taxol. In [**9-/2173**], she was treated with
letrozole and Herceptin and was then switched to Aromasin and
Herceptin in 11/[**2174**]. Upon progression [**Male First Name (un) **] was switched to the
lapatinib phase II trial in [**7-28**], and herceptin was
discontinued. She has received 8 cycles of lapatinib.
.
PAST MEDICAL HISTORY:
1. Metastatic breast cancer as above.
2. Autologous bone marrow transplant in [**2169**].
3. History of meningoceles.
4. Hyperlipidemia.
Social History:
A single parent. She lives with her 13-year-old daughter. [**Name (NI) **]
tobacco, alcohol, or drugs.
Family History:
Father has lymphoma.
Physical Exam:
Blood pressure was 116/66 mm Hg while seated. Pulse was 73
beats/min and regular, respiratory rate was 15 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of less than 6 cm. The carotid waveform was normal. There
was no thyromegaly. The were no chest wall deformities,
scoliosis or kyphosis. The respirations were not labored and
there were no use of accessory muscles. The lungs were clear to
ascultation bilaterally with normal breath sounds and no
adventitial sounds or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, clicks or gallops.
There was a slight [**1-28**] HSM.
.
There is a pericardial drain in place in the sub-xiphoid
position. Drainage bag connected, contains approx 10 cc of
serosanguinous fluid.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing. There is slight (1+), diffuse, Lt. UE edema. There
were no abdominal, femoral or carotid bruits. Inspection and/or
palpation of skin and subcutaneous tissue showed no stasis
dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Labwork on admission:
[**2177-3-10**] 04:15PM WBC-4.2 RBC-3.40* HGB-10.8* HCT-31.0* MCV-91
MCH-31.9 MCHC-35.0 RDW-14.8
[**2177-3-10**] 04:15PM PLT COUNT-161
[**2177-3-10**] 04:15PM GLUCOSE-99 UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12
.
Labwork on admission:
C.CATH Study Date of [**2177-3-10**]
*** Not Signed Out ***
BRIEF HISTORY:
This 55 year old female with known diagnosis of metastatic
breast cancer
presented with pericardial effusion diagnosed on echocardiogram
with
significant respiratory mitral flow variation. Patient was
therefore
referred for pericardiocentesis.
INDICATIONS FOR CATHETERIZATION:
Pericardial effusion.
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Pericardiocentesis: was performed via the subxyphoid approach,
using an
18 gauge thin-wall needle, a guide wire, and a drainage
catheter.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: m2
HEMOGLOBIN: gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 14/12/10
RIGHT VENTRICLE {s/ed} 35/12
PULMONARY ARTERY {s/d/m} 35/15/21
PULMONARY WEDGE {a/v/m} 16/16/12
AORTA {s/d/m} 140/65/95
PERICARDIUM {m} 12
**CARDIAC OUTPUT
HEART RATE {beats/min} 70
RHYTHM SINUS
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 45 minutes.
Arterial time = 45 minutes.
Fluoro time = 2.3 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 20 ml,
Indications - Renal
Anesthesia:
1% Lidocaine subq.
Cardiac Cath Supplies Used:
- [**Company **], PERICARDIOSENTISIS SET
- ALLEGIANCE, CUSTOM STERILE PACK
COMMENTS:
1. Resting hemodynamics were performed. The right sided filling
pressures were mildly elevated (mean RA pressure was 12mmHg and
RVEDP
was 12mmHg). The pulmonary artery pressures were mildly elevated
measuring 35/15mmHg. The left sided filling pressures were
equalized to
the right (mean PCW pressure was 12mmHg). There was significant
respiratory variation of systemic arterial pressure up to
20mmHg. There
was equalization of RA and pericardial pressures.
2. Pericardiocentesis was performed under fluoroscopy guidance.
Pericardial drain was subsequently placed with 240cc
serosanguinous
fluid removed. Repeat measurement of pericardial pressure and RA
pressure demonstrated clear seperation.
FINAL DIAGNOSIS:
1. Elevated right sided filling pressures with equlization of
RA/LA/pericardial pressures.
2. Successful placement of pericardial drain.
.
ECHO Study Date of [**2177-3-10**]
Conclusions:
Overall left ventricular systolic function is low normal (LVEF
50-55%). There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2177-3-7**],
there is now minimal residual pericardial effusion.
.
ECG Study Date of [**2177-3-10**] 1:00:10 PM
Sinus rhythm
Normal ECG
Since previous tracing, no significant change
.
CHEST (PORTABLE AP) [**2177-3-11**]
IMPRESSION: AP chest, small right pleural effusion is present.
Right lower lobe atelectasis is new since [**2-28**]. Consolidation
in the anterior segment of the right upper lobe and a right
apical paramediastinal mass are unchanged. Left lung is clear.
Several loops of pericardiocentesis catheter projecting over the
subxiphoid midline, the base of the heart and superiorly to the
level of the pulmonary outflow tract, are acutely coiled and
should be evaluated clinically to see if they are draining
properly. No pneumothorax.
.
ECHO Study Date of [**2177-3-11**]
Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There is a small
circumferential pericardial effusion primarily inferolateral to
the left ventricle with minimal effusion anterior to the right
ventricle. No echocardiographic signs of tamponade physiology
are seen.
Compared with the prior study (images reviewed) of [**2177-3-10**],
the inferolateral effusion is more prominent.
.
Labwork on discharge:
[**2177-3-12**] 09:25AM BLOOD WBC-5.6 RBC-3.67* Hgb-11.9* Hct-36.0
MCV-98# MCH-32.3* MCHC-32.9 RDW-14.2 Plt Ct-185
[**2177-3-12**] 09:25AM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-136
K-3.7 Cl-104 HCO3-21* AnGap-15
Brief Hospital Course:
55 year-old female with metastatic breast cancer presenting with
pericardial effusion.
.
1. Pericardial effusion. Likely malignant. Pericardiocentesis
was performed with approximately 250 cc of serosanguinous fluid
output and normalization of right heart pressures. A pericardial
drain was placed with 320 cc of serosanguinous fluid output the
first 12 hours, then 75 cc over 6 hours, then no output. A
repeat echocardiogram showed a small pericardial effusion
without evidence of tamponade as above. The pericardial drain
was removed. An echocardiogram the next morning showed stable
small pericardial effusion. Cultures were negative at the time
of discharge and cytology was pending. The patient will have a
repeat echocardiogram five days after discharge and will
follow-up with her oncologist. The patient may need a
pericardial window or balloon pericardiotomy procedure if the
effusion increases in size.
.
2. Infectious disease. The patient had a temperature to 100.8
the second day of admission. The patient's only localizing
symptom was a nonproductive cough the patient has complained of
for the past three weeks, overall improved since that time.
Chest x-ray showed atelectasis but no new consolidations.
Urinalysis negative for infection. Urine, blood, and pericardial
fluid cultures without growth at the time of discharge. The
fever was likely secondary to atelectasis or the patient's
underlying malignancy.
.
3. Breast cancer. The patient is now off the lapatinib study.
The patient is followed by oncology.
.
4. Anemia. The patient's hematocrit remained stable at 31-36
during admission. The patient's iron studies showed an iron to
TIBC ratio of 5%, although ferritin was within normal limits.
Folate and B12 were within normal limits. Further management
deferred to the patient's primary physician.
Medications on Admission:
Simvastatin 20 mg QD
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pericardial effusion status post pericardiocentesis and
pericardial drain placement/removal
.
Secondary:
1. Metastatic breast cancer
2. Autologous bone marrow transplant in [**2169**]
3. History of meningoceles
4. Hyperlipidemia
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were hospitalized after a procedure to remove fluid from
your pericardial sac. You will need a repeat echocardiogram to
assess for fluid reaccumulation. The office of your oncologist,
Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] contact you regarding scheduling of your
repeat echocardiogram and follow-up with oncology.
.
You spiked a fever during admission without any localizing
symptoms. Your oncologist should follow-up the urine, blood, and
pericardial fluid cultures drawn during this admission.
.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, palpitations, or any other
concerning symptoms.
.
Please take your medications as prescribed. There were no
changes made to your medications.
.
Please keep your follow-up appointments as below.
Followup Instructions:
The office of your oncologist, Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] contact you
regarding scheduling of your repeat echocardiogram and follow-up
with oncology on Monday, [**3-17**]. Please call the office at
([**Telephone/Fax (1) 21188**] with any questions or concerns or if you do not
hear from a representative by this Friday.
.
Previously scheduled appointments:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2177-3-17**] 10:45
ICD9 Codes: 5180, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7529
} | Medical Text: Admission Date: [**2101-10-3**] Discharge Date: [**2101-10-6**]
Date of Birth: [**2052-8-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 25876**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Implantation of L-sided pleural bases pigtail catheter.
History of Present Illness:
49 yo female with metastatic melanoma dx in [**2093**], found to have
mets to the lung by CXR in [**2099-11-18**], CT confirmed
a right lower lobe and left lower lobe nodules. She underwent
bilateral VATS resection with pathology consistent with
melanoma. In [**2101-1-19**], follow-up CT revealed a
right pleural abnormality and she underwent a repeat bronc
and right VATS with talc poudrage on [**2101-2-18**]. Biopsy
confirmed recurrent melanoma. Pt presented to ED today with
increasing dyspnea for the past 3-4 days and new cough
productive of white sputum. Pt did note blood in sputum on one
occasion over the weekend. Denies fevers or chills, chest pain.
Has had poor appetite and decreased po intake. No black or
bloody stools reported. Further ROS negative.
.
In the [**Name (NI) **], pt was found to have B/L multi-loculated pleural
effusions, with L>R. IP was consulted and pt underwent
thoracentesis with placement of pigtail catheter under CT
guidance. Patient was admitted to MICU for further observation
given episodes of tachycardia, transient hypotension, tachypnea.
Past Medical History:
metastatic melanoma s/p Flex Bronch, VATs, TALC, Pleurex Cath
PMH/PSH:HChol, Migraines, metastatic melanoma, s/p L vats c
pleural bx and bilateral lower lobe nodule wedges [**9-22**], s/p
L-heel excision c STSG '[**93**], s/p R VATS w/ pleural biopsies and
talc pleurodesis [**2101-2-18**]
Social History:
lives in [**Location 686**] w/ 2 sons
separated from husband, has 3 sons. Pt lives in [**Location 686**].
former smoker- quit [**2083**], glass of wine 3x/week
Family History:
NC
Physical Exam:
PE: vitals 99.2/hr 100/bp 152/90/ rr 30/ 100% oxygen sat
GEN: thin, pale, anxious female
HEENT: atraumatic, anicteric, EOMI, mmm, PERRLA, OP clear
NECK: no JVD
CV: tachy, no murmurs, no rubs
LUNGS: decreased BS at bases, + conversational dyspnea, + wheeze
ABD: soft, nt, hypoactive BS, non-distended
EXT: warm, dry. No [**Location (un) **]. Proximal muscle strength 5/5 and intact
B/L in both UE and LE. DP pulses palpable B/L
NEURO: A/O X3, CN II-XII grossly intact, no focal deficits
Pertinent Results:
[**2101-10-3**] 10:15AM BLOOD WBC-3.0* RBC-2.67*# Hgb-7.4*# Hct-20.7*#
MCV-78* MCH-27.9 MCHC-35.8* RDW-15.4 Plt Ct-81*#
[**2101-10-3**] 10:15AM BLOOD Neuts-64.9 Lymphs-24.0 Monos-11.0 Eos-0.2
Baso-0
[**2101-10-3**] 10:15AM BLOOD PT-14.8* PTT-22.0 INR(PT)-1.3*
[**2101-10-3**] 10:15AM BLOOD Glucose-145* UreaN-18 Creat-0.7 Na-133
K-4.0 Cl-93* HCO3-23 AnGap-21*
[**2101-10-3**] 10:15AM BLOOD CK(CPK)-45
[**2101-10-3**] 10:15AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2101-10-4**] 03:45AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.2*
[**2101-10-3**] 09:14PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
Brief Hospital Course:
The patient with past medical history as detailed above with
initially admitted to the ICU for shortness of breath. She had
a placement of a L pleural based pigtail catheter for palliative
purposes. She was transferred to OMED and while on the floor,
it was decided that the patient was to receive comfort measures.
While being made comfortable the patient passed on [**2101-10-6**].
.
Family was present at the bedside.
Medications on Admission:
Discharge Disposition:
Home With Service
Facility:
VistaCare
Discharge Diagnosis:
Primary Diagnosis: Metastatic Melanoma
Discharge Condition:
Expired
Completed by:[**2101-10-11**]
ICD9 Codes: 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7530
} | Medical Text: Admission Date: [**2130-12-6**] Discharge Date: [**2130-12-18**]
Date of Birth: [**2074-3-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
CHEST PAIN
Major Surgical or Invasive Procedure:
[**12-8**] CABGx5(LIMA->LAD, SVG->Diag, Ramus, OM, PLV)
History of Present Illness:
56 yo F presented to MWMC wiht chest pain and underwent cardiac
cath which showed 3VD. Referred for CABG.
Past Medical History:
DM, HTN, HChol, DOE/Angina, [**Month/Year (2) **] (L ICA) GERD
CCY [**10-15**], TAH, CSXN x 2
Family History:
NC
Physical Exam:
AAOx3
RRR no M/R/G, 2/6 SEM
CTAB
Abdomen soft, minimally tender in RUQ (recent CCY)
No CCE
Pertinent Results:
[**2130-12-14**] 06:15AM BLOOD WBC-11.3* RBC-2.98* Hgb-9.0* Hct-25.9*
MCV-87 MCH-30.2 MCHC-34.7 RDW-15.1 Plt Ct-227
[**2130-12-13**] 03:21AM BLOOD WBC-11.4* RBC-2.88* Hgb-8.7* Hct-25.2*
MCV-88 MCH-30.3 MCHC-34.6 RDW-15.2 Plt Ct-173#
[**2130-12-14**] 06:15AM BLOOD Plt Ct-227
[**2130-12-10**] 02:16AM BLOOD PT-13.0 PTT-33.5 INR(PT)-1.1
[**2130-12-14**] 06:15AM BLOOD UreaN-15 Creat-0.7 K-3.4
[**2130-12-13**] 03:21AM BLOOD Glucose-58* UreaN-22* Creat-0.8 Na-141
K-3.4 Cl-104 HCO3-27 AnGap-13
CHEST (PORTABLE AP) [**2130-12-13**] 12:03 PM
CHEST (PORTABLE AP)
Reason: ? Pneumothorax post CT removal
[**Hospital 93**] MEDICAL CONDITION:
56 year old woman s/p bilateral pectoral flap [**12-10**]
REASON FOR THIS EXAMINATION:
? Pneumothorax post CT removal
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Assess for pneumothorax. Patient is post
bilateral pectoral flap.
Comparison is made with prior study performed a day earlier.
Right IJ line remains in place with tip in the lower SVC. No
clear pneumothorax is identified. Bibasilar opacities obscuring
the hemidiaphragms consistent with atelectasis are new on the
right and slightly increased on the left. There has been
interval increase in now mild-to-moderate pulmonary edema. Small
bilateral pleural effusions. Patient is post median sternotomy
and CABG.
CAROTID SERIES COMPLETE [**2130-12-13**] 1:44 PM
CAROTID SERIES COMPLETE
Reason: assees for stenosis
[**Hospital 93**] MEDICAL CONDITION:
56 year old woman s/p cabg w neuro changes
REASON FOR THIS EXAMINATION:
assees for stenosis
CAROTID STUDY.
HISTORY: Neurologic changes after cardiac bypass.
FINDINGS: No significant plaque or wall thickening involving the
right carotid system. Some predominantly hyperechoic left ICA
and CCA and ECA wall thickening. The peak systolic velocities on
the left are 131, 108, 94, 73 and 112 cm/sec for the proximal,
mid and distal ICA and CCA and ECA respectively. There is
antegrade flow involving the left vertebral artery. The right
vertebral artery was not visualized, presumed hypoplastic or
occluded. The ICA/CCA ratio is 0.89 on the right and 1.7 on the
left.
IMPRESSION: Findings as stated above which indicate:
1. Normal right carotid system.
2. 40-59% left ICA stenosis.
3. Non-visualized right vertebral artery, presumed hypoplastic
or occluded.
CT HEAD W/O CONTRAST [**2130-12-11**] 11:02 AM
CT HEAD W/O CONTRAST
Reason: r/o cva
[**Hospital 93**] MEDICAL CONDITION:
56 year old woman s/p CABG(POD3)now with neuro changes
REASON FOR THIS EXAMINATION:
r/o cva
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post CABG, now with neural changes. Rule out
CVA.
COMPARISON: None.
TECHNIQUE: MDCT acquired images of the head obtained without IV
contrast.
CT HEAD WITHOUT CONTRAST: There is a hypodensity in the right
frontal lobe white matter as well as hypodensity in the region
of the left basal ganglia and adjacent to the left lateral
ventricle within the white matter consistent with chronic
ischemic change/infarction. No evidence of acute intra- or
extra-axial hemorrhage. There is no shift of normally midline
structures. There is no sulcal effacement. [**Doctor Last Name **]-white matter
differentiation appears preserved. There is minimal bilateral
maxillary sinus opacification. There appears to be a skin
thickening in the left frontal region.
IMPRESSION:
1. Evidence of chronic infarction.
2. Left frontal skin thickening. Correlate clinically.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75973**] (Complete)
Done [**2130-12-8**] at 11:34:03 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2074-3-1**]
Age (years): 56 F Hgt (in): 64
BP (mm Hg): / Wgt (lb): 163
HR (bpm): BSA (m2): 1.79 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 410.91, 440.0, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2130-12-8**] at 11:34 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW4-: Machine: 4
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Peak Pulm Vein S: 0.3 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Left Atrium - Peak Pulm Vein A: 0.1 m/s < 0.4 m/s
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Left Ventricle - Lateral Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *20 < 15
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 2.00
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.
MITRAL VALVE: Myxomatous mitral valve leaflets. Moderate mitral
annular calcification. Calcified tips of papillary muscles.
Trivial MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Overall left ventricular systolic function is normal
(LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened. Trace
aortic regurgitation is seen.
6. The mitral valve leaflets are myxomatous. Trivial mitral
regurgitation is seen.
7. The tricuspid valve leaflets are mildly thickened.
POST-BYPASS:
Pt removed from CPB on phenylephrine infusion and epinephrine
infusion and AV paced.
1. Initially post-bypass, mitral and tricuspid regurgitation
increased to moderate and resolved soon thereafter.
2. Biventricular function is maintained, LVEF>55%.
3. Aortic contours are intact post-decannulation.
Brief Hospital Course:
She underwent preop work up and was taken to the operating room
on [**12-8**] where she underwent a CABG x 5. She was transferred to
the ICU in critical but stable condition. She was given 48 hours
of perioperative prophylactic vancomycin as she was in the
hospital preoperatively. She was extubated on POD #1, her
epinephrine was weaned and she was started on milrinone. She was
started on amiodarone for Vtach postop. On POD #3 she was found
to have right hemiparesis and neurology was consulted, head CT
was negative and the weakness improved. Her milrinone was weaned
and she was transferred to the floor on POD #4. Bedside swallow
was performed, she tolerated thin liquids and ground solids. She
was ready for discharge to rehab on POD # 6.
Medications on Admission:
Zocor 80', Zetia 10', Toprol XL 50', Enalapril 20", ASA 81',
Plavix 75' (cath), HCTZ 25', Reglan 10', Humulin 70 qAM, RISS
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. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Five (35) units Subcutaneous once a day.
8. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale Subcutaneous four times a day.
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day). Tablet(s)
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 3 days: 400 daily x 3 days then decrease to 200
daily ongoing until dc'd by cardiologist
. Tablet(s)
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 2 weeks.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
s/p CABGx5
PMH: DM,HTN,^[**Last Name (LF) **],[**First Name3 (LF) **](L ICA stenosis),GERD
PSH: CCY,TAH, C-section x2
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications asprescribed.
Call for any fever, redness or drainage from wounds.
No heavy lifting or driving
Followup Instructions:
[**Hospital Ward Name 121**] 6 for wound check 2 weeks
Dr [**First Name (STitle) **] 4 weeks
Dr [**Last Name (STitle) 73**] 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2130-12-14**]
ICD9 Codes: 4271, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7531
} | Medical Text: Admission Date: [**2132-4-27**] Discharge Date: [**2132-5-1**]
Date of Birth: [**2065-10-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
(R)UQ abdominal and epigastic pain radiating to the back.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 31303**] is a 66 yo F with CLL s/p multiple rounds of
chemotherapy, last in [**10-9**] (Campath), with ongoing bulky
adenopathy and splenomegaly who presents today with [**Date Range 5283**] and
epigastric pain that radiates to her back. The pain started an
hour or so after dinner and grew progressively worse throughout
the evening. The pain is sharp and constant, rated as a [**9-11**] on
arrival and [**6-11**] out of 10 currently. She has been nauseated
throughout the evening and morning as well. She reports one
episode of emesis. She denies fevers or chills. She has been
having regular BM's. She denies melena, hematochezia, or
[**Male First Name (un) 1658**]-colored stools. She knows that she has cholelithiasis, but
denies any history of biliary colic.
Past Medical History:
Oncologic Hx:
She completed two cycles of R-CVP back in [**7-/2130**] as part of her
initial treatment for CLL. She did not have a significant
response to treatment though her white count did normalize after
treatment. However, the patient remained with a predominance of
lymphocytes. She continued to have bulky lymphadenopathy both
above and below the diaphragm following this treatment, did have
slight interval decrease overall with the exception of a slight
increase in the size of her lymph nodes in the right
supraclavicular chain. She has remained with massive
splenomegaly. She had an extended hospitalization in [**8-/2130**] for
further workup for fever and night sweats. Her disease status
was reassessed with a bone marrow biopsy, which confirmed her
known history of CLL. She also had a lymph node biopsy of the
right supraclavicular node in order to rule out transformation
of her disease, which was also consistent with CLL without any
evidence of transformation. However, there was note of caseating
granuloma concerning for TB. She did have a PPD placed, which
was positive. Of note, she also developed a rash in this
setting, which eventually resolved. However, it was thought to
be related to TB, noted to be granuloma annulare on biopsy.
Ultimately, it was felt that she had extrapulmonary TB. She was
ultimately started on TB medication regimen with rifampin, INH,
ethambutol, and pyrazinamide. The patient was started on that at
the time of discharge from hospital on [**2130-8-18**]. At that
point, she was still having high fevers. After a few days of
being on this regimen, her high fevers improved. Of note, due to
a poor tolerability with anorexia, nausea, weight loss, and
fatigue, we switched her regimen. The ethambutol and
pyrazinamide were discontinued on [**2130-8-28**] and moxifloxacin
was added. She completed a six-month course of her TB medicines,
which she completed back in 02/[**2131**]. The patient refused to take
the medications any longer. She then had a slowly rising white
blood count over the past
couple of months. Also has had a depressed platelet count. Her
CT scans have overall been stable, but remained with persistent
bulky disease above and below the diaphragm with massive
splenomegaly. Our recommendation had been to proceed with a
fludarabine-based regimen given her bulky disease, but until
recently the patient refused any treatment and we had been
monitoring her off treatment. She noted at the beginning of
[**2-/2131**] of her plans to go to [**Country 27587**] in [**Month (only) 116**] for five or six
months. As a result, she agreed to receive treatment with FCR
regimen, which she began on [**2131-2-14**]. The goal of this was to
cytoreduce her disease before she leaves for [**Country 27587**]. Our plan
is to try to get two cycles in with time to recover prior to her
departure. She presents today for evaluation and countcheck
following her second cycle.
.
OTHER Past Medical History:
1. CLL. Please refer to OMR note [**2131-4-4**] for extensive details.
2. Extrapulmonary TB diagnosed [**8-8**], now s/p 6 months of 4-drug
therapy with rifampin, INH, ethambutol, and pyrazinamide.
3. Hypothyroidism
4. OA
4. OA
Social History:
From [**Country 27587**]. Tobacco: [**1-6**] PPD x 45 years, no alcohol, other
drugs. Lives at home with her husband, daughter, and grandson.
Owns and works at her own business "Helping hands" as a home
health aide.
Family History:
Non-contributory
Physical Exam:
VS: T: 99.3 PO,BP: 134/64, HR: 81, RR: 18, SaO2: 96% RA
GEN: Well appearing, pleasant female in NAD.
HEENT: Sclerae anicteric. O-P intact.
NECK: Supple. No lympadenopathy.
LUNGS: CTA(B).
CARDIAC: RRR; nl S1/S2 w/o m/c/r.
ABD: Normoactive BSX3. Soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.
SKIN: Intact.
Pertinent Results:
[**2132-4-27**] 04:55PM GLUCOSE-87 UREA N-11 CREAT-0.6 SODIUM-141
POTASSIUM-4.4 CHLORIDE-114* TOTAL CO2-22 ANION GAP-9
[**2132-4-27**] 04:55PM ALT(SGPT)-134* AST(SGOT)-148* ALK PHOS-138*
AMYLASE-1756* TOT BILI-0.6
[**2132-4-27**] 04:55PM LIPASE-2693*
[**2132-4-27**] 04:55PM ALBUMIN-3.3* CALCIUM-7.8* PHOSPHATE-3.3
MAGNESIUM-1.7
[**2132-4-27**] 04:55PM IgG-597*
[**2132-4-27**] 04:55PM WBC-1.2* RBC-2.94* HGB-9.2* HCT-27.1* MCV-92
MCH-31.4 MCHC-34.1 RDW-14.1
[**2132-4-27**] 04:55PM PLT COUNT-46*
[**2132-4-27**] 03:42AM LACTATE-1.1
.
[**2132-4-27**] Abdominal U/S:
1. Cholelithiasis with mild intrahepatic biliary dilatation.
Common bile
duct is dilated measuring up to 9 mm but appears to taper
distally. This is likely due to mass effect from surrounding
lymph nodes and could be confirmed with CT.
2. Fatty infiltration of the liver.
3. Multiple pathologic enlarged lymph nodes at porta hepatis
consistent with patient's known CLL.
Brief Hospital Course:
Patient admitted to SICU on [**2132-4-27**] for abdominal pain and
hypotension. Hypotension responded to multiple IV fluid boluses.
Made NPO. Status post ERCP with sphincterotomy and sludge/stone
removal from CBD; tolerated well. Foley placed. Given IV
Dilaudid for pain with good effect. Started on IV Zoysn.
Hemodynamically stable. Oncology consulted during this
admission; recommendations appreciated and followed.
[**2132-4-28**]: Diet advanced to sips; tolerated well. Transferred to
[**Hospital Ward Name 121**] 9 inpatient floor. Remained stable. Labs improved.
[**2132-4-29**]: Diet advanced to clears; continued good tolerability.
Foley discontinued. Ambulated frequently.
[**2132-4-30**]: Advanced to regular diet with good intake. Started on
Neupogen for leukopenia with associated total granulocyte count
of 380.
[**2132-5-1**]: Total granulocyte count 1600. IV antibiotics
discontinued. Voiding, ambulating independently. Tolerating
regular diet. Discharged home on Augmentin for three remaining
days. Has follow-up this Saturday at the [**Hospital **] Clinic;
follow-up labs to be done at that time to determine if futher
Neupogen dose needed. patient hemodynamically stable.
Medications on Admission:
Levothyroxine 137mcg Po daily; Vitamin D
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Levoxyl 137 mcg Tablet Sig: One (1) Tablet PO once a day.
4. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gallstone Pancreatitis and cholangitis.
Secondary: CLL s/p multiple rounds of chemotherapy
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of [**Hospital 1440**], or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-11**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
You have an appointment THIS SATURDAY [**5-3**] at Heme/[**Hospital **] clinic:
BED 4-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2132-5-3**] 10:30
You have an appointment with Dr. [**Last Name (STitle) **] (Surgery) on [**2132-5-12**] at 11:45am; Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]. Tel:
([**Telephone/Fax (1) 2828**].
Other appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2132-5-12**] 9:00
Provider: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2132-5-12**] 9:00
Completed by:[**2132-5-1**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7532
} | Medical Text: Admission Date: [**2157-10-13**] Discharge Date: [**2157-10-21**]
Date of Birth: [**2102-1-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Phenobarbital / Percocet / Percodan / Demerol / Nsaids
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest discomfort, dyspnea
Major Surgical or Invasive Procedure:
[**2157-10-14**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary to left anterior descending, vein
grafts to obtuse marginal and right coronary artery.
History of Present Illness:
Mrs. [**Known lastname 18252**] presented to outside hospital with seven day history
of exertional chest pain associated with dyspnea. On the morning
of admission, she awoke with chest pain. EKG on admission showed
new lateral T wave abnormalities. She ruled for myocardial
infarction with positive troponin. Stress MIBI revealed anterior
apical defect consistent with ischemic heart disease. Subsequent
cardiac catheterization showed severe three vessel coronary
artery disease including an 80% ostial left main lesion. Given
her critical coronary anatomy, she was transferred to the [**Hospital1 18**]
for surgical intervention.
Past Medical History:
Coronary Artery Disease
Hypertension
Hypercholesterolemia
Diabetes Mellitus Type II
History of Herpes Zoster
Osteoarthritis
Gout
Gastroesophogeal Reflux Disease
History of Asthma(Cold-induced)
s/p Laminectomy
s/p Bilateral Total Knee Replacements
s/p Bilateral Shoulder Surgery
s/p Cholecystectomy
s/p Cervical Fusion
s/p Lasery Eye Surgery
s/p Carpal Tunnel Surgery
Social History:
Works as [**Name8 (MD) **] RN, lives alone. Denies tobacco and ETOH.
Family History:
Father has history of MI. Sister underwent PTCA at age 60.
Physical Exam:
Vitals: T 98.0, BP 139/77, HR 72, RR 16, SAT 96% 2L
General: WDWN femaile in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, no murmur or rub
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 1+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2157-10-20**] 04:45PM BLOOD WBC-11.3*# RBC-4.24 Hgb-12.6 Hct-35.4*
MCV-84 MCH-29.7 MCHC-35.6* RDW-13.6 Plt Ct-520*
[**2157-10-13**] 10:59AM BLOOD WBC-7.8 RBC-4.27 Hgb-12.9 Hct-36.1 MCV-85
MCH-30.2 MCHC-35.7* RDW-13.4 Plt Ct-342
[**2157-10-20**] 04:45PM BLOOD Plt Ct-520*
[**2157-10-14**] 12:31PM BLOOD PT-13.5* PTT-34.3 INR(PT)-1.2*
[**2157-10-13**] 10:59AM BLOOD Plt Ct-342
[**2157-10-13**] 10:59AM BLOOD PT-12.8 PTT-57.6* INR(PT)-1.1
[**2157-10-14**] 11:13AM BLOOD Fibrino-122*
[**2157-10-20**] 04:45PM BLOOD Glucose-159* UreaN-17 Creat-1.0 Na-137
K-4.1 Cl-94* HCO3-31 AnGap-16
[**2157-10-13**] 10:59AM BLOOD Glucose-218* UreaN-24* Creat-1.0 Na-140
K-4.0 Cl-103 HCO3-27 AnGap-14
[**2157-10-20**] 04:45PM BLOOD ALT-89* AST-58* LD(LDH)-243 AlkPhos-105
Amylase-49 TotBili-0.4
[**2157-10-20**] 04:45PM BLOOD Lipase-52
[**2157-10-13**] 10:59AM BLOOD cTropnT-0.01
[**2157-10-20**] 04:45PM BLOOD Albumin-3.7 Calcium-10.0 Phos-4.7* Mg-1.6
[**2157-10-13**] 10:59AM BLOOD %HbA1c-6.5*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2157-10-18**] 3:45 PM
CHEST (PA & LAT)
Reason: eval ptx s/p CT d/c
[**Hospital 93**] MEDICAL CONDITION:
55 year old woman s/p CABG
REASON FOR THIS EXAMINATION:
eval ptx s/p CT d/c
REASON FOR EXAM: S/P CABG, chest tube removed.
PA AND LATERAL VIEWS OF THE CHEST, THREE RADIOGRAPHS: Patient is
post median sternotomy and CABG. Cardiac size is normal. Left
lower lobe atelectasis has improved, almost completely resolved.
Otherwise, the lungs are clear. There is a questionable small
apical left pneumothorax.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved: WED [**2157-10-19**] 9:37 AM
Cardiology Report ECG Study Date of [**2157-10-15**] 2:07:26 PM
Sinus rhythm. Findings are as previously described on the
tracing of [**2157-10-14**]
and are probably without change, although baseline artifact
makes comparison
difficult.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
95 118 94 326/387 11 23 67
Cardiology Report ECHO Study Date of [**2157-10-14**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for CABG procedure
Height: (in) 66
Weight (lb): 193
BSA (m2): 1.97 m2
BP (mm Hg): 156/78
HR (bpm): 67
Status: Inpatient
Date/Time: [**2157-10-14**] at 10:32
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.0 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 0.88
TR Gradient (+ RA = PASP): >= 19 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF
(>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient appears to be in sinus rhythm.
Results were
Conclusions:
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2.Regional left ventricular wall motion is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is
not present. No aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
Post Bypass
1. Biventricular systolic function is unchanged.
2. Mild mitral regurgitation persists.
3. Aorta intact post decannulation
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2157-10-14**] 11:54.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mrs. [**Known lastname 18252**] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation. She remained pain
free on intraveous therapy. Workup was unremarkable and she was
cleared for surgery. On [**10-14**], she underwent coronary
artery bypass grafting by Dr. [**Last Name (STitle) 914**]. For surgical details,
please see seperate dicatated operative note. Following the
operation, she was brought to the the CSRU for invasive
monitoring. Within 24 hours, she awoke neurologically intact and
was extubated without incident. Due to hypertension, she
initially required Nitro drip. Over several days, medical
therapy was titrated accordingly and she transferred to the SDU
for further care and recovery. Chest tubes and pacing wires were
removed without complication. She had several episodes of
agitation and confusion after receiving dilaudid and IV ativan,
the confusion resolved after discontinuing the medications.
However On POD # 5 was seen by psychiatry for disorientation and
agitation after receing ambien for sleep. She was given Haldol
and she improved over a few hours. She was pleasant and
cooperative in the afternoon and interacting with visitors. She
was ready for discharge to rehab on POD 7.
Medications on Admission:
IV Heparin, Aspirin 81 qd, Lasix 40 qd, Glyburide 2.5 [**Hospital1 **],
Lopressor 50 [**Hospital1 **], Cytotec 200 [**Hospital1 **], Relafen, Protonix 40 qd,
Crestor 10 qd, Effexor XL 150 qd, Calan 240 qd, Citracal
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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
7. Misoprostol 200 mcg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous once a day.
14. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38640**] [**Doctor Last Name **]
Discharge Diagnosis:
Coronary Artery Disease. Acute MI - s/p CABG
Hypertension
Hypercholesterolemia
Diabetes Mellitus Type II
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
[**Telephone/Fax (1) 170**].
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. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] in [**5-19**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39975**] in [**3-19**] weeks, call for appt
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**3-19**] weeks, call for appt [**Telephone/Fax (1) 74697**]
Completed by:[**2157-10-21**]
ICD9 Codes: 4019, 2749, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7533
} | Medical Text: Admission Date: [**2158-11-4**] Discharge Date: [**2158-11-12**]
Date of Birth: [**2094-3-2**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 64-year-old female
with a history of MDS diagnosed in [**2157-2-18**] requiring
serial platelet and RBC transfusions every two weeks
presenting with a history of bronchitis, who was treated as
an outpatient with Augmentin, who was then admitted to the
Medicine service on the [**3-4**]. Patient was
initially treated with the following antibiotics: Zithromax,
cefepime, and Vancomycin. Her chest x-ray was consistent
with pneumonia on the right side and mild volume overload.
The patient was persistently febrile with a cough and had new
onset atrial fibrillation with hypoxic episodes. There was
concern regarding her relative immunosuppression and
therefore, the patient was started on Bactrim treatment and
was transferred to the MICU for management of hypoxia,
possible intubation, and concern for PCP [**Name Initial (PRE) 1064**].
In the MICU, the patient's oxygen saturations fluctuated.
She was 93% on 100% nonrebreather. She continued to complain
of sensation of shortness of breath, but denied any chest
pain, nausea, vomiting, abdominal pain. She was delirious
and somewhat confused at her initial presentation in the
MICU.
PAST MEDICAL HISTORY: As noted above.
1. MDS.
2. CHF.
3. AFib.
4. CVA diagnosed in [**2156**].
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: No alcohol abuse. No tobacco. She has two
grown children and lives at home.
PHYSICAL EXAMINATION: Her physical exam was notable for a T
max of 102.6. She was tachycardic, atrial fibrillation at
126-136 was her ventricular rate, blood pressure ranged from
95-111/48-55. Her respiratory rate ranged from 33-40. She
was 93-94% on 100% nonrebreather. Her exam was notable for
elderly appearing frail female, who was oriented x1. She had
regular tachycardia, S1, S2. Pulmonary examination:
Bronchial breath sounds with bibasilar crackles. Abdominal
examination was soft, obese. Extremity examination was
unremarkable.
Her EKG showed sinus tachycardia with normal axis and
intervals. She had old T-wave inversions in V1 through V4,
otherwise no evidence of acute ischemia.
LABORATORY STUDIES: Remarkable for platelets of 13,000 and
hematocrit of 28.3. Upon admission to the MICU, her ABG was
7.52, 23, 66. Lactate 2, TSH 1.4, fibrinogen 818.
Echocardiogram from the [**2-23**]: Ejection fraction
60%, left atrial dilatation, [**12-22**]+ TR, no vegetations.
RADIOGRAPHIC DATA: Showed pulmonary congestion with possible
infiltrates.
CT of her abdomen from the [**3-4**] notable for
ground-glass opacities at the lung bases, otherwise it was
unremarkable.
HOSPITAL COURSE BY PROBLEM:
1. Respiratory failure, pneumonia, and CHF: The patient had
persistent temperature spikes. She was maintained on triple
antibiotic regimen, however, persistently spiked and without
any change in her chest x-ray or symptoms. In the setting of
her immunosuppression, there is a higher suspicion for PCP
and fungal etiologies, therefore, the patient was maintained
on Vancomycin, azithromycin, cefepime, and Bactrim.
The patient had a history of oral herpetic lesions in the
past and was started on acyclovir as well. Given the
patient's poor respiratory status as well as overall poor
prognosis. The patient's family agreed to pursue comfort
measures only.
2. MDS: The patient's platelets remained below 15,000
despite multiple transfusions. There is no evidence of
active bleeding.
3. Change in mental status and fever: CT of the head was
performed to evaluate any evidence of an acute intracranial
hemorrhage. There was no evidence of that. CTA was also
performed to evaluate for any evidence of a pulmonary embolus
given the patient's ongoing hypoxia.
In summary, given the patient's overall poor prognosis and
ongoing hypoxia despite very broad coverage with
antimicrobials, a family meeting confirmed the patient's code
status DNR/DNI as well as pursuing comfort measures only.
The patient proceeded to become more tachypneic and
tachycardic throughout her hospital course. All of her
antibiotics were withdrawn and the patient was put on a
Morphine drip titration to comfort measures.
On [**2158-11-11**], patient was sedated and reportedly
unresponsive to verbal stimuli, and was persistently
tachycardic. On the [**11-12**], the patient died.
Family members were present at the time of death which was
4:20 a.m. Family declined an autopsy.
CAUSE OF DEATH: Respiratory distress secondary to pneumonia
and myelodysplastic syndrome. Immediate cause of death was
respiratory failure.
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**], M.D. [**MD Number(1) 1178**]
Dictated By:[**Last Name (NamePattern1) 1600**]
MEDQUIST36
D: [**2158-11-27**] 12:58
T: [**2158-11-29**] 06:29
JOB#: [**Job Number 97463**]
ICD9 Codes: 486, 4280, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7534
} | Medical Text: Admission Date: [**2160-12-6**] Discharge Date: [**2160-12-7**]
Date of Birth: [**2091-1-12**] Sex: F
Service: Neurology
CHIEF COMPLAINT: Basal ganglia hemorrhage.
HISTORY OF PRESENT ILLNESS: This is a 69-year-old woman with
a past medical history of hypertension, who complained of a
stiff neck and headache for days, and then suddenly collapsed
at home with slurred speech, left arm weakness, left facial
droop, and progressive had headache, nausea, vomiting, and
rapid progressive loss of consciousness.
She was seen at [**Hospital3 3765**], intubated there. She was
med flighted to [**Hospital1 69**] for
further care and had a CT scan at the [**Hospital1 190**] ED which showed roughly 200 cc sized right
sided basal ganglia hemorrhage.
PAST MEDICAL HISTORY: Hypertension.
MEDICATIONS: None.
ALLERGIES: None.
HABITS: Not known.
SOCIAL HISTORY: Currently lives at home, married, and two
sons.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 94.8 axillary, blood
pressure 143/86 on Nipride drip, heart rate 53, respiratory
rate 14 on mechanical ventilation. General: Elderly woman
intubated. Mental status: Patient is comatosed, turning her
head to nasopharyngeal stimulation, but not responding to sternal
rub, voice, or pain. Cranial nerves: Does not blink to
threat. Pupils fixed at roughly 6 mm and do not respond to
night. Subtle corneal responses bilaterally. Head turn to
nasopharyngeal stim. No oculocephalic reflexes. No gag.
There is, however, some gagging with deep suctioning by the
respiratory therapist. Motor and sensory: Tone decreased
throughout all four limbs. There is slight dorsiflexion and
hip flexion with nailbed stim on the right lower extremity.
There is slight dorsiflexion on the left lower extremity to
nailbed stimulation. Otherwise, there is no movement
elsewhere. Reflexes: Mute toes bilaterally.
LABORATORIES UPON PRESENTATION: Chem-7 normal except for a
potassium of 3.1. Coags normal with an INR of 0.98. White
blood cell count 8.2, hematocrit 38.9, platelets 200.
IMAGING: CT of the head: 6 x 7 cm bleed on 11 slices with
interventricular blood in the third, fourth, and occipital
horns of the lateral ventricles.
HOSPITAL COURSE:
Basal ganglia hemorrhage: The estimated volume of the bleed
was approximately 200 cc and as explained to the family, the
size of the bleed was virtually unsurvivable. She already
had minimal brain stem reflexes and for that reason, it was
explained to the family that she would progressively loose
those brain stem reflexes given the amount of swelling and
blood in the intracranial space. The family did agree for
comfort measures only, however, they did want to pursue the
possibility of organ donation. For this reason, she was
admitted to the ICU on the ventilator and a Nipride drip to
maintain her hemodynamics until brain death was declared.
She had an arterial line placed for blood pressure
monitoring. She maintained a good urine output. By the
following morning, she only had one cornea that was reactive
and had minimal triple flexion on the right lower extremity
to nailbed stimulation. The family was updated and they
wished that the patient be extubated, and did not want to
wait further for brain death or harvesting of organs. The
patient was declared at 2:09 p.m. after extubation and she
died of apnea within minutes.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**]
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2160-12-8**] 13:46
T: [**2160-12-8**] 14:12
JOB#: [**Job Number 53820**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7535
} | Medical Text: Admission Date: [**2186-12-14**] Discharge Date: [**2186-12-23**]
Date of Birth: [**2116-4-8**] Sex: M
Service: SURGERY
Allergies:
Vancomycin / Shellfish Derived
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Non-productive cough, lethargy and 13 point drop in Hct, CXR
from PCP showed no acute process.
Major Surgical or Invasive Procedure:
[**2186-12-14**] Endovascular repair of aortic psuedoaneurysm and
placement R renal stent for aortic graft leak.
[**2186-12-16**] Oral exploration and extraction of infected foreign body
and teeth #s 2, 3, 4, 5 and 6.
History of Present Illness:
70 y-o gentleman presents as transfer from [**Hospital1 6687**] for
low HCT. The patient initially presented to his PCP today with [**Name Initial (PRE) **]
new non-productive cough and lethargy. The PCP obtained [**Name Initial (PRE) **] CXR
that showed no acute process. During the patient's workup, the
patient's HCT was found to be 18.1. His baseline is low 30's,
and
the most recent documented HCT before today was 31 in 5/[**2186**].
Even though the patient had no complaints of abdominal pain or
vomiting, an NGT was placed in the patient in [**Hospital1 6687**] - lavage
was guaiac negative. The patient was transferred to [**Hospital1 18**] for
further eval, given his history of recent surgery at this
hospital. On arrival the patient reports no chest pain or
abdominal pain. He has no leg pain and he says he walks around
with a cane without any cramps in his legs. He occasionally
feels pain in his left foot when in bed at nighttime. He denies
any recent fevers or chills. His last BM was yesterday, and the
patient states there was no blood in his stool. Of note, the
patient was admitted to [**Hospital1 18**] in [**2186-2-10**] for melanotic stools -
UGI and colonoscopy obtained at the time were normal. [**Year (4 digits) **]
surgery was consulted for potential aorto-enteric fistula in
this
patient, given his history of aorta repair and his seemingly
sudden drop in HCT. Of note, the patient received 2 units of
pRBCs prior to transfer to [**Hospital1 18**].
Past Medical History:
Hyperlipidemia
HTN
Embolic stroke history, with extended hospitalization and
rehabilitation after bowel surgery [**4-/2185**]
CAD w/ severe 3-vessel disease shown in [**2166**]
AAA - infrarenal 4.8cm s/p repair
PVD
CRI
CHF - reported in prior echo as "depressed EF" without exact
quanitification
Afib s/p ablation [**12-11**]
SDH fall in [**10-16**]
Right fem [**Doctor Last Name **] in situ (93)
s/p Left fem [**Doctor Last Name **] in situ (93)
Vein angioplasty of left femoral artery 01
Hearing impairment
Ischemic bowel s/p SB resection [**4-17**] with MSA stent
Past history EtOH abuse
Social History:
Heavy drinker in past, indicates stopped drinking 1 year ago,
1ppd tobacco for many years until 1 year ago, used to work as a
lawyer (real estate property) and retired in his 50s, now lives
in [**Hospital1 6687**] with wife, who is a school teacher.
Family History:
NC
Physical Exam:
VS T 98.8 P 68 BP 128/48 RR 16 O2 sat 93% on 2 L O2
Gen: NAD, alert and oriented
Heart: RRR, no murmur
Lungs: exp. wheezes b/l, diminished bases
Abd: distended, soft, non-tender, positive bowel sounds
Ext: well perfused b/l
Pulses: DP PT
R Dop palp
L palp palp
Pertinent Results:
[**2186-12-19**] 05:23AM BLOOD
WBC-6.7 RBC-3.21* Hgb-9.3* Hct-27.9* MCV-87 MCH-28.9 MCHC-33.3
RDW-17.5* Plt Ct-94*
[**2186-12-18**] 06:00AM BLOOD
WBC-5.1 RBC-3.07* Hgb-9.4* Hct-26.8* MCV-87 MCH-30.5 MCHC-34.9
RDW-18.2* Plt Ct-88*
[**2186-12-19**] 05:23AM BLOOD
Plt Ct-94*
[**2186-12-19**] 05:23AM BLOOD
Glucose-95 UreaN-26* Creat-1.6* Na-140 K-3.4 Cl-103 HCO3-30
AnGap-10
[**2186-12-19**] 05:23AM BLOOD
Calcium-7.6* Phos-2.3* Mg-1.7
Cardiology:
ECG Study Date of [**2186-12-13**] 5:31:56 PM
Sinus bradycardia. Poor R wave progression. Lateral ST-T wave
changes
suggest myocardial ischemia. Compared to the previous tracing of
[**2186-3-9**]
the lateral T wave inversions are new.
RADIOLOGY:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2186-12-13**] 8:57
PM
Final Report: Comparison is made with a prior study from
[**2186-3-10**].
IMPRESSION:
Adequate position of right IJ and NG tubes.
Mild congestion with increased retrocardiac density which may
reflect
atelectasis or pneumonia. Small left pleural effusion.
CTA PELVIS W&W/O C & RECONS Study Date of [**2186-12-14**] 12:00 AM
IMPRESSION:
1. Interval development of a large amount of intraperitoneal
fluid measuring 10 Hounsfield units. Althouhg this could be
related to cirrhotic liver, differential diagnostic
consideration includes blood tracking into the peirtoneum from
the presumed retroperitoneal fluid (?blood) collection. The low
attenuation of the peritoneal fluid low may be due to patient's
anemia.
2. Low-density fluid collection along the left psoas muscle is
highly
suspicious for a retroperitoneal bleeding.
3. Abdomanial aortic thrombus at the superior aspect of the
graft.
The findings were discussed with Dr. [**Last Name (STitle) 31549**] at the time of
interpretation.
CHEST (PORTABLE AP) Study Date of [**2186-12-14**] 8:24 PM
The patient was intubated in the meantime interval with the ET
tube tip being 6.5 cm above the carina. The right internal
jugular line tip is in distal SVC. The NG tube tip is in the
stomach. There is interval worsening of aeration of the left
lower lung and bilateral increase in pleural effusion. There is
no significant change in perihilar interstitial opacities most
likely representing pulmonary edema since they have been absent
on the study from [**2185-5-31**], and demonstrates fluctuating on
several subsequent radiographs including [**2186-3-10**]. the
appearance on [**2186-12-13**] study suggests acute origin of
the findings rather than chronic interstitial changes.
The aortic graft is noted in the abdomen.
Brief Hospital Course:
[**2186-12-14**] 70 y-o gentleman transfer from [**Hospital1 6687**] for low HCT.
Days prior presented to his PCP today with [**Name Initial (PRE) **] new non-productive
cough and lethargy. Work-up CXR
showed no acute process. HCT was found to be 18.1. His baseline
is low 30's. [**Name Initial (PRE) **]
surgery was consulted for potential aorto-enteric fistula given
his history of aorta repair and his sudden drop in HCT. Patient
received 2 units of pRBCs from OSH prior to transfer to [**Hospital1 18**].
- CT pelvis- showed large amount of intraperitoneal fluid
measuring 10 Hounsfield
units from Leaking of pseudoaneurysm from proximal aortic
graft anastomosis.
- Pre-oped and taken to OR for:
1. Ultrasound-guided puncture of right common femoral
artery.
2. Ultrasound-guided puncture of left brachial artery.
3. Introduction of catheter into aorta.
4. Abdominal aortogram.
5. Proximal cuff extension placement x 2 to previously
placed aortobifemoral bypass graft.
6. Right renal artery stent.
7. Selective renal arteriogram.
8. Percutaneous groin closure of right common femoral
arteriotomy.
- Post-op admitted to CV ICU
- Transfused with 2 units FFP post-op.
- Intubated
- Sedated
- serial HCT
- DVT prophylaxis
[**2186-12-15**] Remains sedate,intubated. Weaned and extubated later.
Nitro drip for BP control.
- Hepatology consult- for elevated LFT's -likely 2nd to liver
cirrhosis- following.
[**2186-12-16**] Serial Hct, transfused with 1 unit PRBC's for Hct 24.8.
Noted to have rash throughout body.
- Started Lasix [**Hospital1 **].
- Started on Cipro for E-coli in urine
- Pain control
- Transferred to [**Hospital Ward Name 121**] 5 VICU
- Oral surgery consulted for infected tooth/upper quadrant
bridge, consented and taken to the OR for eploration and removal
of infected foreign body (upper quadrant bridge) and #'s 2, 3,
4, 5 and 6 teeth and roof fixation.
[**Date range (1) 106728**] VSS. Monitoring Hct-27.9.
- continued to diurese with Lasix
- Floor status, A-line d/c'd, central line kept
- Physical therapy consult, out of bed
- Diet advanced t o as tolerated, aspiration precaution
[**2186-12-19**] No acute events, extra Lasix dose given for respiratory
congestion and diminished breath sounds.
- CXR-Probable no interval change in left pleural effusion and
left lower lobe
atelectasis.
- Electrolytes repleted.
- INR persist to be elevated- Hepatology re-consulted, will
follow.
- Continues on Cipro- urine culture came back with E-coli
sensitive to Cipro.
[**12-20**] - [**12-22**]
[**Hospital 25403**] rehab, coordination of transportation by
ambulance/ferry to [**Hospital1 6687**].
Stable for DC
Medications on Admission:
Keppra 500 mg [**Hospital1 **]
Lamotrigine 50 mg qhs
Lipitor 80 mg qd
Venlafaxine 25 mg [**Hospital1 **]
Lomotil 2.5 mg tid prn
Metoprolol ER 200 mg qd
Plavix 75 mg qd
Mirtazapine 15 mg qd
Trazodone 25 mg prn qhs
Discharge Medications:
1. Levetiracetam 250 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
2. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. Lamotrigine 25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
4. Diphenhydramine HCl 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H
(every 6 hours) as needed.
5. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
8. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
10. Allopurinol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Lipitor 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
12. Venlafaxine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
13. Keppra 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
14. Mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
15. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO at bedtime.
16. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
[**Hospital1 **]: One (1) Tablet Sustained Release 24 hr PO once a day.
17. Lomotil 2.5-0.025 mg Tablet [**Hospital1 **]: One (1) Tablet PO three
times a day: prn. Tablet(s)
18. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily) for 10 days. Tablet(s)
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
20. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) NEB IH
Inhalation Q6H (every 6 hours).
21. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
22. Oxycodone 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every 4-6 hours as
needed for pain.
23. Venlafaxine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
24. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) NEB INH Inhalation Q6H (every 6
hours).
25. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
injection Injection TID (3 times a day).
26. Insulin Sliding Scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Primary:
Aortic psuedoaneurysm
aortic graft leak
UTI
Acute on chronic systolic CHF - requiring Lasix
Infected foreign body and teeth #s 2, 3, 4, 5 and 6.
Secondary:
PVD
Hyperlipidemia
HTN
Embolic CVA (after SBR in [**2185**])
CAD
CRI
PMH: SDH ([**2184**]), ischemic colitis
PSH: Aortobifem bypass [**2173**], SB resection ([**Doctor Last Name **]) & SMA Stent
[**2185**], A Fib s/p ablation [**12/2179**], R SFA occlusive disease, L
SFA occlusive disease s/p angioplasty [**2179**]
Discharge Condition:
Stable
Discharge Instructions:
Division of [**Year (4 digits) **] and Endovascular Surgery
Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? 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 [**2-12**]
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 [**3-14**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2187-1-18**] 11:45
Completed by:[**2186-12-23**]
ICD9 Codes: 5180, 5990, 2851, 2724, 5859, 4439, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7536
} | Medical Text: Admission Date: [**2143-3-9**] Discharge Date: [**2143-3-12**]
Date of Birth: [**2069-7-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Left and right heart catheterization from right femeral artery
Drug eluting stent placement to RCA
History of Present Illness:
73 y/o F w/ no previous PMH, on no home meds. Was shopping w/
daughter when developed acute onset of CP, assoc w/ SOB &
diaphoresis. Described CP as band-like tightness. Denies n/v.
Presented to OSH, found to have inferior STE on EKG and positive
troponins. She was started on ASA, plavix, lopressor, and
aggrestat. She was placed on a nitro gtt for SBP in 200s. She
was then transferred to [**Hospital1 18**] for intervention.
.
Of note, daughter won $10,000 scratch lottery on Monday.
.
ROS: Active, cares for grandchild. Denies PND, orthopnea.
Past Medical History:
s/p vaginal hysterectomy
Social History:
Retired, previously worked in housekeeping at [**Hospital 1474**] Hospital.
Is widowed. Husband was murdered 30+ years ago, so she raised
her 7 children on her own. She is a prior smoker, though she
quit around age 60. She has a 60 pack-year history. Denies EtOH
or illicits. Is very active and takes care of her grandchildren.
Of note, her daughter won $10,000 on a scratch ticket earlier in
the week (? cause of her excitement/surprise/stress)
Family History:
7 grown children, all healthy. Brother had first MI at age 40.
Physical Exam:
PE (post-cath):
VS - T 97.5, HR 61, BP 129/74, RR 20, O2 sat 100% 3L NC
general - in bed, comfortable, NAD
HEENT - OP clr, MMM, JVP difficult to assess supine
CV - RRR, nl s1 s2, no m/r/g
chest - CTAB
abd - NABS, soft, NT, no g/r
ext - no edema, 1+ DP/PT pulses
R groin - dressing intact, small hematoma, no bruit, R femoral
venous catheter intact
Pertinent Results:
Labs on admission:
WBC 8.7, Hgb 12.2, Hct 36.1, MCV 90, Plt 316
PT 13.9*, PTT 138.6*, INR(PT) 1.2*
Na 137, K 4.1, Cl 105, HCO3 21, BUN 17, Cr 0.6, Glu 118
Ca 8.6, Phos 3.8, Mg 1.9, ALT 11, AST 35
ABG: pO2-138* pCO2-39 pH-7.41 calHCO3-26
.
[**2143-3-9**] 07:23PM BLOOD CK(CPK)-153* CK-MB-18* MB Indx-11.8*
cTropnT-0.68*
[**2143-3-10**] 03:16AM BLOOD CK(CPK)-143* CK-MB-17* MB Indx-11.9*
.
[**2143-3-11**] 05:30AM BLOOD Chol 179, TG 90, HDL 56, CHOL/HD 3.2,
LDLcalc 105
.
Labs on discharge:
WBC 7.7, Hgb 11.6*, Hct 34.5*, MCV 88, Plt 284
Na 142, K 4.3, Cl 106, HCO3 27, BUN 18, Cr 0.7, Glu 86, Mg 2.1
.
Imaging:
CARDIAC CATH [**2143-3-9**]:
1. Coronary angiography revelaed a right dominant system. The
LMCA
showed no significant stenoses. The LAD showed a smooth 60%
midsegment
stenosis and a smooth 50% distal segment stenosis. The LCX
showed no
significant stenoses with minimal luminal irregularities. The
RCA showed
serial 60% mid and 60% distal stenoses which appeared irregular
and
potentially consistent with resolution of previously ruptured
plaques.
2. Hemodynamic studies demonstrated normal filling pressures
with
severely reduced cardiac index initially measured at 1.6
L/min/m2, which
was likely altered by falsely elevated initial hemoglobin
measurement.
3. Left ventriculography was notable for symmetric
anterolateral,
apical, and inferior wall akinesis suggestive of apical
ballooning
syndrome. The anterobasal and inferobasal regions were
hyperkinetic with
estimated ejection fraction of 40-50%. There was no evidence of
mitral
regurgitation.
4. Successful placement of two overlapping Cypher drug-eluting
stents
(3.5 x 28 mm proximally with 3.5 x 23 mm distally) in the
mid-RCA. Final
angiography demonstrated minimal residual stenosis in the
proximal
stent, moderate disease in the jailed acute marginal, no
angiographically apparent dissection, and normal flow (See PTCA
Comments).
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease in setting of possible RCA
plaque
rupture.
2. Normal filling pressures suggestive of normal diastolic
function.
3. Severely abnormal systolic function suggestive of apical
ballooning
syndrome.
4. Successful placement of drug-eluting stents in mid-RCA.
.
ECHO [**2143-3-12**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left
ventricular cavity size is normal. The left ventricle appears
hyperdynamic in all segments except for the apex, which is
hypokinetic (but not akinetic or dyskinetic) relative to the
rest of the left ventricle. The overall left ventricular
ejection fraction is approximately 70 percent. No left
ventricular aneurysm is seen. No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion. Impression: apex is hypokinetic relatiive
to the rest of the left ventricle (hyperdynamic).
Brief Hospital Course:
73 yo F, with no previously known CAD, here for CP, ECG changes,
and troponin leak - ? STEMI vs Takatsubo.
.
# Ischemia - Mrs. [**Known lastname 3068**] was taken straight to the cath lab and
her cath showed RCA & LAD lesions, but nothing that looked
suspicious for the cause of her acute chest pain. A DES was
placed in her RCA, but then hemodynamic measurements were taken
and were significant for a depressed cardiac index. A subsequent
LV-gram showed apical akinesis consistent with Takotsubo
cardiomyopathy. The PA catheter was left in overnight so that
her PA pressures could be monitored. She was continued on
aggrestat until the morning after her catheterization. She did
well overnight, her PA catheter was pulled the next morning, and
she was transferred out to the floor. Daily ECGs were checked
and Mrs. [**Known lastname 3068**] had resolution of inferior ECG changes but
persistent lateral ST elevations and deepening T wave
inversions. She was started on ASA, plavix, bblocker, ACE-i and
a statin. Her lipid panel was checked and was significant for an
LDL of 105 so she was kept on high dose lipitor. Her cardiac
enzymes were cycled x2 after her catheterization and were
trending down. On arrival to the OSH, she already had a troponin
leak so it was unclear if her infarction happened earlier than
the actual onset of her pain. She had no further episodes of
chest pain during her admission, but it was recommended that she
have a stress test as an outpatient to look for other areas of
ischemia.
.
# Pump - Mrs. [**Known lastname 3068**] had a depressed EF and CO by LV-gram, with
apical akinesis being the most prominent finding. This was felt
to be more consistent with Takotsubo cardiomyopathy than MI, but
an exact etiology was not able to be determined. By exam, she
remained euvolemic and her cardiac function improved. Prior to
discharge, an ECHO revealed a restored EF (LV was hyperdynamic
w/ EF of 70% and only hypokinetic apex). She will continue the
bblocker and ACE-i until she follows up with her new outpatient
cardiologist, Dr. [**Last Name (STitle) 7047**], at [**Hospital 5164**] Medical
on [**2143-3-22**].
.
# Rhythm - She was monitored on telemetry throughout her
hospital stay and remained in NSR. Her daily EKGs showed
persistent ST elevations in the lateral leads with deepening T
wave inversions but she remained chest pain free.
.
# Glycemic control - She was started on HISS on admission for
tight glycemic control during her acute coronary syndrome, but
since she has no h/o DM and her cardiac function was improving,
the HISS and fingersticks were discontinued after 48 hours. She
only had one elevated serum glu throughout her stay (glu was 118
on admission).
.
# FEN - She was given a regular, low sodium, cardiac, heart
healthy diet. She received no IVF. Her electrolytes were checked
daily and were repleted prn to keep K >4 and Mg >2.
.
# PPX - Heparin SC for DVT ppx, no need for PPI, bowel regimen.
.
# Code - Presumed full
.
# Dispo - To home, with f/u appts scheduled with her PCP and [**Name Initial (PRE) **]
new outpt cardiologist, Dr. [**Last Name (STitle) 7047**].
Medications on Admission:
Tylenol prn
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:*90 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute coronary syndrome
Takotsubo cardiomyopathy
Discharge Condition:
Good. Afebrile, BP 109/59, HR 93. EKG shows persistent ST
elevations in lateral leads with deepening T wave inversions.
She is chest pain free.
Discharge Instructions:
1. Please call your PCP or go to the ER if you develop any of
the following symptoms: fever, chills, dizziness, headaches,
chest pain, chest pressure, shortness of breath, nausea,
vomiting, leg numbness, tingling or swelling, or any other
worrisome symptoms.
2. Please take all your new medications as prescribed. It is
very important that you take plavix and aspirin EVERY DAY
because they will help keep your stent open. Do not stop these
medications unless your cardiologist instructs you to.
3. Please follow-up with your PCP and your new cardiologist as
directed below.
Followup Instructions:
1. You have an appointment with Dr. [**Last Name (STitle) **], your PCP, [**Name10 (NameIs) **] [**3-21**] at 3:45pm. Please call her office at [**Telephone/Fax (1) 3183**] if you
have any questions or need to reschedule.
2. You have an appointment with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7047**], your new
cardiologist, on Friday [**2142-3-22**] at 1:45 pm. His
office is located at [**Hospital 5164**] Medical, [**Street Address(2) 34489**], [**Hospital1 1474**], MA. His phone number is ([**Telephone/Fax (1) 29561**]. Please call his office with any questions or
re-scheduling needs. You should have a stress test performed as
an outpatient and Dr. [**Last Name (STitle) 7047**] will be able to help you set this
up.
ICD9 Codes: 4111 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7537
} | Medical Text: Unit No: [**Numeric Identifier 70078**]
Admission Date: [**2192-12-5**]
Discharge Date: [**2193-1-26**]
Date of Birth: [**2192-12-5**]
Sex: F
Service: NB
IDENTIFICATION: Baby Girl [**Known lastname 70079**] #I is a 7.5 week old former
30-5/7 week premature twin who is being discharged from the
[**Hospital1 69**] Neonatal Intensive Care
Unit.
HISTORY: Baby Girl [**Known lastname 70079**] #I was born on [**2192-12-5**]
as the 1680 gram product of a 30-5/7 week twin gestation
pregnancy to a 34 year-old gravida I, para 0 to II mother.
Prenatal screens included blood type A positive, antibody
negative, RPR nonreactive, rubella immune, hepatitis B
surface antigen negative and group B strep unknown. Pregnancy
was notable for monochorionic-diamniotic twin gestation with
early ultrasound showing mildly discordant growth. However,
subsequent ultrasounds showed resolution of growth
discrepancy and concordant growth thereafter. Fetal surveys
were otherwise unremarkable. The pregnancy was complicated by
gestational diabetes and cervical shortening noted around 26
weeks, prompting a course of betamethaone. Mother experienced
intermittent preterm contractions since that time and presented
on the day of admission with preterm premature rupture of
membranes. Given twin gestation, mother was taken for cesarean
section delivery.
Family and social history is notable for father with a limb
abnormality and a history of cystic fibrosis in the father's
family. Mother is of [**Name (NI) 70080**] origin.
At delivery twin #I emerged vigorous with Apgars of 9 and 9.
Infant was brought to the Neonatal Intensive Care Unit for
prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Notable for weight of
1680 grams or 75th percentile, length of 42 cm, 50th to 75th
percentile and head circumference of 29.5 cm, 75th
percentile. Infant was pink and active in no significant
distress. Features were nondysmorphic. Red reflex was present
bilaterally. Palate was intact. Neck was supple. Lungs were
clear with mild intermittent retractions. Cardiac was regular
rate and rhythm without murmurs. Abdomen was soft without
masses or hepatosplenomegaly. Anus was patent. Genitalia was
that of normal preterm female. Hips and back were normal.
Extremities were warm and well perfused. Tone and activity
were appropriate.
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Infant initially exhibited minimal
respiratory insufficiency and was maintained in room air
for the first several days of life. Over the first 2 to 3
weeks of life infant did require intermittent treatment
with nasal cannula and CPAP therapy for mild respiratory
distress and frequent apnea spells. The infant never
required significant oxygen and was maintained on CPAP
for a total of 9 days. The infant was weaned to room air
alone by day of life 20 and has remained in room air
since that time. Moderate apnea of prematurity was noted
treated with caffeine. Caffeine was discontinued at
approximately 34 weeks corrected gestational age. Since
that time intermittent spells have been noted, with slow
resolution. By the time of discharge, the infant has been
without spells for 5 days.
2. Cardiovascular: The infant has remained hemodynamically
stable since birth without need for cardiovascular
support. An intermittent murmur was heard although no
other signs of a patent ductus arteriosus were noted.
Over the last several weeks of hospitalization the murmur
became more persistent and evaluation was performed on
[**1-15**] to [**1-16**] including a chest x-ray, 4
extremity blood pressures and an electrocardiogram, all
of which were within normal limits. Cardiology was consulted
on [**2193-1-25**], and thought the murmur was consistent with a
flow murmur; routine monitoring by pediatrician was
recommended.
3. Fluids and nutrition: The infant was initially maintained
on IV fluids with introduction of enteral feeds on day of
life 2. Enteral feeds were advanced without difficulty to
full volume and eventually 28 calories per ounce. Infant
was fed primarily breast milk supplemented with
additional calories as well as some Similac Special Care
formula. On day of life 26, [**2192-12-31**], the infant
was noted to have grossly bloody stools. Infant was
otherwise well appearing and evaluation including CBC,
blood culture and KUB were reassuring. The infant was
monitored for 48 hours off of enteral feeds and
examination remained reassuring. Enteral feedings were
restarted after 48 hours, but using nutramigen.
Feedings were then advanced to maximum caloric density of
Nutramigen 24 calories per ounce without difficulty.
Since that time the infant has tolerated feedings well
without evidence of abdominal distention or significant
aspirates. Stools have remained intermittently heme
positive although otherwise normal in appearance. The
infant was initially fed via gavage feedings and
gradually transitioned to oral feedings as tolerated. By
the time of discharge the infant has been feeding all
p.o. for over 2 weeks with intake of 150 to 200 ml per
kilogram per day and with steady weight gain. The infant
was maintained on multivitamins during hospitalization
but will not be discharged on these as the infant will be
receiving primarily formula. In the future if the infant
remains well appearing a transition back to breast milk
from Nutramigen can be considered. Weight at the time of
discharge was 3065 gm.
4. Gastrointestinal: Infant did experience mild
hyperbilirubinemia of prematurity requiring phototherapy
for 48 hours. The maximum bilirubin level was 9.0/0.4 on
day of life 3. As described above, the infant also
experienced presumed allergic colitis or protein
intolerance.
5. Heme: The infant was noted to develop anemia of
prematurity requiring a blood transfusion on day of life
17 for hematocrit of 26. The infant was maintained on
iron and hematocrit following transfusion was 33.
Hematocrit was noted to gradually decline since that
time, with the last hematocrit on [**1-17**] of 24.7
with a reticulocyte count of 2.4. Repeat hematocrit on
[**2193-1-21**] was 23.2 with retic 2.7. Given this anemia
iron dose was increased to 4 mg per kilograms per day;
hematocrit will need to be monitored as an outpatient.
6. Infectious disease: Infant underwent a sepsis evaluation
at birth with an unremarkable CBC and a negative blood
culture. The infant was treated with ampicillin and
gentamicin for 48 hours at that time. On day of life 7 to
8 repeat sepsis evaluation was performed due to frequent
spells. Blood culture eventually grew staph streptococcus-
non-aureus species. Infant was treated for 1 week with
vancomycin and gentamicin. A lumbar puncture was
performed and was unremarkable. As described above a repeat
sepsis evaluation was performed on day of life 26 due to
bloody stools; blood cultures were negative and infant
was treated with 48 hours of ampicillin and gentamicin.
No other infectious disease issues have been noted.
7. Neurology: Infant has maintained an appropriate
neurologic examination throughout admission. Head
ultrasound was performed on 1 week of age and again at 1
month of age and both of these were within normal limits.
8. Sensory: Ophthalmology examination was performed for
screening for retinopathy of prematurity, revealing
initially immature retinas and then mature retinas without
evidence of ROP. Examination at 9 months of age is
recommended. Hearing screen was performed and passed
bilaterally.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], phone #[**Telephone/Fax (1) 43818**]
at [**Hospital1 2025**] at [**Location (un) **].
CARE RECOMMENDATIONS:
A. Feedings: Infant will be discharged on Nutramigen 24. A trial
of breast milk can be considered in 2 to 4 weeks.
B. Medications: Fer-In-[**Male First Name (un) **] 4 mg per kilogram per day,
equivalent to 0.5 mL per day.
C. Car seat positioning screening was performed and passed.
D. Newborn screens were sent per protocol. Initial newborn
screen on [**2192-12-8**] was normal with exception of an
elevated 17OH progesterone level. A repeat newborn screen on
[**12-20**] was within normal limits.
E. Immunizations received: The infant received hepatitis B
vaccine on [**2192-12-30**]. Synagis was given on [**2193-1-24**].
F. 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 32 weeks, 2) Born
between 32 and 35 weeks with 2 of the following: Day care
during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings, or 3) with chronic lung disease.
Influenza immunizations 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 care-givers.
FOLLOW-UP: Infant will follow up with primary pediatrician 2 to
3 days following discharge. VNA referral will be made.
DISCHARGE DIAGNOSES:
1. Prematurity at 30-5/7 weeks.
2. Twin gestation.
3. Mild respiratory distress syndrome.
4. Apnea of prematurity.
5. Presumed allergic colitis.
6. Staph streptococcus non-aureus sepsis.
7. Physiologic murmur.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2193-1-18**] 09:56:34
T: [**2193-1-18**] 12:15:45
Job#: [**Job Number 70081**]
ICD9 Codes: 769, 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7538
} | Medical Text: Admission Date: [**2197-8-28**] Discharge Date: [**2197-9-9**]
Date of Birth: [**2113-6-14**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Painless jaundice
Major Surgical or Invasive Procedure:
ERCP with precut sphincterotomy [**2197-8-28**]
EGD [**2197-8-31**]
History of Present Illness:
84 yo F with history HTN, HL, and Type 2 DM who presented with
fatigue, nausea, was noted to be jaundiced at initial
presentation to [**Hospital3 **] on [**8-26**]. Patient reports eating
avocados from [**Country 149**], which triggered her nausea and vomiting
about 2 weeks ago. She has had increased confusion over past few
weeks, forgetting her way home once, so that her husband took
her license away. No longer able to do daily 1 hour walk. At
OSH, she was found to have Total bilirubin of 8.7, direct
bilirubin 5.7, AST=2319, ALT=[**2144**], alk phos 132, and INR 1.9.
RUQ ultrasound showed gallbladder wall thickening but no stones
in GB or bile ducts, no CBD dilation, and question of
intrahepatic bile duct dilation. Acetaminophen level was
negative. She had a U/A showing [**5-15**] WBC and received one dose of
Ceftriaxone and Flagyl for asymptomatic bacteriuria.
She underwent ERCP and small sphincterotomy at [**Hospital1 18**] on [**8-28**],
which showed only mildly dilated CBD 8 mm. Hepatitis serologies
were sent. AST and ALT continued to trend down to 1808 and 1632,
respectively. Her T. Bili was 10.7, D. Bili was 7.7, and alk
phos was 113. Hepatology was consulted on [**8-29**]. Per report,
patient was found to be encephalopathic with food all over her
and asterixis. She has had no recent changes in meds. FSG was
106. Per PCP, [**Name10 (NameIs) **] only has very very mild cognitive deficit
at baseline. She was transferred to ICU for management of
altered mental status in setting of fulminant liver failure.
On the floor, her VS were T 99.3, HR 77, BP 133/51, 18, 94% RA.
She was AOx3. She has lost 10 pounds in past 2 weeks due to lost
appetite. She denies nausea, vomiting, abdominal pain,
constipation, or diarrhea.
Past Medical History:
Hypertension
Hyperlipidemia
Hard of Hearing
Anemia
Cataracts s/p surgery
Type II DM - diet controlled
Social History:
Lives with her husband; previous homemaker. Has several adult
children who live nearby. Life-long non-smoker. No ETOH use.
Family History:
Sister died of ovarian cancer. No family history of liver
disease.
Physical Exam:
ADMISSION EXAM
T=96 BP=114/56 HR=60 RR=16 SaO2=97%RA
Pleasant, alert, awake, in NAD.
Jaundiced.
HEENT negative.
Neck - no adenopathy or masses
Lungs-CTAB
CV-RR, grade II/VI systolic murmur at base
Abd-soft, non-tender, non-distended, NABS. No HSM.
Extr-non-pitting symmetric edema bilaterally in both LE (not
acute, per patient).
Neuro-A&Ox3. Negative neuro exam. Mild asterixis
.
DISCHARGE EXAM
97.8 131/63 72 18 98% RA
General: Alert, oriented, jaundiced
HEENT: Sclera icteric, ecchymosis over L. eye MMM, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: inspiratory crackles at bases b/l. Good air movement. No
respiratory distress.
CV: RRR normal S1 + S2, II/VI systolic murmur at apex
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
GU: foley
Ext: warm, well perfused, 2+ pulses, trace edema in LE.
Neuro: A&Ox3, CN II-XII intact. Strength 4/5 in upper and lower
extremities
Skin: jaundiced
Pertinent Results:
At [**Hospital3 **]:
[**2197-8-27**]
Creat = 0.6
T. Bili=9.3
D. Bili=5.2
AST=2319
ALT=[**2144**]
Troponin I <0.06 x2
Alk phos = 120
Amylase =74
WBC=8400
Hct=37.3
Acetaminophen level = negative
UA=[**5-15**] WBC
Hepatitis serologies as per OSH ([**Hospital1 **]):
- Hep A Ag Total - reactive
- HbSAg - reactive
- HbSAb- non-reactive
- Hb core Ab: reactive
- HCV Ab: non-reactive
CA-19 33 (ref value 33)
---
At MICU:
ALT 1632-->752
AST 1808-->619
Alk Phos 113-->81
T. Bili 10.7-->9.5
Lipase 188
GGT 114
AMA neg, Smooth pos (1:20)
[**Doctor First Name **] neg
AFP 23.3
HIV neg
calTIBC-243* Ferritn-1266* D-Dimer-296 TRF-187*
Hapto-50
IgM HBc-POSITIVE*
HBcAb-POSITIVE IgM HAV-NEGATIVE
HBsAg-POSITIVE* HBsAb-NEGATIVE IgM HAV-NEGATIVE
IgG-1871* IgA-699* IgM-114
.
OTHER IMAGING/STUDIES
Liver ultrasound with Dopplers [**2197-8-29**] - Normal appearance of
the liver parenchyma and liver vasculature.
No ascites.
.
Liver biopsy
Liver, transjugular needle core biopsy:
Markedly fragmented biopsy demonstrating:
1. Nodular hepatic parenchyma with cholangiolar proliferation,
septal and bridging fibrosis with multifocal incomplete nodule
formation and paucity of identifiable central veins, suspicious
for cirrhosis (trichrome and reticulin stains evaluated).
2. Moderate portal/septal, periseptal and lobular mixed
inflammation consisting of lymphocytes, plasma cells,
neutrophils and few eosinophils with scattered apoptotic
hepatocytes and focal hepatocyte necrosis with drop-out/minimal
collapse.
3. Moderate cholestasis with focally prominent feathery
degeneration of hepatocytes.
4. No viral inclusions or granulomata identified on H&E;
immunostains for CMV, HSV, HBSAg and HBCAg are in progress and
will be reported in an addendum.
5. Iron stain is negative for significant iron deposition.
.
Head CT without contrast [**8-30**]
1. Left cerebral hemisphere hyperdensity likely due to
calcification but
hemorrhage can not be excluded. Repeat non-contrast CT of the
head is
recommended.
2. Symmetric ventriculomegaly with prominent sulci and
preservation of
white/[**Doctor Last Name 352**] matter differentiation. Most likely secondary to
normal
age-related volume loss. Diffuse periventricular and deep white
matter
hypodensities most likely secondary to chronic small vessel
ischemic disease.
.
Head CT without contrasts [**9-7**] (after fall)
1. Hematoma overlying the superior aspect of the left orbit.
2. Punctate focus of hyperdense material in the right parietal
lobe within an extra-axial location. Although this may be due to
streak, given its location, this would be concerning for a tiny
focus of subarachnoid hemorrhage.
3. Stable calcification or mineralization within the left
cerebellum.
4. Stable atrophy and small vessel microvascular change
6. Focal steatosis present; no areas of hemorrhagic necrosis
seen.
Note: The features are suspicious for cirrhosis (within the
limits of evaluation given specimen fragmentation), with a
superimposed significant active hepatitis. The differential
includes viral, drug or autoimmune-mediated etiologies. Further
correlation with clinical and serologic findings is needed to
distinguish amongst these entities.
.
Repeat Head CT
1. No hemorrhage.
2. Hematoma over left supraorbital ridge, unchanged.
.
ERCP
Multiple ulcers were seen in duodenum.
Major papilla was floppy.
There was a long intramural course of distal CBD.
Deep cannulation of CBD was not successful. Given the rising
bilirubin and reported intrahepatic ductal dilatation on
ultrasonogram, the decision was made for precut sphincterotomy.
Because of the elevated INR, only small sphincterotomy was
performed.
The intrahepatic ducts were partially opacified. They appeared
normal.
CBD was normal and measured 8 mm.
The pancreatic ducts of the head, neck and body of pancreas were
normal.
No filling defect was seen.
Otherwise normal ercp to third part of the duodenum.
.
EGD [**8-31**]
No esophageal varices.
Friability and erythema in the whole stomach compatible with
gastritis
Blood in the second part of the duodenum coming from the
ampulla; consistent with hemobilia.
Ulceration in the first part of the duodenum compatible with
superficial ulceration without stigmata of recent bleeding.
Otherwise normal EGD to third part of the duodenum
.
EGD [**9-3**]
Ulcer in the stomach body
Ulcer in the duodenal bulb
Active bleeding from ampulla was noted, most likely hemobilia
from transjugular liver biopsy, 4cc Epi injection was performed
in the setting of prior pre-cut at the ampulla. (injection)
Otherwise normal EGD to third part of the duodenum
.
DISCHARGE LABS:
[**2197-9-9**] 05:26AM BLOOD WBC-7.9 RBC-3.62* Hgb-11.6* Hct-33.1*
MCV-92 MCH-32.0 MCHC-35.0 RDW-19.2* Plt Ct-79*
[**2197-9-9**] 05:26AM BLOOD PT-19.5* PTT-38.2* INR(PT)-1.8*
[**2197-9-9**] 05:26AM BLOOD Glucose-101* UreaN-19 Creat-0.5 Na-139
K-3.4 Cl-104 HCO3-30 AnGap-8
[**2197-9-9**] 05:26AM BLOOD ALT-81* AST-80* AlkPhos-81 TotBili-15.8*
[**2197-9-9**] 05:26AM BLOOD Calcium-7.7* Phos-2.3* Mg-1.7
Brief Hospital Course:
84yo F p/w painless jaundice to OSH transferred to [**Hospital1 18**] for
further workup found to have serologies indicative of active
Hepatitis B infection, hospital course complicated by GI bleed
secondary to transjugular liver biopsy.
.
# Liver failure - Patient initially admitted with painless
jaundice, found to have marked tranaminitis >1000 and Tbili
10.7. She also had mild encephalopathy with asterixis on exam.
RUQ u/s without concern for obstruction or cholecystitis.
Tylenol level 0. ERCP was unremarkable except for multiple
duodenal ulcers; hepatitis serologies demonstrated HBsAg
positive, HBsAb negative, HBcAb positive, suggesting new HBV
infection vs reactivation. Patient underwent transjugular liver
biopsy, which demonstrated cirrhosis and active hepatitis; it
was felt this was consistent with reactivation of infection.
Patient was started on tenofovir. LFTs trended down.
Encephalopathy improved.
.
# GI Bleed - Patient's course was complicated by melena and
acute anemia following transjugular liver biopsy. EGD showed
hemobilia. Angiogram during active bleeding was negative, and
thus her bleed was thought to be venous. The patient was
followed by liver, IR, and surgery for persistent bleed. The
patient was stabilized with transfusions. On day 6 of
admission, patient had large episode of BRBPR. Massive
transfusion protocol was intitiated. She underwent repeat EGD
that showed persistent hemobilia. The ampulla was injected with
epinephrine and bleeding remained stable. During admission, the
patient received a total of 13 U PRBC, 11 FFP, 2 platelets, 4
cryoprecipitate, and Vit K. HCT remained stable in the 30s prior
to discharge with no additional evidence of rebleeding.
