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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7600
} | Medical Text: Admission Date: [**2163-12-13**] Discharge Date: [**2163-12-19**]
Date of Birth: [**2093-12-23**] Sex: F
Service:
DIAGNOSES:
1. Intraparenchymal hemorrhage.
2. Placement issues.
HISTORY OF PRESENT ILLNESS: This is a 69 year-old woman with
a history of dementia and no known vascular risk factors who
was last seen around 12:00 p.m. noon at the [**Hospital3 **]
facility where she lives. She was found down around 2:00
p.m. unresponsive and incoherent. At baseline she is active,
interactive, likes to walk and read, but has memory problems.
She goes to church by bus every Sunday.
When they found her down she had right sided flaccid weakness
and intermittent shaking of the left hand. She was taken to
[**Hospital6 6640**] where a head CT showed a left
frontal bleed. The patient was transferred to [**Hospital1 18**] for
further evaluation.
PAST MEDICAL HISTORY: Dementia.
MEDICATIONS AT HOME: 1. Celexa. 2. Aricept.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On admission respiratory rate 16.
Blood pressure 150/70. Heart rate 60. Temperature 95.8.
98% on room air. The patient has a 2/6 systolic murmur heard
best at the left second intercostal space and apex, regular
rate and rhythm. Clear to auscultation bilaterally. Soft,
nontender, nondistended. Positive bowel sounds. There is a
small ecchymosis over the right shin. Positive pulses and
symmetric. Neurological examination on admission, alert,
follows one step command. She shows two finger, sticks out
her tongue, smiles, lifts up her left arm responsively,
wiggles left toes. Repeat questions yes and no
intermittently. She could not name. She neglects the right
side and expose visually to the left. On cranial nerve
examination there is no papillary edema. Visually, there is
no response to visual threats on the right. Extraocular
movements intact. She does not look over to the right. V1
to 3 responds to pain bilaterally. Right nasal labial fold
smooth. Tongue is midline. Motor examination, normal bulk
and tone on the left, however, tone on the left has
cogwheeling rigidity and left arm is flaccid. On the right
upper extremity there is positive spasticity on the right
lower extremity. There is no movement on right upper
extremity for pain. There is positive minimal flexion on
right lower extremity to pain. On the left there is
spontaneous movement upper and lower extremity. There is
positive intermittent increased tone with tremor on pain with
the left arm. Sensory, there is positive grimacing
bilaterally.
CAT shows 4.2 times 5 times 4 cm left frontal lobe
hemorrhage.
HOSPITAL COURSE: The patient was initially admitted to the
Neurological/Surgical Intensive Care Unit where she was
monitored closely for any worsening of neurological symptoms
due to potential edema. However, she fared well and was
transferred to the floor on the [**12-16**] for further
management. She was evaluated for swallowing studies and she
failed to [**Last Name (LF) **], [**First Name3 (LF) **] we have kept her nasogastric tube and
agreed to initiate process of PEG tube placement. She
currently has an increased white blood cell count to 15 and
we are following this up with a urinalysis. Since she has
been afebrile we will hold off on any further workup, but
will consider a chest x-ray and blood cultures if tomorrow's
white blood cell continues to be increased.
The patient is now DNR/DNI and physical therapy has been
involved and we have already started the process of screening
her for a nursing home depending on physical therapy
recommendations.
MEDICATIONS ON DISCHARGE: The patient will be discharged on
tube feeds with 250 cc water bolus q 6. Droperidol 0.625 mg
intravenous q 8 prn nausea. Celexa. Aricept. Please note
that a final medication list on discharge will be noted as an
addendum.
FOLLOW UP: The patient's follow up will be arranged by the
time of discharge.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 396**] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 11440**]
MEDQUIST36
D: [**2163-12-19**] 16:42
T: [**2163-12-20**] 06:54
JOB#: [**Job Number 38843**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7601
} | Medical Text: Admission Date: [**2147-5-6**] Discharge Date: [**2147-5-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
low HCT
Major Surgical or Invasive Procedure:
EGD with epinephrine and clipping, [**2147-5-8**]
History of Present Illness:
Pt is a 85 yo female with a Hx significant for A-fib on aspirin
325BID, who presented to OSH with a HCT of 16 and report per son
that patient had experienced increased fatigue and unsteady gait
yesterday. with two episodes of near syncope since than. NP saw
pt and had discovered low BP and recommended transfer to ED
given her low BP and weakness. No other complains or symptoms
had been endorsed. She was taken to [**Hospital1 2025**] and was transfered
without prior transfusion to [**Hospital1 18**] based on family request.
.
ROS: pt denies categorically any complain
Past Medical History:
[**Name (NI) 17584**], unclear why not on anticoagulation, no history of falls
Dementia
Incontinence
Arthritis
.
Social History:
lives with husband at assisted [**First Name9 (NamePattern2) 62680**] [**Location (un) **], walks with
walker, no tobacco or alcohol abuse
Physical Exam:
T 99.4 BP: 108/33 HR 77 SPO2 100% 3L
General: pale appearing female in NAD, AOx1, flat affect
HEENT: pale conjunctiva, dry MM, no dentition
Neck: supple, no LAD
Lungs: CTA bilaterally
Heart: RRR, no m/r/g
Abdomen: obese, soft, epigastric tenderness
Extremities: cool, without clubbing or edema
Pertinent Results:
[**2147-5-6**] 03:45PM WBC-17.5*# RBC-1.92*# HGB-5.9*# HCT-18.5*#
MCV-96 MCH-30.7 MCHC-31.9 RDW-14.7
[**2147-5-6**] 03:45PM NEUTS-82.0* LYMPHS-14.7* MONOS-2.8 EOS-0.3
BASOS-0.3
[**2147-5-6**] 08:30PM GLUCOSE-113* UREA N-73* CREAT-1.2* SODIUM-140
POTASSIUM-4.3 CHLORIDE-111* TOTAL CO2-20* ANION GAP-13
.
EGD ([**2147-5-8**])
Esophagus:
Lumen: A complex, sliding, medium paraesophageal hernia was
seen.
Stomach: Normal stomach.
Duodenum: Excavated Lesions. A single cratered ulcer was found
in the duodenal bulb. A clot suggested recent bleeding. 4
cc.Epinephrine 1/[**Numeric Identifier 961**] hemostasis with success. [**Hospital1 **]-CAP
Electrocautery was applied for hemostasis successfully. A single
superficial ulcer was found in the distal bulb. A visible vessel
suggested recent bleeding. 4 cc.Epinephrine 1/[**Numeric Identifier 961**] hemostasis
with success. A hemoclip was then applied to the visible vessel.
Brief Hospital Course:
MICU course: 2 large-bore IVs were placed. The pt's ASA, BB,
ACEi and Lasix were held. She had no further BMs or melena. She
remained HD stable with SBP in 110s and HR in 70s after initial
2L NS bolus. She was transiently on a PPI drip and was
transfused a total of 4U with HCT coming up to 27 from 18. Her
HCT remained stable after these initial 4 units.
.
GI did not feel that the pt was still actively bleeding, thus no
urgent scope was performed in the MICU. She was switched to PPI
IV bid and started on clears which she tolerated well. The pt
was transferred to the medicine floor for further management.
.
Floor Course:
# GI bleed: The pt required a total of 7 units pRBCs to maintain
her HCT over her hospital course. She had an EGD performed by GI
which demonstrated a single cratered ulcer in the duodenal bulb
with stigmata of recent bleeding. This was injected with
epinephrine and clipped; GI indicated that a risk of rebleeding
remained. The pt was treated with a Protonix gtt for >48 hours
and then transitioned to PO therapy [**Hospital1 **]. The pt's HCT was stable
for the remainder of her [**Hospital 62681**] hospital stay at
around 27 to 28. The pt's antihypertensives were held in this
setting and her blood pressure was well-controlled with only
diltiazem. The pt's home aspirin was held.
.
# A-fib/SVT: At the time of admission, the pt was taking ASA 325
[**Hospital1 **] for her prior history of PAF; this was stopped at the time
of admission. In the setting of having her beta blocker held,
the pt was noted to have several episodes of AF with RVR (HR to
the 140s), as well as two episodes of SVT (HR again to 140s)
that was thought to likely represent AVNRT. All of these
episodes were asymptomatic for her and she remained HD stable. A
TSH and CXR were checked and were unremarkable. Although the
pt's HR responded well to re-initiation of her beta blocker,
this did not suppress her SVT, and thus her beta blocker was
transitioned to PO diltiazem. At the time of discharge, she had
not had any SVT for 24 hours. We would suggest possible
up-titration of her diltiazem as allowed by her HR and BP, and
eventual conversion to the long-acting form of the medication.
.
# Diastolic dysfunction: The pt appeared euvolemic throughout
her stay. A chest x-ray after several days without Lasix did not
demonstrate any evidence of failure. A echo in [**2145**] demonstrated
preserved EF and mild AR. As above, the pt's ACEi, beta blocker
and lasix were held at admission; ***these may need to be
restarted in the future.***
.
# CAD: The pt had a negative stress-MIBI in [**2145**]. Her ASA was
held throughout her hospital stay as described above. When her
HR was elevated, the pt was noted to have fairly diffuse ST
depressions which resolved with better HR control, thus
continued aspirin therapy, likely at 325 mg daily, would be
ideal. This was deferred at the time of discharge so that the
pt's HCT could be followed for another 1-2 weeks.
.
# Dementia: The pt remained pleasantly and mildly demented
throughout her hospital course. There was no evidence of
delirium.
Medications on Admission:
Aspirin 325 [**Hospital1 **]
Lasix 20 mg daily
Metoprolol 25 [**Hospital1 **]
Lisinopril 2.5
Citalopram 20mg QHS
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] [**Hospital1 **] [**Hospital1 1501**]
Discharge Diagnosis:
Primary:
upper GI bleeding
atrial fibrillation
other SVT (suspected AVNRT)
.
Secondary:
coronary artery disease
diastolic dysfunction
Discharge Condition:
Improved. Vital signs and HCT stable. Pt moderately
deconditioned.
Discharge Instructions:
-You were admitted with bleeding in your GI tract that was
caused by an ulcer. We have treated you with blood transfusions,
applied clips to the blood vessels in your ulcer and are giving
you medications to help prevent a recurrence. You are being
discharged to rehab before going home to help regain your
strength.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> Aspirin was held because of bleeding. Talk with your doctor
about when or if to restart this.
--> Your home metoprolol was changed to diltiazem. This is a
similar medicine that we think will do a better job of
controlling your heart rate.
--> Your Lasix was stopped because your blood pressure was
normal. Please talk with your doctor about when to restart this.
--> Your lisinopril was stopped because your blood pressure was
normal. Please talk with your doctor about when to restart this.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Dr. [**Last Name (STitle) 5351**] is aware that you have been discharged from the
hospital. Her office will contact you to arrange follow-up in
the next few days. Please call her office at [**Telephone/Fax (1) 608**] if you
have not heard from them by then.
ICD9 Codes: 5849, 2762, 2851, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7602
} | Medical Text: Admission Date: [**2199-8-24**] Discharge Date: [**2199-9-13**]
Date of Birth: [**2127-2-13**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Atenolol / Provera / Inderal La / Latex / Norvasc /
Levaquin / Diovan / Ambrisentan
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
GI bleed, decompensated pulmonary hypertension
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
72 yo F with idiopathic pulmonary hypertenstion (PA pressured
90-100) on 5L O2 nc, remodulin pump and sildenafil, h/o PE in
[**2194**] on coumadin. She presented to [**Hospital3 **] yesterday
with nausea and hematemesis. She had hct drop from baseline of
45--->29. She developed hypoxia to 74% in the setting of
hematemesis and was intubated. Her INR was reversed. She
received a total of 5u RBC. She underwent endoscopy in the ICU
at OSH that showed a large gastric ulcer that was not actively
bleeding. She was placed on a PPI ggt. She was transferred to
[**Hospital1 18**] as she receives her out patient care here and the OSH did
not know how to administer remodulin.
Past Medical History:
- Pulmonary embolism in [**2194**], on anticoagulation
- Severe pulmonary hypertension, O2 dependent
- COPD
- Supraventricular tachycardia
- Hypertension
- s/p Right leg vein stripping
- Arthritis
Social History:
Patient is widowed and lives alone. She has three sons. She has
a 50 pack year history and quit less than 1 year ago.
Family History:
Father had a stroke in his 80??????s. Sister had a stroke in her mid
40??????s.
Physical Exam:
98 79 115/54
Sedated, NAD
HEENT: PERRL, EOMI, Right IJ trauma line, +JVD
Lungs CTA bil
CV: irreg irreg
Abd: soft hypoactive bs, nt
Ext: 2+ DP pulses, no peripheral edema, +boots
Pertinent Results:
[**2199-8-24**] 02:42AM WBC-11.1*# RBC-3.64* HGB-11.1*# HCT-33.0*#
MCV-91 MCH-30.4 MCHC-33.6 RDW-16.0*
[**2199-8-24**] 02:42AM PLT COUNT-196
[**2199-8-24**] 02:42AM PT-16.2* PTT-24.2 INR(PT)-1.4*
[**2199-8-24**] 02:42AM GLUCOSE-112* UREA N-41* CREAT-1.0 SODIUM-150*
POTASSIUM-3.5 CHLORIDE-115* TOTAL CO2-26 ANION GAP-13
[**2199-8-24**] 02:42AM ALT(SGPT)-11 AST(SGOT)-12 LD(LDH)-184
CK(CPK)-48 ALK PHOS-44 TOT BILI-0.7
[**2199-8-24**] 02:42AM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-3.1
MAGNESIUM-1.9
[**2199-8-24**] 02:42AM cTropnT-LESS THAN
[**2199-8-24**] 03:40AM LACTATE-1.0
[**2199-8-24**] 03:40AM TYPE-ART PO2-96 PCO2-51* PH-7.32* TOTAL
CO2-27 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED
..
[**2199-9-12**] 05:50AM BLOOD WBC-8.0 RBC-3.62* Hgb-10.9* Hct-33.2*
MCV-92 MCH-30.1 MCHC-32.8 RDW-16.0* Plt Ct-326
[**2199-9-9**] 06:08AM BLOOD Neuts-80.6* Lymphs-7.2* Monos-3.4
Eos-8.7* Baso-0.1
[**2199-9-12**] 05:50AM BLOOD PT-18.5* PTT-25.1 INR(PT)-1.7*
[**2199-9-12**] 05:50AM BLOOD Plt Ct-326
[**2199-9-12**] 05:50AM BLOOD Glucose-80 UreaN-32* Creat-1.0 Na-141
K-3.4 Cl-99 HCO3-34* AnGap-11
[**2199-9-10**] 03:27AM BLOOD Digoxin-0.9
..
Blood Cultures from [**2199-9-7**]: Pending
..
Imaging:
CXR [**8-24**]: An endotracheal tube tip lies 5.7 cm above the carina.
Nasogastric tube appears appropriately positioned. The patient
is rotated. The cardiomediastinal silhouette is obscured by a
prominent retrocardiac opacity with air bronchograms. The
central vessels are enlarged consistent with known pulmonary
hypertension. There is also a right basilar opacity.
.
Brief Hospital Course:
72 y/o F with hx of pulm HTN on Remodulin, PE and CHF who
presented to an OSH on [**8-23**] with hematemesis and hct form
45-->29. She clinically deteriorated from a respiratory
standpoint, sats in 70s while vomiting, and was urgently
intubated. Her INR was reversed with FFP and she received a
total of 5 u PRBCs. She then had an endoscopy showing a
non-bleeding gastric ulcer. She was transferred to [**Hospital1 18**] for
Remodulin therapy given the OSH pharmacy did not carry the
medicine.
.
On arrival here, she was intubated and sedated. She had a stable
hct. Her SBP was moderately low and levophed was started. Her BP
was thought to be secondary to sedation. GI was consulted and
did not feel a need to rescope her given her stable hct.
Pharmacy was consulted and converted her remodulin to an IV pump
form.
.
# UGIB: OSH report with photos of large gastric ulcer, no longer
bleeding. Her anticoagulation was held, her hct remained stable,
and she was placed on a PPI. GI was consulted and saw no
indication for further endoscopy.
.
# Hypotension: Occurred in setting of sedation for vent/line and
with increase in PEEP. She required levophed transiently, and
was weaned successfully.
.
# Hypoxic respiratory failure: In setting of UGIB likely [**3-12**]
aspiration. Has underlying hypoxia at baseline from Pulmonary
Hypertension (on baseline 5L nc). No pneumonitis or infiltate
seen on CXR but given underlying lung disease was treated
empirically until cultures returned negative. For her severe
pulmonary hypertension she was continued on remodulin and
sildenafil, and the remodulin was discontinued successfully
prior to discharge. She was successfully weaned from the
ventilator.
.
# SVT: Intermittently tachy to 130s with a known h/o SVT. Here
she intermittently converted in to Afib/flutter. She was kept
on telemetry, resuscitated with blood, and treated with AV nodal
blocking agents, including diltiazem and digoxin.
.
# Pulmonary Embolus: On admission the patient was anticoagulated
for a recent PE. Her INR was reversed given GIB. Her
anticoagulation was held for a period and then restarted to in
light of need to minimize right heart strain in pt with severe
pulmonary hypertension.
.
# The patient is DNR/DNI.
Medications on Admission:
Amlodipine 5 mg Tablet
Warfarin 2 mg (held and INR reversed yesterday)
Furosemide 60mg qd
Sildenafil 80 mg TID
Gabapentin 300 mg qhs
Triamcinolone Acetonide Topical
Remodulin 16.25 ng/kg/min
Discharge Medications:
1. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 6-10 MLs
Miscellaneous Q6H (every 6 hours) as needed for wheeze.
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
3. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO
twice a day: Please take with lasix dose.
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
7. Sildenafil 20 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. Morphine Sulfate 2-4 mg IV Q2H:PRN pain, shortness of breath
hold if sedated
13. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Gastrointestinal Bleed with Gastric Ulcer
Decompensated Pulmonary Hypertension
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 with a bleed from an ulcer and
trouble breathing due to pulmonary hypertension. You were
intubated because you were having troulbe breathing. You were
taken off the ventilator successfully. Your blood thinner was
held briefly and then restarted. Your pulmonary hypertension
medication, remodulin, was causing you pain. It was stopped
successully.
..
The following changes were made to your medications:
You were STARTED on diltiazem, morphine, trazodone, sarna
lotion, potassium, docusate (colace), and pantoprazole.
Your furosemide (lasix) dose and gabapentin dose were INCREASED.
Your triamcinolone cream was STOPPED.
Followup Instructions:
GI [**Hospital **] Clinic 4 weeks post GI Bleed
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2199-9-18**] 2:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2768, 5070, 2851, 2760, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7603
} | Medical Text: Admission Date: [**2153-2-7**] Discharge Date: [**2153-2-12**]
Date of Birth: [**2069-11-11**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 y/o F with history of HTN presents s/p mechanical fall
today. Per EMS patient was at a high school basketball game when
she tripped and fell striking her head. She unconscious for 5
minutes per witnesses. She was taken to OSH where she was a GCS
of 15. CT head revealed a traumatic SAH. Patient had some n/v
and
was intubated for airway protection. She was also given 2 units
of FFP and transferred to [**Hospital1 18**] for further evaluation. On
arrival, patient was sedated and intubated. SBP was elevated to
215.
Past Medical History:
HTN, colon CA s/p chemotherapy and radiation,
cholecystectomy
Social History:
HTN, colon CA s/p chemo/radiation, cholecystecomy
Family History:
non-contributory
Physical Exam:
On admission:
O: BP:138/69 HR: 56 R 17 O2Sats: 100%
Gen:intubated and sedated
HEENT: R eye periorbital ecchymosis and edema
Pupils: 4-3mm L pupil, R ecchymotic and edematous
L eye open to voice
No commands
Localize BUE to nox
BLE w/d to nox
On Discharge:
awake, a+ox3 although she was confused/speaking inappropriately
at times.
PERRL,EOMI
face symmetric, tongue midline
facial ecchymosis
no drift
MAE's [**5-19**]
Pertinent Results:
CT head [**2-7**]
IMPRESSION: Stable appearance of right frontal/supra-orbital
scalp subgaleal hematoma, few right frontal punctate parenchymal
hemorrhages, and subarachnoid hemorrhage in the quadrigeminal
and left perimesencephalic cisterns.
NOTE ADDED IN ATTENDING REVIEW:
1. The focal basal cisternal subarachnoid hemorrhage is in a
non-aneurysmal distribution, and likely represents
coup-contre-coup mechanism.
2. The superficial frontal punctate hemorrhagic foci lie in a
linear array
along the [**Doctor Last Name 352**]-white matter interface, and may represent
underlying diffuse axonal ("shear") injury.
3. There is a minimally-displaced fracture of the right orbital
floor,
associated with a small "trapdoor" fragment (103b:19-22). This
is associated with layering hemorrhagic fluid within the
ipsilateral maxillary sinus (2:5). There is no evidence of
significant herniation of intra-orbital contents or impalement
of extra-ocular muscles; correlate with clinical evidence of
"entrapment." No other facial fracture is seen.
X-Ray left knee [**2-7**]
Two views of the left knee were obtained. There is soft tissue
swelling along the medial border of the distal femur. However,
no fractures or dislocations. Mild medial degenerative changes
are visualized with small osteophytes and probably similar
changes patella (poorly assesss on cross table lateral image).
No radiopaque foreign bodies. Can't assess presence of effusion
X-Ray right shoulder [**2-7**]
Three views right shoulder. There is marked superior and
anterior subluxation of humeral head and related cartilage loss
and subchondral erosions. These appearances are chronic and no
acute fractures suggested. Can't exclude incidental bursal
calcifications (difficult asssessment secondary to sclerosis.
X-ray left hand [**2-7**]
Extensive degenerative changes with joint space narrowing and
osteophytes are visualized at the 3nd MCP joint and at the first
CMC joint. Minor DJD at first IP joint. Equivocal widening of
scapho-lunate joint. No acute
fractures. Normal alignment is maintained. No soft tissue
calcifications or radiopaque foreign bodies.
CT head [**2-7**]
1. Stable subarachnoid hemorrhage involving the
perimesencephalic and
quadrigeminal plate cisterns.
2. Stable small subdural hematoma along the tentorium.
3. Small punctate hemorrhages at the bifrontal [**Doctor Last Name 352**]-white
mattter junction, one of which appears new, likely reflects
diffuse axonal injury.
4. Probable layering hemorrhage in the right maxillary sinus.
5. Right orbital floor fracture.
6. Stable right periorbital subgaleal hematoma.
CTA Head/Neck [**2-7**] IMPRESSION:
1. No evidence of intracranial aneurysm larger than 2 mm in
diameter. The
stable small amount of subarachnoid hemorrhage in the left
posterior fossa is likely post-traumatic.
2. Principal cervical and intracranial vessels are patent, with
only
scattered atherosclerotic disease but no flow-limiting stenosis.
3. Acute right facial traumatic injury, with minimally-displaced
right
orbital floor fracture. better assessed in the prior
non-contrast head CT
studies.
[**2-8**] MRI Brain: IMPRESSION:
1. Blood products in the subarachnoid right frontal region,
quadrigeminal
plate cistern and 4th ventricle. No evidence of intraparenchymal
hemorrhage.
2. Bilateral periventricular and subcortical T2 FLAIR
hyperintensities likely related to microangiophatic chronic
ischemic changes.
[**2-9**] CT max/face: IMPRESSION:
1. Non-displaced subtle right orbital floor fracture. No
evidence of
herniation of orbital fat or extraocular muscles.
2. No other acute facial fractures identified.
Brief Hospital Course:
Patient was admitted to the ICu under the neurosurgery service
after having a mechanical fall with subsequent findings of
traumatic SAH and tentorial SDH. She was intubated prior to
arrival at [**Hospital1 18**] and remained intubated during the day on [**2-7**].
She was following commands off sedation while intubated. She was
extubated the evening of [**2-7**] without incident. Her CT scans
were stable and a CTA of the head and neck was obtained which
showed no signs of vascular abnormality. On AM rounds on [**2-8**]
she was deemed fit for transfer to the Step Down unit. MRI
Brain with and without constrast was performed on [**2-8**] and was
negative for uderlying mass.
Plastic surgery was consulted on [**2-9**] for orbital fracture and
they recommended a dedicated CT facial bones. She was noted to
have a heart rate in the 130-150's. She was asymptomatic and all
other vital signs were stable. An EKG revealed Afib vs Aflutter.
she was given IV lopressor and converted to SR. She was started
on 12.5 of Metoprolol at this time.
On [**2-10**] in the early AM she again was noted to have a heart rate
in the 130-150's. She was asymptomatic and all other vital signs
were stable. An EKG revealed Afib vs Aflutter. she was given IV
lopressor and converted to SR. Her Metoprolol was increased to
25mg at this time. Medicine consultation was requested. CE's
were cycled, a TSH and echo were ordered and metoprolol was
increased to 37.5. She was otherwise neurologically stable.
Plastic surgery final recommendation were no intervention was
needed and she could follow up PRN.
On [**2-11**] she was stable without any further episodes of
tachycardia. TSH was WNL and CE's were negative x3. She was
cleared for transfer to floor status and PT/OT were ordered.
On [**2-12**] she was neurologically stable. She complained of some
right shoulder pain which was noted to be bruised. An xray was
performed on [**2-7**] and was negative for fracture. ROM was
decreased and pain subsided with rest. The echocardiogram was
performed and revealed mild mitral regurgitation, otherwise no
major structural abnormality.
She was seen and evaluated by PT/OT who felt that she could be
discharged home with 24hr supervision. At this time she was
cleared for discharge. This was discussed with the patient's
daughter who was in agreement with this plan.
Medications on Admission:
lisinopril
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO DAILY (Daily).
Disp:*120 Tablet Extended Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 16426**] home health care
Discharge Diagnosis:
Subarachnoid Hemorrhage
Tentorial Subdural Hemantoma
Atrial Fibrillation vs Atrial Flutter
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
?????? You were diagnosed with a heart arrythmia
(afib/aflutter)while you were inhouse. You were started on new
medication to decrease your heart rate. It was determined that
you do not need to start anti-coagulation. You need to follow up
with your PCP [**Name Initial (PRE) 176**] 7-10 days to have your heart rate and blood
pressure checked. You were also noted to have decreased
potassium levels over many days so you were started on a
potassium supplement. You should have your level checked with
your PCP [**Name Initial (PRE) 151**] 7 days.
?????? You were evaluated by the Plastic Surgery service for your
facial fractures. You do not require any surgery and it was
recommended that you follow up with your PCP if any problems
arise.
Completed by:[**2153-2-12**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7604
} | Medical Text: Admission Date: [**2131-6-3**] Discharge Date: [**2131-6-12**]
Date of Birth: [**2073-8-9**] Sex: F
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Hepatitis B, cirrhosis with
hepatocellular carcinoma who presents for a liver transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
female with hepatitis B, cirrhosis, hepatocellular carcinoma
who presents for a liver transplant. Her current MELD score
is 24/26. The patient has undergone previous RFA of hepatoma.
The patient has no history of nausea or vomiting, diarrhea,
fever, chills, no problems eating, no history of hepatic
encephalopathy.
PAST MEDICAL HISTORY: Hepatitis B cirrhosis and
hepatocellular carcinoma, no diabetes mellitus, no
hypertension, no MI.
PAST SURGICAL HISTORY: RFA in [**2130-5-9**], status post
appendectomy.
MEDICATIONS: Lopressor, ranitidine, Aldactone, Interferon.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco, no alcohol and no IV drug abuse.
LABORATORY: On admission, WBC was 3.4, hematocrit 27.4, PT
of 12.2, INR 1.0, PTT 27.6 and platelets 69. Electrolytes -
sodium 140, potassium 4.0, chloride 114, bicarbonate 18, BUN
21 and creatinine 0.7. ALT is 349, AST 263, alkaline
phosphatase 49, total bilirubin 1.3, calcium 7.3, phosphorus
2.7, magnesium 1.9. HBsAb is positive.
The patient was operated on [**2131-6-3**] with a cadaver
liver transplant, piggyback technique, portal vein to portal
vein anastomosis, reconstructed superior mesenteric artery to
common hepatic artery, gastroduodenal artery branch patch,
bile duct to bile duct performed by Drs. [**Last Name (STitle) 816**] and [**Name5 (PTitle) **].
Please see operative note for more details. Postoperatively,
she went to ICU. The patient was on Hep-B immune globulin,
insulin, morphine, propofol and Unasyn. The patient was
intubated and sedated. A duplex of the liver was obtained on
postop day 1 with a patent hepatic vasculature, small fluid
collection in the porta hepatis. Dr. [**Last Name (STitle) 497**] from Hepatology
saw the patient and recommended receiving 10,000 units of Hep
BIG on postop day 1. The patient was making good urine. The
patient had JP drains in place. The patient's platelets
dropped to 50 and the patient received 2 units of platelets
and 2 units of packed red blood cells for a decreased
hematocrit. The patient was extubated on postop day 2.
Another duplex ultrasound was obtained on postop day 2
demonstrating satisfactory Doppler studies of the liver
transplant with fully patent arteries and veins. Resistive
indices ranged from 0.74-0.77. There was a small 2 cm
subhepatic fluid collection, probably representing a hematoma
and a right pleural effusion is also noted. The patient's FK
level on the 28th was 3.4 and since then on [**6-7**] was 18.5.
On [**6-10**], it was 7.5. The patient had a right IJ placed. The
patient continued MMF, Solu-Medrol and continued to be in the
ICU on postop day 4. The patient continued to have Lasix
p.r.n. Physical Therapy was consulted and that was on [**6-8**].
WBC was 2.9, hematocrit 30.8, PT of 12.3, PTT 19.8, platelets
of 80, sodium 139, potassium 3.4, chloride 105, bicarbonate
27, BUN 27 and creatinine 0.7. Glucose is 62. ALT is 172, AST
61, alkaline phosphatase 106, total bilirubin 2.7, albumin
2.7, calcium 6.9, phosphorus 2.7, magnesium 1.6. HBsAb titer
was greater than 450 million per ml. Levels on [**2131-6-8**]
demonstrated an FK of 16.7. On postop day 6, the patient was
transferred to the floor, afebrile and vital signs were
stable. The patient was on immunosuppression per liver
protocol. The patient was on TPN, but that was discontinued.
Nutrition was consulted. Her medial drain was removed on
postop day 7 with no complications. The patient was continued
on Lasix 20 b.i.d., out of bed, improving with her p.o.
intake so the patient continues to do well. She is afebrile
and vital signs are stable. The patient was on tacrolimus,
MMF and prednisone 20 mg daily. I's and O's were excellent.
There were decreased breath sounds on the right. Abdomen -
positive bowel sounds and was nontender. Labs on [**2131-6-12**]
demonstrate a WBC of 5.7, hematocrit of 32.2, platelets 95,
sodium 137, potassium 3.6, chloride 102, bicarbonate 25, BUN
20 and creatinine 0.8 with glucose of 96. ALT is 91, AST 25,
alkaline phosphatase 82, total bilirubin 0.3, albumin 2.5. FK
tacrolimus level on [**2131-6-12**] was 5.0.
The patient will be leaving to go to home on the following
medications - adefovir dipivoxil 10 mg daily, Colace 100 mg
b.i.d., fluconazole 400 mg q.24, Lasix 20 mg p.o. b.i.d.,
Valcyte 900 mg daily, insulin sliding scale, ranitidine 100
mg daily, Lopressor 25 mg b.i.d., MMF 1000 mg b.i.d.,
Protonix 40 mg q.24, prednisone 20 mg daily, Bactrim SS 1
tablet daily and tacrolimus at this point 4 mg and 4 mg. The
patient should call the Transplant Surgery immediately if
any fevers, chills, nausea, vomiting, abdominal pain, any
difficulty with urination, any change in abdominal incision,
the color of the incision or any discharge from the incision.
The patient should call Transplant Surgery immediately if the
patient has sustained decrease in appetite, lethargy, change
in mental status, difficulty walking. The patient needs labs
every Monday and Thursday starting on [**6-15**]. The patient
will need a Chem-7, CBC, calcium, phosphorus, AST, ALT,
alkaline phosphatase, total bilirubin, albumin and Prograf
level. These labs need to be drawn at [**Last Name (NamePattern1) 439**],
located in the LMOB basement on the [**Hospital 18**] Campus. Please fax
results immediately to ([**Telephone/Fax (1) 12146**]. The patient is to have
a CAT scan in the [**Hospital Ward Name 23**] Center Radiology Department on
[**2131-7-11**] at 10:50 a.m. Please call ([**Telephone/Fax (1) 6713**] and
please call Dr. [**Last Name (STitle) **] from the Transplant Surgery office at
([**Telephone/Fax (1) 3618**] for follow-up appointment.
FINAL DIAGNOSIS: Status post piggyback liver transplant for
HBV, cirrhosis and hepatoma on [**2131-6-3**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2131-6-12**] 14:23:40
T: [**2131-6-12**] 15:23:07
Job#: [**Job Number 52606**]
ICD9 Codes: 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7605
} | Medical Text: Admission Date: [**2174-12-16**] Discharge Date: [**2174-12-21**]
Date of Birth: [**2100-3-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3513**]
Chief Complaint:
Change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74F with mixed dementia, ESRD on HD, admitted on [**12-16**] with
change in mental status/seizures at HD on the date of admission.
In the ED, the patient was afebrile, with HR 61 BP 251/82. Given
10mg hydralazine with BP noted to improve to SBPs 170. Patient
was started on nipride gtt and admitted to [**Hospital Unit Name 153**] for hypertensive
urgency.
.
In the [**Name (NI) 153**], Pt. was treated with nipride gtt, then transitioned
to labetalol gtt, then to CCB and [**Last Name (un) **], on which she was
normotensive. AMS thought to be multifactorial, secondary to
worsening dementia, hypertensive encephalopathy, hypercalcemia.
Pt. also noted to have labile blood glucose in ICU. Per renal,
goal SBP 140-150. Upon arrival to floor, Pt. is disoriented and
refuses to answer questions. She reports that she is at a
party, knows it is "[**Holiday 944**] month", does not know first name,
year.
Past Medical History:
1. End-stage renal disease.
2. Diabetic nephropathy.
3. Hemodialysis for years.
4. Right AV fistula.
5. Noninsulin-dependent diabetes mellitus.
6. Hypertension.
7. Encephalopathy.
8. Cholecystectomy.
9. Nephrectomy.
10. Angioplasty of AV fistula in [**2171-12-1**].
11. s/p recent corn removals on L foot
12. mixed vascular and alzheimer's dementia
Social History:
Denies alcohol, drug use, smoking. Lives in the bottom floor of
an apartment - family lives in floors above her. Says she is
independent with her activities of daily living.
Family History:
Unable to obtain.
Physical Exam:
PE: afebrile, 241/88 73 20 99%RA
HEENT: PERRL, EOMI, OP clear, not LAD
CVS: nl s1s2, RRR, no m/r/g
Chest: CTA b/l
Abd: soft, NT/ND, +bs, no organomegaly
ext: no c/c/edema; +OA in knees, AV fistula RUE.
neuro: awake, orientated to person, and month. Speech coherent,
though tangential; mild preservations. 4/5 strength BUE/BLE +2
patella and biceps tendon
Pertinent Results:
[**2174-12-16**] 06:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2174-12-16**] 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-NEG
[**2174-12-16**] 06:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2174-12-16**] 12:24PM LACTATE-1.3
[**2174-12-16**] 12:12PM GLUCOSE-120* UREA N-17 CREAT-5.0*# SODIUM-144
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-34* ANION GAP-19
[**2174-12-16**] 12:12PM WBC-4.7 RBC-4.71 HGB-14.3 HCT-44.6 MCV-95
MCH-30.3 MCHC-32.0 RDW-18.4*
[**2174-12-16**] 12:12PM NEUTS-62.1 LYMPHS-30.1 MONOS-4.8 EOS-1.8
BASOS-1.3
[**2174-12-16**] 12:12PM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-1+
[**2174-12-16**] 12:12PM PLT COUNT-132*
[**2174-12-16**] 12:12PM PT-12.4 PTT-38.7* INR(PT)-1.0
.
ECG: sinus brady with prolonged Qtc, LAD, LVH, with STE in V2/V3
likely representing repolarization abnormalities; no other acute
St/T wave changes
.
CXR: No radiographic evidence of pneumonia.
.
CT head: No evidence of acute intracranial hemorrhage.
Brief Hospital Course:
74F with mixed dementia, presenting with a one week history of
mental status changes / increased confusion, also with
hypertensive urgency.
.
On the floor, the Pt. was treated with hydralazine PRN for
elevated systolic pressure, and was transitioned back to
amlodipine and losartan, with goal SBP 140-150. Metoprolol was
discontinued. Pt. was normotensive at the time of discharge.
.
Pt's change in mental status thought to be multifactorial: ddx
included worsening dementia with possible contribution of
hypertensive encephalopathy and hypercalcemia. With continued
orientation and support from family members and nursing staff,
Pt.'s mentation improved. Her donepezil was continued.
.
Per records, Pt. has chronic hypercalcemia thought to be related
to her chronic renal insufficiency/failure and secondary
hyperparathyroidism. Tums and Vit. D were held. Sevelamer was
continued for hyperphosphatemia at an increased dose (2400mg
TID), and the Pt. was started on sensipar 30mg QD.
.
The Pt. was seen and evaluated by social work. It is probable
that Pt. will require increased amounts of support at home over
the coming months/years in performing her ADLs.
.
The Pt. will continue hemodialysis on M,W,F.
.
An SPEP was checked just before discharge, at the request of the
renal team. The result can be followed up at the Pt's next
appointment.
Medications on Admission:
Norvasc 10
renal caps
Zantac 150 [**Hospital1 **]
Glucotrol xl 10
Tums tid
aricept
asa
Cozaar
metoprolol 100
Renagel 800 tiw
calcijex
Epo
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day): please take with food/drink.
7. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day.
9. humalog insulin sliding scale
10. Glucotrol 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Sensipar 30 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. End-stage renal disease, on hemodialysis
2. NIDDM
3. dementia/encephalopathy
Discharge Condition:
Fair, stable.
Discharge Instructions:
Please continue to take all your medications exactly as
prescribed. If you experience chest pain, shortness of breath,
fevers, or abdominal pain, plesae call your PCP or return to the
hospital.
Followup Instructions:
Please continue to follow up with your PCP as you have been
doing.
.
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] [**Name Initial (NameIs) **]., [**Street Address(1) **]Date/Time:[**2175-2-2**]
8:00
Completed by:[**2174-12-22**]
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7606
} | Medical Text: Admission Date: [**2176-9-2**] Discharge Date: [**2176-9-7**]
Date of Birth: [**2141-9-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**2176-9-2**] AVR (On-X Conform-X Mechanical Valve)
History of Present Illness:
34 yo M with known murmur and echo with moderate AI since [**2169**].
Past Medical History:
AI-bicuspid AV, ^chol
Social History:
works as software engineer
no smoker
rare etoh
lives with wife and children
Family History:
NC
Physical Exam:
Gen: WDWNM in NAD
AVSS
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat with rad. murmurs
Lungs: Clear to A+P
CV: RRR without R/G +SEM
Abd: +BS, soft, nontender without masses or hepatosplenomegaly
Ext: without C/C/E, pulses 2+=bilat. throughout
Neuro: nonfocal
Pertinent Results:
[**2176-9-7**] 09:51AM BLOOD WBC-7.0 RBC-3.96* Hgb-11.6* Hct-33.1*
MCV-84 MCH-29.3 MCHC-35.0 RDW-14.1 Plt Ct-340
[**2176-9-7**] 09:51AM BLOOD Glucose-114* UreaN-13 Creat-1.1 Na-140
K-4.3 Cl-101 HCO3-30 AnGap-13
[**2176-9-7**] 08:00AM BLOOD PT-19.7* PTT-55.1* INR(PT)-1.9*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2176-9-7**] 8:26 AM
CHEST (PA & LAT)
Reason: Check L ptx
[**Hospital 93**] MEDICAL CONDITION:
34 year old man s/p AVR now s/p L chest tube removal
REASON FOR THIS EXAMINATION:
Check L ptx
EXAMINATION: PA lateral chest.
INDICATION: Left-sided pneumothorax.
PA and lateral views of the chest are obtained on [**2176-9-7**] and
compared with the prior afternoon's radiographs.
Cardiomediastinal silhouette is unremarkable. There has been
further decrease in the retrosternal air present. The vertical
lucency seen on the prior radiograph is not apparent on the
current study. The small left-sided apical pneumothorax has
significantly decreased with a tiny residual amount remaining.
There is no evidence of acute infiltrate. There is evidence of
prior cardiothoracic surgery.
IMPRESSION:
Further improvement in the small left pneumothorax. Reduction in
retrosternal air.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: SAT [**2176-9-7**] 12:19 PM
Cardiology Report ECHO Study Date of [**2176-9-2**]
PATIENT/TEST INFORMATION:
Indication: Aortic valve disease. Shortness of breath.
Status: Inpatient
Date/Time: [**2176-9-2**] at 12:44
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW3-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aorta - Arch: *3.2 cm (nl <= 3.0 cm)
Aortic Valve - Pressure Half Time: 106 ms
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast is
seen in the LAA.
Good (>20 cm/s) LAA ejection velocity. All four pulmonary veins
identified and
enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thickness. Moderately dilated LV cavity.
Mild regional
LV systolic dysfunction. Mildly depressed LVEF. Transmitral
Doppler and TVI
c/w Grade I (mild) LV diastolic dysfunction.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal
anteroseptal - hypo; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Sinus of Valsalva
aneurysm. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta
diameter.
AORTIC VALVE: Bicuspid aortic valve. Mildly thickened aortic
valve leaflets.
No masses or vegetations on aortic valve. No AS. Moderate to
severe (3+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was under
general anesthesia throughout the procedure. The patient
received antibiotic
prophylaxis. The TEE probe was passed with assistance from the
anesthesioology
staff using a laryngoscope. No TEE related complications.
Conclusions:
PRE-CPB:1. The left atrium is normal in size. No spontaneous
echo contrast is
seen in the left atrial appendage. No atrial septal defect is
seen by 2D or
color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
is moderately dilated. There is mild regional left ventricular
systolic
dysfunction with basal antroseptal hypokinesis.. Transmitral
Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic
dysfunction.
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic root is moderately dilated at the sinus level.
There is a sinus
of Valsalva aneurysm. The aortic valve is bicuspid. The aortic
valve leaflets
are mildly thickened. No masses or vegetations are seen on the
aortic valve.
There is no aortic valve stenosis. Moderate to severe (3+)
aortic
regurgitation is seen.
5. The mitral valve appears structurally normal with trivial
mitral
regurgitation.
6. There is no pericardial effusion.
POST-CPB: On infusion of phenylephrine. Well-seated mechanical
valve in the
aortic position. Trace AI, washing jets. Mild aortic gradient.
Aortic contour
normal post-decannulation. Trace MR. Preserved LV systolic
function.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2176-9-2**] 14:02.
Brief Hospital Course:
He was taken to the operating room on 09.10 where he underwent
an AVR with a #27/29 On-X Conform-X Mechanical Valve. He was
extubated later that same day. He was found to have a left
pneumothorax postop and a left chest tube was placed on POD #1.
He was started on coumadin for his mechanical valve. He was
transferred to the floor on POD 1 and had his mediastinal chest
tubes d/c'd on POD#2. He had his L chest tube d/c'd on POD#4
and his epicardial wires d/c'd on POD#3. He was anticoagulated
with heparin and coumadin and was discharged in stable condition
on POD#5.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-29**]
hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily) for 7 days.
Disp:*7 Capsule, Sustained Release(s)* Refills:*0*
9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 2
days: Take as directed by Dr. [**Last Name (STitle) 8049**] for an INR goal of [**1-26**].5.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
AI
Hyperlipidemia
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.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**Last Name (STitle) 8049**] 2 weeks
Dr. [**Last Name (STitle) 5874**] 2 weeks
Completed by:[**2176-9-7**]
ICD9 Codes: 4241, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7607
} | Medical Text: Admission Date: [**2181-4-19**] Discharge Date: [**2181-4-25**]
Service: MED
CHIEF COMPLAINT: Hypotension.
86-year-old woman with history of atrial fibrillation,
hypertension and chronic painful sense of weakness and
temperature of 101. Reports six days prior to admission had
diarrhea for two days, this resolved and reoccurred three
days later with greater than 10 bowel movements a day for one
day. One day prior to admission had weakness when standing,
also had temperature of 101, decreased p.o.'s. After arrival
in the emergency department urinalysis was positive. The
patient was started on Levofloxacin, Gentamicin. Her
systolic blood pressure fell to 70's, given intravenous fluid
replacement. Dopamine drip was started. The patient was
admitted directly to the Care Unit.
PAST MEDICAL HISTORY: Pertinent for hypertension, status
post pacer, macular degeneration, chronic lower back pain,
atrial fibrillation.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Lidoderm patch.
2. Nitroglycerin paste.
3. Oxycodone 5 mg p.o. q 4 hours p.r.n.
4. Ultram 25 mg to 50 mg four times a day.
5. Tylenol.
6. Senna.
7. Multivitamin.
8. Oscal.
9. Colace.
10. Coumadin 2 mg and 3 mg on alternating days.
11. Cozaar 50 mg a day.
12. Sotalol 160 mg in the morning, 250 mg in the PM.
13. Norvasc 7.5 mg daily.
14. Lasix 60 mg and 40 mg on alternating days.
15. Pravachol 20 mg
16. Potassium chloride three times a day, 20 mg three
times a day.
SOCIAL HISTORY: The patient lives with her husband.
UNIT COURSE: The patient was started on vasopressin. The
patient's son said that his mothers code was DNR/DNI.
Levofloxacin was stopped because of continue reversible
Rituxan. Felt that with the Lithium she more likely have
Levo sensitive bacterial Levophed was also changed.
Vasopressor was discontinued due to suspicion of urosepsis.
Cultures were grown pan sensitive Escherichia coli. She was
off pressors for 24 hours on [**2181-4-20**]. Examination at the
time was unremarkable with white blood cell counts within
normal limits 8.6, hematocrit 30.9, BUN and creatine 24 and
0.8 respectively. Folate 15.7, B12 41, TIBC is 325. INR
1.9.
PA and lateral chest views showed atelectasis in the left
lower lobe and large hiatal hernia. Cultures from [**2181-4-19**],
blood cultures on that day grew out E. Coli that are pan
sensitive. Urine culture on [**4-19**] showed E. Coli greater than
100,000 pan sensitive as well as a second blood culture from
[**2181-4-19**] positive for E. Coli.
HOSPITAL COURSE: On the floor the patient was continued on
Levofloxacin 500 mg q day for a total of seven days. She
should be started 1 mg a day, then 2 mg a day to achieve an
INR goal of 2.3 for atrial fibrillation. The patient did
well, blood pressure stable. Her blood pressure medications
gradually added on. The patient will be discharged in stable
condition on:
1. Levofloxacin 500 mg p.o. q day for three more days, total
of seven days.
2. Protonix 40 mg.
3. Tylenol
4. Oxycodone 5 mg q 4 to 6 hours p.r.n.
5. Sotalol 160 mg in the morning 240 mg in the evening.
6. Trazodone 165 mg once daily.
7. Losartan 50 mg a day.
The patient is doing well and will be discharged in stable
condition with those medications indicated above with INR
checks, to achieve INR of 2 to 3. Warfarin will be dosed at 2
and 3 mg respectively on alternating days. INR checks until
therapeutic. Follow-up with primary care physician.
[**First Name5 (NamePattern1) 4036**] [**First Name9 (NamePattern2) **] [**Doctor Last Name **], INT [**Numeric Identifier 96942**]
Dictated By:[**Doctor Last Name 12733**]
MEDQUIST36
D: [**2181-4-24**] 16:02:04
T: [**2181-4-24**] 16:30:56
Job#: [**Job Number 96943**]
ICD9 Codes: 5990, 5849, 2765, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7608
} | Medical Text: Admission Date: [**2197-3-13**] Discharge Date: [**2197-3-19**]
Service:
NOTE: This Discharge Summary will cover the period of [**2197-3-13**] until [**2197-3-19**].
HISTORY OF PRESENT ILLNESS: The patient is an 87-year-old
male with multiple medical problems which include a 3-vessel
coronary artery bypass graft in [**2189**], type 2 diabetes
mellitus, peripheral vascular disease, and a recent transient
ischemic attack.
Over the past two days, the patient reported shortness of
breath. Last night he experienced 8/10 chest pain and
diaphoresis. He went to [**Hospital 26200**] Hospital this
morning and was found to have an anterior ST-elevation
myocardial infarction. He was transferred to [**Hospital1 346**] for cardiac catheterization.
In the Catheterization Laboratory the patient was found to
have a total occlusion of the mid left anterior descending
artery, a total occlusion of first obtuse marginal and second
obtuse marginal, total occlusion of posterolateral right
coronary artery, and saphenous vein graft to left anterior
descending artery graft was totally occluded as well. The
saphenous vein graft to left anterior descending artery graft
was noted to have large thrombus burden. There were
thromboses aspirated with an Angio-Jet device, yet the
saphenous vein graft remained occluded.
The patient was transferred to the Coronary Care Unit on an
intra-aortic balloon pump and dobutamine. His
electrocardiogram disclosed evidence of an intraventricular
conduction delay, a new right bundle-branch block, and ST
segment elevations across the precordium.
PAST MEDICAL HISTORY:
1. Myocardial infarction in [**2189**].
2. A 3-vessel coronary artery bypass graft in [**2189**].
3. Left endarterectomy.
4. Status post right and left total hip replacements.
5. Spinal stenosis.
6. Colon cancer.
7. Emphysema.
8. Type 2 diabetes.
9. Cerebrovascular accident in [**2187**].
10. Peripheral vascular disease.
11. Basal cell carcinoma.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Zestril 20 mg p.o. twice per day.
2. Atenolol 25 mg p.o. once per day.
3. Norvasc 7.5 mg p.o. once per day.
4. Allopurinol 300 mg p.o. once per day.
5. Enteric-coated aspirin 325 mg p.o. once per day.
6. Lasix 40 mg p.o. once per day.
7. Zocor 40 mg p.o. once per day.
8. Glucotrol 5 mg p.o. three times per day.
9. Multivitamin one tablet p.o. every day.
SOCIAL HISTORY: The patient was employed as a salesman. He
is now retired. He is a former smoker. He quit 12 years
ago.
PHYSICAL EXAMINATION ON PRESENTATION: General physical
examination revealed alert and awake. In no apparent
distress. Vital signs revealed temperature was 97.6, blood
pressure was 116/74, heart rate was 77, respiratory rate was
17, and oxygen saturation was 97% on 5 liters. Head, eyes,
ears, nose, and throat examination revealed normocephalic and
atraumatic. Pupils were equal, round, and reactive to light.
The mucous membranes were moist. The oropharynx was clear.
Neck examination revealed jugular venous pulsation at
mandible. Heart examination revealed a 2/6 systolic murmur.
A positive third heart sound. A regular rate and rhythm.
The lungs were clear to auscultation anteriorly. The abdomen
was soft, nontender, and nondistended. Positive bowel
sounds. Extremity examination revealed no cyanosis,
clubbing, or edema. Good distal pulses. Swan-Ganz catheter
in right groin. Intra-aortic balloon pump in the left groin.
Neurologic examination revealed alert and oriented times
three. Cranial nerves II through XII were grossly intact.
Otherwise a nonfocal examination.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram status post
catheterization revealed a normal sinus rhythm at 78 beats
per minute, a prolonged P-R interval, axis was indeterminate,
a new right bundle-branch block, ST segment elevations in
leads V2 through V5.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data
revealed white blood cell count was 13.8, hematocrit was
41.4, and platelets were 174. Blood urea nitrogen was 48 and
creatinine was 1.7. Creatine kinase was 4337, MB was 331,
index was 7.6, and troponin was greater than 50.
IMPRESSION: This is an 87-year-old male with diabetes,
coronary artery disease (status post coronary artery bypass
graft), and chronic obstructive pulmonary disease who was
transferred to the Coronary Care Unit status post
catheterization with disclosed 2-vessel coronary artery
disease. The patient was noted to have a totally occluded
saphenous vein graft to left anterior descending artery with
large thrombus burden. An unsuccessful percutaneous
transluminal coronary angioplasty of occluded saphenous vein
graft to left anterior descending artery. The patient now on
an intra-aortic balloon pump and on a dobutamine drip.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR SYSTEM: (a) Ischemia: Catheterization
as noted above. The patient with a large anterior wall
myocardial infarction with unsuccessful percutaneous
transluminal coronary angioplasty of saphenous vein graft to
left anterior descending artery. The patient with elevated
creatine kinases and ST segment elevations anteriorly. The
patient was maintained on aspirin, intra-aortic balloon pump,
and a statin.
(b) Pump: The patient was maintained on dobutamine and
intra-aortic balloon pump. The patient's hemodynamics were
followed q.4h. Multiple unsuccessful attempts were made to
wean the intra-aortic balloon pump, but on [**2197-3-18**] the
balloon pump was discontinued. Pressors were discontinued on
[**3-18**] as well.
The patient maintained his blood pressure with systolic blood
pressures from 80 to 100 following discontinuation of the
balloon pump.
An echocardiogram revealed an ejection fraction of 20%. The
apex was heavily trabeculated, but there was no thrombus. No
ventricular septal defect, 1+ mitral regurgitation, 1 to the
patient tricuspid regurgitation, left ventricular hypertrophy
was present.
(c) Rhythm: Upon admission, there was concern for complete
heart block given prolonged P-R interval and new right
bundle-branch block. A temporary pacing wire was placed.
The patient did not require pacing [**Last Name (LF) **], [**First Name3 (LF) **] this was
ultimately discontinued. The patient was monitored on
telemetry during his hospital stay.
(d) Anticoagulation: The patient was continued on heparin
while intra-aortic balloon pump was in place.
2. NEUROLOGIC ISSUES: The patient was noted to have waxing
and [**Doctor Last Name 688**] mental status during his hospital stay. A
Neurology consultation was placed for evaluation of his
neurologic symptoms.
The impression by the Neurology Service was that the
patient's waxing and [**Doctor Last Name 688**] mental status was due to cerebral
hypoperfusion from his poor ejection fraction. The Neurology
Service recommended keeping his blood pressure as high as
possible.
3. RENAL ISSUES: The patient's renal function remained
stable from admission until [**3-19**].
4. ENDOCRINE ISSUES: The patient was initially maintained
on an insulin drip. On [**3-18**], the insulin drip was
discontinued. On [**3-19**], he was put back on his outpatient
diabetes medication.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) 5092**]
MEDQUIST36
D: [**2197-3-19**] 23:37
T: [**2197-3-19**] 23:40
JOB#: [**Job Number 49382**]
ICD9 Codes: 5849, 2875, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7609
} | Medical Text: Admission Date: [**2111-5-19**] Discharge Date: [**2111-5-23**]
Date of Birth: [**2033-12-17**] Sex: F
Service: ICU
HISTORY OF PRESENT ILLNESS: The patient is a 77 year-old
woman with a history of hypertension, peripheral vascular
disease, former smoker who had presented to [**Hospital6 42638**] on [**2111-5-8**] with four to six weeks of a hoarse voice
and a few days of cough and shortness of breath. Initially
the patient was thought to be in congestive heart failure and
was treated as an outpatient, but represented on [**5-10**] to the
outside hospital for worsening shortness of breath. She was
admitted with presumptive diagnosis of chronic obstructive
pulmonary disease flare. She had been evaluated by ENT and
was found to have right cord paralysis. She had a chest CT,
which showed a mediastinal mass compressing her trachea and
she was transferred to the [**Hospital1 188**] on [**2111-5-19**] for evaluation for possible causes of
airway mass. She was sent over for evaluation and for
treatment.
PAST MEDICAL HISTORY: 1. Peripheral vascular disease. 2.
Hypertension. 3. Chronic renal insufficiency. 4.
Osteoporosis. 5. Abdominal tumor status post resection in
[**2103**].
ALLERGIES: Aspirin question response.
MEDICATIONS: Zestril, Albuterol, Atrovent, Plavix, Celebrex,
Fosamax, Xanax, Humibid, Prednisone.
SOCIAL HISTORY: Widowed, former smoker.
FAMILY HISTORY: Positive lung cancer.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.4. Blood
pressure systolic equals 100. Heart rate 78. Intubated on
SIMV mode, FIO2 0.3. In general, the patient is intubated.
Neck edematous, erythematous. Lungs coarse breath sounds
bilaterally. Neurologically sedated.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit and was evaluated for the possibility of PE and SVC
thrombus. The patient's clinical condition continued to
deteriorate despite the involvement of interventional
pulmonology and the hematology/oncology service and on
hospital day five the patient was made CMO by her health care
proxy. She had been on blood pressure support and
medications, which were discontinued. The patient expired
later that day hospital day five.
FINAL DIAGNOSIS:
Airway obstruction from tumor.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 1897**]
MEDQUIST36
D: [**2111-6-22**] 16:56
T: [**2111-6-30**] 06:48
JOB#: [**Job Number **]
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7610
} | Medical Text: Admission Date: [**2117-7-4**] Discharge Date: [**2117-8-5**]
Date of Birth: [**2065-6-17**] Sex: F
Service: MEDICINE
Allergies:
All drug allergies previously recorded have been deleted
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Altered mental status, septic shock
Major Surgical or Invasive Procedure:
Intubation, central line placement, tunnelled line placement,
deep tissue biopsy of thigh, CVVH, hemodialysis. tracheostomy
History of Present Illness:
52 year old woman with hx of lupus nephritis, multiple
sclerosis, hypertension who is presenting with altered mental
status, fever, and shock. The patient was in her usual state of
health until yesterday when she noticed a rash late in the
evening which she mentioned to her family. Per family, at that
time she had no other symptom that she mentioned including
headache or vomiting. Early on the day of admission, the
patient was found minimally responsive and moaning on her bed.
EMS was called.
.
Of note she was recently seen in her nephrology clinic on [**2117-6-30**]
at which time her blood pressure was 150/90 with HR 68. At the
time she had 3+ bilateral lower extremity edema. Her lisinopril
was increased from 5mg to 10 mg daily and her lasix was
increased from 20 mg to 40 mg daily.
.
In the ED, her initial vital signs were 104 140 60/palp 16
86% on 100%. She received 6L of NS. She was intubated for
airway protection. A RIJ central line was placed after a failed
attempt at the left IJ. A CXR, CT head/torso were done. She
received vancomycin and ceftriaxone at meningitic dosing. She
received decadon 10mg x1. A FAST u/s showed free fluid in the
abdomen.
Past Medical History:
SLE
Lupus nephritis (baseline Cr 0.9->1.2 on [**2117-5-29**])
Multiple sclerosis
Depression
Panic disorder
Social History:
Stopped smoking [**2109**]. Degree in computer programming. Immigrated
from [**Location (un) 104733**] at 10 years of age. Lives with son.
Family History:
Unremarkable
Physical Exam:
T 99.9 HR 133 BP 74/37 RR 30 O2sat 100%
vent: AC 450x20 PEEP 5 FIO2 0.7 PIP 16
GEN: intubated
HEENT: AT, NC, PERRLA (4->2mm bilat), no conjuctival injection,
anicteric, OP clear, MMM, Neck supple, no LAD, no carotid
bruits. trachea midline. RIJ in place. small evidence of LIJ
attempt. no subcutaneous crepitus. mild neck stiffness
CV: regular tachy, nl s1, s2, no m/r/g
PULM: coarse crackles bilaterally
ABD: soft, ND, + BS, no HSM
EXT: cool, dry, +2 distal pulses BL, no femoral bruits. 3+ pedal
edema
NEURO: intubated/sedated. opens eyes to command. pupils round
and reactive. oculocephalics intact. withdrawals to noxious
stimuli. unable to do strength or sensory testing.
SKIN: multiple erythematous lesions on right thigh. petechial
rash to lower back.
PSYCH: unable to assess
Pertinent Results:
[**2117-7-4**] CXR -
1. ET tube approximately 1 cm above the carina. NG tube in
appropriate position and IJ catheter within the cavoatrial
junction.
2. Left suprahilar increased rounded density and left mid lung
zone 1.7 cm nodule. Dedicated lateral view may be of use in
determining what these structures are.
.
[**2117-7-4**] CT torso -
1. Moderate pleural effusions, pericardial effusion, ascites,
subcutaneous edema, and mild interstitial pulmonary edema are
all consistent with volume overload.
2. Small anterior left pneumothorax.
3. Consolidation in the lower lobes of the lungs bilaterally,
most suggestive of aspiration, probably with a component of
atelectasis as well. Infection cannot be excluded.
4. Fibroid uterus.
.
[**2117-7-4**] CT head - Limited study without evidence of hemorrhage or
mass effect.
.
[**2117-7-6**] CT abdomen/pelvis:
1. Worsening of bibasilar effusions and associated airspace
disease, most
likely atelectasis, underlying infection cannot be excluded.
Slight decrease in pericardial effusion.
2. Persistent, diffuse simple ascites, with new
ascending/transverse colitis without dilatation or perforation.
No definable abscess or focal collection, as clinically
questioned. Findings are suspicious for infectious colitis;
however, this could also be seen with ischemic bowel as a result
of prior hypoperfusion episode and/or ongoing vasculitis, given
the history of SLE. Diffuse mild small bowel thickening is felt
to be due to third spacing.
3. Delayed enhancement and no evident excretion of contrast
through the
kidneys at this time, compatible with ATN.
4. Fibroid uterus.
.
[**2117-7-6**] CT Right lower extremity:
1. Surgical wound as described above in the mid thigh anteriorly
with packing material. No soft tissue or muscle fluid collection
or abscess.
2. Diffuse low-attenuation throughout the muscles of the thigh,
which may represent muscle edema. Muscle infarct is not entirely
excluded.
3. Fluid tracking in both the deep and superficial fascial
compartments of the anterior and posterior thigh. No soft tissue
gas is present.
4. Probable bone infarct of the proximal tibia.
.
[**2117-7-4**] echo: The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. Overall left
ventricular systolic function is severely depressed (LVEF= 20
%). Right ventricular chamber size is normal. with mild global
free wall hypokinesis. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate to severe(3+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is a
moderate sized pericardial effusion, mostly posterior (minimal
anterior fluid seen). There are no echocardiographic signs of
tamponade.
IMPRESSION: Cardiomyopathy. Moderate pericardial effusion
without overt tamponade.
.
[**2117-7-14**] echo: The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is unusually small. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). 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
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is a small to moderate sized pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
Brief Hospital Course:
52 year old woman with history of multiple sclerosis, SLE c/b
nephritis presenting with altered mental status found to be in
shock complicated by multi-organ failure.
.
# Septic shock: [**2-27**] serratia bacteremia presumably from GI
source given pancolitis on CT abdomen/pelvis. Shock requiring
max dose 4 pressors on presentation and she was initially
started on broad spectrum antibiotics and stress dose steroids
until blood cultures grew serratia bacteremia. Also cardiogenic
in setting of sepsis as EF was severely depressed on initial
echo obtained upon presentation to the ED (since normalized s/p
treatment of sepsis). Serratia was initially covered with
cefepime which was then changed to ciprofloxacin given
sensitivities as per ID recs. She completed a full 2 week
course of the above antibiotics with resolution of her shock and
discontinuation of pressor support. Of note, she also grew
serratia from right leg deep tissue biopsy (performed by surgery
on presentation), but suspect leg was seeded from blood as
opposed to leg as source of bacteremia. CT right LE was
negative for fluid collection/abscess/air. At the time of
discharge, her BP was stable, she was afebrile, and there was no
leukocytosis.
.
# Livedo necrosis: Right lower extremity biopsied on initial
presentation out of concern for necrotizing fasciitis and source
of sepsis. General surgery and dermatology were consulted and
deep tissue biopsy did not show e/o nec fasciitis however did
also grow serratia to lesser degree than in blood. CT right
lower extremity was unrevealing for abscess and air was leg was
presumably seeded from bacteremia as opposed to leg as source.
Aggressive wound care was performed daily. She will need follow
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (surgery) as outpt. for wounds (ph#
[**Telephone/Fax (1) 2723**]). Will need wound care per wound care
recommendations.
.
# Fungemia: [**Female First Name (un) 564**] albicans grew from [**7-19**] blood cultures
presumably from line source as initial cultures were drawn from
tunnelled line. She was started on caspofungin pending [**Female First Name (un) **]
sensitivities and tunnelled, PICC and A-line were all
discontinued. Surveillance cultures were monitored without
subsequent growth after initial positive. Caspofungin was then
changed to fluconazole as it was sensitive and she completed a 2
week course from date of first negative blood culture.
.
# RIJ/Rt brachial DVT: Developed in the setting of right sided
tunnelled line. She was started on heparin gtt and tunnelled
line was discontinued. She was started on coumadin, and the
heparin gtt until INR [**2-28**]. goal PTT should be between 50-70.
.
# Anemia/hct drop: Has baseline anemia from underlying renal dz
and renal failure however now with acute drop while on heparin
gtt. She did have bloody oral secretions but not enough to lose
that amount of blood (23.5-->19). She has had no gross blood
per GI tract however concerning is the increase in her BUN. No
other clear source of blood loss. Prior to discharge, she had
some frank blood from her tracheostomy, and heparin gtt was
stopped. Her HCT remained stable. Repeat bronchoscopy did not
show any areas of frank bleeding, and it was thought to be
secondary to trauma from the tube. Heparin was stopped for 2
days, and then restarted without incident. Her HCT remained
stable.
.
# Respiratory failure: Initially intubated on presentation in
the setting of altered mental status. She was extubated,
however failed x1 and was reintubated due to profound
respiratory muscle weakness, copious oral secretions and
inability to clear them. She was again extubated however had
probable aspiration event with acute hypoxia and brdaycardia
again requiring reintubation. given her prolonged intubation,
she was trached and a PEG was placed by interventional
pulmonology. She tolerated this well, and at the time of
discharge, she was on a tracheosty mask at 35% FiO2. The
tracheostomy tube was replaced with a shorter tube on the day of
discharge.
.
# Acute renal failure/Lupus nephritis: patient had rising Cr
thought to be lupus nephritis prior to this admission. She
became oliguric on admisison requiring initiation of CVVH which
she tolerated well and was transitioned to HD. In the setting
of fungemia, however, her tunnelled line was discontinued and
her UOP continued to improve. Her cellcept was held on
presentation and briefly restarted before again being held in
the setting of fungemia. Stress dose steroids were initiated on
presentation and hydrocortisone was subsequently titrated down
to prednisone 10mg daily and she was discharged on cellcept
500mg qid. She should also receive epogen per her regular
schedule and follow up with her nephrologist.
.
# Oral ulcers: During her course, she developed severe oral
ulcers involving her lips and within the oropharynx. HSV1 was
cultured from lip ulcers and she was started on valtrex for a
14-21 day course. Topical viscous lidocaine was used for pain
control. She is currently on a prophylactic dose of valtrex.
.
# Pancytopenia: Leukopenia on presentation secondary to
sepsis/DIC vs. due to lupus vs. in setting of cellcept. Her
cellcept was held and her sepsis was treated and her WBC count
and hct improved. Platelet recovery lagged however improved to
the 100K range where they remained stable.
.
# SLE: With lupus nephritis as above. Off cellcept temporarily
given fungemia and on hydrocortisone. She was discharged on
prednisone 10mg qdaily and cellcept [**Pager number **] qid.
.
# MS: Stable without active issues.
.
# nutrition: A PEG tube was placed and she tolerated tube feeds.
She was started on an oral diet after a speech and swallow
evaluation. When she has adequate nutritional intake by mouth
her tubefeeds can be weaned. She had some discomfort surrounding
her PEG tube and was evaluated several times by interventional
pulmonology and no problems were found. This is likely due to
pain at the surgical site.
.
# hypertension: maintained with good blood pressure control on
his current medications.
Medications on Admission:
celexa 10 mg daily
lasix 40 mg daily
prednisone 20 mg TID
Cellcept [**Pager number **] mg [**Hospital1 **]
omeprazole 20 mg daily
aspirin 81 mg daily
multivitamin daily
lisinopril 10 mg daily (increased from 5 daily on [**2117-6-30**])
Discharge Medications:
1. Mupirocin Calcium 2 % Cream [**Date Range **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
2. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Hospital1 **]: One (1)
Appl Ophthalmic PRN (as needed).
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: [**1-27**] PO BID (2 times a
day).
4. Simvastatin 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
5. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Day (2) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
6. Lidocaine HCl 2 % Solution [**Month/Day (2) **]: One (1) ML Mucous membrane
TID (3 times a day) as needed.
7. Atovaquone 750 mg/5 mL Suspension [**Month/Day (2) **]: Ten (10) ml PO DAILY
(Daily).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
9. Valacyclovir 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily ().
10. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO
TID (3 times a day).
11. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
14. Prochlorperazine 10 mg IV Q6H:PRN
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
16. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution [**Last Name (STitle) **]: Five Hundred (500) units/hour Intravenous
continuous infusion.
17. Morphine Sulfate 1 mg IV Q4H:PRN
18. Chlorhexidine Gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
19. Warfarin 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at
4 PM.
20. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
21. Mycophenolate Mofetil 200 mg/mL Suspension for
Reconstitution [**Hospital1 **]: One (1) PO QID (4 times a day).
22. Sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times
a day).
23. Papain-Urea 830,000-10 unit/g-% Ointment [**Hospital1 **]: One (1) Appl
Topical DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **], [**Location (un) 701**]
Discharge Diagnosis:
Primary
Deep venous thrombosis
Acute renal failure
Respiratory failure
Oral ulcers
Septic shock
Secondary
Discharge Condition:
stable
Discharge Instructions:
You were admitted with altered mental status and low blood
pressures. You were treated with medications to bring up your
blood pressure. You were treated for a severe cellulitis of your
leg and a fungal infection of your blood. Additionally, your
respiratory status required that you receive ventilatory
support. A tracheostomy and percutaneous endoscopic gastrostomy
tube were placed during your stay to support your respiration
and nutrition. Plastic surgery and wound care were consulted to
help take care of your wounds. There wound care recommendation
will be followed at the rehabilitation facility.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 610**] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 1047**]
Date/Time:[**2117-8-16**] 12:00
Provider: [**Name10 (NameIs) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6929**], MD Phone:[**Telephone/Fax (1) 1682**] Date/Time:[**2117-8-17**]
2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2117-9-14**] 11:30
Please follow up with [**Last Name (LF) 5059**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the next 2-4 weeks.
His office can be reached at ([**Telephone/Fax (1) 9000**].
Completed by:[**2118-6-23**]
ICD9 Codes: 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7611
} | Medical Text: Admission Date: [**2185-1-4**] Discharge Date: [**2185-1-24**]
Date of Birth: [**2116-8-2**] Sex: F
Service: SURGERY
Allergies:
Dilaudid / Morphine
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Bright red blood per rectum.
Major Surgical or Invasive Procedure:
1) [**2185-1-5**] Proctosigmoidoscopy, fulguration of rectal bleeding
point at 13 cm, injection of epinephrine and irrigation with
epinephrine.
2) [**2185-1-5**]: Right IJ central venous line placement
3) [**2185-1-12**] Flexible sigmoidoscopy to 50 cm (no bleeding seen)
4) [**2185-1-15**] Flexible sigmoidoscopy with [**Hospital1 **]-CAP Electrocautery
applied for hemostasis successfully at 10cm
History of Present Illness:
68 year-old female known to Dr. [**Last Name (STitle) 957**] presented to [**Hospital1 5109**] today with bright red blood per rectum. This morning
she experienced lower abdominal pain and had copious blood per
rectum in the toilet. She no longer has pain. She has had two
subsequent bloody bowel movements today. She was well until
this morning. She denies nausea and/or vomiting. She has no
fever, chills, no weight loss or change in appetite.
Past Medical History:
CHF (ECHO [**9-3**]: EF 55%)
Hypertension
Mild carotid stenosis
Hyperlipidemia
Sigmoid diverticulitis
Enterocutaneous fistula
Thyroid nodules
Peripheral vascular disease (lower extremities) followed by Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
.
PSH:
[**9-4**] s/p Left renal stent
[**7-4**] s/p L fem-AK [**Doctor Last Name **], left profunda- patch angioplasty
[**9-2**] s/p cholecycectomy
[**5-1**] incisional hernia repair, s/p Chole, s/p appendectomy, s/p
sigmoid colectomy, Resection of a pilonidal cyst, T&A
[**4-29**] Aortobifemoral bypass graft c/b a splenic laceration
requiring splenectomy, ischemic proctitis, an infarcted left
colon, s/p left colectomy and transverse colostomy (since
reversed), Enterocutaneous fistula, subphrenic abscess
Social History:
She is a widow and lives alone. She admits to occasional ETOH
and tobacco use.
Family History:
Non-contributory
Physical Exam:
PE: Afebrile, HR 70, BP 160/80
GEN: no acute distress, alert and oriented x 3, appears
comfortable
HEENT: no scleral icterus or jaundice, neck supple
CARDIAC: regular rate and rhythm
LUNG: clear to ausculation bilaterally
ABD: soft, non tender, non distended, guaiac positive
Rectal: no hemorrhoids, no obvious source of bleeding, no masses
Ext: symmetrical pulses bilaterally
Pertinent Results:
Admission Labs:[**2185-1-4**] 06:55PM
---------------
GLUCOSE-101 UREA N-11 CREAT-0.7 SODIUM-141 POTASSIUM-4.3
CHLORIDE-106 TOTAL CO2-24 ANION GAP-15 CALCIUM-8.8 PHOSPHATE-3.3
MAGNESIUM-2.0
WBC-10.1 RBC-4.33 HGB-13.3 HCT-38.3 MCV-88 MCH-30.8 MCHC-34.9
RDW-17.1* NEUTS-58.2 LYMPHS-33.2 MONOS-6.9 EOS-1.6 BASOS-0.2 PLT
COUNT-289 PT-12.8 PTT-21.0* INR(PT)-1.1
.
Serial hematocrits:
[**1-19**]: 29.8
[**1-20**]: 29.8
[**1-21**]: 28.0
[**1-22**]: 28.2
[**1-23**]: 29.1
[**1-24**]: 28.4
.
Nutrition Labs:
---------------
Date---Fe---TIBC---TRF---[**Last Name (un) **]---Alb---TG
[**1-5**]----109--333----256---31-----3.9---..
[**1-11**]---31---289----222---43-----3.4---137
[**1-16**]---22---283----218---28-----3.3---338
.
Radiology
---------
[**2185-1-4**] ~ GI BLEEDING STUDY(Tag RBC Scan)
IMPRESSION: Increase blood flow in the region of the descending
colon. No
evidence of active GI bleed during the time of the study.
.
[**2185-1-5**] ~ GI BLEEDING STUDY (Tag RBC Scan)
Bleeding was first noticed at 6-8 minutes.
IMPRESSION: Evidence of bleeding in the pelvic bowel loops
notable within first 10 minutes. Further angiographic/surgical
correlation to determine the vscular site of origing is
recommended.
.
Cultures:
[**Date range (1) 43171**] C.diff: Negative
[**1-9**] C.diff toxin B (send out): Negative
[**1-20**] C.diff: Negative
Brief Hospital Course:
Ms. [**Known lastname **] is known to Dr.[**Name (NI) 6275**] [**Name (STitle) 4869**] and presented with
bright red blood per rectum.
GI: She was admitted to the ICU for recusitation. She was kept
NPO, central venous access was obtained, and a PPI was started
prophylactically. 3 units of PRBCs were transfused after her
HCT dropped from 42-> 38-> 33. She was started on Cipro and
Flagyl empirically and a Pitressin drip. A tagged RBC scan on
[**2185-1-4**] did not indicate an active bleed. A CT scan revealed no
extravasation of contrast, but there was new wall thickening of
the 7-8cm segment of distal colon just proximal to the distal
surgical anastomosis. GI Service was consulted for further
evaluation of her bleed. Patient continued to pass large
amounts of fresh bloody stool. A gastric lavage was bilious
without evidence of blood. A second ([**2185-1-5**]) tagged RBC scan
revealed bleeding in the rectosigmoid area, probably right
around the sacral and coccygeal hollow. This was the area where
the right colon was connected to the rectum. She was taken to
the operating room for a proctosigmoidoscopy and had
fulguration of a rectal bleeding point at 13 cm, injection of
epinephrine and irrigation with epinephrine. She was monitored
in the ICU and passed maroon to green stool with presence of
clots. C. Diff cultures x3 were all negative and C. Diff toxin
B negative. Her HCTs were stable and she remained on a
vasopressin drip that was titrated down daily. On Hospital Day
8 she experienced maroon stool with clots, her HCT dropped to 24
from 28 so she was transfused 2units of PRBCs. She had a
flexible sigmoidoscopy to 50cm that showed no bleeding. She
remained in the ICU for monitoring. She continued to have
maroon stools on Hospital Day 11. The GI service performed
another flexible sigmoidoscopy that revealed 2 bleeding ulcers
at 20cm, the distal ulcer was injected with epinephrine. Her
hematocrits subsequently remained stable at 29-30. She was
transferred out of the ICU and had no more melenic stools. She
did have a high amount of liquid diarrhea and was empirically
started on PO Vanc. A repeat C.diff was negative, but it was
decided to finsih a 7 day course of the Vancomycin. Her diet
was slowly advanced from sips to a regular house diet. At the
time of discharge she was having regular formed bowel movements
and had no melena for 4 days.
.
GU (Urinary tract Infection): A urine culture from the ED grew
Klebsiella pneumoniae. She was treated with a course of
Ciprofloxacin.
.
Anemia (Blood Loss and Iron Deficiency): On arrival to the
hospital she her Fe was 109 and her HCT was 38. Her iron levels
dropped to 31 ([**1-11**]) and 22 ([**1-16**]). She received a total of 5
units PRBC while in the ICU for the GI bleed. She was started
on Iron 325mg orally. At the time of discharge, she was advised
to continue with the iron supplements. Her hematocrit was
stable at 29-30.
.
Nutritional: Due to her prolonged NPO status, on HD9 TPN was
started to deliver 25kcal/kg and 1.5g protein/kg for an IBW of
64kg. TPN was cycled for 12hours overnight on HD15 and
discontinued on HD17. Once stablized on the floor, she was
started on a clear liquid diet and slowly advanced to a low
residue diet.
.
Hypertension: Patient was managed with Lopressor 5mg every
6hours to maintain SBP <140 and HR 60-80. She has had no acute
cardiovascular events during this admission and was resumed on
her home regimen.
Medications on Admission:
Aspirin 325mg daily
Atenolol 25mg daily
Fish oil
Zocor 10mg daily
MVI
HCTZ 12.5mg daily
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI Bleed - requiring 5 units of PRBCs
Acute blood loss/Iron Deficiency Anemia
Urinary Tract Infection - treated with Bactrim DS
H/O CHF (EF 55% on ECHO in [**2182**])
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) 957**] for any of the following:
-Fever >101.5
-Chills
-Nausea
-Vomiting
-Abdominal pain and/or tenderness
-Rectal Bleeding
-Changes in bowel habits ?????? such as constipation or diarrhea
-Changes in urinary habits ?????? frequency, difficulty or pain while
urinating
-Any serious change in your symptoms, or any new symptoms that
concern you.
.
Please resume your home medications except for the aspirin.
Please continue taking the antibiotic, Vancomycin, until it is
gone. Dr. [**Last Name (STitle) 957**] will instruct you when it is safe to resume
the aspirin.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 957**] in [**12-29**] weeks. Please call
[**Telephone/Fax (1) 2359**] to schedule your appointment.
ICD9 Codes: 2851, 5990, 4019, 2724, 4439, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7612
} | Medical Text: Admission Date: [**2199-8-4**] Discharge Date: [**2199-8-8**]
Date of Birth: [**2126-2-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
nausea, vomitting, poor po intake x2-3 days
Major Surgical or Invasive Procedure:
Bone marrow biopsy
History of Present Illness:
Mr. [**Known lastname **] is a 73 year old male with history of CAD s/p CABG,
hypercholesterolemia, depression, GERD who presents with 2 days
of nausea and vomiting. He had been in his usual state of
health when he began to feel "bad", developed nausea and
non-bilious, non-bloody emesis. He has been unable to take PO
for the past two days which is in addition to his typical poor
diet. He reported some right sided sharp chest pain during
episodes of emesis as well as some LUQ pain with emesis as well.
He had no chest pain aside from that which he experienced with
wretching. He denies any subjective fevers, chills, cough. He
has not had any diarrhea, last BM was normal and was 2-3 days
PTA. Denies lightheadedness, dizziness. He has no dysuria and
no change in urinary frequency.
.
On a usual day he eats toast and scrambled eggs for breakfast
then he will have a frozen meal 4x/week. He often does not have
much of an appetite and will often not eat anything after
breakfast. He drinks 2 vodka drinks/night to help him sleep.
He denies any history of alcohol withdrawal seizures or symptoms
of any kind.
.
In the ED his vitals were T 101.6 rectally, HR 84, BP 137/58, RR
18, O2 sat 100% on 2L NC. Labs were remarkable for ARF (Cr
1.4), bicarb 8, lactate 2.8, and anion gap of 34. ABG
7.28/18/148/9. Breathalyzer negative for alcohol. Blood
cultures were sent. He was given aspirin 325mg, zofran x1,
tylenol, and 2L NS. CT Abd/Pelvis was negative for acute
infection. Also seen by EP in ED, interrogated pacer showed
normal pacemaker function.
.
On arrival to floor he denied chest pain, shortness of breath,
abdominal pain, fevers, chills, lightheadedness or weakness.
Past Medical History:
1. Coronary artery disease. The patient is status post
coronary artery bypass graft one and a half years ago.
2. Hypercholesterolemia
3. Hypertension
4. Depression
5. GERD.
6. Chronic anemia with pancytopenia
7. EtOH abuse
8. History of asthma.
9. History of allergic rhinitis.
10. Status post pacemaker placement.
11. Status post tonsillectomy.
Social History:
The patient lives alone in [**Location 1268**]. Married, wife lives
elsewhere. Smoked " a lot" from the ages of 20-31. History of
chronic alcohol use, drinks 2 vodka drinks/night. No drug use.
No history of EtOH withdrawal.
Family History:
mother and father died in their 80s of an unknown cancer
Physical Exam:
VS T 98.5, HR 76, BP 125/51, O2sat 99% RA, RR 21
Gen: Well appearing elderly male in NAD. Conversant. Asking
for water.
HEENT: dry MM, OP clear. PERRL. EOMI.
Neck: No JVD, supple
CV: Regular rhythm, nl s1 s2, no m/r/g appreciated
Chest: Mild wheezing. Otherwise clear
Abd: Soft, NT, moderately distended, +BS. No rebound or
guarding.
Ext: No edema, 1+ DP pulses
Neuro: A&Ox3. Appropriate affect. Grossly normal strength and
sensation. No asterixis.
Rectal: Guaiac negative in ED.
Pertinent Results:
[**2199-8-4**] 09:54PM GLUCOSE-209* UREA N-28* CREAT-1.3* SODIUM-135
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-21* ANION GAP-16
[**2199-8-4**] 09:54PM CALCIUM-7.7* PHOSPHATE-2.2* MAGNESIUM-2.4
[**2199-8-4**] 03:36PM GLUCOSE-113* UREA N-26* CREAT-1.3* SODIUM-136
POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-15* ANION GAP-24*
[**2199-8-4**] 03:36PM LD(LDH)-135
[**2199-8-4**] 03:36PM cTropnT-0.02*
[**2199-8-4**] 03:36PM CALCIUM-7.9* PHOSPHATE-3.4 MAGNESIUM-1.9
[**2199-8-4**] 03:36PM VIT B12-331 FOLATE-GREATER TH
[**2199-8-4**] 03:36PM OSMOLAL-301
[**2199-8-4**] 03:36PM ASA-NEG
[**2199-8-4**] 03:36PM WBC-5.6 RBC-2.84* HGB-9.5* HCT-28.0* MCV-99*
MCH-33.5* MCHC-33.9 RDW-13.8
[**2199-8-4**] 03:36PM PLT COUNT-134*
[**2199-8-4**] 11:48AM TYPE-ART PO2-148* PCO2-18* PH-7.28* TOTAL
CO2-9* BASE XS--15
[**2199-8-4**] 11:13AM LACTATE-2.8*
[**2199-8-4**] 09:36AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2199-8-4**] 09:36AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2199-8-4**] 09:36AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-8-4**] 09:36AM URINE RBC-0 WBC-0 BACTERIA-OCC YEAST-NONE
EPI-0
[**2199-8-4**] 09:00AM GLUCOSE-124* UREA N-26* CREAT-1.4* SODIUM-139
POTASSIUM-5.2* CHLORIDE-97 TOTAL CO2-8* ANION GAP-39*
[**2199-8-4**] 09:00AM ALT(SGPT)-13 AST(SGOT)-35 CK(CPK)-51 ALK
PHOS-122* AMYLASE-102* TOT BILI-1.1
[**2199-8-4**] 09:00AM LIPASE-16
[**2199-8-4**] 09:00AM cTropnT-0.01
[**2199-8-4**] 09:00AM CK-MB-NotDone proBNP-6659*
[**2199-8-4**] 09:00AM ACETONE-LARGE
[**2199-8-4**] 09:00AM ASA-NEG ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
[**2199-8-4**] 09:00AM WBC-9.1 RBC-3.38* HGB-10.8* HCT-33.9*
MCV-100*# MCH-32.1* MCHC-32.0 RDW-13.8
[**2199-8-4**] 09:00AM NEUTS-94.8* BANDS-0 LYMPHS-3.2* MONOS-1.8*
EOS-0.2 BASOS-0
[**2199-8-4**] 09:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2199-8-4**] 09:00AM PLT SMR-NORMAL PLT COUNT-180
.
CT abd [**8-4**]:
Small bilateral pleural effusions and stable parenchymal
calcifications which may reflect amiodarone usage.
Cholelithiasis. Stable 1.3 cm left adrenal lesion statistically
representing an adenoma. Stable 2.2 cm septated right renal
cyst. Nodular liver reflecting underlying cirrhosis.
.
CXR [**8-4**]:
Small right pleural effusion. No evidence of congestive heart
failure. No focal infiltrates. There is a small right pleural
effusion. There is no left pleural effusion. Old rib fractures
of several right ribs are unchanged compared to [**2196-12-27**].
Brief Hospital Course:
Hospital Course by Problem:
.
1) Acidosis: The patient was found to have an anion gap
metabolic acidosis with pH 7.28 in ED. Ketones were noted in
his urine. Gap in ED was 34 prior to fluids, improved to 19
after 2L NS in ED. Delta delta is 22, so corrected bicarb is 30
- some component of metabolic alkalosis possibly from vomiting.
Differential diagnosis for anion gap metabolic acidosis includes
DM, alcohol, starvation - all of which are typically seen with
ketones as in this patient. Lactic acidosis (also mildly
present here) caused by circulatory/respiratory failure, sepsis,
ischemic bowel, sz, liver failure - patient is hemodynamically
stable so makes these unlikely. Ingestions also a possibility -
urine and serum tox negative. Osmolar gap is 13, typically
osmole gap > 10 indicative of ingestion. Likely a component of
starvation ketosis/ alcoholic ketosis and lactic acidosis in
setting of dehydration and renal failure.
.
Etiology was felt most likely [**12-28**] starvation ketosis (acute on
chronic), with possibility of some component of ingestion. Pt
was hydrated with 2L IVF in ED, then given additional 3L IVF (2L
d5w + HCO3, 1L D5 NS) in MICU, with closure of GAP. ethylene
glycol, methanol, isopropyl alcohol level were sent and were
unremarkable. salicylates unremarkable. D lactate was not sent.
.
After being transferred form the MICU to the regular floor, the
patient's electrolytes were followed and remained stable.
.
2) EtOH abuse: The patient reports drinking two drinks each
night. LFTs were within normal limits. A CT scan showed signs
c/w likely cirrhosis. The patient was treated with CIWA scale
for withdrawal symptoms (did not require any benzos), IV
thiamine, and folic acid. B12, folate levels were normal.
Coags unremarkable, albumin c/w poor nutritional status. The
patient was seen by social work. He admitted to drinking more
than he should, but was not interested in AA or other programs.
He was given information on antabuse, which he will follow up
with his PCP [**Name Initial (PRE) **]. He also consented to meals on wheels
service, which will call him when he gets home for interview/set
up, and his wife will help him with his food until that service
begins.
.
3) Nausea/Vomiting: The patient's nausea and vomitting quickly
improved after admission, and may have been due to viral
gastroenteritis or acidosis. He was given PO Zofran, which
helped a lot, and he was eating well without nausea or vomitting
prior to discharge.
.
4) Cardiac:
* Ischemia: CAD s/p CABG: Chest pain with wretching. The
patient's cardiac enzymes were negative x3 and EKG not
significantly changed from prior EKGs. On further interview,
symptoms suggestive of GERD (typically occur with pepsi, [**Location (un) 2452**]
juice, right side chest burning, never elicited by exertion).
The patient was continued beta blocker and statin. He was
continued on a PPI for GERD symptoms, and his chest pain
resolved.
* Rhythm: Seen by EP in ED, normal pacemaker function. Multiple
polymorphic PVCs.
The patient was moniroed on telemetry with no events. He was
continued on his outpatient beta blocker. Because his pacemaker
was interrogated during this admission, the is no need for
follow up at device clinic next week.
* Pump: Euvolemic on exam.
.
5) Acute renal failure: The patient's ARF was likely related to
dehydration, and quickly improved with rehydration (Cr
1.4-->0.9).
.
6) Pancytopenia: On admission, the patient was 9.1>33.9<180
which steadily decreased to a low of 2.1>25.8<78 before
starting to stabilize the day prior to discharge. His CBC on
the day of discharge was 2.5>28.7<81. In [**Hospital1 34374**] records, the
patient has had episodes of pancytopenia in past, thought to be
[**12-28**] chronic alcohol use. He was last seen on heme onc at [**Hospital1 **] in
[**2193**] when counts had recovered after stopping alcohol use.
Talking to his PCP revealed that the patient's baseline
chronically low with his last outpatient CBC being 3.3>29.1<132.
He was referred to a hematologist at [**Hospital6 **] and
scheduled for a bone marrow biopsy in [**7-1**] but never followed
up.
.
The hematology-oncology team was consulted and performed a bone
marrow biopsy prior to discharge. Results are pending. He will
follow up with Dr. [**First Name (STitle) **] in hematology clinic on [**2199-8-16**] for
the results.
.
7) Hypertension: Well controlled, pt continue on home regimen of
beta blocker.
.
8) Asthma: The patient had mild wheezing on exam. A CXR showed
only a small effusion. The patient was treated with nebulizers
and inhalaers PRN. He was breathing comfortably on room air
prior to discharge (o2 sat 97% on RA) with only occasional
wheezes.
.
9) Depression: The patient was continued on his home dose of
zoloft. He was seen by social work, who also spoke with his
wife who says that he has been depressed for some time now. He
will follow up with his PCP.
.
10) GERD: Continued on his outpatient PPI.
.
11) FEN: The patient was fed a regular diet, and electrolytes
were aggressively repleted to prevent against refeeding
syndrome. As mentionned above, the patient will be set up with
meals on wheels to help encourage better nutritional habits at
home.
.
12) PPx: The patient was on SC heparin for DVT prophylaxis.
.
13) Code: He was full code during this admission.
Medications on Admission:
Medications: (List lost in ED. Confirmed with [**Location (un) 535**])
Lipitor 10 mg daily
Vicodin 7.5/750 mg 1 tablet every 6 hours p.r.n. low back pain
Multivitamins 1 tablet daily
Zoloft 50 mg daily
Prevacid 30 mg daily
Metoprolol 25 mg b.i.d. (oer pharmacy daily dosing)
Iron pills 324 mg daily
Zyrtec 10 mg daily
Folic acid
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO every 6 hours as needed as needed for low back pain.
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Iron 325 (65) mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
7. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 8 hours as needed as needed for nausea
for 7 days: If you continue to feel nauseated, please see your
primary care doctor, Dr. [**Last Name (STitle) **]. .
Disp:*5 Tablet, Rapid Dissolve(s)* Refills:*0*
11. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: anion metabolic acidosis
pancytopenia
Secondary:
Coronary artery disease s/p CABG
Status post pacemaker placement
hyperlipidemia
Hypertension
Depression
GERD
EtOH abuse
asthma
Discharge Condition:
vital signs stable, afebrile, eating, ambulating
Discharge Instructions:
Please take all of your medications as presribed.
Return to the ED if you have chest pain, shortness of breath,
fevers, chills, nausea, vomiting, or any other symptom that is
of concern to you.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) 30623**]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 30837**]) on Thursday [**2199-8-15**] at your original
appointment time.
Please follow up with Dr. [**First Name (STitle) **] at the hematology clinic on
Friday [**2199-8-16**]. His office will call you with the exact
time. If you do not hear from his office, you should call to
find out the time of your appointment. ([**Telephone/Fax (1) 34375**]
Completed by:[**2199-8-11**]
ICD9 Codes: 5849, 2762, 2724, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7613
} | Medical Text: Admission Date: [**2109-8-8**] Discharge Date: [**2109-8-20**]
Date of Birth: [**2091-5-5**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
2 days of shortness of breath and cough
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
History of Present Illness:
18M with no significant past medical history but with recent
travel to [**Country 1684**] presents with 2 days of fevers, productive
cough and shortness of breath. Pt states that he had nausea and
2 days of diarrhea that has now resolved. Patient noted
headache and fatigue and weakness.Pt initially presented to
[**Hospital6 3105**] where he was noted to have an ABG of
7.45/31/60 while satting 92% on 3L. CXR showed bilateral
infiltrates and patient had a leukocytosis. Blood cultures were
drawn and patient was given one dose of IV vanc, levquin and
rocephin and transferred to the [**Hospital1 **] for further evaluation.
.
In the ED, T 100.6 121 130/80 18 94% on 3L. Patient received ~5
L IVFs but BP trended down to a nadir systolic of 83 just prior
to transfer. He was ordered for levophed, however, he arrived
at the [**Hospital Unit Name 153**] with the drip in place but the tube was clamped so
it is unclear as to whether or not he actually received any
pressors. By the time of his arrival, he was normotensive
without any blood pressure support. Pt received one dose vanc
and azithro in the ED. Sats were stable in mid-90s on 5L. Did
desat when he removed his nasal cannula. RIJ was placed [**1-5**]
poor access and urine legionell and mycoplasma serologies were
sent.
.
Of note, patient returned from [**Country 1684**] on [**7-28**] after a 3 weeks
visit. He denies any sick contacts, contact with rodents or
birds, rash, insect bites. He states that most of his time was
spent in the city but he did go hiking one day. The patient was
born in [**Country 1684**] and moved to the US when he was 8 years old. He
recalls having multiple vaccinations prior to immigration but
cannot recall the names. Does believe that he had a negative
ppd within the last 4-6 years. Patient denies any unprotected
sex or IVDU. Works partime as a bank teller and is attending
college at [**Location (un) 270**].
Past Medical History:
none
Social History:
Lives at home with parents. Works part-time as bank teller and
attends college at [**Location (un) 270**]. Non-smoker, no alcohol, no
illicits/IVDU. Denies sexual intercourse within the past year.
No history of unprotected sex. Born in [**Country 1684**], moved to the US
at age 8.
Family History:
non contributory
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2109-8-8**] 10:30PM PLT COUNT-245
[**2109-8-8**] 10:30PM NEUTS-84.0* LYMPHS-9.1* MONOS-4.5 EOS-2.1
BASOS-0.2
[**2109-8-8**] 10:30PM WBC-17.5* RBC-4.59* HGB-12.8* HCT-36.0*
MCV-79* MCH-28.0 MCHC-35.6* RDW-13.1
[**2109-8-8**] 10:30PM CORTISOL-23.6*
[**2109-8-8**] 10:30PM CALCIUM-7.5* PHOSPHATE-1.5* MAGNESIUM-1.7
[**2109-8-8**] 10:30PM LIPASE-9
[**2109-8-8**] 10:30PM ALT(SGPT)-10 AST(SGOT)-11 ALK PHOS-54 TOT
BILI-0.7
[**2109-8-8**] 10:30PM estGFR-Using this
[**2109-8-8**] 10:30PM GLUCOSE-106* UREA N-10 CREAT-0.7 SODIUM-138
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17
[**2109-8-8**] 10:36PM LACTATE-1.0
[**2109-8-8**] - CT OF THE CHEST WITHOUT IV CONTRAST: The patient is
intubated. The tip of the endotracheal tube is at 4.5 cm from
the carina. Bilateral multifocal consolidations with air
bronchograms are seen, worse at the bases. Bilateral
mild-to-moderate pleural effusions, right greater than left.
Multiple borderline in size mediastinal lymph nodes are seen.
The heart and great vessels are normal in size. Trace
pericardial effusion is seen. Right-sided central venous
catheter with tip at the lower SVC. An NG tube is seen with the
tip in the stomach. The visualized portions of the upper abdomen
are unremarkable.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified.
IMPRESSION: Findings likely represent multifocal pneumonia.
[**8-8**] chest x-ray IMPRESSION: Diffuse, heterogeneous airspace and
interstitial opacities. Differential is wide, but favors
atypical infection, such as mycoplasma, mycobacteria, legionella
if GI symptoms are present, or fungal if patient is
immunocompromised.
[**8-17**] CT chest - IMPRESSION:
1. Marked interval improvement in multifocal consolidations with
only
residual ground-glass opacities in the bilateral upper lobes and
right middle
lobe.
2. Persistent small bilateral pleural effusions.
[**8-16**] chest x-ray IMPRESSION:
1. Overall, no significant change compared to the study from
[**8-15**]. Multiple support lines and tubes as described
above and unchanged bilateral pleural effusions and pulmonary
opacities.
Brief Hospital Course:
# Respiratory Distress/Sepsis - On admission patient meet SIRS
criteria with temp>38, heart rate >90, and WBC > 12,000. Likely
source considered pneumonia, as had diffuse bilat patchy
infiltrates on CXR, new O2 requirement, and increase work of
breathing which was consistent with acute eosinophilic
pneumonia. Initially differential included bacterial pneumonia
vs. viral infection with ARDs type pathology. Blood cultures
were negative. Urine culture no growth. Initial bronc had 90%
polys and grew had gram negative coccobacilli. Repeat bronch
demonstrated 28% eosinophils. Patient was treated with broad
spectrum antibx including vancomycin, ceftriaxone, and levoquin.
Elective inbution was performed for respiratory distress on day
of admission. RIJ was placed and a-line was also placed.
Patient was agressively fluid resuscitated with goal to
maintain CVP 8-12 with UOP > 30 cc/hr. Patient initially was
also on levophed (norepinephrine) for persistent hypotension
despite fluid resuscitation. On night of admission, cardiology
called to come [**Month (only) 11197**] patient as small pericardial effusion on
chest CT in the context of hypotension and tachycardia and
sepsis; fellow did not see any evidence of large pericardial
effusion or evidence of tamponade physiology. Patient had to be
proned one day in order to maintain oxygenation status. APACHE
II score was calculated and patient was not felt to be a
candidate for activated protein c administration. Urine
legionella was sent and was negative. As cultures were all
essentially negative, patient was started on stress dose
steroids for presumed acute eosinophilic pneumonia. Urine
legionella was negative. CMV was negative. Patient was HIV
negative with rapid screen as well as with viral load studies.
With initial concern for patient's status, patient was also
started on ambisome for fungal coverage. Once culture negative
for evidence of gram +, vancomycin was discontinued. Ambisome
was continued until patient significantly improved, as urine
histo was still pending. Additional cultures were drawn. O+P was
negative. C. diff negative. mycoplasma negative. Pt. was felt
to possibly have adrenal insufficiency based on testing in the
icu, felt possibly induced by etomidate. Imaging did not show
adrenal infarct or pathology. He was written for a lengthy
steoid taper on discharge and arranged to see endocrine in
follow up for continued evaluation.
.
Pt rapidly improved with steroids and antibiotics, and all
infectious work up was negtive including multiple serologies for
infectious and other causes of his resp. failure. He was
ultimately felt to have AEP and will see pulmonary in follow up
after steroid taper.
.
On the day of discharge, he was feeling well, af and vss, and
room air saturations were normal.
.
Medications on Admission:
none
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: TAKE THIS
MEDICATION DAILY WHILE YOU ARE TAKING PREDNISONE.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday) for 42 days: TAKE
THIS MEDICATION WHILE YOU ARE TAKING PREDNISONE, THREE TIMES
WEEKLY.
Disp:*20 Tablet(s)* Refills:*0*
3. Prednisone 5 mg Tablet Sig: as per taper schedule, below
Tablet PO once a day for 42 days: 8 tab/d X 7 d then 6 tab/d X 7
d then
4 tab/d X 7 d then
2 tab/d X 7 d then
1 tab/d X 14 days then stop.
Disp:*154 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute eosinophilic pneumonia, complicated by respiratory failure
Possible adrenal insufficiency, felt most likely to have been
induced by etomidate
Discharge Condition:
Stable. Room air saturations normal, no complaints, ambulatory,
eating and voiding independently.
Discharge Instructions:
Take all medications as prescribed.
Return to the [**Hospital1 18**] Emergency Department immediately for:
Fevers, shortness of breath, lightheadedness
Call your primary doctor for a follow up appointment for within
two weeks of leaving the hospital, at: [**Last Name (LF) **],[**First Name3 (LF) **] [**0-0-**]
It is imperative that you keep the follow up appointments listed
below, with the pulmonary doctors and with the endocrine doctors
to further [**Name5 (PTitle) 11197**] you lung function and to [**Name5 (PTitle) 11197**] for adrenal
insufficiency.
DO NOT STOP TAKING THE PREDNISONE SUDDENLY. YOU NEED TO TAKE
ALL OF THIS MEDICATION AS PRESCRIBED. STOPPING THIS MEDICATION
SUDDENLY CAN HAVE LIFE THREATENING CONSEQUENCES
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37077**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2109-8-30**] 3:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2109-9-2**] 3:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2109-9-2**] 4:00
ICD9 Codes: 0389, 2761, 4589, 2859, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7614
} | Medical Text: Admission Date: [**2151-4-22**] Discharge Date: [**2151-4-26**]
Date of Birth: [**2084-5-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Transfer s/p Bronchoscopy
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
Mrs. [**Known lastname 65384**] is a 66 year old woman with a history of metastatic
colon cancer s/p colon resection in [**2143**], recurrence in [**2146**] s/p
thoracotomy/left lower lobectomy who is transferred to the MICU
after a rigid brochoscopy for altered mental status and question
of acute CVA. Please see admit note for full details.
Briefly, Mrs. [**Known lastname 65384**] was transfered in [**8-/2150**] here from [**Hospital 8641**]
Hospital with hemoptysis and collapse of the left upper lobe and
found to have left main bronchus tumor with surrounding blood
clot. This was debrided using both cryotherapy as well as
mechanical debridement. The left upper lobe was also notable for
tumor and was further debrided. She had been hemoptysis free for
2 months at most after this procedure but reported hemoptysis
restarting with her chemotherapy regimen. She had been receiving
chemotherapy q 3 weeks with Flourouricil through mid-[**Month (only) 958**]. This
was switched to irinotecan last week with some improvement in
the hemoptysis. She has been having 3-5 episodes of hemoptysis a
day, about 1 tsp of pink-tinged sputum each. She returned to the
Chest Disease Center yesterday for further evaluation.
In the bronch suite yesteday, bronchoscopy demonstrated left
main stem brochus obstructing necrotic lesion with moderate
bleeding. No intervention was done. She was transferred to IR
for bronchial artery embolization of tumor. In the IR suite,
initial access through right groin was difficult due to bad
atherosclerotic disease, so access was re-tried through left
groin. This was also difficult but catheter was able to be
passed with successful embolization. She did have a L groin
hematoma extending over abdomen as access was slightly higher
than ideal but pt remained HD stable. She was transferred to the
floor with plan for OR on [**4-23**] for rigid bronchoscopy and
electric cautery by IP. On transfer, VS: AF, P 72, BP 117/48,
O2sat 97% on RA.
In the OR today, patient underwent rigid bronchoscopy for tumor
debridement after embolization yesterday. She received argon
thereapy for several seconds, but this was discontinued when
bubbles were seen on TEE in the left atrium with positive
pressure ventilation. Flex bronch did not reveal open blood
vessels. After this ST depressions over 2 mm were noticed on
telemetry for approximately 20 minutes, so she was started on a
Nitro drip for presumed NSTEMI, running at 0.5 mcg/kg/min. She
was received one dose of Epinephrine 150 mcg x1, and was started
on Phenylephrine drip at 0.3 mcg/kg/min. She also received 2 30
mg IV boluses of esmolol and 2 2mg IV boluses of Metoprolol. She
was extubated at 953 am, but patient was not responding to
commands so there was concern for CVA given findings on bubble
study.
On transfer to the MICU, patient is awake but unable to phonate,
likely due to recent bronch. She follows commands and appears
oriented. She denies chest pain, shortness of breath, dysphagia,
and weakness.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
HTN
Hypercholesterolemia
DM
GERD
Anxiety
Colon Cancer s/p colon resection [**2143**], recurrent disease s/p
thoracotomy left lower lobectomy [**2148**], chemo/XRT (last chemo
[**2149-10-29**])
Right portacath
Left portacath s/p removal [**2143**]
Tubal ligation
Social History:
Lives with family. Retired, worked at school cafeteria as
manager. Smoked 40 pack years, quit [**2146**]. Has 2 EtOH drinks 3
times/week
Family History:
Mother with cerebral aneurysm at 84. Father with pancreatic ca
in 70s. Brother with throat ca, another brother with unknown
cancer. Grandfather with laryngeal ca. Grandmother with breast
ca.
Physical Exam:
Vitals: T: BP: 100/48 P: 80 R: 18 O2: 97% on FM 12 L
General: Alert, cooperative, Sleepy but easily arousable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A and Ox3, CN II-XII intact, MAEs, 5/5 strength in UE and
LEs, negative babinski bilaterally, 2+ patellar bilaterally
Pertinent Results:
LABS ON ADMISSION:
[**2151-4-22**] 11:02PM HCT-25.3*
[**2151-4-22**] 02:10PM UREA N-9 CREAT-0.6
[**2151-4-22**] 02:10PM estGFR-Using this
[**2151-4-22**] 02:10PM WBC-3.8*# RBC-3.42* HGB-9.3*# HCT-28.8*#
MCV-85# MCH-27.1# MCHC-32.1 RDW-18.0*
[**2151-4-22**] 02:10PM PLT COUNT-221
[**2151-4-22**] 02:10PM PT-13.6* INR(PT)-1.2*
CXR [**2151-4-23**]:
There is only minimal aeration in the previously collapsed
postoperative left lung. Heterogeneous opacification in the
right lung could be edema, since the pulmonary vasculature in
the right lung is congested, but I am concerned about
disseminated tumor with lymphangitic extension. Infusion port
ends in the upper SVC. Mediastinum is shifted into the left
chest, therefore displacement of the right heart border to the
right of the spine, probably represents interval increase in
heart size or pericardial effusion. No pneumothorax.
ECHO/BUBBLE STUDY:
No atrial septal defect is seen by 2D or color Doppler. 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. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
Very few air bubbles seen in the left atium when cold saline was
injected. There was no hemodynamic compromise associated with
it. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2151-4-23**]
at 845 am.
9:03 AM
Argon coagulation commenced and immediately significant amount
of air bubbles noted in the left atrium and left ventricle.
Procedure terminated right away by Dr [**Last Name (STitle) **]. This was associated
with ST and T wave changes as well as hypotension. LV was
globally down and there was a big pocket of air noted in the
apex of the LV which resolved right away. Wall motion improved
with resuscitation using epinephrine and phenylephrine.
Subsequently with positive pressure ventilation there were more
air bubbles noted in the LV. At the end of the case patient was
breathing spontaneously and there were less bubbles noted in the
LV. All findings were communicated with Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **]
throughout the case.
Brief Hospital Course:
66 year-old female with metastatic colon cancer with ongoing
hemoptysis, evidence of left mainstem bronchus necrotic lesion
on bronch, now s/p IR embolization and rigid bronch with Argon
therapy leading to left-sided bubbles on TEE, now transferred to
MICU for concern of NSTEMI and CVA.
# Altered mental status: Concern for CVA given positive bubbles
on TEE, and question of air emboli to cranial circulation.
However, mental status rapidly improved making CVA less likely.
Neuro exam reassuring and stable. Mental status rapidly
improved.
# ST depressions: STDs noted on tele peri-bronchoscopy, but 12
lead EKG reassuring. No baseline for comparison. Patient without
known CAD history. Asymptomatic, but given DM could be at risk
for silent ischemia. Continued on beta blocker. Started on full
strength aspirin. Cardiac enzymes cycled and troponins down
trended with flat CK's, thought to be most likely demand
ischemia.
# Hypoxia: Downtitrated oxygen as tolerated. ABG with excellent
oxygenation, with acute acidosis and hypercarbia. Likely due to
recent procedure and poor ventilation. Oxygenation rapidly
improved as her mental status improved and she was easily weaned
to room air.
# Hypotension: Baseline SBP on the floor 80s to 100s, maintained
pressures of SBP ~80 while in the ICU post procedure. Her blood
pressure returned to her baseline on the floor after her call
out of the ICU.
# Hemoptysis: Left mainstem bronchus necrotic lesion likely
representating metastatic disease, s/p IR embolization and rigid
bronch with argon therapy. Continued on advair and nebulizers as
needed. Her hemoptysis improved significantly post procedure,
with only small amounts of blood tinged sputum being coughed up
at the time of discharge.
# L groin/abdomen hematoma: S/p cath with difficult access for
the IR embolization. Pt remained hemodynamically stable without
back pain suggestive of an RP bleed. Her hematocrit remained
stable, and the groin hematoma improved and was soft with
overlaying ecchymosis at the time of discharge.
# Metastatic colon cancer: Followed at [**Location (un) 8641**], on irinotecan,
will continue outpatient follow up.
# DM: Blood sugars controlled with a humalog sliding scale.
# Anxiety/insomnia: Continued lorazepam.
# GERD: Continued famotidine.
Medications on Admission:
Albuterol Sulfate prn
Famotidine 20 mg daily
Fluticasone-Salmeterol 100 mcg-50 mcg/Dose [**Hospital1 **]
Insulin Aspart sliding scale
Lorazepam 0.5 mg daily
Metoprolol Tartrate 50 mg [**Hospital1 **]
Tiotropium Bromide 18 mcg daily
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-30**] Inhalation four times a day as needed for shortness of
breath or wheezing.
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for anxiety/insomnia.
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
7. insulin
please resume the insulin sliding scale that you had prior to
discharge
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA
Discharge Diagnosis:
Major: colon cancer metastatic to the lung
hemoptysis secondary to lung cancer
.
minor:
HTN
HL
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 after coughing up blood. This blood was
thought to be from your lung tumors. You were taken to the
operating room for an Argon procedure to help with this
bleeding. This was successful. You had a repeat chest CT prior
to discharge. You should follow up with your PCP, [**Name10 (NameIs) 5564**]
and Interventional Pulmonology.
.
You were started on medications for constipation (senna and
colace).
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 6811**] M.
When: [**Last Name (LF) 766**], [**5-3**], 3:45pm
Address: [**Apartment Address(1) 82860**], [**Location (un) **],[**Numeric Identifier 30816**]
Phone: [**Telephone/Fax (1) 59340**] .
.
Department: INTERVENTIONAL PULMONARY
When: TUESDAY [**2151-7-27**] at 11:30 AM [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: CHEST DISEASE CENTER
When: TUESDAY [**2151-7-27**] at 12:00 PM [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: CHEST DISEASE CENTER
When: TUESDAY [**2151-7-27**] at 12:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 9971, 2762, 2851, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7615
} | Medical Text: Admission Date: [**2145-6-27**] Discharge Date: [**2145-7-7**]
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Respiratory distress and aspiration
Major Surgical or Invasive Procedure:
EGD with removal of food impaction x 2
ERCP with major papilla sphincterotomy, stent placement, and
biopsy of ampullary mass
History of Present Illness:
79 year old male with multiple sclerosis and paraplegia,
coronary artery disease status post coronary artery bypass
graft, history of cerebrovascular accident and dementia was
transfered from the [**Hospital3 **]
after likely aspiration event during lunch.
Patient's daughter was present with him in the room when he was
eating lunch and visibly choked and regurgitated undigested food
and oral secretions while eating meat. He then continued to spit
up oral secretions. O2 sat was 83% on RA. The patient was
brought to the [**Hospital1 69**] Emergency
room where oxygen saturation was 98% on 2L of oxygen.
The patient denies odynophagia, dysphagia in the past, nausea
and vomiting, abdominal pain. He has had a 20 lb weight loss
over several months most likely due to poor intake.
The patient was admitted to the medical intensive care unit for
Esophageal-gastroduodenoscopy to rule out a foreign body
aspiration.
Past Medical History:
1. Multiple sclerosis-paraplegia since [**2091**]
2. CAD s/p CABG in [**2139**]
3. Left Carotid endarterectomy
4. L occipital/parietal CVA
5. Appendectomy
6. CHF with EF of 25%
7. Right femur fracture
8. L proptosis with visual loss
9. Constipation
Social History:
Lives at [**Hospital3 **] Center with his girlfriend of
many years. Has a daughter in [**Name (NI) 86**] who is very involved in his
care.
Family History:
Non-contributory.
Physical Exam:
T 98.3 HR 74 BP 175/53 RR 18 O2 sat 98%
GEN: Elderly male, alert and oriented to person and place,
comfortable.
HEENT: PERRL, moist mucous membranes, no JVD, good dentition.
LUNGS: Decreased breath sounds throughout. No wheezes, rales or
rhonci.
CV: Regular. Normal S1 and S2. III/VI systolic ejection murmur
at left upper sternal border.
ABD: Soft, non-tender, non-distended with bowel sounds present
and bilateral renal bruits.
EXT: Upper extremity fractures. LE without edema.
NEURO: Awake and interactive. No short term memory. Language and
comprehension are intact. Repetition is intact and naming is
decreased. CN: Right hemianopsia. PERRL. EOMI without nystagmus.
Facial movement is symmetric. Palate elevation is symmetric.
Tongue protrudes midline. Motor: Bulk is diminished. Tone is
increased in the legs. Spastic paresis in the legs.
Sensation is intact to touch, temperature. Reflexes: present and
symmetric. Plantar rflexes are extensor. Sensation is intact to
touch and temperature. Coordination intact.