Remained on protonix [**Hospital1 **] on discharge until further follow up.
.
#H. pylori - EGD showed ulcers in stomach and duodenum. H.
pylori antibody positive. Patient was started on triple therapy
with clarithromycin, amoxicillin, and pantoprazole for 2 weeks.
.
#HTN - Blood pressures remained stable. Home medications
(lisinopril, HCTZ/triamterene, and diltiazem) were held
initially. Lisinpril was restarted prior to discharge.
#DM - Patient on Janumet at home. D/C'ed janumet for question of
drug-related injury and risk of lactic acidosis with underlying
hepatic dysfunction. Patient placed on SS humalog while
inpatient. A1c most recently of 5.7 and therefore, well
controlled. Can continue to hold Janumet after discharge with
plans to follow up blood sugars with PCP.
.
TRANSITIONAL ISSUES:
- liver enzymes should be checked in 1 week and faxed to Dr.
[**Last Name (STitle) **]
- patient should follow up in liver clinic as [**Last Name (STitle) 1988**]
- Blood pressures will need to be followed. Diltiazem and
HCTZ/triamterene were stopped on this admission and may need to
be restarted if blood pressures remain elevated.
- Janumet was stopped. Patients blood sugars will need to be
followed.
- Patient will need to complete treatment for H. pylori (ends
[**9-16**]). She will need an H. pylori stool antigen checked to
ensure eradication after completion of treatment.
- Pantoprazole 40 mg [**Hospital1 **] should be continued until follow up
with primary care or liver doctor. At this point, she may be
able to decrease dose back to once daily.
- Patient will need a follow up EGD in [**6-14**] weeks.
- Aspirin was stopped in the setting of GI bleed. If blood
counts remain stable, can consider restarting at follow up
appointment.
Medications on Admission:
ASA 81 mg/day
Protonix 40mg/d
HCTZ/triamterene (37.5/25) qday
Diltiazem CD 120mg qd
MOM [**Name (NI) **] PRN constipation
NTG sl prn cp
Lisinopril 10 mg qd
Janumet (sitagliptin/metformormin)
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H
(every 4 hours) as needed for encephalopathy.
6. amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 7 days.
7. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 7 days.
8. insulin lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous ASDIR (AS DIRECTED): administer QACHS as per
sliding scale .
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnoses: Hepatitis B reactivation, GI bleed, H. pylori
infection
Secondary diagnoses: Hypertension, Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 91568**],
You were admitted with weakness, jaundice, and elevated liver
enzymes in your blood suggesting some injury to your liver. You
had a procedure called an ERCP with sphincterotomy and this did
not show any blockage in your bile ducts. It did not show the
reason behind the liver injury. It did, however, show that you
have ulcers in your small intestine. You also were found to be
positive for an infection called H. pylori which can cause these
ulcers, and you were started on 3 medications which you will
need to take for a total of 14 days.
You were also found to be bleeding likely from the site of your
liver biopsy and had 2 upper endoscopies to help fix this. In
the process, you were given a lot of blood products.
Your liver blood work studies revealed that you have a
reactivation of Hepatitis B. You were started on a medication
called tenofovir. You should continue taking this medication and
you will need to follow up with your liver doctor [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
You also fell and hit your head. You had a scan of your head
which did not show any evidence of a bleed.
The following changes have been made to your medication regimen:
You should STOP taking:
- Janumet
- HCTZ/triamterene
- diltiazem
- milk of magnesia
- aspirin (You can discuss restarting Aspirin with your primary
care doctor if your blood counts continue to remain stable)
You should START
- tenofovir
- lactulose
- rifaxamin
- clarithromycin (until [**9-7**])
- amoxicillin (until [**9-7**])
Please start taking pantoprazole twice daily
You should STOP taking the medication Janumet. The metformin
component in this medication can cause a serious (potentially
fatal) complication called lactic acidosis if your liver is not
working normally. Your diabetes was controlled reasonably well
by diet alone here. Please continue following a diabetic diet,
check your blood sugars at home, keep a log of the results and
bring the log to your primary care physician to determine what,
if any, medications you need to switch to for your diabetes.
You should avoid medications such as aspirin, advil (ibuprofen),
alleve (naproxen), and other medications in this family (NSAIDs)
as it can worse or cause additional stomach ulcers.
If you need to use Tylenol (acetaminophen) for pain or fever, do
NOT exceed [**2186**] mg per day (500 mg four times per day) as higher
doses can cause further liver injury.
Followup Instructions:
Department: LIVER CENTER
When: FRIDAY [**2197-9-22**] at 9:00 AM
With: [**Last Name (LF) **],[**First Name3 (LF) **] (LIVER CENTER) [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will need to follow up with your primary care doctor within
7 days of discharge from your extended care facility.
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital3 **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 41731**], [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 17503**]
Completed by:[**2197-9-10**]
ICD9 Codes: 2761, 2851, 5715, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7539
} | Medical Text: Admission Date: [**2135-11-14**] Discharge Date: [**2135-11-19**]
Date of Birth: [**2077-7-15**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 58-year-old
man who reports earlier in this past year he began to develop
severe exertional chest discomfort associated with shortness
of breath. It has been progressive over the past several
months and now is occurring at rest. He describes it as
severe chest pain that is associated with bilateral arm
tingling. He has used over 100 sublingual nitroglycerin over
the past few months.
PAST MEDICAL HISTORY:
1. Status post anterior MI.
2. Hypertension.
3. Hyperlipidemia.
4. Arthritis.
5. Severe back pain.
6. No TIA.
7. No CVA.
PAST SURGICAL HISTORY: Negative.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Amitriptyline 25 mg p.o. q.h.s.
3. Flexeril 10 mg p.o. q.h.s.
4. Naproxen 500 mg p.o. b.i.d.
5. Atenolol 100 mg p.o. q.d.
6. Imdur 30 mg p.o. q.d.
7. Hydrochlorothiazide 25 mg p.o. q.d.
8. Lipitor 10 mg p.o. q.d.
LABORATORY DATA ON ADMISSION: White count 8.2, hematocrit 46,
platelets 262,000. Chem-7 140/4.2/101/31/12/1.0.
HOSPITAL COURSE: The patient was admitted and was noted to
have severe three vessel coronary artery disease. The
patient was taken to the Operating Room on [**2135-11-15**]
and underwent a four vessel CABG with LIMA to LAD, saphenous
vein graft to OM-I, saphenous vein graft to OM-II and
saphenous vein graft to PDA.
The patient did well postoperatively and was transferred to
the CSRU where he was extubated on the evening of [**2135-11-15**]. On postoperative day number two, the patient was
transferred to the floor and was up ambulating with physical
therapy. On postoperative day number three, the patient had
his chest tube and wires removed.
On postoperative day number four, the patient was ambulating
at a level V and was discharged home in good condition. The
patient was discharged on the following medications.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg p.o. b.i.d.
2. Atorvostatin 10 mg p.o. q.d.
3. Cyclobenzaprine 10 mg p.o. q.h.s.
4. Amitriptyline 25 mg p.o. q.h.s.
5. Percocet one to two tablets p.o. q. 4-6 hours p.r.n.
6. Aspirin 325 mg p.o. q.d.
7. Lasix 20 mg p.o. b.i.d. times seven days.
8. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. times seven days.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] in
four weeks.
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
graft times four.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2135-11-19**] 22:08
T: [**2135-11-21**] 09:05
JOB#: [**Job Number 105132**]
ICD9 Codes: 4241, 4111, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7540
} | Medical Text: Admission Date: [**2200-2-6**] Discharge Date: [**2200-2-13**]
Date of Birth: [**2114-4-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Levaquin / Macrodantin / Propranolol / ibuprofen
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Coronary artery disease.
Major Surgical or Invasive Procedure:
[**2200-2-7**]: Coronary artery bypass grafting x3 with a left
internal mammary artery to left anterior descending artery
and reverse saphenous vein graft to the distal right coronary
artery and obtuse marginal artery.
History of Present Illness:
85 year old male that presented to [**Hospital3 **] hospital after
awaking from sleep [**2-3**] night with severe cough, nausea, and
chest discomfort. In the emergency room he was treated for
rapid atrial fibrillation and with Duonebs, unasyn,
azithromycin, and IV solumedrol due to wheezing. On [**2-4**] he
became acutely short of breath in the hospital and was placed on
bipap and treated with IV lasix due to pulmonary edema. He
ruled in for non st elevation myocardial infarction with
troponin 4.01 and was referred for cardiac catheterization that
he had [**2-7**] which revealed significant coronary artery
disease. He is now transferred for surgical evaluation
Past Medical History:
Congestive heart failure
Atrial fibrilliation no Coumadin high risk of falls
Non ST elevation myocardial infarction ([**Hospital3 **] [**1-/2200**])
Hypothyroid
Lumbar stenosis
Compression fracture L5
Right Thyroid nodule
Hypertension
CKD stageIII
GERD
Hypercholesterolemia
Osteoarthritis
Diabetes mellitus type 2
Neurogenic bladder(chronic Foley)
Past Surgical History
Rt carpel tunnel
Total hip replacment, right [**2195**]
TURP [**2186**]
Appendectomy
Biliary bypass [**2193**]
decompressive laminectomy at L4 and L5,microdiskectomy at L4 L5
Kyphoplasty L5 [**2-/2197**]
Social History:
Lives with: wife and son (at son's home)
Contact: [**Name (NI) **] (wife) Phone # [**Telephone/Fax (1) 92469**]
Occupation: retired firefighter
Cigarettes: Smoked no [] yes [x] last cigarette 50 years ago
ther
Tobacco use: denies
ETOH: < 1 drink/week [x]
Family History:
mother deceased 82 diabetes, father deceased 48
[**Name2 (NI) 92470**], brother DM, heart disease deceased ? 60's, brother
sudden death 70's, brother diabetes deceased 85, brother mastoid
cancer deceased in 50's, sister diabetes, coronary disease s/p
stent alive, brother alzheimer alive, brother diabetes, vascular
disease deceased 60's, son s/p cabg in his 40's
Physical Exam:
Pulse: 38 Resp: 18 O2 sat: 97 RA
B/P Right: 107/65 Left: 115/63
General: Resting in be no acute distress
Skin: Dry [x] intact [x] right groin cath site
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x] HOH
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
Admission Labs:
[**2200-2-6**] 01:18PM URINE RBC-3* WBC-29* BACTERIA-NONE YEAST-NONE
EPI-3
[**2200-2-6**] 01:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-MOD
[**2200-2-6**] 01:18PM PT-11.6 PTT-25.7 INR(PT)-1.1
[**2200-2-6**] 01:18PM NEUTS-61.4 LYMPHS-29.8 MONOS-5.9 EOS-2.5
BASOS-0.4
[**2200-2-6**] 01:18PM WBC-8.7 RBC-3.28* HGB-10.2* HCT-30.5* MCV-93
MCH-31.1 MCHC-33.5 RDW-13.7
[**2200-2-6**] 01:18PM %HbA1c-7.8* eAG-177*
[**2200-2-6**] 01:18PM ALBUMIN-3.2* CALCIUM-8.6 PHOSPHATE-2.7
MAGNESIUM-2.1
[**2200-2-6**] 01:18PM CK-MB-5 cTropnT-0.64*
[**2200-2-6**] 01:18PM ALT(SGPT)-52* AST(SGOT)-69* LD(LDH)-244
CK(CPK)-78 ALK PHOS-61 TOT BILI-0.3
[**2200-2-6**] 01:18PM GLUCOSE-182* UREA N-54* CREAT-1.4* SODIUM-139
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-34* ANION GAP-9
Discharge labs:
[**2200-2-13**] 04:20AM BLOOD WBC-14.0* RBC-3.10* Hgb-9.6* Hct-28.7*
MCV-93 MCH-31.0 MCHC-33.4 RDW-14.7 Plt Ct-203
[**2200-2-13**] 04:20AM BLOOD Plt Ct-203
[**2200-2-13**] 04:20AM BLOOD Glucose-114* UreaN-39* Creat-1.6* Na-138
K-4.5 Cl-103 HCO3-28 AnGap-12
[**2200-2-13**] 04:20AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
[**2200-2-11**] 04:20AM BLOOD ALT-26 AST-39 AlkPhos-73 Amylase-12
TotBili-0.4
TTE [**2200-2-7**]
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Arch: 2.8 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.0 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized. No
spontaneous echo contrast in the RAA. No ASD by 2D or color
Doppler.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in ascending aorta. Complex (>4mm) atheroma in
the aortic arch. Complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Cannot
exclude AS. Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Mild to moderate ([**2-10**]+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
GENERAL COMMENTS: The patient was under general anesthesia
throughout the procedure. No TEE related complications.
Suboptimal image quality. Results were personally reviewed with
the MD caring for the patient.
Conclusions
Due to the patient's history of dysphagia and resistance felt at
40cm, the probe was not advanced past 40cm.
PRE-BYPASS:
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.
The left ventricle was assessed in the mid esophageal views.
There is mild LV septal hypokineses. The remaining segments move
and thicken well, estimated EF 50-55% from limited study.
There are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. The study is
inadequate to exclude significant aortic valve stenosis but
leaflets appear to have normal motion in the available views.
Trace aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild to
moderate ([**2-10**]+) mitral regurgitation is seen.
Radiology Report CHEST (PA & LAT) Study Date of [**2200-2-12**] 1:56 PM
Final Report
FINDINGS: As compared to the previous radiograph, there is
substantially
increased ventilation of the lung parenchyma. No pulmonary
edema. On the
left, a small retrocardiac atelectasis persists and on the
right, seen mainly on the lateral radiograph, a small pleural
effusion is present. No other pleural or parenchymal changes.
Borderline size of the cardiac silhouette.
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of
[**2200-2-12**] 1:55 [**Hospital 93**] MEDICAL CONDITION:85 year old man s/p
CABG
REASON FOR THIS EXAMINATION: eval for aspiration
Preliminary Report Swallowing video fluoroscopy: oropharyngeal
swallowing video fluoroscopy was Preliminary Reportperformed in
conjunction with the speech and swallow division. Multiple
Preliminary Reportconsistencies of barium were administered.
Oral and pharyngeal swallow delay
were observed. There was aspiration of thin liquids and
penetration with nectar.
Brief Hospital Course:
85 year old male that presented to OSH after awaking from sleep
[**2-3**] night with
severe cough, nausea, and chest discomfort. In the emergency
room he was treated for rapid atrial fibrillation and with
Duonebs, Unasyn, azithromycin, and IV solumedrol due to
wheezing. He ruled in for non st elevation myocardial infarction
with troponin 4.01 and was referred for cardiac catheterization.
He underwent cath on [**2-7**] which revealed significant coronary
artery disease. He was now transferred for surgical evaluation
to [**Hospital1 18**]. After preoperative work up was complete, he was
brought to the operating room on [**2-8**] where the patient
underwent a coronary artery bypass grafting x3 with a left
internal mammary artery to left anterior descending artery and
reverse saphenous vein graft to the distal right coronary artery
and obtuse marginal artery. CROSS-CLAMP TIME:69 minutes PUMP
TIME:79 minutes. See operative note for full 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 on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. He
was in a atrial fibrillation/flutter with rates from 60-120's.
Lopressor was titrated and he was placed back on his home dose
of Digoxin for better rate control. He had up to 2.6 second
pauses in his chronic atrial fibrillation and EP was consulted.
Digoxin was stopped and Lopressor was titrated. He was not
anticoagulated for his atrial fibrillation due to his high risk
of falls. He had a chronic Foley in place for a history of
neurogenic bladder. He also had a swallow evaluation postop due
to a preoperative history of dysphagia which showed possible
aspiarion and he underwent a video study which showed aspiration
of thin liquids, penetration of nectar, and he was put on a
modified diet. He had a poor oral intake and was started on
supplements. His po intake improved at the time of discharge.
The patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued per
cardiac surgery protocol without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 6 the
patient was able to stand at bedside with assistance, but
required [**Doctor Last Name 2598**] lift to get OOB to chair. His wound was healing
and pain was controlled with oral analgesics(Tylenol). He failed
to void after Foley catheter removal and required reinsertion of
catheter, of note patient with neurogenic bladder had chronic
foley for 5 years prior to surgery. The patient was discharged
to [**Hospital 38**] rehab on POD 6 in good condition with appropriate
follow up instructions.
Medications on Admission:
Simvastatin 5 mg daily
Prilosec 20 mg daily
Neurontin 600 mg [**Hospital1 **]
Levothyroxine 25 mcg daily
Ferrous sulfate 325 mg daily
Glipizide 2.5 mg [**Hospital1 **]
Aspirin 325 mg Daily
Diltiazem 120 mg daily
Digoxin 0.125 mg daily
Bethanechol 25 mg TID
Centrum silver daily
Calcium 500 with Vitamin D [**Hospital1 **]
Medications outside hospital at transfer:
Unasyn 1.5 gm q12h
Heparin gtt
Aspirin 81 mg daily
zocor 5 mg daily
multivitamin 1 tab daily
glipizide 2.5 mg [**Hospital1 **]
Gabapentin 600 mg [**Hospital1 **]
Diltazem 120 mg daily
Digoxin 0.125 mg daily
Calcium/vitamin D 2 tabs daily
Bethanechol 25 mg TID
Insulin SS
Lopressor 5 mg q6h
Protonix 40 mg IV daily
Levothyroxine 12.5 mcg IV daily
Atrovent nebs prn
Albuterol nebs prn
Nitrostat 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 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
4. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. bethanechol chloride 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
15. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/temp.
16. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
19. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
once a day.
20. insulin regular human 100 unit/mL Solution Sig: sliding
scale units Injection Q AC&HS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
[**Last Name (un) 72255**] Artery disease s/p CABG x3
Congestive heart failure
Atrial fibrilliation no Coumadin-high risk of falls
Non ST elevation myocardial infarction ([**Hospital3 **] [**1-/2200**])
Hypothyroid
Lumbar stenosis
Compression fracture L5
Right Thyroid nodule
Hypertension
CKD stageIII
GERD
Hypercholesterolemia
Osteoarthritis
Diabetes mellitus type 2
Neurogenic bladder(chronic Foley)
Past Surgical History
Rt carpel tunnel
Total hip replacment, right [**2195**]
TURP [**2186**]
Appendectomy
Biliary bypass [**2193**]
decompressive laminectomy at L4 and L5,microdiskectomy at L4 L5
Kyphoplasty L5 [**2-/2197**]
Discharge Condition:
Alert and oriented x3 nonfocal
Able to stand at bedside w/assistance. Requires [**Doctor Last Name **] lift to
get OOB-chair
Sternal pain managed with oral analgesics-Tramadol
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
**Please call 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 1/12 at 10:15am, Cardiac Surgery [**Hospital Ward Name 92471**]
Medical Office Building [**Hospital Unit Name **] [**Telephone/Fax (1) 170**]
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**3-20**] at 1:00pm, Cardiac Surgery
[**Hospital Ward Name 92471**] Medical Office Building [**Hospital Unit Name **] [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**Last Name (STitle) **] on [**3-5**] at 11:00am
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 25693**] in [**5-15**] weeks [**Telephone/Fax (1) 25694**]
****Needs outpatient video swallow before advancing diet****
**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:[**2200-2-13**]
ICD9 Codes: 2875, 4280, 5990, 4240, 2859, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7541
} | Medical Text: Admission Date: [**2124-1-11**] Discharge Date: [**2124-1-14**]
Date of Birth: [**2049-2-1**] Sex: M
Service: SURGERY
Allergies:
Ambien
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
rectal bleeding and rectal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC:[**CC Contact Info 107401**]
HPI: This is a 74M with a history of a rectosigmoid polyp
resection and subsequent rectal bleeding with multiple
sigmoidoscopies c/b perforation requiring a Hartmann procedure
[**2123-10-25**]. He came back to the clinic today to discuss
reversing his colostomy but was found to have new bright red
rectal bleeding since this past Thursday. The bleeding soaks
four 4x4 gauzes per day. The patient denies any dizziness or
LOC
associated with the bleeding. He does report rectal pain and a
feeling of rectal fullness that has been present since his
surgery in [**Month (only) **]. He also complains of new pain to the left
of the ostomy. He denies F/C/N/V. The ostomy is functioning
well.
Of note, the patient has a mechanical AV and MV for which he is
on coumadin. His INR today was 2.9.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
# Mechanical MVR/AVR ([**2098**]) [**1-12**] rheumatic fever
# Atrial fibrillation s/p AV node ablation, biventricular pacer
([**2115**]) on anticoagulation
# Biventricular pacer
.
3. OTHER PAST MEDICAL HISTORY:
# COPD
# Asthma
# GERD
# Osteoarthritis
# Bilateral total knee replacements [**1-12**] OA
# Gout
# Hypothyroidism [**1-12**] amiodarone
# Chronic Kidney Disease Stage II, baseline cr 1.6
# anemia
# Melanoma
# obesity
# ETOH use
# insomnia
# hemorrhoids
# h/o cellulitis
# h/o MRSA PNA
# osteopenia
# # s/p Cholecystectomy
# s/p Appendectomy
Social History:
Social Hx: Lives with wife.
Family History:
# Mother d 85: Asthma
# Father d 99 [**10-21**]: PAD, HTN
# Siblings (5B, 2S): HTN, unknown, rheumatic fever
Physical Exam:
PE: upon admission [**2124-1-11**]
97.1 69 132/70 20 98%RA
Gen NAD, AAOx3, mentating well
CV RRR, audible clicks
Pulm CTAB, no w/r/r
Abd soft, obese, TTP to L of ostomy and inferior to ostomy, no
G/R, no hernias noted, incisions healing well but area of
panniculitis inferior to ostomy, minimal erythema; ostomy
retracted but functioning - brown stool and air in bag
Ext wwp, 2+ edema bilaterally in LE
DRE: stricture ~4cm from anal verge, BRB; on anoscopy, clots can
be seen but no identifiable source of bleeding
Pertinent Results:
[**2124-1-14**] 06:00AM BLOOD WBC-8.3 RBC-3.44* Hgb-9.5* Hct-29.5*
MCV-86 MCH-27.7 MCHC-32.3 RDW-17.3* Plt Ct-154
[**2124-1-13**] 03:30PM BLOOD WBC-7.5 RBC-3.47* Hgb-9.6* Hct-29.4*
MCV-85 MCH-27.6 MCHC-32.6 RDW-17.2* Plt Ct-151
[**2124-1-13**] 01:52AM BLOOD WBC-7.5 RBC-3.34* Hgb-9.6* Hct-28.4*
MCV-85 MCH-28.7 MCHC-33.8 RDW-17.8* Plt Ct-156
[**2124-1-12**] 11:10AM BLOOD Hct-30.5*
[**2124-1-11**] 09:59PM BLOOD Hct-26.5*
[**2124-1-14**] 06:00AM BLOOD Plt Ct-154
[**2124-1-13**] 03:30PM BLOOD Plt Ct-151
[**2124-1-13**] 03:30PM BLOOD PT-24.0* PTT-30.5 INR(PT)-2.3*
[**2124-1-13**] 01:52AM BLOOD Plt Ct-156
[**2124-1-13**] 01:52AM BLOOD PT-30.0* PTT-33.7 INR(PT)-3.0*
[**2124-1-12**] 04:18AM BLOOD PT-34.8* PTT-35.5* INR(PT)-3.6*
[**2124-1-14**] 06:00AM BLOOD Glucose-101* UreaN-17 Creat-0.8 Na-138
K-3.7 Cl-104 HCO3-26 AnGap-12
[**2124-1-13**] 03:30PM BLOOD Glucose-131* UreaN-16 Creat-0.8 Na-137
K-3.6 Cl-102 HCO3-25 AnGap-14
[**2124-1-14**] 06:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.8
[**2124-1-13**] 03:30PM BLOOD Calcium-8.9 Phos-2.4* Mg-1.9
[**2124-1-11**]: Cat scan of abdomen and pelvis:
IMPRESSION:
1. No evidence of leak of the Hartmann pouch or pelvic fluid
collection.
2. Filling defects along the lower rectum/anus. This may
represent
hemorrhoids, hemorrhage, or other intraluminal lesions. Please
correlate
clinically.
3. Small fat-containing ventral hernia/abdominal wall defect.
[**2124-1-12**]: EKG:
Ventricular paced rhythm. Underlying atrial rhythm is
uncertain, probably
atrial fibrillation. Since the previous tracing of [**2123-10-8**] no
significant
change.
Brief Hospital Course:
74 year old gentleman who presented to the Acute Care clinic
with rectal bleeding.
Upon admission he was made NPO, had intravenous fluids started
and had imaging study done. He was monitored in the intensive
care unit where he had serial hematocrits. The GI service was
consulted. A cat scan of his abdomen did show a possible soft
tissue mass within the rectum. He was taken to the operating
room on [**1-13**] where he had a rectal examination and sigmoidoscopy
under anesthesia. He tolerated the procedure well without
evidence of bleeding.
He is preparing for discharge home with VNA services. His
vital signs are stable. He is tolerating a regular diet and has
been ambulating. He is not having any active bleeding from his
rectum. His hematocrit is stable at 29.5. He has resumed his
pre-hospital medications including his coumadin. He has been
evaluated by physical therapy for recommendations for his
deconditioning. He has also been seen by the ostomy nurse. His
last INR is 2.3. He will follow-up with his primary care
provider for monitoring of his INR.
Medications on Admission:
[**Last Name (un) 1724**]:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: 1 tab
on [**Last Name (un) 766**] and Friday, 1.5 tabs on all other days.
2. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
3. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
7. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for gout.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
9. ciclopirox 0.77 % Gel Sig: One (1) application to abdomen
folds Topical twice a day.
10. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-12**]
Puffs Inhalation Q6H (every 6 hours) as needed for SOB.
13. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) neb Inhalation four times a day as
needed for shortness of breath or wheezing.
14. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. orphenadrine citrate 100 mg Tablet Sustained Release Sig:
One (1) Tablet Sustained Release PO twice a day as needed for
back pain.
16. sildenafil 50 mg Tablet Sig: One (1) Tablet PO once as
needed for sexual activity.
17. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
18. trazodone 50 mg Tablet Sig: [**12-12**] to 1 Tablet PO at bedtime as
needed for insomnia.
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for diarrhea.
20. sodium chloride 0.65 % Aerosol, Spray Sig: Three (3) Spray
Nasal TID (3 times a day).
21. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
22. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: hold for diarrhea.
23. nitrofurantoin
Discharge Medications:
1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for wheeze.
5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day) as needed for
wheeze.
6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)) as needed for gout.
7. warfarin 5 mg Tablet Sig: 1.5 Tablets PO 5X/WEEK
([**Doctor First Name **],TU,WE,TH,SA).
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,FR).
9. levothyroxine 50 mcg Capsule Sig: One (1) Capsule PO once a
day.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. nitrofurantoin (macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Rectal bleeding, stricture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with rectal bleeding. You
were monitored in the intensive care unit. During your stay, you
had a blood transfusion. Your vital signs and hematocrit are
normal and you are now preparing for discharge home with VNA
services. Please follow these instructions upon discharge:
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2124-1-25**] 12:50
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2124-1-26**]
9:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2124-1-26**]
10:00
ICD9 Codes: 2724, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7542
} | Medical Text: Admission Date: [**2106-2-10**] Discharge Date: [**2106-2-23**]
Date of Birth: [**2044-3-28**] Sex: M
Service: SURGERY
Allergies:
Demerol / Ativan
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Severe ischemia of lower extremities/ s/p R. ilio-femoral and
femoral-femoral bypass graft.
Major Surgical or Invasive Procedure:
Thrombectomy of right iliofemoral graft, femoral-femoral graft,
patch angioplasty of right femoral artery and left femoral
artery with saphenous vein.
History of Present Illness:
The patient is a 60M with history of right sided stage III
laryngeal cancer diagnosed in [**2099**] and treated with chemotherapy
(adjuvant taxol and cisplatin followed by taxol, cisplatin and
etoposide for three total cycles) and radiation (62g to right
neck and vocal cords). He was last admitted to [**Hospital1 18**] [**2105-6-29**]
with disabling claudication and rest pain in his bilateral lower
extremities. For this, right common iliac artery to common
femoral artery bypass and femoral-femoral cross-over graft were
performed.
Past Medical History:
Hyperlipidemia
laryngeal CA
basal cell ca
peptic ulcer dz
hx. of esophageal stricture
ETOH abuse
Known aortic dissection
Iliac stent with fem - fem graft
Social History:
Pos alcohol
pos smoker
Family History:
non contributary
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
Groins dressed so femoral nodes not assessed
Fem pulses present b/l
Bil LE warm; + pulses by doppler
Pertinent Results:
CHEST (PORTABLE AP) [**2106-2-15**] 9:06 AM
CHEST: AP portable semi-upright view. The nasogastric tube and
the left internal jugular central venous catheter remain in good
positions. There is interval worsening of bilateral perihilar
and basilar opacities, consistent with increasing congestive
heart failure. There are persistent opacities in the right and
left upper lobe, consistent with pneumonia or aspiration.
Multiple surgical clips are again seen in the upper mid abdomen
and just above the gastroesophageal junction.
IMPRESSION:
1. Worsening congestive heart failure.
2. Unchanged right and left upper lobe pneumonia versus
aspiration.
CT CHEST W/CONTRAST [**2106-2-15**] 4:20 PM
CHEST CT WITH INTRAVENOUS CONTRAST: Emphysema is again noted,
with multiple bullae in the middle and upper lobes. There are
confluent ground-glass opacities as well as interlobular septal
thickening in both upper lobes, right middle lobe, lingula, and
the superior and anterior portions of the lower lobes. The
opacities are most dense in the upper lobes. Small peripheral
centrilobular ground-glass opacities are present throughout both
lower lobes, similar in appearance to [**2104-7-16**]. While the
centrilobular and confluent ground glass opacities are
consistent with aspiration or pneumonia, presence of
interstitial septal thickening also suggest pulmonary edema.
While there is some nodularity within the opacities, nodular
opacities that were seen in the left upper and right lower lobes
on [**2105-7-16**] are no longer present. There is no evidence of an
abscess.
The trachea, right and left main stem bronchi are mildly
dilated. Mild-to- moderate bronchiectasis is noted in the upper
lobes, right middle lobe and lingula. Dependent secretions are
noted in the trachea.
There are numerous enlarged mediastinal lymph nodes, increased
in number and size compared to [**2104-7-16**]. The largest right
superior mediastinal node measures 12 mm in short axis diameter.
The largest upper right paratracheal node measures 11 mm. The
largest lower right paratracheal node measures 9 mm. The largest
right para-aortic node measures 12 mm. The largest subcarinal
node measures 15 mm. The largest right para-esophageal node
measures 13 mm. Numerous subcentimeter nodes are present in both
hila.
There are small bilateral pleural effusions. There is no
pericardial effusion. Scattered atherosclerotic calcifications
are present in the thoracic aorta. Mural thrombus is noted in
the proximal abdominal aorta.
There is an unchanged ill-defined hypodensity in the right lobe
of the thyroid gland, measuring approximately 2 x 1 cm.
There is an approximately 4 cm hypodense lesion in the lower
pole of the spleen, unchanged compared to the [**2106-2-13**] abdominal
CT, which may represent a splenic infarction. Scattered
calcified granulomas are again noted in the liver. Stones are
again seen in the gallbladder. Surgical clips are again noted in
the porta hepatis and in the region of the gastroesophageal
junction. The imaged portions of the pancreas, adrenal glands,
and kidneys appear unremarkable. The imaged bones appear
unremarkable.
IMPRESSION:
1. Diffuse bilateral pulmonary opacities, confluent in the upper
and middle lobes, consistent with aspiration or pneumonia.
Recurrent interlobular septal thickening is consistent with
superimposed pulmonary edema. Given foci of nodularity,
follow-up is recommended after treatment. No evidence of an
abscess.
2. Small bilateral pleural effusions.
3. Mild central tracheal dilatation. Diffuse mild-to-moderate
bronchiectasis in the upper and middle lobes.
4. Increased number and size of mediastinal and bilateral hilar
lymph nodes, which may be reactive. However, metastatic disease
cannot be excluded, and follow-up after treatment is
recommended.
5. Hypodense splenic lesion, unchanged since [**2106-2-13**], compatible
with an infarct.
6. Cholelithiasis.
7. Unchanged hypodense lesion in the right lobe of the thyroid.
[**2106-2-13**] 11:08:22 PM
EKG
Sinus tachycardia. Right bundle-branch block. Compared to
tracing #1, no
diagnostic change.
[**2106-2-13**] 3:20 PM
CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST
CT ABDOMEN WITHOUT AND WITH IV CONTRAST:
Hazy nodular opacities about the airways within the lower lungs
have increased since the prior study consistent with small
airways disease. There is mild hazy opacity within the lung
bases which could represent normal lung at expiration, however
mild ground glass airspace disease cannot be excluded.
There is a hepatic granuloma within the dome of the liver. No
concerning hepatic lesions. There are multiple small gallstones
dependently within the gallbladder. No gallbladder wall
thickening. No biliary ductal dilatation or choledocholithiasis
evident. There is a choledochojejunostomy, which is normal in
appearance.
Within the inferior aspect of the spleen, there is a large
hypodense lesion, without enhancement measuring 4.4 x 4.3 x 3.9
cm that has significantly increased since the [**5-7**] study. There
is an adjacent smaller similar- appearing lesion lateral to this
larger lesion. These are nonspecific but considerations would
include a splenic infarct. There is no stranding around these
lesions, however infection of the lesions cannot be excluded.
Small splenic hemangioma is also again noted unchanged.
The pancreas is normal in appearance. The patient has undergone
gastric bypass with a gastrojejunostomy. Adrenal glands are
normal in appearance. No bowel wall thickening. No evidence of
bowel wall thickening or bowel obstruction. The appendix
contains contrast within it and gas, possibly from prior CT
scan. No evidence for appendicitis. Small amount of fluid within
the right lower quadrant is nonspecific.
The kidneys show heterogeneous hypoenhancement symmetrically in
a patchy geographic pattern in some locations. These areas have
heterogeneous enhancement still on nephrographic phase. There is
no persistent staining on the delayed images, nor is there
contrast within the kidneys on the pre- contrast CT remaining
from [**2106-2-11**] angiogram. These findings are nonspecific but
considerations would include embolic phenomenon such as
cholesterol or other emboli. Of note, there is a large calcified
plaque within the right renal artery just beyond its origin with
at least moderate narrowing of the right renal artery. There is
also moderate narrowing of the left renal artery at its origin.
There are multiple cysts within the kidneys bilaterally. There
are multiple hypoattenuating lesions which are too small to
characterize but likely cysts.
No lymphadenopathy or ascites.
CT PELVIS WITHOUT AND WITH IV CONTRAST:
The urinary bladder has a Foley catheter within it and is
incompletely distended. No definite urinary bladder abnormality.
There is a small amount of free fluid within the pelvis. Bowel
within the pelvis is within normal limits. There is a rectal
tube with balloon inflated within the rectum. Subsequent
administration of rectal contrast shows no leakage of contrast
and no other abnormality. No lymphadenopathy.
CT ARTERIOGRAM WITH IV CONTRAST:
There is diffuse atherosclerotic plaque within the aorta with a
large amount of plaque within the infrarenal aorta. There is an
ulcerated plaque within the infrarenal aorta with a small neck.
This does not extend beyond the normal contour of the aorta. The
left common iliac artery is occluded, as before. There is
reconstitution of the left external iliac artery from retrograde
flow and there is minimal flow within the left internal iliac
artery. The right common iliac artery is patent at its origin
and then there is a bypass graft from the right common iliac
artery to the right common femoral artery. Native right common
iliac artery distally and the external iliac artery is occluded
with an old stent in place. The iliac-femoral graft is widely
patent. Just distal to its insertion within the right common
femoral artery, there is a right to left femoral-femoral bypass
graft which is widely patent. This is just superior to an
excluded partially thrombosed old femoral- femoral bypass graft
which contains gas within it, likely from recent surgery.
Bilateral superficial femoral arteries are patent proximally
though diminutive. There are small fluid collections about
bilateral common femoral arteries near the graft
origin/insertions, both of which contain small amounts of gas,
likely related to recent surgery. Just distal to the insertion
site of the femoral-femoral bypass graft on the left is a round
fluid collection that on pre-contrast images is heterogeneous in
density and post-contrast images shows a small amount of
contrast outside the lumen of the adjacent arteries with
progressive increased density dependently within the collection
seen, making this highly suspicious for a pseudoaneurysm. This
is best demonstrated on series 2, 3, and 4, images 90-94 and
series 6 B, images 186-189. The arteries distal to the graft
sites are patent within the visualized portions.
SMA, [**Female First Name (un) 899**], and celiac artery are all patent and without evidence
of proximal stenoses. As mentioned above, the right renal artery
has a large calcified plaque just beyond its origin with at
least moderate stenosis. The left renal artery has moderate
stenosis at its origin.
BONE WINDOWS: There is multilevel lumbar disc degeneration. No
suspicious bone lesions.
IMPRESSION:
1. Aortic atherosclerosis with ulcerated plaque in the
infrarenal aorta. Occluded left common iliac artery with
external iliac artery reconstitution from retrograde flow from
fem-fem bypass graft. Patent right common iliac- femoral bypass
graft and right to left femoral-femoral bypass graft with patent
superficial femoral artery distal to the bypass grafts in the
visualized portions.
2. Just distal to the left insertion of the fem-fem bypass graft
with findings are highly suspicious for a pseudoaneurysm.
[**Female First Name (un) **] ultrasound of this area is recommended to further
evaluate.
3. Gas and fluid about the bilateral femoral [**Female First Name (un) 1106**] operative
sites and gas within the old thrombosed fem-fem bypass graft
likely related to surgery.
4. Increased size of hypodense splenic lesions that could
represent infarcts. No secondary signs of infection, however
this cannot be excluded.
5. Patent SMA and [**Female First Name (un) 899**] without evidence of bowel abnormality.
6. Bilateral patchy heterogeneous perfusion abnormalities within
the kidneys suggesting recent bilateral renal insult, possibly
from embolic phenomenon such as cholesterol emboli. There is
also bilateral renal artery stenosis, slightly worse on the
right than the left, at least a moderate degree.
7. Bilateral pulmonary small airways disease, worse in the bases
than in [**2105-5-3**]. If clinically indicated, high resolution chest
CT could be performed.
[**2106-2-23**] 04:30AM
COMPLETE BLOOD COUNT
White Blood Cells 8.3
Red Blood Cells 3.76*
Hemoglobin 11.2* g/dL
MCV 89
MCH 29.9
MCHC 33.7
RDW 16.4*
Platelet Count 298 K/uL 150 - 440
[**2106-2-23**] 12:01PM
PT 15.8*
PTT 34.2
INR(PT) 1.4*
[**2106-2-20**] 06:00AM
RENAL & GLUCOSE
Glucose 86 mg/dL
Urea Nitrogen 14 mg/dL
Creatinine 0.7 mg/dL
Sodium 137 mEq/L
Potassium 3.9 mEq/L
Chloride 104 mEq/L
Bicarbonate 24 mEq/L
Anion Gap 13
CHEMISTRY
Calcium, Total 7.8*
Phosphate 2.5*
Magnesium 2.1
GENERAL URINE INFORMATION
Urine Color Amber
Urine Appearance Cloudy
Specific Gravity 1.049* 1.001 - 1.035
DIPSTICK URINALYSIS
Blood LG
Nitrite NEG
Protein 30 mg/dL
Glucose NEG mg/dL
Ketone NEG mg/dL
Bilirubin NEG EU/dL
Urobilinogen NEG mg/
pH 6.5
Leukocytes NEG
MICROSCOPIC URINE EXAMINATION
RBC >50
WBC 1 #
Bacteria MOD
Yeast NONE
Epithelial Cells 0 #/hpf
Transitional Epithelial Cells 1 #/hpf
Granular Casts 0-2 #/lpf 0 - 0
Amorphous Crystals FEW
[**2106-2-15**]
SWAB
No VRE isolated.
Brief Hospital Course:
Patient was admitted and started on anti-coagulation secondary
to LE graft coagulopathy. Patient was started on a heparin gtt
with goal of 60-80. Patients Coumadin was initially held.
Patient had groin exploration/angiogram. Patient was given an
epidural. Patient tolerated procedure and in PACU area it was
noticed that Hct levels had come down. Patient was transfused 2
units. Patient's anticoags were held while he got his
transfusion and then was re-started. Heme was consulted for
this and suggested HIT. Patient most-likely was sub-therapeutic
on lovenox. Typical dosing for Lovenox is 1mg/kg [**Hospital1 **] and he was
only on 30mg/day. Patient was admitted to SICU. Patient was
continued on broad spctrum
antibiotics(Vanco/Clinda/Ceftaz/Flagyl). Patient's groin
dressings were continually monitored during this time while in
the unit where it was noticed to be draining. Patient was
screened for HIT and started on Argatroban. Patients Argatroban
was started/stopped [**Hospital 58097**] hospital stay. Patients
epidural and NG-tube were DC's post-op day 4 and Clinda was DC'd
as per IS requests. Patient transferred to VICU and Argatroban
and Coumadin were re-started. Through-out the patients entire
hospital stay the goal was to acquire a therapeutic state
between (2.0-3.0) Patient was started on Lovenox sq on final
hospital day and it was explained to patient that when he get's
discharged from hospital he won't be able to check his lovenox
levels. It was suggested to patient that he stay in the
hospital until his PT becomes therapeutic but the patient
requested he leave and go home on Lovenox sub-q. Patient was
instructed to f/u w/ PCP(Dr. [**Last Name (STitle) 5456**] qod for coag checks.
Patient wwas also Dc'd on Coumadin 3mg hs, ASA 81mg qd. Patient
was also given Abx- (Levo/Flagyl).
Medications on Admission:
Coumadin,
asa,
percocet
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*4 inhalers* Refills:*2*
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*4 inhalers* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*100 ML(s)* Refills:*0*
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous twice
a day for 4 days.
Disp:*8 Lovenox (Subcutaneous) 60 mg/0.6 mL Syringe* Refills:*1*
9. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*6*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. 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*
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 weeks.
Disp:*63 Tablet(s)* Refills:*0*
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
South Eastern [**State 350**] VNA
Discharge Diagnosis:
Thrombosed femoral-femoral graft and iliofemoral graft with
bilateral extremity ischemia.
Hypercoagulable state.
Discharge Condition:
Stable
Discharge Instructions:
Please restart your home medications. You may shower regularly,
but no tub baths. Pat your incisions dry. If there continues
to be drainage from your incision, place dry gauze over it.
Call a physician or go to the emergency room if you experience
fever >101.4F, pain unrelieved by medication, or foul-smelling
drainage coming from your incision.
Discharge Instructions:
You are to be discharged on coumadin. You must have your INR
followed. This measures the level of coumadin in the blood. This
level must be between [**2-5**]. Your PCP [**Name9 (PRE) **] been [**Name (NI) 653**]. [**Name2 (NI) **] will
follow your INR.
You are also on Lovenox this is again a blood thinner, You must
give yourself shots twice a day. You are to take Lovenox untill
the Coumadin (INR ) is between [**2-5**]. When your coumadin level is
appropriate. You may stop the Lovenox.
WOUND CARE:
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your wound(s).
New pain, numbness or discoloration of your lower or upper
extremities (notably on the side of the incision).
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
OTHER INFORMATION:
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re wound / incision site and this should
be left in place for three (3) days. Remove it after this time
and wash your incision(s) gently with soap and water. You will
have sutures, which are usually removed in 4 weeks. This will be
done by the Surgeon on your follow-up appointment.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for
removal.).
When the sutures / staples are removed the doctor may or may not
place pieces of tape called steri-strips over the incision.
These will stay on about a week and you may shower with them on.
If these do not fall off after 10 days, you may peel them off
with warm water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
two weeks after surgery.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re wound / incision site and this should
be left in place for three (3) days. Remove it after this time
and wash your incision(s) gently with soap and water. You may
have staples and or sutures, which are usually removed in 4
weeks. This will be done by the Surgeon on your follow-up
appointment.
Limit strenuous activity and or heavy lifting until the wound
is well healed. Activity may prevent the wound from healing.
Do not drive a car unless cleared by your Surgeon.
Try to keep your affected limb elevated when not in use, This
decreases swelling to the affected wound and helps in the
healing process.
You may have an ace wrap around the affected limb with the
wound. This helps prevent swelling to the area. You may take
this off at night. But when you are doing activity the ace wrap
should be worn.
ANTIBIOTICS:
You may have a prescription for antibiotics. Take as directed.
Be sure you take the full course even if the wound looks well
healed. Failure to do so may lead to infection.
Followup Instructions:
Call Dr.[**Name (NI) 1720**] clinic at [**Telephone/Fax (1) 1241**] to schedule a follow-up
appointment in [**2-5**] weeks.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB)
Date/Time:[**2106-4-15**] 10:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2106-4-15**] 10:30
Test for consideration post-discharge: Activated Protein C
Follow - up with Dr [**Last Name (STitle) 5456**] for your INR. VNA will moniter your
INR. Dr [**Last Name (STitle) 5456**] will adjust your coumadin accordingly. VNA will
fax the results to Dr [**Last Name (STitle) 5456**] office at [**Telephone/Fax (1) 32161**].
Completed by:[**2106-2-23**]
ICD9 Codes: 4280, 5070, 2851, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7543
} | Medical Text: Admission Date: [**2128-1-22**] Discharge Date: [**2128-1-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Aspiration
Major Surgical or Invasive Procedure:
PEG tube placement, trach tube replacement
History of Present Illness:
[**Age over 90 **]yo M w/ h/o endstage alzheimer's, afib, esophageal stricture
s/p 3 diliataions, and recurrent aspiration who presented from
nursing home for lethargy, and cough w/sputum over last couple
days. Wife says 1 wk ago pt (?partially)pulled out his g-tube,
and nurse put back in place. Pt was looking more emaciated and
his feeds were increased from 12h to continuous over 24h, which
is when she thinks pt started to decline, and may have been
aspirating. Over the last couple days pt became more
unresponsive and also developed a cough w/ sputum. Pt was on
levoflox for pna as outpt.
Of note pt was discharged on [**2127-11-27**] with asp pna, treated with
vanco/cipro/zosyn. During that admission pt failed extubation
twice due to mucous pluging and tracheostomy was placed. J-tube
and G-tube were placed to prevent aspiration. (Also had C5-6
fusion then)
Required bag masking at NH, hemodynamically stable, then
transported to [**Location (un) **], cxr showed pna, no ivf, then transferred
to [**Hospital1 18**].
In [**Hospital1 18**] ED, t99.8, 136/91, 104, 22, 99%ra, cachectic,
non-responsive, rhonchi at R base, suctioning pus from lungs,
abd soft, IVF initiated - given 1.5L, ceftaz, vanco, and azithro
initiated. HR 88, sats 50% 15L, rr26, 149/94, T 100.8 on
transfer.
Past Medical History:
Esophageal stricture ? s/p [**Hospital 81947**]
Hiatal hernia
Hypertension
S/p aortic valve replacement 3 years ago bovine per wife
Hip fracture s/p repair
H/o aspiration pneumonia, ? recurrent aspiration
H pylori gastritis
Dementia
Social History:
Patient is a retired ENT surgeon per out side hospital report.
He lives at home with his wife. Independent ADLs until last
summer
Family History:
non contributory
Physical Exam:
GENERAL: late-stage alzheimer's - nonresponsive
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRL 2mm->1mm. MMM. OP clear.
NECK: trach present. Neck Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=flat
LUNGS: course rhonchi, and rales throughout
ABDOMEN: +BS Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Pt non-responsive to commands. Somnolent.
Pertinent Results:
[**2128-1-27**] 04:06AM BLOOD WBC-7.6 RBC-3.87* Hgb-11.3* Hct-33.5*
MCV-87 MCH-29.3 MCHC-33.8 RDW-15.8* Plt Ct-373
[**2128-1-22**] 02:30PM BLOOD Neuts-85.0* Lymphs-10.6* Monos-4.0
Eos-0.2 Baso-0.2
[**2128-1-23**] 04:00PM BLOOD PT-13.7* PTT-24.9 INR(PT)-1.2*
[**2128-1-27**] 04:06AM BLOOD Glucose-115* UreaN-19 Creat-0.7 Na-141
K-3.8 Cl-106 HCO3-28 AnGap-11
[**2128-1-22**] 02:30PM BLOOD CK(CPK)-16*
[**2128-1-22**] 02:30PM BLOOD cTropnT-0.01
[**2128-1-27**] 04:06AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.2
[**2128-1-22**] 03:30PM BLOOD Lactate-1.9
[**2128-1-27**] 04:49AM URINE Color-Pink Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2128-1-27**] 04:49AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2128-1-27**] 04:49AM URINE RBC-756* WBC-87* Bacteri-FEW Yeast-NONE
Epi-0
Sputum culture: MRSA
Urine and blood cultures: neg
[**2128-1-22**] CXR: 1. Patchy opacity in the right lower lobe concerning
for pneumonia. 2. Dense retrocardiac opacity, which could
represent second area of pneumonia or atelectasis.
[**2128-1-26**] Replacement of G/J tube: Uncomplicated placement of
gastrojejunostomy tube through the patient's existing tract. The
tube may be used immediately.
Brief Hospital Course:
[**Age over 90 **]yoM htn, afib, esophageal stricture transferred from nursing
home with lethary and fever, diagnosed at OSH ED with pna,
transferred to [**Hospital1 18**], diagnosed with pna, admitted to [**Hospital Unit Name 153**] for
tx of aspiration pna/HAP.
# [**Name (NI) 10227**] Pt has had recurrent pneumonia. Pt had aspiration
pneumonia on this admission. It is possible that pt had
aspiration with increasing his feeds from 12h to continuous 24h.
His trach was also replaced with one with a cuff to further
prevent aspiration risk. He was treated w/ Vancomycin and Zosyn.
Cipro was not started during this admission as there is no
recorded Pseudomonas infection on cultures. Pt required frequent
suctioning initially q1h, which is now improved. Pt is now
afebrile and wbc is coming down. He showed moderate growth of
STAPH AUREUS COAG +, and his zosyn was discontinued. Pt needs
Vanc 1g IV q24 (as only coag + SA on cx data) x8 days ([**4-26**]) for
two more days.
# Hypernatremia - Pt's Na was 158, and improved with free water
replacement. Now resovled at 141.
# 1st degree AV block - overnight once, now resolved in sinus
60-80s HR
#. H/o Atrial Fibrillation - currently not in afib, but rate
controlled.
#. Hypertension- currently controlled, will moniter
#. UTI- UA with neg nitrates but pos leukocytes, few bacteria,
WBC 21-50, 90 on repeat, Urine Culture with minimal yeast and
GNR. Treated while pt was on Zosyn
#. Hiatal hernia- gave home omezprazole
Medications on Admission:
Lasix 40 [**Hospital1 **]
Aricept 10 QD
ASA 81
Omep 40 QD
KCl suspension 20 [**Hospital1 **]
Levaquin 250 x9d
Ativan 0.5mg q6 prn
Twocal HN continuous @ 50ml/h via g-tube
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Aspiration Pneumonia, MRSA
Secondary: Alzheimers dementia
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted with fevers, increased secretions thought to
be due to an aspiration pneumonia. We treated you with
antibiotics to cover the bacteria which grew from your cultures.
Followup Instructions:
please follow up with your PCP as necessary
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2128-1-27**]
ICD9 Codes: 5070, 5849, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7544
} | Medical Text: Admission Date: [**2175-9-21**] Discharge Date: [**2175-10-6**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
Percutaneous gastrostomy tube placement
History of Present Illness:
[**Age over 90 **] yo female restrianed passenger s/p head on motor vehicle
crash. No reported LOC. She was transported to [**Hospital1 18**] for further
care.
Past Medical History:
HTN
Legally blind
Social History:
Lives with son
Family History:
Noncontributory
Pertinent Results:
[**2175-9-21**] 10:53AM GLUCOSE-142* LACTATE-1.8 NA+-144 K+-4.1
CL--107 TCO2-21
[**2175-9-21**] 10:45AM UREA N-24* CREAT-0.9
[**2175-9-21**] 10:45AM WBC-12.2* RBC-4.30 HGB-12.8 HCT-37.6 MCV-88
MCH-29.7 MCHC-33.9 RDW-13.8
[**2175-9-21**] 10:45AM PLT COUNT-313
[**2175-9-21**] 10:45AM PT-14.3* PTT-38.6* INR(PT)-1.2*
[**2175-9-21**] Head CT scan
IMPRESSION: No acute intracranial pathology. Age-related
atrophy.
Periventricular white matter ischemic changes are chronic.
[**2175-9-21**] Cervical spine CT scan
IMPRESSION:
1. Fractures through the left C2 and C3 transverse processes
extending into
the foramen transversarium. These fractures put the patient at
increased risk
for possible vertebral dissection which could be better
evaluated with a
dedicated CTA or MRA (with T1 fat supression sequences) of the
neck.
2. Nondisplaced fracture of the right lamina of C2.
3. Extensive degenerative changes of the cervical spine
including C2-C3
moderate to severe spinal stenosis. In the setting of trauma,
these
degenerative changes put the patient at increased risk for
ligamentous injury
or cord injury, which cannot be fully evaluated by CT and would
recommend MRI
for further evaluation if clinical suspicion for neck injury
persists.
ECHO [**2175-9-22**]
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein A: *0.4 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: *5.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 70% >= 55%
Aorta - Sinus Level: 2.5 cm <= 3.6 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.4 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *23 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 13 mm Hg
Mitral Valve - E Wave: 1.5 m/sec
Mitral Valve - A Wave: 1.5 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: *282 ms 140-250 ms
TR Gradient (+ RA = PASP): *43 to 62 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity.
Overall normal LVEF (>55%).
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.
Focal calcifications in ascending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (AoVA 1.2-1.9cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Severe
mitral annular calcification. Mild thickening of mitral valve
chordae. Calcified tips of papillary muscles. No MS. Mild to
moderate ([**12-14**]+) MR. [Due to acoustic shadowing, the severity of
MR may be significantly UNDERestimated.]
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Normal tricuspid valve supporting structures. No TS. Moderate
[2+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is small. Overall left
ventricular systolic function is normal (LVEF 70%). Right
ventricular chamber size and free wall motion are normal. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is severe mitral
annular calcification. Mild to moderate ([**12-14**]+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2175-9-22**] MR [**Name13 (STitle) **]; Thoracic Spine
CERVICAL SPINE: Fractures of C2 and C3 are better visualized on
the recent
CT.
Prevertebral soft tissue swelling extends from C2 to the
inferior endplate of
C4. While this implies ligamentous injury, no definite
ligamentous injury is
identified.
Epidural hematoma is seen posteriorly, extending from C2 through
the inferior
endplate of T2. In addition, there are multiple disc
herniations/bulges.
These combined changes result in narrowing of the spinal canal,
however, there
is no cord signal abnormality to suggest cord compression.
At C2-3, there is left paracentral disc protrusion. At C3-4,
disc bulge
compresses upon the ventral aspect of the thecal sac. At C4-5,
there is canal
narrowing due to midline and left foraminal disc protrusion that
indents the
cord and narrows the left neural foramen.
At C5-6, high signal within the disc space anteriorly indicates
an annular
tear. Osteophyte indents the ventral aspect of the cord. This
may be acute
or chronic, although there is no associated prevertebral soft
tissue swelling.
At C6-7, disc herniation indents the cord, however, there is no
cord signal
abnormality.
There is blood within the left occipital [**Doctor Last Name 534**], seen on the most
superior axial
images (5:2).
THORACIC SPINE: An acute T12 compression fracture with
retropulsed bone
severely narrows the spinal canal, however, there is no cord
deformity and the
spinal cord demonstrates normal signal. There is acute
compression fracture
of T2, without retropulsion. A T4 compression deformity is
chronic.
At T6-7, disc protrusion results in cord compression, although
this is not
acute.
IMPRESSION:
1. Blood in the left occipital [**Doctor Last Name 534**]. Followup head CT is
recommended.
2. Prevertebral cervical hematoma. While this is suggestive of
ligamentous
injury, no ligamentous injury is identified.
3. Cervical prevertebral hematoma, epidural hematoma and disc
herniations/protrusions result and narrowing of the cervical
spinal canal,
however, there is no evidence of cord compression.
4. Acute compression fracture of T2.
5. Acute T12 compression fracture with retropulsed bone,
severely narrowing
the canal. No cord deformity or cord signal abnormality is
identified. FINDINGS: Previously placed left-sided PICC line
cannot be identified at the
present study in the left arm or chest. Left retrocardiac
opacity is
unchanged. Interval development of pleural effusion bilaterally.
Old right-
sided rib fractures are again seen. Compression deformity of a
lower thoracic
vertebral body again seen. The nasogastric tube was removed. A
G-tube
projects in the left upper quadrant.
Brief Hospital Course:
She was admitted to the Trauma Service. Orthopedic spine surgery
was consulted given her injuries which were non operative. She
was fitted for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36323**] brace (TLSO with a cervical extension)
and began working with Physical therapy thereafter. Because of
her rib fractures she remained in the Trauma ICU for several
days because of concern for her pulmonary status. There were
initial discussions regarding the possibility that she would
require a tracheostomy for airway management. She was able to
manage her airway effectively, maintaining oxygen saturations
between 92-94% with 2 liter s of nasal oxygen. She also had
episodes of paroxysmal atrial fibrillation during her ICU stay
and required an Amiodarone drip; she was also started on beta
blockade. Once her Amiodarone drip was stopped she was changed
to the oral form; initially 400 mg [**Hospital1 **], the dose will need to be
decreased over the next week.
Because of dysphagia Speech and Swallow were consulted; a
bedside swallow was done and it was recommended that she remain
NPO because of risk for aspiration. Discussions took place for
placement of PEG with patient and family. A percutaneous PEG was
placed without complications. Her medications were all changed
to via PEG; including her Amiodarone.
Because of poor venous access a left arm PICC was placed for
which patient removed as she reported it was causing her pain.
She did develop arm swelling following this an underwent an
upper extremity ultrasound which did reveal a thrombus in the
left axillary and cephalic veins. Vascular Surgery was consulted
an no further intervention was warranted. The area was monitored
closely and did resolve over time.
She did have intermittent blood pressure issues with SBP
readings high 170's; her medications were adjusted several
times; systolic blood pressure on morning of discharge after her
morning medications was 138.
She is being recommended for acute rehab after her hospital
stay.
Medications on Admission:
Nifedipine
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 3 days.
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Begin on [**2175-10-10**].
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Isosorbide Dinitrate 20 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
6. Acetaminophen 160 mg/5 mL Solution Sig: Fifteen (15) ML's PO
every 4-6 hours as needed for pain.
7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
9. Protonix 40 mg Susp,Delayed Release for Recon Sig: Forty (40)
MG PO once a day.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection [**Hospital1 **] (2 times a day).
11. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: One (1) NEB Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-14**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes: both
eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 86**]
Discharge Diagnosis:
s/p Motor vehicle crash
C2/C3 transverse process fracture
C2 lamina fracture epidural hematoma C2-T2
T2 and T12 compression fracture
Rib fractures - left 2-8,10
Small pneumothorax
Secondary diagnosis:
Hypertension
Discharge Condition:
Hemodynamically stable, tolerating tube feedings, pain
adequately controlled.
Discharge Instructions:
The brace must be worn at all times while out of bed.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 363**], Orthopedic Spine Surgery in 2 weeks,
call [**Telephone/Fax (1) 3573**] fo an appointment.
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery, in 2 weeks. Call
[**Telephone/Fax (1) 6429**] for an appointment.
Completed by:[**2175-10-6**]
ICD9 Codes: 486, 5990, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7545
} | Medical Text: Admission Date: [**2107-5-17**] Discharge Date: [**2107-6-10**]
Date of Birth: [**2030-4-19**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Altered mental status
Diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77 y/o man with PMH significant for Crohn's disease and colon CA
s/p resection on [**Hospital 3454**] transferred from the ICU after being
admitted on [**5-17**] with confusion and weakness. On [**5-17**], the pt
was admitted through the ED with five days of increased diarrhea
(has chronic diarrhea at baseline) with new weakness and
confusion. At that time, the pt reported decreased PO intake and
some nausea but no vomiting. In the ED, the pt's VS were 98.7
88 133/56 16 95% 2 L NC. Labs were significant for a bicarb
of less than 5 and a creatinine of 2.1 His VBG was 6.92/16/64.
CT of the head was negative for acute process. The pt was
admitted to the MICU for further care.
.
In the MICU, the pt was treated for his metabolic acidosis that
was thought to be a combonation of gap acidosis from ARF and non
gap acidosis from GI losses/diarrhea with a compensatory
respiratory alkalosis. GI was consulted and has been following.
The pt received bicarb for repleation. By [**5-18**], his bicarb had
increased to 12 and his creatinine had improved to 1.4. However,
the pt remained very agitated and confused. He received 1 unit
PRBC for a Hct of 23.4.
.
His mental status then returned to baseline. Infectious workup
of the diarrhea was negative. At the time of transfer to the
floor, his bicarb had increased to 23 and his creatine to 0.7.
Past Medical History:
1. Crohn's disease for 40 years
2. Type 2 diabetes mellitus
3. Colon CA s/p resection- Pt is on FOLFOX chemotherapy. He got
his last dose of leucovorin and 5FU on [**5-9**]. His chronic
diarrhea has been worse over the last 2 months while on chemo.
4. S/P testicular surgery
5. S/P appendectomy
6. Enterocutaneous fistula
Social History:
Pt lives with his wife. [**Name (NI) **] ETOH or tobacco use.
Physical Exam:
97 112/p 80 14
Gen- Ill-appearing, lying in bed, eyes closed, responds
appropriately
HEENT- MMM
Cardiac- RRR, normal s1s2, no murmurs
Pulm- Decreased BS at R base, fine crackles at L base, o/w clear
Abdomen- Soft, NT, ND, vertical midline scar well-healed, R
sided hernia nontender and reducible
Extremities- no edema, pneumoboots on
Neuro- A+O x 3, appropriate, humorous but not talkative
spontaneously. Moves all 4 extr spontaneously.
Pertinent Results:
.
EKG [**2107-5-17**]: Sinus rhythm at 99 bpm, with atrial premature
depolarizations. Left axis deviation. Left anterior fascicular
block. Diffuse non-diagnostic repolarization abnormalities.
Compared to the previous tracing of [**2106-9-15**] no definite change.
.
Stool studies:
C diff ([**5-18**], [**5-19**], [**5-28**] and [**5-31**], 55)- Negative
Other stool studies from [**5-18**] also negative.
.
Urine culture ([**5-18**])- 10,000 to 100,000 alpha hemolytic
colonies consistent with alph strep or lactobacillis.
.
[**2107-5-17**]: No overt CHF or infiltrate.
.
ct abd/pelvis [**2107-5-24**]:
1. New small bilateral pleural effusions.
2. Anasarca.
3. Stable subcentimeter low attenuation lesions in the liver and
left kidney.
4. Progression of severe pancreatic atrophy. Stable pancreatic
cysts.
New subcentimeter low attenuation lesions in the spleen, which
appear nonspecific but may represent infarct.
[**2107-5-17**] 10:00AM BLOOD WBC-8.1 RBC-3.28* Hgb-11.0* Hct-34.9*
MCV-107* MCH-33.6* MCHC-31.6 RDW-22.2* Plt Ct-209
[**2107-5-17**] 10:00AM BLOOD Neuts-77* Bands-3 Lymphs-13* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2107-5-17**] 11:16PM BLOOD PT-17.4* PTT-31.4 INR(PT)-1.9
.
[**2107-5-17**] 10:00AM BLOOD Glucose-215* UreaN-25* Creat-2.1*# Na-133
K-3.1* Cl-113* HCO3-<5.0
.
[**2107-5-17**] 03:00PM BLOOD Acetone-MODERATE
[**2107-5-17**] 03:08PM BLOOD Type-[**Last Name (un) **] pO2-130* pCO2-16* pH-6.92*
calHCO3-4* Base XS--29
[**2107-5-17**] 07:48PM BLOOD Glucose-218* Lactate-3.3* Na-134* K-2.3*
Cl-115* calHCO3-9*
.
[**2107-5-22**] 04:06PM BLOOD Ret Aut-5.8*
[**2107-6-2**] 06:00AM BLOOD Ret Aut-0.6*
.
[**2107-5-22**] 04:06PM BLOOD Iron-18* calTIBC-138* VitB12-1516*
Folate-18.7 Ferritn-170 TRF-106*
[**2107-5-23**] 06:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- positive
.
[**2107-6-10**] 05:14AM BLOOD Glucose-44* UreaN-9 Creat-0.7 Na-137
K-3.6 Cl-103 HCO3-27 AnGap-11
Brief Hospital Course:
77 y/o man with PMH significant for Crohn's disease and colon CA
admitted with severe metabolic acidosis due to diarrhea. Had had
less diarrhea; on [**5-21**] starting to have more, and on [**5-23**]
started on somatostatin.
.
1. Severe diarrhea - The patient's diarrhea continued without
significant change despite scheduled imodium for the last week
in addition to escalating doses of somatostatin. CT of the
abdomen was without evidence of Crohn's flare. The pt's diarrhea
was initially attributed to a very common and severe
complication of leukovorin/F5U treatment, per discussions with
the pt's oncologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He was sequentially
started on standing imodium and questran. However, given that
the diarrhea lasted longer than the [**3-3**] week expected time frame
of chemo induced diarrhea despite the aggressive treatment, and
with stool studies continuing to remain negative, he was
ultimately titrated up on prednisone. The thought was that the
initial chemotherapy induced diarrhea may have precipated a
Crohn's flare. His diarrhea slowly began to improve and was at
his baseline at discharge. He was maintained on a lactose free,
low residue diet.
.
2. Crohn's -
- He was initially placed on cipro prophylaxis for Crohn's, but
this was eventually discontinued. His Crohn's was thought to
have flared after a severe bout of chemotherapy induced
diarrhea. His home dose of prednisone 5mg qod was titrated up
as above.
.
3. Colon CA - Per discussion btw patient, family, and Dr.
[**Last Name (STitle) **] on [**5-23**], the pt will not continue chemotherapy as the
side effects are too severe.
.
4. ARF - Resolved prerenal ARF with hydration; baseline .7; to
peak of 2.1 on admission.
.
5. DM2 - His blood sugars were wel controlled until he started
on the high dose prednisone. He subsequentally had brittle BG
on prednisone, with NPH added to his RISS regimen for better
control. The titration of his insulin however was very
difficult as he had multiple episodes of asymptomatic
hypoglycemia when placed on more aggressive insulin regimens.
It is expected that this should improve once his prednisone is
tapered.
.
6. Coagulopathy - On home Vitamin K 7.5mg qod. INR stable.
.
7. Anemia - Hct slowly trending down. Iron studies show a mixed
picture, likely combination of ACD and iron deficiency. We did
not start epogen at this time. His hct trended down to 24 from
28 on [**5-31**], for which he got 2 units PRBC's. His post
transfusion HCT stablized at 32-34. We continued home vit B12
and folate. Iron supplements were also given.
.
8. Thrombocytopenia - HIT POSITIVE. We held all heparin
products.
.
9. UTI-the patient had leucocytosis to 11 on [**6-1**] w/ dysuria and
hypoglycemia. Ua was grossly positive. repeated urine cx c/w
skin flora-sent straight cath [**6-5**] which is still growing skin
flora-isolated 2 types of enterococci. While the speciation was
pending, we empirically started bactrim but persistently
positive ua so this was d/c'd after 6 days. A straight cath ucx
grew enterococci sensitive to ampcillin and macrodantin. We
started macrodantin x 7 days on [**6-9**].
.
10. Proph - Pneumoboots, PPI. NO heparin products.
.
11. Lines - PIV, portacath.
.
12. FEN - Cardiac, DM diet, lactose free
- Repleted lytes [**Hospital1 **]->now qd
- Continued home Vitamin D/calcium.
- started on po bicarb
.
13. DNR/DNI
Medications on Admission:
1. Ciprofloxacin 500 mg Q12H
2. Insulin SS
3. Prednisone 5 mg QOD
PRNs- Tylenol
Discharge Medications:
1. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO Q4H
(every 4 hours): Max of 16mg/day .
Disp:*180 Capsule(s)* Refills:*2*
2. Nitrofurantoin Macrocrystal 100 mg Capsule Sig: One (1)
Capsule PO QID (4 times a day) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Phytonadione 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
Disp:*120 capsules* Refills:*2*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO
DAILY (Daily).
Disp:*30 Packet(s)* Refills:*2*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
11. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Octreotide Acetate 500 mcg/mL Solution Sig: One (1) ml
Injection three times a day.
Disp:*21 mL* Refills:*0*
13. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5)
units Subcutaneous qam: before breakfast.
Disp:*300 units* Refills:*2*
14. Insulin Regular Human 300 unit/3 mL Syringe Sig: qs
Subcutaneous before meals (breakfast, lunch, dinner): per
attached sliding scale.
15. Syringe & Needle Dispenser Misc Sig: One (1) syringe and
needle Miscell. three times a day.
Disp:*30 syringe/needle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Chemotherapy induced severe diarrhea
Crohn's flare
Metabolic acidosis
Urinary tract infection
Brittle Diabetes Mellitus
Discharge Condition:
stable with improved diarrhea and resolved metabolic acidosis
Discharge Instructions:
Please call your doctor or go to the ER if you have fever
greater than 101, shaking chills, lethargy or change in your
mentation, muscle cramps, palpitations, chest pain, shortness of
breath, worsening diarrhea or other symptoms of concern to you.
Followup Instructions:
1. Please follow up in Dr.[**Name (NI) 16937**] office on Thursday [**2107-6-16**] at 10:15 am. Call [**Telephone/Fax (1) 682**] if you need to reschedule.
2. Please follow up with your oncologist, Dr. [**Last Name (STitle) **], on
Wednesday [**2107-6-22**] at 3:00 pm. Call [**Telephone/Fax (1) 6568**] if you need
to reschedule.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
ICD9 Codes: 5849, 2765, 2875, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7546
} | Medical Text: Admission Date: [**2176-3-13**] Discharge Date:
Date of Birth: [**2117-2-17**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 59-year-old man,
who was recently treated for endocarditis by Dr. [**First Name (STitle) 24344**]. He
was referred to [**Hospital1 69**] for an
outpatient cardiac catheterization prior to have mitral valve
surgery. He was in his usual state of health until [**Month (only) 359**]
of last year, when he was running and noticed chest
tightness. He went to bed that night and had nightsweats
throughout the night. He lost over 20 pounds over the next
two months and he diagnosed with hypothyroidism and anemia at
[**Hospital3 4527**] Hospital. He was diagnosed with
endocarditis and an echocardiogram on [**2176-2-2**]
showed moderate-to-severe mitral valve prolapse, partial
mitral leaflet failure and severe mitral regurgitation, and a
small pericardial effusion. He was discharged in early
[**Month (only) 404**] and had one month of IV Ceftriaxone at home. Since
then he has been feeling better. He denied any chest pain,
shortness of breath, lightheadedness, and his lower extremity
edema have all resolved. He denied claudication and edema,
however, he had two plus pillow orthopnea. Risk factors for
coronary artery disease included hypertension and heavy
cigarette history.
PAST MEDICAL HISTORY:
1. Rheumatic fever.
2. Renal calculus.
PAST SURGICAL HISTORY: The patient has a past surgical
history for tonsillectomy and adenoidectomy. He denied any
blood in his stools, black stool, stroke, TIA, cancer.
ALLERGIES: He had allergies to Ceftriaxone, which resulted
in extreme rash and no shellfish or dye allergies.
MEDICATIONS AT HOME:
1. Synthroid 50 mg a day.
2. Ferrous sulfate 325 mg three times a day.
LABORATORY DATA: Laboratory data on [**2176-3-9**] revealed CBC of
7.5, 29.9, 202, chemistry of 139, 4.4, 102, 29, 19 and 1.4.
The INR is 1. He is divorced. He denied any alcohol abuse.
Cardiac catheterization done on [**2176-3-13**] showed three-vessel
coronary artery disease with severe stenosis in the RCA, LAD,
and the OM. He had 4+ MR.
The patient was admitted to the cardiothoracic surgery under
the care of Dr. [**Last Name (STitle) 70**]. The patient was taken to the
operating room on [**2176-3-14**], where he has CABG times three and
MVR #31 carbomedical mechanical valve. He was joined by
Dr. [**Last Name (STitle) 70**] and [**Doctor Last Name **]. Dr. [**Last Name (STitle) 70**] was the attending of
record.
Postoperatively, the patient was transferred to the
cardiothoracic Intensive Care Unit, where he was doing well.
After three units of packed red blood cells, platelets were
transfused, he was transferred to the floor. The patient had
a good blood pressure. Vancomycin was infused to the patient
secondary to a mitral valve Gram stain from the operative
session, which showed gram-positive cocci.
The Department of Infectious Disease recommended blood
cultures and the continuation of the Vancomycin initially.
Mitral valve cultures showed nothing and grew out negative.
Blood cultures failed to show any growth. Multiple blood
cultures, were sent off during the hospitalization.
The patient continued on Vancomycin until [**2176-3-21**], when he
was switched over to Penicillin. In light of his known
allergy to Ceftriaxone, the patient was first evaluated by
the allergy specialist who felt that his allergy to
Ceftriaxone was not a real allergy and that he would tolerate
Penicillin. With the consultation and expert advice, we gave
him a test dose of Penicillin, which was tolerated well
without incident. The patient had a MRI of the back done on
[**2176-3-19**], which showed some osteal changes suggestive of
osteomyelitis on T10 and then L5 to S1, possible small
epidural collection around S1 to the right side. The
Infectious Disease was aware of this and we did a CAT scan
the following day. The abdomen failed to show any focal area
of collection or lesions, however, multiple cyst were noted
in the liver and spleen, which could not be ruled out as
being microabscesses. However, the patient was afebrile and
vital signs were stable. The patient had anticoagulation
started during this admission to reach an INR of about 3 to
3??????, since the patient had a mechanical valve. The patient is
on Lovenox, which will be discontinued until the INR is
therapeutic.
On [**2176-3-11**] it was noted that the patient's left leg was
inflamed during the course of his admission. With
antibiotics his leg showed some resolution and no signs of
acute infection, which warranted a new opening of the wound.
The ultrasound done the same day showed that there was no DVT
and the patient had bruising and pain about the leg, most
likely due to the slightly inflamed left incision, which at
no time showed any pus or extensive cellulitis.
During the course of this stay, the patient also had chest
tube and wires discontinued, which was tolerated well with no
pneumothorax. The patient is ready for discharge to home for
a total of four weeks of antibiotics, Penicillin, after a
PICC line was placed on [**3-19**] with cephalic vein position
around the midclavicular area.
The patient is being discharged home likely within the next
two days. The patient will followup with MRI in four weeks
with x-ray of the abdomen and spine. The patient will also
have an appointment with the Department of Infectious Disease
in four weeks for followup with Dr. [**Last Name (STitle) **]. The patient will
also followup with the primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 29111**] [**Name (STitle) 24344**], who will manage his INR
anticoagulation.
CONDITION ON DISCHARGE: Afebrile, good health. The patient
will go home with home VNA and infusion pump.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-358
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2176-3-21**] 21:05
T: [**2176-3-22**] 09:15
JOB#: [**Job Number 38210**]
ICD9 Codes: 2449, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7547
} | Medical Text: Admission Date: [**2114-10-4**] Discharge Date: [**2114-10-8**]
Service: [**Last Name (un) 7081**]
ADMISSION DIAGNOSES:
1. Right pleural effusion.
2. Stage IV colon cancer (metastases to liver, pleura).
3. Chronic obstructive pulmonary disease (home oxygen
dependent, steroid dependent).
4. Congestive heart failure.
5. Pulmonary hypertension.
6. Macular degeneration.
7. Hypertension.
8. Status post torn right rotator cuff.
9. Atrial fibrillation.
DISCHARGE DIAGNOSES:
1. Acute respiratory failure.
2. Status post insertion of right thoracic PleurX catheter.
3. Right pleural effusion.
4. Stage IV colon cancer (metastases to liver, pleura).
5. Chronic obstructive pulmonary disease (home oxygen
dependent, steroid dependent).
6. Congestive heart failure.
7. Pulmonary hypertension.
8. Macular degeneration.
9. Hypertension.
10.Status post torn right rotator cuff.
11.Atrial fibrillation.
ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname 30984**] is an 84-year-old
man with stage IV colon cancer with metastases to his liver
and his pleura, who has been accumulating large right-sided
pleural effusions. He underwent a thoracentesis late in the
summer of [**2113**], which drained over a liter of fluid. The
cytology at that time was negative for malignancy. He had
reaccumulated a large pleural effusion on his right side and
was therefore admitted for elective drainage of this
effusion, and insertion of a PleurX catheter for future
management of his effusion. He was admitted electively in
order to allow his INR to become subtherapeutic, as he had
been on Coumadin for atrial fibrillation.
HOSPITAL COURSE: The patient was admitted on [**2114-10-4**]. His INR had come down to 1.4 by then and the plan was
for him to undergo an elective drainage of his effusion on
[**10-5**]. The patient became acutely hypoxic on the evening
of [**2114-10-4**] secondary to what was felt to be
worsening pulmonary edema, given the patient had not been
taking his Lasix for several days. He was diuresed
aggressively with Lasix at which time his oxygenation
improved, and his mental status and respiratory status
improved. On the morning of [**2114-10-5**] the patient
became increasingly confused and agitated. An arterial blood
gas was drawn which showed a pCO2 of 112, indicating that the
patient had developed some acute on chronic CO2 retention as
his pH at that time was not significantly low (7.27). As the
patient was DNR/DNI, his only option was positive pressure
ventilation. Therefore, he was transferred to the ICU for
drainage of his effusion and possible initiation of positive
pressure ventilation if necessary. The patient stabilized
with additional diuresis not requiring a BiPAP mask, and on
that same day underwent drainage of his pleural effusion, at
that time 2.4 liters of clear fluid were drained. There was
no evidence of hemothorax or infection in the fluid. A PleurX
catheter was placed. The patient's respiratory status still
remained somewhat tenuous although he symptomatically felt
better and his mental status improved. Extensive discussions
were held with the family and eventually the palliative care
service, who had been seeing the patient, met with the family
and the decision was made that the patient would be placed in
hospice palliative care without further aggressive
intervention. He was transferred back to the floor on the
[**10-6**] and since that time has been doing well,
maintaining an oxygen saturation of 93% on 2 liters, which
was his baseline. There was no significant reaccumulation of
his catheter. He was then set up with discharge to hospice
and palliative care on the [**2114-10-8**]. He was
discharged afebrile with normal hemodynamics and as noted an
oxygen saturation of 93% on 2 liters.
DISCHARGE MEDICATIONS: Included albuterol nebulizer
treatments q.6h. as needed, diltiazem extended release 240 mg
p.o. once daily, fluticasone, Solu-Medrol inhaler 250/50 one
inhalation b.i.d., Lasix 80 mg p.o. b.i.d., lisinopril 40 mg
p.o. once daily, prednisone 40 mg p.o. once daily until
[**10-13**], after that time taper down to 20 mg once daily
and continue taper thereafter, Senna 2 mg p.o. at bedtime,
tiotropium bromide 1 tablet inhaled daily.
DISCHARGE CODE STATUS: DNR/DNI.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 286**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2114-10-8**] 10:46:38
T: [**2114-10-8**] 18:09:28
Job#: [**Job Number 102774**]
ICD9 Codes: 4280, 4168, 4019, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7548
} | Medical Text: Admission Date: [**2188-4-19**] Discharge Date: [**2160-3-24**]
Service: Trauma Surgery
ADDENDUM: This Addendum is in regard to Neurosurgery
recommendations. A repeat computed tomography of the head
was reviewed with Radiology and Neurosurgery showing an
unchanged left frontoparietal subdural hematoma.
Neurosurgery recommendations included followup with Dr. [**First Name (STitle) **] in
one month with a repeat head computed tomography. The
patient was cleared by Neurosurgery to go back to nursing
home.
On discharge, the patient was stable. Afebrile with stable
vital signs. Physical examination remarkable for ecchymosis
of the left forehead which is stable. The patient was
tolerating a regular diet and had good urine output; although
incontinent at baseline.
DISCHARGE DIAGNOSES: (Add to discharge diagnoses)
1. Status post fall.
2. Left frontoparietal subdural hematoma (stable).
3. Dementia.
4. Congestive heart failure.
5. Hypertension.
6. Degenerative joint disease.
7. History of cerebrovascular accident.
8. Depression.
9. History of breast cancer.
10. History of hiatal hernia.
11. Chronic anemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 27744**]
MEDQUIST36
D: [**2188-4-22**] 09:59
T: [**2188-4-22**] 10:10
JOB#: [**Job Number 39244**]
ICD9 Codes: 5990, 4280, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7549
} | Medical Text: Admission Date: [**2120-12-20**] Discharge Date: [**2120-12-25**]
Service: NEUROLOGY
Allergies:
Penicillins / Aspirin / Sulfa (Sulfonamides) / Duragesic
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
sudden right sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81 yo woman with a history of HTN and recent bout of bronchitis
and [**First Name3 (LF) **] fractures who was in her USOH earlier today, about to
eat lunch with her husband, when suddenly she slumped to the
right at 12:20pm. She was weak on the right and nonverbal. EMS
took patient to [**Hospital3 4107**] where she was noted to have
right hemiplegia and aphasia. Vitals at [**Hospital1 **]: 171/114, 92
NSR, RR 18, 100% on 2LNC (at 14:10). She had a head CT negative
for bleed, and was transferred to the [**Hospital1 18**] for IV t-PA.
Patient arrived at [**Hospital1 18**] at 1448. Stroke team was notified at
1430 and responded at 1430. Labs were drawn at OSH. CT done at
OSH and films available for our review. EKG ordered at 1450 and
results available at 1505. IV t-PA was administered at 1510
based on her weight of 122 pounds.
Initially, her exam by the [**Hospital1 18**] ED neurologist was as follows:
she was awake, alert, following one step commands only, very
dsyarthric but able to say, "Ahh...", unable to comprehend her
speech output. She had a left gaze preference and eyes did not
move past midline, right face droop. Right body flacid plegia
without response to noxious stimuli. She did extend the right
toe to noxious stimuli. Right foot with upgoing toe.
After IV t-PA administration she was taken to MRI. MRI showed a
large left MCA stroke. Her exam transiently improved in that she
was able to lift her right arm to gravity. This improvement was
short lived. Started on labetolol gtt in ED for SBP 190's.
No vision loss (TIA), no weakness in the past.
Past Medical History:
-Hypertension
- Renal cancer, s/p nephrectomy by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2643**] at
[**Hospital1 756**] 1.5 years ago, s/p chemotherapy (last dose 6 months ago)
follwed by Dr. [**Last Name (STitle) 53761**] at [**Hospital3 328**]. Has a portacath over the
right chest.
- Bladder cancer vs spread of renal cancer, unclear
- Recent bronchitis and [**Hospital3 **] fractures
- Endometriosis with small bowel obstructions requiring surgery
(last obstruction 3 yrs ago)
- DJD
Social History:
Lives at home, married, one son estranged, never smoked, one
glass of wine with dinner, no drugs, no alternative medicine. No
aids to walk. Using visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] fracture/bronchitis.
Retired head teller and book keeper at a bank. Director of
volunteers at a library, not currently working. Lives in
[**Location 5110**], MA.
Family History:
Husband unable to answer, has a twin brother who is obese and
another brother and sister.
Physical Exam:
VITALS: FS 106, T 97, P 80, BP 170/80, 100%
GEN: frail elderly appearing woman in NAD
SKIN: no rash
HEENT: NC/AT, anicteric sclera, mmm
NECK: supple, no carotid bruits
CHEST: normal respiratory pattern, course BS bilaterally
CV: regular rate and rhythm with ? sys murmur
ABD: softly distended, rare BS
EXTREM: no edema
NEURO:
Mental status: Patient is alert, awake, pleasant. Oriented to
person, place "hospital" when given a list of places to chose
from, "[**2117**]" and "winter". Mildly inattentive. Language: speaks
primarily with single words but will repeat and string 4 words
together, good comprehension following multistep commands,
marked dysarthria. Is aware that she had a stroke. Pays less
attention to the right but is able to look to the right. Did
not count one person standing far to the right. No left/right
mismatch, recognizes her right arm as her own.
Cranial Nerves: Visual fields: full to left/right/upper/lower
fields. Pupils:3->2 mm, consenual constriction to light. EOMS
full, gaze conjugate. No nystagmus or ptosis. Facial sensation
intact over V1/2/3 to light touch. Both upper and lower face
weakness on the right. Hearing decreased on the right. Marked
dysarthria. Symmetric elevation of palate. Trapezius [**3-27**]
bilaterally. Tongue midline without atrophy or fasciulations.
Sensory: No sensation to touch right leg, decreased in the right
arm, normal right face. No withdrawl to pain right arm but does
withdrawl right leg to pain.
Motor: Right flacid. No adventitious movements.
Strength-
- Left side is essentially full strength throughout.
- Right side: lifts right arm to gravity but unable to provide
any resistence. Right biceps weak [**12-28**]. Right triceps 4-/5
(provide minimal resistence). Right hand is completely weak
unable to wiggle fingers/grasp/straighten fingers. Right leg is
stronger - [**2-25**] IP/Ham/DF. Quads/plantar flexion full.
Reflexes:
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 1 0 0 0 0 down
LEFT: 2 2 2 1 1 down
Coordination: intact on left
Gait: patient on bedrest
Pertinent Results:
Labs:
CBC normal except Hct 33.7, chem7, coags and UA normal
Cardiac enzymes negative.
Risk factor screening:
HbA1c 5.6 Triglyc 184 TChol 172 LDL 102 HDL 33
Radiology:
BRAIN MRI: Acute left MCA infarct, sparing basal ganglia. MRA
with occlusion of the posterior division of the left middle
cerebral artery in its proximal portion.
CT HEAD W/O CONTRAST (s/p tPA): No acute intracranial
hemorrhage.
CAROTID SERIES: Scattered bilateral ICA plaque, no appreciable
associated stenosis, however (graded as less than 40%
bilaterally).
ELBOW (AP, LAT & OBLIQUE) RIGHT: Large elbow joint effusion. No
distinct fracture line is identified.
TTE: EF>55%. Trivial MR. Otherwise normal.
Brief Hospital Course:
81 yo female with history of hypertension, renal and bladder
cancer s/p chemotherapy p/w acute onset of lack of speech and
right-sided weakness. Taken by EMS to [**Hospital3 **].
Presentation was concerning for new stroke. Noncontrast head CT
was negative for a bleed and she was transferred to [**Hospital1 18**] for IV
t-PA. Received t-PA on [**2120-12-20**] at 15:10 (2hrs 50 min after
onset of symptoms). Transiently improved - able to lift right
arm, attended to the right, followed commands, no verbal output.
Transferred to SICU for 24 hour monitoring and post t-PA
protocol.
MRI confirmed large acute infarct in left MCA distribution with
occlusion on MRA. Patient had no known history of
stroke/seizure, no known cardiac arrhythmias, was a nonsmoker
and nondiabetic. On [**2120-12-23**] she went into rapid afib with HR in
150's ~2am. 5mg IV lopressor was administered with conversion
to sinus rhythm. She experienced a second episode of afib (HR
130's, SBP 160's) ~5:30am on [**2120-12-24**], which resolved before
metoprolol administration. SBP's remained above 140, and [**Hospital1 **]
dosing of 25 mg metoprolol was initiated and maintained until
discharge with good rate control achieved. She was changed to
toprol XL for easier dosing on day of discharge. Dose may need
to be titrated as needed for rate control. Additionally, ACE
inhibitor should be added as tolerated, with goal SBP<120.
Coumadin 2mg was started on [**2120-12-23**] for secondary stroke
prevention given the atrial fibrillation, with plan of allowing
INR to rise slowly over 1 week due to size of infarct. Baseline
INR on [**12-24**] was 1.0.
Echocardiogram with normal LA size, normal LV systolic function
and no
thrombus. Carotid US without significant stenosis (< 40%
stenosis bilaterally).
Blood sugars remained between 85 and 130, with fingersticks
discontinued on hospital day 5. HgbA1c was 5.6. Lipid
screening revealed total cholesterol of 172, LDL 102, HDL 33 and
triglycerides 184. Atorvastatin 20 mg QD started on [**12-23**] once
she was cleared to take PO.
Given severe dysarthria, speech and swallow evaluation was done
to evaluate for aspiration. Video swallow study cleared her for
pureed solids and nectar prethickened liquids with chin tuck,
pills administered whole in puree.
Patient complained of R elbow pain on [**12-24**]. Films revealed large
joint effusion without fracture line. Additional history that
patient's husband grabbed arm to prevent her from falling during
onset of symptoms was elicited. Pain and effusion most likely
secondary to traumatic hyperextension of elbow. Recommend ice
and analgesics. In [**11-24**] weeks if pain not improved, her elbow
should be re-evaluated. Can contact Dr. [**First Name5 (NamePattern1) 9527**] [**Last Name (NamePattern1) 9620**] in
Rheumatology, [**Telephone/Fax (1) 2226**], for further assistance if needed.
Patient was given standing percocets for [**Telephone/Fax (1) **] fractures with
option of refusal, due to Broca's aphasia and inability to ask
for meds when in pain.
Neuro exam on discharge was somewhat improved. She was aware
that she had a stroke, was oriented to person, place and date.
She was able to repeat and name high frequency objects but was
not fluent, had severe dysarthria, right face droop, with a very
weak right hand but able to lift arm to gravity. On discharge
she was able to move fingers and wrist slightly with gravity and
was felt to be improving somewhat. She had decreased tone in R
upper extremity. Lower extremities had full strength
bilaterally.
Medications on Admission:
- Lorazepam 0.5mg twice a day prn for anxiety, Darvocet
100-650mg one to two tabs every 4 hours prn, albuterol and cough
medicine with codeine for bronchitis, z-pack (completed [**2-25**]
days), MVI
- NOT TAKING ANTIHYPERTENSIVES, formerly took norvasc
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day) as needed for dvt prophylaxis.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours): Pt may refuse, but please offer as Broca's
aphasia makes it difficult for her to ask.
7. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed.
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed: Alternatively, may give PR.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] TCU
Discharge Diagnosis:
Left middle cerebral artery infarction complicated by dysphagia
Atrial fibrillation
Hypertension
Hypercholesterolemia
[**Hospital3 **] fractures (prior to admission)
Elbow pain, likely due to traumatic hyperextension
Discharge Condition:
Improved, though still with right hemiparesis with significant
right arm and face weakness. Also still with Broca's aphasia and
severe dysarthria.
Discharge Instructions:
Take all medicines as prescribed. We have started you on two new
medications, lipitor for your cholesterol and coumadin to thin
your blood.
Keep all follow-up appointments.
Call your doctor or return to the ED if you develop new weakness
on your left side, difficulty seeing or understanding.
Followup Instructions:
Follow-up with your PCP 1-2 weeks after discharge from rehab.
Dr. [**Last Name (STitle) 17669**] will continue to manage your blood pressure and
coumadin dosing.
Follow-up in [**Hospital 4038**] Clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] in about 3
months on [**2121-4-8**] at 1pm. Call [**Telephone/Fax (1) 2574**] for more
information or to reschedule.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7550
} | Medical Text: Admission Date: [**2151-5-27**] Discharge Date: [**2151-5-31**]
Service: [**Last Name (un) **]
DATE OF DEATH: [**2151-5-31**], at 5:38 p.m.
CHIEF COMPLAINT: Status post fall.
HISTORY OF PRESENT ILLNESS: An 84-year-old female after a
fall from standing for unknown reason. The patient had
respiratory arrest and brief asystole. The patient was
intubated at the scene and brought to the emergency
department. The patient was found to be flaccid on initial
exam. The patient had a CT of the head and C-spine. C-spine
showed a comminuted type 2 dense fracture nearly 30 degrees
of leftward rotation of C1 on C2.
PAST MEDICAL HISTORY: Hypertension, history of multiple PEs,
interstitial lung disease on home O2, room air saturating
around 88% to 89%, diabetes, pulmonary artery hypertension,
DJD, history of stroke x2, the last one was [**2140**], without any
residual effect, status post cholecystectomy.
ALLERGIES: Vasotec.
MEDICATIONS: At home, Coumadin, metoprolol, Lasix,
glyburide, Protonix, Lipitor, Macrodantin.
PHYSICAL EXAMINATION: On physical examination, her
temperature was 98 degrees, heart rate was 43, blood pressure
was 117/47, respirations 12, saturating 100%. Her pupils were
2 mm and reactive. She was intubated. She was moving both
upper and lower extremities to pain. The patient had regular
rate and rhythm. The patient's lungs were clear. Abdomen was
soft, nontender, nondistended. The patient was guaiac
negative. Normal tone. There were no step-offs on the
examination of the spine. The patient had C-collar in place.
The patient had a CT of the C-spine and CT of the head that
showed no intracranial hemorrhage. CT of the C-spine showed
the comminuted type 2 dense fracture. CTA of the neck showed
no dissection. MR of the C-spine showed cord contusion at C2
and disruption of anterior ligaments. The patient's white
count was 8.9, hematocrit was 44. BUN was 18, creatinine was
1.3. UA was negative. Toxicology was negative.
HOSPITAL COURSE: The patient was admitted to the trauma
surgery service and was taken to the intensive care unit. The
patient was started on steroids with a bolus and a drip for
the concern for spinal cord injury. Cardiology was consulted
and recommended continuing supportive medical care. Ortho-
spine was consulted who recommended continuing the collar.
The patient had an elevated coag with 2.4 INR and that was
reversed and the patient was continued on ventilation. On
hospital day #2, the patient was continued on C-collar. The
patient had echocardiogram that showed significant pulmonary
artery hypertension with systolic around 80s with a very poor
right ventricular function. Per cardiology, recommend to
continue supportive care. The patient was kept NPO with a
Foley and the patient was slowly weaned from the ventilation.
On hospital day #3, the patient had acute change in ability
to move the upper extremity. The patient was given vitamin K
and FFP to reverse the coagulopathy for concern for possible
hemorrhage into the C-spinal canal. CT of the C-spine showed
a superior fragment of odontoid fracture, most posteriorly
displaced but not impinging on the cord. MR of the spinal
cord showed no cord compression but continued to have spinal
cord edema. CT of the head showed no acute process. The
patient also had acute respiratory decompensation where the
patient had CTA that initially showed no PE. The patient was
continued to be supported throughout. On hospital day #4,
the patient remained afebrile with stable vital signs and was
continued to be weaned from the propofol. The patient had
decreased movement of the upper extremity and only moved the
lower extremity with decreasing the vent support. The patient
was placed on Augmentin for Enterococcus urinary tract
infection. Approximately noon on hospital day #4, the patient
developed a significant respiratory and cardiac
decompensation. The patient was hypotensive, also tachycardic
to 150s, and urgent echocardiogram was obtained which showed
that the patient did not have a functioning right ventricle
and also the patient desaturated which were clinically
consistent with pulmonary emboli. At this time with her
injuries and also development of a new pulmonary emboli,
discussion was made with the family who made her DNR. The
patient was continuously supported with pressors and full
vent support and after subsequent discussion, the patient was
then made CMO. After the patient was CMO, the patient expired
at 5:38 p.m. on [**2151-5-31**].
CONDITION ON DISCHARGE: Death.
DISCHARGE STATUS: Death.
DISCHARGE DIAGNOSES:
1. Cervical spine fracture after a fall.
2. Pulmonary emboli.
3. Status post cholecystectomy.
4. Hypertension.
5. History of multiple pulmonary emboli.
6. Interstitial lung disease.
7. Diabetes.
8. Pulmonary artery hypertension.
9. Degenerative joint disease.
10. History of stroke.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
Dictated By:[**Doctor Last Name 6052**]
MEDQUIST36
D: [**2151-5-31**] 19:01:33
T: [**2151-5-31**] 20:07:36
Job#: [**Job Number 28464**]
ICD9 Codes: 2760, 5990, 496, 4019, 2768, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7551
} | Medical Text: Admission Date: [**2154-5-21**] Discharge Date: [**2154-5-28**]
Date of Birth: [**2120-11-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
RUE pain and SOB x 1 day
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 33yo male with ESRD on HD since [**12/2152**], HTN and h/o
noncompliance who p/w RUE pain and SOB X1 day, the morning after
dialysis. Pt was dialyzed the night before admission and then
awoke 6/24AM with SOB and pain in his right arm. He describes
the RUE pain as sharp, localized to site of port-a-cath. Pt
admits to HTN medication non-compliance the night before
admission. He denies associated chest pain/palpitations,
fever/chills/cough. He notes some abdominal pain and nausea
earlier in the day which had since resolved. No HA/dizziness. No
diarrhea/constipation. At baseline is able to climb steps w/o
SOB. Does not check his BP at home.
In the ED he had a set of cardiac enzymes that was lower than
his baseline and EKG unchanged from baseline. CTA was negative
for acute PE, but did reveal chronic segmental PE in RUL. RUE
U/S showed a non-occlusive thrombus in the R IJ and a heparin
drip was started. Pt was noted to have BP of 205/144 in the ED
and was subsequently treated with a nitro drip. CXR in the ED
showed pulmonary edema.
Past Medical History:
-ESRD [**12-29**] HTN - started on dialysis in [**12/2152**]
-HTN
-medication non-compliance
-h/o intubation in the setting of hypertensive urgency/flash
pulmonary edema
Social History:
He used to work as a plasterer, but is now on disability.
tobacco - 1PPD x 20 years, recently decreased to
two cigarettes a day. no recent alcohol use, + cocaine- denies
recent use, does endorse recent marijuana use, denies any
intravenous drugs; spent time in jail.
Family History:
Father - dead at age 36 from unknown cancer
Mother - alive, 56, + HTN
maternal grandmother - on hemodialysis for end-stage renal
disease.
- The patient has a younger sister and an older brother,
both alive and well.
- son - 7, alive and well
Physical Exam:
T 97.4 BP 130-140/90-100 HR 64 RR 20 SaO2 99% on 4L N/C
General: speaks in complete sentences, NAD
HEENT: NCAT PERRL EOMI o/p clear +JVD
Chest: no palpable cord/tenderness at site of line, no
erythema/edema noted
Heart: RRR, [**1-31**] holosystolic murmur radiating to L axilla
Pulmonary: bilateral basilar crackles
Abdomen: scar noted, S/NT/ND +BS
Extremity: + ecchymoses RUE, no C/C/E
Neuro: AOX3, CN3-12 intact
Skin: no rashes, warm and dry
Pertinent Results:
[**2154-5-28**] 07:00AM BLOOD WBC-4.9 RBC-3.65* Hgb-10.6* Hct-32.8*
MCV-90 MCH-28.9 MCHC-32.2 RDW-15.8* Plt Ct-257
[**2154-5-27**] 06:55AM BLOOD WBC-4.7 RBC-3.60* Hgb-10.5* Hct-32.6*
MCV-91 MCH-29.3 MCHC-32.3 RDW-16.5* Plt Ct-265
[**2154-5-26**] 06:18AM BLOOD WBC-5.0 RBC-3.72* Hgb-10.8* Hct-33.8*
MCV-91 MCH-29.2 MCHC-32.0 RDW-16.1* Plt Ct-240
[**2154-5-25**] 07:15AM BLOOD WBC-5.0 RBC-3.50* Hgb-10.2* Hct-32.5*
MCV-93 MCH-29.0 MCHC-31.3 RDW-15.9* Plt Ct-231
[**2154-5-24**] 07:47AM BLOOD WBC-5.5 RBC-3.92* Hgb-11.1* Hct-35.6*
MCV-91 MCH-28.4 MCHC-31.2 RDW-16.0* Plt Ct-237
[**2154-5-23**] 04:10AM BLOOD WBC-5.9 RBC-3.51* Hgb-10.4* Hct-31.2*
MCV-89 MCH-29.7 MCHC-33.5 RDW-16.4* Plt Ct-220
[**2154-5-22**] 05:09AM BLOOD WBC-7.6 RBC-3.58* Hgb-10.3* Hct-31.9*
MCV-89 MCH-28.8 MCHC-32.4 RDW-16.0* Plt Ct-225
[**2154-5-21**] 02:58PM BLOOD WBC-6.7 RBC-3.77* Hgb-11.2* Hct-33.7*
MCV-90 MCH-29.7 MCHC-33.2 RDW-16.1* Plt Ct-238
[**2154-5-28**] 07:00AM BLOOD PT-20.5* PTT-70.3* INR(PT)-1.9*
[**2154-5-27**] 06:55AM BLOOD PT-18.7* PTT-102.3* INR(PT)-1.7*
[**2154-5-26**] 06:18AM BLOOD PT-16.9* PTT-95.7* INR(PT)-1.5*
[**2154-5-25**] 07:15AM BLOOD PT-15.1* PTT-84.9* INR(PT)-1.3*
[**2154-5-24**] 07:30AM BLOOD PT-13.3 PTT-65.3* INR(PT)-1.1
[**2154-5-23**] 04:10AM BLOOD PT-13.3 PTT-92.6* INR(PT)-1.1
[**2154-5-21**] 10:54PM BLOOD PT-14.3* PTT-130.0* INR(PT)-1.2*
[**2154-5-21**] 02:58PM BLOOD Glucose-106* UreaN-53* Creat-11.1*#
Na-145 K-4.7 Cl-102 HCO3-26 AnGap-22*
[**2154-5-21**] 02:58PM BLOOD ALT-42* AST-31 LD(LDH)-384* CK(CPK)-261*
AlkPhos-76 Amylase-97 TotBili-0.3
[**2154-5-21**] 02:58PM BLOOD Lipase-24
[**2154-5-21**] 02:58PM BLOOD cTropnT-0.07*
[**2154-5-28**] 07:00AM BLOOD Calcium-9.1 Phos-5.0* Mg-2.6
[**2154-5-22**] 05:09AM BLOOD Calcium-7.4* Phos-8.2*# Mg-2.0
[**5-21**] CXR (Portable AP):
Pulmonary edema without evidence of focal infiltrate.
[**5-21**] U/S:
Findings suggestive of a nonocclusive thrombus within the right
internal jugular vein, immediately upstream from the expected
location of the hemodialysis catheter.
[**5-21**] CTA Chest:
1. Diffuse ground-glass opacities bilaterally, with intralobular
septal
thickening. These findings are similar to prior CT from [**2154-5-6**], with
marked improvement on subsequent radiograph of [**2154-5-7**].
Given these
time course of findings, as well as a history of end-stage renal
disease on
hemodialysis, these findings likely reflect pulmonary edema.
2. Previously noted chronic segmental pulmonary embolism in the
right upper
lobe is not fully assessed on this study due to respiratory
motion. No large
central or large segmental pulmonary embolism identified.
3. Large calcified right upper pole renal lesion, incompletely
evaluated, and
appears largely unchanged.
[**5-23**] Renal U/S:
Limited study with delayed systolic upstroke in the left
parenchymal arteries. Renal artery stenosis in the setting
cannot be excluded.
Brief Hospital Course:
In the MICU:
Pt continued his heparin gtt from the ED for his R IJ
tunneled-cath clot. Blood pressure elevated to 205/144 and was
controlled with a labetalol gtt and a nitro gtt. Pt presented
in pulmonary edema and was subsequently taken to HD the night of
admission - pt did not require additional intervention. Pt
developed one episode of bloody emesis and was taken off of his
heparin gtt. By the time of transfer the pt was weaned off of
his labetalol/nitro gtt and was down to 4L of O2 with adequate
sats.
.
On the general medicine floor:
.
Nonocclusive right IJ thrombus:
Pt was treated with heparin to coumadin bridge. The plan was
discussed with Vascular and Renal and it was decided that the R
IJ tunneled-cath would be left in place. The catheter was
accessed for HD throughout the pt's stay. Transplant surgery
will evaluate the pt for placement of a fistula. Pt has missed
last 5 appointments as an outpatient. Social work was contact[**Name (NI) **]
and will help facilitate the outpatient appointment. Scheduled
appointment with transplant surgery on [**6-6**] with Dr. [**Last Name (STitle) 816**].
The pt was treated with warfarin 5mg x 3 days, warfarin 7.5mg x
3 days and finally warfarin 10mg x 1 day to reach the target
INR. On the day of discharge pt had been therapeutic on heparin
for 7 days, had an INR of 1.9 and was given lovenox 30mg x 1
dose before leaving. This plan was discussed with renal and
they approved the use of lovenox in the setting of this pt's end
stage renal disease managed with dialysis. Pt will follow with
Dr. [**Last Name (STitle) **] in dialysis for coumadin management until he sees his
PCP (pt never had a regular PCP, [**Name10 (NameIs) **] appointment) Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 12101**] this Thursday for further management.
.
Bloody emesis:
The pt had only 1 episode in the MICU [**5-22**]. Heparin and
coumadin were briefly held and restarted once the pt's HCT was
stable. Pt was placed on pantoprazole [**Hospital1 **] and had no further
issues on the floor.
.
Fluid overload:
Pt initially presented with a BNP >[**Numeric Identifier **] and with pulmonary
edema. Once stabilized in the MICU pt was able to maintain
adequate O2 sats on the floor without supplemental O2 and
demonstrated no clinical evidence of pulmonary congestion.
.
Hypertension:
Pt was weaned off of nitro gtt and labetalol gtt in the MICU.
Pt typically with BP 160s/100s on the floor with elevation to
180-200/110-120 in the early AM. Pt asymptomatic with these
episodes. BP responded to hydralazine IV prn. Pt was initially
treated with nifedipine 40mg q6h, labetalol 300mg [**Hospital1 **] and
lisinopril 40mg [**Hospital1 **]. Given the pt's history of non-compliance
and difficult to control BP within the hospital, the pt's
nifedipine was switched to 90mg [**Hospital1 **] to facilitate compliance and
minoxidil 5mg qdaily was added for better BP control. Renal
doppler was ordered for RAS w/u and could not r/o RAS on the L.
MRA was not pursued in the setting of ESRD [**12-29**] the risk of NSF.
Pt may continue w/u as an outpatient with renal.
.
ESRD:
Pt tolerated HD throughout hospital stay without issues. Pt was
maintained on nephrocaps and sevelamer. Pt required increased
dosing of both nephrocaps and sevelamer. Appreciate input from
Renal - no new recommendations. Pt will resume outpatient
regimen of MWF at the [**Hospital **] Clinic.
.
FEN:
Pt tolerated PO intake. Electrolytes managed with HD.
.
PPX: Maintained on heparin, coumadin (once HCT stabilized) and
PPI.
.
# Access: PIV and tunneled R IJ for HD
.
# Code: FULL
Medications on Admission:
Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. Nifedipine 10 mg Capsule Sig: Four (4) Capsule PO Q6H (every
6 hours).
Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
2. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO three
times a day.
Disp:*270 Tablet(s)* Refills:*2*
3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Right internal jugular vein thrombus
Hypertension
Pulmonary edema
End stage renal disease
Discharge Condition:
Good, hemodynamically stable, adequate O2 sats.
Discharge Instructions:
You were diagnosed with a blood clot in the neck vein that
contains your dialysis catheter and also had an elevated blood
pressure which caused fluid to accumulate in your lungs. You
were started on a blood thinner for your blood clot with a
medication called coumadin and received dialysis to remove the
excess fluid from your body.
You will need to continue coumadin (blood thinner) until further
notified to prevent future blood clots from forming. You will
need to get blood tests at your dialysis clinic to monitor your
coumadin levels. This will be done by Dr. [**Last Name (STitle) **] until you see
your new PCP.
Your blood test should be drawn tomorrow at dialysis.
The following changes were made to your medications:
Your Nifedipine, renagel and PhosLo regimens were changed.
You were also started on a new BP med called minoxidil.
Please continue with your outpatient dialysis regimen MWF at the
[**Hospital **] clinic.
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Thursday.
Please follow-up with your transplant clinic appointment so that
you can be evaluated to have new dialysis access placed.
Please call your doctor or go to the ED for worsening symptoms
including headache, blurry vision, shortness of breath, chest
pain, arm pain or other concerning symptoms.
Followup Instructions:
Please continue your outpatient dialysis regimen at the [**Hospital **]
clinic beginning this Wednesday ([**5-29**]). Dr. [**Last Name (STitle) **] at the
dialysis clinic will monitor your coumadin levels and adjust
your medication as necessary.
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12101**] on [**5-30**] at
2:00 PM. Your appointment is in the [**Hospital Ward Name 23**] Building, [**Location (un) 6750**], North Suite. Please call ([**Telephone/Fax (1) 1300**] with any
questions.
Please follow-up at the [**Hospital 1326**] clinic with Dr. [**Last Name (STitle) 816**] on [**6-6**] at 10AM. Please call [**Telephone/Fax (1) 5537**] with any questions.
Completed by:[**2154-5-28**]
ICD9 Codes: 5856, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7552
} | Medical Text: Admission Date: [**2185-2-17**] Discharge Date: [**2185-2-20**]
Date of Birth: [**2119-1-11**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Dilantin
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Left flank pain and urosepsis.
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube placement on [**2185-2-17**].
History of Present Illness:
[**Known firstname 1439**] [**Known lastname **] is a 66-year-old woman, with history of left
temporal lobe glioblastoma, status post gross total resection,
and currently on daily temozolomide chemotherapy and radiation
therapy, who presented to [**Hospital3 417**] Hospital with left
flank pain for one day duration. Yesterday afternoon, after her
radiation treatment, she starting complaining of abrupt onset
pain in her left flank with an intensity of [**8-6**], which was
gradually moving up left side, worse with cough. By report, she
was in her usual state of health until 1 day prior to
presentation. She presented to [**Hospital3 417**] Hospital, where
she developed temperature of 102 F, and underwent CT of the
abdomen and pelvis showing mild to moderate left kidney
hydronephrosis, pyelonephritis, UPJ obstruction and peri-renal
stranding. She was given morphine 2 mg IV, Zofran 4 mg IV,
Levaquin 750 mg IV and 1L normal saline. She was transferred to
the emrgency department at [**Hospital1 69**]
for further management, as she receives her oncology care here.
In the emergency department, initial vitals were: Temperature
102.2 F, pulse 103, blood pressure 94/69, respiration 18, and
oxygen saturation 94% in room air. Laboratory studies on
arrival were significant for leukocytosis 16, Hct 34, lactate
1.4 and positive urinalysis. Shortly after arrival, the
patient's blood pressure dropped to 80/50s, she was given Zosyn,
Reglan, Tylenol 1 gm PO, Valium 5 mg PO and Ativan 1 mg IV for
agitation, Hydrocortisone 100 mg IV, and 5 L IVF. Blood
pressure transiently improved to low 100s, but again declined to
80s. A right subclavian was placed for central access. Patient
was evaluated by urology, who suggested a percutaneous
nephrostomy tube be placed by Interventional Radiology given her
high grade obstruction and risk over lowering seizure threshold
with general anesthesia. While in the emergency department, she
was awake, alert, and oriented times 2, intermittently confused
and forgetful (per husband, this is not her baseline - since
surgery has been [**Doctor Last Name 11506**], but generally oriented). She was
transferred to the [**Hospital 332**] Medical ICU for further management.
Currently, patient complaining that she feels cold, but
declining to answer other questions. States she does not know
where she is or what the date is. Denies pain, difficulty
breathing.
Review of systems: Unable to obtain, patient refusing to answer
most questions.
Past Medical History:
- Osteoporosis
- Glioblastoma - resected in a gross total fashion from the left
temporal lobe glioblastoma approximately 3 weeks ago, currently
undergoing chemo and radiation (surgery at [**Hospital3 2005**], Dr.
[**First Name (STitle) **] [**Doctor Last Name 60420**]).
- s/p hysterectomy in [**2151**] for fibroids and endometriosis
Social History:
She is retired. She smoked less than 1 pack of cigarettes per
day for 38 years. She drank 1 pint of alcohol per day for 5
years until her seizure. She does not use illicit drugs.
Family History:
Her mother died at age 78 from pancreatic cancer. Her father
died of complications from an abdominal aortic aneurysm. She
has one sister and 2 brothers; one of the brothers had a stroke.
She has 3 sons and they are healthy.
Physical Exam:
Physical Examination On Admission:
Vital Signs: Temperature 97.8 F, pulse 78, blood pressure
85/42, respiration 18, oxygen saturation 97% on 2 liters via
nasal cannula, and CVP 5
General: Somnolent, opens eyes to light physical stimuli,
declines to answer orientation questions
Skin: Fine papular rash over abdomen
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple
Lungs: Unable to perform adequate exam [**12-29**] patient not
cooperating. Generally clear anteriorly
Cardiovascular: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: Soft, non-tender, mildly distended, hypoactive bowel
sounds present, no rebound tenderness or guarding
Genitourinary: Foley in place draining clear yellow fluid, no
left CVA tenderness (wouldn't roll over)
Extremities: Warm, well perfused, 2+ DP pulses, no clubbing,
cyanosis or edema
Neurological Examination on Hospital Day 1 ([**2185-2-17**]):
Her Karnofsky Performance Score is 90. She is awake, alert, and
oriented times 3. Her language is fluent with good
comprehension, naming, and repetition. Her recent recall is
good. Cranial Nerve Examination: Her pupils
are equal and reactive to light, 4 mm to 2 mm bilaterally.
Extraocular movements are full; there is no nystagmus or
saccadic intrusion. Visual fields are full to confrontation.
Her face is symmetric. Facial sensation is intact bilaterally.
Her hearing is intact bilaterally. Her tongue is midline.
Palate goes up in the midline. Sternocleidomastoids and upper
trapezius are strong. Motor Examination: She does not have a
drift. Her
muscle strengths are [**3-31**] at all muscle groups. Her muscle tone
is normal. Her reflexes are 2- and symmetric bilaterally. Her
ankle jerks are absent. Her toes are down going. Sensory
examination is intact to touch and proprioception. Coordination
examination does not reveal dysmetria. Gait and stance are
deferred.
Pertinent Results:
Labs On Admission:
[**2185-2-17**] 04:45AM BLOOD WBC-16.0* RBC-3.23* Hgb-11.9* Hct-33.7*#
MCV-104* MCH-36.8* MCHC-35.4* RDW-12.0 Plt Ct-314
[**2185-2-17**] 04:45AM BLOOD Neuts-89.8* Lymphs-4.4* Monos-1.9*
Eos-3.7 Baso-0.2
[**2185-2-17**] 05:54AM BLOOD PT-14.3* PTT-31.1 INR(PT)-1.2*
[**2185-2-17**] 04:45AM BLOOD Glucose-85 UreaN-9 Creat-0.7 Na-136 K-3.5
Cl-103 HCO3-23 AnGap-14
[**2185-2-17**] 04:45AM BLOOD ALT-12 AST-21 LD(LDH)-154 AlkPhos-57
TotBili-0.7
[**2185-2-17**] 04:45AM BLOOD Albumin-3.1*
[**2185-2-17**] 03:00PM BLOOD Calcium-7.8* Phos-3.9 Mg-1.2*
[**2185-2-17**] 04:45AM BLOOD Cortsol-26.8*
[**2185-2-17**] 03:05PM BLOOD Type-[**Last Name (un) **] pH-7.34*
[**2185-2-17**] 04:45AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.035
[**2185-2-17**] 04:45AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2185-2-17**] 04:45AM URINE RBC-8* WBC-51* Bacteri-NONE Yeast-NONE
Epi-<1
[**2185-2-17**] 04:45AM URINE Mucous-RARE
DISCHARGE:
[**2185-2-19**] 06:05AM BLOOD WBC-9.5 RBC-3.25* Hgb-11.4* Hct-33.4*
MCV-103* MCH-35.0* MCHC-34.1 RDW-11.7 Plt Ct-296
[**2185-2-19**] 06:05AM BLOOD Glucose-83 UreaN-3* Creat-0.6 Na-138
K-3.5 Cl-105 HCO3-26 AnGap-11
Brief Hospital Course:
The patient is a 66-year-old woman with recent diagnosis of left
temporal glioblastoma, status post resection, currently
undergoing temozolomide chemotherapy and radiation, who
presented with UPJ obstruction, pyelonephritis, and hypotension
suggestive of urosepsis, with improvement after percutaneous
nephrostomy tube and antibiotics. Patient was intially admitted
to the [**Hospital 332**] Medical ICU for management of septic shock.
(1) Hypotension/Shock: The patient met criteria for septic
shock on admission. She initially required norepinephrine for
blood pressure support, but her blood pressure quickly improved
after antibiotic treatment and fluid resuscitation of about 6
liter. She was weaned off pressors after several hours. She
initially had significant mental status changes, suggesting end
organ dysfunction, although other parameters such as lactate
remained normal. This had improved by the next day. The most
likely source remains urinary given her CT findings. Her
urinary obstruction and pyelonephritis were treated with
meropenem 500 mg IV Q6H and percutaneous nephrostomy tube
placement.
(2) Urinary Obstruction: She had a left percutaneous
nephrostomy tube placed on [**2185-2-17**] with drainage of clear
urine. Her creatinine was normal on admission and has remained
stable.
- The etiology of her obstruction remains unclear. She will
have an outpatient CT abdomen and pelvis to evaluate the cause
further.
- She will follow up with Interventional Radiology and Urology
for further management of her nephrostomy tube and potential for
any further intervention.
(3) Pyelonephritis:
- Initially managed in the ICU setting with IV Meropenem
- Urine culture from [**Hospital3 417**] was positive for E. Coli,
sensitive with MIC <0.12 to levofloxacin.
- She was transitioned to PO Levaquin on [**2185-2-20**] and given
3-day supply in the outpatient setting for a total course of 7
days.
(4) Macrocytic Anemia: Her Hct has dropped from 44 to 33.7 in
the past week with no current evidence of bleeding. Her Hct was
42.9 at OSH, so lower Hct could be secondary to hemodilution.
She was continued on B12 and folate supplementation.
(5) Glioblastoma: Patient currently undergoing temozolomide
chemotherapy and radiotherapy. Per outpatient provider, [**Name10 (NameIs) **]
glioblastoma was completely resected and survival likely at
least 2-3 years. She is planned for resuming radiotherapy on
Monday.
- She will follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] in the outpatient
setting
Medications on Admission:
levetiracetam 500 mg PO BID
oxycodone-acetaminophen 5 mg-325 mg [**11-28**] Tablet(s) PO qdaily
prochlorperazine maleate 10 mg PO daily
temozolomide 110 mg PO daily x45 days (from [**2185-2-7**])
cyanocobalamin 100 mcg PO daily
docusate sodium 100 mg PO daily
multivitamin 1 Tablet(s) PO daily
thiamine HCl 100 mg PO daily
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
8. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary: Pyelonephritis, Uretero-Pelvic Junction Obstruction
Secondary: Glioblastoma Multiforme
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs [**Known lastname **],
You were admitted to [**Hospital1 18**] for evaluation and treatment of a
urinary tract infection near your kidney, a condition called
pyelonephritis. You also underwent a percutaneous nephrostomy
tube placement to relieve an obstruction in your ureter.
You will take a medication called levofloxacin to finish your
antibiotic course for pyelonephritis.
You will follow up with the Interventional Radiologist tomorrow
to discuss management of your percutaneous nephrostomy.
You will have a CT scan as an outpatient on [**2185-2-28**] to evaluate
your abdomen for a cause of the narrowing or blockage in your
ureter. They will call you with a specific time to arrive.
Medications:
Added: Levofloxacin
Changed: None
Removed: None
Followup Instructions:
Interventional Radiology:
Monday, [**2-21**] anytime between 7a and 1pm
Call [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 6745**] [**Telephone/Fax (1) 56404**] or pager #[**Numeric Identifier 5603**]
when you go for radiation treatment tomorrow and he will come
meet you
Department: MRI
When: MONDAY [**2185-2-28**] at 1 PM
With: MRI [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: MONDAY [**2185-4-4**] at 11:15 AM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2185-4-4**] at 1 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7553
} | Medical Text: Admission Date: [**2134-5-31**] Discharge Date: [**2134-6-9**]
Date of Birth: [**2077-9-3**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
OSH transfer for seizure
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
56 y.o. male w/ Hep. C c/b cryoglobulinemia, ESRD on HD, s/p MVC
with slight trauma to the head some weeks ago, who woke up this
morning complaining of a HA after which he was found seizing in
bed. According to the patient's son, he was in a car accident
approximately 3 weeks ago after which he began
experiencing "migraines" again. He reportedly has a history of
migraines that had long resolved. He additionally had been
complaining of "kaleidoscope vision" saying specifically that
his vision was blurry, similar to looking through a
kaleidoscope. He was also reportedly unstable on his feet, but
never noted to fall. He does not have a prior history of
seizures, does not consume alcohol, use illicit drugs or smoke.
He had been taking Benadryl in excess because of his headaches.
He ordinarily takes Benadryl to sleep. He has been chronically
ill for many years, but sees doctors [**Name5 (PTitle) 83371**]. Of note,
patient had been taking Alka-Seltzer for the past 3 days and has
a history of a severe, but unknown allergy to aspirin.
Patient was taken to [**Hospital6 302**] where additional
history raised the possibility of Benadryl ingestion and ? TCA
ingestion. Given a QRS of 116, he was started on bicarb drip.
Additionally, because of a fever to 102.7 and a WBC of 22 in the
setting of these neurological symptoms, Ceftriaxone and
Vancomycin were started empirically and he was intubated to
protect his airway after seizing two additional times (given
Ativan) prior to being transferred to [**Hospital1 18**] for further
evaluation.
In the [**Hospital1 18**] ER, Acyclovir was added prior to performing an LP,
which was unremarkable for infection. CT head and spine were
unremarkable and neuro and toxicology were consulted.
Past Medical History:
Hepatitis C c/b by cryoglobulinemia
ESRD on HD (last on HD one year ago, reportedly told he no
longer needed it)
Migraines
Social History:
lives in [**Location (un) 5503**] with son, remote smoking history, no
alcohol or illicits.
Family History:
NC
Physical Exam:
Vitals: T: 102.6, BP: 139/81 P: 109 R:21 O2: 100% AC
500/20/.50/5
General: Sedated, intubated
HEENT: NC/AT; pupils small, but equally round and reactive to
light, sclera anicteric; OG with bloody secretions
Neck: Supple, no LAD
Lungs: CTAB
CV: S1, S2 nl, no m/r/g appreciated
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Limited due to sedation, but notable for clonus b/l and
equivocal babinksi. Patient does not follow commands
Skin: No rash, no jaundice
Pertinent Results:
[**2134-5-31**] WBC-20.4* RBC-4.14* Hgb-12.8* Hct-37.6* Plt Ct-170
[**2134-6-1**] WBC-13.4* Hct-30.4* Plt Ct-148*
[**2134-6-2**] WBC-12.3* RBC-3.80* Hgb-11.8* Hct-34.6* Plt Ct-142*
[**2134-6-5**] WBC-8.3 RBC-3.86* Hgb-12.1* Hct-35.1*31.3 Plt Ct-151
[**2134-6-6**] WBC-6.7 RBC-4.03* Hgb-12.4* Hct-36.4* Plt Ct-151
[**2134-6-8**] WBC-5.2 RBC-3.81* Hgb-11.7* Hct-34.8* Plt Ct-180
[**2134-6-9**] WBC-5.2 RBC-3.79* Hgb-11.6* Hct-34.2* Plt Ct-189
[**2134-5-31**] Glucose-347* UreaN-38* Creat-3.6* Na-139 K-5.0 Cl-103
HCO3-18*
[**2134-6-2**] Glucose-141* UreaN-32* Creat-3.7* Na-142 K-4.0 Cl-106
HCO3-22
[**2134-6-3**] Glucose-105 UreaN-32* Creat-4.2* Na-139 K-4.1 Cl-108
HCO3-22
[**2134-6-4**] Glucose-113* UreaN-32* Creat-4.0* Na-146* K-3.8 Cl-111*
HCO3-21*
[**2134-6-5**] Glucose-109* UreaN-33* Creat-3.5* Na-142 K-3.4 Cl-108
HCO3-17*
[**2134-6-6**] Glucose-105 UreaN-35* Creat-3.4* Na-143 K-3.4 Cl-109*
HCO3-20*
[**2134-6-8**] Glucose-131* UreaN-41* Creat-3.4* Na-142 K-3.8 Cl-108
HCO3-22
[**2134-6-9**] Glucose-99 UreaN-42* Creat-3.3* Na-141 K-3.9 Cl-108
[**2134-5-31**] ALT-18 AST-38 CK(CPK)-147 AlkPhos-71 TotBili-0.2
[**2134-6-1**] ALT-15 AST-36 LD(LDH)-274* CK(CPK)-284* AlkPhos-56
TotBili-0.3
[**2134-6-6**] LD(LDH)-250 CK(CPK)-151
[**2134-5-31**] CK-MB-4 cTropnT-0.03*
[**2134-6-1**] CK-MB-6 cTropnT-0.05*
[**2134-5-31**] Lipase-106*
[**2134-6-6**] Lipase-37
[**2134-6-6**] calTIBC-309 VitB12-324 Folate-11.0 Ferritn-162 TRF-238
[**2134-6-1**] Phenyto-4.7*
[**2134-6-3**] Phenyto-12.6
[**2134-6-6**] Phenyto-<0.6*
[**2134-6-6**] Phenyto-1.8*
[**2134-6-7**] Phenyto-1.2*
[**2134-5-31**] Lactate-2.4*
[**2134-6-1**] Lactate-0.8
Brief Hospital Course:
Patient was admitted as a transfer to the ICU.
Seizure: Seizure was of unclear etiology and patient without a
known history of seizures. Differential would include brain
trauma s/p MVA, acute bleed, infection, intracranial mass and
toxic/metabolic derrangement. Patient underwent a lumbar
puncture that was negative. Patient had head imaging that
revealed as fluid collection at C2 which after serial imaging
was felt to be a hematoma. The patient loaded intially started
on Keppra, renally dosed. Attempt was made to switch patient to
dilantin given renal clearance of Keppra, but depsite several
loads, dilantin level stayed subtherapeutic. Patient was finally
transitioned to keppra monotherapy. Patient was on morphine for
pain control for his neck pain attributed to the C2 lesion. He
was discharged then on Valium as needed and oxycontin twice
daily for pain.
C2 Hematoma: Secondary to fall, confirmed on MRI. Pain control
as above.
Toxic Ingestion: Per report, patient may have taken Benadryl or
TCAs. Tox screen negative up transfer to ED. EKG with QRS of 116
initially. Patient was briefly on a bicarbonate drip. Toxicology
felt it was inconclusive and that whatever ingestion may have
occured the patient had recovered.
Leukocytosis: With initially elevated lactate, suggestive of
infection. CNS was of obvious concern for source given seizure,
but LP is negative. Other culture data was negative. Patient is
was initially on Ceftriaxone, Vancomycin and Acyclovir for
empiric coverage intially, he was briefly off antibiotics, but
when a question of the fluid collection at C2 being an abscess
the patient was restarted on vancomycin and ceftazidime that
were discontinued [**2134-6-7**] when the fluid collection was concluded
to be hematoma on MRI ([**2134-5-27**]).
Mental status. A+Ox3, but unclear about details and slow to
respond and complained of poor memory. Patient reports that
memory is improving, and much improved on discharge.
Depression: restarted home sertraline, avoided home triazolam
due to altering effect. Held amitryptiline on discharge as well.
HTN: increased home amlodipine dose of 5mg to 10mg daily, and
continued this on discharge. Patient initially on labetolol in
unit but transitioned to home diovan on the floor.
Hyperglycemia: Mild, on ISS in the hospital, by end of hospital
course, no longer requiring.
Respiratory Failure: Intubated in the setting of seizing to
protect airway. Patient was able to be rapidly extubated.
CKD Stage IV: Previously been on HD. Currently with good urine
output. Patient maintained on his nephrocaps. Medications
renally dosed.
Hepatitis C: Unclear status of liver disease. Stable LFTS and
good synthetic function during this hospitalization
Elevated Troponin: EKG with non-specific changes and troponin
elevated in the setting of renal failure. Patient ruled out for
myocardial infarction.
The patient was FULL CODE during this admission.
Medications on Admission:
Per PCP's office:
amtriptyline 50 qhs
amlodipine 5 mg qhs
valsartan 80 qday
nephrocaps
parvocet prn
triazolam 0.25 mg qhs
sertraline 100 qday
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for muscle pain.
Disp:*90 Tablet(s)* Refills:*0*
6. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*200 Tablet(s)* Refills:*0*
8. OxyContin 15 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day.
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Spine hematoma
Seizures
Secondary:
Discharge Condition:
stable
Discharge Instructions:
You were admitted to hospital after having a seizure. You had
neck pain and imaging of your spine show a blood collection in
your cervical spine. This blood collection should clear slowly
on its own. The seizure is likely secondary to either the blood
collection or trauma from the motor vehicle accident you were in
several weeks ago.
You should also take precautions given that you have new
seizures. This would mean, that you should NOT drive, operate
machinery, or bathe alone.
The following were made your medication regimen:
1. Amlodipine (for blood pressure) was increased from 5mg to
10mg daily. Continue to take Diovan as well.
2. Keppra 500mg twice a day was started for seizures.
3. For pain, you should take 1gm of tylenol up to 4 times a
day.
4. For muscle spasms, take [**1-8**] pills of Valium as needed, up to
3 times a day.
5. For pain you should take Oxycontin 15mg twice a day. If you
still have pain, you can take percocet 2 pills up to 4 times a
day. You should discuss tapering this with your primary care
doctor, as your pain should decrease as the blood collection in
your neck resolves
6. Do not take Triazalam and Amitriptyline. You can discuss the
need for these with your Primary care doctor
Please call your doctor or return to the hospital if you have
fevers, chills, numbness or tingling in your fingers or legs,
increased severity of neck pain or any other concerning
symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 71087**] on [**2134-6-24**] at 130Pm.
([**Telephone/Fax (1) 50234**]
Dr. [**First Name (STitle) **], the neurologist, on [**2134-7-8**] at 9am. She is located
[**Location (un) **], the [**Hospital Ward Name 23**] building, [**Location (un) **]. [**Telephone/Fax (1) 83372**].
Completed by:[**2134-7-3**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7554
} | Medical Text: Admission Date: [**2127-8-27**] Discharge Date: [**2127-8-29**]
Date of Birth: [**2073-3-2**] Sex: M
Service:
Th[**Last Name (STitle) 44544**]a 54-year-old male with a known mitral valve prolapse
since adolescence who developed significant regurgitation.
He was taken to the Operating Room on [**2127-8-27**] where a mitral
valve repair was done. The patient did well postoperatively
and was transferred to the CSRU. He was fully weaned from
his ventilator and extubated. He continued to improve.
Physical therapy was consulted for ambulation and he did well
postoperatively. The chest tube was removed. His Foley was
pulled and he was kept on A-pacing due to slow return of
sinus rhythm. He was transferred to the floor on
postoperative day #2. He continued to improve. His chest
tube was pulled. His Foley had been removed at midnight. He
improved and physical therapy came to see him. They
suggested for him to go home with full ambulation. His wires
were removed on postoperative day #2 and on postoperative day
#3, the patient was discharged home on stable condition. He
was given prescriptions for Percocet 1 to 2 tablets po q4h,
Zantac 150 po bid, Colace 100 po bid, KCL 20 milliequivalents
po bid, Lasix 20 mg po bid, Motrin 400 po q6h prn. The
patient is instructed to follow up in one to two weeks with
is primary care physician and four to six weeks with Dr. [**Last Name (Prefixes) 2545**]. The patient is discharged in stable condition.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2127-8-29**] 10:36
T: [**2127-8-29**] 10:45
JOB#: [**Job Number 44545**]
ICD9 Codes: 4240, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7555
} | Medical Text: Admission Date: [**2114-5-30**] Discharge Date: [**2114-6-14**]
Service: MEDICINE
Allergies:
Ranitidine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
87 year-old female with history of hiatal hernia/GERD, AF,
history of recent aspiration pneumonia presents with progressive
SOB.
She was recently admitted to [**Hospital1 18**] for pneumonia and treated
wtih Levofloxacin for 14 days. She completed her antibiotics and
presented to her PCPs office where a CXR was performed. The CXR
was unchanged so she had a CT which showed multifocal
infiltrates, ? aspiration versus infectious. She was told to eat
smaller meals and avoid eating quickly. For the last week, she
has had increased shortness of breath. Five days prior to
admission she was having lots of coughing and shortness of
breath. 911 was called but didn't bring her to the ED. On
Sunday, she was at the [**Last Name (un) 4068**] because she swallowed a hearing
aid. A CXR was performed but no further intervention was
performed.
Over the past week, she notes increasing fatigue and shortness
of breath. she endorses a mild non-productive cough, worse at
night. No fever/chills. No orthopnea, PND, or edema.
In the ED, a CXR showed new multifocal infiltrates. A chest CT
was subsequently obtained, which showed worsening
consolidations, especially in RML with RML collapse, with ? RML
abscess. She was given Ceftriaxone, Atithromycin and Flagyl.
Past Medical History:
1. Hiatal hernia with gastroesophageal reflux disease
2. Paroxysmal atrial fibrillation, on Coumadin
3. Iron deficiency anemia.
4. Recurrent UTIs.
5. Hyperthyroidism attributed to Amiodarone toxicity
6. History of iatrogenic pneumothorax following line placement
in 02/[**2112**].
7. Colonic polyps
8. s/p Appendectomy.
9. Impaired visual acuity
Social History:
She does not smoke or drink. She walks with a cane at baseline.
She lives in [**Location (un) **] with a young woman who helps with her
care.
Family History:
Non-contributory.
Physical Exam:
Physical examination on admission:
VS: T 98.8, Pulse 66, BP 116/76, RR 17, 95% on RA
Gen: Alert, oriented, cooperative female in NAD
HEENT: EOMI, anicteric, mildly dry MM
Neck: Supple, -LAD, JVP not elevated
Lungs: Distant lung sounds (difficult exam as in [**Doctor Last Name **] in noisy
ED), no rhales appreciated
Heart: RRR, nl S1S2, no murmers
Abd: Soft, obese, mild distension, NT +BS
Ext: 2+ edema bilaterally, ecchymoses at left calf, slight
tenderness on anterior palpation of shin bilaterally
Neuro: A&OX3, responding to all ?'s, moving all ext
Pertinent Results:
Relevant laboratory data:
CBC:
WBC-10.3# RBC-4.00* HGB-11.2* HCT-33.3* MCV-83 MCH-28.0
MCHC-33.7 RDW-15.0
NEUTS-81.9* LYMPHS-13.4* MONOS-3.4 EOS-0.5 BASOS-0.7
PLT COUNT-508*
Chemistry:
GLUCOSE-115* UREA N-12 CREAT-0.8 SODIUM-138 POTASSIUM-4.5
CHLORIDE-97 TOTAL CO2-31 ANION GAP-15
LACTATE-1.1
Coagulation:
PT-34.2* PTT-31.0 INR(PT)-3.7*
Cardiac enzymes:
[**2114-5-30**] 01:30PM CK(CPK)-34
[**2114-5-30**] 01:30PM cTropnT-<0.01
Relevant imaging data:
[**2114-5-30**] CXR: AP chest compared to [**5-1**] and [**5-17**]. Right
upper lobe pneumonia is appreciably larger. Small region of
pneumonia at the right base is stable. Heart size top normal.
Small right pleural effusion, stable. No pneumothorax.
[**2114-5-30**] CT CHEST: No evidence of pulmonary embolism. 2.
Interval increase in the size of right middle lobe consolidation
with further progression and increase in size of an area of low
attenuation measuring 2.3 x 2.6 cm representing an abscess.
There is stable appearance of the right lower lobe consolidation
and slight interval decrease in the size of small nodular
consolidation in the left apex. 3. Large hiatal hernia.
[**2114-5-31**] Barium swallow: Large axial hiatal hernia with the
gastric fundus above the diaphragm. Persistent retention of
barium in the herniated fundus at the conclusion of the exam. No
evidence of reflux, but poor compliance.
[**2114-6-2**] ECHO: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6878**]. LV wall thicknesses and cavity size
normal. Overall LVEF normal (LVEF>55%). RV chamber size and free
wall motion are normal. AV leaflets are mildly thickened. The
aortic valve is not well seen. No AS, mild (1+) AR. MV valve
leaflets are mildly to moderately thickened. Mild (1+) mitral
regurgitation is seen. LV inflow pattern suggests impaired
relazation. TV valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
no
pericardial effusion.
[**2114-6-5**] CT CHEST: 1. Minimal improvement in extensive
necrotizing pneumonia in the right upper lobe. Slight
improvement in the left upper lobe nodular opacity. No change in
the right lower lobe consolidation. 2. Increasing right pleural
effusion and new left pleural effusion. 3. Stable appearance of
enlarged thyroid and large hiatal hernia.
[**2114-6-11**] CXR: 1. Resolving multifocal pneumonia and small
bilateral pleural effusions. 2. Hiatal hernia.
Brief Hospital Course:
87 year old female with a large hiatal and probable aspiration
events, admitted with worsening shortness of breath, with
imaging studies showing progression of her multifocal
infiltrates.
1. Multifocal pneumonia and ? RML abscess: Pulmonary was
consulted on admission, and she was placed on Ceftriaxone and
Flagyl for coverage of probable multifocal aspiration pneumonia.
Blood cultures drawn prior to initiation of antibiotics remained
negative. Given concern over aspiration events, she was
evaluated by speech and swallow, and a barium swallow was
obtained on [**2114-5-31**] which revealed retention of contrast in the
hernia without overt reflux. The study, however, was limited by
poor patient compliance. On [**2114-5-31**], she was noted to be more
somnolent, with increasing oxygen requirement and a temperature
to 101.7. Vancomycin was added for broader coverage. A CXR
obtained at that time showed some pulmonary edema, and she was
treated with Lasix diuresis. She, however, remained somnolent,
and an ABG obtained the following morning showed 7.34/62/65. She
was transferred to the MICU for further monitoring and
management. She spontaneously improved, and did not require
BiPAP. Her decompensation was ultimately attributed to
anxiolytic administration. She was transferred back to the floor
after 1 day in the ICU. While in the ICU, an echo was obtained,
which showed preserved systolic function, evidence of diastolic
dysfunction, and non-significant valvular disease. Note was made
of thickened MV valve leaflets, non-specific, no obvious
vegetation.
On the floor, she was changed to Clindamycin. A repeat CT on
[**2114-6-5**] showed "minimal improvement in extensive necrotizing
pneumonia in the RUL, slight improvement in the LUL opacity, no
change in the RLL consolidation. Note was also made of
increasing right pleural effusion and new left pleural
effusion.". Given these findings, a thoracentesis was
entertained, and Coumadin was held in anticipation for this. A
repeat CXR on [**6-11**], however, showed decreased effusions, and a
bedside ultrasound performed by IP on [**2114-6-12**] showed
insufficient fluid to tap. She continued to improve, eventually
without oxygen requirement. She will complete a prolonged course
of Clindamycin (5 additional weeks), and will follow-up in the
Pulmonary clinic with Dr. [**Last Name (STitle) **]. They will contact her with
the appointment date and time. She is also scheduled for a
repeat CT chest on [**7-5**] at 1130. Lenght of antibiotic
therapy will ultimately be dictated by clinical/radiographic
resolution.
Emphasis was placed on aspiration precautions, and eating small
meals.
2. Paroxysmal atrial fibrillation: As noted above, her Coumadin
was held in anticipation for a possible thoracentesis. She was
given 2 doses of Vitamin K to expedite reversal of Warfarin
therapy. She was started on Heparin IV when INR<2. Coumadin was
eventually resumed at 5 mg daily (her out-patient dose) on
[**2114-6-12**], and she was placed on Lovenox (1mg/kg [**Hospital1 **]) to brige
until therapeutic INR (goal INR [**3-2**]). She remains on amiodarone.
Please discontinue Lovenox when INR [**3-2**].
3. COPD: She was continued on Fluticasone and Combivent, with
bronchodilator therapy via nebulizers as needed.
4. Hypertension: She was continued on Lisinopril 5 mg daily.
Hydralazine was held in the hospital given good blood pressure
control on the latter. If her blood pressure remains elevated,
please consider addition of Hydralazine 25 mg PO QID
(pre-hospital regimen).
5. Hyperthryoidism: She was continued on Methimazole 5 mg daily.
6. Code: DNR/DNI. On this admission, there was a conversation
with the patient and family regarding code status. It was
determined that she wanted to be DNR/DNI.
Medications on Admission:
Senna 8.6 mg [**Hospital1 **]
Pantoprazole 40 mg daily
Amiodarone 100 mg daily
Hydralazine 25 mg QID
Methimazole 5 mg daily
Psyllium 1.7 g daily
Fluticasone 110 mcg/Actuation Aerosol 2 puffs [**Hospital1 **]
Warfarin 5 mg daily
Lisinopril 5 mg daily
Combivent 103-18 mcg/Actuation Aerosol 1 inh QID
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please give 5 mg daily 6X/week, and 7.5 mg daily 1X/week. Please
monitor INR, and discontinue Lovenox when INR between [**3-2**]. .
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1)
inhalation Inhalation four times a day.
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP<100.
13. Enoxaparin 100 mg/mL Syringe Sig: 90 mg SC Subcutaneous [**Hospital1 **]
(2 times a day): Please monitor INR, and discontinue Lovenox
when INR between [**3-2**].
14. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 4 weeks: Please continue until patient
follows-up in pulmonary clinic. .
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Multifocal pneumonia
Probable right middle lobe lung abscess
Secondary diagnoses:
Paroxysmal atrial fibrillation
Hyperthyroidism
Discharge Condition:
Patient discharged to a rehab facility in stable condition.
Oxygen saturation stable on room air.
Discharge Instructions:
Please note that we have started an antibiotic for your lung
infection called Clindamycin. Please take 300 mg four times
daily. Please continue to take it until you follow-up in the
pulmonary clinic.
You need to sleep with the head of the bed elevated to prevent
further aspiration events.
Please call your doctor or return to the ED if you develop
worsening shortness of breath, chest pain, worsening cough, or
new fever, or any symptoms of concern to you.
Followup Instructions:
1. You need to follow-up with Dr. [**Last Name (STitle) **] in the pulmonary
clnic. They are looking for an appointment for you in 4 weeks.
Please contact his office this week, and schedule an appointment
to be seen in 1 month. His office number is [**Telephone/Fax (1) 612**]. You
will need a repeat CT scan prior to your appointment. Ask them
to schedule that as well.
2. Please also schedule a follow-up appointment with your
primary care doctor to be seen in the next 2-3 weeks to discuss
your hospital admission.
Completed by:[**2114-6-14**]
ICD9 Codes: 5070, 5119, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7556
} | Medical Text: Admission Date: [**2126-11-5**] Discharge Date: [**2126-11-18**]
Date of Birth: [**2103-9-21**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Motor vehicle crash
Major Surgical or Invasive Procedure:
-Intramedullary fixation, left tibia.
-Placement of external fixator, right distal tibia, angle
spanning.
-Open reduction and internal fixation of right pilon fracture.
-Open reduction and internal fixation of distal fibula.
History of Present Illness:
23yo F presents to [**Hospital1 18**] by med-flight s/p MVC on [**2126-11-5**]. Pt
found at scene moving all extremities but not following
commands. Intubated for altered mental status, not following
commands & combative. Obvious bilateral lower leg fractures
with deformity.
Past Medical History:
Fibromyalgia
Chronic pain syndrome
Chronic fatigue
PTSD
Depression
Panic disorder
Social History:
H/o cocaine use in distant past, no current illicit drug use.
Lives with mother.
Family History:
Non-contributory
Physical Exam:
VS - pulse 100, bp 118/p, resp 16 intubated, sat 100%
HEENT - AT/NC, pupils fixed @ 4mm non-reactive
Neck - cervical collar, trachea mid-line, no JVD, no mass
Chest - bruising B chest, CTA bilat
CV - tachy, RR
Abd - bruising RUQ, soft, non-distended, nl rectal tone, guiac
neg, neg FAST
Pelvis - stable
Ext - palpable distal pulses B
Neuro - unresponsive
Pertinent Results:
[**2126-11-13**] 06:10AM BLOOD WBC-9.3 RBC-3.13* Hgb-8.5* Hct-26.0*
MCV-83 MCH-27.0 MCHC-32.4 RDW-13.7 Plt Ct-360
[**2126-11-5**] 10:39PM BLOOD WBC-7.5 RBC-4.21 Hgb-11.9* Hct-35.9*
MCV-85 MCH-28.4 MCHC-33.2 RDW-13.7 Plt Ct-232
[**2126-11-5**] 10:39PM BLOOD PT-12.9 PTT-25.7 INR(PT)-1.1
[**2126-11-5**] 10:39PM BLOOD Fibrino-302
[**2126-11-6**] 04:16AM BLOOD Glucose-111* UreaN-11 Creat-0.6 Na-140
K-3.6 Cl-106 HCO3-26 AnGap-12
[**2126-11-12**] 09:30AM BLOOD ALT-95* AST-59* AlkPhos-477* Amylase-34
TotBili-1.1
[**2126-11-6**] 02:06AM BLOOD ALT-322* AST-372* AlkPhos-204* Amylase-33
TotBili-0.5
[**2126-11-6**] 11:00AM BLOOD CK(CPK)-319*
[**2126-11-12**] 09:30AM BLOOD Lipase-46
[**2126-11-6**] 02:06AM BLOOD Lipase-76*
[**2126-11-10**] 04:35AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0
[**2126-11-5**] 10:39PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2126-11-6**] 02:12AM BLOOD Type-ART Temp-36.3 Rates-16/ Tidal V-500
PEEP-5 O2-60 pO2-244* pCO2-50* pH-7.35 calHCO3-29 Base XS-1
Intubat-INTUBATED Vent-IMV
Brief Hospital Course:
[**11-5**] - brought to [**Hospital1 18**] by med-flight intubated, diagnosed with
liver laceration, bilateral tib/fib fx's. Admitted to T/SICU,
orthopedics consulted.
[**11-6**] - taken to OR for IM nail L tibia shaft fx, ORIF R tibia
pilon fx, ORIF R fibula fx, and ex-fix placement R tibia/ankle.
[**11-7**] - pt remained intubated in T/SICU, pain service consulted.
[**11-8**] - pt extubated, surgical drains d/c'd, consults placed to
PT/OT & psych.
[**11-9**] - pt started on lovenox, regular diet
[**11-10**] - transferred from T/SICU to floor, AFO splint to L leg
for foot drop.
[**11-11**] - begin screening for rehab
[**11-12**] - repeat CT abd demonstrates stable liver injury, no acute
bleeding
[**11-13**] - Continuing PT/OT & pursuing placement options: acute
rehab vs home with services
[**11-18**] - D/C to home with VNA & home PT.
Medications on Admission:
Lexapro 10mg qhs
Elavil 75mg qhs
Klonopin 1mg [**Hospital1 **]
Ambien 10mg qhs prn
Methadone 100mg qd
Zonagram 25mg qhs
Topamax 50mg qd
Zanaflex 4mg qhs
Discharge Medications:
1. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
Disp:*15 Patch Weekly(s)* Refills:*0*
2. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 2 weeks.
Disp:*28 syringe* Refills:*0*
3. Methadone HCl 10 mg Tablet Sig: Three (3) Tablet PO Q AM ().
Disp:*45 Tablet(s)* Refills:*0*
4. Methadone HCl 10 mg Tablet Sig: Three (3) Tablet PO Q PM ().
Disp:*45 Tablet(s)* Refills:*0*
5. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Methadone HCl 40 mg Tablet, Soluble Sig: One (1) Tablet,
Soluble PO Q HS ().
Disp:*15 Tablet, Soluble(s)* Refills:*0*
7. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed for insomnia.
Disp:*15 Tablet(s)* Refills:*0*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*30 Tablet(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*30 Capsule(s)* Refills:*0*
12. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Motor vehicle crash
Liver laceration
Bilateral tibia/fibula fractures
Discharge Condition:
Good, stable.
Discharge Instructions:
-Weight bearing as tolerated, left leg
-Non-weight bearing, right leg until ex-fix removed in 8 weeks
-Follow-up with both Orthopedics & Trauma in clinic
-Call the clinic or return to ER for worsening pain or signs of
infection.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1005**] in [**Hospital **] Clinic in 10 days,
call ([**Telephone/Fax (1) 8746**] for appointment.
Follow-up in Trauma Clinic in [**1-11**] weeks, call ([**Telephone/Fax (1) 376**] for
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7557
} | Medical Text: Unit No: [**Numeric Identifier 74611**]
Admission Date: [**2104-10-21**]
Discharge Date: [**2104-11-6**]
Date of Birth: [**2104-10-21**]
Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 1007**] was admitted to the newborn
intensive care unit for management of prematurity. She is a
2865 gm product of a 34-3/7 weeks gestation, born to a 34-
year-old, gravida 3, para 2, now 3 mother, by spontaneous
vaginal delivery. Prenatal screens were blood type A-
positive, antibody negative, hepatitis B surface antigen
negative, RPR nonreactive, rubella immune, and group Beta
Strep positive. The pregnancy was complicated by gestational
diabetes requiring insulin. Also complicated by subchorionic
hematomas with vaginal bleeding at 10 and 14 weeks gestation
and 23 and 24 weeks gestation. She then developed prolonged
premature rupture of membranes at 25 weeks gestation on about
[**2104-8-19**]. She presented with leaking of fluid, mild
oligohydramnios on ultrasound, and positive fetal
fibronectin. She was managed expectantly with bed rest,
ampicillin and erythromycin and betamethasone. Through the
past 10 weeks she has not developed any fevers. The infant's
biophysical profile has remained [**8-13**] and her amniotic fluid
index has been [**7-17**]. The subchorionic hematomas resolved.
On the morning of delivery, mom went into spontaneous labor.
She was given a dose of penicillin 1-1/2 hours prior to
delivery though she had been on ampicillin and gentamicin
prior to the onset of labor. Fetal tachycardia to the 170s
and maternal temp of 99.3 were noted during labor. Delivery
occurred at 7:57 a.m. The infant emerged vigorous with a
strong cry. She was resuscitated with warming, drying,
stimulation and bulb suctioning and brief blow by oxygen.
Apgars scores were 8 at one minute and 9 at five minutes of
age. She was then transferred to the newborn intensive care
unit for further management.
BIRTH PARAMETERS: Weight 2865 gm (90th percentile). Length
49.5 cm (90th percentile). Head circumference 33 cm (75th
percentile).
PHYSICAL EXAMINATION AT TIME OF DISCHARGE: Weight 3020 grams.
Length 49 cm. Head circumference 33.5 cm. At the time of
discharge, a well-appearing, alert term female with stable
temperature in open crib. HEENT: Anterior fontanel soft and
flat, most of molding resolved, positive red reflex
bilaterally, patent nares, lips/gums/palate intact. Neck: No
masses noted. Cardiovascular: Heart regular rate and rhythm
without any murmurs. +2 pulses in upper and lower
extremities. Respiratory: Breath sounds clear and equal
bilaterally and easy, comfortable respiratory pattern.
Abdomen: Soft, nontender, active bowel sounds, no
hepatosplenomegaly. GU: Normal female genitalia, patent anus.
Spine: Straight, no dimples, hair [**Hospital1 **] noted. Extremities:
Moving all extremities symmetrically with normal tone, hips
stable to maneuvers and clavicles intact. Skin: Pink with no
lesions. Neuro: Alert, normal tone, positive grasp and
positive Moro.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: This
girl's name is [**Name (NI) **], has been in room air for the duration of
her hospitalization. Respiratory rates have been in the 30s-
60s range, and she has had one apneic spell during her
hospitalization on [**10-26**]. She did not require any
methylxanthine for apnea of prematurity.
Cardiovascular: [**Month (only) **] has had a normal blood pressure
throughout her hospitalization. No fluid bolus' or pressors
were required for blood pressure support. Heart regular rate
and rhythm. No murmurs auscultated.
Fluids, electrolytes and nutrition: Upon admission to the
newborn intensive care unit a d-stick and found to be 35 at
which time she received a 2 cc/kg bolus of D10W for
hypoglycemia. A repeat d-stick shortly thereafter was 75. She
has not had any other issues with hypoglycemia during her
hospitalization. Shortly after that bolus, IV fluids of D10W
were started at 80 cc/kg/day. The infant started p.o. feeds
within 24 hours of age and the IV fluids were weaned off. She
is currently successfully ad lib demand breast and bottle
feeding. Her weight at time of discharge is 3020 grams, length
49 cm, head circumference 33.5. She is going home
breastfeeding and supplementing with breast milk enriched to
24 calories per ounce with Enfamil powder. A set of
electrolytes was drawn at 24 hours of age. Sodium was 139,
potassium 5.1, chloride of 104, and a bicarb of 25.
Gastrointestinal: Phototherapy was initiated on day of life 2
for a total bilaterally of 11.2. Phototherapy was
subsequently discontinued on day of life 4 with a rebound on
day of life 5 of 7.8. Followup bilis on day of life 7 and day
of life 8 were 11.2 and 10.5, respectively.
Hematology: [**Month (only) **]'s blood type is A-positive, Coombs'
negative. She has not required any blood products during her
hospitalization.
Infectious disease: Upon admission to the newborn intensive
care unit, a CBC with differential and blood cultures were
drawn and the infant was started on ampicillin and
gentamicin. That CBC had a [**Known lastname **] count of 9, hematocrit of
54.9, a platelet count of 361,000, with 7% polys and 1 band,
and that blood culture was positive for Group B Strep. An LP was
performed on day of life 2 which showed a total protein of 167, a
glucose of 46, 4 [**Known lastname **] blood cells and [**Pager number **] red blood cells. The
Group Beta Strep species was noted to be sensitive to ampicillin
and the gentamicin was discontinued on day of life #3. She
continued on ampicillin for a full 10 days. Her last dose of
ampicillin was given on [**10-31**]. Blood culture that was drawn
at 24 hours after abx initiated was negative. Despite her Group B
Strep bacteremia, [**Month (only) **] remained stable and appeared clinically
well throughout her NICU admission.
Neurology: A head ultrasound was not indicated for this 34-
3/7 weeks infant.
Sensory: A hearing screen was performed with automated
auditory brainstem responses. She passed in both ears on
[**10-31**].
Ophthalmology: Eye exam not indicated for this 34-3/7 weeks
infant.
Psychosocial: The [**Hospital1 69**] social
work department has been involved with the family. The
contact social worker can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: [**Telephone/Fax (1) **] is stable in room air. Ad lib
feeding without difficulty. She has completed her 10-day
course of ampicillin for Group B Strep bacteremia and is
clinically well.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 73591**], MD, phone
number ([**Telephone/Fax (1) 68662**].
CARE RECOMMENDATIONS: Feeds at time of discharge: Ad lib
breast feeding with supplements of breast milk enriched to 24
calories per ounce with Enfamil powder.
Medications: Iron supplements and Tri-Vi-[**Male First Name (un) **] supplements.
Iron and vitamin D supplementation. Iron supplementation is
recommended for preterm and low birth weight infants until 12
months corrected age. All infants fed predominantly breast
milk should received vitamin D supplementation at 200
international units (may be provided as a multivitamin
preparation) daily until 12 months correct age.
Car seat position screening: [**Male First Name (un) **] failed her car seat test on
[**2104-10-30**]. A repeat car seat test was performed on [**2104-11-5**] for 3
hours and she passed.
State newborn screening status: State newborn screen was sent on
[**2104-10-24**]. No abnormal results have been reported.
Immunizations received: [**Date Range **] received her first hepatitis B
vaccine on [**10-27**]. No further immunizations have been
given.
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 4 criteria:
1. Born at less than 32 weeks.
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.
3. Chronic lung disease
4. Hemodynamically significant congenital heart 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. This infant has not
received rotavirus vaccine. The American Academy of
Pediatrics recommend initial vaccination of preterm infants
at or following discharge from the hospital if they are
clinically stable and at least 6 weeks but fewer than 12
weeks of age.
A follow-up appointment with Dr. [**Last Name (STitle) **] has been scheduled.
DISCHARGE DIAGNOSES:
1. Prematurity at 34-3/7 weeks.
2. Group B Strep bacteremia.
3. Hyperbilirubinemia.
4. Infant of diabetic mother.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2104-10-31**] 18:30:05
T: [**2104-11-3**] 09:03:54
Job#: [**Job Number 74612**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7558
} | Medical Text: Admission Date: [**2144-5-25**] Discharge Date: [**2144-6-3**]
Date of Birth: [**2095-1-9**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
Exploratory laparotomy, small bowel resection, end-ileostomy
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a 49 year old male who complains of
FEVER/ABD PAIN.
49M with hx of T2DM and previous hx of unexplained
neutropenia who now presents with 3-4 days of fever and
chills with one day of right sided abdominal pain.
+ nausea, - Vomiting.
Pt with previous neutropenia that was possibly attributed to
his glipizide use, and subsequent BMBx was unrevealing. He
was hospitalized in [**Month (only) **] for neutropenia again, and this
was possibly attributed to ongoing cocaine use -- "Recently,
numerous case reports have related neutropenia and ANCA
positivity with cocaine mixed with an anti-helminthic [**Doctor Last Name 360**]
known as levamisole (a cutting [**Doctor Last Name 360**]).
The patient was reluctant to divulge his recent use, but
eventually admitted to
ongoing cocaine use over the past year at least. A serum
test
for levamisole was pending at discharge."
here w/ rigors, hypotensivge and abd pain- TRIGGER
Timing: Gradual
Quality: Dull
Duration: Hours
Past Medical History:
Type 2 diabetes-on oral medications
Chronic back pain-evidence of DJD
Status post tonsillectomy
Status post appendectomy
Recent admission in [**Month (only) **] for chin abscess/neutropenia
Microscopic hematuria with neg w/u
Social History:
The patient is married. Patient lives with his wife and his 12
year old son. [**Name (NI) **] currently takes care of his sister who is
ill. He works as an electrical engineer and travels to NH three
times weekly which is adding stress. Sister has a dog and a cat
but no scratches or bites recently. Drinks 0-1 drinks a week. No
tobacco history. He denied illicit drug use on admission, but
later admitted to recent and ongoing cocaine use during this
past year, with unclear details as to the duration of use.
Family History:
Sister with ALS
Dad with DM CVA MI
Mom with DM
Physical Exam:
PHYSICAL EXAMINATION
HR:132 BP:86/44 Resp:26 O(2)Sat:98 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm- tachy
Abdominal: Soft, diffusely tender r>L no rebound.
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2144-5-31**] 05:38AM BLOOD WBC-11.2* RBC-4.35* Hgb-11.4* Hct-35.3*
MCV-81* MCH-26.2* MCHC-32.3 RDW-15.6* Plt Ct-70*
[**2144-5-30**] 04:59AM BLOOD WBC-9.6 RBC-4.49* Hgb-11.9* Hct-36.0*
MCV-80* MCH-26.4* MCHC-33.0 RDW-15.9* Plt Ct-90*
[**2144-5-29**] 05:20AM BLOOD WBC-12.5*# RBC-4.71# Hgb-12.5* Hct-38.0*
MCV-81* MCH-26.6* MCHC-33.0 RDW-15.4 Plt Ct-116*
[**2144-5-25**] 03:44PM BLOOD WBC-0.7* RBC-3.98* Hgb-10.7* Hct-30.6*
MCV-77* MCH-27.0 MCHC-35.1* RDW-15.0 Plt Ct-190
[**2144-5-25**] 05:12AM BLOOD WBC-0.9* RBC-4.00* Hgb-11.0* Hct-31.3*
MCV-78* MCH-27.5 MCHC-35.2* RDW-14.8 Plt Ct-247
[**2144-5-24**] 08:17PM BLOOD WBC-0.5*# RBC-3.86* Hgb-10.4* Hct-29.8*
MCV-77* MCH-27.0 MCHC-35.1* RDW-14.4 Plt Ct-281
[**2144-5-27**] 02:03AM BLOOD Neuts-48* Bands-6* Lymphs-23 Monos-17*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-5* NRBC-1*
[**2144-5-26**] 01:54AM BLOOD Neuts-11* Bands-20* Lymphs-48* Monos-10
Eos-0 Baso-0 Atyps-9* Metas-2* Myelos-0
[**2144-5-31**] 05:38AM BLOOD Plt Ct-70*
[**2144-5-30**] 04:59AM BLOOD Plt Smr-LOW Plt Ct-90*
[**2144-5-29**] 05:20AM BLOOD Plt Ct-116*
[**2144-5-27**] 02:03AM BLOOD PT-16.3* PTT-37.3* INR(PT)-1.4*
[**2144-5-26**] 01:54AM BLOOD Plt Smr-NORMAL Plt Ct-198
[**2144-6-3**] 06:15AM BLOOD Glucose-98 UreaN-17 Creat-0.9 Na-135
K-3.8 Cl-98 HCO3-31 AnGap-10
[**2144-5-31**] 05:38AM BLOOD Glucose-204* UreaN-24* Creat-0.9 Na-141
K-3.9 Cl-105 HCO3-31 AnGap-9
[**2144-5-30**] 04:59AM BLOOD Glucose-213* UreaN-29* Creat-1.0 Na-140
K-3.7 Cl-103 HCO3-32 AnGap-9
[**2144-5-24**] 08:17PM BLOOD Glucose-138* UreaN-32* Creat-1.7* Na-135
K-3.9 Cl-95* HCO3-26 AnGap-18
[**2144-5-27**] 02:03AM BLOOD ALT-69* AST-61* AlkPhos-40 TotBili-3.9*
DirBili-3.5* IndBili-0.4
[**2144-5-26**] 06:15AM BLOOD DirBili-3.5*
[**2144-5-26**] 06:15AM BLOOD DirBili-3.5*
[**2144-5-26**] 01:54AM BLOOD ALT-73* AST-54* LD(LDH)-162 AlkPhos-31*
TotBili-4.4* DirBili-3.6* IndBili-0.8
[**2144-5-24**] 08:17PM BLOOD ALT-22 AST-23 AlkPhos-46 TotBili-1.1
[**2144-5-25**] 05:12AM BLOOD CK-MB-3 cTropnT-<0.01
[**2144-6-3**] 06:15AM BLOOD Calcium-7.8* Phos-4.1 Mg-1.7
[**2144-5-31**] 05:38AM BLOOD Calcium-7.5* Phos-3.3 Mg-1.9
[**2144-5-30**] 04:59AM BLOOD Calcium-7.6* Phos-3.4 Mg-2.1
[**2144-5-27**] 02:12AM BLOOD Lactate-2.2*
[**2144-5-25**] 03:20AM BLOOD Glucose-213* Lactate-2.9* Na-133* K-4.6
Cl-103
[**2144-5-26**] 03:24AM BLOOD freeCa-1.17
[**2144-5-25**] 09:05PM BLOOD freeCa-1.18
[**2144-5-24**]: x-ray of the abdomen:
IMPRESSION: Nonspecific bowel gas pattern, with a few mildly
dilated loops of
small bowel and small scattered air-fluid levels, which could
reflect
gastroenteritis or ileus. Early or partial obstruction cannot be
excluded and
could be further evaluated on CT as clinically warranted.
[**2144-5-24**]: chest x-ray:
IMPRESSION: Low lung volumes, but no focal consolidation. No
evidence of
free air beneath the diaphragm.
[**2144-5-25**]: Echo:
CLINICAL IMPLICATIONS:
The patient has moderate mitral regurgitation. Based on [**2139**]
ACC/AHA Valvular Heart Disease Guidelines, a follow-up
echocardiogram is suggested in 1 year.
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2140**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
[**2144-5-25**]: cat scan of the abdomen:
IMPRESSION: Findings concerning for distal ileal
inflammation,perforation,
and ischemia. Potential etiologies include neutropenic
enterocolitis, cocaine vasculopathy, and inflammatory bowel
disease.
[**2144-5-28**]: Echo:
Conclusions
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. Normal interatrial septum by
color doppler. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. No mitral regurgitation is seen. Tricuspid valve is
normal. No tricuspid regurgitation. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetations demonstrated. Preserved
biventricular systolic function. Normal cardiac valves.
[**2144-5-29**]: x-ray of the abdomen:
Stacked dilated loops of small bowel with distal air seen in the
colon and
rectum may be postoperative ileus but concerning for partial or
evolving
small-bowel obstruction is also considered. Followup radiographs
should be
considered as clinically indicated.
[**2144-5-29**]: chest x-ray:
IMPRESSION: Bilateral subsegmental atelectasis. Small left
effusion.
Minimal right pleural effusion. Increased density at the left
lung base
consistent with worsening atelectasis or consolidation.
Brief Hospital Course:
49 year old gentleman admitted to the acute care service with
abdominal pain and fever. Upon admission, he was found to be
hypotensive, tachycardic and neutropenic. He was admitted to
the intensive care unit where he required pressor support to
maintain his blood pressure. He was made NPO, given intravenous
fluids antibiotics, and had imaging studies of his abdomen which
were concerning for a perforation of his ileum. Infectious
disease was consulted and made recommendations regarding his
managment.
He was emergently taken to the operating room where he was
found to have a perforated terminal ileum. He underwent an
exploratory laparotomy, lysis of adhesions, distal ileum
resection, ileostomy, and [**Doctor Last Name 3379**] pouch. He also had placment
of a right sided abdominal drain. His operative course was
stable with a 500cc blood loss. He required blood products
,crystalloid, and pressors for maintainence of his blood
pressure. He was transported to the intensive care unit after
his surgery for monitoring where he was hypotensive and
tachycardic. He underwent a bedside Echo which showed
hypokinesis. He also had blood cultures drawn which showed
GPR's and recommendations were made for vancomycin, meropenum,
and micafungin.