Pertinent Results:
[**2145-6-27**] 05:30PM GLUCOSE-108* UREA N-31* CREAT-0.8 SODIUM-141
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-27 ANION GAP-17
[**2145-6-27**] 05:30PM CALCIUM-9.5 PHOSPHATE-3.6 MAGNESIUM-2.5
[**2145-6-27**] 05:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2145-6-27**] 05:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2145-6-27**] 05:30PM NEUTS-69.2 LYMPHS-26.5 MONOS-2.9 EOS-1.0
BASOS-0.3
[**2145-6-27**] 05:30PM MACROCYT-1+
[**2145-6-27**] 05:30PM PLT COUNT-220
[**2145-6-27**] 05:30PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2145-6-27**] 05:30PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2145-6-27**] 05:30PM URINE RBC-[**4-2**]* WBC-[**7-8**]* BACTERIA-FEW
YEAST-FEW EPI-0-2
[**2145-6-27**] 05:30PM URINE AMORPH-FEW
ECG: Sinus rhythm. Prominent precordial QRS voltage is
non-specific but consider
left ventricular hypertrophy. Non-specific inferolateral ST-T
wave
abnormalities. Clinical correlation is suggested. Since the
previous tracing
of [**2143-1-30**] sinus tachycardia is absent and ST-T wave changes are
slightly more
prominent. Rate 86. Intervals: PR 122 QRS 84 QT/QTc 384/427
Axis: P 71 QRS 49 T -60
CXR [**2145-6-27**]: There is no radiographic evidence of acute
cardiopulmonary
abnormality. The appearance of the chest radiograph is
unchanged when
compared to [**2143-1-30**].
UGI/SBFT [**2145-6-29**]: 1. Long segment of narrowing and mucosal
irregularity in the
distal esophagus, may represent a stricture and/or ongoing
esophagitis.
2. Two filling defects on the proximal duodenum probably
corresponding to the
abnormality seen on EGD. Contrast passed freely through the
pylorus in the
small bowel.
MRCP [**2145-7-1**]: 1) There is an enhancing 1.5 cm mass in the right
lateral aspect of
the ampulla, which only obstructs the common bile duct. There
are multiple
surrounding lymph nodes, the largest of which measures 1.6 cm in
short axis.
2) Multiple tiny dependent stones within the intrahepatic
biliary ducts and a
single stone within the CBD.
KUB [**2145-7-2**]: IMPRESSION: Retained barium within the colon.
Brief Hospital Course:
1. Aspiration/Food impaction: Patient underwent EGD x 2 on [**6-28**]
with removal of 20 cm of lodged undigested food. Initial EGD
removed the first 15 cm. The procedure was terminated due to
trauma from the scope and duration of anesthesia. Second EGD
removed remainder of food. Patient had minor hematoma
formation/abrasions [**3-1**] vigorous instrumentation. EGD also
revealed a mass at the pancreatic ampulla and a mobile duodenal
polyp. The GI service recommended an upper GI with small bowel
follow through to further elucidate the nature of the esophageal
narrowing. This study showed a narrowed esophagus with
non-distensibility. Patient underwent a speech and swallow
evaluation with no evidence of aspiration with any food
consistency consistent with normal oropharyngeal function. The
patient was kept on a liquid diet due to concern for possible
reaccumulation of the food prior to further studies. The patient
underwent a repeat EGD on [**2145-7-5**] which showed normal esophageal
mucosa and no evidence of constriction, therefore dilation was
not performed. Patient was maintained on protonix and
sucralfate.
2. Ampullary Mass: Patient underwent MRCP which showed an
enhancing mass, 15 mm x 11 mm at the right lateral aspect of the
base of the common bile duct. There was intrahepatic and
extrahepatic duct dilatation with a common bile duct of 2 cm.
The pancreatic duct was not dilated. There were several enlarged
periportal abnormal lymph nodes. It was thought that the mass
was consistent with ampullary adenoma or adenocarcinoma. The
patient underwent ERCP on [**2145-7-5**] which showed a large fungating
malignant appearing mass in the major papilla. The common bile
duct was dilated along the entire length down to the level of
the mass. A small spincterotomy was perfomed. A 10 mm by 4 cm
coated metal wall stent was placed successfully. Cold forceps
biopsies were perfomred for histology from the mass.
The patient was seen by Dr. [**Last Name (STitle) **] from pancreatic surgery
who felt that the mass could be a benign adenoma or an
adenocarcinoma. Depending on the nature of the mass, Dr. [**Last Name (STitle) **]
felt that surgery may be indicated. If the mass were to be
malignant then the patient would need to undergo a Whipple
procedure, which would likely present too great a risk of
morbidity and mortality for the patient. If, however, the mass
were an adenoma, then the patient could undergo a local
resection. This would necesitate a prior ERCP with removal of
the metal stent and placement of a plastic stent. Dr. [**Last Name (STitle) **]
will confer with Dr. [**Last Name (STitle) **] as to the best plan. The patient
will follow up with Dr. [**Last Name (STitle) **] in clinic for further
discussion. Patient is to follow up biopsy results with his
physician at [**Hospital 100**] Rehab.
3. Cholestasis: Patient had full obstruction of the common bile
duct by the ampullary mass. His peak bilirubin was 5.2 with a
direct bilirubin of 3.2. ALT was 124, AST 115, Alkaline
phosphatase peaked at 857. Patient was notably jaundiced. He did
have mild RUQ pain to deep palpation, but did not develop fevers
or signs of infection. His bilirubin was already trending down
at the time of discharge.
3. Coronary artery disease-The patient was mainted on his beta
blocker and ACE inhibitor. Beta blocker was titrated up to
Toprol XL 37.5 qd for better blood pressure and heart rate
control.
4. Urinary tract infection: Patient's urine culture initially
grew coagulase negative staph. However, repeat urine culture was
negative so this was thought to be a contaminant.
5. Multiple Sclerosis: The patient was seen by the neurology
service who were at first unsure that his presentation was
consistent with multiple sclerosis. An MRI of the C spine was
obtained which showed mild degenerative disease at multiple
levels. No definitive evidence of central canal stenosis. Some
increased cord signal at C4 that could reflect demyelination
consistent with multiple sclerosis. The neurology service
recommended follow up with an outpatient neurologist to discuss
pharmacologic treatments for Multiple sclerosis such as
interferon.
6. FEN: Full pureed diet. NS with 20 KCL at 100/hr. Will need
to address nutritional needs at rehab as he is not adequately
nourished with PO intake alone.
7. Prophylaxis: Heparin SC q8; proton pump inhibitor, multi
podus boots,
Medications on Admission:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
3. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO QD (once a
day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
5. Sorbitol 70 % Solution Sig: One (1) ML Miscell. QD (once a
day).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO QD (once a day).
7. Folate 1 mg PO QD
8. Milk of Magnesia 30 cc QHS
9. Multivitamin 1 po qd
10. Vitamin C
11. Zinc sulfate
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection Q8H (every 8 hours).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
6. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO QD (once a
day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Sorbitol 70 % Solution Sig: One (1) ML Miscell. QD (once a
day).
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1.5) Tablet Sustained Release 24HR PO QD (once a day).
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
12. M-Vit Tablet Sig: One (1) Tablet PO once a day.
13. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
15. Milk of Magnesia 7.75 % Suspension Sig: Thirty (30) ML PO at
bedtime as needed.
16. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Esophageal impaction with food
Esophageal narrowing and thickening
Ampullary mass c/w adenocarcinoma, pathology pending
Cholestasis
Painless jaundice
Discharge Condition:
Stable--improving serum bilirubin, afebrile.
Discharge Instructions:
Call your primary care physician if you experience pain,
jaundice, vomiting, nausea, fevers, or inability to tolerate
food.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 21140**] in gastroenterology if you have
additional swallowing problems or wish to discuss your condition
further. Call ([**Telephone/Fax (1) 24237**] for an appointment.
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in two weeks. Call ([**Telephone/Fax (1) 15807**] for an appointment.
ICD9 Codes: 5070, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7616
} | Medical Text: Admission Date: [**2118-1-28**] Discharge Date: [**2118-1-30**]
Date of Birth: [**2075-7-20**] Sex: M
Service: NEUROLOGY
Allergies:
Benzodiazepines
Attending:[**First Name3 (LF) 17813**]
Chief Complaint:
Called by Emergency Department to evaluate
increased seizure activity
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 17797**] is a 42-year-old right-handed man with a history
of intractable epilepsy who presents with a cluster of seizures.
He has such clusters about once per month, the last being about
4
weeks ago. They usually occur out of sleep, as happened this
morning. At 5:30 am, his wife was awakened to by his convulsion.
He had a generalized ("full-body") seizure lasting 2-3 minutes
with a 20-minute period of heavy breathing and confusion
following, typical of his usual events. His wife gave him 0.5 mg
Ativan SL and he went back to sleep afterwards.
At 7:30 am, he had another similar episode, possibly more
violent
convulsing, again lasting about 3 minutes. Post-ictal period
lasted 20 minutes, although he never really regained
consciousness because his wife tried to give him 1 mg SL Ativan
(per Dr.[**Name (NI) 17796**] advice, whom she called after the second
event). However, he did not wake up significantly.
He slept heavily until 9 am, when he had another [**2-8**] minute GTC
seizure. At that point, his wife called EMS. They administered 2
more mg IV Ativan, for a total of 3.5 mg in 4 hours. He has been
somnolent since.
Although his intended dose of [**Month/Day (3) 17802**] was 200/500, he had been
decreasing the dose during [**Month (only) 404**] of his own [**Location (un) **], down to
200/300. This was due to concerns that sleepiness, poor
concentration, and memory difficulty were due to the [**Location (un) 17802**]
(although may equally have been due to more seizures). He has
had
no evidence of infection per his wife.
In terms of recent history, he was admitted to the Epilepsy
service from [**12-27**] to [**12-29**] after a flurry of seizures and some
concern for post-ictal psychosis. He was treated briefly with
Haldol, but discharged on his usual home dose of [**Month/Year (2) 17802**] and
prn
Ativan. Since discharge, he has had several isolated seizures.
He
had the sense of a seizure coming on [**1-2**], but it did not
progress. On [**1-4**] and [**1-5**], he had repetitive swallowing and
unresponsiveness for about 5 minutes.
From my note of [**2117-11-17**]: "He typically has clusters of
generalized
seizures in the early morning hours, usually several over the
course of 30 minutes to 2 hours, without return to baseline in
between. He typically has such clusters every 4 to 6 weeks. ...
Prior antiepileptics include the following: Initially on
Dilantin, not tolerated due to gait and memory problems. [**Name (NI) **]
on
[**Name (NI) 17802**] as single [**Doctor Last Name 360**], again with gait and memory problems.
[**Name (NI) **] added Lamictal and weaned off [**Name (NI) 17802**]. [He
self-discontinued Lamictal in [**2117-3-6**] due to belief that it
caused psychosis.] ...Increased seizures as weaned down
[**Year (4 digits) 17802**].
Started on Trileptal [around [**2117-7-6**]], stopped Lamictal. He
has
titrated up on Trileptal and [**Year (4 digits) 17802**] doses, but continues to
have frequent clusters of seizures." He has since stopped
Trileptal and stopped gabapentin in [**Month (only) 1096**] due to concerns of
somnolence (although only a dose of 300 mg per day was reached).
Formal ROS is not possible due to his current somnolence, but
his
wife is unaware of any new complaints recently.
Past Medical History:
Epilepsy as above
Bipolar disorder
Hyperlipidemia
Social History:
Former ppd smoker for 20 years, quit in [**Month (only) 205**]. Denies
EtOH. History of marijuana use, quit. No other illicit drugs.
Family History:
adopted, unknown
Physical Exam:
Physical Exam:
Vitals: T: 98.6 P: 77 R: 12 BP: 126/74 SaO2: 100%RA
General: Asleep, quiet, breathing regularly.
HEENT: NC/AT, no scleral icterus noted, resists oropharyngeal
exam.
Neck: No meningismus.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft
Neurologic:
-Mental Status: Asleep, but opens eyes briefly to voice. Follows
no commands, produces only grunts. Resists examination,
attempting to cover himself with blanket when it's removed,
moving arms and legs away, closing eyes and mouth.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6 to 2mm and brisk. Resists funduscopic exam.
III, IV, VI: Horizontal EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to voice.
IX, X: Resists testing.
[**Doctor First Name 81**]: Not tested.
XII: Uncooperative with testing.
-Motor: No adventitious movements, such as tremor, noted. Moves
all extremities spontaneously against gravity easily.
-Sensory: Responds to light touch in all four extremities.
-DTRs: Uncooperative with testing.
-Coordination & Gait: Could not be tested due to lack of
cooperation and somnolence.
Pertinent Results:
[**2118-1-28**] 05:51PM URINE HOURS-RANDOM
[**2118-1-28**] 05:51PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2118-1-28**] 05:51PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2118-1-28**] 05:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2118-1-28**] 02:07PM GLUCOSE-157* LACTATE-6.9* NA+-142 K+-4.6
CL--108 TCO2-15*
[**2118-1-28**] 02:05PM UREA N-17 CREAT-1.1
[**2118-1-28**] 02:05PM ALT(SGPT)-35 AST(SGOT)-30 LD(LDH)-302* ALK
PHOS-80 TOT BILI-0.1
[**2118-1-28**] 02:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2118-1-28**] 10:34AM LACTATE-4.3*
[**2118-1-28**] 10:25AM GLUCOSE-163* UREA N-17 CREAT-1.1 SODIUM-141
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-19* ANION GAP-17
[**2118-1-28**] 10:25AM estGFR-Using this
[**2118-1-28**] 10:25AM ALT(SGPT)-35 AST(SGOT)-24 LD(LDH)-192 ALK
PHOS-81 TOT BILI-0.1
[**2118-1-28**] 10:25AM ALBUMIN-4.4 CALCIUM-8.9 PHOSPHATE-2.1*#
MAGNESIUM-2.8*
[**2118-1-28**] 10:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2118-1-28**] 10:25AM WBC-8.7# RBC-5.25 HGB-15.5 HCT-44.3 MCV-84
MCH-29.5 MCHC-34.9 RDW-14.1
[**2118-1-28**] 10:25AM NEUTS-86.0* LYMPHS-10.7* MONOS-2.6 EOS-0.5
BASOS-0.1
[**2118-1-28**] 10:25AM PLT COUNT-281
[**2118-1-28**] 10:25AM PT-12.6 PTT-21.1* INR(PT)-1.1
Brief Hospital Course:
Mr. [**Known lastname 17797**] is a 42-year-old right-handed man with a history of
intractable epilepsy who presents with a cluster of seizures.
His neurologic exam was quite limited on admission by his
somnolence after 3 seizures and 3.5 mg of Ativan and by the fact
that he is awake enough to resist passive examination. Although
this event is in keeping with the natural history of his
intractable epilepsy - as he
historically has such clusters every 4-6 weeks - it may have
been triggered by his self-decrease in his dose of [**Known lastname 17802**]. He
was admitted to ICU for close monitoring. He did NOT require
intubation. He was continued on [**Known lastname 17802**] 200/500 (Brand name
only) and standing Ativan 1 mg po tid. Initial EEG did not show
any evidence of nonconvulsive status epilepticus and his mental
status began to improve. His EEG showed 2 electrographic
seizures during the first 24 hours, then a very brief event the
next morning. However, he returned to baseline and was very
anxious to go home. He was discharged on [**Known lastname 17802**] 200/500 and
ativan taper. He will follow-up in clinic with Dr. [**Last Name (STitle) **].
Medications on Admission:
LORAZEPAM 1 mg by mouth as needed for after seizures as needed
may
use up to 2 mg after 1st seizure
LORAZEPAM 0.5 mg by mouth as needed for seizures
ZONISAMIDE [[**Last Name (STitle) **]] 200 mg qam, 400 mg qhs
Discharge Medications:
1. Zonisamide 100 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
[**Last Name (STitle) **]:*60 Capsule(s)* Refills:*2*
2. Zonisamide 100 mg Capsule Sig: Five (5) Capsule PO QHS (once
a day (at bedtime)).
[**Last Name (STitle) **]:*60 Capsule(s)* Refills:*2*
3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO as bellow for 2
days: Take 1 tab [**Hospital1 **] today and 1 tab tomorrow.
[**Hospital1 **]:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a cluster of seizures. You were in ICU
but did not require intubation.
You should take [**Hospital1 **] 200mg AM and 500mg PM. You should also
take ativan as per prescriptions today and tomorrow.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 17798**], MD Phone:[**Telephone/Fax (1) 3506**]
Date/Time:[**2118-2-2**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1682**]
Date/Time:[**2118-2-2**] 2:30
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2118-2-4**] 12:00
Completed by:[**2118-1-30**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7617
} | Medical Text: Admission Date: [**2165-5-4**] Discharge Date: [**2165-5-25**]
Date of Birth: [**2093-12-17**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
transfer from outside hospital for respiratory failure and shock
Major Surgical or Invasive Procedure:
Mechanical ventilation
Central venous line placement
History of Present Illness:
Mr. [**Known lastname **] is a 75 year-old man with a history of COPD, CAD,
CHF who presents with respiratory failure, transferred from an
OSH.
.
Per the OSH records, patient had a gradual onset of shortness of
breath over the 24 hours prior to admission. Also with cough;
no reported fevers or chills.
.
Per EMS report, "pt had been having difficulty breathing and
chest pain since yesterday which worsened this morning...Pt
states pain and difficulty breathing began at the same time...he
points just to the (R) of his sternum and on his sternum
mid-chest when asked for the location of the pain. O2 sat 97%
on NRB."
.
Vitals at the OSH showed a temparature of 97.2, BP of 114/90, HR
90, RR 35 and an oxygen saturation of 88% on room air. Lungs
were reported as "diminished but clear". The O2 deteriorated to
the 50s on 3 liters and the patient was intubated with a #8 ETT.
Subsequently, blood pressure fell and dopamine was started.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease
2. Congestive heart failure
3. Chronic obstructive pulmonary disease on 1 liter home O2
4. Hypetension
5. History of DVT
6. Atrial fibrillation
7. s/p PPM
.
PAST SURGICAL HISTORY:
1. s/p Total hip replacement ([**6-/2153**])
2. s/p Breast mass biopsy ([**12/2162**])
3. s/p Umbilical hernia repair ([**4-/2161**])
4. s/p Vasectomy ([**11/2143**])
5. s/p Ankle (left) fracture/repair with screws ([**12/2132**])
Social History:
Until most recent admission, was still smoking and drinking.
Lives at home.
Family History:
not obtained
Physical Exam:
Vitals - T 99.4, BP 106/39, HR 123
GEN - Intubated. Not responsive.
HEENT - Sclera anicteric. No palor. Prominent jugular
pulsations.
CV - Irregular and tachycardic. No obvious murmurs.
PULM - Moving air without rales/rhonchi.
ABD - Soft. Non-distended. No apparent tenderness. RLQ scar and
midline herniation noted.
EXT - Warm. Venous stasis changes. +edema. Scar from prior ankle
surgery noted on left.
NEURO - Pupils 3mm --> 2mm and equal.
Pertinent Results:
[**2165-5-4**] 01:54PM BLOOD WBC-4.1 RBC-4.18* Hgb-13.0* Hct-44.0
MCV-105* MCH-31.2 MCHC-29.6* RDW-14.7 Plt Ct-192
[**2165-5-7**] 02:12AM BLOOD WBC-13.2* RBC-3.56* Hgb-11.1* Hct-35.2*
MCV-99* MCH-31.2 MCHC-31.6 RDW-15.3 Plt Ct-124*
[**2165-5-13**] 03:06AM BLOOD WBC-9.7 RBC-3.15* Hgb-9.9* Hct-32.4*
MCV-103* MCH-31.4 MCHC-30.5* RDW-15.8* Plt Ct-162
[**2165-5-22**] 03:07AM BLOOD WBC-6.5 RBC-2.71* Hgb-8.5* Hct-26.4*
MCV-98 MCH-31.3 MCHC-32.1 RDW-17.3* Plt Ct-232
[**2165-5-23**] 03:37AM BLOOD WBC-6.3 RBC-2.76* Hgb-8.8* Hct-26.3*
MCV-96 MCH-31.8 MCHC-33.3 RDW-17.6* Plt Ct-247
[**2165-5-4**] 01:54PM BLOOD PT-68.9* PTT-56.7* INR(PT)-8.4*
[**2165-5-11**] 03:33AM BLOOD PT-39.8* PTT-43.6* INR(PT)-4.3*
[**2165-5-22**] 03:07AM BLOOD PT-14.2* PTT-96.4* INR(PT)-1.2*
[**2165-5-23**] 03:37AM BLOOD PT-15.0* PTT-64.6* INR(PT)-1.3*
[**2165-5-4**] 01:54PM BLOOD Glucose-86 UreaN-60* Creat-1.9* Na-137
K-4.2 Cl-94* HCO3-34* AnGap-13
[**2165-5-13**] 04:40PM BLOOD Glucose-105 UreaN-75* Creat-2.0* Na-146*
K-5.0 Cl-118* HCO3-21* AnGap-12
[**2165-5-15**] 05:18PM BLOOD Glucose-84 UreaN-87* Creat-2.4* Na-149*
K-3.1* Cl-115* HCO3-22 AnGap-15
[**2165-5-17**] 06:28PM BLOOD Glucose-146* UreaN-84* Creat-2.3* Na-145
K-3.8 Cl-112* HCO3-25 AnGap-12
[**2165-5-19**] 02:52AM BLOOD Glucose-173* UreaN-60* Creat-1.7* Na-148*
K-3.9 Cl-114* HCO3-27 AnGap-11
[**2165-5-21**] 03:30AM BLOOD Glucose-146* UreaN-35* Creat-1.1 Na-142
K-4.0 Cl-107 HCO3-31 AnGap-8
[**2165-5-4**] 01:54PM BLOOD ALT-14 AST-17 LD(LDH)-210 CK(CPK)-20*
AlkPhos-65 TotBili-0.8
[**2165-5-7**] 05:30PM BLOOD Fibrino-1773*
[**2165-5-7**] 06:02AM BLOOD Hapto-417*
[**2165-5-12**] 02:30AM BLOOD TSH-2.5
[**2165-5-12**] 09:29AM BLOOD Cortsol-18.1
[**2165-5-12**] 10:35AM BLOOD Cortsol-25.1*
[**2165-5-4**] 04:30PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2165-5-10**] 04:30PM PLEURAL TotProt-1.4 Glucose-186 LD(LDH)-414
Albumin-LESS THAN
[**2165-5-10**] 04:30PM PLEURAL WBC-2250* RBC-[**Numeric Identifier 36575**]* Polys-88*
Lymphs-9* Monos-3*
[**2165-5-4**] 1:55 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2165-5-8**]**
GRAM STAIN (Final [**2165-5-4**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Final [**2165-5-8**]):
RARE GROWTH OROPHARYNGEAL FLORA.
YEAST. RARE GROWTH.
STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH.
[**2165-5-12**] 2:20 am BLOOD CULTURE Source: Line-aline.
**FINAL REPORT [**2165-5-18**]**
Blood Culture, Routine (Final [**2165-5-18**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final [**2165-5-15**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 77738**] @ 0315 ON
[**2165-5-15**]-CC6D-[**Numeric Identifier 19457**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
All other Cx including blood, sputum, urine, pleural fluid were
negative
CXR [**5-4**]
There is new right IJ line with tip in the SVC. The pacemaker is
unchanged. ET tube tip is 6.9 cm above the carina. The NG tube
tip is not well visualized. The right-sided airspace opacities
are again visualized as is volume loss/infiltrate in the left
lower lobe. The CP angles are off the film, and thus difficult
to assess for effusion on this film. Overall with exception of a
new line, there has been no significant interval change
EKG on admission:
Atrial fibrillation with a ventricular premature beat and
probably two
ventricular paced beats. Since the previous tracing of [**2165-5-5**]
ventricular
pacing is new. The first paced beat appears early and may be
related to
a non-sensed ventricular premature beat. Clinical correlation is
suggested.
Portable TTE (Complete) Done [**2165-5-7**] at 3:05:11 PM
The left atrium is markedly dilated. The right atrium is
markedly dilated. The estimated right atrial pressure is
10-15mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. There is mild global
left ventricular hypokinesis (LVEF = 40-50 %), most likely due
in part to the presence of reduced ventricular filling secondary
to atrial fibrillation with relatively rapid ventricular rate.
There is no ventricular septal defect. The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated with depressed free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. 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.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2165-5-12**] 2:49 PM
Cholelithiasis, and mild gallbladder wall thickening without
significant gallbladder distention. Wall thickening may be
secondary to underdistention of the gallbladder, or third
spacing. Given the minimal gallbladder distention, this is less
likely secondary to acute cholecystitis. Evaluation of the
common duct in the region of the pancreatic head is limited by
ultrasound technique.
US EXTREMITY NONVASCULAR RIGHT [**2165-5-12**] 2:09 PM
Focused ultrasound scanning was performed in the area of the
patient's pacemaker in the right upper chest. Pacemaker leads
are identified in the subcutaneous tissues, and there is no
evidence of surrounding fluid collection or abscess.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2165-5-12**] 11:55 AM
No evidence of acute sinusitis
CT CHEST/ABD W/CONTRAST [**2165-5-12**] 11:56 AM
1. There is no CT evidence of an inflammatory collection or an
inflammatory process in the chest, abdomen, or pelvis to explain
the patient's symptoms.
2. Bilateral bibasilar mild-to-moderate pleural effusion with
adjacent bibasilar atelectasis. No radiographic evidence of
pneumonia.
3. Ascites confined to the right upper quadrant with no
enhancing wall septations or loculations.
4. Sludge/stones in the gallbladder.
5. Cluster of calcification and hypodensity seen in the head and
uncinate process of the pancreas in close proximity may
represent a focus of chronic pancreatitis.
6. Equivocal filling defect in the lower CBD and prominant
appearance of the region of the papilla. As the patient has a
pacemaker, MR evaluation is precluded. ERCP may be useful for
further assessment/diagnosis as clinically dictated.
7. A complex cystic mass with solid enhancing rim is seen
arising from the left kidney suspecious for a renal cell
carcinoma. A targeted renal US should be confirmatory.
Brief Hospital Course:
NEURO: The patient was transferred intubated and sedated on the
ventilator. Throughout his hospital course, he had daily
wake-ups through the sedation and pain medication. Early in his
course, he awoke very agitated and not following commands,
though was alert, looking around the room and moving all
extremities with equal and reactive pupils. He had a history of
alcohol use, and had experienced DT's in the past with
withdrawal. Consequently, he was maintained on a versed drip and
much of the confusion was attributed to possible withdrawal in
addition to delerium. With re-evaluation by wake-ups, the
patient slowly became more attentive and did not have
tremors/shakes, was following commands and communicated that he
was not in any discomfort. After extubation, a full neuro exam
was normal including strength/sensation, cranial nerves, DTRs,
cerebellar exam and speech/memory.
HEENT: The patient was noted to have poor dentition, but no
signs of abscess/infection on oral exam. In addition, a CT scan
of his head was normal and showed no signs of sinusitis.
PULMONARY: His active problems during this admission were
respiratory failure, pneumonia, pleural effusion. The main
concern for this patient was that of pneumonia, and strep
pneumonia grew in the first sputum culture on admission. He was
noted to have a large R pleural effusion, which was tapped, but
did not show evidence of empyema. He remained on the ventilator
for 17 days. Upon extubation, he did well, had minimal
secretions and strong cough, O2 sats in the 90's, work of
breathing was easy.
CARDIAC: Active issues during this admission included
hypotension and atrial fibrillation, with a history of CAD and
CHF. The hypotension was not fluid responsive and he required
levophed pressor support for the first 15 days of
hospitalization. This was weened off and he was eventually
restarted on all of his home HTN medication. The hypotension was
felt to be sepsis physiology, without evidence of new mycardial
injury. The atrial fibrillation remained rate controlled, and at
first anticoagulation was held [**3-9**] a supratherapeutic INR. This
came down to normal levels, and a heparin drip was started and
he is being bridged back onto coumadin. In terms of his CHF, an
echo revealed only mildly depressed LVEF at 40-50%, and
specifics are listed in the report above.
GI/FEN: patient was aggressively volume resuscitated early on,
being at the highest 27 liters positive on his i/o's. This
eventually was diuresed to a slightly positive volume status,
and he will go to rehab with continued diureses. He was started
on tube feeds with help from the nutritionists, and will be
going to rehab taking PO.
RENAL/GU: The patient came to the service with mildly reduced
renal function. Upon receiving his CT his renl function
deteriorated and was felt to have contrast nephropathy. Over the
next week this resolved to his baseline.He responded well to
Lasix and metolazone diuresis as described above.
HEME/ID: Active issues included elevated INR (as described
above), and positive cultures included strep pneumonia on sputum
and 1/2 bottles of GPC bacteremia. His antibiotic course
intially was broad, including levaquin, ceftriaxone, vancomycin
and zosyn (broad plus double coverage). This was tailored down
to ceftriaxone to cover the strep pneumonia that was speciated
from the sputum. The patient started requiring slightly higher
pressor support 1.5 weeks into admission, started spiking
nocturnal fevers, and subsequently grew the coag negative staph.
He was broadened again for this, though was felt this was likely
contaminant. His fever curve and white count normalized and the
course of antibiotics was d/c'd. He also developes some
diarrhea, but c.diff was negative x 3 (got PO flagyl until
negative cx came back)
Prophylaxis: remained on sch, then hep gtt/coumadin, pneumoboots
and PPi
Code: remained full code throughout
Dispo: discharge to rehab facility
Medications on Admission:
1. Atenolol 50mg [**Hospital1 **]
2. Diamox 500mg daily
3. Torsemide 100mg daily
4. Digoxin 0.25mg daily
5. Coumadin 5mg daily
6. Duoneb QID
7. Theophylline 200mg [**Hospital1 **]
8. Floridil x1 month
9. Flovent 110mcg [**Hospital1 **]
10. Spiriva daily
11. Tylenol PRN
12. Mucinex 400mg PRN
13. Viagra 100mg PRN
14. Chantix
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): hold for loose stool.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for agitation or anxiety.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Titrate to INR [**3-10**].
9. Heparin Drip
Titrate to goal PTT 60-80. Discontinue once INR = [**3-10**].
10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day:
Check digoxin level qweek. .
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
12. Diamox Sequels 500 mg Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO once a day.
13. Torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day.
14. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
15. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: [**2-6**] capsule Inhalation once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] ne [**Location (un) **]/[**Hospital1 **]
Discharge Diagnosis:
Sepsis
Streptococcal Pneumonia
respiratory failure
Acute renal failure
congestive heart failure
COPD
Atrial fibillation with rapid ventricular response
kidney cystic lesion
Discharge Condition:
Stable
Discharge Instructions:
During this admission you were treated for a severe pneumonia,
requiring intubation and life support. You will be discharged
to a rehab facility. Please continue to take all medications as
prescribed, and follow up with your PCP within [**Name Initial (PRE) **] few days of
leaving rehab.
On the CT scan of your abdomen, there was a cystic lesion found
on your left kidney. This was an incidental finding and not
associated with your problems during this hospitalization,
however, this should be followed up with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 6349**], as it is possible this may represent
carcinoma.
Followup Instructions:
follow up with your PCP within [**Name Initial (PRE) **] few days of leaving rehab.
[**Last Name (LF) 16826**],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 33980**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2165-5-23**]
ICD9 Codes: 5845, 5119, 5990, 2760, 4280, 496, 5859, 2767, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7618
} | Medical Text: Admission Date: [**2144-4-14**] Discharge Date: [**2144-5-18**]
Date of Birth: [**2068-6-9**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
75yo woman w T cell lymphoma, s/p CHOP D11, presents to clinic
with 1 day of fatigue and subjective fevers. Noted to have T
101.2 in clinic. Denies any symptomatic focus of infection. Had
one day of loose watery diarrhea x 4 episodes 2 days prior to
admission but none since. She is also complaining of poor po
intake due to oral mucositis. Denies cough, SOB, dysuria,
sputum.
.
ROS
Apart from mouth sores, otherwise negative in detail.
Past Medical History:
1. Lumbar spinal spondylosis.
2. Hypertension
3. Bronchiectasis.
4. Hyperlipidemia.
5. History of pancreatic cyst.
6. Elevated 5-HIAA, without further w/u
7. Irritable Bowel Syndrome
8. spinal stenosis
9. Newly diagnosed T cell lymphoma s/p 1 cycle of CHOP
Social History:
Originally from [**Country 5881**], moved here 40 years ago. Now splits time
in homes in [**Location (un) 2624**] and [**Location (un) 9188**]; also goes to [**Hospital3 **], but not
recently. No recent travel; has mostly stayed indoors in the
last few months. Denies tobacco use, social drinker, no IVDU.
Family History:
Father died of complications of EtOH use. Mother died of TB of
spine when pt was 3 yo, and sister had TB ~60-70 years ago, when
they were in [**Country 5881**]. Does not recall ever having TB herself.
Physical Exam:
On admission -
Exam: T99.3 BP 150/86 HR 80 RR 18 sats 98% RA
Gen: resting comfortably, NAD
HEENT: Anicteric MMM OP clear
Neck: no palp LAD. Healed mediastinoscopy scar. JVP NE
Lungs: L basal crackles
Cards: RRR no MGR
Abd: BS+ NT ND soft, no HSM
Ext: no edema
Pertinent Results:
==========
Labs
==========
admission -
[**2144-4-13**] 12:00PM BLOOD WBC-0.5*# RBC-3.51* Hgb-10.3* Hct-29.5*
MCV-84 MCH-29.2 MCHC-34.8 RDW-15.2 Plt Ct-117*
[**2144-4-13**] 12:00PM BLOOD Glucose-140* UreaN-12 Creat-0.8 Na-134
K-3.7 Cl-100 HCO3-26 AnGap-12
[**2144-4-14**] 11:30AM BLOOD ALT-15 AST-11 LD(LDH)-164 AlkPhos-44
TotBili-0.4
[**2144-4-14**] 11:30AM BLOOD Albumin-2.6* Phos-1.9* Mg-1.1*
===========
Microbiology
===========
Urine [**4-14**] and [**4-15**]
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
=============
Radiology
=============
CT Head [**4-18**]
Extensive chronic microvascular infarct without evidence of
neoplastic or infectious process; however, MRI remains more
sensitive for this indication.
.
CT Torso [**4-18**]
1. Prominent mediastinal and hilar adenopathy is slightly less
bulky along
the right paratracheal region but unchanged in the subcarinal
region.
Adenopathy in the abdomen is improved.
2. Since [**2144-3-31**], there has been interval near-complete
resolution of right
pleural effusion but the patient now has new small to moderate
left pleural
effusion with adjacent compressive atelectasis. However, no
evidence of new
pneumonia.
3. Distended gallbladder with cholelithiasis, but no wall
thickening or
pericholecystic fluid.
4. Small hiatal hernia. Sigmoid diverticulosis.
.
MRI Head [**4-21**]
1. No acute infarction. No focal lesions in the brain parenchyma
to suggest
neoplastic or infectious etiology. Nonspecific white matter
changes in the
cerebral white matter on both sides, likely due to sequelae of
chronic small vessel occlusive disease, with other etiologies
being less likely, due to lack of IV contrast enhancement.
.
CT Head [**4-23**]
IMPRESSION:
1. No intracranial hemorrhage.
2. Periventricular white matter changes, stable from prior,
likely
representing chronic microvascular disease.
.
CT head [**5-2**]
IMPRESSION:
1. No acute intracranial process. Meningeal inflammation cannot
be excluded on this non-contrast study.
2. Stable extensive microvascular disease.
.
MR head [**5-13**]
IMPRESSION:
1. Stable patchy confluent nonenhancing T2/FLAIR
hyperintensities within the subcortical white matter, centrum
semiovale, corona radiata, and periventricular regions. This is
nonspecific and likely represents chronic microangiopathic small
vessel ischemic changes.
2. No evidence for acute infarct or hemorrhage.
Brief Hospital Course:
# Fever and Neutopenia: Patient initially covered with broad
spectrum antibiotics including Vancomycin and Cefepime. Culture
data only revealed Eneterococcus in the urine sensitive to
Vancomycin. Counts recovered with Neupogen but patient remained
febrile. CT Torso was unremarkable and blood cultures were
negative. As mental status progressively deteriorated (see
below) antibiotics were changed to Ceftriaxone, Ampicillin,
Vancomycin and Acyclovir for meninigitis coverage.
.
# Altered mental status: Patient's mental status worsened and
eventally became non-responsive. LP was not consistent with
bacterial meningitis, but since WBC was poly predominant
meningitis doses of antibiotics were administered. Viral studies
and CSF culture data were negative. An EEG revaled that patient
was in nonconvulsive status epelepticus. Patient was started on
Keppra and Ativan, and mental status cleared. An MRI head
revealed signs consistent with CNS lymphoma and CSF revealed
atypical cells. Goals of care were changed to comfort measures
only on [**4-23**], and confirmed on [**4-24**], but family decided to
discontinue CMO order on [**4-25**]. After further conversations with
family, the decision was made to make her FULL CODE and to
proceed with further chemotherapy.
.
Events in chronological fashion:
[**4-27**]: Pt received a one-time administration of high dose
methotrexate intravenously on the night of [**4-27**]. She was given
aggressive hydration with bicarb solution to keep her urine
alkalinized (pH>8.0), promoting elimination of methotrexate.
Despite this, serial levels showed that the clearance of
methotrexate was delayed. In the first few days after
methotrexate, pt remained alert and oriented x 3, although her
mentation did wax and wane at times for unclear reasons.
[**4-28**]: Keppra was uptiratred from 750 mg to 1000 mg IV BID
[**4-29**]: New hives on back. Derm consult was obtained. NOT thought
to be due to any medications, more likely dermatographism. Pt
c/o itchiness however only topical sarna lotion was used in
favor of avoiding sedating medications.
[**4-30**]: Pt became febrile to 100.5 early morning of [**4-30**]. Cefepime
was started. In the afternoon of [**4-30**], pt was noted to be more
somnolent and yet more irritable. Pt appeared very
uncomfortable. Pt did not answer questions or follow commands
consistently. She failed to make eye contact. She was noted to
have body tremors, which subsided briefly after 1 mg of Ativan
then returned.
[**5-1**]: Overnight of [**2050-4-29**] pt continued to be somnolent and
tremulous. Multiple doses of ativan were given to little effect.
Acyclovir was started for concern of HSV encephalitis.
Infectious work up was initiated.
[**5-2**]: CT scan did not show any acute changes. Vancomycin was
started. 24hr video EEG monitoring was begun.
[**5-3**]: Pt was noted to be back in status epilepticus. Keppra was
increased to 1 g TID. Pt was loaded with phenytoin 1 g followed
by 100 mg IV Q8 hrs, Dexamethasone 10 mg IV then 4 mg IV BID.
EEG monitoring was continued. All antimicrobials were continued
although microbiology data so far had been negative. A lumbar
puncture was performed for interval check of lymphoma in CNS and
pt was also given IT Ara-C.
[**5-4**]: Pt remained in status despite the multiple anti-epileptics
and pt was transferred to the ICU for phenobarbital
administration.
MICU course:
She was transferred to [**Hospital Unit Name 153**] for elective intubation for
initiation of phenobarbital
# Sedation/ Unresponsiveness: Her mental status continued to be
nonresponsive for >1 week. This was likely secondary to
persistent phenobarbital, as levels were high. This trended
down from a peak of 35 but has persisted in the low 20s for
days. Portions of her neuro exam improved slowly, and when her
level fell to 16 she was able to follow simple commands. She
had a repeat MRI that was unchanged. . Neuro has said that
there is no role for rpt imaging.
.
# Seizures/Status Epilepticus: She was initially on continuous
EEG monitorring. She stopped seizing, so EEG was discontinued.
Keppra and fosphenytoin were continued. Phenobarbital levels
trended down. Neurology trended down.
.
# Ventilatory support.: Intubated electively for phenobarb
initiation without underlying acitve pulmonary issues. She was
initially apneic when on PSV but later had spontaneous
breathing.
# Bacteremia: On [**4-14**], patient developed leukocytosis and
low-grade fever. Vanc/Zosyn were started for possible VAP. On
[**4-15**], blood cultures grew gram positive cocci in short chains
and pairs, suspicious for VRE. Goals of care were revised, so
all antibiotics were stopped.
.
# Hyponatremia: Urine lytes and osms were consistent with SIADH,
likely secondry to her intracranial process. Free water was
restricted.
# T Cell Lymphoma: BMT service followed her. She was s/p CHOP,
MTX, and IT cytaribine. Leukovorin was stopped given
undetectable MTX levels. Dexamethasone and PCP/HSV ppx were
continued.
# Hypertension: well controlled on metoprolol
# Goals of care: Given poor prognosis of her T-cell lymphoma as
well as the complicated ICU course including bacteremia, the
patient's family elected to extubate and move toward comfort
measures. All medications including antibiotics were stopped,
dexamethasone was continued given chronic steroid use, morphine
was started PRN. She was extubated and called out to the BMT
service. Pt was given morphine drip for comfort and valium to
suppress any seizure activity. Pt passed the morning of [**2144-5-18**].
Medications on Admission:
Acyclovir
Clotrimazole Troche
Fluconazole
Folic Acid
Levofloxacin [[**Date Range **]]
Lorazepam
Metoprolol Tartrate
Omeprazole
Ondansetron [ZOFRAN ODT]
Cholecalciferol (Vitamin D3) [Vitamin D-3]
Discharge Medications:
N/A
Discharge Disposition:
Expired
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
T cell lymphoma with CNS involvement
Sepsis
Pneumonia
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2144-5-19**]
ICD9 Codes: 5990, 5849, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7619
} | Medical Text: Admission Date: [**2191-3-25**] Discharge Date: [**2191-4-14**]
Date of Birth: [**2127-11-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right upper lobe lung cancer.
Major Surgical or Invasive Procedure:
1) [**2191-3-25**]: Video-assisted thoracic surgery (VATS) right
upper lobectomy and mediastinal lymph node dissection.
[**1-1**]) [**2191-3-28**], [**2191-3-31**], [**2191-4-1**], [**2191-4-9**]: Flexible
bronchoscopy
6) [**2191-4-7**]: Right thoracotomy, right middle lobectomy
History of Present Illness:
The patient is a 63-year-old gentleman who has at least stage
IIA non-small-cell lung cancer. He presents for resection.
Past Medical History:
PMH: glaucoma, AFib (last event [**2180**]), ex-lap and washout for
abdominal stab wound
[**Last Name (un) 1724**]: none
Social History:
Married lives with wife. [**Name (NI) 1139**] 40 pack-year. ETOH none
Family History:
Mother died at 86, unknown
Father died at 93, unknown
Physical Exam:
VS:T: 96.9 HR: 68-71 SR BP: 122-140/60 RR 18 Sats: 99% RA
Wt: 80.2
General: 63 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes
Neck: supple
Card: RRR
Resp: decreased breath sounds at bases otherwise clear
GI: benign
Extr: warm R 2+ edema, Left 1+ edema
Incision: R VATs site clean dry margins well approximated. 1
chest tube site margins not well approximated
Neuro: awake, alert, oriented.
Pertinent Results:
[**2191-4-14**] WBC 12.1 HCT 25 Plts 616
[**2191-4-13**] WBC 13.8 HCT 26 PLT 698
[**2191-4-10**] WBC 17.8 HCT 27 PLT 604
[**2191-4-14**] INR 1.8 (2.0 mg Coumadin)
[**2191-4-13**] INR 1.5 (2.5mg Coumadin)
[**2191-4-12**] INR 1.3 (2.5 mg Coumadin)
[**2191-4-14**] Na 136 K 3.7 Cl 101 HCO3 27 BUN 31 CRE 2.8
[**2191-4-13**] Na 137 K 3.6 CL 100 HC03 28 BUN 28 CRE 2.7
[**2191-4-12**] Na 136 K 3.2 CL 99 HCO3 31 BUN 26 CRE 2.6
[**2191-4-11**] NA 134 K 3.5 CL 98 HCO3 27 BUN 20 CRE 1.9
[**2191-4-10**] NA 133 K 3.8 CL 96 HCO3 29 BUN 10 CRE 0.9
[**2191-3-28**] CK-MB-3 cTropnT-0.02* [**2191-3-27**] CK-MB-3 cTropnT-0.01
[**2191-3-27**] CK-MB-3 cTropnT-0.01
[**2191-4-4**] Calcium-8.7 Phos-2.4* Mg-2.1
Micro:
C. diff negative [**2191-4-14**]
Urine Cx negative
BC x 4 no growth
[**2191-4-7**] Pleural culture Strep Viridens
[**2191-4-7**] Tissue no growth
[**2191-4-7**] BAL commensal
CXR:
[**2191-4-12**]:The previously present right-sided chest tube
terminating in the apical area has been removed. No pneumothorax
has developed. A right-sided chest tube terminating in the
pleural space on the right lung base remain in unchanged
position. No new pulmonary or pleural abnormalities are seen.
The amount of remaining pleural effusion in the posterior
pleural sinus appears grossly unchanged when comparing the
findings on the lateral views.
[**2191-4-9**]: Improved aeration in right lung compared with earlier
the same day However, considerable persistent opacity diffusely
throughout right lung, which appears to represent a combination
of diffuse
alveolar opacity and pleural thickening and/or fluid.
2. Retrocardiac patchy opacity, worse compared with the most
recent prior
film.
[**2191-4-4**]: Improving right upper lung postoperative hematoma
Decreased asymmetric right pulmonary edema. Decreased minimal
bibasilar atelectasis.
Unchanged small left and tiny right pleural effusions
[**2191-4-3**]: The patient is status post right upper lobe
resection. Large
homogeneous opacity extending from the right apex to the right
hilum appears similar compared to the previous post-operative
studies and could reflect a large hematoma. Heart size remains
normal. Linear bibasilar atelectasis is present, left greater
than right, with interval worsening on the left compared to the
prior study. Small left pleural effusion is apparently new.
[**2191-4-1**]: An endotracheal tube and nasogastric
tube remain in place. The changes of right upper lobectomy are
redemonstrated as is right pleural fluid, presumably hematoma.
The degree of subsegmental atelectasis in the left lower lobe
has improved and right middle lobe atelectasis is unchanged.
[**2191-3-30**]: New right lower lobe opacity is consistent with large
right lower lobe atelectases. Patient has known right middle
lobe atelectases. There is probably a small right pleural
effusion. The cardiomediastinum is shifted towards the right
side. In the left lung, there is a small left pleural effusion
and left lower lobe atelectases.
[**2191-3-26**]: new right paramediastinal opacity, which is
concerning for either mediastinal hematoma or newly developed
atelectasis of right middle lobe with questionable torsion.
CCT
[**2191-3-27**]: Area of contrast extravasation in the expected
location of the right middle lobe.
A severe narrowing, just distal to the origin of the artery
supplying the
right middle lobe and incomplete visualization of the right
middle lobe
bronchus are concerning for right middle lobe torsion with
active
extravasation into a small hematoma in the region.
Atelectasis in the superior segment of the right lower lobe.
Echocardiogram
[**2191-3-27**]: The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded, but none are seen. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. The mitral valve leaflets are grossly normal. There
is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 4949**] was admitted [**2191-3-25**] following Video-assisted
thoracic surgery (VATS) right upper lobectomy and mediastinal
lymph node dissection. He was extubated in the operating room,
monitored in the PACU prior transfer to the floor with a left
chest tube, Foley, Dilaudid PCA for pain.
Event: [**2191-3-31**] flexible bronchoscopy in the operating room,
transfer to the ICU intubated, bedside bronchoscopy [**2191-4-1**]
successfully extubated, transfer to the floor [**2191-4-2**].
Respiratory: incentive spirometer and nebs were done. On
[**2191-3-28**] his chest film showed right middle collapse. He was
taken to the operating room for bronchoscopy with showed large
mucus plug. He transfer to the floor in stable condition. On
[**2191-3-31**] his CXR showed collapsed right lung he was taken to the
operating room for flexible bronchoscopy and removal of small
clot in the distal bronchus intermedius. He transfer to the ICU
intubated for positive pressure support. He underwent bedside
flexible bronchoscopy on [**2191-4-1**] and was successfully
extubated. With continued aggressive chest PT, nebs and good
pain control he titrated off oxygen with saturation off 93-95%
RA at rest and with activity. Pt was transferred to the floor
with improving oxygen saturation. Series of quotidien fevers
and spike to 101.8 [**4-6**] prompted CT chest concerning for
infection/necrotic RML. Taken to OR [**4-7**] for R thoracotomy,
RMLobectomy and placement R chest tubes x 2, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain.
Tolerated procedure well and was xferred to the SICU for
extubation on [**4-8**]. Bronchoscopy performed [**4-9**] for concern of
mucus plugging in RLL. CXR improved post-procedure.
Transferred to floor [**4-10**] satting well and ambulating. Pulmonary
toilet and ambulation were encouraged on the floor. Room air
oxygen saturations 99% on discharge.
Chest-tube: right initially with a large amount of drainage,
slowly taper off and was removed on [**2191-3-30**]. Two additional R
chest tubes and [**Doctor Last Name **] drain placed in OR [**4-9**]. R antero-apical
CT d/c'd [**4-11**]. R postero-apical CT d/c'd [**4-12**].
Chest-film serial CXR showed see above reports.
Cardiac: intermittent atrial fibrillation 100-140's. He was
started on amiodarone infusion converted to sinus rhythm within
24-48 hrs, but continued to have intermittent atrial
fibrillation with rates of 140-150's with hypotension requiring
low-dose pressors, IV amiodarone & PO 400 mg [**Hospital1 **] transitioned to
200 mg daily [**2191-4-6**] after completing 6 gm load. Diltiazem was
started for RVR and titated too 30 mg qid. He converted to sinus
rhythm [**2191-4-3**] 50-60's on amiodarone and diltiazem and remained
in sinus. The cardiac enzymes were negative. Echocardiogram
[**2191-3-27**] with Normal left ventricular cavity sizes with low
normal global systolic function. No pericardial effusion. No
left atrial dilation. Amiodarone and diltiazem were titrated in
relationship to HR and systolic blood pressure with patient
intermittently alternating between afib and sinus rhythm. On
discharge his he was in sinus rhythm 60's. Blood pressure
130-140 stable.
GI: PPI and bowel regime. Tolerated a regular diet
Renal: Foley required re-insertion for low urine output. Over
his hospital course he was hypervolemic reqiring gentle
diuresis. His renal function was normal. His electrolytes were
replete. Serum creatinine increased from 0.9, Peak 2.8 in
setting of tobramycin, vancomycin, flagyl, zosyn for RML
necrotizing PNA s/p resection. Tobramycin discontinued.
Vancomycin and zosyn renally dosed. FeNa: 1.1% and FeUrea 42%
consistent with ATN likely secondary to aminoglycoside toxicity.
Electrolytes checked [**Hospital1 **]. His discharge CRE 2.7. His Chem 7
will be monitored with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
ID: low-grade fevers with mild leukocytosis he was started on
Levofloxacin [**2191-4-2**] for possible PNA. Pan cultured with no
growth. Giving finding of necrotic RML, started on vancomycin,
tobramycin and zosyn [**4-9**]. Flagyl started [**4-10**]. Tobra
discontinued [**4-11**] in setting of ATN. Flagyl discontinued [**4-11**].
Vancomycin was stopped with increased CRE, Zosyn dosed renally
continued until discharge on [**2191-4-14**] when he was changed to 14
day course of Moxifloxacin. Infectious disease signed off and
will follow as needed.
Heme: Cardiology recommended anticoagulation. He was started on
heparin/Coumadin bridge on [**2191-4-3**] he received 2.5 mg [**2191-4-3**]
(INR 1.3) [**2191-4-4**] 2.5 (INR 1.5). Coumadin held and vitamin K
given [**4-8**] in preparation for OR [**4-9**]. Anticoagulation resumed
[**4-10**] with heparin gtt. Coumadin resumed [**4-11**]. Heparin was
stopped [**4-11**]. His INR on discharge was 1.8. He was instructed
to take 2 mg Warfarin and to follow-up with his PCP as an
outpatient.
Pain: Dilaudid PCA transition to PO with good pain control
Disposition: Home with his wife and [**Name (NI) 269**] on [**2191-4-14**]. He will
follow-up with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for warfarin follow-up and Dr.
[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. warfarin 1 mg Tablet Sig: One (1) Tablet PO as directed: Goal
INR 2.0-3.0.
Disp:*100 Tablet(s)* Refills:*2*
6. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 IH* Refills:*2*
7. diltiazem HCl 180 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Outpatient [**Last Name (STitle) **] Work
Chem 7 Monday [**2191-4-18**].
Please fax results to Dr. [**Last Name (STitle) **] PCP office
Phone: [**Telephone/Fax (1) 7751**] Fax: [**Telephone/Fax (1) 7752**]
12. Outpatient [**Name (NI) **] Work
PT/INR 3 x week prn
Please fax results to Dr. [**Last Name (STitle) **] PCP office
Phone: [**Telephone/Fax (1) 7751**] Fax: [**Telephone/Fax (1) 7752**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Right upper lobe nodule
Glaucoma
Paraoxysmal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
-Cover 1 chest tube site with a dry dressing until healed
-Daily weights. Support stockings for lower extremity swelling
Pain
-Take acetaminophen 650 mg every 8 hrs as needed for pain
-Oxycodone 5 mg every 4-6 hours as needed for pain.
New Medication:
-Amiodarone 200 mg daily. Please follow-up with Dr. [**Last Name (STitle) **]
regarding stopping this medication.
-Diltiazem 180 mg daily.
-Warfarin for atrial fibrillation. INR Goal 2.0-3.0
Activity
-Shower daily. Wash incision with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tub until incision healed
-No lifting greater than 10 pounds until seen
-Walk frequently
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2191-4-28**]
3:00
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center.
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Follow-up with Dr. [**Last Name (STitle) **] Tuesday [**4-19**] at 3:30 pm
Blood draw Monday [**2191-4-18**] to monitor renal function and INR
Friday and Monday. Please call Dr.[**Name (NI) 7753**] office [**Telephone/Fax (1) 7751**],
Fax [**Telephone/Fax (1) 7752**] for a follow-up appointment
Please call Dr.[**Name (NI) 7753**] office for a follow-up appointment
regarding your heart medication.
Completed by:[**2191-4-14**]
ICD9 Codes: 486, 5845, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7620
} | Medical Text: Admission Date: [**2155-7-30**] Discharge Date: [**2155-8-1**]
Date of Birth: [**2090-1-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
100% occlusion of RCA s/p aspiration thrombectomy and Promus DES
to prox RCA; also with normal LMCA, 60% eccentric mid-distal
LAD, 70-80% mid long LCx lesion
History of Present Illness:
65yoM with NO h/o CAD but with active smoking, +FHx, and ? HL
who presented to [**Hospital6 10353**] after awakening with
substernal CP at 3am, radiating to both shoulders. He was unable
to get back to sleep, so eventually went to [**Hospital1 392**] at 9am. He
also reported some lightheadedness and SOB on the prior day, but
no CP.
.
There, EKG showed elevation in III with inferior Q waves, STD in
V2, and sub millimeter depressions in lateral/high lateral
leads. Cardiac enzymes and all other labs were pending there by
transfer here. There, he was given 325 ASA, Plavix 600 mg PO, 1
SL NTG, 1L NS, and 1mg Ativan. He was transferred to [**Hospital1 18**] for
further management.
.
Here, he was taken to cath lab and found to have 100% proximal
RCA culprit lesion and had aspiration thrombectomy followed by
DES (2.5 x 15 Promus) to prox RCA with post-dilation, no
residual stenosis, and TIMI 3 flow to distal vessel. Also noted
to have normal LMCA, 60% eccentric mid-distal LAD, 70-80% mid
long LCx lesion. He had R radial approach.
.
On arrival to CCU, pt is currently resting comfortably with
stable hemodynamics and Integrilling running. ROS reviewed, as
above o/w negative, pt was in good health, working, etc. Denied
any CP, decrease in exercise tolerance, orthopnea, SOB, syncope,
leg swelling.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia (states "cholesterol was
350" was previously on meds but none currently, +FHx as below
2. CARDIAC HISTORY:
- Inferior STEMI [**2155-7-30**]: 100% occlusion of RCA s/p aspiration
thrombectomy and Promus DES to prox RCA; also with normal LMCA,
60% eccentric mid-distal LAD, 70-80% mid long LCx lesion
3. OTHER PAST MEDICAL HISTORY:
- Bladder cancer: per pt this is not active
- Active smoker ~1 ppd
Social History:
SOCIAL HISTORY: Lives at home with wife and has 2 children.
Lives in [**Hospital1 392**]. Was a bartender for a long time, now currently
working as a courier and able to do ADL's, can ambulate well.
Smoker for 25 yrs, then quit for 10, restarted 15 yrs ago and
smokes a little less than 1 pdd. States he drinks 3-4 drinks per
day but no eye openers, denies withdrawal sxs, seizures,
hallucinations, DT's. No illicit drugs
Family History:
Mother: deceased at 70 yo, [**Name (NI) 64763**]
Father: deceased at 50 yo of MI
[**Name (NI) **] brother: CABG
[**Name (NI) **] 5 brothers, 2 with prostate ca; has 3 sisters, 2 with
Parkinsons
Physical Exam:
PHYSICAL EXAMINATION:
95.6 135/60 p55 12 99%RA
Well, healthy appearing M in no distress, is not obese, sleeping
comfortably but awoken easily, pleasant
EOMI, no scleral icterus, mouth slightly dry but no OP lesions,
no JVD or HJR
CTAB with good air movement, no adventitious lung sounds at all
RRR with soft S1/S2, best heard LUSB, no murmurs. Strong L
radial pulse, R radial band on.
Abd normal, not obese, soft NT ND, benign
BLE's are without edema, all extrems are warm well perfused, no
cyanosis
CN 2-12 grossly intact, moving extremities, no gross focal neuro
deficits noted
Pertinent Results:
[**2155-7-30**] 10:46PM CK(CPK)-2520*
[**2155-7-30**] 10:46PM CK-MB-269* MB INDX-10.7* cTropnT-2.49*
[**2155-7-30**] 10:46PM HCT-40.2
[**2155-7-30**] 05:05PM HCT-39.7*
[**2155-7-30**] 01:13PM PLT COUNT-245
[**2155-7-30**] 11:00AM GLUCOSE-118* UREA N-13 CREAT-0.6 SODIUM-141
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-20* ANION GAP-20
[**2155-7-30**] 11:00AM estGFR-Using this
[**2155-7-30**] 11:00AM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-1.9
CHOLEST-280*
[**2155-7-30**] 11:00AM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-1.9
CHOLEST-280*
[**2155-7-30**] 11:00AM %HbA1c-5.3 eAG-105
[**2155-7-30**] 11:00AM TRIGLYCER-217* HDL CHOL-69 CHOL/HDL-4.1
LDL(CALC)-168*
[**2155-7-30**] 11:00AM WBC-9.1 RBC-4.01* HGB-14.9 HCT-39.9* MCV-100*
MCH-37.0* MCHC-37.2* RDW-14.0
[**2155-7-30**] 11:00AM NEUTS-78.6* LYMPHS-17.5* MONOS-3.1 EOS-0.7
BASOS-0.2
[**2155-7-30**] 11:00AM PLT COUNT-231
[**2155-7-30**] 11:00AM PT-12.1 PTT-23.8 INR(PT)-1.0
.
[**2155-7-30**]
Cardiac Cath:
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated severe 2 vessel CAD. The LMCA was normal. The mid
LAD had a
60% eccentric lesion. The mid LCX had a long 70-80% lesion. The
dominant
RCA was 100% occluded proximally.
2. Left ventriculography was deferred.
3. Successful thrombectomy and PCI of the proximal RCA with
Promus DES.
4. Terumo band to the right radial artery.
5. No complications of the procedure .
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease (RCA, LCX).
2. Acute inferior STEMI, managed by acute PTCA of the culprit
lesion.
3. Successful thrombectomy and PCI of the proximal RCA with a
2.5x15mm
Promus DES.
4. Aspirin 325mg/day for one month, followed by 81mg/day
indefinitely.
5. Plavix (clopidogrel) 75mg/day for 12 months.
6. Consideration of PCI of the LCX with residual ischemia.
.
Echo: [**2155-7-31**]
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with
inferior/inferolateral akinesis/hypokinesis (see diagram).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). The right ventricular cavity is
mildly dilated with focal basal free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
.
discharge:
[**2155-8-1**] 07:50AM BLOOD WBC-8.6 RBC-3.77* Hgb-13.6* Hct-38.6*
MCV-102* MCH-36.0* MCHC-35.2* RDW-13.4 Plt Ct-195
[**2155-8-1**] 07:50AM BLOOD Plt Ct-195
[**2155-8-1**] 07:50AM BLOOD PT-11.9 PTT-22.0 INR(PT)-1.0
[**2155-8-1**] 07:50AM BLOOD Glucose-94 UreaN-22* Creat-0.8 Na-140
K-3.8 Cl-102 HCO3-29 AnGap-13
[**2155-7-30**] 11:00AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.9 Cholest-280*
[**2155-7-30**] 11:00AM BLOOD %HbA1c-5.3 eAG-105
[**2155-7-30**] 11:00AM BLOOD Triglyc-217* HDL-69 CHOL/HD-4.1
LDLcalc-168*
Brief Hospital Course:
65yoM with no prior cardiac history but with long smoking
history, family history, and possible hyperlipidemia but no
known HTN, DM who is admitted to CCU after inferior STEMI now
s/p aspiration thrombectomy and DES applied to proximal RCA with
good flow afterwards.
.
1. Inferior STEMI: Pt presented with trop 2.49, ekg showed
elevation in III with inferior Q waves, STD in V2, and sub
millimeter depressions in lateral/high lateral leads. Pt went
for emergent cath, and had DES put in prox RCA with improved
flow afterwards. He was given integrillin for 18hrs post cath
and started on ASA 325 for one month and then will transition to
81mg daily, plavix daily for one year, lisinopril 5mg daily,
atorvastatin 80 mg daily and metoprolol XR 25mg daily. He
remained hemodynamically stable and was transferred to the
floor. Post-cath echo showed: mild regional left ventricular
systolic dysfunction with inferior/inferolateral
akinesis/hypokinesis with EF of 45%. He was monitored on
telemetry with no events. PT evaluated pt and determined that
he was safe to go home with no needs for acute rehab. He was
counseled on lifestyle changes and demonstrated good
understanding. Pt will need repeat echo in one month and close
PCP/cards follow up.
.
.
Transitional
.
PCP needs to know about LDL goal of 70, f/u A1C
repeat echo in one month
Medications on Admission:
OTC allergy meds
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. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Inferior ST Elevation Myocardial Infarction
Acute systolic heart failure with ejection fraction of 45%
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 33856**],
It was a pleasure taking care of you. You were admitted to the
hospital after having sustained a heart attack. You underwent a
cardiac catheterization and had a stent placed. You also had an
echocardiogram which showed your heart function was good. You
were started on a number of medications which you will need to
continue to take daily as prescribed. We also HIGHLY recommend
that you quit smoking, this is the single most important thing
you can do at the moment to prevent another heart attack.
Please talk with your PCP about strategies to help you quit.
You will need to follow up with you PCP in [**Name Initial (PRE) **] weeks time as well
as your cardiologist in [**1-2**] weeks. Call your PCP if you notice
that your weight increases more than 3 pounds in 3 days.
MEDS:
Start atorvastating 80 mg by mouth daily
Start clopidogrel 75 mg by mouth daily
Start asprin EC 325 mg by mouth daily
Start Lisinopril 5 mg by mouth daily
Start metoprolol succinate 25 mg by mouth daily
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2155-8-8**] at 3:15 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73069**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*Dr [**Last Name (STitle) **] is your new physician at [**Name9 (PRE) 191**]. He works
closely with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in your
care.
Department: CARDIAC SERVICES
When: FRIDAY [**2155-9-5**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4280, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7621
} | Medical Text: Admission Date: [**2128-3-24**] Discharge Date: [**2128-10-17**]
Date of Birth: [**2066-4-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Fatigue/Shortness of Breath
Major Surgical or Invasive Procedure:
Right PICC placement [**2128-3-25**]
Central line placement [**2128-3-25**]
Bone marrow biopsy [**2128-3-25**]
Left subclavian central line placement [**2128-3-26**]
Bone marrow biopsy [**2128-4-8**]
Left PICC placement [**2128-4-10**]
Left internal jugular central line placement [**2128-4-20**]
Bone marrow biopsy [**2128-5-7**]
Bone marrow biopsy [**2128-5-27**]
Bone marrow biopsy [**2128-6-9**]
Bronchoscopy [**2128-6-10**]
Bone Marrow Biopsy on [**2128-6-29**]
Percutaneous cholecystostomy tube placement [**2128-8-9**]
PICC placement on [**2128-8-14**]
History of Present Illness:
Mr. [**Known lastname 74075**] is a 61 yo M with PMH of hyperlipidemia presenting
with 1-2 months of progressive fatigue and DOE. Patient reported
worsening fatigue/DOE in last few months to the point where it
was interfering with his ADLs. Pt was feeling lightheaded and
palpitations when standing up. He presented to [**Hospital3 7569**]
on [**3-24**] and found to have HCT of 10% and WBC of 99,000. Given 1L
NS and 1 unit pRBCs and transferred to [**Hospital1 18**] for further
evaluation and management.
Patient denied fevers or night sweats but does endorse
intermittently feeling hot/cold. Also endorsed anorexia and
poor PO intake for one week. Complained of 50 lb weight loss in
about 6 months. He had nausea and dry heaving one day prior to
DOE, no vomiting. Also had constipation for two weeks.
In the ED inital vitals were, 99.3 98 113/58 16 99% on RA.
Heme/onc was consulted and patient was admitted to the ICU.
On arrival to the ICU, patient complained of mild headache, no
visual changes, numbness or other symptoms.
Past Medical History:
Hyperlipidemia
Hepatosteatosis
?Kidney stones
Social History:
Worked in construction in the past, unclear exposure to
chemicals. Last worked in [**2110**], for the State. He is widowed,
currently lives with girlfriend Girlfriend [**Name (NI) 553**] [**Name (NI) 496**] (HCP)
[**Telephone/Fax (1) 110427**]. Has 1 daughter who he is not in communication
with.
Questionable history of criminal record for armed robbery.
TOBACCO: smoked 1-1.5 ppd for ~40 years, quit in [**2128-1-4**]
ETOH: used to drink [**7-11**] drinks/week, none recently
ILLICITS: tried "different things" in the past, denies IV drug
use. None currently.
Family History:
Denies family history of leukemia, lymphoma or other
malignancies, but his family did not speak much of their
history. Has 1 sister with whom he does not speak.
Physical Exam:
ADMISSION EXAM:
General: very pale appearing male. alert, oriented to
person/date, knows he's in [**Location (un) 86**] and in a hospital, no acute
distress. speaking in full sentences.
HEENT: Anicteric sclera, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur best heard at LLSB and axilla. No rubs, gallops
Abdomen: soft, slightly tender to palpation on RUQ,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, palpable DP bilaterally, no clubbing,
cyanosis or edema
Neuro: PERRL, EOMI without nystagmus, sensation intact to light
touch in V1-V3 distribution, able to keep eyes closed to
resistance, hearing intact to finger rubbing bilaterally, tongue
midline and palates elevate equally. SCM and trapezius [**5-8**]
bilaterally.
Motor: [**5-8**] in elbow flexor/extensor, finger grips, [**5-8**] in hip
flexors, knee flexors/extensors, ankle plantar
flexor/dorsiflexor.
Reflexes: 1+ in biceps and patellar bilaterally
[**Doctor First Name **] intact bilaterally
gait deferred
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
===============
[**2128-3-24**] 10:45PM BLOOD WBC-68.5* RBC-0.97* Hgb-3.3* Hct-10.3*
MCV-106* MCH-33.9* MCHC-32.0 RDW-20.3* Plt Ct-85*
[**2128-3-24**] 10:45PM BLOOD Neuts-0* Bands-0 Lymphs-4* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Other-96*
[**2128-3-24**] 10:45PM BLOOD PT-14.9* PTT-37.1* INR(PT)-1.4*
[**2128-3-24**] 10:45PM BLOOD Fibrino-426*
[**2128-3-24**] 10:45PM BLOOD Glucose-126* UreaN-19 Creat-1.4* Na-138
K-3.8 Cl-105 HCO3-23 AnGap-14
[**2128-3-24**] 10:45PM BLOOD ALT-15 AST-26 LD(LDH)-304* CK(CPK)-66
AlkPhos-73 TotBili-0.6
[**2128-3-24**] 10:45PM BLOOD Albumin-3.9 Calcium-8.1* Phos-3.5 Mg-2.5
UricAcd-8.6*
CBC TREND:
==========
[**2128-3-24**] 10:45PM BLOOD Neuts-0* Bands-0 Lymphs-4* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Other-96*
[**2128-3-25**] 07:57AM BLOOD WBC-53.2* RBC-1.40*# Hgb-4.5* Hct-14.0*#
MCV-100* MCH-32.2* MCHC-32.1 RDW-20.5* Plt Ct-80*
[**2128-3-26**] 01:58AM BLOOD WBC-45.4* RBC-2.11* Hgb-6.9* Hct-20.1*
MCV-96 MCH-32.6* MCHC-34.1 RDW-19.6* Plt Ct-61*
[**2128-3-27**] 06:00AM BLOOD WBC-17.5* RBC-2.24* Hgb-7.2* Hct-21.3*
MCV-95 MCH-32.0 MCHC-33.6 RDW-18.8* Plt Ct-46*
[**2128-3-31**] 12:00AM BLOOD WBC-1.2* RBC-2.40* Hgb-7.7* Hct-22.6*
MCV-94 MCH-32.1* MCHC-34.1 RDW-16.3* Plt Ct-12*#
[**2128-4-4**] 04:10AM BLOOD WBC-.6* RBC-2.28* Hgb-7.1* Hct-21.0*
MCV-92 MCH-31.0 MCHC-33.6 RDW-15.3 Plt Ct-8*
[**2128-4-10**] 06:35AM BLOOD WBC-0.5* RBC-2.64* Hgb-8.0* Hct-22.8*
MCV-86 MCH-30.1 MCHC-34.9 RDW-14.5 Plt Ct-9*#
[**2128-4-14**] 12:00AM BLOOD WBC-0.6* RBC-2.76* Hgb-8.3* Hct-23.4*
MCV-85 MCH-30.0 MCHC-35.4* RDW-14.4 Plt Ct-13*
[**2128-4-20**] 12:10PM BLOOD WBC-0.6* RBC-2.95* Hgb-8.6* Hct-25.2*
MCV-85 MCH-29.1 MCHC-34.1 RDW-14.0 Plt Ct-43*
[**2128-4-27**] 12:00AM BLOOD WBC-0.4* RBC-2.52* Hgb-7.3* Hct-20.6*
MCV-82 MCH-29.1 MCHC-35.6* RDW-13.3 Plt Ct-9*
[**2128-5-4**] 12:00AM BLOOD WBC-0.4* RBC-2.65* Hgb-7.7* Hct-21.3*
MCV-80* MCH-29.0 MCHC-36.1* RDW-13.1 Plt Ct-6*#
[**2128-5-7**] 12:00AM BLOOD WBC-0.4* RBC-2.84* Hgb-8.3* Hct-22.8*
MCV-80* MCH-29.3 MCHC-36.5* RDW-13.0 Plt Ct-18*
[**2128-5-13**] 12:23PM BLOOD WBC-0.8* RBC-2.84* Hgb-8.1* Hct-22.8*
MCV-80* MCH-28.7 MCHC-35.7* RDW-13.0 Plt Ct-23*
[**2128-5-21**] 12:00AM BLOOD WBC-0.2* RBC-2.77* Hgb-8.1* Hct-21.8*
MCV-79* MCH-29.3 MCHC-37.2* RDW-12.7 Plt Ct-23*
[**2128-5-25**] 12:00AM BLOOD WBC-0.2* RBC-2.59* Hgb-7.4* Hct-20.6*
MCV-80* MCH-28.5 MCHC-35.8* RDW-12.9 Plt Ct-13*
[**2128-6-1**] 12:00AM BLOOD WBC-0.2* RBC-2.65* Hgb-7.7* Hct-21.2*
MCV-80* MCH-29.2 MCHC-36.4* RDW-13.0 Plt Ct-16*
[**2128-6-6**] 12:00AM BLOOD WBC-0.3* RBC-2.66* Hgb-7.5* Hct-21.0*
MCV-79* MCH-28.2 MCHC-35.7* RDW-12.7 Plt Ct-7*
[**2128-6-13**] 12:00AM BLOOD WBC-0.2* RBC-2.54* Hgb-7.5* Hct-20.4*
MCV-80* MCH-29.6 MCHC-36.8* RDW-13.4 Plt Ct-15*
[**2128-6-20**] 12:00AM BLOOD WBC-0.3* RBC-2.63* Hgb-7.6* Hct-21.6*
MCV-82 MCH-28.7 MCHC-35.1* RDW-13.2 Plt Ct-12*
50* Hgb-7.6* Hct-20.9* MCV-84 MCH-30.2 MCHC-36.2* RDW-13.9 Plt
Ct-17*
[**2128-7-17**] 01:19AM BLOOD WBC-0.9* RBC-2.39* Hgb-7.0* Hct-20.0*
MCV-84 MCH-29.2 MCHC-34.9 RDW-13.7 Plt Ct-26*
[**2128-7-23**] 12:00AM BLOOD WBC-0.5* RBC-2.76* Hgb-8.4* Hct-22.5*
MCV-82 MCH-30.5 MCHC-37.4* RDW-13.4 Plt Ct-44*
[**2128-7-27**] 12:00AM BLOOD WBC-0.1* RBC-2.53* Hgb-7.4* Hct-20.7*
MCV-82 MCH-29.1 MCHC-35.7* RDW-13.4 Plt Ct-14*
[**2128-8-2**] 12:00AM BLOOD WBC-<0.1* RBC-2.66* Hgb-7.7* Hct-21.5*
MCV-81* MCH-28.8 MCHC-35.7* RDW-13.3 Plt Ct-8*
[**2128-8-6**] 12:00AM BLOOD WBC-<0.1* RBC-2.28* Hgb-6.7* Hct-18.2*
MCV-80* MCH-29.6 MCHC-36.9* RDW-13.5 Plt Ct-5*#
[**2128-8-10**] 05:20PM BLOOD WBC-<0.1 RBC-2.73* Hgb-7.9* Hct-22.1*
MCV-81* MCH-29.0 MCHC-35.8* RDW-15.4 Plt Ct-13*
[**2128-8-12**] 02:36AM BLOOD WBC-0.1* RBC-2.50* Hgb-7.2* Hct-20.2*
MCV-81* MCH-28.9 MCHC-35.8* RDW-14.4 Plt Ct-<5*
[**2128-8-15**] 05:22AM BLOOD WBC-0.2* RBC-2.76* Hgb-7.8* Hct-22.5*
MCV-81* MCH-28.4 MCHC-35.0 RDW-15.2 Plt Ct-15*
[**2128-8-18**] 03:20AM BLOOD WBC-0.5* RBC-2.81* Hgb-8.1* Hct-22.3*
MCV-80* MCH-28.7 MCHC-36.1* RDW-15.2 Plt Ct-5*
[**2128-8-20**] 12:38AM BLOOD WBC-0.6* RBC-2.43* Hgb-7.1* Hct-19.3*
MCV-80* MCH-29.1 MCHC-36.6* RDW-14.9 Plt Ct-<5
[**2128-8-22**] 01:00AM BLOOD WBC-0.5* RBC-2.44* Hgb-7.2* Hct-19.7*
MCV-81* MCH-29.6 MCHC-36.6* RDW-14.7 Plt Ct-19*#
[**2128-8-24**] 12:00AM BLOOD WBC-0.7* RBC-2.37* Hgb-7.2* Hct-19.4*
MCV-82 MCH-30.4 MCHC-37.1* RDW-14.2 Plt Ct-14*#
[**2128-8-25**] 02:00AM BLOOD WBC-1.2*# RBC-2.09* Hgb-6.3* Hct-17.4*
MCV-83 MCH-30.2 MCHC-36.3* RDW-14.4 Plt Ct-5*#
[**2128-8-27**] 12:00AM BLOOD WBC-2.5* RBC-2.40* Hgb-7.5* Hct-20.6*
MCV-86 MCH-31.1 MCHC-36.3* RDW-14.2 Plt Ct-11*
HEPATOBILIARY IMAGING:
==================
RUQ US ([**2128-3-31**]):
1. Biliary sludge with gallbladder and adherent stone or small
polyp. No biliary ductal dilation.
2. Normal liver.
3. Splenomegaly.
HIDA SCAN ([**2128-6-17**]): Normal hepatobiliary scan.
RUQ US [**2128-6-17**]:
1. Distended gallbladder filled with sludge without specific
signs of
cholecystitis. If there is clinical concern for acalculous
cholecystitis, HIDA scan is recommended.
2. Splenomegaly.
HIDA ([**7-20**]): Lack of tracer activity in the gallbladder is
consistent with acute cholecystitis.
U/S ABDOMEN ([**7-20**]):
1. The gallbladder is distended and contains a large volume of
sludge. There are no obstructing calculi identified. No
gallbladder wall thickening to suggest inflammatory etiology.
However, if there is ongoing clinical concern for cholecystitis,
a HIDA scan is recommended.
2. The spleen measures 14 cm, decreased compared to the
previous ultrasound.
U/S ABDOMEN ([**8-20**]):
1. Percutaneous cholecystostomy tube remains in place within a
decompressed gallbladder without evidence of adjacent fluid
collection.
2. Splenomegaly.
3. Right pleural effusion.
ABDOMINAL IMAGING:
==================
CT ABDOMEN ([**2128-4-6**]):
1. Ascending and transverse colon wall thickening with adjacent
stranding is compatible with colitis which may be infectious,
inflammatory, or less likely ischemic given distribution.
Colonoscopy is recommended to exclude underlying malignancy
after resolution of acute process.
2. Small bilateral pleural effusions with adjacent atelectasis.
11-mm
nodular focus at the left lung base may represent atelectasis
but consider followup.
3. Splenomegaly.
4. Small-to-moderate ascites.
5. Rounded lucency in L3 vertebral body without cortical
destruction is
likely hemangioma.
CT ABDOMEN & PELVIS [**2128-6-7**]:
1. No evidence of residual colitis or other abdominal process to
explain the patient's clinical symptoms.
2. 3mm lingular nodule. If the patient is low risk, no further
imaging is
required. If high risk such as smoking, follow up imaging in 12
months is
recommended.
3. Stable splenomegaly
CT ABDOMEN ([**8-8**]):
1. No evidence of bowel perforation or abscess.
2. Mild retroperitoneal edema with small amount of free fluid
collecting in the pelvis. Nonspecific.
3. Chronic mural stratification involving areas of the small
bowel is nonspecific. Mild wall thickening on current exam may
represent enteritis.
4. Mildly distended gallbladder without evidence of
inflammation.
CT ABDOMEN & PELVIS ([**8-12**]):
1. No evidence of complication of the percutaneous
cholecystostomy tube which is within a decompressed gallbladder.
2. New small bilateral pleural effusions. Stable, small,
pericardial
effusion.
3. Continued retroperitoneal and mesenteric fat stranding.
Normal lipase
makes pancreatitis unlikely but correlate with amylase levels as
appropriate.
4. Significantly increased abdominal and pelvic free fluid as
well as
generalized anasarca.
CHEST IMAGING:
==============
CT CHEST W/OUT CONTRAST [**2128-6-9**]:
2 cm Medial right upper lobe subpleural opacity could represent
a consolidation from an infection, but exclusion of malignancy
is necessary. Several pulmonary nodules measuring up to 12 mm,
some with spiculations, have characteristics concerning for
metastases. The possibility of a CT guided biopsy can be
discussed with the cross-sectional interventional radiologists.
Alternatively, a followup CT should be performed in no more than
four weeks.
CT TORSO [**2128-6-16**]:
IMPRESSION:
1. Right upper lobe pneumonia, progressed from [**2128-6-9**].
2. Multiple pulmonary nodules as described on CT of [**2128-6-9**].
As stated on prior report, these can be followed up with a CT
chest within four weeks or the possibility of biopsy can be
considered.
3. Coronary artery disease.
CT CHEST [**6-21**]:
IMPRESSION:
1. Right apical consolidation and two left upper lobe nodules
have not changed since the most recent scan, but right lower
lobe nodules have improved. Overall appearance is most
consistent with an acute infectious process, either fungal (e.g.
Aspergillus) or bacterial in etiology. Cryptogenic organizing
pneumonia may also have a similar imaigng appearance.
2. Coronary artery calcifications
CT CHEST [**7-1**]:
1. Focal right upper lobe consolidation is slightly smaller in
size and
several pulmonary nodules have resolved, consistent with an
improving
infectious process.
2. New pericardial and bilateral pleural effusions of unclear
etiology, as
well as interval enlargement in several mediastinal lymph nodes
may be related to the patient's history of malignancy or the
subsequent treatment. Clinical correlation is recommended.
CT CHEST [**8-20**]:
1. Multifocal pneumonia, new from [**2128-7-1**].
2. Small pericardial effusion is unchanged and small bilateral
pleural
effusions are decreased.
CT CHEST [**8-26**]:
1. Increasing large right pleural effusion, persistent right
upper lobe
consolidation.
2. Enlarging and new left lower lobe nodular consolidations.
No specific pathogen is suggested but a right-sided
thoracentesis may be
considered for diagnostic and therapeutic purposes.
HEAD IMAGING:
=============
MRI HEAD ([**2128-6-14**]):
1. No acute intracranial abnormality. No abnormal enhancement
seen.
2. Small vessel ischemic disease.
MRI HEAD ([**2128-8-16**]):
1. Small vessel white matter ischemic changes. Otherwise normal
study.
MRI NECK ([**2128-8-16**]):
1. Study somewhat degraded by motion. No evidence of abscess.
CT HEAD ([**2128-8-16**]): Normal study. No bleed.
ECHOCARDIOGRAPHY:
=================
TTE [**2128-3-25**]:
IMPRESSION: Normal global and regional biventricular systolic
function. Mild pulmonary hypertension.
TTE ([**2128-4-13**]): Normal global and regional biventricular systolic
function. Mild mitral regurgitation. Borderline pulmonary
hypertension.
TTE ([**2128-8-24**]) - The atria are mildly dilated. An echodense
structure is seen in the right atrium suggestive of a catheter
tip. An adjacent mobile structure might represent Eustachian
valve but a vegetation or small thrombus cannot be excluded.
BONE MARROW STUDIES:
====================
[**2128-3-24**] TISSUE IMMUNOPHENOTYPING:
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast/lymphocyte yield. Abnormal lymphoid cells
comprise 10% of total analyzed events. Of these, B cells
comprise 27% of lymphoid-gated events, are polyclonal, and do
not express aberrant antigens. T cells comprise 73% of lymphoid
gated events, express mature lineage antigens (CD2, CD3, CD5,
CD7) and have a helper-cytotoxic ratio of 1.3.
Cell marker analysis demonstrates that the majority of the cells
in the CD45 moderate/dim , moderate side scatter "blast" gate
express immature antigens CD34, HLA-DR, myeloid associated
antigens CD13, CD15, CD117, CD11c, TdT (dim, subset), lymphoid
associated antigens CD2 (dim, subset), CD7 (dim) lack other B
and T cell associated antigens are CD10 negative, and are
negative for CD14, CD41, CD56, CD64. Blast cells comprise 61%
of total events.
INTERPRETATION:
Immunophenotypic findings consistent with involvement by acute
myeloid leukemia. Correlation with clinical findings and
morphology (See S12-12756N) is recommended.
[**2128-3-25**] BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
ACUTE MYELOID LEUKEMIA.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Red blood cells are
markedly reduced in number, variably hypochromic with
anisopoikilocytosis including occasional dacrocytes and
elliptocytes seen. The white blood cell count appears increased
and consists almost entirely of variably-sized blasts with scant
light blue cytoplasm and nuclei with moderately coarse
chromatin, scalloped borders and distinctive nucleoli. A minor
subset of large cells with more abundant cytoplasm is present.
Platelet count appears decreased; large forms are seen.
Differential shows 4% neutrophils, 0% bands, 1% monocytes, 20%
lymphocytes, 0% eosinophils, 0% basophils, 75% blasts.
Aspirate Smear:
The majority of the cellularity is comprised of blasts
morphologically similar to those described in the peripheral
blood. The remaining cellularity shows mild dyspoiesis in
erythroid precursors along with scattered myeloid precursors. A
500 cell differential shows: 79% Blasts, less than 1%
Promyelocytes, 4% Myelocytes, 3% Metamyelocytes, 2%
Bands/Neutrophils, less than 1% Plasma cells, 9% Lymphocytes, 3%
Erythroid.
Clot Section and Biopsy Slides:
It consists of a 0.7 cm core biopsy of periosteum, cortical bone
and trabecular marrow with a cellularity of 70-80%. Most of the
cellularity is comprised of immature mononuclear cells
consistent with blasts, which occupying 80% of overall marrow
cellularity. The blasts are moderate in size with scant amounts
of amphophilic cytoplasm and oval to irregularly-shaped nuclei
with vesicular chromatin and small, yet distinctive nucleoli.
[**2128-3-25**] CYTOGENETICS:
KARYOTYPE: 47,XY,+14[13]/46,XY[7]
INTERPRETATION: Of 20 cells studied, thirteen comprised an
ABNORMAL clone with trisomy 14. This result is consistent
with myeloid disease, specifically the pathologic diagnosis
of AML. Trisomy 14 is not associated with a particular
cytogenetic prognosis.
Small clonal populations and small chromosome anomalies
may not be detectable using the standard methods employed.
Bone marrow biopsy [**2128-4-8**]:
PERSISTENT INVOLVEMENT WITH ACUTE MYELOBLASTIC LEUKEMIA.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Red blood cells are
hypochromic and normocytic with anisopoikilocytosis including
elliptocytes, rare dacrocytes and target cells. The white blood
cell count appears decreased. Platelet count appears decreased;
large and giant forms are not seen. Differential shows 6%
neutrophils, 0% bands, 3% monocytes, 84% lymphocytes,0%
eosinophils, 2% basophils, 5% blasts.
[**2128-5-7**] IMMUNOPHENOTYPING:
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast yield. Cell marker analysis demonstrates that
the majority of the cells isolated from this bone marrow express
immature antigens CD34, HLA-DR, myeloid associated antigens
CD13, CD15, CD117, lymphoid associated antigens CD2 (subset)
(partial dim).
INTERPRETATION
Immunophenotypic findings consistent with involvement by
persistent acute myeloid leukemia. Please correlated with
S12-15199N.
[**2128-5-7**] BONE MARROW CORE BIOPSY:
HYPOCELLULAR MARROW WITH RESIDUAL BLASTS AND SCANT
ERYTHROPOIESIS (SEE NOTE)
Note: The marrow aspirate and core biopsy reveals residual
blasts (~40-50%). Within the aspirate many of the blasts show
degenerative changes. In a patient with chemo-ablation, these
residual blasts may indicate residual leukemic blasts, some
undergoing chemotherapy induced cell death. Residual
hematopoiesis is scant and is mostly within erythroid cells.
While highly consistent with residual / recurrent / refractory
disease, the clinical course is best assessed by following
peripheral blood counts and cytogenetics in conjunction with
clinical correlation. The findings were discussed with Dr. [**Last Name (STitle) **].
[**Doctor Last Name **] and Dr. [**Last Name (STitle) **]. Arnason.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear: The smear is adequate for evaluation and
shows pancytopenia. Red blood cells are decreased in number,
with minimal anisocytosis and mild poikilocytosis.
The white blood cell count appears decreased. A limited 50 cell
differential count is performed and shows predominantly
lymphocytes and a few neutrophils. Rare cells with blast
morphology seen, but cannot be definitely categorized. Platelet
count appears decreased.
Differential (50 cells) shows 8% neutrophils, 2 % bands, 90%
lymphocytes.
Aspirate Smear:
The aspirate material is sub-optimal and it lacks spicules.
The M:E ratio is not assessed. Erythroid precursors are rare.
Normal maturing myeloid precursors appear decreased to scant in
number. The majority of cells in this smear are located at the
edges and are abnormal blasts, some with degenerative changes.
They are large cells with irregular nuclei, some of which is
smudged, and some with a prominent nucleoli. Granules are not
readily seen. Megakaryocytes are scant to absent. Scattered
histiocytes with intracytoplasmic cellular debris seen.
A differential shows (300 cells): 46% Blasts, 2% Promyelocytes,
1% Myelocytes, 4% Metamyelocytes, 6% Bands/Neutrophils, 1%
Plasma cells, 29% Lymphocytes, 11% Erythroid. (many of the
blasts show degenerative changes).
Clot Section and Biopsy Slides:
The core biopsy material is adequate for evaluation with a core
biopsy approximately 1 cm in length. At least half the core
biopsy is cortical bone and cartilage. The residual marrow is
subcortical and has a cellularity of 20%. M:E ratio estimate is
1:1. Erythroid precursors are seen scattered in small pockets
within the marrow fat. Myeloid precursors are seen, but without
any maturation. The myeloid elements are mostly blasts, and are
seen in large aggregates, some with degenerative changes. Plasma
cells, stromal cells and histiocytes are also seen within the
interstitium. Megakaryocytes are rare.
Special Stains:
Iron stain reveal mostly storage iron within empty appearing
spicules. Sideroblasts or ringed sideroblasts are not seen.
KARYOTYPE: 47,XY,+14[3]/46,[**Last Name (LF) **],[**First Name3 (LF) **](9)(q22)[1]/46,XY[17]
Four of 20 cells examined demonstrated the abnormal clones seen
in previous analyses ([**Numeric Identifier 110428**], [**2128-3-25**]; [**Numeric Identifier 110429**], [**2128-4-8**]).
This finding is consistent with the persistent disease. Small
clonal populations and small chromosome anomalies may not be
detectable using the standard methods employed.
[**2128-5-27**] BONE MARROW BIOPSY:
MARKEDLY HYPOCELLULAR ERYTHROID-DOMINANT BONE MARROW WITH
LEFT-SHIFTED HEMATOPOIESIS AND SCANT MEGAKARYOCYTES. THE
FINDINGS ARE CONSISTENT WITH A CHEMOABLATED MARROW.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Red blood cells are
decreased in number and normocytic with minimal
anisopoikilocytosis including rare spherocytes, dacrocytes and
elliptocytes. The white blood cell count appears markedly
decreased and is composed exclusively of lymphocytes. Platelet
count appears markedly decreased. Large and giant forms are not
seen. Differential shows 100% lymphocytes
BM Biopsy [**2128-6-9**]:
MARKEDLY HYPOCELLULAR ERYTHROID DOMINANT BONE MARROW WITH
DYSPLASTIC HEMATOPOIESIS AND INCREASED BLASTS, SEE NOTE.
Aspirate Smear:
The aspirate material shows numerous markedly hypocellular
spicules consisting of stromal cells, histiocytes, and plasma
cells. A limited 100 cell differential count shows: 0% Blasts,
0% Promyelocytes, 2% Myelocytes, 2% Metamyelocytes, 3%
Bands/Neutrophils, 61% Lymphocytes, 16% Plasma Cells, 13%
Erythroid Precursors. Myeloid precursors are decreased with
abnormal nuclear lobation. Blasts are present but are difficult
to quantify in this hypocellular smear. Megakaryocytes are not
seen.
Clot Section and Biopsy Slides:
The biopsy material consists of core of about equal parts
cortical bone and subcortical trabecular marrow space that is
virtually acellular, precluding blast count by
immunohistochemistry.
Note: The findings are consistent with a hypoplastic marrow
after multiple rounds of induction chemotherapy.
BM Cytology [**2128-6-9**]
KARYOTYPE: NO ABERRATIONS DETECTED; SEE BELOW
KARYOTYPE: 46,XY[8].nuc ish(CCND1,IGH@)x2[100]
Cell culture of this specimen yielded only eight metaphase
cells for chromosome analysis. No aberrations were
detected in study of these eight cells. Interphase FISH
did not detect any evidence of the trisomy 14 present in
prior specimens.
BM Biopsy [**2128-6-29**]
DIAGNOSIS: Hypocellular marrow with decreased trilineage
hematopoiesis.
Note: No evidence of acute myelogenous leukemia is seen.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
Red blood cells are normochromic with anisopoikilocytosis
including macrocytes, elliptocytes and spherocytes seen. The
white blood cell count appears decreased. Platelet count
appears significantly decreased; large forms are seen.
Differential shows 27% neutrophils, 6% bands, 16%
monocytes, 23% lymphocytes, 0% eosinophils, 0% basophils, 3%
blast, 14% atypical lymphocyte, 1% promyelocyte, 1% myelocyte
and neutrophils with hypolobation and disjointed lobation are
seen.
Aspirate Smear:
The aspirate material is inadequate for evaluation due to
aspicular aspirate and hemodilution. Erythroid precursors are
not seen. Rare myeloid precursors are seen. Neutrophils with
disjointed nuclear robes, abnormal nuclear lobation and
hypogranular forms are seen. No megakaryocytes are seen. A
limited cell count of 100 is performed with similar profile as
the peripheral blood is seen. A 100 cell differential shows:
3% Blasts, 2% Promyelocytes, 3% Myelocytes, 5% Metamyelocytes,
35% Bands/Neutrophils, 0% Plasma cells, 37% Lymphocytes, 0%
Erythroid, 5% monocytes and 10% atypical lymphocytes.
Clot Section and Biopsy Slides:
The core biopsy material is adequate for evaluation. It
consists of a 1.6 cm core of periosteum, cortical bone,
trabecular marrow with a cellularity of [**5-13**]%. Rare clusters of
erythropoietic colonies are seen comprising of less than 5% of
the marrow. Occasional myeloid precursors are seen.
Megakaryocytes are focally seen in loose clusters.
Hemosiderin-laden macrophages and pockets of scattered plasma
cell and stromal cells are seen.
[**2128-6-24**]
PATHOLOGY REPORT: Investigation of transfusion reaction:
Mr. [**Known lastname 74075**] experienced rigors, chills and hives during his pRBC
transfusion on [**2128-6-24**]. Laboratory workup revealed no evidence
of hemolysis, as his plasma remained yellow and clear and
testing demonstrated a negative DAT. The chills/rigors are
consistent with an afebrile non-hemolytic transfusion reaction.
Additionally the patient experienced an urticarial reaction
likely secondary to soluble substances in the plasma of the
product. These reactions are idiosyncratic in nature and the
occurence of one reaction is not predictive for subsequent
reactions. Thus, no changes in current transfusion management
are recommended at this time.
BM Cytogenetics ([**2128-6-29**]):
DIAGNOSIS: Hypocellular marrow with decreased trilineage
hematopoiesis.
Note: No evidence of acute myelogenous leukemia is seen.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is for evaluation adequate for evaluation. Red blood
cells are normochromic with anisopoikilocytosis including
macrocytes, elliptocytes and spherocytes seen. The white blood
cell count appears decreased. Platelet count appears
significantly decreased; large forms are seen. Differential
shows 27% neutrophils, 6% bands, 16% monocytes, 23%
lymphocytes, 0% eosinophils, 0% basophils, 3% blast, 14%
atypical lymphocyte, 1% promyelocyte, 1% myelocyte and
neutrophils with hypolobation and disjointed lobation are seen.
Aspirate Smear:
The aspirate material is inadequate for evaluation due to
aspicular aspirate and hemodilution. Erythroid precursors are
not seen. Rare myeloid precursors are seen. Neutrophils with
disjointed nuclear robes, abnormal nuclear lobation and
hypogranular forms are seen. No megakaryocytes are seen. A
limited cell count of 100 is performed with similar profile as
the peripheral blood is seen. A 100 cell differential shows:
3% Blasts, 2% Promyelocytes, 3% Myelocytes, 5% Metamyelocytes,
35% Bands/Neutrophils, 0% Plasma cells, 37% Lymphocytes, 0%
Erythroid, 5% monocytes and 10% atypical lymphocytes.
Clot Section and Biopsy Slides:
The core biopsy material is adequate for evaluation. It
consists of a 1.6 cm core of periosteum, cortical bone,
trabecular marrow with a cellularity of [**5-13**]%. Rare clusters of
erythropoietic colonies are seen comprising of less than 5% of
the marrow. Occasional myeloid precursors are seen.
Megakaryocytes are focally seen in loose clusters.
Hemosiderin-laden macrophages and pockets of scattered plasma
cell and stromal cells are seen.
BM Immunophenotyping ([**2128-6-29**]):
DIAGNOSIS:
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD antigens 2,
7, 13, 15, 34, 45, 117.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast yield. A limited panel is performed to determine
look for residual disease.
No blasts seen in gated events. Differentiating myeloid cells
present.
INTERPRETATION
Immunophenotyping findings consistent with involvement by: No
evidence of increased blasts.
Microbiology
================
[**2128-9-15**]**
GRAM STAIN (Final [**2128-9-10**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2128-9-15**]):
ENTEROCOCCUS SP.. RARE GROWTH.
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ 1 S
[**Hospital Unit Name 110430**] [**Date range (1) 110431**]
[**2128-10-11**] 12:00AM BLOOD WBC-3.3*# RBC-2.44* Hgb-8.1* Hct-22.8*
MCV-93 MCH-33.0* MCHC-35.4* RDW-20.5* Plt Ct-19*
[**2128-10-13**] 03:57AM BLOOD WBC-1.4* RBC-2.35* Hgb-7.9* Hct-22.4*
MCV-95 MCH-33.5* MCHC-35.1* RDW-20.5* Plt Ct-19*
[**2128-10-15**] 03:54AM BLOOD WBC-1.5*# RBC-2.20* Hgb-7.2* Hct-21.0*
MCV-96 MCH-32.8* MCHC-34.3 RDW-19.8* Plt Ct-16*
[**2128-10-16**] 05:26AM BLOOD WBC-6.8 RBC-2.66* Hgb-8.3* Hct-25.6*
MCV-96 MCH-30.7 MCHC-32.3 RDW-19.5* Plt Ct-22*
[**2128-10-17**] 03:41AM BLOOD WBC-11.1*# RBC-2.70* Hgb-8.7* Hct-25.8*
MCV-96 MCH-32.0 MCHC-33.5 RDW-19.6* Plt Ct-11*
[**2128-10-11**] 07:30PM BLOOD PT-14.0* PTT-40.1* INR(PT)-1.3*
[**2128-10-17**] 03:41AM BLOOD PT-17.3* PTT-64.2* INR(PT)-1.6*
[**2128-10-11**] 07:30PM BLOOD Glucose-85 UreaN-56* Creat-1.5* Na-149*
K-4.6 Cl-118* HCO3-17* AnGap-19
[**2128-10-12**] 03:42PM BLOOD Glucose-114* UreaN-67* Creat-1.7* Na-146*
K-5.0 Cl-115* HCO3-18* AnGap-18
[**2128-10-15**] 11:57PM BLOOD Glucose-134* UreaN-104* Creat-2.9* Na-138
K-4.9 Cl-108 HCO3-16* AnGap-19
[**2128-10-16**] 01:40PM BLOOD Glucose-167* UreaN-109* Creat-3.1*
Na-132* K-5.0 Cl-101 HCO3-15* AnGap-21*
[**2128-10-17**] 03:41AM BLOOD Glucose-95 UreaN-109* Creat-3.4* Na-128*
K-5.0 Cl-96 HCO3-12* AnGap-25*
[**2128-10-11**] 12:00AM BLOOD ALT-14 AST-24 LD(LDH)-274* AlkPhos-211*
Amylase-42 TotBili-4.5* DirBili-3.6* IndBili-0.9
[**2128-10-11**] 07:30PM BLOOD ALT-13 AST-24 CK(CPK)-31* AlkPhos-193*
TotBili-5.8*
[**2128-10-12**] 03:42PM BLOOD ALT-14 AST-24 LD(LDH)-296* AlkPhos-208*
TotBili-7.0* DirBili-5.7* IndBili-1.3
[**2128-10-13**] 03:57AM BLOOD ALT-15 AST-23 AlkPhos-244* Amylase-162*
TotBili-7.3*
[**2128-10-14**] 02:54AM BLOOD ALT-12 AST-23 LD(LDH)-236 AlkPhos-318*
TotBili-7.9*
[**2128-10-15**] 03:54AM BLOOD ALT-11 AST-26 CK(CPK)-14* AlkPhos-532*
TotBili-10.0*
[**2128-10-17**] 03:41AM BLOOD ALT-58* AST-247* LD(LDH)-1487*
AlkPhos-792* TotBili-12.2*
[**2128-10-11**] 07:30PM BLOOD Lipase-369*
[**2128-10-12**] 01:05AM BLOOD Lipase-337*
[**2128-10-13**] 03:57AM BLOOD Lipase-28
[**2128-8-20**] 05:34AM BLOOD cTropnT-0.05*
[**2128-9-10**] 02:58PM BLOOD proBNP-1210*
[**2128-10-12**] 06:17AM BLOOD Albumin-2.4* Calcium-7.9* Phos-4.9*
Mg-2.0
[**2128-10-17**] 03:41AM BLOOD Calcium-7.2* Phos-3.8 Mg-2.4
[**2128-10-11**] 04:32PM BLOOD Lactate-0.9
[**2128-10-16**] 05:33AM BLOOD Lactate-2.2*
[**2128-10-16**] 06:44AM BLOOD Lactate-2.1*
[**2128-10-17**] 01:33AM BLOOD Lactate-4.5*
[**2128-10-17**] 03:58AM BLOOD Lactate-5.0*
[**2128-10-17**] 06:33AM BLOOD Lactate-5.4*
CT abdomen and pelvis [**10-15**]
1. Displaced percutaneous cholecystostomy tube terminating
anterior to the
liver, similar to [**2128-10-10**]. Injection of contrast
through this tube
demonstrates free contrast bathing the intraperitoneal cavity
and draining
along the right paracolic gutter to become contiguous with a
pelvic fluid
collection.The amount of fluid present has not changed
significantly pover the CT dated [**2128-10-10**]. Sample fluid
was aspirated via the catheter and sent for analysis.
2. Air within the gallbladder attests patency of the common
bile duct stent. There is no intra- or extra-hepatic bile duct
dilatation.
3. Widespread airspace consolidations are compatible with
pneumonia,
potentially fungal or bacterial in etiology, or aspiration.
4. Moderate-sized bilateral pleural effusions with adjacent
compressive
atelectasis.
5. Diffuse anasarca.
6. Colonic intramural fat is similar to prior and may represent
chronic
colitis but this finding can also be observed as a normal
finding-epsecially in patients with intrabdominal fat
Brief Hospital Course:
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PRIMARY REASON FOR HOSPITALIZATION
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[**3-25**]: Admitted with 1-2 months of progressive fatigue, found to
have acute leukemia - WBC 68k (96% blasts), hct 10%, plt 85k.
Admitted to ICU for hct of 10%.
[**Date range (1) 14685**]: 7+3 high dose daunorubicin. Started on
vanc/cefepime.
[**Date range (1) 110432**]: 5+2 idarubicin
[**Date range (1) 110433**]: Mitoxantrone/Etoposide/Cytarabine
[**7-20**]: HIDA (+) for cholecystitis but not a surgical candidate.
Started meropenem.
[**7-30**]: Double cord hematopoetic stem cell transplant.
[**8-6**]: Develops febrile neutropenia.
[**8-7**]: Abdominal exam worsens, (+) RUQ pain, (+) rebound. Started
vancomycin, pip-tazo.
[**8-9**]: IR places biliary drain. Bile grows vanc-sensitive
enterococcus.
[**8-10**]: Blood culture grows VRE x 1, subsequent surveilance
cultures (-). Switched vanc -> daptomycin.
[**8-12**]: Began granulocyte infusion x 5 days. Transferred to MICU
for agitation, altered mental status, increased nursing
requirement.
[**8-13**]: Central line removed for concern for line infection, no
growth from line.
[**8-14**]: PICC placed
[**8-15**]: EEG for altered mental status, dysarthria - generalized
periodic epileptic wave forms. Started keppra 250mg IV q12h
[**8-17**]: Transferred back to BMT for clinical improvement.
[**8-20**]: CT chest shows multifocal pneumonia suggestive of fungal
process.
[**8-24**]: TTE shows "echodensity" in RA, likely from PICC
malpositioning. PICC repositioned, but consistently has
problems drawing back requiring tPA.
[**8-26**]: progression of multifocal pneumonia noted on Chest CT
[**9-5**]: stable multifocal pneumonia, stable b/l pleural effusions
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#) ACUTE MYELOID LEUKEMIA: Found to have WBC of 99,000 at OSH
initially, and on examination of peripheral smear, found to have
96% blasts, no Auer rods. Heme/onc was consulted from the ED.
Given the degree of leukocytosis, he was started on hydroxyurea
overnight. He had bone marrow done on [**2128-3-25**]. Started on 7+3
on [**2128-3-26**]. Given persistence of disease based on bone marrow
biopsy on [**2128-4-8**], he completed 5+2 regimen. Repeat biopsy still
showed residual biopsy. Thus, he completed another round of
chemotherapy (MEC D1C1 [**2128-5-15**]) after which repeat biopsy
revealed that the bone marrow had been ablated. Pt remained
persistently neutropenic. The bone marrow remained acellular on
repeat BMBx on [**2128-6-29**] with no leukemic cells. He was
transplanted with double cord blood on [**2128-7-30**]. Persistently
neutropenic on filgrastim until WBC counts began to recover
[**2128-8-12**] to > 0.1 and continued to uptrend to 2.5 by [**8-27**].
#) COLITIS: IV flagyl was initiated on [**4-4**] and CT abdomen
showed colitis on [**2128-4-6**]. Stool Cdiff negative and noro
negative. Lower Abd tender but soft and better than prior
(diffuse tenderness) and improving. KUB not concerning. CMV VL
not detected. Repeat CT on [**2128-4-13**] shows improvement in colitis,
and stools decreased to 1 per day and no BM over the last 4
days. Repeat CT scan on [**6-7**] showed resolution of previously
seen colitis. Despite this improvement pt still had much
difficulty taking in po's. Etiology of lack of po intake is
likely multifactorial. While he did complain of "occasional"
abdominal pain, nausea and vomiting, he also felt a lack of
motivation and "decreased taste" for food. Consulted psychiatry
on [**6-11**], who recommended starting mirtazapine qhs for appetite
and sleep, which was started but then discontinued on [**6-13**] given
concern for increased somnolence. TPN was discontinued on [**6-23**]
in an attempt to stimulate appetite. He was also started on a
calorie count and ritalin on [**6-24**]. Ritalin increased to [**Hospital1 **]
dosing on [**6-25**]. Pt did ~300Kcal/day on calorie count and
received Megace for appetite stimulation. TPN was not restarted.
Flagyl and megace eventually discontinued, but meropenem
continued in setting of persistent neutropenia.
#) FEBRILE NEUTROPENIA: Patient had low grade temperature on
admission, and continued to have temperatures in 99-100s. He was
initially started on Cefepime ([**2128-3-25**]) for febrile neutropenia
(WBC was high, but had 0% neutrophils) without improvement in
his fever curve.
FEVER CLUSTER #1 - Vancomycin was added on [**2128-3-26**] for continued
low grade temperature. Blood cultures and urine cultures were
sent with no growth. CXR showed some suggestion of LLL
infiltrate. Vancomycin was discontinued [**4-10**] given no fevers.
FEVER CLUSTER #2 - Vancomycin was added on [**6-8**] and fungal
coverage was broadened to Ambisome on [**6-9**] given subpleural based
opacity and multiple pulmonary nodules. Based on CT scan, pt
underwent bronch with BAL on [**6-10**] (no growth). Daptomycin
converted to vancomycin for increased lung penetration. Flagyl
restarted on [**6-15**] given persistent fevers. Vancomycin was DC'd
on [**6-25**] as pt was persistently afebrile and acyclovir was DC'd
on [**6-29**] for the same reason. Ambisome was DC'd on [**7-2**] when
repeat chest CT showed improvement of nodules.
FEVER CLUSTER #3 - Spiked fever again on [**8-9**] and ultimately grew
VRE from blood and biliary source. Perc chole tube placed [**8-9**].
Essentially spiking daily fevers from [**Date range (2) 110434**]. Comparison
of Chest CTs from [**8-20**] and [**8-26**] showed interval worsening of
multifocal pneumonia and right side pleural effusion. Of note,
the patient's WBC count has been within normal limits from
[**Date range (1) **]. Repeat echocardiogram on [**8-31**] showed no valvular
abnormalities suggestive of endocarditis, EF >55%. Repeat Chest
CT [**2128-9-5**] showed little interval change.
#) ACUTE KIDNEY INJURY: Baseline creatinine 1.0.
[**Last Name (un) **] #1: Cr elevated to 1.9 on [**6-25**] from baseline of 1.0.
Etiology was likely multifactorial including dehydration from
discontinuation of TPN/poor po intake and multiple nephrotoxic
medications (vancomycin, ambisome and acyclovir). Vanc trough
was elevated to 25.7 and therefore evening dose on [**6-25**] was
held.
[**Last Name (un) **] #2: Creatinine increasing around [**8-18**] after VRE grew from
blood likely sepsis related with peak at 2.0. Gentamycin
started for synergy which likely worsened [**Last Name (un) **] but eventually
downtrended back to baseline on IVF.
#) ANEMIA/THROMBOCYTOPENIA: Found to have HCT of 10% on
admission. Thought to be due to bone marrow suppression from
leukemia, as patient did not have elevated bilirubin or other
laboratory findings to suggest hemolysis. S/p _______ units of
blood and ________ units of platelets. Has refractory
thrombocytopenia likely [**2-5**] splenomegaly and alloimunization.
There was concern for autoantibodies to platelets but PRA
testing was negative.
#) ACUTE CHOLECYSTITIS: Diagnosed with acute cholecystits on
HIDA after gallbladder U/S read as intermediate. No obstructing
stone was found. As pt improved clinically with minimal RUQ and
able to tolerate PO intake, decision made to forego surgical
interventio in setting of pancytopenia. LFT's and clinical
status monitored daily. Patient received biliary drain placement
on [**8-9**] as non-operative intervention for cholecystitis. General
surgery saw patient, felt patient needed cholecystectomy but not
a good surgical candidate. General surgery reevaluated the
patient on [**9-1**] and commented that the perc chole is draining
well; cholecystectomy not indicated at this time due to poor
health status and other foci of infection.
#) ALTERED MENTAL STATUS: Patient transferred to MICU on [**8-20**]
due to altered mental status in setting of initiating
granulocyte infusion, supratherapeutic tacrolimus level to 12,
and difficulty caring for patient on the floor. Patient not
following commands and alert and oriented only to self. Mental
status was thought to be secondary to toxic / metabolic in
setting of previously untreated VRE sepsis as well as
contributing hepatic encelopathy [**2-5**] shock liver, potential
obstruction. Lactulose was started. Neurology was consulted
because of dysarthria and weakness on exam. EEG was performed,
which was not consistent with seizures. Weakness was thought to
be proximal, likely due to myopathy. Consideration was also
paid to potential role of tacrolimus, levels of which were
significantly elevated during [**Last Name (un) **]. Tacro was held. Patient's
mental status improved over course of MICU stay, with patient
being oriented to person, place, time and transferred back to
BMT floor. While on the BMT floor the patient's mental status
waxed and waned. A repeat MRI head was done on [**9-1**] which showed
small vessel disease, but no acute process. An incidental
finding of asymmetric mastoid air cell enhancement raised the
question of supperative mastoiditis. ENT was consulted and thin
cut CT of the sinuses was performed. No bony erosion was evident
and therefore no ENT intervention needed. Improvement in
mental status was noted with the the onset of less frequent
fevers and decreased morphine basal dose on PCA. Repeat EEG was
performed on [**2128-9-4**].
ICU Issues:
================
62yo M with refractory AML admitted on [**3-24**] and now s/p double
cord SCT on [**2128-7-30**]. Hospital course complicated by biliary
sepsis, respiratory failure, and encephalopathy. In [**Month (only) 216**], had
severe biliary sepsis (not choly candidate, so perc tube
placed). Since [**Month (only) **], had course c/b fungal pna, CMV viremia,
mental status changes (thought to be due to PRES [**2-5**]
cyclosporine). Admitted to [**Hospital Unit Name 153**] ([**9-10**] - [**9-17**]) for respiratory
failure and hypotension. Readmitted to [**Hospital Unit Name 153**] on [**10-11**] - [**10-17**] for
biliary sepsis/peritonitis and hypoxic respiratory distress post
ERCP stent placement procedure on [**10-11**].
# Course prior to patient's death: Mr. [**Known lastname 74075**] [**Last Name (Titles) **] during
morning of [**10-17**]. Interdisciplinary meeting held with BMT, ICU,
ID, ERCP, IR, Surgery, and SW on [**10-15**] to discuss management of
biliary sepsis as patient was deteriorating. His mental status
was worsening, Tbilis trending up, increasing abdominal pain and
distention, worsening sepsis despite broad coverage antibiotics
and antifungals. Decision was made to intubate the patient and
go for a CT guided paracentesis and perc chole drain
interrogation study with IR. Paracentesis showed that fluid in
the abdomen was bile and the tube interrogation demonstrated
that bile was leaking into the peritoneum and that the perc
tube was displaced and terminating anterior to the liver. On
[**10-17**] 0000, patient had fever and became hypotensive in the
77-80s requiring three different pressors (vasopressin,
phenylephrine, and NE) at maxed doses. Labs showed increasing
lactic acid with severe metabolic acidosis. He was given 150 of
bicarb in hopes that pressors effectiveness would improve. His
vent settings was changed to pressure support to allow him to
increase his respirations and help decrease his acidosis.
Continued to be hypotensive in the 80s and given 2L LR boluses.
[**Name (NI) 553**] (girlfriend and HCP) updated and she arrived with her
sister to the patient's bedside at 0245. Patient's pressures
held in the 70s-80s (MAP ~50), but he was unresponsive. Code
status was discussed with [**Doctor First Name 553**] and she decided to not
resuscitate. Patient [**Doctor First Name **] at approximately 0830.
# Hypotension/Sepsis:
Initially transferred to ICU for likely septic shock. Lactate
was low at 0.3 and continues to be low at 0.7. Pt spiked a fever
to 102F on [**2128-9-10**] and no fevers since. Source appears to be
biliary VSE. Pt had suspicion of multifocal pneumonia with
unclear pathogen but Pt has been on broad abx coverage. Pt
previously had acute cholecystitis with VSE and also VRE
bacteremia of unclear source in early [**Name (NI) 216**]. He had a
percutaneous cholecystostomy tube placed. His blood cultures
have been negative since then but a repeat bile culture from
[**8-31**] again grew vanc sensitive enterococcus. And bile
cultures from [**9-10**] is growing rare enterococcus in aerobic vile.
Echo did not show evidence of endocarditis on [**8-31**]. His
urine cultures have remained negative. He had an MRI brain on
[**9-1**] that did not show any evidence of acute infection. He
has not had an LP due to severe thrombocytopenia. Culture of
PICC tip removed on [**9-1**] yielded no growth. He does not have any
diarrhea or leukocytosis, and his C diff stool PCR was negative
on [**2128-9-7**], but he seems to have significant abdominal pain. CT
[**9-11**] showed no intrabdominal abscess but mild edema of the colon
c/w volume overload vs colitis/typhilitis and stable bilateral
pleural effusions. Despite his large pleural effusions,
thrombocytopenia has made prior teams hesitant to pursue
thoracentesis. Radiology also feels these are not empyemas. PE
remains a possibility but LENIs negative. Currently off of
pressors. Another explanation for his hypotension may be adrenal
insufficiency given random cortisol of 8.6 which is
inappropriately low given current severe illness. VSE grown in
bile cx found to be sensitive to daptomycin. His mental status
improved with continued treatment and given his prior RUQ pain,
suspect biliary souce w/ possible biliary sepsis. No organisms
grew probably because he was on very broad antibiotic coverage.