His vital signs stablized, pressors weaned off, and he was
successfully extubated on POD #1. His post-operative pain was
managed with dilaudid PCA. His micafungin was discontinued on
POD #1 and his vancomycin discontinued on POD #2, meropenum on
POD #6.
He was transferred to the surgical floor on POD # 2. He did
continue to have episodes of tachycardia and underwent a TEE
which showed no valvular vegatation and an LVEF >55%.
Infectious disease continued to monitor his progress. The
abdominal drain was discontinued on POD# 3. The ostomy nurse
was consulted and provided care and supervison in the management
of his ostomy. Because of his deconditioning, physical and
occupational therapy were consulted and evaluated his physical
status for discharge. He was started on clear liquids with
advancement to a regular diet.
His vital signs are stable and he is afebrile. His white blood
cell count is 10. He has been ambulating in the [**Doctor Last Name **] with
assistance. He is tolerating a regular diet and is voiding
without difficulty. His ostomy was draining a large amount of
watery stool, but now slightly formed stool. He has not resumed
his daily home dose of insulin because of his tenuous GI status
but his blood sugars have been closely monitored.
He is preparing for discharge home with VNA services. He will
follow-up in the acute care clinic in 2 weeks.
Medications on Admission:
[**Last Name (un) 1724**]: glargine 25 units QHS, Lispro, Vicodin prn, ASA 81, ferrous
sulfate 325'
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
4. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20) units
Subcutaneous daily: please monitor blood sugars and increase
dose to pre-hospital as per blood sugars.
5. insulin lispro 100 unit/mL Cartridge Sig: 2-30 units
Subcutaneous prior to meals: as per sliding scale.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Bowel ischemia
neutropenia
sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were cared for in our hospital for neutropenia and
enterocolitis requiring surgery. Your illness may have been
attributed to a unhealthy lifestyle. You have been advised to
alter your lifestyle to prevent a recurrence.
Our general surgery team performed surgery on you first with an
exploratory laporatomy. Part of your small bowel was removed
and an end-ileostomy was performed. You were monitored in the
intensive care unit after the procedure, requiring antibiotics.
Your clinical status has improved and you are now preparing for
discharge home with VNA assistance. Please follow these
instructions:
You experience new chest pain, pressure, squeezing or tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-16**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Please notify us if you have an increase in your ostomy
drainage, any change in your ostomy.
Followup Instructions:
Please follow-up with the acute care service in 2 weeks. You
can schedule this appointment by calling # [**Telephone/Fax (1) 600**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2144-6-10**]
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7559
} | Medical Text: Admission Date: [**2162-3-2**] Discharge Date: [**2162-3-12**]
Service: MEDICINE
Allergies:
Ceftriaxone Sodium / Cefotaxime / Ace Inhibitors
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Renal failure
Major Surgical or Invasive Procedure:
central line placement
respiratory mechanical ventilation
IV pressors
thoracentesis of pleural effusion
History of Present Illness:
[**Age over 90 **] year old female with exquisitely complex medical history,
transferred from [**Hospital **] rehab for evaluation of renal failure
and consideration for dialysis.
.
Of note, pateint was recently discharged from [**Hospital1 18**] in [**12-5**]
after a very complicated MICU stay. She was initially admitted
for respiratory distress likely from decompensated CHF and ?MRSA
pneumonia. SHe was treated with vancomycin for pneumonia. She
was also diurese and had afterload reduction. She also had
multiple thoracentesis with transudative effusion and rapid
reaccumulation. She was eventually intubated and trach on
[**2161-12-30**]. Weaning has been mainly unsuccessful.
.
Patient was transferred to rehab on pressure support but was
switched to AC becuase of intolerance. Weaning attempts were
unsuccessful.
She actually was admitted to ICU at [**Hospital1 **] becuase of
arrhythmia. Her SVT was controlled with increasing doses of
metoprolol and digoxin but she became bradycardic. Patient went
into monomorphic VTs that resolved spontaneouly. Patient was
given amiodarone 150mg IV 2 weeks ago. Serial CKs and troponin
were negative
Her course was also complicated by hemoptysis and [**Hospital1 4532**],
aspirin and coumadin has been d/c'd.Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**] [**Last Name (NamePattern1) 47786**] her
and did not find source of bleeding.
Patient was also started on imipenem for presumed ventilator
associated pneumonia([**1-25**]- [**2162-2-4**]). SHe was also on Bactrim for
anterobacter on her sputum.
Her BUn and creatinine begin to climb around [**2-17**] t0 1.9 and 3.3
on day of admission. Renal consult suggested dialsysis. Family
meeting was held with son on [**2-19**] who insisted everything to b
done
Past Medical History:
CAD s/p bare metal stent to OM1 [**7-5**]
gallstone pancreatitis
cholecystitis
s/p percutaneous cholecystostomy tube
h/o CVA
anemia
CRI
hemorrhoids
AF
junctional arrhythymias
htn
h/o pna
s/p PEG tube placement feeds d/c [**2161-6-25**]
tracheostomy
s/p bilateral thoracentesis
s/p hip replacement
necrotic right foot
CHF, hx of diastolic dysfxn
R foot dry gangrene s/p AKA [**9-4**]
Social History:
Lives with son (healthcare proxy) in [**Hospital1 **], but has been in
rehab for many months.
Family History:
non contributory
Physical Exam:
PHYSICAL EXAMINATION:
Gen- frail looking elderly female lying in bed, only responsive
to noxious stimuli
HEENT- anicteric, flushed and swollen looking face, oral mucosa
dry, neck supple, trach site looks clean
CV- 2/6 SEM at apex, irregular heart sound
resp- decreased breath sound right more than left
abdomen- PEG site clean, no distension, unable to assess
tenderness
ext- 3+ pitting edema in all extremity, right AKA noted.
skin- multiple bruises and also excoriation from anasarca, clean
ulcer noted on left foot.
Pertinent Results:
Please refer to OMR records for CXR, abdominal U/S, ECG,
echocardiogram, and lab results.
Blood Cx with ENTEROBACTER CLOACAE
Urine Cx with pseudomonas
Sputum Cx with pseudomonas and proteus
Brief Hospital Course:
[**Age over 90 **] year old female with extensive cardiac history, AF, sick
sinus syndrome, presents with acute renal failure to be
considered for dialysis.
.
# Code Status / Overall Goals of Care: Patient was initially
"Full code," confirmed with son. Over the course of her
hospitalization, the patient's very grave prognosis and very
limited potential quality of life (even if all acute issues were
effectively treated) led to frequent discussions between the ICU
team and the patient's family (son). Given the patient's
deteriorating status and grave prognosis, the patient's code
status was changed to DNR/I, CPR not indicated. The patient's
son and ICU team decided to discontinue Levophed on [**3-12**] and
the patient passed away within 1-2 hours.
.
# ID: The patient's clinical picture at admission very
consistent with sepsis (including WBC 16 with 39% bands) and pt
was started empirically on vancomycin and meropenem and given
aggressive IVF resuscitation. Two out of two blood Cx bottles
drawn on day of admission grew ENTEROBACTER CLOACAE, sensitive
to meropenem, which pt was continued on for the remainder of her
hospital stay. Patient was apparently on Flagyl 250 Q6
prophylactically at rehab facility, although C diff was negative
on [**2162-2-1**]. Flagyl was not continued in the hospital. Stool
studies were negative for C.diff here as well. Thoracentesis was
performed and revealed a transudative process. [**Last Name (un) **] stim test
was WNL.
.
# Acute Renal Failure: Creatinine was increased at admission but
urine output was initially WNL. Pt's renal function continued to
deteriorate and she became anuric. Work-up was entirely
negative, including abdominal ultrasound (no hydronephrosis
seen), urine eosinophils negative. Pt had history of renal
artery stenosis (angiography showed high grade stenosis of the
left renal artery but with normal perfusion and moderate
stenosis of the right renal artery which previously had been
demonstrated to be atrophic with flow studies indicative of
significant stenosis too diffuse to intervene). Renal followed
the patient throughout her hospitalization. The possibility of
initiating dialysis was discussed at length with the patient's
family (son) and the renal team and in view of the patient's
grave overall prognosis and very limited potential quality of
life even with dialysis, the decision was made not to pursue
dialysis.
.
# Hypotension: was likely from sepsis. Pt required levophed for
BP support despite aggressive IVF.
.
# CAD: Patient had a trop of 0.21, MB 22. ECG revealed Afib,
nonspecific St-T changes, poor RWP(not new); likely demand
ischemia. Patient was maintained on aspirin and lipitor. Cardiac
enzymes
- cycle cardiac enzymes
- cardiology consult
- bare metal stent placement in [**Month (only) **] to OM #1, doubt it is in
stent thrombosis, no acute EKG a changes and completed at least
3 month of [**Month (only) 4532**]
.
# Diastolic heart failure; echo [**12-5**]:EF>55%, 2+MR, 1+TR.
Patient was discharged on daily laisx and mitolazone; this is
probably now complicated by acute renal failure
- d/c afterload reduction(isordil, metoprolol and Hydralazine)
until sure that BP is stable, Losartan was d/c on last admission
due to ARF
.
# Anasarca: from admission, pt was grossly edematous with weepy
skin. This was likely from low albumin state, diastolic heart
failure, and complicated by acute renal failure. Pt received
aggressive skin care.
.
# Afib with history of junctional arrythymias. EP felt that
there was no indication for amiodarone during past admission,
however, given one time dose of amiodarone at NH (last dose 2
weeks ago). Patient intermittently was in NSR and Afib
throughout hospitalization. Anticoagulation was not initiated
given recent report of hemoptysis.
.
# Respiratory failure: combination of pleural effusion, ?PNA. Pt
was continued on ventilatory support via her trach throughout
her hospitalization.
.
# Thrombocytopenia: stable throughout admission but lower than
her plt count in [**2161-12-31**]. Could have been from low-grade
DIC (high LDH, high Ddimer), although fibrinogen was high.
.
# Hypothyroidism - the patient was continued on her outpatient
regimen of levothyroxine.
.
# Hemoptysis at [**Hospital1 **], apparently broch'd by Dr. [**First Name (STitle) 1726**] and
was negative. Held [**Last Name (LF) 4532**], [**First Name3 (LF) **] and coumadin.
.
# Psych: pt had very minimal mental status throughout her
hospitalization, only wincing to noxious stimuli but otherwise
not interactive.
.
# CVA: pt had a history of a subacute right occipital infarct
and was on [**First Name3 (LF) **].
.
# Anemia: Work up consistent with ACD and iron deficiency
.
# Diabetes- on RISS and lantus
.
# Prophylaxis: Pt was initially on SC heparin prophylaxis but
this was discontinued due to skin weeping (from anasarca). Pt
was maintained on a PPI throughout her hospitalization.
*
# FEN: pt tolerated tubefeeds via PEG (placed [**2161-12-18**]).
.
# Access: a right-subclavian line was placed on [**2162-3-3**] and PICC
line was removed.
.
# Communication: the patient's only son, [**Name (NI) **] [**Name (NI) **]
[**Telephone/Fax (1) 47781**], was updated on the patient's status on a daily
basis by the ICU attending and team.
Medications on Admission:
flagyl 250 Q6
diphenhydramine 50mg Q8
ativan 2mg Q4
lopressor 12.5mg Q12
RISS
morphine Q1 prn
hydralazine 40 Q6
lipitor 10
MVI
synthroid 0.088 mg
lansoprazole 30
isosorbide 10 Q8
ascorbic acid 250 every 12h
artificial tears
docusate and senna
[**Last Name (LF) 4532**], [**First Name3 (LF) **] and coumadin held becuase of hemoptysis through
trach
Discharge Medications:
(deceased)
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis, bacterial
acute renal failure
respiratory failure
atrial fibrillation
coronary artery disease, stable
thrombocytopenia
pleural effusion, transudative
Discharge Condition:
(deceased)
Discharge Instructions:
(deceased)
Followup Instructions:
(deceased)
Completed by:[**2162-3-12**]
ICD9 Codes: 5849, 4240, 4280, 5789, 5119, 486, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7560
} | Medical Text: Admission Date: [**2105-2-18**] Discharge Date: [**2105-2-21**]
Date of Birth: [**2052-9-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
acute shortness of breath and elevated INR s/p
AVR(mechcanical)Ascending Aortic arch replacment on [**2-3**].
Major Surgical or Invasive Procedure:
evacuation of pericardial effusion
History of Present Illness:
SOB onset about 5 days ago, increasing with any movement. Saw
cardiologist yesterday had echo today with effusion.
Past Medical History:
Complete Heart Block(PPM)
Postop DVT in LUE [**2104-3-12**] following lead extraction
Hyperlipidemia
s/p Dual chamber pacemaker placement in [**2087**]
s/p replacement of PM generator [**2096**]
s/p Lead extraction and reimplantation of PPM [**3-/2104**]
Hernia repair as child
s/p AVR(mechcanical)Ascending Aortic arch replacment on [**2-3**].
Social History:
Lives with: Wife in [**Name2 (NI) 1727**]
Occupation: Production manager on ship yard
Tobacco: Quit 1.5 years ago. 40 pack year history
ETOH: [**12-14**] drinks per week
Family History:
non-contributory
Physical Exam:
Physical Exam
Temp 98.6 Pulse: 70 Vpaced Resp: 16 O2 sat: 96% 3LNP
B/P Right: 109/70 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [] Edema 2+ bilat
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: Left:
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Pertinent Results:
[**2105-2-18**] 03:02PM PT-59.9* PTT-34.8 INR(PT)-6.8*
[**2105-2-21**] INR 2.2
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83779**]Portable TTE
(Focused views) Done [**2105-2-18**] at 5:00:00 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2052-9-21**]
Age (years): 52 M Hgt (in): 70
BP (mm Hg): 130/79 Wgt (lb): 277
HR (bpm): 70 BSA (m2): 2.40 m2
Indication: cath lab pericardiocentesis monitoring.
ICD-9 Codes: 423.3
Test Information
Date/Time: [**2105-2-18**] at 17:00 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**]
[**Last Name (NamePattern1) 4135**], RDCS
Doppler: No Doppler Test Location: West Cath/EP Lab
Contrast: None Tech Quality: Adequate
Tape #: 2010W000-: Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Findings
Limited views were done with sterile probe cover to assess fluid
position during attempted pericardialcentesis.
PERICARDIUM: Large pericardial effusion. RV diastolic collapse,
c/w impaired fillling/tamponade physiology.
Conclusions
There is a large pericardial effusion. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2105-2-18**] 17:47
Post-op echo [**2105-2-20**]
Conclusions
Overall left ventricular systolic function is normal (LVEF>55%).
A bileaflet aortic valve prosthesis is present. There is a
moderate sized pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
There are no echocardiographic signs of tamponade. No right
ventricular diastolic collapse is seen.
Compared with the findings of the prior study (images reviewed)
of [**2105-2-18**], the pericardial effusion is smaller, now with
signs of consolidation; no evidence of cardiac tamponade.
Brief Hospital Course:
Mr [**Known lastname **] was admitted on [**2105-2-18**] and taken to the Operating Room
for evacuation of large pericardaicl effusion. See operative
note for details. POst operatively he was transferred to the
CVICU intubated and sedated for hemodynamic and ventilator
management. He awoke neurologically intact and was extubated. He
was tarnsferred from the ICU to the step down unit on POD#1. His
couamdin was resumed for anticoagulation of mechanical aortic
valve. His statin, betablocker and diuretic were also resumed.
He was evaluated by physical therpay for strength and
conditioning and was claered for discharge to home on POD#3.
Medications on Admission:
1. Simvastatin 40'
2. Aspirin 81'
3. Acetaminophen 325-650/PRN
4. Hydromorphone 2-4 mg/Q4H/PRN
6. Warfarin 5QD: **dose will change daily for goal INR 2.5-3.5,
7. Potassium Chloride 20 Q12H (every 12 hours) x5 days.
8. Ranitidine HCl 150'
9. Docusate Sodium 100"
10. Metoprolol Tartrate 25"
11. Furosemide 40"
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
10. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
take 5mg on [**2-22**] then as directed by Dr. [**Last Name (STitle) 83780**].
Disp:*60 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
INR check on [**2105-2-22**] and call results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] NP
[**Telephone/Fax (1) 170**]
AFTER [**2105-2-22**] INR check and call results to Dr. [**Last Name (STitle) 80724**]
[**Telephone/Fax (1) 8226**]; Fax [**Telephone/Fax (1) 83781**]
Discharge Disposition:
Home With Service
Facility:
VNA of Southern [**State 1727**]
Discharge Diagnosis:
Complete Heart Block(PPM)
Postop DVT in LUE [**2104-3-12**] following lead extraction
Hyperlipidemia
s/p Dual chamber pacemaker placement in [**2087**]
s/p replacement of PM generator [**2096**]
s/p Lead extraction and reimplantation of PPM [**3-/2104**]
Hernia repair as child
Past Surgical History: [**2105-2-3**]
1. Ascending aortic replacement with 28-mm Gelweave graft
under deep hypothermic circulatory arrest.
2. Aortic valve replacement, 25-mm St. [**Hospital 923**] Medical Regent
mechanical valve.
3. Coronary artery bypass grafting x1 of the left internal
mammary artery graft to left anterior descending.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Recommended Follow-up:
Surgeon Dr. [**Last Name (STitle) **] [**2105-3-12**] at 1pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments:
Primary Care Dr. [**Last Name (STitle) 28272**] [**Telephone/Fax (1) 83777**] in [**12-13**] weeks
Cardiologist Dr. [**Last Name (STitle) 80724**] in [**12-13**] weeks.
Dr. [**Last Name (STitle) 80724**] will follow your coumadin starting monday [**2105-2-23**].
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2105-2-21**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7561
} | Medical Text: Admission Date: [**2118-3-17**] Discharge Date: [**2118-3-25**]
Date of Birth: [**2073-4-21**] Sex: M
Service: MEDICINE
Allergies:
Aloe / Levaquin / Tape [**12-6**]"X10YD / Penicillins / Betaseron /
vancomycin
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
44 year old male with history of multiple sclerosis, baseline
cognitive defects, chronic indwelling suprapubic catheter and
recurrent resistant urinary tract infections presenting with
UTI. He was recently hospitalized [**Date range (3) 45860**] for UTI
complicated by encephalopathy (somnolent, difficult to arouse).
Urine culture grew staph aureus; sensitivities were not back by
time of discharge. He improved on bactrim and discharged on 14
day course. However, sensitivities after discharge returned with
MRSA.
.
He was seen by his outpatient urologist (Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**])....
.
In the ED, initial VS: 95.1 75 151/100 16 97%. He received 1g IV
vancomycin. Previously, he had had an erythematous skin reaction
on the arm that vancomycin had been infusing. No history of resp
distress on vancomycin. Per ED, he had no ostensible reaction
while receiving the vancomycin. Per wife, he appeared more red
than usual in face and upper chest. Urology was called (but did
not officially consult) and agreed with admission to medicine
with urology following.
.
Within minutes of arrival to the floor, patient began to have
active seizures. Per wife, he does not have history of seizures
and was conversing and at baseline mental status while in ED. He
began to groan, head moving side to side, upper extremities
twitching and outstretched. During the first episode, he had
oxygen desaturation briefly to the mid 70s on room air for a few
seconds. Blood pressure was in systolic 180s; HR in 110s. He
then fell into stupor and within a few minutes again became
tremulous in upper extremities. Pupils were not reactive to
light. He received a total of 10mg iv ativan. Neurology was
consulted who recommended 1g loading dose of iv fosphenytoin.
Wife confirmed that pt is [**Name (NI) 835**]/DNR.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Multiple sclerosis diagnosed in '[**03**]. Wheel chair bound.
- Neurogenic bladder s/p suprapubic catheter '[**10**]
- Multiple urinary tract infections (Providencia, Pseudomonas,
MRSA)
- Multiple episodes Bacteremia and urosepsis
- Nephrolithiasis s/p R ureteral stent placement [**11-11**], multiple
lithotripsy procedure, s/p L ureteral stent exchange [**2114-12-7**].
s/p removal of L stent on [**1-6**].
Social History:
- Lives with wife who is primary caretaker.
- Former electrician/web designer.
- Wheelchair bound.
- No tobacco
- No Alcohol
- No illicits
Family History:
no history of seizures
Physical Exam:
Admission exam
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-9**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Discharge exam
98.3 111/77 84 20 97%2L
GENERAL - ill-appearing caucasian male,A+O x 2 (not to time),
looks improved
HEENT - PERRLA, sclerae anicteric, MMd, OP clear. Face is
erythematous.
NECK - Supple, no JVD
HEART - RRR, no MRG
LUNGS - bibasilar crackles
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - face is red, w/ well-demarcated areas, though this is
improving
NEURO - awake, A+ O x 2, PERRL. CNs II-XII grossly intact muscle
strength decreased globally, increased muscle tone/spasticity
are somewhat better since baclofen restarted
Pertinent Results:
Admission labs
[**2118-3-17**] 09:33PM BLOOD WBC-7.6 RBC-5.12 Hgb-14.4 Hct-45.3 MCV-89
MCH-28.2 MCHC-31.9 RDW-15.4 Plt Ct-152
[**2118-3-17**] 09:33PM BLOOD Neuts-74.2* Lymphs-17.4* Monos-6.5
Eos-1.0 Baso-0.9
[**2118-3-17**] 09:33PM BLOOD Glucose-114* UreaN-12 Creat-0.9 Na-135
K-4.5 Cl-96 HCO3-32 AnGap-12
[**2118-3-18**] 05:57AM BLOOD Albumin-3.5 Calcium-9.1 Phos-4.6*# Mg-1.9
Other labs
[**2118-3-19**] 03:06AM BLOOD ALT-55* AST-49* AlkPhos-87 TotBili-0.1
[**2118-3-22**] 06:00AM BLOOD ALT-37 AST-42* AlkPhos-87 TotBili-0.4
[**2118-3-19**] 03:06AM BLOOD TSH-2.9
[**2118-3-22**] 09:26PM BLOOD HEPARIN DEPENDENT ANTIBODIES- negative
Discharge labs
[**2118-3-25**] 06:16AM BLOOD WBC-6.1 RBC-3.93* Hgb-11.5* Hct-36.1*
MCV-92 MCH-29.2 MCHC-31.8 RDW-15.9* Plt Ct-181
[**2118-3-25**] 06:16AM BLOOD Glucose-72 UreaN-15 Creat-0.8 Na-141
K-3.7 Cl-102 HCO3-28 AnGap-15
[**2118-3-25**] 06:16AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.9
Studies
EEG [**3-18**]: CONTINUOUS EEG RECORDING: Began at 12:05 on [**3-18**]
and continued until 7:O0 the next morning. At the beginning, it
showed a low voltage faster pattern in all areas with bursts of
focal slowing especially in the left temporal region. There were
also some runs of rhythmic 6 Hz slowing in the left temporal
area and other runs of periodic slowing with sharp features,
none lasting for more than 8-10 seconds or so. On video, they
did not appear to have any clinical correlate. By the
evening, the background was more suppressed and, while left
temporal
slowing was still evident, the sharp features were not. SPIKE
DETECTION PROGRAMS: Showed a few of the left temporal sharp
features, especially early in the record. SEIZURE DETECTION
PROGRAMS: Showed no electrographic seizures. PUSHBUTTON
ACTIVATIONS: There were none. SLEEP: No normal waking or sleep
patterns were evident. CARDIAC MONITOR: Showed a generally
regular rhythm. IMPRESSION: This telemetry captured no
pushbutton activations. There was continued focal slowing in the
left temporal region. Early in the record, this also included
some runs of irregular sharp activity and some 6 Hz rhythmic
slowing in the same area, but these episodes did not appear to
show any clinical evidence of seizure on video. They were brief.
No more prolonged and clear electrographic seizures were
recorded.
CXR [**2118-3-18**]: Portable AP chest radiograph demonstrates low lung
volumes and worsening basilar atelectasis. The left PICC has
been removed. There is no focal consolidation, large pleural
effusion, or pneumothorax. The
cardiomediastinal silhouette is partially obscured.
MR head [**2118-3-19**]: FINDINGS: The study is compared with most
recent enhanced MR examination of [**2-/2118**], as well as the remote
study of [**2109-9-11**].
Again demonstrated is the extensive confluent
T2-/FLAIR-hyperintensity
throughout bihemispheric subcortical and periventricular white
matter, with similar abnormality involving the posterior fossa,
including the brainstem, cerebellar peduncles and cerebellar
hemispheres. Allowing for the motion artifact, above, the
overall appearance is unchanged. By and in-large, the extensive
lesions demonstrate intrinsic T1-hypointensity, representing
"black holes" of irreversible demyelination. However, there is a
prominent curvilinear or "targetoid" 16 mm focus of enhancement
in the right corona radiata with a possible second enhancing
focus in the corresponding location on the left. The right-sided
focus appears new since the [**4-/2117**] examination, though
previously, there was a smaller, more nodular focus in the
immediately adjacent centrum semiovale. Allowing for the marked
limitation in the post-contrast imaging, no other definite
enhancing focus is seen, with apparent interval resolution of
the left-sided subcortical white matter, temporal lobar and
cerebellar hemispheric foci. Currently, there is no pathologic
leptomeningeal or dural focus of enhancement. There is no
definite focus of slow diffusion to suggest an acute ischemic
event, and the principal intracranial vascular flow-voids,
including those of the dural venous sinuses are preserved and
these structures enhance normally. In comparison to the more
remote study there is no definite progression of the marked
global atrophy (particularly given the patient's age) or the
severe diffuse atrophy of the corpus callosum. Limited imaging
of the upper cervical spinal cord, through the mid-C4 level,
demonstrates no definite abnormality.
IMPRESSION: The study, particularly the post-contrast MP-RAGE
acquisition, is quite limited by motion artifact, with:
1. No significant change in the overall extensive demyelinating
"disease
burden." 2. Curvilinear rim-enhancing focus in the right corona
radiata appears new since the [**2117-4-6**] study and likely
represents a site of active inflammation; allowing for the
limitation above, there is no definite additional enhancing
focus, with apparent interval resolution of many of the foci
demonstrated on that study. 3. Marked global and corpus callosal
atrophy, not significantly changed since the [**9-/2109**] study.
CXR [**2118-3-25**]: : A right-sided PICC terminates within the distal
SVC. The aeration of the lungs has improved compared to the
prior study. Cardiac silhouette is stable. No large pleural
effusions are seen. There is no pneumothorax. Bones are intact.
IMPRESSION: Right-sided PICC terminating within the distal SVC.
Brief Hospital Course:
Mr. [**Known lastname 45855**] is a 44yoM with h/o multiple sclerosis, baseline
cognitive defects, chronic indwelling suprapubic catheter and
recurrent resistant urinary tract infections presenting with a
UTI and new onset seizures.
.
After initially being admitted to the floor, he developed
seizures requiring 10mg IV ativan and started on fosphenytoin
with a load and transferred to the MICU. He was noted to be
increasingly somnelent with periods of central apenea. ABG
showed acidemia with CO2 on the 70s. He was started on Bipap
with improvement in his CO2. It was presumed that his central
apnea was secondary to his large ativan dose which slowly
improved with clearance of the ativan. He was started
emperically on vanc/ctx/amp/acyclivir to cover both his UTI and
for empiric coverage for meningitis given his AMS. A head MRI
was done, which showed unchanged appearance of extensive
demyelinated, w/ new curvilinear rim focus in corona radiatia,
likely site of active inflammation, no evidence of ischemic
event, unchanged marked global atrophy. Given that meningitis
was less likely he was narrowed to vanc/[**Known lastname **]. He began to
wake up over the day on [**3-19**] and was weaned off BiPap to a
shovel mask and transferred to the floor.
.
On the floor, he remained stable throughout the day on [**3-20**].
However, that morning was noted to be more tachycardic and
febrile to 103 in the setting of hypoxia to the 80s. He was put
on a NRB and sats remained in the 80s for a while before
improving to the mid- 90s. ABG on NRB was 7.48/40/72. His eyes
were open but wasn't following commands and appeared obtunded on
the floor. CXR on the floor showed no new infiltrate. Patient
was transitioned to the MICU and briefly broadened to
vanco/[**Month/Year (2) **]/flagyl for aspiration pneumonia, but quickly
narrowed given rapid improvement of respiratory status. By
morning patient was alert and oriented X3, communicating and
breathing comfortably on 2L nasal cannula with saturation in mid
to high 90s. Abx were again narrowed to [**Month/Year (2) 21347**]/Vanco for
coverage of UTI. Patient was then called out to floor.
.
#) Seizures (new): several possible etiologies in this patient;
he has severe multiple sclerosis, and though he has never had a
seizure before, there is a new area of inflammation on his MRI.
Infectious causes in setting of severe MS [**First Name (Titles) **] [**Last Name (Titles) 45861**]
seizures, most notably his UTI. He was started on fosphenytoin
IV initially, then transitioned to phenytoin PO once mental
status improved. There was no sign of further seizure activity.
He will f/u w/ [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] in ~2 weeks
.
# Altered mental status: per wife, was at baseline until the
seizures. 24h EEG did not show status epilepticus. Mental status
then to near baseline by discharge suggesting largely resultant
from infections/medications/post-ictal state.
.
#) Apnea/Hypercarbia: fully resolved as his mental status
improved once coming out of the MICU the 2nd time.
.
#) UTI: growing MRSA and pseudomonas. He will is on
vancomycin/ceftazidime, and will complete a 14 day course. A
PICC line was insserted and home infusion company will assist w/
antibiotics. There was a question of home aids flushing his
foley, thus potentially introducing pathogens. There should be
no flushing of the foley and this was addressed w/ wife and in
page 1 instructions.
.
#) Rash w/ vancomycin: pt did develop red rash on arms and face
w/ vancomycin infusion. Component of redman syndrome was
suspected. Benedaryl was given w/ vancomycin and this improved
his symptoms. There was no other evidence of allergic disease,
and no facial swelling or airway obstruction.
.
#) Thrombocytopenia- Bseline ~150's, went downt to 89 this
admission. No signs of active bleeding. No rashes on exam. He
had been exposed to heparin in the last 30 days, so PF4 antibody
was checked and was negative. His platelets responded to
baseline by discharge, and likely this was all secondary to
acute infection.
.
#) Multiple sclerosis: initially held home home baclofen given
AMS, but restarted by discharge once mental status improved.
.
#) HTN: continued home amlodipine
.
# CODE: DNI/DNR (confirmed with wife)
.
=======================================
TRANSITIONAL ISSUES
# further seizure care per Dr [**Last Name (STitle) **] in Neurology
# PICC line is to be d/c'ed by home infusion company
# Foley catheter should NOT be flushed, except at the direct
recommendations of [**Name8 (MD) **] MD
Medications on Admission:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. baclofen 10 mg Tablet Sig: Two (2) Tablet PO 5X/DAY (5 Times
a Day).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
Discharge Medications:
1. ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours) for 6 days.
Disp:*19 Recon Soln(s)* Refills:*0*
2. vancomycin 1,000 mg Recon Soln Sig: 1250mg Intravenous twice
a day for 6 days: Start on [**3-26**] AM. Give IV benadryl prior to
infusion. Infuse over 2 hours.
Disp:*12 doses* Refills:*0*
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. baclofen 10 mg Tablet Sig: Two (2) Tablet PO 5X/DAY (5 Times
a Day).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
9. phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO 3 tabs in the morning, 3 tablets at noon, and 4
tablets in the evening.
Disp:*300 Tablet, Chewable(s)* Refills:*1*
10. Benadryl 25 mg Capsule Sig: One (1) Capsule PO twice a day:
give 20 minutes before vancomycin infusion.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] [**Hospital1 269**]
Discharge Diagnosis:
Primary: MRSA urinary tract infection, seizure
Secondary: multiple sclerosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr [**Known lastname 45855**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for a urinary tract infection. You then developed seizures. You
had a head MRI, which showed a new area of multiple sclerosis,
and this plus the infection is probably why you had a seizure.
You were started on antibiotics and anti-seizure medications,
and got much better.
The following changes have been made to your medications:
** START phenytoin (dilantin) [anti-seizure medication]. Take
150mg in the morning and at noon, and 200mg at night (3 total
doses per day)
** START vancomycin [antibiotic]
** START ceftazidine [antibiotic]
** START benadryl, take 20 minutes before vancomycin infusion
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] D.
Address: [**Location (un) 45857**], [**Location (un) **],[**Numeric Identifier 45858**]
Phone: [**Telephone/Fax (1) 45859**]
Appointment: Friday [**2118-4-1**] 10:15am
Department: NEUROLOGY
When: MONDAY [**2118-4-4**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD [**Telephone/Fax (1) 5434**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
When: MONDAY [**2118-4-11**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: FRIDAY [**2118-5-20**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD [**Telephone/Fax (1) 5434**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
ICD9 Codes: 5990, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7562
} | Medical Text: Admission Date: [**2103-7-25**] Discharge Date: [**2103-8-2**]
Date of Birth: [**2051-2-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Codeine / Morphine / Amitriptyline / Neurontin /
Tramadol / Percocet / Niacin / Naprosyn
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Head Injury scalp laceration
Major Surgical or Invasive Procedure:
Craniotomy for Subdural Hematoma Evacuation
History of Present Illness:
52 y/o male found in the middle of a four [**Male First Name (un) **] highway with
trauma to scalp. Pt brought in by ems for eval on arrival to ER
to see pt for SAH/ SDH and IPH. On arrival to ER pt was
combatitive and and speaking. He became obtunded prior to our
team assessing him. We asked for a stat CT which showed SAH
predominently on the left side with left temporal IPH 1.8 x 1.1
with SDH with associated MLS. No obvious bone fracture noted.
Past Medical History:
Alcoholism
Left leg skin graft
Social History:
Unmarried has four children. Disabled after work injury. Post
traumatic stress disorder treated at VA
Family History:
Unknown
Physical Exam:
BP: 169/94, HR: 86 R22 99 O2Sats on 100% NRB
Gen: WD/WN
HEENT: NC, abrasion with STS to right parietal region - no open
lacs noted. Negative battles, negative raccoon sign, unable to
visualize left TM, Right TM without hemotypanum.
Pupils: 3mm trace reaction / + corneals, roving eye movements /
non attentive to examiner, no eye opening to voice or noxious,
no
grimace.
Neck: IN collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: GCS= 3 Eye=1, Voice =none/ 1 Motor= 1
s at 5 minutes.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 trace reaction
bilaterally.
III, IV, VI: Extraocular movements = not able to test/ roving
eye
movements
V, VII: unable to assess.
VIII: unable to assess.
IX, X: unable to assess.
[**Doctor First Name 81**]: unable to assess.
XII: unable to assess.
Motor: Strength full power [**4-21**] throughout on arrival - now with
some finger movement and toe movement on the left without w/d to
noxious.
Toes downgoing bilaterally
Pertinent Results:
[**2103-7-25**] 02:00AM PT-11.9 PTT-24.9 INR(PT)-1.0
[**2103-7-31**] 02:45AM BLOOD Plt Ct-279
[**2103-7-31**] 02:45AM BLOOD Glucose-121* UreaN-12 Creat-0.5 Na-134
K-4.2 Cl-104 HCO3-22 AnGap-12
[**2103-7-31**] 02:45AM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.9 Mg-2.2
[**2103-7-25**] 02:00AM BLOOD ASA-NEG Ethanol-460* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2103-7-31**] 03:11AM BLOOD Type-ART pO2-138* pCO2-31* pH-7.48*
calTCO2-24 Base XS-1
[**2103-7-31**] 03:11AM BLOOD Lactate-1.6
[**2103-7-25**] 06:14AM BLOOD Hgb-10.0* calcHCT-30
[**2103-7-31**] 03:11AM BLOOD freeCa-1.17
Brief Hospital Course:
Mr [**Known lastname 1007**] was seen by Neurosurgery and taken emergently to the OR
to undergo a left sided craniotomy for evacuation of left sided
subdural hematoma and partial lobectomy. Post operatively he
did not respond to any painful stimuli until approx 24 hours
post operatively. He would attempt to localize his right arm
and infrequently his left arm with very little movemment of his
lower extremeties. His immediate post op course was complicated
by high fevers with only source was HFlu in his sputum.
His post operative CT that showed extensive hemorrhagic
contusion within the left temporal lobe, a large quantity of
pneumocephalus within the left frontal region, as well was as
within an apparent partially evacuated left cerebral convexity
subdural hematoma. There does appear to be persistent mass
effect, as well as continued rightward subfalcine herniation.
An EEG showed some generalized slowing.
His exam continued to show roving eye movement, occasional eye
opening, localizing on right>left. On [**7-30**] a CT showed some
increase mass effect causing midline shift.
His family was adament that Mr [**Known lastname 1007**] would not want a Trach or
PEG or 24 hour nursing care on [**8-1**] they made him CMO. He was
started on a Morphine drip and passed away on [**8-2**].
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Traumatic Brain Injury
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2103-8-6**]
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7563
} | Medical Text: Admission Date: [**2151-1-12**] Discharge Date: [**2151-1-19**]
Date of Birth: [**2123-10-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
fever, hypotension
Major Surgical or Invasive Procedure:
1. Withdrawal Right tunneled line.
2. Placement and withdrawal of right subclavian line.
3. Placement and withdrawal of right femoral line.
4. Placement of left subclavian tunneled line.
History of Present Illness:
27 yo M w/ESRD on HD presented to the ED [**1-12**] with fever and
hypotension. He was feeling well after HD day pta, when he
developed fever and rigors. These were associated with nausea,
leading to vomiting every 20-30 minutes overnight.
.
Day of admission Mr. [**Known lastname 34030**] felt so weak that he fell to the
floor multiple times on his way to the bathroom, though he never
lost consciousness. His profound weakness and persistent nausea
prompted his call to EMS, and he was brought by ambulance to the
[**Hospital1 18**] ED. He admits to diarrhea since day pta. Per his wife, he
has had no chest pain, dyspnea, abd pain, melena, or
hematochezia.
.
In the ED, he had a temp of 103.6, BP 70/30, HR 140. He was
treated with 6.5 liters NS, and SBP transiently improved to
100s, then drifted down to 80's-90's. he was treated empirically
with IV vanco, ceftazidime, doxycycline, and dexamethasone.
Phenylephrine gtt and norepi gtt were started for BP support. He
was transfused 2 units FFP for unclear reasons. UA, CXR, and abd
CT were completed and showed no localizing signs of infection.
He was admitted to the MICU.
.
MICU course - found to have bacteremia, MSSA, treated now with
nafcillin. TEE neg. for endocarditis, but needs TLC pulled and
cultured once piv access established.
Past Medical History:
ESRD [**1-1**] reflux nephropathy
s/p failed kidney transplant in [**2-2**] and again in [**8-5**]
HTN
UTIs
s/p Tenckhoff placement
s/p tunnelled line placement
Social History:
Pt denies any tobacco, alcohol, or IVDU. Pt currently on
disability.
Family History:
Mother's side of the family with kidney disease (uncertain
etiology). Father with DM.
Physical Exam:
PLEASE NOTE THAT WHAT FOLLOWS IS THE PHYSICAL EXAM AFTER THE
PATIENT WAS TRANSFERRED OUT OF THE MICU ON [**2151-1-17**]. THERE ARE
NO PHYSICAL EXAMS IN THE SYSTEM FOR THE ADMISSION DATE. VITALS
IN THE EMERGENCY ROOM WERE 103.6, BP 70/30, HR 140.
NAD
98.3 120/70 80 16 98 2L
NAD
RRR, [**1-5**] hsm at apex
CTA, min expiratory wheeze
NT, ND, BS+, no HSM, soft
No edema
Pertinent Results:
[**2151-1-12**] 08:29PM TYPE-MIX TEMP-39.1 PO2-42* PCO2-38 PH-7.29*
TOTAL CO2-19* BASE XS--7
[**2151-1-12**] 08:29PM O2 SAT-63
[**2151-1-12**] 08:21PM GLUCOSE-126* UREA N-33* CREAT-13.0*#
SODIUM-137 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-18* ANION GAP-20
[**2151-1-12**] 08:21PM CK(CPK)-413*
[**2151-1-12**] 08:21PM CK-MB-7 cTropnT-0.07*
[**2151-1-12**] 08:21PM CALCIUM-8.2* PHOSPHATE-2.2*# MAGNESIUM-0.9*
[**2151-1-12**] 08:14PM WBC-23.2*# RBC-2.92* HGB-10.2* HCT-29.8*
MCV-102* MCH-34.9* MCHC-34.3 RDW-16.3*
[**2151-1-12**] 08:14PM PLT COUNT-153
[**2151-1-12**] 07:08PM LACTATE-2.4*
[**2151-1-12**] 05:45PM LACTATE-2.0
[**2151-1-12**] 04:51PM LACTATE-2.1*
[**2151-1-12**] 03:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2151-1-12**] 03:30PM URINE RBC->50 WBC-[**2-1**] BACTERIA-RARE YEAST-NONE
EPI-0
[**2151-1-12**] 01:07PM LACTATE-4.6*
[**2151-1-12**] 01:05PM GLUCOSE-107* UREA N-37* CREAT-14.6*#
SODIUM-135 POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-24 ANION GAP-22*
[**2151-1-12**] 01:05PM CK(CPK)-149
[**2151-1-12**] 01:05PM cTropnT-0.09*
[**2151-1-12**] 01:05PM CK-MB-1
[**2151-1-12**] 01:05PM CALCIUM-10.6* PHOSPHATE-0.6*# MAGNESIUM-1.2*
[**2151-1-12**] 01:05PM CORTISOL-28.7*
[**2151-1-12**] 01:05PM CRP-69.6*
[**2151-1-12**] 01:05PM WBC-11.6*# RBC-3.75* HGB-13.2* HCT-38.3*
MCV-102* MCH-35.2* MCHC-34.5 RDW-15.6*
[**2151-1-12**] 01:05PM NEUTS-73* BANDS-19* LYMPHS-6* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2151-1-12**] 01:05PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+
[**2151-1-12**] 01:05PM PLT COUNT-196
[**2151-1-12**] 01:05PM PT-15.6* PTT-29.1 INR(PT)-1.4*
.
[**2151-1-12**] 1:05 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2151-1-15**]):
[**2151-1-13**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29926**] AT 7:30 AM.
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
PENICILLIN------------ 0.25 R
ANAEROBIC BOTTLE (Final [**2151-1-15**]):
STAPH AUREUS COAG +. SENSITIVITIES PERFORMED FROM
AEROBIC BOTTLE.
.
[**2151-1-12**] CT-TORSO WITH CONTRAST IMPRESSION:
1. No pulmonary embolism or aortic pathology noted.
2. Minimal bibasilar atelectasis left worse than right with
small bilateral pleural effusions.
3. CT findings consistent with aggressive fluid resuscitation.
4. Questionable bowel wall thickening involving the cecum,
ascending colon, and proximal transverse colon. Diagnostic
considerations include pseudomembranous colitis, typhlitis (if
immunocompromised), further sequela of fluid resuscitation, and
much less likely ischemia.
5. Internal fluid within the colon highly suggestive of
diarrhea.
6. No intra-abdominal abscess. Explanted kidney transplant site
unremarkable.
.
[**2151-1-15**] CXR AP PORTABLE.
Worsening of alveolar consolidative process within right upper,
right lower, and retrocardiac regions probably pneumonia or
multifocal alveolar hemmorhage, edema less likely.
.
[**2151-1-18**] CXR PA/LAT
IMPRESSION: Marked interval improvement in the diffuse
opacities. In retrospect this behavior is most concordant with
alveolar edema. Minimal left base atelectasis and left
costophrenic angle blunting.
.
[**2151-1-19**] tunneled line placement.
IMPRESSION: Successful placement of a 14.5 French double lumen
hemodialysis catheter via the left subclavian vein, with 19 cm
tip to cuff in length and tip in the right atrium. The line is
ready for use.
Brief Hospital Course:
By Problem:
1. Sepsis: The patient was admitted to the MICU on phenylephrine
and norepinephrine drips. The patient did not require
intubation. Blood cultures grew MSSA. It was felt that the
patient's sepsis originated from the tunneled hemodialysis
catheter. Another possible source was the finding on the
abdominal CT of bowel wall thickening. The dialysis catheter
was removed and the tip failed to grow any bacteria. Access was
obtained by the angiography service who placed a right
subclavian central venous catheter. The patient was treated
with naficillin, levofloxacin and vancomycin. The patient's WBC
dropped, the fever resolved, the blood pressure stablized. An
ECHO on [**1-16**] showed that there was a possible vegatation at the
tip of the new catheter. A right femoral central venous
catheter was placed and the right subclavian catheter was
removed. A tip culture from the right subclavian line failed to
grow bacteria. On [**1-18**] the patient went for dialysis and after
3 hours the line clotted off. It could not be cleared. On [**1-19**]
the femoral line was removed and the angiography service placed
a left subclavian tunneled catheter. All surveillance cultures
of the blood, urine and stool, including three serial C.diffs
were negative. Despite the growth of MSSA the renal service
asked that the patient be kept on Vancomycin for ease of dosing
at dialysis. The Nafcillin and levofloxacin were discontinued.
The patient will complete 2 weeks on vancomycin.
.
2. ESRD: Secondary to reflux nephropathy. The renal service
helped ensure that the patient recieved hemodialysis and guided
the management of the patient's electrolytes.
.
3. Hypoxia: The patient had an oxygen requirement of uncertain
etiology. Possible etiologies considered were DAH, PNA, and
ARDS. The patient was put on levofloxacin until the CXR on the
19th showed that the parenchymal opacities had resolved. In
retrospect this was likely just pulmonary edema from aggressive
fluid resucitation.
Medications on Admission:
1. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
3. Renagel 800 mg Tablet Sig: Four (4) Tablet PO three times a
day: Please take with meals. .
4. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Medications:
1. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
3. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous QHD (each hemodialysis) for 7 days: This will be
managed at dialysis.
4. Renagel 800 mg Tablet Sig: Four (4) Tablet PO three times a
day: Please take with meals. .
5. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis likely originating in right tunnled line.
Discharge Condition:
Afebrile, blood pressure stable, patient ambulating.
Discharge Instructions:
Please return to the hospital if you have fevers, chills,
nightsweats, if you notice blood around the catheter site, or if
you are just not feeling well.
.
Please follow up with plans for dialysis tomorrow, Wednesday
[**2151-1-20**].
.
Please note that you will need to recieve antibiotics at
dialysis at least until [**2151-1-26**].
.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2151-1-21**]
8:20
You should present for dialysis on [**2151-1-20**].
Per our discussion your wife has your primary care [**Name (NI) 48924**]
contact information and you will make a follow up appointment in
the next week. Of note the number listed above for Dr. [**First Name (STitle) **]
is not active.
Completed by:[**2151-1-20**]
ICD9 Codes: 5856, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7564
} | Medical Text: Admission Date: [**2125-4-10**] Discharge Date: [**2125-4-18**]
Service: NSU
HISTORY OF PRESENT ILLNESS: This is an 84-year-old man with
a history of hypertension who woke up at 2:30 in the morning
on [**4-10**] confused per his wife, not giving appropriate
answers to questions. The patient went back to bed and woke
up still confused. EMS was called to bring the patient to the
emergency room.
His wife denied any trauma. The patient's baseline is fully
functional. He recently drove back to [**State 350**] from
[**State 108**].
Head CT in the emergency room showed a large left frontal 7
cm bleed, likely to be amyloid related to history and age.
PAST MEDICAL HISTORY: Asthma and hypertension.
LABORATORY DATA: On admission sodium was 139, potassium 4.5,
chloride 100, CO2 29, BUN 20, creatinine 1.2, sugar 138;
hematocrit 41.5, white count 9.4, platelet count 167; INR
1.0.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.3, blood
pressure 170/69, respirations 18, oxygen saturation 92% on
room air. General: He was alert to voice stimulation.
Cardiovascular: Regular, rate, and rhythm. Lungs: Clear
bilaterally. Abdomen: Soft and nondistended. Neurologic: EOMs
full. Visual fields full to confrontation. Pupils 2.5-1.5
bilaterally. No weakness. Symmetric motor strength. Speech
was fluent. He was only alert and oriented times one. Motor
exam was 2+ in his uppers and patellas and 1+ in his
Achilles. Again strength was 5 out of 5 in both upper and
lower extremities.
HOSPITAL COURSE: The patient was brought emergently to the
operating room where he underwent a left frontal craniotomy
for evacuation of this hematoma. Postoperatively he was awake
however intubated over night. He was moving his left upper
extremity was good strength with full movement. He was able
to raise his right upper extremity with a strong grip. His
blood pressure was in the 116-130 range. Heart rate was 58.
He was loaded with Dilantin in the emergency room and was
continued on Dilantin 100 mg t.i.d.
He was monitored in the intensive care unit. On his first
postoperative day, his blood pressure was 116-140s. He was
alert and following commands times three. He had some less
movement in his right upper extremity. He was extubated on
his first day.
His head CT showed good evacuation of the hemorrhage. He did
have some gas collection within the subdural and subgaleal
compartments.
On his postoperative day, he was extubated as previously
mentioned, and he was found to be aphasic, and alert and
oriented times two. His blood pressure was kept strictly less
than 140. He was weaned from his Nipride drip and started on
Lopressor and Norvasc, and he was evaluated by speech and
swallow and physical therapy.
On his second postoperative day, he was found to be aphasic
with problems with naming objects but alert and attentive
following commands. Pupils were equal and reactive. EOMs were
full.
He had a bed side swallow evaluation which at that time felt
for him to be too lethargic to complete the exam appropriate,
and he appeared to be aspirating thin liquids. He was started
on a diet of nectar-thick liquids and soft solids.
On his third postoperative day, he appeared much improved;
however, he was having some periods of agitation for which
neurology was consulted. They were consulted to rule out the
possibility of having seizures, which they felt he did not
have seizures but that his change in mental status was
probably secondary to the intracerebral bleed and increased
edema. They recommended possibly starting him on Decadron to
minimize the inflammation.
During his hospitalization, he was found to have some periods
of respiratory difficulties. He had had a chest x-ray which
noted to have a hazy opacity in the left mid and lower lung
zones which resolved over the following three days serially
and treating with albuterol inhalers. Most likely it was
found to be pleural fluid and atelectasis.
On [**2125-4-16**], he was transferred to the neurology step-down
unit. He appeared much more awake and following simple
commands. Speech was nonfluent; however, he was able to name
[**12-17**] objects. He had no drift. His wound was clean, dry, and
intact. He appeared much more appropriate. He was transferred
to the step-down unit for blood pressure monitoring to keep
strictly in the 140 range.
He had a repeat head CT which showed a stable appearance of
the left frontal intraparenchymal hemorrhage and left frontal
infarct. There were no new areas of hemorrhage identified
within the brain.
On [**4-17**] fiberoptic endoscopic evaluation of his swallowing
was done that showed a functional oral pharyngeal swallowing
ability of pureed food and nectar-thick liquids. They
recommended continuing a diet of pureed foods and nectar-
thick, that he should take two swallows per bit or sip and
alternate between one bite and one sip to clear residue from
his throat. He should only eat when fully seated upright. A
video swallow could be performed at rehabilitation to see is
his diet can be advanced.
He remained neurologically improved on [**4-18**], which is his
discharge date. He is awake, alert, and oriented times three.
He had a slight droop and left-sided weakness. His lungs were
clear on discharge. He had no further respiratory
difficulties; however, we do recommend to have a chest x-ray
in the next week at rehabilitation to follow-up for clearance
of his pleural fluid and atelectasis. Also they had found an
oval-shaped opacity adjacent to the left hemidiaphragm which
they felt was due to nipple shadow but also recommended
following up to rule out a pulmonary nodule.
He should continue on his Dilantin until he follows up with
Dr. [**First Name (STitle) **] and have a weekly Dilantin level checked, and he needs
aggressive and physical and occupational therapy. His Foley
remains in and may be discontinued at the rehabilitation
facility's guidance.
DISCHARGE INSTRUCTIONS: Keep incision clean and dry until
staples are removed. They may be removed at the
rehabilitation facility on [**2125-4-20**]. He is to watch
incision for redness, drainage, bleeding, swelling, or any
fever greater than 101. He is to call Dr.[**Name (NI) 14510**] office. He
should continue with aggressive physical therapy and
occupational therapy.
FOLLOW UP: With Dr. [**First Name (STitle) **] on [**5-11**] at 10:15 at the [**Hospital Ward Name **]
radiology for head CT and follow-up with Dr. [**First Name (STitle) **] at 11
o'clock. Again he should have a chest x-ray at the
rehabilitation facility to follow-up on the resolution of his
atelectasis and questionable opacity that was seen on
previous chest x-ray.
DISCHARGE MEDICATIONS: Tylenol as needed, heparin 5000 units
t.i.d., Norvasc 5 mg half tablet daily, artificial tear
p.r.n., Protonix 40 mg daily, Dilantin 50 mg 2 tab p.o.
t.i.d., hydralazine 25 mg 1 tab p.o. t.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern1) 12790**]
MEDQUIST36
D: [**2125-4-18**] 11:03:49
T: [**2125-4-18**] 12:14:26
Job#: [**Job Number 99645**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7565
} | Medical Text: Admission Date: [**2181-7-22**] Discharge Date: [**2181-7-30**]
Date of Birth: [**2102-3-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
79 y/o M w/HTN, CHB s/p PPM, end-stage dementia, who was
admitted on [**2181-7-22**] after he presented from his nursing home
([**Hospital3 537**]) in respiratory distress. Per notes, he was found
to have O2 sats in the 70s, and he was sent here.
.
In the ED, he had temp of 101.4, HR of 60 (paced), BP of 150/90,
RR of 45-50, sats of 70s on RA -> 90% on NRB. He was given Lasix
100mg IV x1, and placed on BiPAP, along with a nitro gtt to
lower his BP. He was given Levaquin 500mg IV x1, Vanco 1g IV x1,
and Flagyl 500mg IV x1 for aspiration PNA vs NH-associated PNA.
His RR decreased down to the 20s and his BiPAP was discontinued
and switched back to a NRB. He was evaluated by cards for a
troponin of 0.08 who felt it was likely demand ischemia, no
indication for heparin. He had a bedside ultrasound, which was
negative for pericardial effusion. Per ED request, His nitro gtt
was d/c'ed prior to arrival to the floor.
.
On the floor, he was felt by the medicine team to have more of
an aspiration pneumonia and they did not feel he was in florid
CHF. He was kept on vanco/levo/flagyl. Per NH staff, he gets an
aspiration pna "every now and then". He was supposed to have a
speech and swallow today, but when they arrived to evaluate him,
he was clearly aspirating his oral secretions and they deferred.
He was made NPO. He was found to have a LUE DVT and was begun on
a heparin gtt. He was transfused 2U PRBCs for hypoxia and Hct
23. His O2 was weaned (from NRB to 2.5L earlier tonight).
.
On night of HD #1, respiratory was called to see him for
inability to clear secretions. He was audibly gurgling when they
arrived. They eventually got him to cough up some secretions, at
which point he respiratory arrested for approximately 3 minutes
(was bagged throughout). [**Name8 (MD) **] RN he was blue. He then began
breathing spontaenously with a RR in the mid 20s, pulse
110s-130s, bp 150s. He then grew very agitated and was
grimacing, so he received morphine 8 mg IV. His wife and son
were notified, and they confirmed that he was DNR/DNI on [**2181-7-23**].
He was transferred to the ICU for frequent suctioning.
.
Patient remained stable in the medicine ICU for two days with
normotensive BP, though he had frequent desats due to mucus
plugging and airway congestion. Per DNR/DNI status, he did not
get endotracheal suctioning, only what he could bring up on his
own after turnovers. He was transferred out of the ICU to the
medicine service on [**7-26**] after family meeting with palliative
care. It was decided that he would complete 10 day antibiotic
course, currently day 5, after which he will be on comfort
measures only. He will be discharged to [**Hospital3 537**] on [**7-27**].
Please note family discussion under dispo plans.
Past Medical History:
Frequent aspiration pnas (per wife, 6-7 times recently)
HTN
Cardiomyopathy
Complete heart block s/p pacer
Dementia
RA
Social History:
No smoking, occasional alcohol, no drug use.
Family History:
non-contributory
Physical Exam:
VS: T: 101.6 RR 24 BP:154/80 HR: 90 RR:28 O2sat: 90% 3L
GEN: Elderly male, awake&alert, not following commands
HEENT: MMM
RESP: coarse rhonchi throughout
CV: Regular, nml s1,s2. No murmurs.
ABD: Not distended. No HSM appreciated. +BS.
EXT: 2+ edema to mid-shins bilat. ext cool. LUE also with 1-2+
edema
Pertinent Results:
[**2181-7-21**] 08:50PM BLOOD WBC-25.7* RBC-3.09* Hgb-10.1* Hct-30.1*
MCV-97 MCH-32.6* MCHC-33.5 RDW-16.4* Plt Ct-352
[**2181-7-24**] 01:39AM BLOOD WBC-12.8* RBC-3.77*# Hgb-11.8*#
Hct-34.7*# MCV-92 MCH-31.2 MCHC-33.9 RDW-17.1* Plt Ct-201
[**2181-7-21**] 08:50PM BLOOD Neuts-86.2* Lymphs-11.4* Monos-1.7*
Eos-0.6 Baso-0.1
[**2181-7-24**] 01:39AM BLOOD PT-16.6* PTT-141.4* INR(PT)-1.5*
[**2181-7-23**] 01:20PM BLOOD PT-20.6* PTT-150.0* INR(PT)-2.0*
[**2181-7-22**] 07:00PM BLOOD Ret Aut-2.9
[**2181-7-24**] 01:39AM BLOOD Glucose-197* UreaN-19 Creat-0.8 Na-145
K-3.4 Cl-108 HCO3-25 AnGap-15
[**2181-7-21**] 08:50PM BLOOD Glucose-287* UreaN-16 Creat-1.0 Na-146*
K-4.7 Cl-107 HCO3-26 AnGap-18
[**2181-7-22**] 07:00PM BLOOD LD(LDH)-260* TotBili-0.8
[**2181-7-22**] 05:27AM BLOOD LD(LDH)-319*
[**2181-7-21**] 08:50PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2181-7-24**] 01:39AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.1
[**2181-7-21**] 08:50PM BLOOD Albumin-3.9 Calcium-8.4 Phos-6.3* Mg-2.4
[**2181-7-22**] 07:00PM BLOOD Hapto-99
[**2181-7-21**] 08:50PM BLOOD Valproa-18*
[**2181-7-23**] 08:20AM BLOOD Lactate-1.9
[**2181-7-21**] 11:04PM BLOOD Lactate-4.0*
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2181-7-28**] 06:25AM 8.3 3.57* 11.2* 33.3* 93 31.4 33.7 15.9*
120*
Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2181-7-29**] 06:30AM 111* 13 0.7 144 3.71 108 25
15
.
Imaging Studies:
.
CHEST (PORTABLE AP) [**2181-7-21**] 8:56 PM
FINDINGS: Bibasilar costophrenic angles are blunted by small
bilateral pleural effusions. The left diaphragmatic border is
obscured by retrocardiac opacity, atelectasis versus pneumonia.
The heart and mediastinal contours are stable. The pulmonary
vasculature is engorged, and the septal lines indicate a small
degree of pulmonary edema.
.
IMPRESSION:
1. Mild pulmonary edema and bilateral pleural effusions.
2. Retrocardiac opacity is atelectasis versus pneumonia.
.
ECG Study Date of [**2181-7-21**] 10:59:50 PM
Normal sinus rhythm
AV nodal wenckebach block
Low voltage
Anterolateral ST-T wave changes, consider ischemia/myocardial
infarction
No previous tracing available for comparison
.
UNILAT UP EXT VEINS US LEFT [**2181-7-22**] 12:35 PM
LEFT UPPER EXTREMITY ULTRASOUND: No prior studies for
comparison. [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 867**] was
performed of the left upper extremity including the internal
jugular, subclavian, axillary, brachial, basilic veins. There is
occlusive thrombus extending through one of the axillary veins,
as well as throughout the course of the basilic vein. These
veins are non- compressible and demonstrate no demonstrable
flow. The jugular vein is patent with normal compressibility and
waveforms. The subclavian vein is difficult to evaluate on this
study but is patent were visualized. There may be a collateral
vein that parallels the subclavian vein which contains clot.The
brachial veins are patent with normal compressibility, flow, and
waveforms. The cephalic vein compresses normally. The axillary
and subclavian veins on the contralateral right side demonstrate
normal flow, waveforms, and compressibility.
.
IMPRESSION: DVT involving the left axillary vein, basilic veins,
and possibly a small collateral paralleling the subclavian vein.
Findings discussed with the ordering physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **]
immediately after the study.
.
CHEST (PA & LAT) [**2181-7-22**] 1:19 PM
IMPRESSION: PA and lateral chest compared to [**7-21**].
Bibasilar consolidation and small bilateral pleural effusions
have increased since [**7-21**], consistent with pneumonia. Heart
size is normal. Upper lungs show vascular engorgement, but are
otherwise clear. Transvenous right atrial and right ventricular
pacer leads are unchanged in their standard placements. A large
curvilinear calcification over the left ventricle is probably an
aneurysm.
Brief Hospital Course:
79 y/o M with PMHx of HTN, CM, s/p pacer, dementia, who
presented from NH today with resp distress.
.
# Resp Failure:
Most likely etiology was aspiration pna, given numerous episodes
of this in past, and witnessed aspiration of oral secretions
while on floor. Likely had mucus plug on floor causing prolonged
hypoxic event. Pt unable to clear secretions and protect airway
[**1-18**] dementia. Pt had not improved despite broad spectrum
antibiotics. ICU team had lengthy discussion with wife and son,
and they did not wish to pursue further aggressive measures.
They do not wish to continue oro-tracheal suctioning pt given
its obvious discomfort. They understood he was likely going to
continue aspirating, and they do not wish for him to be
sustained on mechanical ventilation or tube feeds. Patient
received morphine IV/elixer PRN for discomfort after transfer to
medicine floor from CCU. He was treated for aspiration pneumonia
with Vanco/Levaquin/Flagyl to complete 10 day course, though
there was no source of infection from blood or urine cultures.
Scopolamine patch was placed to aid clear secretions. He
received anti-pyretics for febrile episodes.
.
# Septic shock
Likely from aspiration pneumonia. No other clear source
identified. Pt with a lactate of 4.0 in the ED, received 1L NS
(limited by pulmonary edema). Currently, pt hemodynamically
stable. BP currently stable. Blood/urine cx after admission were
negative. Patient's urine culture on [**7-27**] was positive for
yeast. Blood pressure was stable with SBP in 120s-130s through
most of hospital stay, but declined to SBP 80-90s two days prior
to death.
.
# HTN
Held antihypertensives given hypotensive on arrival, although
likely due to morphine. He was administered IVF on admission for
resucitation efforts and also once he was made NPO by family
during his CCU course.
.
# CHB s/p pacer
Pt with paced rhythm in the 50s.
.
# Dementia
Unclear patient's baseline, here nonverbal and not responding to
verbal stimuli. On Zyprexa at baseline at NH. Per family, they
feel he sometimes recognizes them and interacts with them but
mental status waxes and wanes. Speech and swallow study
determined pt. to be aspiration risk with oral secretions as
well as PO nutrition. He was made NPO to prevent further
aspirations and CCU team discussed plan with family.
.
# DISPO:
Below is discussion summary between palliative care and family
regarding patient care plan:
Signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC on [**2181-7-26**] Affiliation: [**Hospital1 18**] Met
with Mrs. [**Known lastname 69686**], daughter and son, Dr. [**Last Name (STitle) **], [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 805**], Sw to discuss plan of care for [**Known firstname **]. Family
understands [**Known firstname **] has a progressive dementia with frequent
episodes of asp. pneumonia. The last one was 2 wks ago. They do
not want him to recieve a PEG, they do not want further
hospitalizations. they like the care he receives at the [**Last Name (un) **]
Home [**Hospital1 1501**], he has been there for just over a year. We discussed
possible outcomes- clearly no matter what care he receives he is
in his dying phase, they understand that but are uncomfortable
with stopping all his meds and fluids right now. We agreed we
would continue IV abx and gentle IVF for a total 10 day course.
At the end of that period he would have either improved and be
able to take in some fluids and nurtrition- we discussed it
would never be enough to maintain life but would offer
pleasure/memories. If he deteriorates during the 10 day course
the decision to stop treatment sooner should be discussed. Once
this treatment course is finished, family agrees he should not
be hospitalized, or treated except for comfort when he
re-infects.
.
We discussed he may die tomorrow or in a few days, weeks or
months if he improves with antibiotics. His wife has made
funeral plans already. She is prepared for his death and wants
him to die peacefully. She is not interested in hospice care as
she feels hospice hastens death. We discussed this in detail-
she may be open to hearing from the individual hospice program
but he will not be eligible for hospice until
after abx are finished.
Patient was made DNR/DNI by family during hospital course in
CCU. After being transferred to medicine service on [**2181-7-26**],
plan was for him to be cared at the [**Hospital3 537**] as he
approached end-of-life and family would consider hospice
services. Patient at that time was in midst of completing
antibiotic course with 4 days remaining. In order to be
transferred to [**Hospital3 537**] with vancomycin, patient would need
a PICC line, instead of a peripheral IV. However, family did not
wish for him to have a PICC line but desired for him to complete
the full course of antibiotics. This would thus be done in the
hospital and they agreed that on Monday, [**7-30**] he could be
transferred to [**Hospital3 537**].
.
Over the course of the weekend, however, patient continued to
have desaturations in the 60s-70s and remained on 3-4L oxygen.
His BP had continued to decline with SBP in 80s. Per nursing
reports, patient was having respiratory distress and was made
comfortable with morphine drip and ativan. On morning of Monday
[**2181-7-30**], patient remained in respiratory failure and oxygen
saturations were staying in 60-70% range. Family was notified of
patient's deteriorating clinical condition. Morphine IV was
titrated up until patient appeared comfortable and not
tachypneic and ativan was also administered. Patient was in
peaceful state and he died at 10:23am on [**2181-7-30**]. Family
members were arrived to see the patient. Death report was filed
and submitted to Admitting Office. Cause of death was
respiratory failure secondary to aspiration pneumonia. [**Name (NI) **]
wife [**Name (NI) 53564**] [**Name (NI) 69686**] declined autopsy. Medical examiner
evaluation was not indicated.
Medications on Admission:
Prednisone 7.5
Duonebs
Lasix 20mg 3x/week
Prilosec 20
ASA 325
Plaquenil 400
Lisinopril 5
Zyprexa 5mg q1400
Depakaote 250
Exelon 3 [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
2. Morphine Concentrate 20 mg/mL Solution Sig: [**12-18**] PO Q3H
(every 3 hours) as needed for respiratory distress.
3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnosis:
Respiratory distress secondary to pneumonia/mucus plugging
Hypotension secondary to sepsis
.
Secondary diagnoses:
Frequent aspiration pnas (per wife, 6-7 times recently)
HTN
Cardiomyopathy
Complete heart block s/p pacer
Dementia
RA
Discharge Condition:
Deceased.
Discharge Instructions:
None.
Followup Instructions:
None.
ICD9 Codes: 0389, 2760, 5070, 4254, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7566
} | Medical Text: Admission Date: [**2180-11-18**] Discharge Date: [**2180-12-8**]
Date of Birth: [**2115-8-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Cardiogenic shock s/p STEMI and VF arrest
Major Surgical or Invasive Procedure:
Pulmonary Intubation
Intracardiac Defibrillator implantation
Cardiac catheterization with placement of three bare metal
stents
PICC line placement
History of Present Illness:
Mr. [**Known lastname 27063**] is 65 year-old man who does not regularly seek
medical care a history of myocardial infarction and pulseless
arrest five days prior to admission who was transferred to [**Hospital1 18**]
early this AM for urgent CABG. Mr. [**Known lastname 27063**] was in his usual
state of health until [**Known lastname 766**], [**11-13**]. On [**11-13**], after pt had
been complaining of 3d chest pain, he had witnessed cardiac
arrest. His female companion, a retired nurse, initiated CPR
and performed until arrival of EMS 8-10min later. Found to be
in agonal respirations, monitor showed VF, and pt was shocked
twice --> en route to hospital, noted asystole --> epi and
atropine --> A-fib --> amiodarone bolus --> ER, where intubated
(sats 84%), in cardiogenic shock with SBPs in 90s, then in VF
again, shocked once --> EKG revealed STEMI --> took to cath lab,
where stented BMSx3 to LAD. Once opened LAD, went into VFib,
shocked 360J x1 and given amiodarone bolus 450mg. Went to CCU
with intra-aortic balloon pump, and began cooling protocol. CXR
at that time showed multifocal lobar PNA (presumed aspiration
PNA), and was started on Ceftriaxone and Unasyn.
.
On [**11-15**], pt was noted to have Torsades vs polymorphic VT, given
K and Mg, and shocked with 200J. He was extubated [**11-17**].
Following extubation his family reports that his mental status
gradually improved to baseline on Thursday evening. Early this
AM, c/o 10/10 chest pain. EKG with ST elevatations in V1-4 -->
heparin, plavix, morphine, SL nitro x3, taken to cath lab, where
BMS placed to proximal LAD. Then dissected mid LAD, which
required stenting of the dissected area. It was presumed that
the culprit lesions were the proximal and mid LAD in-stent
thromboses.
.
Neurology was consulted after admission given concern for anoxic
brain injury. They had been following, and daughter expressed
concern re: some difficulties with time perception (he thought
that hours were passing when only minutes had passed) on morning
of transfer. RNs also noted him to be less conversant, mumbling
and unable to focus on their questions.
.
Note, pt also had episode of bloody secretions from OG tube at
OSH
.
Transferred to CCU for management of cardiogenic shock.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: CAD, Smoker
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
**[**2180-11-13**], Cardiac Catheterization: LM: 50%, heavily calcified
LAD, 100% proximal thrombotic occlusion, calcified LCX with 90%
stenosis, 100% RCA occlusion, 55% LVEF, LV pressures 85/2, LVEDP
18 --> BMSx2 to ostium of LAD, BMSx1 to proximal LAD
**[**2180-11-18**], Cardiac Catheterization: BMS placed to proximal LAD.
Then dissected mid LAD, which required stenting of the
dissected area.
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-At 3-4y of age, had severe pertussis with high fevers. Lapsed
into a coma lasting weeks. Did not speak for three years but
gradually resumed full childhood levels of activity.
-Lifelong focal learning impairment presumed to be from the
above-described encephalopathy.
-? aortic aneurysm
-PVD
Social History:
SOCIAL HISTORY: Son is [**Name2 (NI) 87760**] surrogate decision maker, but
pt's siblings have been supportive and assist with decision
making. One sister is [**Name8 (MD) **] RN
and helps interpret medical information for pt's children.
Children report pt lives alone at baseline, currently on
disability. Pt was divorced when children were young, pt had
minimal contact with them when they were growing up. Son sees
pt
once per month or so and takes pt shopping. [**Last Name (un) **] rarely sees pt.
Son relayed hx of pt having anoxic brain injury as a child. Pt
has residual cognitive impairment, notably impaired judgment.
Children report pt has had a hard life. They report pt has a
significant other, who is [**Name8 (MD) **] RN. Children express concern pt
has
always been avoidant of seeing doctors and taking [**Name5 (PTitle) 4982**],
and fear he will not comply with treatment. Sister relayed
life-long hx of familytrying to meet pt's care needs. She
herself has made extensive
attempts at arranging home care and psychiatric services, but pt
never keeps appts, and often is not home to allow services in.
Per family t has hx of 1 psych admission for SI in the past. Pt
has extensive hx of impulsive behavior and poor judgement.
Family relayed that they promised pt's mother they would look
after him. SW advised family to allow professionals at rehab
to help determine and plan for pt's long term care needs.
Family History:
per OSH records, strong family hx CAD, but details unknown
Physical Exam:
On Admission:
GENERAL: Intubated, sedated. Withdrawing to pain
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink
NECK: Supple with JVP to ears.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Mostly clear without crackles, wheezes or rhonchi except
R lateral lung with decreased BS.
ABDOMEN: Soft, NTND. No HSM.
EXTREMITIES: Cool to touch. L 1st and 2nd toes blue, and 2nd
toe with area of ulcer at tip of toe ~3/4 cm.
SKIN: see above.
PULSES: Carotid L 2+, R 1+; Radial L R ; Femoral L R ; DP L R
On discharge:
97.3 (97.8 Max) 93/51 (90s/50s)- 60 (60s) 96% on 0.5L
GENERAL: sitting up in bed eating, alert, NAD.
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva pink, poor
dentition
CARDIAC: RRR, normal S1, split S2. [**1-29**] holosystolic murmur
loudest at LLSB. No thrills, lifts.
LUNGS: transmitted upper airway sounds bilaterally, Equal air
entry BL.
CHEST: L sided ICD in place. No erythema.
ABDOMEN: Soft, ND. nontender. No HSM.
EXTREMITIES: FROM. No edema. Warm, no cyanosis of toes, stable
ulcer over L 2nd phalanx
Neurologic: Alert and answering questions appropriately.
Responding to simple commands, moving all extremities. Oriented
x3.
Pertinent Results:
Admission Labs:
[**2180-11-18**] 06:20AM PT-12.5 PTT-31.5 INR(PT)-1.0
[**2180-11-18**] 06:20AM WBC-13.9* RBC-3.91* HGB-12.1* HCT-35.9*
MCV-92 MCH-31.0 MCHC-33.7 RDW-14.5
[**2180-11-18**] 06:20AM CALCIUM-8.2* PHOSPHATE-4.6* MAGNESIUM-2.1
[**2180-11-18**] 06:20AM CK-MB-GREATER TH cTropnT-20.83*
[**2180-11-18**] 06:20AM GLUCOSE-152* UREA N-15 CREAT-0.7 SODIUM-137
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15
[**2180-11-18**] 06:30AM O2 SAT-86
[**2180-11-18**] 06:30AM GLUCOSE-141* LACTATE-2.5* K+-4.0
[**2180-11-18**] 06:30AM TYPE-ART TEMP-36.1 PO2-50* PCO2-34* PH-7.38
TOTAL CO2-21 BASE XS--3
[**2180-11-18**] 09:27AM URINE RBC->1000* WBC-59* BACTERIA-NONE
YEAST-NONE EPI-0
[**2180-11-18**] 09:27AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
[**2180-11-18**] 09:27AM URINE COLOR-Red APPEAR-Hazy SP [**Last Name (un) 155**]-1.041*
[**2180-11-18**] 11:23AM freeCa-1.15
[**2180-11-18**] 11:23AM LACTATE-3.0* K+-4.6
[**2180-11-18**] 11:23AM TYPE-ART PO2-58* PCO2-36 PH-7.40 TOTAL CO2-23
BASE XS--1
[**2180-11-18**] 03:05PM PT-14.0* PTT-35.5* INR(PT)-1.2*
[**2180-11-18**] 03:05PM PLT SMR-NORMAL PLT COUNT-192
[**2180-11-18**] 03:05PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2180-11-18**] 03:05PM NEUTS-86* BANDS-0 LYMPHS-7* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2180-11-18**] 03:05PM WBC-12.0* RBC-3.91* HGB-12.3* HCT-35.8*
MCV-92 MCH-31.4 MCHC-34.3 RDW-14.4
[**2180-11-18**] 03:05PM %HbA1c-5.9 eAG-123
[**2180-11-18**] 03:05PM ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-5.3*
MAGNESIUM-2.7*
[**2180-11-18**] 03:05PM CK-MB-423* MB INDX-5.1 cTropnT-20.85*
[**2180-11-18**] 03:05PM LIPASE-13
[**2180-11-18**] 03:05PM ALT(SGPT)-720* AST(SGOT)-1152* LD(LDH)-2750*
CK(CPK)-8221* ALK PHOS-80 AMYLASE-27 TOT BILI-0.8
[**2180-11-18**] 03:05PM GLUCOSE-144* UREA N-22* CREAT-0.9 SODIUM-139
POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16
[**2180-11-18**] 06:00PM O2 SAT-96
[**2180-11-18**] 06:00PM LACTATE-2.0
[**2180-11-18**] 06:00PM TYPE-ART TEMP-37.6 RATES-16/ TIDAL VOL-500
PEEP-5 O2-50 PO2-97 PCO2-39 PH-7.41 TOTAL CO2-26 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED
.
Labs on Discharge:
[**2180-12-8**] 06:45AM BLOOD WBC-9.8 RBC-3.40* Hgb-10.2* Hct-31.3*
MCV-92 MCH-30.1 MCHC-32.6 RDW-16.8* Plt Ct-220
[**2180-12-8**] 06:45AM BLOOD PT-34.4* PTT-35.6* INR(PT)-3.5*
[**2180-12-8**] 06:45AM BLOOD Glucose-90 UreaN-24* Creat-0.8 Na-139
K-4.0 Cl-104 HCO3-28 AnGap-11
[**2180-12-8**] 06:45AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.2
ECHO [**11-18**]:
The left atrium is normal in size. The right atrial pressure is
indeterminate. Left ventricular wall thicknesses and cavity size
are normal. There is severe regional left ventricular systolic
dysfunction with akinesis of the anterior and anterolateral
walls, dyskinesis of the anteroseptal wall, and hypokinesis of
the mid inferoseptum and inferolateral walls. Overall left
ventricular systolic function is severely depressed (LVEF= 20-25
%). The estimated cardiac index is depressed (<2.0L/min/m2). The
right ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. with moderate global free wall
hypokinesis. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is at least mild pulmonary artery systolic hypertension. There
is a trivial/physiologic pericardial effusion.
CT FINDINGS [**11-18**]: There is no evidence of intracranial
hemorrhage, edema, mass effect, or large acute territorial
infarction. There are diffuse
periventricular, subcortical and semiovale hypodensities,
slightly more focal left superior periventricular (series 2,
image 22); all representing a sequela of chronic small vessel
disease. The ventricles are minimally dilated, nonspecific.
Incidental note is made of basal ganglia calcifications as well
as calcifications of the left greater than right internal
carotid arteries. Mild mucosal thickening of the maxillary
sinuses bilaterally as well as the ethmoid air cell and the
sphenoid sinus. Mastoid air cells are clear and well aerated. No
suspicious lytic or sclerotic bony lesions. IMPRESSION: 1. No
acute intracranial process.
2. Minimal, nonspecific dilatation of the ventricles.
CXR [**11-18**]: Portable AP chest radiograph was reviewed with no
prior studies available for comparison. Heart size is mildly
enlarged. Mediastinum is unremarkable. Widespread alveolar
opacities in the perihilar, upper lung, and lower lobe areas are
most likely consistent with pulmonary edema giving patient's
history. They are accompanied by minimal amount of pleural
effusion. Otherwise, the differential diagnosis would include
ARDS or extensive infections. Pulmonary contusions are less
likely.
.
[**2180-11-23**]:
Cardiac Catheterization:
COMMENTS:
1. Limited selective coronary angiography showed two vessel
coronary
artery disease. The LMCA had 60% origin stenosis. The LAD had
50-60
origin calcified stenosis prior to previous stents. Prior LAD
stents
were patent. The LCx had 80-90% origin stenosis as well as a 70%
mid LCx
stenosis. The RCA was known to be totally occluded and fills via
left to
right collaterals and was not engaged.
2. Resting hemodyamics revealed elevated right and left sided
filling
pressure with RVEDP of 14 mmHg and mean PCWP of 25 mmHg. There
was
moderate pulmonary hypertension with pasp of 54/23 mmHg. There
was
borderline cardiac index of 2.4 L/min/m2 on dopamine. There was
normal
blood pressure of 106/67 mmHg, however in the setting of
moderate
dopamine.
3. Successful placment of IABP.
4. Successful placement of temporary pacemaker via right femoral
vein.
5. Successful PTCA and stenting of mid LCx with a 3.0x18mm
Vision bare
metal stent and origin of LM into Lcx with a 3.0x23mm Vision
bare metal
stent. The LM stent segment was postdilated to 4.0mm.
6. Successful PTCA only rescue of LAD with 3.0x15mm NC balloon
with 40%
residual stenosis.
.
[**11-27**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. There is severe regional left
ventricular systolic dysfunction with akinesis of the mid
inferior and inferolateral wall, mid to distal anterior wall and
anterior septum and all apical segments. No masses or thrombi
are seen in the left ventricle. 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 to moderate ([**12-25**]+) mitral regurgitation is seen.
There is a small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: Severe regional LV systolic dysfunction consistent
with mutli-vessel coronary artery disease. Mild to moderate
mitral regurgitation.
.
[**12-4**]: CXR
FINDINGS: As compared to the previous radiograph, there is a
massive increase in density of the pre-existing relatively
extensive bilateral apical opacities. Given the co-existing
increase in size of the cardiac silhouette, increasing pulmonary
edema must be suspected.
On the right, a small pleural effusion could have newly
occurred.
.
ECG [**12-5**]:
Sinus rhythm. Left atrial abnormality. Right bundle-branch
block. Right axis deviation. Q waves with ST segment elevations
in leads V1-V5 raise concern for evolving myocardial infarction
with possible involvement of the conduction system. Clinical
correlation is suggested.
.
Brief Hospital Course:
A 65M with PVD, static encephalopathy [**1-25**] childhood pertussis,
lost to medical care who presented to OSH in VF/asystolic arrest
on [**11-13**] and s/p BMx3 to LAD on [**11-14**] c/b another VF arrest.
Placed on cooling protocol and treated for pneumonia; shocked
for torsades on [**11-15**], extubated on [**11-17**]. Had STEMI on [**11-18**]
with LAD in-stent restenosis; placement of BMS c/b mid-LAD
dissection; EF 20-25%. [**Hospital1 **] course since [**11-18**] c/b CHF (EF
20-25%, [**12-25**]+ MR) with difficulty weaning off pressors, ischemic
right foot (improved on A/C), PEA arrest on [**11-22**], NSTEMI on [**11-23**]
with LCx dz s/p POBA & BMSx2, VT/VF arrest on [**11-28**] on amio and
s/p ICD on [**11-29**].
.
# s/p STEMI x2, Vfib arrest, and cooling protocol, transferred
to [**Hospital1 18**] for CABG. It was eventually determined that he is not a
candidate for CABG. He was continued on ASA, Plavix,
Atorvastatin 40 mg. While in the unit, on [**11-22**] he had a PEA
arrest and was successfully resuscitated. EKG showed NSTEMI and
he was taken to the cath lab which demonstrated LCx disease and
he had 2 bare-metal stents placed. On [**11-28**] he had a VT/VF
arrest and was cardioverted and loaded with amiodarone. On [**11-29**]
he had an ICD device implanted and actively diuresed. He is on
aspirin and Prasugrel and should remain on these medicines
unless Dr. [**Last Name (STitle) 31888**] (out patient cardiologist) says that it is OK
to stop them. Any discharge plan will need to include strict
adherance to Prasugrel regimen. He was started on coumadin [**1-25**]
low EF, INR 3.4 at time of discharge and warfarin held. Will
need INR checked on Saturday [**12-9**] and restart Warfarin at low
dose because of interaction with amiodarone and vancomycin,
suggest 1-2 mg daily. He was discharged on Amiodarone 400mg [**Hospital1 **]
and will need to decrease dose to Amiodarone 400mg daily x 3
weeks, final day [**2180-12-29**] then change to Amiodarone to 200mg
daily.
.
# Acute systolic Congestive Heart Failure: On recent ECHO,
overall left ventricular systolic function is severely depressed
(LVEF= 20-25 %). He was initially on dopamine for pressure
support, weaned off of dopamine and diuresed when he presented
with what was likely flash edema secondary to a panic attack.
His weight at discharge is 59.6 (131 pounds) kg and he is
euvolemic on 80 mg of Lasix daily. Lasix was decreased to 40 mg
daily today and additional 40 mg can be given in pm if weight
starts to increase. ACEi therapy has been held secondary to
borderline BP. Lisinopril at 2.5 mg should be started when BP
allows.
.
# Anoxic brain injury: suspected given amount of time with poor
circulation. CT without acute inschemia, however, this does not
rule out anoxic brain injury. As per family he was back to his
baseline following extubation the second time. This baseline
seems to be quite limited and has impaired his judgement and
ability to care for himself in the past per family. He will need
social service evaluation.
.
# Multilobar PNA concerning for aspiration PNA; unclear
circumstances of re-intubation prior to arrival at [**Hospital1 18**],
however, likely in setting of cardiogenic shock to preserve
airway. He developed fever, leukocytosis, with productive cough
and infiltrates on CXR and was treated with Cefepime/Vancomycin
for health care assoicated pneumonia. Antibiotics now finished
and stable on RA.
.
# Clostridium Difficile: Patient developed diarrhea and
leukocytosis and was found to be c. diff positive. He was
started on Metronidazole 500mg TID and chagned to vancomycin
250mg PO Q6H after ID consult. He will need a 2 week course of
this medication. His stool is now formed and WBC trending down.
.
# H/o bloody secretions from OGT at OSH before admission. He was
started on Pantoprazole 40 mg IV Q24H and then was transitioned
to a PO regimen. Hct has been stable with no further evidence of
GI bleed.
.
# Elevated LFTs, likely related to ischemic injury. These
trended downwards.
Admit to OSH: Pt had c/o 3 days of CP but refused to be
evaluated.
.
# Peripheral Vascular Disease: After cardiac cath, left #1-#3
toes became acutely cyanotic likely related to pressors vs
embolic phenomenon vs Intra aortic balloon pump-related. IABP
was discontinued and he was started on heparin gtt with bridge
to warfarin. Perfusion improved after pressors d/c and IABP d/c.
Peripheral pulses palpable but faint at the time of discharge.
He will need to continue warfarin with goal INR 2.0-2.5 for 3
months as above. He will need follow up with ankle brachial
index measurement.
[**Hospital1 **] on Admission:
None
Discharge [**Hospital1 **]:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**12-26**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
5. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
8. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 weeks: Start [**2180-12-9**].
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Start: [**2180-12-30**] after 400 mg daily is finished
.
11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): Day #1 [**12-4**], needs total of 2 weeks course.
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
15. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6
hours) as needed for pain.
16. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
Please give additional 40 mg in afternoon if weight is trending
up.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**]
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Ventricular Fibrillation Arrest
C difficile colitis
Multilobar Pneumonia
Acute systolic Congestive Heart Failure
Cardiogenic shock
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had a cardiac arrest and a heart attack and needed shocks
and CPR to start your heart again. Three bare metal stents were
placed in your heart arteries. You underwent a cooling protocol
to protect your brain after the heart attack. During your
hospital stay, you developed a pneumonia from the cardiac
arrest, and a bowel infection with a bacteria called c
difficile. Your heart function is very weak and an internal
defibrillator was placed so that it will shock your heart muscle
if you ever have a cardiac arrest again. No lifting your left
arm over your head for at least 6 weeks, you may shower and wash
your hair. No lifting more than 10 pounds with your left arm for
6 weeks. You will need to stay on Plavix every day until Dr.
[**Last Name (STitle) 31888**] tells you it is OK to stop. No not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**].
Weigh yourself every morning, call Ddr. [**Last Name (un) 31888**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
Medication changes: (no prescriptions taken at home)
1. Start a multivitamin and folic acid to help your nutrition
2. Start Amiodarone and Metoprolol to control your heart rhythm
3. Start Atorvastatin to lower your cholesterol
4. Start Aspirin and Prasugrel to keep the stents open. Do not
stop taking these medicines unless Dr. [**Last Name (STitle) 31888**] says that it is OK.
5. Start furosemide to keep fluid from accumulating
6. Start Imdur to prevent chest pain, take nitroglycerin if you
have chest pain. Dr. [**Last Name (STitle) 31888**] should know about any chest pain.
7. Start Olanzapine to help you stay calm at night
8. Start pantoprazole to prevent bleeding
9. Start Vancomycin to treat the diarrhea
10. Start tylenol and oxycodone to help with any pain.
Followup Instructions:
Name: [**Last Name (LF) 31888**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: HEART CENTER OF [**Hospital1 **]
Address: [**Location (un) **],2ND FL, [**Location (un) **],[**Numeric Identifier 7398**]
Phone: [**Telephone/Fax (1) 6256**]
Appointment: [**Last Name (LF) 766**], [**12-26**], 11AM
.
ICD9 Codes: 4275, 5070, 486, 4271, 4280, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7567
} | Medical Text: Admission Date: [**2203-10-26**] Discharge Date: [**2203-10-31**]
Date of Birth: [**2133-2-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
exertional chest pain
Major Surgical or Invasive Procedure:
[**2203-10-26**]
1. Re-do sternotomy.
2. Re-do coronary artery bypass graft x2: Saphenous vein
graft to left anterior descending artery and saphenous
vein graft to obtuse marginal.
3. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
70M was diagnosed with rectal cancer
in [**2202-12-30**]. He received chemotherapy and radiation in
[**Month (only) 404**]-[**2203-3-31**] and underwent an open proctosigmoidectomy
with
diverting loop ileostomy [**2203-6-29**]. A cardiac catheterization was
done at [**Hospital1 18**] on [**2203-6-24**] prior to his surgery. This was notable
for a patent SVG to RCA, occluded SVG to OM, and LIMA, and
severe
proximal LAD and LCX disease. PCI was deferred at that time due
to urgency of his surgery and the need to be off ASA and Plavix
prior to surgery. He will be having ileostomy reversal sometime
in the near future.
Since surgery, he has started to experience chest pain with
exertion, e.g. walking or taking out garbage. He had a stress
test in [**Month (only) **] at Dr.[**Name (NI) 31668**] office that was notable for EKG
changes. On cardiac catheterization, he was found to have total
occlusion in LIMA and heavily calcified LAD. He is now being
referred to cardiac surgery for redo-CABG.
Past Medical History:
Diabetes type II
Hyperlipidemia
CAD s/p MI/CABG [**2193**]
Carotid disease
Rectal cancer s/p resection and cyber knife radiation (finished
[**8-15**])
C spine injury [**3-3**] fall at work [**2198**] s/p repair
[**Doctor Last Name **] [**Location (un) 2452**] exposure
Past Surgical History:
right carotid endarterectomy [**2196**]
proctosigmoidectomy, diverting loop ileostomy [**2203-6-29**]
cholecystectomy
placement of left portacath
Past Cardiac Procedures:
Surgery: CABG (LIMA to LAD, SVG to OM, and SVG to PDA)
Date: [**2193-4-17**] with Dr. [**Last Name (STitle) 2230**]
Social History:
Lives with: wife
Contact: [**Name (NI) **] (Wife) Phone #[**Telephone/Fax (1) 37867**], cell # [**Telephone/Fax (1) 37868**]
Occupation: Retired air force and postal service
Cigarettes: Smoked no [] yes [x]Hx: quit [**2180**]
Other Tobacco use: denies
ETOH: < 1 drink/week [x] [**3-8**] drinks/week [] >8 drinks/week []
Illicit drug use: denies
Family History:
Mother died from heart disease at age 67
Physical Exam:
Pulse: 94 Resp: 16 O2 sat: 98/RA
B/P Right: Left: 130/76
Height: 5'8" Weight: 183 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x], well healed midline
sternotomy incision
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel
sounds+
[+], well healed midline incision, ileostomy pink w/ gas + stool
in bag
Extremities: Warm [x], well-perfused [x] Edema [] _____, LLE
with well healed SVG harvest site
Varicosities: None [x]
Neuro: Grossly intact []
Pulses:
Femoral Right: Left:
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left: none
Pertinent Results:
Conclusions
PRE-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
A tiny patent foramen ovale is present. A left-to-right shunt
across the interatrial septum is seen at rest.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40 - 45 %). with mild global free wall hypokinesis.
The ascending aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened and
hypo-motile. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). No aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Physiologic
mitral regurgitation is seen (within normal limits). There is no
pericardial effusion.
Intra-op the patient's RV was cut by the sternotomy saw, causing
early move onto fem-fem bypass. Then several episodes of Vfib
occurred, and air was found in the LV cavity.
Post-CPB:
The patient is in SR, on an infusion of epinephrine.
Biventricular systolic fxn is worse, with EF now 30 - 35%.
Inferior wall and inferior septum are hypokinetic.
MR remains trace. No AI. Aorta intact.
Discussed with Dr [**First Name (STitle) **] in the OR.
.
[**2203-10-31**] 08:05AM BLOOD Hct-27.2*
[**2203-10-30**] 06:05AM BLOOD WBC-8.0 RBC-2.90* Hgb-8.0* Hct-24.2*
MCV-84 MCH-27.4 MCHC-32.9 RDW-16.3* Plt Ct-227#
[**2203-10-29**] 06:00AM BLOOD WBC-8.2 RBC-2.83* Hgb-8.0* Hct-23.7*
MCV-84 MCH-28.2 MCHC-33.7 RDW-16.1* Plt Ct-149*
[**2203-10-31**] 08:05AM BLOOD UreaN-21* Creat-1.0 Na-141 K-4.7 Cl-103
[**2203-10-30**] 06:05AM BLOOD Glucose-139* UreaN-17 Creat-0.8 Na-140
K-4.2 Cl-103 HCO3-28 AnGap-13
[**2203-10-29**] 06:00AM BLOOD Glucose-108* UreaN-17 Creat-0.8 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
[**2203-10-28**] 03:55AM BLOOD Glucose-164* UreaN-13 Creat-1.0 Na-138
K-4.0 Cl-103 HCO3-29 AnGap-10
Brief Hospital Course:
The patient was brought to the Operating Room on [**2203-10-26**] where
the patient underwent redo sternotomy, CABG x 2 with Dr. [**First Name (STitle) **].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He remained
intubated overnight and on Nitro for hypertension. This was
weaned and 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. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 5 the patient was ambulating freely, the
[**First Name (STitle) **] 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:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Gabapentin 400 mg PO TID
2. Clopidogrel 75 mg PO DAILY
3. GlipiZIDE 10 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1500 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) [**1-31**] TAB PO Q4H:PRN pain
8. Rosuvastatin Calcium 10 mg PO DAILY
9. Tamsulosin 0.4 mg PO HS
10. Aspirin 81 mg PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 400 mg PO TID
5. GlipiZIDE 10 mg PO BID
6. MetFORMIN (Glucophage) 1500 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) [**1-31**] TAB PO Q4H:PRN pain
8. Rosuvastatin Calcium 10 mg PO DAILY
9. Tamsulosin 0.4 mg PO HS
10. Metoprolol Tartrate 75 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 50 mg 1.5 tablet(s) by mouth three times
a day Disp #*150 Tablet Refills:*0
11. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
12. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth daily
Disp #*7 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Diabetes type II
Hyperlipidemia
CAD s/p MI/CABG [**2193**]
Carotid disease
Rectal cancer s/p resection and cyber knife radiation (finished
[**8-15**])
C spine injury [**3-3**] fall at work [**2198**] s/p repair
[**Doctor Last Name **] [**Location (un) 2452**] exposure
Past Surgical History:
right carotid endarterectomy [**2196**]
proctosigmoidectomy, diverting loop ileostomy [**2203-6-29**]
cholecystectomy
placement of left portacath
Past Cardiac Procedures:
Surgery: CABG (LIMA to LAD, SVG to OM, and SVG to PDA)
Date: [**2193-4-17**] with Dr. [**Last Name (STitle) 2230**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
no edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
The cardiac surgery office will call you with the following
appointments:
[**Telephone/Fax (1) 409**] Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**]
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 16827**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2203-10-31**]
ICD9 Codes: 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7568
} | Medical Text: Admission Date: [**2104-4-2**] Discharge Date: [**2104-4-11**]
Date of Birth: [**2068-11-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
jaundice, BRBPR
Major Surgical or Invasive Procedure:
Endoscopy x 2 with variceal banding
History of Present Illness:
35F with long history of etOH abuse (last drink 10 PTA), s/p
gastric bypass, 4 days BRBPR, and new jaundice. She also reports
abdominal bloating but denies pain, F/C/NS or melena prior to
admission. She intially presented to [**Hospital **] hospital where she
was found to have a HCT 21 and TBili 17. NG lavage was negative.
She recieved 2U pRBCs, 6U FFP, and levofloxacin for a preseumed
UTI. She was transfered to [**Hospital1 18**] for further management.
.
In the ED her VS were T99.0 P101 BP99/53 R18 95% on RA. She was
comfortable but jaundiced on exam with a distended, nontender
abdomen. Exam was notable for appreciable fluid in abdomen and
mild to moderate ascites by bedside US. Her intitial HCT here
was 23 so she received an additional 2U pRBCs. She was initially
admitted to the MICU for management of her acute alcoholic
hepatitis and presumed GIB.
.
In the MICU she started on IV PPI, octreotide, and ciprofloxacin
for UTI. She was seen by the hepatology team who did an EGD
which revealed 3 cords of grade I and 1 [**Last Name (un) 4782**] II varices and a
colonscopy which revealed melena and medium grade 2 external
hemorrhoids. An ECHO was performed for low voltage EKG and
peripheral edema to rule out pericardial effusion and dilated
cardiomyopathy, which was negative. A CT abdomen was performed
which showed an 18cm distended gall bladder for which surgery
was consulted.
.
Past Medical History:
Alcohol abuse
Gastric bypass in [**2100**]
Chronic neck pain
Suicide attempt with flexeril overdose in [**2103**]
Social History:
[**2-1**] PPD for the past year. Drank about 3L wine per day for past
year. Vodka often. Last drink 10 days PTA. Denies other
substance abuse.
Family History:
CAD in father and grandfather, breast cancer in grandmother
Physical Exam:
GEN: NAD, jaundiced, talkative
VS: T:98.6 BP:98/64 P:98 RR:18 O2Sat 97% RA
HEENT: Clear OP, MMM, icteric sclera, no JVD, no LAD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA on R, bronchial breath sounds at L base
ABD: Collateral veins present. BS+. Distended with shifting
dullness. Tender epigastrium, no rebound, liver palpable 4cm
below the costal margin in the mid-axillary line and spleen
palpable 1-2cm belowe the costal margin in the anterior axillary
line
EXT: 1+ edema
SKIN: jaudniced, dry
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**2-1**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission labs:
[**2104-4-2**] 09:30PM BLOOD WBC-14.5* RBC-2.32* Hgb-8.3* Hct-23.0*
MCV-100* MCH-35.8* MCHC-35.9* RDW-22.2* Plt Ct-248
[**2104-4-2**] 09:30PM BLOOD PT-21.3* PTT-41.8* INR(PT)-2.0*
[**2104-4-2**] 09:30PM BLOOD Glucose-79 UreaN-21* Creat-0.6 Na-125*
K-3.5 Cl-87* HCO3-25 AnGap-17
[**2104-4-2**] 09:30PM BLOOD ALT-67* AST-240* AlkPhos-159*
TotBili-14.4* DirBili-9.6* IndBili-4.8
[**2104-4-2**] 09:30PM BLOOD Albumin-2.3* Calcium-7.4* Phos-3.1 Mg-2.4
.
Discharge labs:
[**2104-4-11**] 10:35AM BLOOD WBC-16.9* RBC-2.88* Hgb-9.9* Hct-28.7*
MCV-100* MCH-34.3* MCHC-34.4 RDW-19.8* Plt Ct-266
[**2104-4-11**] 10:35AM BLOOD PT-19.9* PTT-49.0* INR(PT)-1.9*
[**2104-4-11**] 10:35AM BLOOD Glucose-76 UreaN-14 Creat-1.0 Na-133
K-3.2* Cl-105 HCO3-19* AnGap-12
[**2104-4-11**] 10:35AM BLOOD ALT-43* AST-123* LD(LDH)-151 AlkPhos-113
TotBili-13.7*
[**2104-4-11**] 10:35AM BLOOD Calcium-7.6* Phos-2.3* Mg-2.1
.
Serologies:
[**2104-4-2**] 09:30PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2104-4-2**] 09:30PM BLOOD HCV Ab-NEGATIVE
[**2104-4-3**] 04:03AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2104-4-3**] 04:03AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2104-4-3**] 04:03AM BLOOD AFP-4.1
[**2104-4-3**] 04:03AM BLOOD IgG-1397 IgA-723* IgM-154
.
Urine studies:
[**2104-4-2**] 10:00PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-15 Bilirub-LG Urobiln-12* pH-6.5 Leuks-NEG
[**2104-4-2**] 10:00PM URINE RBC-0-2 WBC-[**7-9**]* Bacteri-FEW Yeast-NONE
Epi-[**4-3**] TransE-[**4-3**] RenalEp-0-2
.
Tox screen:
[**2104-4-2**] 10:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
DUPLEX DOP ABD/PEL LIMITED Study Date of [**2104-4-2**] 9:35 PM
FINDINGS: The liver is diffusely echogenic consistent with fatty
infiltration. While no focal hepatic lesion is identified,
evaluation is limited by difficult son[**Name (NI) 493**] penetration.
There is no intrahepatic biliary ductal dilatation. While portal
venous flow is intermittently identified in the left portal and
extrahepatic main portal vein, reliable color flow is not
acheived in the intrahepatic or right portal venous system. The
common bile duct measures 5 mm. The gallbladder is significantly
distended with sludge, but there are no gallstones,
pericholecystic fluid or wall thickening, and the onographic
[**Doctor Last Name **] sign is negative. Small ascites is present. The spleen
appears normal though the pancreas is not well seen. There is no
right hydronephrosis. IMPRESSION: 1. Diffusely echogenic liver
may be consistent with fatty infiltration. However, other forms
of liver disease and more advanced liver disease (i.e.,
significant hepatic fibrosis/cirrhosis) cannot be excluded. 2.
Reliable intra-hepatic portal venous color flow is difficult to
achieve and thrombosis cannot be completely excluded. CT is
recommended for further evaluation. 3. Distended gallbladder
with sludge, but no evidence for cholecystitis. 4. Small
ascites.
.
CT ABDOMEN W/CONTRAST Study Date of [**2104-4-3**] 4:10 PM CT ABDOMEN:
Small effusions are associated with relaxation atelectasis.
There is no consolidation or nodule in the lung bases. Heart
size is normal. There is no pericardial effusion. Diffusely
enlarged fatty liver has patchy enhancement in all phases. The
SMV, splenic and portal veins are patent. There are gastric and
splenic varices. The celiac and superior mesenteric arteries are
patent. Replaced right hepatic artery arises from the SMA. The
pancreas and adrenals are unremarkable. The gallbladder is
markedly distended, measuring 18 (CC) x 6 (AP) x 7 (ML) cm. The
spleen remains mildly enlarged, measuring 12.7 cm. Post-gastric
bypass changes are noted. The imaged intra- abdominal loops of
large and small bowel are unremarkable without evidence of
pneumatosis, free air or obstruction. There is no mesenteric or
retroperitoneal lymphadenopathy. Moderate ascites tracks along
the paracolic gutters into the pelvis. Diffuse subcutaneous
stranding represents anasarca. Bone windows demonstrate no
evidence of lesion that is suspicious for metastasis or
infection. IMPRESSION: 1. No evidence of SMV, splenic or portal
thrombosis. 2. Diffuse anasarca and moderate ascites. 3.
Enlarged fatty liver with heterogeneous perfusion reflects
cirrhosis. 4. Markedly enlarged gallbladder without evidence of
gallstones or cholecystitis. 5. Moderate bilateral pleural
effusions. 6. Gastric and splenic varices.
.
MRCP (MR ABD W&W/OC) Study Date of [**2104-4-5**] 6:11 PM FINDINGS:
The gallbladder is significantly distended and there are some
folds seen within. There is small amount of sludge within the
gallbladder and the wall is not appreciably thickened. The
cystic duct does not appear dilated. The common bile duct is
normal in caliber without evidence of stones. There is no
intrahepatic biliary ductal dilatation. No pancreatic ductal
dilatation. The liver is enlarged measuring 26 cm in length. The
liver is significantly fatty showing signal dropout on the
out-of-phase images. There is a small amount of ascites. There
are also minimal bilateral pleural effusions and subcutaneous
edema and fluid is also seen in the left pararenal space. There
is atelectasis of the bilateral lung bases. Sutures are seen in
the stomach, probably from prior gastric bypass surgery. No
focal masses are seen in the liver on the post-contrast images.
There is mild narrowing of the proximal celiac artery with acute
angulation which could be due to stenosis (this can be a normal
variant in assymptomatic patients). There are two right renal
arteries incidentally noted. There is no bulky adenopathy.
Multiplanar 2D and 3D reformations delineated the dynamic series
with multiple perspectives. IMPRESSION: 1. Hepatomegaly with
fatty liver. 2. Distended gallbladder with minimal sludge. No
evidence of biliary ductal dilatation.
.
CHEST (PA & LAT) Study Date of [**2104-4-4**] 2:26 PM Since yesterday,
lung volumes are still low. Small-to-moderate pleural effusion
is new. Small left pleural effusion increased. Bibasilar
opacities increased, likely atelectasis. Left retrocardiac
opacity increased, could be atelectasis or pneumonia. There is
no other overall change.
Brief Hospital Course:
35F with history of gastric bypass and etOH abuse who was
transfered to [**Hospital1 18**] with acute etOH hepatitis, dilated gall
bladder, evidence of cirrhosis, and GIB with an initial HCT of
21. Endoscopy showed varices and portal gastropathy but no
active bleeding. Tbili rose to >20 and then declined. INR peaked
at 2.0 and began to fall prior to discharge. HCT stabilized. Pt
was incidentally noted to have an enlarged gall bladder but MRCP
was WNL. Her physical exam and CXR were concerining for
pneumonia, which was treated with antibiotics against CAP and
aspiration PNA. She was discharged to her parents' home with
close follow up.
.
#. Alcoholic hepatitis: New onset jaundice for 2 weeks prior to
admission. Max AST/ALT of 250/67 with max Tbili 21.3. Had GI
bleed from portal gastropathy. Evidence of collaterals on CT
concerning for chronic underlying cirrhosis. Viral hepatitis
negative as were serologies for autoimmune hepatitis. This was
likely all related to alcohol abuse. Management of varices as
below. Started on spironlactone 50mg PO daily for LE edema as
well as midodrine for orthostatic hypotension.
.
#. Possible PNA: Pt with rising WBC and bilat bronchial breath
sounds of exam as well as worsening infiltrates on CXR
concerning for PNA. Unclear if this is a communitiy acquired PNA
or [**3-3**] aspiration from endoscopy. Treated with levofloxacin 750
mg PO Q24H for community aquired PNA from [**2104-4-6**] to [**2104-4-11**] for
a 5 day course
and clindamycin 300 mg PO Q6H hepatically dosed for anaerobic
coverage for possible aspiration from [**2104-4-6**] to [**2104-4-11**] for a 5
day course.
.
#. GI bleed: likey secondary to portal hypertensive gastropathy
seen on EGD. She recieved initial 4U pRBCS and additional units
PRN later in the admission. She was treated with an IV PPI and
octreotide. Her HCT has stabilized around 27. Had variceal
banding at repeat EGD on [**2104-4-7**]. Discontinued Nadolol as s/p
banding and had been hypotensive. Switch to Pantoprazole 40 mg
PO daily and discharged on this medication at this dose.
.
#. Hypotension / orthostatic hypotension: Recurrent this
admisison likely due to hypovolemia and hypoalbuminemia. DCed
nadolol. Started midodrine 10mg PO TID with good effect.
Discharged on this medication.
.
#. Dilated gall bladder: mildly painful, 18cm on CT scan, does
not appear infected, but like obstructed, no gall stones but +
sludging. [**Month (only) 116**] be a normal variant from gastric bypass. MRCP read
showed hepatomegaly with fatty liver, a distended gallbladder
with minimal sludge, and no evidence of biliary ductal
dilatation.
.
#. UTI: Levaquin given at OSH. Repeat UCx no growth (final).
Repeat UA with 6-10 WBC. Initially on Ciprofloxacin HCl 500 mg
PO Q12H, but then treated with levofloxacin for PNA as above
which would cover common UTI pathogens.
.
#. Alcohol abuse: Reportedly last drink was >2 weeks ago. SW
Consulted with patient. Will continue to have close follow up on
this issue.
Medications on Admission:
Multivitamin
Vitamin A
Vitamin D
Vitamin K
Iron
Discharge Medications:
1. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day: for swollen legs.
Disp:*30 Tablet(s)* Refills:*5*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): for
bleeding in your stomach.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*5*
3. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): for low blood pressure.
Disp:*90 Tablet(s)* Refills:*5*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary: Alcoholic hepatitis, GI bleeding
.
Secondary: Cirrhosis, alcohol abuse
Discharge Condition:
Stable vital signs, tolerating POs
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**].
.
You were admitted for alcoholic hepatitis. This is injury to
your liver from drinking alcohol. You had bleeding in your GI
tract from this. We did an endoscopy and placed bands on varices
or dilated veins in your esophagus. You improved and are being
discharged home with physical therapy and close follow up.
.
Please take your medications as ordered.
.
Do no drink alcohol. Alcoholic hepatitis is a potentially fatal
condition.
.
Please attend your follow up appointments.
.
Please call your doctor or come to the emergency room if you
experience confusion, bleeding, excessive bruising, fevers,
chest pain, shortness of breath, decrease in urine output,
passing out, or other concerning symptoms.
Followup Instructions:
[**2104-4-21**] 11:10a [**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] (LIVER CENTER)
LM [**Hospital Unit Name **], [**Location (un) **]
LIVER CENTER (SB)
[**Telephone/Fax (1) 2422**]
Completed by:[**2104-4-14**]
ICD9 Codes: 486, 2761, 2762, 5990, 5070, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7569
} | Medical Text: Admission Date: [**2144-9-6**] Discharge Date: [**2144-9-15**]
Date of Birth: [**2070-1-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Altered mental status and CT scan at outside hospital with
colonic abcess, right renal artery embolus
Major Surgical or Invasive Procedure:
[**2144-9-7**] PICC line placed RUE
History of Present Illness:
74 y/o F with a h/o HTN, RA, hypercholesterolemia who presents
from OSH for further w/u of R renal artery embolus and sigmoid
diverticulosis with intramural abscess, and slurred speech. Pt.
is delirious and is unable to relay a history; history is
obtained from her daughter and EMS reports.
.
Per report she fell at home 3 days PTA. She does not remember
the fall. She says that her friend found her beside the bed
yesterday morning and called EMS. She reports L lower back pain
since the fall. She reports that she has felt "generally down
and punk" for several days, and that her speech has been "heavy,
thick and boozy" for about 2 weeks. She denies numbness
anywhere, has noticed generalized weakness but no focal
weakness, denies dysphagia, word finding difficulties, bowel or
bladder incontinence. She denies fevers, chills, N/V, abd pain,
or dysuria at home.
.
Per EMS records they were called to pt's house on [**9-5**] at 18:00.
Pt. was complaining of lower back pain and LUQ abd pain. Family
reported to them that pt. fell 3 days ago, that she has been
increasingly confused over the past few days, that her speech
has been "slightly slurred," and that she has had generalized
weakness for several days.
.
Pt. was brought to an OSH, where head CT showed age-related
atrophy but no infarcts. CT abd performed and showed R renal
artery embolus and diverticulosis with chronic-appearing
intramural abscess. CEs negative x 1, WBC Ct 18. Pt. received
Clindamycin, transferred here for further w/u.
.
In the ED she underwent evaluation by the neurology, vascular
surgery, and general surgery teams. CXR showed a hilar mass.
Vascular surgery recommended medical management of renal embolus
due to new finding of hilar [**Hospital3 **] surgery recommended
antibiotics and NPO status to manage diverticular abscess. She
received 1 mg of ativan in the ED, mucomyst, ASA, and
levo/flagyl.
.
ROS (per family): Pt is s/p fall 6 mos ago and experienced a
vertebral fracture. Denies fever or chills. 10 pound weight loss
over past 6 months. Denied headache, cough, chest pain. Denied
nausea, vomiting, diarrhea, or abdominal pain. No dysuria. No
rash.
Past Medical History:
HTN
Hypercholesterolemia
Rheumatoid arthritis
Vertebral fracture
Multiple falls per pt., etiology unclear
spont pneumothorax - [**2097**]
Social History:
lives alone in [**Location (un) 4047**] with home health asst several times a
week. Tobacco: 1.5 PPD since age 16. No EtOH, no illicits.
Family History:
emphysema - mother
glomerulonephritis - son
Physical Exam:
Vitals: T: 97.8 ax P: 86 BP: 120/60 RR: 18 SaO2: 95% on 2L O2
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI, sclera anicteric. MMM, OP without
lesions
Neck: supple, no JVD or carotid bruits appreciated
Pulm: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G appreciated
Abdomen: soft, NT/ND, + BS, no masses or organomegaly noted.
Ext: No clubbing cyanosis or edema.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert & Oriented x [**2-10**] (occaisionally correctly
identifies this as a hospital).
-cranial nerves: intact except unable to protrude tongue.
-motor: reduced bulk. Able to hold limbs against gravity but
would not resist. So [**4-12**] throughout. Possibly confounded by
effort.
-sensory: No deficits to light touch detected.
-cerebellar: dysarthric.
-DTRs: 2+ biceps, triceps.
Pertinent Results:
CBC:
[**2144-9-6**] 02:00AM WBC-15.1* RBC-4.35 HGB-10.9* HCT-32.3*
MCV-74* MCH-25.0* MCHC-33.7 RDW-16.3*
[**2144-9-6**] 02:00AM PLT COUNT-364
[**2144-9-6**] 02:00AM NEUTS-87.9* LYMPHS-9.5* MONOS-2.0 EOS-0.5
BASOS-0.1
.
Chemistries:
[**2144-9-6**] 02:00AM GLUCOSE-112* UREA N-10 CREAT-0.8 SODIUM-142
POTASSIUM-3.0* CHLORIDE-103 TOTAL CO2-29 ANION GAP-13
[**2144-9-6**] 02:00AM ALT(SGPT)-25 AST(SGOT)-21 ALK PHOS-107
AMYLASE-17
[**2144-9-6**] 02:00AM LD(LDH)-767*
[**2144-9-6**] 02:00AM ALBUMIN-2.4* CALCIUM-11.1* PHOSPHATE-2.2*
MAGNESIUM-2.4
[**2144-9-6**] 02:00AM TSH-2.3
[**2144-9-6**] 09:00PM PTH-13*
[**2144-9-6**] 09:00PM calTIBC-203* FERRITIN-252* TRF-156*
.
Serum Tox:
[**2144-9-6**] 02:00AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
.
Coags:
[**2144-9-6**] 04:25AM PT-13.9* PTT-20.7* INR(PT)-1.2*
.
Urine studies:
[**2144-9-6**] 04:40AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2144-9-6**] 04:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
.
CXR [**9-6**]: Right hilar mass, with associated airspace opacity
within the right upper lobe. These findings are concerning for
malignancy within the right hilum, and secondary
post-obstructive pneumonia or consolidation. Further evaluation
with a CT scan is recommended.
.
CT Pelvic [**9-6**]: 1. Tubular filling defect measuring 1.2 cm in
proximal right renal artery with hypoperfusion of right kidney,
most likely representing right renal artery emboli. Persistent
non-perfusion areas seen in the right kidney on delayed images.
2. Inflammatory changes in sigmoid colon with fat stranding, and
1.3 cm fluid collection versus small abscess.
3. Compression fracture of lower thoracic vertebra.
4. Right hilar mass noted on chest x-ray was not imaged on this
abdominal CTA.
.
Renal US [**9-6**]: 1. No hydronephrosis.
2. The renal vein was difficult to assess.
3. The resistive indices are slightly less within the right
kidney compared to the left. Further evaluation with a CTA study
is recommended.
.
CAROTID U/S [**9-8**]: No plaque or wall thickening of either carotid
artery. Diffuse low velocity seen b/l suggesting low cardiac
output.
.
CHEST CT [**9-7**]: 1. A very large heterogeneous right hilar mass
measuring 7 cm with multiple areas of central necrosis extending
to the level of the thyroid with associated mediastinal
adenopathy. The mass extends into the SVC as well as the right
mainstem bronchus with a short segment demonstrating 50%
occlusion. 2. Lack of perfusion of right kidney secondary to
previously identified thrombus. 3. Multiple hypodensities in the
liver, the largest representing a simple cyst, the smallest too
small to characterize, but may also represent cysts. 4.
Compression deformity of T9 of indeterminate age.
.
Echo [**9-8**]: The left atrium is normal in size. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. Left ventricular wall thickness,
cavity size, and 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 regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There a moderate-sized
(1.2 cm-thick) echogenic anterior space which most likely
represents an epicardial fat pad, though a loculated, organized
anterior pericardial effusion cannot be excluded.
.
L-spine film [**9-10**]: 1. Chronic-appearing L1 vertebral body
compression fracture. 2. Likely small fusiform abdominal aortic
aneurysm which was seen on the prior CTA abdomen of [**2144-9-6**].
.
FNA, Right supraclavicular lymph node [**9-10**]: POSITIVE FOR
MALIGNANT CELLS
consistent with non-small cell carcinoma.
.
CT Head with Contrast [**9-12**]: Single focus of low density within
the white matter of the right frontal lobe likely representing
chronic microvascular infarct. No evidence of enhancing lesions
to suggest metastatic disease.
.
CXR [**9-14**]: 1. Worsening right upper lobe post-obstructive
pneumonia secondary to right hilar mass. Increased right lung
volume loss.
2. Bilateral pleural effusions
.
RUQ US [**9-14**]: No evidence of acute cholecystitis.
Brief Hospital Course:
Ms. [**Known lastname 19961**] is a 74 year old female with a history of HTN, RA,
hypercholesterolemia, who presents from OSH for work up of R
renal artery embolus and sigmoid diverticulosis with intramural
abscess, delirum and slurred speech, now with hypercalcemia and
likely nephrogenic DI. Hospital course outlined by problem
below:
.
1. Right hilar mass - This was concerning for malignancy given
history of tobacco and appearance on imaging. The CT scan found
a 7cm mass in the right lung which invades into the SVC and
right mainstem bronchus. Intervential pulmonology was consulted
for possible stenting of right mainstem bronchus. They did not
feel it was necessary at the time. Thoracic surgery was
consulted for a fine needle aspiration of the supraclavicular
node for diagnosis and to see if she was a surgical candidate.
The FNA preliminarily showed malignant cells consistent with
non-small cell carcinoma. Hematology/oncology and radiation
oncology were consulted and treatment options were discussed the
with the patient and the family. Outpatient appointments were
established. A bone scan was to be performed to look for bony
mets on day of discharge, but this was discontinued secondary to
a change in the patient's treatment goals (see below). On the
last night of admission, the patient had an acute increased need
for oxygen therapy (she was on room air prior). A chest x-ray
showed pulmonary effusions and a RUL infiltrate suggestive of
post-obstructive pneumonia vs lobe collapse. The patient
remains afebrile but her WBC was elevated to 20K on discharge
from 16K and 18K a fews days prior. She was already receiving
levofloxacin and metronidazole for the diverticular abscess, and
she was given furosemide to help with the pleural effusions. In
a family discussion with the medical team, the patient and her
daughter decided that no further aggressive treatment was
wanted. Hospice consult was placed per Ms. [**Known lastname 19961**]' request.
Extensive conversations had been held with the patient and the
daughter throughout her stay regarding her code status and
wishes towards treatment and this decision is consistent with
those prior conversations.
.
2. Hypercalcemia - The patient presented with delirium and
slurred speech. She was found to have hypercalcemia and
hypernatremia which was thought to be a paraneoplastic syndrome.
Her PTHrp was found to be elevated at 8.6. Her hypercalcemia
was causatively linked to nephrogenic diabetes insipidus. Renal
consult was placed and she was agressively treated with IVF,
furosemide, calcitonin, and pamidronate to decrease her calcium
levels. She spent one night in the ICU mostly for nursing
issues regarding her frequent lab checks and electrolyte
monitoring. Once they were within normal limits, her sodium
levels dropped to normal range and she was no longer delirious.
.
3. Hypernatremia - secondary to nephrogenic diabetes insipidus.
See above.
.
4. Diverticulitis with localized abscess - surgery consult was
obtained and they recommened conservative treatment given her
comorbidities. She was placed on levofloxacin and
metronidazole. She was initially NPO, but as her delirium
resolved, surgery recommended normal diet. She was cleared by a
speech and swallow evaluation and placed on soft foods and thin
liquids along with Boost supplementation per nutrition
recommendations.
.
5. Right renal emboli - Normal renal function on admission but
large renal artery emboli noted. At first this was thought to
be likely due to cholesterol emboli per the renal team given h/o
hypercholesterolemia and did not require anticoagulation. At
discharge it was unclear whether this thrombus is secondary to
cholesterol emboli or to her hypercoagulable state secondary to
malignancy. Her renal function is still within normal limits.
.
6. Leukocytosis - The patient's WBC was stable around 16K on
levofloxacin and metronidazole for her diverticular abscess. A
few days prior to admission, her WBC rose to 18K, but she
remained afebrile. Work up showed no urinary tract infection
(patient had foley cath in place for close monitoring of
ins/outs for DI treatment) and a RUQ ultrasound showed no
cholecystitis (patient had RUQ pain on exam on the day prior to
discharge. The chest x-ray the night prior to admission showed
possible post-obstructive pneumonia which may account for her
increased WBC. She was discharged on oral antibiotics.
.
7. Anemia - iron studies are consistent with anemia of chronic
disease. Her Hct remained stable throughout admission. No
transfusion was required.
.
8. Rheumatoid arthritis - The patient was not taking medications
at admission and treatment was defered. She was given
acetaminophen for pain. During admission, the patient
complained of lower back pain and a lumbar spine x-ray showed
only an old compression fracture of L1. No new fractures. A
bone scan was to be performed to look for bony mets on day of
discharge, but this was discontinued secondary to a change in
the patient's treatment goals.
.
*FEN: eating soft foods and thin liquids with boost after
cleared by speech and swallow.
*Comm: daughter [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 69496**] cell [**Telephone/Fax (1) 69497**]
home
*Code Status: DNR/DNI per HCP (daughter) and per patient
Medications on Admission:
(not taking any of these medications)
atenolol
prednisone
folic acid
fosamax
methotraxate
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily) for 6 weeks.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2-3H (every 2-3 hours).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
8. Morphine 10 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4
to 6 hours) as needed for dyspnea/pain.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis:
Lung cancer- cytology consistent with NSCLC
Hypercalcemia causing nephrogenic diabetes insipidus
Right renal artery embolus
Intramural sigmoid abscess
.
Secondary diagnosis:
Anemia
Rheumatoid arthritis
Discharge Condition:
stable, on 5L oxygen via nasal canual
Discharge Instructions:
You have been diagnosed with lung cancer and are being
discharged to a hospice facility to make you comfortable.
.
You have been prescribed antibiotics for a pneumonia. You have
also been given morphine and lorazepam to help with the back
pain and shortness of breath.
Followup Instructions:
none
Completed by:[**2144-9-15**]
ICD9 Codes: 2760, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7570
} | Medical Text: Admission Date: Discharge Date: [**2150-4-2**]
Date of Birth: [**2089-9-10**] Sex: M
Service: CSU
ADMISSION DIAGNOSES:
1. Hypotension.
2. Status post AVR/MVR/MAZE.
3. Atrial fibrillation.
4. History of rheumatic heart disease.
DISCHARGE DIAGNOSES:
1. Pericardial effusion, status post pericardial window.
2. Rheumatic heart disease, status post aortic valve
replacement (21 [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**]) mitral valve replacement (29
[**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**]).
3. Status post MAZE procedure.
4. Atrial fibrillation.
5. Pleural effusion.
ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname **] is a 60 year-old
gentleman with a history of rheumatic heart disease, who
underwent an AVR, MVR, MAZE procedure on [**2150-3-12**]
without significant complication in his postoperative course.
He was discharged to home in good condition. He presented to
his primary care physician on [**2150-3-23**] with some fatigue
and light headedness. He was found to be hypotensive at the
time and in rapid atrial fibrillation. He was, therefore,
admitted to the Emergency Department for management of this.
He was cardioverted in the Emergency Department. It was felt
that his rapid atrial fibrillation was the cause of his
hypotension. He was subsequently admitted to the medical
service for further management. On his initial examination,
his temperature was 98.3; pulse was in the 1-teens to 130's.
His blood pressure was 88/53 and he was saturating 96 percent
on room air. He followed commands. He had a significant
amount of jugulovenous distention and his heart sounds were
distant. His breath sounds were decreased in the lower lobes.
His abdomen was otherwise soft and his extremities had no
edema. His initial white blood cell count was 20.1 with a
hematocrit of 28. His INR was markedly elevated at 6.0 and
his BUN and creatinine were 34 and 1.6.
The patient's initial chest x-ray showed low lung volumes,
ill-defined bibasilar opacities, which were thought to
represent consolidation and presence of cardiomegaly.
HOSPITAL COURSE: The patient was admitted as noted to the
medical service for further work-up. Given his clinical
scenario, it was felt prudent to obtain an echocardiogram to
rule out tamponade or pericardial effusion, responsible for
his hypotension and his acute renal insufficiency. He did
undergo this echocardiogram which revealed presence of
significant pericardial effusion, although there was no
evidence of pericardial tamponade. The effusions seemed
loculated and it was felt that interventional attempts at
drainage would be unsuccessful. Therefore, he was
transferred to the cardiac surgery service and taken to the
operating room on [**2150-3-24**] at which time he had a
pericardial window created and evacuation of his pericardial
effusion. Notably preoperatively, the patient had markedly
elevated transaminases with an ALT of 1139 and an AST of 1415
with a normal total bilirubin and normal alkaline
phosphatase, amylase and lipase. A right upper quadrant
ultrasound was obtained on our service and didn't show any
evidence of biliary tract obstructions. It was felt that
this may have been secondary to cardiogenic etiology and
congestion. The liver function tests subsequently normalized
without any intervention after his pericardial window.
Postoperatively, the patient did quite well. We initially
held his Coumadin until his INR drifted back down towards
2.5. He had multiple episodes of atrial fibrillation
postoperatively which required starting Amiodarone. By the
time he was ready for discharge, though, his rate was
controlled with a blood pressure in the 100/60's and rate of
80 to 90 and atrial fibrillation. To note, the patient
developed an increase in oxygen requirement towards the
latter part of his hospitalization and chest x-ray showed
accumulation of a large right pleural effusion. A pig-tail
drain was placed in this effusion and approximately 2.2
liters of old blood and serous fluid were drained. The
pigtail catheter remained in place for two days and was
subsequently removed without reaccumulation of the fluid. By
hospital day number 11, as the patient had been afebrile and
otherwise hemodynamically normal with rate controlled atrial
fibrillation and lungs clear to auscultation on examination,
it was felt that he could be discharged to home in stable
condition. By the time of his discharge, his liver function
tests had normalized and his white blood cell count had
normalized to 8.8. To note, his hematocrit was 36.4 and his
INR was 3.0. His renal function had normalized to its
baseline with BUN and creatinine of 22 and 0.9. His
transaminase, as noted, had normalized and his chest x-ray
showed the presence of no significant effusion and he only
had small apical pneumothoraces which had been stable.
To note, he was treated empirically with Vancomycin and
levofloxacin throughout his hospitalization for the question
of infection of his pericardial effusion, given that his
white blood cell count was elevated. This was discontinued
prior to his discharge as none of his culture data showed any
growth. He was discharged to home on [**2150-4-2**] on the
following medications:
1. Colace 100 mg p.o. twice a day when taking narcotics.
2. One multi-vitamin a day.
3. Percocet prn.
4. Aspirin 81 mg daily.
5. Protonix 40 mg p.o. once daily.
6. Amiodarone 400 mg p.o. once daily for seven days and then
200 mg once per day.
7. Lasix 40 m once per day for 10 days and then 20 mg once a
day.
8. Coumadin as directed for a goal INR of 3 to 3.5.
9. Lopressor 12.5 mg p.o. twice a day.
10. Potassium chloride 20 meq p.o. once daily when
taking Lasix.
FOLLOW UP: He was to follow up in Dr.[**Name (NI) 57924**] clinic on the
following day for INR check. She manages Coumadin and INR
levels.
She is to follow up with Dr. [**Last Name (STitle) 7047**] and Dr. [**Last Name (STitle) 70**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2150-4-2**] 17:17:19
T: [**2150-4-2**] 18:02:03
Job#: [**Job Number 57925**]
ICD9 Codes: 5849, 5119, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7571
} | Medical Text: Admission Date: [**2107-5-26**] Discharge Date: [**2107-6-9**]
Date of Birth: [**2029-5-6**] Sex: F
Service: SURGERY
Allergies:
Cortisone / Percocet / Prednisone / Advair Diskus
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2107-5-26**]: Exploratory laparotomy with ileocolectomy
History of Present Illness:
78F s/p laparoscopic converted to open right hemicolectomy for
Stage 1 (T1N0) right colon cancer on [**2106-10-29**], now being
transferred from OSH with diffuse abdominal pain and guarding on
exam. She started with diffuse abdominal pain at 9am yesterday
and went to [**Hospital3 4485**] at 9pm. She had some nausea and
bilious emesis x5, but had been passing flatus and bowel
movements. A non-contrast CT was performed and she was sent here
as her abdominal exam was concerning. In ED with A.fib w/RVR,
hypertension up to 200/100.
Past Medical History:
CAD s/p PCI (last '[**02**]), pAFib, CHF, HTN,
hyperchol, interstitial lung disease, GIB, GERD, CRI (baseline
Cr
1.3-1.8), NIDDM, hypothyroid, TIA, parkinson's, low back pain
Past Surgical History:
Diverting transverse loop colostomy after colonic perforation
from colonoscopy,, colostomy reversal, ventral hernia repair
with mesh, Laparoscopic converted to open right hemicolectomy
[**2106-11-15**].
Social History:
Patient is retired, lives at home with husband. Former [**Name2 (NI) 1818**].
Denies alcohol or other drugs.
Family History:
NC
Physical Exam:
On admission:
Vitals: T 101.1 HR 160 BP 120/90 RR 20 SO2 96%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Firm, nondistended, severely tender diffusely, mild rebound
tenderness and voluntary guarding.
DRE: normal tone, no gross or occult blood
Ext: 1+ LE edema b/l, LE warm and well perfused
On Discharge:
Pertinent Results:
ADMISSION LABS
--------------
[**2107-5-26**] 12:30AM BLOOD WBC-29.3*# RBC-4.63# Hgb-13.3# Hct-42.3#
MCV-91 MCH-28.8 MCHC-31.5 RDW-15.8* Plt Ct-263#
[**2107-5-26**] 12:30AM BLOOD PT-30.3* PTT-23.7 INR(PT)-3.0*
[**2107-5-26**] 12:30AM BLOOD Glucose-182* UreaN-40* Creat-1.6* Na-143
K-6.0* Cl-107 HCO3-19* AnGap-23*
[**2107-5-26**]: TEE
No intracardiac thrombus. Mild mitral regurgitation.
[**2107-5-26**]: CT abd/pelvis:
- Diffuse bowel wall dilatation, with lack of mural enhancement
in the
distal ileum, concerning for bowel ischemia or necrosis. There
is an
occlusion of an ileal branch of the superior mesenteric artery
suggesting an embolic cause for bowel ischemia upstream of
affected areas.
- Extensive atherosclerotic disease of the aorta and iliac
arteries.
[**2107-5-30**]: MRI Head
- Acute infarction in the left middle cerebral artery
distribution involving the left parietal lobe.
- Small old infarct in the right cerebellum.
- No evidence of susceptibility artifact to suggest intracranial
hemorrhage.
[**2107-6-3**]: KUB
- ileus
[**2107-6-4**]: KUB
- There has been no significant change. There remains air and
stool seen
throughout the colon and some mildly prominent loops of small
bowel. Left
side down decubitus radiograph, shows no free intra-abdominal
gas present. Surgical skin staples are seen projecting over the
midline.
[**2107-6-4**]: CT HEAD:
- Evolving left parietal infarct. No evidence of hemorrhagic
transformation.
- Global atrophy and chronic small vessel change.
- Small old right cerebellar infarct.
[**2107-6-8**] 05:10AM BLOOD WBC-7.8 RBC-3.43* Hgb-10.1* Hct-31.3*
MCV-91 MCH-29.6 MCHC-32.4 RDW-15.6* Plt Ct-454*
[**2107-6-7**] 05:22AM BLOOD WBC-7.6 RBC-3.28* Hgb-9.5* Hct-30.5*
MCV-93 MCH-29.1 MCHC-31.3 RDW-15.8* Plt Ct-438
[**2107-6-6**] 05:00AM BLOOD WBC-7.8 RBC-3.15* Hgb-9.3* Hct-29.0*
MCV-92 MCH-29.4 MCHC-32.0 RDW-15.9* Plt Ct-361
[**2107-6-5**] 05:37PM BLOOD WBC-8.8 RBC-3.24* Hgb-9.2* Hct-29.2*
MCV-90 MCH-28.4 MCHC-31.5 RDW-16.3* Plt Ct-313
[**2107-6-5**] 09:24AM BLOOD WBC-8.0 RBC-3.16* Hgb-9.3* Hct-28.5*
MCV-90 MCH-29.3 MCHC-32.5 RDW-16.2* Plt Ct-310
[**2107-6-5**] 01:42AM BLOOD WBC-7.3 RBC-3.02* Hgb-9.2* Hct-26.5*
MCV-88 MCH-30.6 MCHC-34.9 RDW-15.9* Plt Ct-268
[**2107-6-4**] 12:11AM BLOOD WBC-7.1 RBC-3.61* Hgb-10.6* Hct-32.7*
MCV-91 MCH-29.5 MCHC-32.5 RDW-16.3* Plt Ct-307
[**2107-6-3**] 05:12AM BLOOD WBC-5.3 RBC-3.42* Hgb-10.0* Hct-31.5*
MCV-92 MCH-29.3 MCHC-31.8 RDW-15.9* Plt Ct-245
[**2107-6-2**] 05:25AM BLOOD WBC-4.1 RBC-3.44* Hgb-10.1* Hct-31.5*
MCV-92 MCH-29.4 MCHC-32.1 RDW-15.8* Plt Ct-200
[**2107-6-1**] 05:20AM BLOOD WBC-3.0* RBC-3.64* Hgb-10.9* Hct-32.8*
MCV-90 MCH-29.8 MCHC-33.1 RDW-15.8* Plt Ct-157
[**2107-5-31**] 05:10AM BLOOD WBC-4.0# RBC-3.83* Hgb-11.4* Hct-34.1*
MCV-89 MCH-29.8 MCHC-33.5 RDW-15.9* Plt Ct-132*
[**2107-5-26**] 12:30AM BLOOD Neuts-93* Bands-0 Lymphs-2* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2107-5-26**] 12:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear
Dr[**Last Name (STitle) 833**] [**Name (STitle) 4486**]
[**2107-6-9**] 11:10AM BLOOD PT-24.3* PTT-26.1 INR(PT)-2.3*
[**2107-6-8**] 05:10AM BLOOD Plt Ct-454*
[**2107-6-8**] 05:10AM BLOOD PT-25.3* PTT-28.1 INR(PT)-2.4*
[**2107-6-7**] 05:22AM BLOOD Plt Ct-438
[**2107-6-7**] 05:22AM BLOOD PT-39.7* PTT-29.9 INR(PT)-4.1*
[**2107-6-6**] 05:00AM BLOOD Plt Ct-361
[**2107-6-6**] 05:00AM BLOOD PT-39.0* PTT-29.5 INR(PT)-4.0*
[**2107-6-5**] 05:37PM BLOOD Plt Ct-313
[**2107-6-5**] 09:24AM BLOOD Plt Ct-310
[**2107-6-5**] 01:42AM BLOOD Plt Ct-268
[**2107-6-5**] 01:42AM BLOOD PT-39.8* PTT-28.6 INR(PT)-4.1*
[**2107-6-4**] 12:11AM BLOOD Plt Ct-307
[**2107-6-4**] 12:11AM BLOOD PT-38.6* PTT-26.7 INR(PT)-3.9*
[**2107-6-3**] 05:12AM BLOOD PT-38.4* PTT-27.4 INR(PT)-3.9*
[**2107-6-2**] 11:20AM BLOOD PT-34.5* PTT-68.9* INR(PT)-3.5*
[**2107-6-1**] 12:58PM BLOOD PT-17.7* PTT-45.5* INR(PT)-1.6*
[**2107-6-1**] 05:20AM BLOOD Plt Ct-157
[**2107-6-1**] 05:20AM BLOOD PT-16.7* PTT-44.1* INR(PT)-1.5*
[**2107-5-31**] 05:10AM BLOOD PT-16.1* PTT-26.0 INR(PT)-1.4*
[**2107-5-30**] 03:20PM BLOOD PT-17.6* PTT-25.5 INR(PT)-1.6*
[**2107-5-28**] 03:10AM BLOOD PT-16.8* PTT-28.7 INR(PT)-1.5*
[**2107-5-27**] 12:26PM BLOOD Plt Ct-120*
[**2107-5-27**] 12:26PM BLOOD PT-23.0* PTT-32.7 INR(PT)-2.1*
[**2107-5-27**] 03:29AM BLOOD PT-31.2* PTT-35.1* INR(PT)-3.1*
[**2107-5-26**] 07:22AM BLOOD PT-19.8* PTT-29.8 INR(PT)-1.8*
[**2107-5-26**] 12:30AM BLOOD PT-30.3* PTT-23.7 INR(PT)-3.0*
[**2107-6-9**] 11:10AM BLOOD Glucose-90 UreaN-13 Creat-1.3* Na-146*
K-3.6 Cl-111* HCO3-23 AnGap-16
[**2107-6-8**] 05:10AM BLOOD Glucose-90 UreaN-13 Creat-1.2* Na-141
K-3.1* Cl-112* HCO3-21* AnGap-11
[**2107-6-7**] 05:22AM BLOOD Glucose-93 UreaN-16 Creat-1.3* Na-141
K-3.8 Cl-108 HCO3-21* AnGap-16
[**2107-6-6**] 05:00AM BLOOD Glucose-91 UreaN-15 Creat-1.3* Na-142
K-4.1 Cl-111* HCO3-21* AnGap-14
[**2107-6-5**] 05:37PM BLOOD Glucose-110* UreaN-15 Creat-1.3* Na-140
K-4.2 Cl-111* HCO3-20* AnGap-13
[**2107-6-5**] 07:23AM BLOOD Creat-1.3* Na-140 K-4.2 Cl-113*
[**2107-6-5**] 01:42AM BLOOD Glucose-125* UreaN-17 Creat-1.4* Na-139
K-4.0 Cl-110* HCO3-21* AnGap-12
[**2107-6-4**] 12:11AM BLOOD Glucose-136* UreaN-16 Creat-1.1 Na-141
K-3.4 Cl-110* HCO3-22 AnGap-12
[**2107-6-3**] 05:12AM BLOOD Glucose-94 UreaN-17 Creat-1.2* Na-143
K-3.4 Cl-111* HCO3-21* AnGap-14
[**2107-6-2**] 05:25AM BLOOD Glucose-109* UreaN-23* Creat-1.3* Na-143
K-3.3 Cl-111* HCO3-21* AnGap-14
[**2107-6-1**] 12:44PM BLOOD Glucose-118* UreaN-29* Creat-1.4* Na-142
K-3.4 Cl-108 HCO3-23 AnGap-14
[**2107-6-1**] 05:20AM BLOOD Glucose-102* UreaN-30* Creat-1.4* Na-142
K-3.3 Cl-107 HCO3-23 AnGap-15
[**2107-5-31**] 05:10AM BLOOD Glucose-120* UreaN-36* Creat-1.4* Na-143
K-3.6 Cl-107 HCO3-24 AnGap-16
[**2107-5-29**] 07:55PM BLOOD Glucose-121* UreaN-36* Creat-1.4* Na-140
K-3.5 Cl-105 HCO3-20* AnGap-19
[**2107-5-29**] 01:35AM BLOOD Glucose-97 UreaN-39* Creat-1.8* Na-142
K-3.8 Cl-110* HCO3-21* AnGap-15
[**2107-5-28**] 03:10AM BLOOD Glucose-90 UreaN-36* Creat-1.7* Na-141
K-4.6 Cl-108 HCO3-22 AnGap-16
[**2107-6-6**] 05:00AM BLOOD ALT-9 AST-13 LD(LDH)-178 AlkPhos-40
TotBili-0.3
[**2107-5-26**] 12:30AM BLOOD ALT-14 AST-42* AlkPhos-41 TotBili-0.3
[**2107-6-7**] 05:50PM BLOOD CK-MB-5 cTropnT-0.04*
[**2107-5-29**] 01:35AM BLOOD CK-MB-2 cTropnT-0.05*
[**2107-6-9**] 11:10AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.8
[**2107-6-8**] 05:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.9
[**2107-6-7**] 05:22AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.9
[**2107-6-6**] 05:00AM BLOOD Calcium-7.8* Phos-4.2 Mg-2.0
[**2107-6-5**] 05:37PM BLOOD Calcium-7.9* Phos-3.7 Mg-2.0
[**2107-6-4**] 12:11AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0
[**2107-6-3**] 05:12AM BLOOD Calcium-7.8* Phos-2.9 Mg-2.3
[**2107-6-2**] 05:25AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9
[**2107-6-1**] 12:44PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0
[**2107-5-31**] 05:10AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.1 Cholest-97
[**2107-5-30**] 05:35AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.1
[**2107-5-29**] 01:35AM BLOOD Calcium-8.2* Phos-3.7# Mg-2.3
[**2107-5-28**] 03:10AM BLOOD Calcium-8.7 Phos-5.5* Mg-2.1
[**2107-5-27**] 12:26PM BLOOD Calcium-7.9* Phos-4.5 Mg-2.0
[**2107-6-2**] 05:25AM BLOOD Triglyc-193*
[**2107-5-31**] 05:10AM BLOOD Triglyc-212* HDL-16 CHOL/HD-6.1
LDLcalc-39
[**2107-5-31**] 05:10AM BLOOD Vanco-19.5
[**2107-5-28**] 06:00AM BLOOD Vanco-13.7
[**2107-6-6**] 05:00AM BLOOD Digoxin-0.9
[**2107-5-28**] 03:10AM BLOOD Digoxin-0.7*
Brief Hospital Course:
Ms. [**Known lastname **] was taken emergently to the OR for exploratory
laparatomy on [**2107-5-26**]. She was transferred to the SICU in fair
condition postoperatively, intubated and sedated. Her hospital
course is discussed below by system:
Neuro: Patient's pain was controlled with PCA and transitioned
to IV and po pain medications when appropriate. During her ICU
stay, she was noted to have word finding difficult and
sundowning. Family felt that patient was confused but otherwise
at baseline and her neurologic exam was nonfocal. As her overall
condition improved and sundowning resolved, her word finding
difficulty became more apparent and an MRI of her head was
performed on [**2107-5-30**] with acute infarction in the left middle
cerebral artery distribution involving the left parietal lobe
noted. She was started on a heparin drip and her afib was
controlled as below. Over the following 48 hours, her speech
improved and a speech and swallow evaluation was performed prior
to starting po intake. Patient improved daily until [**2107-6-3**] when
she developed hypertension into the 200s with associated
worsening speech. A CT head was performed which showed no
hemorrhagic conversion and evolving stroke. She was continued on
coumadin once therapeutic on heparin, and her dose of this was
titrated to an appropriate level. She had been initially
supratherapeutic with a maximum INR during her admission of 4.1,
following which her coumadin was held. This was restarted on
0.5mg of Warfarin at discharge with a plan to follow her INR at
rehab.
CV: Patient was in Afib RVR upon admission. IV metoprolol was
used for rate control. TEE showed no evidence of intracardiac
thrombus to explain her synchronous embolization to her small
bowel and brain. Patient required multiple IV antihypertensives
(metop, labetalol, hydralazine) for BP control. On [**2107-6-3**],
patient's hypertensive episode prompted a transfer to ICU where
she was controlled with a labetalol drip to maintain systolic
blood pressure <140. Patient was eventually transitioned to PO
metoprolol and IV metoprolol PRN and transferred back to the
general surgery service. Following transfer she was started on
lisinopril and her blood pressure remained stable and
appropriate and continued on an increased dose of Lopressor. Her
blood pressure was improved and appropriate.
Resp: Patient showed evidence of moderate pulmonary edema and
was diuresed with IV lasix. She was given nebulizer treatments
and encourage to use her IS. Her O2 was weaned.
Abd: Patient's abdomen was distended with a prolonged ileus
postoperatively. Initial attempts at diet advanced with speech
and swallow recommendations were met with abdominal distension
and pain. On [**2107-6-3**], patient complained of severe abdominal pain
with nausea. KUB showed an ileus. NG tube was placed with 500 cc
of bile drained and improvement in pain. NG tube was removed
while patient in ICU and abominal distension was improved. Her
diet was advanced to a regular diet and calorie counts were
followed. She was given supplementation with ensure and was
instructed to continue this on discharge.
Wound: The midline surgical incision was closed with staples
post-operatively. The inicsion line was intact without signs of
infection. These staples were removed on discharge and replaced
with steri-strips. The patient was to wear an abdominal binder
when out of bed.
Renal: Patient's mild renal insufficiency was unchanged
throughout admission.
Heme: Patient received one unit of FFP prior to ex lap on [**5-27**],
one unit of PRBC on [**2107-5-29**] and one unit of PRBC on [**2107-6-3**] for
low Hct. Her INR rose from 1.4 to 3.5 with one dose of coumadin
once therapeutic on heparin. Her INR peaked at 4.1 and then
trended down. She was kept therapeutic on her coumadin
thereafter with a low dose. Patient was also kept on Heparin SC
with venodynes for DVT prophylaxis.
ID: The patient was ruled out for C. Diff suring this admission.
Consulting teams: During this admission the patient was followed
closely by neurology, geriatric medicine, speech and swallow,
phyiscal therapy, and social work.
Medications on Admission:
Coumadin 2', ASA 81', toprol XL 75', digoxin
0.125qod, lipitor 40', omeprazole 20', glipizide 2.5', fentanyl
patch 50, topamax 25', sinemet 25/100''', seroquel
25'am-50'pm-100'hs, remeron 30'hs, divalproex 250am/500pm,
ativan
0.5'''prn, ambien 10'prn, MVI, colace 100", CaCarb 1000''', Fe
65', fish oil, ?lasix 20', toprol 75', mirtazapine 30',
Omeprazole 20',
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
11. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
12. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
13. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
15. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the
evening)).
16. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
17. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
18. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. metoprolol tartrate 25 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
21. warfarin 1 mg Tablet Sig: [**1-30**] Tablet PO QHS (once a day (at
bedtime)) for 1 doses: Please give at 1600 on [**2107-6-9**] and
recheck INR on [**2107-6-10**]. Goal INR 2.0-3.0, pt have been difficult
to manage, very sensitive to warfarin.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **] in [**Location (un) **]
Discharge Diagnosis:
Mesenteric Ischemia
Ileal Resection
CVA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a an open colectomy for
surgical management of your mesenteric ischemia. It is thought
that this mesenteric ischemia was caused by a blood clot in the
membranes attatched to your intestine caused by your heart
condition atrial fibrillation. During this time, it is thought
that you also suffered from a stroke related to a blood clot
which traveled to your brain. It is very important that you
continue your coumadin therapy which ahs been difficult to
manage, however, will be managed by the [**Hospital 4487**] hospital
providers. You have recovered from this surgery well and you are
now ready to be discharged to rehabilitation. From the stoke,
you have difficulty saying words and it is our hope as well as
the hope of the neurology team that this will improve over time
with the help of occpational therapy and speech therapy. Please
continue to hope and work for improvement in your symptoms.
Please participate in physical therapy to regain your strength.
You have tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth.
Please monitor your bowel function closely. You have had a bowel
movement. After anesthesia it is not uncommon for patient??????s to
have some decrease in bowel function but your should not have
prolonged constipation. Some loose stool and passing of small
amounts of dark, old appearing blood are explected however, if
you notice that you are passing bright red blood with bowel
movments or having loose stool without improvement please call
the office or go to the emergency room if the symptoms are
severe. If you are taking narcotic pain medications there is a
risk that you will have some constipation. Please take an over
the counter stool softener such as Colace, and if the symptoms
does not improve call the office. If you have any of the
following symptoms please call the office for advice or go to
the emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonges loose stool, or
constipation.
You have a long vertical incision on your abdomen the staples
have been removed prior to your discharged and steri-strips have
been applied. This incision can be left open to air or covered
with a dry sterile gauze dressing if the incision becomes
irritated from clothing. Please monitor the incision for signs
and symptoms of infection including: increasing redness at the
incision, opening of the incision, increased pain at the
incision line, draining of white/green/yellow/foul smelling
drainage, or if you develop a fever. Please call the office if
you develop these symptoms or go to the emergency room if the
symptoms are severe. You may shower, let the warm water run
over the incision line and pat the area dry with a towel, do not
rub. Please wear an abdominal binder provided to you at all
times while out of bed.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
excersise after follow up.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol.
You will take 0.5mg coumadin today [**2107-6-9**]. Your INR today
[**2107-6-9**] is 2.3. The rehab facility will need to check daily INRs
until your INR is stable and therapeutic, with a goal INR of
2.0-3.0.
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 plan to follow up in Dr. [**Last Name (STitle) 4488**] clinic in approximately 2
weeks. Call ([**Telephone/Fax (1) 3378**] to make an appointment.
Completed by:[**2107-6-9**]
ICD9 Codes: 2762, 2930, 2720, 5859, 2449, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7572
} | Medical Text: Admission Date: [**2120-1-4**] Discharge Date: [**2120-1-9**]
Date of Birth: [**2056-5-26**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old man
with a history of atrial fibrillation, prior ischemic
strokes, most recently in the right MCA, who was discharged
on [**2119-12-30**] with a recent right MCA ischemic infarction. He
was left with a left hemiparesis which had improved
remarkably by the time of discharge. He had been doing well
at rehabilitation until the day prior to admission when he
developed a right frontal headache which had gotten
progressively worse over 24 hours. He also had chest pain
which was sharp and intermittent without radiation. The
patient was unable to provide any history besides this.
There was no report of his left-sided weakness becoming worse
again.
A noncontrast head CT at the [**Hospital1 188**] Emergency Department showed an intraparenchymal bleed
into the old MCA ischemic infarction.
PAST MEDICAL HISTORY: 1. Right MCA stroke in 01/[**2119**]. 2.
Atrial fibrillation on Coumadin. 3. Stroke in [**2117**].
MEDICATIONS ON ADMISSION: Lopressor 50 mg p.o. b.i.d.;
Coumadin 3 mg p.o. q.h.s.; Zantac 150 mg p.o. b.i.d.;
trazodone 50 mg p.o. q.h.s.; Percocet 1-2 tablets p.o. q. 4-6
hours p.r.n.; Colace 100 mg p.o. b.i.d. p.r.n.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient quit smoking 30 years ago. He
is a retired woodcutter and has a sixth grade level of
education. He is illiterate and he lives with his wife.
PHYSICAL EXAMINATION: Examination on admission showed vital
signs with a temperature of 98.6, blood pressure 174/100,
heart rate 95, respiratory rate 18, oxygen saturation 96% on
room air. In general he was well-developed, well-nourished.
He did not appear to be in any distress. Head and neck were
normocephalic, atraumatic. Neck was supple. Mucous
membranes were moist. There were no bruits. Cardiovascular
examination showed an irregular rhythm with normal rate.
Pulmonary examination showed his lungs to be clear
bilaterally. His abdomen was soft and nontender. He had
positive bowel sounds. There was no distention. Extremities
were warm. There was mild edema at the ankles.
Neurologically his mental status was awake, alert and
oriented to name, place, year and situation. Language and
comprehension were intact. Cranial nerves: Pupils reacted
normally to light. Visual fields showed a left hemianopsia.
The funduscopic examination was normal. Extraocular
movements were full without nystagmus. Facial movement
showed a left facial droop. Palate elevation was symmetric.
His tongue protruded in the midline. Sensation was intact to
touch, temperature and pinprick. There was no evidence of
neglect. Motor examination showed normal tone and bulk. The
left arm was flaccid. He had mild to moderate left leg
weakness in an upper motor neuron pattern. Reflexes were
diminished in his left arm. Plantar reflexes were extensor.
Sensory examination showed sensation to be intact to
pinprick. Gross touch was decreased in the left arm.
Coordination showed finger-to-nose and alternating movements
intact on the right arm.
LABORATORY STUDIES: On admission his white count was 10,
hematocrit 37, platelet count 340, PT 23, INR 3.6, sodium
143, potassium 3.9, chloride 101, bicarbonate 25, BUN 28,
creatinine 1, glucose 101, CK 69, troponin 0.1.
EKG showed atrial fibrillation. Head CT showed an
intraparenchymal bleed into the old ischemic infarct in the
right MCA distribution. There was minimal shift.
HOSPITAL COURSE: The patient was admitted to the neurology
service initially to the intensive care unit and he was later
transferred to the floor. His Coumadin was discontinued and
he was given three doses of subcutaneous vitamin K. The
patient had several CT scans while in the hospital. The scan
taken on [**1-8**] demonstrated an increase in the size of
his bleed compared to [**1-7**]. However he had no clinical
correlation for this finding.
The patient was started on an aggressive bowel regimen and
pain relievers to prevent rise in his intracranial pressure.
His systemic blood pressure was controlled with a combination
of Lopressor, hydralazine and Norvasc. The patient
complained of a right-sided headache until [**1-8**]. By
[**1-9**] his headache was resolved. The patient will be
discharged to rehabilitation on [**2120-1-9**].
DISCHARGE DIAGNOSES:
1. Right MCA territory hemorrhage on top of an old ischemic
infarct.
2. Prior strokes.
3. Atrial fibrillation.
4. Hypertension.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Protonix 40 mg p.o. q.d.
3. Hydralazine 10 mg p.o. q. 6 hours.
4. Tylenol 650 mg p.o. q. 4-6 hours p.r.n.
5. Morphine sulfate 2 mg p.o. q. 3-4 hours p.r.n.
6. Lactulose 30 mL p.o. t.i.d.
7. Dulcolax 10 mg p.o. p.r. q.d. p.r.n.
8. Lopressor 100 mg p.o. t.i.d.
9. Norvasc 5 mg p.o. q.d. His blood pressure should be kept
under 140 systolic.
10. Aspirin should be restarted two weeks after discharge, on
approximately [**2120-1-24**], with consideration being
given to Coumadin in about two months.
CONDITION ON DISCHARGE: The patient is being discharged in
improved condition. He will require further rehabilitation
for his left-sided weakness.
FOLLOW UP: The patient will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
as an outpatient.
[**Name6 (MD) 11982**] [**Last Name (NamePattern4) 11983**], M.D. [**MD Number(1) 11984**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2120-1-9**] 10:38
T: [**2120-1-9**] 10:49
JOB#: [**Job Number **]
ICD9 Codes: 431, 4240, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7573
} | Medical Text: Admission Date: [**2169-9-5**] Discharge Date: [**2169-9-6**]
Date of Birth: [**2120-8-10**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5084**]
Chief Complaint:
IPH and IVH.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known firstname 3968**] is a 49 y/o female who was found down and
unresponsive this morning. Her husband states that he found her
around 8 a.m. and that he last spoke with her at 1 a.m. at which
time she was "normal." She was transferred via EMS to [**Hospital **]
Hospital and underwent a head CT which showed a intraparenchymal
and intraventricular hemorrhage. A chest x-ray showed bilateral
infiltrations, likely aspiration from being obtunded. She was
intubated and transferred to [**Hospital1 18**] via [**Location (un) **]. She received
Mannitol 60mg IV in flight. Her SBP dropped into the 50s and
she
received 3 liters of IV fluids as well as Levophed and
Neo-Synephrine yet continued with systolic blood pressures in
the 50-60s upon arrival to [**Hospital1 18**]. She received Dilantin 1gram IV
x1. She underwent a repeat CT of the head and a CTA which
revealed a left frontal intraparenchymal and intraventricular
hemorrhage. CTA showed a right ophthalmic aneurysm but no
aneurysm in the
region of the bleed. She received Mannitol 50mg IV x1 in the
emergency department.
Past Medical History:
Hyperlipidemia; Lymphoma 20 years ago.
Social History:
Resides with husband and three children.
Family History:
non contributory
Physical Exam:
On admission [**2169-9-5**]: PHYSICAL EXAM:
BP: 97/50 on Levophed and Neo
Gen: Lying on bed; intubated. Does not open eyes spontaneously
or
on command.
HEENT: Pupils: Right 5mm and fixed; left pupil 3mm and fixed.
EOMs unable to assess.
Positive gag and cough.
Negative Corneals Bilat.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated; unresponsive.
Motor: Extensor posturing x 4 extremities.
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Formal motor examination and pronator drift could not
be
assessed.
Pertinent Results:
CTA NECK W&W/OC & RECONS Study Date of [**2169-9-5**] 11:08 AM CTA
HEAD W&W/O C & RECONS Study Date of [**2169-9-5**] 11:08 AM
IMPRESSION:
1. Large flame-shaped left paramedian frontal hemorrhage
extending into the corpus callosum bilaterally, with associated
anterior interhemispheric fissure and bifrontal sulcal
subarachnoid blood.
2. Intraventricular extension of hemorrhage, with blood filling
the third
ventricle, partially filling the fourth ventricle, and expanding
the body and atrium of the right lateral ventricle. The
temporal [**Doctor Last Name 534**] of the right lateral ventricle is dilated,
presumably due to obstruction.
3. Diffuse cerebral edema. Left subfalcine herniation.
Significant
rightward shift of midline structures. Crowding of the
cerebellar tonsilsin the foramen magnum.
4. Though an aneurysm of the anterior communicating artery is
suspected based on the pattern of intracranial hemorrhage, no
such aneurysm is seen. Please note that a small aneurysm may be
compressed by the hemorrhage. There is a fenestration of the
right aspect of the anterior communicating artery, and 2-mm
fusiform dilatation of the proximal A2 segment of the right
anterior cerebral artery. Consider conventional angiography.
5. 3 x 2-mm aneurysm of the supraclinoid right internal carotid
artery near the ophthalmic artery origin.
6. 4 x 2.5-mm aneurysm of the paraclinoid left internal carotid
artery.
7. Fenestration of the proximal basilar artery.
8. Atherosclerosis at the origins of the cervical internal
carotid arteries with mild, less than 40% stenoses.
9. 2-cm right thyroid nodule. Recommend further assessment by
[**Name (NI) 13416**], if not previously performed elsewhere.
10. Large dependent opacities in the imaged upper lungs with
partial air
bronchograms. Recommend correlation with chest radiography.
11. Air in the venous structures of the upper chest and neck,
mostly on the right, which is most likely related to line
placement or a line placement attempt. Please correlate
clinically.
CHEST PORT. LINE PLACEMENT Study Date of [**2169-9-5**] 3:51 PM
Diffuse pulmonary edema, likely neurogenic rather than
cardiogenic. Right subclavian central line in appropriate
position with the tip in lower SVC. Bibasilar hazy opacities,
left greater than right,
suggestive of possible pleural effusion and/or aspiration.
Brief Hospital Course:
Ms. [**Known firstname 3968**] is a 49 year old female who was found down and
unresponsive this morning. Her husband states that he found her
around 8 a.m. and that he last spoke with her at 1 a.m. at which
time she was "normal." She was transferred via EMS to [**Hospital **]
Hospital and underwent a head CT which showed a intraparenchymal
and intraventricular hemorrhage. A chest x-ray showed bilateral
infiltrations, likely aspiration from being obtunded. She was
intubated and transferred to [**Hospital1 18**] via [**Location (un) **]. She received
Mannitol 60mg IV in flight. Her SBP dropped into the 50s and
she received 3 liters of IV fluids as well as Levophed and
Neo-Synephrine yet continued with systolic blood pressures in
the 50-60s upon arrival to [**Hospital1 18**]. The patient was evaluated by
Neurosurgery. She received Dilantin 1gram IV x1. She underwent a
repeat CT of the head and a CTA which revealed a left frontal
intraparenchymal and intraventricular hemorrhage. CTA showed a
right ophthalmic aneurysm but no aneurysm in the region of the
bleed. She received Mannitol 50mg IV x1 in the emergency
department. On exam the patients Pupils were fixed and dilated.
She was Intubated and exhibiting extensor posturing.
A family meeting was held in the Emergency Room Department, and
given the severity of the bleed and the very poor neurological
exam it was explained that the patient had a very grave
diagnosis and that surgery would not benefit the patient at this
time. The patient was transferred to the intensive care unit
and another meeting was held with the family and the intensive
care physicians and it was determined that given the patient's
grave prognosis the patient will be DNR/DNI status. The patient
was on 4 agents for hypotension on [**9-6**] and her neurologic exam
did not improve. She transitioned to CMO status this day after
discussion with the husband and she expired with family at the
bedside.
Medications on Admission:
Lipitor, dose unknown.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
intraparenchymal hemorrhage
interventricular hemorrhage
Hypotension
Pneumonia
cerebral edema
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
expired
Completed by:[**2169-9-6**]
ICD9 Codes: 431, 5070, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7574
} | Medical Text: Admission Date: [**2154-5-31**] Discharge Date: [**2154-6-6**]
Date of Birth: [**2081-6-6**] Sex: M
Service: SURGERY
Allergies:
Morphine / Haldol
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Residual colostomy from diverticular perforation
Giant abdominal Hernia residual from dehiscence with open
abdomen.
Major Surgical or Invasive Procedure:
[**2154-5-31**] [**Doctor Last Name **] reversal
History of Present Illness:
This is a 72-year-old man who presented three months ago with
perforated diverticulitis and severe peritonitis. He had a
Hartmann's procedure for this. He developed an open abdomen 2'
to abdominal sepsis. This was eventually closed with full
thickness skin flaps. After discharge he also developed a
retracted colostomy with stenosis of the skin aperture.
Therefore, he is now taken for a colostomy take-dow. This is
much earlier than would be normally be planned due to the
expectation of a 'hostile abdomen'.
Past Medical History:
PMH: HTN, CAD s/p CABG, BPH, Diverticulosis s/p sigmoid
resection, AFib (on coumadin), DVT
PSH: Hartmann's ([**1-/2154**]) c/b dehiscence, Wound Closure 3/[**2153**].
AAA repair [**2146**], CABG [**2127**]
Social History:
Lives with family, works part time as an Optometrist. No
tobacco use.
Family History:
Non-contributory
Physical Exam:
(at discharge)
NAD/AAO, pleasant gentleman
in afib, regular rate
CTA b/l
soft, nondistended abdomen, with midline incision, no erythema,
no drainage
no peripheral edema
Brief Hospital Course:
The patient was admitted to the surgical service to a floor bed
after his surgery. He was initially kept NPO and his diet was
slowly advanced as tolerated once he was passing flatus. He
remained afebrile with a normal WBC and his wound had no signs
of infection. His pain was initially controlled with a pca and
this was converted to oral medications once he was taking oral
intake. At time of discharge he was ambulating without
difficulty, tolerating a regular diet, and passing flatus.
Medications on Admission:
1. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion.
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO BID (2 times a day).
4. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
5. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion.
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO BID (2 times a day).
4. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
5. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation: Take as needed for
constipation while taking pain medication.
Disp:*30 Capsule(s)* Refills:*0*
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Reversal of [**Doctor Last Name 3379**] pouch
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 reversal of your
colostomy.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-30**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
Please follow up with the Acute Care Service next week for
removal of your staples. You can schedule this appointment by
calling # [**Telephone/Fax (1) 600**]
Please follow-up with your PCP as usual for monitoring of your
INR (coumadin level).
ICD9 Codes: 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7575
} | Medical Text: Admission Date: [**2181-4-15**] Discharge Date: [**2181-4-15**]
Service: MEDICINE
Allergies:
Nsaids / Sulfa (Sulfonamide Antibiotics) / Zosyn
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
central line
a-line
bronchoscopy
History of Present Illness:
This is a Mr [**Name13 (STitle) 21658**] is an 85 year old man, recently discharged
from the intensive care unit, with history of prior DVT (now s/p
IVC
filter), intracranial bleeding, HTN, CKD on HD, right lower
extremity dry gangrene who presents with hypotension,
aspiration, fever. Patient transfered from [**Hospital1 **] after being
found aspirating from TF. Became hypoxic to 80%, was suctioned
with vomintous removed, placed on 100% NRB with improvement of
sats. Per ED call in, T 101.8, BP 120/70 at [**Hospital1 **] which is
actually thought to be elevated from baseline of 80/50. Per
[**Hospital1 **], he is oriented x 2 at baseline with some AMS but was
more lethargic after the event.
.
Of note, he has had two complicated admissions this year. His
first admission, he had DVT, SHD [**1-15**] heparin gtt, sezures,
embolic stroke, poor mental status, inability to swallow, low
BP's, tachycardia, demand ischemia and PAD with distal ischemia.
He was then discharged to [**Hospital1 **]. He was readmitted a month
later on [**2180-2-29**] for ? PNA, with cough and SOB, initially tx'ed
with Vanc and Zosyn. He was also found to have a VRE UTI and was
treated with 14 days of Linezolid, finished [**2181-3-26**]. He also
developed a rash and eosinophilia which may have been due to
Zosyn. He was also in the CCU for hypotension, tachycardia, was
breifly on vasopression and amiodarone drip. Amiodarone was
eventually discontinued.
.