Pt tranferred back to the floor but returned to the ICU on [**10-11**]
for biliary sepsis post ERCP procedure where stent was placed to
redirect bile from gallbladder to the bowel. He was continued on
zosyn, dapto, micafungin, and bactrim ppx per ID
recommendations. Vanco was also added the following day. Zosyn
was switched to [**Last Name (un) 2830**] for broader coverage. His bilirubin and alk
phos continued to trend up despite the stent placement. Tbilis
from 4 to 12.2 and alk phos from 200s to 790s. Lipase was
elevated in the 300s. Patient also had worsening abdominal pain
and distention.
# Acute respiratory failure: Pt extubated successfully on [**9-15**].
Pt suffered acute respiratory distress. Pt's ABG showed CO2
retention and hypoxia. Unclear etiology, but likely due to
sepsis and was very broadly covered with abx as above.
Bronchoscopy did not show obvious pathology and BAL cultures are
pending. CT scan shows stable to slightly increased bilateral
pleural effusions and interval increase of parenchymal
atelectasis vs consolidation at bases, no evidence of empyema.
Thoracentesis contraindicated given bleeding risk with
thrombocytopenia. RSBI 27, satting well on PEEP 5, RAS -1.
When patient returned to the ICU on [**10-11**] post ERCP, he was kept
intubated due to tachypnea and tachycardic pre-procedure. He was
able to be succesfully extubated in a few hours and kept on
facemask. Hypoxic respiratory distress was thought to be
secondary to sepsis. He was continued to be broadly covered for
possible pneumonia with micafungin, bactrim ppx, dapto, and
[**Last Name (un) 2830**]. CXR did not show any signs of consolidation. There is also
contribution from pain and distended abdomen pressing on lungs
and causing respiratory distress. His pain was treated with
dilaudid.
# [**Last Name (un) **]: on [**10-11**], his creatinine noted to rise up to 3.4. Thought
to be multifactorial including ATN/prerenal secondary to sepsis
and AIN secondary to CMV and/or meds (foscarnet). CPK was
checked and was 14. Renal was consulted and thought it was
likely due to ischemic renal insult without frank ATN. Continued
to fluid resuscitate as needed. All medications were also
renally dosed.
# cholecystitis/biliary leakage/biliary peritonitis:
percutaneous tube placed on [**8-/2128**] given that patient was not
candidate for cholecystectomy. Drain put out about >1L per day
and there was concern for nutritional and medication losses in
bile. Initially, patient had intermittent RUQ pain but CT
abd/pelvis and RUQ u/s showed no biliary dilation or other acute
intraabdominal pathology likely responsible for pain. A HIDA
scan on [**10-11**] showed CBD obstruction and patient sent for ERCP
and placement of stent. He was continued on ursodiol.
#AML: Pt is s/p double cord allo transplant with evidence of
engraftment. Pt previously unable to tolerate PO meds and was
transitioned from tacto to cyclosporine IV. Cyclosporine has
been adjusted multiple times for elevated levels (goal 200).
Fish XY test was sent to test if blood cells were from engrafted
XX cord transplant. Result showed that patient had 70% xx and
30% xy suggestive of possible recurrence of AML. He continued
immunosupression with mychophenolate and cyclosporine.
Cyclosporine levels were checked daily. BMT team was following
throughout stay at [**Hospital Unit Name 153**].
# thrombocytopenia: ranging from 11-20s. PTT, PT, fibrinogen
377, LDH 274 not suggestive of DIC. Likely multifactorial
including zosyn, possibly developing antibodies against
platelets, bone marrow suppression from infection, and AML.
Patient with no signs of bleeding.
# CMV Viremia: CMV viral load 31,000 <-- 11,500 ([**9-29**]) <--
10,900 ([**9-27**]) <-- 8,100 ([**9-23**]) <-- 2,640 ([**9-20**]). CMV IgG
positive. Initially on gancyclovir but viral load continued to
rise and was switched to Foscarnet, which was renally dosed.
# PRES: diagnosed on MRI head on [**9-30**] and emperically treated
for HSV encephalitis. EEG on [**9-4**] with no seizure activity. Per
BMT team, thought secondary to tacrolimus and switched to
cyclosporine. BMT team also states that patient's mental status
has significantly improved and is now alert and oriented x3,
able to carry conversation. Cyclosporine was titrated to goal of
200. His fluid status was optimized. Patient appeared to have
good mental status (A&Ox3 and able to carry conversations) from
[**Date range (1) 100888**], then deteriorated secondary to sepsis.
# Hypernatremia: [**Month (only) 116**] be related to free water losses in setting
of sepsis. Repleted water deficit slowly and sodium corrected.
# Metabolic acidosis: initially he had a non-anion gap acidosis
with hyperchloremia, likely due to free water depletion and
concomitant hypovolemia.
# anemia: in the low 20s but appears to be chronic. Indirect
bili 0.9 and haptoglobin 212, thus unlikely to be hemolysis.
Most likely multifactorial including ACD, immunosuppresants, and
bone marrow suppression. Hct was monitored daily with a
transfusion goal of hct<21
#Hypogammaglobulinemia: The pt's IgG level from [**9-15**] was low in
the 500 range. The patient received a one time dose of IVIG on
[**9-15**] 500mg/kg IV (sucrose-free IVIG) X 1 dose
#Adrenal insufficiency: Diagnosis based on hypotension and
random cortisol level of 8.6. Steroids have been tapered.
Rechecked cortisol was 12.5
ISSUES ONLY PERTAINING TO [**9-10**] - [**9-17**] [**Hospital Unit Name 153**] admission
#Skin ulceration: Pt noted to have ulceration on L forearm with
surrounding erythema. No bleeding or exudate. unclear etiology,
unchanged
# Encephalopathy: unclear etiology but [**Last Name 19390**] problem.
[**Name (NI) **] been attributed to delirium. MRI brain on [**9-1**] showed no
acute process. EEG on [**2128-9-6**] did not show epileptiform activity
and levetiracetam was discontinued. Pt was seen by neurology,
who recent signed off and felt delirium was the most likely
explanation. Mental status has greatly improved therefore we
will not pursue LP at this time given bleeding risk with
thrombocytopenia, although ID recommends further workup rather
than keeping on high dose acyclovir due to fear of inducing
renal failure given Pt is also on ambisome and cyclosporine.
Suspect component of delirium given rapid waxing and [**Doctor Last Name 688**].
Doubt HSV encephalitis given rapid changes in condition. Will
discuss w/ BMT regarding decreasing acyclovir dose back to ppx
dosing as above.
# Volume status: Net positive 13 L since admission. Right
pleural effusion appears slightly larger. Want to move more
toward net even given recent respiratory failure.
-continue diuresis with furosemide 20mg iv (possibly [**Hospital1 **]) goal
neg 2 L daily
-Check pm lytes
# GIB: Resolved. Likely [**2-5**] instrumentation from OG tube
placement in setting of thrombocytopenia. H/H currently stable.
Stool guiaic negative.
- Trend H/H [**Hospital1 **], goal >21
-Continue PPI [**Hospital1 **], carafate
-f/u w/ GI regarding duration of PPI and carafate
# elevated alkaline phosphatase: unclear etiology, but peaked
at 900 on [**2128-9-5**]. Pt has a percutaneous cholecystostomy tube in
place, which continues to drain small amounts of bilious fluid.
Continues to trend down.
# refractory AML: s/p multiple rounds of chemotherapy and double
cord SCT on [**2128-7-30**]. Pt does require frequent RBC and platelet
transfusions. Received per BMT recs.
-transfuse with goal Hct > 25, Plt > 15
-continue ursodiol for [**Last Name (un) **]-occlusive disease prevention
-continue prior mycophenolate for GVHD prophylaxis
-transition from tacrolimus to cyclosporine today
-f/u tacrolimus and cyclosporine levels
-f/u oncology recs
TRANSITIONAL ISSUES:
====================
- Will need colonsocopy for transverse colon focal thickening
once clinical status improves (i.e non-neutropenic)
Medications on Admission:
None.
Discharge Disposition:
[**Last Name (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Biliary sepsis and peritonitis
Acute myeloid leukemia
Vancomycin-resistant enterococcal sepsis
Pneumonia
Acute cholecystitis
Encephalopathy - bifrontal spikes on EEG
PRES
CMV viremia
Mucositis
Neuropathy
Neutropenic fever
SECONDARY DIAGNOSES:
Colitis
Hyperlipidemia
Discharge Condition:
[**Last Name (un) **]
Completed by:[**2128-10-20**]
ICD9 Codes: 5849, 2762, 2724, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7622
} | Medical Text: Admission Date: [**2175-9-14**] Discharge Date: [**2175-9-20**]
Date of Birth: [**2110-9-18**] Sex: F
Service: Neurology
HISTORY OF PRESENT ILLNESS:
65-year-old woman who presents with left leg weakness. The
patient was found to have a stenosis of the brachiocephalic
artery on an MRA/MRI. MRI of the entire spine was obtained
by her PCP for suspicion of disc disease. The rationale for
pursuing of an MRA is unknown. She saw Dr. [**Last Name (STitle) **] from
vascular surgery who referred her to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5730**]. He
performed an angiogram and confirmed the stenosis. On [**9-14**],
a stent was placed but afterwards she developed flaccid left
hemiparesis of arm and leg. She was taken back to angiography
where she had another stent placed for "another
blockage." The radiology report of the angio states that
there was an apparent narrowing of the proximal common
carotid artery. It was felt that the patient had developed a
flap distal to the site in the common carotid artery. She
received three further stents of the carotid. Afterwards,
Dr. [**Last Name (STitle) 5730**] states that her left sided weakness resolved.
After the second visit to the angio suite, the patient says
she developed a drop in hematocrit, requiring three units of
packed red blood cells. She does not know if she had a
hematoma. Before discharge, the patient said she still had some
weakness which significantly improved but she also developed
left leg numbness while in the hospital which progressively
worsened after she was discharged. She came to the Emergency
Department because the numbness has worsened to the point
where she felt the leg feels "dead". She is walking without
support but she leans to the left and is not steady.
PAST MEDICAL HISTORY:
1) Restless leg syndrome
2) Duodenal ulcer
Medications:
Coumadin-started after the stent
Plavix
Klonopin
SOCIAL HISTORY: The patient lives with two sons.
Independent in activities of daily living. No tobacco or
ETOH.
On physical examination, blood pressure 140/70, heart rate 70
and regular. The patient appeared comfortable. OP clear,
right carotid bruit, no JVD, no thyromegaly. Cardiac
examination was notable for a regular rate and rhythm. Chest
was clear to auscultation, and abdomen was benign. No
clubbing, cyanosis, or edema of the extremities.
On neurological examination,
Mental Status: The patient was awake, alert, and oriented
times three. The patient stated the months of the year
backwards and forwards. Language testing demonstrated normal
naming of high and low frequency objects, good repetition.
Normal fluency and comprehension. The patient could write a
sentence to dictation.
Memory: Registered and recalled [**3-19**] objects at one and five
minutes. Calculations were normal. The patient could
demonstrate how to strike a match, light a cigarette, puff
it, throw it to the ground, and stamp it out.
CN: Optic disks were normal. PERRLA, EOMI, VFFTC, V1-V3
intact to light touch and to pinprick. Face, tongue, palate,
SCM move symmetrically. Hearing intact to finger rub
bilaterally.
Motor: Normal tone and bulk. No pronator drift. No
asterixis.
D B T WE WF FE FF IO IP H Q G AT [**Last Name (un) 938**]
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 3 4 5 5 4 4
Sensory: LT and PP severely reduced on the left leg compared
to the right. Poor JPS of the left toe. There is no sensory
level.
Reflexes:
B, T, BR, patella, ankle Plantar
R 3 3 3 3 2 down
L 3 1 2 2 2 down
Coordination: [**Last Name (LF) 43945**], [**First Name3 (LF) **], FFM were normal. Romberg maneuver
was negative.
Gait: She does lean to the left.
Labs: INR 1.4
ASSESSMENT AND PLAN: 65-year-old woman who developed left
sided weakness and left common carotid artery stenosis found
to have common carotid artery dissection requiring further
stents. On examination she has UMN weakness in the left leg with
concurrent sensory loss. Given the clinical setting, the most
worrisome possibility is a stroke. The vascular distribution
would be ACA territory (unusual compared to MCA).
If imaging is negative, then the second possibility is lumbar
disc disease, although the history is not consistent.
RECOMMENDATIONS:
1) MRI with DWI, MRA of the brain. If stents are
prohibitive, then proceed with CT and CTA (of neck as well)
if renal function allows.
2) If imaging negative, then we should consider imaging of
the L-spine.
3) Her Coumadin needs to be continued and brought up above
2.0 given the dissection.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-224
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2175-9-22**]
T: [**2176-4-8**] 17:27
JOB#:
ICD9 Codes: 9971, 4280, 2859, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7623
} | Medical Text: Admission Date: [**2197-1-3**] Discharge Date: [**2197-1-16**]
Date of Birth: [**2117-10-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
Thoracic instrumented fusion with pedicle screws and iliac crest
bone graft
History of Present Illness:
HPI:This is a 79 year old patient admitted from [**Hospital **] Hospital
with recent history of a slip and fall on the ice on thursday
[**2196-12-29**] while walking his dog. He seen on [**2196-12-29**] and discharge
home that day, then readmitted Saturday was discharged and
admitted Sunday due to excessive pain and inability to care for
himself at home. On admission, his cardiac enzymes were
borderline elevated. He denies syncopy, angina, sob, excessive
exertion prior to the fall. He reports severe pain since the
fall that radiates around his truck to abdomen and down to right
hip.At the time of the fall he experienced posterior radiation
right numbness to thigh He denies LOC following the fall. He
denies numbness, tingling, radiation of pain into legs, bowel or
bladder incontinence. Patient became obtunded per family reports
in the hospital last night and transferred to the ICU at [**Hospital **]
Hospital following pain medication administration.
Past Medical History:
PMHx:HTN,dislipidemia,TIA, ankylosing spondylitis, sleep apnea,
BPH s/p prostatectomy and removal of colon polyps.
Social History:
Social Hx:lives alone in [**Hospital3 4634**]
Family History:
Family Hx: widowed with 6 children
Physical Exam:
PHYSICAL EXAM:
O: T: BP: 167/81 HR: 86 R:14 O2Sats:95% on room air
Gen: comfortable, appears to be experiencing severe pain- facial
grimacing during exam.
HEENT: Pupils: EOMs grossly intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person
Motor: patient c/o servere pain with testing of biceps and
ileopsoas
D B T grip IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5
Sensation: decreased sensation over right abdomen at T10
Toes equivicol bilaterally
Rectal exam normal sphincter control
point tenderness noted T4-T10
Pertinent Results:
CT CHEST WITHOUT CONTRAST from [**Hospital **] Hospital [**2197-1-2**]:
FRACTURE THROUGH THE VERTEBRAL BODY EXTENDING INTO THE RIGHT
TRANSVERSE PROCESS AND THE RIGHT COSTOVERTEBRAL JOINT. tHERE IS
SOME RETROPULSION OF FRAGMENTS INTO THE CANAL LIKELY CAUSING
MASS EFFECT ON THE THECAL SAC. nO OBVIOUS EXTRA AXIAL BLOOD IS
SEEN.THERE IS LIKELY PARA VERTEBRAL SOFT TISSUE SWELLING.
LUMBAR SPINE W/O CONTRAST [**2197-1-2**] from [**Hospital **] Hospital
:markedly limited study due to patient motion. No evidence of
acute fracture or subluxation. Findings compatabile with known
ankylosing spondylitis. Edema along right posterior paraspinal
musculature which may represent a muscle strain versus partial
tear.
CT Abdomen [**2197-1-2**] from [**Hospital **] Hospital : consistent with T10
fracture
[**2197-1-3**] 09:57PM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG
[**2197-1-3**] 09:57PM URINE RBC-100* WBC->1000* BACTERIA-MANY
YEAST-NONE EPI-4
[**2197-1-3**] 09:57PM URINE WBCCLUMP-MANY MUCOUS-FEW
[**2197-1-3**] 07:35PM GLUCOSE-162* UREA N-29* CREAT-1.0 SODIUM-141
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-33* ANION GAP-11
[**2197-1-3**] 07:35PM CK(CPK)-67
[**2197-1-3**] 07:35PM CK-MB-NotDone cTropnT-0.08*
[**2197-1-3**] 07:35PM CALCIUM-8.6 PHOSPHATE-2.1* MAGNESIUM-2.3
Brief Hospital Course:
Pt was admitted to the hospital and kept at bedrest. He was
seen in consultation by both medicine and cardiology for his HTN
and recent MI. He was treated for UTI. He was fit for TLSO
which he wore when HOB was elevated, he remained at bedrest. He
had full work up and treatment and was made ready for surgery.
On [**1-11**] he was brought to the OR where under general anesthesia
he underwent posterior thoracic instrumented fusion with pedicle
screws and iliac crest bone graft. He tolerated this procedure
well. Remained extubated post op due to facial/laryngeal
swelling and was transferred to the ICU where he was monitored
closely. He underwent CT showing goood hardware placement and
spinal alignment. he was extubated on [**2196-1-12**]. he was
transferred to the floor [**1-13**]. his diet and activity were
advanced. His foley was removed. he transitioned to PO pain
medication. He had full motor strength throughout, his wound was
clean and dry. Prior to discharge is INR was noted to be
elevated to 1.8 he was given vitamin K and on discharge his INR
was 1.2, if further elevation consideration of holding heparin
might be considered. He was mobilized and seen by PT and OT who
recommended disposition to a rehab facility.
Medications on Admission:
dilacor XR 300 mg, percocet,ibuprofen, lovastatin, triamterene,
ticlid, allopurinol,flonase,ambien
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
T10 fracture
anklyosing spondilitis
constipstion
NSTEM MI
respiratory distress
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have your incision checked daily for signs of infection
?????? You are required to wear back brace as instructed
?????? You may shower briefly without the back brace ??????
Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
You have thyroid nodule found on CT that should be follow up
with Ultrasound with your PCP.
Have your staples removed [**1-20**] at rehab or follow up with Dr. [**Name (NI) **] office - call for appt if needed.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT
Completed by:[**2197-1-16**]
ICD9 Codes: 5849, 5990, 2930, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7624
} | Medical Text: Admission Date: [**2112-12-30**] Discharge Date: [**2113-1-5**]
Date of Birth: [**2048-9-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization [**2113-1-2**]
History of Present Illness:
Please see the CT surgery admission note and Cardiology consult
H&P for full details.
In brief, this is a 64yo M w/CAD s/p CABG X 3 who presented to
an OSH with chest pain that began after shoveling snow on
[**2112-12-28**]. He describes the pain as a sharp sensation below his
right lower rib. He took 2 NTG tablets without effect and
presented to [**Location (un) 1514**] (NH) Hospital where biomarkers were
positive (peak Tn 2.4, CKMB 10.8, CK 147). He underwent cardiac
catheterization which showed a patent vein graft to the LAD with
the remaining grafts and native vessels occluded or severely
diseased. Following the procedure he had persistent chest pain
despite high dose nitro gtt. He was felt not to be a candidate
for re-do bypass by the surgeon at the OSH. An intraaortic
balloon pump was placed and he was transferred to [**Hospital1 18**] under
for evaluation by Dr. [**Last Name (STitle) 914**]. On arrival to the CCU, he
continued to c/o CP but soon thereafter became pain free on a
heparin gtt, integrilin and a nitro gtt. He was evaluated by CT
surgery and Dr. [**Last Name (STitle) **] and was transferred to the CCU service on
[**2112-1-1**] to proceed with
.
Family reports he developed slurred speech 3 days ago the day
prior to the onset of his chest pain. Denied motor deficits or
disorientation. Of note, he had run out of his oxycodone for
several days. He has had chronic anterior chest pain as a result
of his repeated sternotomies for which he takes oxycodone x 10
years.
.
On cardiac review of symptoms, cardiac and musculoskeletal chest
pain as above. No PND, orthopnea, DOE, [**Location (un) **].
Past Medical History:
DM
HTN
Hyperlipidemia
CAD
chest pain syndrome
Cardiac Risk Factors include diabetes, hyperlipidemia and
hypertension.
Social History:
former smoker, social EtOH, no illicits
Family History:
NC
Physical Exam:
Vitals: T99.6 HR 60 BP 150/50 RR 17 O2 sats 94% 4L
GENERAL: Well-appearing, NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP flat.
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: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. L Femoral catheter in
place with IABP.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2112-12-30**] 10:08PM BLOOD WBC-6.1 RBC-3.03* Hgb-10.1* Hct-27.8*
MCV-92 MCH-33.2* MCHC-36.2* RDW-13.5 Plt Ct-151
[**2112-12-31**] 05:26AM BLOOD PT-12.2 PTT-31.5 INR(PT)-1.0
[**2112-12-30**] 10:08PM BLOOD Glucose-360* UreaN-12 Creat-0.9 Na-132*
K-3.5 Cl-97 HCO3-24 AnGap-15
[**2112-12-31**] 05:26AM BLOOD CK(CPK)-71
[**2113-1-1**] 04:44AM BLOOD CK(CPK)-53
[**2113-1-1**] 11:08AM BLOOD CK(CPK)-55
[**2112-12-30**] 10:08PM BLOOD CK-MB-3 cTropnT-0.21*
[**2113-1-1**] 04:44AM BLOOD CK-MB-NotDone cTropnT-0.22*
[**2113-1-1**] 11:08AM BLOOD CK-MB-NotDone cTropnT-0.26*
[**2112-12-30**] 10:08PM BLOOD Calcium-8.1* Phos-3.7 Mg-1.8
[**2113-1-1**] 04:44AM BLOOD Cholest-117 Triglyc-161* HDL-31
CHOL/HD-3.8 LDLcalc-54
[**2112-12-31**] 07:34AM BLOOD Type-ART pO2-84* pCO2-38 pH-7.46*
calTCO2-28 Base XS-2
--------------
DISCHARGE LABS:
--------------
STUDIES:
.
ECG [**2112-12-30**]: SR 64 bpm. Q III, small avF. t wave flattening III,
avL, avF. Unchanged from EKG [**2112-12-29**] from OSH.
.
CARDIAC CATHETERIZATION [**2112-12-30**] at [**Hospital 1514**] Hospital: patent
SVG-LAD, LMCA 80% distal stenosis, LAD occluded at midportion,
LCx proximally occluded, RCA occluded, SVG->OM/Diag not able to
be engaged despite use of JR4, [**Last Name (LF) 84183**], [**First Name3 (LF) 899**] or [**Doctor First Name 48**].
.
ECHO [**2112-12-31**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is top
normal/borderline dilated with focal hypokinesis of the distal
septum. The remaining segments contract normally (LVEF = 55 %).
The right ventricular cavity is mildly dilated with depressed
free wall contractility. 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.
Trace aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
IMPRESSION: Suboptimal image quality. Right ventricular cavity
enlargement with free wall hypokinesis. Focal left ventricular
systolic dysfunction c/w CAD. Mild pulmonary artery systolic
hypertension.
Brief Hospital Course:
Mr. [**Known lastname 13712**] is a 64M with severe CAD s/p CABG x 3. He is not a
surgical candidate per CT surgery.
.
#. CORONARY ARTERY DISEASE: Patient with CAD s/p CABG x 3. Prior
to transfer from OSH to [**Hospital1 18**], he underwent cardiac
catheterization which showed a patent vein graft to the LAD with
the remaining grafts and native vessels occluded or severely
diseased. Following the procedure he had persistent chest pain
despite high dose nitro gtt. He was felt not to be a candidate
for re-do bypass by the surgeon at the OSH. An intraaortic
balloon pump was placed and he was transferred to [**Hospital1 18**] for
evaluation by Cardiac Surgery (Dr. [**Last Name (STitle) 914**]. On arrival to the
CCU, he continued to c/o CP but soon thereafter became pain free
on a heparin gtt, integrilin and a nitro gtt. On HD 3, patient
spiked a fever to 103.7 with accompanying low flank pain and
there was concern that this represented an infection of the
IABP. His IABP was then pulled on HD 4, but given his persistent
fever cardiac catheterization was postponed and Vancomycin
started. Patient c/o abdominal pain and a CT abdomen/pelvis was
obtained after removal of the IABP that demonstrated
inflammation of his ascending [**Last Name (STitle) 499**] so he was started on Flagyl
& Ciprofloxacin. On HD 6, he became afebrile and all of his
blood cultures were negative, so his Vancomycin was stopped. He
was cleared for cardiac catheterization, but his Hct was 20.0
and the patient refused blood products because of his religious
beliefs. He subsequently underwent a cardiac catheterization on
HD6 with a radial approach to minimize blood loss, but none of
his lesions were intervenable. He was advised to return for
repeat cardiac catheterization in approximately 1 month when his
blood counts improve for a re-attempt. As an inpatient, he was
maintained on his home Gemfibrozil 600 mg PO BID, Zetia 10mg
daily, Atorvastatin 80mg daily, Aspirin 325mg daily and
Metoprolol 12.5mg [**Hospital1 **]. He was discharged on the above
medications in addition to Imdur 30mg daily, Toprol XL 50mg
daily, and Lisinopril 10mg daily. He was scheduled for
Cardiology and PCP [**Last Name (NamePattern4) 702**].
.
#. Fever & Abdominal/Flank pain: Patient with fever, abdomen &
flank pain on HD3 as noted above. After removal of balloon pump,
patient had CT abdomen & pelvis that demonstrated thickening of
the cecum and ascending [**Last Name (LF) 499**], [**First Name3 (LF) **] his IV Flagyl/Cipro/Vancomycin
was continued. After the balloon pump was removed, he remained
pain free and defervesced quickly. His blood cultures remained
negative and his Vancomycin was held. He was continued on his
Ciprofloxacin and Flagyl and was discharged to complete a 10 day
course.
.
#. Anemia: Patient with Hct of 27.8 on admission, that dropped
to 20.0 by HD 6. This was thought to be [**1-24**] hemolysis from the
balloon pump and from some bleeding at the IABP site. His
Heparin gtt was held and pneumoboots started. He was found to be
guaiac positive, but had no e/o frank blood in his stools. U/A
was negative for blood. CT did not demonstrate an RP bleed or
free fluid in the abdomen. As the patient is Jehovah's Witness,
he declined pRBC's, so he was started on Epogen & Ferrous
Sulfate on HD 5 and monitored closely. He was advised to have an
outpatient GI work-up for his anemia.
.
#. PUMP: TTE showed distal septal hypokinesis, EF 55%. Patient
appeared euvolemic on exam without evidence of failure. He was
maintained on Metoprolol and Captopril as an inpatient and
transitioned to long-acting agents as an outpatient.
.
#. RHYTHM: Patient was in sinus rhythm, he was monitored on
telemetry and maintained on Metoprolol.
.
#. DIABETES: His home Glyburide and Metformin were held as an
inpatient in lieu of a humalog sliding scale. A HbA1c was 8.0%.
.
#. HYPERCHOLESTEROLEMIA: Patient's lipid profile showed
Cholest-117 Triglyc-161* HDL-31 CHOL/HD-3.8 LDLcalc-54. He was
continued on Gemfibrozil 600 mg PO BID, Zetia 10mg daily and was
placed on Atorvastatin 80mg daily.
.
#. FEN: Patient was given cardiac/diabetic diet, he tolerated
POs well.
.
#. Code Status: FULL
.
To do:
F/U outstanding blood cultures from [**1-1**], [**1-2**]/, and [**1-3**]
Medications on Admission:
TRANSFER MEDICATIONS:
ASA 325mg qd
Atenolol 50mg [**Hospital1 **]
Norvasc 10mg qd
Zetia 10mg qd
Gemfibrizol 600mg [**Hospital1 **]
Glyburide 5mg qd
Protonix 40mg [**Hospital1 **]
Quinapril 10mg [**Hospital1 **]
Ranexa
Zocor 80mg qd
Integrilin gtt
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Non ST elevation myocardial infarction
Ascending Colitis (likely ischemic)
Secondary:
Iron Deficiency Anemia
Diabetes Mellitus, Type II
Hypertension
Hyperlipidemia
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 chest pain and a small
heart attack. In the hospital, you were seen by cardiac surgery
and they determined that you were not a surgical candidate. You
were also seen by interventional cardiology and they started a
procedure to reopen a blocked vessel. Unfortunately, due to
your low blood count, they did not feel that an opening
procedure would be safe at this time. Therefore, we recommended
that you return in approximately 1 month when your blood counts
are higher to re-attempt an intervention.
Additionally, in the hospital you had some fevers and abdominal
pain. A CT was performed that showed inflammation in your [**Hospital1 499**].
The surgery team saw you and did not feel that you required
surgery at this time. You were started on antibiotics and your
fever and abdominal pain resolved. You will need to finish six
more days of antibiotics after your discharge.
The following medications were STARTED:
-Isosorbide Mononitrate (IMDUR): This is a NEW medication to
treat your blood pressure and chest pain
-Metoprolol Succinate (TOPROL XL): This is a NEW medication to
treat your blood pressure and heart rate. It is intended to
REPLACE your home Atenolol.
-LISINOPRIL: This is a NEW medication to treat your blood
pressure. It is intended to REPLACE your home Quinapril.
-Ferrous Sulfate: This is a NEW medication to treat your anemia.
-Ascorbic Acid (Vit C): This should be taken with the iron and
will help absorb it
-Ciprofloxacin (CIPRO): This is an antibiotic to treat the
inflammation in your gut. Please continue to take this
medication as prescribed until [**1-11**].
-Metronidazole (FLAGYL): This is an antibiotic to treat the
inflammation in your gut. Please continue to take this
medication as prescribed until [**1-11**].
The following medications were STOPPED:
Atenolol
Quinapril
Amlodipine (NORVASC)
Ezetimibe (ZETIA)
Clopidogrel (PLAVIX)- stopped while your blood counts are low
Followup Instructions:
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 84184**]
Specialty: PCP
[**Name Initial (PRE) 2897**]/ Time: Wednesday, [**1-11**] at 10:30am
Location: [**University/College **] HITCHCOCK-[**Location (un) **], [**Street Address(2) 84185**],
[**Location (un) **],[**Numeric Identifier 84186**]
Phone number: [**Telephone/Fax (1) 62229**]
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 84187**]
Specialty: PCP
[**Name Initial (PRE) 2897**]/ Time: Monday, [**2-13**] at 10 am
Location: [**Location (un) 84188**], [**Location (un) 5450**], [**Numeric Identifier 84189**]
Phone number: ([**Telephone/Fax (1) 84190**]
Dr [**Last Name (STitle) **] would like to attempt to reopen your closed vessels to
your heart once your blood counts have returned to [**Location 213**]. Once
your PCP has recorded that your blood counts have normalized you
can contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 83585**] to schedule a time for a
repeat angiogram.
Finally, you will need to be seen by a gastroenterologist for an
evaluation of your low blood counts and recent gastrointestinal
inflammation.
ICD9 Codes: 5849, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7625
} | Medical Text: Admission Date: [**2194-6-9**] Discharge Date: [**2194-6-21**]
Date of Birth: [**2173-1-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3977**]
Chief Complaint:
LLQ/flank pain.
Major Surgical or Invasive Procedure:
Picc line placed, then removed at discharge.
History of Present Illness:
Mr. [**Known lastname **] is a 21 y.o. man w/ a history of AIHA s/p splenectomy
([**3-/2194**]) on prednisone, PE and portal vein thrombosis (on
warfarin), and IgA deficiency, who presented with 3 days of
nausea/vomiting and suprapubic/LLQ pain accompanied by dark
urine. He noted that his vomiting began 3 days ago at night. He
did not see what his vomit looked like at that time. He then had
another episode the next morning, which he said appeared
"brown." Altogether, he notes vomiting more than 10 times in the
last three days, with some of the vomit appearing to be
"coffee-ground" in nature. He felt as if having a bowel movement
would make him feel less nauseous, but he had one earlier today
but it did not help him. He said his stool was hard, brown, and
non-bloody.
One day ago he began having LLQ/suprapubic pain which was
stabbing in nature and would radiate to his back and left flank.
He would not be able to get comfortable due to this pain, which
he said would range from [**2192-4-16**]. He said in this setting his
urine began looking like "cola," and it would hurt him when he
urinated. He noticed what looked like blood in his urine as
well.
Of note, he was healthy until [**9-/2193**], when he visited [**Hospital1 **] to see a friend who just had a child and was noted to
be jaundiced and unsteady. He was found to be profoundly anemic
and was diagnosed with autoimmune hemolytic anemia (Coombs+) and
IgA deficiency. He underwent a splenectomy 4/[**2193**]. He developed
chest pain in [**4-/2194**], and he was found on OSH imaging to have
bilateral PEs and portal vein thrombosis. He was also treated
for pneumonia in this setting.
He has been chronically SOB, especially on exertion, noting that
he can only walk up 1 flight of stairs or walk about 20 yards
without needing to rest. He says he wheezes in the setting of
exertion. He has had chest pain ever since his PE diagnosis in
[**Month (only) 116**], although the pain has decreased since then.
He also noted fevers, chills, 50-60 lb weight gain since
beginning prednisone in [**9-/2193**], weakness since beginning
prednisone. He has chronic headaches. He denied dizziness and
lightheadedness. He takes "8 tylenol on average" per vascular
surgery note.
He originally presented to [**Hospital3 **], where WBC 65.5 and
Hct 19.5. 11% bands, 5% metamyelocytes, 122 nucleated RBCs. He
received a CT abdomen/pelvis, which found persistent
non-occlusive extrahepatic portal vein thrombosis, R hepatic
lobe intrahepatic portal vein thrombosis, L renal swelling, fat
stranding, and perinephric fluid. L mid-hydroureter w/ the
distal L ureter appearing relatively collapsed. No apparent
ureterolithiasis. He received hydrocortisone, ondansetron,
Zosyn, and ceftriaxone. He was then transferred to the [**Hospital1 18**] ED
for further management.
In the ED, initial VS were: T 97.2, HR 90, BP 144/88, RR 18,
O(2)Sat: 98%. WBC 26.5, HCT 18.6, ALT 51, AST 166, LDH 4070,
Tbili 2.8, and Dbili 1.0. Haptoglobin <5. U/A significant for
WBC 47, RBCs 36, but negative nitrite, trace leukocyte esterase,
few bacteria, 0 epis. Hematology was consulted and recommended
1mg/kg solumedrol, PPI, checking H.pylori, giving 5 mg folate
QD, IV heparin, and bone marrow bx/aspirate. Vascular surgery
was consulted and recommended a renal US. A preliminary read of
a Renal US indicated L renal vein thrombosis. Urology was
consulted and did not feel that there was a focal arterial
process to intervene upon.
On arrival to the MICU, T99, HR 112, BP 117/68, RR 26, 94% on 2L
NC. He was fatigued but not in any apparent distress. He was
started on vancomycin/cefepime for his suspected pyelonephritis
and ordered for 2U packed RBCs.
Review of systems:
(+) Per HPI. Also notes b/l hand tremor, b/l elbow pain, and
acne formation on arms b/l.
(-) Denies night sweats. Denies sinus tenderness, rhinorrhea or
congestion. Denies cough. Denies rash.
Past Medical History:
Autoimmune Hemolytic Anemia
Hx Bilateral PE ([**4-/2194**], on warfarin)
Portal Vein Thrombosis
IgA Deficiency
Hx Pneumonia (1 time in setting of b/l PE [**4-/2194**] and treated
[**Date range (1) 112318**])
Hearing Loss (since birth, has used hearing aid since age [**3-13**])
S/P Splenectomy [**3-/2194**]
S/P Tonsillectomy
S/P B/L Tympanostomy tube placement as child
Social History:
Mr. [**Known lastname **] lives with his grandfather in [**Location (un) 10072**], MA. He used
to work at [**Last Name (un) 6058**] but can no longer work given the
limitations from his illness. He has an 8 pack-year smoking
history (1 pack/day since age 14), but he recently quit
following his diagnosis of PE. He has [**2-9**] alcoholic
drinks/week. He denies a history of recreational drug use.
Family History:
He notes that his grandfather, mother, father, aunt, cousin, and
brother all have hematologic abnormalities. Great grandmother
w/ breast cancer, grandfather w/ skin cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 99, HR: 119, BP: 124/60, RR: 25, 94% on 3L
General: Alert and oriented x3 , fatigued
HEENT: Sclera icteric, MMD, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, nl S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft, TTP in LLQ, non-distended, bowel sounds present,
no organomegaly
GU: TTP in Left Flank, nauseous when palpating suprapubic region
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, grossly intact strength/sensation
upper/lower extremities, gait deferred, coordination grossly
intact
Pertinent Results:
ADMISSION LABS:
[**2194-6-12**] 03:19AM BLOOD WBC-37.1* RBC-2.59* Hgb-7.9* Hct-21.6*
MCV-83 MCH-29.5 MCHC-36.3* RDW-25.5* Plt Ct-178
[**2194-6-11**] 10:00PM BLOOD WBC-33.0* RBC-2.39* Hgb-6.8* Hct-19.9*
MCV-83.0 MCH-27.4 MCHC-34.2 RDW-25.7* Plt Ct-145*
[**2194-6-11**] 04:29PM BLOOD WBC-44.3* RBC-2.32* Hgb-6.8* Hct-19.7*
MCV-85 MCH-29.2 MCHC-34.4 RDW-26.1* Plt Ct-143*
[**2194-6-11**] 04:17AM BLOOD WBC-47.3* RBC-2.20* Hgb-6.4* Hct-18.7*
MCV-85 MCH-29.0 MCHC-34.1 RDW-25.6* Plt Ct-126*
[**2194-6-10**] 04:55PM BLOOD WBC-44.6* RBC-2.40* Hgb-7.0* Hct-20.4*
MCV-85 MCH-29.2 MCHC-34.3 RDW-26.3* Plt Ct-125*
[**2194-6-10**] 10:32AM BLOOD WBC-35.0* RBC-2.44* Hgb-7.2* Hct-20.8*
MCV-85 MCH-29.6 MCHC-34.7 RDW-25.4* Plt Ct-122*
[**2194-6-10**] 02:46AM BLOOD WBC-36.0* RBC-2.30* Hgb-6.8* Hct-19.6*
MCV-85 MCH-29.6 MCHC-34.6 RDW-27.0* Plt Ct-115*
[**2194-6-9**] 02:45PM BLOOD WBC-26.5* RBC-2.19*# Hgb-6.4*# Hct-18.6*#
MCV-85# MCH-29.1 MCHC-34.2 RDW-30.5* Plt Ct-140*
[**2194-6-10**] 02:46AM BLOOD Neuts-81* Bands-2 Lymphs-5* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-3* NRBC-66*
[**2194-6-9**] 02:45PM BLOOD Neuts-80* Bands-0 Lymphs-7* Monos-4 Eos-1
Baso-1 Atyps-0 Metas-2* Myelos-5* NRBC-85*
[**2194-6-10**] 02:46AM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-2+
Macrocy-2+ Microcy-2+ Polychr-1+ Spheroc-OCCASIONAL Stipple-1+
Tear Dr[**Last Name (STitle) 833**]
[**2194-6-9**] 02:45PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-NORMAL
Macrocy-1+ Microcy-3+ Polychr-3+
DISCHARGE LABS:
[**2194-6-12**] 03:19AM BLOOD PT-13.0* PTT-64.2* INR(PT)-1.2*
[**2194-6-11**] 10:00PM BLOOD PT-13.0* PTT-62.9* INR(PT)-1.2*
[**2194-6-11**] 04:28PM BLOOD PT-12.9* PTT-84.9* INR(PT)-1.2*
[**2194-6-11**] 07:30AM BLOOD PT-13.0* PTT-45.2* INR(PT)-1.2*
[**2194-6-11**] 01:42AM BLOOD PT-13.5* PTT-66.4* INR(PT)-1.3*
[**2194-6-10**] 04:55PM BLOOD PT-13.8* PTT-58.6* INR(PT)-1.3*
[**2194-6-10**] 10:32AM BLOOD PT-13.8* PTT-60.3* INR(PT)-1.3*
[**2194-6-10**] 02:46AM BLOOD PT-14.4* PTT-55.1* INR(PT)-1.3*
[**2194-6-9**] 02:45PM BLOOD Fibrino-426*
[**2194-6-9**] 02:45PM BLOOD Ret Man-29.6*
[**2194-6-12**] 03:19AM BLOOD Glucose-149* UreaN-15 Creat-1.5* Na-132*
K-4.1 Cl-96 HCO3-19* AnGap-21
[**2194-6-11**] 04:28PM BLOOD Glucose-106* UreaN-17 Creat-1.3* Na-134
K-3.8 Cl-97 HCO3-23 AnGap-18
[**2194-6-11**] 04:17AM BLOOD Glucose-181* UreaN-16 Creat-1.3* Na-131*
K-4.2 Cl-96 HCO3-24 AnGap-15
[**2194-6-10**] 11:03AM BLOOD Glucose-134* UreaN-18 Creat-1.3* Na-131*
K-5.0 Cl-100 HCO3-21* AnGap-15
[**2194-6-10**] 02:46AM BLOOD Glucose-162* UreaN-19 Creat-1.3* Na-133
K-5.2* Cl-100 HCO3-22 AnGap-16
[**2194-6-9**] 02:45PM BLOOD Glucose-141* UreaN-18 Creat-1.3* Na-136
K-5.5* Cl-100 HCO3-25 AnGap-17
[**2194-6-12**] 03:19AM BLOOD ALT-47* AST-91* LD(LDH)-3994* AlkPhos-104
TotBili-2.9*
[**2194-6-9**] 02:45PM BLOOD ALT-51* AST-166* LD(LDH)-4070*
AlkPhos-117 TotBili-2.8* DirBili-1.0* IndBili-1.8
[**2194-6-12**] 03:19AM BLOOD Albumin-3.2* Calcium-8.7 Phos-2.0* Mg-2.1
[**2194-6-12**] 06:02AM BLOOD UricAcd-5.1
[**2194-6-11**] 04:28PM BLOOD Calcium-8.4 Phos-2.7 Mg-2.3
[**2194-6-10**] 02:46AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.0
[**2194-6-9**] 02:45PM BLOOD UricAcd-6.9 Iron-52
[**2194-6-9**] 02:45PM BLOOD calTIBC-341 VitB12-640 Hapto-<5*
Ferritn-118 TRF-262
[**2194-6-12**] 06:02AM BLOOD Osmolal-280
[**2194-6-10**] 02:46AM BLOOD b2micro-2.7* IgG-673* IgA-<5* IgM-63
[**2194-6-12**] 06:02AM BLOOD Vanco-15.1
[**2194-6-9**] 02:59PM BLOOD Lactate-1.1
[**2194-6-12**] 03:19AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
[**2194-6-9**] CXR: IMPRESSION: No acute cardiopulmonary process.
.
[**2194-6-9**] RENAL U/S: IMPRESSION: Reversal of diastolic flow in the
two identified separate left main renal arteries and overall
decreased vascularity in the left kidney is most consistent with
left renal vein thrombosis, including no identifiable flow in
the left main renal vein.
.
[**2194-6-16**] MR ABD
IMPRESSION: 1. Unchanged thrombus within the left renal vein
with absent enhancement and restricted diffusion of the left
renal medullary pyramids compatible with infarction.
2. Blood clot noted within the left collecting system and
ureter.
3. Hemosiderin deposition within the renal cortices
bilaterally, likely secondary to intravascular hemolysis.
4. Unchanged portal venous thrombus.
.
[**2194-6-18**] Tagged RBC scan for accessory spleen eval. IMPRESSION:
Inconclusive study due to inadequate RBC damaging. A sulfur
colloid could be used to try to identify accessory splenic
tissue.
.
[**2194-6-20**] RENAL FUNCTION SCAN- IMPRESSION: 1- Absence of blood
flow and decreased renal uptake noted in the left kidney and
adequate blood flow noted in right kidney. 2- Left kidney shows
approximately 10% of the total renal function and the right
kidney shows 90%.
.
DISCHARGE LABS:
[**2194-6-21**] 05:22AM BLOOD WBC-25.0* RBC-3.89* Hgb-11.3* Hct-33.2*
MCV-85 MCH-29.0 MCHC-34.1 RDW-24.6* Plt Ct-393
[**2194-6-20**] 06:00AM BLOOD WBC-26.8* RBC-3.94* Hgb-11.3* Hct-33.2*
MCV-84 MCH-28.8 MCHC-34.1 RDW-25.5* Plt Ct-332
[**2194-6-18**] 05:20AM BLOOD Neuts-85* Bands-0 Lymphs-1* Monos-8 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-3* NRBC-173*
[**2194-6-20**] 06:00AM BLOOD Glucose-304* UreaN-13 Creat-1.0 Na-135
K-4.7 Cl-95* HCO3-28 AnGap-17
[**2194-6-21**] 05:22AM BLOOD UreaN-17 Creat-0.9
[**2194-6-21**] 05:22AM BLOOD LD(LDH)-1661*
[**2194-6-20**] 06:00AM BLOOD ALT-55* AST-25 LD(LDH)-[**2145**]* AlkPhos-88
TotBili-1.0
[**2194-6-20**] 06:00AM BLOOD Albumin-4.0 Calcium-9.1 Phos-4.0 Mg-2.2
[**2194-6-19**] 06:00AM BLOOD calTIBC-319 Hapto-<5* Ferritn-181 TRF-245
[**2194-6-10**] 02:46AM BLOOD b2micro-2.7* IgG-673* IgA-<5* IgM-63
Brief Hospital Course:
21 y.o. man with PMH of AIHA s/p splenectomy, IgA deficiency,
PE, and portal vein thrombosis (on warfarin) who presented w/
n/v, suprapubic/LLQ pain, found to have renal vein thrombosis as
well as a markedly elevated WBC (37.1 this AM), the underlying
etiology of which is not clear. However, his diagnosis is
related to either a warm auto-immune hemolytic process and/or
paroxysmal nocturnal hemoglobinuria processes.
.
Briefly, the patient was started on hi dose steroids and danazol
and now has stabilized his blood counts. Rituximab was initially
considered for concern of refractory hemolytic anemia as
supported by Coomb's positive studies. However, he developed C
Diff in the interim and Rituximab therapy was deferred. During
the workup for his hypercoaguable state, flow cytometry studies
suggested he had PNH cells. Therefore the use of rituximab came
into question as he may have a better diagnosis of PNH to
explain his hemolytic anemia and thrombosis. He is clinically
stable and his Hgb is stable for several days now at time of
discharge. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from the hematology service will follow
this patient as an outpatient and met the patient several times.
.
Attention was given to his complicated discharge plans including
ensuring he will have his medications when he returns home and
close followup. Other details below.
.
1. Warm AIHA: Positive DAT IgG+, C3b negative. HIV and
hepatitis B/C serologies negative. Panagglutinating antibody by
routine method [solid phase], autoanti-c in [**Last Name (un) 101**]. BMB showed an
appropriate erythroid hyperplasia, no lymphoma.
Beta2-glycoprotein-1 negative. [**Doctor First Name **] negative. Flow for PNH show
acquired PNH phenotype. Bone marrow cytogenetics normal.
- Received 3 units PRBC [**6-9**], [**6-10**], [**6-13**]
- D/c methylprednisolone [**2194-6-20**].
- Change to po steroids ([**2194-6-20**])- prednisone 120 mg daily (1
mg/kg daily). Dr [**Last Name (STitle) **] from hematology will manage next dose
change.
- Cotinue danazol, dose increased from 200 to 400mg [**Hospital1 **] on
[**2194-6-13**]. This will be continued as outpatient.
- Initially planned for rituximab 375mg/m2. However, given new
information regarding PNH, this plan may change. NO RITUXUMAB
FOR NOW. Eculizumab may be indicated (outpatient therapy). Need
to confirm dx of PNH. Antibody therapy deferred at this time.
- Folic acid repletion of cell turnover.
- [**2194-6-18**] tagged RBC (heat damaged) scan looking for accessory
spleen as contributor to AIHA; was inconclusive on study because
of technical issues. Consider repeat if need to assess for
accessory spleen.
- Haptoglobin [**2194-6-19**] still low.
.
2. Abdominal/back pain: Due to renal vein thrombosis, renal
infarction, and portal vein thrombosis. Pain service consulted.
CT at OSH showed renal vein thrombosis, renal infarction, and
unclear if accessory spleen is present.
- D/C hydromorphone PCA pump on [**2194-6-18**].
- Was on OxyContin 40mg [**Hospital1 **]. Oxycodone breakthru pain.
- Change to Morphine sulfate long and short acting due to
insurance.
- Lidocaine patch. Consider d/c.
- D/C Heparin gtt on [**2194-6-18**]. Warfarin failure unclear, but
possible. INR 1.3 with renal vein thrombosis. However he has
been compliant and has not had low INRs previously. Transition
to enoxaparin 1mg/kg [**Hospital1 **] on [**2194-6-18**] PM. Check anti-Xa levels to
ensure adequate anticoagulation in this high risk patient.
- Blood cultures from [**Hospital3 **] NGTD.
- Consider scheduled acetaminophen.
- Avoid NSAIDs with anti-coagulation and steroids.
.
3. Chronic PE, acute left renal vein thrombosis, portal vein
thrombosis: Unknown hypercoagulable state, though flow cytometry
shows acquired PNH; beta2-glycoprotein-1 negative,
anti-cardiolipin Ab neg; JAK2 negative.
- Urology following. Repeat U/A normal.
- Heparin gtt d/c'd, started on enoxaparin as discussed above.
- Discontinued telemetry [**2194-6-18**].
- Consider further workup of coagulopathy as needed as
outpatient.
.
4. Acute Kidney Injury - Left renal medullary infarct. As
discussed above.
- Cr normal now in fact after acute kidney injury.
- Nephrology consulted for management of ongoing renal
infarction.
- MR kidney shows patent left renal arteries, but evidence of
medullary infarct. No progression of clot in renal vein per se.
- MAG3 renal scan for quantification of remaining renal function
shows 10% of total function through left kidney. done Friday
[**6-20**].
- Patient will have renal follow up with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**].
- Left ureteral blood clot, seen on MRI. Since minimal function
remaining, no urgent intervention at this time.
.
5. Hi dose steroid-related Issues:
- HYPERGLYCEMIA - steroids induced. on insulin sliding scale.
- Started on insulin sliding scale [**2194-6-19**]. Insulin will not be
continued as outpatient given COMPLEX medication situation.
- Will start on glipizide today [**2194-6-20**].
- PCP (SS Bactrim daily) and HSV PROPHYLAXIS (acyclovir)
- Patient was educated carefully on these medications. Patient
demonstrated understanding of these matters.
.
6. Hx Tachycardia: Due to severe anemia, chronic PE, and
diarrhea (volume depletion). Stable today. Non-issue at this
time.
- Monitor clinically.
.
7. Leukocytosis: Unclear etiology, possibly due to splenectomy
and steroids. Extreme leukocytosis reported (then corrected
daily in OMR) is an error due to the automated counter mistaking
nucleated RBCs for WBCs. Resolving C. diff diarrhea. BM bx
consistent with AIHA.
-monitor. No fever.
.
8. Hx Thrombocytopenia: Mild, suspect ITP ([**Doctor First Name **] syndrome)
given autoimmune predisposition. Resolved with steroids.
.
9. Nucleated RBCs: Due to asplenia and extreme erythropoiesis
during acute hemolysis. Physiologic.
.
10. Diarrhea: C. diff PCR POSITIVE. Stool culture negative.
- No response to metronidazole; changed to PO vancomycin on
[**2194-6-16**], will have 1 week course post discharge.
- Much improved, was getting better several days ago.
- Does not have celiac disease; workup done (TTG IgG and
anti-gliadin Ab) given its association with IgA deficiency and
his chronic GI complaints. TTG IgA not useful because of IgA
deficiency. Also at risk for giardiasis. *TISSUE
TRANSGLUTAMINASE AB is negative. Anti-gliadin ab negative.
.
11. Hx Pruritus: Suspect this was due to indirect
hyperbilirubinemia from hemolysis. No acute issues at discharge.
- Continue with diphenhydramine PRN.
- Added fexofenadine early on in course. Will d/c now ([**2194-6-19**]).
.
12. IgA deficiency: Rare infections (recent pneumonia, current
C. difficile colitis). No need for treatment for this
diagnosis.
- Was on nystatin during early during course. No thrush at this
time. D/c on [**2194-6-19**].
.
13. GI PPx: PPI with steroids use. Bowel regimen with narcotic
analgesia held for diarrhea.
.
# Lines: PICC placed [**2194-6-14**]. D/c'd at discharge.
.
# CODE: FULL.
.
# Contact: Grandparents. Not close with parents who live in
[**State 85653**] and Mid-West.
Medications on Admission:
Warfarin 10 mg PO QD
Prednisone 20 mg PO QD
Acetaminophen PRN
Discharge Medications:
1. morphine 15 mg tablet Sig: One (1) tablet PO every four (4)
hours as needed for acute pain.
Disp:*90 tablet(s)* Refills:*0*
2. enoxaparin 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y
(120) MG Subcutaneous Q12H (every 12 hours).
Disp:*1 Month supply* Refills:*11*
3. morphine 30 mg tablet extended release Sig: One (1) tablet
extended release PO twice a day: Total morphine ER dose 45 mg
[**Hospital1 **]. .
Disp:*60 tablet extended release(s)* Refills:*0*
4. morphine 15 mg tablet extended release Sig: One (1) tablet
extended release PO twice a day: Total morphine ER dose 45 mg
[**Hospital1 **]. .
Disp:*60 tablet extended release(s)* Refills:*0*
5. danazol 200 mg capsule Sig: Two (2) capsule PO BID (2 times a
day).
Disp:*120 capsule(s)* Refills:*2*
6. folic acid 1 mg tablet Sig: Five (5) tablet PO DAILY (Daily).
Disp:*150 tablet(s)* Refills:*2*
7. senna 8.6 mg tablet Sig: Two (2) Tablet PO at bedtime: For
constipation prophylaxis while on pain meds. .
Disp:*60 Tablet(s)* Refills:*2*
8. pantoprazole 40 mg tablet,delayed release (DR/EC) Sig: One
(1) tablet,delayed release (DR/EC) PO Q24H (every 24 hours): For
stomach ulcer prevention with steroid use. .
Disp:*30 tablet,delayed release (DR/EC)(s)* Refills:*2*
9. diphenhydramine HCl 25 mg capsule Sig: One (1) capsule PO Q6H
(every 6 hours) as needed for pruritis.
10. vancomycin 125 mg capsule Sig: One (1) capsule PO Q6H (every
6 hours) for 7 days: for treatment of c.diff diarrhea. Take for
7 days only. .
Disp:*28 capsule(s)* Refills:*0*
11. prednisone 50 mg tablet Sig: Two (2) tablet PO DAILY
(Daily): Total daily dose is 120 mg per day. .
Disp:*60 tablet(s)* Refills:*2*
12. prednisone 20 mg tablet Sig: One (1) tablet PO once a day:
Total daily dose is 120 mg per day. .
Disp:*30 tablet(s)* Refills:*2*
13. acyclovir 400 mg tablet Sig: One (1) tablet PO twice a day:
For HSV prophylaxis while on hi dose steroids. .
Disp:*60 tablet(s)* Refills:*2*
14. sulfamethoxazole-trimethoprim 400-80 mg tablet Sig: One (1)
Tablet PO DAILY (Daily): For PCP prophylaxis while on high dose
steroids. .
Disp:*30 Tablet(s)* Refills:*2*
15. glipizide 5 mg tablet Sig: 0.5 tablet PO DAILY (Daily): For
Steroid induced hyperglycemia. Can skip dose if not eating well.
See med instructions.
.
Disp:*15 tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
1. Abdominal pain.
2. Back pain.
3. Autoimmune hemolytic anemia (low red blood cells due to your
own immune system).
4. C. diff colitis (bowel infection).
5. Renal vein thrombosis (blood clot in vein coming from
kidney).
6. Portal vein thrombosis (blood clot in vein going to liver).
7. Pulmonary embolism (PE, blood clot in lung).
8. Question of PNH (Paroxysmal Nocturnal Hemoglobinuria)
9. Left Kidney Infarct and Dysfunction
10. Steroid-induced hyperglycemia
11. IgA Deficiency
12. Clostridium Difficile Diarrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for abdominal pain and severe
anemia (low red blood cell count). The anemia was a flare of
your autoimmune hemolytic anemia, a condition were your own
immune system attacks your red blood cells. The abdominal pain
was likely due to a blood clot in the vein coming from the
kidney as seen by a CT scan. For the anemia, you were started
on high-dose steroids and danazole. You were also given red
blood cell transfusions. Your blood disease stabilized with this
regimen and you are currently doing very well. There was concern
that you may also have another condition called PNH (paroxysymal
noctural hemoglobinuria). However, this remains to be
determined. Importantly, you will have follow up with our
hematologists here for this complicated condition. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
will be taking care of you once you leave the hospital. You will
have a visit with him within one week. See below for [**Last Name (NamePattern1) 648**]
details.
.
During the hospitalization, you developed diarrhea and were
found to have an infection of your colon called "C. diff"
colitis, a type of bacterial infection. This was treated with
antibiotics (vancomycin)and you will need to complete a one week
course of this at home.
.
Your left kidney was injured from the blood clot in the left
renal vein and it has lost most of its function. You were seen
by our kidney doctor, Dr [**Last Name (STitle) 16449**] [**Name (STitle) 1366**], and he will follow your
care as an outpatient. You will be alright with one right kidney
for now, but you will need to be monitored closely by a kidney
doctor over time. An [**Name (STitle) 648**] with them will be arranged for
you over the next 4-6 weeks, as your blood issues are the
priority currently.
.
You will also need to take several new medications, including
the following with explanations:
1. Lovenox - this is a blood thinner which is used by injection
to treat your blood clots. You will remain on this for at least
several months. Your hematologist will discuss further plans at
your next visit.
2. Prednisone - This is an anti-immune system medication which
has helped treat your blood disease as discussed above. You will
be on a high dose of this medication for at least 3-4 weeks.
Your hematologist will discuss further plans at your next visit.
3. Glipizide - Diabetes treatment. The steroids that you are
using, such as prednisone, can cause high blood sugar levels in
the blood. This medication will better control diabetes.
4. Acyclovir - Herpes prophylaxis. Prednisone can also
reactivate herpes, which most of use have been infected with and
have under control. However, long term prednisone can increase
risk of shingles, a complication of herpes. Acyclovir is an
anti-viral medication that will decrease the risk of shingles.
5. Bactrim - Prednisone can also predispose you to an infection
called PCP, [**Name Initial (NameIs) **] lung infection. Prednisone lowers the immune
system. Bactrim is an antibiotic that decreases the risk of this
PCP lung infection.
6. Morphine pain pills - You will be on a pain regimen of long
acting and short acting pain meds. This medication should be
decreased over time as your pain resolves. You may want to
contact your PCP or hematologist to help with this matter. The
goal will be to get you off of pain medications completely.
These medications can cause constipation so you will also need
to take laxatives and stool softeners.
7. VANCOMYCIN ORAL LIQUID - This is an antibiotic that you will
take for 7 more days at home for treatment of your C.difff
diarrheal infection. Though your symptoms are better, to
complete the treatment course, 7 days of addition medication is
needed. Then you can stop taking vancomycin.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2194-6-26**] time to be determined
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 9645**] (PLEASE CALL TO CONFIRM;
BUT DR [**Last Name (STitle) **] OFFICE WILL ALSO BE NOTIFIED TO CONTACT YOU AS
WELL)
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] - Kidney Doctor
[**First Name (Titles) **] [**Last Name (Titles) 648**] will be made for you for 4-6 weeks.
Please contact your PCP as well to arrange for follow up so that
he is updated in your care. A copy of a discharge summary will
be faxed.
GENERAL: Please call [**Telephone/Fax (1) 2756**] during weekday business hours
8am-5pm and ask for DR [**First Name (STitle) **] [**Doctor Last Name **] (INPATIENT ONCOLOGY
HOSPITALIST) if there are any questions during this time of
transition prior to your meeting with Dr [**Last Name (STitle) **]. Afterwards, all
questions should be directed to Dr [**Last Name (STitle) **].
ICD9 Codes: 5849, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7626
} | Medical Text: Admission Date: [**2110-4-6**] Discharge Date: [**2110-4-11**]
Date of Birth: [**2036-5-23**] Sex: F
Service: Neurology
CHIEF COMPLAINT: Right-sided weakness.
HISTORY OF PRESENT ILLNESS: This is a 73-year-old
right-handed woman with history of multiple vascular risk
factors, PFO, Raynaud's, and Sjogren's, who presents with
acute onset of right-sided weakness. She went to bed feeling
well at 11 p.m. She then got up at 2 a.m. to urinate when
she noted that she was walking unsteadily almost falling to
the floor. The patient retrospectively thought her right
side was weak, but had not thought much of it at 2 a.m.
because she was sleepy. She then woke up at 6 a.m. with
right-sided weakness and dysarthria. She denies any
diplopia, dysphagia, visual changes, headache, numbness, or
tingling. As of 6 a.m., she noted that her voice had gotten
increasingly softer.
Of note, patient was discontinued on her statin medications
secondary to muscle cramps. Her blood pressure has been in
the range to 170s systolically and sugars in the 300s.
REVIEW OF SYSTEMS: On review of systems, the patient denies
any fever, chills, nausea, vomiting, headache, neck pain,
numbness, tingling, visual changes, hearing changes, chest
pain, dysuria, hematuria, diarrhea, bright red blood per
rectum, or bowel or bladder problems. She has abdominal
cramps and shortness of breath at baseline. She also has
vertigo secondary to her Meniere's disease.
PAST MEDICAL HISTORY:
1. Sjogren's disease.
2. Raynaud's.
3. Diabetes mellitus.
4. Hypothyroidism secondary to thyroid removal for
hyperthyroidism.
5. Pernicious anemia.
6. Colon cancer status post resection.
7. Seizure disorder sustained after a trauma to the left
temporal lobe 25 years ago with two generalized tonic-clonic
seizures in her life, now controlled with phenobarbital.
8. [**Doctor Last Name **] mal seizure with lip smacking and isolating every
four months.
9. SIADH with Meniere's disease.
10. Polycystic ovarian syndrome with hysterectomy.
11. Endometriosis.
12. Fracture left patella.
13. Status post cataract operation bilaterally.
FAMILY HISTORY: Son has [**Name2 (NI) 1557**] [**Doctor Last Name **] variant of
Guillain-[**Location (un) **] syndrome.
SOCIAL HISTORY: The patient lives at home and performs all
of her activities of daily living independently. Her son
lives next door. She is a retired saleswoman for [**Company 2892**].
There is no history of alcohol or drug abuse. She quit
smoking at age 37 with a 30-pack year history before that.
MEDICATIONS AT HOME:
1. Plavix 75 mg a day.
2. Meclizine 25 mg a day.
3. Percocet [**1-3**] tablet every four hours prn pain.
4. Tramadol 50 mg p.o. q.4h. prn pain.
5. E-Vista 60 mg p.o. q.d.
6. Celebrex 200 mg p.o. b.i.d.
7. Aspirin 81 mg p.o. q.d.
8. Phenobarbital 60 mg p.o. q.a.m. and 120 mg p.o. q.p.m.
9. Synthroid 150 mcg p.o. q.d.
10. Nifedipine control release 30 mg p.o. q.d.
11. Prevacid 50 mg p.o. q.d.
12. Fludrocortisone 0.1 mg p.o. q.d.
13. Quinapril 40 mg p.o. b.i.d.
14. Azathioprine 75 mg p.o. b.i.d.
15. Prednisone 10 mg p.o. q.d.
ALLERGIES: Codeine causes vomiting.
EXAM UPON ADMISSION: Temperature 97.2, blood pressure
203/92, pulse 88, respiratory rate 22, and 100% on 2 liters
of nasal cannula. Generally: A pleasant female in no acute
distress. Neck is supple without carotid bruits. Heart has
regular rate and rhythm with no murmurs or gallops. Lungs
are clear to auscultation bilaterally. There is no clubbing,
cyanosis, or edema on extremities.
On neurologic exam, the patient is awake and alert,
cooperative with exam. She has normal affect. She is
oriented to person, place, and date. She is able to series
subtractions. She is fluent with good comprehension,
repetition. Naming is intact. There is no dysarthria or
paraphasic errors. There is no apraxia or neglect. [**Location (un) **]
is intact. On cranial nerve exam, the patient's pupils are
equal, round, and reactive to light 2.5 to 2 mm bilaterally.
Unable to view the fundus. Visual fields are full to
confrontation. Extraocular eye movements are intact
bilaterally without nystagmus. Facial sensation is intact
and symmetric. She has a right upper motor and facial droop.
Hearing is intact to finger rub bilaterally. Palatal
elevation and sensation is intact and symmetric. She has a
weak cough and a soft voice. Sternocleidomastoids are normal
bilaterally. Right trapezius is 0/5. Tongue is midline
without vesiculations. On motor exam, patient has normal
bulk bilaterally. She has decreased tone on the right side.
There is minimal movement at the right shoulder and hip, but
otherwise is 0/5 on the right arm and leg. Left side has
full power at 5/5. On sensory exam, she is intact to light
touch, pinprick, temperature, vibration, and proprioception.
On the reflex exam, she is [**1-5**] in the right upper extremity
and [**2-5**] in the left upper extremity. There are no reflexes
in the right leg. The left patella is [**2-5**] and left plantar
is [**1-5**]. Grasp reflex is absent. Toes are downgoing in the
left, but upgoing on the right. She has normal
finger-to-nose-to-finger test on coordination test. Gait was
not assessed due to the severe right-sided weakness.
LABORATORIES UPON ADMISSION: White count 4.6, hematocrit
39.6, platelets 360. INR 1.1. PTT 23.9, PT 12.7.
Urinalysis shows positive nitrites, 1000 glucose, [**3-7**] white
cells, and [**3-7**] red cells, [**6-12**] epithelial cells. Chemistry:
sodium is 137, potassium 4.4, chloride 105, bicarbonate 19,
BUN 22, creatinine 0.8, glucose 164. CK is negative.
Troponin is negative.
MRI/MRA shows left corona radiata infarct in the posterior
aspect of the left lateral ventricle. There were no occluded
vessels on the MRA.
HOSPITAL COURSE:
1. Ischemic cerebrovascular infarction: It was not known
whether the patient's stroke was secondary to her underlying
connective tissue disease or vasculitis process. An
angiogram was performed showing no evidence of vasculitis. A
lumbar puncture was performed, which was normal, showing 0
white cells, 1 red cell, 36 protein, and glucose of 138.
There was no evidence of vasculitis on the lumbar puncture
results.
Given these findings, it was felt that she had infarction
secondary to her underlying connective tissue disease. Her
aspirin was increased from 81 to 325 mg a day. She was continued
on her Plavix. Her cholesterol was checked and found to be
elevated at 228 with triglyceride 183, HDL 67, LDL 124. She
was then started on simvastatin 10 mg a day.
Given that she had a history of PFO, lower extremity Dopplers
were obtained, but there was no evidence of a clot. She was
also ruled out for a myocardial infarction and put on
telemetry, which showed no atrial fibrillation.
Hypercoagulable workup was done. The factor VIII, C3, C4,
lupus, antithrombin-III, protein-C, [**Doctor First Name **], and protein-S were
all normal. The beta-2 glycoprotein antibody and
anticardiolipin antibody, prothrombin mutation, factor V
Leiden were all pending upon discharge. If her
anticardiolipin or beta-2 glycoprotein antibody becomes
positive, it is most likely she needs to be anticoagulated
with Coumadin. She was not given anticoagulation during this
hospital course because those results were still pending.
Carotid ultrasound and transthoracic echocardiogram was not
performed on this admission given that she had one done back
in [**2110-2-2**].
2. Rheumatology: Sjogren's and Raynaud's disease as
mentioned above, angiogram and lumbar puncture did not
support any evidence of vasculitis. This was done in light
of the fact that she had a slightly elevated ESR of 46.
Rheumatology was consulted and they asked for a hepatitis B
and C antibody and antigen, which were all negative.
Rheumatoid factor was 317 and C-reactive protein was 7.3.
Her [**Doctor First Name **] was positive at titer 1:1280. SPEP and C3, C4, and
RPR were all done and found to be normal. Cryoglobulin and
UPEP were still pending upon discharge.
Patient also has underlying chronic infiltrative lung disease
secondary to her rheumatological disease. A chest x-ray was
performed showing a right lower lobe opacity. A CT of the
chest was done to further delineate this finding. However,
the CT of the chest showed no evidence of pulmonary embolism
or changes from her prior CT of the chest.
For her Sjogren's and Raynaud's, she was initially put on
methylprednisolone 30 mg twice a day and that was weaned down
to prednisone 10 mg a day. Rheumatology also recommended
restarting her nifedipine to prevent any vasospasm.
3. Infectious disease: Patient was screened for MRSA and
VRE, which were both negative. Urinalysis that was done
later did show evidence of a urinary tract infection. Urine
cultures grew Enterococcus that were susceptible to
levofloxacin. She was treated with a seven-day course of
levofloxacin.
DISCHARGE DIAGNOSES:
1. Left thalamic/corona radiata cerebrovascular ischemic
infarct.
2. Sjogren's.
3. Raynaud's.
4. Urinary tract infection.
DISCHARGE MEDICATIONS:
1. Prednisone 10 mg p.o. q.d.
2. Nifedipine 40/20/40 mg a day.
3. Aspirin 325 mg a day.
4. Plavix 75 mg a day.
5. Levofloxacin 500 mg p.o. q.d. x7 day course.
6. Protonix 40 mg a day.
7. Simvastatin 10 mg a day.
8. Azathioprine 75 mg p.o. b.i.d.
9. Synthroid 150 mcg a day.
10. Phenobarbital 120 p.o. q.p.m. and 60 mg p.o. q.a.m.
11. Tramadol 50 mg p.o. q.4h. prn.
12. Hydrocodone/acetaminophen 1-2 tablets p.o. q.4-6h. prn.
13. Meclizine 25 mg p.o. q.d.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehabilitation center.
FOLLOWUP: The patient is to followup with Dr. [**Last Name (STitle) 3057**] in
Rheumatology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Neurology, Dr. [**Last Name (STitle) 2146**] in
Pulmonology, and her primary care doctor.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5930**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6125**]
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2110-4-11**] 07:20
T: [**2110-4-11**] 07:30
JOB#: [**Job Number 104360**]
ICD9 Codes: 5990, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7627
} | Medical Text: Admission Date: [**2156-1-21**] Discharge Date: [**2156-2-5**]
Date of Birth: [**2113-7-10**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Paxil / Sulfa(Sulfonamide Antibiotics) /
Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
line infection and bradycardia
Major Surgical or Invasive Procedure:
Removal of pacemaker and wires
Placement of PICC line
History of Present Illness:
Patient is a 42yo male with PMH of Down's Syndrome, sick sinus
syndrome, and hypothyroidism who presented to OSH because of
increased drainage from a shoulder wound associated with recent
manipulation of his pacemaker.
.
Patient received the dual-chamber [**Company 1543**] Sigma, serial number
PJD [**Numeric Identifier 91991**], placed initially in [**2146-10-17**], insertion of a
new [**Company 1543**] atrial lead because of fractured wire was done on
[**2153-1-10**]. In [**2155-12-14**], the tie down sleeve of the
atrial lead was noted to be visible at the site of the right
clavicle. There had previously been granulation tissue/eschar
there since [**Month (only) 116**] the previous year. He reportedly is always
picking at the site. He presented to his PCP and was treated
with a 10-day course of Keflex 500mg PO QID for 10 days. Wound
culture was negative before that treatment. He presented to his
electophysiologist on [**2156-1-9**] where he was noted to have an
obviously exposed pacemaker lead. A lead extraction was planned
on [**2156-1-22**]. However, patient noted increased drainage from the
wound site prior to the scheduled date and presented to OSH on
[**2156-1-15**] for evaluation. At that time he had no fevers/chills, no
abdominal pain, no nausea and vomiting, and no other pain. He
was placed on mupirocin ointment and IV cephazolin. He was
transferred to [**Hospital1 18**] for lead removal.
.
On arrival to the floor, patient is accompanied by two people
who work for his home aid/group home services. His vitals on
arrival are T98.1, BP123/77, HR59, RR20, O2sat 98%RA. He reports
diffuse pain symptoms but staff that know him and report that
his expression of "pain" is in fact an obsessive/compulsive
discomfort with the sticky leads on his body. He reportedly will
point and react with grimace when is feeling pain. He knows not
to pick at the leads.
.
ROS: difficult to assess, but staff reports he has not had pain,
shortness of breath, or fever.
Past Medical History:
Down's Syndrome
Hypothyroidism
Sinus Node dysfunction s/p pacemaker with lead revision
Social History:
lives in a group home
no tobacco
no alcohol
Family History:
Father had leukemia, mother has multiple cardiac stents, no FH
of pacemaker
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VITALS: T98.1, BP123/77, HR59, RR20, O2sat 98%RA
GENERAL: NAD, resting comfortably in chair
HEENT: prominant facial features stereotypic of Down's Syndrome,
large, semi-protuberant tongue, atraumatic skull, PERRL, EOMI,
MMM
NECK: no JVD, no LAD
CHEST WALL: dime to quarter-sized area of exposed granulation
tissue over the right anterior chest wall
HEART: RRR, no M/R/G
LUNGS: CTAB
ABDOMEN: soft, nontender, nondistended, NABS, no organomegaly
EXTREMITIES: no peripheral edema, no [**Last Name (un) **] lesions or splinter
hemorrhages.
PHYSICAL EXAM ON DISCHARGE
VITALS: T:97.7, BP:99/59, HR68, RR18, O2sat:100%RA
CHEST WALL: steristrips covering a wound that appears clean,
dry, intact with no surrounding erythema
EXTREMITIES: venous catheter in place on left arm
Pertinent Results:
Labs on Admission:
[**2156-1-21**] 06:10PM BLOOD WBC-5.3 RBC-3.87* Hgb-13.9* Hct-43.7
MCV-113* MCH-35.9* MCHC-31.8 RDW-14.5 Plt Ct-194
[**2156-1-22**] 07:55PM BLOOD PT-11.6 PTT-33.2 INR(PT)-1.1
[**2156-1-21**] 06:10PM BLOOD Glucose-115* UreaN-19 Creat-1.0 Na-143
K-4.0 Cl-109* HCO3-28 AnGap-10
[**2156-1-21**] 06:10PM BLOOD Calcium-8.7 Phos-2.8 Mg-2.2
TTE [**1-22**]:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. 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 estimated
pulmonary artery systolic pressure is normal. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
Visualization of the pacemaker leads throughout their course is
incomplete, but no large pacer vegetations are seen.
IMPRESSION: No vegetations seen. Normal global and regional
biventricular systolic function. Mild functional tricuspid
regurgitation.
TEE [**1-22**]:
The left atrium is normal in size. A probable thrombus is seen
in the wall of the right atrium. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is a probable thrombus or vegetation
on the tricuspid valve. There is a very small pericardial
effusion.
Micro:
[**2156-1-22**] 4:00 pm SWAB RIGHT SHOULDER.
**FINAL REPORT [**2156-1-24**]**
GRAM STAIN (Final [**2156-1-22**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2156-1-24**]): NO GROWTH.
[**1-21**], [**1-22**], [**1-27**] BC: no growth
2/14UC: negative
[**1-28**] stool C. diff: negative
[**2156-1-28**] 10:46
[**Location (un) **]-LIKE VIRUS (NLV) ANTIGEN, EIA
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Norovirus, EIA (Stool)
Norovirus Antigen Positive
LAB RESULTS ON DISCHARGE:
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2156-1-26**] 12:04 PM
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Tip of the right PIC line ends near the superior cavoatrial
junction, would need to be withdrawn 2 cm to competently
re-position it in the low third of the SVC. Lungs clear. Heart
size normal. No pneumothorax.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2156-1-27**] 7:30
PM
IMPRESSION: AP chest compared to [**1-26**]:
Previous left long line catheter or lead has been removed.
Normal heart,
lungs, hila, mediastinum, and pleural surfaces.
Radiology Report PORTABLE ABDOMEN Study Date of [**2156-1-28**] 9:47 AM
IMPRESSION: Focally dilated loops of small bowel and colon
within the mid
abdomen with otherwise gasless abdomen raises concern for
obstruction.
CT is recommended for further delineation of etiology as
clinically indicated.
Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
[**2156-1-28**] 6:04 PM
IMPRESSION:
1. No small-bowel obstruction.
2. Abnormal location of the small bowel suggestive of an
internal hernia;
however, this is uncomplicated. There is no evidence of
strangulation or
obstruction and is probably congenital in origin.
3. Small fat-containing umbilical hernia.
4. Air within the bladder may relate to recent catheterization.
[**2-5**] CXR: Read over the phone, Tip of PICC is at upper SVC,
showing that the line is CENTRAL
Lab results on Discharge:
[**2156-2-1**] 02:59AM BLOOD WBC-3.1* RBC-3.02* Hgb-11.0* Hct-34.0*
MCV-113* MCH-36.4* MCHC-32.3 RDW-14.8 Plt Ct-215
[**2156-2-1**] 02:59AM BLOOD Plt Ct-215
[**2156-2-1**] 02:59AM BLOOD Glucose-75 UreaN-12 Creat-0.9 Na-142
K-3.8 Cl-114* HCO3-24 AnGap-8
[**2156-2-1**] 02:59AM BLOOD CK(CPK)-26*
[**2156-2-1**] 02:59AM BLOOD Albumin-3.2* Calcium-7.9* Phos-3.4 Mg-2.1
[**2156-1-27**] 06:40AM BLOOD VitB12-801 Folate-GREATER TH
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Mr. [**Known lastname 91992**] is a 42yo male
with PMH of Down's Syndrome, sick sinus syndrome and
hypothyroidism who presented for extraction of exposed and
infected pacer wires. The leads were extracted and though
patient remains bradycardic, he is asymptomatic and has not
experienced any episodes of light-headedness or fainting. He is
afebrile and on abx and shows no signs of systemic disease.
.
ACUTE CARE:
1. INFECTED PACEMAKER LEADS: Patient has a long-standing
implanted pacemaker because he previously had experienced
syncopal episodes related to sick-sinus syndrome. He had begun
to pick at an area where the pacer wires were close to the skin
and developed a complicated infection with exposed pace wires.
There was granulation tissue over the site of patient's previous
intervention and a previous wound culture grew MSSA for which he
had undergone a course of Keflex. This is in addition to
multiple antibiotic treatment course in sequence beginning in
spring of [**2154**]. Because of inability to eliminate infection and
continued exposure of the pacer wires, a scheduled explant of
the pacemaker was planned. Because patient had increased
purulent drainage from the site, he presented to [**Hospital3 3583**]
where he was started on vanc and cefazolin. Upon transfer to [**Hospital1 **],
a TEE was performed that showed a potential vegetation on the
tricuspid valve vs. fibrous tissue from exposure to pacemaker
leads. His pacemaker was explanted on [**1-22**], procedure
complicated by hematoma at right groin site which self-resolved
with some inital pressure and asymptomatic bradycardia to
30s-40s. [**Hospital3 **] microbiology records show that blood
cultures drawn prior to the initation of antibiotics were all No
Growth Final. Blood cultures drawn here are NGTD. IV cefazolin
and topical mupirocin was continued, and patient was switched to
IV daptomycin. He remained afebrile and with no signs of
systemic infection. He is to receive a total of 6 weeks of IV
daptomycin for treatment of potential endocarditis given the
finding of vegetation vs. fibrous tissue on the tricuspid valve.
Chest X-ray on [**2156-2-5**] confirmed that the tip of the PICC is in
a central location.
2. Sick Sinus Syndrome: Patient is s/p pacer explantation on
[**1-22**]. Intra-operatively, his HR was noted to be in 30s-40s, but
he was asymptomatic. He was sent to the CCU for closer
bradycardia monitoring overnight after the procedure, and HR
remained in the 50s with no arrhythmic events. On the medical
floors, he remained with bradycardia to the 50's and sometimes
40's without symptoms. Telemetry was discontinued because
patient was assymptomatic for days with this bradycardia.
Patient should be considered for reimplantation of PM once
infection is cleared.
3. Norovirus: Patient contracted norovirus during his hospital
stay. He experienced fever to 104F, vomiting, abdominal pain,
and diarrhea that all resolved in 24 hours time. His last
symptom was diarrhea on the morning of [**2156-1-29**] and has been
asymptomayic since.
CHRONIC CARE:
1. Mental Disability: Patient has downs syndrome, and at
baseline is able to respond to many questions and communicates
needs well with provider. [**Name10 (NameIs) 91993**] caregivers from his group
home are often with him and understands his needs. Per his
mother, he has mood disturbances secondary to Down's and takes
mood stabilizers; he has been stabilized on this regimen. He
was continued on lithium and topomax per home regimen. He was
written for oral ativan prn agitation which he rarely required
as he responded to redirection very well when having episodes of
agitation.
.
2. Hypothyroidism: Patient was continued on home levothyroxine.
.
3. Skin Care: Patient has chronic problems with skin dryness
likely related to obsessive cleaning behaviors and picking at
his skin. Per group home, patient's skin becomes red/irritated,
and this is his baseline. He was continued on antifungal and
moisurizing agents per home regimen.
.
TRANSITIONS IN CARE:
1. CODE STATUS: FULL CODE (mother is still thinking about this
issue and will get back to us if things change)
2. CONTACTS: [**Name (NI) **] [**Name (NI) 91992**], mother and legal guardian [**Telephone/Fax (1) 91994**]
(cell)
[**First Name5 (NamePattern1) 4457**] [**Last Name (NamePattern1) 91995**] Nursing Supervisor at patient's group home
[**Telephone/Fax (1) 91996**]
3. MEDICATION CHANGES:
1. START Daptomycin 400mg iv daily until [**2156-3-4**].
4. FOLLOW-UP:
Department: CARDIAC SERVICES
When: TUESDAY [**2156-3-9**] at 12:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2156-2-10**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2156-3-1**] at 10:30 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], 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: CARDIAC SERVICES
When: TUESDAY [**2156-3-9**] at 12:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You should have the rehab schedule a follow-up appointment with
your PCP on discharge.
5. OUTSTANDING CLINICAL ISSUES:
-Patient expected to stay at rehab for less than 30 days.
-Monitoring of CBC, CMP, and CPK weekly while on daptomycin
-follow-up with infectious disease and cardiology
Medications on Admission:
Lithobid 600 mg q.h.s
Buspirone 10 mg twice a day
Topamax 100 mg in the morning and 50 mg in the evening
Levoxyl/Synthroid 75 mg daily
Metamucil two tablets daily
Colace 100
multivitamins
potassium 20 mEq b.i.d.
folic acid 1 mg daily
ferrous gluconate 325
Lamisil cream
hydrocortisone ointment
ketoconazole cream,
Lactaid
acetaminophen
Eucerin cream
Denorex shampoo.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 3320**]
Discharge Diagnosis:
Vegetative endocarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 91992**],
It was a pleasure taking part in your care. You were admitted to
the hospital because there was an infection around your
pacemaker wires that extended to your heart. This type of
infection requires removal of the pacemaker and wires to allow
healing. The pacemaker was removed and you will need to complete
a course of IV antibiotics to completely treat the remaining
infection on the heart.
Please make the following changes to your medications:
1. START Daptomycin 400mg iv daily until [**2156-3-4**].
Please take all other medications as previously prescribed.
You will need lab work done at the outside facility and have the
results faxed to the number provided.
Please keep all follow-up appointments.
Followup Instructions:
Please have the rehab facility schedule a primary care follow-up
for you on discharge.
Department: CARDIAC SERVICES
When: TUESDAY [**2156-3-9**] at 12:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2156-2-10**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2156-3-1**] at 10:30 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], 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: CARDIAC SERVICES
When: TUESDAY [**2156-3-9**] at 12:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7628
} | Medical Text: Admission Date: [**2144-11-19**] Discharge Date: [**2144-11-20**]
Date of Birth: [**2095-12-5**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Transfer from [**Hospital **] Hospital
for interventional coronary catheterization. A 48-year-old
male with past medical history with end-stage renal disease
on hemodialysis, hepatitis C, coronary artery disease, status
post coronary artery bypass graft x2 vessels in [**2143-6-28**],
transferred from outside hospital for interventional
catheterization. Admitted to [**Hospital **] Hospital on [**2144-11-15**] with chest discomfort and dyspnea. Had laboratories
there which showed a CK of 300, MB of 10, and troponin of 43.
The patient underwent cardiac catheterization which showed a
cardiac output of 8.7, wedge pressure 24, PA pressure of
65/30, a 70% stenosis in the left main coronary artery, and a
totally occluded left circumflex artery, right coronary
artery dominant system with 90% stenosis in the right
coronary artery at the bifurcation of the PDA and PL
branches. The patient had [**Female First Name (un) 899**] to left anterior descending
artery graft and saphenous vein graft to OM-2 graft which
were patent.
The patient was then transferred for interventional cardiac
catheterization at [**Hospital1 69**] and
possible stent placement. At catheterization at [**Hospital1 346**], the patient had a cardiac output of
3.5, a wedge pressure of 32, PA pressure of 78/36, right
coronary artery showed diffuse calcification, distal 90%
lesion at the bifurcation of the PDA/PL. A stent was then
placed in the distal right coronary artery. The patient was
transferred to the CCU for further care because he continued
to have searing 10/10 chest pain after stent placement.
PAST MEDICAL HISTORY:
1. Chronic renal failure on hemodialysis on Monday,
Wednesday, Friday reportedly secondary to hypertension.
2. Congestive obstructive pulmonary disease. The patient
continues to smoke one pack per day.
3. Hepatitis C, open sores secondary to pruritus.
4. Coronary artery disease.
5. History of flash pulmonary edema.
6. Hypertension.
7. Gastritis.
SOCIAL HISTORY: Smoking greater than one pack per day.
History of intravenous drug abuse.
ALLERGIES: Aspirin leads to bleeding. Norvasc leads to
unknown reaction.
MEDICATIONS AT HOME:
1. Nitroglycerin.
2. Lasix unknown dose.
VITAL SIGNS: Temperature 96.5, temperature max of 98.4,
heart rate 110-78, blood pressure 90-132/50-73. Pulse
oximetry is 95-99% on room air. Patient on a ReoPro drip 0.1
mcg/minute.
PHYSICAL EXAMINATION: General, deconditioned, belligerent
male verbally abuse. Cardiovascular: 3/6 systolic murmur at
the precordium, regular, rate, and rhythm. Patient refused
rest of the examination.
INITIAL LABORATORIES: White blood cell count is 7.2,
hematocrit 29.3, platelets 163, 88% neutrophils, 5.1%
lymphocytes, INR 1.3. Chem-7: Sodium 130, potassium 5.3,
chloride of 98, bicarb of 25, BUN of 45, creatinine 5.2,
glucose of 118, magnesium of 2.0. CPK of 45, AST 17, ALT 6,
alkaline phosphatase 281.
INITIAL ASSESSMENT: A 48-year-old male with a past medical
history of end-stage renal disease, hepatitis C, substance
abuse, coronary artery disease status post coronary artery
bypass graft x2 here in CCU after a successful stent
placement to the distal right coronary artery.
HOSPITAL COURSE: Patient was extremely combative initially
during hospital course, and he required several doses of
Haldol 5 mg IV as well as Ativan. Patient slept only
intermittently requested to leave the hospital to smoke
cigarettes. Extremely belligerant to team. Finally
requesting to sign out against medical advice. The patient
refused his morning dialysis, assisted in signing out. The
patient underwent an extensive discussion with the medical
team, and understood that he was at risk at sudden cardiac
death, congestive heart failure, and complications leading to
skipping dialysis. All of this was discussed in detail. He
remained adamant upon leaving.
We spoke to his nephew, who then spoke to the patient.
Patient continued to refuse to remain in the hospital, and
insisted on signing out against medical advice, which the
patient eventually did.
A phone call was placed to his local pharmacy to have Plavix
prescription filled for the patient, and his wife was
[**Name (NI) 653**] and the importance of taking the Plavix as he had a
recent stent placement was stressed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 8279**]
MEDQUIST36
D: [**2144-12-28**] 10:43
T: [**2144-12-31**] 04:42
JOB#: [**Job Number 35681**]
ICD9 Codes: 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7629
} | Medical Text: Admission Date: [**2162-8-28**] Discharge Date: [**2162-9-1**]
Date of Birth: [**2162-8-28**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname **] was born at
34 4/7 weeks gestation and admitted to the NICU for
prematurity. Maternal history: Mother is a 32-year-old G3, P0
now 1 woman with a past OB history notable for an SAB x 2.
Medical history was notable for chronic hypertension treated
with nifedipine and type 2 diabetes mellitus, on
insulin. Prenatal screens were as follows: Blood type B
positive, DAT negative, HBSAG negative, RPR nonreactive,
rubella immune, GBS unknown. Antenatal history: The EDC was
[**2162-10-5**]. Pregnancy was complicated by maternal
hypertension and diabetes mellitus as above mentioned and
hyperemesis gravidarum requiring IV therapy. Induction of
labor for neuropathy then proceeded to cesarean section after
fetal decelerations were noted on intrapartum monitoring.
There was no fever or other clinical evidence for
chorioamnionitis. Artificial rupture of membranes occurred 2
hours prior to delivery and yielded clear amniotic fluid.
Intrapartum antibacterial prophylaxis was administered
beginning 6 hours prior to delivery. A full course of
betamethasone was completed prior to delivery. In the
delivery room the infant was vigorous, was orally and nasally
bulb suctioned, dried, and subsequently pinked on her own and
was in no distress on room air. The Apgar scores were 8 and 8
at 1 and 5 minutes.
PHYSICAL EXAMINATION: The physical examination on admission
showed a well-appearing preterm infant consistent with
gestational age of 34 weeks gestation, birth weight 1,760
grams which is the 25th percentile. Head circumference 30.25
cm which is 25th-50th percentile, length 43 cm which is 25th
percentile. HEENT: Anterior fontanelle soft and flat.
Nondysmorphic facies. Intact palate. No nasal flaring. Chest
shows no retractions, good breath sounds bilaterally. No
adventitious sounds. CV: Well perfused. Normal rate and
rhythm. Femoral pulses were normal. Normal S1, S2. No murmur.
Abdomen: Soft, nondistended. No organomegaly. No masses.
Bowel sounds active. Patent anus. Three-vessel umbilical
cord. GU normal genitalia. CNS active, alert, responds to
stimuli. Tone was appropriate for gestational age and
symmetric. Moves all extremities well. Root, suck, and gag
reflexes were intact. Skin normal. Musculoskeletal normal
spine, limbs, hips, and clavicles.
HOSPITAL COURSE:
1. RESPIRATORY: The infant has remained on room air since
birth. She has had no issues with apnea of prematurity
and has required no methylxanthine.
2. CARDIOVASCULAR: She has been free of murmur since birth,
has had a normal heart rate and rhythm, normal blood
pressure. No issues.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: IV fluids were
administered on admission to the NICU due to concern for
hypoglycemia. The D stick never dropped lower than 47.
She was started on D10W and on the newborn day was also
started on feedings p.o./PG. She weaned off IV fluids by
day #1 of life and started to take all p.o. feeds up
until day #4 of life at which time she started to tire,
requiring some PG feeds. She has required PG feeds
occasionally all the way up until [**2162-9-8**], at which
time she became all p.o. feeds. She has exhibited good
weight gain. She is above birth weight at this time with
her most recent weight being [**2161**] grams on [**2162-9-11**]. She is presently on 24 calorie per ounce feeds of
breast milk with NeoSure powder or NeoSure 24 calorie per
ounce and she is taking approximately 150 ml per kilogram
per day. Elemental iron was started on [**2162-9-2**]. She
continues to take an additional 2 mg per kilogram per day
of elemental iron.
4. GI: Her peak bilirubin level was 5.2/0.4 on day of life
#1. She has required no phototherapy. She had heme-
positive stool on [**2162-9-9**], at which time a tiny
rectal fissure was noted. She has since had negative heme
stools. She is voiding and stooling normally.
5. HEMATOLOGY: No blood typing has been done on this infant.
Her crit at birth was 48.7, platelet count 291. She has
had no further crit measured.
6. INFECTIOUS DISEASE: A CBC and blood culture were screened
on admission to rule out sepsis. Antibiotics were not
indicated at that time. The blood culture remained
negative. The CBC was benign with a white blood cell
count of 9.7, 36 polys, 5 bands, 46 lymphs.
7. NEUROLOGY: She maintained a normal neurologic exam for
gestational age.
8. SENSORY/AUDIOLOGY: A hearing screen was performed with
automated auditory brainstem responses in which she
passed in both ears.
9. PSYCHOSOCIAL: A [**Hospital1 18**] social worker has been involved with
the family. There are no active ongoing psychosocial
issues at this time but if there are any concerns the
social worker can be reached at [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Discharged home with the family, both
parents.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 12332**], telephone number [**Telephone/Fax (1) 69808**].
CARE RECOMMENDATIONS: Ad lib p.o. feeding of breast milk
with 4 calories per ounce of NeoSure powder added or NeoSure
24 with iron and some breast feeding per day with
supplementation.
MEDICATIONS: Elemental iron.
CAR SEAT SCREENING: Performed and the infant passed.
STATE NEWBORN SCREEN STATUS: The infant had a state screen
sent on day of life #3. The results are still pending.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine was given on
[**2162-9-9**].
IMMUNIZATIONS RECOMMENDED:
1. 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 less than 32 weeks
gestation. 2) Born between 32 and 35 weeks gestation with
2 of the following, either Daycare during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings or 3) with chronic
lung disease.
2. Influenzae 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 influenzae is
recommended for household contacts and out of home
caregivers.
FOLLOW-UP APPOINTMENTS: [**Month (only) **] with the pediatrician on
[**2162-9-14**]. Visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 1988**] for [**2162-9-12**].
DISCHARGE DIAGNOSIS:
1. Prematurity, born at 34 4/7 weeks gestation.
2. Sepsis, ruled out.
3. Infant of a diabetic mother.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2162-9-10**] 20:13:40
T: [**2162-9-10**] 23:39:34
Job#: [**Job Number 69809**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7630
} | Medical Text: Admission Date: [**2120-6-26**] Discharge Date: [**2120-7-2**]
Date of Birth: [**2073-12-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Headache for 2-3 days and s/p unwitnessed fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. [**Known lastname 29425**] is a 46 yoF with polymyositis who was admitted
to the neuro ICU with right temporal lobe intraparenchymal
hemorrhage, SDH and SAH on [**6-26**]. She was found down at home
after several days of HA, and it is suspected she fell from the
IPH and then sustained a SDH/SAH. She was originally taken to an
OSH, but then transferred her after head CT showed the IPH.
.
She was transferred to the floor on [**6-27**], and her head bleeds
have been stable clinically and radiographically. She had
elevated troponins noted in the ED (peaked at 4.15). She has
been followed by cardiology. TTE showed moderate to severe TR
and pulmonary HTN, and she is scheduled for a cath on Monday for
further workup. There is concern this may be early ILD from the
polymyositis.
.
ROS is negative for CP, PND, orthopnea, [**Location (un) **], weight changes,
N/V, change in BM, F/C, NS, and arthralgias. She does encorse
SOB with climbing stairs, which she feels is worse over the last
few years. She had attributed this to muscle weakness with her
polymyositis. She continues to have a frontal headache, though
it is better than on admission, and she has mild back pain over
her tailbone.
Past Medical History:
Polymyositis
Chronic headache
Social History:
Lives in [**Location (un) 5503**] with her two children. No EtOH, smokes
1ppd, no illicits.
Family History:
No history of aneurysm, intracranial bleeding
Physical Exam:
Physical Exam on admission:
T: 96.9 HR: 97 BP: 106/77 RR:18 Sat: 98
Gen: comfortable, anxious
HEENT: Pupils: 4->3 EOMs - full
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to
3 mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5- 5 5 3- 4 4 5 5 5
L 5- 5 5 3- 4 4 5 5 5
Motor: Normal bulk and tone bilaterally. No pronator drift
Sensation: Reports numbness to light touch in bilateral lower
extremity - calf up to thighs. Also reports numbness in abdomen
up to chest.
Physical exam on discharge:
VS on transfer: 98.8, 125/74, 90, 16, 99% RA
General: comfortable,laying in bed
HEENT: OP clear, no LA, conjunctiva non-icteric
LUNGS: LCTA bil, no wheezing
CARDIO: rate regular, no murmurs appreciated
ABD: soft, NTND
SKIN: no rashes, no ecchymoses
NEURO: AA, Ox3, CNII-XII in tact, speech normal, strength 5/5
throughout, reflexes 2+ throughout, gait deferred
Pertinent Results:
[**2120-6-26**] 02:30AM BLOOD WBC-11.2* RBC-4.21 Hgb-14.8 Hct-40.9
MCV-97 MCH-35.1* MCHC-36.1* RDW-13.1 Plt Ct-226
[**2120-7-1**] 05:27AM BLOOD WBC-4.4 RBC-3.93* Hgb-13.4 Hct-38.6
MCV-98 MCH-34.1* MCHC-34.7 RDW-13.5 Plt Ct-201
[**2120-6-26**] 02:30AM BLOOD PT-14.2* PTT-22.1 INR(PT)-1.2*
[**2120-6-26**] 02:30AM BLOOD Glucose-187* UreaN-5* Creat-0.6 Na-138
K-3.6 Cl-101 HCO3-21* AnGap-20
[**2120-7-1**] 05:27AM BLOOD Glucose-88 UreaN-4* Creat-0.5 Na-134
K-3.4 Cl-100 HCO3-26 AnGap-11
[**2120-6-26**] 02:30AM BLOOD ALT-56* AST-69* LD(LDH)-438*
CK(CPK)-6134* AlkPhos-75 TotBili-0.7
[**2120-6-28**] 05:15AM BLOOD CK(CPK)-2972*
[**2120-7-1**] 05:27AM BLOOD CK(CPK)-1294*
[**2120-6-26**] 07:52PM BLOOD cTropnT-4.15*
[**2120-6-28**] 05:15AM BLOOD CK-MB-48* MB Indx-1.6 cTropnT-1.87*
[**2120-7-1**] 05:27AM BLOOD cTropnT-0.35*
[**2120-6-26**] 02:30AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.5*
[**2120-7-1**] 05:27AM BLOOD Albumin-2.9* Calcium-8.4 Phos-4.0 Mg-2.0
[**2120-6-28**] 05:15AM BLOOD Phenyto-7.8*
[**2120-7-1**] 05:27AM BLOOD Phenyto-9.3*
.
CT HEAD [**6-26**] AM
1. Possibly mildly increased IPH centered in the R temporal
lobe, now
measuring 3.2 x 2.0 cm.
2. Unchanged 5mm leftward shift. Effacement of the RIGHT-sided
sulci.
3. Unchange RIGHT-sided SDH, with max thickness of 5 mm.
4. Small amount of RIGHT-sided SAH.
5. No intraventricular hemorrhagic extension. No developing
hydrocephalus.
.
CTA HEAD [**6-26**]
Overall stable appearance of R temporal hematoma with slight
increased edema but stable mild left shift. No herniation.
Stable R frontal SDH and stable amount of SAH. No new focus of
hemorrhage. COW vessels patent without large aneurysm. [**Doctor Last Name **] x pg
[**Numeric Identifier 27921**]
.
MRI HEAD W and W/O [**6-26**]
IMPRESSION: Right-sided temporal intraparenchymal hemorrhage
identified with extension to the subarachnoid space and subdural
space. Post-gadolinium images are limited for evaluation of any
enhancement in the area. There is no evidence of abnormal
vascular structures in the region. It is recommended that if
clinically indicated the post-gadolinium imaging should be
repeated if necessary with sedation.
.
CT Head [**2120-6-27**]:
Stable appearance of bleed and midline shift.
.
L-spine [**2120-6-28**]: Mild degenerative changes. Grade 1
anterolisthesis of L4 over L5.
.
CTA chest w/ w/o contrast [**2120-6-28**]: No segmental, subsegmental
pulmonary embolism or acute aortic syndromes. Punctate left
lower lobe pulmonary nodule. In the absence of risk factors, no
further followup is necessary.
.
ECHO [**2120-6-28**]:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate to severe tricuspid regurgitation. Severe pulmonary
hypertension. Calcified mitral and aortic valve. Mild to
moderate aortic regurgitation.
.
Right-sided cardiac catherization [**2120-7-1**]: Coronary arteries
are normal. Normal ventricular function.
Brief Hospital Course:
# Intracranial hemorrhage: Prior to admission, patient had been
complaining of worsening headaches for 2 -3 days accompanied by
nausea and vomiting. On [**2120-6-25**] she was found down in the
bathroom by family members after a presumed fall from standing.
The patient reports headaches were common for her but the recent
headaches were much more severe. She initially presented to an
OSH where a noncontrast CT scan of the head was obtained which
showed a right temporal intraparenchymal hemorrhage, a Right
subdural hematoma, and a small Right subarachnoid hemorrhage.
Following the results of the imaging she was transferred to
[**Hospital1 18**] for further care. Upon arrival in the emergency room she
was evaluated and found to have slight proximal muscle weakness
secondary to her polymyositis. She also complained of numbness
in both calves, thighs, and on her abdomen up to her mid chest.
She was admitted to the intensive care unit for monitoring. A
neurology consult was also called in order to better evaluate
her presenting symptoms. On the morning of [**2120-6-26**] she was
evaluated on rounds and found to be neurologically intact. In
order to attempt to determine the etiology of her IPH in
conjunction with recommendations from neurology, a CTA of the
head and MRI with and without contrast of the head were
obtained. The CTA showed that there was a stable appearance of
her intracranial blood and that there were no aneurysms
appreciated. Her MRI showed stable appearance of her bleed and
no underlying mass but motion artifact resulted in non-ideal
study. While in the ICU she exhibited periods of confusion and
impulsiveness, which resolved. She was transferred to the
medical floor on [**2120-6-30**]. Patient was started on Dilantin for
seizure prophylaxis and levels were appropriate after adjustment
with albumin.
.
# Cardiac: On admission, Troponin was elevated. An
echocardiogram was obtained which showed tricuspid and atrial
regurgitation as well as severe pulmonary hypertension
([**2120-6-27**]). After the Echo final read was done, Cardiology was
[**Month/Day/Year 4221**] on [**2120-6-28**] and recommended a CTA to rule a PE. The CTA
was performed which did not show a PE. A right-sided cardiac
catherization was performed, which showed normal biventricular
filling pressures, normal cardiac output, and normal systemic
blood pressure. No further studies were recommended by the
Cardiology service.
.
# Polymyositis: On admission patient had elevated CK up to 6490,
which continued to trend down throughout the hospital course to
1294. She did not report flare of her polymositis and was not
currently on steroid treatment. Followup appointment with
outpatient rheumatologist was made prior to discharge.
Medications on Admission:
Aspirin prn
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Intraparenchymal Hemorrhage
Right Subdural hemorrrhage
Right Subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 29425**], you were admitted to the [**Hospital1 **]
Hospital because you were found down. When you got here, we got
CT scan of your head which showed bleeding inside and around
your brain. You were admitted to the Neurosurgery service, where
they decided not to treat you surgically. Instead, you were
given a medication called dilantin to prevent seizures, which
can happen in the setting of a brain bleed. When you got the
hospital blood tests showed that you heart enzymes were
elevated, which can be due to damage to the heart. We got an
ultrasound of your heart which suggested that you might have
high blood pressure in the your lung vessels. Thus the
cardiology doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**] and they threaded a catheter
into your heart to take a closer look. The results of the
right-catherization was normal. You should follow up with your
neurosurgeon, rheumatologist, and primary care physician after
discharge. We have made those appointments for you.
You should also remember to:
- Take your pain medicine as prescribed.
- Exercise should be limited to walking; no lifting, straining,
or excessive bending.
- Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
- Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
- If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
We made the following changes to your medication:
1. Phenytoin Sodium Extended 100 mg by mouth three times a day
Followup Instructions:
Please follow up with your primary care doctor - Dr. [**Last Name (STitle) 47242**]
508-993-00 with in [**11-18**] weeks. You will need your primary care
doctor to order a repeat cardiac echocardiogram.
It is very important to have a doctor that you have a good
relationship. If you Dr. [**Last Name (STitle) 47242**] is no longer available would
be happy to see you at our clinic at [**Hospital6 733**].
Please give us a call to set up an appointment at [**Telephone/Fax (1) 250**]
if you would prefer to transfer your care to [**Hospital1 **].
Please call [**Telephone/Fax (1) 1669**] and make a follow up appointment for
4-6 weeks with a non-contrast Head CT with Dr. [**Last Name (STitle) 548**], your
neurosurgeon.
Please also make an appointment with your rheumatologist Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by calling [**Telephone/Fax (1) 9674**] within the next month.
Completed by:[**2120-7-2**]
ICD9 Codes: 431, 4019, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7631
} | Medical Text: Admission Date: [**2156-1-11**] Discharge Date: [**2156-1-21**]
Date of Birth: [**2074-11-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2156-1-16**] Redo-Sternotomy, Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**]
Epic Bioprosthetic)
[**2156-1-13**] Cardiac Catheterization
History of Present Illness:
81 year old male that presents with two recent syncopal episodes
& loss of conciousness 5 days ago in context of progressive
fatigue and dyspnea on exertion but without chest pain.
Evaluated at [**Hospital3 **] and was ruled-out for Myocardial
infacrtion or stroke. He has known coronary artery disease and
is s/p CABG [**2134**], as well as aortic stenosis ([**Location (un) 109**] 0.5cm on echo
[**2155-12-7**]). He was transferred from [**Hospital1 **] to be evaluated for an
aortic valve replacement.
Past Medical History:
1. CAD s/p CABG, [**2135-1-26**] CABG ([**Hospital1 18**])
2. Hypercholesteremia
3. HTN
4. Aortic stenosis (dx in [**2145**])
Social History:
- Lives with wife. Married for 53 years, 2 daughters and 1
[**Name2 (NI) 12496**]
- Retired farmer (grew tomatoes)
- Denies smoking and alcohol
Family History:
Non-contributory
Physical Exam:
Pulse: 73 SR Resp: 16 O2 sat: 98/RA
B/P: 121/84
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] sternal incisional scar
Heart: RRR [x] Irregular [] Murmur III/VI @base -> neck
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x] well-perfused [x] Edema/Varicosities:
None
Neuro: Grossly intact
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit can not assess due to AS murmur
Pertinent Results:
[**2156-1-11**] WBC-9.7 RBC-5.29# Hgb-15.7# Hct-46.0# Plt Ct-276
[**2156-1-11**] PT-12.2 PTT-24.3 INR(PT)-1.0
[**2156-1-11**] Glucose-224* UreaN-33* Creat-1.4* Na-137 K-4.2 Cl-96
HCO3-27
[**2156-1-11**] ALT-45* AST-23 LD(LDH)-202 AlkPhos-73 TotBili-0.9
[**2156-1-11**] Albumin-4.3 Calcium-10.0 Phos-4.0 Mg-2.4
[**2156-1-13**] %HbA1c-6.4* eAG-137*
[**2156-1-20**] Hct-27.6*
[**2156-1-20**] WBC-11.1* RBC-2.99* Hgb-8.7* Hct-25.2* Plt Ct-152
[**2156-1-19**] WBC-13.7* RBC-2.62* Hgb-7.8* Hct-22.9* Plt Ct-137*
[**2156-1-21**] UreaN-21* Creat-1.2 K-3.6
[**2156-1-20**] Glucose-84 UreaN-22* Creat-1.1 Na-137 K-3.0* Cl-99
HCO3-32 AnGap-9
[**2156-1-19**] Glucose-101* UreaN-25* Creat-1.2 K-3.7 HCO3-31
[**2156-1-18**] Glucose-159* UreaN-23* Creat-1.3* Na-136 K-3.7 Cl-102
HCO3-28 A
[**2156-1-21**] Mg-2.4
[**2156-1-19**] Chest PA and lateral: There are small bilateral pleural
effusions. Again noted is a tortuous aorta and the sternotomy
wires, which are stable. The cardiac, mediastinal and hilar
contours are unremarkable.
[**2156-1-16**] Intraop TEE:
Pre-bypass:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. There are simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic aorta as well as a 0.6 cm complex atheroma.
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Mild
(1+) aortic regurgitation is seen. A proper annular diameter is
difficult to measure in face of heavy calcification.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-bypass:
The patient is receiving no inotropy support post-bypass. There
is a well seated bioprosthetic valve in the aortic position.
There is no aortic perivalvular or valvular leak. There is no
evidence of LVOT obstruction. The mean gradient across the
aortic valve is 8 mmHg. Biventricular function is preserved
post-bypass at >55% EF. All other findings are similar to
prebypass findings. The aorta is intact post-decannulation.
Findings were discussed in person with surgeon.
Brief Hospital Course:
Transferred from outside hospital for evaluation due to syncope.
Underwent cardiac catheterization that revealed no obstructive
coronary disease with a widely patent left internal mammary
artery to left anterior descending artery. Surgery was
consulted for aortic valve replacement and he underwent
preoperative workup and monitoring of creatinine which increased
from admission 1.4 to 1.7 on [**1-13**] preoperatively. On [**2156-1-16**] he
was brought to the operating room and underwent redo sternotomy,
and aortic valve replacement. See operative report for further
details. Given he was in the hosptial for greater than 24 hours
preoperatively, he received Vancomycin for perioperative
antibiotics. Postoperatively he was transferred to the
intensive care unit for management. In the first twenty four
hours he was weaned from sedation, awoke neurologically intact
and was extubated without complications. His CVICU course was
otherwise uneventful, and on postoperative day two, he
transferred to the SDU. He remained in a normal sinus rhythm as
beta blockade was advanced as tolerated. Postoperatively, his
renal function remained stable. Over several days, he continued
to make clinical improvements with diuresis and he was ready for
discharge to home on post operative day five.
Medications on Admission:
Amlodipine 5mg daily
aspirin 81 mg daily
atenolol 25mg [**Hospital1 **]
cilostazol 50mg [**Hospital1 **]
Fexofenadine ([**Doctor First Name **]) 60mg [**Hospital1 **]
Rosuvastatin 40mg daily
HCTZ 25mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 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. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO BID ().
Disp:*60 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Take for 7 days, then stop. Please take with KCL.
Disp:*7 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily):
Please take for 7 days, then stop. Take with Lasix.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Aortic Stenosis s/p Redo-Sternotomy, Aortic Valve Replacement
Coronary Artery Disease s/p Coronary Artery Bypass Graft
??????89(LIMA/LAD only),
s/p PTCA/DESx3 ??????05(RCA)
Hyperlipidemia
Hypertension
Arthritis
Allergic rhinitis
Chronic low back pain
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
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2156-2-16**] 3:00
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) 8098**] in [**11-29**] weeks [**Telephone/Fax (1) **]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2156-1-21**]
ICD9 Codes: 4241, 2851, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7632
} | Medical Text: Admission Date: [**2160-2-11**] Discharge Date: [**2160-2-15**]
Date of Birth: [**2096-2-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization with Balloon Angioplasty to OM2
History of Present Illness:
Mr. [**Known lastname 58248**] is a 64yo M w/ PMH of GERD, anxiety, and spinal
stenosis who presented to OSH this AM after waking up with 8/10
chest pain. He described it as diffuse, across his chest,
radiating through to his back. Was short of breath, but did not
wake his wife for 3 hours. No diaphoresis, + nausea. At 5am,
woke his wife who brought him to OSH where he was found to have
ST depressions in V1, V2. He was given ASA, SL ntg, lopressor IV
x1, and heparin bolus + heparin gtt and then transferred to
BIMDC for cath. On admission here, he had possible ST elevations
in inferior leads and diffuse J point elevation in precordial
leads. Cardiac enzymes on admission were negative. He was given
SL ntg and ativan, started on nitro gtt, and transferred to cath
lab.
.
ALLERGIES: NKDA
Past Medical History:
GERD
Anxiety
h/o atypical chest pain
Hard of hearing
Social History:
Patient lives with his wife in [**Name (NI) 1474**]. Has 3 sons, 1 daughter,
3 grandkids. Used to work for [**Company 2318**] until a fall several years
ago (? from spinal stenosis) at which point he retired (denies
any head trauma from his falls). Was in [**Country 3992**] War, has not
smoked or drank since. Prior to then, used to smoke 2ppd.
Family History:
+ CAD in his father, [**Name (NI) 9876**], and brothers -> no sudden death
Physical Exam:
PE:
VS - T 98.4, BP 130/71, HR 82 (78-82), RR 17 (17-21), sats 98%
3L nc
PA 36/21 (mean 26)
GEN - WDWN elderly male, appears older than stated age, in NAD.
Lying flat post-cath.
HEENT - Sclera anicteric. EOMI, PERRL. MMM. Dentures not in
place.
NECK - Neck supple. JVP not able to be appreciated [**1-24**] body
habitus.
CV - RR, normal S1, S2. No m/r/g.
LUNGS - CTA anteriorly, no crackles.
ABD - Distended, but soft. Tender in LUQ. + BS. No masses.
EXT - Cool, well perfused. No edema. 2+ PT/DP pulses
bilaterally. Sheath still in place in R groin, PA cath in.
SKIN - No rashes.
NEURO - CN II-XII grossly intact.
Pertinent Results:
Admission Labs:
[**2160-2-11**] 08:10PM O2 SAT-70
[**2160-2-11**] 07:37PM POTASSIUM-4.3
[**2160-2-11**] 07:37PM CK(CPK)-23* AMYLASE-25
[**2160-2-11**] 07:37PM LIPASE-21
[**2160-2-11**] 07:37PM CK-MB-NotDone cTropnT-<0.01
[**2160-2-11**] 07:37PM MAGNESIUM-1.9
[**2160-2-11**] 07:37PM PLT COUNT-248
[**2160-2-11**] 12:00PM GLUCOSE-124* UREA N-17 CREAT-1.2 SODIUM-137
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
[**2160-2-11**] 12:00PM ALT(SGPT)-31 AST(SGOT)-21 CK(CPK)-29* ALK
PHOS-87 TOT BILI-0.5
[**2160-2-11**] 12:00PM cTropnT-<0.01
[**2160-2-11**] 12:00PM CK-MB-NotDone
[**2160-2-11**] 12:00PM WBC-15.7* RBC-5.03 HGB-15.6 HCT-45.3 MCV-90
MCH-31.1 MCHC-34.4 RDW-13.1
[**2160-2-11**] 12:00PM NEUTS-84.5* LYMPHS-11.1* MONOS-3.8 EOS-0.3
BASOS-0.2
[**2160-2-11**] 12:00PM PLT COUNT-285
[**2160-2-11**] 12:00PM PT-12.7 PTT-82.0* INR(PT)-1.1
Pertinent Labs/Studies:
.