In the ED: The patient arrived in distress, tachpnic. Vitals on
arrival: temp 99, HR 115, BP 60/40 97% NRB. BP's ranged from
SBP's 60's -100's. Hr 130's, then [**Month (only) **] to 100's. When his BP's
dropped, he was started on fluids, levophed and had a right
femoral line placed; BP now 116/64. The patient was also
intubated for tachpnea and airway protection with copious
vomitous noted in his airways. He was started on fentanyl and
Versed for sedation. He was also noted to have loose stool in
the rectum. The patient was started on Zosyn/Vanc/Flagyl. Vitals
on transfer: HR 98, BP 116/74, on CMV FIO2 100%
Past Medical History:
HTN
thoracic and abdominal aortic aneurysm
h/o transitional cell bladder cancer
CKD
h/o lumbar laminectomy
tertiary hyperparathyroidism
BPH
DVT in the past, s/p IVC filter placement
bilateral cataracts s/p removal
glaucoma
s/p L TKR
?[**Name (NI) **] unclear per records
PVD ? Fem/[**Doctor Last Name **] bipass
Social History:
Formerly worked in family business, now retired. Was living
independently until [**12/2180**] hospitalization. More recently lived
in [**Hospital1 **].
Family History:
Non-contributory.
Physical Exam:
General: intubated, sedated
HEENT: + cataracts, dry MMM, no lesions noted in OP
Neck: supple, no JVD
Chest: left IJ, right subclavian HD line
Pulmonary: Lungs with diffuse rhonchi
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, subcutaneous
hematoma in RLQ
Extremities: 4+ edema, right foot with dry gangrene in toes as
well as a 5 cm patch gangrene on shins
Skin: no rashes or lesions noted.
Neurologic: intubated and sedated
Pertinent Results:
CXR:
1. Bibasilar opacification, with bilateral pleural effusion,
which could suggest bibasilar atelectasis, volume overload;
however, consolidation cannot be excluded.
2. ETT, NG and left IJ, and right central venous line in
appropriate
placement.
3. Right PICC line with tip terminating in the mid subclavian
vein.
.
KUB:
Nonspecific bowel gas pattern with no evidence of obstruction,
bowel wall thickening, pneumatosis or free air.
.
Micro: results returned after pt expired
- Blood: 3/4 bottles GNR
- BAL:
GRAM STAIN (Final [**2181-4-15**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2181-4-17**]):
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
GRAM NEGATIVE ROD #1. 10,000-100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #3. 10,000-100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #4. 10,000-100,000 ORGANISMS/ML..
.
Labs:
CBC
[**2181-4-15**] 09:55AM BLOOD WBC-37.5*# RBC-2.76* Hgb-8.2* Hct-27.3*
MCV-99* MCH-29.6 MCHC-29.9*# RDW-21.0* Plt Ct-315#
[**2181-4-15**] 01:29PM BLOOD WBC-4.2# RBC-2.76* Hgb-8.8* Hct-28.7*
MCV-104* MCH-31.7 MCHC-30.6* RDW-22.0* Plt Ct-272
[**2181-4-15**] 03:23PM BLOOD WBC-8.4# RBC-2.57* Hgb-7.9* Hct-26.0*
MCV-101* MCH-30.6 MCHC-30.3* RDW-21.0* Plt Ct-206
.
Coags
[**2181-4-15**] 09:55AM BLOOD PT-14.9* PTT-33.5 INR(PT)-1.3*
[**2181-4-15**] 01:33PM BLOOD PT-14.4* PTT-42.2* INR(PT)-1.3*
[**2181-4-15**] 03:23PM BLOOD Fibrino-320#
.
Chem 10
[**2181-4-15**] 09:55AM BLOOD Glucose-113* UreaN-65* Creat-2.5* Na-136
K-4.5 Cl-95* HCO3-26 AnGap-20
[**2181-4-15**] 01:29PM BLOOD Glucose-115* UreaN-64* Creat-2.4* Na-137
K-4.2 Cl-98 HCO3-24 AnGap-19
[**2181-4-15**] 01:29PM BLOOD Calcium-8.5 Phos-2.9 Mg-1.9
[**2181-4-15**] 03:23PM BLOOD Calcium-7.4* Phos-2.9
.
ABG
[**2181-4-15**] 01:54PM BLOOD Type-ART pO2-70* pCO2-79* pH-7.04*
calTCO2-23 Base XS--11
[**2181-4-15**] 02:40PM BLOOD Type-ART Temp-37.6 Rates-30/ Tidal V-380
PEEP-10 FiO2-100 pO2-65* pCO2-68* pH-7.09* calTCO2-22 Base
XS--10 AADO2-599 REQ O2-95 Intubat-INTUBATED Vent-CONTROLLED
[**2181-4-15**] 05:03PM BLOOD Type-ART pO2-44* pCO2-51* pH-7.26*
calTCO2-24 Base XS--4
MISC:
[**2181-4-15**] 09:55AM BLOOD ALT-15 AST-28 CK(CPK)-77 AlkPhos-110
TotBili-0.2
[**2181-4-15**] 09:55AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 19213**]*
[**2181-4-15**] 09:55AM BLOOD cTropnT-0.57*
[**2181-4-15**] 10:00AM BLOOD Lactate-2.8*
[**2181-4-15**] 01:46PM BLOOD Lactate-4.0*
[**2181-4-15**] 03:29PM BLOOD Lactate-4.8*
[**2181-4-15**] 05:03PM BLOOD Lactate-5.7*
[**2181-4-15**] 01:46PM BLOOD O2 Sat-68
[**2181-4-15**] 03:29PM BLOOD O2 Sat-80
[**2181-4-15**] 03:29PM BLOOD freeCa-1.06*
Brief Hospital Course:
The patient was admitted with aspiration pneumonia, sepsis and
respiratory failure. He was admitted on a ventilator and on
levophed. Initially, his BP was 90's/40's - not markedly off his
baseline. However, soon after admission to the ICU, his blood
pressures dropped precipitously to 60's/ 40's. Lactate started
rising. pH fell to low 7.0's. An a-line was placed. Bicarbonate
drip started. Vassopressin and then subsequently phenylephrine
were added to levophed. The patient was also given benadryl and
famotidine given the question of anaphlyaxis in the setting of
possible Zosyn allergy. However, the patient was not
bronchospastic and did not have hives. He was intially given
Vancomycin and Cefepime. Vanc changed to Linezolid as prior VRE.
PO Vanc added empirically for possible C.diff as pt was having
diarrhea and has been on abx recently.
.
An emergent bronchoscopy was performed, BAl obtained and
secretions suctioned out. The patient's abdomen was noted to
slightly firm but not rigid. A KUB showed mildly dilated
transverse colon. Given the concern for C.diff, rising lactate,
? dilated colon, surgery was consulted for evaluation of
megacolon. However, prior to the arrival of surgical consult,
the patient's condition deteriorated. The patient required
maximum doses of three pressors. Was receiving frequent IVF
bolusus. Albumin was given in an attempt to salvage his blood
pressure. Sedation was withheld to maximize pt's BP. In
addition, PEEP was decreased. However, with [**Month (only) **] PEEP the
patient's oxygenation deteriorated despite FiO2 100%.
.
The patient's son was at the patient's bedside the entire time.
The son indicated that the patient should be DNR, no
defibrillation or CPR. It was also decided with the patient's
family that surgery was not indicated as the source of sepsis
was most likely pulmonary and as surgery would most likely be
fatal. Per family request, the chaplain came to the patient's
bedside to perform last rites. Ultimately, the family chose to
withdraw care, stop pressors and give morphine for dyspnea. The
patient passed away quickly at 9:12pm. After the patient passed
away, sputum cx's returne with GNR's and blood cx's returned
with 3/4 bottles GNR's, making GNR sepsis from PNA the final
diagnosis.
Medications on Admission:
Home Medications:
Latanoprost 0.005 % Drops [**Month (only) **]: One (1) Drop Ophthalmic HS
Levetiracetam 500 mg [**Hospital1 **]
Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Timolol Maleate 0.5 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **]
Simvastatin 80 mg DAILY
Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Omeprazole 20mg daily
Xenaderm Ointment q 12hrs to gangrene
Heparin (Porcine) 5,000 TID
Oxycodone 5 mg/5 mL Solution [**Hospital1 **]: Five (5) mg PO Q4H
Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every eight hrs
Calcium 500 mg Tablet TID
Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
Fentanyl 75 mcg/hr Patch 72 hr One (1) patch Transdermal every
seventy-two (72) hours.
Bacitracin ointment
Citalopram 10mg daily
Collagenase q 12hr sto sacral sound
Darbepoetine alfa 200mg q Wednesday
Midodrine 15mg prior to HD
Sodium bicarbonate 10cc with omperazole
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis
Discharge Condition:
expired
ICD9 Codes: 2762, 4589, 5859, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7576
} | Medical Text: Admission Date: [**2115-7-4**] Discharge Date: [**2115-7-19**]
Date of Birth: [**2052-12-23**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
R-sided chest pain, SOB
Major Surgical or Invasive Procedure:
Left-sided thoracentesis
History of Present Illness:
62M with T3, N0, M0 (stage IIb) recurrent esophageal
adenocarcinoma s/p neoadjuvant chemoradiation [**2114-1-4**], then
esophagectomy 5/[**2113**]. He had a positive margin on the surgical
resection and has undergone palliative chemo with
epirubicin/oxaliplatin/5FU x 5cycles starting 5/[**2113**]. Started
palliative taxotere [**2115-1-24**] - C5D1 [**2115-5-30**], C6D1 held today. Pt
admitted from clinic for R-sided chest pain and SOB. Pt with h/o
of bilateral pleural effusions s/p L thoracentesis [**5-29**],
cytology neg. Pt on lasix after thoracentesis and did better for
a period of time, but worsening the past couple of weeks. Pt
sent for CTA chest today: neg for PE, showed reaccumulation of
large bilateral pleural effusions.
Pt reports R-sided chest pain x2-2.5wks. Reports pain constant,
[**4-11**] at baseline and increases with movement and deep
inspiration. Pain [**9-11**] with [**Month/Year (2) **]. Pt reports chest pain
located over R anterior chest with radiation around to the back.
Pt also with dry [**Month/Year (2) **] for same time period. Pt reports SOB at
rest, worse with exertion. Pt also reports PND, orthopnea. No LE
edema or pain. No fevers/chills, n/v, abdominal pain. Eating
poorly but enough to maintain weight. Pt reports seen in clinic
[**6-27**] and given robitussin but no improvement in [**Last Name (LF) **], [**First Name3 (LF) **] no
longer taking it. Pt also recently treated for thrush with
nystatin swish and swallow, but no longer taking.
On arrival to the floor, pt reports continued R-sided chest pain
and SOB.
Past Medical History:
ONCOLOGIC HISTORY:
Mr. [**Known lastname 26973**] presented with a sensation of food getting stuck in
his chest in the fall of [**2112**]. Barium swallow demonstrated a
stricture in the distal esophagus. ECG demonstrated
circumferential narrowing and thickening at the GE junction (40
cm), and extended proximally to 35 cm. Biopsies were performed
and pathology demonstrated adenocarcinoma, mucin-producing with
few signet ring cells, moderately differentiated. He underwent
PET/CT scan [**2113-12-31**], which showed FDG uptake in the GE junction
but no evidence of regional or distant metastases. He was
referred for EUS staging, performed on [**2114-1-5**], which
demonstrated
a mass at the distal esophagus/GEJ consistent with known
adenocarcinoma, maximum depth 1 cm, with extension beyond the
muscularis propria. There were no concerning lymph nodes
identified. By EUS, the tumor was staged as T3N0Mx, Stage IIB
esophageal adenocarcinoma.
.
He began concurrent chemoradiation with cisplatin/5-FU on
[**2114-1-23**]. He had a J-tube placed prior to treatment. His last
radiation treatment was on [**2114-3-1**], total dose 5040 cGy. His
last
cycle of chemotherapy (C2D1) was [**2114-2-19**]. He underwent
[**Month/Day/Year 12351**]-[**Doctor Last Name **] esophagectomy [**2114-4-25**] which demonstrated residual
disease, including a positive proximal margin. Surveillance
endoscopy demonstrated friable and nodular distal esophagus and
biopsy demonstrated adenocarcinoma.
.
[**2114-9-3**] C1D1 Epirubicin, Oxaliplatin, 5-fluorouracil (5-FU given
by continuous infusion pump Mon-Fri x96 hours given his
difficulty swallowing pills)
[**2114-9-24**] C2D1 Epirubicin, Oxaliplatin, 5-fluorouracil
.
PAST MEDICAL HISTORY:
-Myocardial infarction in [**2101**] treated with plain old balloon
angioplasty to one vessel and a stent in another vessel.
-Open gall bladder surgery
-Kidney stones
-Osteoarthritis: mainly neck and right knee
-Low back injury
-GERD
Social History:
Married to his wife of 40 years. two children, & two
grandchildren.
He works in software and customer teaching for an electronic
access device maker.
Smoked half a pack to pack a day for approximately 30 years, but
quit in [**2101**] with his heart attack. He does not drink alcohol
regularly.
Family History:
Parents both died of heart attack. He has a sister who has had
breast cancer twice and a brother with diabetes.
Physical Exam:
Admission PE:
Vitals - T: 98.3 BP: 114/68 HR: 98 RR: 18 sat: 100% RA
GENERAL: sitting up in bed, pleasant, in NAD
HEENT: AT/NC, PERRLA, anicteric sclera, pink conjunctiva, patent
nares, MMM, a few small white plaques on R side inside mouth,
nontender supple neck, no cervical/supraclavicular/axillary LAD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: speaking in short sentences, tachypneic, inspiratory rales
on R > L, decent air movement bilaterally
CHEST: anterior chest tender to palpation around ribs [**2-3**] on the
right
ABDOMEN: nondistended, decreased BS, nontender
EXTREMITIES: no LE edema or tenderness
NEURO: 5/5 strength in UE and LE bilaterally, sensation to light
touch intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge PE:
VS: Tc-98, HR 110-120s, BP 98-110s/60-70s, RR 20-22, 94-100% RA
I/O: 770(PO) + 737(IV)/1575 + 525 from L pleurex
GENERAL: Chronically ill appearing gentleman, pleasant, in no
acute distress
HEENT: thrush resolved, dry MM
CHEST: inpsiratory rales at L base but improved BS on L
compared to prior, coarse inspiratory rales on the R throughout,
decent air movement, pigtail on L capped
CARDIAC: Tachycardic, regular rhythm, no MRG
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: 1+ LE edema with support stockings on; edema of L
arm slightly increased with clear demarcation just proximal to
the elbow
Pertinent Results:
Admission Labs:
[**2115-7-4**] 08:50AM UREA N-16 CREAT-0.6 SODIUM-138 POTASSIUM-3.9
CHLORIDE-102 TOTAL CO2-29 ANION GAP-11
[**2115-7-4**] 08:50AM ALT(SGPT)-7 AST(SGOT)-19 ALK PHOS-77 TOT
BILI-0.7
[**2115-7-4**] 08:50AM CALCIUM-8.4 PHOSPHATE-2.1* MAGNESIUM-1.8
[**2115-7-4**] 08:50AM WBC-13.5* RBC-4.10* HGB-11.3* HCT-35.3*
MCV-86 MCH-27.6 MCHC-32.0 RDW-16.4*
[**2115-7-4**] 08:50AM PLT COUNT-347
[**2115-7-4**] 08:50AM GRAN CT-[**Numeric Identifier 26974**]*
MICRO
Pleural [**Numeric Identifier 26975**]:
[**2115-7-4**] 6:13 pm PLEURAL [**Month/Day/Year **] **FINAL REPORT [**2115-7-10**]**
GRAM STAIN (Final [**2115-7-4**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
[**Month/Day/Year **] CULTURE (Final [**2115-7-7**]): NO GROWTH.
[**2115-7-5**] 11:35 am PLEURAL [**Month/Day/Year **] **FINAL REPORT [**2115-7-10**]**
GRAM STAIN (Final [**2115-7-5**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
[**Month/Day/Year **] CULTURE (Final [**2115-7-10**]):
LACTOBACILLUS SPECIES. RARE GROWTH.
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. RARE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # 352-0143D [**2115-7-6**].
ANAEROBIC CULTURE (Final [**2115-7-10**]): NO ANAEROBES ISOLATED.
[**2115-7-6**] 4:00 am BLOOD CULTURE No growth x2
[**2115-7-6**] 2:52 pm PLEURAL [**Year (2 digits) **]
GRAM STAIN (Final [**2115-7-6**]):
Reported to and read back by [**First Name8 (NamePattern2) 26976**] [**Last Name (NamePattern1) **] @ 7PM [**2115-7-6**] .
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
[**Month/Day/Year **] CULTURE (Preliminary):
LACTOBACILLUS SPECIES. MODERATE GROWTH.
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. MODERATE
GROWTH.
Susceptibility testing requested by [**First Name9 (NamePattern2) **] [**Doctor Last Name **] #[**Numeric Identifier 26977**]
[**2115-7-12**].
ANAEROBIC CULTURE (Final [**2115-7-10**]): NO ANAEROBES ISOLATED.
[**2115-7-8**] 1:35 pm PLEURAL [**Month/Day/Year **] **FINAL REPORT [**2115-7-13**]**
GRAM STAIN (Final [**2115-7-9**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
[**Month/Day/Year **] CULTURE (Final [**2115-7-13**]):
LACTOBACILLUS SPECIES. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2115-7-13**]): NO ANAEROBES ISOLATED.
IMAGING:
TTE [**2115-7-19**]: Moderate circumferential pericardial effusion. No
clear-cut evidence of tamponade physiology. However, the
presence of tachycardia and relatively small chamber sizes along
with hyperdynamic left ventricular systolic function is
suggestive of poor diastolic filling. Compared with the prior
study (images reviewed) of [**2115-7-9**] and [**2115-7-8**], the findings are
similar.
CT Chest [**2115-7-18**]:
Moderate layering nonhemorrhagic left pleural effusion is larger
today than on [**7-11**]. Left pleural catheter enters laterally,
traverses the major fissure and ends superiorly alongside the
spine at the level of the fourth posterior interspace. No left
pneumothorax:
Moderate-to-large right pleural effusion is larger, particularly
in the right lower and anterolateral hemithorax where [**Month (only) **] now
replaces previous air component. Fissural and paramediastinal
components of the moderate-to-large right pleural effusion have
also increased. More extensive ground-glass opacification in the
upper aspect of the right lower lobe which is still consolidated
at the base could be edema associated with pleural [**Month (only) **]
interfering with lymphatic milking due to pleural restriction
that prevents ventilatory change in lobar volume, however, could
also be progression of pneumonia even though cavitation present
previously has not worsened. The residual esophagus or upper
neoesophagus is still distended above the alimentary stent,
which though unchanged in position, roughly from the level of
the T5-T9 is still largely occluded with semisolid material.
Large pericardial effusion, also nonhemorrhagic, is larger. The
superior vena cava above the pericardial reflection is larger
than the intrapericardial segment, and the right atrium and
ventricle are both smaller today than on [**7-11**], warranting
evaluation for possible early cardiac tamponade.
Mild atelectasis in the lingula and left lower lobe are probably
due to
ventilatory compromise by the larger left pleural effusion.
Left-sided central venous line ends at the superior cavoatrial
junction.
Atherosclerotic coronary calcification is heavy in the left
main, anterior descending and circumflex vessels.
Discharge Labs:
[**2115-7-19**] 06:12AM BLOOD WBC-7.6 RBC-3.58* Hgb-9.5* Hct-29.5*
MCV-82 MCH-26.6* MCHC-32.3 RDW-18.2* Plt Ct-328
[**2115-7-19**] 06:12AM BLOOD Glucose-112* UreaN-7 Creat-0.4* Na-137
K-3.5 Cl-101 HCO3-34* AnGap-6*
[**2115-7-19**] 06:12AM BLOOD Calcium-7.8* Phos-2.3* Mg-1.7
Brief Hospital Course:
62M with T3, N0, M0 (stage IIb) recurrent esophageal
adenocarcinoma s/p neoadjuvant chemoradiation [**2114-1-4**], then
esophagectomy [**4-/2114**] admitted from clinic with R-sided CP and
SOB. CTA showing reaccumulation of large bilateral pleural
effusions.
.
Active diagnoses:
#Bilateral pleural effusions, R-sided empyema: CT on admission
showed large bilateral pleural effusions, with the right one
being loculated, which had reaccumulated from prior drainage
6/[**2114**]. Pigtail placed on L [**2115-7-4**] by IP with pleural [**Month/Day/Year **]
exudative, cytology neg, no growth from culture. Pt had R
pigtail placed [**2115-7-5**] by IP with pleural [**Month/Day/Year **] exudative,
cytology neg, culture with rare growth of lactobacillus and
STREPTOCOCCUS ANGINOSUS. Pt transferred to [**Hospital Unit Name 153**] for hypotension
(SBP to 80s) and tachycardia [**2115-7-5**]. Pt started on Vanc and
ceftriaxone initially. Because of the potential for sepsis,
Ceftriaxone was broadened to Cefepime. Bl cultures from [**2115-7-6**]
negative x2. A repeat gram stain of the right pleural [**Month/Day/Year **] was
sent, which showed polymicrobial results. Flagyl was added.
This repeat pleural [**Month/Day/Year **] culture from R on [**2115-7-6**] with moderate
growth of lactobacillus and STREPTOCOCCUS ANGINOSUS. Chest tube
placed on R [**2115-7-8**] with pleural [**Month/Day/Year **] culture without growth.
Given the concern for an esophageal-pleural fistula, a CT thorax
with PO contrast was done on [**7-7**] which was inconclusive, so an
esophagram was performed on [**7-9**] that did not show evidence of
esopahgeal leak. R sided pleural effusion loculations and
bacterial growth concerning for empyema. In pt with h/o
bilateral effusions with reaccumulation, seems that pt likely
infected preexisting effusions. Bacteria are consistent from
oral flora per ID. This suggests microaspiration caused
infection and organization of R pleural effusion. Cytology has
been repeatedly negative. R sided effusion/empyema concerning
for abscess or necrotizing pneumonia per CT chest [**2115-7-11**].
Initial etiology of pt's pleural effusions still unclear since
cytology consistently negative but known to reaccumulate. L
effusion exudative but does not appear infected on pleural [**Month/Day/Year **]
culture. Bl cx neg. The patient was seen by Thoracic Surgery as
well as Interventional Pulmonology. The tubes continued to
[**Month/Day/Year 19843**] serosanguinous [**Month/Day/Year **] with intermittent instillations of
alteplase and dronase. Thoracic surgery felt intervention would
not be beneficial given his overall clinical picture. ID was
consulted and pt was switched to meropenem monotherapy [**2115-7-11**]
with plan for 4wk IV ABX course (starting [**2115-7-8**]). Pt to be
discharged on IV ertapenem q24h with plan to follow-up with ID
and complete at minimum of 4wk course ([**2115-8-5**]). On [**2115-7-14**], L
pigtail exchanged for pleurex. [**2115-7-15**] smaller R pigtail removed
by IP. On [**7-17**], pt accidentally pulled remaining R chest tube.
Pt had CT chest to evaluate if repeat pigtail needed to be
placed. IP reported no need for placing another chest tube on
the R. They want to follow-up with repeat chest CT and then appt
in clinic to evaluate if reaccumulation occurs to require a
chest tube. Pt with small PTX after L tube exchanged. Persisted
for many days. L tube capped with plan for intermittent drainage
M, W, F up to 1L each time. Again, thoracic surgery was
contact[**Name (NI) **] regarding possibility of intervention based on CT
chest [**7-17**]. They reported they did not feel he would benefit
from decortication based on mainly parenchymal abnormalities on
imaging.
.
#Pericardial effusion: The patient had a TTE that noted an
approximately 1cm effusion located posteriorly but had no
echocardiographic signs of tamponade. His pulsus paradoxus
remained approximately 6-8 mmHg during his ICU stay. Cardiology
recommended following the effusion with a repeat echo in 2 weeks
(~[**2115-7-23**]). Pt found to have slight increase in pericardial
effusion on chest CT [**7-17**], so TTE completed [**7-18**]. Showed
moderate effusion without clear tamponade physiology. Talked to
cardiology about poor diastolic filling on repeat TTE from [**7-18**]
and they said that without clear tamponade physiology they did
not want to do a pericardiocentesis. Patient will follow-up with
cardiology on [**8-1**] as an outpatient.
.
#Hypotension: The patient occasionally became hypotensive with
systolics in the high 80s. His hypotension responded well to
boluses of NS. His antihypertensive medications were held. His
SBPs came up to 100-120 range. BP meds continue to be held on
discharge.
.
#Tachycardia: Pt remained tachycardic throughout hospital stay.
HR in 100-110s mostly with occasional elevation to 120s.
.
#Thrush: pt put on fluconazole on admission because of inability
to tolerate nystatin secondary to severe worsening of GERD.
Thrush resolved during hospital stay.
.
#Edema: from IVF, pt was positive during admission resulting in
LE edema. Pt also developed asymmetric edema of L arm distal to
the elbow. Pt had duplex U/S on [**7-14**] which was neg for DVT. L
arm edema worsened, so pt had repeat duplex U/S on [**7-18**]. ACE
wraps started on L arm to mobilize [**Month/Year (2) **].
.
Chronic diagnoses:
# Recurrent esophageal adenocarcinoma: s/p C5D1 [**2115-5-30**], cycle 6
held [**7-4**]. Continued pain mgmt, nausea mgmt, home ativan.
# CAD s/p MI: Continued home [**Month/Day (2) **], atenolol held for low BPs.
# GERD: continued home PPI
Transitional issues:
# Pt to f/u with ID in [**Hospital 4898**] clinic, IP with plan for repeat
chest CT prior to appt, cards for pericardial effusion f/u
# Pt will also f/u with OP oncologist, Dr. [**Last Name (STitle) 3274**]
# Pt will require weekly lab draws: CBC with diff, Chem7, AST,
ALT; please fax results to ([**Telephone/Fax (1) 4591**]. All questions
regarding outpatient parenteral antibiotics should be directed
to the Infectious Disease R.N.s at ([**Telephone/Fax (1) 21403**] or to the
on-call ID fellow when the clinic is closed.
# Full Code
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Aspirin 325 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Fentanyl Patch 25 mcg/hr TP Q72H
4. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
5. FIRST-Mouthwash BLM *NF* (lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **])
200-25-400-40 mg/30 mL Mucous Membrane TID
6. Lorazepam 0.5 mg PO Q4H:PRN nausea, insomnia
7. Ondansetron 8 mg PO Q12H:PRN nausea
8. Naproxen 500 mg PO Q12H:PRN pain
Discharge Medications:
1. Fentanyl Patch 25 mcg/hr TP Q72H
2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
3. Lorazepam 0.5 mg PO Q4H:PRN nausea, insomnia
4. Naproxen 500 mg PO Q12H:PRN pain
5. Aspirin 325 mg PO DAILY
6. FIRST-Mouthwash BLM *NF* (lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **])
200-25-400-40 mg/30 mL Mucous Membrane TID
7. Ondansetron 8 mg PO Q12H:PRN nausea
8. ertapenem *NF* 1 gram Intravenous daily
end date earliest [**2115-8-5**] - or longer per ID recommendation
9. Docusate Sodium 100 mg PO BID
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
hold for sedation, RR <12
11. Senna 1 TAB PO BID:PRN constipation
12. HYDROmorphone (Dilaudid) 1-2 mg IV QMWF PRN for pain from
chest tube drainage
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Bilateral Pleural effusions
Right empyema
Secondary diagnosis:
Recurrent esophageal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 26973**],
It was a pleasure taking care of you at [**Hospital3 **]. You came
into the hospital because of right-sided chest pain and
shortness of breath. Your pleural effusions were found to be
increased on the CT scan of your chest. We had the lung doctors
[**Name5 (PTitle) 19843**] the [**Name5 (PTitle) **] from your left lung and leave in a [**Name5 (PTitle) 19843**]. They
then drained the right lung as well and left a [**Name5 (PTitle) 19843**] in place. A
repeat CT scan on [**7-11**] showed that the infection in your lung had
not gotten better. You had a third drainage tube placed in your
right lung. Your two right lung drains were removed. The chest
tube in your left chest will remain in place and will be drained
every M, W, F up to 1L each time.
Your home medications were not changed. Please see the attached
list for new medications added to your regimen.
Please follow-up at the appointments listed below.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2115-8-1**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2115-8-6**] at 10:00 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2115-8-9**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2115-8-16**] at 9:45 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY/Interventional Pulmonology
When: THURSDAY [**2115-8-22**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**You will get a repeat chest CT on this same day [**2115-8-22**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2115-7-19**]
ICD9 Codes: 5119, 412, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7577
} | Medical Text: Admission Date: [**2182-10-30**] Discharge Date: [**2182-11-26**]
Date of Birth: [**2122-3-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Actos / Percocet / Cephalosporins
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Epigastric pain and shortness of breath
Major Surgical or Invasive Procedure:
Intubated
IABP
RIJ
History of Present Illness:
Mr. [**Known lastname **] is a 60 y.o male with a history of nonischemic
cardiomyopathy with an ejection fraction of 20% and ICD who
presented to [**Hospital6 **] with epigastric chest
pain and shortness of breath. At [**Hospital1 487**], he was found to have
a left bundle branch block that was not known to be old and as
such was taken to the cath lab. The LBBB was later noted to be
old, however during cath he was noted to have a total occlusion
to the OM2 as well as 2 tight lesions in the RCA. Of note, the
patient had been found to have inferior septal ischemia on a
stress test during outpatient workup.
In the cath lab, the patient subsequently developed acute
shortness of breath, at which point he was given 100mg of lasix
and started on a nitroglycerin drip. His symptoms did not
improve, at which point he was intubated and an intra-aortic
balloon pump was placed through right femoral access. He also
received angiomax and 300mg of clopidogrel. A swan was placed
which showed elevated pulmonary artery pressures and wedge
pressures between 37-44. Laboratory exam at [**Hospital1 487**] was
significant for Na 129, K 4.1, BUN 53, Cr 1.3, hemoglobin 16.6
and platelets of 135. Her PT was 19.4 and INR was 1.8. Dig level
of 0.8, and cardiac enzymes significant for CK of 135, MB of 7
and Troponin of 0.08 which was negative in their reference
range.
.
Review of systems could not be obtained due to intubation.
Past Medical History:
CARDIAC HISTORY: Positive for non-ischemic cardiomyopathy with
ejection fraction 16%.
-PACING/ICD: VVI AICD implated on [**2180-4-26**]
3. OTHER PAST MEDICAL HISTORY:
Diabetes type II on insulin
Hypercholesterolemia
Peripheral neuropahty
Hypertriglyceride
CHF
Afib
Dilated non-ischemic cardiomyopathy
Multinodule goitor likely due to amiodarone
Past surgical history:
Appy
Chole
Epigastric hernia repair
Tonsillectomy
AICD/pacemaker implanted [**2180-4-8**]
.
Social History:
-Tobacco history: Former smoker
-ETOH: no etoh
Is not married.
Family History:
Father died with rectal cancer
Mother has [**Name2 (NI) **] of colon ca, rheumatic valvular dz
Physical Exam:
PHYSICAL EXAMINATION on Admission:
VS: T=97.5 BP= 87/38 HR=89 RR=16 O2 sat=100% on 500/18/5/40
GENERAL: Intubated, sedated.
HEENT: NCAT. Sclera anicteric. PERRL, Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
CARDIAC: Fast, irregular, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Diffusely rhonchorous with crackles throughout.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace lower extremity edema. Right femoral sheath
introducer sheeth and swan in place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Radial, DP 2+ bilaterally.
.
Pertinent Results:
Admission Labs:
[**2182-10-30**] 11:04PM BLOOD WBC-12.7* RBC-4.68 Hgb-15.5 Hct-44.1
MCV-94 MCH-33.1* MCHC-35.1* RDW-17.0* Plt Ct-157
[**2182-10-30**] 11:04PM BLOOD Neuts-83.9* Lymphs-10.4* Monos-4.5
Eos-0.6 Baso-0.6
[**2182-10-30**] 11:53PM BLOOD PT-33.4* PTT-150* INR(PT)-3.4*
[**2182-10-30**] 11:04PM BLOOD Plt Ct-157
[**2182-10-30**] 11:04PM BLOOD Glucose-243* UreaN-54* Creat-1.6* Na-133
K-4.4 Cl-96 HCO3-29 AnGap-12
[**2182-10-30**] 11:04PM BLOOD ALT-22 AST-31 LD(LDH)-313* CK(CPK)-126
AlkPhos-89 TotBili-0.3
[**2182-10-30**] 11:04PM BLOOD CK-MB-10 MB Indx-7.9* cTropnT-0.17*
[**2182-10-30**] 11:04PM BLOOD Calcium-7.9* Phos-5.3* Mg-1.9
[**2182-10-30**] 11:04PM BLOOD TSH-3.9
.
STUDIES:
CHEST (PORTABLE AP) Study Date of [**2182-10-30**]
Large right upper lobe opacity is consistent with a right upper
lobe collapse. The NG tube tip is in the distal right mainstem
bronchus. The aortic balloon pump tip is 2.4 cm from the aortic
arch. ET tube tip is 2.3 cm above the carina. Swan-Ganz catheter
from inferior approach is in the main right pulmonary artery.
Left transvenous pacemaker lead terminates in the standard
position in the right ventricle. There is moderate-to-severe
cardiomegaly. Left perihilar and left upper lobe opacities
could be atelectasis or infection. There is gastric distention.
There is mild shifting of the cardiomediastinum towards the
right side.
.
Portable TTE (Complete) Done [**2182-10-31**]
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
There is severe global left ventricular hypokinesis (LVEF = 15
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular chamber size is
normal. with normal free wall contractility. The aortic valve
leaflets are mildly thickened (?#). There is mild aortic valve
stenosis (valve area 1.5 cm2). The aortic stenosis is likely the
"low flow/low gradient" type. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
CT Ab/Pelvis [**2182-11-13**]
1. Findings suggestive of mild-to-moderate pulmonary edema. More
focal small nodular opacities within the lungs as described
above may represent focal regions of underlying
pneumonitis/pneumonia, possibly aspiration related in this
patient with distal trachea secretions. Small right simple
pleural effusion. Follow up CT chest in [**4-13**] months recommended
to confirm nodular opacity resolution.
2. No definite source of infection noted within the
abdomen/pelvis. No
biliary ductal dilatation.
3. Moderate sized right piriformis collection, probably
intramuscular
hematoma, particularly in the setting of anticoagulation
(infected collection cannot be excluded).
4. Dense atherosclerotic calcifications involving the aorta and
coronary
tree. Cardiac enlargement dilatation of both the left ventricle
and left
atrium.
.
CARDIAC CATH [**2182-11-21**]
1.Selective coronary angiography in this right dominant system
demonstrated two vessel coronary artery disease. The LMCA was
free of
angiographically-apparent disease. The LAD was heavily
calcified with
mild luminal irregularities. The LCx had a short total
occlusion in the
mid CX into the OM2 which filled via collaterals from the OM1
and LAD.
The RCA had severe diffuse calcific diesease with calcific
70-80%
stenoiss in the proximal vessel, distal 50% stenosis adn 99%
calcific
stenosis at the RPDA/RPL bifurcation.
2.Resting hemodynamics revealed normal right and left sided
filling
presures with RVEDP 13 mmHg and PCWP 12 mHg. The cardiac index
was
preserved at 2.6 l/min/m2. There was mild systolic hypotension
SBP 87
mmHg.
3. Left ventriculography was deferred.
4. Successful PCI of RCA lesions with rotablation and DES via R
radial
approach and balloon pump support
5. Unsuccessful PCI of the OM.
6. Secondary prevention of CAD
7. Plavix 75mg daily for 12 months
8. Monitor for signs of left leg ischemia
9. Follow creatinine and HCT
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful PCI to RCA with rotablation and IABP support.
3. Unsuccessful PCI of the OM.
4. Successful removal of IABP.
.
DISCHARGE LABS:
Na 134, K 4.8, BUN 35, Creat 1.2, WBC 3.7, HCT 27, HGB 8.9, plt
116, INR 1.6
.
ECHO [**11-25**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is severely
dilated. There is severe global left ventricular hypokinesis
with near akinesis of the inferior septum, inferior, and
inferolateral wall. The anterior wall and anterior septum
contracts best, but are hypokinetic. Global systolic function is
severely depressed. (LVEF = 20 %). No masses or thrombi are seen
in the left ventricle. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Trace 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 mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior study (images unavailable for review) of
[**2182-10-31**], left ventricular systolic function is similar. Mild
mitral regurgitation is now seen.
.
Micro data: (unless noted positive, result is negative)
[**2182-11-13**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2182-11-12**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL;
TOXOPLASMA IgM ANTIBODY-FINAL INPATIENT
[**2182-11-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-11**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-11**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-11**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-9**] CATHETER TIP-IV WOUND CULTURE-FINAL
INPATIENT
[**2182-11-9**] CATHETER TIP-IV WOUND CULTURE-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE
NEGATIVE} INPATIENT
[**2182-11-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-11-8**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE};
BLOOD/AFB CULTURE-FINAL; Myco-F Bottle Gram Stain-FINAL
INPATIENT
[**2182-11-8**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-FINAL INPATIENT
[**2182-11-7**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL;
TOXOPLASMA IgM ANTIBODY-FINAL INPATIENT
[**2182-11-7**] Immunology (CMV) CMV Viral Load-FINAL
INPATIENT
[**2182-11-7**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG
AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **]
VIRUS VCA-IgM AB-FINAL INPATIENT
[**2182-11-7**] SEROLOGY/BLOOD VARICELLA-ZOSTER IgG
SEROLOGY-FINAL INPATIENT
[**2182-11-7**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG
AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **]
VIRUS VCA-IgM AB-FINAL INPATIENT
[**2182-11-7**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV
IgM ANTIBODY-FINAL INPATIENT
[**2182-11-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-11-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-6**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-5**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-3**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-3**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-3**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-11-3**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2182-11-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-1**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-10-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-10-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-10-30**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
Brief Hospital Course:
60 year old man who presented to an outside hospital emergency
room with epigastric pain and shortness of breath, who was
subsequently taken to the cath lab after being found to have a
LBBB which was later demonstrated to be old. The patient
subsequently became dyspneic in the cath lab, was intubated,
became hypotensive, and an IABP was placed with phenylephrine
started. He was subsequently transferred to the [**Hospital1 18**] CCU for
further care.
.
# Shock and Dyspnea: The patient initially had elevated
biventricular elevated filling pressures, increased cardiac
output and low SVR. He was therefore thought to have
distributive shock with potential sepsis. Our initial chest
x-ray after new OG tube placement showed a collapsed right upper
lobe of his lung which later resolved after replacement of the
OG tube. He was pan-cultured and started on broad spectrum
antibiotics including Vancomycin and Zosyn, later switched to
Vancomycin, Cefepime, and Ciprofloxacin. His pressors remained
marginal, and he required levophed to maintain MAPs >65. Due to
persistently adequate cardiac output readings from his Swan, his
intra-aortic balloon pump and Swan were removed. Repeat chest
x-rays showed pulmonary edema and acute exacerbation of his
systolic congestive heart failure. Extubation was attempted on
[**2182-11-1**], but afterwards his oxygenation decreased acutely most
likely secondary to flash pulmonary edema. He failed a trial of
BiPAP and became acutely agitated, requiring emergent
re-intubation. He was subsequently aggressively diuresed with
IV boluses of furosemide in addition to a furosemide drip with
metolazone. After the initial diuresis, he was transitioned to
Torsemide PO and developed hyponatremia. The Torsemide dose was
adjusted to 10 mg and he appears to be at his dry weight today
of 200 pounds. He is ambulating on RA with O2 sats in high 90's,
no peripheral edema and clear lung sounds. Given his very low
EF, he should be started in spironolactone and digoxin as his BP
allows. Please weight daily and adjust diuretics to maintain
weight at 200 pounds. He is being considered for a heart
transplant and transplant workup was started during this
hospital stay. He will follow up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] and
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP here for continued workup and evaluation.
.
# Coronary artery disease: The patient had evidence of a
reperfusion defect on recent SPECT stress test and evidence of
tight lesions in RCA from his cardiac catheterization at the
outside hospital. His troponins were mildly elevated which could
have represented demand ischemia and/or congestive heart
failure, but less likely acute coronary syndrome. His ECG
showed a LBBB that remained unchanged throughout his CCU stay.
He was medically managed with 48 hours of a heparin drip, full
dose aspirin, atorvastatin 40mg daily, loaded with 300mg plavix
and then given plavix 75mg daily. He underwent catheterization
prior to discharge with stenting of an RCA lesion (see cath
report.) Note that in the setting of a heparin gtt, the patient
developed a piriformis hematoma; his HCT remained stable.
.
# Atrial fibrillation and Ventricular Tachycardia: The patient
was persistently in atrial fibrillation and had several episodes
of ventricular tachycardia prompting firing of his ICD. His
beta blocker was held secondary to his hypotension requiring
pressors. He was seen by our electrophysiology team and
received a AV nodal ablation following by a BiV pacer upgrade.
He has been restarted on his betablocker at a lower dose and
amiodarone was loaded. He has had no further VT within the last
4-5 days and he is [**Age over 90 **]% AV paced on telemetry.
.
# Acute renal failure: This was most likely secondary to poor
forward flow in the setting of an acute on chronic systolic CHF
exacerbation. His lisinopril was held, medications were renally
dosed and his renal function improved with diuresis. ACEi was
restarted before discharge at lower dose.
.
# Diabetes mellitus type 2: The patient was maintained on
glargine and an ISS without complications. Metformin was d/c'ed
because of his CHF. His glargine may need to be uptitrated as
his appetite improves. Please continue to do fingerstickes
before meals with Humalog insulin coverage per sliding scale.
.
#Transaminitis: LFTs trending down. Thought to be secondary to
poor forward flow with CHF exacerbation. Statin has been
restarted.
.
# Anemia: Hct has slowly trended down during hospital stay. He
has no evidence of acute bleeding at present and piriformis
hematoma development did not seem to drop his hct precipitously.
It is thought that anemia a combination or phlebotomy, ARF and
critical illness. His hct should be monitored and iron studies
sent if hct/hgb continues to drop. Stools should be Guiaiced.
.
# Hyponatremia: now resolved. Thought secondary to overdiuresis.
Torsemide dose has been adjusted and should be titrated to
maintain dry weight of 200 pounds.
.
# Social: Patient lives alone with an elderly aunt and uncle as
[**Name2 (NI) **] supports.He was functionally independent before admission
and goal is to return to this.
Medications on Admission:
Home medications
Aspirin 81mg daily
lipitor 40mg daily
lisinopril 40mg qd
lopressor 150mg [**Hospital1 **]
digoxin 0.375mg MWF, 0.25mg TTSS
furosemide 160mg [**Hospital1 **]
metolazone 2.5 qweek
Gemfibrozil 600mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
lantus 48 units qd
multivitamin
coumadin 5mg TWFSS, 7.5mg MT
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not skip doses or stop taking unless Dr. [**Last Name (STitle) **] says
it is OK.
Disp:*30 Tablet(s)* Refills:*11*
6. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Insomnia.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. torsemide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold for SBP < 70.
11. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
12. insulin lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous three times a day: before meals.
13. warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X per week
(Sun, Tues, Wed, Fri): Please check INR on Thursday [**11-28**].
14. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 3X/week
(Mon, Thurs, Sat).
15. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. multivitamin Tablet Sig: One (1) Tablet PO once a day.
17. Outpatient Lab Work
[**Last Name (un) 6267**] check IR, PT, CBC and Chem 7 on [**2182-11-28**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Atrial fibrillation s/p AV node ablation
Acute on chronic systolic congestive heart failure
Anemia
Hypothyroidism
Ventricular Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of you in the hospital. You were
admitted for heart failure and required a lengthy stay in the
ICU. During your time in the ICU you were intubated and had
pneumonia. Also, three important procedures were performed.
First, you had an AV nodal ablation which allowed your heart to
beat more slowly. Second, you had a revision to your pacer to
help your heart work better. Finally, you had a catheterization
of your heart during which stents were placed to open blocked
vessels.
You should make the following changes to your medications:
CHANGE THE FOLLOWING DOSES:
- Change aspirin 81 mg daily to aspirin 325 mg daily
- Change Lisinopril 40 mg daily to Lisinopril 5 mg daily
- Change Metoprolol 150 mg [**Hospital1 **] to Toprol XL 12.5 mg daily
- Change Furosemide to torsemide 10 mg daily
STOP THE FOLLOWING MEDICATIONS:
- Digoxin, Metolozone, metformin, spironolactone
START THE FOLLOWING NEW MEDICATIONS:
- Plavix to keep the stents open. You will need to take this
medicine every day for at least one year with a 325 mg aspirin.
Do not stop taking these medicines unless Dr. [**First Name (STitle) 437**] tells you it
is OK.
- Start Amiodarone to control your heart rhythm
- Start Trazadone to help you sleep
- start senna as needed if you get constipated.
- Ranitidine to protect your stomach from the Plavix and
aspirin.
Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
Please go to all of the recommended followup appointments that
are listed below.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2182-12-16**] at 9:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 63252**] when you get out of
rehab to schedule appts.
Completed by:[**2182-11-27**]
ICD9 Codes: 0389, 486, 5845, 4271, 2760, 4254, 2761, 7907, 4280, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7578
} | Medical Text: Admission Date: [**2119-1-9**] Discharge Date: [**2119-1-14**]
Date of Birth: [**2087-4-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Type A dissection
Major Surgical or Invasive Procedure:
[**2119-1-9**] Replacement of Ascending aorta with 28mm Gelweave graft
History of Present Illness:
This 31 year old male awoke on [**1-9**] with substernal chest pain
radiating to his back and then legs with shortness of breath. A
CTA elsewhere revealed a Type A dissection, extending to the
renal, without visualization of the right kidney.
He was Life Flighted here after diversion from [**Hospital1 2025**].
Past Medical History:
Remote stroke after rodding, no residual
Left deep vein thrombophlebitis
Chronic low back pain
Obstructive sleep apnea
Sinusitis- completed course antibiotics/prednisone
s/p Lumbar laminectomies
s/p femoral rodding
h/o tympanic membrane surgeries
Social History:
15pk year history (active smoker)
heavy ETOH until 2years ago
disabled from back pain
Family History:
noncontributory
Physical Exam:
admission:
Pulse: 88 Resp: O2 sat:
B/P Right: 116/60 Left:
Height: Weight: 95 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: dop
PT [**Name (NI) 167**]: dop Left: dop
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left:
Pertinent Results:
[**2119-1-9**] Echo: PRE-CPB:1. The left atrium is normal in size. No
atrial septal defect is seen by 2D or color Doppler. 2. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is mildly dilated. Overall left ventricular systolic
function is mildly depressed (LVEF= 50 %). 3. Right ventricular
chamber size and free wall motion are normal. 4. The aortic root
is mildly dilated at the sinus level. The ascending aorta is
mildly dilated. The descending thoracic aorta is mildly dilated.
A mobile density is seen in the ascending aorta consistent with
an intimal flap/aortic dissection. The aortic wall is thickened
consistent with an intramural hematoma, which extends into the
descending aorta. 5. There are three aortic valve leaflets.
There is no aortic valve stenosis. Mild to moderate ([**1-8**]+)
aortic regurgitation is seen. Mild (1+) mitral regurgitation is
seen. 6. There is a small left pleural effusion. 7. There is a
trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results. POST-CPB: On infusion of
phenylephrine. A pacing for slow sinus. Repaired ascending aorta
with synthetic material seen. No residual dissection flap seen.
Preserved biventricular systolic function. No AI seen. MR
remains 1+. The descending aortic contour is unchanged post
decannulation. I certify that I was present for this procedure
in compliance with HCFA regulations.
[**2119-1-10**] Kidney U/S: 1. No normal arterial venous waveforms noted
within the right kidney with an abnormal-appearing pulsatile
flow only seen within the right renal hilum likely representing
collateral flow from lumbar vessels. 2. More normal-appearing
arterial and venous waveforms within the left kidney. Although,
this also appears slightly hypoperfused as demonstrated by the
lack of significant vascularity extending out into the cortex on
the color images.
[**2119-1-13**] CXR: The heart size is stable. Post-sternotomy wires are
unremarkable. The aortic contour is still enlarged which might
be related to recent surgery and the presence of known
dissection. There is no pneumothorax. There is small amount of
left pleural effusion but overall the aeration at the lung bases
has improved in the interim.
[**2119-1-9**] 07:20PM BLOOD WBC-13.4* RBC-3.79* Hgb-11.0* Hct-33.1*
MCV-88 MCH-29.0 MCHC-33.2 RDW-12.9 Plt Ct-297
[**2119-1-11**] 01:51AM BLOOD WBC-25.1*# RBC-3.44* Hgb-10.3* Hct-29.8*
MCV-87 MCH-30.1 MCHC-34.7 RDW-13.4 Plt Ct-238
[**2119-1-14**] 05:50AM BLOOD WBC-14.4* RBC-3.21* Hgb-9.4* Hct-28.3*
MCV-88 MCH-29.4 MCHC-33.4 RDW-14.2 Plt Ct-316
[**2119-1-9**] 07:20PM BLOOD PT-16.3* PTT-27.4 INR(PT)-1.4*
[**2119-1-11**] 01:51AM BLOOD PT-17.7* PTT-28.8 INR(PT)-1.6*
[**2119-1-9**] 07:20PM BLOOD UreaN-15 Creat-1.5*
[**2119-1-10**] 04:56AM BLOOD Glucose-112* UreaN-15 Creat-1.5* Na-137
K-4.6 Cl-108 HCO3-23 AnGap-11
[**2119-1-14**] 05:50AM BLOOD Glucose-94 UreaN-20 Creat-1.5* Na-134
K-4.0 Cl-100 HCO3-26 AnGap-12
Brief Hospital Course:
Following admission he was taken in stable condition emergently
to the Operating Room where the ascending aorta was replace.
Please see operative report for surgical details. He tolerated
the procedure well and weaned from bypass on Neo-Synephrine and
Propofol and transferred to the CVICU for invasive monitoring in
stable condition. He remained stable, weaned from sedation,
awoke neurologically intact and extubated with 24 hours. During
surgery, the aorta appeared abnormal and aortitis was
considered. Biopsy was sent from the Operating Room.
Rheumatology and Infectious Disease were consulted for
assistance in elucidation of this. Blood cultures were sent. He
was transferred to the floor on post-op day #2 to begin
increasing his activity level. He was gently diuresed toward his
preop weight. His pathology report suggested a differential
diagnosis that included Ehlers-Danlos Type IV. As such he was
referred to see the genetic counselling service at [**Hospital1 11900**] of [**Location (un) 86**] as an outpatient. As mentioned earlier
Infectious disease was consulted to evaluate for an infectious
cause of his dissection or aortitis but it was felt that there
was not evidence for either. He continued to make good progress
and by post-operative day five he was ready for discharge to
home with VNA services, appropriate medications and follow-up
appointments.
Medications on Admission:
Naprosyn PRN
Amoxicillin 500 mg PO TID-just completed 10 day course for
sinusitis
Cipro 500 mg PO BID for 14 days-just completed 14 day course
Prednisone taper just completed 5 days ago for sinusitis
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. 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. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
7. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 3 days.
Disp:*3 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Type A Aortic dissection s/p Replacement of ascending aorta
Postop UTI
Past medical history:
Remote stroke
Chronic low back pain
Obstructive sleep apnea
s/p Lumbar laminectomies
s/p femoral rodding
h/o tympanic membrane surgeries
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
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) **] ([**Telephone/Fax (1) 170**]) on Wednesday [**2-1**] at 1:00
([**Hospital Ward Name **] 2A)
*** Cardiologist: Please ask Dr. [**Last Name (STitle) **] for a referral to a
cardiologist and make appt for 4 weeks
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office from genetic testing at [**Hospital1 11900**] of [**Location (un) 86**] will be calling you on Monday to arrange an
appointment. His office phone is ([**Telephone/Fax (1) 77621**].
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **] in [**4-11**] 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:[**2119-1-14**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7579
} | Medical Text: Admission Date: [**2131-2-10**] Discharge Date: [**2131-2-17**]
Date of Birth: [**2085-9-12**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Progression of stroke
Major Surgical or Invasive Procedure:
CTA
MRI/MRA
ECHO
History of Present Illness:
HPI: The pt is a 45 year-old left-handed man with a long tobacco
history and a recent stroke who presented to the ED today with
complaints of new L facial tingling. He states that about 3-4
weeks ago, he was in his USOH driving home on a snow mobile when
he developed abrupt onset dizziness (spinning) and severe nausea
and vomiting. He tried to drive and had to look down on the
ground to decrease the sensation of spinning. He did not have
diplopia or weakness and was able to drive himself slowly home
but required help to get up to the house as he was "weak all
over".
He then spent the next few days in bed, as he thought he had a
"stomach bug". His symptoms persisted however, so he went to see
his PCP who told him he had an ear infection and vertigo. He was
treated with meclizine and antibiotics. His symptoms gradually
improved over the next few days, however 7 days ago, he woke at
3am with severe room spinning, double vision and slurred speech.
His wife also noted that his R eye was "turned out". Mr. [**Known lastname **]
states the diplopia is intermittent and is unable to
characterize
the diplopia further (unsure if it is vertical or horizontal or
for near vs far). He again waited for a couple of days, but by
Monday his symptoms were persistent and he had developed severe
tinnitus in the L ear. He therefore went to his PCP who sent him
to [**Hospital **] [**Hospital3 **].
There he was admitted and was told he had a stroke. He states
that he had an MRI and what seems to be at TEE ("camera down the
throat to look at the heart"). Per the family report, they were
unable to identify a source of stroke and started him on ASA 325
and Simvastatin. He was discharged home 3 days ago, despite
persistent difficulty with his gait and slurring of his speech.
Yesterday evening, he developed abrupt onset tingling over the L
side of his mouth around 8:30 pm. He decided to go to bed, but
then woke with L sided tingling over his arm as well. He and his
wife therefore decided to come here for further care. He has had
persistent slurred speech and intermittent diplopia since last
Saturday as well as falling to the L side when walking. He
denies
dysphagia or hearing difficulties now.
ROS: per HPI. The pt denied recent fever or chills. No night
sweats or recent weight loss or gain. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias. Denied rash.
Past Medical History:
- as above
- R steel plate in leg
Social History:
-beer 6-8 per day (max 12 per day, denies hx of DT's or
withdrawal)
-tobacco [**12-29**] ppd
-drug: denies
-works as a mechanic
-lives w/ wife
Family History:
mother: HTN, DM
-father: no medical problems
-aunt: stroke in her 50's
Physical Exam:
NIH SS: 2
1a. Level of Consciousness: 0
1b. LOC questions: 0
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 0
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb ataxia: 0
8. Sensory: 0
9. Best language: 0
10. Dysarthria: 1
11. Extinction and inattention: 0
Vitals: 97.6 72 148/66 16 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: 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 edema or rashes
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension but significant dysarthria. Normal
prosody. There were no paraphasic errors. Pt. was able to name
both high and low frequency objects. Able to read without
difficulty. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
CN
I: not tested
II,III: VFF to confrontation, pupils 3mm->2mm bilaterally, fundi
normal but narrow vessels
III,IV,V: EOMI, slight R exotropia (no clear skew). mild
bilateral ptosis. No nystagmus
V: sensation intact V1-V3 to LT (despite persistent feeling of L
face tingling); + corneals & nasal tickle bilaterally
VII: slight R facial droop, symm forehead wrinkling
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline; + gag
[**Doctor First Name 81**]: SCM/trapezeii [**5-1**] bilaterally
XII: tongue protrudes midline, able to move tongue symmetrically
L/R
Motor: Normal bulk and tone; slight asterixis; no myoclonus. No
pronator drift.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 5 5 5
R 5 5 5 5 5 5
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 1--------------- Flexor
R 1--------------- Flexor
-Sensory: No deficits to light touch, pinprick. No extinction to
DSS.
-Coordination: No intention tremor, mild dysmetria bilaterally
with FNF. Overshoots w/ mirror testing bilaterally
-Gait: deferred given concern for acute stroke
Pertinent Results:
[**2131-2-15**] 06:20AM BLOOD WBC-10.3 RBC-4.39* Hgb-13.3* Hct-39.2*
MCV-89 MCH-30.2 MCHC-33.9 RDW-12.8 Plt Ct-200
[**2131-2-14**] 06:00AM BLOOD WBC-10.0 RBC-4.45* Hgb-13.6* Hct-40.2
MCV-90 MCH-30.6 MCHC-33.8 RDW-12.8 Plt Ct-187
[**2131-2-13**] 03:45AM BLOOD WBC-9.7 RBC-4.50* Hgb-13.8* Hct-40.1
MCV-89 MCH-30.8 MCHC-34.5 RDW-12.9 Plt Ct-218
[**2131-2-12**] 06:18AM BLOOD WBC-10.7 RBC-4.43* Hgb-13.6* Hct-39.1*
MCV-88 MCH-30.6 MCHC-34.7 RDW-13.0 Plt Ct-188
[**2131-2-11**] 03:16AM BLOOD WBC-10.1 RBC-4.68 Hgb-14.4 Hct-41.7
MCV-89 MCH-30.7 MCHC-34.5 RDW-12.9 Plt Ct-203
[**2131-2-10**] 09:42PM BLOOD WBC-13.3* RBC-4.92 Hgb-15.1 Hct-44.0
MCV-89 MCH-30.6 MCHC-34.2 RDW-12.8 Plt Ct-200
[**2131-2-10**] 12:20PM BLOOD Neuts-71.6* Lymphs-20.0 Monos-4.8 Eos-3.2
Baso-0.4
[**2131-2-15**] 10:30AM BLOOD PTT-50.1*
[**2131-2-15**] 06:20AM BLOOD Plt Ct-200
[**2131-2-15**] 03:08AM BLOOD PTT-46.3*
[**2131-2-14**] 05:05PM BLOOD PTT-48.2*
[**2131-2-12**] 06:18AM BLOOD Plt Ct-188
[**2131-2-12**] 06:18AM BLOOD PT-12.5 PTT-72.4* INR(PT)-1.1
[**2131-2-10**] 09:42PM BLOOD PT-12.8 PTT-33.0 INR(PT)-1.1
[**2131-2-10**] 08:00PM BLOOD PTT-25.1
[**2131-2-10**] 12:20PM BLOOD Plt Ct-185
[**2131-2-10**] 08:00PM BLOOD ACA IgG-PND ACA IgM-PND
[**2131-2-10**] 08:00PM BLOOD AT III-94 ProtCFn-123 ProtSFn-100
[**2131-2-10**] 08:00PM BLOOD Lupus-NEG
[**2131-2-15**] 06:20AM BLOOD Glucose-102 UreaN-11 Creat-0.8 Na-142
K-4.2 Cl-111* HCO3-23 AnGap-12
[**2131-2-13**] 03:45AM BLOOD Glucose-108* UreaN-16 Creat-0.8 Na-141
K-3.5 Cl-106 HCO3-28 AnGap-11
[**2131-2-11**] 01:42AM BLOOD Glucose-100 UreaN-12 Creat-0.7 Na-146*
K-5.5* Cl-115* HCO3-20* AnGap-17
[**2131-2-10**] 12:20PM BLOOD Glucose-90 UreaN-15 Creat-0.9 Na-142
K-4.3 Cl-106 HCO3-24 AnGap-16
[**2131-2-10**] 08:00PM BLOOD ALT-28 AST-23 LD(LDH)-171 CK(CPK)-49
AlkPhos-63 TotBili-0.5
[**2131-2-12**] 06:18AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2131-2-15**] 06:20AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.1
[**2131-2-10**] 09:42PM BLOOD Calcium-9.4 Phos-2.7 Mg-1.9
[**2131-2-10**] 08:00PM BLOOD %HbA1c-5.4
[**2131-2-10**] 08:00PM BLOOD Homocys-9.7
[**2131-2-12**] 10:27AM BLOOD Osmolal-280
[**2131-2-10**] 08:00PM BLOOD TSH-4.1
[**2131-2-12**] 10:27AM BLOOD CRP-4.1
[**2131-2-10**] 12:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2-10**] CT: 1. Multiple cerebellar hypodensities, bilaterally. In
the absence of prior studies, exact age is difficult to
determine. However, the left inferior cerebellar hypodensity
could be chronic in nature. Right-sided hypodensiies are
concerning for acute ischemia. MRI is recommended for further
evaluation. 2. No intracranial hemorrhage.
[**2-10**] CTA brain: IMPRESSION:
1. No abnormalities are detected on CTA of the neck.
2. CTA of the head demonstrates suspicion for subtle filling
defect from
thrombus in the distal basilar artery.
3. Posterior fossa infarcts are again identified. MRI can help
for further
assessment if clinically indicated.
[**2131-2-10**] MRI brain:
IMPRESSION:
1. Acute infarctions in the lateral aspect of the right
cerebellar hemisphere and in the right midbrain. While the
basilar artery is not evaluated on this study, the pattern of
infarction is congruent with basilar artery disease.
2. Encephalomalacia and gliosis in the inferior left cerebellar
hemisphere
may be related to chronic infarction.
[**2-11**] MRI:
IMPRESSION:
1. New acute infarction involving the superior left cerebellar
hemisphere,
left superior vermis, and left midbrain compared to one day
earlier.
2. Acute infarctions are again seen in the lateral aspect of the
right
cerebellar hemisphere and the right midbrain.
3. While the basilar artery is not well evaluated on this study,
the pattern of infarctions is concordant with the previously
suspected basilar artery disease.
[**2-11**] CTA: 1. Unchanged appearance of bilateral cerebellar and
midbrain infarctions. 2. Persistent non-occlusive central
filling defect in the proximal V3 segment of the left vertebral
artery. 3. Persistent filling defect in the right aspect of the
basilar tip. Persistent nonvisualization of the right superior
cerebellar artery and of the proximal P1 segment of the right
posterior cerebral artery. These findings are concerning for
thromboembolic occlusion.
[**2-13**] CT head: Grossly unchanged appearance of bilateral
cerebellar and midbrain infarcts. It is unclear if the fourth
ventricle is minimally smaller. Recommend short- interval
follow-up.
CT Torso: 1. Unusual appearance of the duodenal bulb, most
likely represents passing of a bolus of solid food mixed with
contrast.
2. L5 compression deformity, with roughly 25% loss of vertebral
body height and grade 1 retrolisthesis of L5 on S1. Without
prior comparison imaging, acuity of this finding is uncertain.
Brief Hospital Course:
Pt was admitted to the stroke service for further work-up and
management of his stroke. Admission to the floor included
frequent neuro-checks, cardiac telemetry, frequent glucose
checks. The night of admission he had a change in his exam
significant for worsening dizziness, face weakness and decreased
extraocular movements. CTA of the brain showed an occlusion in
the right P1 segment of the PCA. This occlusion was seen on
brain imaging studies from [**Hospital6 204**] from [**2132-2-5**]
and [**2131-2-6**]. He also had a filling defect in the right side of
the distal basilar artery. Discussion with Dr. [**First Name (STitle) **], of
interventional neuro-radiology, was made about possible
neuroradiology intervention. He was deemed inappropriate for
mechanical intervention or intra-arterial tpa. Hypercoagulable
panel was sent. He was transfered to the ICU and started on
heparin gtt.
During the morning of [**2-11**], he was alert but not oriented to
place or month. He knew the year. He was able to say phrases and
follow bilateral commands. He had mild to moderate dysarthria.
Patient had impaired vertical upgaze. His right eye could not
fully abduct to the right. When he looked to the left, the left
eye would skew downwards. The right eye could not look
inferiorly. The right pupil was reactive from 5 to 3mm. The left
pupil was reactive from 4 to 3mm. He had mild bilateral ptosis.
Decreased sensation to light touch and pinprick of V1 to V3.
There was a right lower facial droop. Decreased gag on the
right. He was full strength in all four extremities. He had a
marked ataxia of left fnf (greater than ataxia of right
fnf).Intact sensation of all four extremities.
MRI of the brain on [**2131-2-11**] showed new left superior cerebellar
and left midbrain infarcts. CTA neck on [**2-11**] showed again a
filling defect of the right side of the distal basilar artery.
There was a small filling defect of the right V3 segment of the
left vertebral artery. He was probably having artery to artery
emboli from the left vertebral artery to the basilar artery and
its tributaries. Another possibility is that the left V3
thrombus originally came from the heart or aorta.
That night he became more somnolent and had a stat CT which
showed slight swelling of the cerebellum. He was started on
mannitol and had improvement in his exam. He was weaned off the
manitol without significant change in exam. He was eventually
transfered to Stepdown. He continued to improve clinically
while on the floor. His BP was allowed to autoregulate. TTE did
not show a cardioembolic source. He did not have further cardiac
imaging due to report of negative TEE at OSH within 1-2 weeks.
He was then started on coumadin with goal INR of 2.0 to 3.0.
His discharge exam is significant for decreased upgaze
bilaterally, left worse than right, though he has full upward
movements with Bells phenomenon. He has slurred speech and a
slight left facial droop. He has full strenght but clumsiness
with the left arm and leg. He also has truncal ataxia. He will
follow-up with the stroke clinic as an outpt and should continue
coumadin for at least three months. Will obtain a CTA brain and
neck as an outpatient in three months.
Medications on Admission:
- ASA 325mg PO QD
- Simvastatin 10mg PO QD
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
5. Pantoprazole 40 mg IV Q24H
6. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: Nine Hundred (900) units/hr Intravenous ASDIR (AS
DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Cerebellar and brainstem infarcts
Cerebellar and brainstem infarcts
Discharge Condition:
Improved
Discharge Instructions:
You were admitted with because of new strokes. These new
strokes were caused by a blood clot in the ateries inthe back of
your head. You will need to remain on a blood thinner until
furhter instructed. You will need to routinely have the
coumadin checked as an outpt.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2131-4-20**] 3:00
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7580
} | Medical Text: Admission Date: [**2148-12-13**] Discharge Date: [**2148-12-18**]
Date of Birth: [**2096-9-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
s/p VT arrest
Major Surgical or Invasive Procedure:
Cardiac catheterization s/p MiniVision LAD stent
Intubation
R arterial line placement
History of Present Illness:
Mr. [**Known lastname 29887**] is a 52 yo male with significant PMH significant for
HTN, smoking, who collapsed and hit his head at work this
afternoon. The fall was witnessed by his collegue. There is no
report of chest pain, SOB, or any other symptoms prior to his
fall. He was found to be breathing when he was found down. He
was given 5 minutes of CPR with no respirations. Paramedics
arrived, he was found to be in VF (no strips available)and was
shocked. He remained in a ventricular rhythm with a rate of 20,
and then converted spontaneously to sinus rhythm. Patient had
agonal respirations at the time of the arrest. He was brought to
[**Hospital1 **] [**Location (un) 620**] where he was found to have posturing. The patient was
given Ativan, Versed, and Nitro and a CT of the head was done
which suggested subdural hematoma vs. meningioma. EKG showed ST
elevations in 1, aVL, V2-V6. The patient did not receive ASA,
heparin, or integrilin for concern for a possible intracranial
bleed. He was transferred to [**Hospital1 18**] for cardiac catheterization
and closer monitoring.
In the cath lab he was found to have occluded LAD after D1 & S1
and 1 subbranch with long subtotal occlusion with collateral
filling of distal vessel. MiniVision stent was placed into D2.
Hemodynamic parameters as follows: CO 6.5, CI 3.3 and PCWP 23.
Past Medical History:
Hypertension
Social History:
The pt is a CEO/CPA in [**Location (un) 620**]. He is an 80 pack year smoker, no
alcohol.
Married, has 1 son. [**Name (NI) **] illicit drugs.
Family History:
Possible CAD
Physical Exam:
vitals T 98.8 BP 137/89 AR 88 RR 20 02 sat 100%
vent settings: AC FIO2 0.5 TV 650 RR 20 PEEP 5
Gen: Pt sedated; not responsive to sternal rub or pain
HEENT:PERRLA, ETT in place
Lungs:Course breath sounds
Heart:Distant heart sounds
Abdomen: soft, NT/ND, +BS
Extremities: no edema, 2+ DP/PT pulses
Neuro:Does not respond to pain stimuli
Pertinent Results:
Laboratory Results:
[**2148-12-13**] 08:01PM HGB-12.5* calcHCT-38 O2 SAT-98
[**2148-12-13**] 08:01PM GLUCOSE-105 LACTATE-0.8 K+-3.4*
[**2148-12-13**] 08:01PM TYPE-ART TIDAL VOL-880 O2-100 PO2-371*
PCO2-49* PH-7.26* TOTAL CO2-23 BASE XS--5 AADO2-305 REQ O2-56
INTUBATED-INTUBATED
[**2148-12-13**] 09:08PM O2 SAT-99
[**2148-12-13**] 09:08PM TYPE-ART TIDAL VOL-700 O2-100 PO2-437*
PCO2-37 PH-7.35 TOTAL CO2-21 BASE XS--4 AADO2-251 REQ O2-48
INTUBATED-INTUBATED
[**2148-12-13**] 10:34PM PT-13.1 PTT-36.7* INR(PT)-1.1
[**2148-12-13**] 10:34PM PLT COUNT-330
[**2148-12-13**] 10:34PM CALCIUM-7.9* PHOSPHATE-2.3* MAGNESIUM-1.7
[**2148-12-13**] 10:34PM CK-MB-35* MB INDX-9.0* cTropnT-0.73*
[**2148-12-13**] 10:34PM GLUCOSE-146* UREA N-20 CREAT-1.0 SODIUM-140
POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-22 ANION GAP-13
[**2148-12-15**] 04:06PM CK 1048*
[**2148-12-15**] 05:45AM CK 1011*1
[**2148-12-15**] 04:06PM CKMB 15* MBI 1.4
[**2148-12-15**] 05:45AM CKMB 17* MBI 1.7
.
EKG: nl sinus rhythm, ST elevations in 1, aVL, V2-V6, reciprocal
ST depressions in III, aVF, t wave inversions laterally, LAFB
.
Relevant Imaging:
1)Cardiac Catheterization ([**2148-12-13**]): 1. Selective coronary
angiography in this right dominant system revealed severe two
vessel coronary artery disease. The LMCA had diffuse mild
disease. The LAD was totally occluded after D1 and S1. The
distal LAD was a small diffusely disease vessel that filled via
right to left collaterals. The first diagonal was severely
diffusely disease. The second diagonal was a large vessel with
a large subbranch with a long subtotal occlusion; this vessel
filled distally via collaterals. The LCx had a 30% proximal and
a 50% mid occlusion. 2. Left ventriculography was deferred. 3.
Hemodynamics revealed elevated left and right sided filling
presures. The LVEDP was 23 mmHg. The RVEDP was 16 mmHg. There
was pulmonary artery hypertension. Pulmonary artery pressure wa
41/21 mmHg with a mean of 30 mmHg. Cardiac index was perserved
at 3.25 l/min/m2.
2)C,T,L-spine CT ([**2148-12-14**]): no evidence of fracture or
malalignment.
3)CT head ([**2148-12-15**]): There is a 5-mm hyperdensity along the
right frontal falx of uncertain etiology. There is no evidence
of hemorrhage, mass effect, shift of normally midline
structures, hydrocephalus, or infarction. The density values of
the brain parenchyma are within normal limits and the [**Doctor Last Name 352**]-white
matter differentiation is preserved. The ventricles and sulci
are normal in size. The surrounding osseous and soft tissue
structures are unremarkable. The imaged portions of the
paranasal sinuses are well-aerated.
4)MRI/MRA Head ([**2148-12-16**]): Study is limited due to patient
motion artifact. However, the major vessels of the circle of
[**Location (un) 431**] appear patent. There do not appear to be any large areas
of intracranial atherosclerotic disease. The right vertebral
artery is dominant. There appears to be a fetal origin to the
right posterior cerebral artery.
Brief Hospital Course:
Mr. [**Known lastname 29887**] is a 52 yo male with HTN who is now s/p anterolateral
STEMI and VF arrest s/p LAD stent, and s/p intubation. He was
extubated following cardiac catheterization. He remained stable
thereafter, but did have some residual short term memory
deficits.
1)STEMI: The patient had evidence of an anterolateral STEMI and
subsequent Vfib arrest. He was taken to the cath lab where he
was found to have occluded LAD after D1 & S1 and 1 subbranch
with long subtotal occlusion with collateral filling of distal
vessel. A MiniVision stent was placed into the mid-LAD. The
patient was maintained on ASA 325 mg, Lipitor 80mg, Plavix 75mg
daily X 1 month, Lisinopril 10 mg QD, and Metoprolol titrated to
50mg TID. The patient was made a follow up appointment with Dr.
[**Last Name (STitle) **], cardiologist.
2)Pump: The patient had an ECHO 2 days after PCI and VF arrest
which showed an EF~ 30% with an akinetic apex. Although the PCWP
23 on cardiac cath, the patient was diuresed during his
hospitalization and was euvolemic on exam by time of discharge.
Given the akinetic apex found on echo and increased risk of clot
formation, the patient was started on a heparin drip as a bridge
to coumadin. Upon discharge the patient's INR was 1.4. He was
discharged on Lovenox SQ and Coumadin. He was told to have his
INR checked on Friday and have the results faxed to Dr.[**Name (NI) 5907**]
office.
3)Rhythm: The patient is s/p vfib arrest secondary to an
anterolateral STEMI. He stayed in normal sinus rhythm throughout
his hospitalization. His Metoprolol was titrated up to 50mg TID.
4)Fall: The patient is s/p posterior head trauma prior to the VF
arrest. Head CT head showed a 5-mm hyperdense focus along
anterior falx. Differential included meningioma vs. bleed. This
focus was thought to be stable after the patient was therapuetic
on heparin. Neurosurgery was involved throughout and recommended
follow-up in [**5-1**] weeks with an outpatient CT and appointment
with Dr. [**Last Name (STitle) **]. CT of the C- T- and L-spine ruled out fracture.
5)Short term memory: The patient's STM deficit was thought to be
secondary to anoxic brain injury from poor perfusion during the
Vfib arrest. It was stable to slightly improved by the time of
discharge. Both neurology and psychiatry were consulted. They
recommended follow up in the [**Hospital 29888**] clinic for further
testing. A follow up appointment was made with Dr. [**Last Name (STitle) **] for this
purpose.
6)Leukocytosis: The patient's leukocytosis was attributed to the
recent STEMI. The patient was clinically asymptomatic and over
the course of the hospitalization. UA and CXR were negative for
UTI and PNA respectively. The leukocytosis slowly improved and
was WNL by discharge.
Medications on Admission:
None
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 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous twice a day for 3 days.
Disp:*6 injections* Refills:*0*
8. Outpatient Lab Work
Please check PT, PTT, INR
please call in results to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 5909**] fax ([**Telephone/Fax (1) 29889**].
Discharge Disposition:
Home With Service
Facility:
Visiting Nurse [**First Name (Titles) **] [**Last Name (Titles) 269**] [**Location (un) 270**]
Discharge Diagnosis:
Primary diagnosis:
ST elevation MI with stent placement
V-fib arrest
New systolic dysfunction (EF 30%) with apical akinesis
Meningioma
.
Secondary diagnosis:
Hypertension
Discharge Condition:
Safe for discharge home.
Discharge Instructions:
1. Please continue to take your Lovenox as instructed for three
additional days.
.
2. Please have your coumadin level (INR) checked on Friday and
the results sent to Dr.[**Name (NI) 5907**] office phone([**Telephone/Fax (1) 5909**].
.
3. Please take all medications as prescribed. Most importantly,
you must take your aspirin and plavix every day. Please do not
miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]. Failure to take these medications can result in
stent closure which could be life threatening.
.
4. If you develop any chest pain, shortness of breath,
lightheadedness or dizziness, or any other concerning symptoms,
please contact your doctor or report to the nearest ER.
Followup Instructions:
1. Please contact Dr.[**Name2 (NI) 5907**] office (cardiologist) to follow
up Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2149-1-14**] 3:20. Please have your
coumadin level checked this Friday at his office.
.
2. Please contact Dr. [**First Name (STitle) **] [**Name8 (MD) **], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 1690**]
Date/Time:[**2149-1-8**] 1:00 [**Hospital 29890**] Clinic.
.
3. Please follow up with Dr. [**Last Name (STitle) **] from Neurosurgery in [**5-1**]
weeks with a head CT. Please call [**Telephone/Fax (1) 2731**] to make these
arrangements after discharge.
.
4. Previously scheduled appointments:
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2148-12-31**] 12:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 4275, 4271, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7581
} | Medical Text: Admission Date: [**2178-6-28**] Discharge Date: [**2178-7-5**]
Date of Birth: [**2122-5-24**] Sex: F
Service: NEUROSURGERY
Allergies:
Nitrofurantoin Sodium / Ergotamine
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Transfer from OSH with large intracranial hemorrhage
Major Surgical or Invasive Procedure:
Craniotomy for evacuation of intraparenchymal hemorrhage
History of Present Illness:
This is a 56 year old female that was at pilates class this
afternoon at 1230 pm when she reportedly experienced the worst
headache of life and became unresponsive. The patient was noted
by observers to be posturing but was breathiung spontaneously.
EMS arivved at the scence and note a right blown pupil on on
route the the emergency department
Past Medical History:
xx
Social History:
Married and lives with husband
Family History:
NC
Physical Exam:
GCS 4t E:1 V:1 Motor:2
Gen: INTERBATED UNRESPONSIVE
Neuro:
intubated, no eye opening, R pupil 6mm fixed, L 3mm, extending
bilat UEs, min movement bilat LEs
CT:massive right temporal IPH
Pertinent Results:
CT HEAD [**6-27**]
There is a very large right temporoparietal acute hemorrhage,
causing prominent compression of the right lateral ventricle,
and nearly 7 mm leftward subfalcine herniation. There is a mild
degree of edema surrounding this very large hemorrhage. There is
also accompanying uncal and hippocampal herniation on the right
side. There is moderate dilatation of the right temporal [**Doctor Last Name 534**]
tip, likely due to entrapment.
The surrounding osseous and extracranial soft tissues do not
reveal additional abnormalities. CT angiography of the head
reveals displacement of the right middle cerebral artery
branches, consequence of the large right temporoparietal lobe
hemorrhage.
CT HEAD [**6-28**]
1. Status post evacuation of a large right hemispheric
intraparenchymal
hematoma via a right craniotomy, with expected post-surgical
changes and mild
residual subarachnoid blood.
2. Slightly increased intraventricular blood.
3. Improved leftward subfalcine herniation.
4. Improved mild uncal herniation.
5. Unchanged mild effacement of the quadrigeminal cistern.
CT HEAD [**6-29**]
Slight decrease in left subfalcine herniation and
pneumocephalus; other
findings
MRI Head [**6-29**]
1. Acute infarcts involving the left paramedian pons, right
thalamus and
subthalamic nuclei of the midbrain, and at the margins of the
resection bed in the right temporoparietal lobe, as described.
2. Similar degree and appearance of blood products in the
resection margin,
as well as in the ventricles, compared to several hours earlier
in the day, allowing for difference in imaging modality.
3. No abnormal vascular flow void or enhancing vessel to suggest
residual
AVM, but evaluation for enhancing abnormality is limited due to
intrinsically T1-hyperintense blood products
Brief Hospital Course:
Pt was admitted to the neurosurgery service and underwent an
elective craniotomy for evacuation of left temporal ICH. SHe
tolerated this procedure well with no complications. Post
operatively she was transferred to the ICU for further care. She
remained intubated and on post op exam she did improve. She had
no eye opening but moved her LE's to noxious and moved both
upper extremities with left greater than right. Her pupils
remained asymetric but reacted to light. Her post op head ct
showed good evacuation of ICH. On [**6-29**] her dilantin was reloaded
for a level of 6.5. She also underwent angiography and an MRI.
The angio revealed no vascular abnormality but the MRI revealed
thalamic and pons infarcts. On [**6-30**] her neurological exam was
slightly improved but still poor. She was started on tube feeds
via an NG Tube.An MRI was obtained to help with prognosis and
this showed left sided acute strokes. A family meeting was held
and the family decided to make her CMO. Pt was extubated and
past away on [**2178-7-5**].
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracranial hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
Followup Instructions:
xx
Completed by:[**2178-7-5**]
ICD9 Codes: 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7582
} | Medical Text: Admission Date: [**2179-1-20**] Discharge Date: [**2179-2-5**]
Date of Birth: [**2144-5-28**] Sex: F
Service: NEUROLOGY
Allergies:
Shellfish Derived / Pineapple / Apple / Wheat Starch / Soy /
Potato Starch / Rice / Milk
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
Right sided weakness/confusion
Major Surgical or Invasive Procedure:
Intra-arterial-tissue plasminogen activator.
MERCI - mechanical intra-arterial clot retrieval.
Embolization of a right pulmonary arterial venous fistula.
History of Present Illness:
HPI: 34yo right-handed woman with PMH significant for migraines
and depression presents as a transfer from an outside hospital
with right hemiparesis and aphasia. She was in her USOH this
morning, lying in bed after awakening as her children did not
need to go to school, when she had acute change at 7:25am
witnessed by her husband. She had a blank look, moved around in
the bed, not responding to him, and tried to get up but could
only move her left side. She became nonverbal. EMS was called
and
she was brought to Caritas [**Hospital6 5016**] in [**Location (un) 7661**].
At the OSH, VS were T 96.5, HR 82, BP 103/64, RR 20, SaO2 100%.
She was noted to be lethargic and witnessed to have convulsive
activity of her right leg. She was aphasic and would not follow
commands. She had a right hemiparesis. She had a head CT showing
a hyperdense left MCA. Neurology at [**Hospital1 18**] was called; IV tPA was
suggested, but the family preferred to wait for transfer and
evaluation as she was just outside of the 3 hour window at that
time (3.5hrs). Prior to transfer, she was given ativan 1mg, ASA
325mg, and she was put on a heparin gtt (at 1055). She was
transferred to [**Hospital1 18**] at 1125.
On arrival to [**Hospital1 18**], CODE STROKE was called. Neurology was at
bedside prior to the CODE STROKE page at 1229pm. Heparin was
stopped as soon as it was found to have been started, which was
at 1235. Bloodwork was drawn, she was examined by the stroke
fellow (see below), and sent to the CT scanner.
ROS: No recent head or neck trauma, no chiropracty or
professional massage, occ massage by husband, no martial arts.
?Mild dysarthria the day prior to presentation noted by
patient's
mother, patient said she was tired, and husband did not notice
any change in speech prior to the am events as above. No recent
fevers, chills, +diaphoresis last two nights, not previously.
+10lbs weight loss with diet over last several months. H/o
miscarriage x 1, no other clotting (see below). Told
mother-in-law she had fallen down stairs several weeks ago, but
did not seem like there was any significant injury (mentioned in
passing when mother-in-law said she tripped up the stairs, pt
said she fell down the stairs, not mentioned to husband).