CK: 29 -> 23 -> 23 -> 91 -> 114 -> 100 -> 55
CK-MB: not done -> 13 -> 7 -> not done
Troponin: < .01 -> .12 -> .21 -> .16 -> .21
.
[**2160-2-11**] Cardiac Cath:
RA 25/19/18
RV 37/15/20
PW 31/30/26 -> 22/21/18
PA 45/23/36 -> 42/18/30
PA sat 67%
.
COMMENTS:
1. Selective coronary angiography of this left dominant system
revealed
two vessel coronary artery disease. The LMCA was patent. The LAD
had
70-80% proximal stenosis. The LCX had 90% lower pole OM1
stenosis. The
RCA was small without significant stenoses.
2. Resting hemodynamics demonstrated elevated right and left
sided
pressures (mean RA pressure was 18mmHg, mean PCWP was 18mmHg,
and
LVEDP was 31mmHg). There was evidence of moderate pulmonary
hypertension (mean PAP was 30mmHg). The cardiac index was low at
1.7
L/min/m2.
3. Left ventriculography revealed 2+ mitral regurgitation
without wall
motion abnromalities. Calculated ejection fraction was 50%.
4. Successful POBA of OM2 (see PTCA comments).
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Cardiogenic shock with severe diastolic and mild systolic
dysfunction.
3. Mild-moderate mitral regurgitation.
4. Successful PTCA of OM2.
.
Imaging:
[**2160-2-11**] ECHO: The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild regional left ventricular systolic
dysfunction with focal hypokinesis of the basal third of the
inferolateral wall and the distal third of the anterior wall.
The remaining segments contract well. The aortic root is mildly
dilated. The ascending aorta is mildly dilated. The aortic valve
leaflets appear structurally normal with good leaflet excursion.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion. IMPRESSION: Mild symmetric
left ventricular hypertrophy with regional systolic dysfunction
c/w multivessel CAD. Mild aortic regurgitation. Mild mitral
regurgitation. Pulmonary artery systolic hypertension.
.
[**2160-2-11**]: Portable Chest - The heart is upper limits of normal in
size. The lung volumes are decreased bilaterally with bilateral
elevation of the hemidiaphragms. There is no pneumothorax. The
osseous structures appear within normal limits.
IMPRESSION: No evidence of pneumonia.
.
[**2160-2-12**]: CTA Chest - There is a small focal opacification within
the right upper lobe that may represent a focal atelectasis.
Atelectasis is seen at the lung bases bilaterally. A small
amount of concavity is noted in the left main stem bronchi, best
seen on sagittal views. There are no pleural effusions. Both
lungs are otherwise unremarkable. Soft tissue windows
demonstrate no appreciable lymphadenopathy. The heart and great
vessels are unremarkable.
.
A Swan-Ganz catheter is seen extending into the distal aspect of
the right pulmonary artery. There are no filling defects.
There is no
evidence of pulmonary embolism. The visualized aorta shows no
evidence of dilatation or dissection.
BONE WINDOWS: There are no suspicious lytic or sclerotic bony
lesions.
IMPRESSION: No evidence of pulmonary embolism, aortic aneurysm,
aortic
dissection.
.
[**2160-2-12**]: CT A/P - There is moderate cardiomegaly. There is
bibasilar atelectasis and tiny pleural effusions. The liver,
gallbladder, pancreas, spleen, adrenal glands, kidneys, stomach,
and bowel loops are unremarkable within the limits of this
noncontrast study. There is no free air or free fluid. No
mesenteric or retroperitoneal lymphadenopathy is identified.
CT PELVIS: Foley catheter and air are observed in the bladder.
There are multiple prosthetic calcifications. Scattered sigmoid
diverticula are observed without evidence of diverticulitis.
There is a stranding and a small amount of fluid in the pelvis
along the iliac vessels. No large retroperitoneal hematoma is
identified. Stranding in the right groin is consistent with the
recent arterial puncture.
BONE WINDOWS: There are no suspicious lytic or sclerotic
osseous lesions.
IMPRESSION: Small amount of stranding and fluid along the right
common iliac vessels consistent with a small amount of blood.
No large retroperitoneal hematoma is identified.
Discharge Labs:
.
[**2160-2-15**] 06:10AM BLOOD WBC-9.7 RBC-4.38* Hgb-13.6* Hct-38.6*
MCV-88 MCH-31.0 MCHC-35.1* RDW-13.1 Plt Ct-294
[**2160-2-15**] 06:10AM BLOOD Glucose-101 UreaN-21* Creat-1.0 Na-135
K-3.6 Cl-102 HCO3-25 AnGap-12
[**2160-2-15**] 06:10AM BLOOD Mg-1.9
Brief Hospital Course:
A/P: Patient is a 64 year old Male who presents with chest pain
with inferolateral ECG deviation on admission s/p POBA to OM2,
with small enzyme leak. The etiology of clinical presentation
not completely clear, question UA, NSTEMI, vs. myopericarditis.
.
#. CAD: With regards to his symptoms of chest pain and
inferolateral ST changes, the patient was brought to the cath
lab for evaluation. Cardiac cath revealed a left dominant system
with 70-80% proximal stenosis of the LAD and LCx remarkable for
a 90% lower pole stenosis of OM1. Hemodynamics revealed elevated
left and right sided pressures with depressed cardiac index of
1.7. The patient underwent POBA to OM2 and was transferred to
the CCU with plan at that time for likely repeat cath in a.m.
for LAD lesion. The patient's course was complicated by
persistent chest pain s/p cath with increasing ST segment
elevations in the inferior leads despite intervention. At this
time, all cardiac enzymes were negative. This pain was
refractory to a nitro gtt but was noted to be resolved with
Maalox. Given these persistent pains, it was questioned whether
the etiology of the patient symptoms was an alternative
diagnosis such as PE, coronary vasospasm, or myopericarditis.
Although the patient was having ongoing pain and ECG changes,
his ECG changes were not in the distribution of the LAD, again
making it less likely that the patient's unopened LAD was the
source of his ongoing symptoms. The patient underwent a CTA that
did not reveal any PE. The patient was additionally started
empirically on a trial of a calcium channel blocker given
consideration of coronary vasospasm. The patient did eventually
have resolution of his pain although the exact alleviating
intervention, if any, is unknown. The patient did demonstrate
eventually a bump in his cardiac enzymes, although of note this
was after signficant resolution of his symptoms. Ultimately,
given that the etiology of the patient's symptoms were not clear
and there was no evidence for a dynamic lesion as the cause of
the patient's pain, the decision was made to postpone repeat
cardiac catheterization until this acute event had resolved,
after which the patient could have the procedure performed
electively as an outpatient.
.
#. Pump: The patient had an echo performed post-cath that
revealed an EF of 40% with focal hypokinesis of the basal third
of the inferolateral wall and the distal third of the anterior
wall. Given evidence of elevated left and right sided pressures
on cath, the patient was gently diuresed with 10mg IV lasix on
transfer to the CCU. Throughout his hospital course the patient
appeared euvolemic to mildly hypervolemic given obligate fluids
for post-cath hydration as well as contrast studies. The patient
was given one additional bolus of 10mg IV lasix only for the
remainder of his stay only. Throughout his course with movement
and ambulating the patient's O2 requirement resolved and his
pulmonary exam cleared. His ACE was reinitiated the day prior to
discharge and tolerated well.
.
#. RHYTHM: Patient remained in NSR throughout his admission
without significant events on telemetry.
.
#. Anemia - The patient was noted to have a significant Hct drop
from 45.3 on admission with serial values of 36.5 to 29.4. Given
this precipitous drop post cath there was concern for a possible
RP bleed. Of note however, other than persistent chest pain as
above, the patient remained hemodynamically stable without a
significant tachycardia which would be expected in the setting
of an acute bleed. CT of the abdomen and pelvis without contrast
was performed and revealed no evidence for an RP bleed. Of note,
the patient's next Hct level without transfusion was 39.8,
demonstrating that the previous values were likely spurious.
.
#. HTN: On transfer to the CCU the patient's antihypertensive
medications were held given depressed cardiac index. Low dose
metoprolol 12.5mg po bid was first introduced for it's
cardioprotective effects, then titrated to 25mg po tid. As
above, given consideration of vasospasm as the etiology of the
patient's symptoms amlodipine 5mg po qd was additionally added
to the patient's regimen. Finally, the patient's ACE was
serially added and tolerated well. Upon discharge all meds were
converted to once daily formulations as detailed in med
discharge list.
Medications on Admission:
Paxil 20mg PO QD
Ranitidine 150mg PO QD
Norpramin 2 tabs PO BID
ASA 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:*30 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary:
NSTEMI with ? vasospasm s/p balloon angioplasty to OM2
.
Secondary:
GERD
Anxiety
Hx of atypical chest pain
Hard of hearing
Discharge Condition:
1. Good. Patient is chest pain free, afebrile, hemodynamically
stable, with O2 sat > 94% on room air. Patient is able to walk
without assitance or oxygen. Patient has appropriate follow up
planned for repeat evaluation/intervention of 70% occlusion of
LAD.
Discharge Instructions:
1. Please take all medications as prescribed.
.
2. Please keep all outpatient appointments. You will need to be
followed by your PCP within the next two weeks.
.
3. Please return to the hospital immediately for symptoms of
chest pain, shortness of breath, nausea/vomiting, dizziness or
any other concerning symptoms.
.
4. You have a diagnosis of congestive heart failure. It is very
important that you weigh yourself every morning. If your weight
increases by more than 3 pounds from your baseline, you should
call your PCP or cardiologist to evaluate the need for any
changes in your medical regimen. It is additionally very
important that you adhere to a low salt diet with daily intake
less than 2 grams per day.
.
5. You underwent cardiac catheterization during your admission
to [**Hospital1 18**]. During this procedure you received balloon angioplasty
to one of your blood vessels. It was also observed that another
blood vessel is stenotic and will require intervention. You will
be contact[**Name (NI) **] at home by the nursing staff at [**Hospital1 18**] to schedule a
time for you to come and have this procedure performed
electively as an outpatient.
.
6. Your home medications have changed since you were admitted to
[**Hospital1 18**]. In addition to Paxil, you will now need to take a number
of new medications for your heart. These include ASA, Plavix,
Atorvastatin, Amlodipine, Lisinopril, Toprol XL. These new
medications will be reviewed with you before you go home and VNA
nursing staff will additionally visit you at home to review
these medications with you and make sure they are being taken
properly.
Followup Instructions:
1. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] within one to two weeks. You have an appointment on Tuesday
[**2-26**] at 2:00 p.m. at his office. His address is [**Street Address(2) **], [**Hospital1 1474**] [**Numeric Identifier 8728**]. Please call his office at
[**Telephone/Fax (1) 3183**] with any questions or scheduling needs.
.
2. You should receive follow up care with a cardiologist from
now on. You may follow up with the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital1 18**]. His office number is ([**Telephone/Fax (1) 5909**]. You currently have
an appointment with Dr. [**Last Name (STitle) **] [**3-14**] at 11:00 a.m., after
your repeat cardiac cath will be performed. Please call his
office if you would like to cancel or change this appointment.
If you would prefer to be followed by a cardiologist in [**Hospital1 1474**]
instead, please contact your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and request
that he refer you to a cardiologist closer to your home.
.
3. You underwent cardiac catheterization during your admission
to [**Hospital1 18**]. During this procedure you received balloon angioplasty
to one of your blood vessels in the heart, called OM2. It was
also observed that another blood vessel is stenotic and will
require intervention. You will be contact[**Name (NI) **] at home by the
nursing staff at [**Hospital1 18**] to schedule a time for you to come and
have this procedure performed electively as an outpatient within
the next one to two weeks. If you or your family have any
questions regarding this procedure please contact Dr. [**Last Name (STitle) **] at
[**Hospital1 18**] at ([**Telephone/Fax (1) 5909**].
ICD9 Codes: 4280, 4240, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7633
} | Medical Text: Admission Date: [**2131-11-8**] Discharge Date: [**2131-11-14**]
Date of Birth: [**2060-1-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Albuterol / Demerol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional angina with nausea/vomiting
Major Surgical or Invasive Procedure:
CABGx5 (LIMA->LAD, SVG->diag, SVG->OM1, SVG->OM2, SVG->PLV)
[**2131-11-8**]
History of Present Illness:
71 yo female with exertional symptoms and abnormal ETT. Referred
for cath which revealed severe three vessel CAD.
Past Medical History:
HTN
elev. lipids
NIDDM
gout
arthritis
prior bronchitis/PNA
obesity
PSH: hysterectomy for uterine
polyps,tonsillectomy,appendectomy,resection of benign left
breast tumor
Social History:
semi-retired, lives alone, widowed
no tobacco use, occasional ETOH
Family History:
non-contrib.
Physical Exam:
5'4" 179#
NAD lting flat after cath
skin/HEENT unremarkable
neck with full ROM and no carotid bruits appreciated
CTAB anterolaterally
RRR with distant heart sounds, no murmur
soft, NT, ND, +BS, obese with well-healed abd. scar
extrems warm, well-perfused, no edema or varocosities noted
neuro grossly intact
2+ bil. fem/DP/PT/radials
Pertinent Results:
[**2131-11-13**] 05:33AM BLOOD WBC-8.3 RBC-3.47* Hgb-10.8* Hct-32.0*
MCV-92 MCH-31.1 MCHC-33.8 RDW-15.1 Plt Ct-181
[**2131-11-13**] 05:33AM BLOOD Plt Ct-181
[**2131-11-12**] 03:11AM BLOOD PT-12.1 PTT-24.8 INR(PT)-1.0
[**2131-11-13**] 05:33AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-144
K-3.7 Cl-107 HCO3-32 AnGap-9
[**2131-11-13**] 05:33AM BLOOD Mg-2.3
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Findings
LEFT ATRIUM: Normal LA size.
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: Normal LV cavity size. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
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. The left atrium is normal in size.
2. No atrial septal defect is seen by 2D or color Doppler.
3. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the descending thoracic aorta.
6. The aortic valve leaflets (3) are mildly thickened. Trace
aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
8. The pulmonic valve is not well seen.
Post-Bypass:
1. Biventricular function is preserved.
2. There is noted increase in tricuspid regurgitation from
trace, pre-bypass, to mild to moderate ([**1-30**]+) post bypass
without noted increases in PA systolic pressure or change in
biventricular functions.
3. Aortic contours are intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
[**2131-11-13**] 05:33AM BLOOD WBC-8.3 RBC-3.47* Hgb-10.8* Hct-32.0*
MCV-92 MCH-31.1 MCHC-33.8 RDW-15.1 Plt Ct-181
[**2131-11-12**] 03:11AM BLOOD WBC-10.3 RBC-3.38* Hgb-10.5* Hct-29.6*
MCV-88 MCH-31.1 MCHC-35.5* RDW-15.6* Plt Ct-144*
[**2131-11-13**] 05:33AM BLOOD Plt Ct-181
[**2131-11-12**] 03:11AM BLOOD Plt Ct-144*
[**2131-11-13**] 05:33AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-144
K-3.7 Cl-107 HCO3-32 AnGap-9
[**2131-11-12**] 10:18AM BLOOD K-4.8
Brief Hospital Course:
Admitted [**11-8**] and underwent cabg x5 with Dr. [**Last Name (STitle) **].
Transferred to the CVICU in stable condition on titrated
propofol and phenylephrine drips. Extubated the following
morning and gentle diuresis started. Beta blockade also
titrated. Chest tubes removed on POD #2 and transfused 2 u PRBCs
and then a third unit on POD #3. Neo then successfully weaned
off and she was transferred to the floor on POD #4 to begin
increasing her activity level. She was ready for discharge to
rehab on POD #6. She will need to be restarted on her metformin
once her po intake has returned to [**Location 213**].
Medications on Admission:
diovan 160 mg daily
atenolol 50 mg daily
HCTZ 12.5 mg daily
metformin 500 mg [**Hospital1 **]
lovastatin 10 mg daily
indomethacin 50 mg prn gout
ASa 81 mg daily
nitroglygerin SL prn
tylenol prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
8. Lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
once PO intake adequate.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
Discharge Diagnosis:
CAD s/p cabg x5
HTN, hyperlipidemia, DM, GERD, gout, arthritis, prior PNA, s/p
TAH for uterine polyps, tonsillectomy, appendectomy, L breast
mass excision
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 daily, no baths, no lotions, creams or powders to
incisions.
No lifting more than 10 pounds for 10 weeks.
No driving for one month.
Followup Instructions:
Dr. [**Last Name (STitle) 34561**] 1-2 weeks
Dr. [**Last Name (STitle) **] in [**3-3**] weeks
Dr. [**Last Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2131-11-14**]
ICD9 Codes: 4111, 4019, 2724, 2749, 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7634
} | Medical Text: Admission Date: [**2130-12-18**] Discharge Date: [**2130-12-22**]
Date of Birth: [**2060-12-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Trazadone overdose
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Patient 69 y/o female with PMHx significant for depression,
alcoholism who was reported to take 2800mg of trazadone. When
patient arrived to the ED she had altered mental status with
vomiting and was unarousable. She was intubated for airway
protection and got narcan, sorbital and charcoal. Toxicology
aware of patient and states that trazadone should wear off
eventually.
Of note patient was recently d/c from [**Hospital1 18**] on [**2130-11-29**] where she
was reported to say she was suicidal with a plan to take an
overdose of trazadone when she went home. After some counseling,
she changed her mind if she would be able to get services at
home. Psychiatry was consulted who cleared her from inpatient
psychiatric hospitalization.
.
When pt arrived to the [**Hospital Unit Name 153**] she was awake and alert with good
air leak and was extubated quickly without difficulty. When
patient extubated she stated that she took 30 pills of 100mg
trazodone to "stop the psychological pain." Patient denies any
other pain. No CP or abdominal pain.
Past Medical History:
Past Medical History
1)Ulcerative colititis: diagnosed in late 90's, followed by Dr.
[**Last Name (STitle) **] from [**Hospital1 112**], last flare was 1 yr ago. Last colonoscopy was
[**3-27**] at [**Hospital1 112**], reported negative for suspicious lesions.
2)Depression
3)Hx of alcoholism
4)Gastritis
5)Fe deficient anemia
6)HTN
7)L ankle/R hip fracture in '[**18**]
8)Familial essential tremor
Past Psychiatric History:
psychiatrist Dr. [**Known firstname **] [**Last Name (NamePattern1) 5263**] [**Telephone/Fax (1) 98672**] @ [**Location (un) **]
Psychiatric Association pg [**Telephone/Fax (1) 98673**]
therapist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 98674**] social worker at the [**Name (NI) **] Senior
Center
3 previous hospitalizations @ [**Hospital6 1597**] x 2 and
[**Hospital 8**] Hospital in the early 80's
denies h/o suicide attempts
multiple detoxes
last hospitalized [**4-27**]
Social History:
She is a former [**Hospital1 **] OR nurse, long hx of tobacco use but quit in
the 80's. Hx of alcohol abuse/alcoholic but has been sober for 7
years. She lives alone in [**Location (un) **].
*
The patient was born in [**Country 28334**] and worked at the American
Hospital in [**Location (un) **] as a nurse where is she met her husnabd who
was working for NATO. She married in [**2086**] moved to the States
then to [**Country 2784**] and settled in [**Location (un) 86**] in [**2096**]. She has 2 grown
children and divorced her husband because she said " he had
PTSD"
from when he was stationed in [**Country 3992**]. She also said " his
family had trouble accepting me."She worked as an OR nurse for
many years and last worked in [**State 108**] as a triage nurse for a
gated community. She moved back to [**Location (un) **] about a year and
half ago because she couldn't afford to stay in [**State 108**]. She now
lives in [**Location 98675**] housing alone.
*
SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE):
alcohol: started drinking heavily at age 45 positive hx of
blackouts, denies w/d sz, sober for the past 7 yrs, has had
multiple detoxes
drugs: denies
tobacco: stopped in the mid 80's
caffeine: drinks coffee all days
Family History:
No hx of IBD/IBS, no colon cancer, +HTN, no DM
Physical Exam:
Vitals: T 98.5
BP 127/50
HR 89
R 25
Sat 100% 2L NC
*
PE: G: Elderly female, anxious appearing, non-dyspneic
HEENT: Clear OP, dry MM
Neck: Supple, No LAD, No JVD
Lungs: CTA, BS BL, No W/R/C
Cardiac: RR, NL rate. NL S1S2. 2/6 systolic murmur at RUSB,
non-radiating.
Abd: Soft, ND. Decr BS. Tender over lower abdomen, without
rebound or guarding. No HSM.
Ext: No edema. 2+ DP pulses BL.
Neuro: A&Ox3. Flattened affect. CN 2-12 grossly intact. [**3-28**]
proximal strength, equal BL UE and LE. [**4-27**] distal muscle
strength throughout. No asterixis. No pronator drift. Resting
tremor, decreases with intention.
Pertinent Results:
Admission Labs:
[**2130-12-18**] 12:40PM BLOOD WBC-8.5 RBC-3.73* Hgb-11.5* Hct-33.1*
MCV-89 MCH-30.9 MCHC-34.9 RDW-13.0 Plt Ct-227
[**2130-12-18**] 12:40PM BLOOD Plt Ct-227
[**2130-12-18**] 12:40PM BLOOD Fibrino-319
[**2130-12-18**] 12:40PM BLOOD Glucose-125* UreaN-29* Creat-1.1 Na-137
K-3.4 Cl-97 HCO3-24 AnGap-19
[**2130-12-18**] 12:40PM BLOOD Amylase-89
[**2130-12-19**] 04:13AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8
[**2130-12-18**] 12:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2130-12-18**] 12:48PM BLOOD Glucose-128* Lactate-3.2* Na-140 K-3.3*
Cl-99* calHCO3-27
CT Head: No intracranial hemorrhage or mass effect. Stable
appearance of the brain since the prior study from [**2130-10-10**].
.
CXR: An ET tube is present, the tip lies in satisfactory
position approximately 4.6 cm above the carina. The heart is not
enlarged. The aorta is mildly tortuous. There is no CHF, focal
infiltrate or effusion. Osteopenia, rotatory scoliosis, and
degenerative changes of the thoracolumbar spine are noted. No
pneumothorax is identified. Tube is present, tip beneath
diaphragm overlying stomach.
.
EKG: Sinus Brady at 53; QTc 490, TWI in V2
EKG on discharge: Sinus rhythm with PVC. Baseline tremor. QTc
442ms.
Brief Hospital Course:
69F PMH significant for depression, alcoholism admitted on [**12-18**]
for trazadone overdose. Pt brought into ED unarousable and
vomiting. She was intubated for airway protection and given
narcan, sorbital and charcoal. Of note patient was recently d/c
from [**Hospital1 18**] on [**2130-11-29**] where she was reported to say she was
suicidal with a plan to take an overdose of trazadone when she
went home. After some counseling, she changed her mind if she
would be able to get services at home. Psychiatry was consulted
who cleared her from inpatient psychiatric hospitalization. The
patient was admitted to the [**Hospital Unit Name 153**], where she was extubated
without complications. After being extubated she stated that
she took 30 pills of 100mg trazodone to "stop the psychological
pain."
*
She was seen by psychiatry, who said that she would need medical
clearance prior to transfer to inpatient psychiatry. She was
noted to have low-grade fevers in the ICU to 100.4, with
negative UA, CXR, and Blood cultures to date. Infectious workup
remained negative. Her QTc remained at the upper limit of
normal at 442ms on discharge, which was discussed with
toxicology and determined that the patient was outside of the
time frame of the trazodone effect. She was extremely
depressed, and at times anxious on the floor, which was treated
with low dose ativan. She was noted to have an iron deficiency
anemia, which was treated with oral iron. At the recommendation
of her covering attending, repeat iron studies, as well as B12,
folate, and TSH were checked and are pending at the time of
discharge. She was restarted on her outpatient medications for
blood pressure. She was also started on macrobid for a possible
UTI. She is discharged to inpatient psychiatry for further
management of her depression.
Medications on Admission:
Meclizine 12.5 mg Tablet PO at bedtime as needed for dizziness.
Atenolol 75 mg Tablet PO once a day.
Lisinopril 20 mg PO QAM
Hydrochlorothiazide 25 mg PO DAILY
Lorazepam 0.5 mg PO BID PRN
Trazodone 25 mg Tablet HS
Primidone 50 mg Tablet PO QAM.
Propoxyphene N-Acetaminophen 100-650 mg PO QAM
Docusate Sodium 100 mg PO BID
Psyllium 1.7 g Wafer PO DAILY.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Nitrofurantoin 100 mg Capsule Sig: One (1) Capsule PO QID (4
times a day) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
Trazodone overdose
Depression
Iron deficiency anemia
Hypertension
Anxiety
Discharge Condition:
Medically stable
Psychologically distressed
Discharge Instructions:
Please take medications as written.
Followup Instructions:
Continue follow up with psychiatry.
Follow up with PCP [**Last Name (NamePattern4) **] [**12-25**] weeks.
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2131-1-1**] 1:00
ICD9 Codes: 5990, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7635
} | Medical Text: Admission Date: [**2109-8-23**] Discharge Date: [**2109-9-5**]
Date of Birth: [**2028-12-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Open cholecystectomy and intraoperative cholangiogram
History of Present Illness:
This is a 80 year old who presented to the ED with abdominal
pain. He complains of nausea and vomiting and diarrhea. Th pain
is worse in the RUQ. He can only eat small amounts. He denies
chest pain, has no SOB. He reports falling 2 days ago and being
unable to get up. It is unclear if he had LOC. He does not have
headaches or weakness. He also reports no dysuria, but
discolored urine.
Past Medical History:
Afib
HTN
Deaf/mute
Falls
Social History:
Independent with ADLs. Brother and other family members nearby
and available.
Family History:
NC
Physical Exam:
VS: 99.2, 126, 122/72, 16, 98% RA
Gen: NAD, alert, awake, responsive, able to answer questions,
read statements and follow commands. He is a poor historian
despite sign language services.
Head: PERRLA, EOMI, + scleral icterus, obvious jaundice. Right
eye with bruising laterally
CV: irregular, irregular tachy rhythm
Chest: clear to auscultation bilat.
Abd: soft, nontender, nondistended, no hepatosplenomegaly, old
healed scars at midline and right inguinal hernia.
Pertinent Results:
CHEST (PA & LAT) [**2109-8-23**] 2:06 PM
CHEST (PA & LAT)
Reason: rib fracture? pneumo?
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with fall
REASON FOR THIS EXAMINATION:
rib fracture? pneumo?
INDICATION: Assessment for rib fracture or pneumonia in a
patient with fall.
TECHNIQUE: PA and lateral view of the chest. Comparison
available from [**2108-8-20**].
FINDINGS: Heart, mediastinal, and hilar contours are normal.
Right lung is clear. Left lung has basilar atelectasis and
pleural thickening. There is no pleural effusion. The remainder
of left lung is clear.
IMPRESSION: Atelectasis and pleural thickening in basilar
portion of left lung. Otherwise, normal study.
ABDOMEN U.S. (COMPLETE STUDY)
Reason: cholecystitis? cholelithiasis?
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with jaundice and RUQ pain
REASON FOR THIS EXAMINATION:
cholecystitis? cholelithiasis?
INDICATION: Jaundice and right upper quadrant pain. Question
cholecystitis.
COMPARISON: [**2109-2-20**].
FINDINGS: There is marked edema, hyperemia, and a ragged
appearance of the gallbladder wall. The gallbladder is
mildly/moderately distended with multiple gallstones. There is
trace pericholecystic fluid. There is no intrahepatic ductal
dilation, and the proximal common bile duct measures 6 mm.
Extrahepatically, the common bile duct dilates to 12 mm. The
common bile duct is not visualized adequately throughout its
course, and the evaluation for stones is not reliable. The
pancreatic duct measures 3 mm. The proximal pancreas appears
normal.
There is a focal area of gallbladder wall thickening measuring
14 x 8 mm. This likely represents an area of adenomyoma
(malignancy is less likely, but also a diagnostic
consideration).
The right kidney measures 10.7 cm and contains a 7-mm echogenic
focus in the lower pole of the right kidney. Shadowing indicates
this to be a nonobstructing stone. Previously described 5-mm
angiomyolipoma in the lower pole is not clearly seen. The left
kidney measures 10.6 cm. The spleen is not enlarged.
IMPRESSION:
1. Acute cholecystitis with gallbladder stones, thickened and
edematous gallbladder wall.
2. A focal area of gallbladder wall thickening is most likely
adenomyoma, but malignancy is a diagnostic consideration.
3. Right lower pole nonobstructing stone.
CT HEAD W/O CONTRAST [**2109-8-23**] 3:27 PM
CT HEAD W/O CONTRAST
Reason: bleed?
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with fall
REASON FOR THIS EXAMINATION:
bleed?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Fall.
COMPARISON: None.
TECHNIQUE: Non-contrast axial head CT.
FINDINGS: There is no evidence for intracranial hemorrhage.
There is no mass effect or shift of normally midline structures.
The ventricles, cisterns, and sulci maintain a normal
configuration. There is atherosclerotic calcification of the
cavernous carotids. The osseous structures are unremarkable
without evidence for fracture. The visualized paranasal sinuses
are clear. The mastoid air cells are clear. The patient is
edentulous. Note is made of a left phthisis bulbi.
IMPRESSION: No intracranial hemorrhage.
CT ABDOMEN W/CONTRAST [**2109-8-23**] 3:28 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: divertic? soild organ damage? free fluid?
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
80 year old man with abd pain s/p fall
REASON FOR THIS EXAMINATION:
divertic? soild organ damage? free fluid?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Abdominal pain, status post fall.
COMPARISON: [**2109-1-10**].
TECHNIQUE: Contrast-enhanced axial CT imaging of the abdomen and
pelvis was reviewed.
CT ABDOMEN WITH CONTRAST: There is a small left pleural effusion
and associated atelectasis. The liver enhances without
suspicious lesions. The gallbladder is distended with
gallbladder wall thickening and multiple stones. Please see
ultrasound report from the same day for further details. The
pancreas, spleen, stomach, small bowel loops are unremarkable,
and there is no free air, free fluid, or pathologic adenopathy.
CT PELVIS WITH CONTRAST: There is a very mild bowel wall
thickening of the colon that is nonspecific, and may be related
to its collapsed state. There is diverticulosis of the sigmoid
colon. There is a 4-mm thin rectangular metallic object in the
deep pelvis, unchanged. The kidneys enhance and excrete
normally. Bilateral inguinal hernias, the left containing small
bowel loops, and the right containing a small amount of free
fluid is unchanged. Note is made of a giant sigmoid
diverticulum.
BONE WINDOWS: No suspicious lesions are identified.
IMPRESSION:
1. Moderately distended gallbladder with gallbladder wall
thickening and multiple gallstones, most consistent with acute
cholecystitis. For further information, please see the
ultrasound report from same day.
2. No evidence for bowel obstruction or traumatic injury.
3. Bilateral inguinal hernias containing free fluid and small
bowel loops.
4. Small left pleural effusion.
Atrial fibrillation with slow ventricular response
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
59 0 90 444/441.72 0 26 21
PATIENT/TEST INFORMATION:
Indication: r/o Myocardial infarction.
Weight (lb): 150
BP (mm Hg): 120/80
Status: Inpatient
Date/Time: [**2109-8-29**] at 14:18
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W030-0:00
Test Location: West Echo Lab
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.5 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.6 cm
Left Ventricle - Fractional Shortening: 0.37 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.0 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
TR Gradient (+ RA = PASP): *20 to 28 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild (non-obstructive) focal hypertrophy of the
basal septum.
Normal LV cavity size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR.
Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated.
There is mild (non-obstructive) focal hypertrophy of the basal
septum. The
left ventricular cavity size is normal. Overall left ventricular
systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are
mildly thickened. There is borderline pulmonary artery systolic
hypertension.
There is no pericardial effusion.
CHEST (PORTABLE AP) [**2109-8-30**] 8:45 PM
CHEST (PORTABLE AP)
Reason: eval for change
[**Hospital 93**] MEDICAL CONDITION:
80 year old man s/p open CCY w/ acute desaturation.
REASON FOR THIS EXAMINATION:
eval for change
INDICATION: Status post cholecystectomy with acute desaturation.
TECHNIQUE: AP radiograph of the chest, compared with examination
of [**2109-8-23**].
FINDINGS: Cardiac and mediastinal silhouettes remain unchanged.
There is increase in retrocardiac opacity since the prior
examination. There is persistence of pleural thickening and
atelectasis at the left base. Pulmonary vascularity is slightly
more prominent than the prior examination, more so on the left
than right. Linear tubular lucency seen inferior to the heart is
compatible with postoperative intraabdominal free air, status
post open cholecystectomy.
IMPRESSION:
1. Retrocardiac opacity and slight left lobe opacity, possibly
representing atelectasis/volume loss in a postoperative patient.
2. Left-sided pleural effusion and pleural thickening.
RADIOLOGY Preliminary Report
CHOLANGIOGRAM,IN OR W FILMS [**2109-8-30**] 4:35 PM
CHOLANGIOGRAM,IN OR W FILMS
Reason: CHOLANGIGRAM-CHECK DUCTS
INDICATION: Intraoperative cholangiogram.
COMPARISONS: None.
FINDINGS: A single fluoroscopic spot image obtained during
recent intraoperative cholangiogram obtained without a
radiologist present is submitted for review. This image
demonstrates opacification of the cystic duct and common bile
duct with no evidence of stones, other filling defects,
extrinsic compression or structural ductal abnormalities.
Contrast is seen draining into the duodenum.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2109-8-31**] 6:21 AM
CHEST (PORTABLE AP)
Reason: eval for aspiration/pneumonia
[**Hospital 93**] MEDICAL CONDITION:
80 year old man s/p open CCY w/ acute desaturation, now s/p
intubation.
REASON FOR THIS EXAMINATION:
eval for aspiration/pneumonia
INDICATION: Cholecystectomy, acute desaturation, evaluate for
aspiration or pneumonia.
SINGLE AP RADIOGRAPH: Compared with examination performed 22:49
on [**2109-8-30**].
FINDINGS: Tip of the endotracheal tube remains approximately 3
cm above the carina. Abdominal free air remains evident.
The cardiac and mediastinal silhouettes remain unchanged. The
aeration of the left and right lungs is essentially unchanged
when compared with the prior examination. There is persistent
blunting of the left costophrenic angle, similar in morphology
to the preoperative examination of [**2109-8-23**], and likely
representing pleural thickening. Persistent mild increase in
opacity at the left lung base may represent a mild effusion
versus atelectasis. No new opacities are present to suggest
aspiration.
[**2109-8-23**] 1:40 pm BLOOD CULTURE
**FINAL REPORT [**2109-8-26**]**
AEROBIC BOTTLE (Final [**2109-8-26**]):
[**2109-8-24**] REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 63655**] AT 7:15 AM.
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 63656**]
[**2109-9-2**].
ANAEROBIC BOTTLE (Final [**2109-8-26**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 63656**]
[**2109-8-23**].
[**2109-8-25**] 1:42 am BLOOD CULTURE Site: ARM 1 OF 2.
**FINAL REPORT [**2109-8-31**]**
AEROBIC BOTTLE (Final [**2109-8-31**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2109-8-31**]): NO GROWTH.
Brief Hospital Course:
He was admitted to [**Hospital1 18**] on [**2109-8-23**]. An US showed acute
cholecystitis with gallbladder stones and a CT confirmed a
moderately distended gallbladder with gallbladder wall
thickening and multiple gallstones, most consistent with acute
cholecystitis. A head CT was performed due to his fall injury
and was negative.
GI: An ERCP on [**2109-8-24**] showed the major papilla appeared patulous
suggesting recent stone passage. Cannulation of the biliary duct
was successful and deep with a sphincterotome using a free-hand
technique. He was placed on intravenous antibiotics and bowel
rest. The patient was monitored expectantly until his pancreatic
enzymes normalized. A cholecystectomy was next performed. He did
well from a surgical standpoint and his diet was slowly advanced
over the next few days. He was tolerating a diet and had +flatus
and +BM prior to discharge.
Resp: s/p open cholecystectomy on [**2109-8-30**], he was difficult to
arouse and dropped his Os sats to the 50s. He was reintubated at
the bedside. The next day he was extubated and doing well.
Abd: His abdomen remained soft, slightly tender along the
incision line and non-distended. His staples remained in place
and will be D/C'd at his follow-up appointment.
Pain: He was started on a PCA and his pain was well controlled.
Once tolerating a PO diet, he was started on Percocet.
ID: A blood culture on [**2109-8-23**] was positive for ESCHERICHIA COLI
and he was started on Levo and Flagyl. A repeat blood culture on
[**2109-8-25**] showed no growth.
CV: A-fib. He received Lopressor and Diltiazem for rate control.
His INR was 2.0 and he received 6 units of fresh frozen plasma
prior to surgery. His Coumadin was held and he was on a heparin
drip for anticoagulation prior to surgery. Coumadin was
restarted POD 3. A trigger was called for A-fib with a rate of
157 POD 4. He was given his Toprol XL 200 mg and started back on
Diltiazem 240 mg. His rate stabilized in the 80's.
Physical Therapy: PT recommended home with physical therapy and
VNA was arranged.
Medications on Admission:
coumadin 1', Atorvastatin 40', Diltiazem SR 240', Toprol XL 200'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 4 weeks.
Disp:*40 Tablet(s)* Refills:*0*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*qs Tablet(s)* Refills:*2*
5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks: Please have your blood drawn and monitor your INR.
Follow-up with Dr. [**Last Name (STitle) 5351**] for your Warfarin dose.
Disp:*14 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
VNA - please check INR on Friday and inform Dr. [**Last Name (STitle) 5351**]
[**Telephone/Fax (1) 608**] of the results.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute cholecystitis and gallstone pancreatitis
Discharge Condition:
Good
Discharge Instructions:
You may resume your regular medications. Take all new
medications as directed.
You may resume your regular diet.
You may shower. Allow water to run over the wound and pat dry.
No baths for 2 weeeks.
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1924**].
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1927**]
Date/Time:[**2109-9-10**] 11:00
Completed by:[**2109-9-5**]
ICD9 Codes: 2875, 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7636
} | Medical Text: Admission Date: [**2150-11-6**] Discharge Date: [**2150-11-11**]
Date of Birth: [**2093-8-2**] Sex: F
Service: MEDICINE
Allergies:
Oxycontin
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD
Angiography with embolization
Central line placement
History of Present Illness:
Pt is a 57 yo F w/ metastatic ampullary carcinoma of pancreas
admitted [**11-6**] for thrombocytopenia and trace guiaic + emesis,
now transferred from [**Hospital Unit Name 153**] for CMO. She failed systemic therapy
with irinotecan, and began rx one wk ago with
oxaliplatin/avastin/5FU. She had increased bruising, emesis x 3
[**11-5**], and fell night of [**11-5**] on L buttock into dresser. She was
sent to ED from [**Hospital **] clinic after found emesis heme + (pt brought
sample of emesis), hct 25, plt 9. In ED couple hours later, hct
24, plt 5. Transfused 2 units pRBCs and 2 packs of platelets;
repeat hct 24 and plt 18. Sent to floor [**11-6**] afternoon.
.
ROS: +Chronic LBP since ERCP in [**7-12**]. No melena or blood in
stool. nl BM [**11-6**]. able to take in POs. no dysuria, gum
bleeding, vaginal bleeding, swelling/pain in joints. no F/C/S.
no confusion, dizziness, LOC. +Memory loss on chemotherapy (pain
meds).
Past Medical History:
metastatic ampullary carcinoma - lung nodules
h/o SBO in [**8-11**] s/p duodenal stent
HTN
internal hemorrhoids
DCIS of breast [**2141**] s/p excision and XRT
osteoarthritis
history of positive PPD in [**2115**] - tx c anti-TB tx x 1 yr
hyperlipidemia
LBP- prior hx unrelated to new LBP
Social History:
Lives with mentally disabled daughter in [**Name (NI) 4047**]. Former ICU
nurse, on disability for LBP x 10 yrs. Tob 28 pk yrs and quit 15
years ago. No EtOH. HCP [**Name (NI) **] [**Name (NI) 14407**], nurse friend, at
[**Telephone/Fax (1) 14408**].
Family History:
Her father had multiple myeloma. A non-smoker paternal aunt had
lung cancer.
Physical Exam:
Vitals: T 96.5 BP 128/67 P 58 R 12 O2 97% 3L NC
Gen: Pale female in no acute distress lying in bed, lethargic
appearing
HEENT: Anicteric. PERRL, EOMI. Pale mucous membranes. Palatal
petechiae
Heart: Regular rate and rhythm. Normal s1,s2. III/VI SEM at LUSB
Lungs: Decreased breath sounds on right, left lung clear to
ausculation.
Abd: Soft, nondistended, normal active bowel sounds, tender to
palpation in epigastrium with minimal involuntary guarding, no
rebound
Ext: warm and well perfused, without cyanosis or edema.
Skin: 2x3 cm bruises noted on her left buttock. Multiple bruises
on both arms
Neuro: Awake, alert and oriented x 3. Moving all extremities
equally and spontaneous
Pertinent Results:
[**Age over 90 **]|99|14/104
3.4|32|0.7\
>9.624.0<5
N:91 B:0 L:5 M:4 E:0 Bas:0
Granct:[**Numeric Identifier 14409**]
PT:12.9 PTT:25.7 INR:1.1
...........
[**2150-11-6**] 07:36AM PLT SMR-RARE PLT COUNT-9*#
[**2150-11-6**] 07:36AM WBC-14.0*# RBC-2.99* HGB-8.1* HCT-25.1*
MCV-84 MCH-27.0 MCHC-32.2 RDW-16.2*
[**2150-11-6**] 09:55AM PT-12.9 PTT-25.7 INR(PT)-1.1
[**2150-11-6**] 09:55AM WBC-9.6 RBC-2.83* HGB-7.9* HCT-24.0* MCV-85
MCH-27.8 MCHC-32.8 RDW-16.2*
[**2150-11-6**] 09:55AM GLUCOSE-104 UREA N-14 CREAT-0.7 SODIUM-138
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-32 ANION GAP-10
[**2150-11-6**] 03:33PM PLT COUNT-18*#
[**2150-11-6**] 03:33PM HCT-23.9*
Brief Hospital Course:
57 year-old female with metastatic pancreatic ampullary
carcinoma who presented with hematemesis, anemia, and
thrombocytopenia. On first night of admission the patient had 2
episodes of hematemesis, 70cc and ~100cc - the first episode
during plt transfusion and associated with diffuse abdominal
pain and hypotension to SBP 70s. KUB revealed no free air.
Surgery was called and did not eval the patient. GI recommended
adequate access, PPI, volume resuscitation. She was transferred
to [**Hospital Unit Name 153**] after 2nd episode of hematemesis on [**11-7**].
.
In the [**Hospital Unit Name 153**], she underwent EGD for which she was electively
intubated, which revealed large amounts of blood and clot in the
stomach. There was no evidence of active bleeding. Three
lesions at the gastroesophageal junction were cauterized
although these lesions had a low probability to be contributing
to her hematemesis. Shortly after the EGD, she developed
massive amounts of hematemesis (1.5 L) and became
hemodynamically unstable. She required a total of 13 units of
red cells, 6 L of crystalloid, 2 units of platelets, 2 units of
fresh frozen plasma. She was taken to IR for embolization. On
angiography, she had a clear bleed in the pacreatoduodenal
branch of the SMA that was successfully embolized. While she
remained hemodynamically stable over the next 12 hours, her
hematocrit trended down and she continued to have 100 cc/hr
output from her OG tube. IR was ready to take the patient back
for another angiography; however, the health care proxy decided
not to pursue further treatments. At that point the patient was
extubated and made comfort measures only.
.
The patient was transfered back to the floor on MSO4 and ativan
drips at 160 mg/hr and 2 mg/hr respectively to control her pain.
Her HCP, [**Name (NI) **], was at patient's side. At 4:30 am the night
float resident was called to evaluate the patient because she
had stopped breathing. The patient was found to have no
pupillary reaction to light, no breath sounds, and no pulse.
.
The patient was maintained NPO. Her calcium, magnesium, and
potassium were repleted before she was made comfort measures
only. She was maintained on pneumoboots and PPI before she was
made comfort measures only.
.
Initially the patient was DNR, but once she continued to bleed
post-embolization, she was made comfort measures only.
Medications on Admission:
dilaudid 4 mg Q4
fentanyl 250 mcg Q3 days
protonix 40 iv BID
lorazepam 1 mg Q4 prn
neurontin 300 TID,
naprosyn [**Hospital1 **]
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
UGIB
metastatic ampullary carcinoma - lung nodules
........
HTN
internal hemorrhoids
DCIS of breast [**2141**] s/p excision and XRT
osteoarthritis
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7637
} | Medical Text: Admission Date: [**2109-2-1**] Discharge Date: [**2109-2-11**]
Date of Birth: [**2036-2-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
[**2109-2-2**]: Left Burr Hole evacuation of SDH
History of Present Illness:
72 yo left handed male w/ PMHx [**Month/Day/Year 65**] for CAD s/p MI, CABG, CHF w/
EF 15% who presents as transfer from OSH for SDH. The history
is obtained through wife as patient appears fatigued and in
slight resp distress. His wife found him outside a couple of
months ago crawling to the house. He said that he had fallen.
She then noticed 1-2 days ago that he had trouble walking. He
stayed in bed almost all of yesterday. Today she notice that
his R arm and leg were not working very well. He also saying
things that did not make sense at times like he was "going back
to [**State 108**]" when there were no plans to do so. He could only
walk [**1-25**] steps with a walker yesterday. He was brought to an
OSH today where head CT showed a large 3 cm L SDH with 1 cm
midline shift.
.
The patient was given Vitamin K, FFP, and platelets prior to
transfer to [**Hospital1 18**]. Upon arrival he was note to have erythema of
his skin concerning for rash and he was given benadryl and
Solu-Medrol out of concern for a transfusion reaction.
Past Medical History:
DM, CAD s/p MI, CABG, Afib, CHF w/ EF 15% s/p ICD, sleep apnea
on BIPAP
Social History:
Retired, lives with wife. In dependant of ADLs. Smoker in past.
Family History:
non-contributory
Physical Exam:
Vitals: T 99.8; BP 110/70; P 98; RR 22; O2 sat 88%
.
General: lying in bed, wearing face mask, appears in mild
distress.
HEENT: NCAT, dry mucous membranes
Pulmonary: upper airway rhonci, shallow breath sounds
Cardiac: irreg irreg
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: cool no edema.
.
Neurological Exam:
Mental status: awake, states name, place - [**Hospital1 **], year [**2108**], month
[**Month (only) **]. Does not repeat no ifs ands or buts. Names thumb but
cannot name tuning fork. Some L/R confusion.
.
Cranial Nerves:
I: Not tested
II: R pupil surgical, L pupil 4-->2mm with light.
III, IV, VI: does not comply formally with eye movements.
VII: R NLF flattening
XII: Tongue midline slightly clumsy side to side movements.
.
Motor: Normal bulk. Normal tone. Difficulty lifting R arm off
bed. Does not comply with formal testing but appears to have
right hemiparesis.
.
Sensation: intact to light touch
.
Reflexes: 1+ throughout
Pertinent Results:
Labs on Admission:
[**2109-2-2**] 12:00AM BLOOD WBC-10.4 RBC-5.85 Hgb-14.5 Hct-45.8
MCV-78* MCH-24.7* MCHC-31.6 RDW-16.7* Plt Ct-247
[**2109-2-2**] 12:00AM BLOOD Neuts-86.5* Lymphs-8.5* Monos-4.5 Eos-0.2
Baso-0.3
[**2109-2-2**] 12:00AM BLOOD PT-13.4 PTT-26.6 INR(PT)-1.1
[**2109-2-2**] 12:00AM BLOOD Glucose-193* UreaN-33* Creat-1.3* Na-139
K-4.1 Cl-97 HCO3-30 AnGap-16
[**2109-2-2**] 12:00AM BLOOD CK(CPK)-85
[**2109-2-2**] 12:00AM BLOOD CK-MB-2 cTropnT-0.02*
[**2109-2-2**] 12:00AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.2
.
Labs on Discharge:
[**2109-2-11**] 03:59AM BLOOD WBC-10.6 RBC-6.52* Hgb-16.3 Hct-54.1*
MCV-83 MCH-24.9* MCHC-30.1* RDW-18.6* Plt Ct-175
[**2109-2-11**] 03:59AM BLOOD PT-18.4* PTT-33.2 INR(PT)-1.7*
[**2109-2-11**] 03:59AM BLOOD Glucose-208* UreaN-156* Creat-3.4* Na-143
K-5.0 Cl-101 HCO3-24 AnGap-23*
[**2109-2-10**] 03:19AM BLOOD ALT-64* AST-185* AlkPhos-126 TotBili-1.4
[**2109-2-11**] 03:59AM BLOOD Calcium-9.1 Phos-5.6* Mg-3.2*
[**2109-2-11**] 03:59AM BLOOD Digoxin-1.2
.
---------------
IMAGING:
---------------
CT head w/o contrast [**2109-2-2**]:
There is a large 3.3 x 7.8 x 11.7 cm lentiform predominantly
low-density extra-axial fluid collection overlying the left
cerebral hemisphere, which has high density rim and internal
septations, compatible with chronic subdural hematoma. This
causes substantial mass effect on the adjacent sulci, as well as
effacement of the left occipital [**Doctor Last Name 534**], and 13-mm rightward shift
of normally midline structures, resulting in rightward
subfalcine herniation. There is mild left uncal herniation and
relative widening of the cerebellomedullary cistern on the left
compared to the right. These findings are not changed from one
day prior. Also not changed is area of low density with loss of
[**Doctor Last Name 352**]-white matter differentiation along the posterior right
temporoparietal lobe, consistent with evolving subacute infarct.
No evidence of acute intracranial hemorrhage, edema, mass
effect, hydrocephalus, or acute large vascular territory
infarction is seen compared to one day prior. Note is made of
stranding within the right occipital scalp (2:18). The patient
has left lens replacement. No skull fracture is seen. 6-mm round
well-circumscribed focus in the left frontal bone (3:36) is well
circumscribed and has nonaggressive features. Mild mucosal
thickening is noted at the left frontoethmoid junction. Vascular
calcifications are noted along the cavernous carotid arteries.
IMPRESSIONS:
1. Large lentiform predominantly hypodense extra-axial
collection along the left cerebral hemisphere, with hyperdense
rim and internal septations,
compatible with chronic subdural hematoma. This collection
causes substantial mass effect, including rightward subfalcine
herniation and early left uncal herniation. Findings not changed
from one day prior.
2. Hypodense evolving subacute-to-chronic posterior right
temporoparietal
lobe infarct, unchanged.
.
CT head w/o contrast [**2109-2-3**]: Substantial reduction in size of
the subdural hemorrhage, but with presence of what is likely an
acute component along its superficial aspect, as noted above.
.
CT head w/o contrast [**2109-2-4**]: Little change in comparison to one
day prior, with persistent presence of likely acute subdural
hematoma along the superficial aspect of the subdural
collection.
.
CT head w/o contrast [**2109-2-7**]: No significant interval change
with persistent left subdural extra-axial collection with some
residual acute hemorrhage, with grossly stable mass effect on
the left hemisphere, and stable shift of midline structure.
.
CXR [**2109-2-6**]:
The moderate cardiomegaly with associated pulmonary edema is
unchanged. Right lower lobe collapse persists. There are mild
small bilateral pleural effusions. Pacer/defibrillator wires
terminate appropriately, unchanged. Sternal wires are intact.
IMPRESSION:
Unchanged moderate cardiomegaly with mild pulmonary edema.
Persistent right lower lobe collapse.
.
Echocardiogram [**2109-2-3**]:
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
severely depressed (LVEF= 15 %). The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. There
is a very small pericardial effusion.
Brief Hospital Course:
Neurosurgery Intensive Care Unit Course: He was initially
admitted to the neurosurgical ICU with confusion. Head imaging
showed a subacute subdural hematoma. He underwent evacuation of
the subdural hematoma with burrhole. The procedure was
uncomplicated. The evening following the extubation he was found
to be in worsened respiratory distress. He had pre-existing
central sleep apnea for which he used bipap however he had
worsened from his baseline. He had gone into afib with RVR in
the setting of his rate controlling metoprolol for his PAF being
held. His home lasix had also been held. A chest x-ray showed
evidence of flash pulmonary edema. He was transferred to the
Cardiology Cricitcal Care Unit (CCU).
.
CCU Course:
.
Acute on chronic systolic congestive heart failure: On transfer
to the CCU service he was found to be in respiratory distress
with evidence of volume overload. His apneic episodes from his
central sleep apnea worsened due to [**Last Name (un) **] [**Doctor Last Name 6056**] respirations
from heart failure and he required frequent bipap. He was
switched from lasix boluses to lasix gtt,diurel, and then
subsequently metolazone with vigorous urine output. His CVP was
initially 24 and trended into the normal range. He initially had
a FENA of 0.8. His Cr worsened initially from 1.8 to 2.8 with
lasix drip, then improved to 2.4 with IV fluids but began to
worsen, reaching 3.4 at the time of transfer.
.
Cheynes-[**Doctor Last Name **] Respirations: The patient developed alternate
tachypnea and apnea, consistent with Cheynes-[**Doctor Last Name **]
respirations. This was felt to be due to the patient's central .
He should follow up his outpatient cardiologist Dr [**Last Name (STitle) **] on
discharge. It is very important that that the patient use BIPAP
at night AND during the day when less alert.
.
Acute kidney injury: The patient creatinine rose with diuresis,
then improved with small boluses of IV fluids, then continued to
rise. The patient's creatinine had reached 3.4 by the time of
transfer.
.
Anion gap: The patient was noted to have an anion gap of 23 on
the day of transfer. A peripheral venous lactate was 3.0 at the
time of discharge. The patient's gap acidosis was thought to be
multifactorial, related renal failure and to lactic acidosis.
Following transfer, attention should be given to maintaining
adequate perfusion without compromising the patient's
respiratory status.
.
Atrial fibrillation: The patient's atrial fibrillation was
initally rate controlled with carvedilol which was subsequently
switched switched to metoprolol. Anticoagulation was held in the
setting of the patient's subdural hematoma. The patient cannot
restart anticoagulation with warfarin or heparin until she
follows up with neurosurgery and is cleared for anticoagulation.
.
Subdural hematoma: Serial CT scans were stable, although the
patient's mental status remained altered. The patient was
continued on Keppra for seizure prophylaxis. The neurology
service was consulted and recommended doing a routine EEG if the
patient's mental status changes persist. Neurosurgery was
consulted regarding anticoagulation and felt that it was safe to
restart aspirin. Per neurosurgery, the patient should not start
heparin or Coumadin until at least [**2109-2-27**], and only after being
seen in follow-up by neurosurgery. The neurology service should
be consulted at [**Hospital 8641**] hospital for management of the patient's
seizure prophylaxis.
.
Delirium: The patient would become agitated at night.
Benzodiazepines were avoided and frequent reorientation was
encouraged. Neurology was consulted and recommended checking an
EEG. This should be done if the patient's altered mental status
persists.
Medications on Admission:
ASA 81mg
Carvedilol 12.5m [**Hospital1 **]
Lisinopril 10mg daily
Plavix 75mg daily
Lasix 40m [**Hospital1 **]
Zocor 40mg daily
KCl 20meq daily
Prilosec 20mg daily
MVI
Novolog 70/30.
Discharge Medications:
1. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Metoprolol Tartrate 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
three times a day.
6. Keppra 1,000 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
7. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
[**Last Name (STitle) **]: Ten (10) units Subcutaneous qam.
8. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
[**Last Name (STitle) **]: Six (6) units Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Left Chronic subdural hematoma
Cardiomyopathy(LEVF<20%)
Acute on chronic kidney injury
Discharge Condition:
Hemodynamically stable; not oriented to person, place, or time;
intermittently responsive to simple commands; intermittently
apneic tachypneic, with cheynes-[**Doctor Last Name 6056**] respirations
Discharge Instructions:
You came to the hospital because of bleeding in your head. You
had a neurosurgical procedure to remove some blood from your
head. Your heart failure worsened post-operatively, requiring
transfer to the cardiac intensive care unit. You were treated
with diuretic medications.
.
Your family requested transfer to [**Hospital 8641**] Hospital, closer to
home. At the time of discharge, there were several active issues
that still needed attention:
1. Your kidney function was getting worse. This should be
followed closely at [**Hospital 8641**] Hospital.
2. You were not as alert as you usually are. Consideration
should be to doing an EEG if this persists.
3. You have staples in your head from the neurosurgical
procedure. These should be removed on [**2109-2-12**].
.
You will be transferred to [**Hospital 8641**] Hospital for further care.
.
You will need to follow up with neurosurgery (Dr. [**First Name (STitle) **] in 4
weeks for further evaluation. You should not start
anticoagulation with Coumadin or heparin until you are seen by
Dr. [**First Name (STitle) **].
Followup Instructions:
Dr. [**Last Name (STitle) **]: Monday [**2109-2-18**], 10:40am. [**Location (un) 8641**]
Cardiology, [**Apartment Address(1) **] [**Street Address(2) 86734**] [**Location (un) 8641**] Newhampshire, [**Numeric Identifier **].
Tel: [**Telephone/Fax (1) 86735**]
.
Dr [**First Name (STitle) **] (neurosurgery):
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2109-3-7**] 11:15
ICD9 Codes: 5849, 2762, 4254, 2930, 4280, 412, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7638
} | Medical Text: Admission Date: [**2172-9-22**] Discharge Date: [**2172-10-13**]
Date of Birth: [**2093-3-7**] Sex: M
Service: MEDICINE
Allergies:
Insulin,Beef
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Intubation, Artic Sun cooling protocol, hemodialysis
History of Present Illness:
Patient is a 79 year-old Russian male with a past medical
history significant for multivessel CAD s/p MI '[**45**], s/p OM PCI
to LCX '[**60**], s/p BMS to D1 of LAD '[**66**] with stable exertional
angina, atrial fibrillation on coumadin, diastolic heart
failure, PVD, hypertension, hyperlipidemia, DM2, long history of
medication non-compliance presented with CHF exacerbation,
elevated INR, now transferred to CCU due to asymptommatic
hypotension during diuresis.
.
Per patient, had N/V/Diarrhea 3 days ago reported to be
self-resolving. After resolution, noted worsening LE edema,
orthopnea, fatigue and decreased PO intake. No PO intake since
illness. On day of admission, he was so weak that he crawled to
phone to be brought to ED. In the ED was found to have slow
atrial fibrillation, unchanged EKG. CXR with e/o of pulmonary
edema and right sided pleural effusion. INR was 19. Due to
back bruise, CT scan done which was negative for RP bleed.
However, did note moderate pericardial effusion. Echo with no
tamponade physiology. Recieved 10 mg Vitamin K to reverse INR,
Lasix 80 mg IV with 75 cc UOP and admitted to the floor.
.
Overnight, he was placed on lasix gtt with subsequent
hypotension this morning. Urine output total 261 cc in 12
hours. Lasix gtt was discotninued and blood pressures improved
to mid-90's, however, no urine output. Blood pressure slowly
declined to mid-80's off the lasix gtt and now transferred to
CCU.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, constipation, BRBPR, melena, hematochezia,
dysuria.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
-- Multivessel CAD - s/p MI '[**45**], s/p OM PCI to LCX '[**60**], s/p BMS
to D1 of LAD '[**66**]; stable exertional angina, rare with climbing
hills, stairs;
MIBI ETT in [**2166**] - anignal symptoms with no ischemic changes,
52% predicted max HR
-- Chronic AF - on warfarin
-- Diastolic HF - orthopnea, paroxysmal nocturnal dyspnea,
exertional dyspnea; Echo in [**2166**] - mild MR, normal EF; normal
spirometry testing in [**2168**]
-- PVD - calf claudication bilaterally
-- Hypertension - normally 161-170/80 mmHg at home
-- Dyslipidemia - most recent cholesterol 98, LDL 46
-- Diabetes. Most recent A1c was 7.7
-- Proteinuria
-- Chronic anemia
-- BPH
-- H/o TB.
-- Medication noncompliance.
-- asthma
-- DVT [**2170**] while on coumadin
Social History:
Retired electrician, widowed, has no children, lives alone in
[**Location (un) 86**]. He quit smoking many years ago and does not drink
alcohol nor use other drugs. He has had occupational lead
exposure.
Family History:
[**Name (NI) **] CA - father
Physical Exam:
Admission physical exam:
VS: T= Afebrile BP= 108/61 HR= 51 RR= 18 O2 sat= 92% pulsus
[**8-5**]
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: left eye conjunctiva injected, [**Last Name (un) **], MMM (but lips appear
dry).
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of *** cm.
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: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Discharge physical exam
deceased
Pertinent Results:
Admission labs:
[**2172-9-22**] 02:30PM BLOOD WBC-5.0 RBC-3.07* Hgb-9.1* Hct-27.9*
MCV-91 MCH-29.7 MCHC-32.7 RDW-16.9* Plt Ct-321
[**2172-9-22**] 02:30PM BLOOD Neuts-81.7* Lymphs-13.0* Monos-4.0
Eos-0.9 Baso-0.4
[**2172-9-22**] 02:30PM BLOOD PT-150* PTT-71.6* INR(PT)-19.2*
[**2172-9-29**] 10:55AM BLOOD Fibrino-481*
[**2172-9-28**] 12:50PM BLOOD Thrombn-14.8*
[**2172-9-22**] 02:30PM BLOOD Glucose-360* UreaN-83* Creat-2.5* Na-139
K-4.2 Cl-101 HCO3-27 AnGap-15
[**2172-9-22**] 02:30PM BLOOD ALT-7 AST-13 AlkPhos-173* TotBili-2.1*
[**2172-10-2**] 06:00AM BLOOD ALT-184* AST-383* AlkPhos-129
TotBili-3.5*
[**2172-9-22**] 02:30PM BLOOD Lipase-35
[**2172-9-22**] 02:30PM BLOOD CK-MB-3 proBNP-4878*
[**2172-9-22**] 02:30PM BLOOD cTropnT-0.13*
[**2172-9-22**] 05:05PM BLOOD cTropnT-0.13*
[**2172-9-23**] 12:00PM BLOOD CK-MB-4 cTropnT-0.12*
[**2172-9-30**] 07:20AM BLOOD CK-MB-9 proBNP-7367*
[**2172-9-30**] 11:37PM BLOOD CK-MB-15* MB Indx-1.8 cTropnT-0.15*
[**2172-9-22**] 02:30PM BLOOD Albumin-3.1* Calcium-9.3 Phos-4.6* Mg-2.5
[**2172-9-29**] 07:30AM BLOOD TotProt-6.0* Calcium-8.5 Phos-6.1*#
Mg-2.5
[**2172-10-3**] 06:03AM BLOOD Hapto-93
[**2172-9-29**] 10:55AM BLOOD D-Dimer-<150
[**2172-9-23**] 12:00PM BLOOD TSH-3.3
[**2172-10-4**] 06:22AM BLOOD Cortsol-15.4
[**2172-9-30**] 11:43PM BLOOD Lactate-10.8* K-4.9
.
[**2172-9-30**] 11:37PM BLOOD WBC-8.3 RBC-2.66* Hgb-7.8* Hct-25.2*
MCV-95 MCH-29.3 MCHC-31.0 RDW-17.3* Plt Ct-285
[**2172-10-4**] 06:22AM BLOOD PT-17.0* PTT-44.0* INR(PT)-1.5*
[**2172-10-3**] 06:03AM BLOOD Ret Aut-3.5*
[**2172-10-1**] 11:48AM BLOOD Glucose-256* UreaN-94* Creat-5.0* Na-140
K-4.5 Cl-101 HCO3-14* AnGap-30*
[**2172-10-4**] 05:25PM BLOOD Glucose-125* UreaN-87* Creat-4.8* Na-139
K-3.8 Cl-105 HCO3-14* AnGap-24*
[**2172-10-4**] 06:22AM BLOOD ALT-102* AST-184* TotBili-7.9*
[**2172-10-4**] 06:43AM BLOOD Glucose-110* Lactate-1.6
[**2172-9-23**] 06:59AM URINE Hours-RANDOM UreaN-241 Creat-73 Na-82
K-37 Cl-80
[**2172-9-24**] 08:00AM URINE Blood-LG Nitrite-POS Protein-300
Glucose-NEG Ketone-TR Bilirub-MOD Urobiln-1 pH-5.5 Leuks-LG
[**2172-9-24**] 08:00AM URINE RBC->182* WBC-151* Bacteri-MANY
Yeast-NONE Epi-0
[**2172-9-24**] 08:00AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2172-9-30**] 11:00PM ASCITES WBC-250* RBC-[**Numeric Identifier **]* Polys-18*
Lymphs-12* Monos-0 Mesothe-5* Macroph-65*
[**2172-9-30**] 11:00PM ASCITES TotPro-3.3 Glucose-167 LD(LDH)-185
Amylase-20 Albumin-1.8
[**2172-9-30**] 11:00PM PERICARDIAL FLUID WBC-5000* RBC-[**Numeric Identifier 110831**]*
Polys-7* Lymphs-83* Monos-5* Macro-5*
[**2172-9-30**] 11:00PM PERICARDIAL FLUID TotProt-4.8 Glucose-144
LD(LDH)-2680 Amylase-16 Albumin-2.2
[**2172-9-30**] 11:00PM PERICARDIAL FLUID ADENOSINE DEAMINASE,
FLUID-PND
.
DISCHARGE LABS: N/A
.
MICROBIOLOGY
[**2172-9-22**] Urine Cx: SKIN AND/OR GENITAL CONTAMINATION.
[**2172-9-23**] MRSA screen: No MRSA isolated.
[**2172-9-24**] Urine Cx: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML.
ENTEROCOCCUS SP.
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN------------ <=2 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- =>16 R 8 I
VANCOMYCIN------------ 1 S 1 S
[**2172-9-30**] ASCITES
GRAM STAIN (Final [**2172-10-1**]): NO POLYMORPHONUCLEAR LEUKOCYTES
SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2172-10-4**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2172-10-1**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2172-9-30**] PERICARDIAL FLUID
GRAM STAIN (Final [**2172-10-1**]): 1+ POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2172-10-4**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2172-10-1**]): NO ACID FAST BACILLI SEEN ON
CONCENTRATED SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
[**2172-9-30**] PERICARDIAL FLUID CULTURE: pending
[**2172-9-30**] ASCITIC FLUID CULTURE: pending
.
IMAGING:
- [**2172-9-22**] ECHO: FOCUSED STUDY: Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is low
normal (LVEF 50-55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic valve
leaflets are mildly thickened (?#). Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-29**]+) mitral regurgitation is seen. There is a small
to moderate sized pericardial effusion. The effusion appears
circumferential. No right atrial diastolic collapse is seen. No
echocardiographic evidence of tamponade physiology. Compared
with the findings of the prior study (images reviewed) of
[**2171-11-6**], the pericardial effusion is new. Left ventricular
function appears less vigorous. The severity of mitral
regurgitation is increased.
.
[**2172-9-22**] CHEST (PORTABLE AP): Portable semi-upright chest
radiograph demonstrates an interval increase in right basilar
opacity, which likely represents a component of pleural
effusion. Superimposed atelectasis and/or consolidation is not
excluded. The heart size is moderately enlarged. The mediastinal
contours are notable only for calcification of the aortic arch.
The pulmonary vasculature is within normal limits.
.
[**2172-9-22**] CT ABD & PELVIS W/O CONTRAST:
LUNG BASES: Granulomata are seen within the lungs bilaterally.
There is a
large right and small left pleural effusion with a density of
simple fluid. Compressive atelectasis is seen at the right
greater than left lower lobes. There is a moderate-sized
pericardial effusion, with the attenuation of slightly complex
fluid ([**Doctor Last Name **] 15-30). There is coronary arterial calcification, and
the heart is moderately enlarged.
ABDOMEN: Evaluation of the abdominal viscera is limited by lack
of
intravenous contrast. The liver is grossly unremarkable, without
intrahepatic biliary ductal dilatation. The spleen is normal
appearing with note made of marked splenic arterial
calcification. The adrenals are normal bilaterally. The
pancreas demonstrates coarse calcification as noted previously,
consistent with diagnosis of chronic pancreatitis, with atrophy
of the distal body and tail. Within the body of the pancreas,
there is a 1.8 cm ovoid soft tissue focus which is more dense
than the surrounding gland and is stable compared with multiple
priors. A calcification is seen within the wall of the
gallbladder which was not seen on the prior which is likely a
non-dependent or adherent stone. The gallbladder is otherwise
unremarkable. The kidneys are atrophic and there is perinephric
stranding. There is no hydronephrosis and there are no stones,
though note is made of diffuse vascular calcification.
Paraesophageal lymphadenopathy is noted, increased in size
compared with
prior, and likely reactive. The stomach is collapsed and not
well evaluated. Loops of small bowel are normal in caliber and
enhancement. There is fecalization of distal loops of ileum.
There is a moderate amount of abdominal ascites. There is no
intraperitoneal free air. The aorta is
calcified along its course, though normal in caliber. There is a
small
fluid-filled periumbilical hernia. There is no retroperitoneal
hematoma.
There is a fluid-filled left inguinal hernia. There is diffuse
body wall
stranding compatible with anasarca.
PELVIS: The bladder is normal appearing. The prostate and
seminal vesicles
are unremarkable. The rectum is normal. The [**Doctor Last Name 499**] is normal. The
appendix
is normal. There is haziness of the central mesentery and
retroperitoneum,
which is likely resulting from similar process from the
patient's ascites.
BONE WINDOWS: There is multilevel degenerative change of the
thoracolumbar
spine, but no concerning lytic or blastic osseous lesions.
.
[**2172-9-23**] ECHO (TTE): The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild global left ventricular hypokinesis (LVEF = 45-50 %).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
mild pulmonary artery systolic hypertension. There is a small to
moderate sized pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: Moderate pericardial effusion with no echo signs of
tamponade. Mild symmetric left ventricular hypertrophy with mild
global left ventricular hypokinesis. Mild pulmonary
hypertrension.
Compared with the prior study (images reviewed) of [**2171-11-6**],
the pericardial effusion is new. Left ventricular function is
now mildly depressed. Estimated pulmonary artery pressures are
similar.
.
[**2172-9-23**] ABDOMEN U.S. (COMPLETE STUDY): Study is technically
limited. The liver is grossly normal without focal lesion or
intra- or extra-hepatic biliary ductal dilatation. Moderate
volume ascites is noted. The gallbladder is minimally distended
without wall thickening or edema. There may be a small tiny
adherent stone. The common bile duct is not dilated measuring 3
mm. Pancreas and aorta are not well seen due to overlying bowel
gas. The imaged IVC is unremarkable. The spleen is top normal in
size measuring 12.1 cm. There is no hydronephrosis, stone or
mass bilaterally with the right kidney measuring 10.7 cm and the
left kidney
measuring 10.8 cm.
Pericardial fluid:
NEGATIVE FOR MALIGNANT CELLS.
MRI Head
. Multiple punctate foci of restricted diffusion in the left
cerebellar
hemisphere which represent small acute infarcts in the left
posterior inferior cerebellar artery territory. These are likely
of embolic or hypoxic etiology. MRA was not performed but major
flow voids are grossly patent.
TTE [**10-12**] There is mild symmetric left ventricular hypertrophy
with normal cavity size and global systolic function (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened (?#). There is a very small circumferential
pericardial effusion without RA or RV diastolic collapse. There
are very prominent left pleural and right pleural effusions as
well as ascites.
Brief Hospital Course:
79M with CAD, diastolic CHF (EF 50-55%), afib on Coumadin
admitted with volume overload in setting of N/V at home x 3
days, found to have INR 19 with no bleeding complications and
moderate pericardial effusion with no tamponade physiology
transferred to CCU for hypotension in setting of diuresis. He
was stabilized and went to the floor. On the floor, the patient
was unwilling to participate in most aspects of care. He took
off his telemetry leads, then was found unresponsive by a nurse
and was found to be in PEA arrest, likely secondary to cardiac
tamonade. There was a prolonged amount of time without a pulse.
He was taken back to the CCU, where he underwent intubation and
cooling protocol. Off of sedation, there was evidence of
extensive neurologic damage, and a poor functional recovery was
expected. Because of underlying kidney failure and uremia, he
received hemodialysis to achieve a BUN less than upon admission
(when he was mentating well). Because of poor renal clearance,
serum benzos remained positive. He was given flumazenil to
reverse any effect they may be having, and there was a minimal
response. Ethics was involved and after extensive discussion
with all available contacts, it was decided to make the patient
CMO. The patient expired several hours later on [**2172-10-13**].
Medications on Admission:
HOME MEDICATIONS:
warfarin 3 mg daily
Lipitor 40 mg/day
cilostazol 50 mg [**Hospital1 **]
Vitamin B12
doxazosin 4 mg qhs,
Lasix 40 mg/day
ImDur 90 mg/day
insulin
lisinopril 5 mg daily
Toprol XL 100 mg/day
NTG prn
aspirin 81 mg/day
Protonix 40 mg/day
iron
.
MEDICATIONS ON TRANSFER
- Metolazone 2.5 mg [**Hospital1 **]
- Lasix 15 mg/h IV gtt
- Tylenol 325-650 mg q6h prn pain
- ASA 81 mg daily
- Pantoprazole 40 mg q24h
- Insulin sliding scale
- Atorvastatin 20 mg daily
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
ICD9 Codes: 5845, 2762, 2851, 5990, 3572, 4280, 412, 4439, 4019, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7639
} | Medical Text: Admission Date: [**2110-12-8**] Discharge Date: [**2110-12-19**]
Service: MEDICINE
Allergies:
Aspirin / Codeine / Sulfa (Sulfonamides) / Morphine / Dilaudid
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
fever, decreased PO intake
Major Surgical or Invasive Procedure:
1. Swan Ganz catheter (performed at outside hospital)
2. Percutaneous coronary intervention
History of Present Illness:
81 yof admitted to OSH [**2110-12-7**] with approximately 1 week of
feeling weak with decreased po intake. In ER, temp was 105 and
UA grossly positive. BC grew +GNR 3/4 bottles c/w urosepsis.
Received levoquin and one dose each of ceftriaxone and
ceftazadine. Patient ruled in for MI with tropI of 12, 25.3,
13.5. Patient became hypotensive and was started on dopamine ggt
overnight and levophed the following morning. PA line was placed
with wedge 16 mmHG, RA 11. Cardiac index started to drop around
12pm (1.8)-dobutamine was started.
.
She had also been on heparin overnight, platelets started to
drop and D-Dimer + at 5000. Heparin was changed to lovenox [**Hospital1 **].
.
Echo [**2110-12-8**] showed EF 25-30% and anteroapical akinesis. About
4pm patient began to develop chest discomfort. EKG with ST
elevation in anterior leads (V2-V4). Dobutamine was stopped at
this point and IV nitro started. She became pain free and was
subsequently transferred by helicopter to [**Hospital1 18**] for further
management. Pt cath'd with LAD 60% occlusion otherwise patent
RCA and LCx, abnormal LV gram.
.
On review of systems, denies headache, dizziness, cough, chest
pain, shortness of breath, nausea, dysuria, urinary frequency,
back pain. Per patient's family, she has not been feeling well
for approximately 1 week, occasionally vomitting and with
decreased PO intake.
Past Medical History:
1. hypertension
2. rheumatoid arthritis
3. anemia
4. s/p fracture of clavicle
5. s/p left total knee replacement
6. s/p hysterectomy
7. s/p CCY
Social History:
No tobacco, no etoh. Lives at home with her husband. [**Name (NI) **] adopted
older daughter who lives nearby. Retired, used to work for the
government.
Family History:
denies family history of heart disease
Physical Exam:
VS T 96.6 BP 96/63 MAP 74 HR 78 RR 18 100% NC 6L
PAP 34/19 CVP 14
Ht 5??????2?????? Weight 50 kg.
GEN: elderly, NAD, lying flat
HEENT: PERRL 2mm to 1mm, EOMI, o/p clear, dry mm
NECK: supple
CV: RRR S1S2, no m/r/g
LUNG: decreased BS at left base and clear on right
ABD: soft, nt, bs+
EXT: nonpitting 2+ edema in ankles b/l and 1+ nonpitting edema
in hands b/l, DP dopplerable, PT 1+, right groin with dressing
NEURO: alert, oriented to person, place (knew city but not
hosp), time (knew [**Holiday **] was near but not year was [**2109**])
Pertinent Results:
U/A leuk tr, nitr neg, WBC [**6-27**], bact many, epi [**3-22**]
Gluc 187, Na 136, K 3.8, Cl 108, HCO3 16, BUN 18, Cr 1.0
CK 538 MB 85 MBI 15.8 TropT 1.80
Ca 6.9 Mg 1.6 P 2.9
ALT 49 AST 132 AP 159 TB 0.9 Alb 2.2
WBC 45.5 HBG 9.8 Hct 29.1 Plat 122
N 56 Bands 39 L 1 M 2 E 0 Bas 0 Metas 2
PT 13.9 PTT 58.5 INR 1.3
ABG 7.34/26/83/15
[**2110-12-8**] Plt Ct-122*
[**2110-12-11**] Plt Ct-62*
[**2110-12-13**] Plt Ct-127*#
[**2110-12-18**] Plt Ct-333
[**2110-12-12**] Fibrino-302
[**2110-12-12**] %HbA1c-6.1*
[**2110-12-12**] Triglyc-134 HDL-22 CHOL/HD-5.4 LDLcalc-70
[**2110-12-12**] HIT Ab [**Doctor First Name **] negative
[**2110-12-16**] HIT Ab [**Doctor First Name **] negative
[**2110-12-19**] PT-19.4* INR(PT)-2.6
Microbiology:
urine culture at outside hospital E Coli pansensitive
[**12-8**] blood culture no growth
[**12-8**] urine culture no growth
c diff negative x3
.
EKG: NSR 79 bpm, left axis, 1.0mm ST elevation V1, 2.0mm ST elev
V2, .5mm depressions in V4-5, 1.0mm depression V6, TW
flattening/TWI throughout?
.
Cath [**12-8**]: LAD 60% occlusion, nl LCx and RCA.
.
CXR: cardiomegaly no CHF, LLL atelectasis/infiltrate, biapical
pleural thickening/scarring ?prior granulomatous disease,
density in the right mid zone extending to the right hilum,
osteopenia.
.
CAROTID SERIES COMPLETE [**2110-12-12**]
No hemodynamically significant stenosis was identified in the
bilateral extracranial carotid arteries
.
CT HEAD W/O CONTRAST [**2110-12-11**]
IMPRESSION: No evidence of acute intracranial hemorrhage. No
evidence of acute infarction. MRI is more sensitive for the
detection of acute infarction.
.
MR HEAD W/O CONTRAST [**2110-12-11**] 12:33 PM
CONCLUSION: Unremarkable MRI and MRA of the head for age. No MR
features of acute vascular territorial infarct.
.
[**12-13**] EEG
IMPRESSION: Probably normal awake and drowsy EEG without focal,
lateralizing, or epileptiform features seen. A senile drowsy
pattern is
considered normal for this age although deep midline dysfunction
cannot
be fully excluded.
.
UNILAT LOWER EXT VEINS RIGHT [**2110-12-14**]
No right lower extremity DVT
Brief Hospital Course:
81 year old woman with h/o htn and rheumatoid arthritis (on
chronic steroids) admitted with urosepsis and found to have
stress-induced cardiomyopathy (s/p cath [**12-8**]). Found to have
thrombocytopenia consistent with HIT and may have suffered a TIA
with negative head CT and MRI/MRA. Was placed on argatroban gtt
and aggrenox and bridged to coumadin while HIT Ab test was
pending.
.
## Thrombocytopenia: Patient's platelet count was 122K on
admission and dropped three days later to 62K. Differential
diagnosis included sepsis, possible HIT I or II. SQ heparin and
all flushes stopped. Concurrently, patient developed facial
droop, ptosis, tongue deviation and right LE swelling concerning
for arterial and venous thrombi. US of right LE negative for
DVT. While HIT Ab was pending, patient was started on argatroban
gtt. Hematology/oncology was consulted and recommended bridging
patient to warfarin. First HIT Ab [**Doctor First Name **] test returned as
negative. Argatroban ggt was discontinued after the INR was >3
after a 3 hour trial off argatroban. Second HIT Ab [**Doctor First Name **] was
negative suggesting no HIT Ab. Also, per heme/onc time course of
thrombocytopenia was shorter than expected for development of
HIT Ab (usually 5-6 days) however in the setting of a possible
TIA, patient will continue warfarin with goal INR betw [**2-20**] until
follow-up at hematology/oncology clinic.
.
## Neuro: Had new facial droop and tongue deviation on [**12-11**]
thought be a TIA likely secondary to HIT Ab. Head CT was
negative for bleed. Head MRI/MRA was negative for acute
ischemia. Carotid doppler showed no significant stenosis. HBAIC
6.0 and lipid panel within normal limits. Stroke team was
consulted and recommended starting ASA. Patient was switched
from salsalate to ASA without adverse drug rxn (hx of asa
allergy), and then switched to aggrenox. Patient placed on baby
ASA while on coumadin. Unclear whether facial signs were TIA or
twitching so EEG was performed which was negative for
epileptiform activity. Per stroke, continue ASA until outpatient
follow-up. Recommended increasing ASA dose to 325mg once off
warfarin.
.
## Cardiac: likely stress-induced cardiomyopathy (Takotsubo)
versus secondary to sepsis.
# Ischemia: patient had PTCA [**12-8**] revealing an LAD 60% occlus,
patent Lcx & RCA. Repeat echo [**12-9**] EF 25-30% severe LV
hypokinesis and LV sys fcn depression, RV sys fcn depression, no
endocarditis. TropI peaked at 25.3 at outside hospital, tropT
1.80 on admission. Patient started on toprol XL 25mg QD,
lisinopril 5mg PO QD and baby ASA. Nifedipine was held.
# Pump: Patient with low EF in setting of sepsis. Initially
hypotensive on levophed and aggressively fluid resuscitated.
Patient was on also hydrocortisone and fludrocortisone for 1
week course and then resumed on her outpatient dose of
prednisone 1mg PO BID. Patient was gradually weaned off
pressors. Patient became hypotensive again secondary to
excessive diarrhea which improved with fluid boluses and
resolution of her dairrhea.
# Rhythm: Sinus with PVCs. Cont telemetry.
.
#. Fever/Leukocytosis: Likely [**2-19**] E coli UTI and +BC GNR, has
been afebrile since admission, leukocytosis may also be
secondary to steroids, newly diagnosed lymphoma. OSH cx ([**Location (un) **]
ICU [**Telephone/Fax (1) 31585**])-> E. Coli pansensitive. Possible LLL pna on
CXR however sat'ing well on room air and asymptomatic. Repeat
U/A + for UTI & urine cxr no growth. C. diff negativex3. Patient
to complete a 2 week course of levoquin until [**12-19**]
urosepsis and possible LLL pneumonia. C. diff negativex3.
.
#. Acidosis: mixed venous pH 7.31, HCO3 15, AG adj for
hypoalb=13 HCO3 16. Likely mixed picture, nongap and gap
acidosis. Etiology likely secondary to septic shock, decreased
PO intake and fluid resuscitation with NS. Her 1.5 days of
diarrhea likely contributed to her nongap acidosis. HCO3 at
discharge 22 with no anion gap.
.
# Aphthous ulcer: likely [**2-19**] HSV 1 and stress.
- topical acyclovir to lip
- magic mouthwash for tongue/throat
- pureed diet for now as pt's dentures don't fit
- consider adding sulcrafate if not feeling better
.
# Diarrhea: likely [**2-19**] to abx v c diff v [**2-19**] too aggressive
bowel regimen. Resolving. Changed to lactose free diet.
- cont Imodium
- Hold bowel regimen
- C diff negative x3
.
#. Rheumatoid arthritis: initally held methotrexate and
prednisone. Should resume outpatient regimen.
.
#. FEN: repleting lytes, cardiac healthy diet as tolerated.
Nutrition was consulted given history of decreased intake and
low albumin, boost breezes with meals, zinc oxide, vitamin C for
wound healing (sacral irritation) and calcium vit D
supplementation for chronic steroid use.
.
#. Code status: full
.
#. Communication: Husband ([**Telephone/Fax (1) 31586**], Daughters: [**Name2 (NI) **] ([**Telephone/Fax (1) 31587**], [**Doctor First Name **] ([**Telephone/Fax (1) 31588**]
Medications on Admission:
at home
1. calcium c D 600U [**Hospital1 **]
2. folate 1mg qd
3. toprol XL 37.5mg qd (?)
4. nifedipine 60mg qd
5. salsalate 750mg [**Hospital1 **]
6. methotrexate 2.5mg [**Hospital1 **] qFri, qSat
7. prednisone 1mg [**Hospital1 **]
.
at OSH
1. ceftriaxone 1gm IV x1
2. ceftazadine 1gm IV x1
3. levoquin 250mg IV x1
4. levophed @ 12mcg/min
5. IV nitro @ 20mcg/min
6. dobutamine (now off)
7. NS 75 cc/hour
8. toprol 25mg QD
9. lovenox 50mg q12(10am/pm)
Discharge Medications:
1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
2. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic OU QD.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-19**]
Drops Ophthalmic PRN (as needed).
4. Prednisone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral PRN (as
needed).
8. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed.
9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days: Until [**12-21**].
13. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 6X/D (6
times a day).
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
16. Lidocaine Viscous 2 % Solution Sig: 15-20 cc Mucous membrane
QACHS as needed for mouth/throat discomfort.
17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed: Not to exceed 4g/day.
19. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain: Please take with food.
20. Calcium 500 500 mg Tablet Sig: One (1) Tablet PO three times
a day: Please give before meals and at least 30 minutes before
or after giving levoquin and protonix.
21. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a
day: Please give before meals.
22. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
23. Methotrexate 2.5 mg Tablet Sig: One (1) Tablet PO twice a
day: Fridays and Saturdays ONLY.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
1. Urosepsis
2. Cardiomyopathy
3. Pneumonia
4. Thrombocytopenia
5. TIA
Secondary Diagnosis:
6. Hypertension
7. Rheumatoid arthritis
Discharge Condition:
Good
Discharge Instructions:
Please take the medications as prescribed.
Please check INR level tomorrow Saturday [**2110-12-20**] and adjust
warfarin dose as needed for goal INR between 2 and 3.
Please keep your follow-up appointments.
If you have any chest pain, fevers/chills, difficulty breathing
or any other worrying symptoms please call your primary care
physician or come to the emergency room.
Followup Instructions:
1. Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) 17863**] on [**2111-1-2**] 3:30pm
([**Telephone/Fax (1) 31589**].
.
2. Please follow-up in Cardiology clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**]
on [**2111-1-5**] 10:30 Location: [**Hospital Ward Name 23**] Clinical Center Floor 7
Phone: ([**Telephone/Fax (1) 9490**].
.
3. Please follow-up in Heme/[**Hospital **] clinic with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3060**]
on [**2110-2-20**] 10:00 Location: [**Hospital Ward Name 23**] Clinical Center Floor 9 Phone:
([**Telephone/Fax (1) 31590**].
.
4. Please follow-up in [**Hospital 878**] clinic with Dr. [**First Name4 (NamePattern1) 1104**] [**Last Name (NamePattern1) 4638**]
on [**2110-3-24**] 3:00pm Location: [**Hospital Ward Name 23**] Clinical Center Floor 8
Phone: ([**Telephone/Fax (1) 22692**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2110-12-19**]
ICD9 Codes: 5990, 4254, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7640
} | Medical Text: Admission Date: [**2181-6-25**] Discharge Date: [**2181-7-5**]
Date of Birth: [**2119-3-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
- recurrent L malignant pleural effusion [**3-16**] metastatic gastric
cancer
Major Surgical or Invasive Procedure:
- thoracentesis
- Pleurodesis
- placement of chest tube
History of Present Illness:
62 M with metastatic gastric cancer now with c/o shortness of
breath and recurrant pleural effusion
Past Medical History:
PMH: gastric adenoCa-s/p chemo, HTN, MPE, ^lipidemia
Social History:
non-contrib
Family History:
non-contrib
Physical Exam:
on discharge
vitals: 99.1 106 126/69 24 97% 2.5 L (needs to be updated)
WD, cachectic, NAD
alert and oriented, moves all extremities
tachy, regular rate/rhythm
bilateral slight decrease BS at bases, CTA otherwise
soft, nt, nd, nabs
no c/c/e; bilateral lower extrem warm
Pertinent Results:
[**2181-7-3**] 12:30PM BLOOD WBC-8.2 RBC-3.06* Hgb-9.3* Hct-28.0*
MCV-92 MCH-30.5 MCHC-33.3 RDW-17.3* Plt Ct-336
[**2181-7-3**] 12:30PM BLOOD Neuts-80.9* Lymphs-5.5* Monos-9.2
Eos-4.3* Baso-0.1
[**2181-7-3**] 12:30PM BLOOD Plt Ct-336
[**2181-6-27**] 05:38PM BLOOD PT-14.6* PTT-29.5 INR(PT)-1.3*
[**2181-7-3**] 12:30PM BLOOD Glucose-92 UreaN-14 Creat-0.9 Na-137
K-3.8 Cl-98 HCO3-32 AnGap-11
[**2181-7-1**] 04:55AM BLOOD ALT-10 AST-18
[**2181-7-1**] 04:55AM BLOOD proBNP-428*
[**2181-7-3**] 12:30PM BLOOD Calcium-8.4 Phos-3.9 Mg-1.9
[**2181-7-1**] 04:55AM BLOOD Albumin-2.4* Calcium-8.2*
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2181-7-4**] 2:47 PM
History of pleural effusion with pleurodesis and chest tube
removal.
Since the previous study of [**2181-7-3**], the left chest tube has
been removed. There is consistent small left pleural effusion
and loculated hydropneumothorax anteriorly in the left lower
hemithorax, unchanged since the prior film. The diffuse
bilateral interstitial densities and right pleural effusion are
also unchanged.
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Approved: WED [**2181-7-4**] 4:15 PM
Brief Hospital Course:
The pt. was admitted to the oncology service on [**6-25**] with
complaints of recurrant pleural effusions related to his
metastatic gastric cancer. For the past week prior to admission
the pt. had been suffering from progressive shortness of breath.
A CXR was done on admission showing and expanding pleural
effusions. The IP team was contact[**Name (NI) **] and the pt. was set up for
pleurodesis and pleurex catheter placement. On HD 2 the pt.
went to the IP suite and pleurodesis was attempted. The pt.
became bradycardic to the 20s and a code was called. The pt.
was immediately intubated and bronched -> a large mucous plug
was extracted and the patient's vitals immediately improved.
With the pt. intubated the pleurodesis was completed. A left
side chest tube was placed and the pt. was transferred to the
ICU. The pt. was extubated overnight and transferred to the
floor with telementry. The pt. did well for the next several
days. On PPD2 the pt. had an aspiration event during which his
O2 sats dropped briefly and he became tachycardic. This
resolved with nebulizers, cough medicine, and lopressor. The
pt. did well for the next two days. His chest tube remained on
suction until PPD3 at which time it was placed to water seal. A
post-water seal cxr was unchanged and on the morning of PPD 4
the ct was clamped. A four hour post cxr showed no change and
the chest tube was pulled. Post pull CXR was again stable with
no evidence of a new pneumothorax. By HD 11 the pt. was doing
well post pull and ready for discharge. He was still requiring
supplemental oxygen and arrangements were made for a VNA to
visit and check the pt.s oxygen saturation as well as chest tube
site. He was tolerating a regular diet, was given instructions
regarding follow-up appoinments, medications, and post-procedure
care. He understood this information well and was ready for
discharge.
Medications on Admission:
compazine
zofran
ativan
hyzaar
lipitor
Discharge Medications:
1. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
Disp:*120 Tablet Sustained Release(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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain: - do not drive while taking this
medication.
Disp:*30 Tablet(s)* Refills:*0*
8. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
- Metastatic gastric cancer
- Malignant pleural effusion
- s/p pleurodesis and chest tube placement
Discharge Condition:
- good
Discharge Instructions:
- you may shower; no soaking in a bath tub, swimming pool, or
hot tub for several weeks
- you should eat a regular diet as tolerated
- you should take pain medications as needed
- do not drive while taking pain medications
- every day you take pain medication you should take a stool
softener: colace, senna, or dulcolax are all good options
- you should continue to use supplemental oxygen during the day
- the chest tube site dressing may come off on Saturday morning
- please call the Interventional Pulmonology clinic at
[**Telephone/Fax (1) 10084**] if T>101.5, nausea, emesis, redness or smelly
drainage from chest tube site, shortness of breath, swelling in
your extremities, or any other concern.
Followup Instructions:
**it is very important that you call to confirm the following
appointments**
Provider [**Name9 (PRE) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) **]:[**0-0-**]
Date/Time:[**2181-7-3**] 1:00
.
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2181-7-3**] 2:00
.
Provider [**First Name8 (NamePattern2) **] [**Name9 (PRE) **], [**Name Initial (PRE) **].D.
Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2181-7-12**] 2:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2181-7-11**] 2:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
ICD9 Codes: 5070, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7641
} | Medical Text: Admission Date: [**2153-12-24**] Discharge Date: [**2154-1-1**]
Date of Birth: [**2093-7-11**] Sex: M
Service: NEUROLOGY
Allergies:
Glucocorticoids
Attending:[**First Name3 (LF) 1032**]
Chief Complaint:
Witnessed Seizure.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
60 yo man w/ hx of ESRD on HD, HTN, cocaine abuse p/w
seizure five hours ago. Pt reports that he had hemodialysis as
usual 2 days ago and stopped his anti-hypertensive meds 2 days
PTA. He felt fine until today when he stood up from a sitting
position to open the window, and as he was opening the window,
he
blacked out, but on his way down he thinks the clock said
4:37pm.
His last cocaine use was 5 days PTA. No other illicits.
In ED, was encephalopathic/aggitated, got lots of 8mg ativan,
sent to ICU for concern for airway protection. Noted to have
bites on his tongue, quite swollen, suscipicious for seizure.
Last seizure [**10-13**] resulting in a fall, he was found to have a
left parafalcine and tentorial subdural hematoma which was not
thought to require evacuation by neurosurgery. Due to agitation,
he received 5 mg Haldol and 4 mg ativan, after which he became
unresponsive and required an emergent tracheostomy after failed
intubation attempts (during last admission in [**10-13**]).
Past Medical History:
1. hepatitis C, last viral load [**10-13**] 1,120,000 but LFTs normal
2. subdural hematoma (small left parafalcine and tentorial)
3. ESRD on HD 3 days/wk from uncontrolled HTN (MWF)
4. substance abuse (cocaine, oxycontin)
5. prostate cancer unknown treatment, no PCP followup, PSA 7
[**10-13**]
6. diabetes
7. goiter
8. seizure two months ago
Social History:
Lives at home, non compliant with meds. Heavy cocaine and
oxycontin user per family history. They feel concerned that he
cannot take care of himself.
Contact[**Name (NI) **] Dr. [**Last Name (STitle) 31394**] (oncologist at [**Hospital3 328**]); his NP
states that the patient's prescription for Oxycontin 160mg po
bid was discontinued in [**2153-11-9**] owing to concerns of opiate
abuse on the patient's part. The patient was put on a taper, but
stopped coming for his weekly prescriptions once this became
conditional on urine sample testing.
Family History:
Non-contributory
Physical Exam:
GEN: Obese man appearing his stated age, sleeping, but
arousable,
lying in bed wearing hospital gowns breathing comfortably on
oxygen via NC, in NAD
SKIN: no rash
HEENT: NC/AT, anicteric sclera, mmm
NECK: supple
CHEST: normal respiratory pattern, CTA bilat
CV: regular rate and rhythm without murmurs
ABD: Normal bowel sounds in all 4 quadrants, obese, soft,
nontender, softly distended, no rebound or guarding, liver edge
3
cm below costal margin
EXT: Right wrist/hand in a brace, IV in right antecubital fossa
in place, no clubbing, cyanosis or edema, AV fistula in left
arm.
NEURO: Mental status: Patient is sleepy but awakens to voice and
can engage in conversation for several minutes before returning
to sleep. Oriented to person, place, time and president.
Language
is fluent with good comprehension, repitition, able to read, no
dysarthria. Unable write secondary to inattentiveness. Unable to
name MOYB. No apraxia, agnosias, no neglect. No left/right
mismatch.
Cranial Nerves: I: deferred II: Visual acuity: deferred
secondary
to patient unable to read card without his glasses. Visual
fields: full to left/right/upper/lower fields Pupils: 1mm,
consenual constriction to light. (pin point) III, IV, VI: EOMS
full, gaze conjugate. No nystagmus or ptosis. V: facial
sensation
intact over V1/2/3 to light touch and pin prick. VII: smile
slightly asymmetric secondary to swelling of tongue, brusises on
face, etc. VIII; hearing intact to finger rubs IX, X:
voice/swallowing normal. Symmetric elevation of palate. [**Doctor First Name 81**]: SCM
and trapezius [**6-13**] bilaterally XII: tongue midline without
fasciulations, but enlarged.
Sensory: Normal touch, proprioception, pinprick, sensation.
Motor: Normal bulk, tone. No fasciculations. Unable to assess
drift. No adventitious movements. There is mild asterixis of
the
left hand.
Strength: Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF
Toe
LEFT: limited by pain 5 5 5 5 4*
5 5
RIGHT: limited by pain 5 5 5 (unable to assess)5 4*
5 5
*holds legs up for 5 seconds, difficult to assess formal
strength. Proximal arm strength difficult to assess secondary
to
pain, could also have weakness
Reflexes: 2+ throughout. Toes downgoing bilaterally.
Coordination: mild dysmetria on finger-to-nose difficult to
asses
secondary to shoulder pain. Normal [**Doctor First Name **] bilaterally.
Gait: Not assessed.
Pertinent Results:
Cultures:
[**12-26**]: blood, urine, sputum pending
[**12-25**]: sputum oral flora
[**12-25**]: blood pending, urine negative
[**12-24**]: blood--coag negative staph in 1 bottle (likely
contaminant)
[**12-24**]: urine negative
[**12-27**] labs (on transfer to floor)
cbc: 14.7>30<253
lytes: Na 138, K 4.2, Cl 99, CO2 28, BUN 25, Cr 6.1, gluc 107,
Ca 8.7, Mg 1.8, Phos 5.2
[**2154-1-1**] 08:06AM 8.0 3.59* 10.8* 30.3* 84 30.0 35.6* 16.5*
380
call critical results to [**3-/8916**]
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2153-12-30**] 05:44AM 59.7 27.6 9.9 2.6 0.3
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2153-12-30**] 05:44AM 1+
BASIC COAGULATION PT PTT Plt Smr Plt Ct INR(PT)
[**2154-1-1**] 08:06AM 380
call critical results to [**3-/8916**]
HEMOLYTIC WORKUP Ret Aut
[**2153-12-27**] 10:03AM 2.8
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2154-1-1**] 08:06AM 128* 63* 7.8*# 131* 3.7 92* 21* 22*
call critical results to [**3-/8916**]
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2153-12-29**] 03:05AM 17 27 154 234*1 198* 0.4
ADD ON
1 NOTE UPDATED REFERENCE RANGES AS OF [**2152-8-8**]
OTHER ENZYMES & BILIRUBINS Lipase
[**2153-12-29**] 03:05AM 62*
ADD ON
CPK ISOENZYMES CK-MB cTropnT
[**2153-12-24**] 12:00PM 4 0.08*1
1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2154-1-1**] 08:06AM 3.1* 9.1 3.4 2.1
call critical results to [**3-/8916**]
HEMATOLOGIC calTIBC Ferritn TRF
[**2153-12-27**] 10:03AM 178* 702* 137*
VANCO: @RANDOM
PITUITARY TSH
[**2153-12-23**] 09:11PM 0.951
1 NEW METHOD AS OF [**2152-5-1**]
HEPATITIS HBsAg HBsAb
[**2153-12-28**] 04:15PM NEGATIVE POSITIVE
ANTIBIOTICS Vanco
[**2153-12-27**] 10:03AM 9.3*
VANCO: @RANDOM
NEUROPSYCHIATRIC Phenyto Phenyfr %Phenyf
[**2153-12-29**] 03:05AM 11.0
ADD ON
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
[**2153-12-23**] 05:45PM NEG1 NEG2 NEG NEG NEG NEG
ADDED SPECIMENS:STOX.
1 NEG
NEW UNITS IN USE AS OF [**2146-3-14**]
2 NEG
NEW UNITS IN USE AS OF [**2146-3-14**]: 80 (THESE UNITS) = 0.08 (% BY
WEIGHT)
LAB USE ONLY RedHold
[**2153-12-23**] 05:45PM HOLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP O2 O2 Flow pO2 pCO2
pH calHCO3 Base XS
[**2153-12-28**] 04:55AM ART 100 56* 7.30* 29 0
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate
[**2153-12-24**] 11:29AM 1.7
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) O2 Sat
[**2153-12-27**] 04:09AM 98
CALCIUM freeCa
[**2153-12-26**] 04:01AM 1.13
Brief Hospital Course:
ICU COURSE:
Neuro: Pt was loaded with dilantin, levels were followed and
were theraputic. An EEG was performed on [**12-25**] that showed
slowing c/w encephalopathy, but no seizure activity. Because of
hepatotoxicity in teh setting of hepatitis, on [**12-27**] a plan was
made to wean dilantin and start keppra. It is stil unclear why
he seized or had change in mental status, likely either HTN
encephalopathy, RPLE, or withdrawl. An MRI was scheduled but
pt's agitation made the study impossible to obtain.
Psych: Pt showing signs of withdrawal (from cocaine,
oxycontin?), namely HTN, tachycardia, hyperthermia, and extreme
agitation. He was initially treated with percedex (an alpha 2
agonist), and prior to transfer to the floor was switched to a
fentanyl patch, zyprexa, haldol prn, ativan prn (none), morphine
prn (none), oxycontin q12.
ID: He was intermittently febrile , tmax 102.4 ([**6-26**]), during
his hospital course. In the ER he refused an LP, and it was
deferred in teh ICU b/c he was clinically improving. Cultures
were no growth to date as of [**12-27**]. It was thought that, given
his clinical history and a concerning chest xray, that likely
that he had an aspiration pneumonia, and he was started on
levofloxacin on [**12-25**]. He also received one dose of ceftriaxone
and one dose of vancomycin empirically for fever in the ICU.
Resp: Pt was initially on bipap, primarily because of his
extremely swollen tongue. As the swelling improved and his
sedation improved, he was weaned to NC.
GI: He was NPO in the ICU, and on [**12-27**] with the improvement in
his tongue swelling he began to PO. He was started on
Multivitamin, B12, folate, thiamine.
Renal: Pt gets hemodialysis three times a week and was followed
by renal in the ICU. Prior ot transfer he was started on phoslo.
Heme: Pt was consistently anemic, likely due to renal disease,
but iron studies and retic count were sent on [**12-27**], will ask
renal about starting epo.
CV: Pt's blood pressure 200'/100's upon admission. He initially
was on nipride and nicardipine drip, then these were able to be
weaned and on transfer he was stable on clonidine patch,
hydralazine prn, and lopressor.
Ppx: SC heparin and proton pump inhibitor
General Neurology [**Hospital1 **] (Transferred on [**12-29**]):
While on the [**Hospital Ward Name 121**] 5 General Neurology Service, the patient's
mental status and strength gradually improved. He had no
seizures or new neurologal changes while on the unit. He was
alert and oriented x 3, with fluent speech and good
comprehension for the duration of his course on the neurology
unit. He was irritable at times, but had no episodes of
agitation and no hallucinations. The patient expressed his wish
to stop using cocaine and to seek psychiatric help for dealing
with depression about the loss of his wife 15 years ago. A
discussion was had with the patient in which the risks of
continuing to use cocaine were explained to him. An appointment
was made for the patient to follow up with an addiction recovery
doctor at the [**Location (un) 538**] [**Hospital **] Hospital.
Further, with the patient's permission, his oncologist (Dr.
[**Last Name (STitle) 31394**] at [**Hospital3 328**] was contact[**Name (NI) **]. Dr.[**Name8 (MD) 57285**] NP
explained that the patient does not have any history of bone
mets from his prostate cancer. He had been receiving Oxycontin
160mg po bid until [**Month (only) 359**]. At that time, Dr. [**Last Name (STitle) 31394**] became
suspicious that the patient was dealing his prescription. He
therefore made further prescriptions of Oxycontin contingent
upon urine screening and would only offer prescriptions for 1
weeks worth of Oxycontin. At that point, the patient stopped
coming to see Dr. [**Last Name (STitle) 31394**].
The patient's Hemodialysis team at the [**Location (un) 538**] VA was also
contact[**Name (NI) **]. [**Name2 (NI) 6**] appointment was made for the patient to follow up
there. See the follow up appointment list for details.
Lastly, the patient was given an appointment to see a PCP at the
[**Location (un) 538**] VA, with the plan to obtain a referral for a
psychiatric appointment.
The remainder of the [**Hospital 228**] hospital course was
uncomplicated. He was seen by physical therapy, who had him walk
with a cane (his baseline), and observed him walking stairs. The
physical therapy service recommended home physical therapy for a
home safety evaluation.
Lastly, prior to D/C, the patient received a final treatment of
hemodialysis.
Medications on Admission:
- nifedipine 30 qd
- ambien prn
- percocet prn
- thiamine
- flomax 0.4 qd
- calcitriol 0.25 qd
- oxycontin 160 [**Hospital1 **]
- metoprolol 50 [**Hospital1 **]
- ASA 81 qd
- Nephrocaps
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO DAILY (Daily).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*0*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
4. Clonidine HCl 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QMON (every Monday).
Disp:*3 Patch Weekly(s)* Refills:*0*
5. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Tablet(s)* Refills:*0*
6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
8. Lorazepam 0.5 mg Tablet Sig: Two (2) Tablet PO twice a day:
Lorazepam 0.5mg po: dispense 45 tablets total. Patient should
take as follows: take 2 0.5mg tablets twice a day x 3 days, then
take 1 0.5mg tablets twice a day for 3 days, then 1 0.5 mg
tablet once a day for 3 days.
Disp:*21 Tablet(s)* Refills:*0*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Home physical therapy
Patient is to have home physical therapy for home safey
evaluation.
11. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-9**] Inhalation Q6
hours/prn.
Disp:*1 90mcg* Refills:*0*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary Diagnosis: Generalized tonic-clonic seizure
Secondary Diagnoses: End Stage Renal Disease (on hemodialysis),
Type 2 diabetes, chronic back pain, prostate cancer,
hypertension, cocaine abuse, opiate dependence
Discharge Condition:
Stable, back to baseline.
Discharge Instructions:
Call your primary care doctor or go to the nearest emergency
department if you have any sudden onset of numbness/tingling,
weakness, change in speech, change in vision, or new seizures.
Followup Instructions:
1. Follow up at Dr.[**Name (NI) 11858**] [**Name (STitle) **] [**Hospital 878**] Clinic with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7673**] in 2 months: call [**Telephone/Fax (1) 541**] to register for the
appointment
2. Follow up at the [**Location (un) 538**] VA for hemodialysis this
Friday [**2154-1-4**] at 11-11:30AM with Dr. [**Last Name (STitle) 4660**]/Dr.
[**Last Name (STitle) 19334**]
3. Follow up with your Primary Care intake apppointment to see
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Location (un) 538**] VA on [**1-15**]
at 3:30PM. You may call to confirm the appointment at
[**Telephone/Fax (1) 57286**]
4. You have an appointment for addiction recovery with Dr.
[**First Name4 (NamePattern1) 19948**] [**Last Name (NamePattern1) 57287**] at the [**Location (un) 538**] VA for Novemner 30th at
12pm. It's in [**Apartment Address(1) 57288**], [**Location (un) **], 4B.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7642
} | Medical Text: Admission Date: [**2133-4-26**] Discharge Date: [**2133-5-2**]
Date of Birth: [**2070-6-27**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Transfer from [**Hospital6 33**] with bright red blood per
ileostomy
Major Surgical or Invasive Procedure:
Ligation of bleeding varix at ostomy site
History of Present Illness:
62 yo F h/o hypothyroid, UC s/p colectomy and colostomy 20 yrs
ago, tx from [**Hospital3 **] for blood per R sided ileostomy. She
first noticed some increased bleeding from her ileostomy about a
week PTA. On Friday [**4-24**], she noticed a large amount of bleeding
and had to empty her bag of red blood and clots x 3. + LOC at
that time and admitted by ambulance to OSH - HCT 19. At OSH,
intermittent blood in ostomy and tx x 5u. Abd CT reportedly
showed no masses but moderate ascites. EGD showed no evidence of
bleeding. Scope through her ileostomy limited by blood. On
[**2133-4-26**] she was tx'd here after she put out 1.2liters of blood
through her ostomy. In total she got 9u pRBC at the OSH.
.
.
Past Medical History:
PAST MEDICAL HISTORY
Hypothyroidism
Ulcerative colitis
.
Social History:
SOCIAL HISTORY
Pt admits to drinking "several" (approx [**4-30**]) glasses of white
wine daily. Her last drink was 3days prior to presenting at
[**Hospital6 33**]. She does not smoke but her husband smokes
3ppd so is exposed to a lot of second hand smoke. Per her
daughter, she has been under a lot of stress lately. Her
daughter also reports greater etoh intake (2 bottles wine per
day).
.
She is under a lot of stress at home regarding grandchildren
custody issues.
Physical Exam:
VS: 99.0 (tm=Tc), 93/47 (75-100/33-68), 86 (81-93), sat 94-99%
3L
I/O: 24hr: 4.6L/1.4L (LOS: +3.3L)
BG: 168, 146
GEN: NAD, interactive, often vague answers.
HEENT: OP clear, no sclera under tongue, MMM, PERRL, sclerae
anicteric.
CV: Normal s1/s2, RRR, no m/r/g
PUL: lungs with decreased breath sounds at bases to halfway up
lungs, no wheezes. Some crackles at bases.
ABD: Soft, NT, midline scar, ileostomy in RLQ without bleeding.
Ext: No edema, DP full, RP full
Neuro: A&Ox3, speech fluent, voice without fluctuations in
tone/strength. CN intact with lateraly nystagmus on extreme
gaze. Moves all extremities. No tremor
Pertinent Results:
ADMISSION LABS:
[**2133-4-26**] 11:07PM BLOOD WBC-8.9 RBC-3.52* Hgb-11.1* Hct-31.0*
MCV-88 MCH-31.6 MCHC-36.0* RDW-17.0* Plt Ct-126*
[**2133-4-27**] 02:49AM BLOOD Hct-25.3*
[**2133-4-27**] 09:45AM BLOOD Hct-27.6*
[**2133-4-27**] 03:42PM BLOOD Hct-27.3*
[**2133-4-26**] 11:07PM BLOOD Neuts-68.3 Lymphs-23.4 Monos-4.8 Eos-3.0
Baso-0.4
[**2133-4-26**] 11:07PM BLOOD PT-16.2* PTT-32.5 INR(PT)-1.5*
[**2133-4-26**] 11:07PM BLOOD Plt Ct-126*
[**2133-4-26**] 11:07PM BLOOD Glucose-134* UreaN-3* Creat-0.6 Na-141
K-3.3 Cl-111* HCO3-22 AnGap-11
[**2133-4-26**] 11:07PM BLOOD ALT-13 AST-41* LD(LDH)-135 CK(CPK)-68
AlkPhos-77 Amylase-19 TotBili-2.3*
[**2133-4-27**] 09:45AM BLOOD DirBili-1.3*
[**2133-4-26**] 11:07PM BLOOD Lipase-18
[**2133-4-26**] 11:07PM BLOOD CK-MB-2 cTropnT-<0.01
[**2133-4-26**] 11:07PM BLOOD Albumin-2.3* Calcium-6.8* Phos-2.5*
Mg-1.5*
[**2133-4-26**] 11:07PM BLOOD TSH-0.59
.
[**Name (NI) **] Studies (Pt has had recent blood tx):
[**Name (NI) **]: 29
calTIBC: 148
Ferritn: 97
TRF: 114
.
Peritoneal Fluid:
Albumin < 1 (SAAG ~ 1.4)
Protein 0.8
Glucose 93
LDH 44
WBC 23, RBC 2611
N17, L 38, M 10, Mesothelial 12, Macroph 23
Gram Stain negative
.
Culture data Negative throughout hospital stay
.
Abd U/S [**4-27**]:
1 Coarsened liver echotexture consistent with fatty
infiltration. More advanced forms of liver disease such as
fibrosis/cirrhosis cannot be excluded.
2. Small amount of perihepatic ascites.
3 Distended gallbladder containing sludge and wall edema, likely
related to underlying liver disease.
4 Slow velocity but hepatopetal flow within the portal vein.
5 Small right pleural effusion.
.
CXR [**4-27**]:
Findings consistent with pulmonary edema from fluid overload
with associated pleural effusions.
.
Tagged RBC Scan [**4-27**]:
No active GI bleeding at the time of study.
.
ECHO [**4-27**]:
Conclusions:
The left atrium is mildly dilated. The interatrial septum is
aneurysmal. 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 root is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is an anterior fat pad.
.
CT abd [**4-28**]: Findings are consistent with cirrhosis,
decompensation as evidenced by ascites and varices. (Liver with
nodularity and irregularity, no splenomegaly, paraumbilical vein
recannulization, bibasilar effusions, GB with stones/sludge.)
.
CHEST AP [**4-29**]: There is stable appearance of the vascular
engorgement, perihilar haziness and diffuse bilateral
interstitial opacities representing fluid overload along with
small bilateral pleural effusions.
.
EGD:
Impression:
Small hiatal hernia
Erythema, congestion and mosaic appearance in the antrum and
stomach body compatible with portal gastropathy
Erythema in the gastroesophageal junction
Varices at the lower third of the esophagus
Otherwise normal egd to second part of the duodenum
Recommendations:
Follow-up biopsy results
Continue Protonix.
Hold Nadolol given low BP and minimal varices.
Repeat EGD in 2years.
F/U in Liver Ctr upon discharge from hospital.
.
LENI [**5-1**]: Negative for DVT.
.
CTA Chest [**5-2**]:
1. No pulmonary embolism.
2. Pulmonary edema with Moderately bilateral pleural effusion.
3. Large amount of intra-abdominal ascites.
.
Brief Hospital Course:
ICU Course:
In the ICU she continued to have intermittent bleeding from her
ostomy. SBP has remained in the 90s with pt mentating and
stable. NG lavage (~500cc) was negative, the patient did not
tolerate the procedure well so a complete liter could not be
administered. Surgery and GI saw the pt. Surgery put Vicryl and
one silk suture in an actively bleeding vessel at the ostomy
site on [**2133-4-26**] with subsequent hemostasis. Afterward, a tagged
RBC scan failed to reveal any extravazation of blood and HCT
remained stable. GI scoped the ostomy and found no further sites
of bleeding (superficial scope, not extensive). Ultrasound
showed an enlarged liver with fatty infiltration and sluggish
portal vein flow with peri-hepatic ascites. The pt was then felt
to be stable to tx to the floor.