Past Medical History:
migraines
depression
food allergies - hives to most foods, but she eats them anyway,
breathing difficulties with pineapples and tabouli (new over the
last several months)
miscarriage x 1, no known reason, s/p 3 c-sections (first child
SVD, second c-section for failure to progress, third and fourth
children repeat c-sections)
occasional kidneystones
frequent UTIs
Social History:
married, 4 children, husband [**Name (NI) **] [**Telephone/Fax (1) 77824**], no
tobacco, rare EtOH, no drug use
Family History:
kidneystones; no strokes, miscarriages, clotting problems
Physical Exam:
T 99.3, HR 106, BP 116/71, RR 23, SaO2 97%/RA, BG 91
Gen: Lying in bed and looking to left
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
NIHSS
1a. LOC: 1, arousable to gentle stim
1b. LOC q's: 1, mute
1c. LOC commands: 1, squeezes hand, does not close eyes
2. gaze: 1, left gaze preference
3. visual field: 2, no blink to threat from right
4. facial palsy: 3, R facial palsy
5a. RUE motor: 4
5b. LUE motor: 0
6a. RLE motor: 2, lifts, cannot sustain
6b. LLE motor: 0
7. ataxia: 0, hemiplegic
8. sensory: 0
9. language: 2, follows some 1 step commands
10. dysarthria: 2, mute
11. neglect: x unable to test
NIHSS total: 19
Mental status: Mute but alert, cooperative with exam. Could not
check orientation. Attentive with exam.
Speech: some intact comprehension, no repetition, no speech
heard.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation from left
but not from right, could not check formal visual fields, eyes
looking to left side, does not cross midline, no nystagmus.
Sensation decreased to LT on right. Facial movement
decreased on right side. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical.
Sternocleidomastoid and trapezius not checked. Tongue midline,
movements intact
Motor:
Normal bulk bilaterally. Tone decreased in right upper and
lower.
No observed myoclonus or tremor, could not check full formal
muscle strength.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
L 4 4 4 4 4 4 4 4 4 4 4 4 4 4
R 0 0 0 0 0 0 0 3 3 3 3 3 3 3
Sensation: Intact to light touch throughout trunk and
extremities.
Reflexes:
+2 on right, +2 on left side,
Toes downgoing on right and left,
Coordination: unable to check
Gait: could not check
Romberg: not checked,
Pertinent Results:
[**2179-1-20**] 10:41PM PT-12.2 PTT-27.6 INR(PT)-1.0
[**2179-1-20**] 08:09PM TYPE-ART PO2-165* PCO2-36 PH-7.36 TOTAL
CO2-21 BASE XS--4
[**2179-1-20**] 07:48PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2179-1-20**] 07:48PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2179-1-20**] 07:47PM GLUCOSE-117* UREA N-7 CREAT-0.6 SODIUM-146*
POTASSIUM-4.1 CHLORIDE-116* TOTAL CO2-21* ANION GAP-13
[**2179-1-20**] 07:47PM CK(CPK)-272*
[**2179-1-20**] 07:47PM CK-MB-10 MB INDX-3.7 cTropnT-0.22*
[**2179-1-20**] 07:47PM CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-2.3
[**2179-1-20**] 05:10PM WBC-13.0* RBC-4.36 HGB-12.5 HCT-37.5 MCV-86
MCH-28.6 MCHC-33.3 RDW-13.1
[**2179-1-20**] 03:18PM %HbA1c-5.5
[**2179-1-20**] 12:13PM GLUCOSE-107* UREA N-14 CREAT-0.7 SODIUM-142
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-21* ANION GAP-15
[**2179-1-20**] 12:13PM CHOLEST-157
[**2179-1-20**] 12:13PM TRIGLYCER-67 HDL CHOL-46 CHOL/HDL-3.4
LDL(CALC)-98
[**2179-1-20**] 12:13PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2179-1-20**] 12:13PM WBC-11.9* RBC-4.75 HGB-13.7 HCT-40.3 MCV-85
MCH-28.9 MCHC-34.1 RDW-12.9
[**2179-1-20**] 12:13PM NEUTS-92.6* BANDS-0 LYMPHS-5.2* MONOS-1.6*
EOS-0.4 BASOS-0.1
[**2179-1-20**] 12:13PM PT-12.9 PTT-34.5 INR(PT)-1.1
[**1-20**]: CT/CTA/CTP: Dense left MCA sign, increased mean transit
time within a large area of the left MCA territory with
corresponding decreased blood flow, but normal blood volume. CTA
shows complete occlusion of the left MCA. The patient had
already been taken to the interventional suite by the time of
dictation.
[**1-20**]: repeat CTH: New hemorrhage in the left basal ganglia and
frontal [**Doctor Last Name 534**] of the left lateral ventricle, with some residual
contrast posteriorly.
[**1-20**]: repeat CTH: Increase in the extent of the parenchymal
hemorrhage centered primarily within the area of the left basal
ganglia, with new rightward shift of the septum pellucidum, and
intraventricular extension as described above.
[**1-21**]: CT/CTA: Extensive blood within the putamen and caudate
nucleus on the left, with persistent intraventricular blood.
Midline shift is similar to prior study. CTA shows the left MCA
is still open.
Studies:
[**1-21**]: echo: The left atrium is normal in size. An atrial septal
defect (most likely secundum) is present (positive bubble study
at rest). The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 60%) There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild to moderate ([**12-9**]+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion. There is an anterior space
which most likely represents a fat pad.
[**1-21**]: LENIs: FINDINGS: No DVT was demonstrated in either leg.
[**1-21**]: EEG:
IMPRESSION: This is an abnormal portable EEG due to the marked
voltage
asymmetry between the hemispheres with decreased voltages noted
broadly
over the left side consistent with either a structural or
destructive
process affecting the left hemisphere or material interposed
between the
left cortex and skull. In addition, the background was
disorganized,
poorly modulated, consisting of a fast alpha or slow beta
frequency
rhythm admixed with frequent and, at times, prolonged bursts of
moderate
amplitude mixed theta and delta frequency slowing. This latter
constellation of findings is consistent with a mild to moderate
encephalopathy suggesting dysfunction of bilateral subcortical
or deep
midline structures. Medications, metabolic disturbances, and
infection
are among the common causes of encephalopathy but there are
others.
There were no areas of prominent focal slowing although
encephalopathic
patterns can sometimes obscure focal findings. There were no
epileptiform features. No electrographic seizure activity was
noted.
CT of the torso with and without contrast: [**2179-1-27**]
IMPRESSION:
1. Large pulmonary arteriovenous malformation in the right
middle lobe, corresponding to chest radiograph abnormality. This
likely explains the embolic source related to patient's recent
cerebrovascular infarct. The presence of pulmonary AVM raises
the possibility of Osler-[**Doctor Last Name 11586**]-Rendu syndrome.
2. Two additional tiny right lower lobe nodules, nonspecific but
possibly suggestive of additional small pulmonary AVM.
3. 1.4-cm segment VI hepatic lesion with features most
consistent with hemangioma.
4. Tiny cortical hypodensities in the kidneys bilaterally could
represent cysts or other hypodense lesions too small to
characterize, although the possibility of scarring from prior
renal cortical infarcts cannot be excluded.
Brief Hospital Course:
The patient was initially found to have significant clot in
distal ICA and MCA on the left side. She was brought emergently
to the angiography suite where an angiogram was performed. IA
TPA was given and MERCI clot retrieval was performed. Flow
through the ICA and MCA on the left was restored at the end of
the procedure. Post procedure CT's showed hemorrhagic
conversion in the basal ganglia with intraventricular extension.
Clinically, in the ICU, she was aphasic, not following commands.
She was awake, alert, but did not attend, and did not track.
She had a left gaze preference, but with equally reactive
pupils, + corneals, + OCR, + gag. She had spontaneous movements
of the L side. She continued to be hemiparetic on the right
side even after transf from the ICU.
A hypercoagulable workup was commenced given the patient's youth
and significant clot burden. Factor V leiden, prothrombin gene
mutation, homcysteine, protein S, and anticardiolipin IgG and
IgM were all normal or negative. Protein C level was 68 (low
normal is 70). This was not felt to be significant. She was
started on an aspirin. A CT scan obtained inorder to assess
for infectious or metastatic disease (the former to explain a
fever, and the latter to assess for hypercoagulability) was
obtained. This revealed an unexpected finding - a large AVM in
the right lung. This was deemed by radiology to be the likely
source of the embolus that caused her stroke. Pulmonary was
called and suggested that we see if interventional radiology
would embolize the lesion. IR agreed, assessed the patient and
agreed to the procedure, which they perfromed on [**2179-2-3**]. A 1cm
coil was placed with good hemodynamic effects.
CV: echo revealed was initally read as demonstrating an ASD, but
was subsequently hypothesized to be demonstrating flow throught
the pulmonary AVm. LENIs were negative. She was started on a
statin.
ID: she was diagnosed with UTI and was treated with ceftriaxone.
she continued to spike fevers and cultures sent which were
negative. A CXR was without obvious consolidation. A CT torso
was ordered which did not reveal any metastatic or infectious
disease (it did show the AVM as above). An LP revealed a
possible meningitis with 42 WBC, 281 RBC, 47 protein and 44
glucose. This was hypothesized to represent a partially treated
meningitis. The patient was started on ceftriaxone and
vancomycin which should be continued for a total of a two week
course.
Endo: The patient exhibited dilute urine loss immediately post
procedure. With increasing Na and dilute urine she was
suspected of having diabetes insipidus. DDAVP given with good
response suggesting Central DI. The patient was ultimately able
to be weened off of the DDAVP and sodiums normalized.
Physical therapy felt that the patient would benefit from a
rehab admission.
The patient will be discharged with follow up with Dr. [**First Name (STitle) **].
Medications on Admission:
xyzal 5mg daily - started recently for food allergies
effexor XR 75mg daily
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg
PO BID (2 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Metoclopramide 5 mg/mL Solution Sig: Ten (10) mg Injection
Q6H (every 6 hours).
13. Ceftriaxone-Dextrose (Iso-osm) 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q12H (every 12 hours) for 6 days: this
is to complete a 2 week course that started on [**2179-1-28**].
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours): this is to complete a 2
week course that started on [**2179-1-28**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Left MCA infarct.
Right pulmonary AVM - suspicious for Hereditary Hemorrhagic
Telangiectasia - Osler-[**Doctor Last Name 15716**]-Rendu.
Discharge Condition:
Vtal signs stable. The patient has right sided weakness of the
arm greater than leg. She has right sided facial droop. She
has a non-fluent aphasia.
Discharge Instructions:
Please take your medications as prescribed.
Please follow up with your appointments as documented below.
Please return to the hospital if you should have any concerning
symptoms. These include, but are not limited to, worsening limb
weakness, slurred speech or numbness.
Followup Instructions:
Please make an appointment to see your primary care physician in
the next two weeks to discuss the details of this admission.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2179-3-12**] 8:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
ICD9 Codes: 431, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7583
} | Medical Text: Admission Date: [**2134-3-14**] Discharge Date: [**2134-3-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6029**]
Chief Complaint:
resp distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Pt is a [**Age over 90 **] F who was admitted on [**2134-3-14**] from [**Hospital1 10151**] Center with cough, wheezes, tachypnea, and fever.
She was found to be influenza-A positive. Her hospital course
was also complicated by atrial fibrillation with rapid
ventricular response. She required two separate transfers to the
[**Hospital Unit Name 153**] due to respiratory distress and hypercarbic respiratory
failure. Patient is DNR/DNI, but she required frequent CPAP
therapy and was not able to be weaned off completely. A family
meeting was held on [**2134-3-19**] and the decision was made to change
the goals of care to comfort.
Past Medical History:
1. history of UTI's
2. 2nd degree HB s/p PPM
3. s/p TIA
4. HTN
5. RA
6. hypothyroid
7. varicose veins b/l LE insufficency
8. uterine prolapse with pessary
9. s/p R cataract surgery
[**38**].kyposcoliosis with severe osteoporosis and T8 compression
fracture
11.diabetes mellitus type 2
Social History:
Lives with daughter [**Name (NI) **] and her husband who themselves are
in their 70's and 80's, respectively. Has required acute rehab
at Heb reb in the past after hospital discharge. Grandson is an
immunologist.
Family History:
NC
Physical Exam:
vitals: Temp 97.9 BP 111/72 HR 105 RR 30 Pulse Ox 97% on 15L
mask
GEN: lethergic, Opens eyes spontaneously, paradoxical breathing,
accessory muscle use
HEENT: PERRL, anicteric, dry MM
NECK: JVD difficult to assess, no LAD
CHEST: irreg, irreg, tachy
LUNGS: coarse BS b/l, + accessory muscle use, no wheeze
ABDOMEN:soft, nt, nd, hypoactive BS
EXT: 1+ pitting edema, extremities warm
Brief Hospital Course:
This is a [**Age over 90 **] y/o female with influenza, rapid afib requiring
BIPAP therapy now with comfort as main goal of care. Her
respiratory distress was multifactorial including influenza,
COPD, possible secondary bacterial pneumonia. Unable to wean off
BiPAP for any extended period of time. Family meeting on [**2134-3-19**]
decided to make the patient DNR/DNI no BiPAP, no blood draws, no
finger sticks. No morphine drip, but morphine prn. The patient
was made as comfortable as possible with ativan, morphine, nebs,
and steroids prn. She passed away at 6 am on [**2134-3-24**] from
hypoxic respiratory failure.
Medications on Admission:
Meds on Xfer:
Heparin 5000 UNIT SC TID
Hydrochlorothiazide 25 mg PO DAILY
Insulin SC Sliding Scale
Ipratropium Bromide Neb 1 NEB IH Q6H
Levofloxacin 250 mg PO Q48H
Aspirin 81 mg PO DAILY
Levothyroxine Sodium 50 mcg IV DAILY
Clopidogrel Bisulfate 75 mg PO DAILY
Methylprednisolone Na Succ 60 mg IV Q24H
Diltiazem 30 mg PO QID
Pantoprazole 40 mg PO Q24H
Diltiazem 10 mg IV TID:PRN tachycardia
GlyBURIDE 1.25 mg PO DAILY
Guaifenesin [**5-19**] ml PO Q6H
Xopenex *NF* 0.31 mg/3 mL Inhalation [**Hospital1 **]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory distress, influenza
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 6035**]
Completed by:[**2134-3-24**]
ICD9 Codes: 5849, 2767, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7584
} | Medical Text: Admission Date: [**2184-10-10**] Discharge Date: [**2184-10-16**]
Date of Birth: [**2134-3-31**] Sex: M
Service: MED
Allergies:
Penicillins / Nsaids / Ciprofloxacin
Attending:[**First Name3 (LF) 1190**]
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
50 yo male with PMH significant for EtOH abuse as well as
several psychological diagnoses, presents to ER for evaluation
of rash on his chest and legs/groin 1 week after starting
ciproflox for R hand cellulitis. Rash is pruritic. No associated
fever, no respiratory compromise. In ER noted to be quite
tremulous. Stated last drink was within 24h, has a history of
"getting shaky" if EtOH withdrawal. No known seizure history.
Given total of 16mg ativan in the ER as well as a total of 100mg
valium. Also given atenolol, clonidine (on this at baseline),
thiamine/folate, B12, magnesium (Mg 0.8), calcium (ionized Ca
0.77). Treated for allergic rxn with SQ epi, atarax, zantac and
60mg prednisone. No respiratory compromise. He was initially
admitted to [**Hospital Unit Name 153**] for DTs, observation. On arrival to [**Hospital Unit Name 153**], the
patient was diaphoretic and tremulous, oriented x 3, cooperative
with history and physical exam. Given 10mg valium x 2 and then
20mg. Labs rechecked--iCa up to 0.99, repeated 3amps Ca
gluconate.
Past Medical History:
1. Extensive history of substance abuse with EtOH and benzo use.
He drinks regularly and has intermittent binges of several days
with very heavy consumption. These are typically in response to
feeling sad or happy. Has been at several hospitals including
[**Doctor First Name 1191**] for inpt detox from benzo's including Valium and Serax.
Denies other recreational drugs.
2. Atrial fibrillation. He was admitted in [**2171**] for AF with
rapid response, and converted spontaneously to NSR with only
rate control. It was felt to be holiday heart. TSH was normal,
and echo showed mild MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] AI.
3. L pectoralis muscle strain after a URI.
4. Low back pain, seen at [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic
5. Hypertension
6. Migraines
7. AI - longstanding murmur consistent with AI, documented by
echo [**2171**]
8. bipolar
9. OCD
10. PTSD
11. R hand cellulitis s/p trauma, cipro course [**Date range (1) 1195**]
Social History:
Married, in the past stated that he lived with wife, now living
in group home per MICU. No children. Currently unemployed. No
tobacco.
Family History:
Brother with heart murmur. Father died of melanoma; mother has
chronic bronchitis (tobacco user).
Physical Exam:
General: awake and alert, cooperative
Vital Signs: 98.2, HR 68, BP 126-141/43-60, SaO2 99-100% on RA
HEENT: NC/AT, perrl, sclerae anicteric, o/p with MMM, no thrush
neck supple, FROM, no LAD
Pulmonary: scattered crackles at the L base, otherwise clear
CV: rrr, nl s1 and s2
Abdomen: distended, obese, soft, palpable liver edge. no
rebound or guarding. no caput
Extremities: trace to 1+ edema in bilaterally LE's. ecchymosis
LUE(s/p phlebotomy there 1 week ago in ER)
Neuro: awake, alert, oriented x 3. moves all extremities.
Pertinent Results:
[**2184-10-10**] 12:20AM BLOOD WBC-8.0 RBC-3.84* Hgb-13.7* Hct-38.9*
MCV-102* MCH-35.6* MCHC-35.1* RDW-14.2 Plt Ct-227
[**2184-10-16**] 06:53AM BLOOD WBC-6.1 RBC-3.34* Hgb-11.4* Hct-35.1*
MCV-105* MCH-34.0* MCHC-32.4 RDW-14.4 Plt Ct-264
[**2184-10-10**] 12:20AM BLOOD Neuts-45.0* Lymphs-47.7* Monos-5.0
Eos-1.5 Baso-0.8
[**2184-10-10**] 11:00AM BLOOD Neuts-81.9* Lymphs-14.3* Monos-2.7
Eos-0.8 Baso-0.3
[**2184-10-10**] 12:20AM BLOOD Glucose-122* UreaN-8 Creat-0.5 Na-137
K-3.9 Cl-93* HCO3-21* AnGap-27*
[**2184-10-16**] 06:53AM BLOOD Glucose-91 UreaN-12 Creat-0.7 Na-136
K-5.0 Cl-98 HCO3-29 AnGap-14
[**2184-10-10**] 11:00AM BLOOD ALT-105* AST-403* AlkPhos-305*
TotBili-0.8
[**2184-10-13**] 04:31AM BLOOD ALT-78* AST-215* AlkPhos-247* TotBili-1.2
[**2184-10-10**] 02:11PM BLOOD Phos-4.1 Mg-1.2*
[**2184-10-16**] 06:53AM BLOOD Calcium-9.1 Phos-4.5 Mg-1.4*
[**2184-10-10**] 08:30AM BLOOD Calcium-6.1* Phos-4.6* Mg-0.8*
[**2184-10-10**] 11:00AM BLOOD VitB12-334 Folate-5.0
[**2184-10-10**] 02:11PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
AEROBIC BOTTLE (Final [**2184-10-16**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2184-10-16**]): NO GROWTH.
URINE CULTURE (Final [**2184-10-12**]): NO GROWTH.
AEROBIC BOTTLE (Final [**2184-10-17**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2184-10-17**]): NO GROWTH.
RAPID PLASMA REAGIN TEST (Final [**2184-10-13**]): NONREACTIVE.
[**10-10**] CXR: There is no focal consolidation, and the lateral
costophrenic foci are sharply delineated. Pulmonary vascular
markings are normal. The heart size is at the upper limits of
normal, and the mediastinum is otherwise unremarkable.
[**10-10**] EKG: Baseline artifact. Sinus rhythm. Prolonged QTc
interval. Prominent precordial QRS voltage - consider left
ventricular hypertrophy. Prominent lateral T waves of uncertain
significance - could be within normal limits or early
repolarization pattern. Clinical correlation is suggested. Since
the
previous tracing of [**2173-11-9**], QTc interval is longer and early
repolarization
pattern less prominent.
[**10-12**] SKIN L BACK: Skin left back (A): Perivascular lymphocytic
infiltrate with eosinophils consistent with dermal
hypersensitivity reaction. Note: No intraepidermal neutrophils
are seen on multiple levels. The results of a PAS stain will be
reported in an addendum.
Brief Hospital Course:
1) EtOH withdrawal: EtOH neg on tox screen. Pt states he has
baseline tremor ("shaky jakey" he calls himself), but it's not
clear whether the hx of tremor might be due to episodes of Etoh
withdrawl. Valium given per CIWA scale. His beta blocker and
clonidine were continued. Thiamine, folate, B12, and MVI were
supplemented. Urine and blood cultures were negative. He
exhibited sx of insomnia, tremulousness, anxiety,
gastrointestinal upset, headache, diaphoresis, disorientation,
tachycardia, hypertension, and agitation during this
hospitalization. He was still mildly disoriented when he signed
out AMA on the last day of hospitalization.
2) Drug rash - Treated in the ER with SQ epinephrine, steroids,
atarax, and zantac. Biopsy was consisted with drug rash, likely
secondary to ciprofloxacin. He should be recorded as having an
allergy to ciprofloxacin. His rash resolved.
3) FEN - He had low Ca, Mg, P04 on admission, which were
repleted.
4) Gap acidosis: He had a gap acidosis on admission that
resolved - likely alcoholic ketoacidosis +/- starvation.
5) Hematuria - The patient's foley was removed on [**10-15**], and he
subsequently complained of hematuria. A UA was ordered, however
the patient signed out AMA shortly thereafter, before the UA
could be obtained.
The patient was transfered to the floors on [**10-15**], and
subsequently signed out against medical advice.
Medications on Admission:
atenolol 100mg
clonidine 2 tabs [**Hospital1 **] (? dose)
effexor 50mg
paxil 50mg
Discharge Medications:
Signed out AMA
Discharge Disposition:
Home
Facility:
Signed out against medical advice.
Discharge Diagnosis:
Signed out against medical advice.
Discharge Condition:
Stable.
Discharge Instructions:
Signed out against medical advice.
Followup Instructions:
Signed out against medical advice. Usual PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7585
} | Medical Text: Admission Date: [**2194-12-11**] Discharge Date: [**2194-12-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Elevated Cr, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo male with h/o Parkinsons, HTN, and worsening renal failure
who presents with w/ K>6, Cr 4 from NH. a few days ago at [**Hospital 100**]
Rehab, he spiked a fever to 102. No night sweats or recent
weight loss or gain. Denies headache, rhinorrhea or congestion.
Positive cough productive of white phlegm. Patient also reports
that he has had DOE and shortness of breath for the last 6
weeks. He does not know whether this has changed recently.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting but developed diarrhea today. Patient states that he
has had constipation on and off and he was given something at
his rehab today to get his bowels moving. Then this afternoon he
devloped loose stools. The patient also c/o abdominal distention
which is not new. The patient also complains of chronic low back
pain radiating to the groin which is similar to the pain he had
on last admission when a compression fx was discovered. The
patient also states that he has had decreased PO intake over the
last week. He states that he has not felt hungry and "everything
tastes wrong"
.
The patient was recently admitted with worsening low back pain.
CT and plain films revealed a compression fracture. MRI spine
showed no evidence of epidural abscess, cord compression, osteo.
But may have acute compression of vertebrae causing pain. Pain
control was with tylenol standing, morphine prn, calcitonin
nasal spray. Patient with significant SOB and new oxygen
requirement that was thought [**2-20**] CHF exacerbation. CXR showed
atelectasis vs. PNA and evidence of CHF. The team held
Amiodarone in this patient as Amiodarone toxicity was thought to
possibly be contributing to his shortness of breath and hypoxia.
He was also treated for pneumonia given possible infiltrate in
gentleman with no clear source for fever, he was afebrile after
day one of admission. Echo during hospital stayed showed
decreased EF to 30% - 35% from 40% in [**Month (only) 404**]. He was
significantly volume overloaded on initial exam, with edema,
crackles and evidence of pulm edema and diuresed throughout the
admission.
.
In the ED today, EKG showed old AV delay, old LBBB, no TW
peaking.
CBC/chem revealed an AG of 16, elevated WBC. CEs showed an
elevated troponin but this is in the setting of ARF. MB was
flat. Guaiac test of stool was positive in setting of loose
stools. CXR/KUB -> bowel loops herniating to thorax but no
obstruction.
Past Medical History:
1. Parkinson's
2. Hypertension
3. Atrial fibrillation
4. CAD s/p MI [**2192**], recent cath in [**1-24**] showed right dominancy
circulation with 3VD, s/p stenting of mid LAD at that time
5. Ulcers
6. Asthma
7. Chronic renal insufficiency, baseline Cr 2.5-2.8
8. Diverticulosis
9. L groin hernia
10. h/o GIB (10y ago)
Social History:
Retired salesman. Widower. Lives independently in senior
housing. Nonsmoker. Only socially drinks ETOH. No IVDU. No
children.
Family History:
Mother- died at 86 of MI.
Father- heavy [**Name2 (NI) 1818**] and drinker. Died at 75y (? cause)
Brother- died of complications from [**Name (NI) 5895**]
Physical Exam:
Vitals: T 96.9 P 76 BP 110/70 97% 2L
General: Elderly man resting in bed, appears in mild respiratory
distress, NAD
HEENT: NC/AT, PERRL, EOMI, sclera anicteric. MM dry, OP without
lesions
Neck: supple, no JVD or carotid bruits appreciated
Pulm: Decreased air movement, diffuse wheezes
Cardiac: RRR, nl S1/S2, II/VI SEM at RUSB
Abdomen: distended, soft, typanic, hyperactive bowel sounds, in
ED good rectal tone, guiac negative.
Ext: 1+ bilateral pitting edema to knees, 1+ DP pulses
Lymphatics: No cervical, supraclavicular, axillary, or inguinal
LAD.
Skin: no rashes or lesions noted.
Neurologic: AAO x3, CN II-XII intact, muscle strength 5/5 in all
4 extremities.
Pertinent Results:
Labs on admission:
[**2194-12-11**] 12:55PM BLOOD WBC-12.6*# RBC-3.71* Hgb-11.7* Hct-34.1*
MCV-92 MCH-31.5 MCHC-34.3 RDW-14.6 Plt Ct-368
[**2194-12-11**] 12:55PM BLOOD Neuts-90.5* Bands-0 Lymphs-4.1* Monos-4.7
Eos-0.5 Baso-0.1
[**2194-12-11**] 12:55PM BLOOD PT-12.5 PTT-22.6 INR(PT)-1.1
[**2194-12-11**] 12:55PM BLOOD Glucose-123* UreaN-104* Creat-5.1*#
Na-128* K-6.4* Cl-90* HCO3-22 AnGap-22*
[**2194-12-11**] 12:55PM BLOOD CK(CPK)-675*
[**2194-12-11**] 09:30PM BLOOD CK(CPK)-536*
[**2194-12-12**] 06:10AM BLOOD CK(CPK)-389*
[**2194-12-11**] 12:55PM BLOOD cTropnT-0.37*
[**2194-12-11**] 09:30PM BLOOD CK-MB-8 cTropnT-0.34*
[**2194-12-12**] 06:10AM BLOOD CK-MB-6 cTropnT-0.35*
[**2194-12-11**] 12:55PM BLOOD Calcium-8.5 Phos-6.4*# Mg-4.3*
.
CXR [**12-11**]: Portable upright chest radiograph reviewed. Again
seen is a complex hiatal hernia containing stomach and bowel
loops. Evaluation of the heart size is thus limited. The lungs
are grossly clear though limited secondary to large hernia. The
right costophrenic angle is sharp. The left costophrenic angle
is obscured by mediastinal contour secondary to hernia. The
pulmonary vessels are within normal limits.
.
EKG: NSR rate 83, 1st degree AV block, LAD, LBBB
.
Renal U/S [**12-11**]: The right kidney measures 8.6 cm. The left
kidney measures 8.4 cm. Again seen are two right renal cysts.
There is no evidence of hydronephrosis, stones, or mass. The
distended bladder is unremarkable.
.
CT head [**12-11**]: There is no evidence of intracranial hemorrhage,
mass effect, hydrocephalus, shift of normally midline
structures, or major vascular territorial infarction.
Hypodensities in the periventricular and deep cerebral white
matter consistent with chronic microvascular infarction.
[**Doctor Last Name **]-white differentiation is preserved. Prominence of the
ventricles and sulci is consistent with brain atrophy. There are
bilateral basal ganglia calcifications. Extensive carotid
calcifications are also identified. Surrounding osseous and soft
tissue structures are unremarkable.
.
Urine Cytology- [**2194-12-22**] **atypical urothelial cells.
.
VIDEO OROPHARYNGEAL SWALLOW [**2194-12-22**] 11:15 AM
The study was performed in conjunction with the speech
pathologist. Various consistencies of barium were administered
to the patient under video fluoroscopy. Aspiration was
demonstrated with consecutive straw sips of thin liquids. The
patient had a spontaneous, ineffective cough. After the first
sip of thin liquids, a small amount of penetration was also
noted which was stripped out by the patient. Please see the
speech pathologist's report in CareWeb for more details and
treatment recommendations.
Brief Hospital Course:
Mr. [**Known lastname 1395**] is a pleasant and witty [**Age over 90 **] year old gentleman with h/o
Parkinsons, HTN, and worsening renal failure who presented with
a potassium of >6, Cr 4 from his nursing home. On admission he
developing worsening dyspnea requiring MICU transfer and around
the clock nebulizer treatments. He was never intubated and only
required 2L oxygen for mild hypoxia, and was transferred to the
general medical floor for management. It was thought severe
reflux and his very large paraesophageal hernia were primarily
related to his episode of dyspnea. The patient sustained an
NSTEMI and revealed worsening LV systolic function to 25% EF.
Coronary revascularization was not recommended given the
patient's episode of GI bleeding with heparinization and
baseline poor functional status. His medical therapies were
maximized from cardiac, renal and pulmonary perspectives.
#. Shortness of breath: No evidence of CHF or PNA on CXR.
Patient's lung exam + for wheezes. Does no appear overloaded on
pulmonary exam, however his significant lower extremity edema
was likely secondary to decreased oncotic pressures due to
nutritional depletion/low albumin. Given IV steroids and
nebulizers initially q30min but nebs were spaced to q2hours then
q4hours prn. Unfortunately patient had to relapsing episodes of
dyspnea requiring increased frequency in nebulizers. On his 2nd
relapse, LENI's were performed to rule out DVT's. A CTA was not
performed due to the patient's poor creatinine clearance. He
was started empirically on a heparin drip to PEs but it had to
be stopped because of rectal bleeding. Serial CXR did not reveal
a CHF picture. Pulmonary consultation was obtained and it was
thought his wheezing was secondary to his large paraesophageal
hernia in combination with severe reflux symptoms. He was placed
on [**Hospital1 **] pantoprazole, and slowly tapered down on prednisone to
30mg daily. He should continue his slow prednisone taper at the
MACU.
.
#. Acute on Chronic renal failure:
Pt with worsening renal function over the last year. Baseline
Creat is 2.3-2.6 and recent discharge Cr was 2.7. On admission
Creat was 5.1 in setting of probable dehydration. He likely has
prerenal ARF from poor forward flow from CHF, and also decreased
PO intake. No evidence of obstruction or hydronephrosis u/s done
in ED. Urine lytes c/w prerenal etiology with FeNa <1%.
Patient received gentle fluids overnight and Cr decreased to
4.4. UOP was steady following normalization of cardiac
function. We held ACE-I in the setting of his renal failure. We
did not diurese the patient in this setting either, but
maximized his heart function medically and allowed him to
autodiurese likely post-ATN. His BUN/Cr function was steadily
improving at time of discharge. Renal was consulted and
recommended the above measures. Urine cytology was ordered and
revealed atypical urothelial cells. This finding is of
indeterminant significance given his multiple medical problems
and high variability among urine cytology specimens. This should
be followed up on as an outpatient by Dr. [**Last Name (STitle) 1266**] to repeat
the study or decide with pt and family to pursue further
work-up.
.
#. Guaiac positive stool and loose stools:
Pt recently completed a course of Levaquin for PNA on admission.
Possible C. Diff in setting of Abx. Pt started on heparin for
presumed PE but had to be stopped because of bright red blood
per rectum. Pt's hematocrit remained stable. He was having
intermittent guaiac positive stools throughout the admission,
but did not significantly drop his hematocrit.
.
#. Back/Groin Pain:
Pt with recent CT and plain films which revealed compression
fracture. Recent MRI spine showed no evidence of epidural
abscess, cord compression, osteo. But may have acute compression
of vertebrae causing pain. His pain was well-controlled with
tylenol standing, morphine prn, calcitonin nasal spray. We had
PT see the patient daily to work on mobility.
.
.
#. Congestive heart failure:
Echo [**12-2**] showed decreased EF to 30% - 35% from 40% in [**Month (only) 404**].
Repeat echo on admission revealed an EF of 25-30%. This
worsening is likely related to an NSTEMI. Cardiology was
consulted and recommended maximizing medical therapy.
Revascularization is not a good approach given the pt's
intolerance of heparin, and would not do well with the plavix,
argatroban loading required for repeat PCI. We salt restricted
his diet. And allowed him to autodiurese. Aggressive diuresis
was not pursued given pulmonary function that was not supportive
of CHF. His lower extremity edema can be treated with
compression stockings/ACE bandages.
.
# CAD:
Pt has known 3VD, cath [**1-24**] with stent of LAD. No ECG changes
but pt has a LBBB. Tn elevated to 0.37 on admission and peaked
at 2.54 in the setting of his renal failure. His CK-MB fraction
trended down and normalized several days prior to admission. He
did not have any anginal symptoms. Pt was seen by cardiology who
recommended maximizing medical management given poor
risk/benefit of further PCI. We maximized statin to 80mg per
day, titrated his metoprolol to 37.5mg [**Hospital1 **], and continued
aspirin and plavix. We held ACE-I due to renal insufficiency.
.
#. Abdominal distension:
Noted on prior admission, pt with significant abdominal
distension, minimal discomfort with palpation. no evidence of
fluid. KUB showed many loops of gas filled bowel but no evidence
of bowel obstruction. Suspicion for C. diff infection was
considered given leucocytosis, but c. diff studies while in
hospital were negative.
.
#. Parkinson's disease: We continued ropinarole.
.
#. FEN: Cardiac diet. We obtained a video swallow evaluation
that cleared the patient for regular diet with only restriction
of avoiding straws for beverages given that they repeatedly
caused him to aspirate.
.
#. Prophylaxis: PPI, SC heparin, holding bowel regimen
.
#. Code: DNR/DNI as discussed with HCP.
.
#. Dispo: Pending clinical improvement
Medications on Admission:
1. Morphine 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4
hours) as needed for pain.
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Ropinirole 1 mg Tablet Sig: Eight (8) Tablet PO TID (3 times
a day).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain control.
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 4 days.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Psyllium Packet Sig: One (1) Packet PO BID (2 times a
day) as needed for constipation.
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for bloating.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for wheezing/sob.
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q12H ON, Q12H OFF ().
18. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
19. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
20. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TIDAC (3 times a day (before meals)).
21. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
22. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
23. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
24. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Discharge Medications:
1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Ropinirole 1 mg Tablet Sig: Eight (8) Tablet PO tid ().
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Albuterol Sulfate 0.083 % Solution Sig: [**1-20**] Inhalation every
4-6 hours as needed for shortness of breath.
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
14. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
18. Risperidone 0.5 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO BID, MR X1 [**Hospital1 **] ().
19. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
20. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
21. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
23. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
24. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Heart Failure
Secondary:
Paraesophageal hernia
gastroesophageal reflux
renal insufficiency
Parkinson's disease
Discharge Condition:
fair
Discharge Instructions:
You were admitted for kidney failure and shortness of breath.
You were treated with steroids and breathing treatments to
improve your breathing. Your kidney faily was likely related to
worsening function of your heart because of another heart
attack. You were seen by doctors [**Name5 (PTitle) 65386**] in your heart,
lungs, and kidneys who recommended changes to medications to
help with each of these organ systems. Ultimately your heart
function is the underlying problem for many of your symptoms and
we are currently giving you the best therapy possible given your
complex medical condition.
.
Please call Dr. [**Last Name (STitle) 65387**] or 911 if you experience any chest
pain, shortness of breath not responsive to nebulizer
treatments, high fevers or diarrhea,
Followup Instructions:
You will be seen regularly by Dr. [**Last Name (STitle) 1266**] at [**Hospital 100**] Rehab.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
ICD9 Codes: 5849, 2767, 4280, 5789, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7586
} | Medical Text: Admission Date: [**2127-2-14**] Discharge Date: [**2127-2-28**]
Service: SURGERY
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 7760**]
Chief Complaint:
Transfer from [**Last Name (un) 4068**] to [**Hospital1 18**] SICU
Major Surgical or Invasive Procedure:
s/p I&D ([**2-13**])
s/p Debridement ([**2-14**])
History of Present Illness:
Mr. [**Known lastname 31251**] is a 86 yo male transferred from [**Hospital1 **]-[**Last Name (un) 4068**]. He
developed right foot pain the Sunday prior to admission and was
seen by his Podiatrist, who diagnosed him with gout. He was
given colchicine and prednisone. Mr. [**Known lastname 31251**] then developed more
pain and warmth to his right foot later in the week and
presented to the [**Hospital1 **]-[**Last Name (un) 4068**] ED. At this hospital he underwent an
I&D ([**2-13**]) of a right foot infection and subsequently underwent
re-exploration ([**2-14**]) for developing necrotizing fascitis. He
was transferred to [**Hospital1 18**] for further care.
Past Medical History:
PMH: Prostate Ca, Glaucoma
PSH: RIH repair, s/p TURP, s/p thyroid excision
Social History:
EtOH
Physical Exam:
98.9, 93, 137/78, 16, 98%
GEN: NAD
HEENT: EOMI, anicteric, OP pink
NECK: no masses, supple
CV: RRR, no m/r
RESP: clear
GI: soft/NT/ND
EXT: R foot with erythema/swelling; muscle and tendons exposed,
with necrotic edges, some fibrinous exudate
NEURO: AxOx3
Pertinent Results:
MRI RLE [**2-17**]
"1. 7 cm linear fluid collection running between the anterior
and lateral muscle compartments, extending from a large area of
soft tissue loss seen in the distal lateral foreleg to roughly
the mid tibia/fibula, 18 cm distal to the knee joint line. The
collection is largest at its most proximal extent, measuring 1.4
x 0.7 cm in the transverse dimension.
2. Non-specific myositis involving multiple muscle groups in the
foreleg, most severe in the anterior, lateral, and posterior
deep compartments.
3. Tendinosis of the posterior tibialis and peroneus brevis
tendons. No tendon tear.
4. No evidence of abnormal bone marrow signal intensity or
intraosseous abscess."
RLE Angio [**2-17**]
"1. Mild but multifocal atherosclerotic disease involving the
infrarenal aorta and iliac arteries, with no significant
pressure gradient associated.
2. Significant segmental stenosis (approx. 5-6 cm long) in the
mid right superficial femoral artery.
3. High bifurcation of the popliteal artery at the knee level.
4. In the proximal calf, severe stenosis or occlusion of the two
terminal branches arising from this popliteal bifurcation
(likely the anterior tibial and the peroneal arteries). Two
significant focal stenoses of the distal right anterior tibial
artery. Right posterior tibial artery completely occluded.
5. Patent medial and lateral plantar arteries, filled through
collaterals arising mostly from the peroneal artery. Dorsalis
pedis artery not seen."
Brief Hospital Course:
Mr. [**Known lastname 31251**] was admitted to the TSICU. He was placed on
Penicillin G, Clindamycin. for empiric coverage of his wound,
with Group A strep growth from the [**Hospital1 **]-[**Last Name (un) 4068**] cultures. He was
transferred to the floor on HD#2. He continued to undergo [**Hospital1 **]
dressing changes.
Plastic surgery was asked to evaluate the patient. Per their
recommendations, silvadine was applied to the tendons to prevent
dessication.
Vascular surgery was also asked to evaluate the patient's right
lower extremity blood flow. An angiogram on HD#4 showed severe
tibial disease and moderate SFA disease, no DP artery was seen.
The vascular team recommended a femoral-peroneal bypass for
revascularization and performed this operation on HD #5. He
tolerated the procedure well, please see Dr.[**Name (NI) 1392**]
Operative Note for detail.
On POD#1, Mr. [**Known lastname 31251**] received 2 units of pRBCs for post-op
anemia (Hct 25). Mr. [**Known lastname 31251**] continued to be followed by
Infectious Disease, whose recommendations were to complete a [**12-26**]
week course of Penicillin G and Clindamycin after the foot was
completely debrided and the skin flaps completed. His wound
continued to heal well and by POD #6 a VAC dressing was placed.
He received a PICC on POD#7 for his long-term antibiotic
therapy.
At the time of discharge, Mr. [**Known lastname 31251**] had good pain control, was
tolerating a regular diet, had a well-healing wound treated with
a VAC dressing, and was to continue his IV PCN G and
Clindamycin. He was discharged to a rehab facility in fair
condition.
Medications on Admission:
Timolol .5%
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Right lower extremity necrosing fascitis
history of prostate cancer s/p TURP
glaucoma
Discharge Condition:
Fair
Discharge Instructions:
If you have any fevers/chills, nausea/vomiting, chest pain, foot
pain, please seek medical attention.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 6633**] in one week, call [**Telephone/Fax (1) 2998**]
for an appointment.
Follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks, call [**Telephone/Fax (1) 1393**] for an
appointment.
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7587
} | Medical Text: Admission Date: [**2150-2-19**] Discharge Date: [**2150-4-15**]
Date of Birth: [**2089-5-20**] Sex: M
Service: SURGERY
Allergies:
Desipramine Hcl
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatic cancer
Major Surgical or Invasive Procedure:
Whipple procedure with J tube placement,
Exploratory laparotomy for wound dehisence.
s/p closure with rentention sutures [**2-25**],
s/p Trach [**3-9**],
s/p open drainage of splenic abscess [**3-26**]
History of Present Illness:
This 60-year-old man has COPD and coronary artery disease as
well as bipolar depression and he originally presented with two
weeks of nausea, diarrhea, dark colored urine and jaundice. He
has been suffering from upper respiratory symptoms for the last
three weeks and saw his pulmonologist who started on antibiotics
for the steroid taper. He reported diarrhea at this time and he
actually had C. diff colitis identified. He reports no change
in appetite, recent weight loss or other particular symptoms.
He underwent an ERCP/stent placement on [**1-27**] which showed a
distal CBD stricture and atypical cells.
CTA abdomen showed a 3.6 cm head of pancreas mass.
He had a Whipple and J-tube on [**2150-2-19**]
Past Medical History:
COPD (Chronic Bronchitis, Emphysema), CAD, OSA (thumbs,
right shoulder and neck), Melanoma, Bipolar/manic depression,
sleep apnea, Hx C.diff
PSH: Cardiac Stent x4 ([**2145**]), Melanoma excision (abdomen) [**2140**]
Social History:
Lives alone in [**Location (un) 5289**]. Quit tobacco [**2145**]. No EtOH.
Works part-time in sales.
Family History:
Mother with breast CA
Physical Exam:
Gen: Looks a bit disheveled, but is awake and oriented x3 and
fully conversant.
HEENT: No evidence of scleral icterus at this point.
Chest: clear to auscultation.
CV: Cardiac exam shows a regular rate and rhythm.
Abd: soft, nontender, and nondistended with positive bowel
sounds and is quite protuberant and rotund.
Ext: show no cyanosis, clubbing, or edema.
Pertinent Results:
On admission:
[**2150-2-19**] 10:44PM BLOOD WBC-25.0*# RBC-4.04* Hgb-12.1* Hct-36.0*
MCV-89 MCH-30.1 MCHC-33.7 RDW-15.5 Plt Ct-195
[**2150-2-19**] 10:44PM BLOOD PT-15.0* PTT-43.8* INR(PT)-1.3*
[**2150-2-19**] 10:44PM BLOOD Glucose-186* UreaN-14 Creat-1.0 Na-140
K-5.0 Cl-107 HCO3-22 AnGap-16
[**2150-2-19**] 10:44PM BLOOD ALT-1015* AST-818* AlkPhos-96 Amylase-24
TotBili-2.1*
[**2150-2-19**] 10:44PM BLOOD Lipase-15
[**2150-2-19**] 10:44PM BLOOD Calcium-8.8 Phos-5.6*# Mg-1.7
[**2150-2-19**] 12:18PM BLOOD Type-ART pO2-93 pCO2-49* pH-7.28*
calTCO2-24 Base XS--3 Intubat-INTUBATED
.
CXR [**2150-2-20**]
IMPRESSION: AP chest compared to [**2-19**]:
Lung volumes remain quite low. Mild pulmonary edema is new,
accompanied by increased caliber to mediastinal and hilar
vessels. Small left pleural effusion is presumed. Tip of the
Swan-Ganz catheter projects over the right descending pulmonary
artery. ET tube tip ends at the thoracic inlet, partially
withdrawn since the prior study. Nasogastric tube passes below
the diaphragm and out of view. Small left pleural effusion is
presumed. No pneumothorax.
.
Duplex Doppler Abd/Pelvis [**2150-2-20**]
HISTORY: 60-year-old male status post Whipple's procedure.
IMPRESSION: Replaced common hepatic artery posterior to the
portal vein was not visualized; however, normal arterial
waveforms were obtained in the right and left hepatic arteries.
.
CXR [**2150-2-20**]
REASON FOR EXAM: Increased O2 requirement.
FINDINGS: There are low lung volumes. Increased diffuse density
of the left hemithorax is most likely due to layering pleural
effusion. Cardiac silhouette is accentuated by the low lung
volumes, appears to be mildly enlarged. There is engorgement of
the mediastinal and pulmonary vasculature with no overt
pulmonary edema. Right lower lobe atelectasis is new. NG tube
tip is out of view, below the diaphragm.
IMPRESSION: Increased left pleural effusion with increased
adjacent atelectasis.
[**2150-4-14**] 05:05AM BLOOD WBC-23.9* RBC-3.93* Hgb-11.1* Hct-34.6*
MCV-88 MCH-28.3 MCHC-32.2 RDW-17.5* Plt Ct-988*
[**2150-4-13**] 05:10AM BLOOD WBC-19.5* RBC-3.81* Hgb-10.8* Hct-33.7*
MCV-88 MCH-28.3 MCHC-32.0 RDW-17.5* Plt Ct-940*
[**2150-4-13**] 05:10AM BLOOD calTIBC-186* Ferritn-561* TRF-143*
[**2150-4-6**] 02:49PM BLOOD calTIBC-120* Ferritn-610* TRF-92*
[**2150-4-6**] 02:49PM BLOOD Triglyc-140
[**2150-3-25**] 02:21AM BLOOD Lithium-0.8
.
CHEST (PA & LAT) [**2150-4-12**] 10:18 PM
IMPRESSION: Persistent but slightly improved retrocardiac
opacity which may be secondary to aspiration, pneumonia, or
atelectasis. Left pleural effusion is unchanged. Subsegmental
right lower lobe atelectasis.
.
VIDEO OROPHARYNGEAL SWALLOW [**2150-4-7**] 1:23 PM
IMPRESSION: Penetration and intermittent aspiration with thin
and nectar consistency barium.
.
CHEST (PORTABLE AP) [**2150-4-5**] 4:47 AM
FINDINGS: The left chest tube is unchanged. There continued to
be bilateral pleural effusions moderate in size that layer
posteriorly, given positioning it is unclear but these are
likely increased compared to prior. There is pulmonary vascular
re-distribution, perihilar haze consistent with fluid overload.
There is obscuration of both hemidiaphragms due to the effusions
and an underlying infiltrate cannot be excluded.
.
ECHO
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
CT ABDOMEN W/CONTRAST [**2150-3-31**] 11:16 AM
IMPRESSION:
1. Overall, no significant change. Infarcted spleen and
subsequent hematoma is unchanged in size, with indwelling
large-bore catheter. Heterogeneity within the hepatic
parenchyma, left lobe, likely due to retractor injury, no
definite evidence for infection at this time.
2. Loculated left pleural effusion with near-complete collapse
of the left lower lobe. Small right effusion and atelectasis.
.
CT PERITINEAL DRAIN EXCLUDING APPENDICEAL [**2150-3-21**] 2:39 PM
IMPRESSION: Successful CT-guided percutaneous drainage of
splenic collection.
.
CT PELVIS W/CONTRAST [**2150-3-10**] 3:33 PM
IMPRESSION:
1. Splenic vein thrombosis with extensive splenic infarction.
Interval development of gas within the infarcted splenic
parenchyma concerning for infection.
2. Multiple poorly defined hypoenhancing areas in the left
hepatic lobe that may be related to retractor injury. However,
superimposed infection cannot be excluded.
3. Small left pleural effusion and near complete collapse of the
left lower lobe.
4. Emphysema.
5. No definite evidence of enterocutaneous fistula. However,
please note that the small bowel was not well opacified with
oral contrast at the time of the examination which limits the
sensitivity of this exam.
.
Brief Hospital Course:
Patient was admitted after a Pylorus-preserving Whipple w/
J-tube placement and placement of gold fiducial seeds for
CyberKnife therapy (please see full operative note for details).
Because of the pt's baseline cardiopulmonary issues, he
remained intubated and was transferred directly to the ICU.
Neuro: He was awake and alert after extubation and was
successfully transitioned to a PCA for pain control.
.
Cardiac: He initially had a Swan-Ganz catheter, which was
removed with stable cardiac function. He was maintained on ASA.
.
Pulmonary: Pt was extubated on POD 2 and eventually transitioned
to O2 by nasal canula. However, he was electively re-intubated
on [**2-25**] after his wound dehiscence and emergent return to OR.
He required ventilatory support post-op was he had a
percutaneous tracheostomy placed on [**2150-3-9**].
.
FEN: Pt was on a lasix drip initially for diuresis and was
eventually transitioned to intermittent doses. He responded
well to the treatment.
Trophic J tube feeds were started on POD#4 and were slowly
advanced towards goal. He tolerated them well. They were held
briefly during his evisceration but was eventually restarted and
advanced to goal. Nutrition was following for tube feed
recommendations.
He was evaluated by Speech and Swallow and he was cleared for
ground solids and nectar thick liquids.
.
GI: Immediately post-op, he had elevated LFTs but ultrasound of
the hepatic vasculature was negative for pathology.
He developed a wound infection that required re-opening of his
wound. With the infection and his concurrent steroids, he
eviscerated through his wound after a violent cough. He was
brought back to the OR emergently on [**2-25**] and his wound was
irrigated/debrided and primary closed with retention sutures.
He required large amounts of PEEP up to 15 to maintain his
oxygenation. He continued to be hypotensive requiring
vasopressors for several post-operative days. His cortisol stim
test showed a marginal response (34 to 41) and steroids were not
restarted. An ECHO was obtained which showed intact LV function
with no thrombi.
On [**3-7**] he developed an low-output colocutaneous fistula through
his abdominal wound. It's output was bilious and did not appear
to have any tube feeds or methylene blue when placed via the
NGT. A vacuum dressing was applied after initially using wet to
dry dressings.
His wound continued to improved and he will need continued wound
care.
.
ID: He spike fevers intermittently and cultures were positive
for: enterococcus faecium on [**2-21**] in blood x2 bottles, sputum
culture for sparse yeast [**2-21**]; Sputum cultures from [**2-26**], [**3-2**],
[**3-4**] revealed enterobacter cloacae and he was treated with
appropriate ABX.
On [**3-4**] (POD 13 and 7) he developed a fever to 102 and
leukocytosis to 34K. CT showed Infarction of the spleen with
thrombosis identified within the splenic vein and colitis. He
was treated non-operatively with bowel rest for the colitis and
an Aspirin for the splenic vein thrombus.
.
Heme: Pt had consistently decreasing platelet count while on
heparin. All heparin products were d/c'd and he was maintained
on pneumoboots for prophylaxis throughout his ICU stay. CT abd
[**3-4**] showed infarction of the spleen with thrombosis.
CT abd [**2150-3-10**] showed splenic abscess, which was drained on
[**2150-3-12**] via IR. Approximately 800cc blood/foul-smelling fluid
was drained and a drain was left in place.
.
Endo: Pt was adrenally deficient on POD#1 and started on a
steroid taper, which was appropriately weaned and then stopped
after he eviscerated from his incision.
His blood sugars continued to be elevated and [**Last Name (un) **] Diabetes
was seeing him and adjusting his sliding scales.
.
Psych: Lamictal and lithium were restarted on POD#4 through the
J tube. Psych continued to see him and he was discharged with
Diazepam PRN.
Medications on Admission:
ASA, Plavix 75', Toprol 25', Lipitor 80', atacand 4', prilosec',
lamictal 200', lithium 900', valium 5-10mg'' prn, advair
500/50'', celebrex 200', colace prn
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
3. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Ascorbic Acid 90 mg/mL Drops [**Last Name (STitle) **]: Five Hundred Four (504) mg
PO DAILY (Daily).
6. Ferrous Sulfate 300 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO DAILY
(Daily).
7. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q6H (every 6 hours) as needed for wheeze.
8. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: One (1) Cap PO DAILY
(Daily).
9. Papain-Urea 830,000-10 unit/g-% Ointment [**Last Name (STitle) **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
11. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO
TID (3 times a day).
12. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
13. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
14. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: [**4-12**]
Puffs Inhalation Q4H (every 4 hours).
15. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day (3) **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
16. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) [**Hospital1 **]: [**4-12**] Caps PO QIDWMHS (4 times a day
(with meals and at bedtime)).
17. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Month/Day (3) **]: 5-10 MLs
PO Q6H (every 6 hours) as needed.
18. Cholestyramine-Sucrose 4 gram Packet [**Month/Day (3) **]: One (1) Packet PO
QID (4 times a day).
19. Insulin NPH Human Recomb 100 unit/mL Suspension [**Month/Day (3) **]: Twenty
Five (25) Units Subcutaneous twice a day.
20. Lithium Carbonate 300 mg Capsule [**Month/Day (3) **]: Three (3) Capsule PO
QHS (once a day (at bedtime)).
21. Lamotrigine 100 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO QHS (once a
day (at bedtime)).
22. Miconazole Nitrate 2 % Powder [**Month/Day (3) **]: One (1) Appl Topical TID
(3 times a day) as needed.
23. Clopidogrel 75 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily).
24. Zolpidem 5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO HS (at bedtime)
as needed.
25. Vancomycin 250 mg Capsule [**Month/Day (3) **]: Two (2) Capsule PO Q6H (every
6 hours) for 1 weeks.
26. Metronidazole 500 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO TID (3
times a day) for 1 weeks.
27. Diazepam 5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO TID (3 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Whipple, J-tube [**2-19**]
wound dehiscence s/p closure with rentention sutures [**2-25**],
s/p Trach [**3-9**],
s/p open drainage of splenic abscess [**3-26**]
Adrenal Insufficiency, enterococcal bacteremia, MRSE line
sepsis, wound infection, splenic vein thrombosis, splenic
infarct respiratory failure, enterocutaneous fistula
Discharge Condition:
Good
Tolerating tubefeedings
Wound Healing
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**10-21**] lbs) for 6 weeks.
* Monitor your incision for signs of infection
* Keep your incision clean and dry.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on [**5-15**] at 10:30am. Call
[**Telephone/Fax (1) 1231**] with questions or concerns.
Completed by:[**2150-4-15**]
ICD9 Codes: 5119, 5180, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7588
} | Medical Text: Admission Date: [**2139-5-25**] Discharge Date: [**2139-6-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Transfer for possible placement of BiV pacer
Major Surgical or Invasive Procedure:
[**Hospital1 **]-ventricular pacer placement
History of Present Illness:
Patient is a 84 year old man with ischemic cardiomyopathy (EF in
the 30's, 2+ TR, 2+MR [**First Name (Titles) **] [**Last Name (Titles) **] on [**2138-10-22**])admitted [**2139-5-19**] to
[**Hospital3 3583**] with complaints of several weeks of generalized
fatigue. He was r/o for MI and was found to have a UTI for which
he was given ceftriaxone 1g IV yesterday ([**2139-5-24**]). His
creatinine was 1.7 on admission but has since improved to 1.2.
He was also found to be hyperglycemic with positive ketones
secondary to self dicontinuation of glyburide. During his
hospital stay he developed a right lower extremity DVT and is
now on heparin drip 900u/hour. During this admission he also had
a head CT which showed moderate atrophy. The reason for this
was not clarified as he was not reported to have any mental
status changes. They also did an abdominal u/s as his LFT's were
elevated which showed hepatic steatosis.
Upon admit to [**Hospital3 **] he was also found to have new
onset RAF to the 110's. While on telemetry he had a 13 beat run
of NSVT. They were trying to manage his rate but last Friday he
did have some pauses up to 3 seconds, therefore his digoxin
(level 1.2 on [**2139-5-19**] admission) and verapamil were held. He
has not had any pauses in 3 days. He was transferred for
possible placement of BiV pacer.
Past Medical History:
1. Ischemic cardiomyopathy, EF 30%
2. CAD s/p CABGx3
2. New onset AF
3. hypertension
4. hyperlipidemia
5. DM
6. Prostate cancer- dx mid-[**2123**]'s with urinary retention
7. CRI
8. glaucoma
9. right total hip replacement
10. LBBB
Social History:
Rarely uses alcohol, former smoker quit 55 years ago
Family History:
Father-Died of MI in 70's
Mother lived into her 90s and was healthy
Brother 87 with CAD and ICD placed a year ago
Brother 79-healthy
Sister in her 90's had stroke at age [**Age over 90 **]
Physical Exam:
General: Elderly gentleman lying supin in NAD.
Vitals:t. 96 BP 122/52 P 104 R 20 O2sats 99% on 2L Wt. 77.6 kg
CV: irreularly, irregular, no murmur
Pulm:CTA b/l
Abd: +BS, soft, NT/ND
Ext: 3+ pitting edema on right up to hip, 2+ pitting edema on
left up to knee
ROS: Denies N/V, abdominal pain, dysuria, fever, chills.
Pertinent Results:
[**2139-5-25**] 11:26PM PTT-131.1*
[**2139-5-25**] 03:34PM GLUCOSE-372* UREA N-52* CREAT-1.3* SODIUM-141
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
[**2139-5-25**] 03:34PM ALT(SGPT)-285* AST(SGOT)-211* ALK PHOS-190*
TOT BILI-0.4
[**2139-5-25**] 03:34PM CALCIUM-7.8* PHOSPHATE-3.0 MAGNESIUM-2.2
[**2139-5-25**] 03:34PM WBC-9.5 RBC-4.11* HGB-13.2* HCT-39.7* MCV-97
MCH-32.2* MCHC-33.3 RDW-14.9
[**2139-5-25**] 03:34PM PLT COUNT-119*
[**2139-5-25**] 03:34PM PT-17.4* PTT-150* INR(PT)-2.0
[**2139-5-28**] 01:16PM BLOOD Glucose-265* UreaN-68* Creat-1.7* Na-137
K-4.2 Cl-103 HCO3-25 AnGap-13
[**2139-5-28**] 05:05PM BLOOD Creat-1.7*
[**2139-5-28**] 01:16PM BLOOD ALT-235* AST-102* LD(LDH)-1065*
AlkPhos-158* TotBili-0.4
[**2139-5-28**] 01:16PM BLOOD Mg-2.2
[**2139-5-27**] 04:04PM BLOOD Smooth-NEGATIVE
[**2139-5-27**] 04:04PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2139-5-27**] 06:20AM BLOOD IgG-439* IgM-94
[**2139-5-27**] 06:20AM BLOOD HCV Ab-NEGATIVE
[**2139-5-25**] 03:34PM BLOOD WBC-9.5 RBC-4.11* Hgb-13.2* Hct-39.7*
MCV-97 MCH-32.2* MCHC-33.3 RDW-14.9 Plt Ct-119*
[**2139-5-27**] 06:20AM BLOOD WBC-8.4 RBC-3.86* Hgb-12.3* Hct-37.8*
MCV-98 MCH-31.9 MCHC-32.5 RDW-15.2 Plt Ct-104*
[**2139-5-30**] 06:15AM BLOOD WBC-13.3* RBC-3.38* Hgb-10.6* Hct-32.5*
MCV-96 MCH-31.5 MCHC-32.7 RDW-15.3 Plt Ct-166
[**2139-5-31**] 05:13AM BLOOD WBC-13.9* RBC-2.88* Hgb-9.0* Hct-27.0*
MCV-94 MCH-31.3 MCHC-33.3 RDW-15.2 Plt Ct-138*
[**2139-5-25**] 03:34PM BLOOD PT-17.4* PTT-150* INR(PT)-2.0
[**2139-5-27**] 03:12PM BLOOD PT-13.2 PTT-64.7* INR(PT)-1.2
[**2139-5-30**] 06:15AM BLOOD PT-26.2* PTT-58.7* INR(PT)-4.6
[**2139-5-31**] 05:13AM BLOOD PT-32.1* PTT-44.9* INR(PT)-6.8
[**2139-5-25**] 03:34PM BLOOD Glucose-372* UreaN-52* Creat-1.3* Na-141
K-4.4 Cl-105 HCO3-26 AnGap-14
[**2139-5-27**] 06:20AM BLOOD Glucose-274* UreaN-50* Creat-1.2 Na-141
K-4.1 Cl-105 HCO3-27 AnGap-13
[**2139-5-29**] 06:25AM BLOOD Glucose-127* UreaN-83* Creat-2.2* Na-139
K-4.5 Cl-103 HCO3-25 AnGap-16
[**2139-5-30**] 06:15AM BLOOD Glucose-151* UreaN-104* Creat-3.5* Na-136
K-4.9 Cl-103 HCO3-20* AnGap-18
[**2139-5-31**] 05:13AM BLOOD Glucose-106* UreaN-130* Creat-4.5* Na-137
K-5.2* Cl-106 HCO3-18* AnGap-18
[**2139-5-25**] 03:34PM BLOOD ALT-285* AST-211* AlkPhos-190*
TotBili-0.4
[**2139-5-28**] 01:16PM BLOOD ALT-235* AST-102* LD(LDH)-1065*
AlkPhos-158* TotBili-0.4
[**2139-5-30**] 06:15AM BLOOD ALT-174* AST-107* LD(LDH)-1132*
AlkPhos-125* TotBili-0.3
[**2139-5-28**] 01:16PM BLOOD GGT-417*
[**2139-5-30**] 06:15AM BLOOD TotProt-3.8* Albumin-2.0* Globuln-1.8*
Phos-6.5*# Mg-2.2 Iron-62
[**2139-5-30**] 06:15AM BLOOD Ammonia-49*
Brief Hospital Course:
84 y/o man with PMH significant for ischemic cardiomyopathy (EF
in the 30s, 2+ TR, 2+ MR) admitted on [**5-25**] for placement of BiV
pacer. Prior to admission, the pt had been admitted to [**Hospital1 3325**] on [**6-18**] with several weeks of generalized fatigue. He
was ruled out for MI. However, the pt was found to have new
onset rapid atrial fibriallation with a rate in the 110s. He
also had a 13 beat run of NSVT and up to three second pauses.
This prompted the transfer for possible BiV pacer. During the
OSH admission, the pt was also found to have a UTI and was
started on treatment with ceftriaxone. In addition, he developed
a right LE DVT and was started on treatment with a heparin drip.
.
Following admission at [**Hospital1 18**], the pt was seen by EP and
underwent placement of a BiV pacemaker on [**5-28**]. The procedure
was uncomplicated. However, the pt began to have dramatically
decreased urine output (less than 500 cc on [**5-28**]) and a rising
Hct. His creatinine went from 1.3 on admission --> 1.7 on [**5-28**]
--> 2.2 on [**5-29**] --> 3.5 on [**5-30**] --> 4.5 on [**5-31**]. A renal
consult was obtained on [**5-30**]. They felt that his ARF picture
was most consistent with ATN but extensive evaluation and
treatment (dialysis) was deferred as the pt decided to become
CMO. In addition to the repidly worsening renal failure, a
hepatology consult was obtained as the pt was found to have
elevated transaminitis and fatty infiltration of the liver.
Further evaluation of this will also be deferred at this time.
Pt also began to suffer from hypotension starting on [**5-28**]. This
has continued.
.
Prior to the pt becoming CMO, he was transferred to the CCU on
[**5-30**] when it was considered that more agressive treatments
might be benificial. It was thought that his multisystem failure
(severe ARF, hepatic failure, hypotension) was most likely [**12-31**]
poor forward flow from his CHF/CM. Upon transfer, the pt decided
that he wanted to be DNR/DNI. He was very clear about his wishes
not to have heroic measures, further treatment, or anything that
might cause him discomfort. His family was present and supported
him in his decision to be comfort measures only. Therefore, the
pt was transferred to the floor for CMO care. He was maintained
on morphine drip, and all other medications held.
At 5pm on [**6-1**], housestaff (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4154**]) was called to
bedside to pronounce Mr. [**Known lastname **] death. On exam, his pupils
were fixed and dilated, and he had no pulse, respirations, or
heart sounds. He was pronounced dead at 5:05pm. His family
declined a post-mortem examination.
Medications on Admission:
asa 81, KCL, insulin, alphagan eye gtts, lispro insulin,
ceftriaxone, avandia, aldactone, lasix 20, lisinopril 15, coreg
3.125 [**Hospital1 **], heparin 900u/hour. (recently decreased as PTT 128
this morning)- PTT due for 4pm.
Discharge Medications:
None
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Congestive heart failure
Acute renal failure
Hepatic failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
ICD9 Codes: 5849, 4280, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7589
} | Medical Text: Admission Date: [**2198-3-2**] Discharge Date: [**2198-3-3**]
Date of Birth: [**2145-3-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Blood transfusions
History of Present Illness:
52 F with metastatic cholangiocarcinoma to liver and lungs, dxed
[**2196**], with bright red blood in her stool x past month. On
[**2198-2-26**], she was going to but did not receive her second cycle
of carboplatin/Taxol with sorafenib. She received her first
cycle of [**Doctor Last Name **]/Taxol/sorafenib 3 weeks ago, which she appeared
to have tolerated well initially, but has had significant
weakness and SOB x weeks afterward. Her Hct was found to be 18,
she was transfused 2 URBC. Today in followup with Dr. [**First Name (STitle) **]
[**Name (STitle) **], her Hct was 18, and she noted that she has been having
small amounts of BRBPR in her stool, no melena, no hemoptysis.
Sorafenib was stopped.
Past Medical History:
Cholangiocarcinoma w/ liver mets dx [**2196**], s/p common
hepatic duct stent [**12-2**], s/p 2 cycles, last chemo [**1-17**]
(cis/gem)
GERD
Mastitis after first pregnancy
2 separate breast bx??????s (both neg)
Migraines
[**Doctor First Name **] Hx:
Appendectomy with L oopherectomy about 30 yrs ago
Diagnostic laproscopy for suspected endometriosis (neg)
Recent FNA of thyroid nodule (neg)
Social History:
Lives in [**Location 620**] with husband and daughter, one other daughter
at college. She is employed as a social worker. She [**Name2 (NI) 100360**] 1mile
2-3x per week, does not drink, smoked socially (tobacco and
marijuana) 30 years ago. Denies current drug use although she
states she had a dependency on pain-killers 30 years ago.
Family History:
Mother died of breast CA as did Grandmother and two maternal
great-aunts. One aunt died of pancreatic CA and another from
stomach CA. She denies other familial illnesses. She gets
regular mammogram and screening but does not want genetic
screening for BRCA.
Physical Exam:
VS: 99.1 / 122/80 / 12 / 92 / 99% RA
GEN: Pleasant thin female in no acute distress, in bed
HEENT: PERRL, no LAD, JVD flat, anicteric sclerae
LUNGS: CTA B
HEART: RRR, no m/r/g
ABD: Very mild epigastric tenderness to palpation, no rebound,
no guarding, soft, +BS, ND
EXTR: No c/c/e
NEURO: [**6-2**] motor, normal gait
SKIN: No rash
Pertinent Results:
Hct: 18.4 - 24.8 - 27 - 29.4
.
[**2198-3-2**] 10:40AM BLOOD WBC-8.2 RBC-2.17* Hgb-6.3* Hct-18.4*
MCV-85 MCH-29.0 MCHC-34.2 RDW-22.7* Plt Ct-127*
[**2198-3-2**] 07:16PM BLOOD WBC-5.4 RBC-3.04*# Hgb-8.8*# Hct-24.8*#
MCV-82 MCH-29.0 MCHC-35.5* RDW-20.0* Plt Ct-76*
[**2198-3-3**] 04:00AM BLOOD WBC-6.1 RBC-3.38* Hgb-9.8* Hct-27.0*
MCV-80* MCH-29.1 MCHC-36.3* RDW-19.1* Plt Ct-70*
[**2198-3-3**] 01:32PM BLOOD WBC-6.6 RBC-3.57* Hgb-10.1* Hct-29.4*
MCV-82 MCH-28.2 MCHC-34.3 RDW-19.6* Plt Ct-71*
[**2198-3-2**] 07:16PM BLOOD PT-22.3* PTT-22.3 INR(PT)-1.1
[**2198-3-2**] 07:16PM BLOOD Glucose-96 UreaN-18 Creat-0.5 Na-139
K-4.2 Cl-106 HCO3-25 AnGap-12
[**2198-3-2**] 07:16PM BLOOD CK-MB-1 cTropnT-<0.01
[**2198-3-2**] 07:16PM BLOOD Albumin-2.9* Calcium-8.0* Phos-2.4*
Mg-2.1 Iron-238*
Brief Hospital Course:
52 F with metastatic cholangiocarcinoma to liver and lungs, dxed
[**2196**], with bright red blood in her stool x past month. Hospital
course by problem:
.
# BRBPR:
Appears to be mild and chronic over a month. [**Month (only) 116**] be associated
with sorafenib treatment, but this drug was only started [**2197-2-5**],
and she received only one treatment dose. She has received
Avastin in the past. The patient was given 3u of PRBCs with an
improvement in her hematocrit to 29 from 18. She was
hemodynamically stable and not experiencing melana or
hematochezia. She ambulated without significant presyncopal
symptoms. GI was consulted who recommended an EGD and
colonoscopy with 2-3 days following her initial evaluation. We
discharged the patient with instructions on how to communicate
with the GI team to set up her procedures.
.
# Metastatic cholangiocarcinoma:
Most recent treatment was [**2197-2-5**] of Cycle 1 of
[**Doctor Last Name **]/taxol/sorafenib. Cycle 2 was held on [**2-26**] for low Hct.
Most recent CT abd [**2198-1-31**]. Followed by Dr. [**First Name (STitle) **] [**Name (STitle) **]. We
ordered a CT of the torso for the patient to get done as on
outpatient. We also continued her actigall.
.
# Chronic abdominal pain:
Well controlled on dilaudid 1-2mg q 3 hours prn.
.
# Depression:
We continued Celexa per home regimen.
Medications on Admission:
1. Ursodiol 300 mg QD
2. Lorazepam 0.5 mg Q8H
3. Citalopram Hydrobromide 40 QD
4. Ciprofloxacin 500 mg QD
5. Prochlorperazine 10 mg Q6H prn
6. Dilaudid 1-2 mg Q3H prn
7. Methylphenidate 5 [**Hospital1 **]
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet PO BID
9. Potassium Chloride 20 mEq Packet QD
10. Loperamide 2 mg prn
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO once a day.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
3. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for nausea.
5. Dilaudid 2 mg Tablet Sig: 0.5-1 Tablet PO every four (4)
hours as needed for pain.
6. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- BRBPR
- cholangiocarcinoma
- anemia
Secondary:
- Migraines
- s/p appy
Discharge Condition:
well
Discharge Instructions:
You were admitted with with bleeding out of your rectum. We
treated you with three units of blood and you were evaluated by
the GI physicians. Your hematocrit stabilized.
.
The GI physicians would like to perform an EGD and colonoscopy
on Tuesday, [**3-6**]. Dr. [**First Name4 (NamePattern1) 14992**] [**Last Name (NamePattern1) 9746**] will call you on
Sunday to discuss the prep. You may eat normally today. On
Sunday, please switch to a full liquid diet. Please avoid seeds
and high fiber foods in the meantime. On Monday night, please
have nothing to eat after midnight.
.
Please take your medications as instructed. Please contact your
doctor if you feel short of breath, chest pain, fever, chills,
weakness.
.
Please have a CT scan done on [**2198-3-5**]. You need to contact the
radiology department by [**Telephone/Fax (1) **] to confirm this
appointment.
Followup Instructions:
Please have a colonoscopy and EGD on Tuesday. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 100361**]
will call you to set this up.
.
Please call [**Telephone/Fax (1) **] to confirm your CT scan for [**2198-3-5**].
The time needs to be confirmed by phone. Please followup with
Dr. [**Last Name (STitle) **] within the next two weeks.
ICD9 Codes: 2875, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7590
} | Medical Text: Admission Date: [**2183-8-17**] Discharge Date: [**2183-9-13**]
Date of Birth: [**2143-12-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
shortness of breath -> admitted to the floor then transferred to
the ICU for hypotension and hypoxic respiratory failure
Major Surgical or Invasive Procedure:
- nasotracheal intubation
- central line placement
History of Present Illness:
39 y.o. male with past history of morbid obesity, sleep apnea,
who was admitted originally with rapid weight gain, increasing
exertional dyspnea, and lower extremity edema. He was initially
admitted to the MICU for desaturations. While in the MICU,
patient subsequently became obtunded and was found to have
acidosis from hypercarbic respiratory failure and required
nasotracheal intubation. While evaluating the etiology of his
respiratory failure, echocardiogram revealed severe global
reduction in LV systolic function with EF of 20%. Given this
finding and above symptoms consistent with failure, PA catheter
was placed for tailored diuresis and patient was transferred to
CCU.
.
While in the CCU, patient was diuresed ~6 litres on furosemide
and dobutamine gtt. This did not improve his oxygenation.
Despite this, his hypoxia persisted even as FiO2 was increased
to 100% and PEEP increased to 20. Given lack of improvement in
oxygenation, shunt physiology was then evaluated with bubble
echocardiogram but this did not reveal right-to-left shunting.
Next, a trial of inhaled nitric oxide was attempted to relieve
his elevated pulmonary artery hypertension, in case this was
contributing to his hypoxia. Again, no improvement was noted and
this was discontinued. Finally, a diagnosis of ARDS was then
entertained and patient was placed on APRV mode for ventilation
and paralyzed with cisatracurium. At this point, given concern
for ARDS, it was decided to transfer patient back to MICU
service. A Chest CT was obtained en route to further
characterize the question of ARDS and also to evaluate a
possible infectious source of recurrent fevers patient had been
having, but the results of imaging did not correlate with the
clinical diagnosis. Of note, prior to transfer, patient was
transiently hypotensive, presumably from overdiuresis and
responded well to normal saline 1 liter bolus.
Past Medical History:
Morbid Obesity
Social History:
The patient lives in [**Location **] with his family including sister
and grandparents. He is employed as an assistant manager at
Domino's pizza.
Tobacco: 1 PPD x 5 years -> 5 pack-year
ETOH: None
Illicits: None including IVDU
Family History:
Father - [**Name (NI) 3730**] unknown type
Mother - [**Name (NI) 3730**] unknown type
- denies family history of cardiac disease, cardiomyopathy,
liver disease
Physical Exam:
Vitals: T-99.8 BP-145/76 HR-102 RR-20 O2- 92% on APRV
(PHigh 38, PLow 14, High Time 2.6, Low time 0.4).
.
General: Morbidly obese Asian Male intubated, paralyzed
HEENT: NCAT, EOMI. Sclera anicteric, nasotracheal tube in left
nares, right nares occluded by clot formation.
Neck: Obese, right IJ PA catheter in place
Chest: Coarse breath sounds bilaterally
Cor: Distant heart sounds, No M/G/R
Abdomen: Markedly obese and distended. Firm but not rigid to
palpation with blanching erythema. Skin is chronically
indurated, + striae and anasarca.
Extremity: Chronic venous stasis changed, + pitting edema
bilaterally. Warm with good pulses
Pertinent Results:
[**2183-9-13**] 04:05AM BLOOD WBC-9.9 RBC-4.87 Hgb-11.4* Hct-35.4*
MCV-73* MCH-23.3* MCHC-32.1 RDW-16.8* Plt Ct-282
[**2183-9-10**] 04:43AM BLOOD Neuts-58.4 Lymphs-25.4 Monos-3.0
Eos-12.6* Baso-0.5
[**2183-8-27**] 04:05AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2183-9-13**] 04:05AM BLOOD Plt Ct-282
[**2183-9-12**] 03:58AM BLOOD PT-14.3* PTT-31.2 INR(PT)-1.3*
[**2183-9-13**] 04:05AM BLOOD Glucose-97 UreaN-46* Creat-2.0* Na-146*
K-4.4 Cl-117* HCO3-19* AnGap-14
[**2183-9-12**] 03:58AM BLOOD ALT-29 AST-28 AlkPhos-158* TotBili-0.5
[**2183-9-1**] 04:17AM BLOOD Lipase-127*
[**2183-8-17**] 06:25AM BLOOD CK-MB-8 cTropnT-0.02*
[**2183-8-16**] 10:30PM BLOOD CK-MB-8 cTropnT-0.02* proBNP-1625*
[**2183-9-13**] 04:05AM BLOOD Calcium-8.5 Phos-4.8* Mg-2.0
[**2183-8-17**] 06:25AM BLOOD Triglyc-133 HDL-37 CHOL/HD-4.1 LDLcalc-89
[**2183-8-17**] 05:00PM BLOOD TSH-5.7*
[**2183-8-17**] 05:00PM BLOOD T4-5.8
[**2183-8-17**] 05:00PM BLOOD Cortsol-21.7*
[**2183-8-31**] 04:39AM BLOOD Vanco-16.8
[**2183-9-13**] 04:19AM BLOOD Type-ART Temp-38.3 PEEP-20 pO2-89 pCO2-35
pH-7.38 calTCO2-22 Base XS--3 Intubat-INTUBATED Vent-CONTROLLED
[**2183-9-12**] 07:09PM BLOOD Lactate-1.8 Na-147 K-4.3
[**2183-9-12**] 07:09PM BLOOD O2 Sat-92
[**2183-9-12**] 07:09PM BLOOD freeCa-1.21
.
CHEST (PORTABLE AP) [**2183-9-13**] 2:54 AM
CHEST (PORTABLE AP)
Reason: Assess for interval changes s/p ET tube change from nose
to
[**Hospital 93**] MEDICAL CONDITION:
39 year old man with resp failure, reintubated.
REASON FOR THIS EXAMINATION:
Assess for interval changes s/p ET tube change from nose to
oral.
STUDY: AP chest [**2183-9-13**].
HISTORY: 39-year-old man with respiratory failure. Assess for
interval change.
FINDINGS: Comparison is made to previous study from [**9-12**], [**2182**].
The study is very limited due to technique and poor inspiratory
effort. The patient has cardiomegaly. There is likely no
interval change with bilateral pleural effusions, left
retrocardiac opacity and pulmonary edema.
.
[**9-4**] ECHO
Conclusions:
The left ventricular cavity is mildly dilated. Due to suboptimal
technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall
left ventricular systolic function is moderately depressed
(LVEF= 30-35 %).
The right ventricular cavity is dilated. Right ventricular
systolic function
appears depressed. The aortic valve is not well seen. The mitral
valve
leaflets are not well seen. The estimated pulmonary artery
systolic pressure
is normal. There is a trivial/physiologic pericardial effusion.
Compared with the prior studies (images reviewed) of [**2183-8-31**]
and [**2183-8-21**],
unable to adequately compare ventricular function, although
function may have
been more vigorous (estimated ejection fraction then ~40%) in
the study of
[**2183-8-21**] in which images were of better quality.
.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2183-8-20**] 5:24 PM
CT SINUS/MANDIBLE/MAXILLOFACIA
Reason: r/o infection; PLEASE DO WITHOUT CONTRAST
[**Hospital 93**] MEDICAL CONDITION:
39 year old man with 39 year old man with abdominal distention,
DOE for 3 weeks with LE edema, [**Hospital1 **]-V heart failure w/ fevers
REASON FOR THIS EXAMINATION:
r/o infection; PLEASE DO WITHOUT CONTRAST
CONTRAINDICATIONS for IV CONTRAST: ARF
INDICATION: Fever and abdominal distension. History of heart
failure.
TECHNIQUE: Multidetector CT imaging of the sinuses was performed
without intravenous contrast and displayed in 2.5 mm axial
collimation. No comparison is available.
FINDINGS: The patient is intubated. There is near complete
opacification of all of the visualized paranasal sinuses and of
the mastoid air cells. There is only partial aeration of the
left frontal sinus. Frontal sinus demonstrates no
aerosolization. An endotracheal tube passes through the left
naris. An orogastric tube is present. The mastoid air cells are
poorly pneumatized, although there is also partial opacification
of the bilateral mastoid air cells. Visualized portions of the
brain are unremarkable.
IMPRESSION: Near total opacification of the paranasal sinuses
and mastoid air cells. These may reflect retained fluid due to
prolonged intubation, but CT cannot distinguish sterile from
infection fluid.
.
CT ABDOMEN W/O CONTRAST [**2183-8-20**] 5:25 PM
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST
Reason: r/o infectious process
Field of view: 60
[**Hospital 93**] MEDICAL CONDITION:
39 year old man with 39 year old man with abdominal distention,
DOE for 3 weeks with LE edema, [**Hospital1 **]-V heart failure w/ fevers
REASON FOR THIS EXAMINATION:
r/o infectious process
CONTRAINDICATIONS for IV CONTRAST: ARF;ARF
INDICATION: Abdominal distention, dyspnea on exertion, and lower
extremity edema with fever, evaluate for infectious process.
TECHNIQUE: Multidetector CT imaging of the chest, abdomen, and
pelvis was performed without intravenous contrast. Oral contrast
was administered. Multiplanar reconstructions were obtained.
CT OF THE CHEST WITHOUT CONTRAST: The exam is limited by the
patient's inability to raise the arms above the head as well as
a significant artifact secondary to marked subcutaneous anasarca
and obesity. Bibasilar consolidations and bilateral pleural
effusions (right greater than left) have worsened in the
interval. Scattered triangular pulmonary nodules measuring up to
6 mm, likely represent small lymph nodes, are indeterminant.
Swan-Ganz catheter appears to terminate in the main hepatic
artery though evaluation is limited by cardiac motion. The
patient is intubated with the ET tube terminating in the mid
thoracic trachea. The airways are patent to the subsegmental
level. The heart is enlarged. The great vessels of the
mediastinum are, otherwise, unremarkable. There is no pathologic
adenopathy.