Hospital [**Hospital1 **] Course by Problem:
.
# SOB: The patient developed shortness of breath during her
hospital stay. CXR suggested volume overload, but because of
the acuity of onset, the patient was sent for LE dopplers and,
eventually, a CTA. She ruled out for PE/DVT and was treated
with lasix. Her SOB improved with lasix treatment. The volume
overload was thought to be due to her multiple blood
transfusions and IVF support while in the ICU. Echo showed no
systolic dysfunction and was not suggestive of diastolic
dysfunction.
.
# GI Bleed: When the patient was transferred out of the ICU,
sutures were in place. and there was no further bleeding. She
was seen by the ostomy nurse and follow-up with surgery was
established for after the patient's discharge.
.
# Anemia - Though the patient's [**Hospital1 **] studies were unreliable due
to recent bleed and transfusions, they were suggestive of [**Hospital1 **]
deficiency, and the pt was started on [**Hospital1 **].
.
# Cirrhosis - During the workup for her GI bleed, imaging
repeatedly revealed small to moderate ascites, and liver
silhouette suggestive of cirrhosis. The pt has a history of
etoh abuse that she was reluctant to talk about. Per her
family, she drinks 1-2 bottles of wine each evening. This was
thought to be the most likely cause of hepatic dysfunction. PSC
was entertained given her history of UC, however there was no
ductal change on liver US. There was no sign of [**Hospital1 **] overload
suggestive of hemachromatosis. Sm muscle antibody for PBC was
weakly positive and not suggestive of this entity. The
hepatology service was consulted and suggested nadolol,
aldactone, and lasix qd. Hepatitis panel was negative for Hep
B, Hep C, and Hep A. EGD revealed no esophogeal varices.
Therefore the nadolol was discontinued.
.
# etoh abuse: The pt was not forthcoming regarding her etoh use.
It was an obviously emotional topic for pt and family. She
stated she had wine with dinner. Per her daughter she had been
drinking heavily (bottles of wine per night) for years. Recent
family stresses relating to custody have caused her to escalate
her drinking recently per the daughter. Family members also
give a history of daily vomiting and shakes if she did not
drink. She required very little benzodiazapines per CIWA. She
was treted with IV thiamine and PO folic acid. She was seen by
SW for etoh abuse counselling and took information regarding
rehab, but stated that she did not want to become involved and
she would be able to quit drinking on her own.
.
# Hypotension - The pt had a low blood pressure throughout the
hospitalization but was stable. It was felt that this baseline
low BP was likely due to cirrhosis.
.
# h/o hypothyroidism: - TSH was checked and was wnl. Continued
prior dose of synthroid 75mcg
.
# Prurigo Nodularis: The pt had a chronic skin finding over her
exposed skin. She had been told in the past that it was due to
her nervous habit of scratching her skin. Ddx could include
dermatitis herpetiformis, though it would be an odd presentation
of this. She was treated with Sarna lotion and the skin
remained stable to improved over her hospital course.
.
# UC - The pt had curative colectomy for her dz. No extra-gi
symptoms were apparent. She received ostomy care per ostomy
nurse as noted above.
.
# Ppx: The patient did receive Heparin SQ at this
hospitalization.
.
# Code: Remained Full, confirmed with patient, family.
.
# Communication: [**First Name4 (NamePattern1) **] [**Known lastname **] home: [**Telephone/Fax (1) 109094**], cell:
[**Telephone/Fax (1) 109095**]. PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66568**] ([**Hospital1 112**]).
Medications on Admission:
MEDS ON TRANSFER
Octreotide drip
Nexium 40mg twice daily
Ativan prn
Bannana bag
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Primary:
GI Bleed: Bleeding vessel at ostomy
New diagnosis of cirrhosis
Hypotension
Anemia of blood loss and [**Location (un) **] deficiency
Secondary:
Ulcerative Colitis s/p colostomy
Hypothyroid
Discharge Condition:
Stable HCT x >48 hours, no orthostatic symptoms, O2 saturation
on RA while ambulating > 90%, no symptoms of SOB
Discharge Instructions:
You were admitted with bleeding from your ostomy site. This was
caused by dilation of the blood vessels in this area. The
dilation was likely caused by your liver disease. Your liver
disease may be related to alcohol.
You should not drink any alcohol anymore. If you need help as
you stop drinking all alcohol, please contact the hospital or
the contact alcoholics anonymous directly.
You will have a number of follow up [**Location (un) 4314**] to ensure you
are treated properly for your liver disease and to prevent
further bleeding. Please do not miss [**First Name (Titles) 9278**] [**Last Name (Titles) 4314**]:
Dr. [**Last Name (STitle) **] (Colorectal surgery) - he will need to examine
your ostomy and the stitches that were placed at this
hospitalization. Your appointment is for: [**2133-5-18**] at 1:15pm at
the [**Hospital Unit Name **] (facing the ER). It is [**Location (un) 470**], [**Hospital Unit Name **].
Please bring ostomy supplies as he will want to remove your
current ostomy bag.
You should make an appointment to see your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66568**], within 2 weeks.
You should follow up with the liver team in the next 1-2 weeks.
Please call for an appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **]: ([**Telephone/Fax (1) 16686**].
If you develop recurrent bleeding, light headedness, fevers,
chills, severe nausea or vomiting or other worrisome symptoms
please seek immediate medical attention.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Date/Time:[**2133-5-18**] 1:15
Dr. [**Last Name (STitle) 66568**] (PCP) - pt to call.
Pt to call for hepatology follow up: Dr. [**Last Name (STitle) **]: ([**Telephone/Fax (1) 16686**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2133-5-18**]
ICD9 Codes: 2851, 5119, 5180, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7643
} | Medical Text: Admission Date: [**2111-6-9**] Discharge Date: [**2111-6-18**]
Date of Birth: [**2046-6-27**] Sex: F
Service: [**Doctor Last Name 1181**]
HISTORY OF PRESENT ILLNESS: The patient is a 64 year old
African American female with HIV, last CD4 count 240 and
viral load of undetectable in [**2111-4-19**], and a history of
Factor VIII deficiency, chronic obstructive pulmonary
disease, asthma, hypertension, diabetes mellitus, who
presents to [**Hospital1 69**] for
shortness of breath.
The patient was in her usual state of health until the
evening prior to presentation on [**2111-6-9**], when she began
having chief complaint of shortness of breath. This shortness
of breath subsequently progressed and became very acute on
the morning of presentation approximately 6:00 a.m. She took
her usual MDIs but had no relief. She called the EMTs who
subsequently brought the patient to the Emergency Department
of [**Hospital1 69**].
Upon arrival, the patient was noted to be tachypneic and
wheezing. On review of systems, the patient's granddaughter
had an upper respiratory infection. The patient denied any
fever, chills, nausea, vomiting, chest pain or headache. She
denied any rhinorrhea but did have mild pharyngitis, sinus
congestion. She still smokes one half pack to one pack per
day. She has a chronic nonproductive cough which is
unchanged. The patient also reported that she had been
relatively noncompliant with all her medications.
While in the Emergency Department, the patient was given
nebulizers times two with no improvement. She was given a
trial of Heliox with a little improvement. Chest x-ray
revealed bilateral infiltrates. She was given intravenous
Solu-Medrol and intravenous Levofloxacin and Bactrim.
PAST MEDICAL HISTORY:
1. HIV diagnosed in [**2104**], last CD4 approximately 230 in
[**2111-4-19**], with a viral load undetectable.
2. Hypertension.
3. Diabetes mellitus times twenty-five years.
4. Chronic obstructive pulmonary disease.
5. Chronic bronchitis.
6. Asthma since childhood, no history of intubation
required.
7. Factor VIII deficiency, status post steroids followed by
hematology/oncology periodically.
8. History of alcohol abuse in the past.
9. Spinal stenosis, L4-L5.
10. History of renal failure secondary to volume depletion.
MEDICATIONS ON ADMISSION:
1. AZT 200 mg p.o. b.i.d.
2. 3TC 150 mg p.o. b.i.d.
3. Nevirapine 200 mg p.o. b.i.d.
4. Glyburide 5 mg p.o. b.i.d.
5. Megace 400 mg p.o. q.d.
6. Timoptic 0.5% O.U. b.i.d.
7. Multivitamins one tablet p.o. q.d.
8. Bactrim one DS tablet p.o. q.d.
9. Mycelex troches p.r.n.
10. Albuterol two puffs inhaled q6hours p.r.n.
11. Atrovent two puffs b.i.d.
12. Accubid two puffs b.i.d.
13. Prilosec 20 mg p.o. q.d.
14. Lopressor 50 mg p.o. b.i.d.
15. Reglan 10 mg p.o. t.i.d.
16. Epogen 5000 units subcutaneous Monday, Wednesday and
Friday.
ALLERGIES: Motrin causes bleeding.
PHYSICAL EXAMINATION: Upon presentation, temperature is
95.9, pulse 133, blood pressure 180/71, respiratory rate 32,
saturating 95% in room air. In general, the patient was an
ill appearing black female sitting upright, tachypneic and
short of breath with short sentences. Head, eyes, ears, nose
and throat examination is normocephalic and atraumatic.
Extraocular movements are intact. The pupils are equal,
round, and reactive to light and accommodation. The
oropharynx was clear. No lymphadenopathy was appreciated.
The neck was supple. Chest examination - expiratory wheezes
noted, decreased breath sounds throughout, no stridor, no
crackles. Cardiovascular examination - tachycardia, II/VI
systolic murmur heard best at the right upper sternal border.
Abdominal examination is soft, normoactive bowel sounds,
nontender, nondistended, no guarding, no rebound.
Extremities no cyanosis, clubbing or edema. Neurologically,
the patient is [**Year (4 digits) 3584**] and oriented, responds to commands,
speaks in short sentences. Deep tendon reflexes are 2+
throughout. Cranial nerves II through XII are intact.
Sensation intact.
LABORATORY DATA: Upon presentation, white count was 10.1,
hematocrit 24.9, platelet count 343,000, 42% neutrophils, 52%
bands, 4% monocytes, 0.7% eosinophils. Sodium 136, potassium
5.0, chloride 106, bicarbonate 15, blood urea nitrogen 53,
creatinine 3.6, glucose 325. CK enzymes 130. Arterial blood
gases on 100% nonrebreather was pH 7.21, pCO2 46, paO2 296.
Electrocardiogram revealed sinus tachycardia at 140, left
ventricular hypertrophy, T wave inversion and ST depression
in lead V5 through V6. T wave inversions noted in lead III.
Chest x-ray revealed the heart size normal, diffuse bilateral
interstitial process with septal lines, pulmonary edema
versus interstitial pneumonitis.
HOSPITAL COURSE: This is a 64 year old female with HIV,
diabetes mellitus, asthma and chronic obstructive pulmonary
disease presenting with acute shortness of breath.
1. Cardiac - The patient was admitted originally to the
Medicine Service and placed on telemetry for rule out
myocardial infarction protocol. The patient subsequently
ruled in for myocardial infarction with shortness of breath.
Her troponins were positive at 9.0. CK enzymes were 130 and
upward trending. At that time, cardiology consultation was
called and evaluated the patient. Echocardiogram was
obtained which revealed ejection fraction of less than 40%
with wall motion abnormality consistent with ischemia.
That evening after cardiology consultation, the patient
subsequently became hypotensive and CK enzymes subsequently
increased to 1600 with positive MB index and positive
troponin greater than 50. The patient was found with agonal
respirations. The patient was emergently intubated and was
brought to the Medical Intensive Care Unit and subsequently
brought to the Cardiac Catheterization Suite where a cardiac
catheterization was performed.
A tight mid left circumflex lesion was seen. Percutaneous
transluminal coronary angioplasty was performed and a stent
was placed. The patient subsequently did well post cardiac
catheterization. The patient was continued on Aspirin and
started on Plavix. The patient's Lopressor was subsequently
titrated up. Given the fact that the patient had acute renal
failure post cardiac catheterization and unable to tolerate
ace inhibitor, the patient was started on Hydralazine and
Isordil in order to decrease morbidity and mortality.
Congestive heart failure - The patient during hospital course
had an episode of flash pulmonary edema, congestive heart
failure from a blood transfusion. Upon initial admission,
cardiac echocardiogram revealed ejection fraction of less
than 40% and wall motion abnormalities consistent with
ischemia. During hospital course, the patient was
subsequently diuresed well. Repeat echocardiogram revealed
ejection fraction of 40% with 3+ mitral regurgitation and
akinesis of the basal inferior and lateral walls with mild
regional left ventricular systolic dysfunction. The patient
was subsequently diuresed further and I&Os were followed.
2. Neurology - The patient upon admission was relatively
[**Name2 (NI) 3584**] and oriented times three, however, during hospital
course status post cardiac catheterization and intubation and
acute renal failure, the patient's mental status subsequently
waxed and waned and the patient was subsequently confused
most of the time. Neurology service was consulted and the
patient's mental status was thought secondary to toxic
metabolic encephalopathy and related to her uremia and other
medical conditions. The patient's mental status was
subsequently improved with resolution of her uremia.
3. Pulmonary - The patient was originally admitted to the
Medicine service, however, when the patient became
hypotensive and was emergently intubated, the patient was
subsequently transferred to the Medical Intensive Care Unit.
Status post cardiac catheterization, the patient was
subsequently Dopamine pressors for blood pressure support for
a brief period of time. The patient was subsequently rapidly
extubated and subsequently did well after extubation. The
patient was able to be weaned down from face mask to nasal
cannula as well as maintaining her oxygen saturation
relatively well. The patient has a history of chronic
obstructive pulmonary disease and asthma and was continued on
nebulizer treatment and continued her MDIs with good effect.
4. Infectious disease - The patient has a history of HIV
positivity since [**2104**], on highly active antiretroviral
therapy with her last CD4 count of 230 and a viral load which
was undetectable. Upon admission to [**Hospital1 190**], the patient was subsequently continued on her
highly active antiretroviral therapy. However, when the
patient's acute renal failure subsequently began, the
patient's medication therapy was renally adjusted.
5. Renal - The patient had an episode of acute renal
failure, status post cardiac catheterization. The patient's
renal failure was thought secondary to possibly contrast
nephropathy, cardiac catheterization versus emboli from
cardiac catheterization to the renal glomerulus. The
patient's creatinine subsequently began increasing and
subsequently plateaued at 6.1 to 6.2 and remained stable at
that time level. However, approximately a week into the
[**Hospital 228**] hospital course, the patient subsequently began
making some urine and responded well with Lasix and the
patient was subsequently diuresed with Lasix and renal
function was observed very carefully. The patient's renal
function at the time of this dictation remains stable at 6.1
and was expected to subsequently trend downward. However, if
renal function does not improve, the patient will
subsequently require temporary dialysis.
6. Diabetes mellitus - The patient had a history of diabetes
mellitus and was continued on fingerstick glucoses and
sliding scale insulin with good effect.
7. Hematology - The patient had a history of acquired Factor
VIII deficiency. During her last hospitalization, the
patient required multiple transfusions of Factor VIII.
However, during this hospital course, hematology/oncology
service was consulted in regards to the patient's care. As
per hematology/oncology, the patient's Factor VIII deficiency
seemed to have resolved and did not require any transfusions
during this hospital course. However, the patient required
transfusion of packed red blood cells secondary to her
anemia. However, during transfusion, the patient had
subsequently flash pulmonary edema requiring Lasix therapy
and intubation. As per hematology/oncology, transfusion of
packed red blood cells will be held off until absolutely
necessary due to the fact that the patient has a
predisposition for congestive heart failure.
8. Fluids, electrolytes and nutrition - During her stay in
the Medical Intensive Care Unit, the patient was intubated
and did not have good nutrition and subsequently after the
patient was successfully extubated, the patient was able to
tolerate sips and moderate p.o. Nutrition consultation was
consulted in regards to help with the patient's nutritional
status and the patient was encouraged to take p.o. liquids
and solids.
9. Lines, access - The patient has a poor peripheral access.
During her stay in the Medial Intensive Care Unit, the
patient had a right internal jugular triple lumen as a
central line for venous access. On [**2111-6-17**], the triple
lumen central line was changed over a wire.
10. The patient is full code, full care.
DISCHARGE DIAGNOSES:
1. Myocardial infarction, status post percutaneous
transluminal coronary angioplasty with stent placement to
the mid left circumflex.
2. Acute renal failure.
3. HIV.
4. Hypertension.
5. Diabetes mellitus.
6. Chronic obstructive pulmonary disease.
7. Congestive heart failure.
An addendum to this discharge summary will be performed at a
later date for the patient's multiple medical problems.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**]
Dictated By:[**Last Name (NamePattern1) 5588**]
MEDQUIST36
D: [**2111-6-17**] 17:15
T: [**2111-6-17**] 19:27
JOB#: [**Job Number 102138**]
ICD9 Codes: 5849, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7644
} | Medical Text: Admission Date: [**2112-8-18**] Discharge Date: [**2112-9-3**]
Date of Birth: [**2048-1-4**] Sex: M
Service: SURGERY
Allergies:
Imodium
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Diarrhea, black stool
Major Surgical or Invasive Procedure:
[**2112-8-31**]: PICC line placement
History of Present Illness:
64M with EtOH cirrhosis (Child's B, MELD 14) s/p antrectomy with
roux-en-Y gastrojejunostomy reconstruction for a bleeding
duodenal ulcer in [**2112-5-15**]. His postop course was complicated by
take-back for hematoma evacuation, suture ligation of a bleeding
varix behind the head of the pancreas, and suture ligation of
bleeding varix in the anterior abdominal wall. Postoperatively
he also developed a duodenal stump leak, effectively drained by
the JP placed intraoperatively. He was hospitalized in [**2112-6-15**]
with c. diff infection and again in [**2112-7-15**] for diarrhea and
abdominal pain with CT scan concerning for colitis, primarily in
the descending colon, though c. diff cultures and pcr were all
negative. He was treated with a two week course of PO vanc and
flagyl and ultimately discharged on a post-gastrectomy diet and
tube feeds. Of note, just prior to discharge, Mr. [**Known lastname 515**]
duodenal stump drain was inadvertently dislodged.
Today he returns with four episodes of diarrhea which he reports
as "black." He also had an episode of non-bilious emesis last
night. He currently denies any fevers or sick contacts.
Review of Systems:
(+) per HPI
(-) denies headache, numbness, tingling, fevers, chills,
fatigue, malaise, changes in hearing or vision, chest pain,
shortness of breath, DOE, hemoptysis, cough, wheeze,
palpitations, abdominal pain, constipation, denies dysuria,
rash, pruritis, joint pain, heat intolerance, cold intolerance,
easy bruising, bleeding, mood changes
Past Medical History:
[**2112-5-25**]: antrectomy, Roux-en-Y gastrojejunostomy for a bleeding
duodenal ulcer
EtOH abuse
EtOH Cirrhosis, Child's class B, MELD 17, c/b Grade 1 varices
seen [**2111-11-19**] on EGD, portal HTN
Barrett's esophagus
Multiple UGI Bleeds since [**2109**]
heterozygote for hemachromatosis
Cholecystectomy performed [**2109**]
Diverticulitis
Hemicolectomy 15 years ago
Tubular adenoma on colonoscopy [**2109-3-26**],
Macrocytic Anemia
Social History:
Retired treasurer from [**University/College 5130**] [**Location (un) **] in [**2105**]. Lives
alone, has 4 daughters in the area. Prior smoker; smoked 1 ppd x
10 years, quit 35 years ago. Previously drank heavily hard
alcohol + wine for most of his life, [**7-24**] quit drinking wine.
Had quit drinking hard liquor previously. Denies illicit or IV
drug use. Denies recent ETOH use
Family History:
No hx of liver disease in the family. Father with high
cholesterol. Mother with HTN.
Physical Exam:
T: 97.7 P: 68 BP: 128/72 RR: 16 O2sat: 97 RA
General: awake, alert, NAD
HEENT: NCAT, EOMI, anicteric
Heart: RRR, NMRG
Lungs: CTAB, normal excursion, no respiratory distress
Abdomen: soft, well healed midline incision, non-distended,
mildly tender to palpation across inferior abdomen
Extremities: WWP, no CCE, no tenderness
Rectal: Appropriate tone, no gross blood, guaiac negative
Pertinent Results:
On Admission: [**2112-8-18**]
WBC-5.9# RBC-3.12* Hgb-10.8* Hct-30.9* MCV-99* MCH-34.6*
MCHC-34.9 RDW-18.9* Plt Ct-110*#
PT-17.7* PTT-35.1* INR(PT)-1.6*
Glucose-113* UreaN-18 Creat-0.8 Na-133 K-5.0 Cl-99 HCO3-27
AnGap-12
ALT-16 AST-36 AlkPhos-79 TotBili-2.4*
Albumin-2.8* Calcium-9.1 Phos-4.1 Mg-1.9
At Discharge: [**2112-9-1**]
WBC-7.6 RBC-2.64* Hgb-9.3* Hct-26.6* MCV-101* MCH-35.3*
MCHC-35.0 RDW-17.9* Plt Ct-114*
Glucose-134* UreaN-8 Creat-0.6 Na-132* K-4.5 Cl-98 HCO3-30
AnGap-9
ALT-12 AST-20 AlkPhos-50 TotBili-2.0*
Calcium-8.7 Phos-4.6*# Mg-1.8
Vanco-18.3
Brief Hospital Course:
64 y/o male who presents with recurrent diarrhea. Due to his
history of recurrent C diff and recent gastrectomy and duodenal
stump leak (and inadvertant drain removal) an abdominal CT was
obtained. The CT shows "Mild stranding adjacent to the
anastomotic site, improved from previous exam without evidence
of fluid collection or abscess. There is no contrast
extravasation to suggest leak at that site.
There was improvement in diffuse colonic wall thickening. In the
hepatic flexure,
there is a focal area of wall thickening out of proportion to
the remainder of
the colon."
Initial C diff cultures that were sent were negative, however
repeat stool cultures sent on [**8-23**] as patient fevered to 102.9
were now found to be C Diff positive and PO Vanco and IV Flagyl
were initiated.
Blood cultures were also sent at this time and grew MRSA. IV
Vanco was started on [**2112-8-25**] and an infectious disease consult
was called, and they have followed throughout the
hospitalization. Their recommendations include TTE, 6 weeks of
IV Vanco, IV Flagyl until stooling has lessened and PO Vanco for
an extended course due to the recurrent C diff.
Medications on Admission:
nadolol 40', spironolactone 25', furosemide 40'', folic
acid', pantoprazole 40 delayed release'', ferrous sulfate 300'
Discharge Medications:
1. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 6 weeks.
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. psyllium 1.7 g Wafer Sig: One (1) Wafer PO once a day.
10. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
twice a day: Please give 2 hours away from other medications.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: 2 grams maximum daily.
12. Probiotic Colon Support 240 mg (3 billion cell) Capsule Sig:
One (1) Capsule PO once a day: [**Doctor Last Name **] Colon Healthy.
13. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
14. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC line
care.
15. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 2
weeks.
16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) as needed for gram positive
for 5 weeks: End Date [**2112-10-6**].
17. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED): Follow provided scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
MRSA bacteremia
C diff colitis (recurrent)
s/p gastric antrectomy and Roux-en Y gastrojejunostomy [**2112-5-22**]
malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr [**Last Name (STitle) 9411**] office at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, increased drainage from the abdominal
opening (controlled fistula), change in mental status, issues
with the tube feedings or dislodgement of the feeding tube, PICC
line issues, stooling greater than 6 times daily, dark tarry
stool or bright red blood per rectum.
IV Vancomycin is to be continued 1 gram twice daily through [**10-6**], [**2112**] for presumed endocarditis. (MRSA bacteremia)
IV Flagyl should be continued until patient stools 3 or less
times daily, and PO Vanco 500 mg QID is to be continued
indefinitely for recurrent C Diff infection.
Tube feeds via post pyloric feeding tube. Patient may eat, but
should have small frequent meals and incorporate low fat and low
glycemic index foods into his diet (post gastrectomy diet)
Continue to ambulate and retain and improve endurance and
strength
No heavy lifting greater than 10 pounds
Encourage taking Banana flakes, 3 packets per day. These can be
mixed into yogurt or sprinkled on food to help increase fiber
Check finger stick blood sugars four times daily and dose
insulin per sliding scale
CBC, Chem 7, Vanco trough level once weekly with results to Dr
[**First Name (STitle) **] office (fax [**Telephone/Fax (1) 22248**]) and Infectious disease at
[**Hospital1 18**], fax [**Telephone/Fax (1) 1419**]
Followup Instructions:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **](nutrition) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-9-15**]
2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-9-15**] 2:40
[**Hospital **] Medical Building [**Location (un) **], [**Last Name (NamePattern1) **], [**Location (un) 86**] MA
.
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2112-9-22**] 12:00 [**Last Name (NamePattern1) 10357**], [**Hospital Unit Name **] [**Location (un) 858**], [**Location (un) 86**], MA
.
Infectious Disease Follow Up appointment Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], [**9-27**], [**2112**] 9:00 AM, [**Hospital **] Medical Building, [**Last Name (NamePattern1) **], [**Location (un) 86**]
MA
Completed by:[**2112-9-3**]
ICD9 Codes: 7907, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7645
} | Medical Text: Admission Date: [**2167-1-13**] Discharge Date: [**2167-1-23**]
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
gentleman with a past medical history significant for
coronary artery disease status post multiple stents and a
history of three myocardial infarctions, hypertension,
hypercholesterolemia, diabetes mellitus, prostatic carcinoma
status post radiation therapy and chemotherapy.
Briefly, the patient came in with an elevated blood pressure
to an outside hospital, [**Hospital3 3583**], and was transferred
to [**Hospital1 69**] upon finding of the
ischemic changes. He has actually had an echocardiogram on
[**2167-1-5**], which also showed mild mitral regurgitation,
tricuspid regurgitation and an ejection fraction of 35%. A
multi-gated scan in [**2166-8-2**] showed reversible
inferoseptal ischemia.
ALLERGIES: He has no known drug allergies.
MEDICATIONS AT HOME:
1. Atenolol 25 once a day.
2. Aspirin 81 once a day.
3. Zestril 5 once a day.
4. Lipitor 10 once a day.
5. Lasix 20 mg once a day.
LABORATORY: A catheterization showed 80% left anterior
descending occlusion, 40% stent at VISR, 50 to 60% of the
middle right coronary artery, and 100% distal right coronary
artery.
HOSPITAL COURSE: This gentleman was taken for a coronary
artery bypass graft on [**2167-1-15**], by Dr. [**Last Name (STitle) 70**] with the
diagnosis of unstable angina and tolerated the procedure.
Postoperatively, the patient was transferred to the
Cardiothoracic Intensive Care Unit on pressor support and was
extubated. The patient was gradually weaned off the
Neo-Synephrine pressor support and his chest tubes were
discontinued on postoperative day number three after
inserting for the original pneumothorax.
The patient was transferred to the Floor as of [**2167-1-18**],
and during the course of the rest of his admission, his wires
and Foley were discontinued, in fact, they were discontinued
on [**2167-1-19**]. On [**1-19**], it was noticed that his hematocrit
was somewhat low with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] of 22.0. The decision was
made to transfuse him one unit of blood, which was done;
however, at this point, it was noted that there was some
slight sternal drainage which did not look infected with
serous sanguinous. The patient was started on Kefzol
empirically. By postoperative day number seven, [**2167-1-22**],
the sternal drainage had decreased and his wound was
progressively dry and intact with minimal signs of
irritation.
His physical examination revealed breath sounds positive
bilaterally and no jugular venous distention. His heart was
not muscled in character and his abdomen was obese and soft.
The patient's leg wound on the right leg from the vein
harvest site was clean, dry and well approximated, using the
Dermabond Closure System.
NOTE TO [**Hospital 894**] REHABILITATION FACILITY: Do not put salves
or any soluble type of ointment of this. Please protect the
area.
The patient's Lopressor was increased gradually during the
course of his admission and his heart rate and blood pressure
were well controlled. He is being discharged to
Rehabilitation on [**2167-1-23**], on the following medications.
DISCHARGE INSTRUCTIONS:
1. He is to follow-up with Dr. [**Last Name (STitle) 70**] in six weeks for
his surgical issues.
2. He is to follow-up with his primary care doctor, Dr.
[**Last Name (STitle) **] [**Name (STitle) 20784**].
3. To follow-up with the attending of record, Dr. [**Last Name (STitle) **].
DISPOSITION: The patient is being discharged to
rehabilitation on the following medications.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg p.o. twice a day.
2. Kefzol one gram q. eight hours intravenously times five
days to one week.
3. Albuterol MDI, two puffs four times a day p.r.n.
4. Lipitor 40 mg p.o. q. day.
5. Folate 1 mg p.o. q. day.
6. Diphenhydramine hydrochloride 25 mg p.o. q. h.s.
7. Percocet one to two tablets for pain.
8. Aspirin 325 mg p.o. q. day.
9. Lasix 40 mg p.o. q. 12 hours times five days, then to
resume his regular dose of 20 mg p.o. q. day.
10. Potassium chloride 20 mEq p.o. twice a day.
11. Colace 100 mg p.o. twice a day.
12. Zantac 150 mg p.o. twice a day.
CONDITION ON DISCHARGE: The patient is being discharged in
stable condition.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2167-1-22**] 20:40
T: [**2167-1-22**] 22:32
JOB#: [**Job Number 32082**]
ICD9 Codes: 4111, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7646
} | Medical Text: Admission Date: [**2102-1-10**] Discharge Date: [**2102-1-14**]
Date of Birth: [**2020-2-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
Chills.
Major Surgical or Invasive Procedure:
Intubation in the medical intensive care unit.
History of Present Illness:
Mr. [**Known lastname 4743**] is an 81 yo male with PMH of CAD and alzheimers dz
who presents from [**Hospital 100**] Rehab with fever and hypoxia. He was
empirically started on Doxycycline 100 mg po bid for UTI one day
prior to admission. This evening he developed shaking chills and
??????looks sick?????? according to RN. Temperature 99.8. BP 140/70. HR
100, RR 28, O2 Sat was 86% on RA-->94% on 3L. Patient was put on
NRB and O2 Sat improved to 97%. WBC yesterday 13.4. Urine C&S
was obtained yesterday and pending.
.
In the emergency department, initial vital signs were: T 99.7 HR
96 BP 93/44 RR 16 95% on 3L. Labs were notable for a lactate of
3.7, bicarb of 21, AG of 15, a UA with 21-50 WBCs, ARF with Cr
1.5 (BL 0.9), and trop of 0.04 with nl CK/CKMB. He received 2L
of IVF, Vancomycin, Zosyn and Cefepime, and a right IJ CVL was
placed. Of note the patient had a chronic foley in place. This
was removed in the ED. Upon removal, there was quite a bit of
bleeding at the meatus. Urology was called, and placed a new
foley. Vitals prior to transfer BP 94/50 HR 104 RR 25 99% on
NRB. CVP was 9. Patient was intubated prior to transfer. He
received fentanyl and versed, and was subsequently started on
low dose levophed.
.
On the floor, patient is intubated and sedated.
Past Medical History:
-Alzheimers Dementia: Dx [**2089**], chair bound, disinhibited
-Hypertension
-diastolic CHF with reported EF 65% (no echo in our system)
-CVA: in [**7-28**]
-CAD s/p MI in [**7-28**]
-CRI: since [**2097**]
-Penile cancer: Dx [**2098**] with 2 areas of ulceration at end of
penis
-Normal pressure hydrocephalus (with ataxia, dementia,
incontinence)
-Upper back cyst resection
-C. diff: resolved in [**6-/2098**] on Vanc taper
-Prostate cancer: ~[**2091**], treated with radiation and ? surgery.
Social History:
At baseline, he lives in [**Hospital 100**] Rehab where he has been for the
past 4 years. His is wheelchair bound but can move his own wheel
chair. Dines with a group but sometimes forgets that he is
eating. Occasionally sexually inappropriate. In the past, he
dranks very rarely and never heavily. He smoked one pack of
cigarettes a day for many years.
Family History:
His mother died at 77 allegedly of a heart attack. His father
died at 78 of unknown causes. Allegedly, they had normal
memories at the end, but the patient did not keep up with his
parents who lived in [**Location 5976**]. He has a brother age 80 in good
health. He has a sister age 67 also in good health. We don't
know details about their memory. He has three daughters, 42, 38
and 34, all in good health. He has ten grandchildren, all well.
Physical Exam:
Vitals: T: BP: 108/64 P:90 R: 18 O2: 97% on AC FiO2 100%, Tv
500, RR 16, PEEP 5
General: Intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally on anterior exam, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Penis wrapped. Foley present.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Complete Blood Count:
[**2102-1-9**] 10:10PM BLOOD WBC-7.9 RBC-4.75 Hgb-14.2 Hct-41.4 MCV-87
MCH-29.8 MCHC-34.2 RDW-13.8 Plt Ct-135*#
[**2102-1-10**] 02:53AM BLOOD WBC-24.3*# RBC-4.01* Hgb-11.7* Hct-35.0*
MCV-87 MCH-29.1 MCHC-33.4 RDW-14.1 Plt Ct-161
[**2102-1-11**] 02:51AM BLOOD WBC-16.3* RBC-3.91* Hgb-11.2* Hct-33.9*
MCV-87 MCH-28.7 MCHC-33.1 RDW-14.3 Plt Ct-144*
[**2102-1-12**] 06:09AM BLOOD WBC-11.2* RBC-3.98* Hgb-11.4* Hct-34.5*
MCV-87 MCH-28.7 MCHC-33.1 RDW-14.2 Plt Ct-158
[**2102-1-13**] 07:25AM BLOOD WBC-11.5* RBC-4.20* Hgb-11.7* Hct-35.3*
MCV-84 MCH-27.9 MCHC-33.2 RDW-13.8 Plt Ct-150
.
Coagulation Profile:
[**2102-1-9**] 10:10PM BLOOD PT-14.2* PTT-30.3 INR(PT)-1.2*
[**2102-1-10**] 02:53AM BLOOD PT-14.6* INR(PT)-1.3*
[**2102-1-11**] 02:51AM BLOOD PT-12.9 PTT-34.7 INR(PT)-1.1
[**2102-1-9**] 10:10PM BLOOD Glucose-118* UreaN-48* Creat-1.5* Na-141
K-3.9 Cl-105 HCO3-21* AnGap-19
[**2102-1-10**] 02:53AM BLOOD Glucose-155* UreaN-43* Creat-1.4* Na-142
K-3.5 Cl-111* HCO3-20* AnGap-15
[**2102-1-11**] 02:51AM BLOOD Glucose-139* UreaN-28* Creat-1.1 Na-143
K-4.1 Cl-114* HCO3-21* AnGap-12
[**2102-1-12**] 06:09AM BLOOD Glucose-90 UreaN-15 Creat-0.9 Na-142
K-3.4 Cl-107 HCO3-25 AnGap-13
[**2102-1-13**] 07:25AM BLOOD Glucose-77 UreaN-14 Creat-0.9 Na-140
K-3.5 Cl-105 HCO3-23 AnGap-16
[**2102-1-10**] 02:53AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.5*
[**2102-1-11**] 02:51AM BLOOD Calcium-7.6* Phos-2.2* Mg-2.2
[**2102-1-12**] 06:09AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.9
[**2102-1-13**] 07:25AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9
.
Cardiac Enzymes:
[**2102-1-9**] 10:10PM BLOOD CK(CPK)-302
[**2102-1-10**] 02:53AM BLOOD CK(CPK)-264
[**2102-1-10**] 09:59AM BLOOD CK(CPK)-159
[**2102-1-12**] 06:09AM BLOOD ALT-25 AST-27
[**2102-1-9**] 10:10PM BLOOD CK-MB-4
[**2102-1-9**] 10:10PM BLOOD cTropnT-0.04*
[**2102-1-10**] 02:53AM BLOOD CK-MB-4 cTropnT-0.07*
[**2102-1-10**] 09:59AM BLOOD CK-MB-4 cTropnT-0.03*
.
Blood Gases:
[**2102-1-10**] 03:13AM BLOOD Type-MIX Temp-38.5 pO2-205* pCO2-47*
pH-7.26* calTCO2-22 Base XS--5 Comment-GREEN TOP
[**2102-1-10**] 04:08AM BLOOD Type-ART pO2-398* pCO2-38 pH-7.32*
calTCO2-20* Base XS--5
[**2102-1-10**] 06:56AM BLOOD Type-ART Temp-37.2 Rates-16/3 Tidal V-500
PEEP-5 FiO2-40 pO2-139* pCO2-37 pH-7.33* calTCO2-20* Base XS--5
-ASSIST/CON Intubat-INTUBATED
[**2102-1-10**] 10:30AM BLOOD Type-ART Temp-37.1 pO2-120* pCO2-39
pH-7.33* calTCO2-21 Base XS--4 -ASSIST/CON Intubat-INTUBATED
[**2102-1-11**] 02:57AM BLOOD Type-ART pO2-131* pCO2-34* pH-7.42
calTCO2-23 Base XS--1
.
[**2102-1-9**] 10:14PM BLOOD Lactate-3.7*
[**2102-1-10**] 03:13AM BLOOD Lactate-2.8*
[**2102-1-10**] 10:30AM BLOOD Lactate-1.8
.
Urine:
[**2102-1-9**] 10:21PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.015
[**2102-1-9**] 10:21PM URINE Blood-LG Nitrite-POS Protein-300
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-8.5* Leuks-LG
[**2102-1-9**] 10:21PM URINE RBC->50 WBC-21-50* Bacteri-MOD Yeast-NONE
Epi-0-2
.
[**1-9**] Blood Culture: proteus mirabilis, enterococcus
[**1-10**] Urine Culture: probable enterococcus
[**1-10**] Urine Legionella Antigen negative
[**1-10**] DFA Influenza A and B negative
[**1-10**] Blood Culture X 2: No growth to date
[**1-12**] Blood Culture: Pending
.
[**1-9**] CXR: IMPRESSION: Left lower lobe opacity, atelectasis or
consolidation.
.
[**1-12**] CXR: IMPRESSION: Mild-to-moderate cardiomegaly is stable.
Right IJ catheter tip is in the cavoatrial junction. The aorta
is tortuous. Bibasilar opacities are likely atelectasis and are
unchanged. The lungs are hyperinflated. There is no pneumothorax
or enlarging pleural effusion.
.
[**1-13**] CXR: FINDINGS: Interval removal of right internal jugular
vascular catheter with no evidence of pneumothorax. Unchanged
cardiomegaly and tortuosity of the thoracic aorta. New patchy
opacities have developed at the periphery of both lung bases and
are nonspecific. Their rapid development favors either
atelectasis or aspiration over infectious pneumonia, but a
followup radiograph may be helpful in this regard. There are
probable small pleural effusions.
.
[**1-10**] Renal Ultrasound: IMPRESSION: 1. No evidence of
obstruction. 2. Unchanged right renal stone. 3. Multiple
bilateral renal cysts, not significantly changed from prior.
.
[**2102-1-9**] ECG: Sinus tachycardia. Left atrial abnormality. Right
bundle-branch block. Left anterior fascicular block. Consider
left ventricular hypertrophy. Consider prior anterior myocardial
infarction, although it is non-diagnostic. Anterolateral ST-T
wave abnormalities are primary and they are non-specific. Since
the previous tracing of [**2101-4-23**] the marked inferior and
precordial lead T wave inversions are now absent, sinus
tachycardia is now present and atrial ectopy is not seen.
Brief Hospital Course:
This is a 81 year old with PMH significant for CAD, multiple
UTIs in the past, who was admitted with sepsis secondary to
sepsis. Status post 3 day course in the MICU, called out to the
general medicine floor.
.
#. Sepsis: Presented with altered mental status, leukocytosis,
fever in the setting of positive urine analysis. In the ED,
patient was started on vancomycin, zosyn, and cefepime and
central line was placed. Urology placed new foley. Was
initially intubated and placed on low dose levophed in the MICU.
Blood cultures found to grow proteus and enterococcus, with
presumed urinary source. Was found to have positive U/A and
growth of enterococcus in urine culture. Levophed was
successfully weaned without difficulty and extubated without
issue. Upon transfer to general medicine floor, hemodynamically
stable with downtrending leukocytosis. Will continue IV
Vancomycin and Zosyn as an outpatient for 14 day course (day 1
on [**2102-1-10**]). Will complete course at MACU of [**Hospital 100**] Rehab.
.
#. Hypoxia: Unclear etiology, though chest radiograph on [**2102-1-13**]
showed new patchy opacities at the periphery of both lung bases.
Their rapid development favored either atelectasis or aspiration
over infectious pneumonia. Also with history of diastolic CHF
as per OMR notes, but appeared euvolemic on physical exam.
Urine legionella and influenza DFA were negative. Will continue
IV vancomycin and zosyn as above for full 14 day course. Zosyn
will provide appropriate anaerobic/gram negative coverage for
aspiration.
.
#. Acute renal failure: Resolved with IV hydration. Elevated on
admission to 1.5. Baseline per OMR appears to be 0.9, though he
has CRI listed as a problem. Likely secondary to poor forward
flow in the setting of sepsis. Renal ultrasound showed no
obstruction.
.
#. Renal cysts: Pt was noted to have multiple hypoechoic kidney
lesions involving both kidneys on Renal US done [**2101-4-1**], also
present on repeat imaging during this admission. These were
previously known to both Dr. [**Last Name (STitle) 9125**] and family; they elected not
to pursue further workup, given the patient's comorbidities.
.
#. Tortuous aorta on CXR, question for aneurysm. Will monitor
as an outpatient. No aggressive intervention at this time.
.
#. Anion gap metabolic acidosis: Resolved. Likely from lactic
acidosis in the setting of poor end organ perfusion. Repeat
lactate resolved with fluids.
.
#. Alzheimers dementia: Stable. Per family, close to baseline
mental status, where he is usually able to recognize faces and
family members.
.
#. HTN: Holding home atenelol and finasteride in the setting of
resolving sepsis. Will need to discuss reinitiation of these
medications as an outpatient.
.
#. CAD: Stable, ECG shows TWI that are non-specific and similar
to previous ECG. Enzymes flat. Continued on ASA 81mg and statin.
Beta blocker was held as above.
Medications on Admission:
1.Senna 8.6 mg po bid
2.Aspirin 81 mg po daily
3.Atenolol 50 mg po daily
4.Calcium Carbonate 500 mg po bid
5.Cholecalciferol (Vitamin D3) 1,000 unit po daily
6.Finasteride 5 mg po daily
7.Simvastatin 40 mg po daily
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID:
PRN as needed for thrush.
7. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 11 days.
8. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 11 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Sepsis secondary to urinary tract infection
Hypoxia
Acute renal failure
Alzheimer's dementia
Hypertension
Coronary artery disease
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:
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital due to fever
and low oxygen levels and found to have a urinary tract
infection that spread to your bloodstream. You were placed
temporarily on a breathing machine and required medications to
keep your blood pressure within normal range. You were given IV
fluids, starting on IV antibiotics and have improved.
.
We have made the following changes to your medications:
- STARTED vancomycin (last dose on [**2102-1-23**])
- STARTED zosyn (last dose on [**2102-1-23**])
- HOLD atenolol until you see your primary care physician
[**Name Initial (PRE) **] [**Name10 (NameIs) **] finasteride
.
Please seek medical attention should you develop confusion, pain
with urination, urinary frequency, cough, fever, chills, nausea,
vomiting, or diarrhea.
Followup Instructions:
Your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 105268**] of [**Hospital 100**] Rehab, will
see you upon your return to the facility.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**]
ICD9 Codes: 5849, 5070, 486, 5990, 2762, 5180, 5859, 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7647
} | Medical Text: Admission Date: [**2182-11-4**] Discharge Date: [**2182-11-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo M w/ CAD s/p CABG, AF s/p ppm on coumadin, presents with
fevers, productive cough (brown sputum) and worsening SOB over
[**12-29**] day. In the ED: he presented in respitory distress with
initial vitals: T 102.2, BP 140/70, HR 72, RR 40's 02sat
78RA->93% on NRB. A CXR showed evidence of a LLL infiltrate. His
labs were significant for a WBC count of 11.6 (16 bands),
bun/crt 50/2. BNP 7359. lactate 2.9. Negative CE. He was started
on BIPAP with good effect (PS 12, PEEP 8, 100%, 99% 02sats with
RR of 20's), he was given fluids 1L NS, azithro, ceftrioxone,
tylenol. Admited to the ICU for BIPAP and treatment of his PNA.
ROS: significant for productive cough, SOB, decreased appetite
over past 2 days. Denies any dietary indescretions.
Past Medical History:
1. Coronary artery disease.
(a) Status post acute myocardial infarction in [**2149**].
(b) Status post coronary artery bypass graft in [**2165**].
2. Prostate cancer; status post radiation therapy.
3. Status post permanent pacemaker placement.
4. Status post left total hip replacement surgery.
5. History of melanoma.
6. History of atrial fibrillation.
7. Hypercholesterolemia.
Social History:
accountant and retired lawyer, [**Name (NI) 25190**] [**Name2 (NI) **]. no smoking,
minimal etoh. no drugs. lives with his wife.
Family History:
Family History: A daughter died of unknown CA at the age of 54.
No other family history of cancer, diabetes, HTN, stroke, or
heart disease.
Physical Exam:
VS: Temp: 97.3 BP: / HR: 63 RR: O2sat
GEN: venti mask in place, NAD, pleasant elderly M
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: JVD approx 8-10cm
RESP: rales throughout
CV: heart sounds obscured by rales.
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3.
Pertinent Results:
[**2182-11-3**] 11:48PM WBC-11.6* RBC-4.22* HGB-12.8* HCT-36.6*
MCV-87 MCH-30.3 MCHC-35.0 RDW-14.0
[**2182-11-3**] 11:48PM NEUTS-69 BANDS-16* LYMPHS-13* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2182-11-3**] 11:48PM PLT COUNT-213
[**2182-11-3**] 11:48PM CK-MB-2 cTropnT-<0.01 proBNP-7359*
[**2182-11-3**] 11:48PM GLUCOSE-165* UREA N-50* CREAT-2.0* SODIUM-139
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-24 ANION GAP-17
[**2182-11-3**] 11:54PM LACTATE-2.9*
[**2182-11-4**] 12:07AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2182-11-4**] 05:58AM CK-MB-3 cTropnT-<0.01
.
CXR: LLL infiltrate, mild CHF
Brief Hospital Course:
Pneumonia: Pt admitted to ICU and respiratory distress resolved
with BIPAP. LLL infiltrate on CXR, prominent vasculature.
Improved with coverage with ceftrioxone/azithro for CAP.
A.fib: Stable, h/o afib, followed closely by cardiology.
Therapeutic on coumadin.
Bacteremia: Patient was admitted to ICU on presentation. Blood
cultures with strep pneumonia, thought secondary to pneumonia,
sensitive to levofloxacin.
On hospital day 3, pt had normal O2 sat, looked and felt well.
WBC count normalized and pt was afebrile. He asked to be
discharged home, and was discharged to complete a 10 day course
of levofloxacin.
Medications on Admission:
Amlodipine 2.5mg qdaily
simvastatin 80mg qdaily
toprol XL 50mg qdaily
coumadin 2mg/1mg/1mg
triamterene 37.5 qdaily
ocutabs qdaily
Discharge Medications:
1. Continue all home medications
2. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 6 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please take your antiobiotic every other day until the pills are
completed.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 14069**] within 2 weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2182-11-27**]
ICD9 Codes: 486, 5849, 5859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7648
} | Medical Text: Admission Date: [**2196-10-6**] Discharge Date: [**2196-10-9**]
Date of Birth: [**2128-1-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest Pain x 3 days
Major Surgical or Invasive Procedure:
Cardiac catheterization with placement of 2 bare metal stents in
the RCA
History of Present Illness:
68 year old male with PMHx of CAD, Type I DM, Stage IV lung
cancer s/p two wedge resections and h/o PE with stuttering chest
pain for the last month and worsening dyspnea on extertion that
culminated with an acute episode today while waiting for
cataract surgery.
Of note, the patient had an episode of chest pain while driving
one month ago that resolved spontaneously, which was the first
chest pain since his MI in [**2176**]. Tuesday the chest pain returned
while watching TV. It was epigastric pain that did not radiate
and improved with pepto bismo. The night prior to presentation,
the epigastric chest pain returned again while resting and went
away without intervention. This morning while in [**Hospital Ward Name 23**] for
cataract surgery the patient felt sudden onset of sharp,
substernal chest pain and started feeling worse. An ECG was
preformed and Mr. [**Known lastname 1395**] had ST elevations in leads II, III, and
aVF with ST depressions in leads I and aVL. The patient was
transferred to the cath lab where he received two BMS in the RCA
and PTCA of the PDA. The cathertization demonstrated TIMI three
flow after stent placement. There were no immediate
complications. There was normalization of the ST segment
elevations, but the ST segments did not return to baseline. At
this time his chest pain decreased from [**8-9**] to [**2-10**]. The
patient was transferred to the CCU for close monitoring.
On review of systems, he denies any prior history of stroke,
TIA, cough, hemoptysis, black stools or red stools. He denies
recent fevers, chills or rigors. He denies exertional buttock or
calf pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable chest pain and recent
dyspnea on exertion. Patient denies paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
CARDIAC RISK FACTORS: + Type I Diabetes, + Dyslipidemia
CARDIAC HISTORY:
PERCUTANEOUS CORONARY INTERVENTIONS: 2 BMS RCA and PTCA PDA; LAD
Mid 50%, D1 60%; LCx - OM1 80%
OTHER PAST MEDICAL HISTORY:
GERD
HLD
Type I DM x 48 years
Stage IV Bronchial Adenocarcinoma s/p 2 pulmonary wedge
resections
Hypothyroidism s/p radiation
History of MI in [**2176**]
Back Pain s/p Laminectomy
3 pulmonary emboli four years ago s/p foot fracture
Social History:
Tobacco history: 1.5 - 2 ppd x 34 years, quit 20 years ago
ETOH: none
Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T=97.5 BP=130/34 HR=69 RR=11 O2 sat= 98% on RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of [**7-7**] cm, no carotid bruits appreciated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g appreciated
LUNGS: Respirations were unlabored, no accessory muscle use.
CTAB, no crackles, wheezes or rhonchi anteriorly and laterally
ABDOMEN: Soft, Non-distended, TTP in LLQ, Insulin pump in RLQ
EXTREMITIES: No c/c/e. Right femoral sheath in place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Carotid 2+ and DP 2+ bilaterally
Pertinent Results:
Admission Labs:
[**2196-10-6**] 06:25PM SODIUM-138 POTASSIUM-3.8 CHLORIDE-104
[**2196-10-6**] 06:25PM CK(CPK)-613*
[**2196-10-6**] 06:25PM CK-MB-28* MB INDX-4.6
[**2196-10-6**] 06:25PM PLT COUNT-183
[**2196-10-6**] 01:29PM CK(CPK)-408*
[**2196-10-6**] 01:29PM CK-MB-19* MB INDX-4.7 cTropnT-0.51*
[**2196-10-6**] 09:45AM GLUCOSE-151* UREA N-15 CREAT-1.0 SODIUM-141
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-29 ANION GAP-11
[**2196-10-6**] 09:45AM estGFR-Using this
[**2196-10-6**] 09:45AM cTropnT-0.01
[**2196-10-6**] 09:45AM WBC-7.2 RBC-4.61 HGB-14.3 HCT-41.9 MCV-91
MCH-31.0 MCHC-34.2 RDW-13.6
[**2196-10-6**] 09:45AM PLT COUNT-192
[**2196-10-6**] 09:45AM PT-13.5* PTT-18.3* INR(PT)-1.2*
Imaging:
Cardiac Catheterization [**2196-10-6**]:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated three
vessel disease. The LMCA had no angiographically apparent
disease. The
LAD had a 50% mid stenosis and a 60% stenosis of D1. The LCx had
an 80%
stenosis of OM1. The RCA had an anomalous origin from the high
anterior
position and was proximally occluded after an early conus
branch. PDA
had 70% focal stenosis at its origin.
2. Limited resting hemodynamics revealed normal systemic
arterial blood
pressure with SBP 126mmHg and DBP 64mmHg.
3. Successful thrombectomy and baremetal stenting of prox/mid
RCA with
overlapping 3.0 X 28 and 3.0 X 23 mm Vision deployed at 14 and
16 atms
with 0% residual and TIMI 3 flow.
4. Balloon angioplasty of the origin of right posterior
descending
artery, with 20-30% residual and no dissection with normal flow.
5. ASA 325 mg daily, plavix 75 mg daily (patient on long term
coumadin,
so will need to risk stratify for continuing plavix beyond 30
days.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Proximal RCA occlusion.
3. Successful thrombectomy and bare metal stenting of RCA and
PTCA ofthe
origin of right posterior descending artery.
TTE [**2196-10-6**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Doppler parameters
are indeterminate for left ventricular diastolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The tricuspid
valve leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No significant valvular abnormality seen.
Discharge Labs:
[**2196-10-9**] 06:45AM BLOOD WBC-6.1 RBC-3.85* Hgb-11.9* Hct-34.3*
MCV-89 MCH-31.0 MCHC-34.8 RDW-13.7 Plt Ct-171
[**2196-10-9**] 06:45AM BLOOD PT-15.1* PTT-29.0 INR(PT)-1.3*
[**2196-10-9**] 06:45AM BLOOD Glucose-200* UreaN-12 Creat-0.8 Na-140
K-4.2 Cl-104 HCO3-32 AnGap-8
[**2196-10-8**] 06:50AM BLOOD CK-MB-16* MB Indx-4.1
Brief Hospital Course:
68 year old male with CAD, Type I DM, Stage IV lung cancer, and
h/o PE with an inferior STEMI s/p two BMS in the RCA and PTCA of
the PDA admitted to the CCU service for peri-STEMI observation.
# Inferior ST-Elevation Myocardial Infarction: ECG on admission
pointed to an RCA lesion, with ST elevations greater in III than
II, later corroborated by findings on catherization as described
above. Troponins were elevated on admission and CK/CKMB were
19/408; CK/CKMB peaked at 36/666 prior to discharge. Two
overlapping BMS were placed in the proximal/mid RCA and
angioplasty of the origin of the RPDA was performed. The patient
tolerated the procedure well and returned to the CCU in stable
condition for further monitoring, after which he remained
hemodynamically stable without evidence of arrhythmic or
mechanical complications of STEMI in the acute setting. Echo was
performed with results as detailed above. The patient was
discharged in stable condition. His anticoagulation regimen on
discharge was ASA 325 mg daily, Plavix 75 mg daily for a planned
course of 1 month with close follow-up scheduled with his home
cardiologist, and his home dose of coumadin; celebrex was
discontinued. He was also discharged on crestor 40 mg daily,
co-Q10 50 mg daily, lisinopril 5 mg daily, and carvedilol 6.25
mg twice daily.
# H/O PE in the setting of a foot fracture on life long coumadin
therapy: Coumadin was held peri-catheterization and restarted
prior to discharge. The patient was to follow-up with his
primary cardiologist regarding continuing plavix in the setting
of lifelong coumadin. He was discharged on a Lovenox bridge and
will followup with his cardiologist coumadin clinic two days
after discharge.
# Hypothyroidism s/p radiation: Continued home dose of
levothyroxine 112 mcg and showed no signs of hypo or
hyperthyroid.
# BPH: Continued on home doses of Finesteride and Continue
Doxazosan.
# GERD: Admitted on a PPI that was discontinued when Plavix was
started; Ranitidine was started in its place prior to discharge.
Medications on Admission:
Levoxal 112 mcg q day
Celebrex 400 mg [**Hospital1 **]
Nexium 40 mg q day
Metoprolol 12.5 mg qHs
Lisinopril 2.5 mg q day
Doxazosan 8 mg q day
Finasteride 5 mg q day
Zocor 20 mg T,W,R,S
Insulin Pump
Coumadin 3 mg Tuesday and Sunday; 1.5 MWF
Calcimate 800 mg
Vitamin C
Centrum Silver
Coenzyme Q-10 50 mg
D-3 [**2185**] IU
Vitamin E 400 mg
Magnesium 150 mg
Omega 3 1000mg
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:*0*
3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. doxazosin 8 mg Tablet Sig: One (1) Tablet PO once a day.
7. warfarin 1 mg Tablet Sig: 1.5 Tablets PO DAYS (MO,WE,FR).
8. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once daily on
Sunday, Tuesday, Thursday, Saturday.
9. Calcimate Tablet Sig: One (1) Tablet PO once a day.
10. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
11. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
12. coenzyme Q10 50 mg Capsule Sig: One (1) Capsule PO once a
day.
13. Vitamin D-3 2,000 unit Tablet Sig: One (1) Tablet PO once a
day.
14. vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a
day.
15. magnesium 100 mg Capsule Sig: 1.5 Capsules PO once a day.
16. Omega-3 Fish Oil 1,000 (120-180) mg Capsule Sig: One (1)
Capsule PO once a day.
17. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) 80 mg Subcutaneous
twice a day.
Disp:*2 80 mg syringe* Refills:*5*
18. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
19. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
20. carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
21. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
22. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
23. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Myocardial Infarction (Heart Attack)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It has been our privilege to take care of you in the hospital.
You were hospitalized for a heart attack. You were treated with
a procedure called a cardiac catheterization in which two bare
metal stents were deployed in the blood vessels that supply your
heart; this was done to restore blood flow and the delivery of
oxygen to your heart muscle. You tolerated the procedure well.
As a result of this procedure and your heart attack, several
changes were made to your medications.
We STOPPED the FOLLOWING MEDICATIONS:
- STOPPED Nexium
- STOPPED Celebrex
- STOPPED Metoprolol
- STOPPED Zocor
We STARTED the following medications:
- STARTED Aspirin 325 mg by mouth daily
- STARTED Plavix 75 mg by mouth daily- your cardiologist will
decide when to stop this.
- STARTED Ranitidine 150 mg by mouth twice daily
- STARTED Percocet (as needed)
- STARTED Lovenox (temporarily until INR is therapeutic on
Coumadin.)
- STARTED Carvedilol 6.25 mg twice daily
- STARTED Rosuvastatin 40 mg daily
Because you will be taking Lovenox temporarily until your INR is
therapeutic from Coumadin, you need to get your INR checked on
Tuesday at your outpatient cardiology clinic. That clinic will
tell when you can stop taking the Lovenox.
Please follow-up with your primary cardiologist as detailed
below.
Followup Instructions:
[**2196-10-24**] 2pm, Dr. [**Last Name (STitle) 20683**] (Cardiology, [**Hospital3 1280**])
Completed by:[**2196-10-9**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7649
} | Medical Text: Admission Date: [**2120-10-25**] Discharge Date: [**2120-10-28**]
Date of Birth: [**2099-11-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
polyuria, polydypsia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
20yo man with no significant past medical history presented to
the ED with 2 weeks fo worsening polyuria and polydypsia. He
reported increasingly frequent urination up to every 1-2 hrs, as
well increasing thirst and dry mouth. Preserved appetite.
.
No unintentional weight loss, fever, chills, nausea/vomiting,
sore throat, cough, shortness of breath, chest pain, abdominal
pain, dysuria, meningismus, skin rashes, joint complaints, or
any other significant events. He has no known obstructive
coronary
disease. No drug abuse. No sick contacts. [**Name (NI) **] recent travel. No
other
major stressors.
.
In ED, noted to have hyperglycemia to 477, anion gap of 17,
urine with 1000 glc and 150 ket, and serum acetone large.
He was given volume resuscitation with 3L in NS boluses followed
by D5 1/2 NS c 20 KCl at 150cc/hr once finger stick dropped
below
250. He was given 12U of regular insulin initially, followed by
Insulin gtt of 8U/hr titrated up to 14U/hr.
Past Medical History:
obesity
Social History:
College student at [**Location (un) 12918**] School of Music, lives in the dorm.
No Tob/EtOH/IVDU.
Family History:
father with DM
Physical Exam:
98.6, 103, 146/83, 16, 99% on room air
gen-well appearing in NAD
heent-NC/AT, PERRL, EOMI, anicteric, OP wnl without erythema or
exudate, dry MM
neck-supple, no JVD, no LAD,
cvs-RRR, nl S1/S2, no M/R/G appreciated
pulm-CTAB
back-symmetric, no vetebral tenderness, no CVA tenderness
abd-soft, NT, ND, NABS without HSM
ext-no c/c/e, 2+ DPs b/l
skin-WWP, no rash, eccyhmosis or other lesions
neuro-A&O times 3, CNs [**3-9**] roughly intact, no obvious cognitive
disorder, answers questions and follows commands appropriately,
strength 5/5 distal/proximal times 4 ext, sensation to light and
pin intact thru/o
Pertinent Results:
[**2120-10-27**] 08:00AM BLOOD WBC-5.9 RBC-4.60 Hgb-13.5* Hct-38.6*
MCV-84 MCH-29.3 MCHC-35.0 RDW-12.8 Plt Ct-183
[**2120-10-25**] 03:27PM BLOOD Neuts-64.3 Lymphs-28.6 Monos-2.8 Eos-4.0
Baso-0.3
[**2120-10-27**] 08:00AM BLOOD Plt Ct-183
[**2120-10-25**] 03:27PM BLOOD Glucose-477* UreaN-13 Creat-0.9 Na-129*
K-4.2 Cl-95* HCO3-17* AnGap-21*
[**2120-10-27**] 08:00AM BLOOD Glucose-302* UreaN-7 Creat-0.8 Na-137
K-4.3 Cl-102 HCO3-23 AnGap-16
[**2120-10-27**] 12:35AM BLOOD Glucose-283* UreaN-8 Creat-0.9 Na-135
K-3.7 Cl-101 HCO3-24 AnGap-14
[**2120-10-26**] 08:30PM BLOOD Glucose-335* UreaN-7 Creat-0.8 Na-134
K-4.0 Cl-102 HCO3-22 AnGap-14
[**2120-10-26**] 02:27PM BLOOD Glucose-308* UreaN-8 Creat-0.8 Na-135
K-4.1 Cl-104 HCO3-21* AnGap-14
[**2120-10-26**] 04:39AM BLOOD Glucose-189* UreaN-9 Creat-0.7 Na-138
K-3.1* Cl-107 HCO3-20* AnGap-14
[**2120-10-26**] 12:15AM BLOOD Glucose-196* UreaN-12 Creat-0.8 Na-138
K-3.2* Cl-106 HCO3-19* AnGap-16
[**2120-10-25**] 09:00PM BLOOD Glucose-236* UreaN-12 Creat-0.8 Na-137
K-3.4 Cl-103 HCO3-18* AnGap-19
[**2120-10-25**] 05:00PM BLOOD Glucose-305* UreaN-14 Creat-0.8 Na-138
K-3.6 Cl-103 HCO3-17* AnGap-22*
[**2120-10-25**] 03:27PM BLOOD Glucose-477* UreaN-13 Creat-0.9 Na-129*
K-4.2 Cl-95* HCO3-17* AnGap-21*
[**2120-10-27**] 01:49PM BLOOD Calcium-9.3 Phos-3.4 Mg-1.9
[**2120-10-26**] 12:15AM BLOOD calTIBC-207* VitB12-878 Folate-7.8
Ferritn-309 TRF-159*
[**2120-10-25**] 03:27PM BLOOD Acetone-POS. LARGE
[**2120-10-26**] 08:30PM BLOOD GLUTAMIC ACID DECARBOXYLASE-PND
[**2120-10-26**] 02:26PM BLOOD ISLET CELL ANTIBODY-PND
Brief Hospital Course:
20yo man with no significant past medical history presents with
new onset DKA/DM with no clear precipitating events.
1. Diabetic ketoacidosis
- This is his initial presentation of Diabetes, given body
habitus and presentation with DKA suspect flatbush diabetes,
antibody panel sent and pending at time of discharge.
- No clear inciting event. No evidence of UTI by UA or PNA by
pa/lat chest film. No localizing symptoms.
- Anion gap closed with insulin drip
- once anion gap closed patient started on [**Hospital1 **] NPH and sliding
scale insulin, which was titrated up as blood glucose remained
in 200s. Electrolytes were checked frequently and no anion gap
developed.
- nutrition consulted for diabetic diet teaching
- pt scheduled to follow-up with [**Last Name (un) **] diabetes clinic as
outpatient, will need a lot of diabetic teaching
.
2. Anemia
- Normocytic anemia, folate, B12 normal,
- retic count normal, iron studies with decreased iron and TIBC,
possibly related to diabetes
- recommend outpatient follow-up
Medications on Admission:
none
Discharge Medications:
Insulin NPH
Discharge Disposition:
Home
Discharge Diagnosis:
Flatbush diabetes
Discharge Condition:
Stable
Discharge Instructions:
Follow instructions from [**Last Name (un) **] regarding glucose monitoring and
insulin dosing.
Follow instructions from Nutrition for diabetic diet.
Please follow up with the [**Hospital **] clinic as scheduled. Call if
you develop any increased thirst, urination or if you have any
other questions or concerns.
Followup Instructions:
Follow up with [**Last Name (un) **] appointment
Completed by:[**2120-11-6**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7650
} | Medical Text: Admission Date: [**2185-7-6**] Discharge Date: [**2185-7-15**]
Date of Birth: [**2136-12-24**] Sex: F
Service:
CHIEF COMPLAINT: Fevers.
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
morbidly obese female with a past medical history significant
for insulin-dependent diabetes mellitus complicated by severe
gastroparesis (on intermittent total parenteral nutrition),
coronary artery disease (status post coronary artery bypass
graft in [**2179**]), sarcoidosis (status post tracheostomy), and
multiple admissions for line an urinary tract infections
(most recently for a Escherichia coli resistant emphysematous
cystitis and Staphylococcus epidermidis line infection
treated with an 8-week course of meropenem and linezolid) who
presents with 24 hours of fevers, shaking chills, nausea,
vomiting, shortness of breath, and complaints of
foul-smelling urine.
The patient was recently admitted to [**Hospital1 190**] from [**5-24**] to [**5-28**] for emphysematous
cystitis with multiple drug resistant Escherichia coli. The
patient was discharged to a rehabilitation facility and
treated with an 8-week course of broad spectrum antibiotic of
meropenem and linezolid with reported resolution of the
urinary tract infection.
The patient was recently discharged from rehabilitation to
home; and while at home developed the acute onset of fevers
to 103, associated with shaking chills, nausea, vomiting, and
shortness of breath. The patient also notes a pustular
discharge from her right upper extremity peripherally
inserted central catheter line site through which she
received total parenteral nutrition. The peripherally
inserted central catheter line was placed during her prior
hospitalization.
In the Emergency Department, the patient was found febrile to
103.3 and hemodynamically unstable with a blood pressure of
86/39, heart rate was 119, and oxygen saturation was 100% on
a 10-liter tracheal mask. While in the Emergency Department,
the patient's blood pressure dropped to a systolic blood
pressure in the 60s, and the patient was started on
aggressive intravenous hydration as well as dopamine for
blood pressure support. The peripherally inserted central
catheter line site was noted to be markedly erythematous with
pustular discharge. The peripherally inserted central
catheter line was removed, and the patient was meropenem and
linezolid empirically. An ultrasound of the right upper
extremity demonstrated a thrombus of the distal right
brachial vein; however, no abscess was noted.
PAST MEDICAL HISTORY:
1. Type 1 diabetes mellitus diagnosed at the age of 16.
2. Morbid obesity.
3. History of emphysematous cystitis in [**2185-5-10**] with
resistant Escherichia coli; treated with a course of
meropenem.
4. History of vancomycin-resistant Staphylococcus
epidermidis as well as methicillin-resistant Staphylococcus
aureus.
5. History of sternotomy; status post osteomyelitis
following coronary artery bypass graft in [**2179**].
6. History of coronary artery disease; status post coronary
artery bypass graft in [**2179**] (with left internal mammary
artery to the left anterior descending artery, saphenous vein
graft to the first obtuse marginal, and saphenous vein graft
to second obtuse marginal) with an ejection fraction of 40%
in [**2185-5-10**] (known to have reversible defects).
7. Hypertension.
8. Asthma.
9. History of sarcoidosis with upper airway obstruction
leading to permanent tracheostomy and history of mucus
plugging.
10. History of pleural effusions with atypical cells.
11. History of neurogenic bladder with urinary incontinence
as well as retention.
12. History of mild chronic renal insufficiency with
proteinuria.
13. History of depression.
14. History of severe gastroparesis; status post
gastrojejunostomy tube placement in [**2184-12-10**]
requiring intermittent total parenteral nutrition.
15. Status post cholecystectomy as well as appendectomy.
16. History of small-bowel obstruction; status post
small-bowel resection.
17. Iron deficiency anemia.
18. History of peripheral neuropathy.
19. History of bilateral vitrectomy and multiple laser
surgeries.
ALLERGIES: Allergies included VANCOMYCIN (with a reaction of
leukocytoclastic vasculitis), PAPER TAPE, and INTRAVENOUS
DYE.
MEDICATIONS ON ADMISSION:
1. Multivitamin one tablet p.o. every day.
2. Reglan 10 mg p.o. three times per day.
3. Zofran 8 mg p.o. four times per day as needed.
4. Compazine 10 mg p.o. four times per day as needed (for
nausea).
5. Protonix 40 mg p.o. once per day.
6. Neurontin 300 mg p.o. q.a.m. and 300 mg p.o. at noon and
400 mg p.o. q.h.s.
7. Lopressor 25 mg p.o. twice per day.
8. Ultram 50 mg p.o. three times per day.
9. Darvocet N twice per day.
10. Cogentin 2 mg p.o. twice per day.
11. NPH 30 units subcutaneously q.a.m. and 20 units
subcutaneously q.p.m. with sliding-scale prior to meals.
SOCIAL HISTORY: The patient lives with a partner who is a
nurse as well as the partner's mother. She denies current
alcohol use and reports a distant history of tobacco use.
FAMILY HISTORY: Family history is notable for diabetes
mellitus, hypercholesterolemia, and coronary artery disease.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed temperature was 103.3, blood pressure
was 79/33, heart rate was 99, respiratory rate was 25, and
oxygen saturation was 100% on 10-liter tracheal mask. In
general, the patient was a morbidly obese female who appeared
older than her stated age, in mild distress. Head, eyes,
ears, nose, and throat examination revealed normocephalic and
atraumatic. Pupils were equal, round, and reactive to light
and accommodation. Extraocular movements were intact
bilaterally. Mucous membranes were dry. The oropharynx was
clear. The neck was supple with no lymphadenopathy or
jugular venous distention. Tracheostomy in place. The lungs
were clear to auscultation bilaterally. No wheezes, rhonchi,
or rales. Cardiovascular examination revealed tachycardic
with a regular rhythm. Normal first heart sounds and second
heart sounds. No murmurs, rubs, or gallops were appreciated.
Abdominal examination revealed obese, soft, and nontender.
Jejunostomy tube in place with foul-smelling discharge.
Extremity examination revealed right upper extremity
peripherally inserted central catheter site was indurated
with erythema. No fluctuance; however, the presence of
pustular discharge. The lower extremities were warm and well
perfused with no evidence of edema. Neurologic examination
revealed awake, alert and oriented times three with a
nonfocal neurologic examination.
NOTE: The remainder of this dictation including the
hospital course will be dictated at a later date.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12974**], M.D. [**MD Number(1) 12975**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2185-7-15**] 11:05
T: [**2185-7-18**] 10:33
JOB#: [**Job Number 17051**]
ICD9 Codes: 5849, 5990, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7651
} | Medical Text: Admission Date: [**2192-9-24**] Discharge Date: [**2192-10-5**]
Date of Birth: [**2148-6-18**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
ESLD secondary to Hep C cirrhosis
Major Surgical or Invasive Procedure:
s/p Liver transplant cadaveric [**2192-9-24**]
History of Present Illness:
44 yo male with ESLD secondary to HCV cirrhosis
Past Medical History:
Hep C
EtOH abuse
HTN
Portal HTN
Social History:
EtOH abuse
Physical Exam:
NAD
AAO times 3
PERRLA, EOMI
RRR S1+S2
CTA Bilat
Soft, NT Mild Distention
Pertinent Results:
Pathology Examination
DIAGNOSIS:
Liver, native hepatectomy:
1. Established cirrhosis, trichrome stains evaluated.
2. Mild to moderate septal mononuclear inflammation with
minimal lobular inflammation (grade [**1-13**] inflammation).
3. Mild predominantly macrovesicular steatosis.
4. Mild increase of iron in Kupffer-cells and hepatocytes seen
on special stain.
5. Small cell dysplasia nodule with focal area suggestive of
early evolving hepatocellular carcinoma. The dysplastic nodule
measures 1 cm in maximum dimension.
6. Negative vascular and biliary margins.
7. Chronic cholecystitis.
[**2192-9-24**] 11:29AM BLOOD WBC-2.9*# RBC-3.21* Hgb-11.3* Hct-31.4*
MCV-98 MCH-35.2* MCHC-36.0* RDW-14.8 Plt Ct-35*
[**2192-9-24**] 11:29AM BLOOD PT-14.4* PTT-34.1 INR(PT)-1.3
[**2192-9-24**] 11:29AM BLOOD Glucose-247* UreaN-16 Creat-0.9 Na-134
K-4.0 Cl-100 HCO3-25 AnGap-13
[**2192-9-24**] 11:29AM BLOOD ALT-30 AST-61* AlkPhos-218* TotBili-4.3*
[**2192-9-24**] 09:16PM BLOOD ALT-2308* AST-4755* AlkPhos-84 Amylase-62
TotBili-3.6* DirBili-2.8* IndBili-0.8
[**2192-10-5**] 10:00AM BLOOD WBC-7.0 RBC-3.66* Hgb-11.4* Hct-32.6*
MCV-89 MCH-31.1 MCHC-34.9 RDW-16.5* Plt Ct-68*
[**2192-9-25**] 03:57AM BLOOD Glucose-256* UreaN-34* Creat-1.8* Na-139
K-4.4 Cl-103 HCO3-19* AnGap-21*
[**2192-9-25**] 10:33AM BLOOD Glucose-141* UreaN-38* Creat-2.2* Na-140
K-4.5 Cl-104 HCO3-20* AnGap-21
[**2192-9-25**] 01:45PM BLOOD Glucose-137* UreaN-42* Creat-2.5* Na-140
K-4.8 Cl-105 HCO3-20* AnGap-20
[**2192-9-26**] 05:25AM BLOOD Glucose-123* UreaN-65* Creat-3.7* Na-140
K-4.9 Cl-102 HCO3-18* AnGap-25*
[**2192-9-29**] 11:19AM BLOOD Glucose-197* UreaN-147* Creat-6.8* Na-141
K-3.7 Cl-100 HCO3-18* AnGap-27*
[**2192-9-29**] 05:34PM BLOOD Glucose-117* UreaN-148* Creat-7.1* Na-141
K-3.6 Cl-100 HCO3-16* AnGap-29*
[**2192-10-5**] 10:00AM BLOOD Glucose-199* UreaN-110* Creat-4.2* Na-136
K-3.6 Cl-99 HCO3-21* AnGap-20
[**2192-9-25**] 03:57AM BLOOD ALT-2859* AST-[**Numeric Identifier 47481**]* LD(LDH)-7535*
AlkPhos-104 TotBili-4.6*
[**2192-9-26**] 01:45AM BLOOD ALT-2615* AST-6009* AlkPhos-124*
TotBili-3.3*
[**2192-9-29**] 11:19AM BLOOD ALT-1179* AST-450* AlkPhos-174*
TotBili-3.2*
[**2192-10-5**] 10:00AM BLOOD ALT-191* AST-49* AlkPhos-199*
TotBili-3.6*
DUPLEX DOPP ABD/PEL [**2192-9-25**] 9:08 AM
IMPRESSION:
1) Patent intrahepatic vasculature. Please note that no flow was
noted in the retrohepatic vena cava but this was considered most
likely technical since this was a portable study.
2) 5.8 X 5.4 cm rounded hypoechoic structure abutting the vena
cava has son[**Name (NI) 493**] features suggestive of a small hematoma.
Brief Hospital Course:
Pt admitted on [**2192-9-24**] for OLT secondary to h/o HCV cirrhosis.
Pt taken to the OR for OLT and pt tol the procedure. [**Name (NI) **], pt
transeferred to the SICU intubated and sedated. Pt did well in
the immediate post-op period and was extubated on [**2192-9-25**]. Pt
started on MMF 1000mg and a tapering dose of SM. However, pt's
BUN/Cr began to increase on POD 2, with developement of ARF and
oliguria. Pt clinically continued to improve. RUQ US and CT Scan
with evidence of peri-hepatic hematoma and poss compression of
IVC. Pt hydrated and hematoma watched. Oliguria began to resolve
by POD 3 and pt transferred to the floor on POD 5. Pt continued
MMF, SM tapered to 20mg prednisone and CSA 100 [**Hospital1 **] added and
titrated to 125. Pt continued to improve, with resolving ARF. Pt
started with PT and advancing diet. Pt tolerated full diet and
did well in PT. Pt with new onset diabetes secondary to high
dose steroids. [**Last Name (un) **] consulted and BS controlled. Pt mobilized
fluid and decreased weight from 109 kg to 100kg by POD 9. Pt
continued to do well and Pt d/c'd home with VNA for diabetic
teaching on POD 11, [**2192-10-5**]
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QD (once a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
8. Neoral 25 mg Capsule Sig: Five (5) Capsule PO every twelve
(12) hours.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Valcyte 450 mg Tablet Sig: One (1) Tablet PO every other
day.
Discharge Disposition:
Home With Service
Facility:
Care Network VNA
Discharge Diagnosis:
End stage liver disease secondary to Hep C cirrhosis
Discharge Condition:
stable
Discharge Instructions:
Please return for all follow-up appointments
Take all medications as directed
Return to the ER for any increased pain, nausea and vomitting,
shortness of breath, chest pain, significant weight gain or
weight loss, or fevers
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Hospital **] CLINIC TRANSPLANT CENTER (NHB) Where:
LM [**Hospital 5628**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2192-10-8**] 10:40
Provider: [**Name10 (NameIs) **] [**Hospital **] CLINIC TRANSPLANT CENTER (NHB) Where:
LM [**Hospital 5628**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2192-10-15**] 10:40
Provider: [**Name10 (NameIs) **] [**Hospital **] CLINIC TRANSPLANT CENTER (NHB) Where:
LM [**Hospital 5628**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2192-10-22**] 10:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2192-10-8**]
ICD9 Codes: 5715, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7652
} | Medical Text: Admission Date: [**2198-9-5**] Discharge Date: [**2198-9-13**]
Date of Birth: [**2129-6-11**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Respiratory Distress, Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI - This is a 69 y/o Russian-speaking male with PMH
significant for metastatic renal CA to brain and lungs, s/p LLL
lobectomy, s/p TURP [**1-18**] prostate CA, colon CA s/p colectomy, who
presents to the ED from NH with respiratory distress. History is
limited by patient's non-verbal state and wife's limited
English. Per wife, patient has been in the [**Name (NI) **] since [**5-22**] [**1-18**] CVA
involving the right extremities. His mental status has been poor
at baseline and has increasingly worsened to a non-verbal state
approx one month ago. Beginning two nights ago, the patient was
noted to have some respiratory distress, requiring oxygen and
was started on Augmentin for a presumed PNA. However, his
respiratory status did not improve and was noted to have a
low-grade temp of 100.9, RR 30, HR 140, BP 155/88, SaO2 94% on
supplemental O2 (unknown amount), prompting the NH to send the
patient to the ED early this morning.
.
In the ED, he was noted to have a Tc of 103.8 (rectally), HR
134, BP 124/74, RR 42, SaO2 88%/NRB. His labs were notable for a
WBC of 27.9 (97% N, no bands) and lactate of 2. He received
combivent nebs, 1 gm tylenol pr, 500 cc of NS bolus, 1 gm
ceftaz, 500 mg IV flagyl, and 1 gm of vanc. His sats improved
while in the ED and he was weaned down to 4 L NC. ABG on 4L was
7.49/34/82/31.
Patient was admitted to the MICU and admitted on broad spectrum
antibiotics. Discussion was held with family and patient was
made DNR/DNI/no pressors.
Past Medical History:
PMH -
1. Metastatic renal CA - s/p right nephrectomy 17 yrs ago; s/p
immunotherapy in [**2193**], followed at [**Hospital1 336**]. Mets to b/l lungs and
brain, follows with neuro-onc at [**Hospital1 336**].
2. s/p LLL lobectomy - ?[**1-18**] mets from renal CA
3. s/p prostate resection [**1-18**] prostate CA - [**2191**]
4. s/p CVA [**5-22**], affecting right side
5. NIDDM
6. COPD
7. A fib
8. Colon ca, dx [**2197**] - s/p colectomy
Social History:
SH - Lives at [**Location **] since CVA [**5-22**]. Russian-speaking only. Former
smoker, quit in [**2191**]. Occasional EtOH, no illicits. Wife lives
in area, has children living outside of [**Location (un) 86**].
.
Family History:
.
FH - NC
Physical Exam:
VS: Tc , BP , HR , RR , SaO2 98%/3L NC
General: Non-verbal elderly male in NAD. Unable to clear
secretions and copious secretions [**1-18**] food noted.
HEENT: NC/AT, PERRL, able to track movements with eyes.
Anicteric sclerae. MM dry. Food noted in mouth.
Neck: supple, no JVD noted
Chest: Diffuse rhonchi b/l, with rales in RLL.
CV: RRR, s1 s2 normal, no m/g/r
Abd: soft, NT/ND, minimal BS. Midline abdominal scar noted.
Ext: no c/c/e, cool extremities. Pulses 2+ b/l
Neuro: Non-verbal, moves left side freely, withdraws to pain,
tracks movements purposefully with eyes.
.
Pertinent Results:
[**2198-9-8**] 12:28AM BLOOD calTIBC-144* Ferritn-1183* TRF-111*
[**2198-9-5**] 06:15AM BLOOD Glucose-135* UreaN-22* Creat-0.5 Na-147*
K-3.3 Cl-106 HCO3-29 AnGap-15
[**2198-9-11**] 04:40AM BLOOD Glucose-118* UreaN-44* Creat-2.2* Na-145
K-4.2 Cl-109* HCO3-27 AnGap-13
[**2198-9-13**] 04:58AM BLOOD Glucose-187* UreaN-53* Creat-2.0* Na-141
K-4.0 Cl-102 HCO3-27 AnGap-16
[**2198-9-13**] 04:58AM BLOOD WBC-19.0* RBC-3.32* Hgb-8.7* Hct-27.0*
MCV-81* MCH-26.3* MCHC-32.4 RDW-16.8* Plt Ct-580*
[**2198-9-5**] 06:15AM WBC-27.9* RBC-4.40* HGB-12.0* HCT-36.4*
MCV-83 MCH-27.4 MCHC-33.1 RDW-17.1*
.
[**2198-9-9**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2198-9-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST, STAPH AUREUS COAG +} INPATIENT
[**2198-9-5**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2198-9-5**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL INPATIENT
[**2198-9-5**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
.
RENAL ULTRASOUND:
The patient is status post right nephrectomy. The left kidney
measures 13.4 cm. The calyces are mildly prominent throughout
the left kidney, however, there is no frank evidence of
hydronephrosis. No stones or masses are identified. The bladder
is catheterized and empty.
.
Video Swallow:
FINDINGS: Video oropharyngeal fluoroscopic swallowing evaluation
was performed in conjunction with speech and swallow pathology.
Patient was administered various consistencies of barium
including thin, nectar, thick, and ground cookie. Posterior oral
transit was moderately delayed. In addition, swallowing
initiation was severely impaired with significantly delayed
swallowing initiation to large boluses. When swallow was
initiated, there was some adequate epiglottic deflection, and
laryngeal valve closure. However, there was silent aspiration to
thin liquids. The patient had difficulties following commands
during the examination, and would not take cookie or straw.
IMPRESSION: Severe swallow initiation delay with aspiration to
thins. For further details, please consult the speech and
swallow pathology note.
.
CT Head:
CLINICAL INDICATION: Metastatic renal cell carcinoma with
somnolence, assess for intracranial hemorrhage.
There is a large hyperdense lesion involving the left frontal
lobe near the convexity measuring 4.2 x 4 cm and surrounded by
vasogenic edema, with mass effect seen over the left lateral
ventricle. There is minimal midline shift to the right. The
edema extends inferiorly into the left frontoparietal white
matter and the left temporal lobe. The ventricular system is not
dilated. There is no intraparenchymal or subdural hemorrhage.
The fourth ventricle remains in the midline. There is
heterogeneous hyperdense lesion abutting the right frontal
aspect of the calvarium along the midline. This could represent
volume averaging. No lytic lesions are identified. Chronic
mucosal thickening is seen within the paranasal sinuses.
.
IMPRESSION: 4-cm hyperdense necrotic mass lesion involving the
left frontal lobe surrounded by significant vasogenic edema and
associated with sulcal effacement and surrounding mass effect as
noted above. This is most likely metastatic in nature given the
history of renal cell cancer. No intraparenchymal hemorrhage was
seen.
.
CT Chest:
Multidetector CT of the chest was performed without intravenous
or oral contrast administration. Images are presented for
display in the axial plane at both 5-mm and 1.25-mm collimation.
.
There is near complete opacification of the remaining portion of
the left lung with only a small amount of residual aerated lung
at the apical portion. Assessment of the central airways
demonstrates complete obstruction of the left main bronchus just
beyond its origin. The contents within the obstructed bronchus
range from fluid to soft tissue attenuation. Superiorly, there
are some areas of consolidation and ground-glass superimposed
upon underlying areas of emphysema, but beginning in the mid
portion of the left lung, opacified lung is relatively
homogeneous without air bronchograms. An area of curvilinear
calcification is present in the lower left hemithorax
posteriorly and there are surgical clips present in the
paraaortic and perihilar regions.
.
The left lobe of the thyroid gland is markedly enlarged and
heterogeneous. The superior portion of the enlarged lobe is not
completely imaged on this scan, and it is difficult to exclude
adjacent areas of lymphadenopathy in the left neck as well. The
enlarged thyroid gland results in rightward displacement and
coronal narrowing of the trachea which is narrowed to
approximately 8 mm at the thoracic inlet level. There is bulky
mediastinal lymphadenopathy on both sides of midline, with the
right paratracheal lymph node measuring up to 3.6 x 2.7 cm and a
left prevascular node measuring up to 2.5 x 3.0 cm. A bulky left
lower paratracheal lymph node measures 3.1 x 2.0 cm. The left
hilum is difficult to assess without intravenous contrast but
there is probable left hilar lymphadenopathy as well.
.
There is left-sided pleural thickening contiguous with the area
of homogeneous opacification in the left lower lung region. This
is contiguous with an area of chest wall destruction involving a
lower left lateral rib which is partially destroyed by the mass.
Enlarged nodes are also present in the lower left paraaortic
region and in the left extrapleural space.
.
Within the imaged portion of the upper abdomen, there are bulky
lymph node masses which are incompletely imaged on this study.
These are in the region of the celiac axis anterior to the
aorta, measuring up to approximately 5.5 and 6.4 cm in greatest
dimension. A left anterior peridiaphragmatic enlarged node is
present as well as left retroperitoneal node enlargement. The
adrenal glands are incompletely imaged on this study. Calcified
gallstone is observed within the gallbladder. No definite
lesions are seen within the liver but lack of intravenous
contrast limits assessment.
.
As noted, the trachea is compressed and displaced by the thyroid
mass. Fluid level within the intrathoracic trachea is probably
due to retained secretions. Within the right lung, there are
several small pulmonary nodules present, some of which are well
circumscribed, and others of which are more poorly defined. The
largest individual nodule is a poorly defined lateral segment
right middle lobe nodule measuring 10 mm on image 31 of series
3. Respiratory motion limits assessment of the right lower lobe
and right middle lobe.
.
Skeletal structures reveal partial destruction of the left
seventh lateral rib as described above. Post-thoracotomy changes
are present just above this level. Healed lower right anterior
rib fractures are noted without definite associated lytic
lesions.
.
Finally, incidental note is made of a calcified granuloma in the
periphery of the right middle lobe.
IMPRESSION:
1. Complete obstruction left main bronchus. Although possibly
due to retained secretions, obstructing endobronchial lesion is
likely in this patient with history of renal cell carcinoma.
Correlative bronchoscopy would be helpful.
2. Postobstructive collapse/consolidation in left upper lobe
(status post left lower lobectomy). Associated soft tissue mass
with dystrophic calcifications, contiguous or adjacent to chest
wall mass with destruction of the left lateral seventh rib.
3. Bulky mediastinal and upper abdominal lymphadenopathy
consistent with metastatic disease. Dedicated contrast-enhanced
CT torso could be considered to more completely characterize the
extent of metastatic disease if warranted clinically.
4. Marked enlargement of left lobe of thyroid gland with
displacement and compression of trachea. It is difficult to
exclude adjacent lymphadenopathy in the left neck.
5. Left-sided pleural thickening and small amount of pleural
fluid.
6. Scattered nodules in the right lung, some of which are well
defined and likely reflect metastatic foci and others of which
are poorly defined and likely are related to the infection.
.
Brief Hospital Course:
Hospital course, by Problem:
#Respiratory Distress: initially thought to be d/t aspiration
PNA. Was intially treated with broad spectum abx (Vanc, CTX,
Flagyl). Blood and Urine Cx negative but sputum did grow MRSA.
To sort out whether the patient simply had aspiration
pnuemonitis vs PNA, a CT scan of the chest was obtained. This
showed almost complete collapse of the remaining portion of his
left lung from a L mainstem bronchus lesion, concerning for
metastatic disease. It also showed narrowing of the trachea to
approx 8 mm from an enlarged left lobe of the thyroid, which is
stable in size according to his outside oncologists. Because of
renal failure (see below), the patient was switched to Linezolid
to cover MRSA; CTX/Flagyl were continued to cover for ?
post-obstructive process. He will complete a today of a 10 day
course of antitiotics to end on [**9-15**].
.
#Acute Renal Failure: during his hosptial course, his Cr rose
from a baseline of 0.3-0.4 to a peak of 2.2. Renal U/S
negative. Urine indicies not c/w pre-renal state, Urine Eos
neagtive. Renal team consulted; felt to be secondary to ATN,
most likely from vancomycin. Cr now starting to improve (2.0 on
day of discharge).
.
#Cerebral Mets: on CT scan, there was noted to me marked
vasogenic edmema. The patients DMS was increased to 4 mg IV q 8
hours and should be continued indefinatley as the patient
appears to be more awake when on the higher dose. They can be
decreased should the patient develop agitation.
.
#ONC issues/goals of care: after the Left mainstem lesion was
discovered, both interventional pulmonary team and radiation
team were consulted. Both felt that bronchoscopy and radition
therapy would add little to his quality/quantity of life, given
his extremely poor performance status and prognosis. His wife
was in agreement that he should not receive any invasive
procedures in the future. She understood that should the
patient develop subsequent respiratory distress, she should not
be brought back to the hospital but should be given morphine and
ativan for comfort.
.
#Anemia: high ferrtin c/w Anemia of Chronic Disease. Stable.
.
#FEN: the patient had speech/swallow evaluation which showed
moderate-severe oropharyngeal dysphagia characterized by reduced
bolus control and formation as well as a significant pharyngeal
swallow initiation delay with mild silent
aspiration of thin liquids. The speech/swallow team
recommended Nectar thick liquids and pureed solids, PO meds
crushed in purees, along with 1:1 assistance for meals, strict
aspiration precautions.
Medications on Admission:
MEDS (per NH record)
1. Lantus 40 units qHS, Novolin SS
2. Omeprazole 20 mg qd
3. Senna [**Hospital1 **]
4. Klonopin 0.25 mg qd
5. Percocet prn
6. Augmentin 500 mg tid
7. Decadron 1 mg qod (taper)
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed.
Disp:*qs inhalation* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) GM Intravenous Q24H (every 24 hours): course to end [**9-15**].
Disp:*qs qs* Refills:*0*
6. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours): course
to end [**9-15**].
Disp:*qs mg* Refills:*0*
7. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred
(600) mg Intravenous every twelve (12) hours: course to end
[**9-15**].
Disp:*qs qs* Refills:*0*
8. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Four (4)
gm Injection Q8H (every 8 hours).
Disp:*qs gm* Refills:*0*
9. Insulin Glargine 100 unit/mL Solution Sig: Forty Two (42)
units Subcutaneous at bedtime: titrate accordingly.
Disp:*qs units* Refills:*2*
10. Morphine Concentrate 20 mg/mL Solution Sig: One (1) cc PO
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*qs qs* Refills:*0*
11. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for Respiratory distress or anxiety.
Disp:*qs Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses:
1. Post-obstructive PNA vs Aspiration PNA
2. Acute Renal Failure, likely secondary to Vancomycin
3. 8 mm Tracheal Narrowing secondary to thyroid enlargement
4. Complete obstruction left mainstem bronchus; retained
secretions
vs obstructing endobronchial lesion
5. Metastatic chest wall mass with destruction of the left
lateral
seventh rib
6. Renal cell carcinoma with 4-cm hyperdense necrotic mass
lesion
involving the left frontal lobe surrounded by significant
vasogenic edema
Secondary Diagnoses
1. Metastatic renal CA
2. s/p LLL lobectomy - ?[**1-18**] mets from renal CA
3. s/p prostate resection [**1-18**] prostate CA - [**2191**]
4. s/p CVA [**5-22**], affecting right side
5. NIDDM
6. COPD
7. A fib
8. Colon ca, dx [**2197**] - s/p colectomy
Discharge Condition:
DNR/DNI/DNH
Discharge Instructions:
Please make sure that the patient is as comfortable as possible.
Please, note, the patient is DO NOT HOSPITALIZE (DNH) per
discussion with his wife. [**Name (NI) **] should be treated for his
pneumonia until [**9-15**] and receive steroids indefinatley for his
cerebral mets. Should he develop respiratory distress, he
should not to be brought back to the hospital (per Wife's
wishes). In this case, should be given Morphine and Ativan prn,
titrated to comfort.
.
He can continue to receive his blood pressure meds and his
insulin can be titrated accordingly.
Followup Instructions:
None
ICD9 Codes: 486, 5849, 496, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7653
} | Medical Text: Admission Date: [**2153-9-26**] Discharge Date: [**2153-9-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Cough, fever & change in mental status; incidental finding of
maroon stool
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo M with a history of prostate CA and Alzheimer's dementia
who presents after home nurses noted he appeared unwell,
incidentally noted to have maroon, guaiac positive stool. Of
note, the patient has had several recent admissions to [**Hospital1 18**] and
consultations with Gerontology since his wife suffered a recent
stroke.
.
The patient's daughter reports that he lives at home with 24
hour PCA. He was noted to have a non-productive cough for
approximately 1.5 weeks. He was prescribed cough suppresent but
his symptom persisted. On the day of admission he was noted to
appear shaky and generally unwell by his home nurses, including
shakiness and weakness. His PCP was called who referred him to
the ED.
.
In the ED, T 102.8 HR 105 BP 122/64 RR 26 O2Sat 97%2L NC. He was
felt to have 2 possible sources of infection including lung and
urine and received ceftriaxone 1g and Azithromycin 500mg as well
as acetaminophen 650mg. A foley catheter was placed. While
having a diaper change in the ED, the patient was incidentally
found to have maroon, grossly (and confirmed on testing) guaiac
positive stool. He was hemodynamically stable with baseline Hct.
The pateint was admitted to the [**Hospital Unit Name 153**] & transferred to 11R on
[**2153-9-27**].
.
ROS: Patient's daughter denies home fevers, chills, nightsweats,
headaches, blurry vision, chest pain, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, dysuria, lower
extremity edema or weight gain. The patient of note has a long
history of guaiac positive stool by the report of his daughter.
She does not know if his stool is normally maroon in color. At
baseline A&Ox2.
.
Past Medical History:
Alzheimer's dementia, has had wandering & aggitation
h/o Prostate Ca, s/p XRT ([**2149**]), followed by Urology ([**Name8 (MD) **],MD)
CKD, Stage 3 (baseline creatinine ~1.0)
GERD
Anxiety
Depression
Severe degenerative disease in the lumbar spine
Anemia
h/o Diverticulum
h/o Colonic polyps
Internal hemorrhoids
Social History:
Patient is a retired dentist. Lives at home with 24H PCA's. Son
[**Name (NI) **]. [**Name (NI) **] [**Known lastname 7078**], Chief, Division of Oral Medicine, Department
of Surgery, [**Company 2860**]), is primary contact & HCP: [**Telephone/Fax (3) 7079**]. Patient had been living with wife independently at
home until recently. Wife [**Doctor First Name **] - second marriage; patient's
first wife & mother of children died ~ 30 years ago) was
visiting her family in [**State 7080**] and had a stroke (? [**Month (only) **]
[**2153**]). Wife is currently living in [**State 7080**] and
participating in outpatient rehab. Patient has services through
JCFS.
.
Patient is dependent in all ADLs & IADLs.
Family History:
NC
Physical Exam:
ADMISSION PE:
============
T 99.2F 76 103/47 23 92% 6L
Gen: Elderly gentleman. NAD.
HEENT: PERRL.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Upper airway congestion. Possible small amount of left
base rhonchi. Otherwise clear to auscultation.
Abd: Soft, nontender. No organomegaly.
Ext: No edema.
Neuro: A&Ox1. Moving all extremities.
Pertinent Results:
ADMISSION LABS:
==============
[**2153-9-26**] 05:36PM URINE HOURS-RANDOM CREAT-186 SODIUM-39
POTASSIUM-82 CHLORIDE-46
[**2153-9-26**] 05:36PM URINE OSMOLAL-699
[**2153-9-26**] 05:36PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2153-9-26**] 02:49PM URINE HOURS-RANDOM
[**2153-9-26**] 02:49PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
[**2153-9-26**] 02:49PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2153-9-26**] 02:49PM URINE RBC-0-2 WBC->50 BACTERIA-FEW YEAST-NONE
EPI-0
[**2153-9-26**] 02:49PM URINE EOS-POSITIVE
[**2153-9-26**] 03:05PM PT-14.6* PTT-27.7 INR(PT)-1.3*
[**2153-9-26**] 03:02PM LACTATE-2.7*
[**2153-9-26**] 02:49PM GLUCOSE-153* UREA N-35* CREAT-1.3* SODIUM-142
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-28 ANION GAP-12
[**2153-9-26**] 02:49PM ALT(SGPT)-33 AST(SGOT)-21 LD(LDH)-195
CK(CPK)-72 ALK PHOS-72 AMYLASE-106* TOT BILI-0.5
[**2153-9-26**] 02:49PM LIPASE-18
[**2153-9-26**] 02:49PM CK-MB-NotDone
[**2153-9-26**] 02:49PM CALCIUM-9.0 PHOSPHATE-1.8* MAGNESIUM-2.1
[**2153-9-26**] 02:49PM ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG
[**2153-9-26**] 02:49PM WBC-9.7# RBC-3.99* HGB-10.9* HCT-33.3* MCV-83
MCH-27.2 MCHC-32.6 RDW-14.2
[**2153-9-26**] 02:49PM NEUTS-89* BANDS-2 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2153-9-26**] 02:49PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2153-9-26**] 02:49PM PLT SMR-NORMAL PLT COUNT-152
.
MICROBIOLOGY:
============
[**2153-9-27**] URINE (Catheter) - Legionella Urinary Antigen,
PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
IMAGING:
=======
[**2153-9-27**] CHEST (PORTABLE AP) - Feeding tube terminates in the
proximal stomach. Patchy bibasilar opacities, slightly improved
on the left. Although possibly related to atelectasis,
aspiration should also be considered.
.
SPEECH & SWALLOW:
================
RECOMMENDATIONS:
1. Safest recommendation continues to be NPO, however patient's
family understands and is willing to accept risks of aspiration
(patient not yet made CMO) and continue po intake, suggest small
sips of honey thick liquids and puree consistencies;
2. Pills crushed with small bites of puree at home;
3. Monitor hydration as patient at risk of dehydration on
thickened liquids.
.
DISCHARGE LABS:
==============
none
Brief Hospital Course:
# Cough, question of PNA per CXR, Urine legionella screen
positive, fever to 102 in ED & looked unwell to 24H PCA.
Currently patient afebrile & o2 sats stable on RA. Family
desires treatment of any infectious process. Continue
levofloxacin q48h renally dosed for total treatment of 14 days.
Afebrile on discharge.
.
# Urinary Tract Infection
U/A positive on admission, initially placed on Macrodantin, C&S
returned ENTEROCOCCUS SP >100,000 Organisms/ml, sensitive to
Ampicillin, Nitrofurantoin & Vancomycin; resistant to
TETRACYCLINE. Patient continued/placed on ampicillin and has
five days of treatment to complete after discharge.
.
#Dementia
Increase in behavioral symptoms since wife had recent stroke &
is no longer in home, despite 24H PCAs in house. Past recent
[**Hospital1 18**] admissions for wandering, aggitation: has had Psych & [**Last Name (un) **]
consultaions. Reportedly with poor orientation at baseline.
Oriented to self (name & DOB) during this admission. Goals for
patient, per disscussions with family & HCP, now palliation.
Family will pursue home Hospice services and continue 24H PCAs.
Family to discuss w/ primary care physician utility of
continuing medications such as namenda and aricept given current
status. Would also be reasonable to consider [**Doctor Last Name 360**] for
secretions, should they become copious and bothersome to
patient, such as scopolamine. Use as needed low dose risperidal
for agitation.
# Failed swallow study x's 2
The patient continues to present with overt aspiration and had
pulled out a pedi-NGT that had been placed. After discussion
with family & with HCP by Dr [**Last Name (STitle) **] via TC: no more NGT's, no
g-tubes to be placed and the patient will be offered food for
comfort, with the accepted risk of aspiration.
.
# Guaiac positive stool.
Hemodynamically stable, GI was consulted and per discussion with
the family, the patient would likely not want further work-up
for this issue. This has been discussed by their report in the
past with the patient's PCP. [**Name10 (NameIs) **] Hct 32.8 on [**2153-9-28**].
.
# Anemia
Baseline of 30-35. B12 474 (low normal) and folate 14.0 on
[**2153-7-19**]. Current drop in HCT thought due to GIB, but now
stablized. No further W/U at this time.
.
# Acute on chronic renal failure
Cr 1.3 on presentation up from baseline of 1.0, but came down to
0.9 with hydration. IVF were repleted.
# Code Status: DNR/DNI, treat infections with antibiotics, to
consult hospice at home.
Medications on Admission:
Namenda (Memantine) 10 mg PO BID
Aricept (Donepezil) 10 mg PO QD
Risperidone 1mg PO QHS
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO q48h for 6
doses.
Disp:*6 Tablet(s)* Refills:*0*
6. Memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Ampicillin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
8. Risperdal 0.25 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for agitation.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ADMITTING DIAGNOSIS:
===================
Pneumonia, Legionella (Positive Serogroup 1 Antigen Urinary
Screen)
Urinary Tract Infection, Enterococcus Sp
Lower GI Bleed
.
SECONDARY DIAGNOSIS:
===================
Alzheimer's dementia, has had wandering & aggitation
CKD, Stage 3 (baseline creatinine ~1.0)
GERD
Anxiety
Depression
Severe degenerative disease in the lumbar spine
Anemia
h/o Prostate Ca, s/p XRT ([**2149**]), followed by Urology ([**Name8 (MD) **],MD)
h/o Diverticulum
h/o Colonic polyps
Internal hemorrhoids
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with a fever, cough and a
decline in your level of alertness. It was found that you had a
pneumonia and a urinay tract infection and have been started on
antibiotics.
.
Your family is going to arrange for additional professional help
to assist you in having the best quality of life.
.
Please take all of your medications as prescribed.
.
Contact your Primary Care Provider [**Name Initial (PRE) **]/or your other health
profesionals for any health-related concerns.
Followup Instructions:
Please notify your Primary Care Provider that you are back home.
.
Nutrition:
1. Safest recommendation continues to be nothing by mouth,
however as patient's family understands and is willing to accept
risks of aspiration, suggest small sips of honey thick liquids
and puree consistencies;
2. Pills crushed with small bites of puree at home;
3. Monitor hydration as patient at risk of dehydration on
thickened liquids.
.
Family will be contacting and arranging for home hospice
services upon discharge. Contact information will be provided by
Case Management.
Completed by:[**2153-9-29**]
ICD9 Codes: 5849, 5990, 5789, 2851, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7654
} | Medical Text: Admission Date: [**2183-5-7**] Discharge Date: [**2183-5-14**]
Date of Birth: [**2103-4-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Cath with stenting to RCA & intraluminal tPA
History of Present Illness:
80 y/o F with PMHx of HTN, hyperlipidemia who presented with CP
that first began 3 days PTA and radiated to her back. She
reports first episode of CP [**9-19**] began sunday at church with
central chest pressure, lightheadedness, diaphoresis & right arm
pain. The pain lasted approx 6 hrs then resolved spontaneously.
Pt was feeling better on Monday with only mild intermittent CP
and constipation. Then, chest pain awoke her from sleep last
night with assoc left arm pain, diaphoresis & dizziness. Pt
presented to PCP this am still c/o mild residual CP [**2-17**] that
resolved with SL nitro. EKGs were noted to have some mild TWIs
and pt was sent to ED.
.
On arrival to ED, T-97.1, BP 129/52 HR 50 RR 20 Sats 100% on RA.
Pt was denying CP & SOB, noted to be guaic negative. Cardiac
enzymes were positive and TWI noted on EKG, pt was started on
Heparin gtt and admitted for NSTEMI.
.
Pt arrived to floor complaining of mild 3/10 chest pain that
resolved with nitro SL x 1. EKGs essentially unchanged from ED
tracings.
.
On cardiac ROS, pt has dyspnea on exertion with less than 1
block of walking. Sleeps with 4 pillows but they often end up on
floor. Denies PND, ankle edema, palpitations, syncope or
presyncope. Pt denies recent fevers, chills, recent URI. Denies
BRBPR, melena & dysuria. Pt has worsened constipaton over last
month.
Past Medical History:
Hyperlipidemia
Hypertension
Low back pain
Bilateral knee pain
Seborrheic keratoses
S/p L cataract surgery [**2174**]
Social History:
current tobacco use, reports approx 50pack yr history of
smoking. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden cardiac death.
Physical Exam:
VS: T-98.1 BP 126/78 HR 54 RR 20 Sats 100% RA
Gen: WDWN female in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No lymphadenopathy,
no carotid bruits.
Neck: Supple with JVP of 8cm, no hepatojugular reflex
CV: RRR, quiet heart sounds, prominent S2. No m/r/g. No thrills,
lifts. No appreciable S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e
Skin: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
[**2183-5-10**] 07:00AM BLOOD WBC-9.2 RBC-3.56* Hgb-10.7* Hct-32.4*
MCV-91 MCH-30.1 MCHC-33.0 RDW-13.0 Plt Ct-321
[**2183-5-7**] 02:05PM BLOOD WBC-11.5* RBC-4.22 Hgb-12.6 Hct-38.7
MCV-92 MCH-29.9 MCHC-32.6 RDW-13.1 Plt Ct-363
[**2183-5-7**] 02:05PM BLOOD Glucose-104 UreaN-10 Creat-0.7 Na-140
K-3.9 Cl-101 HCO3-29 AnGap-14
[**2183-5-7**] 02:05PM BLOOD CK-MB-34* MB Indx-9.8*
[**2183-5-7**] 02:05PM BLOOD CK(CPK)-347*
[**2183-5-7**] 02:05PM BLOOD cTropnT-0.48*
[**2183-5-7**] 11:00PM BLOOD CK-MB-28* MB Indx-8.3* cTropnT-1.01*
[**2183-5-7**] 11:00PM BLOOD CK(CPK)-337*
[**2183-5-8**] 06:40AM BLOOD CK-MB-17* MB Indx-6.7* cTropnT-0.97*
[**2183-5-8**] 06:40AM BLOOD CK(CPK)-254*
[**2183-5-10**] 07:00AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.9
[**2183-5-8**] 06:40AM BLOOD Triglyc-232* HDL-39 CHOL/HD-5.7
LDLcalc-137*
.
[**2183-5-8**]: Cardiac Cath
1. Coronary angiography of this right dominant system
demonstrated 2 vessel coronary artery disease. The LMCA and
LCx had no angiographically apparent flow-limiting disease. The
LAD had a 50% mid-vessel stenosis. The RCA had a 99% proximal
stenosis from a large thrombus.
2. Limited resting hemodynamics revealed mild systemic arterial
systolic
hypertension with a central aortic pressure of 147/71 mmHg.
3. Successful stenting of the proximal RCA with a 4.0 x 12 mm
VISION BMS. Thrombectomy of the proximal RCA with extraction of
some white thrombus but persistent thrombus remained despite
thrombectomy and IC administration of TPA. Final angiography
revealed no residual stenosis in the stent, residual clot in the
vessel and TIMI II flow (See PTCA
comments)
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Mild systemic arterial systolic hypertension.
3. Thrombectomy of proximal RCA.
4. Stenting of the proximal RCA.
.
[**2183-5-9**] ECHO
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with
hypokinesis of the inferior wall and basal inferior septum (RCA
territory). The remaining segments contract normally (LVEF =
45-50%). Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion. There
is an anterior space which most likely represents a fat pad.
.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild pulmonary hypertension. Mildly dilated thoracic
aorta.
.
Compared with the prior study (images reviewed) of [**2182-3-4**], it
appears that the regional LV dysfunction is new, although the
prior study was technically suboptimal. Pulmonary pressures are
higher on today's study.
.
[**2183-5-8**]: Junctional bradycardia. Prior inferoposterior
myocardial infarction. Q-T interval prolongation. Slight ST
segment elevation in leads II, III, aVF. These findings are new
as compared with tracing of [**2165-2-26**]. Followup and clinical
correlation are suggested.
.
Cspine films: Degenerative changes at C5-C6 with narrowing of
the intervertebral disc space, subchondral sclerosis, and
anterior osteophyte formation. If there is concern for nerve
root compression, MR may be performed.
Brief Hospital Course:
80 y/o F with PMHx of HTN, hyperlipidemia who presented with
inferior NSTEMI.
.
# NSTEMI: Pt presented with 3 days of chest pain and was found
to have an inferior NSTEMI. Pt was taken to the cath lab &
found to have an intracoronay thrombus in the RCA. She
underwent PCI to RCA and received intracoronary tPA for
thrombolysis. She complete 36hrs of Integrilin and was monitored
in the CCU for 24hrs post cath. Pt did well and denied any
recurrent CP or SOB while in hospital. Pt was kept in house for
heparin bridge to coumadin given the intracoronary thrombus with
a plan for repeat cath in 4-6wks. Pt was discharged with VNA
to assist with home med teaching & assistance with additional
insurance coverage applications. Pt should continue on Aspirin,
Plavix, Atorvastatin, Metoprolol and Lisinopril. Pt had a TTE on
[**5-9**] that revealed hypokinesis of the inferior wall, basal
inferior septum and EF 45-50%. There was also evidence of mild
pulmonary hypertension. Pt remained euvolemic in house and was
given education about the importance of smoking cessation. Pt
will be following up with PCP for INR monitoring.
.
# Junctional Rhythm: Pt presented on high dose verapamil &
initial ECGs revealed an intermittent junctional rhythm with
very prolonged PR >300msec. Verapamil was stopped repeat EKGs
[**2183-5-10**] showed improved PR interval and return to NSR. A few
days after cath, pt was started on Metoprolol 12.5mg [**Hospital1 **] and
EKGs remained stable with mildly prolonged PR in sinus
bradycardia and q waves in leads II, III and aVF.
.
# HTN: BP was well controlled on regimen of Lisinopril 5mg &
Metoprolol 12.5mg [**Hospital1 **]
.
# R shoulder pain: Pt was c/o shoulder pain and radiating R arm
in house and reported that it had been present for the last
month. ROM was limited by pain. Plain films of shoulder showed
no evidence of fracture or joint space narrowing. Cervical spine
films show DJD & joint space narrowing in C5-C6. Pt denied
weakness, numbness and both strength & sensation were intact on
exam. It was thought likely that C-spine DJD and possible
radiculopathy was contributing to her symptoms. She was treated
with Tylenol 650mg q6hrs and was encouraged to get outpatient
physical therapy.
Medications on Admission:
Diclofenac 75mg daily
Verapamil SR 240mg daily
Verapamil SR 180mg qhs
Lipitor 10mg daily
Glucosamine 500mg TID
Nasacort prn
Discharge Medications:
1. Outpatient Lab Work
Please draw PT/INR and forward results to Dr. [**Last Name (STitle) **] fax [**Telephone/Fax (1) 105404**]
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed): you can take up to three
tabs in 15min for chest pain, please call PCP or come to ED if
the chest pain does not improve .
Disp:*15 Tablet, Sublingual(s)* Refills:*1*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. 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*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*20 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Nasacort AQ 55 mcg Aerosol, Spray Sig: One (1) Nasal three
times a day.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Chest pain
NSTEMI
CAD s/p stenting & intracoronary tPA
.
Secondary:
Hypertension
Hyperlipidemia
Tobacco Dependance
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with chest pain and were found to have a
myocardial infarction. You had a cardiac catheterization and
they placed a stent if your right coronary artery. It is very
important that you continue taking Aspirin & Plavix every day.
We have also started you on a blood thinner called
Coumadin(Warfarin). You will need to get labs drawn regularly
while you taking this medication in order to keep the
appropriate level in your blood. Dr.[**Name (NI) 27495**] office will help
you with this.
.
We have stopped the Verapamil, you should not take that
medication anymore. We have started Metoprolol 12.5mg twice
daily and we have started Lisinopril 5mg daily. We have
increased the Lipitor to 80mg daily. Please discuss these
changes with Dr. [**Last Name (STitle) **] in follow up, you will need to have
labs monitored while on these medications.
.
We have given you a prescription for nitroglycerin to use only
if you develop chest pain. We have also give you prescription
for Colace 100mg twice daily and Pantoprazole 40mg daily.
.
You were given information about quitting smoking. Please try to
quit after you leave the hospital.
.
If you develop any chest pain, shortness of breath, weakness or
any other general worsening of condition, please go directly to
the emergency [**Last Name (un) **].
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) 911**] in Cardiology on
the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Building on [**6-5**] at 4pm.
.
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on
Thursday [**5-22**] at 11:10am. Please call [**Telephone/Fax (1) 10688**] if you
have any questions.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
ICD9 Codes: 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7655
} | Medical Text: Admission Date: [**2143-6-6**] Discharge Date: [**2143-6-19**]
Date of Birth: [**2080-7-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2143-6-11**] Urgent coronary artery bypass grafting x5 with left
internal mammary artery to left anterior descending coronary
artery; reverse saphenous vein single graft from aorta to first
diagonal coronary artery; reverse saphenous vein single graft
from aorta to the first obtuse marginal coronary artery; reverse
saphenous vein single graft from aorta to the second obtuse
marginal coronary artery; as well as reverse saphenous vein
single graft from aorta to posterior descending coronary artery
History of Present Illness:
62 year old man with Diabetes experiencing new onset chest
pressure and right arm numbness since yesterday. Initialy
thought it was indigestion but was concerned about the arm
tingling and therefore presented to ER this AM where he wwas tx
for a STEMI with ASA, integrellin, Plavix and brought to the
cardiac catheterization lab where he was found to have 3VD.