CT ABDOMEN WITHOUT CONTRAST: Again, evaluation is markedly
limited. There is diffuse anasarca of the soft tissues and small
ascites throughout the abdomen and pelvis that may be secondary
to third spacing. Within the limitations of a noncontrast scan,
the gallbladder, spleen, stomach, adrenal glands, and kidneys
are unremarkable. The liver contour is abnormal with a small
right lobe and prominent caudate. This may be secondary to
chronic heart failure. There is very mild stranding about the
pancreas that is nonspecific and likely secondary to third
spacing. Small bowel loops are of normal caliber. There are no
masses or adenopathy. There is no pneumoperitoneum.
CT PELVIS WITHOUT CONTRAST: Again evaluation is markedly
limited. The rectum, sigmoid, and large bowel is unremarkable.
There is a small anasarca in the pelvis. A Foley catheter is in
situ, and the bladder appears normal. No isolated fluid
collections are identified. There is a left fat-containing
inguinal hernia.
BONE WINDOWS: The osseous structures are unremarkable.
IMPRESSION:
1. Limited, but no radiographic explanation for fevers.
2. Marked anasarca, small ascites.
3. Worsening bibasilar atelectases with small pleural effusions.
4. Cardiomegaly.
5. Scattered pulmonary nodules measuring up to 6 mm.
Re-evaluation in 6 to 12 months is recommended when patient's
condition improves.
6. Small right hepatic lobe and prominent caudate, possibly
secondary to chronic heart failure.
.
Brief Hospital Course:
He was initially admitted to the MICU for desaturations. While
in the MICU, patient subsequently became obtunded and was found
to have acidosis from hypercarbic respiratory failure and
required nasotracheal intubation. While evaluating the etiology
of his respiratory failure, echocardiogram revealed severe
global reduction in LV systolic function with EF of 20%. Given
this finding and above symptoms consistent with failure, PA
catheter was placed for tailored diuresis and patient was
transferred to CCU.
.
While in the CCU, patient was diuresed ~6 litres on furosemide
and dobutamine gtt. This did not improve his oxygenation.
Despite this, his hypoxia persisted even as FiO2 was increased
to 100% and PEEP increased to 20. Given lack of improvement in
oxygenation, shunt physiology was then evaluated with bubble
echocardiogram but this did not reveal right-to-left shunting.
Next, a trial of inhaled nitric oxide was attempted to relieve
his elevated pulmonary artery hypertension, in case this was
contributing to his hypoxia. Again, no improvement was noted
and this was discontinued. Finally, a diagnosis of ARDS was
then entertained and patient was placed on APRV mode for
ventilation and paralyzed with cisatracurium. At this point,
given concern for ARDS, it was decided to transfer patient back
to MICU service. A Chest CT was obtained en route to further
characterize the question of ARDS but pt not found to have it.
After transfer to MICU, on [**8-22**] pt had episode of hypotension
and hypoxia. An ECHO was done to r/o shunt physiology and the
bubble study was negative. Pt was continued on APRV with
dobutamine and paralytics.
.
The patient is a 39 year old Male with morbid obesity and no
consistent medical care who presented with 3 weeks of weight
gain, exertional dyspnea, now found to have severe
cardiomyopathy and CHF and persistent hypoxia
.
#. Hypercarbic/Hypoxic Respiratory Failure - Hypercarbic
component may be largely secondary to chronic obesity
hypoventilation and obstructive sleep apnea with superimposed
insult of CHF. Hypoxic component originally felt to be due to
CHF. However, there are no clear infiltrates suggestive of edema
on recent CT. Pt also has global hypokinesis and cardiomyopathy
which may have been caused by a viral myocarditis or other ?
etiology. Pt originally on dobutamine gtt for low BP and to
maintain renal perfusion, UOP. ECHO showed no signifcant
elevated pulmonary artery pressure but multiple repeat ECHos
continued to demonstrate LVEF 15-20% with no seeming improvement
in cardiac function. Pt was sedated with midazolam and fentanyl
and methadone. Increased Valium to 30mg TID with attempt to
reduce Midazolam gtt which was persistantly unsuccessful. Pt
maintained on APRV most of MICU stay with inability to wean down
settings. [**9-12**] Switched from APRV to AC ventilation. Pt was
changed from NT intubation to ETT on [**9-11**]. The goal was to
reduce PEEP and Fio2 requirements in order to possibly set pt up
for a trach.
-On [**9-13**] at 10am pt went into V. Fibb; given pts code status, he
was not rescitated with CPR or defibrillation.
.
# Sinusitis on head CT - Patient apparently had symptoms of this
prior to admission, and likely exacerbated by nasotracheal
intubation. CT scan with opacification of bilateral maxillary
sinus suggestive of sinusitis. Pt initially treated iwth Vanc
and Cefepime which was discontinued b/c it was unlikely
penetrating and pt has had negative cultures until [**9-11**]. On [**9-11**]
pt [**Name (NI) **] tube changed to ETT. ENT consulted and took a middle
meatal culture. Culture with PMNs but no microorganisms seen.
Also need to watch for any indications of spread to skull or
orbit.
.
#Fever - The most likely source is the sinusitis, however pt
taken off abx given negative cultures from blood, urine, sputum
and middle meatal culture. As of [**9-13**] two blood cultures were
positive for Coag negative Staph. Vanc started on [**9-13**].
negative. RUQ U/S negative for cholecystitis. Resiting of the
central line was planned for 9.22 given new positive blood
cultures and continued spiking of fevers.
.
#[**Name (NI) 97683**] Pt began having short runs of [**Name (NI) 6059**]. It was decided per
the team initially not to treat with BB or amiodarone given pt
had low HR and often went down into the 40s. Additionally pts
renal function and UOP depended on higher BP to maintain
adequate output. Cards was consulted and felt that the pt may
benefit from a calcium channel blocker for HTN but didn't have
any indications for amiodarone at the time. On [**9-13**] the
decision was made to begin Metoprolol 12.5mg TID in order to
control the runs of [**Month/Year (2) 6059**].
.
# Acute renal failure- Renal consulted; felt it was most likely
cardiogenic renal hypoperfusion causing ATN. Held on Lasix b/c
pts cardiac function is preload dependent and would like to
avoid removing fluids to keep is cardiac function optimal. Pts
creatinine trended down since admission and UOP maintained
adequate over following 2 weeks. Pts meds were renally dosed and
he was evaluated for HD by renal team but had no indications
over course of stay. Pt started on phosphate binder for high
phosphorus level.
# [**Name (NI) 6059**] - Unclear etiology, electrolytes okay. Will hold on
starting an ACE given elevated Creatinine. Can consider
Amiodarone vs BB but will hold off for now. No further episodes
overnight.
- Spoke with cards- no recs urgent need to start anything but
did recommend calcium channel blocker if needed.
.
#Hypernatremia - Unclear etiology; pt treated with free water
boluses through NGT.
.
.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
chf, cardiopulmonary failure, multisystem organ failure
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 4254, 4280, 5849, 2875, 2760, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7591
} | Medical Text: Admission Date: [**2122-12-5**] Discharge Date: [**2123-1-20**]
Date of Birth: [**2040-12-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
increasing dyspnea
Major Surgical or Invasive Procedure:
R thoracotomy and MVR (SJ mechanical 23 mm valve)[**12-14**]
History of Present Illness:
81 yo F with increasing SOB presented to [**Hospital1 **], underwent
cardiac cath, echo which showed moderate to severe MR. [**First Name (Titles) **] [**Last Name (Titles) 15929**]s was angioplastied. She was transferred for further
intervention.
Past Medical History:
Rheumatic Heart Disease (s/p bioprosthetic AVR), HTN,
Depression, heart failure, hyperlipidemia, Breast CA s/p
lumpectomy & XRT, s/p Hysterectomy, PPM
Social History:
denies etoh, tobacco
Family History:
sister AMI @ 64
Physical Exam:
NAD HR 63 RR 18 BP 101/49
Kungs CTAB
CV RRR
Abdomen benign
Extrem warm, no edema
Mild varicosities
Pertinent Results:
[**2122-12-5**] 07:15PM GLUCOSE-102 UREA N-50* CREAT-1.7* SODIUM-141
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-28 ANION GAP-17
[**2122-12-5**] 07:15PM estGFR-Using this
[**2122-12-5**] 07:15PM ALT(SGPT)-10 AST(SGOT)-14 LD(LDH)-177 ALK
PHOS-71 AMYLASE-123* TOT BILI-0.3
[**2122-12-5**] 07:15PM LIPASE-118*
[**2122-12-5**] 07:15PM ALBUMIN-3.6 CALCIUM-9.7 PHOSPHATE-3.9
MAGNESIUM-2.5
[**2122-12-5**] 07:15PM WBC-9.7 RBC-3.66* HGB-11.3* HCT-32.7* MCV-89
MCH-31.0 MCHC-34.6 RDW-15.4
[**2122-12-5**] 07:15PM PLT COUNT-382
[**2122-12-5**] 07:15PM PT-14.6* PTT-30.4 INR(PT)-1.3*
[**2122-12-5**] 06:16PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2122-12-5**] 06:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**12-27**] CT Torso:
INDICATION: 82-year-old female status post mitral valve repair
with question of increased right hemothorax.
No comparison studies.
TECHNIQUE: MDCT-acquired axial images of the chest, abdomen and
pelvis were performed without IV contrast. Multiplanar
reformations were obtained.
CT CHEST WITHOUT IV CONTRAST: Patient is status post sternotomy
with intact wires. A left cardiac pacer is present with leads
terminating within the right atrium and ventricle. There is
extensive aortic and mitral annulus calcification and there has
been aortic and mitral valve prosthetic repair. Aortic
calcifications extend up along the greater vessels which are
mildly ectatic. The main pulmonary artery is large at 3.7 cm.
There are multiple mediastinal lymph nodes which are enlarged,
most notable within the precarinal region measuring 1.8 x 1.5
cm. Additional nodes are present within the right paratracheal,
AP window stations. There is a small pericardial effusion. There
are enlarged epicardial nodes, the largest 15 x 12 mm (2/38).
There is an enlarged left retrocrural lymph node at 23 x 9 mm.
The lungs are diffusely emphysematous, most notable at the
apices with mild bullous changes. There is diffuse interstitial
thickening which is asymmetric and most consistent with
pulmonary edema with a small to moderate-sized fluid denisty
right pleural effusion with no evidence of blood density. There
is trace fluid within the left pleura.
CT ABDOMEN WITHOUT IV CONTRAST: Within the caudate lobe of the
liver, there is a 1.2 x 1.2 cm hypodensity that is incompletely
characterized. There are several gallstones in an otherwise
unremarkable gallbladder. There are multiple lymph nodes within
the porta hepatis and portocaval region. For example, anterior
to the IVC on series 2, image 55, there is a 15 x 9 mm lymph
node. The pancreas is unremarkable. A nasogastric tube
terminates within the distal stomach. There are extensive
atherosclerotic aortic calcifications that extend into the
mesenteric vessels with heavy calcification seen at the origins
of the celiac and more notably SMA. The spleen is bulky. The
right adrenal gland measures 1.6 x 1.9 cm, demonstrating
fluid-density Hounsfield units likely representing an adenoma.
The left adrenal gland is not well visualized. The kidneys are
unremarkable. The unopacified small and large bowel are within
normal limits. There is no mesenteric lymphadenopathy.
CT PELVIS WITHOUT IV CONTRAST: There is a small amount of
intraperotoneal fluid extending along the paracolic gutters and
most notable anterior to the rectum on the right. Additionally,
there is diffuse stranding within the subcutaneous tissues of
the lower torso.
There is no iliac lymphadenopathy. Overlying the left femoral
vascular sheath, there is a 3.6 x 2.0 cm mildly hyperdense mass
likely representing hematoma, possibly from recent left femoral
access.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. No evidence of hemothorax. Small right pleural effusion with
moderate asymmetric pulmonary edema.
2. Status post mitral and aortic valve replacements with
extensive mitral anulus and aortic valvular and aortic
calcifications.
3. Mediastinal and periportal lymphadenopathy and borderline
enlarged spleen. Recommend correlating with prior history to
determine the cause of these findings. These findings would fit
with prior history of lymphoma, sarcoidosis, or possibly
tuberculosis.
4. Gallstones.
5. No evidence of retroperitoneal hematoma.
6. Small intraperitoneal fluid, most notable in the pelvis along
with subcutaneous edema and right pleural effusion. Together,
these findings ay be representing a unifying cause such as third
spacing.
7. Large left groin hyperdense collection, most consistent with
hematoma.
8. Emphysema.
9. Focal liver hypodensity in caudate lobe, incompletely
characterized. Although probably a benign cyst, a mutliphasic
MRI would better evaluate this lesion is there is further
clinical concern.
10. Right adrenal adenoma.
[**12-28**] ECHO (TEE)
There is mild left atrial enlargement. Mild spontaneous echo
contrast is seen in the left atrial appendage. No mass/thrombus
is seen in the left atrium or left atrial appendage. A color
Doppler signal is seen in the mid-interatrial septum with
bidirectional flow c/w a secundum atrial septal defect. After
agitated saline injection, there is prompt appearance of
contrast in the left atrium c/w a bidirectional shunt. There is
symmetric left ventricular hypertrophy with normal cavity size.
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 ascending aorta. There are
complex (>4mm, non-mobile) atheroma in the descending thoracic
aorta. A well-seated bioprosthetic aortic valve prosthesis is
present. No aortic regurgitation is seen. However evaluation of
the aortic bioprostesis is limited by acoustic shadowing from
the mitral mechanical valve. A bileaflet mechanical mitral valve
prosthesis is present. The valve is well seated with good disc
motion and normal gradient. There is a small paravalvular leak
with regurgitation on the anteroseptal and inferior aspect of
the interatrial septum. There is a very small pericardial
effusion.
CONCLUSION: Well seated bileaflet mitral valve with good disc
motion/normal gradient, but small para valvular leak. Secundum
type atrial septal defect with bidirectional flow.
[**1-1**] ECHO (TEE)
The left atrium is dilated. A patent foramen ovale or a small
ASD is present. Doppler evaluation suggests predominantly
left-to-right shunting during the study, with a Qp:Qs of 1.4.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. A
bioprosthetic aortic valve prosthesis is present. The prosthetic
aortic valve leaflets appear normal. Mild (1+) central aortic
regurgitation is seen. A bileaflet mitral valve prosthesis is
present. The mitral prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. Mitral
regurgitation is present but cannot be quantified. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Small left-ro-right shunt, likely through the atrial
septum. Preserved global biventricular systolic function.
Normally-functioning mechanical mitral prosthesis. Aortic valve
bioprosthesis with mild central regurgitation. Moderate to
severe tricuspid regurgitation. Moderate pulmonary hypertension.
[**1-15**] Sputum Culture:
GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STENOTROPHOMONAS
(XANTHOMONAS) MALTOPHILIA, ACINETOBACTER BAUMANNII}
Brief Hospital Course:
She underwent preop workup for MVR. She had a UTI for which she
was started on cipro. Dental consult recommended extractions
which she underwent on [**12-10**]. She remained on IV lasix for
diuresis. She was taken to the operating room on [**12-15**] where she
underwent MVR (mechanical) via right thoracotomy. She was
transferred to the ICU in critical but stable condition on
levophed, epinephrine, milrinone, and propofol. She was given 48
hours of vancomycin for perioperative prophylaxis since she was
in the hospital preop. She had afib immediately postop and was
cardioverted. She failed spontaneous breathing trial on POD #2.
Her milrinone was dc'd on POD #2 and she was transfused 2 units.
She was extubated on POD #3, however was tired and continued to
require bipap or high flow mask, she as started on tube feeds.
She was started on heparin/coumadin given her afib and
mechanical valve. Right chest tube was placed for 500 cc on
[**12-21**]. She continued to require nightly bipap, her work of
breathing increased and she was reintubated on [**12-24**]. Coumadin
was held for supratherapeutic INR. WBC increased and she was
pancultured. She was transfused for HCT 23. CT scan was negative
for RP bleed. She was started on antibiotics for VAP, and
bronched on [**12-28**]. TEE showed ASD. Thoracic surgery was
consulted and she underwent tracheostomy and PEG tube placement
on [**12-30**]. She was made DNR on [**1-2**]. Family meetings was held
including ethicas consult and Vent wean attempts continued. She
failed trach mask trial. Synthroid was started for TSH 10. She
was seen by pulmonology, her nebulizers were increased, diuresis
continued. She was started on theophylline. The Patient was
made CMO on [**1-20**]. At 6PM, [**1-20**], the patient was placed on
trach mask. The patient expired at 6:25 PM, [**1-20**].
Medications on Admission:
Simvastatin 10', Lasix 40', Toprol 25', Aspirin 325', Imdur 30',
Paxil 10'
Discharge Medications:
Expired
Discharge Disposition:
Extended Care
Discharge Diagnosis:
MR now s/p MVR
post op respiratory failure s/p trach/PEG
chronic diastolic heart failure
Rheumatic Heart Disease (s/p bioprosthetic AVR), HTN,
Depression, heart failure, hyperlipidemia, Breast CA s/p
lumpectomy & XRT, s/p Hysterectomy, PPM
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
ICD9 Codes: 5990, 486, 5185, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7592
} | Medical Text: Admission Date: [**2113-7-10**] Discharge Date: [**2113-7-13**]
Service: VASCULAR SURGERY
CHIEF COMPLAINT: Asymptomatic right carotid artery stenosis.
HISTORY OF THE PRESENT ILLNESS: The patient is a 79-year-old
nondiabetic white female with CAD, cardiac dysrhythmia,
hypertension, severe COPD, oxygen-dependent for approximately
one year, who was noted to have carotid bruits several years
ago with noninvasive studies indicating no significant
stenosis on the right side and 60-79% stenosis on the left.
Recent follow-up carotid noninvasives showed the right side
90-99% stenosis on the right. The patient denied any history
of TIAs or dizziness.
The patient was seen by her pulmonologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 745**], prior to carotid surgery. Dr. [**First Name (STitle) 745**] was concerned
that the patient was at increased risk for complications
secondary to her pulmonary disease which might result in need
for mechanical ventilation with difficulty in weaning. The
patient was given a course of steroids which was tapered
prior to surgery in order to maximize her pulmonary function.
PAST MEDICAL HISTORY:
1. CAD.
2. Cardiac dysrhythmia: Treated with Norpace and
Persantine.
3. Severe air-flow obstruction with chronic respiratory
failure, both hypoxemic and hypercarbic. FEV1/FVC ratio
equals 47% in [**2113-5-7**].
4. GERD.
5. Large hiatal hernia.
6. Upper GI bleed times two while on aspirin.
7. Pneumonia one to two years ago at [**Hospital3 7362**].
8. Arthrosis.
9. Osteoarthritis.
PAST SURGICAL HISTORY:
1. Cholecystectomy in [**2057**].
2. Hysterectomy in [**2082**].
3. Cataract extraction O.S. in [**2106**].
ALLERGIES:
1. Codeine causes chest pain and arm pain.
2. Aspirin contributed to two recent upper GI bleeds.
ADMISSION MEDICATIONS:
1. Disopyramide 150 mg p.o. q. six hours.
2. Accupril 10 mg p.o. q.d.
3. Hydrochlorothiazide 12.5 mg p.o. q.d.
4. Nexium 40 mg p.o. q.d.
5. Oruvail 150 mg p.o. q.d.
6. Multivitamin one p.o. q.d.
7. Combivent inhaler two puffs q.i.d.
8. Prednisone taper.
9. Darvocet p.r.n. pain.
10. Cyclobenzaprine p.r.n.
FAMILY HISTORY: Father died at age 64 with Alzheimer's
disease. Mother died at age 71 secondary to kidney cancer.
One brother had esophageal cancer. One sister died of
Berylliosis. Five children in good health.
SOCIAL HISTORY: The patient is a widow. She lives alone and
is independent, using her oxygen as needed. She quit smoking
cigarettes in [**2092-9-5**] after smoking one pack per day
for 39 years. The patient's husband was a two pack per day
cigarette smoker until his death.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Pulse 102,
blood pressure 155/74, 02 saturation on 2 liters 02 equals
93%. Height 5' 2", weight 130 pounds. General: Alert,
cooperative white female in no acute distress. HEENT:
Normocephalic. Pupils equal and reactive to light. Sclerae
anicteric. Neck: Range of motion within normal limits. No
lymphadenopathy or thyromegaly. Carotids: Palpable with
bruits, right greater than left. No JVD. Chest: Increased
A/P diameter with kyphosis. Heart: Regular rate and rhythm
with occasional extra beat. There was a II/VI systolic
ejection murmur. Lungs: Clear bilaterally. Abdomen: Soft,
nontender, no masses. No hepatosplenomegaly. Extremities:
Warm. No cyanosis, clubbing, or edema. Pedal pulses were 2+
bilaterally. Neurologic: Nonfocal.
LABORATORY/RADIOLOGIC DATA: On admission, hematocrit 41.2,
platelets 521,000. PT 12.6, PTT 22.3, INR 1.1. Sodium 145,
potassium 4.4, BUN 33, creatinine 1.0, glucose 60.
Chest x-ray showed no acute pulmonary disease, large hiatal
hernia present. Khyphosis of the thoracic spine with
multiple compression deformities.
EKG on [**2113-7-5**] showed a sinus rhythm at a rate of 95 with
supraventricular extrasystole.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2113-7-11**] following an uneventful right carotid
endarterectomy. At the end of surgery, the patient was
neurologically intact.
Immediately following surgery, the patient's systolic blood
pressure was maintained at greater than 120 with a
Neo-Synephrine drip. The Neo-Synephrine drip could not be
weaned readily and the patient was transferred to the SICU
for further treatment.
The patient received Kefzol perioperatively.
On postoperative day number two, the patient developed EKG
changes which were concerning for a possible LAD lesion. The
Cardiology Service recommended a cardiac catheterization as
soon as possible. Dr. [**Last Name (STitle) 1391**] suggested waiting two to
three weeks postoperatively would decrease the risk of the
patient developing a neck hematoma. The Cardiology Service
agreed to medically manage the patient since her cardiac
isoenzymes were flat. Disopyramide was resumed. The patient
refused cardiac catheterization.
The patient developed a rapid atrial fibrillation with a
ventricular response of 160. She was anticoagulated with
heparin. She converted to normal sinus rhythm with IV
Lopressor. Disopyramide was resumed. Valsartan 80 mg p.o.
q.d. was started.
The patient was transfused 1 unit of packed red blood cells
on [**2113-7-13**] for a hematocrit of 28. The patient's post
transfusion hematocrit was 31.
At the time of discharge, the patient's neck incision was
clean, dry, and intact. The patient was neurologically
intact. She was instructed to follow-up with Dr. [**Last Name (STitle) 1391**] in
one week for staple removal from her incision.
DISCHARGE MEDICATIONS:
1. The patient was to resume all her preadmission
medications.
2. Hydrochlorothiazide was increased from 12.5 mg to 25 mg
p.o. q.d.
3. Accupril was increased from 10 mg to 20 mg p.o. q.d.
4. Valsartan 80 mg p.o. q.d.
DISPOSITION: Home.
CONDITION ON DISCHARGE: Satisfactory.
PRIMARY DIAGNOSIS:
1. Asymptomatic right carotid artery stenosis.
2. Right carotid endarterectomy on [**2113-7-10**].
SECONDARY DIAGNOSIS:
1. Postoperative hypotension treated with Neo-Synephrine
drip: Resolved.
2. Blood loss anemia; status post transfusion of 1 unit of
packed rd blood cells.
3. Rapid atrial fibrillation: Resolved after treatment with
IV Lopressor.
4. Coronary artery disease: Possible left anterior
descending lesion. Cardiac catheterization recommended, but
declined by patient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2113-7-19**] 07:21
T: [**2113-7-19**] 19:21
JOB#: [**Job Number 51747**]
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7593
} | Medical Text: Admission Date: [**2186-11-14**] Discharge Date: [**2186-12-8**]
Date of Birth: [**2120-9-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
esophageal cancer
Major Surgical or Invasive Procedure:
transthoracic esophagectomy
History of Present Illness:
Mr. [**Known lastname **] is a 66-year-old patient with biopsy-
proven carcinoma of the mid-esophagus from about 25 cm to 29
cm from the incisors. He completed induction
chemoradiotherapy under the care of his physicians at
[**Location (un) 5164**] and was seen after completing this
with evidence for a partial response radiographically. A
transthoracic resection of the mid-esophagus and lymphadenectomy
is planned.
Past Medical History:
HTN, hyperlip, trig neuralgia, esopg ca
Social History:
lives w/ wife
Physical Exam:
general: well appearing male in NAD.
HEENT: unremarkable
Chest: lungs CTA bilat
Cor: RRR S1, S2
Abd: soft, Nt, Nd, +BS
extrem: no C/C/E
neuro: A+Ox3
Pertinent Results:
[**2186-12-5**]: barium swallow: Conray was used in this study. Contrast
passes promptly through the anastomosis into the distal stomach.
A thin stream of contrast is seen extravasating from the
anastomotic site and tracking to the right of the neoesophagus
and collecting slightly more distally. This collection did not
drain during the course of this study.
IMPRESSION: Findings consistent with a small contained leak at
the site of the cervical anastamosis, as described above.
Brief Hospital Course:
Pt was admitted and taken to the OR for Transthoracic
esophagectomy. Apical bullectomy. Left cervical
esophagogastrostomy. Feeding jejunostomy.
OR course uncomplicated. Had epidural, right chest tube to sxn,
cervical JP to bulb abd feeding j-tube to gravity. Remained
intubated post op and admitted to the CSRU for ventilatory
support. Pt was extubated on POD#1. Post op course was
complicated by tacycardia, readmission to the ICU for pulmonary
hygiene on POD#6 and POD#9 for leukocytosis and persistant
cervical anastomtic leak with bilious drainage from chest tube
and JP drain, left pleural effusion which was tapped under
ultrasound for 1100cc, and post op anemia for which he was
transfused. Escalating doses of beta blockade to maintain HR
control. Maintained on triple abx for emperic coverage which
were d/c'd 24hrs prior to d/c after negative culture data. Chest
tube and JP drain were d/c'd once they were no longer draining
bilious fluid.
NPO status maintained d/t anastomotic leak which was still
evident per barium swallow done just prior to d/c. Trophic tube
feeds started via J-tube and titrated to goal once bowel
function returned. Pain was well controlled on roxicet elixir
via J-tube.
Pt will return in one week for a repeat barium swallow and
follow up w/ Dr. [**Last Name (STitle) **].
Medications on Admission:
diltiazem, nexium, zyban, lipitor, tegretol
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*300 ML(s)* Refills:*0*
2. Erythromycin Ethylsuccinate 200 mg/5 mL Suspension for
Reconstitution [**Last Name (STitle) **]: Five (5) ML PO q8hrs ().
Disp:*450 ML(s)* Refills:*2*
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID
(3 times a day): Crush tablet and completely dissolve in 50cc
water and instill via J-tube.
Disp:*180 Tablet(s)* Refills:*2*
5. insulin
pls check you finger stick very 6 hrs and dose yourself with
sliding scale regular insulin.
6. regular insulin
disp one vial with 2 refills
regular insulin per sliding scale q 6hrs based on finger stick
7. NPH insuin
2units sq qam and 4 units sq qpm
disp one vial with one refill
8. insulin syringes
100 unit insulin syringes
disp one box with 2 refills.
9. tube feed
replete w/ fiber cycle over 18hrs goal 100c/hr
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
esophageal CA s/p transthoracic esophagectomy, apical
bullectomy, L-cervical esophagogastrostomy, feeding jej'omy
([**11-14**]), c/b bile in chest tube; L-thoracentesis for
effusion([**11-24**])
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (2) 170**]if you have any fever,
chills, redness or drainage from your incision sites, inability
to tolerate tube feeds, nausea, vomiting.
If your feeding tube falls out, call Dr.[**Doctor Last Name 4738**] office
immediately or go to the nearest emergency room to have the tube
replaced immediately.
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (2) 170**]if you have any fever,
chills, redness or drainage from your incision sites, inability
to tolerate tube feeds, nausea, vomiting.
If your feeding tube falls out, call Dr.[**Doctor Last Name 4738**] office
immediately or go to the nearest emergency room to have the tube
replaced immediately.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] on thursday
[**12-14**] at 4:30pm in the [**Hospital Ward Name 23**] Clinical Center [**Location (un) **].
You need to report to [**Hospital Ward Name **] clinical center [**Location (un) **] at 9am
for a barium swallow.
Completed by:[**2186-12-11**]
ICD9 Codes: 5119, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7594
} | Medical Text: Admission Date: [**2168-8-8**] Discharge Date:
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 77-year-old male
who presented with chest pain, history of coronary artery
disease at baseline sustained a cardiac catheterization and
found to have two vessel disease and a low ejection fraction.
PAST MEDICAL HISTORY: Significant for hypertension, coronary
artery disease, hematochromatosis, hemachromatosis,
hypothyroidism, high cholesterol and anemia.
MEDICATIONS: Aspirin, Imdur, Metoprolol, simvastatin,
Synthroid, Lasix, sublingual nitroglycerin and Lisinopril.
ALLERGIES: Patient no known drug allergies.
PHYSICAL EXAMINATION: He was afebrile. His vital signs were
stable. No jugular venous distention. He had crackles
bilaterally, right greater than left, regular rate and rhythm
with no murmurs, rubs or gallops. His abdomen was benign.
His extremities were warm and well-perfused with no edema.
LABORATORIES: BUN 26, creatinine 1.3, hematocrit 35.9 with
white blood cell count of 11.7.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2168-8-8**] where a coronary artery bypass graft
times three was performed. Patient did well postoperatively
and was transferred to the CSRU where he was fully weaned
from the ventilator. Patient continued to do well and was
extubated postoperatively. Patient was evaluated by Physical
Therapy for mobility and ambulation and he did well. Patient
was transferred on postoperative day number two to the floor.
His chest tube was removed. His Foley was removed and his
wires were removed on postoperative day number three. He
continued to ambulate and Physical Therapy cleared him to go
home. For episodes of agitation, he was given a little bit
of Haldol, but did well and was stopped from his Haldol.
Patient was discharged home on postoperative day number four
after clearing Physical Therapy and stairs with instructions
to follow-up with his primary care physician in one to two
weeks. He was also instructed to follow-up with Dr. [**Last Name (STitle) **]
in four weeks and also to follow-up with Cardiology in the
Congestive Heart Failure Clinic in two to four weeks.
Patient discharged home in stable condition.
DISCHARGE MEDICATIONS:
1. Motrin.
2. Lopressor 50 mg po b.i.d.
3. Synthroid po b.i.d.
4. Simvastatin 10 mg po q.d.
5. Colace 100 mg po b.i.d.
6. KCL 20 mEq po b.i.d.
7. Lasix 20 mEq po b.i.d.
8. Aspirin 325 mg po q.d.
DISCHARGE STATUS: Patient was discharged home.
DISCHARGE CONDITION: Stable.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Doctor Last Name 94723**]
MEDQUIST36
D: [**2168-8-18**] 12:25
T: [**2168-8-18**] 12:25
JOB#: [**Job Number **]
ICD9 Codes: 4280, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7595
} | Medical Text: Admission Date: [**2135-1-17**] Discharge Date: [**2135-1-19**]
Date of Birth: [**2099-9-11**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old
woman, who is a current smoker, with family history of early
coronary artery disease, who developed acute, severe chest
pressure while at work as an emergency medical technician.
The patient initially thought this was musculoskeletal;
however, she became diaphoretic, and the chest discomfort
persisted. So, she was brought to an outside hospital in
[**Hospital1 8**], [**State 350**].
At the outside hospital, the patient received 3 sublingual
Nitroglycerin, as well as aspirin, without relief of pain.
The patient was then given Nitroglycerin drip, as well as
started on heparin drip. The patient had a cardiac arrest at
the outside hospital. It was unclear whether it was
ventricular tachycardia versus ventricular fibrillation, as
the outside hospital did not send any ECG strips. The
cardiac arrest responded to 3 shocks with the defibrillator
with return to normal sinus rhythm. The patient was also
started on lidocaine at the outside hospital. ECG at the
outside hospital showed inferior lead ST elevation with
reciprocal changes throughout. The patient was emergently
transferred to [**Hospital1 18**] for coronary catheterization.
At arrival to the cath lab, the patient reportedly had mild
residual discomfort. In the coronary cath lab at [**Hospital1 18**], the
patient was found to have 95% distal right coronary artery
occlusion which received angioplasty, as well as a stent.
The patient developed bradycardia during catheterization and
hypotension which responded to dopamine which was started, as
well as IV fluids and atropine. Dopamine and lidocaine were
discontinued in the catheterization lab. The patient was
started on Neo-Synephrine; however, in the cardiac
catheterization lab for hypotension just prior to transfer to
the coronary care unit.
Upon arrival to the coronary care unit, the patient
complained of right groin pain at the site of
catheterization, but otherwise denied any shortness of
breath, chest pain, chest pressure, nausea, vomiting,
diaphoresis, or any other symptoms. The patient also denied
palpitations.
PAST MEDICAL HISTORY: The patient is obese, otherwise
without significant past medical history.
SOCIAL HISTORY: The patient is a current cigarette smoker.
FAMILY HISTORY: The patient with an uncle who had a
myocardial infarction in his 30s, as well as a grandfather
with a myocardial infarction in his 50s. The patient's
parents both passed away from pulmonary emboli when they were
elderly and bed bound. The patient works as an EMT in
[**Hospital1 8**].
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: None.
PHYSICAL EXAM ON ADMISSION: An obese, young Caucasian woman
lying in bed, mildly agitated, but in no apparent distress.
Physical exam was within normal limits. The patient was
afebrile, heart rate 90, regular rate, blood pressure 127/80.
Heart exam within normal limits with normal S1, S2, no
murmurs appreciated, no S3 or S4. Lungs were clear to
auscultation bilaterally. Patient with mild chest tenderness
to palpation in the sternal area. The remainder of the
physical exam was within normal limits. Right groin site of
catheterization with some mild oozing of blood, as well as a
small, stable hematoma. The patient's pulses were 2+
throughout.
DIAGNOSTICS ON ADMISSION: ECG upon arrival to the coronary
care unit showed normal sinus rhythm at 68, normal intervals,
axis within normal limits. It showed ST elevations in II,
III and AVF, 1 mm in II, 2 mm in III and AVF with reciprocal
ST depressions in I and AVL with T wave inversions, as well
as [**Street Address(2) 4793**] depression in V2. The patient's chemistries were
within normal limits except for potassium of 3.4 from the
outside hospital.
CARDIAC CATHETERIZATION: Please refer to the full report for
further details. It was notable for a 95% distal right
coronary artery stenosis which was stented, but with good
TIMI to distal flow even prior to stent. It also showed a
diffuse 40% proximal LAD stenosis. The left main was normal.
The patient's filling pressures were slightly elevated in the
cath lab with a right atrial pressure of 15, right
ventricular pressure of 38/20, PA pressure of 38/28, and
wedge pressure of 28.
CONCISE SUMMARY OF HOSPITAL COURSE: This 35-year-old female,
a smoker, brought in from an outside hospital with substernal
chest pain, as well as inferior lead ST elevation, status
post coronary catheterization at [**Hospital1 18**] with stent placement.
The patient notably had cardiac arrest at the outside
hospital which responded to defibrillation. The patient
transferred to coronary care unit after coronary
catheterization for further monitoring.
1) CORONARY ARTERY DISEASE: Patient with inferior myocardial
infarction status post right coronary artery stent. The
patient was started on aspirin, Plavix, Lipitor 20 qd, as
well as Integrilin for 18 hours. The patient was started on
low dose beta blocker which was titrated up the day after
admission. The patient also was adamant that she will quit
smoking, as well as maintain a cardiac diet and exercise
regimen.
The patient's early myocardial infarction was concerning for
possible abnormal coagulation underlying problem. The
patient's family history also concerning, as well as parents
who both had pulmonary emboli, although both were reportedly
bed bound at the time. Recommend outpatient work-up of
coagulation studies. This was passed on to the primary care
physician via [**Name Initial (PRE) **] telephone conversation prior to discharge.
The patient had no further symptoms of coronary artery
disease throughout her hospital stay. The patient's ECG
normalized; however, she did develop inferior Q waves by the
day after her myocardial infarction. The patient's creatine
kinase also trended up to a max of approximately 1,500 and
then trended down again. The patient's lipid profile was
obtained and showed a total cholesterol of 140, triglycerides
198, HDL 33, LDL 67.
2) HEMODYNAMICS: The patient arrived from the
catheterization lab on Neo-Synephrine which was titrated off
overnight. The patient's blood pressure tolerated this well,
did not require pressors, and also tolerated the beta blocker
well.
3) RHYTHM: The patient remained in normal sinus rhythm
throughout the remainder of her hospital stay. The patient
did have a short run of 10 beats of ventricular tachycardia
on her first night in the coronary care unit. Other than
this, the patient's rhythm was normal sinus rhythm with very
occasional premature ventricular complexes seen on telemetry.
4) PUMP: The patient's echocardiogram showed an ejection
fraction of 45-50%, as well as focal, severe hypokinesis of
the basal half of the inferior wall. The remainder of the
echocardiogram was within normal limits with 1+ mitral
regurgitation seen. Please refer to the full report for
further details.
5) FLUID, ELECTROLYTES AND NUTRITION: The patient maintained
on a cardiac diet throughout her hospital stay which she
tolerated well.
6) PROPHYLAXIS: The patient was on Integrilin initially and
then ambulated well. The patient also on a bowel regimen as
needed.
7) CODE STATUS: Full code. Communication was daily with the
patient.
8) ACCESS: The patient initially with a Swan-Ganz catheter
that was placed in the catheterization lab which was
discontinued. The patient did have a small femoral artery
hematoma that was stabilized with direct pressure and was
stable x 48 hours at discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Inferior wall myocardial infarction.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg qd.
2. Plavix 75 mg qd.
3. Lipitor 20 mg qd.
4. Toprol XL 50 mg qd.
FOLLOW-UP PLANS:
1. The patient to follow-up with her primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 26773**], within the next 2 weeks. I spoke to Dr. [**Last Name (STitle) 26773**]
over the phone with a brief update of the hospital course and
the importance of close follow-up with PCP, [**Name10 (NameIs) 3**] well as
cardiologist.
2. The patient has an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17437**] who
is a cardiologist who the patient's primary care physician
referred to.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 16731**]
MEDQUIST36
D: [**2135-1-19**] 12:18
T: [**2135-1-19**] 12:26
JOB#: [**Job Number 108811**]
ICD9 Codes: 4271, 9971, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7596
} | Medical Text: Admission Date: [**2124-4-4**] Discharge Date: [**2124-5-1**]
Date of Birth: [**2078-7-22**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfonamides / Aspirin / Cephalexin / Wellbutrin /
Doxycycline / Compazine / Ciprofloxacin
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Thigh pain, sepsis
Major Surgical or Invasive Procedure:
[**2124-4-4**]:
1. Incision and drainage of bilateral thighs.
2. Cystoscopy, urethroscopy, removal of tension-free vaginal
tape- obturator mesh sling.
[**2124-4-12**]:
1. Incision and drainage of right thigh with subcutaneous tissue
and fascial biopsy.
2. Incision and drainage of left thigh.
[**2124-4-20**]: Change of wound vac
[**2124-4-25**]: Split thickness skin graft, right thigh, 15 cm x
9 cm.
History of Present Illness:
45F s/p patient status post TVT obturator procedure at [**Hospital1 **] [**2124-3-22**] states she began to have thigh pain 3 days after
the surgery. She was sent to the ED by her PCP for failure to
thrive and was found to be hypotensive in the 70s. After 6
liters of fluid and doses of Vancomycin, imipenem, and
clindamycin her
blood pressure returned to her norm (SBP 90s). By report the
patient also had fevers at home.
Past Medical History:
PMH: IBS, GERD, TBI, Migraine, Depression
PSH: R shoulder [**2120**], bladder sling [**2123**], nasal surgery NOS
Social History:
The patient does not work. She is on disability from her TBI.
She was a special needs teacher and was hit in the temporal
lobe. She smokes cigarettes. She does not drink alcohol. She
has 1 son. She is single. She has good family support from her
mother and father
Family History:
Non contributory
Physical Exam:
On admission:
98 121 76/55 16 100
NAD
no respiratory distress
abdomen tender suprapubic and bilateral lower quadrants
pelvic exam unremarkable by report from GYN
extrensive blanching erythema extending from groin to mid thigh,
incisions appear well-healed
At Discharged:
98.3 97.4 95 94/58 18 95RA
NAD, Comfortable, frail woman looking older that stated age
Lungs: Clear b/l
CV: mild tachy, no m/r/g
Abd: soft, non-tender, non-distended
Ext: R inner thigh with skin graft with near 100% take, L inner
thigh with wet-to-dry dressing, no induration or swelling edges
healing well. posterior legs, skin sloughing areas healing well
Pertinent Results:
Radiology:
[**4-4**] C/A/P CT with contrast:(PRELIM) Moderate bilateral pleural
effusions with septal thickening seen throughout the lungs
compatible with pulmonary edema. Diffuse bowel wall thickening
and edema, involving both small and large bowel loops with
marked
mucosal hyperenhancement, suggestive of shock bowel. Diffuse
periportal edema with new moderate ascites. Wedge shaped area of
low attenuation in the right kidney (2:63), may
reflect an infarct. Heterogeneous enhancement pattern of the
spleen, likely moire pattern from contrast timing. New locules
of
air in the right groin, with wound in the medial thighs
bilaterally, likely reflect post-surgical changes following
exploration. Anasarca.
[**2124-4-11**] CT A/P
IMPRESSION:
1. Slight decrease in size of pleural effusion and ascites.
2. Interlobular septal thickening and patchy consolidation at
both lung
bases. Findings consistent with pulmonary edema and superimposed
pneumonia.
3. Foci of low attenuation in the spleen could represent small
parenchymal
infarcts.
4. Fluid within the intermuscular fascia and muscles of the
medial
compartment of both thighs has slightly increased in comparison
to the prior scan, but no new areas of gas are seen with the
muscles or subcutaneous tissues.
Echocardiogram [**2124-4-7**]
Conclusions
Left ventricular wall thicknesses and cavity size are normal.
There is moderate global left ventricular hypokinesis (LVEF =
30%). Right ventricular chamber size and free wall motion are
normal. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderate global left ventricular systolic
dysfunction.
Compared with the prior study (images reviewed) of [**2124-4-5**],
the findings are similar. LV systolic function may have been
slightly underestimated on the prior study.
Pathology: [**2124-4-12**] skin and soft tissue :
DIAGNOSIS:
I. Right thigh, skin and subcutaneous tissue (A-B):
Skin with ulceration and subcutaneous tissue with acute
inflammation, fat necrosis and focal abscess formation.
II. Right thigh, fascia (C):
Gangrenous necrosis of soft tissue.
Micro:
[**2124-4-4**] - implant - BETA STREPTOCOCCUS GROUP A
[**2124-4-12**] - right thigh - [**Female First Name (un) **] ALBICANS
[**2124-4-15**] - yeast
[**4-15**] Stool - CDiff negative
Labs:
[**2124-4-5**] 03:53AM BLOOD WBC-34.8*# RBC-3.67* Hgb-10.8* Hct-32.0*
MCV-87 MCH-29.3 MCHC-33.6 RDW-16.6* Plt Ct-163
[**2124-4-5**] 08:37AM BLOOD WBC-42.0* RBC-3.62* Hgb-10.5* Hct-31.5*
MCV-87 MCH-29.1 MCHC-33.4 RDW-16.4* Plt Ct-142*
[**2124-4-5**] 12:41PM BLOOD WBC-38.0* RBC-3.53* Hgb-10.2* Hct-30.1*
MCV-86 MCH-28.9 MCHC-33.8 RDW-16.5* Plt Ct-101*
[**2124-4-7**] 03:41AM BLOOD WBC-30.3* RBC-2.55* Hgb-7.5* Hct-22.0*
MCV-86 MCH-29.6 MCHC-34.3 RDW-16.7* Plt Ct-38*
[**2124-4-9**] 12:48PM BLOOD WBC-16.9* RBC-3.33* Hgb-9.5* Hct-28.7*
MCV-86 MCH-28.7 MCHC-33.2 RDW-16.7* Plt Ct-49*
[**2124-4-17**] 02:47AM BLOOD WBC-15.2* RBC-2.68* Hgb-7.7* Hct-23.7*
MCV-88 MCH-28.8 MCHC-32.7 RDW-16.5* Plt Ct-357
[**2124-4-18**] 02:18AM BLOOD WBC-12.2* RBC-2.55* Hgb-7.3* Hct-22.4*
MCV-88 MCH-28.5 MCHC-32.4 RDW-16.6* Plt Ct-422
[**2124-4-19**] 05:45AM BLOOD WBC-11.6* RBC-2.55* Hgb-7.4* Hct-22.9*
MCV-90 MCH-29.1 MCHC-32.5 RDW-17.0* Plt Ct-428
[**2124-4-25**] 04:59AM BLOOD PT-13.6* PTT-31.6 INR(PT)-1.2*
[**2124-4-4**] 11:55AM BLOOD Glucose-71 UreaN-76* Creat-5.9*# Na-132*
K-3.6 Cl-94* HCO3-14* AnGap-28*
[**2124-4-5**] 03:53AM BLOOD Glucose-198* UreaN-48* Creat-2.6* Na-135
K-3.0* Cl-103 HCO3-16* AnGap-19
[**2124-4-5**] 12:41PM BLOOD Glucose-208* UreaN-34* Creat-1.9* Na-137
K-3.0* Cl-98 HCO3-20* AnGap-22*
[**2124-4-5**] 08:57PM BLOOD Glucose-187* UreaN-28* Creat-1.6* Na-131*
K-3.3 Cl-94* HCO3-24 AnGap-16
[**2124-4-6**] 06:51AM BLOOD Glucose-124* UreaN-22* Creat-1.2* Na-134
K-3.5 Cl-96 HCO3-26 AnGap-16
[**2124-4-15**] 03:56AM BLOOD Glucose-96 UreaN-25* Creat-0.9 Na-138
K-3.3 Cl-105 HCO3-26 AnGap-10
[**2124-4-19**] 05:45AM BLOOD Glucose-82 UreaN-9 Creat-0.6 Na-137 K-3.7
Cl-112* HCO3-19* AnGap-10
[**2124-4-26**] 04:50AM BLOOD Glucose-93 UreaN-8 Creat-0.5 Na-138 K-3.5
Cl-107 HCO3-25 AnGap-10
[**2124-4-4**] 11:55AM BLOOD ALT-39 AST-149* CK(CPK)-2620*
AlkPhos-111* TotBili-0.6
[**2124-4-5**] 08:57PM BLOOD ALT-40 AST-148* LD(LDH)-358*
CK(CPK)-2299* AlkPhos-80 TotBili-0.6
[**2124-4-9**] 03:30AM BLOOD ALT-24 AST-39 CK(CPK)-163 AlkPhos-122*
Amylase-42 TotBili-0.7
[**2124-4-13**] 04:26AM BLOOD ALT-4 AST-45* CK(CPK)-83 AlkPhos-168*
TotBili-0.6
[**2124-4-13**] 04:26AM BLOOD Albumin-1.7* Calcium-8.6 Phos-4.0 Mg-1.6
Brief Hospital Course:
The patient presented to the emergency room on [**4-4**] in septic
shock. She was given 6 L IVF and 1 dose of vancomycin,
clindamycin, and imipenem prophylactically for concern for
septic shock with necrotizing fascitis. A central line was
placed and
both surgery and GYN were consulted. GYN noted nl pelvic exam
with well healed TVT incision. CT imaging confirmed soft tissue
infection to b/l thighs extending to femur and thus it was
decided to take the pt to the OR urgently for emergent
exploration and removal of her TVT. In the OR, it was
discovered that pt had completely viable fascia and tissue with
no necrosis. A minimal amount of pus was found in the R. inner
thigh which was sent for culture. Pt was continued on IV
vancomycin, clindamycin, and meropenem. She was admitted to the
ICU where she was on 2 vasopressors and in acute renal failure
and was initiated on CVVH. She received a repeat pan CT with
contrast notable for shock liver, shock bowel, and R. kidney
infarct. She remained intubated, sedated on midazolam and
fentanyl.
[**4-5**] POD 1 continued on ventilatory support, CVVH, vasopressors,
vanco/clinda/[**Last Name (un) 2830**], IVIG 50g given
[**4-6**] POD 2 25gm IVIG given, continued on ventilatory support,
CVVH, vasopressors, vanco/clinda/[**Last Name (un) 2830**]
[**4-7**] POD 3 25gm IVIG given, continued on ventilatory support,
CVVH, vasopressors, vanco/clinda, transfused one unit RBC, TNP
initiated, cefepime started, cefepime desensitization started
for allergy history, meropenem stopped
[**4-8**] continued on ventilatory support, CVVH, vasopressors,
vanco/clinda, TPN, levothyroxine started, ancef started,
cefepime stopped
[**4-11**]- dobhoff tube placed, tube feeds started
[**4-12**] - flagyl started, continued ventilatory support, CVVH,
vanco/clinda, vasopressors weaned off, one unit of RBC
transfused, OR for debridement
[**4-14**] - successfully extubated, continued vanco/clinda/flagyl,
tube feeds
[**4-15**] - fluconazole added for yeast in urine, dobhoff removed,
started regular diet
[**4-18**] - transferred to the floor, foley catheter removed, OOB and
ambulating with PT, continued fluc, [**Last Name (un) 2830**]
[**4-20**] - pateint taken back to OR for VAC change to R inner thigh,
no complications
[**Date range (1) 3047**] - ambulating with PT on floor, progressed to regular
diet, normalizing of labs.
[**4-25**] - Taken to OR for STSG to R thigh without complication. VAC
left on as bolster to the graft for 3 days
[**4-28**] - Vac change, graft with near 100% take, other wounds
healing well with granulation tissue and wound care
[**5-1**] - Vac taken down with continued 100% take of graft,
xeroform dressing left in place. Patient ambulatory with PT
assistance, tolerating regular diet, voiding without assistance.
Still weak from prolonged hospital stay but doing significantly
better and ready for d/c to rehab to [**Hospital1 **] in [**Hospital1 8**]. Pt,
family, nursing and MD staff all agree that pt is ready for d/c
to rehab with f/u in 2 weeks.
Medications on Admission:
Albuterol 90 mcg q3-6prn, Alprazolam .125-.375 [**Hospital1 **]/hsprn,
Amantadine 100 mg syrup qd, Abilify 2.5-5hs, Azelastine 1 spray
nasal qid prn, Relpax 20-40 prn migraine, Fluoxetine 60mg qd,
Flovent 110mcg x4 [**Hospital1 **], Atrovent 17mcg 2 [**Hospital1 **] or qid prn,
Synthroid
50 5days/week 100 2 days/week, Pantoprazole 40'',Topiramate
50qam
100qpm, Trazodone 50-150 hs prn, Nasacort 55 both nostrils
daily,
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-20**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
2. Aripiprazole 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety/agitation.
3. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
6. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
7. Topiramate 50 mg Tablet Sig: One (1) Tablet PO qam.
8. Topiramate 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety/agitation.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 2X/WEEK
([**Doctor First Name **],SA).
12. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO 5X/WEEK
(MO,TU,WE,TH,FR).
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-20**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
14. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for anxiety/agitation.
15. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
18. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for anxiety.
19. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
20. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
21. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
22. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for anxiety/insomnia.
23. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 2X/WEEK
([**Doctor First Name **],SA).
24. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO 5X/WEEK
(MO,TU,WE,TH,FR).
25. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Toxic shock syndrome with myocardial depression
2. Bilateral thigh cellulitis and epidermolysis
3. Sepsis
4. Acute renal failure
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:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**3-27**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You VAC and Aquacel dressings will be changed in Rehab as
orderred
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD Phone:[**Telephone/Fax (1) 4775**]
Date/Time:[**2124-4-24**] 10:45 [**Location (un) **]. [**Location (un) **], [**Numeric Identifier 4774**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 3201**]
Date/Time Friday [**2124-5-19**] 1:30
ICD9 Codes: 5845, 5185, 2762, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7597
} | Medical Text: Admission Date: [**2109-11-25**] Discharge Date: [**2109-12-7**]
Date of Birth: [**2066-5-8**] Sex: M
Service: MEDICINE
Allergies:
Azithromycin / Augmentin / Klonopin / Aspirin / Atorvastatin /
Escitalopram / Amlodipine
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Decreased MS
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
History of Present Illness:
43 year-old male with PMH of CAD, [**Hospital **] transferred from the MICU.
Originally, presented with after a week of flu like illness with
altered mental status and thought to have seroquel OD (prior OD
on CCB/BB). Intubated at [**Hospital1 **] [**Location (un) 620**] for airway protection. Of
note, U Tox, S Tox are negative. (though were + for TCA at OSH).
However, it was determined that no meds were missing when
partner counted them. Therefore, episode of altered mental
status is not completely understood. While in the MICU,
patient's sedation was lightened and he self extubated. An LP
was performed for HAs and showed xanthochromia in all 4 tubes.
to exclude possibility of a traumatic tap, LP was repeated and
showed 3550 RBCs in tube 4 without any microorganisms. This was
concerning for SAH vs herpes vs mycotic aneurysm. PCR for HSV is
currently pending. CTA was performed on day of transfer and read
pending at time of this note. MRI spine was ordered to rule out
aneurysm/AVM but patient could not tolerate the procedure
secondary to nausea. He now feels back to normal in terms of his
thinking and fairly decent in terms of his mood. However, he
continues to experience vertigo and nausea especially when he
lays flat. Patient now without headaches.
Past Medical History:
Past Medical History:
1. CAD- s/p multiple stents with stent to LAD, pRCA, RCA, D1,
mid LCX at various times within the past 8 months. Cath [**2108-4-13**]
showed no flow limiting disease with EF=50%. 6 caths since [**11-20**].
His outpatient cardiologist notes that he has a severe coronary
vasculopathy (based on his having quickly developed seperate
coronary occlusions in rapid succession; this is why the stents
were each inserted on seperate occassions; this is also in the
context of presently having clear coronaries)
2. Hypertension
3. Hyperlipidemia
4. Tremor--essential
5. s/p hernia repair
PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Cardiologist is [**Doctor Last Name 5293**] at [**Hospital1 18**].
Past Psychiatric History:
Has had inpatient admissions x 2 on D4 this summer. Both of
these were serious suicide attempts by OD, prompting ICU
admissions. Had stay at [**Location (un) 1475**] for ETOH in past. Followed
outpatient by Dr. [**Last Name (STitle) 48615**] in [**Location (un) 620**] ([**Telephone/Fax (1) 48618**].
4 prior suicide attempts: deliberately crashing car @ 18yo wnen
intoxicated (reported on this interview), OD ~10 years ago
(noted to SW), OD about 2 months ago leading to MICU admit and
OD on Benadryl also leading to brief MICU admit.
Has had ECT since [**2108-5-17**], which has
been helpful. Was receiving maintenance therapy once per week
until late [**Month (only) 216**], then increased to 3x/week secondary to
continued symptoms of depression. Last ECt tx was at least 1
week ago (delayed secondary to medical issues).
Social History:
Born in [**State 5111**], 2nd of 6 children (5 sisters). Moved around
as a child secondary to father's position in Navy, ultimately
settling
on Cape for high school. Had 1 and half years at [**Hospital3 **]
Community College. Took care of mother before she died from
cancer, took care of prior parner before he died from cancer.
Lives with partner ([**Name (NI) **]), partner's sister and mother. [**Name (NI) **] 3
year old Yorkshire terrier, [**Doctor Last Name 3077**]. Enjoys playing with dog,
tending to garden, unable to do much of either secondary to
illness. Works in kitchen at [**Hospital1 **]-[**Last Name (un) 4068**]. Currently applying for
disability.
Substance Abuse History:
Smokes one pack tobacco a day. H/o EtOH dependence with Section
35 to [**Location (un) 1475**] ~15 years ago, in AA, sober since with just
one day of drinking in the spring. Distant h/o experimentation
with MJ as teenager.
Family History:
Father with EtOH dependence. Great aunt with ?depression,
completed suicide.
Physical Exam:
Vitals: T:97.2 P:75 R:12 BP:117/79 SaO2:100% on AC 650/125 x 12
100%
7.24/42/335
General: Intubated and sedated
HEENT: NC/AT, PERRLA, but sluggish, EOMI without nystagmus, no
scleral icterus noted, ET at 21cm
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RR, nl. S1S2, no M/R/G noted
Abdomen: Obese, soft, NT/ND, hypoactive bowel sounds, no masses
or organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted.
Neuro: Sedated. no hypertonia
Pertinent Results:
[**2109-11-25**] 09:00PM GLUCOSE-298* UREA N-33* CREAT-2.5*#
SODIUM-142 POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-17* ANION
GAP-17
[**2109-11-25**] 09:00PM ALT(SGPT)-17 AST(SGOT)-18 CK(CPK)-95 ALK
PHOS-79 AMYLASE-51 TOT BILI-0.2
[**2109-11-25**] 09:00PM LIPASE-60
[**2109-11-25**] 09:00PM cTropnT-<0.01
[**2109-11-25**] 09:00PM CK-MB-NotDone
[**2109-11-25**] 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2109-11-25**] 09:00PM URINE HOURS-RANDOM
[**2109-11-25**] 09:00PM URINE HOURS-RANDOM
[**2109-11-25**] 09:00PM URINE GR HOLD-HOLD
[**2109-11-25**] 09:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2109-11-25**] 09:00PM WBC-18.9*# RBC-3.77* HGB-12.4* HCT-34.7*
MCV-92 MCH-32.9* MCHC-35.8* RDW-12.9
[**2109-11-25**] 09:00PM NEUTS-88.1* BANDS-0 LYMPHS-8.1* MONOS-0.7*
EOS-2.4 BASOS-0.7
[**2109-11-25**] 09:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2109-11-25**] 09:00PM PLT SMR-NORMAL PLT COUNT-401#
[**2109-11-25**] 09:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2109-11-25**] 09:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2109-11-25**] 09:00PM URINE RBC->50 WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-0
[**2109-11-25**] 08:28PM TYPE-ART PO2-335* PCO2-42 PH-7.24* TOTAL
CO2-19* BASE XS--8 INTUBATED-INTUBATED
[**2109-11-25**] 08:28PM TYPE-ART PO2-335* PCO2-42 PH-7.24* TOTAL
CO2-19* BASE XS--8 INTUBATED-INTUBATED
[**2109-11-25**] 08:28PM TYPE-ART PO2-335* PCO2-42 PH-7.24* TOTAL
CO2-19* BASE XS--8 INTUBATED-INTUBATED
[**2109-11-25**] 08:28PM TYPE-ART PO2-335* PCO2-42 PH-7.24* TOTAL
CO2-19* BASE XS--8 INTUBATED-INTUBATED
CXR: 1.9
IMPRESSION: Appropriate placement of endotracheal tube and
nasogastric tube. Prominence of the pulmonary vasculature likely
relates to patient position.
CXR:[**11-27**]
FINDINGS: The patient has been extubated. There is a left-sided
subclavian central venous catheter with the tip in the upper to
mid SVC. Cardiac and mediastinal silhouettes appear within
normal limits. No focal pulmonary opacities, pleural effusions,
or evidence of pneumothorax. Osseous structures appear
unremarkable.
CT HEAD: [**11-26**]
FINDINGS: There is no sign for the presence of an intracranial
hemorrhage, mass effect, or shift of normally midline
structures. There is no evidence for minor or major vascular
territory infarction. The density values of the brain parenchyma
are normal. There is no overt extracranial pathology seen other
than mild bilateral ethmoid sinus mucosal thickening.
MR HEAD [**11-27**]
FINDINGS: The right vertebral artery distal to the origin of the
right posterior inferior cerebellar artery is extremely
hypoplastic. Additionally, there are bilateral fetal-type
posterior cerebral arteries, the latter finding presumably
correlating with the rather diminutive basilar artery. Within
the limitations of MR angiography, there is no definite sign for
the presence of an aneurysm, although conventional angiography
remains the standard study necessary to more unequivocal
exclusion of this pathological process. There are no areas of
hemodynamically significant stenosis identified. Within the
limitations of coverage of this study, there is no overt sign
for the presence of a vascular malformation.
CTA HEAD: [**11-29**]
IMPRESSION: No evidence of aneurysm.
A preliminary report of no subarachnoid hemorrhages seen, no
aneurysm detected on axial images was provided by Dr. [**Last Name (STitle) 41684**] and
confirmed by Dr. [**Last Name (STitle) **].
Echo: [**12-3**]
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Tissue velocity imaging demonstrates an E/e' <8 suggesting a
normal left ventricular filling pressure. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic
pressure could not be quantified. There is no pericardial
effusion.
Compared with the report of the prior study (tape unavailable
for review) of [**2108-6-7**], the findings are similar.
Based on [**2100**] AHA endocarditis prophylaxis recommendations,
the echo findings indicate a low risk (prophylaxis not
recommended). Clinical decisions regarding the need for
prophylaxis should be based on clinical and echocardiographic
data.
MRCSpine [**12-4**]
CONCLUSION: No radiological explanation for the clinical and
laboratory abnormalities noted in your history.
ADDENDUM: There is a mild Chiari I malformation of the
cerebellar tonsils, with the tonsillar tips approximately 5 mm
below the plane of the foramen magnum. Additionally, there are
type 2 degenerative endplate changes involving the C5-6 and C6-7
interspaces. Finally, there is a mild degree of congenital
narrowing of the AP diameter of the cervical spinal canal from
the C3 through C6-7 levels.
MR [**Last Name (Titles) 48643**] [**12-4**]
CONCLUSION: No radiological explanation for the clinical and
laboratory abnormalities noted in your history.
ADDENDUM: There is a mild Chiari I malformation of the
cerebellar tonsils, with the tonsillar tips approximately 5 mm
below the plane of the foramen magnum. Additionally, there are
type 2 degenerative endplate changes involving the C5-6 and C6-7
interspaces. Finally, there is a mild degree of congenital
narrowing of the AP diameter of the cervical spinal canal from
the C3 through C6-7 levels.
MR [**Last Name (Titles) **] 1//18
FINDINGS: There is mild facet joint degenerative change
bilaterally at the L5-S1 interspace, with a 2 mm subchondral
cyst involving the left S1 superior articular facet. There is no
other overt lumbar spinal pathology seen. The rootlets of the
cauda equina do appear apposed at the L4-5 interspace level.
Most probably, this finding relates to the relatively diminished
size of the thecal sac secondary to the presence of abundant
epidural fat at this locale.
CONCLUSION:No definite signs for the presence of spinal
pathology accounting for the clinical and laboratory findings
noted in your history. However, meningitis can be easily
overlooked by even contrast enhanced MRI.
Brief Hospital Course:
43 yo male with multiple h/o of SI, CAD s/p PCI, p/w
apnea/bradycardia/hypotension in setting of OD. Per HCP, only
Seroquel was unaccounted for at home (2300mg...is usually on
150gm/day). Further inquiry revealed a HA preceding the pt's
unresponsiveness. The patient's running problems were MS
changes, Infection, hypotension, Acidosis, respiratory failure,
CAD, ARF, nausea and vertigo.
.
MS changes: Initially thought to be due to seroquel OD, but
history did not ultimately support this initial diagnosis. Ddx
includes CNS infection (likely viral given non-toxic appearance
and prodrome 1 week prior), SAH (supported by xanthochromia on
LP x 2), trauma (no outward evidence of this), HIV sequela.
Intubated [**12-19**] airway protection and self extubated. MS cleared.
However, story remains unclear. Psych consultant believed that
he was not actively SI and felt that suicide attempt with OD was
unlikely the cause of episode. U Tox, S Tox were negative.
(though were + for TCA at OSH). Pt was stabalized in the ICU
and eventually transferred on HD 3 to the floor. His MS [**First Name (Titles) **] [**Last Name (Titles) 48644**]y improved in this process without a clear diagnosis. Pt
had fever on [**11-27**] and so was covered with levo/flagyl and was
cultured. Culture data as follows:
[**11-26**]: BCx with MSSA (1/4 bottles), GNR (1/4 bottles)
[**11-26**]: Sputum with staph aureus [**Last Name (un) 36**] pending
[**11-27**]: Sputum with staph aureus
[**11-28**]: Sputum with staph aureus
Treated with Clinda rather than levo/flagyl since [**11-28**] (emperic
to cover poss comm acquired MRSA). CXR does not indicate a PNA
from aspiration (though there did seem to be an aspiration while
pt was intubated). It was later decided that levo/vanc was a
preferable treatment while pt was in house. Suspician for a
true infection was low per clinical picture, and it was rather
suspected that the growth may have been an unusual contaminant,
however, antiobiotics were administered in case culture was
true. Pt was discharged to finish 14 day course of levo.
.
The CSF revealed persistant blood and xanthocromia and high
protein on two occasions. Pt was covered with empiric acyclovir
until CSF PCR demonstrated no HSV. On workup, pt had MRI
suggesting chiari malformation hypoplastic r vert, small
posterior art, no aneurysm seen, no acute stroke. CTA was also
negative for aneurism or bleed. Defect of the spinal cord such
as AVM or aneurism was suspected due to hyperasthesia in chest
but MR showed no abnormality. The last possibility that had to
be ruled out was a sentinal bleed from a small cranial aneurism
that was being missed by MR/CTA, so a angiogram was performed
which did not demonstrate any major abnormalities on discussion
with the radiologist, however a formal read is pending as of
discharge date.
.
Hypotension: Pt presented with hypotension, considered a
seroquel vs neurovasc event. Resolved on [**11-27**]. Pt [**Name (NI) **] by
enzymes.
.
Acidosis: PT was in primary metabolic on arrival. Which
resolved after stabilization and intubation.
.
Resp Failure: Pt presented with respiratory failure and was
intubated on [**11-26**]. Self extubated [**11-27**] and doing well.
.
CAD: ASA, Plavix (allergies noted; only makes him bleed), held
BB/CCB due to low blood pressure.
.
ARF: Cr 2.2 on presentation: (baseline 0.7): Kept MAP >65mm.
FENA was elevated. ATN is likely given hypotension and high
FeNa. Slowly resolved over course of stay to a Cr=1.3. UA
appears infected, but UCx showed no growth.
Pt was stabalized, feeling well in good mood with no headache,
pain, vertigo, nausea, or any other major complaints and
discharged on [**2109-12-7**]
Medications on Admission:
Atorvastatin Calcium 40 mg Tablet PO QD
Amlodipine Besylate 5 mg PO QAM
Clopidogrel Bisulfate 75 mg qAM
Metoprolol Tartrate 75 mg PO BID
Aspirin 325 mg qd
Quetiapine Fumarate 25mg qAM, 50mg noon, 75mg qHS
Gemfibrizole 600mg po bid
Topomax 75mg po qd
Neurontin 800mg po qHS
Cymbalta 60mg po qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Quetiapine 25 mg Tablet Sig: Five (5) Tablet PO HS (at
bedtime).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*4 Tablet(s)* Refills:*0*
7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day): speak
with your doctor about returning to your normal dose.
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
9. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
10. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
11. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) for 7 days.
Disp:*42 Tablet(s)* Refills:*0*
13. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. Outpatient Lab Work
please ask your doctor's office to check your chem 7 and draw a
blood culture in 1 week. The results must be called to Dr. [**Name (NI) 42449**] office.
Discharge Disposition:
Home
Discharge Diagnosis:
altered mental status
depression
bacteremia
h.flu pneumonia
hematochezia
CAD sp stents
Discharge Condition:
good
Discharge Instructions:
Please continue your home medications, as administered by your
partner. [**Name (NI) **] were found to have blood in your stool, so you need
to have this followed up. Please ask your doctor [**First Name (Titles) **] [**Last Name (Titles) **] you
for a colonoscopy. Please call your doctor if you have further
confusion, fevers, headaches, or notice blood in your stool.
Please discuss further adjustment of your psych medications with
your outpatient psychiatrist.
We've stopped your amlodipine. Instead you will be on toprol and
lisinopril. Please have your doctor's office check your blood
pressure and your lab work. Please finish a course of levaquin.
Followup Instructions:
Please [**Last Name (Titles) **] an appointment to see your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **]
[**Telephone/Fax (1) 17753**] in the next 2 weeks. Please request a repeat guiac
as you were positive during your stay and may require a
screening colonoscopy. You should also see your psychiatrist in
the next 2 weeks. Please [**Telephone/Fax (1) **] an appointment to see Dr.
[**First Name (STitle) 9046**] [**Name (STitle) 7994**] in neurology Phone: [**Telephone/Fax (1) 541**] in the next [**12-20**]
weeks.
Completed by:[**2109-12-9**]
ICD9 Codes: 5845, 7907, 2762, 5990, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7598
} | Medical Text: Admission Date: [**2169-1-9**] Discharge Date: [**2169-1-31**]
Date of Birth: [**2095-1-26**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
woman, status post a motor vehicle accident in [**2168-1-10**], during which she was not injured, but she went to the
local Emergency Room. A chest x-ray done at that time looked
suspicious and a follow up CAT scan was obtained which showed
a thoraco-abdominal aneurysm. She was advised to see a
cardiothoracic surgeon, which she did, following which she
was scheduled for a thoraco-abdominal aneurysm repair.
PAST MEDICAL HISTORY: The patient's past medical history is
significant for hypertension, hypercholesterolemia,
osteoarthritis, non-insulin dependent diabetes mellitus and
low back pain.
PAST SURGICAL HISTORY: Past surgical history is significant
for a left breast lumpectomy, a cholecystectomy, right hand
ganglion resection and a T and A.
MEDICATIONS: Meds at home include Avandia, 4 mg q a.m.;
aspirin, 81 mg daily; Toprol, 10 mg daily; Lipitor, 10 mg
daily; Hydrochlorothiazide, 12.5 mg daily; and Celebrex,
which the patient stopped prior to admission.
SOCIAL HISTORY: Smokes one half to one pack of cigarettes
per day times 33 years. Occasional ETOH use. Denies any
other recreational drug use. She has three children and
lives with her husband.
FAMILY HISTORY: Father died of an MI. Mother died of old
age.
PHYSICAL EXAMINATION: Weight 214 pounds, height 5 feet 4
inches. Vital signs: Temperature 98.9. Heart rate 81.
Blood pressure 137/58. Respiratory rate 18. O2 sat 97
percent on room air. General: No acute distress.
Neurologic: Alert and oriented times four. No focal
deficits. Respiratory: Respiratory clear to auscultation
bilaterally. Cardiovascular: Regular rate and rhythm. S1
and S2. Abdomen: Soft and nontender, non-distended with
normoactive bowel sounds and a well healed cholecystectomy
scar. No bruits appreciated. Extremities: Warm and well
perfused with no ulcers and bilateral lower extremity edema.
LABORATORY DATA: White count 10.6, hematocrit 41, platelets
215. Sodium 145, potassium 4.2, chloride 107, CO2 31, BUN
18, creatinine 0.8, glucose 110. LFT's within normal limits.
Albumin 4.6.
UA was negative.
Chest x-ray showed no cardiopulmonary processes and the
patient was consented for a thoracoabdominal aneurysm repair.
HOSPITAL COURSE: On the first of [**Month (only) 956**] the past was
brought to the operating room. Please see the OR report for
full details. In summary, the patient had a thoracoabdominal
aneurysm resection and replacement of the descending aorta
with a number 28 Hemashield graft from the distal left
subclavian to the suprailiac. She tolerated the operation
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 70 beats per minute with a
mean arterial pressure of 71 and a CVT of 15. The patient
did well in the immediate postoperative period. Her
anesthesia was reversed. The sedation was weaned to the
point where the patient was following commands and moving all
four extremities, and then her sedation was reinstated. She
remained ventilated throughout the course of the operative
day, requiring nitroglycerin and Propofol to maintain an
adequate blood pressure.
On postoperative day the patient continued to do well. By
chest x-ray it appeared that the patient had a left-sided
infiltrate and a bronchoscopy was done at that time which
showed both left upper and left lower lobe mucous plugging,
following which the patient's oxygenation remained a problem,
and therefore she was a slow wean from the ventilator.
On postoperative day two the patient remained hemodynamically
stable. She continued to slowly wean from the ventilator.
However, she did have periods of atrial fibrillation for
which she was begun on beta blockade, as well as Amiodarone.
Additionally the patient underwent a second bronchoscopy,
which showed tenacious secretions in both left upper and
lower airways. Finally the patient was cardioverted from
atrial fibrillation into sinus rhythm.
On postoperative day three the patient continued to do well.
She unfortunately went back into atrial fibrillation
following a short run of sinus rhythm after cardioversion.
She continued to slowly wean from her vaso-active
medications. We were unable to make any progress in her
ventilatory status, and neurologically the patient's sedation
was held to the point where she would follow commands and
move all extremities. However, she became increasingly
agitated and required re-sedation.
Over the next several days, the patient remained
hemodynamically stable. Several attempts were made to wean
the patient from the ventilator, however they were all
unsuccessful.
On postoperative day six the patient again underwent a
bronchoscopy, during which cultures were obtained and sent to
the laboratory. The bronchoscopy again showed left upper
lobe secretions that were tenacious and a clear right airway.
Over the next several days the patient remained
hemodynamically stable. The decision was made to bronch the
patient on a daily basis, following which several attempts
were again made to wean the patient from the ventilator.
Each attempt was unsuccessful.
By postoperative day 13 the patient was able to be weaned to
pressure support ventilation with 5 of pressure support and 5
of PEEP support. The patient tolerated this well.
Throughout the day she was rested on increased pressure
support overnight and the following morning returned to [**4-13**]
and extubated. The patient failed extubation after several
hours, was reintubated. Bronchoscopy was done at that time
that showed patent right upper and lower lobes, and
completely obstructed left lower lobe with mucous plugs in
the left upper lobe as well. At that time the patient
additionally required PEEP 12 in order to oxygenate
adequately and a plan was made for the patient to undergo a
tracheostomy on the following day.
On [**2169-1-26**] the patient underwent tracheostomy with a
number 8 Pore-Tex. The procedure was tolerated well and
there were no complications. Following tracheostomy the
patient was able to be placed back on pressure support
ventilation, and within several days was successfully weaned
to trach collar vent, tolerating placement of the
tracheostomy.
The patient was seen by the speech and swallow service. On
the [**1-30**] she underwent a bedside swallow
evaluation, as well as a video assisted swallow evaluation,
which she passed without restriction. Her diet was advanced
at that time. At that time the decision was made that the
patient was stable and ready to be transferred to
rehabilitation. Rehabilitation screening process was done.
At the time of this dictation, which is the [**1-31**],
the patient's physical exam is as follows:
General: No acute distress. Neurological: Alert and
oriented and moves all extremities. Follows commands.
Respiratory: The patient with a number 8 Pore-Tex trach
ventilating with a 40 percent trach mask, coarse breath
sounds throughout, somewhat diminished in the left lower
lobe. Cardiovascular: Regular rate and rhythm. S1 and S2
with no murmurs. Left thoracoabdominal incision with
staples. Small areas of erythema but no drainage. Abdomen:
Soft and nontender and non-distended with normoactive bowel
sounds. Extremities: Warm and well perfused with 1 plus
bilateral edema. The skin additionally a red, yeasty-looking
rash in the groin and the buttocks, currently being treated
with Miconazole powder.
LABORATORY DATA: White count 12.5, hematocrit 32, platelets
325, PT 14, PTT 25, INR 1.3. Sodium 134, potassium 4.6,
chloride 96, CO2 30, BUN 41, creatinine 0.8, glucose 127.
CONDITION ON DISCHARGE: The patient's condition at the time
of discharge is good.
DISCHARGE DIAGNOSES:
1. Status post thoracoabdominal aneurysm repair with a number
28 Hemashield graft from the distal left subclavian to the
suprailiac done on [**1-10**].
2. Status post tracheostomy with a number 8 Pore-Tex done on
[**1-26**].
3. Hypertension.
4. Hypercholesterolemia.
5. Osteoarthritis.
6. Diabetes mellitus type 2.
7. Low back pain.
8. Cholecystectomy.
9. Breast CA, status post lumpectomy.
DISCHARGE MEDICATIONS: The patient's discharge medications
include:
1. Aspirin, 81 mg daily.
2. Colace, 100 mg [**Hospital1 **].
3. Atrovent inhaler, [**Hospital1 **].
4. Lansoprazole, 30 mg daily.
5. Albuterol inhaler, 4 puffs q4h.
6. Metoprolol, 50 mg tid.
7. Avandia, 4 mg daily.
8. Amiodarone, 400 mg [**Hospital1 **] times 7 days, then 400 mg daily
times 7 days, then 200 mg daily.
9. Miconazole Powder, [**Hospital1 **] prn.
10. Vancomycin, 1 gram q12h times 3 days, the last dose
being on [**2169-2-3**].
DI[**Last Name (STitle) **]ION: The patient is to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] two to three weeks after discharge from
rehabilitation, and follow up with Dr. [**Last Name (Prefixes) **] four weeks
following discharge from [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **].
ADDENDUM: The patient tube feed regime is intact with fiber
via Dobbhoff tube at 65 cc per hour until the patient is
taking adequate oral nutrition, at which time tube feeds and
Dobbhoff can be discontinued.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2169-1-31**] 11:41:59
T: [**2169-1-31**] 12:23:31
Job#: [**Job Number 46105**]
ICD9 Codes: 5185, 5180, 486, 9971, 496, 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7599
} | Medical Text: Admission Date: [**2131-4-25**] Discharge Date: [**2131-4-27**]
Date of Birth: [**2131-4-25**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: The patient is a 2850 gram, 41
week gestation male infant pregnancy. Mother is a 29 year-
old, Gravida I, Para 0 to I mother. [**Name (NI) **] prenatal screens
were unremarkable with blood type 0 positive, antibody screen
negative, RPR nonreactive, Rubella immune. Hepatitis B
surface antigen negative and group B strep negative. The
pregnancy was uncomplicated. Her labor was complicated by
maternal fever to 102.9 and fetal tachycardia and rupture of
membranes for 15 hours prior to delivery. She was treated
with antibiotics 2 hours prior to delivery and delivery was
by vaginal route with Apgars of 8 and 9. The baby was
admitted to the newborn intensive care unit for assessment.
At birth was noted a large port-wine stain on the left side
of the face.
PHYSICAL EXAMINATION: Vital signs: Temperature on admission
was 100.3; heart rate 162; respiratory rate of 46; blood
pressure 64/33 with a mean of 44 and oxygen saturation of 96%
in room air. Weight was 2850 grams. Length was 19 inches or
48.2 cm and head circumference was 33.5 cm. Baby appeared
well with weight appropriate for gestational age. Exam of the
head revealed a soft, anterior fontanel that was flat with
mobile sutures. A port wine stain was present on the left
side of the face in the trigeminal region. It was
approximately 6 x 4 cm. There was a branching macule
extending primarily from the lower lid to the cheek at the
level of the angle of the mouth. This is in a V-2 or [**4-24**]
distribution. The rest of the physical examination revealed
palate intact. Respiratory: Breath sounds clear. Cardiac
exam was unremarkable with no murmur. Abdominal exam was
unremarkable. Three vessel cord was noted to be present.
External genitalia were normal with testes descended
bilaterally. Hip exam normal. Neurologic exam normal.
REVIEW OF SYSTEMS: Infectious disease: The patient had a
sepsis evaluation including a CBC and blood culture. Blood
culture has shown no growth. The CBC revealed a white count
of 17,800 with 70% polys and 1% bands. 48 hour blood
cultures were negative and antibiotics were discontinued. The
baby has had a stable temperature and no other clinical signs
of sepsis. The baby is taking [**Name (NI) 37112**] formula and is
tolerating feedings well. Discharge weight: 2880 grams.
Baby had consultation with dermatology. He was seen by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38485**] who felt that the lesion on his face was
consistent with a port wine stain and felt that he was a good
candidate for laser therapy. Sturge-[**Doctor Last Name 11586**] syndrome was felt
to be unlikely because of the V-2 distribution. Referral to
Dr. [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 24529**] of dermatology is planned and an
appointment should be scheduled with Dr. [**First Name (STitle) 24529**]. The phone
number is [**Telephone/Fax (1) 53430**]. Patient was also seen by
ophthalmology consultant, Dr. [**Last Name (STitle) **] from [**Hospital3 1810**]
and assessment was unremarkable. The ophthalmologic
evaluation was within normal limits. There was very mild
hemorrhages noted in the right eye. These were felt to be
related to birth and no follow-up or intervention was felt to
be needed. Follow-up with ophthalmology has been scheduled.
The date of the follow-up is [**6-27**] at 2:30 p.m. at [**Last Name (un) 58397**] IV
[**Hospital3 **] with Dr. [**Last Name (STitle) 5444**].
The patient was also evaluated by neurology, Dr. [**First Name (STitle) **]
[**Name (STitle) **]. They felt that the baby's neurologic exam was
unremarkable but they did recommend assessment with a MRI and
this will be scheduled in the near future with follow-up to
be arranged with neonatal neurology clinic in 4 to 6 weeks
after the MRI has been performed.
Baby had a bilirubin checked and it was 8.2 at 38 hours of
life.
Neurosensory screen: The baby had a hearing screen
performed and passed in both ears. The baby received vitamin
K routine newborn dose and erythromycin and hepatitis B
vaccine.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: The baby will be discharged to home
in the care of his parents.
FOLLOW UP:
(1) Dr. [**Last Name (STitle) 1256**] of [**Hospital3 **] Health
Center. Fax #[**Telephone/Fax (1) 40665**]. [**Hospital3 29903**]: [**Telephone/Fax (1) 40664**]. Appointment will be scheduled with Dr.
[**Last Name (STitle) 1256**] for Monday morning, [**4-30**].
(2) Dr. [**Last Name (STitle) 5444**], Ophthalmology [**2131-6-27**], 2:30 pm.
(3) Dr. [**Last Name (STitle) 36469**] or [**Doctor Last Name **], Neonatal Neurology Program in [**3-29**]
weeks, Phone [**Telephone/Fax (1) 38046**].
(4) Dr. [**First Name (STitle) 24529**], Dermatology, [**Telephone/Fax (1) 53430**].
(5) MRI, requst has been sent to CH radiology, they are to
contact family with appointment date and time. Phone:
[**Telephone/Fax (1) 66648**].
CARE RECOMMENDATIONS:
1. Feedings at discharge: [**Telephone/Fax (1) 37112**] 20 calories per ounce
p.o. ad lib.
2. State newborn screen has been sent. Results are pending.
DISCHARGE DIAGNOSES:
1. Term infant.
2. Rule out sepsis.
3. Port wine stain, rule out Sturge-[**Doctor Last Name 11586**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (NamePattern4) 55751**]
MEDQUIST36
D: [**2131-4-26**] 16:30:43
T: [**2131-4-26**] 17:43:07
Job#: [**Job Number 66649**]
ICD9 Codes: V290, V053 |
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