Transferrred to [**Hospital1 18**] for CABG. Currently pain free on Heparin
and Ntg infusions.
Past Medical History:
Diabetes Mellitus
Social History:
Race: caucasian
Last Dental Exam:
Lives with: self
Occupation: machinist
Tobacco:pipe
ETOH: 2oz brady/day
recreational drugs: none
Family History:
Brother had CABG at 50yo, father had AAA
Physical Exam:
Pulse: 72 SR Resp: 16 O2 sat: 100%-2LNP
B/P Right: 149/66 Left:
Height: 176cm Weight: 77kg
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur- no M/R/G
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, non-focal exam
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit no
Pertinent Results:
[**2143-6-7**] Carotid U/S: 1. 60-69% right ICA stenosis. 2. 70-79%
left ICA stenosis. 3. Bilateral moderate-to-high grade external
carotid artery stenoses.
[**2143-6-11**] Echo: Pre-bypass: The left atrium and right atrium are
normal in cavity size. No spontaneous echo contrast or thrombus
is seen in the body of the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion. Post-bypass: The patient is
receiving no inotropic support post-CPB. Biventricular systolic
function is preserved and all findings are consistent with
pre-bypass findings. The aorta is intact post-decannulation. All
findings communicated to the surgeon intraoperatively.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] presented to outside hospital
with chest pain and found to be having a myocardial infarction.
Underwent cardiac cath which revealed severe three vessel
coronary artery disease. Transferred to [**Hospital3 **] to undergo
coronary artery bypass surgery. Upon admission he was
appropriately medically managed and underwent pre-operative
work-up while awaiting Plavix washout. On [**6-11**] he was brought to
the operating room where he underwent coronary artery bypass
grafting to five vessels. Please see operative note for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one he was started on beta-blockers and diuretics
and diuresis was started towards his pre-operative weight. He
was then transferred to the telemetry floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. Physical therapy worked with patient during post-op
course for strength and mobility. Ciprofloxacin was started for
treatment of a urinary tract infection. An ace inhibitor was
started given his preoperative myocardial infarction. He had
postoperative anemia which required two transfusions with packed
red blood cells. On POD#2 Mr. [**Name13 (STitle) 10123**] was noted to have scant
serosanguinous drainage from the distal aspect of his chest
incision. Given his history of diabetes and his long beard, he
was started and mainatined on IV cefazolin until his drainage
decreased. His incision was cleansed daily and kept covered.
His WBC remained normal and he was afebrile. On POD# 8 he was
cleared for discharge to home by Dr. [**Last Name (STitle) 914**] with VNA follow-up
and a wound check in one week.
Medications on Admission:
Glyburide
Metformin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 10 days.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
Myocardial Infarction
Past Medical History:
Diabetes Mellitus
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema but scant serosanguinous
drainage from lower aspect of his sternal incision-started on
keflex.
Leg Right/Left - both legs w/ harvest sites healing well, no
erythema or drainage.
Edema -trace edema lower extremity
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. Wash your incision
with soap and water twice daily, pat dry and cover with a clean
dry dressing twice daily.
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on [**7-9**]. [**2142**] at 1:45PM [**Telephone/Fax (1) 170**]
Wound check on [**Hospital Ward Name **] [**6-25**] at 11am.
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 14751**] in [**12-22**] weeks
Cardiologist Dr. [**First Name (STitle) **] [**Name (STitle) 33746**] in [**12-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2143-6-19**]
ICD9 Codes: 5990, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7656
} | Medical Text: Admission Date: [**2165-3-2**] Discharge Date: [**2165-3-4**]
Date of Birth: [**2131-12-18**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
33 year old man with a history of HIV (last CD4 1003 [**2-4**]) and
polysubstance abuse, presents with apnea, cyanosis, and hypoxia
after doing "poppers" (amyl nitrate) with friends. Apparently,
the patient was at a party with a large supply of amyl nitrate.
He mistakenly ingested the amyl nitrate; was also drinking
alcohol and smoking cocaine during this time. His friends
noticed he became altered and called EMS, who brought him to the
ED.
.
In the ED, initial vs were: 97 122 123/75 86%NRB. Patient had 2
PIVs 18G placed. He was apneic and lethargic and given 2.4mg of
narcan with minimal response. He desated to the 85-89% on NRB
and was given etom and succ and intubated easily with 8.0. He
was given fentanyl and versed ( 200mcg and 7 mg) for sedation
and 10mg vecuronium IV ONCE. Patient was found to have evidence
of methemoglobinemia on labs. He was seen by toxicology who
recommended methylene blue 1mg/kg. Patient was given 4L NS and
neosynephrine transiently for hypotension to the 70s, but this
was stopped after pressures normalized. Last set of vitals: 125,
128/48 no pressors, 98% on AC 500, 18, peep 5.
.
On the floor, the patient remains intubated and sedated but
responsive and denies pain. His methemoglobinemia was still
noted to be elevated at 5, and therefore was given a second dose
of methylene blue at 1mg/kg.
.
Review of systems:
Unable to obtain. Per family no complaints. He is a very private
person.
Past Medical History:
1) HIV, last CD4 count 1,003 [**2-4**] - on Atripla, last VL unknown
2) Alcohol abuse - multiple ED admissions for intoxication
3) Marijuana abuse
4) Chronic back pain, seen by pain clinic
5) h/o klonopin abuse
6) Tobacco abuse (14 pack year)
7) Depression
8) s/p ex-lap [**2155**] after stabbing incident
Social History:
MSM. Patient currently on disability for back pain. Has smoked
1 PPD for past 14 years. Has 15-20 beers per day vs. 5 half
pints of vodka per day. Has history of marijuana use, recent
cocaine use. Denies IVDU.
Family History:
Diabetes. No history of TB.
Physical Exam:
PE on admission to MICU:
General: Intubated, sedated, responsive young man in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Exam:
VS: 98.9 132/78 98 20 96% RA
GENERAL: resting in bed, pleasant, NAD
HEENT: NCAT, sclera anicteric, MMM
NECK: supple, no cervical LAD
CARDIAC: RRR, no r/m/g
LUNGS: CTAB, no wheezes, crackles, rhonchi
ABDOMEN: bowel sounds present, soft, NT, ND, no
hepatosplenomegaly, well-healed vertical incision scar, RUQ
incision scar
EXTREMITIES: warm, DT/PT/radial pulses 2+ bilaterally, no edema
NEURO: AAOx3, moving all four extremities
SKIN: excoriations on upper back, no other rashes noted
Pertinent Results:
ADMISSION LABS:
[**2165-3-2**] 05:33AM WBC-17.5* LYMPH-17* ABS LYMPH-2975 CD3-56
ABS CD3-1668 CD4-46 ABS CD4-1379* CD8-9 ABS CD8-270 CD4/CD8-5.1*
[**2165-3-2**] 05:31AM LACTATE-5.6*
[**2165-3-2**] 05:31AM HGB-15.3 calcHCT-46 O2 SAT-43 CARBOXYHB-6*
MET HGB-43*
[**2165-3-2**] 05:33AM FIBRINOGE-272
[**2165-3-2**] 05:33AM PLT COUNT-340
[**2165-3-2**] 05:33AM PT-12.4 PTT-19.3* INR(PT)-1.0
[**2165-3-2**] 05:33AM ASA-NEG ETHANOL-250* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2165-3-2**] 05:33AM ALBUMIN-4.8 CALCIUM-8.7 PHOSPHATE-5.0*
MAGNESIUM-2.5
[**2165-3-2**] 05:33AM CK-MB-3 cTropnT-<0.01
[**2165-3-2**] 05:33AM LIPASE-31
[**2165-3-2**] 05:33AM ALT(SGPT)-45* AST(SGOT)-48* CK(CPK)-303 ALK
PHOS-57 TOT BILI-0.2
[**2165-3-2**] 05:33AM GLUCOSE-186* UREA N-16 CREAT-1.6*
[**2165-3-2**] 05:45AM URINE HYALINE-[**12-15**]*
[**2165-3-2**] 05:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-1
[**2165-3-2**] 05:45AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
DISCHARGE LABS:
[**2165-3-4**] 06:25AM BLOOD WBC-8.2 RBC-4.35* Hgb-13.7* Hct-39.0*
MCV-90 MCH-31.5 MCHC-35.1* RDW-13.1 Plt Ct-293
[**2165-3-4**] 06:25AM BLOOD Glucose-113* UreaN-12 Creat-0.8 Na-140
K-4.1 Cl-106 HCO3-23 AnGap-15
IMAGING:
[**2165-3-2**] EKG: Sinus tachycardia. Baseline artifact. Poor R wave
progression. Non-specific
ST-T wave changes. Compared to the previous tracing of [**2157-5-6**]
baseline artifact is more pronounced.
[**2165-3-2**] CXR:
1. Low lung volumes.
2. Retrocardiac opacity concerning for aspiration.
3. Endotracheal tube in appropriate position.
4. NG tube with tip below GE junction, not clearly visualized
probably
projecting at the stomach.
[**2165-3-3**] CXR: Pulmonary vascular engorgement has resolved. Heart
size is normal. There is
no focal pulmonary abnormality or pleural effusion.
Brief Hospital Course:
33yo male with history of HIV and polysubstance abuse, admitted
with apnea and hypoxia in setting of methemoglobinemia after
ingestion of amyl nitrate.
#) Methemoglobinemia: Almost certainly secondary to amyl nitrate
toxicity. A level of 43 was moderately severe, and toxicology
was consulted. Amyl nitrate is a well known hemoglobin oxidizer
per toxicology, and explains the patients hypoxemia and altered
mental status. Received two treatments of methylene blue
(1mg/kg) and methemoglobin levels trended down to within normal
limits. Patient was initially intubated secondary to his altered
mental status, apnea, and hypoventilatory hypoxia, but was
improved rapidly after treatment and was extubated on [**2165-3-2**].
He was stable for transfer to medicine floor on [**2165-3-3**], and
respiratory status remained stable for remainder of his hospital
course.
.
#) Lactic acidosis: Most likely secondary to reduced O2
delivery, secondary to methemoglobinemia. Resolved with
correction with methylene blue.
.
#) Leukocytosis: WBC elevated at 17.5 on presentation. Given
finding of retrocardiac opacity on CXR with air bronchograms,
was concern for an aspiration pneumonitis or aspiration PNA.
Ceftriaxone 1gm IV Q24H and Azithromycin 500mg PO Q24H were
started. However, subsequent CXR showed that areas of
atelectasis had improved, and antibiotics were discontinued
[**2165-3-3**]. Patient's WBC continued to trend down, and was within
normal limits on day of discharge.
.
#) Depression/History of Suicidal Ideation: Patient with history
of depression and polysubstance abuse. He recently told mother
his back pain was so severe that he wanted to kill himself.
Initially, it was unclear if this incident was secondary to
lapse in judgement or a suicidal attempt. Psychiatry consulted
on [**2165-3-3**], and did not feel patient had suicidal or homicidal
ideation. Per psych recs, patient restarted on zoloft 25mg
daily at time of discharge. He will follow-up with his PCP, [**Name10 (NameIs) 1023**]
will likely be able to coordinate outpatient pysch follow-up at
[**Hospital6 **] Center.
.
#) [**Last Name (un) **]: Patient's Cr elevated at 1.6 on presentation. Was most
likely prerenal, and [**Last Name (un) **] promptly resolved with fluids.
.
#) HIV: Last known CD4 was 1003 in 1/[**2164**]. Patient had not been
taking Atripla as directed, and of note his family was unaware
of his diagnosis. His CD4 count, viral load, and HIV genotype
were checked, with results still pending at time of discharge.
Patient discharged on Atripla, and will follow-up with PCP next
week.
.
#) Transaminitis: Chronic. Most likely secondary to alcoholism,
although, ALT/AST ratio not consistent. Patient had hepatitis
serologies sent, which were still pending at time of discharge.
Will follow-up with PCP.
.
#) Alcoholism: Patient has history of heavy alcohol abuse, and
reports having up to 15-20 beers per day. Last drink was just
prior to admission. He received a banana bag on admission, and
was continued on thiamine, folic acid, and MVI. He was
monitored per CIWA protocol, and did receive diazepam in setting
of mild anxiety, restlessness, and tachycardia. No evidence of
severe withdrawal including DT. Social work was consulted, and
patient was also seen by substance abuse nurse. He was strongly
encouraged to seek to treatment, but declined any inpatient
treatment/detox programs at this time. Was given information
about potential programs and hotlines.
.
#) Cocaine abuse: Patient endorsed use of crack cocaine the
night before admission, and tox screen positive for cocaine.
Social work and substance abuse RN consulted as above.
LABS PENDING AT TIME OF DISCHARGE:
-HIV viral load
-CD4 count
-Hepatitis B, C serologies
-HIV genotype
TRANSITIONAL ISSUES:
-Patient was a full code during this admission
-Patient was counseled about polysubstance abuse as above, will
need outpatient follow-up with PCP, [**Name10 (NameIs) **] work, psych
Medications on Admission:
1) Atripla 1 tab PO daily
Discharge Medications:
1. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
2. Zoloft 25 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Methemoglobinemia secondary to amyl nitrate
ingestion
Secondary Diagnoses: Polysubstance abuse, HIV, depression
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 after you ingested amyl
nitrate (Poppers) at a party, which caused your oxygen levels to
drop dangerously low and also caused you to stop breathing for
periods of time. You were diagnosed with a condition called
methemoglobinemia, in which your blood is unable to carry enough
oxygen to the rest of your body. You were treated with a
substance called methylene blue, which helps to reverse this
condition. You initially had to be admitted to the ICU because
you required a breathing tube, but we were able the take this
tube out later that night. Your breathing significantly
improved, and your oxygen levels returned to [**Location 213**].
We are very concerned about your tobacco, alcohol, and drug use,
and strongly urge you to seek treatment with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 27299**] after you leave the hospital. You were
seen by the psychiatry team, and also the substance abuse nurse,
while you were in the hospital.
They gave you information about the LARK program at the [**Hospital1 **]
(an inpatient 3 month program for people with HIV and
addiction), and also spoke with you about other resources at the
[**Hospital 778**] Health Center. They gave you a Self Help Fact Sheet with
a 24 hour hot line number to call if you need to. It is very
important that you follow-up with your doctor for treatment, in
order to prevent another life-threatening event.
While you were here, we made the following changes to your
medications:
1. STARTED Zoloft
2. CONTINUED Atripla
Please follow-up with Dr. [**Last Name (STitle) **] in clinic.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] C.
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
within 1 week. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.
You also have an appointment scheduled with him for [**2165-3-19**].
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
ICD9 Codes: 2762, 5849, 4589, 3051, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7657
} | Medical Text: Admission Date: [**2193-4-24**] Discharge Date: [**2193-5-8**]
Date of Birth: [**2133-2-13**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Lower extremity weakness and back pain.
Major Surgical or Invasive Procedure:
T8-L5 laminectomy
History of Present Illness:
Mr [**Known lastname **] has a long history of back and leg pain. He has
undergone a previous L4-5 laminectomy which initially helped but
unfortunately his symptoms have returned. His lower extremity
weakness brought him to the Emergency Department where he was
evaulated for surgical intervention.
Past Medical History:
DM2, hypercholesterolemia, HTN, Obesity, Congenital spinal
stenosis
Social History:
Lives with wife
Denies alcohol and tobacco
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, 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- RLE 4+/5 at quads, anterior tib, [**Last Name (un) 938**] and gastrocnemius; he
was [**1-24**] at left quad, [**12-27**] anterior tibia and [**Last Name (un) 938**] and [**2-24**] at
peroneal and gastrocnemius; + sciatica; reflexes deminished and
quads and Achilles bilaterally; good peripheral pulses
Pertinent Results:
[**2193-5-3**] 07:30AM BLOOD WBC-21.4* RBC-3.45* Hgb-9.0* Hct-27.6*
MCV-80* MCH-25.9* MCHC-32.4 RDW-17.2* Plt Ct-216
[**2193-5-2**] 04:17AM BLOOD WBC-18.7* RBC-3.15* Hgb-8.1* Hct-25.0*
MCV-79* MCH-25.9* MCHC-32.6 RDW-15.5 Plt Ct-188
[**2193-5-1**] 03:09AM BLOOD WBC-16.2* RBC-2.80* Hgb-7.1* Hct-21.8*
MCV-78* MCH-25.2* MCHC-32.4 RDW-16.0* Plt Ct-191
[**2193-4-30**] 07:47PM BLOOD WBC-16.7* RBC-2.58* Hgb-6.3* Hct-19.6*
MCV-76* MCH-24.4* MCHC-32.0 RDW-15.7* Plt Ct-196
[**2193-4-30**] 02:01AM BLOOD WBC-20.1* RBC-2.80* Hgb-6.7* Hct-21.5*
MCV-77* MCH-24.1* MCHC-31.3 RDW-14.6 Plt Ct-179
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2193-4-24**] and taken to the Operating [**2193-4-27**] for T9-L5
laminectomy for congenital stenosis. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol.
Post-op his motor exam showed no movement or sensation of his
lower extremities. He was administered a stat MRI of the
cervical, thoracic and lumbar spine to assess for cord
compression. A cord signal change was identified at T10. He
was transfered to the SICU and a neurology consult was obtained
and recommendations followed. An infarct to the anterior spinal
cord was thought to have occurred. He was placed on solumedrol
for 24 hours with mild improvement in hip internal rotation.
Sensation improved.
An additional MRI was obtained which showed a post-operative
hematoma at the surgiclal site and this was aspirated under CT
guidance.
He was kept NPO until bowel function returned then diet was
advanced as tolerated.
He developed a fever and increasing white count and was placed
on antibiotics for a presumed pneumonia. He was screened for
rehab and will follow up in the Orthopaedic Spine clinic in two
weeks.
Medications on Admission:
Amlodipine/ Benzapril, Toprol, lipitor, hctz, [**Last Name (LF) **], [**First Name3 (LF) **],
Pioglitazone, oxycodone, amitriptyline, HCTZ, Ativan
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection [**Hospital1 **] (2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks.
13. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
14. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for spasms.
15. Insulin NPH & Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Congenital cervical, thoracic and lumbar stenosis
Cervical and lumbar spondylosis
Paraplegia
Post-op fever
Post-op ileus
Post-op blood loss anemia
Post-op pneumonia
Discharge Condition:
Stable
Discharge Instructions:
You have undergone the following operation: POSTERIOR
Thoracolumbar Decompression T8-L5
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 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.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-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. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
Treatments Frequency:
Please continue to change the dressing daily with dry, sterile
gauze. Look for signs of skin breakdown.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] in the Orthopaedic Spine
clinic. Call [**Telephone/Fax (1) **] to schedule an appointment in 2
weeks.
Completed by:[**2193-5-6**]
ICD9 Codes: 486, 2851, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7658
} | Medical Text: Admission Date: [**2120-6-10**] Discharge Date: [**2120-6-12**]
Date of Birth: [**2052-10-18**] Sex: F
Service: MEDICINE
Allergies:
Poison [**Female First Name (un) **] / Metallic Poisoning, Agents To Treat / Naprosyn /
Silvadene / Adhesive / nickel metal
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Referred for repeat flutter/pulmonary vein isolation
Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation
History of Present Illness:
67 yo F with hx of bacterial endocarditis s/p porcine MVR in
[**2112**] and MP/MR, Afib/flutter s/p cardioversions, and pulmonary
vein isolation in [**9-/2119**] who intially presented for repeat
flutter/pulmonary vein isolation and subsequently became
hypotensive requiring pressor support in the cath [**Year (4 digits) **] after
sedation.
.
Of note, patient was recently admitted from [**5-29**] to [**2120-5-31**] to
[**Hospital1 18**] c/o rapid palpitations due to atrial tachycardia with HR
15-150. During her admission quinidine was d/c and metoprolol
was initiated for rate control. She was discharged on metoprolol
150 mg daily.
.
In the cath [**Last Name (LF) **], [**First Name3 (LF) **] anesthesia report the pt was intubated and
given fentanyl, propofol and midazolam. Her BPs remained stable
for fisrt 3 hours of the case and then subsequently became
hypotensive with SBPs in the 90s. She was started on
phenylephrine for pressure support. She was given 3L of NS and
then 20 mg IV lasix with 1L of UOP.
.
Currently, her only complaint is generalized itching. She denies
any CP, SOB, palpitations, lightheadedness.
.
On review of systems, she denies any prior history of stroke,
TIA, pulmonary embolism, bleeding at the time of surgery, cough,
hemoptysis. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
DOE, PND, orthopnea, LE edema, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -HTN
2. CARDIAC HISTORY:
Atrial Fibrillation s/p 7 cardioversions
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-History of bacterial endocarditis [**2108**]
-Porcine mitral valve replacement [**2112**]
-Hypothyroidism
-Rheumatoid arthritis
-History of bleeding ulcer
-Low back pain
-Status post foot surgery with titanium implant
-Laminectomy
-Appendectomy
-Endometriosis
-Right oophorectomy
Social History:
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam
GENERAL: NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, MMM
NECK: Supple with no JVD
CARDIAC: RR, normal S1, S2. systolic murmur at RLSB
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: + bowel sounds. Soft, NTND.
EXTREMITIES: No c/c/e. No evidence of hematoma at L. groin.
SKIN: dry
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
.
Discharge Physical Exam
vitals: BP 80s-90s/50s
Gen: NAD
HEENT: NCAT, MMM
NECK: no JVD
CV: RRR, normal s1/s2
Resp: CTAB
ABD: soft, NT/ND
Ext: no peripheral edema bilaterally
Skin: warm, dry
Pertinent Results:
Admission Labs:
[**2120-6-10**]
WBC-4.0 RBC-4.75 Hgb-11.5* Hct-35.7* MCV-75* MCH-24.2* MCHC-32.2
RDW-18.7* Plt Ct-324
PT-22.9* INR(PT)-2.1*
Glucose-96 UreaN-22* Creat-1.2* Na-139 K-3.8 Cl-103 HCO3-26
AnGap-14
.
Discharge Labs:
[**2120-6-12**]
WBC-4.9 RBC-3.60* Hgb-8.5* Hct-26.6* MCV-74* MCH-23.6* MCHC-31.9
RDW-18.5* Plt Ct-210
PT-37.3* INR(PT)-3.8*
Glucose-80 UreaN-20 Creat-1.1 Na-137 K-4.1 Cl-106 HCO3-24
AnGap-11
.
Other Results:
ECG ([**6-12**]): "Slow" atrial flutter or atrial tachycardia with 2:1
response. ST-T wave changes are non-specific. Since the previous
tracing of [**2120-6-10**] the rhythm as [**Date Range 4030**] has replaced atrial
fibrillation.
.
ECG ([**6-10**]): Atrial fibrillation with rapid ventricular response.
Modest ST-T wave changes are non-specific.
Brief Hospital Course:
67 yo F with atrial flutter s/p multiple cardioversions and
pulmonary vein isolation in [**9-/2119**] who presented for repeat
pulmonary vein isolation. Pt's post-procedure course was
complicated by hypotension and return to atrial
flutter/fibrillation.
.
#Hypotension: Patient became hypotensive to the 90s systolic
during pulmonary vein isolation procedure and initially required
pressor support in the cath [**Year (4 digits) **]. This hypotension was most
likely due to the fact that a) this patient's baseline SBP is in
the low 100s and b) the anesthetics used during the procedure
(she received fentanyl, propofol, and midazolam) contributed
significantly to a drop in pressures. In the cath [**Year (4 digits) **], she was
started on phenylephrine for pressure support and she was given
3L of NS and then 20 mg IV lasix with 1L of urine output. In the
CCU, the pt was mentating well, her hematocrit was stable, she
had no signs of infection, and she maintained good urine output
so pressors were weaned the same evening. On transfer to the
floor on [**6-11**], her blood pressures were recorded to be in the
mid 70s systolic though pt was asymptomatic at the time and
again showed no signs of infection or acute blood loss. She
received a 500cc bolus of fluid and her calcium channel blocker
was held. Her pressures gradually improved to the 90s systolic
where she remained until discharge.
.
#Atrial flutter/fibrillation - Pt is s/p multiple cardioversions
and a previous pulmonary vein isolation and she presented for
repeat pulmonary vein isolation. Immediately following the
procedure, the patient was in sinus rhythm but the evening of
[**6-11**] the patient complained of some palpitations and she was
noted to be tachycardic to the 100s, up from 50s previously. ECG
at the time showed atrial flutter with 2:1 conduction. Her blood
pressures remained stable and the patient was otherwise
asymptomatic. She received 5mg IV Lopressor, 50mg PO Lopressor
and 40mg PO verapamil with some improvement of her rate but no
conversion of her rhythm. Per electrophysiology, she was started
on verapamil 40 mg po TID and quinidine 648 po q8. She converted
back into sinus rhythm for a few hours on [**6-11**] but in the late
evening, she was found to be in atrial fibrillation with rates
in the 90s. She continued to alternate between sinus and atrial
arrhythmias throughout the night though she remained
asymptomatic and hemodynamically stable throughout. Patient was
discharged on quinidine; her beta-blocker and CCB were held in
the setting of her low blood pressures (again though this is
likely pt's baseline) and she was given [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor
and was instructed to follow-up with EP.
.
Chronic Diagnoses
.
#MR s/p porcine valve replacement - Stable. Continued
anticoagulation with coumadin.
.
#Hyperlipidemia - Stable. Continued simvastatin.
.
#GERD - Stable. Continued protonix.
.
#Hypothyroidism - Stable. Continued synthroid.
.
#Insomnia - Stable. Continued ambien.
.
Transitional Issues
.
Patient will follow-up with EP this week regarding her
medication adjustments and her [**Doctor Last Name **] of Hearts event recorder
results.
Medications on Admission:
levothyroxine 88 mcg po qd
protonix 40 mg po qam
verapamil ER 120 mg po qd
metoprolol succinate 150 mg po qday
warfarin 5 mg po qd
ASA - 81 mg po qhs
amoxicillin - 500 mg tablet - 4 tabs po 1 hr before dental
procedure
estradiol - 10 mcg po q Tuesday and Friday
ranitidine 300 mg po qhs
ambien 10 mg po qhs prn
diazepam 10 mg po qhs for insomnia
simvastatin 40 mg po qhs
artifical tears
vitamin D
colace
MVI
Discharge Medications:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Do
not take until Friday [**2120-6-14**] after INR drawn and after talking
to Dr. [**First Name (STitle) 679**].
2. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO at bedtime.
8. multivitamin Tablet Sig: One (1) Tablet PO at bedtime.
9. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
10. diazepam 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
11. estradiol 10 mcg Tablet Sig: One (1) tablet Vaginal every
Tuesday and Friday.
12. Artificial Tears Drops Sig: Three (3) drops Ophthalmic
twice a day.
13. ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO at
bedtime.
14. quinidine gluconate 324 mg Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q8H (every 8 hours).
Disp:*240 Tablet Extended Release(s)* Refills:*2*
15. Outpatient [**First Name (STitle) **] Work
Please check CBC, INR on Friday [**6-14**] with results to Dr. [**First Name (STitle) 679**]
at [**Telephone/Fax (1) 250**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Atrial fibrillation/flutter
Secondary Diagnosis:
Dyslipidemia
Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a pumonary vein isolation procedure to try to eliminate
your atrial fibrillation. During the procedure you had some low
blood pressure and needed to be on a medicine intravenously to
keep your blood pressure up. Your blood pressure has been better
but still somewhat low since the procedure. You are now in a
normal sinus rhythm. We have adjusted your medicines to try to
keep you in a regular sinus rhythm. Please keep the follow up
appts below, Dr.[**Name (NI) 12467**] office is working on an earlier
appt for you. Please call his office if you notice any
palpitations, pain at the groin sites, dizziness or
lightheadedness. We made the following changes to your
medicines:
1. Stop taking Verapamil and metoprolol
2. Start taking quinidine again and increase the dose to 2
tablets every 8 hours.
3. Do not take coumadin today or tomorrow, please check your INR
on Friday with results to Dr. [**First Name (STitle) 679**] and he will tell you how much
coumadin to take from then on.
3. Continue your other medicines as before
.
[**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) 16403**] can be reached at ([**Telephone/Fax (1) 16404**] Office Location:
W/[**Location (un) **] 407 to discuss further use of the Lifewatch monitoring
system. For now you will need to use the [**Doctor Last Name **] of Hearts Loop
recorder and send daily transmissions to the holter [**Doctor Last Name **].
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: MONDAY [**2120-7-1**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2120-7-30**] at 11:20 AM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: THURSDAY [**2120-9-5**] at 7:30 AM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INTERNAL MEDICINE
When: WEDNESDAY [**2120-6-26**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
NOTE: Please call the office if you have any issues before
then.
ICD9 Codes: 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7659
} | Medical Text: Admission Date: [**2166-9-14**] Discharge Date: [**2166-9-19**]
Date of Birth: [**2097-5-5**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Dyspnea & weakness
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
69 y/o M w/hx CLL (not on treatment), ESRD (still making urine,
with functional AV fistula in place) listed for transplant,
T2DM, transferred from [**Hospital3 **] ED, where he was
initially brought by EMS with two days of weakness and dyspnea.
[**Hospital1 **] records indicate triage VS of 98.8, 169/69, 85, 26, 99%.
Labs notable for K+ 6.9, Troponin I 0.72, WBC 39.0. CXR
preliminary report noted "? developing right mid lung
infiltrate. Clinical correlation and followup recommended."
There, he was given levofloxacin, calcium chloride, dextrose,
insulin, sodium bicarbonate, and kayexelate. He was transferred
to [**Hospital1 18**] for further management.
.
In [**Hospital1 18**] ED, initial VS were 100.3, 102/66, 85, 22, 96% RA. Exam
notable for decreased BS on right lung, otherwise CTAB. ECG
reported as having peaked T waves. Labs were notable for
potassium of 6.4, and he was given calcium gluconate,
kayexalate, insulin, and glucose. He was given one liter NS and
albuterol nebs. Creatinine was 9 at OSH, 9.5 at [**Hospital1 18**]. Per ED
records, patient was discussed with renal and BMT services.
Patient was given acetaminophen 1g PO.
.
Per admission note, patient was initially found to be lethargic
on the floor, but arousable to voice. Labs drawn in ED (pending
at time of transfer to [**Hospital Ward Name 121**] 2), were notable for leukocytosis to
23K (96% lymphocytes), potassium of 5.8, blood gas of
7.30/23/99/12, with anion gap of 19 on metabolic panel. Renal
was consulted to the floor. A foley catheter was placed. While
on the floor, he received a one liter bolus of normal saline,
and was started on D5W with 150 mE1 NaHCO3 infusion. He was
ordered for 2g calcium gluconate.
.
On assessment by MICU resident, his vitals were 99.4, 151/76,
82, 18, 100% 3L. He reported feeling "better," but does feel
chilled.
Past Medical History:
CLL
Adult onset diabetes c/b peripheral neuropathy
chronic renal failure
coronary artery disease
cataracts
anemia
Social History:
He is a retired [**Location (un) 86**] police officer, lives with his family in
[**Location (un) 86**].
Family History:
Multiple relatives with DM; brother and sister both died from
complications from DM. Sister had fatal ovarian cancer. +CAD in
family.
Physical Exam:
VS: Temp: BP:154/69 HR:87 (regular) RR:27 O2sat:100% RA
GEN: pleasant, comfortable, NAD though mildly tremulous
HEENT: +Bulky bilateral submandibular and submental
lymphadenopathy. PERRL, EOMI, anicteric, MMM, op without
lesions. No jvd, no carotid bruits, no thyromegaly or thyroid
nodules
RESP: CTAB. No wheezes rales or rhonchi. Good air movement
throughout
CV: RRR, Normal S1 and S2, no m/r/g
ABD: Soft, NT/ND, NABS x4, No masses or HSM. No renal bruits.
EXT: no c/c/e. AV fistula in left upper extremity with audible
bruit
SKIN: no rashes/no jaundice/no splinters. +ecchymoses over
distal right 2nd toe and left 3rd toe
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. Gait assessment
deferred
RECTAL: Deferred
Pertinent Results:
Admission labs:
[**2166-9-14**] 07:45PM BLOOD WBC-23.7* RBC-2.94* Hgb-7.5* Hct-24.2*
MCV-83 MCH-25.7* MCHC-31.1 RDW-19.3* Plt Ct-123*
[**2166-9-14**] 07:45PM BLOOD Neuts-4* Bands-0 Lymphs-96* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2166-9-15**] 01:09AM BLOOD PT-14.7* PTT-31.6 INR(PT)-1.3*
[**2166-9-14**] 07:45PM BLOOD Glucose-178* UreaN-143* Creat-9.5* Na-141
K-5.8* Cl-110* HCO3-12* AnGap-25*
[**2166-9-14**] 07:45PM BLOOD ALT-15 AST-36 LD(LDH)-365* CK(CPK)-1378*
AlkPhos-89 TotBili-0.3
[**2166-9-14**] 07:45PM BLOOD Calcium-6.2* Phos-7.5*# Mg-1.7
UricAcd-16.6*
[**2166-9-14**] 09:27PM BLOOD Type-ART pO2-99 pCO2-23* pH-7.30*
calTCO2-12* Base XS--12
[**2166-9-14**] 04:42PM BLOOD Lactate-1.4 K-7.0*
[**2166-9-15**] 02:46AM BLOOD freeCa-0.80*
[**2166-9-14**] 10:40PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2166-9-14**] 10:40PM URINE Blood-LG Nitrite-NEG Protein-150
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2166-9-14**] 10:40PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2 RenalEp-0-2
[**2166-9-16**] 06:23AM URINE CastHy-0-2
[**2166-9-14**] 10:40PM URINE AmorphX-MOD
[**2166-9-16**] 06:23AM URINE Mucous-FEW
[**2166-9-14**] 10:40PM URINE Hours-RANDOM UreaN-526 Creat-79 Na-31
K-35 Cl-24
.
[**9-14**] EKG: Sinus rhythm. Left anterior fascicular block. Prior
anteroseptal myocardial infarction of indeterminate age.
Compared to the previous tracing of [**2166-9-17**] the findings are
similar.
.
STUDIES:
[**9-15**] CXR: Left lower hemithorax is uniformly opacified,
probably by a combination of consolidation and pleural effusion.
Lesser consolidation is present in the right middle lobe
laterally. Heart size is top normal, unchanged since the prior
examination. Small right pleural effusion may be present.
Findings are most consistent with bilateral pneumonia.
Asymmetric edema could be present as well or concurrently given
distention of mediastinal and hilar vessels.
.
[**9-16**] CXR: As compared to the previous radiograph, the extent of
the
pre-existing left pleural effusion has decreased. The
ventilation of the left basal and retrocardiac lung areas, has
improved. The pre-existing right parenchymal opacity is also
smaller than on the previous image. No newly appeared
parenchymal opacity. Moderate cardiomegaly without evidence of
pulmonary edema.
.
Brief Hospital Course:
69 year-old M with CLL, CKD, DMII presents with dyspnea and
weakness found to have elevated lymphocyte-predominant
leukocytosis with electrolyte abnormalities, likely secondary to
leukemoid reaction to CAP and acute on chronic kidney injury,
s/p short MICU course where he received emergent dialysis to
correct metabolic and electrolyte abnormalities
.
# Pneumonia: The patient presented with dyspnea and weakness,
and had an infiltrate on his CXR. He was started on Levofloxacin
for community acquired pneumonia. His fever curve trended down
and his leukocytosis improved. His cough resolved and his
fatigue/weakness dramatically improved. He was satting well on
room air. He was discharged home with antibiotics to complete a
14 day course, and close follow up with his primary care
physician and [**Month/Year (2) 5564**].
.
# Acute on Chronic Renal Failure: The patient has a history of
ESRD, not on HD, still producing urine. He presented with
hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia and
acute on chronic kidney injury, initially concerning for Tumor
Lysis Syndrome, despite no history of chemotherapy or
glucocorticoid use. He was started on intravenous fluids with
bicarb, and underwent emergent hemodialysis in the MICU to
correct his metabolic and electrolyte abnormalities. He was
given intravenous lasix boluses to promote urine output. After
discussion with Hematology/Oncology, Tumor Lysis Syndrome was
thought unlikely (see below). It is possible that his acute
kidney injury was due to urate nephropathy, and the other
electrolyte abnormalities were secondary to the acutely worsened
renal function. He underwent a total of three hemodialysis
sessions with much improvement. For his hypocalcemia he was
treated with IV calcium gluconate. He was started on calcitriol
and calcium carbonate supplements. A vitamin D level is pending.
He was discharged home with close follow up with his
Nephrologist.
.
# Chronic Lymphocytic Leukemia (indolent): The patient has not
required treatment for his CLL. He presented with cervical
lymphadenopathy, a lymphocyte-predominant leukocytosis, elevated
LDH, and electrolyte abnormalities, which were concerning for
[**Doctor Last Name 6261**] transformation to lymphoma with tumor lysis syndrome.
The Hematology/Oncology service was consulted and felt that
there was no evidence for this on his peripheral smear (no
blasts or prolymphocytes), and that the elevated white count was
a leukemoid rection to the pneumonia. The patient was found to
be hypogammaglobulinemic and was treated with IVIG at a dose of
400mg/kg once. He may benefit from additional IVIG in the
future. He will follow up with his [**Doctor Last Name 5564**] after discharge.
.
# Coronary Artery Disease: The patient had elevated CK &
Troponin T on admission, flat CKMB, likely related to increased
demand and decreased clearance of enzymes in setting of ESRD. No
acute ischemic changes were seen on ECG. He was re-started on a
beta-blocker (Metoprolol 50 [**Hospital1 **]) for frequent ectopy. His
primary care physician may wish to consider starting a daily
aspirin once his acute kidney injury resolves.
.
# Hypertension: The patient was mildly hypertensive on arrival
to the MICU. His anti-hypertensives were held, as fluid shifting
during initial hemodialysis sessions was felt to be somewhat
unpredictable. Once stabilized he was started on Metoprolol 50
[**Hospital1 **] (as above), and given intravenous lasix boluses (as above),
which were then transitioned to Lasix 80 PO BID. His blood
pressures remained well-controlled on this regimen, so we asked
the patient to stop his home anti-hypertensives until he follows
up with his nephrologist and primary care physician.
.
# Diabetes Mellitus II: complicated by nephropathy and
peripheral neuropathy. The patient's blood sugars were
controlled with sliding scale insulin. He required very little
insulin. He was discharged on his home regimen of Actos, at half
dose because of the concurrent Levofloxacin, to be continued
until he follows up with his primary care physician.
.
# Code Status: Full Code
.
# Patient was discharged home with VNA and Physical Therapy
services.
.
Medications on Admission:
AMLODIPINE 10 mg PO daily
CALCIUM ACETATE [PHOSLO] 667 mg Capsule PO three times a day
DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] 150
mcg/0.3 mL sq once every other week
DOXAZOSIN 2 mg Tablet PO twice a day
FUROSEMIDE [LASIX] 80 mg PO Qam, 40 mg PO Qpm (depends on edema)
GABAPENTIN 100 mg PO twice a day
NEBIVOLOL [BYSTOLIC] 5 mg PO once a day
PIOGLITAZONE [ACTOS] 15 mg PO once a day
MULTIVITAMIN 1 Tablet by mouth once a day
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO once a day.
2. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
3. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once every
other day for 4 doses: Take on [**10-4**], [**9-24**], [**9-26**].
Disp:*4 Tablet(s)* Refills:*0*
4. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Aranesp (polysorbate) 150 mcg/0.3 mL Syringe Sig: as directed
Injection once every other week.
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO twice a
day.
7. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
8. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
9. Actos 15 mg Tablet Sig: 0.5 Tablet PO once a day.
10. doxazosin 2 mg Tablet Sig: One (1) Tablet PO twice a day.
11. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig:
Three (3) Tablet, Chewable PO QID (4 times a day): Please take
this medication at least 2 hours before or after taking your
Levofloxacin.
Disp:*360 Tablet, Chewable(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Citywide VNA
Discharge Diagnosis:
Primary:
-Community-acquired pneumonia
-Acute on chronic kidney injury
.
Secondary:
-Chronic Lymphocytic Leukemia (indolent)
-Diabetes Mellitus II
-Coronary Artery Disease
-Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 3012**],
.
You were recently transferred to [**Hospital1 1170**] for management of your pneumonia and acute worsening of
kidney function. You were treated with antibiotics, and given
sessions of hemodialysis, and you improved. We are discharging
you home with close follow up with your Primary Care Physician,
[**Name10 (NameIs) **], and Nephrologist. You will be going home with
services to help build strength.
.
We are making some changes to your medication regimen:
-Please START Levofloxacin 250 mg as instructed and take the
last dose on [**9-26**]
-Please START Calcitriol 0.5 mg daily
-Please START Calcium Carbonate 500 mg three times daily
-Please START Metoprolol Succinate 100 mg daily
-Please INCREASE Furosemide (Lasix) to 80 mg twice daily
-Please DECREASE Actos to half your usual home dose until you
follow up with your primary care physician
.
-Please STOP these medications until you follow up with your
Primary Care Physician and Nephrologist:
-Amlodipine
-Nebivolol
It is extremely important that you follow up closely with the
kidney doctor (nephrologist). This will help you safely avoid
the need to be on hemodialysis for as long as possible. You
should also make sure to stay welll hydrated given you are on a
higher dose of Lasix. Please discuss with your nephrologist
whether you should decrease your Lasix dose as an outpatient
back to your previous home dose.
Followup Instructions:
You should follow up with Dr. [**First Name (STitle) 805**], your Nephrologist, on
Monday [**9-22**]. His office phone is: [**Telephone/Fax (1) 2378**].
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Location (un) 35593**], [**Street Address(1) 4323**],[**Numeric Identifier 4325**]
Phone: [**Telephone/Fax (1) 35276**]
Appointment: Thursday [**2166-9-25**] 2:30pm
.
Department: HEMATOLOGY/BMT
When: TUESDAY [**2166-11-11**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: TRANSPLANT CENTER
When: TUESDAY [**2167-3-3**] at 10:40 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 486, 5856, 5849, 3572, 2767, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7660
} | Medical Text: Admission Date: [**2119-12-9**] Discharge Date: [**2119-12-19**]
Date of Birth: [**2065-11-22**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 54 year-old
male who presents with chest discomfort. He has had chest
discomfort for approximately the last six months. The
patient has had pain at rest for the last month.
PAST MEDICAL HISTORY: Hypercholesterolemia, hypertension,
inguinal hernia repair, inner ear surgery in [**2097**].
MEDICATIONS: Ecotrin, aspirin 325 mg q day, Lopressor 50 mg
b.i.d., sublingual nitro prn.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Heart rate 60. Blood pressure 130/80.
Neck no bruits. Chest clear to auscultation. Heart regular
rate and rhythm. No murmurs. Abdomen soft, nontender,
nondistended. Extremities no edema.
HOSPITAL COURSE: Cardiac catheterization was performed. See
the report for full details. Essentially it showed three
vessel disease with 50% occlusion of the left anterior
descending coronary artery, 80% occlusion of diagonal one and
diagonal two. The patient was brought to the Operating Room
on [**2119-12-12**]. The procedure performed was a coronary
artery bypass graft times three with left internal mammary
coronary artery to left anterior descending coronary artery,
saphenous vein graft to obtuse marginal one and diagonal one.
The pericardium was left open and arteriole line Swan-Ganz
catheter was placed, atrial and ventricular wires were
placed. The patient was brought to the Intensive Care Unit
where he was rapidly extubated. The patient was requiring a
neo drip for a hypotensive episode. Electrocardiogram at
that time revealed mild ST elevations for which cardiac
enzymes were cycled. They were mildly elevated with the CKMB
being 14. However, the enzymes cycled into the normal range.
The patient also developed a pneumothorax at that time. A
chest tube was placed in the Intensive Care Unit. On postop
day two the neo drip was appropriately weaned. On postop day
three the patient was transferred to the floor where his
Foley catheter pacing wires were removed. A chest x-ray the
lungs to have tiny bilateral apical pneumothoraces. Due to
minimal drainage the chest tubes were removed. On postop day
four a chest x-ray revealed tiny bilateral apical
pneumothoraces, which were stable. Hematocrit on postop day
four was 20.4 and for this the patient was transfused 2 units
of packed red blood cells. By postop day six the patient was
tolerating a regular diet and was ambulating at a level five
and the pain was properly controlled.
LABORATORY DATA ON DISCHARGE: Hematocrit 30.8, sodium 138,
potassium 4.7, chloride 102, bicarbonate 29, BUN 15,
creatinine .8, glucose 97.
His examination was benign. His sternum was stable with no
drainage.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: Lopresor 25 mg po b.i.d., Lasix 20 mg
po b.i.d. times seven days, K-Ciel 20 milliequivalents po
b.i.d. times seven days, aspirin 325 mg po q.d., Percocet one
to two tab po q 4 to 6 hours prn pain, Colace 100 mg po
b.i.d.
DISCHARGE STATUS: Home. The patient will follow up with his
primary care physician or cardiologist in three weeks and Dr.
[**Last Name (STitle) 70**] in four weeks.
DISCHARGE DIAGNOSIS:
Status post coronary artery bypass graft times three.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2119-12-19**] 09:43
T: [**2119-12-19**] 10:07
JOB#: [**Job Number **]
ICD9 Codes: 4111, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7661
} | Medical Text: Admission Date: [**2166-8-4**] Discharge Date: [**2166-8-18**]
Service:
HISTORY OF THE PRESENT ILLNESS: This 81-year-old white male
was referred to [**Hospital1 18**] for cardiac catheterization after a
positive stress MIBI. He has had a history of prior TIAs and
known atherosclerotic disease. He denied any chest
discomfort or shortness of breath and was in his usual state
of health. He did have a pacemaker implanted several years
ago for a rapid heart rate. He had an echocardiogram in [**Month (only) 205**]
which revealed an EF of 35-40%, severe LVH with anteroseptal,
inferoseptal, and inferior hypokinesis and apical akinesis.
The LA was moderately dilated. He had [**11-21**]+ MR, [**11-21**]+ TR,
moderate pulmonary hypertension, minimal AS and trace AI. He
had a positive stress test on [**2166-7-1**] and was referred for
cardiac catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Infrarenal AAA 4.8 by 4.4 cm.
3. Hypertension.
4. Status post CVA/TIA.
5. Status post bilateral carotid endarterectomies in [**12-21**].
6. History of hyperlipidemia.
7. History of chronic renal insufficiency with a creatinine
of 1.7 to 2 baseline.
8. History of noninsulin-dependent diabetes.
9. Status post pacer placement.
10. Status post appendectomy.
ADMISSION MEDICATIONS:
1. Uniretic 15/25 one p.o. q.d.
2. Lipitor 10 mg p.o. q.d.
3. Toprol XL 25 mg p.o. q.d.
4. Coumadin 4 mg p.o. q.d.
5. Albuterol two puffs q.a.m.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: He lives alone. He quit smoking in [**2108**] and
does not drink alcohol.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION ON ADMISSION: General: He is an
elderly white male in no apparent distress. Vital signs:
Stable, afebrile. HEENT: Normocephalic, atraumatic. The
extraocular movements were intact. The oropharynx was
benign. Neck: Supple, full range of motion. No
lymphadenopathy or thyromegaly. Carotids were 2+ and equal
bilaterally without bruits. Lungs: Clear to auscultation
and percussion. Abdomen: Soft, nontender with positive
bowel sounds and a pulsatile mass. He also had a balloon
pump in place. Extremities: Without clubbing, cyanosis or
edema. Pulses were 2+ and equal bilaterally throughout
except the DP and PT were only Doppler flow.
HOSPITAL COURSE: The patient was admitted for cardiac
catheterization. The patient underwent cardiac
catheterization on [**2166-8-5**]. The left main revealed mild
distal disease, LAD had a proximal 95% stenosis, was heavily
calcified with serial 80% mid and distal stenoses, left
circumflex had a proximal 90% stenosis at the bifurcation of
the left circumflex and OM1 with a questionable occluded
proximal marginal midvessel 80% left circumflex disease. The
RCA had serial diffuse 50-60% stenosis with midvessel 80%
stenosis.
He had a balloon pump placed in the Catheterization
Laboratory and Dr. [**Last Name (STitle) 70**] was consulted. He had carotid
ultrasounds done which revealed no evidence of stenosis.
On [**2166-8-6**], the patient underwent a CABG times three with
LIMA to the LAD, reverse saphenous vein graft to OM, reverse
saphenous vein graft to RPDA. The cross clamp time was 54
minutes. Total bypass time 80 minutes. He was transferred
to the CSIU on Neo, milrinone, and propofol. He was
extubated on postoperative night and he was still on his
milrinone and Neo. He also had his pacemaker interrogated
and the atrial lead was not working appropriately. He will
have this dealt with as an outpatient. He went back into his
chronic atrial fibrillation. He was slowly improving.
On postoperative day number two, he had acute hypoxia and
Pulmonary was consulted. They recommended inhaled steroids.
Following this consult, he had hemoptysis. He had an urgent
intubation and had large clots removed from his airway. He
had hypotension at this time as well. He was re-Swanned.
His cardiac index was stable. This hemoptysis resolved
eventually and he remained sedated and had a slow milrinone
wean for the next couple of days. He was extubated again on
postoperative day number five and required aggressive
respiratory therapy.
He had his chest tubes discontinued on postoperative day
number six. His milrinone was discontinued as well. He was
on levofloxacin for his secretions. He slowly improved,
weaning off his 02 requirement.
On postoperative day number nine, he was transferred to the
floor in stable condition. He continued to improve and was
diuresed. He was also started on nutritional supplements and
he continued to improve. On postoperative day number 13, he
was discharged to rehabilitation in stable condition.
LABORATORY DATA ON DISCHARGE: Hematocrit 29.4, white count
13,300, platelets 347,000. Sodium 139, potassium 4.1,
chloride 104, C02 27, BUN 50, creatinine 1.9, blood sugar 91.
PT 15, INR 1.5.
DISCHARGE MEDICATIONS:
1. Lipitor 10 mg p.o. q.d.
2. Albuterol MDI one to two puffs q.a.m.
3. Combivent one to two puffs q.i.d. p.r.n.
4. Amiodarone 400 mg p.o. b.i.d. times seven days and then
decrease to 400 mg p.o. q.d. times seven days and then
decrease to 200 mg p.o. q.d.
5. Coumadin 1 mg p.o. q.d. for an INR goal of 1.5 to 2.
6. Lasix 20 mg p.o. b.i.d. for seven days.
7. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. q.d. for seven days.
8. Neosporin ophthalmic ointment four times a day to both
eyes for seven days.
FOLLOW-UP: The patient will be followed by Dr. [**Last Name (STitle) 17887**] in
one to two weeks, Dr. [**Last Name (STitle) 1016**] in two to three weeks, and Dr.
[**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 6516**]
MEDQUIST36
D: [**2166-8-18**] 11:22
T: [**2166-8-18**] 11:25
JOB#: [**Job Number 46365**]
ICD9 Codes: 496, 4280, 5119, 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7662
} | Medical Text: Admission Date: [**2122-11-2**] Discharge Date: [**2122-11-14**]
Date of Birth: [**2052-4-9**] Sex: F
Service: MEDICINE
Allergies:
Meperidine / Erythromycin Base / Oxycodone / Fentanyl / Levaquin
/ Cephalosporins
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
mid sternal chest pressure associated with SOB at rest, relieved
with NTG
Major Surgical or Invasive Procedure:
[**2122-11-3**] - CABGx3 (LIMA-->LAD, SVG-->OM, SVG-->RCA), AVR (21mm
CE pericardial model 2800)
[**2122-11-2**] - Cardiac Catheterization
History of Present Illness:
70 year old white female with extensive cardiac history, EF
<20%, past MI's, several RCA PCI's, including rotational
atherectomy/PTCA/stenting of proximal and mid RCA in [**2-21**], HTN,
hyperlipidemia, PVD, Type II DM, presented to osh ER on [**2122-10-30**]
with c/o recurrent angina. States had mid-sternal chest "heavy
pressure" associated with SOB at rest. Took NTG SL and pain
resloved however recurred and she went to ER. Denies
diaphoresis, N/V, palpitations, lightheadedness, PND, orthopnea.
Patient ruled out for MI by enzymes. ECG showed anterolateral
ST depression. She was placed on NTG gtt primarily for BP
control. She was then transferred to [**Hospital1 18**] for cardiac
cath(results below).Referred to Dr. [**Last Name (STitle) **] for AVR/CABG.
Past Medical History:
1. CAD. Cardiac cath in [**2117**] with 80% proximal RCA lesion,
50-60% distal RCA lesion, 50% OM and a 40% distal LM/PLAD
lesion. S/p PTCA and stent placement to the proximal RCA.
Cardiac cath [**2118**]: RCA had an ostial 30-40% stenosis and mild
30-40% diffuse in-stent restenosis. EF of 60%. Cardiac cath
[**2121-12-26**], with 30% instent restenosis in the previously placed
RCA stent, and 95% mid vessel stenosis. PTCA with Cypher stent
placement performed, with 10% residual stenosis.
2. CHF, last EF 60% in [**2118**]. Recent ECHO showed her EF to be
40%.
3. Hypothyroidism
4. Diabetes mellitus type 2
5. COPD
6. mild CRI
7. elev. chol
8. prior GI bleed on ASA/plavix
Past Surgical History:
1. Aorto-bifem bypass [**2111**]
2. Pseudoaneurysm repair '[**17**]
3. Bilateral cataract surgery
Social History:
She lives with her sister, no etOH. Ex-smoker, stopped smoking 9
years ago (smoked [**12-21**] ppd X 35 yrs).
Family History:
noncontributory
Physical Exam:
BP right arm 111/41 left arm 156/52
HEENT: Bliateral carotid bruits present
Chest: CTA, RRR no m/r/g
ABD: S/NT/ND/BS+
EXT: multiple varicosities
Pulses:
right radial + brachial + femoral + DP + PT +
left radial + brachial + femoral + Dp + PT +
Pertinent Results:
[**2122-11-10**] 12:35PM BLOOD WBC-7.6 RBC-4.51 Hgb-13.2 Hct-38.3 MCV-85
MCH-29.3 MCHC-34.5 RDW-14.5 Plt Ct-259
[**2122-11-10**] 12:35PM BLOOD Plt Ct-259
[**2122-11-10**] 12:35PM BLOOD Glucose-184* UreaN-42* Creat-1.5* Na-136
K-4.6 Cl-93* HCO3-30 AnGap-18
[**2122-11-10**] 12:35PM BLOOD Calcium-8.9 Phos-4.0 Mg-2.1
[**2122-11-5**] 06:14PM BLOOD Hapto-217*
[**2122-11-2**] Cardiac Catheterization
1. Selective coronary angiography of this right dominant
system demonstrated severe two (2) vessel coronary artery
disease.
Specifically the left main was heavily calcified and
demonstrated
diffuse disease with a 80% ostial lesion that extended into the
Aorta.
The Left circumflex demonstrated mild illuminal irregularites
throughout
the vessel with no flow limiting lesions. The LAD also
demonstrated
only minor illuminal irregularities. The RCA was diffusely
diseased
throughout the vessel with extensive in-stent restenosis with an
80%
ostial lesion and a 90% mid vessel lesion.
2. LV ventriculography was deferred.
3. Limited resting hemodynamics demonstrated an elevated
central aortic
pressure.
[**2122-11-10**] CXR
Moderate bilateral pleural effusions are increasing in size. In
addition, there is moderate-to-severe bilateral atelectasis.
Pneumonia as an explanation for increasing left lower lobe
opacity cannot be excluded. The heart is normal size, the
mediastinal caliber is within normal limits, and there is no
evidence for pulmonary edema. Right IJ catheter tip projects
over the SVC and pacemaker leads course their anticipated paths.
Median sternotomy wires identified. No pneumothoraces.
[**2122-11-3**] Carotid Series
Moderate plaque with bilateral 40%-59% carotid stenosis. Of
note, on the left vertebral artery, there is increase in
velocity, which is consistent with some intrinsic disease.
[**2122-11-2**] ECHO
The left atrium is normal in size. The left ventricular cavity
size is normal. LV systolic function appears mildly to
moderately depressed. Resting regional wall motion abnormalities
include inferior and inferolateral akinesis/hypokinesis. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is mild
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
There is an anterior space which most likely represents a fat
pad, though a loculated anterior pericardial effusion cannot be
excluded.
Compared with the prior study (tape reviewed) of [**2122-2-27**], the
left ventricle now appears less dilated and left vnetricualr
systolic function appears less depressed. Mitral regurgitation
is now less prominent.
[**2122-11-13**] 07:15AM BLOOD Hct-33.4*
[**2122-11-13**] 07:15AM BLOOD UreaN-59* Creat-2.0*
[**2122-11-12**] 06:55AM BLOOD UreaN-53* Creat-1.8* K-4.2
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2122-11-2**] for further
management of her chest pain. She was taken to the
catheterization lab where she was found to have an 80% stenosed
left main coronary artery and a 90% in-stent stenosed right
coronary artery. Given the severity of her disease, the cardiac
surgical service was consulted for surgical revascularization.
She was worked-up in the usual preoperative manner including a
carotid duplex ultrasound which revealed moderate plaque with
bilateral 40%-59% carotid stenosis. An echocardiogram was
performed which revealed 1+ aortic regurgitation, 1+ mitral
regurgitation and an ejection fraction of 40-45%.
On [**2122-11-3**], Ms. [**Known lastname **] was taken to the operating room. An
intraoperative transesophageal echocardiogram revealed severe
aortic stenosis and EF 30-35% thus she underwent coronary artery
bypass grafting to three vessels and an aortic valve replacement
using a 21mm [**Last Name (un) **] [**Doctor Last Name **] pericardial model 2800
bioprosthesis. Postoperatively she was taken to the cardiac
surgical intensive care unit for monitoring. On postoperative
day one, she awoke neurologically intact and was extubated. The
electrophysiology service was consulted for interrogation of her
internal cardiac defibrillator and some changes were made to the
atrial and ventricular output. Beta blockade and aspirin were
resumed. She was gently diuresed towards his preoperative
weight. As she was anemic postoperatively, she was transfused
with packed red blood cells. Her oxygen requirements remained
high given her COPD however slowly improved over time. On
postoperative day seven, she was transferred to the step down
unit for further recovery. The physical therapy service was
consulted to assist with her postoperative strength and
mobility. Her oxygen saturations improved to 93% on a nasal
canula. Her creatinine rose to 2.0 on POD #10 and her lasix was
decreased to 20 mg qd. She continued to be monitored on the
floor and awaits tranfer to rehab. (stopped [**11-13**]).
Medications on Admission:
Toprol XL 100mg QAM and 200mg QPM
Aldactone 25mg QD
Aspirin 81mg daily
Zocor 40mg daily
Iron
Synthroid 100mcg daily
Glucophage 1000mg twice daily
aldactone 25 mg daily
Imdur 30mg twice daily
Norvasc 5mg daily
Protonix 40mg twice daily
Prednisone for rash ( completed wean off on [**11-1**])
betamethasone ointment to back rash [**Hospital1 **]
Discharge Medications:
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
CHF
HTN
DM, type II
Hypercholesteremia
CAD
PVD
CRI
COPD
Anemia, past GIB on plavix/ASA
Colon polyps
C. Diff [**1-24**]
PCI
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
one week.
3) No lotions, creams or powders to wounds
4) Report any fevers greater then 100.5
5) no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in four weeks ([**Telephone/Fax (1) 11763**]
Follow up with Dr. [**Last Name (STitle) 11493**] in [**12-21**] weeks ([**Telephone/Fax (1) 11764**]
Completed by:[**2122-11-14**]
ICD9 Codes: 4241, 4280, 496, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7663
} | Medical Text: Admission Date: [**2182-2-22**] Discharge Date: [**2182-2-26**]
Date of Birth: [**2129-5-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2182-2-22**] Closure of atrial septal defect with a Dacron patch
History of Present Illness:
52 year old male who was referred to cardiologist last year for
evaluation of hypertension and murmur. He underwent an echo
which revealed a large ASD. He subsequently underwent a cardiac
MRA which also revealed the large secundum ASD with significant
left-to-right shunt. Recent cardiac cath also confirmed this
finding and revealed no coronary artery disease.
Past Medical History:
Hypertension
Hyperlipidemia
trauma R thumb
mild GERD
s/p repair R thumb lac.(pins)
s/p R shoulder [**Doctor First Name **]
Social History:
Race:Caucasian
Last Dental Exam:3 months ago
Lives with:wife
Occupation:[**Name2 (NI) 29798**]
Tobacco: never
ETOH: 2 glasses wine/wk
Family History:
Many siblings with CAD requiring bypass surgery
Physical Exam:
Pulse: 80 Resp: 16 O2 sat: 99%
B/P Right:134/78 Left: 139/65
Height: 5' 6" Weight: 150 lbs
General:NAD, fit-appearing
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera,OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur- 1-2/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x] no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: None [x]
R thumb scarred with decreased flexion, diminutive nail
Neuro: Grossly intact, nonfocal exam; MAE [**3-28**] strengths
Pulses:
Femoral Right:2+ Left:2+ ; fading ecchymosis R cath site
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 1+ Left:1+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2182-2-22**] Echo: Prebypass: No spontaneous echo contrast is seen in
the body of the left atrium or left atrial appendage. A large
secundum atrial septal defect is present with a left-to-right
shunt across the interatrial septum at rest. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The right ventricular cavity is
dilated with normal free wall contractility. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
Postbypass: The patient is in sinus rhythm on an infusion of
phenylephrine. The secundum atrial septal defect has been
closed. No flow is seen between the left and right atria at
rest. Biventricular systolic function continues to be normal
with some right ventricular dilation. Mitral regurgitation and
tricuspid regurgitation are now mild. The thoracic aorta is
intact post decannulation.
[**2182-2-25**] 06:22AM BLOOD WBC-8.1 RBC-3.50* Hgb-11.3* Hct-33.3*
MCV-95 MCH-32.3* MCHC-34.0 RDW-13.0 Plt Ct-157
[**2182-2-26**] 04:35AM BLOOD UreaN-20 Creat-1.0 Na-141 K-4.3 Cl-104
[**2182-2-26**] 04:35AM BLOOD Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 95441**] was a same day admit after undergoing
pre-operative work-up as an outpatient. On [**2-22**] he was brought
directly to the operating room where he underwent closure of his
ASD. Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later that day he was weaned from sedation,
awoke neurologically intact and extubated. On post-operative day
one he was transferred to the step-down floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. He continued to make good progress while working with
physical therapy for strength and mobility. He went iinto A Fib
briefly and was started on amiodarone with conversion to SR. On
post-op day #4 he was ready for discharge home with VNA
services. All appropriate medications and appointments were
made.
Medications on Admission:
Aspirin 325mg daily
Simvastatin 40mg daily
Losartan-HCT 100-12.5mg daily
Bystolic 5mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] through [**3-2**]; then 400 mg daily [**Date range (1) 86878**];
then 200 mg daily ongoing as directed by cardiologist.
Disp:*120 Tablet(s)* Refills:*1*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*7 Tablet(s)* Refills:*0*
8. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO DAILY (Daily) for 5 days.
Disp:*7 Tablet Extended Release(s)* Refills:*0*
9. ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO three times a
day for 1 weeks.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Atrial septal defect (ASD) s/p ASD closure
postop A Fib
Past medical history:
Hypertension
Hyperlipidemia
trauma R thumb
mild GERD
s/p repair R thumb lac.(pins)
s/p R shoulder [**Doctor First Name **].
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
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on...
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7389**] on...
Wound check in [**Hospital Unit Name **], [**Hospital Unit Name **] on...
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**2-26**] 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:[**2182-2-26**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7664
} | Medical Text: Admission Date: [**2184-2-26**] Discharge Date: [**2184-3-6**]
Date of Birth: [**2126-3-11**] Sex: M
Service: Transplant
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
male with end-stage liver disease secondary to hepatitis B
diagnosed in [**2158**]. The patient developed cirrhosis due to
chronic hepatitis B. The patient was diagnosed with
hepatocellular carcinoma in [**2183-7-21**] and underwent a
radiofrequency ablation of the nodule in [**2183-9-20**].
PAST MEDICAL HISTORY: Otherwise, past medical history is
only significant for a gastric polyp and low back pain.
PAST SURGICAL HISTORY: Significant for right inguinal hernia
repair and umbilical hernia repair.
MEDICATIONS AT HOME: Zantac and Aleve.
ALLERGIES: The patient is allergic to COMPAZINE (leading to
locked jaw).
SOCIAL HISTORY: The patient does not smoke. The patient
stopped drinking about six years ago. The patient has a
remote history of cocaine use; quit nine years ago.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 95.8,
his heart rate was 81, his blood pressure was 126/80, his
respiratory rate was 20, and 95% on room air. The patient
was alert and oriented times three and in no apparent
distress. Mildly icteric sclerae. The neck was supple.
Cardiovascular examination revealed a regular rate and
rhythm. Normal first heart sounds and second heart sounds.
No murmurs were heard. Respiratory examination clear to
auscultation bilaterally. Abdominal examination revealed the
abdomen was soft, nontender, and nondistended. There was an
umbilical scar without hernia. There was no
hepatosplenomegaly. The extremities were without edema.
Femoral, dorsalis pedis, and posterior tibialis pulses were
2+ bilaterally.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram
preoperatively revealed a normal sinus rhythm at a rate of 78
without any ST segment changes.
A chest x-ray was clear without any acute cardiopulmonary
process.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 4.8, his hematocrit was 42, and his platelets
were 174. Sodium was 139, potassium was 4.1, chloride was
105, bicarbonate was 26, blood urea nitrogen was 12,
creatinine was 0.8, and his blood glucose was 102. Calcium
was 9.6, his phosphate was 4.6, and his magnesium was 1.
Aspartate aminotransferase was 36, alanine-aminotransferase
was 44, alkaline phosphatase was 79, and his total bilirubin
was 1.3. Prothrombin time was 13.8, his partial
thromboplastin time was 31.8, with an INR of 1.3.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient presented to
[**Hospital1 69**] on [**2184-2-26**] in
preparation for orthotopic liver transplantation and
underwent this procedure on [**2184-2-26**] without any
complications. Please see the Operative Report for further
details.
Prior to surgery, the patient underwent immunosuppressive
induction, receiving CellCept [**Pager number **] mg on call to the
operating room. In the operating room, the patient received
1000 mg of Solu-Medrol as well aspirin 20 mg of Simulect.
The patient also received 10,000 units of hepatitis B
immunoglobulin intraoperatively. In addition, the patient
also received a dose of Unasyn, 400 mg of fluconazole,
Bactrim single strength, and 450 mg of Valcyte on call to the
operating room.
The patient underwent the procedure, was in stable condition,
and was doing so well that the patient was extubated shortly
after arrival to the Intensive Care Unit. The patient's
aspartate aminotransferase and alanine-aminotransferase
levels were elevated postoperatively, which was expected.
Because the patient's INR was 2 postoperatively, the patient
was given 2 units of fresh frozen plasma and 1 unit of
cryoprecipitate.
The patient did well during his brief Intensive Care Unit
stay, having made over 1.2 liters of urine at the end of
postoperative day zero and another 3.8 liters of urine by the
end of postoperative day one. The patient's liver function
tests numbers were appropriately coming down, and during this
time the patient was prophylactically covered with two days
of Unasyn. The patient received intravenous ganciclovir, and
the patient was continued on anti hepatitis B surface
antigen/antibody which was started intraoperatively. The
patient completed a full 7-day course of hepatitis B
immunoglobulin, and therapeutic levels were documented by
quantitating the level of the antibody in the serum. On each
of the days the patient received the medications, the
patient's tidal levels were 450.
The patient underwent an ultrasound of the liver on
postoperative day one which showed normal arterial and venous
phase as well as patent ......... portal vein.
The patient was on the floor by postoperative two, tolerating
diet and making ample amounts of urine. The patient had two
[**Location (un) 1661**]-[**Location (un) 1662**] drains. On postoperative day three, the
patient's lateral [**Location (un) 1661**]-[**Location (un) 1662**] drain was discontinued.
The patient was found to have an elevated total bilirubin on
postoperative day three; jumping from 0.8 on postoperative
day two. Because of the elevations in the total bilirubin
which peaked at 40.2, on postoperative day four the patient
underwent an ultrasound-guided biopsy of the liver which did
not show any evidence of acute cellular rejection. The
patient was found to have reperfusion injury. The patient
also underwent a repeat Duplex ultrasound of the liver which
showed a patent arterial and venous supply to the liver with
normal resistive indices. Given the normal Duplex
ultrasound, there was no need to proceed to angiography.
The patient also underwent tube cholangiogram which showed
good common bile duct anastomosis without any biliary leak
and without any evidence of obstruction or stricture.
Because of the excellent tube cholangiogram results, the
patient's T-tube was capped on postoperative day six. By
then, the patient's total bilirubin was trending downward,
and by postoperative day nine the patient's total bilirubin
came down to 3.4 with a decrease in the aspartate
aminotransferase, alanine-aminotransferase, and alkaline
phosphatase levels as well.
Following summaries the immunosuppressive course therapy for
the patient, as mentioned above, the patient received 1000 mg
of CellCept on call to the operating room, and
intraoperatively received 1000 mg of Solu-Medrol, and 20 mg
of Simulect. The patient was started on Neoral on
postoperative day one at 200 mg by mouth twice per day and
received 240 mg of Solu-Medrol in addition to the ongoing
1000 mg of CellCept twice per day. The patient's Solu-Medrol
dose was tapered down to 120 mg on postoperative day three
and 80 mg on postoperative day four. The patient received 40
mg of by mouth prednisone on postoperative days five and six
and continued to receive 20 mg of by mouth prednisone
starting on postoperative day seven. The patient received a
dose of Simulect 20 mg on postoperative day four as
scheduled, and the patient's Neoral dose was adjusted as per
his C2 level, and on the day of discharge the patient was
discharged on 300 mg by mouth twice per day.
Prior to discharge, the patient experienced intermittent
nausea and vomiting. It was thought that the nausea was due
to gastrointestinal intolerance side effect of CellCept. The
patient was changed from 1000 mg twice per day to 500 mg four
times per day of CellCept which the patient tolerated better
with only mild nausea and no vomiting. Otherwise, the
patient did well. The medial [**Location (un) 1661**]-[**Location (un) 1662**] drain was
discontinued on the day of discharge (on postoperative nine).
Laboratory values on discharge were a white blood cell count
of 6.7, a hematocrit of 35.5, and platelets of 221. Sodium
was 132, potassium was 4.3, chloride was 99, bicarbonate was
23, blood urea nitrogen was 16, creatinine was 0.9, and his
blood glucose was 108. Calcium was 8.2, his magnesium was
1.7, and phosphate was 4.3. Aspartate aminotransferase was
176, his alanine-aminotransferase was 460, his alkaline
phosphatase was 57, and his total bilirubin was 3.4.
DISCHARGE STATUS: To home with services.
CONDITION AT DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. End-stage renal disease due to hepatitis C.
2. Hepatocellular carcinoma.
3. Status post orthotopic liver transplantation on [**2184-2-26**].
MEDICATIONS ON DISCHARGE:
1. Neoral 300 mg by mouth twice per day.
2. CellCept [**Pager number **] mg by mouth four times per day.
3. Prednisone 20 mg by mouth once per day.
4. Fluconazole 400 mg by mouth once per day.
5. Bactrim single strength one tablet by mouth every day.
6. Lamivudine 100 mg by mouth once per day.
7. Valcyte 450 mg by mouth once per day.
8. Protonix 40 mg by mouth once per day.
9. Percocet 5/325-mg tablets one to two tablets by mouth
q.4-6h. as needed (for pain).
10. Colace 100 mg by mouth twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
the Transplant Center on [**2184-3-10**].
2. The patient was to have his laboratories drawn every
Monday and Thursday morning for complete blood count,
Chemistry-10, aspartate aminotransferase, alkaline
phosphatase, total bilirubin, and cyclosporin level drawn
exactly two hours after a.m. Neoral dose.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 10201**]
MEDQUIST36
D: [**2184-3-7**] 01:03
T: [**2184-3-7**] 09:44
JOB#: [**Job Number 102050**]
ICD9 Codes: 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7665
} | Medical Text: Admission Date: [**2154-4-18**] Discharge Date: [**2154-5-1**]
Date of Birth: [**2089-12-28**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Pancreatic Mass
Major Surgical or Invasive Procedure:
s/p Roux-en-Y hepaticojejunostomy, gastrojejunostomy, repair of
duodenal perforation
J-tube
History of Present Illness:
The patient is a 64 year old female who presents with 2-3 weeks
of jaundice and pruritis. She also reports a 17 lb weight loss
in the past month. She had previously been seen in at [**Hospital1 9191**] where she had a ERCP with stent placement and biopsy. A
EUS/FNA was positive for malignant cells. She presents to [**Hospital1 18**]
for a staging laparotomy.
Past Medical History:
Jaundice
Pruritis
Chronic Back Pain
Diverticulitis
Social History:
She is retired worker from a Chocolate Factory
Tobacco 1-2 packs for 30 years
Family History:
Brother and sister with pancreatic cancer
Father with prostate cancer
Niece with liver cancer
Niece with breast cancer
Physical Exam:
VS: HR 64, BP 112/65
HEAD: anterior cervical LAD - one 1cm x 1.5cm LN, soft,
nonmobile
Cardiac: RRR, S1, S2, no murmur
Pulm: RUL field - rhonchi
Abd: no scars, soft, nontender, ND, no HSM
Lymph: no axillary, supraclavicular LAD
Pertinent Results:
SPECIMEN SUBMITTED: GALLBLADDER.
Procedure date Tissue received Report Date Diagnosed
by
[**2154-4-18**] [**2154-4-18**] [**2154-4-22**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/kg
DIAGNOSIS:
Gallbladder:
1. Acute and chronic cholecystitis.
2. Cystic ductal lymph node, with hyperplasia.
3. No calculi in this specimen.
CHEST (PORTABLE AP) [**2154-4-22**] 6:28 PM
CHEST (PORTABLE AP)
Reason: Eval. for CHF
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with pancreatic ca with resp distress
REASON FOR THIS EXAMINATION:
Eval. for CHF
INDICATION: 64-year-old female with pancreatic carcinoma,
respiratory distress.
COMPARISON: [**2154-4-21**].
UPRIGHT CHEST: The tip of a right internal jugular venous
catheter terminates in the distal SVC. There is prior abdominal
surgery with a drain identified projecting over the right upper
quadrant. The tip of a nasogastric tube terminates in the distal
esophagus. The heart size is top normal, and the mediastinal and
hilar contours are stable. There is continued opacification of
the left lower lobe with air bronchograms and layering small
pleural effusion. Mild linear atelectasis is seen at the right
base. The pulmonary vasculature is within normal limits. No
pneumothorax is identified.
IMPRESSION: Nasogastric tube malpositioned in the distal
esophagus. Left lower lobe consolidation, representing a
combination of atelectasis and/or effusion. Pneumonia could be
considered in the right clinical circumstance. No pneumothorax.
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: eval for PE
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with dyspnea and tachycardia and resp distress
REASON FOR THIS EXAMINATION:
eval for PE
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Dyspnea, tachycardia, respiratory distress.
COMPARISONS: None.
TECHNIQUE: CT angiogram of the chest was performed. Axial MDCT
images were obtained through the lungs before and after
administration of nonionic Optiray contrast.
CT CHEST WITH AND WITHOUT IV CONTRAST: There is no evidence of
pulmonary embolism. There are moderate sized bilateral pleural
effusions, right greater than left with associated collapse of
the lower lobes bilaterally. There are scattered ground-glass
opacities within the lungs, predominantly in a perihilar
distribution. The main pulmonary is enlarged measuring 3.2 cm.
There are non-pathologically enlarged mediastinal nodes with no
pathologic lymphadenopathy. Within the anterior mediastinum,
inferior to the thymic bed, there is a 2.1 x 0.9 cm soft tissue
attenuation mass. This mass is immediately posterior to the
internal mammary vessels on the left side of the anterior
mediastinum and is well circumscribed.
Limited views of the upper abdomen are unremarkable.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bilateral pleural effusions with reactive atelectasis.
3. Scattered ground-glass opacities in a perihilar distribution.
These finding are nonspecific, but likely represents pulmonary
edema.
4. 2 cm soft tissue mass in the left anterior mediastinum
posterior to the internal mammary vessels, of undetermined cause
or significance. Correlate clinically to determine nee4ed for
further evaluation which include short term follow up CT or MR
scan versus PET CTscan
Cardiology Report ECHO Study Date of [**2154-4-24**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function.
Height: (in) 61
Weight (lb): 110
BSA (m2): 1.47 m2
BP (mm Hg): 109/56
HR (bpm): 77
Status: Inpatient
Date/Time: [**2154-4-24**] at 13:01
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W018-0:53
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 3.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: 0.33 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 30% (nl >=55%)
Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 0.90
Mitral Valve - E Wave Deceleration Time: 175 msec
TR Gradient (+ RA = PASP): <= 25 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 0.7 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Moderate-severe
regional left ventricular systolic dysfunction. No resting LVOT
gradient. No
LV mass/thrombus. False LV tendon (normal variant).
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior -
hypo; mid anteroseptal - hypo; mid inferolateral - hypo; mid
anterolateral -
hypo; anterior apex - akinetic; septal apex- akinetic; lateral
apex -
akinetic; apex - akinetic;
RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV
systolic
function.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral
annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is moderate to severe regional
left ventricular
systolic dysfunction. No masses or thrombi are seen in the left
ventricle.
Resting regional wall motion abnormalities include hypokinesis
of the mid
antero-septum, anterior and lateral walls with akinesis of the
distal LV and
apex. Right ventricular chamber size is normal. Right
ventricular systolic
function is borderline normal. The aortic valve leaflets (3)
appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
There is no aortic valve stenosis. The mitral valve leaflets are
mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation
is seen. The tricuspid valve leaflets are mildly thickened. The
estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic
pericardial effusion.
IMPRESSION: Moderate to severe regional LV systolic dysfunction
c/w CAD.
[**2154-4-27**] 11:18AM
CHEMISTRY
Amylase, Ascites 6 IU/L
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**2154-4-18**] under Dr.[**Name (NI) 9886**]
care. After the surgery she was NPO/NGT/IVF.
#Pain
She had an epidural for pain control and was followed by the
pain service. Pain was well controlled with the epidural. She
was transitioned to PO pain meds once taking a diet.
#Respiratory
The patient was transferred to the SICU from the floor for O2
saturation in the 70s and HR >120. ABG was PO2 38, PCO2 49, pH
7.41. She required pulmonary toilet, including nebs and chest
PT. A chest X-ray showed LLL consolidation, atelectasis and
effusion. she was started on Levofloxacin for pneumonia. She had
scattered wheezes and was coughing up clear sputum. She required
a face mask and careful monitoring of her respiratory status.
She was transferred back to the floor POD 2. She was again
transferred to the ICU for respiratory distress with O2 sats in
the 70's. She was transferred back to the floor on POD 7 with
much improved respiratory status.
#Hypotension
She was hypotensive immediately post-op BP 80's and was on a Neo
drip and IVF, which improved.
#Incision
The incision was clean, dry, and intact. She had a JP drain
serosanguinous fluid. A JP amylase on POD 7 was 6 and her drain
was D/C'd. The incision was opened slightly on the right lower
side and packed with a wet to dry dressing. There was a
moderated amount of drainage. She is to continue with dressing
changes TID. Her staples were D/C'd POD 13.
#Abdomen
The NGT remained in place to low wall suction. The NGT was
clamped on POD 5 as tube feedings were introduced. Her tube
feedings were held for a short time due to continued respiratory
distress. She was started back on tube feeds on POD 6 and
advanced to goal. Her diet was advanced slowly as she had return
of bowel function and tube feeds were eventually D/C'd.
#Cardiology
POD 5 she awoke with chest pain and O2 sats in the 80's.
Cardiology was consulted. A chest CT showed no evidence of
pulmonary embolism. An ECHO was done that showed moderate to
severe regional LV systolic dysfunction c/w CAD. A EKG showed
changes, troponin was 0.05 x 2. It is likely she had a cardiac
event on POD 5. She is presently chest pain free and
hemodynamically stable. She was treated with Lopressor, ASA and
Lasix per the cardiac recommendations.
Medications on Admission:
Glyburide 2.5 mg [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain for 4 weeks.
Disp:*35 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for GERD.
7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic Head Mass
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Redness/swelling/drainage/odor from wounds
* Other symptoms concerning to you
Please take all your medications as ordered
Pack the incision on the lower right side with a 2x2 damp gauze
and cover with a dry gauze 3x/day until the wound closes.
You may shower and wash incision. Pat incision dry after a
shower.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in 2 weeks. Call ([**Telephone/Fax (1) 27734**] to schedule an appointment.
Completed by:[**2154-5-2**]
ICD9 Codes: 5180, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7666
} | Medical Text: Admission Date: [**2189-2-10**] Discharge Date: [**2189-2-10**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
unresponsivenss, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F with no prior h/o afib BIBA to ED today with worsening
shortness of breath and new onset a-fib with RVR. Per NH notes
and report, pt has had a cough and decreased appetite which led
to increasing unresponsive over the weekend. A CXR was performed
on [**2-7**] that showed slight RLL atelectasis and the pt was given
duonebs and robitussin. Today, the pt was noted to be more SOB
with O2 sats 88% on 2L NC.
In the ED, T 99.0, BP 101/94 --> 88/76, HR 160s, RR 28, O2 sat
86% NRB. She was noted to be in afib to the 160s with SBPs in
the 80s. As the pt was DNR/DNI, which was confirmed by her son
and HCP, she was fluid bolused with 500ccs, given amiodarone 150
mg IV X 1, and started on an amiodarone gtt. Her SBPs
subsequently came up to the 90s; however, the pt appeared to be
in greater respiratory distress. She was placed on BIPAP FiO2
100% 8/5 without much improvement in her respiratory status and
with O2 sats remaining in the mid 80's. A CXR was not
significant for acute cardiopulmonary processes. She was
transferred urgently to the MICU for further management.
Past Medical History:
HTN
Osteoarthritis
GERD
Dementia
Failure to thrive
s/p colostomy
vit B12 deficiency
h/o DVT
Hypothyroidism
Social History:
No smoking, occasional alcohol, no drug use.
Family History:
non-contributory
Physical Exam:
GEN: obtunded, does not withdraw to pain
HEENT: pupils sluggishly reactive to light bilaterally,
anicteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: diffuse upper airway breath sounds
CV: tachycardic, S1 and S2 wnl, no m/r/g
ABD: nd, hypoactive BS, soft, nt, no masses or
hepatosplenomegaly
EXT: no c/c/e, cool to touch
SKIN: no rashes/no jaundice
NEURO: obtunded
Pertinent Results:
ADMISSION LABS:
[**2189-2-10**] 02:10PM BLOOD WBC-19.1* RBC-3.38* Hgb-9.9* Hct-31.6*
MCV-93 MCH-29.4 MCHC-31.4 RDW-14.8 Plt Ct-384
[**2189-2-10**] 02:10PM BLOOD Neuts-90.5* Bands-0 Lymphs-6.5* Monos-2.5
Eos-0.3 Baso-0.2
[**2189-2-10**] 02:10PM BLOOD Glucose-165* UreaN-116* Creat-5.7* Na-143
K-7.1* Cl-108 HCO3-10* AnGap-32*
[**2189-2-10**] 02:10PM BLOOD CK(CPK)-993*
[**2189-2-10**] 02:10PM BLOOD cTropnT-8.44*
[**2189-2-10**] 02:10PM BLOOD CK-MB-18* MB Indx-1.8
[**2189-2-10**] 02:10PM BLOOD Calcium-9.8 Phos-7.1* Mg-2.9*
[**2189-2-10**] 02:21PM BLOOD Lactate-7.0*
EKG: (poor baseline) afib c RVR @ 137 bpm, LAD, nl intervals,
unable to appreciate ST elevations or depression [**3-14**]
Imaging:
CXR: [**Month/Day (2) **] supine frontal chest radiograph is reviewed without
comparison. The lungs are grossly clear aside from scarring or
atelectasis in the right mid lung. There are no effusions. The
heart and mediastinal contours are remarkable for a calcified
and tortuous aorta. The perceived widened mediastinum is likely
secondary to mediastinal fat. Note is made of a skinfold
overlying the left upper lung that should not be confused for
pneumothorax. Degenerative changes are noted throughout the
thoracic spine.
IMPRESSION: No acute cardiopulmonary process
Brief Hospital Course:
[**Age over 90 **] yo F admitted with increasing unresponsiveness, elevated
lactate, SOB and found to be in new onset afib with RVR and
hemodynamic instability. Within 5 minutes of arrival to the
floor, pt's RR noted to be in 8, HR decreased from 140s down to
60s then 40s. O2 sats mid 80s and falling on current BIPAP
settings. Caregiver [**First Name (Titles) **] [**Last Name (Titles) 22157**], BIPAP mask removed and NRB
placed for comfort. Pt appeared comfortable and not in distress.
No additional morphine given. At 3:50pm, pt without spontaneous
breath sounds, no palpable pulse, and no heart sounds
auscultated. Corneal reflex absent. Pt prounounced at 3:50pm.
Family/HCP/son notified, caregiver aware, attempted to call PCP
but number listed not in service.
Medications on Admission:
Metoprolol 50 mg tid
Omeprazole 20 mg daily
Synthroid 150 mcg daily
Iron 325 mg daily
Senna 2 tab qhs
Milk of magnesia 30 cc prn
Duoneb qid prn
Fleet enema prn
Dulcolax 10 mg prn
Acetaminophen 650 mg po q4h prn
Alphagan 0.1% 1 drop R eye tid
Lumigan 0.03% 1 drop each eye qhs
Diet: ground solids, crush meds, nepro can tid
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory distress and suspected sepsis.
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
ICD9 Codes: 0389, 486, 2762, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7667
} | Medical Text: Admission Date: [**2151-6-29**] Discharge Date: [**2151-7-3**]
Date of Birth: [**2128-1-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2151-6-29**] - Mitral valve repair (28mm CG Future Annuloplasty Ring)
History of Present Illness:
This is a 23 year old female with known mitral valve prolapse
which was originally diagnosed at the age of 14. She has been
followed closely with serial
echcocardiograms which reveals worsening mitral regurgitation
and now shows evidence of left ventricular dilatation and left
atrial enlargement. Given the above findings, she was referred
for mitral valve repair/replacement. Of note, she recently had a
high-risk pregnancy and delivered without complication. She
currently has IUD which will prevent pregnancy for the next five
years. She is undecided on whether she wants more children but
has elected for a mechanical valve in the event her valve cannot
be repaired.
Past Medical History:
- Mitral Valve Prolapse with Severe MR
- Mild Depression
- Wrist fracture
- G2P1
Social History:
Mother - hypertension. Father - high cholesterol. Denies
premature coronary artery disease.
Family History:
Last Dental Exam: Yearly exams
Lives with: Parents
Occupation: Works in child care center
Tobacco: Never
ETOH: Rarely
Physical Exam:
Pulse: 83 SR Resp: 16 O2 sat: 100% RA
B/P Right: 116/70 Left: 120/71
Height: 66" Weight: 154 lbs
General: WDWN in NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X] Teeth in good repair. OP
Benign;anicteric sclera
Neck: Supple [X] Full ROM [X]; no JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, IV/VI holosystolic blowing murmur radiates
to carotids
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]no HSM/CVA tenderness
Extremities: Warm [X], well-perfused [X]
Edema-none
Varicosities:None [X]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:None Left:None
Pertinent Results:
[**2151-6-29**]
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are moderately thickened. Moderate to severe (3+)
mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is in SR, on no infusions.
There is a mitral ring in place with no leak and trace MR.
Residual mean gradient = 3 mmHg.
No AI. Aorta intact.
Preserved biventricular systolic fxn.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2151-6-29**] for surgical
management of her mitral valve disease. She was taken to the
operating room where she underwent a mitral valve repair using
an annuloplasty ring. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. Over the next several hours, she awoke
neurologically intact and was extubated. On postoperative day
one, she was transferred to the step down unit for further
recovery. She was gently diuresed towards her preoperative
weight. She was started on lopressor and developed prolonged PR
>.30. The lopressor was discontinued w/ normalization of PR
interval. She was tacycardic in the days following and lopressor
was resumed at a lower dosage which she tolerated. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility. her chest tubes and wires
were removed per protocol. She received 1 unit PRBC for post
anemia with HCT 23 with appropriate response in HCT 24.6. She
was cleared for discharge to home by Dr. [**Last Name (STitle) **] for Dr. [**Last Name (STitle) **].
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Rohcester Rural District VNA
Discharge Diagnosis:
mitral valve prolapse and regurgitation
s/p mitral valve repair
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
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming until cleared by surgeon. Look at your
incisions daily for redness or drainage.
No lotions, cream, powder, or ointments to incisions.
Each morning you should weigh yourself and then in the evening
take your temperature, These should be written down on the chart
.
No driving for approximately one month, until follow up with
surgeon.
No lifting more than 10 pounds for 10 weeks.
Please call with any questions or concerns ([**Telephone/Fax (1) 170**]).
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge of sternal wound.
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**7-29**] at 1pm
Please call to schedule appointments with:
Primary Care: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35507**] in [**1-30**] weeks
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 60004**] in [**1-30**] 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:[**2151-7-3**]
ICD9 Codes: 4240, 311, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7668
} | Medical Text: Admission Date: Discharge Date: [**2138-1-2**]
Date of Birth: [**2065-8-4**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 2646**] is a 72-year-old
woman, admitted to an outside hospital on [**12-22**] with
congestive heart failure. She had a stress test done on the
[**12-23**] that showed inferior infarct and posterior
lateral ischemia with an ejection fraction of 40 percent.
She was transferred to [**Hospital1 69**]
for cardiac catheterization. This revealed three-vessel
disease and an EF of 50 percent, including the left main 50-
70 percent, LAD 70 percent ostial lesion, left circumflex
that was small and totally occluded and an RCA that was also
totally occluded. The patient was then referred for coronary
artery bypass grafting.
PAST MEDICAL HISTORY: Significant for congestive heart
failure, hypertension, depression, diabetes mellitus,
hypercholesterolemia, mild mental retardation, epilepsy,
schizophrenia, senile dementia, osteoarthritis and glaucoma.
PAST SURGICAL HISTORY: Significant only for a cyst removal
of the right breast.
ALLERGIES: The patient states an allergy to Ceftin.
MEDICATIONS ON ADMISSION:
1. Zoloft 75 every day.
2. Remeron 30 q. h.s.
3. Colace p.r.n.
4. Elavil 5 mg q. h.s.
5. Alphagan 0.15 percent, 1 drop o.u. b.i.d.
6. Risperdal .5 b.i.d.
7. Cosopt eye drops 1 drop b.i.d. o.u.
8. Novolin N 86 units in a.m. and 50 units in the p.m.;
regular insulin sliding scale.
SOCIAL HISTORY: Lives in [**Location 5110**] in a nursing home. She
has been there for approximately 2 years. She denies tobacco
use. Denies alcohol use. Parents and siblings have all
passed away.
PHYSICAL EXAM: Height 5 feet; weight 160 pounds. VITAL
SIGNS: Temperature 98, blood pressure 159/61, heart rate 95,
sinus; respiratory rate 20, O2 sat 99 percent on 2 liters.
General: Lying flat in bed in no acute distress. Neuro:
Alert and oriented x3, appropriate, slow to answer questions,
poor historian. Moves all extremities. Follows commands.
Respiratory: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm, S1-S2 with a 3/6
systolic ejection murmur, heard loudest at the base with
radiation to the carotids. Abdomen is soft, nontender,
nondistended with normoactive bowel sounds. Extremities:
Warm and well-perfused with no edema or varicosities.
Pulses: radial two plus bilaterally. Dorsalis pedis 2 plus
bilaterally. Posterior tibial two plus on the right and one
plus on the left.
LABORATORY DATA: White count 8.3, hematocrit 32.9, platelets
209, sodium 139, potassium 4.2, chloride 102, CO2 27, BUN 46,
creatinine 0.8, glucose 318, ALT 8, AST 9, alk phos 63, total
bili 0.7, albumin 3.5, PT 13.8, PTT 25, INR of 1.2.
HOSPITAL COURSE: Prior to being accepted for coronary artery
bypass grafting, the patient was seen by the neurology
service and underwent MRI of the head to rule out infarct as
well as carotids that showed a narrowing 40 percent on the
right and 40 to 59 percent on the left. Psychiatry also
consulted on the patient prior to surgery. Ultimately on
[**12-27**], the patient was brought to the operating room.
Please see the OR report for full details. In summary, the
patient had a coronary artery bypass graft times four with a
left internal mammary artery to the LAD, saphenous vein graft
to the diagonal, saphenous vein graft to obtuse marginal and
saphenous vein graft to PDA. Her bypass time was 89 minutes
and a cross clamp of 50 minutes. She tolerated the operation
well and was transferred from the operating room to the
cardiothoracic intensive care unit. At the time of transfer,
the patient was A paced at 90 beats per minute with a mean
arterial pressure of 66 and a CVP of 12. She had Neo-
Synephrine at 0.5 mcg/kg per minute and propofol at 20
mcg/per kg per minute.
The patient did well in the immediate postoperative period.
She was hemodynamically stable. However, she had a slight
respiratory acidosis and, therefore, remained intubated
overnight. On postoperative day one, the patient was weaned
from the ventilator to minimal support; however, prior to
extubation, she had no air leak from her cuff. She received
IV steroids and remained ventilated throughout the day of
postoperative day one. On postoperative day number two, the
patient was hemodynamically stable and she was successfully
extubated. She remained hemodynamically stable throughout
this period. Additionally, she was begun on beta blockade as
well as diuretic therapy. Following initiation of beta
blockade, the patient was noted to have sinus pauses with a
heart rate down to the 30's and, therefore, she remained in
the cardiothoracic Intensive Care Unit. The beta blockade
was held at that point. On postoperative day three, the
patient remained hemodynamically stable with a heart rate in
the 70s, sinus rhythm. She was monitored throughout the day
in the Intensive Care Unit. Cardiology was consulted and
later in the day, she was begun on low-dose beta blockade
once again which she tolerated well. On the morning of
postoperative day four, the patient had no further sinus
pauses and she was transferred from the cardiothoracic
Intensive Care Unit to the floor for continuing postoperative
care and cardiac rehabilitation. Over the next several days,
the patient had an uneventful hospital course. Her beta
blockade was increased and on postoperative day five, it was
decided that the following morning the patient would be
stable and ready for transfer to rehabilitation center. At
the time of this dictation, the patient's physical exam is as
follows. Vital signs temperature 98, heart rate 85, sinus
rhythm, blood pressure 160/80, respiratory rate 18, O2 sat 95
percent on room air. Weight preoperatively 72 kg, at
discharge 74.4 kg.
LABORATORY DATA: White count 12, hematocrit 32.5, platelets
202, sodium 147, potassium 3.7, chloride 107, CO2 32, BUN 49,
creatinine 0.9, glucose 90, magnesium 1.9.
Physical examination: Neurologic: Alert and responsive,
moves all extremities. Follows commands. Pulmonary: Clear
to auscultation bilaterally. Cardiac: Regular rate and
rhythm, S1-S2 with no murmur. Sternum is stable. Incision
with Steri-Strips. No drainage or erythema. Abdomen soft,
nontender, nondistended with normoactive bowel sounds.
Extremities: Warm with trace edema. Left leg incision with
endoscopic harvest site with Steri-Strips.
The patient is to be discharged to rehabilitation. Her
condition at discharge is good.
DISCHARGE DIAGNOSES:
1. CAD status post coronary artery bypass grafting times four
with LIMA to the left anterior descending; saphenous vein
graft to diagonal; saphenous vein graft to obtuse marginal
and saphenous vein graft to PDA.
2. Hypertension.
3. Diabetes mellitus.
4. Hypercholesterolemia.
5. Depression.
6. Schizophrenia.
7. Mental retardation.
8. Dementia.
9. Osteoarthritis.
10. Glaucoma.
11. Retinopathy.
The patient is to have follow-up with Dr. [**Last Name (STitle) 10165**] in three to
four weeks. Follow-up with Dr. [**Last Name (STitle) 70**] in 6 weeks.
DISCHARGE MEDICATIONS:
1. Lipitor 10 mg q. d.
2. Lasix 20 mg q. d. times 2 weeks.
3. Potassium chloride 20 mV q. d. times 2 weeks.
4. Colace 100 mg b.i.d.
5. Aspirin 81 mg q. d.
6. Percocet 5/325 1-2 tablets q.4-6h. p.r.n.
7. Elavil 10 mg q. h.s.
8. Metazepium 15 mg q. h.s.
9. Sertraline 75 mg q. d.
10. Metoprolol 25 mg b.i.d.
11. Novolin N 86 units q a.m. and 50 units q. p.m.,
along with sliding scale of regular insulin.
12. Finally, the patient is to get Cosopt eye drops, one
drop o.u. twice a day.
13. Alphagan 0.15 percent one drop o.u. twice a day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2138-1-1**] 19:15:36
T: [**2138-1-2**] 08:22:56
Job#: [**Job Number 59879**]
ICD9 Codes: 4280, 2762, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7669
} | Medical Text: Admission Date: [**2186-12-27**] Discharge Date: [**2187-1-9**]
Date of Birth: [**2123-9-9**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Dr. [**Known lastname 38669**] is a 63 year-old right
handed internist who was previously healthy and returned from
a trip to Europe when he developed symtpoms of slurred speech
and unsteady gait. These symtpoms occurred while he was in
the airport and he had previously noted while in flight the
development of a right sided headache. His symptoms
improved, but as he was removing luggage from a cab at
approximately 3:00 p.m. he fell to the ground and was found
to be hemiplegic along his left side. The patient was taken
to [**Hospital6 2561**] where he was intubated for airway
protection and transferred to [**Hospital1 18**] for further management.
An MRI was obtained, which demonstrated large diffusion
abnormality in the right MCA lesion. Susceptibility scan was
negative and his MRA demonstrated right ICA and right MCA
occlusion. The patient underwent tissue plasminogen
activator administration just under six hours after the onset
of symptoms with transient improvement in his left sided
paresis. The patient was noted to be unable to follow
commands, he could localize pain with his right arm and
withdraw his left arm from painful stimulus in a nonspecific
manner and he could also move his right leg more then left.
Tone was decreased in his left lower face. There were no
examination findings suggestive of deep venous thrombosis on
initial presentation. The patient was admitted to the
Neurological Intensive Care Unit for further management.
HOSPITAL COURSE: The patient remained intubated and during
his initial days in the hospital began having episodes of
bradycardia and asystole. This was thought to be possibly be
related to infarction or edema involving the insular region.
The patient had a lower extremity duplex scan that was
normal. Follow up head CT had demonstrated a hemorrhagic
conversion of approximately 3 cm of his right MCA infarction.
A transthoracic echocardiogram with bubble study demonstrated
no PFO and a normal EF, however, the patient was unable to
perform specific maneuvers to aid in the recognition of a PFO
and the study was felt to be limited. The patient underwent
extubation on [**12-28**], but was reintubated on the 25th
after the decision was made to perform a right hemicraniotomy
for decompression of his large MCA infarction. He was
subsequently extubated on [**12-30**] and transferred to the
floor on [**1-3**].
During his Intensive Care Unit stay he was noted to have
intermittent fevers and had one blood culture that was
positive for staph non-aureus for which he was started on
Vancomycin. Subsequent blood cultures showed no growth and
it is likely that the initial blood culture was contaminated.
On transfer to the General Neurologic Service the patient's
examination demonstrated that he was awake, alert and had
mild difficulty providing details of recent events. He was
aware that he had suffered a stroke and could recite the days
events and could also recall remote events without
difficulty. His speech was slow and slurred and consisted of
short sentence structure. He had decrease in flexion. He
was noted to have a right gaze preference and left lower
facial droop. He was flaccid and hemiplegic on his left
side. There was a homonymous hemianopsia in his left visual
field. He had no sensory modalities intact on the left side
and a dense hemi-neglect was present for his left. The
patient was restarted on aspirin and continued to do well
during the remainder of his hospital stay. He had evidence
of a mild pneumonia along the left lingular area and his
Vancomycin was discontinued with the addition of
Levofloxacin. A repeat transthoracic echocardiogram has been
ordered and is to be performed on the day prior to discharge.
The patient also had a hypercoagulability workup performed
and the results of these studies are pending at the time of
this dictation.
DISCHARGE DIAGNOSES:
1. Right internal carotid artery occlusion with right middle
cerebral artery ischemic infarction and subsequent left
hemiplegia with left sided neglect.
2. Pneumonia.
DISCHARGE MEDICATIONS: 1. Aspirin 325 q.d. 2. Tylenol #3
one to two tabs q 4 to 6 hours as needed for neck pain. 4.
Skelaxin 800 mg po t.i.d. 5. Flexeril 10 mg po q day. 6.
Lipitor 10 mg po q.d.
DISCHARGE DIET: Low cholesterol diet. The patient's diet
should include aspiration precautions.
DISCHARGE ACTIVITIES: As defined by physical therapy.
DISCHARGE CONDITION: Good.
SPECIAL CONSIDERATIONS: The patient has undergone a right
hemicraniotomy and the right cranial region is vulnerable to
compressive injury. The patient should not sleep or have
pressure applied to the right side of his head. The patient
should also continue to have deep venous thrombosis
prophylaxis with heparin 5000 units subQ b.i.d. and Venodyne
boots while in bed. The patient will also likely require a
bowel regimen with Colace 100 mg po b.i.d. and Dulcolax
suppositories as needed.
DISPOSITION: The patient is to be discharged to a rehab
facility.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1941**], M.D. [**MD Number(1) 37533**]
Dictated By:[**Doctor First Name 38670**]
MEDQUIST36
D: [**2187-1-9**] 07:35
T: [**2187-1-9**] 08:01
JOB#: [**Job Number 38671**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7670
} | Medical Text: Admission Date: [**2187-5-15**] Discharge Date: [**2187-5-25**]
Date of Birth: [**2106-12-25**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Tip of basilar clot: phenomenologically manifested as flailing
arms, confusion followed by stupor
Major Surgical or Invasive Procedure:
Intravenous t-PA
Cerebral angiogram with clot retrieval
Endotracheal intubation x 2
Transesophageal echocardiography
Central venous line placement
Arterial line placement
History of Present Illness:
Time Code Stroke called: 12:02
Time Neurology at bedside for evaluation: 11:30
Time (and date) the patient was last known well: 8:30
NIH Stroke Scale Score: 21
t-[**MD Number(3) 6360**]: Yes
Time t-PA was given 12:40
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
NIH Stroke Scale score was: 21
1a. Level of Consciousness: 3
1b. LOC Question: 2
1c. LOC Commands: 1
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 2
5b. Motor arm, right: 3
6a. Motor leg, left: 2
6b. Motor leg, right: 3
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 3
10. Dysarthria: UN
11. Extinction and Neglect: 2
HPI: The pt is a 80 year-old right-handed woman with a history
of Afib and HTN who presents with loss of consciousness.
Per discussion with her husband, the patient was sitting at the
table eating breakfast with him this morning, when she asked him
to take some things into the other room so they wouldn't be on
the table. He walked into the other room briefly, and when he
got back into the room she was sitting a the table, arms flexed
towards her face, shaking. He reports that she looked as though
she wanted to tell him something, and that something was wrong,
but wasn't actually speaking. He called EMS, who reportedly
were concerned that she might be seizing, and gave her Ativan
and Narcan. She was taken to [**Hospital3 10310**] hospital, where
she was reported to be obtunded and was intubated because she
was not protecting her airway. She underwent a NCHCT which
showed a 4mm R frontal hyperdensity that was possibly a
hemorrhage, and was then transferred to [**Hospital1 18**] for further
evaluation. Reportedly on arrival she was actively fighting the
ventilator, and was observed to be making purposeful movements
towards the ventilator with both hands. Neurology was then
consulted to examine the patient before she was given sedation.
Intubated, unable to answer ROS
Past Medical History:
- Atrial fibrillation, not on Coumadin
- Dyslipemia
- Osteoporosis
Social History:
Lives in [**Location 14663**] with her husband. Is her husband's carer.
Previously independent in all ADL.
Family History:
Unknown.
Physical Exam:
At Admission:
Vitals: P: 49 R: 16 BP: 99/50 SaO2: 100% intubated
General: Intubated, sedated
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: irregular, bradycardic
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Intubated, makes slight attempts to open eyes in
response to sternal rub and calling her name, but otherwise is
not able to follow commands.
-Cranial Nerves: 2.5mm->2mm bilaterally. Eyes midline, intact
oculocephalics. Intact corneals. Intact gag
-Motor/Sensory: Normal bulk, tone throughout. Purposeful slight
anti-gravity movements with left arm and leg. Extensor
posturing
in right arm, triple flexion in right leg in response to painful
stimuli.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally.
Pertinent Results:
[**2187-5-24**] 05:58AM BLOOD WBC-6.2 RBC-3.30* Hgb-10.2* Hct-30.2*
MCV-92 MCH-31.0 MCHC-33.8 RDW-14.3 Plt Ct-235
[**2187-5-23**] 06:00AM BLOOD WBC-8.8 RBC-3.59* Hgb-11.1* Hct-32.7*
MCV-91 MCH-30.9 MCHC-33.9 RDW-14.2 Plt Ct-202
[**2187-5-17**] 07:44PM BLOOD WBC-3.9* RBC-3.35* Hgb-10.5* Hct-30.6*
MCV-91 MCH-31.2 MCHC-34.1 RDW-13.9 Plt Ct-87*
[**2187-5-15**] 10:56AM BLOOD WBC-5.4 RBC-3.71* Hgb-11.8* Hct-34.6*
MCV-93 MCH-31.8 MCHC-34.1 RDW-13.6 Plt Ct-134*
[**2187-5-23**] 06:00AM BLOOD Neuts-85* Bands-0 Lymphs-7* Monos-3 Eos-3
Baso-1 Atyps-0 Metas-1* Myelos-0
[**2187-5-24**] 05:58AM BLOOD PT-17.9* PTT-30.2 INR(PT)-1.6*
[**2187-5-23**] 06:00AM BLOOD PT-16.4* PTT-27.5 INR(PT)-1.4*
[**2187-5-22**] 02:08AM BLOOD PT-13.7* PTT-19.6* INR(PT)-1.2*
[**2187-5-17**] 03:46PM BLOOD Fibrino-818*
[**2187-5-24**] 05:58AM BLOOD Glucose-106* UreaN-22* Creat-0.7 Na-138
K-4.4 Cl-101 HCO3-30 AnGap-11
[**2187-5-23**] 06:00AM BLOOD Glucose-107* UreaN-14 Creat-0.6 Na-139
K-4.0 Cl-101 HCO3-28 AnGap-14
[**2187-5-22**] 03:14AM BLOOD Glucose-140* UreaN-12 Creat-0.5 Na-136
K-3.4 Cl-99 HCO3-26 AnGap-14
[**2187-5-15**] 10:56AM BLOOD Glucose-123* UreaN-18 Creat-0.7 Na-142
K-4.4 Cl-112* HCO3-24 AnGap-10
[**2187-5-17**] 07:44PM BLOOD ALT-12 AST-35 LD(LDH)-165 AlkPhos-55
TotBili-0.7
[**2187-5-17**] 10:20AM BLOOD ALT-10 AST-29 LD(LDH)-132 AlkPhos-38
TotBili-0.5
[**2187-5-16**] 04:49PM BLOOD CK(CPK)-100
[**2187-5-16**] 12:35AM BLOOD CK(CPK)-62
[**2187-5-18**] 02:58AM BLOOD proBNP-2898*
[**2187-5-16**] 04:49PM BLOOD CK-MB-2 cTropnT-<0.01
[**2187-5-16**] 12:35AM BLOOD CK-MB-2 cTropnT-<0.01
[**2187-5-15**] 10:56AM BLOOD cTropnT-<0.01
[**2187-5-23**] 06:00AM BLOOD Calcium-8.3* Phos-4.3# Mg-1.9
[**2187-5-20**] 05:48PM BLOOD Calcium-8.1* Phos-1.8* Mg-2.1
[**2187-5-16**] 04:49PM BLOOD Calcium-7.6* Mg-1.8
[**2187-5-15**] 10:56AM BLOOD Calcium-7.6* Phos-1.9* Mg-1.5*
[**2187-5-16**] 12:35AM BLOOD %HbA1c-6.1* eAG-128*
[**2187-5-16**] 12:35AM BLOOD Triglyc-54 HDL-50 CHOL/HD-2.2 LDLcalc-48
[**2187-5-21**] 06:44AM BLOOD Vanco-22.5*
[**2187-5-17**] 10:30AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.022
[**2187-5-17**] 10:30AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2187-5-17**] 10:30AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-<1
[**2187-5-17**] 10:30AM URINE CastHy-9*
[**2187-5-15**] 11:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2187-5-15**] 11:05AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2187-5-15**] 11:05AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
[**2187-5-15**] 11:05AM URINE CastHy-8*
[**2187-5-15**] 11:05AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Blood Culture [**2187-5-16**], Routine (Final [**2187-5-20**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 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.
VIRIDANS STREPTOCOCCI. FIRST MORPHOLOGY.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 88786**]
FROM [**2187-5-16**].
VIRIDANS STREPTOCOCCI. SECOND MORPHOLOGY.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 88786**]
FROM [**2187-5-16**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
Aerobic Bottle Gram Stain (Final [**2187-5-17**]):
GRAM POSITIVE COCCI IN PAIRS, CHAINS, AND CLUSTERS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 88787**] AT 0200
[**2187-5-17**].
Anaerobic Bottle Gram Stain (Final [**2187-5-17**]):
GRAM POSITIVE COCCI IN PAIRS , CHAINS AND CLUSTERS.
Sputum Culture [**2187-5-18**]:
GRAM STAIN (Final [**2187-5-18**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2187-5-23**]):
SPARSE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. HEAVY
GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
GRAM NEGATIVE ROD(S). RARE GROWTH.
Mini-BAL [**2187-5-18**]:
GRAM STAIN (Final [**2187-5-18**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2187-5-23**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
>100,000 ORGANISMS/ML..
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
CT/CTA head and neck/CT Perfusion [**2187-5-15**]:
FINDINGS:
NON-CONTRAST HEAD CT: There is hyperdense material within the
basilar artery,
likely thrombus. No evidence of an acute large infarction is
seen, though CT
has limited sensitivity for brainstem infarction. The ventricles
are normal
in size. There is a 3-mm hyperdense focus in the deep white
matter of the
right frontal lobe (image 2:19), without evidence of surrounding
edema. This
most likely represents a cavernous malformation with
calcifications. Absence
of surrounding edema suggests that a recent hemorrhage within
this
malformation is unlikely, though the possibility of a recent
microhemorrhage
cannot be completely excluded. No acute hemorrhage is seen
elsewhere in the
brain or extra-axial compartments.
There is a small amount of fluid in the maxillary and sphenoid
sinuses, and in
the ethmoid air cells bilaterally. Fluid in the nasopharynx and
posterior
nasal cavity. These findings may be related to endotracheal
intubation.
NECK CTA: There is a three-vessel aortic arch. The cervical
common carotid
and internal carotid arteries are patent without evidence of
significant
atherosclerosis or hemodynamically significant stenosis. The
distal cervical
internal carotid arteries measure 3.9 mm in diameter on the
right and 3.7 mm
in diameter on the left. The left vertebral artery is dominant
and patent
throughout its cervical course. The non-dominant right vertebral
artery is
diminutive throughout its cervical course.
There are mild degenerative changes in the imaged cervical and
upper thoracic
spine. There is extensive pleural/parenchymal scarring at the
imaged lung
apices.
HEAD CTA: The non-dominant right vertebral artery has a markedly
hypoplastic
intracranial segment, most likely due to normal anatomic
variation. The
intracranial left vertebral artery is patent. Left posterior
inferior and
anterior inferior cerebellar arteries are patent. There is a
right anterior
inferior cerebellar artery/posterior inferior cerebellar artery
complex, which
appears patent. The distal 1 cm of the basilar artery is
occluded, with
thrombus reaching but not completely occluding the basilar tip.
The right
superior cerebellar and posterior cerebral arteries are patent.
There is a
small right posterior communicating artery, which is patent. The
proximal
left superior cerebellar artery appears occluded, with distal
reconstitution.
There is a small but patent P1 segment of the left posterior
cerebral artery,
with a large left posterior communicating artery. There is a
duplicated P2
segment of the left posterior cerebral artery, with a focal
communication
between the two segments at the level of the posterior
communicating artery
(series 7, image 258, and series 855, image 20).
In the anterior circulation, there is minimal calcified plaque
in the
supraclinoid internal carotid arteries, without a
hemodynamically significant
stenosis.
There is no evidence of an intracranial aneurysm. No abnormal
arteries are
seen in the region of the right frontal hyperdense lesion to
suggest an
arteriovenous malformation. This arterial phase study has
limited sensitivity
for developmental venous anomalies.
CT PERFUSION: There is no evidence of asymmetries in the mean
transit time or
cerebral blood volume to suggest acute ischemia or acute
infarction in a major
vascular arterial territory. Please note that CT perfusion has
limited
sensitivity for acute infarctions related to occlusion of
pontine perforator
arteries or left superior cerebellar artery.
IMPRESSION:
1. Occlusion of the distal 1 cm of the basilar artery, which may
be related
to thrombosis or embolism, given the patient's history of atrial
fibrillation.
The proximal left superior cerebellar artery is occluded, with
distal
reconstitution. The right and left posterior cerebral arteries,
and the right
superior cerebellar artery, are patent.
2. No evidence of an acute major vascular territory infarction
on
conventional imaging or CT perfusion. Please note that MRI would
be more
sensitive for an acute infarction involving the brainstem or
cerebellum.
3. 3-mm hyperdensity in the right frontal deep white matter,
which most
likely represents a cavernous malformation. Absence of
surrounding edema
indicates that a recent hemorrhage within this malformation is
unlikely,
though the possibility of a recent microhemorrhage cannot be
completely
excluded.
4. The non-dominant right vertebral artery is diminutive
throughout its
cervical and intracranial course, likely indicating normal
anatomic variation.
5. Duplicated P2 segment of the left posterior cerebral artery,
with a
communication at level of the posterior communicating artery.
The left P1
segment is small, and the left posterior communicating artery is
large,
indicating fetal-type anatomy.
TTE [**2187-5-16**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is dilated with depressed free wall
contractility. The number of aortic valve leaflets cannot be
determined. 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 moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Left ventricular systolic
function is probably normal, a focal wall motion abnormality
cannot be excluded. The right ventricle appears dilated and
hypokinetic - the RV apex is relatively spared. Mild mitral
regurgitation. Moderately elevated pulmonary artery systolic
pressures.
CT head [**2187-5-16**]:
FINDINGS:
There is no evidence of hemorrhage, mass effect, or shift of
normally midline
structures. The hyperdense appearance of basilar artery seen on
[**2187-5-15**]
exam is not visualized on current study. There is no cerebral
edema or loss
of [**Doctor Last Name 352**]-white matter differentiation to suggest an acute
ischemic event. The
basal cisterns are preserved. The sulci and ventricles are
normal in size and
configuration. A focal hyperdensity of the right frontal lobe
(2:19) appears
unchanged from prior exams and is most compatible with
cavernoma. There is no
significant surrounding edema, which argues against acute bleed.
There are air-fluid levels in bilateral sphenoid sinuses. There
is moderate
mucosal thickening of ethmoid air cells. The remainder of
paranasal sinuses
and mastoid air cells appear well aerated. Visualized soft
tissues and
osseous structures are intact. There is no acute fracture.
IMPRESSION:
1. No evidence infarction or hemorrhage.
2. Stable appearance of focal right frontal hyperdensity, most
compatible
with cavernoma.
CXR [**2187-5-16**]:
FINDINGS: As compared to the previous radiograph, the patient
has been
extubated, the patient also has received a nasogastric tube that
is coiled in
the upper parts of the esophagus. Moderate cardiomegaly with
extensive left
retrocardiac atelectasis and blunting of the costophrenic sinus
so that a
small pleural effusion cannot be excluded. Newly appeared right
basal and
perihilar opacity, making aspiration pneumonia a likely
diagnosis.
ABD U/S [**2187-5-18**]:
ABDOMINAL ULTRASOUND: This is a limited portable US exam. The
liver is
normal in echotexture without focal lesions. There are no stones
and no
intrahepatic or extrahepatic biliary ductal dilatation. The
normal CBD
measures 2 mm in diameter. There is normal hepatopetal portal
venous flow.
The spleen measures 8.6 cm. The visualized pancreas, aorta, and
IVC are
normal.
The right kidney measures 10.7 cm. The left kidney measures 9.8
cm. There is
no hydronephrosis, hydroureter, renal calculus or mass. No
ascites is noted.
Bilateral pleural effusions are incompletely evaluated, but
appear small.
IMPRESSION:
1. Normal abdominal ultrasound. No intra-abdominal free fluid or
fluid
collection to suggest intra-abdominal abscess.
2. Small bilateral pleural effusions.
MRI Brain [**2187-5-18**]:
FINDINGS: There is restricted diffusion seen to the left of
midline in the
pons indicative of an acute infarct. Additionally, there is
increased signal
diffusely identified within the pons extending to the right side
of the
midline which could be due to edema as this area does not
demonstrate
restricted diffusion. There is subtle enhancement in the left
paramedian
region at the infarct site indicative of mild enhancement of the
infarct.
There are no other areas of abnormal enhancement seen. There is
no
significant subcortical ischemic disease identified or midline
shift seen. A
small area of white matter hyperintensity in the right frontal
subcortical
region could be related to prior infarct. Fluid is seen in both
mastoid air
cells.
IMPRESSION:
1. Acute pontine infarct is identified to the left of midline,
with diffuse
increased signal within the pons, which could be due to
vasogenic edema.
Subtle enhancement of the infarct is seen.
2. No other enhancing brain lesions, mass effect or
hydrocephalus.
3. The basilar artery flow void, although narrowed is visualized
and no
abnormal signal seen within the basilar artery region on
T1-weighted images.
CXR [**2187-5-20**]:
One view. Comparison with the previous study done [**2187-5-18**].
Bilateral
interstitial infiltrates consistent with edema persist. Hazy
density at the
lung bases consistent with pleural fluid appears improved,
although this may
be due to more erect positioning. Increased density in the
retrocardiac area
consistent with atelectasis or consolidation is unchanged. The
cardiac
silhouette is prominent as before. An endotracheal tube and
nasogastric tube
remain in place.
IMPRESSION: Possible interval improvement in bilateral pleural
effusions. No other definite change.
CTA Chest and CT Abd/Pelvis [**2187-5-22**]:
TECHNIQUE: MDCT-acquired 2.5-mm axial images of the chest were
obtained prior
to and following the uneventful administration of 130 ml of
Optiray
intravenous contrast. Coronal, sagittal reformations were
performed at 5-mm
slice thickness. Additional right and left oblique
reconstructions were
obtained for further evaluation of the pulmonary vessels. MDCT
acquired 5-mm
axial images of the abdomen and pelvis were then obtained at the
delayed
phase, with 5-mm coronal and sagittal reformations.
CHEST: Bilateral lower lobe consolidations are present with
small bilateral
pleural effusions and adjacent atelectasis. Neighboring
ground-glass
opacities are scattered throughout both lungs. A small amount of
fluid is
present within the lower trachea (2:9). There is no
pneumothorax. The heart
size is top normal with an enlarged right atrium. A trace
pericardial
effusion is present. The great vessels are patent and normal in
caliber.
There is no dissection. No pulmonary embolus is detected to the
subsegmental
levels. Scattered axillary and mediastinal lymph nodes do not
meet CT
criteria for lymphadenopathy. The thyroid is normal.
ABDOMEN: The liver, gallbladder, spleen, adrenal glands,
kidneys, pancreas,
stomach, and intra-abdominal loops of small and large bowel are
normal. A
small left parapelvic renal cysts is present (3b:119). There is
no mesenteric
or retroperitoneal lymphadenopathy, and no free air or free
fluid. The
abdominal aorta, celiac trunk, SMA, and [**Female First Name (un) 899**] are patent and
normal in caliber.
There is no free air or free fluid.
PELVIS: A small amount of air is present within the bladder
(3B:161). The
rectum and uterus are normal. No adnexal masses are detected.
Colonic
diverticulosis is present, with no evidence of diverticulitis. A
trace amount
of intrapelvic fluid is seen. Mild stranding around the right
common femoral
artery is likely from recent vascular access.
OSSEOUS STRUCTURES: There is no acute fracture. No concerning
blastic or
lytic lesions are identified. Mild degenerative changes are
present within
the lumbar spine, including slight loss of the L5/S1 disc height
with
associated vacuum phenomenon and anterior and posterior
osteophytosis.
IMPRESSION:
1. Bilateral lower lobe pneumonia with small pleural and
pericardial
effusions.
2. No intra-abdominal or intrapelvic source of infection
identified.
3. No PE detected to the subsegmental levels.
TEE [**2187-5-24**]:
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. The right atrial appendage
ejection velocity is depressed (<0.2m/s). No atrial septal
defect is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). There are simple
atheroma in the aortic arch. There are complex, non-mobile
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**1-28**]+)
mitral regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: No intracardiac vegetation, abscess or thrombus.
Mild to moderate mitral regurgitation.
Brief Hospital Course:
Mrs. [**Known lastname 81211**] was intubated in the Emergency Room owing to
stupor progressing toward coma. Code stroke was actually not
called until the patient was seen by the Neurology Resident. The
history (including odd arm movements) and examination were more
consistent with top of the basilar ischemia than seizure.
Intravenous t-PA was given followed by clot retrieval. Over the
following hours her exam improved markedly. She was awake and
conversant with mild tetraparesis.
On the day following admission she developed a rapid onset high
fever of 102 F. Tylenol and then cooling blanket were employed.
She became less arousal, but this followed her fever curve and
resolved as fever remitted. This pattern of fever was classic
for central fever after stroke, which is associated with
disruption of pontine function (along with other central sites),
but her blood cultures were positive only a few hours later,
growing staphlococcus, streptococcus viridans and klebsiella
species. Broad specrum antiobiotics were started as soon as
cultures revealed growth (prior to the above organisms being
identified or speciated). Therfore vancomycin, cefepime and
metronidazole were given (tobramycin briefly before
metronidazole).
She was extubated and reintubated several hours later for
hypoxic episodes. This occurred in the context of likely
developing pulmonary infection (best appreciated by later CT
chest) and fluid overload. Diuresis restored respiratory
function but delayed TEE to evaluate for possible endocarditis
given the above organisms in blood.
Atrial fibrillation with rapid ventricular rate appeared on
several occasions in the context of fluid shifts, infection and
pneumonia, so rate control agents were up-titrated and digoxin
introduced.
When medically stable she was transferred to the floor. Her
course on the floor was complicated by continued intermittent
periods of oxygen desaturation and tachypnea. Out of concern for
a PE, she had a CTA of the chest, which was negative for PE, but
did show evidence for B/L pneumonias. She also had a CT of the
Abd/Pelvis to look for source of infection, but it was negative.
She was initially maintained on broad spectrum abx for her
bacteremia, but it was eventially speciated to include strep
viridans and klebsiella which were both broadly sensitive, and
her antiboitics were ultimately restricted to Ceftriaxone only,
which should continue daily through [**2187-6-1**].
TEE was complted [**2187-5-24**] to look for possible endocarditis or
other valve vegetations, however this was negative.
With respect to bacteremia, it is possible that there is a
sequestrum with numerous colonies, the presence of which
increased coagulability. However, on balance, we feel that
cardioembolic stroke in the context of atrial fibrillation is
most likely. Thrombus is frequently not observe in the atrium
given that the whole of it might embolize. In this case, t-[**MD Number(3) 88788**] have also reduced the chance of thrombus being retained.
Given the AF with new stroke, she was started on coumadin with
goal INR of [**3-1**]. INR's should be checked daily until this
therapeutic range is reached. She was bridged with aspirin,
which can be discontinued once the INR is therapeutic.
Medications on Admission:
- Atenolol 12.5mg
- Aspirin 81mg
- Simvastatin 40mg
- Alendronate 70mg weekly
- MVI
- Calcium
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
acute stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with a stroke, which initially left you with
weakness and mental status changes, however, the clot was
retrieved and you were given medicines to break up the clot, and
ultimately, your weakness and mental status improved. The clot
was felt to have likely come from your heart, and you should
continue on the blood thinner coumadin. Your course was
complicated by a blood infection, for which you've been
maintained on antibiotics. You also developed a pneumonia in
both lungs, which caused you to experience some shortness of
breath, and this also is being treated with antibiotics.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2187-5-25**]
ICD9 Codes: 4019, 2724, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7671
} | Medical Text: Admission Date: [**2139-1-2**] Discharge Date: [**2139-1-23**]
Date of Birth: [**2070-12-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
CVVH
Dialysis
History of Present Illness:
Pt is a 68 yo female with DM, HTN, CRI, and recent diagnosis of
small cell lung cancer on chemotherapy who presented to ED with
c/o SOB and wheezing x 2 days on [**2139-1-2**]. Pt was admitted in
[**Month (only) **] for right-sided pleuritic CP, cough, and DOE, which was
thought to be due to post-obstructive PNA (treated with
levaquin/flagyl x 14 days). She had a bronchoscopy w/ needle
aspiration of RUL mass which was positive for malignant cells
consistent with SCLC. After discharge, she was started on
etoposide/cisplatin on [**2138-12-29**] and given IVF hydration.
Ms. [**Known lastname 102272**] presented to the ED [**2139-1-2**] with DOE, found to have
elevated creatinine to 6.2 (baseline 1.2), hyperkalemia,
hyperphosphatemia (9.6), hypercalcemia (8.0). Uric acid found to
be 18.5. Renal felt ARF [**2-19**] tumor lysis and cisplatin toxicity.
Pt was initially on the floor but transferred to the ICU to
initiate CVVH. CVVH was stopped [**2-19**] clot formation.
When pt was transferred to the regular medicine floor, she felt
physically well though anxious. No CP, SOB. No F/C/N/C. +anxiety
about what is going on though feels like she is coping well, son
is coming in in am. She spoke to her therapist who helped her
feel better.
Past Medical History:
1. Small Cell Lung Cancer: T2N2MO(Stage IIIA) s/p
cisplatin/etoposide
2. Diabetes type 2
3. CRI (1.1-1.5), now HD dependent tiw since first cycle of
chemo
4. Hypertension
5. Asthma/ COPD ([**6-22**] FVC 2.2 and FEV1 1.43; FEV1/FVC 91%
predicted)
6. h/o rheumatic fever
7. Cardiomegaly ([**5-22**] nl ETT/pMibi LVEF 57%)
8. Chronic low back pain
9. Obesity
10. Ureteroscopy and shockwave lithotripsy x3
[**44**]. cesarean section.
Social History:
She is a part-time worker in the mailroom at [**University/College 4700**].
She quit smoking in [**2125**] (h/o 1ppd x 40y), she drinks
decaffeinated products once per day and seldom drinks and
alcoholic beverages. Lives with son. Independent, and active.
Family History:
Non-contributory
Physical Exam:
Upon transfer to medicine service [**2139-1-6**]
VS: T: 99.4; BP: 120/60; P: 80; RR:20; O2: 97 RA; FS: 273
Gen: AA female speaking in full sentences, mildly tachpnic, in
NAD
HEENT: MMM; sclera anicteric; OP no thrush
Neck: NO JVD
CV: RRR S1S2. No M/R/G
Lungs: CTA b/l
Abd: +BS. soft, nt, nd. no hepatomelagy.
Back: No spinal, paraspinal, CVA tenderness.
Ext: No edema. DP 2+ b/l. Right femoral line in place. C/D/I
Neuro: Alert and oriented, appropriately conversant.
Pertinent Results:
Labs on admission:
[**2139-1-2**] 12:45PM BLOOD WBC-5.8 RBC-4.12* Hgb-10.7* Hct-32.4*
MCV-79* MCH-26.1* MCHC-33.1 RDW-14.2 Plt Ct-201
[**2139-1-2**] 12:45PM BLOOD Neuts-92.5* Bands-0 Lymphs-6.3*
Monos-0.5* Eos-0.3 Baso-0.5
[**2139-1-2**] 12:45PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-2+
Burr-OCCASIONAL Acantho-OCCASIONAL
[**2139-1-7**] 05:45AM BLOOD Gran Ct-480*
[**2139-1-2**] 12:45PM BLOOD Glucose-137* UreaN-123* Creat-6.2*#
Na-137 K-5.0 Cl-98 HCO3-15* AnGap-29*
[**2139-1-2**] 09:00PM BLOOD UricAcd-18.5*
[**2139-1-4**] 06:29PM BLOOD Type-[**Last Name (un) **] pH-7.41 Comment-GREEN TOP
[**2139-1-4**] 06:29PM BLOOD freeCa-0.76*
_________________
Other Labs:
[**2139-1-7**] 05:45AM BLOOD Gran Ct-480*
[**2139-1-10**] 06:10AM BLOOD Gran Ct-40*
[**2139-1-10**] 06:10AM BLOOD Gran Ct-70*
[**2139-1-12**] 07:10AM BLOOD Gran Ct-890*
[**2139-1-13**] 07:12AM BLOOD Gran Ct-5280
[**2139-1-7**] 05:45AM BLOOD Hapto-129
[**2139-1-6**] 12:53PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2139-1-19**] 07:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-NEGATIVE IgM HAV-NEGATIVE
[**2139-1-19**] 07:50AM BLOOD HCV Ab-NEGATIVE
_________________
Labs on discharge:
[**2139-1-23**] 07:15AM BLOOD WBC-53.1* RBC-3.29* Hgb-9.1* Hct-26.4*
MCV-80* MCH-27.6 MCHC-34.3 RDW-16.6* Plt Ct-350
[**2139-1-17**] 07:00AM BLOOD Neuts-62 Bands-3 Lymphs-8* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-12* Myelos-10* NRBC-1*
[**2139-1-23**] 07:15AM BLOOD PT-13.3 PTT-26.0 INR(PT)-1.2
[**2139-1-23**] 07:15AM BLOOD Glucose-172* UreaN-39* Creat-6.9*# Na-136
K-3.7 Cl-99 HCO3-23 AnGap-18
[**2139-1-23**] 07:15AM BLOOD Albumin-2.6* Calcium-7.8* Phos-4.3 Mg-2.0
UricAcd-8.2*
_________________
Selected Radiology:
[**2139-1-2**]- Renal U/S-
IMPRESSION:
1. No hydronephrosis.
2. Unchanged septated left lower pole Bosniak type 2 cyst.
3. Multiple bilateral simple cysts.
[**2139-1-3**]- Chest PA/Lat-
Again seen is complete right upper lobe collapse due to the
previously described perihilar mass. Compared to the prior study
there has been interval increase in the amount of right upper
lung collapse with associated expansion of the right lower lung.
The left lung appears clear. There is no new infiltrate or
effusion.
[**2139-1-13**]- Chest PA/LAt-
IMPRESSION:
1. Mild congestive failure with cardiomegaly and small bilateral
pleural effusion. Slightly improving atelectasis of the right
upper lobe. Continued right perihilar mass corresponding to the
patient's history of small cell lung cancer.
Brief Hospital Course:
Pt is a 68 yo female with DM, CRI, HTN, recently diagnosed stage
IIIa SCLC on chemo p/w tumor lysis, s/p CVVH now on
hemodialysis. Course was complicated by a pancytopenia, febrile
neutropenia, and respiratory issues.
1 Acute Renal failure- pt with underlying diabetic nephropathy,
baseline creatinine 1.0-1.2. Now with acute on chronic renal
failure. Likely [**2-19**] cisplatin toxicity, possible tumor lysis,
and ATN. She is s/p CVVH for hyperurecemia and hypercalcemia
which had to be stopped secondary to clotted lines. Azotemia
slowly resolved over the course of her stay and she began making
urine. She was continued on allopurinol for hyperurecemia.
Hemodialysis was started and she is s/p tunneled line to the
RIJ; she will continue HD as an outpatient. She was initially on
sevelamer and aluminum hydroxide for hyperphosphatemia which
were d/cd when phosphate levels returned to [**Location 213**]. She was
started on calcium carbonate for persistently low free calcium
which also had to be repleted IV.
2. [**Name (NI) 102273**] Pt had a pancytopenia from cisplatin/etoposide.
Cisplatin usually has a biphasic elimination profile at 24 hours
and 5 days and usually one does not get neutropenia so early.
She may have decreased clearance of cisplatin for some reason.
And etoposide expect decrease counts [**10-31**] d. CBC was checked
[**Hospital1 **].
a. Febrile [**Name (NI) **] Pt was neutropenic with a nadir of 40
neutrophils. She was switched to her own room, put on
neutropenic precautions, and a neutropenic diet. She became
febrile, spiking to 102.5 on [**2139-1-9**]. Vancomycin was started
and dosed by level (<15), and cefepime was started at
neutropenic fever dosing, though dosed for CrCl <10. She was
pancultured multiple times without finding a source (see c.diff
below). She received neupogen until WBC was >10K for a few days.
She devervesced and the antibiotics were stopped.
b. Anemia- Tranfusion criteria was 21 given that she had no
comorbid disease and baseline Hct around 30. However, given that
pt is dialysis patient per renal wanted Hct higher. She was
transfused in HD multiple times.
Iron studies were consistent with ACD. She was also started on
epoegen by renal. Pt had an episode of epistaxis x 1 in MICU,
and gauaic positive stools here.
c. Thrombocytopenia- transfused for platelets <20 or bleeding.
She received 2 pooled units [**2139-1-8**] for tunneled line placement
and counts came up subsequently along with the other lines.
3. Respiratory status- During the middle of hospitalization, pt
started to get wheezy on exam. She does have a history of
asthma/COPD but she had never had anything like this before. Her
O2 Sats went to the mid-80s on RA and she was put on O2. She
developed stridor one night, but was never in respiratory
compromise. She was immediately started on IV solumedrol, and
stridor went away. This was changed to a prednisone taper. Her
symptoms got better and she was satting in the upper 90s on
ambulation upon discharge.
4. Diarrhea- After antibiotics as above were d/cd, pt started to
get profuse diarrhea. 3 c. diff assays were sent and one of them
was positive for c. diff. She was started on metronidazole which
she will continue as an outpatient.
5. N/V- likely secondary to chemotherapy and renal failure. She
was symptomatically treated and did well from this perspective.
6. DM- glucophage and glipizide were held and pt was continued
on a [**Hospital1 **] NPH with SS. During steroid usage (as above) her NPH
was uptitrated and then detitrated afterwards. When she was on
prednisone, BS were as high as >450, however, on discharge, BS
were in the mid 100s. She was also seen by [**Last Name (un) **].
7. Alkalosis-alkalosis on ABG which looked like a metabolic
alkalosis. This was thought to be [**2-19**] diarrhea, renal failure.
8. Lung cancer- with recently diagnosed IIIa SCLC s/p cisplatin
and etoposide as above. Heme/onc saw her in house and followed
her but no therapy was given during this time secondary to every
thing as above. She has follow up with them as an outpatient one
week after discharge.
9. Leukocytosis- WBC peaked in 80.7, and came down to 50K on
discharge. C diff came back positive and it was thought that it
was a combination of c. diff + lung ca. Pt will get WBC checked
as an outpt.
10. asthma/COPD- as above. Continued albuterol, salmeterol, and
fluticasone inhalers.
11. [**Name (NI) 12329**] Held pt's hyzaar (HCTZ/losartan) given renal failure
and eventually also d/cd verapamil as pt's BP was ~100 without
medications. She was discharged on no antihypertensives and this
will need to be reevaluated in the outpatient setting.
12. Anxiety/coping- Spoke a lot with pt's outside psychiatrist
Dr. [**Last Name (STitle) **]. We started pt on risperdal and outside psychiatrist
spoke to pt a lot. SW was consulted.
13. Hypercholesterolemia- continued statin, zetia.
14. F/E/N- [**Doctor First Name **], renal diet. IVF prn. Also neutropenic diet was
when needed as above. Electrolyte supplementation prn (calcium
as above)
15. Vision complaints- complained of double vision, and blurry
vision. Per pt, she has a history of toxoplasmosis scars in
retina. Records were faxed from her opthalmologist and she was
seen by opthalmology while inpatient. Her eye exam was fine.
16. Access- right groin temp dialysis cath was pulled [**1-7**].
Right IJ catheter was placed ([**2139-1-8**]).
17. Prophylaxis- Subcutaneous heparin, outpt PPI, took PO. We
continued ASA.
18. COde status- Discussed with patient. She said that she would
want everything done (Full Code). However, would not want
prolonged intubation if it did not seem reversible.
Medications on Admission:
Insulin NPH 16 units QHS.
Pantoprazole 40 mg PO Q24H
Metformin 1000 mg PO BID
Latanoprost 0.005 % 1 gtt HS
HYZAAR 100-25 mg PO once a day.
Oxycodone-Acetaminophen 5-325 mg PO Q4-6H
Glipizide 5 mg PO DAILY (Daily).
Simvastatin 40 mg PO DAILY
Verapamil 240 mg PO Q24H
Salmeterol 50 mcg/Dose Disk Q12H
Fluticasone 110 mcg/Actuation [**Hospital1 **]
Albuterol 90 mcg1-2 Puffs Inhalation Q6H
Ezetimibe 10 mg PO DAILY
Aspirin 81 mg PO daily
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs inhaler* Refills:*2*
3. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
Disp:*qs Disk with Device(s)* Refills:*2*
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
Disp:*30 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days: For C. diff colitis.
Disp:*24 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic 1 Drop QHS
().
Disp:*qs bottle* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-19**]
Puffs Inhalation Q4H (every 4 hours).
Disp:*qs 1* Refills:*0*
11. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia: Can also take up to two more
times a day for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
12. Insulin Syringe 0.5cc/28G Syringe Sig: One (1) Miscell.
twice a day: Per insulin regimen and sliding scale- up to 6
times a day.
Disp:*qs boxes* Refills:*2*
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: per
sliding scale Subcutaneous twice a day: 18 units qam
16 units qhs.
Disp:*2 bottle* Refills:*2*
14. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four
times a day: Per sliding scale attached.
Disp:*2 bottles* Refills:*2*
15. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*qs 1* Refills:*0*
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO twice a day.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
17. Epoetin
3,000 units qHD given at hemodialysis.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute renal failure on hemodialysis
Febrile Neutropenia
Clostridium Difficile
Anemia
Secondary Diagnosis
Diabettes Mellitus
Hypertension
Small Cell Lung cancer
Discharge Condition:
Good. Pt is ambulating, taking PO, and is afebrile.
Discharge Instructions:
Call your doctor or go to the ED if you have fever, chills,
naseua, vomiting, uncontrollable diarrhea, inability to drink
adequate liquids, problems breathing, shortness of breath, or
any other health concern.
CBC and chemistries will need to be done at dialysis. You may
need blood given to you then if you are anemic. You will also
get a medicine called Epoegin there.
Go to your appointments below
You have dialysis scheduled for this Monday [**2139-1-26**]. YOu need to
come to the [**Hospital1 **] [**First Name (Titles) 2142**] [**Last Name (Titles) **] at 7:30 am that
day and you will be taken to dialysis. You will start your
dialysis at [**Location (un) 1468**] on [**2138-1-29**].
Followup Instructions:
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 7728**]. Please call him this week for follow up.
You will need to call the kidney doctor Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4920**] at :
[**Telephone/Fax (1) 60**] for an appointment in ~2 weeks.
You have an appointment with Dr. [**Last Name (STitle) 102274**]/[**Doctor Last Name **]
[**2138-1-27**] 9:30 am for follow up in oncology clinic. Please call
[**Telephone/Fax (1) 22**] for directions.
ICD9 Codes: 5849, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7672
} | Medical Text: Admission Date: [**2183-1-3**] Discharge Date: [**2183-1-9**]
Date of Birth: [**2183-1-3**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**First Name8 (NamePattern2) 29633**] [**Known lastname 1968**] is a 1470 gram, 32 week
female twin number one, admitted secondary to prematurity.
She was born to a 30-year-old G1, P0 to 1 white female.
PRENATAL SCREENS: A positive, antibody negative, RPR
nonreactive, Rubella immune, hepatitis B surface antigen
negative, GBS unknown.
IUI pregnancy with diamniotic dichorionic twins. Pregnancy
complicated by premature rupture of membranes 40 hours prior
to delivery. Mother was treated with betamethasone (complete)
and antibiotics (greater than four hours prior to delivery).
Mom was transferred to [**Hospital6 256**]
from [**Hospital3 **] and allowed to labor.
Delivery was via cesarean section secondary to nonreassuring
tracing of Twin number 2. Cesarean section was done under
spinal. This baby was vigorous. Received some blow by
oxygen and was [**Last Name (un) 46511**] suctioned. Apgars were 8 and 9.
PHYSICAL EXAMINATION: The exam on admission to the Neonatal
Intensive Care Unit included a female that was pink and
comfortable in room air. The temperature was 97.5. The
pulse was 132. The respiratory rate 70. Blood pressure
71/35 with a mean of 52. Oxygen saturation was 100% on room
air. The weight was 1470 grams (30 percentile). Length 40
cm (25th percentile). Head circumference 28.5 cm (25th
percentile). Anterior fontanel was soft, flat,
nondysmorphic. Palate was intact. Breath sounds were clear.
There was no murmur. Normal pulses. Abdomen was soft, 3
vessel cord was present. There was no hepatosplenomegaly.
Normal female genitalia, patent anus, no sacral dimple, no hip
click. Baby was active with normal tone.
ASSESSMENT: 32 week twin number one female at risk for
sepsis secondary to preterm labor and PROM with unknown GBS
status. Mom received appropriate antepartum antibiotics. No
evidence of respiratory distress.
PLAN: Monitor for evidence of respiratory distress and apnea
of prematurity. NPO with intravenous fluids. Start feeds if
respiratory status remains stable. Routine attention to
electrolytes and dextrsticks. Check a CBC, blood culture.
Start ampicillin and gentamicin for rule out sepsis pending
status of blood cultures and clinical course. Follow
bilirubin. Support parents. To [**Hospital1 2436**] when ready for
level 2 care.
HOSPITAL COURSE: By systems:
Respiratory: Patient remained stable on room air throughout
and had no respiratory distress. On hospital day number four,
the patient started to have some apnea of prematurity that was
associated with significant bradycardia to the 30s and the
40s, so the patient was loaded with 30 mg/kg of intravenous
caffeine citrate on hospital day number five with a planned
course of caffeine citrate for apnea prematurity. The
patient had no other respiratory issues this admission.
Cardiovascular: The patient had no cardiovascular issues
this admission. No murmur was noted, and the patient did not
have any clinical evidence suggesting PDA.
Fluid, electrolytes and nutrition: The baby was started on
gavage feeds at 24 hours with stable respiratory status. The
patient quickly over five days worked up to full feeds of
PE20 via gavage and at time of transfer is on PE22 150
cc/kg/per day, 90% gavage approximately 10% po. An
electrolyte panel was checked on hospital day number four
that was within normal limits. Dextrosticks were within
reason and by day of life number five, the baby had been
gaining weight. The baby's weight is 1390 grams. The mom
does not plan to breast feed.
Gastrointestinal: The patient had evidence of indirect
hyperbilirubinemia that peaked at a total bilirubin of 9.4.
The baby was not a set up for hemolysis. Phototherapy was
instituted for a total of three days and was stocked on
[**1-8**] for a bilirubin of 6.9. The rebound biliribuin is
7.7 total, 0.2 direct.
Infectious Disease: The patient completed a 48 hour rule out
sepsis on ampicillin and gentamicin. Blood cultures were no
growth. Antibiotics were stopped at 48 hours.
Neurological: The patient exhibited no evidence of early
IVH, therefore, a planned head ultrasound between day of life
number seven and ten is anticipated.
Renal: The patient had a prenatal ultrasound diagnosis of
mild pyelectasis on the left. A follow-up post natal
ultrasound was obtained on hospital day number five that
showed bilateral mild hydronephrosis with a full bladder,
borderline normal variant. Prophylactic antibiotics were not
started. Plan was to obtain a repeat abdominal ultrasound to
evaluate hydronephrosis at greater than one week of life or
prior to discharge.
Audiology hearing screens to be performed before the baby is
discharged. Baby is not at high risk for hearing loss.
Ophthalmology: The baby is at low risk for retinopathy of
prematurity with no supplemental oxygen. Baby is 32 weeks
gestation, 1470 gram infant, therefore, would advise at least
one ophthalmologic examination prior to discharge.
Psychosocial: Parents are involved, well-informed and
exceptionally nice. They are eager to have their girls
transferred to [**Hospital3 **] which is closer to home.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: [**Hospital3 **].
MEDICATIONS AT DISCHARGE: None.
FEEDS AT DISCHARGE: PE22 150 cc/kg/per day. PG feeds over 40
minutes with an occasional po feed.
PEDIATRICIAN: None chosen yet.
State newborn screening sent. Immunization received: None.
Immunizations recommended prior to discharge. RSV
prophylaxis should be considered from [**Month (only) **] through [**Month (only) 547**]
for infants born at less than 32 weeks, or born between 32 and
35 weeks with plans for day dare or day care of siblings
during the RSV season, with a smoker in the household, or any
evidence of chronic lung disease. Influenza immunization
should be considered annually in the fall for preterm infants
with chronic lung disease once they reach six months of age.
Before this age, the family and other caregivers should be
considered for immunization against influenza to protect the
infant.
DISCHARGE DIAGNOSES:
1. Prematurity, 32 weeks now 32 6/7 weeks
2. Twin #1
3. Apnea of prematurity, ongoing.
4. Indirect hyperbilirubinemia, improving.
5. Sepsis ruled out
6. Mild hydronephrosis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**]
Dictated By:[**First Name3 (LF) 43833**]
MEDQUIST36
D: [**2183-1-8**] 01:04
T: [**2183-1-8**] 13:17
JOB#: [**Job Number 46512**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7673
} | Medical Text: Admission Date: [**2158-6-16**] Discharge Date: [**2158-6-26**]
Date of Birth: [**2113-1-29**] Sex: M
Service: MEDICINE
Allergies:
Latex / Levaquin
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
bedside drainage of perirectal abscess
PICC line placement
History of Present Illness:
The patient is a 45 year old male with a PMHx of metastatic RCC
(papillary vs clear cell) to lungs & L pleural effusions s/p
multiple chemo regimens (most recently cycle 10 of bevacizumab +
erlotinib on [**2158-4-13**]), presents after a recent admission to
[**Hospital1 18**] for PNA now with dizziness and lightheadedness.
The patient was recently admitted from [**2158-4-10**] to [**2158-4-14**] for
dyspnea. He was started on a 14-day course of unasyn &
doxycycline for post-obstructive pna but was ultimately
discharged on augmentin. He did not, however, complete a 14-day
course; opting to stop antibiotics on [**4-18**] in hopes of being
considered for a clinical trial. He was screened for a clinical
trial for a novel anti-PDL1 antibody that required him to hold
his tarceva for 3 weeks. During this time, he appears to have
clinically deteriorated.
Most recently, he was admitted again from [**2158-5-10**] - [**2158-5-16**]
for
respiratory failure due to post obstructive pneumonia and
progressive metastatic disease to the lungs, as well as the
pleural effusion. He was given vanc/cefepime switched to
Levofloxacin for a total of 8 day course. CT scan showed mild
colitis affecting the distal descending and sigmoid colon. Stool
studies were negative for C. Diff, but he was empirically
treated
with Flagyl and completed a 2 week course of treatment.
He was again admitted from [**5-22**] to [**5-26**] for hypotension. He was
initially started on vanco/zosyn/azithromycin out of concern for
possible sepsis (given patient has recent pneumonia requiring
intubation). Antibiotics were stopped given rapid improvement of
his hypotension and it was thought his hypotension/fever was
felt to be related to underlying RCC and immulogical response by
his primary outpatient oncologist. The patient was started on
Prednisone 40mg daily on discharge.
Since being discharged, he has had increased pain in his
perineum and was evaluated by a surgeon yesterday who
recommended aspiration of a potential abscess today. He has been
n.p.o. since midnight in anticipation of the procedure. He woke
this morning and developed some lightheadedness which he has had
previously with dehydration. He denies chest pain, shortness of
breath, palpitations. He denies fever, nausea, vomiting. He
called EMS and was on a blood pressure that was not palpable
peripherally and a heart rate in the 160s, he was given a 1.5 L
of fluid in the field with improvement of his blood pressure to
be 80s and his heart rate to the 120s.
In the ED, his VS were T 97.9 HR 120 BP 83/51 RR 16 SpO2 99%/4L.
Labs significant for WBC count of 11.9, with 94% neutrophils.
Lactate 2.4. INR 1.7. Colorectal surgery was called and
recommend a CT abdomen. CT showed diffuse colitis from cecum to
hepatic flexure and stable metastatic disease, no focal abscess.
Blood and urine culutres were drawn. Given 5L NS IV. Of note,
pt refused CVL. Given Flagyl, will give CTX. Colorectal
following. On transfer, VS were BP 107/59 HR 112. No fevers
but immunosuppressed, on chemo.
On arrival to the ICU, pt is resting in bed, appears to be in
pain. States she has pain in his lower abdomen, perineum.
Rates it [**7-9**]. States the Dilaudid IV that he got in the ED
helped but wore off. Also, endorses diarrhea but not bloody or
dark stools. Denies fevers.
Past Medical History:
- Renal Cell Carcinoma
---> [**2154**]: Microscoping hematuria
---> CT A/P: 4.5 cm L adrean & periadrenal mass
---> MRI: L periaortic mass 4.6 cm
---> PET CT: lingular nodule, RP lesion adjacent to L adrenal
- [**11/2154**]: underwent resection of mass & L adrenal nodule
---> Pathology revealved metastatic adenocarcinoma of unknown
origin
---> Prominent papillary architecture w abundant eosinophilic or
clear cytoplasm & high-grade nuclear features
- PET [**2-6**]: interval increase in size & update of pulmonary
nodules
- [**3-9**]: 6 cycles carboplatin & Taxotere
---> PET CT: improvement in L lung lesions
- [**9-7**]: Enrolled in phase 1 trial of MET/ALK inhibitor
---> PET CT: Progression of disease in L adrenalectomy bed &
lungs
---> Taken off trial
- THEROS CancerType ID molecular classification test revealed
90.9% probability that cancer is of kidney origin based on 92
gene expression profile
- [**11-7**]: Sunitinib
---> Post-CT: Partial regression of adrenal bed lesion &
stability in pulmonary nodules.
---> Progressed after 6 cycles of sunitinib
- [**8-8**]: Everolimus
- [**9-8**]: Taken off everolimus for disease progression
- [**9-8**]: Cyberknife radiation for mass invading psoas muscle
---> Recovery c/b severe pain [**3-2**] inflammation
---> Fevers to 100-102, SOB, R-sided CP.
- [**10-9**]: Bronch revealed malignant cell
---> No ABPA
- [**10-9**]: Started pazopanib
- [**3-11**]: Disease progression; taken off pazopanib
- [**4-10**]: s/p 10 cycles bevacizumab & erlotinib
Past Medical History:
- Nephrolithiasis (bilateral)
- Mitral valve prolapse
- Colon polyp
- Dysplastic nevus x3
- Necrotic LN in left neck (never biopsied/cultured)
Social History:
- Anesthesiologist at [**Hospital6 **]
- Married with two young children.
- Lives in [**Location **].
- Denies ETOH/tobacco/illicits.
Family History:
- Father: Died in his 60s from brain aneurysm. Hypoplastic
kidney
- Mother: Alive in her 70s.
- All 3 sisters healthy.
Physical Exam:
admission exam
GEN: thin male, appears to be in pain
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
Neck: no LAD
CV: tachycardic, regular rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, non-distended; no guarding/rebounding but +ttp in LUQ
and lower abdomen
EXT: no clubbing/cyanosis/edema; 2+ distal pulses
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, [**6-3**] motor function globally
DERM: no lesions appreciated
.
discharge exam
Pertinent Results:
admission labs
[**2158-6-16**] 12:25PM BLOOD WBC-11.9* RBC-4.14* Hgb-10.8* Hct-37.1*
MCV-89 MCH-26.0* MCHC-29.0* RDW-21.0* Plt Ct-425
[**2158-6-16**] 12:25PM BLOOD Neuts-94.5* Lymphs-2.9* Monos-2.3 Eos-0.2
Baso-0.1
[**2158-6-16**] 12:25PM BLOOD PT-17.6* PTT-25.4 INR(PT)-1.7*
[**2158-6-16**] 12:25PM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-136
K-4.3 Cl-105 HCO3-21* AnGap-14
[**2158-6-16**] 12:25PM BLOOD ALT-79* AST-61* AlkPhos-107 TotBili-1.3
[**2158-6-16**] 12:25PM BLOOD Albumin-2.5* Calcium-7.9* Phos-3.3
Mg-1.3*
[**2158-6-17**] 03:07PM BLOOD Type-[**Last Name (un) **] pH-7.32* Comment-GREEN TOP
[**2158-6-16**] 12:32PM BLOOD Lactate-2.4*
[**2158-6-17**] 03:07PM BLOOD freeCa-1.17
Brief Hospital Course:
45 M w metastatic RCC (papillary vs clear cell) to lungs & L
pleural effusions s/p multiple chemo regimens (most recently
cycle 10 of bevacizumab + erlotinib on [**2158-4-13**]), presents after
multiple recent admissions to [**Hospital1 18**] for PNA, presented with
hypotension and evidence of colitis on CT found to be Cdiff
positive.
.
# Hypotension: Initially thought to be [**3-2**] poor PO vs
distributive physiology from cdiff infection/rectal abscess.
Also considered adrenal insufficiency given patient on
Prednisone taper and adrenal lesion on previous imaging. He
received stress dose steroids and was subsequently transitioned
back to his home dose prednisone. Also, end-stage RCC could be
presenting with immunologic response that is causing this
hypotension. Patient??????s blood pressures remained in the 80s-100s
systolic despite fluid resuscitation and downtrending lactate.
Bedside echo did not show evidence of tamponade. His underlying
infection was treated with antibiotics. In terms of his
tachycardia, patient remained tachycardic despite adequate fluid
resuscitation. His tachycardia is likely multifactorial from
pain, underlying infection and cancer, anxiety. He had worsening
tachycardia and hypotension until the time of his death.
#Hypoxia/Shortness of breath: Patient had worsening dyspnea
throughout his stay. CT scan showed significant worsening of his
pulmonary metastases, stable pleural effusions, and a likely
pneumonia. He was started on vancomycin and cefepime for
pneumonia. He was on and off of BiPap for several days, before
his goals of care were changed towards comfort. Then he was
given IV dilaudid to relieve dyspnea.
.
# Colitis: Cdiff positive. KUB with evidence of worsening
colitis and patient with lower abdominal pain. However abdominal
exam is benign with good bowel sounds. Imaging with no evidence
of perforation or megacolon. Patient continues to be afebrile
with improving leukocytosis and decreased stool output.
Generally improving clinically from a colitis standpoint.
-resolved during ICU stay, continued on PO Vanc/Flagyl
.
# rectal abscess ?????? patient had beside I&D of a rectal abscess by
colorectal surgery (Dr. [**Last Name (STitle) **] without complication.
.
ICU Course:
Patient initially presented with presumptive shock due to c.diff
colitis, the hypotension was resolved promtply with fluid
challenge, however the patient quickly became volume overloaded
due to what was found to be new-onset heart failure with an EF
significantly depressed from previous studies. The patient had
complained of significant abdominal pain, palliative care was
consulted and the patients pain medication regimen was adjusted
with excellent symptomatic control.
-hypoxia, tachypnea, tachycardia has been omnipresent
[**6-20**]
-CTA-Chest revealed new RUL ground-glass opacities c/w likely
hemorrhage vs infectious process; the patient was started on
cefipime, vanc, and bactrim (for PCP empiric treatment). The
patient has been intermittently on bipap for respiratory
distress. The patient was given some volume back with colloid.
[**6-21**]
-Continued progression of respiratory decompensation, CT scan
findings were confirmed to be significant worsening of thoracic
tumor burden, the patient had an episode of tachypnea and
worsening tachycardia overnight which resulted in bipap,
additional doses of ativan, and lasix for diuresis. During this
time the patient declined intubation, and discussion was made
with SW/Onc/Family/MICU with little progression with regard to
end-of-life issues and critical/emergent airway management.
[**6-22**]
-the patients respiratory status continued to decline, tachypnea
persisted and the patient is reliant on a face-mask for
oxygenation, desaturating into the high 80s after less than a
minute with oxygen. A chest xray was performed which revealed
worsening edema and collapse of the RUL, likely c/w obstructive
process due to metastatic disease.
[**Date range (1) 22999**]
-the patient had persistent respiratory distress, palliative
care was consulted and the patient was started on a dilaudid gtt
for pain and respiratory distress management according to
comfort care guidelines; his ativan was titrated back to q6 with
PRN dosing maintained. Abx coverage was continued and
micafungin was added - the patient is chronically on steroids
and had previously been on chemotherapy. Despite these efforts
the patient continued to decline with persistent hypotension,
tachycardia, but improving distress symptoms likely given the
increasing titration and palliative doses of IV narcotics.
[**6-26**]
-the patient remained somnolent, unresponsive to verbal stimuli,
at rounds the patient had rapid/shallow respirations, his blood
pressures were 50's systolic with mottling of his lower
extremities and cool extremities throughout; his appearance was
noted to be peri-arrest. During rounds, Dr [**Known lastname 22998**] became
progressively hypotensive, eventually became bradycardic and
went into cardiac arrest; resuscitation was not initiated
according to standing DNR/DNI; family was present at the bedside
and the patient expired at 0950.
Medications on Admission:
oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily),
now tapered down to 20mg daily
erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Inlyta 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic renal cell carcinoma
Pneumonia
Possible pulmonary hemorrhage
Clostridium Difficile colitis
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2158-6-26**]
ICD9 Codes: 4280, 4589, 5180, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7674
} | Medical Text: Admission Date: [**2155-9-5**] Discharge Date: [**2155-9-14**]
Date of Birth: [**2120-3-28**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
difficulty swallowing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mr [**Known lastname **] is a 35 yo man with history of myasthenia [**Last Name (un) 2902**]
since [**12/2154**] managed with steroids, cellcept, and mestinon. He
has been managed as an outpatient fairly stably, but he reported
today that he has been having some difficulty swallowing pills
or food X 1 day. Reports that they "get stuck in his throat" and
also reports that he "chokes". Denies any trouble swallowing
water, but he has been unable to swallow any of his medications
since yesterday. He denies any changes in his strength,
breathing or vision. He did present to the ED late last night,
but left from
the waiting room as he was afraid of catching a respiratory
infection from other patients.
He denies infection, denies trouble breathing.
ROS:Neg except sl. constipation
Past Medical History:
PAST MEDICAL HISTORY:
-DM, diagnosed some 4 years ago, but he has been having this for
a longer period of time
-pancreatitis some 15 yrs ago in setting of Ethoh
-s/p cyst removal L-groin-
-HTN
-denies hypercholesterolemia
Social History:
Occupation: Not currently employed
Smoking: 2ppd for 20 years, cut back to 1 ppd; EthOH: denies;
drug abuse: denies.
Has fiance; children: 1 son.
Lives with aunt.
Family History:
-DM, hypercholesterolemia, HTN, CAD
-no auto-immune disease
Physical Exam:
T-97.3 BP-148/95 HR-97 RR-16 (12 my exam) O2Sat 99% RA (observed
89-93% during exam)
Gen: Lying in bed, looks unwell, fatigued
HEENT: NC/AT, dry, coated tongue
Neck: normal ROM, supple,
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear bilaterally, decr BS, decr chest expansion
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact. Very dysarthric/dysphonic. [**Location (un) **]
intact.
Registers [**2-8**], recalls [**1-11**] in 10 minutes. No right left
confusion. No evidence of apraxia.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Bilat partial ptosis, rapid closure with sustained
upgaze in 5s. Visual fields are full to confrontation.
Extraocular
movements: limited abduction bilaterally, no nystagmus. Not
endorsing diplopia but also says has it all the time. Sensation
intact V1-V3. Facial movement symmetric. Hearing intact to
finger rub bilaterally. Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor; No pronator drift; [**3-13**] neck flexors; 4+/5 neck extensors
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Fatiguable**
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS
Reflexes:
+2 and symmetric throughout UE and 1+ LE. Toes downgoing
bilaterally
Coordination: finger-nose-finger normal, RAMs normal.
Gait: stands unassisted
Pertinent Results:
[**2155-9-5**] 06:28PM GLUCOSE-140* UREA N-13 CREAT-0.8 SODIUM-144
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-36* ANION GAP-11
[**2155-9-5**] 06:28PM CALCIUM-9.9 PHOSPHATE-3.8 MAGNESIUM-2.0
[**2155-9-5**] 06:28PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2155-9-5**] 06:28PM WBC-12.3* RBC-4.76 HGB-13.0* HCT-37.9*
MCV-80* MCH-27.3 MCHC-34.4 RDW-13.3
[**2155-9-5**] 06:28PM NEUTS-62.1 LYMPHS-31.2 MONOS-4.9 EOS-1.5
BASOS-0.3
[**2155-9-5**] 06:10PM TYPE-ART PO2-72* PCO2-53* PH-7.43 TOTAL
CO2-36* BASE XS-8
Brief Hospital Course:
Pt initially admitted to ICU with concern for respiratory
compromise. Pt received plasmapheresis on night of arrival with
significant improvement in functioning. Pt however, pt HD 2
with continued dysphonia and poor bulbar function and motor
weakness. Pt continued to have plasmapheresis X 5 treatments
(QOD) with subsequent improvement in functioning. After 5th
treatment, pt with 5/5 strength in all extremities with full
power in neck extensors and flexors. pt with continued weakness
in his extraocular muscles but significantly improved as
compared to admission (able to maintain upward gaze ~12 seconds
prior to ptosis and stopping). pt able to count to 30 with 1
deep breath.
Pt had NIFs and VC performed Q8 throughout stay and improved to
VC ~3 and NIFs in -50 range prior to discharge. (as opposed to
VC of 1.3 and NIF of -20 - -30 upon admit).
Pt had speech and swallow evaluation where he was noted to have
silent aspiration. Arrangement made for
cough/swallow/cough/swallow technique for PO intake. However,
with increased treatment, pt with significant improvement and by
discharge, repeat swallow revealed no aspiration. pt advanced
to regular diet by discharge without difficulty.
Pt initially with blunted affect and significant anger.
Psychiatry consulted and felt appropriate depressed mood in
response to diagnosis. Multiple discussions with patient re:
possible pharmacotherapy, all of which were refused by patient.
Pt, however, with significantly improved mood/affect with
improvement in condition during stay. Pt was recommended to
follow up with outpatient psych upon discharge.
Medications on Admission:
Mestinon 60mg [**Hospital1 **]
Cellcept 1500mg [**Hospital1 **]
Prednisone 20mg altern days
Metformin 1000mg [**Hospital1 **]
Glipizide 10 [**Hospital1 **]
Lisinopril 20 or 30mg daily
Discharge Medications:
1. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
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:*2*
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. Lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
[**First Name9 (NamePattern2) **] [**Last Name (un) 2902**]
HTN
DM
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as prescribed. Please call your
doctor or the closest ED if you have new symptoms.
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2155-10-23**] 4:00
Completed by:[**2155-9-16**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7675
} | Medical Text: Admission Date: [**2107-7-29**] Discharge Date: [**2107-8-5**]
Date of Birth: [**2050-4-14**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
gentleman with a past medical history significant for vagal
bradycardia, status post permanent pacemaker insertion, who
presented to his primary care physician with [**Name Initial (PRE) **] history of
exertional angina for two to three months.
The patient underwent a stress test on [**7-29**] which was
markedly positive. The patient began experiencing angina and
was admitted to [**Hospital1 69**] for
cardiac catheterization.
PAST MEDICAL HISTORY:
1. Peptic ulcer disease.
2. Status post gastroenterostomy.
3. Status post permanent pacemaker placement for vagal
bradycardia which was complicated by a pacemaker infection
and requiring pacemaker replacement.
4. Status post cholecystectomy.
ALLERGIES: CODEINE and PERCOCET (which upset his stomach).
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg by mouth once every other day.
3. Klonopin 0.5 mg by mouth twice per day.
4. Zoloft 50 mg by mouth once per day.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] is an
eighth grade History teacher. He denies tobacco or alcohol
use.
PHYSICAL EXAMINATION ON PRESENTATION: Preoperative physical
examination revealed his heart rate was 70 ventricularly
paced, his blood pressure was 130/88, and his oxygen
saturation was 100% on room air. Head, eyes, ears, nose, and
throat examination revealed atraumatic and within normal
limits. Carotids were without bruits bilaterally. The
oropharynx was clear. The heart was regular in rate and
rhythm. No murmurs. The lungs were clear to auscultation
bilaterally. The abdomen was soft, nontender, and
nondistended. A well-healed right upper quadrant surgical
scar. Extremity examination revealed extremities were
without clubbing, cyanosis, or edema. No varicosities.
Pulses were equal in the upper and lower extremities
bilaterally.
PERTINENT RADIOLOGY/IMAGING: Preoperative electrocardiogram
showed a left bundle-branch block, a normal sinus rhythm, and
nonspecific ST-T wave changes.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
directly to the Cardiac Catheterization Laboratory from his
stress test.
The cardiac catheterization showed a normal left ventricular
ejection fraction. No mitral regurgitation. Apical
akinesis/dyskinesis. Anterolateral hypokinesis.
Angiography showed an 80% distal left main occlusion,
proximal mild diffuse left anterior descending artery
disease, with mild thrombotic total occlusion of the distal
vessel, and an 80% right coronary artery lesion.
The patient had an intra-aortic balloon pump placed in the
Catheterization Laboratory due to his severe coronary artery
disease and was admitted to the Coronary Care Unit overnight.
On [**7-30**], the patient was taken to the operating room
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. The patient had a coronary artery
bypass graft times four with left internal mammary artery to
left anterior descending artery, saphenous vein graft to
posterior left ventricular, obtuse marginal, and diagonal.
Please see the Operative Note for further details.
The patient was transferred to the Surgical Intensive Care
Unit in stable condition. The patient was weaned from the
mechanical ventilation on postoperative day two without
difficulty. The patient required a moderate amount of volume
resuscitation and several units of packed red blood cells on
his first postoperative day for hypotension and low cardiac
output. The intra-aortic balloon pump was removed on
postoperative day one without difficulty. The patient
required a Neo-Synephrine infusion to maintain adequate blood
pressures on postoperative day one.
On postoperative day two, the patient was transferred from
the Intensive Care Unit to the floor in stable condition.
The patient remained stable. The patient was started on a
beta blocker. The patient's chest tubes were removed, and a
subsequent chest x-ray was without pneumothorax or effusion.
On postoperative day three, the Electrophysiology Service was
consulted for testing of the patient's permanent pacemaker.
This pacemaker was found to have normal function. The
patient began ambulating with Physical Therapy.
By postoperative day four, the patient was able to complete a
level V of physical therapy which included ambulating 500
feet and climbing one flight of stairs without difficulty and
without requiring oxygen.
On postoperative day five, the patient noted that he
continued to be hoarse and had problems drinking water which
resulted in coughing. It was decided to obtain an
Ear/Nose/Throat consultation. The Ear/Nose/Throat team
performed a fiberoptic laryngoscopy at the bedside which
showed the patient's left vocal cord was dysfunctional. It
was recommended that the patient undergo a Speech and Swallow
evaluation. The bedside Speech and Swallow evaluation
determined that the patient was probably aspirating while
drinking thin liquids.
Subsequently, on postoperative day six, the patient underwent
a videoscopic swallow evaluation which showed the patient was
not aspirating thin liquids. The Ear/Nose/Throat team felt
that the patient's dysphagia and dysarthria would improve and
the vocal cord performance would improve over time. It was
recommended that the patient have outpatient followup with no
treatment needed at this time.
DISCHARGE DISPOSITION: On postoperative day six, the patient
remained hemodynamically stable and without difficulties.
The patient was cleared for discharge to home.
PHYSICAL EXAMINATION ON DISCHARGE: Temperature maximum was
99.5 degrees Fahrenheit, heart rate was 99, blood pressure
was 122/86, respiratory rate was 20, and oxygen saturation
was 95% on room air. The patient was awake, alert, and
oriented times three. Neurologic examination was grossly
intact. The patient's voice was hoarse. There was no
stridor or drooling noted. The patient's lungs were clear to
auscultation and without wheezes, rhonchi, or rales. Heart
was regular in rate and rhythm. No murmurs, rubs, or
gallops. The abdomen was soft, nontender, and nondistended.
The patient was tolerating a regular diet. The patient was
able to drink thin liquids without aspiration and was having
normal bowel movements. Extremity examination revealed the
right lower extremity was without edema. The left lower
extremity had 1 to 2+ pitting edema. The left lower
extremity vein harvest site was clean and dry. The
Steri-Strips were intact. There was no erythema or drainage.
The sternal incision was clean and dry. The Steri-Strips
were intact. There was no erythema or drainage. The sternum
was stable. The patient's chest tube sites had a 0.5-cm area
of surrounding erythema. There was no fluctuance. There was
no drainage.
MEDICATIONS ON DISCHARGE:
1. Enteric-coated aspirin 161 mg by mouth every day.
2. Lasix 20 mg by mouth once per day (times seven days).
3. Potassium chloride 20 mEq by mouth once per day (times
seven days).
4. Hydrocodone one to two tablets by mouth q.4-6h. as
needed.
5. Sertraline 50 mg by mouth q.h.s.
6. Clonazepam 0.5 mg by mouth twice per day.
7. Protonix 40 mg by mouth once per day.
8. Lescol 40 mg by mouth once per day.
9. Lopressor 100 mg by mouth twice per day.
DISCHARGE STATUS: The patient was to be discharged to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with his primary
care physician (Dr. [**Last Name (STitle) 4390**] in one to two weeks.
2. The patient was instructed to follow up with Dr.
[**First Name (STitle) **] [**Name (STitle) 1911**] (his cardiologist) in one to two
weeks.
3. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1537**] in four weeks.
4. The patient had an appointment with the [**Hospital **] Clinic
on [**9-29**] at 5 p.m.
5. The patient was instructed to call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38719**]
office (whose in the Ear/Nose/Throat attending), and the
patient was to see him within one to two weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft.
3. Postoperative dysphagia and dysarthria due to left vocal
cord dysfunction.
4. Status post video-assisted swallow evaluation.
5. Status post fiberoptic laryngoscopy.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 28087**]
MEDQUIST36
D: [**2107-8-5**] 13:02
T: [**2107-8-5**] 13:25
JOB#: [**Job Number 38720**]
ICD9 Codes: 4111 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7676
} | Medical Text: Admission Date: [**2201-2-23**] Discharge Date: [**2201-2-27**]
Date of Birth: [**2180-7-28**] Sex: F
Service: [**Location (un) **]
CHIEF COMPLAINT: Nausea, vomiting, headache, and neck pain.
HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old
woman with a history of asthma and migraine headaches who
reported nasal congestion and sneezing on Saturday ([**2201-2-21**]) relieved with over-the-counter decongestants who
presented on [**2-23**] with an acute onset of nausea,
vomiting, headache, and neck pain.
The patient was well on the morning of admission. She went
to her basketball pregame practice without complaints.
However, shortly thereafter around lunch she noticed that her
appetite was poor and that she felt very fatigued. Prior to
her game that afternoon, she developed the acute onset of
severe nausea and multiple episodes of vomiting. She then
developed a severe throbbing headache, neck stiffness, and
shortness of breath; at which time she presented to the
Emergency Department.
She denied any photophobia. She lives in a dormitory at Pine
[**Doctor Last Name **] College and denied any sick contacts at home, or in
school, or on the basketball team.
In the Emergency Department, she received ceftriaxone and
vancomycin. A lumbar puncture was performed. Tube #1
revealed 34,375 red blood cells, 58 white blood cells; of
which 94% were polys, 1% lymphocytes, and 5% monocytes. Tube
#4 revealed 1,960 red blood cells, 4 white blood cells; of
which 98% were polys and 2% lymphocytes. The protein in the
cerebrospinal fluid was 50, glucose was 69. LDH was 13; and
the Gram stain showed no organisms or polys. The tap was
felt to be negative, so further etiologies of infection were
investigated.
The patient had complained of severe/severe neck pain, and on
examination in the Emergency Department resident noted some
erythema and exudate in the oropharynx. The patient was sent
for a computed tomography of the neck without contrast to
rule out a retropharyngeal abscess. The computed tomography
was negative.
On further investigation in the Emergency Department, review
of systems revealed dysuria for the previous one to two days,
and that the patient was currently menstruating and using
tampons. In fact, on the day of admission, the patient had a
tampon in place for over 12 hours; at which time the concern
for toxic shock syndrome was raised. A pelvic examination
was performed, and a vaginal swab was sent for culture in
addition to gonorrhea and chlamydia.
Due to persistent hypotension with systolic blood pressures
in the 90s (even after receiving 6 liters or normal saline)
and fevers to 104, the patient was admitted to the Medical
Intensive Care Unit for further management.
PAST MEDICAL HISTORY:
1. Asthma.
2. Migraine headaches.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: None.
SOCIAL HISTORY: The patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] at Pine [**Doctor Last Name **]
College. She plays point guard on the basketball team. She
does not use tobacco, alcohol, or any illicit drugs and
denies any sick contacts.
FAMILY HISTORY: Paternal grandmother had multiple myeloma.
History of diabetes in the family as well as
hypercholesterolemia.
REVIEW OF SYSTEMS: Review of systems was again significant
for dysuria, vaginal discomfort, sore throat, and minor
dysphagia.
PHYSICAL EXAMINATION ON PRESENTATION: Examination on
admission revealed the patient was febrile up to 103.7, she
was tachycardic in the 120s to 130s, blood pressure was
90s/50s, with a respiratory rate of 34. She was saturating
100% on room air. Pertinent physical findings on head, eyes,
ears, nose, and throat examination revealed erythema and a
small amount of tonsilar exudate in the oropharynx with
fullness of the carotids bilaterally (which were nontender).
Her neck was very/very tender to passive motion. There was
no palpable lymphadenopathy, and there was reproducible pain
with palpation in the nape of the neck. Her heart
examination was regular and tachycardic without murmurs. Her
lungs were clear bilaterally. Her abdominal examination was
benign with no suprapubic tenderness. Her extremities
revealed a small amount of lower extremity edema of
approximately 1+ with 2+ pulses. Her neurologic examination
revealed negative Kernig and Brudzinski signs. It was
otherwise nonfocal. Examination of her skin revealed no skin
rash.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 22.7 (with a
differential of 72% neutrophils, 19% bands, 1% lymphocytes,
and 6% monocytes), hematocrit was 36.3, and platelets were
241. Chemistry-7 was remarkable only for acute renal failure
with a blood urea nitrogen of 17 and creatinine of 1.1.
Coagulations were within normal limits. Cerebrospinal fluid
studies were reported in the History of Present Illness.
RADIOLOGY/IMAGING: A computed tomography of the neck
revealed no soft tissue fluid collection.
A chest x-ray revealed diffuse interstitial markings which
were thought to possibly represent an atypical pneumonia, a
viral pneumonia, a hypersensitivity pneumonitis, or other
inflammatory process.
MEDICAL INTENSIVE CARE UNIT COURSE: The patient was admitted
to the Medical Intensive Care Unit for further management of
possible sepsis.
Because of the amount of blood persisting through tube #4 in
the lumbar puncture, she was started on acyclovir for the
concern of HSV encephalitis. HSV/PCR was added on to the
cerebrospinal fluid studies as well.
She was continued on vancomycin and ceftriaxone. She
remained febrile, requiring frequent Tylenol dosing.
Clindamycin had been added but was discontinued the following
morning, as it was felt to be unnecessary for additional
coverage. Further blood cultures were sent, and she was
resuscitated with normal saline. Her fever became better
controlled, and her blood pressure normalized, at which time
she was called out to the Medicine floor.
HOSPITAL COURSE ON [**Location (un) 259**] FIRM: The patient was called out
to the floor on [**2201-2-25**].
She was still complaining of neck stiffness but reported that
her headache had been under much better control. She was no
longer feeling feverish nor was she photophobic and denied
any continuation of her nausea and vomiting. However, she
did still report a decrease in her appetite.
Her complete blood count improved from a white blood cell
count of 22 down to 12.7. Her hematocrit was noted to drop
from 36 to 27.9; thought to be dilutional but still a very
low hematocrit for a girl of her age. Hemolysis laboratories
were checked which were negative.
At this time, Infectious Disease was consulted regarding
further management and workup of this patient. The
laboratory data that had been returned by now revealed urine
culture was negative. Blood cultures were negative to date
times four. Gonorrhea and chlamydia cultures were negative.
Culture and sensitivity culture was negative. Toxic shock
antibody panel was sent, and the HSV/PCR was still pending.
Her creatine kinases were noted to be elevated at 411 with a
MB of 1; thought to be a minor amount of rhabdomyolysis.
Infectious Disease consultation thought that the differential
included the possibility of a severe influenza or other viral
syndrome. Still considered toxic shock a real possibility
despite the lack of a skin rash.
The following day (on [**2201-2-26**]), the HSV/PCR returned
negative; at which time the acyclovir was discontinued.
Ceftriaxone was discontinued as well as the concern for
meningitis had been ruled out.
The culture from a vaginal swab at this time was positive for
Staphylococcus aureus; making toxic shock syndrome the most
likely diagnosis. Clindamycin was added to the regimen at
300 mg p.o. t.i.d. and vancomycin was stopped as the
Staphylococcus isolate was sensitive to clindamycin. The
isolate was sent to [**University/College **] for a toxin assay which will be
followed up by the Infectious Disease Department.
On the day of discharge, the patient had been afebrile for 48
hours. She has mobilized large amounts of fluid that had
third-spaced into the lower extremity and likely into the
neck soft tissues causing her neck stiffness and pain. Range
of motion in her neck was greatly improved as was the pain
she was feeling in her neck.
For the last 24 hours prior to discharge, she developed
repeated episodes of diarrhea which could likely be a side
effect from the antibiotics or possibly Clostridium difficile
related to the antibiotics she received as an inpatient.
This was conveyed to the nurse practitioner ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 45707**]) at
Pine [**Doctor Last Name **] College who will follow up with Ms. [**Known lastname **] if the
diarrhea does not improve.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE DIAGNOSES: Toxic shock syndrome.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to see her primary care doctor (Dr.
[**Last Name (STitle) 45708**] at the Pine [**Doctor Last Name **] College on Monday.
2. In addition, she had an appointment to follow up with Dr.
[**Last Name (STitle) 2262**] [**Name (STitle) 45709**] of Infectious Disease in two weeks.
MEDICATIONS ON DISCHARGE: Clindamycin 300 mg p.o. t.i.d.
(to complete a 2-week course).
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Name8 (MD) 3491**]
MEDQUIST36
D: [**2201-2-27**] 09:51
T: [**2201-2-28**] 06:00
JOB#: [**Job Number 45710**]
ICD9 Codes: 2765, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7677
} | Medical Text: Unit No: [**Numeric Identifier 72394**]
Admission Date: [**2173-4-27**]
Discharge Date: [**2173-5-4**]
Date of Birth: [**2173-4-27**]
Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 22771**] #2 is the
second born of twins, born to a 19-year-old G-2, P-1 woman,
gestational age 35 and 1/7 weeks. Prenatal screens: Blood
type O positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group beta
strep status unknown. The pregnancy was notable for
spontaneous dichorionic diamniotic twins. The mother
experienced preterm labor and was transferred from [**Hospital 1474**]
Hospital to [**Hospital1 69**]. She was
taken to cesarean section for unstoppable preterm labor. She
did not receive any doses of betamethasone. Twin #2 emerged
with spontaneous respirations, had Apgars of 8 at one minute
and 8 at five minutes, required blow by oxygen in the
delivery room. She was admitted to the neonatal intensive
care unit for treatment of prematurity.
Birth weight 2.47 kilograms, 25th to 50th percentile, length
50 cm, 90th percentile, head circumference 33 cm, 75th
percentile. Discharge physical: Nondistressed growing preterm
infant requiring isolette for temperature control. Head,
eyes, ears, nose and throat: Anterior fontanelle open and
flat. Sutures approximated. Eyes clear. Mucous membranes
moist and pink. Chest: Clear and equal breath sounds,
comfortable respirations. Cardiovascular: Regular rate and
rhythm, no murmur. Pulses +2. Baseline heart rate 130 to 160
beats per minute. Blood pressure 62/48 with a mean of 54.
Abdomen: Soft, active bowel sounds, no masses, no
organomegaly. Cord on and drying. GU: A preterm female.
Extremities: Straight. Normal sacrum. Moving all. Hips
stable. Neurologic: Active with good tone.
HOSPITAL COURSE: Respiratory: This baby had significant
grunting, flaring and retracting upon admission to the
neonatal intensive care unit. She was placed on continuous
positive airway pressure. Her chest x-ray was consistent with
transient tachypnea of the newborn. Her initial oxygen
requirement was 30% but she weaned to room air shortly after
being started on continuous positive airway pressure. She
weaned to room air by day of life #2. She has continued
in room air since that time with oxygen saturation greater
than 94%. She has had infrequent episodes of spontaneous
apnea and bradycardia.
Cardiovascular: This infant has maintained normal heart rate
and blood pressure. No murmurs have been noted.
Fluid, electrolytes and nutrition: This baby was initially
NPO and maintained on intravenous fluids. Enteral feeds were
started on day of life #2 and gradually advanced to full
volume. At the time of discharge, she is taking 120 to 140
mL/kg/day. All p.o. of breast milk or Similac 20 calorie
formula. She was increased to 24 calories per ounce on [**2173-5-4**]. Discharge weight is 2.295 kilograms with a head
circumference of 33 cm and a length of 50.3 cm.
Infectious disease: Due to prematurity, the unknown group
B strep status of the mother, and her respiratory
distress, this infant was evaluated for sepsis upon admission
to the neonatal intensive care unit. A complete blood count
was within normal limits. A blood culture was obtained prior
to starting intravenous ampicillin and gentamicin. The blood
culture was no growth at 48 hours and the antibiotics were
discontinued.
Hematology: Hematocrit at birth was 45%. This infant has not
received any transfusions of blood products.
Gastrointestinal: Peak serum bilirubin occurred on day of
life #6, total 9.3 mg/deciliter direct.
Neurology: This baby has maintained a normal neurological
exam during admission. There are no neurological concerns at
the time of discharge.
Sensory: Audiology: Hearing screening has not yet been
performed and is recommended prior to discharge.
Psychosocial: [**Hospital1 69**] social
work has been involved with this family. Contact social
worker is [**Name (NI) 46381**] [**Name (NI) 6861**], and she can be reached at [**Telephone/Fax (1) 55529**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transferred to [**Hospital 1474**] Hospital for
continuing level II nursery care.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 60719**] in [**Hospital1 1474**],
[**State 350**].
CARE AND RECOMMENDATIONS: At the time of discharge:
1. Feeding: Breast milk or Similac 24 calories per ounce, ad
lib p.o. 120 mL/kg/day minimum.
2. Medications: Multivitamins, Gold Mine baby vitamins 1 mL
p.o. daily, ferrous sulfate 0.2 mL of 25 mg/mL dilution
p.o. daily.
3. 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 receive vitamin D
supplementation at 200 international units which may be
provided as a multivitamin preparation. This should be
given daily until 12 months corrected age.
4. Car seat position screening is recommended prior to
discharge.
5. State newborn screen was sent on [**2173-4-30**]. No
notification of abnormal results to date. Second follow-
up screening is recommended at 2 weeks of age.
6. No immunizations administered.
7. 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 age sibling, 3. With chronic lung disease or 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 recommends
initial vaccination of preterm infants at or following
discharge from the hospital if they are clinically stable
and at least 6 weeks but fewer than 12 weeks of age.
DISCHARGE DIAGNOSES:
1. Prematurity of 35 and 1/7 weeks gestation.
2. Twin #2 of twin gestation.
3. Respiratory distress secondary to transient tachypnea of
the newborn.
4. Suspicion for sepsis ruled out.
5. Mild hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2173-5-4**] 15:49:11
T: [**2173-5-4**] 16:43:04
Job#: [**Job Number 72395**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7678
} | Medical Text: Admission Date: [**2106-1-9**] Discharge Date: [**2106-1-12**]
Date of Birth: [**2030-9-2**] Sex: F
Service: NEUROLOGY
Allergies:
Urispas / Atorvastatin
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
speech difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75 y RHW had supper with her husband at 6 pm, she went to
the bedroom and was getting into her bed. She slid to the floor
but did not hit her head. Her husband went to find her, and he
tried to ask her questions, but she responded to him in garbled
speech. She also could not get up from the floor.
Past Medical History:
-paroxysmal atrial fibrillation, not on anticoagulation
-hypertension
-hypercholesterolemia
-hypothyroidism
-low back pain
-depression/anxiety
-history of basal cell carcinoma removed from left cheek
-history of multiple skeletal fractures
-history of left hip fracture, status post left ORIF
Social History:
She lives at home with her husband. She is a former hospital
secretary at [**Hospital1 18**]. She has a distant but brief history of
tobacco use. Denied alcohol or illicit drug use.
Family History:
Multiple family members with cardiac disease.
Physical Exam:
NIH SS:
1a. Level of Consciousness: 0
1b. LOC questions: 2
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 1
4. Facial palsy: 3
5a. Motor arm, left: 0
5b. Motor arm, right: 1
6a. Motor leg, left: 0
6b. Motor leg, right: 1
7. Limb ataxia: 0
8. Sensory: 0
9. Best language: 2
10. Dysarthria: 2
11. Extinction and inattention: 1
total score: 13
Vitals: T 96.4, BP 157/93, HR 87, RR 21, SpO2 97%
General: no obvious bruises
CVS: PSM in the mitral area, no carotid bruits, no peripheral
edema
Resp: Lung bases are clear
GI: soft, non-tender, normal bowel sounds
Neurologic examination:
Mental status: Awake and alert, cooperative with exam.
Completely
aphasic, could not read, neglects things on her right.
Cranial Nerves: Fundoscopic examination reveals sharp disc
margins. Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields - right inferior temporal field cut.
Extraocular movements intact bilaterally without nystagmus.
Sensation intact V1-V3. Profound right facial droop. Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
Sternocleidomastoid and trapezius full strength bilaterally.
Tongue midline (compensating for the facial droop), movements
intact.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. right pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE
R 5 5 5 5 5 5 5 5 5 5 5 5
L +4 -5 5 5 5 5 +4 -5 -5 5 5 5
Sensation: Intact to light touch, pinprick. Extinction to DSS on
the right.
Reflexes: 2+ on the right, and 2 on the left. Right-Babinski.
Coordination: finger-nose-finger, heel to shin ataxic on the
right.
Gait:could not assess
Pertinent Results:
[**2106-1-12**] 06:30AM BLOOD WBC-10.4 RBC-3.85* Hgb-12.9 Hct-35.0*
MCV-91 MCH-33.6* MCHC-37.0* RDW-13.4 Plt Ct-228
[**2106-1-11**] 06:00AM BLOOD WBC-8.7 RBC-4.07* Hgb-13.2 Hct-37.5
MCV-92 MCH-32.6* MCHC-35.3* RDW-13.3 Plt Ct-256
[**2106-1-10**] 02:52AM BLOOD WBC-11.5* RBC-3.62* Hgb-11.8* Hct-33.3*
MCV-92 MCH-32.5* MCHC-35.3* RDW-13.2 Plt Ct-226
[**2106-1-9**] 08:05PM BLOOD WBC-11.5* RBC-4.29 Hgb-13.5 Hct-39.1
MCV-91 MCH-31.5 MCHC-34.5 RDW-13.3 Plt Ct-258
[**2106-1-12**] 06:30AM BLOOD PT-16.8* INR(PT)-1.5*
[**2106-1-11**] 06:00AM BLOOD PT-14.3* INR(PT)-1.2*
[**2106-1-10**] 02:52AM BLOOD PT-14.7* PTT-26.4 INR(PT)-1.3*
[**2106-1-9**] 08:05PM BLOOD PT-13.9* PTT-27.4 INR(PT)-1.2*
[**2106-1-9**] 08:05PM BLOOD Fibrino-346
[**2106-1-12**] 06:30AM BLOOD Glucose-101 UreaN-16 Creat-1.5* Na-140
K-3.6 Cl-105 HCO3-24 AnGap-15
[**2106-1-11**] 06:00AM BLOOD Glucose-102 UreaN-15 Creat-1.4* Na-143
K-3.7 Cl-110* HCO3-24 AnGap-13
[**2106-1-10**] 02:52AM BLOOD Glucose-122* UreaN-22* Creat-1.5* Na-138
K-3.6 Cl-106 HCO3-23 AnGap-13
[**2106-1-9**] 08:05PM BLOOD UreaN-24* Creat-1.9*
[**2106-1-10**] 02:25PM BLOOD CK(CPK)-60
[**2106-1-10**] 02:52AM BLOOD ALT-12 AST-19 CK(CPK)-46 AlkPhos-77
[**2106-1-9**] 08:05PM BLOOD Lipase-47
[**2106-1-10**] 02:52AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2106-1-11**] 06:00AM BLOOD Albumin-3.7 Calcium-8.9 Phos-2.6* Mg-2.0
[**2106-1-10**] 02:52AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 Cholest-188
[**2106-1-10**] 02:52AM BLOOD Triglyc-97 HDL-52 CHOL/HD-3.6 LDLcalc-117
[**2106-1-10**] 02:52AM BLOOD TSH-1.5
[**2106-1-9**] 08:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2106-1-9**] 08:13PM BLOOD Type-[**Last Name (un) **] pO2-48* pCO2-48* pH-7.35
calTCO2-28 Base XS-0
[**2106-1-9**] 08:13PM BLOOD Glucose-147* Lactate-1.6 Na-141 K-3.8
Cl-101
[**2106-1-9**] 08:13PM BLOOD Hgb-14.3 calcHCT-43 O2 Sat-82 COHgb-2
MetHgb-0
[**2106-1-9**] 08:13PM BLOOD freeCa-1.16
CTA [**2106-1-9**]: CONCLUSION:
1. Large acute left middle cerebral artery distribution infarct.
2. Thrombotic or embolic occlusion of the left middle cerebral
artery with
reconstitution of flow distally.
3. Anterior communicating artery aneurysm.
4. Possible cavitary lesion in right upper lobe, requiring more
extensive
assessment.
NCHCT [**2106-1-10**]: No intracranial hemorrhage or significant edema
status post TPA
administration. Hyperdense clot noted within the left M1 segment
appears
resolving when compared to pre-treatment scan on [**2106-1-9**]
CT CHEST [**2106-1-10**]:
IMPRESSION:
1. 9 mm right upper lobe nodule with fissural traction, could be
inflammatory, scar or lung cancer, should be followed shortly in
three months.
2. Scattered 6 mm and less lung nodules, should also be
followed. 9 x 3 left
lower lobe nodule could be atelectasis, could be evaluated by
supplemented
prone images on next follow up.
3. Almost complete resolution of septal thickening, likely due
to resolving
interstitial edema.
4. Upper lobe predominant centrilobular nodules, could be due to
respiratory
bronchiolitis.
5. Hyperdense liver, could be due to amiodarone use or iron
loading. Liver
hypodensity too small to characterize, likely a cyst.
7. L1 compression fracture, unchanged since [**2103**].
8. Right breast macrocalcification, likely benign, should be
correlated
with regular mammogram.
TTE [**2106-1-12**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). 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 to moderate
([**2-11**]+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
This 75 yo woman was admitted with acute aphasia as a code
stroke and was found to qualify for thrombolyis with IV tPa. Her
CT and CTA confirmed the presence of acute Lt MCA clot and
partial occlusion, most likely cardioembolic given HX of Afib
without
anticoagulation. Her deficit was mild and improving after the
scan. She continued to improve after tPA, and she was able to
name , read repeat with only mild paraphasic error. Weakness
improved as well (facial weakness and mild drift but no
extremities weakness). She was started on Coumadin and
instructed to follow up with her PCP for measurement of her INR.
Her lipids were elevated, but she had not tolerated a statin in
the past so she was started on zetia 10 mg daily. Her echo
showed no evidence of PFO, thrombus, or atheroma. Nonetheless, a
cardioembolic source was suspected in her case. As part of her
initial CTA neck, there was an incidental finding of a potential
lung lesion and therefore a CT chest was pursued which showed
some scattered nonspecific nodules which she was instructed to
have followed with another CT in 3 months. There were also
breast calcifications present for which she was set up with an
appt for a mammogram. On discharge her neurological exam was
significant for mild right upper motor neuron facial weakness
and mild right pronator drift.
Medications on Admission:
L-thyroxine 75 mcg
Rhythmol SR 325 mg [**Hospital1 **]
Metoprolol 100 mg [**Hospital1 **]
Quinapril 20 mg [**Hospital1 **]
Coumadin (not been taking the medication)
Paroxetine
Omega 3
vitamin D
ASA 81 mg
Centrum silver
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO HS (at bedtime): Should be
discontinued once INR>2.
4. Propafenone 225 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
[**Hospital1 **]:*90 Tablet(s)* Refills:*2*
5. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO at bedtime: Take
2 tabs at bedtime on [**1-12**]. Then on [**1-13**] and thereafter take
only 1 tab at bedtime until instructed otherwise by your PCP.
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*2*
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
8. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
primary diagnosis:
Cerebral Infarction
atrial fibrillation
secondary diagnosis:
hypercholesterolemia
hypertension
hypothyroidism
chronic low back pain
Discharge Condition:
Stable. Mild right upper motor neuron facial weakness and mild
right pronator drift.
Discharge Instructions:
You have been restarted on Warfarin, a blood thinning
medication, since you are at risk for future cardioembolic
strokes with your atrial fibrillation. You need to have your
blood checked frequently (at least twice a week) at your PCP's
office with your goal INR is 2 to 3.
You should make sure when starting any new medications that the
prescribing physician is aware that you are on Warfarin to avoid
any drug-drug interations. They should also touch base with
your primary care physician [**Name Initial (PRE) 96060**].
Since you have not tolerated taking a statin in the past, we
have instead started you on a cholesterol lowering medication
called Zetia.
Please take medications as prescribed.
Please keep your follow-up appointments.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone: [**Telephone/Fax (1) 19196**]
Date/Time:[**2106-1-15**] 9:00AM
You should have your blood drawn at this visit to check your INR
level and have your Warfarin dose adjusted as needed. Goal INR
[**3-15**].
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2106-3-9**] 11:40
Provider: [**First Name8 (NamePattern2) 4267**] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone: [**Telephone/Fax (1) 2574**]
Date/Time: [**2106-2-16**] 2:00PM
Imaging: Chest CT without contrast Phone: [**Telephone/Fax (1) 327**]
Date: [**2106-4-11**]
Please call to schedule a follow-up image during the month of
[**Month (only) 958**] to follow-up pulmonary nodules that were incidentally seen
on your chest CT from this admission.
Imaging: Mammogram Phone: [**Telephone/Fax (1) 327**]
Please call to schedule a mammogram within 2 weeks of discharge
to follow-up microcalcifications that were incidentally noted on
your chest CT.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2106-1-19**]
ICD9 Codes: 4019, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7679
} | Medical Text: Admission Date: [**2112-7-18**] Discharge Date: [**2112-7-27**]
Date of Birth: [**2042-3-22**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
man, status post myocardial infarction in [**2069**], who presents
with increased shortness of breath, dyspnea on exertion. The
patient had cardiac catheterization with 100% left anterior
descending occlusion, left circumflex 90% occlusion, OM1 90%
occlusion.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2.
2. Congestive heart failure.
3. Coronary artery disease, status post myocardial
infarction.
PAST SURGICAL HISTORY:
1. Status post abdominal aortic aneurysm repair.
2. Status post cholecystectomy.
3. Status post right *****************
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.125 mg once daily.
2. Coumadin 5 mg once daily.
3. Lasix 80 mg once daily.
4. Potassium Chloride 20 meq once daily.
5. Lopressor 75 mg p.o. twice a day.
6. Insulin regular 45 units a.m. and p.m. and Lentus 60
units q.h.s.
PHYSICAL EXAMINATION: Blood pressure is 138/70. The chest
is clear to auscultation bilaterally. The heart is regular
rate and rhythm, no murmurs. The abdomen is soft, nontender,
nondistended. The extremities are warm and well perfused, no
edema.
HOSPITAL COURSE: The patient was taken to the operating [**2112-7-18**], and coronary artery bypass graft times two with
left internal mammary artery to left anterior descending and
saphenous vein graft to OM was performed. The surgery was
without complication. Pacing wires as well as mediastinal
pleural tubes were placed intraoperatively.
Postoperative day number one, the patient was afebrile, vital
signs were stable. He was successfully extubated.
Postoperative day number two, the patient converted to atrial
fibrillation with heart rate of 90 to 130. He did not
respond to intravenous Lopressor and he was started on
Amiodarone drip. The patient denied any symptoms during
this episode. The patient was weaned off the Amiodarone drip
that day and started on oral Amiodarone.
[**Last Name (un) **] was consulted for the patient's diabetes mellitus who
recommended to continue his regular insulin and restarting
his long acting insulin postoperative day number three. No
events on Amiodarone and Lopressor. He was transferred to
the floor in stable condition.
Postoperative day number four, the patient was on Heparin,
going in and out of atrial fibrillation. He was continued on
Amiodarone. He was also started on Coumadin for long term
anticoagulation. Postoperative day number five, the patient
remained stable. He had some shortness of breath with
bilateral rales on respiratory examination. He was started
on Lasix. He continued with Morphine, Amiodarone and Heparin
for his atrial fibrillation.
Postoperative day number seven, the patient continued on
Heparin and Coumadin, ambulated without difficulty, some
shortness of breath. The patient had improved since he was
started on Lasix. No concerns and no active issues at this
time.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient is discharged home.
FOLLOW-UP: Dr. [**Last Name (STitle) 70**] in six weeks for postoperative
follow-up. The patient should have his INR drawn on a daily
basis until stable, goal INR is 2.0 to 2.5. The patient
should contact primary care physician with INR results.
Primary care physician will be following the patient's INR.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o. twice a day.
2. Lasix 40 mg p.o. twice a day times ten days.
3. Potassium Chloride 20 meq twice a day times ten days.
4. Enteric Coated Aspirin 325 mg p.o. once daily.
5. Insulin a.m. regular 20 units, p.m. Lantus 40 units and
regular 20 units.
6. Tylenol 650 mg p.o. q4-6hours p.r.n.
7. Ibuprofen 400 mg p.o. q6hours p.r.n.
8. Amiodarone 400 mg p.o. twice a day times two weeks, then
400 mg once daily times four weeks, then 200 mg once daily.
9. Zantac 150 mg p.o. once daily.
10. Captopril 625 mg p.o. three times a day.
11. Coumadin 5 mg p.o. once daily.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft.
2. Diabetes mellitus type 2.
3. Hypertension.
4. Hypercholesterolemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 15509**]
MEDQUIST36
D: [**2112-7-26**] 15:39
T: [**2112-7-26**] 18:05
JOB#: [**Job Number 23351**]
ICD9 Codes: 4111, 4280, 9971, 4019, 2720, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7680
} | Medical Text: Admission Date: [**2157-5-13**] Discharge Date: [**2157-5-30**]
Date of Birth: [**2080-6-4**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 76-year-old woman who
presents as a transfer from [**Hospital6 3105**] after
an episode of syncope in which she fell and fractured her
right wrist on [**2157-5-9**].
A workup there included a head computed tomography which was
negative. As she had a known history of severe aortic
stenosis and aortic insufficiency, it was felt that her
syncopal episode was likely secondary to these conditions,
and she was transferred to [**Hospital1 188**] for further workup.
She was admitted to our hospital on [**2157-5-13**] and underwent
a cardiac catheterization. The results of that
catheterization demonstrated normal coronary arteries with
moderate aortic stenosis with an aortic valve area of
approximately of 1.2 and a peak gradient of approximately 40.
She had a normal ejection fraction.
It was felt that given her presentation of traumatic syncope
with a normal ejection fraction and normal coronary arteries
that she should undergo an aortic valve replacement.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Severe aortic stenosis.
3. Aortic insufficiency.
4. Osteoporosis.
5. Anemia.
6. Arterial venous malformation of the gastrointestinal
tract; not otherwise specified.
7. Large Hiatal hernia.
PAST SURGICAL HISTORY: Back surgery.
MEDICATIONS ON DISCHARGE: (Medications at the time of
admission included)
1. Zocor 20 mg p.o. once per day.
2. Fosamax 10 mg p.o. once per day.
3. Adalat 30 mg p.o. once per day.
4. Calcium carbonate 500 mg p.o. three times per day.
5. Percocet one tablet p.o. four times per day as needed
(for pain).
6. Enteric-coated aspirin 325 mg p.o. once per day.
ALLERGIES: IRON INJECTIONS (cause severe/acute arthralgias).
PHYSICAL EXAMINATION ON PRESENTATION: Examination at the
time of admission revealed she was afebrile, heart rate was
68, blood pressure was 130/64, respiratory rate was 15, and
oxygen saturation was 99% on room air. Her neck was supple
with 1+ carotid pulses. No bruits. Her lungs were coarse at
the bases with basilar crackles on the right. Her heart was
regular with a [**3-10**] holosystolic murmur radiating to her
carotids. Her abdomen was soft, nontender, and nondistended.
Extremity examination revealed she had 2+ dorsalis pedis and
posterior tibialis pulses bilaterally.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram demonstrated
a normal sinus rhythm with no acute ST-T wave changes.
PERTINENT LABORATORY VALUES ON PRESENTATION: Notable
laboratories revealed white blood cell count was 4.4,
hematocrit was 36.3, and platelets were 201. Chemistry-7
revealed sodium was 141, potassium was 3.7, chloride was 104,
bicarbonate was 30, blood urea nitrogen was 10, creatinine
was 0.6, and blood glucose was 86.
HOSPITAL COURSE: The patient was brought to the operating
room on [**2157-5-16**] and underwent a aortic valve replacement
with a 19-mm mosaic tissue valve. She tolerated the
procedure well and came out of the operating room with an
A-paced with an underlying rhythm of sinus at a rate of 60
which was insufficient to maintain an adequate blood
pressure.
She remained A-paced in the early postoperative period which
was notable for a low cardiac index. A chest x-ray was
obtained which demonstrated a left pleural effusion, and a
left chest tube was placed. Her overall condition improved
after the insertion of the chest tube, and she was extubated
without complications.
On postoperative day one, she continued to be A-paced, and
her diet was advanced. By postoperative day two, her pacing
was discontinued. She maintained a sinus rhythm with an
index of 2.1. Her urine output began to drop off.
Therefore, she was transfused with an appropriate response in
urine output. She progressed well throughout the day, and
her pulmonary artery catheter was discontinued along with the
chest tube.
On postoperative day three, the Orthopaedic Surgery Service
was consulted to assess her right hand fracture. She felt
that she had an old left distal radial fracture as well as a
new right scaphoid fracture, for which she was placed in a
B??????hler right thumb spica cast. She was to follow up with Dr.
[**Last Name (STitle) **] in two to three weeks after discharge from the hospital.
At this point, she was off pressors and maintaining and good
urine output and was therefore transferred to the floor on
postoperative day four. A Physical Therapy consultation was
obtained and recommended the patient should be placed in a
[**Hospital 3058**] rehabilitation once medically stable.
On postoperative day five, her wires were discontinued and a
rehabilitation screen was obtained. On postoperative day
six, her Lopressor was started for a heart rate in the 90s;
however, as she had a marginally low blood pressure diuresis
was not begun.
She continued to do well with the exception of persistent
tachycardia for which her Lopressor continued to be titrated
up as her blood pressure would allow.
On postoperative day seven, she was noted to have a white
blood cell count of 16.2 which was elevated from the prior
day's value. She was offered a bed in rehabilitation on
postoperative day eight; however, her white blood cell count
that morning was 22,000.
Blood, urine, and sputum cultures were sent. A chest x-ray
was obtained which was notable for persistent but improved
left lower lobe atelectasis, as well as small bilateral
effusions, and a hiatal hernia. She experienced several
episodes of vomiting, and a nasogastric tube was placed. This
relieved the nausea and vomiting. After several days, the tube
was removed and she tolerated a diet without problem. At the
time of this dictation, it is anticipated that the patient's
white blood cell count will normalize as she is clinically
doing well and
will be transferred to a rehabilitation facility imminently.
PHYSICAL EXAMINATION ON DISCHARGE: The patient's lungs were
clear with slightly diminished air at the bases. She had a
regular heart rate and rhythm. Her incision was clean, dry,
and intact. Her sternum was stable. Her abdomen was soft,
nontender, and nondistended. Her peripheral pulses were
intact. WBC is 13,000 at discharge and decreasing.
MEDICATIONS ON DISCHARGE: (Medications at the time of
discharge)
1. Colace 100 mg p.o. twice per day.
2. Enteric-coated aspirin 325 mg p.o. once per day.
3. Percocet one to two tablets p.o. q.4h. as needed (for
pain).
4. Simvastatin 20 mg p.o. once per day.
5. Alendronate 10 mg p.o. once per day.
6. Lasix 20 mg p.o. twice per day.
7. Lopressor 37.5 mg p.o. twice per day.
DISCHARGE DIAGNOSES:
1. Aortic stenosis/insufficiency.
2. Status post aortic valve replacement.
3. Large hiatal hermia
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) **] in
approximately one week after discharge from rehabilitation.
2. The patient was also to follow up with Dr. [**Last Name (STitle) **] from the
Orthopaedic Service in two to three weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2157-5-25**] 04:00
T: [**2157-5-25**] 07:28
JOB#: [**Job Number 48148**]
ICD9 Codes: 4241, 5119, 5180, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7681
} | Medical Text: Admission Date: [**2164-6-23**] Discharge Date: [**2164-7-5**]
Date of Birth: [**2113-11-22**] Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics) / Penicillins /
Dilaudid
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
feeling unwell, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 yo bedbound morbidly obese female with history of IDDM2, HTN,
HL, OHS on 4L at home, and prior PE who presents with chills and
weakness x 1 day. She reports feeling hot and sweaty at home,
with burning noted in bilateral legs. She has new LLE swelling
and redness. She denies overt fevers at home. She reports a
cough with occaisional yellow sputum. She reports one episode
of coughing a small clot of blood. She denies SOB or CP
currently. She reports dizziness and lightheadedness. She
denies abdominal pain, dysuria, N/V/D. She notes neck and upper
back pain since the top of an ambulance stretcher lowered
quickly while she was on it last week. She has been taking
valium and percocet that was prescribed at a recent epi visit.
In the ED, initial vitals were pain 10 100.3 105 96/40 18 96%
2L.
- hypotensive with sBP in 80's
- meets SIRS criteria
- CBC - WBC 22.1, Chem 7, lactate 1.3, blood cultures
- 3.5L of IVF
- pt cannot fit inside CT scanner so CTA not done
- CXR - central pulm vasc mildly prominent - suggestive of mild
pulmonary vasc congestion, no definite pleural effusion or
pneumo, pleural thickening lateral L lung apex - not
signficantly changed.
- b/l LE ultrasounds ordered but inconclusive
- Tx for presumed cellulitis of LLE - IV vanc and clinda
- c/s surgery - concern for LLE nec fasc - exam consistent with
cellulitis, cont abx, leg elevation. ACS will continue to
follow.
- BP around lower forearm, readings unreliable
- febrile to 101, 1gram of tylenol
- 1500mg of UOP reported in ED
Most recent vitals prior to transfer: afeb 109 30 98/61 99% on
4L.
On arrival to the MICU, she is reporting burning in her left
lower leg.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency.
Past Medical History:
# Morbid obesity -- over 600 lbs, bedbound
# Diabetes mellitus type II
# Hypertension
# Hyperlipidemia
# Hypothyroidism
# Obesity hypoventilation syndrome, on home O2 3-4 L
# Likely OSA -- refused sleep study
# Asthma
# Pulmonary Embolism ([**2163-4-27**]): suspected and treated but
unable to image
# Tracheostomy ([**2163-4-19**]) -- later removed at rehab
# VRE UTI -- during admission ([**Date range (3) 105005**])
# Chronic Lymphedema
# Developmental / Behavioral Issues
# Depression
# Chronic Low Back Pain
# GERD
Social History:
Lives alone, with 24 hour home health aide. She endorses only
rare social alcohol intake and she smokes [**12-19**] cigarettes daily.
She was previously wheelchair bound, but is now bed bound. Her
mother bought her a new [**Name (NI) 2598**] lift but her aides have not been
taught how to use this yet. Home health aide helps her with
cooking, cleaning, and bathing. Patient has a long psychiatric
history including counseling since childhood, learning
disabilities, she has left the hospital AMA on multiple
occasions, she has had Code Purples called for aggressive
behavior, she has been accused of calling EMS inappropriately
(several times per month at one point) for factitious
complaints, and she has reported history of sexual assault.
There have been SW involved to try to have this patient live in
rehab or another situation to better care for herself but these
attempts have all failed.
Family History:
Father with "belly" cancer. Mother alive & healthy, 2
grandparents w/DM. Brother died of illicit drug related causes.
Physical Exam:
Admission physical exam:
Vitals: 101 107 79/22 20 96% on 4L
General: Alert, oriented, difficulty with moving in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops heart
sounds muffled
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: +BS, obese, soft, non-tender, non-distended
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, LLE with warm erythematous confluent rash and small
nontender nonfluctuant bullae
Skin: bilateral erythematous patches under nipples
Neuro: CNII-XII intact, moving all 4 extremities
Discharge physical exam:
Vitals: T98.5, BP 108/64, HR 92, RR 20, 99% on 2L
General: Alert, oriented, difficulty with moving in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
heart sounds muffled
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
Abdomen: +BS, obese, soft, non-tender, non-distended
GU: Foley removed
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, LLE with dramatically improved erythema, with continued
1cm bullae
Skin: bilateral erythematous patches under nipples
Neuro: CNII-XII intact, moving all 4 extremities
Pertinent Results:
Admission labs:
[**2164-6-23**] 02:48PM BLOOD WBC-22.1*# RBC-3.12* Hgb-9.2* Hct-28.9*
MCV-93 MCH-29.4 MCHC-31.8 RDW-14.6 Plt Ct-244
[**2164-6-23**] 02:48PM BLOOD Neuts-93.8* Lymphs-3.7* Monos-2.2 Eos-0.2
Baso-0.1
[**2164-6-23**] 09:23PM BLOOD PT-14.3* PTT-31.5 INR(PT)-1.3*
[**2164-6-23**] 02:48PM BLOOD Glucose-142* UreaN-61* Creat-1.5* Na-140
K-4.6 Cl-92* HCO3-37* AnGap-16
[**2164-6-23**] 09:23PM BLOOD Calcium-8.6 Phos-3.7# Mg-2.2
[**2164-6-23**] 02:47PM BLOOD Lactate-1.3
RELEVENT LABS (LINEZOLID MONITORING):
[**2164-7-5**] 06:00AM BLOOD WBC-14.9* RBC-3.27* Hgb-9.0* Hct-30.4*
MCV-93 MCH-27.6 MCHC-29.7* RDW-15.0 Plt Ct-509*
[**2164-7-3**] 06:00AM BLOOD Neuts-72.3* Lymphs-19.6 Monos-3.8 Eos-3.7
Baso-0.7
[**2164-7-3**] 06:00AM BLOOD ALT-19 AST-18 CK(CPK)-23* AlkPhos-87
TotBili-0.4
[**2164-7-3**] 07:05AM BLOOD Lactate-1.0
Discharge labs:
[**2164-7-5**] 06:00AM BLOOD WBC-14.9* RBC-3.27* Hgb-9.0* Hct-30.4*
MCV-93 MCH-27.6 MCHC-29.7* RDW-15.0 Plt Ct-509*
[**2164-7-5**] 06:00AM BLOOD Glucose-109* UreaN-31* Creat-0.9 Na-139
K-4.8 Cl-93* HCO3-36* AnGap-15
[**2164-7-5**] 06:00AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.6
Microbiology:
[**2164-6-29**] SEROLOGY/BLOOD ASO Screen-FINAL NEGATIVE
[**2164-6-29**] BLOOD CULTURE Blood Culture, Routine-PENDING, no
growth at discharge
[**2164-6-28**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH FINAL
[**2164-6-26**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH FINAL
[**2164-6-25**] BLOOD CULTURE Blood Culture, Routine- NO GROWTH FINAL
[**2164-6-23**] BLOOD CULTURE Blood Culture, Routine- NO GROWTH FINAL
[**2164-6-23**] 2:40 pm BLOOD CULTURE
**FINAL REPORT [**2164-6-29**]**
Blood Culture, Routine (Final [**2164-6-29**]):
VIRIDANS STREPTOCOCCI.
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final [**2164-6-24**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 720PM
[**2164-6-24**].
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2164-6-23**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS}
PERTINENT IMAGING:
pCXR [**2164-6-29**] FINDINGS: Unchanged mild fluid overload.
Unchanged moderate cardiomegaly. No larger pleural effusions.
No focal parenchymal opacity suggesting pneumonia. Retrocardiac
atelectasis is unchanged.
[**2164-6-23**] LENIs
FINDINGS:
The study is suboptimal due to patient's body habitus. Color
flow is seen within the left common femoral vein with
appropriate waveforms. Flow can also be detectted within the
left popliteal vein. The remaining left lower extremity veins
could not be imaged with ultrasound due to patient's body
habitus.
IMPRESSION:
Non-diagnostic study due to patient's body habitus.
Brief Hospital Course:
50 yo bedbound morbidly obese female with history of DM2, HTN,
HL, OHS on 4L at home, and prior PE who presented with weakness
and chills as well as left leg pain found to be hypotensive with
cellulitis of the left lower extremity. Hospital course
complicated by difficult to control blood glucose.
# Hypotension: Most likely related to infection with sepsis.
[**Month (only) 116**] also be related to recent valium/percocet use or medication
administration problems ie overdosing of diuretics. Prior
history of PE with patient reported noncompliance with
anticoagulation. No reason to suspect AI, patient reports
adequate PO intake at home, and no symptoms concerning for ACS.
Valium and percocet were held. The patient's BP was fluid
responsive, though there was difficulty measuring blood pressure
accurately in light of the patient's morbid obesity and
difficulty with proper blood pressure cuff measurement. Upon
transfer to the regular medical floor patient's BP was stable,
with hypotension to SBP of 80s-90s upon restarting home dose
lasix and antihypertensives.
-Blood pressure should be checked at next [**Month (only) 3390**] appointment and
dosage of lasix and antihypertensive adjusted accordingly
# Sepsis due to LLE cellulitis: Presented with low grade fever,
tachycardia, hypotension, and leukocytosis in the setting of new
evidence of rash and erythema on LLE concerning for LE
celluitlis. Patient was started on vancomcyin and cefepime as
well as clindamycin in light of presence of bullae. Blood
cultures returned with 1 bottle growing GPCs, which speciated as
Strep viridans, felt to be a contaminant by ID consult service.
She was continued on vancomycin, cefepime, and clindamycin with
clinical improvement in her lower extremity. On her last day in
the ICU, the patient was transitioned to PO linezolid and PO
metronidazole and PO ciprofloxacin. On the medical floor,
metronidazole was stopped after discussion with ID, but it was
restarted several days later after WBC increased off
metronidazole. Patient completed 10 day course of
cipro/linezolid/flagyl. LLE had minimal erythema at time of
discharge.
#Obesity hypoventilation syndrome: Patient was stable on home
3-4L O2 by nasal cannula but had an episode of tachypnea above
baseline, with wheezing on exam and volume overload on portable
chest xray. Wheezing improved with albuterol nebs, and tachypnea
improved following 80mg IV furosemide. Given difficulty of
ruling out pulmonary embolism with imaging in this patient and
recent refusals of subcutaneus heparin ppx, heparin drip was
started overnight, but discontinued the following morning, given
clinical improvement with diuresis and bronchodilators. BNP
during the episode came back at >1200, and PO furosemide was
restarted (had been held for hypotension as above) at half the
pre-admission dose, and tachypnea improved.
-Follow up with [**Month (only) 3390**] regarding outpatient furosemide dosing
# [**Last Name (un) **]: Likely prerenal in the setting of febrile illness. Serum
creatinine improved with labs after 3.5L of fluid in the ED, and
remained stable in MICU ranging from 1.3-1.5 and further
recovered to 0.7 while on the medicine floor.
-Patient has been advised in not to use NSAIDS, but she insists
that naproxen is the only [**Doctor Last Name 360**] that alleviates her headaches
#uncontrolled DM II: she had an episode of relative hypoglycemia
the day after she was transferred from the MICU, attributed to
decreased po intake. [**Last Name (un) **] was consulted and adjusted her U500
insulin dosing.
CHRONIC ISSUES:
# Possible history of pulmonary embolism: Patient has been
treated empirically in the past for PE, but diagnostic work up
for this morbidly obese patient is challenging. During this
hospital stay patient was briefly anticoagulated overnight as
discussed above, but heparin was stopped when volume overload
and/or mucus plugging was felt to be more likely explanation for
respiratory status. Patient intermittently refused subcutaneous
heparin ppx throughout this hopspitalization.
# Asthma: Patient was stable on home 4L oxygen. Continued
albuterol, advair, fluticasone
#Hypothyroid: continued levothyroxine
#GERD:continued pantoprazole
#Hyperlipidemia: continued rosuvastatin, aspirin
#Hypertension: lisinopril-hydrochlorothiazide were held [**1-19**]
hypotension in the ICU, restarted prior to discharge
#Chronic lower back pain: held naproxen, treated with
acetaminophen while admitted
Transitional issues for this patient:
-Recovery of mobility: mother is very concerned patient has not
been up to chair in a year
-Readdressing doses of antihypertensives and furosemide
-Follow up with [**Last Name (un) **] regarding dosing of U500 insulin
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheezing
2. Diazepam 5 mg PO Q12H:PRN pain, spasm
3. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
5. Furosemide 80 mg PO BID
6. Levothyroxine Sodium 150 mcg PO DAILY
7. lisinopril-hydrochlorothiazide *NF* 20-12.5 mg Oral [**Hospital1 **]
8. Nystatin Powder *NF* 100,000 unit/gram Mucous Membrane prn
irritation
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Prochlorperazine 5-10 mg PO Q6H:PRN nausea, vomiting
12. Rosuvastatin Calcium 40 mg PO HS
13. Aspirin 81 mg PO DAILY
14. Docusate Sodium 200 mg PO BID
15. Naproxen 250 mg PO Q8H:PRN pain
16. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheezing
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb by mouth every
six (6) hours Disp #*1 Unit Refills:*2
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 2 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
RX *Flovent HFA 110 mcg/actuation 1 puff inhalation twice a day
Disp #*1 Inhaler Refills:*0
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
RX *Advair Diskus 250 mcg-50 mcg/Dose 1 puff inhalation twice a
day Disp #*1 Inhaler Refills:*0
6. Levothyroxine Sodium 150 mcg PO DAILY
RX *levothyroxine 150 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*30 Packet Refills:*0
9. Rosuvastatin Calcium 40 mg PO HS
RX *Crestor 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg t tablet by mouth twice a day Disp #*60 Tablet
Refills:*0
11. Diazepam 5 mg PO Q12H:PRN pain, spasm
RX *diazepam 5 mg 1 tablet by mouth twice a day Disp #*30 Tablet
Refills:*0
12. lisinopril-hydrochlorothiazide *NF* 20-12.5 mg ORAL [**Hospital1 **]
RX *lisinopril-hydrochlorothiazide 20 mg-12.5 mg 1 tablet(s) by
mouth twice a day Disp #*60 Tablet Refills:*0
13. Prochlorperazine 5-10 mg PO Q6H:PRN nausea, vomiting
RX *prochlorperazine maleate 5 mg [**12-19**] tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
14. Nystatin Powder *NF* 100,000 unit/gram Mucous Membrane prn
irritation
RX *nystatin 100,000 unit/gram 1 application twice a day Disp
#*60 Gram Refills:*0
15. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet by mouth twice a day Disp #*60
Tablet Refills:*0
16. Sarna Lotion 1 Appl TP QID:PRN itch
RX *Sarna Anti-Itch 0.5 %-0.5 % 1 application to affected areas
four times a day Disp #*1 Tube Refills:*0
17. U500 25 Units Breakfast
U500 12 Units Lunch
U500 25 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *One Touch Ultra Test As directed 5-8 times daily Disp #*1
Box Refills:*2
RX *Humalog 100 unit/mL Up to 25 Units per sliding scale four
times a day Disp #*4 Vial Refills:*2
RX *One Touch Delica Lancets 1 injection 5-8 times daily Disp
#*1 Box Refills:*2
RX *Easy Touch Insulin Syringe 31 gauge X [**5-2**]" As directed [**4-24**]
times daily Disp #*1 Box Refills:*2
RX *Humulin R U-500 "Concentrated" 500 unit/mL (Concentrated) 1
injection as directed. 25 Units before BKFT; 12 Units before
LNCH; 25 Units before DINR; Disp #*7 Vial Refills:*2
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
# Sepsis attributed to cellulitis of the left lower extremity
Secondary diagnoses:
# Type 2 DM - uncontrolled
# Supermorbid obesity
# hypothyroidism
# Hypertension
# Depression/anxiety
# Probable OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 105003**],
It was a pleasure participating in your care during your
hospitalization for a skin infection on your left leg. When you
first came to the hospital you had low blood pressures and were
admitted to the intensive care unit. With antibiotics, your
blood pressure and infection improved on the regular medical
floor. You have cleared your infection and do not need
additional antibiotics.
While you were here, we had difficulty managing your blood
sugars, but the doctors from the [**Name5 (PTitle) **] were consulted to assist
us. Your new insulin regimen is as outlined below. Please
continue to use this sliding scale until you follow up with the
[**Last Name (un) **].
You are on scheduled doses of U500 insulin. One unit of U500
insulin is equal to five units of regular insulin. An outline
of your insulin dosing is attached. It is listed in units of
U500 insulin. Below is a brief summary, but should not be used
to replace the attached insulin outline.
-Breakfast: 25 units of U500 insulin (equal to 125 units of
regular
insulin).
-Lunch: 12 units of U500 insulin (equal to 60 units of regular
insulin).
-Dinner: 25 units of U500 insulin (equal to 125 units of regular
insulin).
-PRIOR to each meal, and at night, you should be monitoring your
blood sugars and giving yourself short acting insulin (Humalog)
based on its level just before eating. The sliding scale doses
are also included in the attached insulin outline.
-You previously were taking 30 units of U500 insulin at home
(equal to 150 units of regular insulin). The doctors at the
[**Name5 (PTitle) **] feel that you will likely require this dose of insulin as
you continue to recover. If you find that your blood sugars are
persistently elevated, please contact the [**Name (NI) **] doctors [**Name5 (PTitle) **] your
[**Name5 (PTitle) 3390**] to speak about adjusting your insulin dosing levels.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2164-7-13**] at 1:45 PM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern1) 105006**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] North [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call your doctor at the [**Last Name (un) **] to schedule an appointment
to help manage your diabetes.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2164-7-5**]
ICD9 Codes: 0389, 5849, 4019, 2724, 2859, 2449, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7682
} | Medical Text: Admission Date: [**2134-3-21**] Discharge Date: [**2134-4-15**]
Date of Birth: [**2087-11-5**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Morphine / Fentanyl
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
somnolence, hypoxic resp failure
Major Surgical or Invasive Procedure:
R femoral line, now d/c'd
right Midline [**3-27**] by IR
History of Present Illness:
46 y/o M w/ h/o morbid obesity, COPD, chronic trach dependence,
DMII, PVD, s/p L BKA, h/o Klebsiella/Proteus UTI, PNA, MRSA,
VRE, who presents with increasing somnolence and hypoxic
respiratory failure
.
Presented to [**Location (un) 620**] ER in respiratory distress, hypoxic to 40's
at home. T to 101.Trach noted to have copius secretions, which
were aggressively suctioned, given o2, nebs, antibiotics
(zosyn/vanco). Improved respiratory status, but still somnolent
and also noted to be hyperkalemic at 6.4. No EKG changes. Given
Insulin/D50, calcium IV. Kayexalate ordered (but not given PTA).
Also had positive troponin of 0.05 (nL <0.01). Acidotic at 7.16
w/ CO2 of 65. Therefore placed on VENT for transport to [**Hospital1 18**].
U/A at OSH pos for WBC >100, Bacteria, neg nitr, Lge leuk's. Hct
31.7, WBC 15.6, Plt 358, 84.5%N. Creat 2.6.
.
Also as patient was leaving, patient care technician who cares
for patient at home says he may have fallen the night PTA.
.
In ED here. Vitals on arrival T99.8, BP 119/51, RR 16, 99% on
Vent. Vanco infusing. BP's subsequently dropped to 80's syst->
then 69/34. Recieved 2L NS IVF PTA and given 1 more L NS in ED.
Started on dopa gtt at 5mcg/kg/min, titrated up to 10
mcg/kg/min. BP initially up to 100's systolic, then back down to
80's. Changed to levophed gtt. ASA 325mg given. Trach tube
changed to Portex 6.0, cuffed to Vent 600/100/16/5. BP
subsequently up to 150's systolic.
.
Vanco given at 1700. Zosyn 4.5 gm prior to arrival at 1415.
Also given 10 U Insulin, 1 amp D50, 1 gm Ca Gluconate. R
Femoral line placed under U/S guidance. EKG w/ NSR. Nl axis. TWI
V1, 1mm ST elev 2.
.
Recent admission [**1-8**] for presumed urosepsis.
.
Past Medical History:
1) DM2 diagnosed [**2114**] with triopathy: Creatinine has been as low
as 0.8 in the last couple of years, however widely fluctuant, as
high as 2 in the recent past. 0.9 in [**1-7**].
2) COPD, on home O2. Multiple episodes of respiratory failure
requiring intubation in recent years. Most recently, was
admitted in [**12-6**] with a perforated transverse colon requiring
partial colectomy and transverse colostomy. This course c/b
anticipated respiratory failure and anticipatory tracheostomy,
pseudomonal and MRSA PNA. Also with acalculous cholecystitis
requiring cholecystostomy tube. Had G-tube placed.
3) OSA on CPAP
3) VRE
4) s/p tracheostomy, as above in [**1-7**]
5) HTN
6) CHF: During hospitalization in [**10-20**] it was thought that
failure contributed to his respiratory failure. Last echo was in
[**12-6**] at which time LVEF thought to be roughly normal, however
very poor study and RV not visualized. Not on lasix.
7) Anemia of chronic disease, multiple transfusions in the past
8) s/p BKA for chronic LE ulcer
9) TIA in [**2125**].
10) Difficult intubation; fiberoptic guidance in [**Month (only) 359**] of
[**2131**].
11) Urinary retention.
12) Osteoarthritis.
13) Depression.
14) C. Difficile in [**2129**].
15) Hypogonadism.
16) Morbid obesity
.
PAST SURGICAL HISTORY:
1. Bilateral carpal tunnel release in [**2123**].
2. Hydrocele repair in [**2126-4-3**].
3. Quadriceps tendon repair in [**2127**].
4. Status post partial resection of transverse colon, end
transverse colostomy, mucus fistula, jejunostomy tube and
percutaneous tracheostomy on [**2132-12-16**].
Social History:
Lives home alone with VNA. Denies etoh. Remote cigar smoking, no
cigarettes. No IVDU or marijuana. Has 1 brother, [**Name (NI) **].
Family History:
Non-contributory
Physical Exam:
Physical Exam- T 99.8, BP 107/38, HR 75, RR 24, 100%
AC 24 x 600. 100FiO2. 10 PEEP
Gen- sleepy but arousable to voice
HEENT- Pupils equal and reactive 3->2 b/l. OP Clear
Neck- trach in place, no purulent secretions
PUlm- Ant w/ coars b/s b/l. no focal ronchi or rales
CV- distant heart sounds, RRR. no m/r/g
ABD- b/l osteomies intact w/o erythema. midline erythematous
scar tissue w/o ulceration.
Ext- 2+ pedal edema on R. R dist LE cellulitis w/o ulceration. L
BKA w/o cellulitic change. stump clean
BAck- no sacral decub. small area of erythema on R upper
buttocks dressed w/ guaze
Neuro-able to grip hands b/l= equal strength. wiggles R toes.
sticks out tongue. opens eyes to voice.
Pertinent Results:
Radiology:
========
CXR [**4-12**]: Tracheostomy tube, nasogastric tube, and right PICC
line remain in place, with a right PICC line continues to
terminate in the right subclavian vein. Cardiac silhouette
remains enlarged, and there is persistent increased pulmonary
vascularity as well as perihilar haziness and bilateral moderate
pleural effusions. Overall, there has not been a significant
change in degree of CHF.
.
LENI RLE [**4-12**]- IMPRESSION: Technically difficult exam, but no
evidence for DVT
.
TTE [**4-5**]: Suboptimal technical quality.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size is normal. The
aortic valve leaflets appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation.
PICC [**2134-3-25**]- IMPRESSION:
1. The tip of the right-sided PICC line in the distal portion of
the right subclavian vein.
2. Moderate congestive heart failure with cardiomegaly and small
bilateral pleural effusion. Bibasilar patchy atelectasis
.
LENI B/L LE's- IMPRESSION: No evidence for DVT.
.
Micro Data:
==========
[**2134-3-26**] 7:04 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2134-3-30**]**
GRAM STAIN (Final [**2134-3-26**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2134-3-30**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
CITROBACTER KOSERI. SPARSE GROWTH. WORK-UP REQUEST PER
DR .
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER KOSERI
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- <=1 S 8 S
CEFTAZIDIME----------- 4 S 32 R
CEFTRIAXONE----------- 16 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S 2 S
IMIPENEM-------------- <=1 S =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S 8 I
PIPERACILLIN---------- =>128 R 64 S
PIPERACILLIN/TAZO----- 64 I 64 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2134-3-22**] 1:52 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2134-3-26**]**
GRAM STAIN (Final [**2134-3-22**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2134-3-26**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 2 S
IMIPENEM-------------- 8 I
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 8 I
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 64 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ <=1 S
.
[**2134-3-22**] 1:52 am URINE
**FINAL REPORT [**2134-3-24**]**
URINE CULTURE (Final [**2134-3-24**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
2ND ISOLATE. <10,000 organisms/ml.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
.
Sputum [**4-5**]:
GRAM STAIN (Final [**2134-4-11**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2134-4-14**]):
OROPHARYNGEAL FLORA ABSENT.
ACINETOBACTER BAUMANNII. HEAVY GROWTH.
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 16 I 16 I
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 2 S 2 S
IMIPENEM-------------- 8 I 8 I
LEVOFLOXACIN---------- 4 I
MEROPENEM------------- 8 I
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
46 y/o M w/ h/o morbid obesity, chronic trach dependence
secondary to OSA, DMII, PVD, s/p L BKA, h/o Klebsiella/Proteus
UTI, MRSA/VRE pneumonias, who initially presented with
increasing somnolence and hypoxic respiratory failure. This was
felt to be secondary to MRSA pneumonia which was treated with a
course of vancomycin and Klebsiella UTI which was treated with
Zosyn. He responded well to antibiotic therapy and was weaned
off ventilatory support. However, he subsequently re-developed
hypoxic respiratory failure. The cause of this second episode
was felt to be multi-factorial from aspiration pneumonia,
pulmonary edema, de-recruitment of alveoli given body habitus
and developement of a new right pleural effusion. He was treated
with an 8 day course of meropenem for ventilator associated
pneumonia and he was diuresed to improve his pulmonary edema.
Recruitment maneuvers, including intermittent APRV ventilation,
were used to bridge him through hypoxic episodes. In addition,
intervential pulmonary re-positioned his trach on [**4-2**] after it
was found to be obstructed against the posterior wall of his
trachea.
.
A brief hospital course by problem is also outlined below:
.
1. Hypoxic Respiratory Failure: Initially admitted for hypoxic
respiratory failure with evidence of pneumonia on CXR with
associated fever and leukocytosis. Sputum culture revealed
evidence of MRSA in addition to Pseudomonas (S to Zosyn), and he
was treated with a 10 day course of Vanco/Zosyn with good
resolution of hypoxia. He was weaned off ventilatory support and
was doing well on trach collar whe he developed a subsequent
episode of hypoxia, with oxygen saturation transiently in the
60's, improved with bag-mask ventilation and placement back on
the ventilator. This second episode was thought to be
multifactorial. He had evidence of aspiration
pneumonitis/pneumonia clinically and radiographically and he was
initially continued on vancomycin and zosyn as above. After
completion of this course of antibiotics he continued to
demonstrate hypoxia. Therefore repeat sputum culture was
performed which also demonstrated citrobacter organism that was
resistant to zosyn, but sensitive to meropenem. Given his
worsening clinical condition he was additionall treated with a
course of meropenem antibiotics. Secondly, he had evidence of
pulmonary edema on CXR which was felt to be contributing to his
respiratory distress. Therefore he was diuresed initially with a
lasix drip and then daily boluses IV. He diuresed well, over 1L
negative per day. Over this hospital course he had also
inadvertantly pulled out his trach and it was replaced
emergently with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] #6. He did well with this new trach,
however did have one episode of acute obstruction on [**4-2**] where
it was found to be lodged against the posterior wall of the
trachea, causing near 80% obstruction of air flow. This was
re-positioned by interventional pulmonary with subsequent
resolution of flow. Lastly, he also developed an increasing R
pleural effusion, suspected secondary to CHF. A right sided
thorocentesis was performed with drainage of 1500cc. The fluid
was c/w a parapneumonic effusion. Of importance, he also had
lower extremity non-invasive ultrasounds to r/o DVT, which were
negative, helping to argue against pulmonary embolism. However
due to size he was not able to undergo CT angiogram and V/Q scan
was felt to be sub-optimal as well, especially while on the
ventilator. It was felt that the other on-going issues, as
described above, were more likely the cause of his acute hypoxic
episodes and therefore he was not anti-coagulated with heparin.
His most recent CXRs have been c/w pulmonary edema and bilateral
pleural effusions. He has diuresed well with Lasix 80mg IV QD
making him negative >1L per day. His oxygenation has improved
with weaning of his vent settings. On discharge he was on PS
[**12-10**], FiO2 of 50%. This should continue to be weaned as he
becomes more euvolemic with diuresis.
.
It is also important to note that his hypoxic episodes were
often concurrent with a large component of anxiety. In fact his
anxiety was difficult to treat throughout his hospital course.
While it was not likely completely causative of his hypoxia, it
certainly exacerbated this acute episodes. He was placed on
standing clonazepam, which he took as outpatient. In addition,
he was given prn doses of zyprexa and evening trazadone.
.
2. Somnolence: He initially presented very somnolent, minimally
responsive to sternal rub and not able to follow commands. This
was felt to be a mixed picture from hypercarbia, infection
(pneumonia, UTI) and hypoxia. ABG w/ CO2 at 65. He had
improvement of his mental status after correcting his
hypercarbia/hypoxia and treating underlying infectious
processes. Upon improvement of his mental status he was found to
have no focal neurologic deficits. Although he had intermittent
episodes of lethargy in the setting of oversedation
(particularly after morphine), he was largely awake and alert
for the remainder of his hospital course.
.
3. Hyperkalemia: Initially hyperkalemic, with potassium of 7.
Likely exacerbated by acidemia and acute renal failure. This was
treated aggressively with D50, Insulin, Calcium, Kayexalate, and
bicarbonate. In addition, the hypercarbic component was
corrected through controlled ventilation. EKG demonstrated no
peaked T's or interval widening throughout and he had no
dysrythmia on telemetry monitoring. Potassium subsequently
normalized and was not an issue the remainder of his hospital
course
.
4. ARF: 2.6 on admission, which was up from 0.9 1 year prior.
BUN also elevated, with pre-renal physiology (FeNa =0.3%, BUN:Cr
ratio >20). No evidence of ATN by urine sediment. He was
initially treated aggressively with IV fluid repletion.
Nephrotoxic agents were held and medications were renally dosed.
Creatinine subsequently improved to 1.0-1.1. He had a second
episode of ARF to 2.0 during his hospital course which
subsequently improved to 1.4 on discharge with diuresis
.
5. Troponin Leak: Max troponin 0.09 (upper limit <0.10) with
flat CK/MB. He also had non-specific ST changes by EKG without
any acute ischemic changes. He was continued on ASA, STATIN,
B-Blocker. Heparin was held as he never had evidence of acute
coronary syndrome.
.
6. Hypotension/SIRS: Early sepsis (distributive) vs hypovolemic
hypotension on admission. SIRS criteria including tachypnea,
leukocytosis of 16,000. Lactate was 2.4 on admission and
systolic blood pressure improved after 3 liter NS IVF. He was
transiently placed on low dose pressors with levophed to
maintain MAP >65, with lactate rising to a peak of 4.8. Pressors
were weaned off after adequate IVF repletion and lacate
normalized. Suspected sourse of infection included pneumonia and
UTI. Importantly, blood cultures remained negative throughout.
His blood pressure remained wnl during the rest of his hospital
stay. His labetolol and captopril were added back to his
antihypertensive regimen.
.
7. Anemia of Chronic Disease: Baseline hematocirt appears to be
around 29, which is where he was at on admission. There was a
spurious level of 12 on admission, however repeat checks did not
corroborate this level. He had no signs of active bleeding and
hematocrit remained stable, although fluctuated from 22-26,
seeming to correlate with volume status. Iron studies were
checked and were felt to be consistent with anemia of chronic
disease. He was started on iron on this hospital stay. He was
placed on EPO for 1 week until his creatinine improved and then
it was d/c'd. He was guiac negative.
.
8. DM2: Initially placed on insulin drip for tight glycemic
control. He was subsequently re-started on glargine with sliding
scale insulin for breakthrough control. On admission he was on
44 units [**Hospital1 **]. This was adjusted based on blood glucose levels as
needed [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. Hi insulin was titrated up to
Glargine 60 u [**Hospital1 **] with SSI QID
.
9. Hypertension: Systolic blood pressures were noted as high as
200's-220's. Often in the setting of anxiety, however it was
also suspected that he also had a component of difficult to
control essential hypertension. His blood pressure medications
were titrated up, with BP's subsequently controlled in
100's-110's. Initially he was on metoprolol, but his was changed
to standing labetolol with good effect. His BP was controlled on
Labetolol and Captopril
.
10. Emesis: Transient nausea, vomiting for 1 day, thought to be
secondary to gastroparesis, exacerbated from recent
hyperglycemia. He was placed on IV reglan w/ improved nausea.
Erythromycin also used transiently, then stopped because of new
rash. Reglan was then titrated off as pt was not having any
residuals from his TF.
.
11. Nutrtion: During most of his hospital course, pt received TF
from an NGT. His prior PEG had been d/c'd before admission as pt
was tolerating pos. Nutrition was consulted and he had a video
swallow test on PS [**12-10**], 50% with no signs of aspiration on
direct visualization. He can tolerate a full diet.
.
12. ID: Pt has grown multiple resistant organisms from his
sputum including MRSA, Pseudomonas, Citrobacter and
Acinetobacter. He was treated with a course of Vanco/Zosyn and
then Meropenem for a VAP. On discharge, he had scant sputum, was
afebrile and showed no signs of focal infiltrates on CXR. He
also has grown resistant Klebsiella from his urine which was
treated. He recently had a negative UA with a Ucx growing G-rods
thought to be a colonizer as he was afebrile without an elevated
WBC. His foley was changed on [**4-14**]. On [**4-13**], vancomycin was
started for a 7 day course for a RLE cellulitis. A vancomycin
trough should be checked [**4-14**] before his evening dose and dose
adjusted accordingly. His cellulitis looked improved on d/c.
.
13. Code status: Full code
.
14. Contact and HCP: brother [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 28633**]
.
15. PPX: heparin sc TID, PPI, bowel regimen, HOB elevated > 30,
peridex oral care
.
16. Access: Midline placed by IR on [**3-27**]
Medications on Admission:
Paxil 40mg 9am, 5pm
Trazadone 100mg qhs prn
MOM 30cc prn
Vicodin q 4 prn
APAP 650mg q4 prn
Klonopin 0.5mg [**Hospital1 **] prn
FS QID: SS humalog
Lopressor 75mg 9 am , 9pm
Flonase 2 spray [**Hospital1 **] prn
senna 2 tabs [**Hospital1 **] prn
neurontin 600mg 6am, 2pm, 10pm
pulmocort 1 puff by mouth 9am,9pm
Heparin SQ TID
Reglan 10mg QID
Albuterol/Atrovent by mouth QID
Lantus 44 units SC qam, qhs
Humalog SS
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO Q12H (every 12 hours).
5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4-6H (every 4 to 6 hours) as needed.
7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day).
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**1-4**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Eight (8) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 8-10 Puffs
Inhalation QID (4 times a day).
14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) ml PO DAILY (Daily).
15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
16. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): hold if sbp<100, pulse<55.
17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
18. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
20. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
21. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day): hold if sbp<90.
22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Ten
(10) ML Intravenous DAILY (Daily) as needed.
23. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg
Injection Q6H (every 6 hours) as needed.
24. Lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4
hours) as needed.
25. Furosemide 10 mg/mL Solution Sig: Eighty (80) mg Injection
DAILY (Daily).
26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 7 days.
27. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty (60) units
Subcutaneous twice a day: see additional sliding scale order.
28. Humalog 100 unit/mL Cartridge Sig: as dir units Subcutaneous
four times a day: Sliding Scale
FS<60 give oj, [**Name8 (MD) 138**] md
FS61-120 mg/dL: 0 units
121-160 mg/dL: 2 units
161-200 mg/dL 4
201-240 mg/dL 6
241-280 mg/dL 8
281-320 mg/dL 10
321-360 mg/dL 12
361-400 mg/dL 14
>400 [**Name8 (MD) 138**] md.
29. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Pneumonia
Obstructive Sleep Apnea
Diabetes type 2
COPD
Urinary tract infection
Anemia
Acute renal failure
Peripheral vascular disease
diastolic chf
Discharge Condition:
stable
Discharge Instructions:
Please check vanco level before next dose ([**4-14**])
Please check electrolytes qod and replete lytes as needed
check hematocrit two times a week and more often if falling from
in hospital value to HCT 22.8. Transfuse if <21
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 22882**] within 2 weeks [**Telephone/Fax (1) 28634**]
Completed by:[**2134-4-14**]
ICD9 Codes: 0389, 5070, 5990, 2767, 2762, 5849, 4280, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7683
} | Medical Text: Admission Date: [**2113-6-9**] Discharge Date: [**2113-6-12**]
Date of Birth: [**2035-2-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 69390**]
Chief Complaint:
Heart block
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
This patient is a 78 year old male with h/o CVA, hypertension,
and [**Hospital 88661**] transferred to the CCU after PPM for treatment
of complete heart block.
.
Per family, patient had been in USOH when went to work this
morning. Per son-in-law was [**Name (NI) 653**] by co-worker after patient
noted to be bleeding from superfical posterior head lacerations.
EMS was activated. On EMS arrival, he was noted to be aggressive
and agitated; and although A&O x 3, he was kicking, yelling;
requirement 4-point restraints. VS at that time notable for
bradycardia to the 20s with preservation of blood pressure at
120 systolic.
.
In the ED, initial VS: 98 73 173/91 18 98% RA. EKG revealed
complete heart block. He was transiently responsive to atropine
(total 3 mg) and calcium but reverted to CHB. He remained
agitated and was thus intubated and started on fent/midaz drips.
Urgent RIJ access obtained by and temporary balloon-tipped PM
wire advanded into the RV with location confirmed by 12-lead
ECG. He underwent a head/spine CT given report of head trauma.
This demonstrated small subdural and subarachnoid hemorrhages.
Neurosurgery saw him and recommended dilantin load and repeat
head CT in the morning. CT spine without fracture or
malalignment. He was also given a tetanus shot (?). He was taken
directly to the cath lab for PPM placement. Prior to transfer,
VS: HR 70s, BP 180/10.
.
In the cath lab, dual chamber AV PPM was set at 60. Temp wire
was removed. He was given one dose of vancomycin with plan for
abx for 3 days (vanc at MN and cephalexin for two more days).
Was on ASA/Plavix in the past (possibly stroke 4 years ago)
.
On review of systems; per family endorses prior history of
stroke, TIA; denies deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools; denies recent fevers,
chills or rigors; denies exertional buttock or calf pain. All of
the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- CVA
- Asthma
Social History:
-Tobacco history: Remote
-ETOH: Social
-Illicit drugs: denies
Works as a custodian; lives with wife, daughter, son-in-law, and
grandchildren in [**Location (un) **]. Close social supports. Completes
all ADLs without problem. [**Name (NI) **] been driving at baseline.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ON ADMISSION:
GENERAL: Intubated, sedated, ETT in place
HEENT: 2 posterior occipital head lacerations; Sclera anicteric.
Pupils sluggish (3->2) Conjunctiva were pink, no pallor; OP with
ETT and OT in place
NECK: Supple; RIJ in place
CHEST: PPM in place; dressing in place: c/d/i
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: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2113-6-9**] 08:45AM WBC-6.7 RBC-4.21* HGB-13.9* HCT-41.1 MCV-98
MCH-33.1* MCHC-33.9 RDW-12.9
[**2113-6-9**] 08:45AM NEUTS-56.1 LYMPHS-37.2 MONOS-4.4 EOS-1.9
BASOS-0.4
[**2113-6-9**] 08:45AM PLT COUNT-213
[**2113-6-9**] 08:45AM PT-11.3 PTT-21.6* INR(PT)-0.9
[**2113-6-9**] 08:57AM GLUCOSE-157* LACTATE-4.2* NA+-141 K+-4.5
CL--100 TCO2-25
[**2113-6-9**] 09:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2113-6-9**] 09:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-500 KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-NEG
[**2113-6-9**] 09:15AM URINE RBC-1 WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0 TRANS EPI-<1
[**2113-6-9**] 09:15AM URINE GRANULAR-7* HYALINE-53*
[**2113-6-9**] 04:24PM GLUCOSE-84 UREA N-19 CREAT-1.0 SODIUM-140
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12
[**2113-6-9**] 04:24PM CK(CPK)-148
[**2113-6-9**] 04:24PM CK-MB-5 cTropnT-0.06*
[**2113-6-9**] 04:24PM CALCIUM-9.3 PHOSPHATE-3.5 MAGNESIUM-1.9
STUDIES:
[**6-9**] TTE: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated with normal free wall contractility.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
[**6-9**] CXR: Single supine AP portable view of the chest was
obtained.
Underlying trauma board partially obscures the view. Given this,
no focal
consolidation or large pleural effusion is seen. The cardiac and
mediastinal silhouettes are unremarkable. No definite
pneumothorax is seen, although a right-sided pneumothorax would
be difficult to exclude given overlying external artifact. No
displaced fracture is identified.
[**6-9**] CT HEAD: 1. Cerebral contusion with associated foci of
acute blood and edema in the left frontal lobe as well as left
frontal subarachnoid hemorrhage. 2. Small acute left subdural
hematoma without midline shift. Questionable small focal acute
right frontal subdural hematoma vs artifact. 2. Subtle
non-displaced right temporal bone fracture. Opacification of the
right mastoid air cells as well as fluid seen within right
external and middle early cavity. 3. Tiny subgaleal/scalp
hematoma over the right occiput.
[**6-9**] CT SPINE: 1. No fracture or malalignment of the cervical
spine.
2. Endotracheal tube seen with retention balloon deployed just
below the
presumed location of the vocal cords.
[**6-9**] CT ORBIT: Longitudinal fracture through the right petrous
temporal bone. No evidence of ossicular disruption.
Opacification of the right mastoid air cells, external auditory
canal and middle ear cavity.
NOTE ADDED IN ATTENDING REVIEW: The right temporal bone fracture
is comminuted and complex, with extensive involvement of its
mastoid segment. A fracture component traverses the middle ear
cavity, where it involves the ossicular chain. While the malleus
and incus appear to maintain a normal relationship, there is
evidence of incudo-stapedial dissociation, with likely fracture
of the stapes superstructure, and the stapes footplate appears
displaced from the oval window; these findings are
best-appreciated on the specialized reformations. The fracture
appears to spare the otic capsule. A fracture component does
exit at the glenoid fossa, but there is no evidence of
subluxation of the TMJ.
There are apparent pan-sinus acute-on-chronic inflammatory
changes, as above, though some of these findings may relate to
intubation. No fracture of the included facial bones is seen.
[**6-10**] CXR: 1. Left-sided pacemaker with leads overlying the
expected locations of the right atrium and right ventricle.
2. Indeterminate mid-thoracic vertebral body compression
fracture (more
likely chronic).
[**6-10**] CT HEAD: 1. Short-interval decrease in size and density of
the thin left frontal subdural hematoma and small frontal lobe
hemorrhagic contusion. 2. Hemorrhagic right mastoid and middle
ear effusion, related to the known complex right temporal bone
fracture.
Brief Hospital Course:
Mr [**Known lastname 12982**] is 78 year-old man with h/o CVA on [**2109**],
hypertension, hyperlipidemia who presents with complete heart
block now s/p PPM.
.
# Complete heart block: Patient was found to have complete heart
block on admission in the ED. Etiology was unclear as no history
of documented arrhythmias or use of nodal agents. Prior EKGS
were not available to assess history of conduction disease.
Cardiac enzymes were negative for acute event. TSH was wnl. No
suspected travel history to suggest Lyme exposure. TTE showed
intact EF and no focal wall motion abnormalities. He underwent
uncomplicated pacemaker placement. Pacemaker was interrogated by
EP after placement and he remained paced between 60 and 70. He
received vancomycin post-procedure and keflex for 2 days for
prophylaxis. He was discharged with instructions to f/u in
Device Clinic in 1 week and with Dr. [**Last Name (STitle) 1911**] thereafter in
clinic.
.
# SDH/SAH: Likely occurred in setting of fall with resultant
head trauma. Both intracranial bleeds are small. Repeat head CT
shows interval decrease in size of bleed. He was seen by
neurosurgery who recommended avoiding anticoagulants and
dilantin for seizure prophylaxis. He was loaded with phenytoin
and discharged with instructions to take 100mg TID for [**7-23**]
days. He was also instructed to schedule neurosurgery f/u with
Dr. [**Last Name (STitle) **] in six weeks.
.
# Temporal bone fracture: ENT consulted and recommended
following CSF leak precautions (HOB elevation, stool softeners,
sneeze with mouth open, no nose blowing) as well as starting
ciprodex otic drops 4 gtt AD [**Hospital1 **] x 10 days. They also
recommended keeping his ear dry (Cotton ball in ear, then
vaseline
smeared over ear and cotton when washing hair) until ENT follow
up in [**4-19**] weeks. In addition to arranging for f/u, patient was
instructed to call [**Hospital 18**] [**Hospital 88662**] clinic to schedule a baseline
audiogram.
.
# CORONARIES: No history of CAD. Cardiac risk factors: HL, HTN;
h/o smoking. Cholesterol:125 Triglyc: 86 HDL: 48 CHOL/HD: 2.6
LDLcalc: 60. He was continued on his home aspirin and
simvastatin 80 mg daily.
.
# s/p CVA. Per family no residual deficits. Per daughter is on
asa and plavix at home, but no record of plavix in Atrius
records.
- Continue ASA
- med rec plavix
.
# PUMP: No history of CHF. No objective signs of heart
failure/volume overload on exam. His ins and outs and daily
weights were monitored. TTE was performed which showed an intact
EF and no focal wall motion abnormalities.
Medications on Admission:
ASA
Plavix
Albuterol
Flovent
Lisinopril
Discharge Medications:
1. phenytoin 125 mg/5 mL Suspension Sig: Four (4) mL PO Q8H
(every 8 hours) for 8 days: take for another 8 days for a total
10 day course.
Disp:*96 mL* Refills:*0*
2. ciprofloxacin 0.3 % Drops Sig: Four (4) Drop Ophthalmic [**Hospital1 **]
(2 times a day): to right ear for 10 days.
Disp:*1 bottle* Refills:*0*
3. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
6. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
7. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Complete Heart Block
2. Subdural bleed
3. Subarachnoid bleed
4. Temporal bone fracture
.
SECONDARY DIAGNOSES:
1. History of CVA
2. Dyslipidemia
3. Hypertension
4. Depression
5. GERD
6. Asthma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 12982**],
You were admitted to the hospital after you had a dangerous
heart rhythm. We believe that this also caused you to fall.
For the heart rhythm, a pacemaker was placed.
When you fell, you had a bleed in your head. This bleed was
stable on a head CT. You will need to follow-up with the
neurosurgeons for this in 6 weeks as below. You will need to
take a medication called dilantin to prevent seizures for the
next 8 days. If you have no seizures during the 8-day period,
you can stop taking this medication.
You had some bleeding from your right ear. You were seen by the
ear nose and throat doctors. [**First Name (Titles) 12410**] [**Last Name (Titles) 7219**] were as
follows:
-CSF leak precautions (head of bed elevation, stool softeners,
sneeze
with mouth open, no nose blowing).
-Start ear drops as below
-Keep ear dry until follow up (Cotton ball in ear, then vaseline
smeared over ear and cotton when washing hair).
The following changes have been made to your medications:
1. Start Ciprodex otic drops 4 gtt AD [**Hospital1 **] x for a total of 10
days.
2. Start dilantin 100mg three times a day for an additional 8
days.
.
Please speak with Dr. [**Last Name (STitle) **] about your regular medications to
be sure they match the doses and names we have here.
.
Your follow-up information is listed below.
Followup Instructions:
You will be called for an appointment by Dr. [**First Name8 (NamePattern2) 2259**] [**Last Name (NamePattern1) **], [**First Name3 (LF) **]
electrophysiologist at [**Location (un) 2274**] [**Location (un) **], for follow-up on your
pacemaker. If you do not hear from him, please call [**Telephone/Fax (1) **]
to schedule an appointment.
.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-15**] weeks. His
phone number is [**Telephone/Fax (1) 85716**].
.
Call for an ear, nose, throat doctor appointment on Tuesday. You
will need an audiogram to test your hearing as well as a
follow-up appointment. The office is at the [**Location (un) 2274**] [**University/College **] site
and the phone number is [**Telephone/Fax (1) 88663**].
.
You will need an appointment with the neurosurgeon, Dr. [**Last Name (STitle) **]
in 6 weeks. Call [**Telephone/Fax (1) 1669**] for an appointment with Dr.
[**Last Name (STitle) **].
[**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 69391**]
ICD9 Codes: 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7684
} | Medical Text: Admission Date: [**2163-11-11**] Discharge Date: [**2163-11-20**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Right lung cancer
Major Surgical or Invasive Procedure:
Bronchoscopy x3
PleurX catheter insertion
Emergent intubation
History of Present Illness:
This patient is an 83 year old female with small cell lung
cancer who was accepted in transfer from [**Hospital 1562**] Hospital.
Patient is with known right small cell lung cancer undergoing
chemotherapy/radiation therapy at [**Hospital3 1563**] [**Hospital3 **]. She
now presents with acute respiratory falure and is status-post
intubation. The reports from the outside hospital indicate
extrinsic compression from right mainstem bronchus obstructing
the proximal airway now with complete collapse of the right
hemithorax with partial collapse of the left hemithroax. CT
scans from [**Hospital1 1562**] indicate a large volume tumor encasing the
right lung. The patient's family was advised of her dismal
prognosis, and the patient was admitted for the possibility of a
meaningful intervention with the goal of palliative therapy.
Past Medical History:
End stage small cell lung canger with known brain metastasis
Now s/p chemo/radiation therapy
Breast cancer
X-Ray therapy pneumonitis
COPD
Osteoporosis
Physical Exam:
T 98.4 HR 86 BP 108/45 RR 22 SpO2 95% on AC
0.45/450/14/PEEP5
Intubated, sedated
RRR
CTA on the left, minimal breath sounds on the right
Abdomen soft, NT/ND
Extremeties with 1+ edema, no cyanosis
Brief Hospital Course:
The patient was admitted to the hospital and underwent a
bronchoscopy on [**2163-11-11**]. This revealed a completely obstructed
right upper lobe with tumor and submucosal infiltration of the
proximal right mainstem bronchus. Post-bronchoscopy, a chest
xray showed partial re-expansion of the right lower lobe. The
patient was placed on a CPAP trial the next morning, which she
passed. She was extubated for a period of a few hours. However,
due to increasing respiratory effort, the patient soon fatigued,
and required emergent re-intubation. The patient was fully
conscious at this time, and willingly indicated a desire to be
re-intubated. A repeat chest xray showed a re-accumulation of
fluid in the right hemithorax with collase of the right lower
lobe. The patient was kept intubated and on supportive care
until [**2163-11-15**], when the patient underwent a repeat bronchoscopy
and placement of a PleurX catheter on the right. This was done
in the hopes that the patient could be extubated once the
pleural effusion was cleared. However, the patient failed to
properly wean off the vent. Following on-going dialogue with the
patient's family, it was decided that the patient would be made
comfort measures only on [**2163-11-20**]. The patient was extubated and
expired several hours later.
Medications on Admission:
IV morphine
Midazolam prn
Hydrocortisone 25mg IV BID
Azithro 500mg IV Q24h
Protonix 40mg IV Q24h
Zosyn 2.25g IV q6h
Albuterol/atrovent nebulizer
Lovenox 40qd
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
Right lung cancer
Obstructive pneumonitis
COPD
Discharge Condition:
Deceased
Followup Instructions:
None
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7685
} | Medical Text: Admission Date: [**2184-10-21**] Discharge Date: [**2184-11-15**]
Date of Birth: [**2116-6-15**] Sex: M
Service: TRAUMA [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 68 -year-old male with
a history of stroke, hypertension, and hypercholesterolemia,
who sustained a motor vehicle accident on [**2184-10-18**]. The
patient was an unrestrained driver of a vehicle that was
rear-ended by a garbage truck. His car then struck another
vehicle and the patient was ejected from the vehicle. The
patient recalled the events at the outside hospital and had [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 2611**] coma scale of 15 on arrival to the hospital. The
patient was at [**Hospital6 5016**].
Initial studies undertaken there showed a CT scan head with a
small contusion in the left posterior parietal region and
there is a question of a small intraparenchymal hemorrhage in
the posterior aspect of the Sylvian fissure. His CT scan
head the following day was completely negative. CT scan of
the cervical spine was negative, CT scan of the chest was
negative, and the CT scan abdomen just revealed a 3.3 cm
abdominal aortic aneurysm. There was a left femoral neck
fracture for which the patient underwent open reduction,
internal fixation at [**Hospital6 5016**]. He also sustained
a left distal radius fracture, right humeral head fracture,
and lacerations of the head.
After going to the Operating Room at the outside hospital,
the patient was noted to have a hematocrit in the low 20s.
He received six units of packed red blood cells. On the
evening of [**2184-10-20**], the patient became markedly hypoxic and
was not responsive to Lasix and nebulizer treatments. The
patient was subsequently intubated and remained hypoxic
despite 100% FiO2. A CT scan of the chest showed bilateral
pneumothoraces, pneumomediastinum, subcutaneous emphysema,
and a right lower lobe pulmonary contusion without rib
fracture. The patient was subsequently transferred to [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for intensive care.
PAST MEDICAL HISTORY:
1. Cerebrovascular accident times two with no residual
deficits.
2. Hypertension.
3. Hypercholesterolemia.
ADMITTING MEDICATIONS: Procardia, Lipitor, and aspirin.
MEDICATIONS ON ARRIVAL: Tequin, Kefzol, Procardia, Lipitor,
and Pepcid.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives at home and has a
supportive family.
PHYSICAL EXAMINATION: On initial visit examination, the
patient had a temperature of 100.2 F, heart rate 114, blood
pressure 121/58, respiratory rate 12, saturating 91% on 80%
FiO2. He was awake, responsive to voice and moving all
extremities. An endotracheal tube and nasogastric tube were
in place. Heart was tachycardic without murmurs, rubs, or
gallops. There were fine crackles on the chest bilaterally
anteriorly. The abdomen was distended and nontender. The
left distal extremity was in a splint. The right arm was in
a sling. Pulses were palpated throughout.
ADMISSION LABORATORY DATA: Initial white count was 12.5,
hematocrit was 26.0. Sodium 141, potassium 3.5, chloride
106, CO2 25, BUN 16, creatinine 0.9, glucose 154. Coag
studies revealed an INR or 3.2.
HOSPITAL COURSE:
1. Respiratory: The patient's respiratory status was his
main issue throughout his hospital course. The patient was
initially admitted to the Intensive Care Unit. Two chest
tubes were placed and the patient remained intubated. This
situation was continued for several days. After several days
of intubation, the patient actually self-extubated and did
well without the breathing tube. After the chest tubes
demonstrated no further air leak, they placed a water seal
and eventually discontinued. The patient continued to do
well and was transferred to the hospital [**Hospital1 **].
The patient did well initially, but eventually decompensated,
had increased wheezes, rhonchorous breath sounds, and
eventually desaturated. He was transferred back to the
Intensive Care Unit and was re-intubated. Chest x-ray showed
multi-focal lung opacities, consistent with an infectious
process or adult respiratory distress syndrome. The patient
remained in the Intensive Care Unit for several more days and
eventually improved markedly. He was extubated successfully.
Since then he has done well with aggressive pulmonary toilet.
He was on nebulizer treatment around the clock and was
getting aggressive chest therapy with incentive spirometry.
He has done much better and on the date of discharge he is
saturating well on room air. Other studies performed here
included chest CT scan angiogram which showed no evidence of
pulmonary embolism, the pneumomediastinum, pneumopericardium,
and pneumothoraces seen initially and consolidations of the
lung bases. Other studies also revealed that the patient has
signs of obstructive pulmonary disease.
2. Orthopedics: The patient has a left hip fracture status
post open reduction, internal fixation. The patient has done
well with this and is now on weight bearing as tolerated
status with his left hip. The patient is remaining on
Coumadin for his hip fracture and deep venous thrombosis
prophylaxis. The patient is also in a cast for his left
wrist and sling for the right arm. These two issues are
non-operative and are to be followed up in several weeks by
Orthopedics.
3. Neurologic: The patient has remained awake and alert
throughout his hospital course; however, since extubation,
the patient has remained somewhat confused as to location and
situation. He is noted to be confabulating. A CT scan head
on [**2184-11-2**] showed no evidence of acute intracranial
pathologic process. The patient was placed on vitamins for a
question of Wernicke - Korsakoff syndrome. This issue was
treated with community reorientation and support from his
family. It was felt that there was no infectious disease or
structural etiology for this cause and was likely secondary
to deconditioning and change in environment after the
accident.
4. Infectious Disease: The patient presented initially on
Tequin and Kefzol. These were discontinued. The patient was
followed for infectious disease throughout his hospital stay.
During his initial Intensive Care Unit course, he had several
days of fever. There was no known source. Numerous sputum
cultures, line cultures, and other investigations for
infectious disease were negative. The patient subsequently
had an ultrasound guided hip joint catheter to rule out
infection there, which was also negative.
At one point, the patient was placed on several antibiotics,
including vancomycin, for empiric treatment. This was
subsequently discontinued after several days and the patient
defervesced. It was unclear if the patient had a febrile
response to the treatment or if he actually had an infectious
disease. For the remainder of this [**Hospital 228**] hospital stay,
he has been off of antibiotics and has been afebrile.
DISPOSITION: The remainder of the patient's issues have been
stable. He has had no cardiovascular issues. He has had
mild tachycardia which we feel is secondary to Albuterol
treatment. He is eating with encouragement and assistance.
He is making urine and stool is to be transferred to [**Hospital6 **] facility today for continued chest
physical therapy and strengthening exercises.
DISCHARGE MEDICATIONS:
1. Folic acid 1.0 mg po q day.
2. Multivitamin one po q day.
3. Nutri-shakes or equivalent nutritional formula, one can
po tid with meals.
4. Milk of Magnesia 30 cc po q day prn.
5. Lopressor 25 mg po bid.
6. Coumadin 1.0 mg po q Monday, Wednesday, Friday, 2.0 mg po
q Tuesday, Thursday, Saturday, and Sunday. The patient
should have frequent INR checks.
7. Tylenol 650 mg po q four hours prn.
8. Colace 100 mg po bid.
9. Flovent four puffs po bid.
10. Albuterol and Atrovent nebulizers q four hours around the
clock.
11. Regular insulin sliding scale.
12. Protonix 40 mg po q day.
13. Lipitor 10 mg po q day.
14. Procardia 10 mg po tid.
DISCHARGE INSTRUCTIONS: For physical therapy, the patient is
to remain nonweight bearing for right upper and lower
extremities, but is weight bearing as tolerated on bilateral
lower extremities. He is to have continued aggressive chest
therapy, including nebulizer treatment and aggressive
physical therapy with incentive spirometry.
DISCHARGE DIAGNOSES:
1. Status post motor vehicle accident.
2. Respiratory failure, including bilateral pneumothoraces
and pneumomediastinum.
3. Pneumopericardium.
4. Left femoral neck fracture.
5. Left distal radius fracture.
6. Right humerus fracture.
7. Hypertension.
8. Hypercholesterolemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 3600**]
MEDQUIST36
D: [**2184-11-15**] 10:01
T: [**2184-11-15**] 10:03
JOB#: [**Job Number 36279**]
cc:[**Telephone/Fax (1) 36280**]
ICD9 Codes: 5185, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7686
} | Medical Text: Admission Date: [**2128-7-5**] Discharge Date: [**2128-7-9**]
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base
Attending:[**Doctor First Name 1402**]
Chief Complaint:
expressive aphasia and right sided weakness
Major Surgical or Invasive Procedure:
Implantation of Carotid Arterial Stent
Thrombin injection of right femoral pseudoaneursym
History of Present Illness:
88-yo-woman w/ CAD (S/P 3 vessle CABG [**41**] years ago) and left ICA
stenosis is now transferred to the CCU for post-procedure
monitoring after left ICA stenting. She was initially admitted
to the Neurology service on [**7-5**] after awaking from a nap w/ new
expressive aphasia and right sided weakness. She emphasizes that
she could not move her right arm, couldn't get up and was unable
to call her husband for help. He eventually found her and by
that time her arm weakness had subjectively improved but she was
still unable to speak. Urgent CTA of the head showed no
intracranial hemorrhage and possible hyperdense left MCA sign at
an outside hospital. She was treated conservatively w/ ASA and
heparin gtt given left ICA stenosis. Cardiac ischemica was ruled
out w/ serial biomarkers. By the morning after admission, her
symptoms had resolved entirely. She was ultimately diagnosed w/
TIA in the setting of significant left ICA stenosis.
.
[**2128-7-7**] she was treated w/ left ICA stent, with no complications.
She is now transferred to the CCU service for post-procedure
monitoring. She reports that her voice is almost back to normal
and that she has some residual right arm pain that she
attributes to the pressure cuff. Otherwise she is feeling much
better.
.
ROS: Incontinence of urine is not new, but more pronounced since
episode on [**2128-7-5**]. Vomited x1 on [**2128-7-6**] - no blood. Patient
denies any fever, chills, nausea, headache, dysphagia, numbness,
tingling, dizziness, visual changes, chest pain, shortness of
breath, diplopia, hearing changes, hematochezia, melena, and
hematuria.
Past Medical History:
- CAD s/p CABG: known LBBB
- left ICA stenosis(60-70% in [**7-/2127**])
- HTN
- hyperlipidemia
- hypothyroidism
- macular degeneration
- OA
- Osteoporosis
- Anxiety
Social History:
significant for the absence of tobacco use.
There is history of moderate alcohol abuse. She is married and
lives in a retirement community; takes care of her husband with
dementia.
Family History:
Family history: Father had MI, HF, mother with HF, brother with
HF
Physical Exam:
VS: T:97.0 BP:144/50 on 0.39mcg/kg/min neosynephrine gtt HR:74
RR:16 O2:98% on 2L.
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Jaw notable for prior osteonecrosis of the jaw - patient
attributes to fosamax.
Neck: Supple with JVP of 5 cm.
CV: PMI located in 5th intercostal space, midclavicular line. RR
2/6 systolic murmur at apex to axilla. No thrills, lifts. No S3
or S4.
Chest: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
Examined anteriorly as sheath had recently been pulled.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation.
Ext: No c/c/e. Patient has a femoral bruit on the right and not
on the left.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro:
MENTAL STATUS: WNL, alert, oriented x 3. Aware of [**Last Name (un) 29999**].
Thinks [**Doctor First Name **] or Romney may become president.
CRANIAL NERVES: II-XII intact.
MOTOR SYSTEM: 5/5 strength in upper and lower extremities
bilaterally.
REFLEXES: 1+ in the patella and ankles bilaterally
SENSORY SYSTEM: intact to LT in the lower extremities
bilaterally.
COORDINATION: FNF intact bilaterally.
GAIT: Not tested.
.
Pulses:
Right: Carotid deferred Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid deferred Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
EKG demonstrated sinus brady at 59 bpm; LBBB; no ischemic
changes; no change from prior dated [**2127-8-20**].
.
Admission labs:
CK: 47
MB: Notdone
Trop-T: 0.02 - 0.01 - 0.01
12.1
10.1 >----< 309
35.3
PT: 12.3 PTT: 27.6 INR: 1.1
.
Hct: 35 - 30 - 26 (multiple times at 26)
Admission Lytes: Gluc-88 UreaN-28* Creat-1.0 Na-138 K-4.6
Cl-109* HCO3-21*
[**2128-7-6**] 04:20AM BLOOD %HbA1c-5.8
[**2128-7-6**] 04:20AM BLOOD Triglyc-72 HDL-49 CHOL/HD-2.7 LDLcalc-69
[**2128-7-6**] 04:20AM BLOOD TSH-2.3
.
[**7-5**] CT A Head:
ROUTINE CTA OF THE HEAD AND NECK WITH CONTRAST USING STANDARD
DEPARTMENTAL PROTOCOL.
There is a large calcified plaque at the origin of the right
internal carotid artery and carotid bulb causing approximately
60% stenosis. A similar circumferential calcified plaque is seen
at the origin of the left internal carotid artery and carotid
bulb causing approximately 63% diameter stenosis. Bilateral
external carotid artery stenosis is also seen.
There is a calcific plaque at the origin of the left vertebral
artery, which is not hemodynamically significant.
Intracranially, there is mild irregularity of the basilar
artery, without hemodynamically significant stenosis. There is
bilateral cavernous carotid calcification. No significant
stenosis is seen. There is a 3-mm aneurysm in the right
supraclinoid ICA, pointing posteriorly. This appears to be
separate from the posterior communicating artery.
IMPRESSION:
Bilateral ICA stenosis at the origin ranging from 60% to 65%
Small right supraclinoid ICA aneurysm pointing posteriorly,
which appears to be separate from the posterior communicating
artery origin.
.
[**7-6**] MRI head: Multiple bilateral deep cerebral and
periventricular white matter chronic small vessel ischemic
changes, with small punctate areas displaying restricted
diffusion, likely representing subacute multiple vascular
territorial infarcts. Please note no corresponding ADC map was
obtained due to the scanner employed, and which would have
helped to confirm the age of the latter infarcts.
.
[**7-6**] ECHO: No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 70%). 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. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial 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
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**7-8**] femoral u/s: 3 cm pseudoaneurysm in right inguinal region
at site of prior vascular intervention. No evidence of AV
fistula formation. Thrombin successfully injected.
.
[**7-9**] u/s: complete thrombosis of pseudoaneurysm. normal arterial
and venous flow.
Brief Hospital Course:
Pt is a 88 year old female with remote hx of CABG and carotid
artery stenosis who presents with right sided weakness and
expressive aphasia. Hospital course by problem:
.
#)Neurologic: Imaging as above. She has bilateral ICA stenosis
but given her symptoms consistent with left sided cerebral
hypoperfusion, she was treated with stent placement to the left
ICA. She tolerated this well and had resolution of her neuro
sx. Imaging as above. The stent was placed on [**2128-7-7**]. We
treated with ASA, plavix, and zocor. She will need plavix for
at least 1 year. Followup ultrasound in one month and f/u with
Dr. [**Last Name (STitle) 911**] thereafter. We maintained her SBP>120 with pressors
temporarily in the CCU. Neuro exam was monitored closely by CCU
and neuro teams.
.
#)Femoral pseudoaneurysm: she had a pseudoaneursym as a
complication of the stent placement. It was detected promptly
and ultrasound showed aneurysm as above. She underwent thrombin
injection which was shown to be successful in followup
ultrasound. She required one unit transfusion given rapid hct
drop (nadir 25). It stabilized at 26 prior to discharge. She
ambulated to bedside commode with assist and was without
presyncopal sx.
.
#) Anemia - normocytic anemia with normal RDW. HCT was 35 on
admission. 31 on transfer to the CCU. Dropped as above.
received one unit with stabilization. Iron studies did not
suggest iron deficieny anemia. She did have an OB positive
stool but it was brown and not consistent with melena. This was
not thought to be her primary source of the hct drop. If she
has melena or her hct drops in followup, this must be considered
and she would benefit from an outpatient GI workup. In the
meantime, her asa and plavix were continued given her recent
stent placement.
.
#)Cards: substantial CAD history - S/P CABG [**41**] years ago.
-Rhythm: tele
-Ischemia: Ruled out for MI with three serial enzymes. Continued
ASA, plavix.
-Pump - TTE with EF 70%, mild MR, mild symmetric LVH
.
#) Endo:
-Synthroid 100 daily
.
#)OA: longstanding. required tylenol #3 for pain control. We
did not treat with nsaids.
.
#)Osteonecrosis of the jaw.
-on Doxycycline 100 [**Hospital1 **] for the last month after having
osteonecrosis of the Jaw from fosamax. continued
-There was no sign of infection on exam.
.
#)Communication - health care proxy is [**Name (NI) **] [**Known lastname 12303**]
Relationship: son
Phone number: [**Telephone/Fax (1) 30000**]
-PCP is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]
.
#)Code: Full for now.
Medications on Admission:
aspirin 325
metoprolol 25 [**Hospital1 **]
Zocor 80 daily
Lasix 40 every other day
Altace 2.5 daily
Synthroid 100 daily
loratadine 10 daily
pepcid 20 daily
oxazepam 10 q6h prn
Pcuvite 1 daily
Doxycycline 100 [**Hospital1 **]
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. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
4. Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Oxazepam 10 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO every other day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary:
-Symptomatic Carotid Stenosis now s/p stent placement
-femoral artery pseudoaneurysm s/p thrombin injection
-anemia likely secondary to mild blood loss at groin site, IVF;
controlled
-CAD
-HTN
-hyperlipidemia
Secondary
-hypothyroidism
-macular degeneratoin
-OA
-osteoporosis
-anxiety
Discharge Condition:
well
Discharge Instructions:
You came in with difficulty speaking and right sided weakness.
We placed a stent in your left carotid artery. You tolerated
this well. You had a pseudoaneurysm of your right femoral
artery and were treated with a thrombin injection.
.
We added plavix and simvastatin to your regimen. It is very
important for you to take all of your medications.
.
Please attend all follow up appointments. If you develop
dizziness, trouble with your vision, difficulty speaking: please
contact your health care providers or return to the ED.
.
Please followup with your PCP. [**Name10 (NameIs) **] may benefit from an
outpatient GI workup given your anemia.
Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:
[**2128-8-17**] 4pm
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2128-10-11**] 1:20
.
Please go to [**Hospital1 18**] [**Location (un) 620**] for a followup ultrasound of your
left carotid on [**8-6**] at 1pm. [**Telephone/Fax (1) 30001**].. Fax#
[**Telephone/Fax (1) 30002**].
.
Please contact your PCP for [**Name Initial (PRE) **] followup appointment within the
next month. You may benefit from an outpatient GI workup.
ICD9 Codes: 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7687
} | Medical Text: Admission Date: [**2137-8-29**] Discharge Date: [**2137-8-29**]
Date of Birth: [**2116-1-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
Endotracheal extubation
History of Present Illness:
A 23M with history of ETOH abuse was found staggering and
banging head against the sidewalk outside of the ED at [**Hospital 8125**]
Hospital. He reports that he had used GHB for the first time
earlier in the day and had taken 6 cap fulls. He remembers
little else throughout the day except for being surrounded by
police. In their ED vitals were HR 66 BP 157/80 SaO2 100% (o2
delivery not recorded) he reportedly became unresponsive with
GCS 3 and was intubated. He received no paralytics. He was then
transferred to the [**Hospital1 18**] ED for further management.
On arrival to our ED, airway was intact w/no tracheal deviation.
Pt became bradycardic to 30s-40s with systolic BPs 130-140s and
O2 sats 100%. Extremieites were cool to touch with slow cap
refill 2+ DP pulses. Secondary survey significant for pupils 2mm
bilaterally and minimally responsive, hypotonia, no rectal tone,
unresponsive to pain, glucose 108. Blood and urine tox screens
were negative. ECG showed sinus brady at 51, LVH, prolonged QTc
460, 437 on repeat EKG. CXR shows ETT in place without acute
process. Non contrast C spine and head CT were negative. CT
C/A/P (prelim) report showed "scattered ground glass nodularity
in bilateral lungs, transient intussusception of prox small
bowel, heterogenous appearance to liver and spleen likely
related to phase of contrast, trace free fluid, pericholecystic
fluid, and a linear lucency in the proximal portion of body of
sternum likely developmental/old injury." Labs were remarkable
for AST/ ALT: 59/55 Tbili 0.9 Lipase 22. Cr 0.7 CK: 522.
On reevaluation at 6:01am found patient responding to pain. Not
localizing. Pupils 4mm->2mm bilaterally. Moving all 4
extremities. HRs high 50s-low 60s. at 7:30 AM he awoke and was
combative. Because his c-spine could not yet be cleared he was
sedated with propofol for safety. He was then admitted to the
MICU for further management.
On arrival to the MICU, patient is intubated, sedated. He was
promptly extubated and reported the above history. He complained
of sore throat and cough, stating that he had not had a cough in
the day preceeding admission.
Review of systems:
(+) per HPI
(-) Denies headache, blurryvision, dyspnea, chest pain, N/V/D,
abdominal pain. Denies numbness/tingling in lower/upper
extremities.
Past Medical History:
ETOH abuse
Bipolar disorder (previously on Depakote)
Social History:
Living in Evergreen sober house in [**Location (un) 29897**]. He is estranged from
his parents and does not have any friends at the sober house
that he wants contact[**Name (NI) **]. [**Name2 (NI) **] has smoked 1 1/2 packs since age 12
(15 pack year history)
Family History:
Denies famliy history of malignancy, cardiovascular disease.
Physical Exam:
ADMISSION EXAM
Vitals: T: 97.6 P:109 BP 135/88 rr16 98% RA
General: Young male breathing comfortably somnolent but
arrousable in NAD
HEENT: Conjunctival injection bilaterally, sclera anicteric,
MMM, oropharynx clear, EOMI, PERRL, a laceration over the right
brow is present with 4 sutures in place
Neck: Cervical [**Last Name (un) **] in place
CV: Tachycardic with SEM at LUSB regular rate and rhythm, normal
S1 + S2,
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound/guarding
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No facial droop, PEERLA, EOMI, Reflexes 2+ in patella and
brachioradialis, no clonus. Moving all 4 extremities motor [**5-11**]
in upper/lower, .
Pertinent Results:
ADMISSION LABS
===============
[**2137-8-29**] 02:55AM BLOOD WBC-10.6 RBC-4.59* Hgb-14.6 Hct-42.2
MCV-92 MCH-31.9 MCHC-34.7 RDW-12.6 Plt Ct-185
[**2137-8-29**] 02:55AM BLOOD Neuts-70.2* Lymphs-22.2 Monos-4.0 Eos-3.2
Baso-0.4
[**2137-8-29**] 11:57AM BLOOD Glucose-98 UreaN-6 Creat-0.6 Na-140 K-3.4
Cl-105 HCO3-27 AnGap-11
[**2137-8-29**] 02:55AM BLOOD Glucose-114* UreaN-13 Creat-0.7 Na-143
K-4.1 Cl-106 HCO3-17* AnGap-24*
[**2137-8-29**] 11:57AM BLOOD CK(CPK)-900*
[**2137-8-29**] 02:55AM BLOOD ALT-59* AST-55* CK(CPK)-522* AlkPhos-70
TotBili-0.9
[**2137-8-29**] 02:55AM BLOOD Albumin-4.5 Calcium-9.0 Phos-2.5* Mg-1.9
Brief Hospital Course:
23M found staggering and banging head against the sidewalk
outside of the ED of [**Doctor First Name 8125**] with course complicated by
unresponsiveness related to GHB intoxication and intubation for
airway protection. He was extubated and left against medical
advice.
#) Unresponsiveness: Patient states that he had ingested
Gamahydroxybutarate (GHB) for the first time the day prior to
admission. Bradycardia, unresponsiveness, amneisa are common
symptoms of GHB ingestion. Lab testing showed negative
toxicology screen and no aniongap at [**Doctor First Name 8125**]. Spontaneous
resolution of symtpoms ~ 6 horus after ingestion are also
consistent with GHB intoxication. Labs on arrival to [**Hospital1 18**]
showed anion gap likely related to starvation ketosis. Though
methanol and ethylene glycol posioning were also considered
osmolar gap was normal. He was seen by social work and demanded
to leave against medical advice.
#) Anion gap acidosis: Patient admitted to [**Hospital1 18**] with anion gap
acidosis, with positive ketones on u/a this was thought likely
starvation ketoacidosis. As above, methanyl and ethylene glycol
ingestion were also considered. Anion gap closed after patient
was given IV fluids.
#) Ground Glass opacities on Chest CT: [**Month (only) 116**] be aspiration related
to toxidrome above. Less likely to be a primary process as
patient did not have any pulmonary signs or symptoms but rather
was intubated because of mental status. Differential includes
malignancy though this is unlikely in this young man. HIV
antibiody was sent and pending at the time that patient left
against medical advice.
#) Status post fall: patient with laceration over right brow and
received in cervical collar. C- collar was cleared. He should
have sutures removed on [**2137-9-12**].
#) Elevated CK: likely related to fall, CK mildly elevated at
500 and uptrending at the time he left to 900. This was thought
unlikely to be rhabdomyolysis as he was not down for a prolonged
period of time.
#) Elevated transaminases: AST/ALT moderately elevated at 55/59.
Patient with history of drinking though he states he has been
adstaining. He has multple tatoos which are not professionally
done. Hepatitis serologies (C and B) were sent and were
pending at the time of discharge.
#) Transient intusussception seen on CT: Surgery reviewed the
imaging with the radiologist in the ED and felt there were no
acute surgical issues. In discussion with radiolgy this is a
common finding in the small bowel and of little clinical
significance. He was asymptomatic with a benign abdominal exam.
# Identity: patient is logged into the hospital as [**Known lastname **] [**Known lastname **]
[**Known firstname 12589**] and states his name is [**Name (NI) **] [**Last Name (NamePattern1) **] DOB [**2114-8-21**]. He does
not have any identification and does not want family called.
Collateral from [**Location (un) **] [**Telephone/Fax (1) 111989**] confirmed the name
he had given us and the story seemed consistent however no
family/friends came to the bedside to identify the patient.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Gammahydroxybutyrate Intoxication (GHB)
Starvation ketoacidosis
Abnormal liver function
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
As you know, you were admitted to [**Hospital1 1170**] after being found down and intoxicated. You were
intubated and admitted to the medical intensive care unit. We
removed the breathing tube and you appeared improved. We
verified that there was no broken bone in you neck. We performed
a CT of the chest which showed focal nodules, the significance
of which is unclear however could represent an infection,
inflammation in the blood vessels. You should see a lung doctor
(pulmonologist to discuss this further).
Your condition improved and you wanted to leave [**Hospital 111990**] medical
advice. We recommend that you abstain from GHB and that you seek
medical and psychiatric treatment.
We sent blood work to test for HIV and Hepatitis, these results
were pending when you left against medical advice.
Your sutures will need to be removed by a physician [**Last Name (NamePattern4) **] [**2137-9-12**].
Followup Instructions:
Please make an appointment for primary care [**2137-9-12**] for suture
removal
Please make an appointment with a pulmonologist (lung doctor) in
[**2-9**] weeks
Please make an appointment with psychiatry in [**2-9**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7688
} | Medical Text: Unit No: [**Numeric Identifier 75311**]
Admission Date: [**2194-11-2**]
Discharge Date: [**2194-12-2**]
Date of Birth: [**2194-11-2**]
Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**Known lastname 75312**] is a 33-2/7 week gestation female
infant admitted to the NICU because of prematurity. Mom is a
39-year-old, G1, P0-1, woman. Her past medical history is
remarkable for her being a carrier for hepatitis B surface
antigen without elevation of LFTs. She also had abdominal and
liver ultrasounds which were normal. Mom also has a history
of seizure disorder at age 24 without any recent seizures and
without treatment. Prenatal screens were as follows: O
positive, antibody negative, RPR nonreactive, rubella immune,
GBS positive. Pregnancy was conceived with the assistance of
IVF and donor egg. The pregnancy was originally a twin
gestation that spontaneously reduced to a single twin
pregnancy. Mother has had illnesses during the pregnancy
including two months of diarrhea. Stool culture reportedly
was not sent prior to delivery. Mom also had a chronic cough
for seven weeks during [**Month (only) 359**] and [**Month (only) **]. Parents are from
[**Country 3396**] and mom is a full-time student.
Mother was admitted to labor and delivery because of
hypertension and mildly elevated LFTs with decreasing urine
output and elevated creatinine. Her magnesium level the day
prior to delivery was 9.5, creatinine 1.5, uric acid 7.6.
Attempt to induce labor was unsuccessful and decision was
made to deliver by C-section. Baby emerged with reduced tone
and respiratory effort. She was treated with bulb suction,
bag and mask ventilation with good response. Apgars were 6
and 7. On admission to the NICU, she was noted to have some
shallow breathing and was placed on nasal CPAP with good
improvement. The mother developed DIC and had to have an
emergent hysterectomy to stop hemorrhaging.
ADMISSION PHYSICAL EXAMINATION: Vital signs: Temperature
35.5, heart rate 140, respiratory rate 36, blood pressure
76/59 (66), O2 saturation in blow-by 95%, weight 1475 grams
(15%), length 43 cm (30-40%), head circumference 29.75 cm
(25%). General appearance: Baby appears [**Name2 (NI) **], of appropriate
gestational age, breathing comfortably on CPAP. HEENT:
Normocephalic. Anterior fontanel soft and flat. Eyes with
normal red reflexes. Ears normal appearance. Palate intact.
Respiratory: Breath sounds clear and equal, initially with
intermittent apnea but improved on CPAP. Cardiovascular: S1,
S2 normal intensity, no murmur. Femoral pulses strong.
Abdomen: Soft with no organomegaly. GU: Normal female. Anus
appears patent and normally placed. Neuro: Overall tone
initially decreased but improved with symmetrical movements.
Skin clear.
DISCHARGE PHYSICAL MEASUREMENTS: Weight 2110 grams. Head
circumference 32 cm. Length 42 cm.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: Upon admission, baby was placed on CPAP
which was weaned to room air on day of life 2. She has
been on room air since that time. She has intermittent
spells but has not had a spell for greater than five
days prior to discharge.
1. CARDIOVASCULAR: Upon admission, baby's blood pressure
and heart rates were normal and she had no murmur. On
day of life 3, she was found to have a new murmur.
Echocardiogram on [**11-11**] showed moderate to large
PDA. She was treated with indomethacin for one course
with a repeat echo on [**2194-11-12**] which showed no
PDA. She has been stable since that time and has no
murmur.
1. FLUIDS, ELECTROLYTES AND NUTRITION: Baby was started
n.p.o. on peripheral nutrition. She was started on feeds
on day of life 2 which were advanced as tolerated. She
is currently on ad lib feeds of breast milk 24 which is
made with Enfamil powder and at discharge she has taken
all p.o.'s for greater than two days.
1. GI: Baby had hyperbilirubinemia at birth with a peak of
9.1 on day of life 4. She was treated with phototherapy
for four days and has had no problems since that time.
1. HEMATOLOGY: Upon admission, baby had a hematocrit of
46.7 with 290 platelets. She was started on iron and
multivitamin which she continues currently. Her last CBC
for hematocrit check was done on [**11-13**] and at that time
her hematocrit was 33.1.
1. INFECTIOUS DISEASE: At birth, baby had a rule out
sepsis. Her white count was 13.5 with 57 polys and 0
bands. She was started on amp and gent which were
stopped after 48 hours when blood cultures were
negative. No current issues.
1. NEUROLOGY: Baby had a normal neurologic exam at birth
which continues to be normal. She did have a head
ultrasound on [**2194-11-7**] which showed a miniscule
subependymal cyst in the left lateral ventricle which
was thought by Radiology to be a normal variant. No
further studies have been done.
1. SENSORY - A) AUDIOLOGY: Hearing screen was performed
with automated auditory brainstem responses on [**2194-12-2**]. B)
OPHTHALMOLOGY: Eyes were examined most recently on
[**11-18**] revealing immaturity of the retinal vessels
but no ROP with immature zone 2 bilaterally. A follow-up
appointment by a pediatric ophthalmologist should be
scheduled for 9 months of age.
CONDITION ON DISCHARGE: Excellent.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: [**First Name11 (Name Pattern1) 72881**] [**Last Name (NamePattern4) 75313**], M.D.
at [**Hospital 1426**] Pediatrics, phone number ([**Telephone/Fax (1) 56268**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: Please continue breast milk 24 kcal
made with Enfamil powder as per recipe given to the
parents.
2. Medications:
a. Goldline baby multivitamin 1 cc p.o. q. day.
b. Ferrous Sulfate 4 mg/kg/D which is 0.4 mL p.o. q.
day of 25 mg/mL concentration.
3. Iron and vitamin D supplementation:
a. Iron supplementation is recommended for preterm
and low birthweight infants until 12 months corrected
age.
b. All infants fed predominantly breast milk should
receive Vitamin D supplementation at 200 international
unit (may be provided as a multivitamin preparation)
daily until 12 months corrected age.
4. Car seat position screening was done which the baby
passed prior to discharge.
5. State newborn screening were sent on [**2194-11-5**] and [**2194-11-16**].
6. Immunizations received: Secondary to mom's hepatitis B
surface antigen positivity, baby was given HBIG on
[**2194-11-2**]. She also received hepatitis B
vaccination at the same time on [**2194-11-2**] with repeat
dose on [**2194-12-1**]. She will still need two more doses of
Hepatitis B vaccine.
7. Immunizations recommended:
a. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criteria: 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 lungs disease; or
4) hemodynamically significant congenital heart
disease.
b. Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of
age. Before this age (and for the first 24 months of
the child's life), immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
c. This infant has not received rotavirus vaccine.
The American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable and at least 6 weeks but fewer than 12 weeks of
age.
8. Follow-up appointments scheduled/recommended:
a. Baby will have follow-up with pediatrician within
two days of discharge.
b. Baby needs follow-up appointment with Pediatric
Ophthalmology at nine months of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 33 2/7 weeks.
2. Rule out sepsis, resolved.
3. Patent ductus arteriosus treated with Indocin.
4. Hyperbilirubinemia, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) **]
Dictated By:[**Last Name (NamePattern1) 69933**]
MEDQUIST36
D: [**2194-12-1**] 14:30:24
T: [**2194-12-1**] 16:09:16
Job#: [**Job Number 75314**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7689
} | Medical Text: Admission Date: [**2112-5-8**] Discharge Date: [**2112-5-11**]
Date of Birth: [**2074-10-30**] Sex: M
Service: MICU/GENERAL MEDICINE, [**Location (un) **] FIRM
CHIEF COMPLAINT: DKA.
HISTORY OF THE PRESENT ILLNESS: This is a 37-year-old
gentleman with a history of Hodgkin's disease, status post
XRT and chemotherapy, also with hypercholesterolemia who
presented with new onset DKA. The patient was in his usual
state of health until two weeks prior to the date of
admission when he began experiencing increasing thirst,
polyuria, weight loss, decreased appetite, and blurry vision
for one week. Over the past three days before the day of
admission, the patient also noted increased fatigue which
brought him to the Emergency Department. The patient denied
any intercurrent illness. The patient denied any fevers,
chills, nausea, vomiting, diarrhea, constipation, or swollen
extremities.
In the Emergency Department, the patient was noted to have a
blood sugar of 1,349, also positive anion gap and ketones in
his urine. He was given IV fluids with normal saline, 10
units of IV insulin, and was then started on IV insulin at 6
units an hour before being transferred to the MICU.
PAST MEDICAL HISTORY:
1. Hodgkin's disease in [**2100**], status post chemotherapy and
XRT.
2. Hypercholesterolemia.
3. Obesity.
4. Transaminitis.
5. Palpitations.
ALLERGIES: Contrast dye gives him hives.
ADMISSION MEDICATIONS:
1. Ventolin p.r.n.
2. Claritin p.r.n.
SOCIAL HISTORY: He is happily married. He works as a web
designer and is a musician.
FAMILY HISTORY: The patient's father had CAD and CABG. No
diabetes.
HABITS: He denied any tobacco use. He drinks alcohol very
occasionally and denied any drug use.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
96.4, blood pressure 133/87, pulse 114, oxygen saturation 97%
at room air, respiratory rate 18. General appearance: The
patient was a very pleasant male in no acute distress.
HEENT: Anicteric. The oropharynx was clear. PERRL.
Cardiovascular: Tachycardiac, S1, S2, no rubs, murmurs, or
gallops. Lungs: Clear to auscultation bilaterally.
Abdomen: Obese, soft, nontender, nondistended, with active
bowel sounds. Extremities: No clubbing, cyanosis or edema.
Neurologic: Alert and oriented times three, mentating well.
LABORATORY ON PRESENTATION: CBC revealed a white count of
16.6, hematocrit 48.4, platelets 319,000. Differential:
Polys 87, lymphs 9, monos 3.6, eos 0.2, basophils 0.3.
Chem-7 initially 123, 6.2, 79, 20, 24, 1.5, 1352. Acetone
1GD. U/A: Negative blood. Negative nitrates. Negative
protein, 1,000 glucose, 15 ketones, negative bilirubin.
Otherwise unremarkable.
HOSPITAL COURSE: The patient is a 37-year-old gentleman with
a past medical history of Hodgkin's disease,
hypercholesterolemia, obesity, and transaminitis, who
presented with new onset DKA and diabetes. He had no
previous history of diabetes, however, he had obesity and
hypercholesterolemia which could suggest that his diabetes is
either type 1 or 2. The diabetic ketoacidosis resolved with
an insulin drip and IV fluids. The patient was then started
on subcutaneous insulin. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was called and
they recommended the following subcutaneous insulin dose
which the patient will be discharged on. These will be
listed in the medications on discharge.
Since the patient was now diagnosed with diabetes, he was
also started on an aspirin a day and an ACE inhibitor.
HYPERTENSION: During his hospital stay, the patient was
noted to have hypertension with a blood pressure ranging to
140-160/70-80. He was, therefore, started on an ACE
inhibitor which would have been started anyway because of his
diagnosis of diabetes and the ACE inhibitor which was
lisinopril was eventually increased to 5 mg p.o. q.d. at
discharge.
DISCHARGE DIAGNOSIS:
1. Diabetic ketoacidosis.
2. Diabetes type 1.
3. Hodgkin's disease in [**2100**], status post chemotherapy and
XRT.
4. Hypercholesterolemia.
5. Obesity.
6. Transaminitis.
7. Palpitations.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home.
FOLLOW-UP: The patient is now in the process of calling
[**Last Name (un) **] to make a follow-up appointment with Dr. [**Last Name (STitle) **] who
is the endocrinologist who saw him here. The date of that
follow-up appointment as suggested by Dr. [**Last Name (STitle) **] should be
[**2112-5-18**] at 2:00 p.m. The patient also received teaching
today and will schedule teaching at the [**Last Name (un) **] by taking the
following classes; What can I eat and my weight?
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Lisinopril 5 mg p.o. q.d.
3. Insulin, Glargine 40 units p.o. q. bedtime, Humalog
sliding scale if fingersticks 50, 1-100; breakfast OJ plus 10
units; lunch OJ plus 8 units; dinner OJ plus 8 units; if
fingersticks 101-150, breakfast 10 units; lunch 10 units;
dinner 10 units; bedtime nothing; if fingerstick 151-200,
breakfast 14 units; lunch 12 units; dinner 12 units; bedtime
nothing; if fingerstick 200-250, breakfast 16 units; lunch 14
units; dinner 14 units; bedtime 2 units; if fingerstick
251-300, breakfast 18 units; lunch 16 units; dinner 16 units;
bedtime 4 units; if fingerstick is 300-400, breakfast 20
units; lunch 18 units; dinner 18 units; and bedtime 6 units.
The patient will also make a follow-up appointment with his
new primary care physician, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 6071**]
MEDQUIST36
D: [**2112-5-11**] 10:48
T: [**2112-5-14**] 09:39
JOB#: [**Job Number 95466**]
cc:[**Last Name (NamePattern1) **]
ICD9 Codes: 2761, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7690
} | Medical Text: Admission Date: [**2106-1-5**] Discharge Date: [**2106-1-8**]
Date of Birth: Sex: M
Service: MED ICU
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: This is a 78 year old gentleman
with a history of alcohol abuse, non-insulin dependent
diabetes mellitus, colonic polyps and hypertension, who
presented to an outside Hospital on [**1-4**], with four
episodes of bright red blood per rectum at home. His
hematocrit was found to be 29 and after transfusion with two
units of packed red blood cells, elevated to 31. The patient
had an additional 1.5 liters of bright red blood per rectum
with syncope and flipped T waves. He ruled out for
myocardial infarction by enzymes, but was transferred to [**Hospital1 1444**] for packed red blood cells
scan. Coagulation studies and liver function tests were
normal at the outside hospital except for an albumin of 2.6
and his EKG demonstrated right bundle branch block, ST
depressions in V2 through V4 and inferior T wave inversions
which are questionably old, by report.
The patient takes a baby aspirin every day; no other NSAIDS.
Drinks a bottle of wine per day, and did eat significant
peanuts the day prior to admission.
No nausea or diaphoresis. No chest pain, abdominal pain or
emesis. Prior bright red blood per rectum eight years ago
and a prior work-up demonstrated a polyp. No known history
of diverticula, no melena, weight loss, fever or cachexia.
PAST MEDICAL HISTORY:
1. Alcohol abuse.
2. Non-insulin dependent diabetes mellitus.
3. History of colonic polyps.
4. Hypertension.
5. Status post transurethral resection of the prostate.
MEDICATIONS:
1. Aspirin 81 mg p.o. q. day.
2. Glucotrol 5 mg p.o. q. day.
3. "blood pressure medications", unknown to the patient at
the time of the admission.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Drinks one bottle of wine a day; denies
alcohol. Has a 40 pack year history discontinued about 18
years prior to admission. He is a retired pilot, married,
lives with wife. Denies any history of withdrawal symptoms
or delirium tremens.
FAMILY HISTORY: Positive for coronary artery disease.
Father with myocardial infarction at 50 years of age. No
diabetes mellitus or cancer in the family.
PHYSICAL EXAMINATION: On admission, temperature 100.1 F.;
pulse 101, blood pressure 139/74; respiratory rate 16; 97% on
room air. Weight 76.2. In general, this is an older
gentleman in no acute distress. Pupils equally round and
reactive to light and accommodation. Extraocular muscles are
intact. Question of slight icterus. Mucous membranes pink
and moist. Neck: Shotty bilateral lymphadenopathy. Plus
one bilateral carotids. Jugular venous pressure at 6 cm.
Heart: Regular rate and rhythm, normal S1, S2. Lungs are
clear to auscultation bilaterally. Abdomen soft, nontender,
nondistended, positive bowel sounds. No hepatosplenomegaly
or masses. Rectal examination with bright red blood; no
fissures or hemorrhoids appreciated. Extremities with no
cyanosis, clubbing or edema. Plus one dorsalis pedis pulses
bilaterally. No palmar erythema. Neurologic: Alert and
oriented times three. Cranial nerves II through XII intact.
No asterixis noted.
LABORATORY: Significant labs on admission: White blood cell
count 11.9, hematocrit 24.1, CK 45, 11, troponin 0.2.
Creatinine 1.4, chloride 97, calcium 8.7.
Chest x-ray with no obvious infiltrate, positive vascular
redistribution.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for observation and red blood cell scan.
1. Gastrointestinal: Packed red blood cell scan was
negative. The patient continued to have a small amount of
bright red blood per rectum and a hematocrit dropping down to
22. He underwent colonoscopy on [**1-6**], which
demonstrated multiple diverticula in his sigmoid and
ascending colon, Grade II internal hemorrhoids, and polyps in
the cecum and sigmoid colon which were nonbleeding and
ranging in size from 3 to 5 mm.
He was begun on Protonix 40 mg p.o. twice a day, decreased to
40 mg p.o. q. day. He underwent transfusion of two units of
packed red blood cells and his hematocrit upon discharge was
stable at 30.9. He had no further bleeding at the time of
discharge.
2. Cardiac: The patient with some flipped T waves upon
presentation at outside hospital which subsequently
reflipped. The patient ruled out for cardiac event by
enzymes but will need follow-up stress testing.
3. Neurologic: The patient did not demonstrate any signs of
withdrawal. He was on a CIWA scale.
4. Endocrinology: Non-insulin dependent diabetes mellitus
was on regular insulin sliding scale with four times a day
fingerstick blood sugars. No issues.
DISPOSITION: The patient was discharged to home.
DISCHARGE INSTRUCTIONS:
1. Will follow-up for Stress Test as an outpatient.
2. Will continue taking Protonix 40 mg p.o. q. day
indefinitely.
3. Will follow-up with primary care physician in three to
four weeks.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q. day.
2. Thiamine.
3. Folate.
4. Colace 100 mg p.o. twice a day.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 20**] 12-650
Dictated By:[**Last Name (NamePattern1) 19212**]
MEDQUIST36
D: [**2106-5-3**] 11:01
T: [**2106-5-4**] 10:22
JOB#: [**Job Number 61597**]
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7691
} | Medical Text: Admission Date: [**2182-1-23**] Discharge Date: [**2182-1-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2182-1-24**]
History of Present Illness:
Mr. [**Known lastname 104620**] is an 89 yo M with HTN, HLD, DMII, moderate AS (valve
area 1.0 cm^2) and CKD who presented with worsening chest pain,
and admitted for elective cardiac cath. Please see Dr. [**Initials (NamePattern4) 104621**] [**Last Name (NamePattern4) 196**] admission note for full details. In brief,
patient noted worsening exertional chest discomfort over the
past few months, with decreased exercise tolerance (unable to
walk ?????? mile without chest pain, and less resolution with rest).
He had a TTE with mildly depressed EF (50%) in [**6-26**], and an
exercise stress test showing a mild, fixed inferior wall defect
and global mild hypokinesis with a calculated left ventricular
ejection fraction is 46 %. As a result of his symptoms and the
above test results, he was admitted to [**Hospital1 18**] on [**2182-1-23**] for
pre-cath hydration prior to elective cardiac catherization.
.
In the cath lab today, patient received total fentanyl 82.5 mg
IV and midazolam 2 mg IV. Right and left heart cardiac
catherization was performed. Left heart cath revealed 2VD, with
a heavily calcified LAD 80% proximal, 90% serial mid, and 70%
distal disease, LCx 40% proximal stenosis and a 60% stenosis of
the ramus, and moderate aortic stenosis. Right heart cath
revealed both elevated left and right sided pressures. Rotablade
was performed on the LAD (2 more proximal lesions followed by
angioplasty). However, at that point, patient became confused,
stated his back was hurting and tried to move off of the cath
table despite requests to stay down, and contaminated the groin
site with his hand. At that point, the cardiac catherization was
stopped (no intervention on the distal lesion). He received 10
mg IV haldol total and 20 mg IV lasix, while in the cath lab.
Urine output unable to be measured due to condom cath being
pulled off by patient. An angioseal was placed for arterial
closure. He was started on integrillin and transferred to the
CCU for closer monitering.
.
In the CCU, he continued to be confused, and attempted to sit up
in bed despite having a venous sheath, and pull on his lines. He
received an extra 5 mg of IV haldol and was placed in 4 point
wrist restraints. He was able to follow most commands, but
unable to answer any review of systems.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Anemia
Chronic Kidney Disease (Baseline Cre 2.1)
Gout
Social History:
Patient was born in [**Country 4754**], moved to the US in [**2125**]. Worked in
construction as a labor foreman. Married x 54 years, with 3
children and 9 grandchildren. Denies tobacco or illicit drug
use. Occasional EtOH use
Family History:
No know FH of cardiac disease, diabetes, no colon/proste/breast
cancer. Parents lived to 70s to 80s with no known medical
problems. Children in good health.
Physical Exam:
VS: T= afebrile BP= 133/59 HR= 75% RR=15 O2 sat= 95% on RA
GENERAL: agitated gentleman attempting to get out of bed and
pulling at lines.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6 cm.
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: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AOX1 ('[**Known firstname **]', but unable to state location or date).
Unable to concentrate (cannot spell 'world' backwards). CN exam
limited due to inability to follow most fine commands, but no
gross deficiencies noted in [**3-1**]. squeezes both hands on
commands, dorsiflexes and plantar flexes feet on command.
appropriate gross sensation and proprioception on both arms and
legs. downgoing Babinski bilaterally. 1+ symmetric reflexes in
biceps and achilles tendons. unable to assess cerebellar
function or gait due to wrist restraints.
.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
===================
ADMISSION LABS:
===================
[**2182-1-24**] 05:55AM BLOOD WBC-6.0 RBC-3.00* Hgb-10.1* Hct-29.9*
MCV-100* MCH-33.6* MCHC-33.6 RDW-13.0 Plt Ct-224
[**2182-1-24**] 05:55AM BLOOD PT-14.7* PTT-31.4 INR(PT)-1.3*
[**2182-1-24**] 05:55AM BLOOD PT-14.7* PTT-31.4 INR(PT)-1.3*
[**2182-1-24**] 05:55AM BLOOD Glucose-77 UreaN-52* Creat-2.3* Na-138
K-5.2* Cl-108 HCO3-24 AnGap-11
[**2182-1-24**] 05:30PM BLOOD CK(CPK)-152
[**2182-1-24**] 05:55AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.1 Cholest-141
[**2182-1-24**] 05:55AM BLOOD Triglyc-111 HDL-27 CHOL/HD-5.2 LDLcalc-92
[**2182-1-25**] 03:09PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029
[**2182-1-25**] 03:09PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2182-1-25**] 03:09PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
[**2182-1-25**] 03:09PM URINE CastGr-1*
====================
DISCHARGE LABS:
====================
[**2182-1-28**] 05:20AM BLOOD WBC-7.4 RBC-2.77* Hgb-9.2* Hct-27.7*
MCV-100* MCH-33.2* MCHC-33.2 RDW-12.9 Plt Ct-214
[**2182-1-28**] 05:20AM BLOOD Glucose-149* UreaN-75* Creat-2.4* Na-138
K-5.0 Cl-106 HCO3-23 AnGap-14
[**2182-1-27**] 05:45AM BLOOD Calcium-8.4 Phos-4.9* Mg-2.2
.
====================
IMAGING/PROCEDURES:
====================
CARDIAC CATH [**2182-1-24**]:
1. Coronary angiography in this left dominant system
demonstrated two
vessel disease. The LMCA had no angiographically apparent
disease. The
LAD was diffusely calcified with a proximal 80% stenosis, 90%
mid
stenosis, and 70% distal stenosis. The LCx had a 40% proximal
stenosis
and a 60% stenosis of the ramus. The RCA was nondominant and had
no
angiographically apparent disease.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP 18mmHg and LVEDP 21mmHg. There was moderate
pulmonary arterial hypertension with PASP 61mmHg. The cardiac
index was
preserved at 2.33 L/min/m2. The SVR was normal at 1300
dynes-sec/cm5.
The systemic arterial blood pressure was normal with SBP 132mmHg
and DBP
63mmHg.
3. There was moderate aortic stenosis with valve area of 1.0cm2
with
mean gradient of 24.3mmHg.
4. Successful rotational atherectomy (1.5mm burr) and PTCA
(2.5mm
balloon) of the proximal and mid LAD.
5. Successful closure of the right femoral arteriotomy site with
a 6F
Angioseal device.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Serial LAD stenoses.
3. Moderate aortic stenosis.
4. Successful atherectomy and PTCA of the proximal and mid LAD.
.
CXR [**2182-1-26**]:The heart size is moderately enlarged, similar
compared to prior, and there are bilateral pleural effusions
with volume loss in both lower lobes. There is pulmonary
vascular re-distribution, but there is less
perihilar haze compared to prior. There is volume
loss/infiltrate in both
lower lobes.
IMPRESSION: Continued but slightly improved CHF.
Brief Hospital Course:
89 yo M with multiple CAD risk factors admitted for elective
cardiac cath for symptoms of unstable angina and mild systolic
dysfunction on TTE, found to have 2 vessel disease(including
severe LAD disease) and moderate aortic stenosis.
.
# CORONARIES: The patient has multiple risk factors for CAD
including HTN, HLD, DM, CKD. He was directly admitted for
cardiac catheterization because of a reversible defect seen on
stress testing. Cardiac catheterization showed 3 tight LAD
lesions and a 40% LCx stenosis. Only 2 of 3 LAD lesions were
intervened on, when the patient became agitated and the
procedure was terminated with the patient sent to the CCU for
close monitoring. He received integrilin post-procedure, and
was maintained on aspirin, plavix, high dose statin and
metoprolol. Additionally, he completed a three day course of
Cefazolin because of contamination of the groin site during the
procedure secondary to the patient's agitation.
.
# Delerium: Peri-procedure, the patient exhibited symptoms of
delerium including difficulty with concentration. The patient's
neurologic exam was non-focal, and the CCU team felt the
delerium was multifactorial in the setting of medication effect
(benzodiazepines given peri-procedure), especially given CKD
with decreased medication clearance, age and lack of sleep in
the hospital prior to procedure. He received haldol with good
effect and the delerium resolved completely prior to discharge.
.
# PUMP: At admission, the patient had no signs or symptoms of
CHF. However, he received prehydration with normal saline and
bicarbonate infusions. During cardiac catheterisation, he was
found to have elevated right and left sided pressures consistent
with systolic and diastolic dysfunction. Additionally, he was
found to have moderate aortic stenosis (aortic valve area 1.0
cm^2, mean gradient 24 mm Hg) with symptoms of [**2-20**] in the AS
triad (angina, CHF). He was diuresed with low dose IV lasix,
with good effect. He was continued on metoprolol, and
lisinopril held secondary to acute renal failure.
.
# RHYTHM: The patient remained in sinus rhythm throughout the
hospital stay, with PR prolongation seen on ECG. He was
continued on metoprolol.
.
# Diabetes Mellitus: The patient's oral hypoglycemics were held
while in-house, and he was maintained on a regular insulin
sliding scale.
.
# Chronic Kidney Disease: Patient with Stage IV CKD, w/ Cre
clearance of 23. He received pre-cath hydration and IV mucomyst
before and after catherization. His creatinine rose after cath
to a peak of 2.9, and then began to decline. Lisinopril was
held for several days prior to hospitalization, and he was
instructed to continue to hold this medication until being
evaluated by his primary care physician.
.
# Hyperkalemia: The patient's potassium was elevated to 5.9 in
the CCU, likely secondary to Acute on chronic renal failure
after contrast load. He received kayexalate, insulin and D5 and
had no ECG changes. His potassium remained stable thereafter.
.
# HTN: Lisinopril was held, and the patient continued on
metoprolol.
# Deconditioning: The patient was evaluated by physical therapy
prior to discharge, who recommended VNA services with a home
physical therapy regimen. .
.
Medications on Admission:
Lisinopril 40mg daily (on hold for past 2 days)
Glipizide 10mg daily
Actos 15mg daily
ASA 81mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Final Diagnoses:
Coronary Artery Disease
Hypertension
Diabetes Mellitus type 2
Chronic Kidney Disease
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You have a history of progressive chest dyscomfort with exertion
and were admitted for a cardiac catheterization to evaluate for
coronary artery disease. You were admitted the night prior to
the procedure in order to give you intravenous hydration to
protect your kidneys from the dye involved in the procedure.
You underwent Cardiac Catheterization on [**2182-1-24**], which showed
narrowing of two of your coronary arteries. You became confused
and agitated during the procedure, which we think was likely
because of sedating medications.
We made the following changes to your medications:
- START plavix: this is a medication to help prevent blockages
in your coronary arteries
- START metoprolol: this medication treats your elevated blood
pressure
- START Atorvastatin: This is a medication to treat your
elevated cholesterol, and helps to prevent blockages in your
coronary arteries
- STOP your lisinopril until you see your PCP at the end of the
week. This medication was stopped prior to the catheterization
to help protect your kidneys. Your PCP may choose to restart
this medication after checking your kidney function at your next
visit.
.
We did not make any further changes to your home medications.
Please take all medications as prescribed.
Followup Instructions:
You have a follow-up appointment with your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**], MD
on Friday [**2182-2-1**] 1:15 PM. Tel: [**Telephone/Fax (1) 133**]
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2182-3-7**] 1:20
ICD9 Codes: 4111, 2930, 4280, 4241, 2767, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7692
} | Medical Text: Admission Date: [**2180-2-12**] Discharge Date: [**2180-2-14**]
Date of Birth: [**2114-6-28**] Sex: M
Service: MEDICINE
Allergies:
Streptomycin / Beeswax
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
SOB, hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 79233**] is a 65 year old gentleman with a history of
esophageal cancer s/p XRT and chemo, chylothorax s/p pleurex
catheter placement, and UE DVTs on lovenox who was transferred
from an OSH to cardiac floors at [**Hospital1 18**] for SOB, enlarging
pleural effusion, and rising troponins. Upon arrival [**2180-2-12**],
patient's SOB was thought to be multifactorial with potential
etiologies considered including CHF, enlarging pleural effusion,
pneumonia, and PEs although on lovenox. His cardiac enzymes were
not felt to be consistent with an NSTEMI as his CKs were not
significantly elevated. In addition to hypoxia, SOB, and
troponin elevation, patient was also found to have
transaminitis, ARF, thrombocytopenia, leukocytosis, and severe
hyponatremia. His clinical status deteriorated on the floor and
he was transferred to the MICU. The day following presentation
to [**Hospital1 18**], family meeting held with MICU team and patient was
made DNR/DNI, CMO. All lab draws and vitals checks were
discontinued. He was started on morphine gtt. His Oncologist
Dr. [**Last Name (STitle) **] has been following and palliative care has been
consulted. Plan for inpatient hospice.
.
Upon evaluation, patient is easily arousable and appears
comfortable. He denies any current SOB. He notes mild pain in
his buttocks. He is otherwise without complaint.
Past Medical History:
- Esophageal Cancer: Diagnosed in [**9-16**]. Stage T2 N1 M1a. Now s/p
2 cycles of cisplatin/5FU and and XRT (most recently [**11-16**]) with
f/u PET [**2180-1-3**] with spread of cancer to multiple lymph nodes
and bony sites. Recently admitted from [**1-26**] to [**1-31**]
- Chylothorax diagnosed [**1-16**] s/p Pleur X catheter placement
- R subclavian DVT (diagnosed [**10-17**]) and L IJ DVT (diagnosed
[**1-16**]) now on lovenox
- Hypertension
- GERD
- Osteoarthritis s/p bilateral hip replacement in [**9-16**]
- Ruptured he urethra during trauma at age 8
- Bilateral hernia repairs
- History of a finger fracture status post pinning
- R common iliac aneurysm seen on PET [**9-16**]
- s/p J-tube placement prior to chemo/XRT
Social History:
Pt smoked 1 pack per day for 20 yrs quitting 20 yrs ago. Mild
use of alcohol as per wife. [**Name (NI) **] illicit drug use. Physically
very active until few months ago.
Family History:
Parents both alive in their 90s with no cardic dz. Pt is retired
electrical engineer.
Physical Exam:
No vitals checked as CMO
chronically ill appearing, cachectic male, asleep, appears
comfortable.
diffuse anasarca
stage 2 decubitus ulcers at gluteal fold
Pertinent Results:
CT [**2-12**]:
1. Left Pleurx catheter now coursing anteriorly and terminating
superomedially. Posteriorly layering left small-to-moderate
pleural effusion is not substantially larger.
2. Substantial increase in right pleural effusion, previously
tiny on
[**2180-1-27**], currently moderate.
3. Increase in extent of interstitial thickening with small
centrilobular nodular opacities concerning for lymphangitic
spread of carcinomatosis rather than pulmonary edema.
Mediastinal lymph nodes not substantially changed.
4. Increase in size of largest liver lesion and suggestion of
increased extent of multiple liver lesions incompletely
characterized on this non-enhanced study.
5. New ascites. New stranding and nodularity within the
mesenteric fat concerning for peritoneal deposit of metastatic
disease.
[**2180-2-12**] 06:00PM BLOOD WBC-16.2*# RBC-3.17* Hgb-10.3* Hct-29.4*
MCV-93 MCH-32.4* MCHC-34.9 RDW-16.2* Plt Ct-68*#
[**2180-2-13**] 06:49AM BLOOD WBC-17.1* RBC-2.98* Hgb-10.0* Hct-27.8*
MCV-93 MCH-33.7* MCHC-36.1* RDW-16.5* Plt Ct-61*
[**2180-2-12**] 06:00PM BLOOD Neuts-94.6* Bands-0 Lymphs-1.9* Monos-2.6
Eos-0.8 Baso-0
[**2180-2-13**] 06:49AM BLOOD Neuts-94.9* Lymphs-1.4* Monos-2.2 Eos-1.5
Baso-0.1
[**2180-2-12**] 06:00PM BLOOD PT-15.8* PTT-41.1* INR(PT)-1.4*
[**2180-2-13**] 06:49AM BLOOD PT-15.7* PTT-36.2* INR(PT)-1.4*
[**2180-2-12**] 06:00PM BLOOD Glucose-128* UreaN-62* Creat-1.3* Na-122*
K-3.9 Cl-82* HCO3-27 AnGap-17
[**2180-2-13**] 06:49AM BLOOD Glucose-110* UreaN-64* Creat-1.4* Na-125*
K-4.0 Cl-86* HCO3-28 AnGap-15
[**2180-2-12**] 06:00PM BLOOD ALT-115* AST-169* CK(CPK)-93 AlkPhos-344*
TotBili-1.0
[**2180-2-13**] 06:49AM BLOOD ALT-102* AST-132* LD(LDH)-276* CK(CPK)-90
AlkPhos-309* TotBili-1.0
[**2180-2-12**] 06:00PM BLOOD CK-MB-NotDone cTropnT-0.44* proBNP-2650*
[**2180-2-13**] 06:49AM BLOOD CK-MB-NotDone cTropnT-0.49*
[**2180-2-12**] 06:00PM BLOOD Albumin-2.6* Calcium-7.9* Phos-4.0 Mg-2.0
[**2180-2-13**] 06:49AM BLOOD Albumin-2.4* Calcium-7.7* Phos-4.4 Mg-1.9
[**2180-2-12**] 07:56PM BLOOD Type-ART pO2-111* pCO2-37 pH-7.50*
calTCO2-30 Base XS-5
[**2180-2-12**] 07:56PM BLOOD Lactate-2.6* Na-119*
Brief Hospital Course:
65 year old gentleman with a history of esophageal cancer s/p
XRT and chemo, chylothorax s/p pleurex catheter placement, and
UE DVTs on lovenox who was transferred for SOB/hypoxia now
transitioned to comfort measures only. He was maintained on
morphine drip with boluses as needed for comfort. He received
supplemental O2 for shortness of breath. He was prescribed
lorazepam boluss prn for anxiety or agitation. All unnecessary
vital sign checks were stopped. Lab draws were discontinued. All
unncessary medications were stopped. The patient died [**2180-2-14**].
Medications on Admission:
Enoxaparin 90 mg [**Hospital1 **]
Clonazepam 0.5 mg [**Hospital1 **]
Pantoprazole 40 mg daily
Senna 1 tab daily
Oxycodone 5-10 mg Q4H:PRN
Colace 100 mg [**Hospital1 **]
Oxycodone SR 20 mg [**Hospital1 **]
Lasix 10 mg IV Q12H
Odansetron 4 mg IV Q8H:PRN
Milk of Magnesium 10 mL daily:PRN
Maalox 30 mL PO Q2-4H:PRN
Tylenol 650 mg PO Q4-6H:PRN
Nitroglycerin PRN
Aspirin 325 mg PO daily
Metoprolol 12.5 mg PO BID
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 5849, 2761, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7693
} | Medical Text: Admission Date: [**2180-4-18**] Discharge Date: [**2180-4-20**]
Date of Birth: [**2139-10-31**] Sex: F
Service: Trauma surgery
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 93857**] is a 40 year-old
female with a history of alcohol and cocaine abuse who
presented to the emergency department approximately one day
after a fall with noticeable with left side ear and head
trauma from either seizure like activity versus an assault.
The patient was initially vague regarding the etiology of
this trauma and refused to answer direct questions regarding
the event. She was complaining of left head and ear pain
with obvious bloody discharge from the left ear canal. She
was brought into the emergency department via ambulance, was
evaluated in the Emergency Room and refused further work up
including computer tomography scan of the head. She was
approximately 12 hours into her course when the scan was
finally completed with the results listed below at which
point the trauma surgery service was asked to evaluate the
patient. At this time the patient complained solely of left
head pain. Denied nausea, vomiting, diplopia, paresthesias
or other cranial nerve signs or symptoms.
PAST MEDICAL HISTORY: Significant for bipolar disorder,
hepatitis C, alcoholic pancreatitis, asthma, hypothyroidism.
PAST SURGICAL HISTORY: Significant for bilateral ureteral
reimplants times two.
SOCIAL HISTORY: Significant for as above alcohol and cocaine
abuse, tobacco use and history of multiple assaults.
ALLERGIES: To penicillin and sulfa.
MEDICATIONS: Include Trileptal 600 b.i.d., Clonidine 0.1 mg
t.i.d., trazodone 300 mg q.h.s., Ativan p.r.n., Levoxyl 0.88
q.d., Protonix 40 mg p.o. q.d.
PHYSICAL EXAMINATION: Neurologic: GCS of 15, alert and
oriented times three. Following all commands, moving all
extremities with full sensory intact. HEENT: pupils equal,
round, reactive to light, 4 to 5 bilaterally, extraocular
movements intact. Bilateral hemotympanum with blood in the
extra auditory canal on the left. Oropharynx was clear.
Cardiovascular examination: Regular rate and rhythm.
Respiratory clear to auscultation bilaterally. Chest without
deformities or tenderness. Abdomen soft, nontender,
nondistended. Pelvis stable. Back and TLS spine without
deformities, step offs of tenderness. C spine without
deformities, step offs or tenderness. Rectal examination
deferred per patient request. Extremities without obvious
deformity, laceration or other injury. Pulses 2+ bilateral
upper and lower extremity.
DIAGNOSTIC STUDIES: On admission include white count of 8,
hematocrit of 39, platelet of 245. Chemistries within normal
limits. Ethanol level 193 on admission. Coags within normal
limits. Radiologic studies: CT of the head revealed
pneumocephalic, left mastoid fracture nondisplaced. Left
occipital subdural hemorrhagic, left temporal hemorrhagic
contusions, left temporomandibular joint fracture. CT of the
C spine negative. Chest x-ray negative. Left elbow without
evidence of fracture. Repeat head CT on the 14th without
change of previously identified injuries. CT of the facial
bones: temporal bone fracture with extension to the
temporomandibular joint without joint disruption.
SUMMARY OF HOSPITAL COURSE: As previously mentioned the
patient was brought into the emergency department by
ambulance and was initially evaluated by the emergency
department staff, was alert and oriented times three refusing
further diagnostic evaluation. After approximately 10 to 12
hours in the emergency department the patient finally
consented to CT scan of the head which revealed the above
mentioned findings at which point the trauma surgery service
and the neurosurgery service were both asked to see the
patient. The patient was admitted to the Trauma Surgical
Intensive Care Unit and underwent q one hour neuro checks
during which time her blood pressure was maintained with the
systolic below 140 using the Nipride drip. Upon admission to
the Trauma Surgical Intensive Care Unit otolaryngology and
plastic surgery were both asked to evaluate the patient
regarding the bilateral hemotympanum and the potential
temporomandibular joint fracture respectively. The
oropharyngology consult placed a wick in the left ear with
otic microbial drops and recommended outpatient follow up
with audiogram. The plastic surgery service felt the above
mentioned radiographic findings and her clinical examination
were not indication for further intervention regarding her
potential temporomandibular joint fracture. On hospital day
two the patient received repeat head CT mentioned above that
was without significant change from prior study and the
neurosurgery service felt that her injuries were stable and
warranted outpatient neurosurgery follow up.
After extensive discussion with the patient's primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 410**], both social work and case management,
the neurosurgical consultation service, otolaryngology, the
[**Hospital1 69**] legal staff and physical
therapy, it was felt that this patient was safe for discharge
to home without services with follow up to be arranged as
described below. On the evening prior to discharge the
patient was transferred to the floor. The patient was
requesting to leave the hospital and was behaving in an
inappropriate manner at which time the Code Purple was
activated and the patient was re-evaluated by psychiatry.
The patient cooperated with the psychiatric examination, was
willingly given sedative in accordance to the CIWA scale and
was re-evaluated in the morning by the above mentioned
services. Upon re-evaluation by psychiatry medical service
was developed in her care and physical therapy, it again was
determined that the patient was safe for discharge and she
was discharged from the floor to home on hospital day three.
DISCHARGE INSTRUCTIONS: The patient was instructed to follow
up with her doctor or return to the Emergency Room for fever,
worsening headache, vomiting or any neuro concerning
symptoms. She was also instructed not to allow any water to
enter her left ear until appropriate otolaryngology follow
up.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
Alcohol intoxication.
Delirium.
Pneumocephalus.
Left occipital subdural hemorrhage.
Left mastoid fracture.
Bilateral hemotympanum.
Left temporal lobe hemorrhagic contusion.
DISCHARGE MEDICATIONS: The patient was to resume her usual
outpatient medications and in addition the patient was to
take ciprofloxacin 0.3 percent drops 3 drops to the left ear
b.i.d. times seven days, dispense 5 ml.
FOLLOW UP PLAN: The patient is to call Dr. [**Last Name (STitle) **] at [**Location (un) **]
Counseling, [**Numeric Identifier 93858**] for an appointment within one week.
Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] directly by the psychiatric service
here at the [**Hospital1 69**]. Patient is
to call neurosurgery for an appointment within two weeks at
[**Telephone/Fax (1) 1669**]. Patient is to call Dr. [**Last Name (STitle) 93859**] at
[**Telephone/Fax (1) 29891**] for an appointment for audiogram. Patient is to
contact Dr. [**Last Name (STitle) 410**], her primary care physician, [**Name10 (NameIs) **] an
appointment as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 10637**]
Dictated By:[**Name8 (MD) 28700**]
MEDQUIST36
D: [**2180-4-20**] 16:08
T: [**2180-4-22**] 19:10
JOB#: [**Job Number 93860**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7694
} | Medical Text: Admission Date: [**2102-11-23**] Discharge Date: [**2102-12-2**]
Date of Birth: [**2043-6-18**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Nonproductive cough
Major Surgical or Invasive Procedure:
Upper endoscopy
Colonoscopy
History of Present Illness:
59yo F with recent prolonged hospitalization for left arterial
embolic clot s/p thrombectomy with course complicated by PCP
pneumonia, new diagnosis of HIV/AIDS as well as occipital stroke
presenting with worsening nonproductive cough and new oxygen
requirement. Patient reports that she developed shortness of
breath and a nonproductive cough approximately 3 days ago. She
denies associated fever or chills. She reports lightheadedness
which is always present, not worse. She denies chest pain. She
reports that the cough is different than her raspy, productive
cough she had during her recent admission. She has been
coughing to the point of dry heaving. Patient was seen for
these symptoms by the [**Hospital3 **] physician today who was
concerned given her new oxygen requirement of 3-4L from baseline
of room air in addition to hypotension.
.
Patient was hospitalized from [**Date range (1) 91031**], initially admitted
with a cool left foot, found to have an arterial embolic clot
requiring thrombectomy and fasciotomy. Her hospital course was
complicated by hypotension and hypoxia requiring multiple
intubations, found to be due to PCP pneumonia for which she
completed a 21 day course of bactrim and steroids. She also had
a superimposed HCAP treated with vancomycin/zosyn for 8 days.
She was discharged on bactrim prophylaxis and a steroid taper
which was completed on [**2102-11-20**]. She was diagnosed with HIV
with a CD4 count of 11, and started on antiretrovirals prior to
discharge. In addition, she was found to have an occipital
stroke, thought to be embolic in nature. A TTE did not identify
a PFO. She had persistent diarrhea, which, in the setting of
CMV viremia, was presumed to be CMV colitis, for which she was
treated with IV gancyclovir (currently day 13).
.
Patient reports that since discharge from the hospital on [**11-15**]
to [**Hospital3 **] she has felt fine until three days ago. She
has had ongoing diarrhea approximately 3 times a day, not
improved with loperamide. She reports that she is barely
eating, mostly due to "stubbornness". She denies dysphagia or
odynophagia. She is drinking fluids frequently.
.
In the ED initial vitals were T 98.3 HR 80 BP 83/47 RR 18 O2Sat
97% 3L NC. Patient reported no acute symptoms. Patient was
given 2L of IVF and pressures increased to 97/50. She received
a dose of vancomycin and zosyn as well as dexamethasone for PCP
treatment, however patient did not receive bactrim. Labs were
notable for an INR of 11.46 and she was given 1U FFP. Given
hypotension, ED was concerned for RP bleed so a CT abd/pelvis
was performed which showed no evidence of a bleed.
.
On arrival to the ICU vital signs were BP 92/5o P 92, RR 24,
O2Sat 96% on 2LNC. When oxygen was turned off, patient desat'ed
to 91-92%.
Past Medical History:
# HIV/AIDS: diagnosed during last admission ([**2102-11-2**]), CD4
count 11
- HAART initiated on [**2102-11-13**] (Ritonavir, Darunavir,
Emtricitabine-Tenofovir), genotyping compatible with regimen
- CMV viremia, treating empirically for CMV colitis given
persistent diarrhea with IV ganciclovir x 21 days (day 1= [**11-10**]),
then transition to maintenance valgancyclovir
- on PCP/toxo prophylaxis with bactrim 1DS daily
- on [**Doctor First Name **] prophylaxis with azithromycin
# Occipital stroke([**11/2102**]): likely embolic, no evidence of PFO
on TTE
# Ischemic left foot s/p thrombectomy and fasciotomy d/t acute
arterial thrombus([**11/2102**])
# h/o pneumothorax ([**11/2102**]):complication of subclavian line
placement
# Depression
# Anxiety
Social History:
From [**Location (un) 5028**], MA. She is not married, but has had one
partner for the past 26 years who lives in the apartment above
her. She lives with a friend. She has been at [**Hospital3 **]
for the days in between discharge and this new admission.
- Tobacco: h/o 1ppd x 30 years, quit in [**2102-7-3**]
- Alcohol: denies
- Illicits: denies
Family History:
No history of lung or heart disease, no history of clotting
disorders
Physical Exam:
Admission exam:
Vitals: BP 92/50 P 92, RR 24, O2Sat 96% on 2LNC
General: Cachectic, alert female in NAD
HEENT: Pupils equal round, but sluggish to light. EOMI. MMM,
dentures on upper palate, with evidence of diffuse oral thrush.
No erythema or exudate
Neck: supple, JVP not elevated, no LAD
Lungs: Fine crackles throughout, more pronounced at bilateral
bases. No wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, nontender, nondistended. Well-healed scar
in left inguinal region
GU: foley in place draining clear urine, mild erythema in
vaginal area without skin breakdown
Rectal: erythema without skin breakdown
Ext: Left foot with dry gangrene of toes extending to MTP of all
toes, skin breakdown below areas of gangrene with areas of
superficial skin excoriation. No exudate or erythema. Left
calf with well healing scars from prior fasciotomy. No erythema
or swelling of bilateral legs. 2+ DP/PT pulses on right.
Discharge Exam:
VS: Tm Afebrile Tc HR 70-80s BP 100s-110s/70s RR 20
SaO2 95-96% RA I/O
GENERAL: [x] NAD [] Uncomfortable
Eyes: [x] anicteric [] PERRL
ENT: [x] MMM [] Oropharynx clear [] Hard of hearing
NECK: [] No LAD [] JVP:
CVS: [] RRR [] nl s1 s2 [] no MRG [] no edema
LUNGS: [x] No rales [x] No wheeze [x] comfortable
ABDOMEN: [x] Soft [x]nontender [x]bowel sounds present []No
hepatosplenomegaly
SKIN: [x]No rashes [x]warm []dry [] decubitus ulcers: Left foot
with black necrotic toes and distal foot. No evidence of
infection or pus. Incision left leg c/d/i
LYMPH: [] No cervical LAD []No axillary LAD [] No inguinal LAD
NEURO: [x] Oriented x3 [x] Fluent speech
Psych: [x] Alert [x] Calm [x] Mood/Affect: appropriate
Pertinent Results:
Admission Labs:
[**2102-11-23**] 03:20PM BLOOD WBC-7.0# RBC-2.62* Hgb-8.1* Hct-24.3*
MCV-93 MCH-30.8 MCHC-33.2 RDW-21.3* Plt Ct-299
[**2102-11-23**] 03:20PM BLOOD Neuts-97.0* Lymphs-2.1* Monos-0.3*
Eos-0.6 Baso-0.1
[**2102-11-23**] 03:20PM BLOOD PT-111.5* PTT-56.0* INR(PT)-11.49*
[**2102-11-23**] 03:20PM BLOOD Glucose-99 UreaN-19 Creat-0.6 Na-128*
K-3.9 Cl-98 HCO3-18* AnGap-16
[**2102-11-23**] 03:20PM BLOOD LD(LDH)-306*
[**2102-11-23**] 03:43PM BLOOD Lactate-2.0
[**2102-11-23**] 05:35PM BLOOD Lactate-1.0
Notable studies:
Microbiology:
[**11-23**] Blood cxs x2: no growth
[**11-23**] Urine cx: URINE CULTURE (Final [**2102-11-26**]):
YEAST. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**11-26**] C. diff toxin negative
[**11-26**] serum Cryptococcal Ag negative
[**11-26**] Toxoplasma IgG positive
[**11-27**] urine cx: no growth
[**11-28**] Stool OandP: Negative including no giardia or
cryptosporidium
[**11-28**] Stool OandP: Negative including no cyclospora or
microsporidium
[**11-29**] stool OandP: Negative
[**11-29**] HIV VL: 4,800 copies/ml
[**11-29**] blood cx: ngtd
Studies:
[**11-23**] CXR: IMPRESSION:
1. Worsening diffuse parenchymal opacities in the lungs
concerning for
worsening PCP. [**Name10 (NameIs) **] focal consolidation in the right lung base
may represent a secondary pneumonic process.
2. Previously noted small right apical pneumothorax is not
visualized on the current exam.
[**11-23**] Chest CT: IMPRESSION:
1. Diffuse bibasilar ground-glass opacities with consolidation
component in
the right lower lobe concerning for worsening of the patient's
known PCP.
2. No intraabdominal or retroperitoneal bleeding is seen.
[**11-24**] CXR: IMPRESSION: Interval worsening of PCP [**Name Initial (PRE) 1064**].
[**11-26**] Chest CT: IMPRESSION:
1. Extensive right lower lobe consolidation dramatically
improved since prior CT [**2102-11-7**].
2. Widespread PCP alveolitis also demonstrates improvement since
CT [**2102-11-7**].
3. 5 mm right upper lobe nodule.
[**12-1**] CXR: IMPRESSION:
1. Left PICC ends in the upper SVC, unchanged in position.
2. Improvement of multifocal opacities when compared to the
chest x-ray of
[**2102-11-24**].
Discharge Labs:
[**2102-12-2**] 05:59AM BLOOD WBC-6.5 RBC-3.76* Hgb-12.2 Hct-36.0
MCV-96 MCH-32.5* MCHC-33.9 RDW-19.2* Plt Ct-494*
[**2102-12-2**] 05:59AM BLOOD PT-10.3 PTT-53.1* INR(PT)-0.9
[**2102-11-24**] 01:13AM BLOOD WBC-4.7 Lymph-3* Abs [**Last Name (un) **]-141 CD3%-59 Abs
CD3-83* CD4%-20 Abs CD4-28* CD8%-40 Abs CD8-57* CD4/CD8-0.5*
[**2102-12-2**] 05:59AM BLOOD Glucose-94 UreaN-20 Creat-0.7 Na-133
K-4.8 Cl-98 HCO3-27 AnGap-13
Studies pending at discharge:
[**11-29**] CMV VL: pending
[**12-1**] CMV cx: pending
[**12-1**] Pathology from EGD biopsies
[**12-2**] H. pylori serology
Toxoplasma serologies
Brief Hospital Course:
59 y/o F with AIDS on HAART, recent PCP pneumonia, CMV viremia
with concern for CMV colitis, admitted with hypotension,
hypoxia, and cough along with worsening anemia and
supratherapeutic INR of 11. Hospital course was notable for
MICU admission followed by evaluation for malnutrition and
persistent diarrhea in addition to prolonged steroid course for
PCP [**Name Initial (PRE) 1064**].
#Hypoxia/PCP [**Name Initial (PRE) 1064**]/bacterial pneumonia/Hypotension:
Patient was initially admitted to MICU and initial imaging
suggested PCP pneumonia vs. health care associated bacterial
pneumonia. Patient was hypotensive and improved with IVF. She
was initially treated with Vancomycin/Zosyn as well as started
on treatment doses of Bactrim and restarted on steroids after
consultation with Infectious Disease for concern of recurrent
PCP [**Name Initial (PRE) 1064**]. Testing for adrenal insufficiency was negative.
Patient had rapid improvement in symptoms in 3 days and was
therefore felt less likely to have true PCP pneumonia or
bacterial pneumonia given the quick resolution of pulmonary
infiltrates. Antibiotics for HCAP were discontinued and patient
did well. It was felt however that pulmonary
inflammation/alveolitis may have been due to withdrawal of
steroids so patient was placed back on 40mg po of prednisone
with plan for slow taper over 4 weeks, dropping dose by 10mg
each week. Pt was changed to prophylactic dose Bactrim as well
as calcium and vitamin D while on prednisone.
#HIV/AIDS:
CD 4 count was 28 on [**2102-11-24**]. Patient was continued on MAC
prophylaxis with azithromycin and PCP [**Name9 (PRE) **] with 1 SS tab daily
Bactrim as above and should continue on PCP prophylaxis until
CD4 count stable >200. Pt was continued on Fluconazole
prophylaxis as well and continued on ART. VL during
hospitalization was 4,800.
#CMV colitis:
Patient was continued on IV gancyclovir for presumptive
treatment of CMV colitis. However, given that the patient's
symptoms never truly improved with IV Gancyclovir it is unclear
whether she did in fact have CMV colitis or rather AIDS
enteropathy. The patient had an EGD and biopsies of the stomach
and small bowel were taken. A flex sigmoidoscopy was attempted,
but the patient refused the prep and therefore biopsies and
adequate visualization could not be accomplished. Patient was
discharged to continue IV gancyclovir until her next outpatient
ID appointment.
#Vancomycin resistant urinary tract infection:
She grew VRE in a urine culture from her foley and she received
4 days of therapy for VRE (short course of daptomycin given that
she didn't have foley till admission) and her repeat UA/culture
improved and her foley was discontinued.
#Anemia/Gastritis:
Given the drop in hematocrit in the setting of a
supratherapeutic INR the patient had an EGD which showed
gastritis and recent bleeding. Biopsies were taken and H. pylori
serologies were sent and pending at time of discharge. The
patient was started on omeprazole for acute gastritis. A
colonoscopy was attempted but the patient refused the prep.
Therefore, she should have a repeat colonscopy after appropriate
prep in the next 4-6 weeks to fully evaluate for potential
bleeding sources. H. pylori serologies can be followed up by PCP
and treatment initiated if positive.
#Diarrhea:
She continued to have frequent diarrhea (non-bloody) which was
an active issue that was evaluated by GI at her last
hospitalization. At that time she had CMV viremia and was
emperically started on treatment with IV ganciclovir. She had
multiple stool studies negative for both parasites and c. diff
by toxin assay. C. diff PCR was negative this admission.
Ultimately, it was felt that the diarrhea was more likely to be
related to AIDS enteropathy than CMV colitis. Biopsies were
taken as above and decision on CMV therapy and course will be
determined at next outpatient ID appointment. CMV cx from
biopsies were pending at time of discharge.
#Arterial Thrombosis/Left foot ischemia/Left foot dry
gangrene/Recent occipital stroke:
Patient presented with supratherapeutic INR and was noted to be
very sensitive to Coumadin on last admit, most probably due to
her many medication interactions with Coumadin. Per review of
[**Hospital1 **] [**Hospital1 8**] notes patient had INR <2 for a number of
days, then one day at 2.4 then a value >3, then >4, then 11 on
day of admission, but the exact Coumadin dosing is unclear.
In-house this admit, patient was maintained on a heparin drip
when INR was <2. She was discharged on heparin drip to Coumadin
bridge at 1mg Coumadin/day. The Coumadin should be titrated at
rehab to goal INR [**1-5**] and care should be taken to keep INR
within range once it starts to approach 2. After discharge from
rehab, the patient's Coumadin will be managed by her new primary
care doctors [**First Name (Titles) **] [**Hospital6 **] Center (Drs. [**First Name8 (NamePattern2) **] [**Name (STitle) 14740**]
and [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **]) who were informed of the patient's admission
and discharge plan. Prior to discharge from rehab, communication
should take place with the patient's outpatient providers
([**Telephone/Fax (1) 798**]) to confirm that they will be following the INR
closely and make adjustments to Coumadin dosing as needed.
During hospitalization, Vascular Surgery service examined her
ischemic L foot with known dry gangrene and felt it did not look
infected. They recommended awaiting further demarcation of the
extent of necrosis prior to any elective amputation and the
patient will follow up in outpatient Vascular Surgery Clinic.
#CODE: FULL
#PPX: Heparin gtt bridge to Coumadin as above
#Disposition: Pt discharged to rehab to continue heparin bridge
to Coumadin with goal INR [**1-5**]. Pt will have outpatient fu with
ID and Vascular surgery within one week and will follow up with
PCP's at [**Hospital6 **] Center (Drs. [**Last Name (STitle) 14740**] and [**Name5 (PTitle) **])
who will follow up multiple medical issues including titration
and monitoring of Coumadin.
Medications on Admission:
# aripiprazole 1 mg/mL Solution 2mg po daily
# sertraline 150 mg PO DAILY
# warfarin 1 mg PO Daily, Goal INR [**1-5**].
# miconazole nitrate 2 % Cream [**Hospital1 **] as needed for ITCH/FUNGAL
RASH.
# lidocaine-prilocaine 2.5-2.5 % Cream [**Hospital1 **] as needed for pain.
# emtricitabine-tenofovir 200-300 mg PO DAILY
# darunavir 800 mg PO DAILY
# ritonavir 80 mg/mL 100mg PO DAILY
# sulfamethoxazole-trimethoprim 200-40 mg/5 mL Susp 10mL po
daily
# azithromycin 1200 mg PO 1X/WEEK (TU)
# ganciclovir sodium 300 mg IV Q12H
# loperamide 2 mg PO QID as needed for diarrhea.
# morphine 2 mg/mL 1-2 mg IV Q4H as needed for pain.
# ondansetron HCl (PF) 4 mg/2 mL IV Q8H (every 8 hours) as
needed for nausea: give 30 minutes before morning meds.
Discharge Medications:
1. warfarin 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
2. sertraline 50 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
3. aripiprazole 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. miconazole nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for itching.
5. emtricitabine-tenofovir 200-300 mg Tablet [**Hospital1 **]: One (1) Tablet
PO DAILY (Daily).
6. darunavir 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
7. ritonavir 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
8. azithromycin 600 mg Tablet [**Hospital1 **]: Two (2) Tablet PO 1X/WEEK
(TU).
9. ondansetron 4 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
10. loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
11. clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day) as needed for anxiety: hold for sedation, RR<10, MAP <55
.
12. insulin regular human 100 unit/mL Solution [**Hospital1 **]: as directed
units Injection ASDIR (AS DIRECTED): see printed sliding scale.
13. glucagon (human recombinant) 1 mg Recon Soln [**Hospital1 **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB.
15. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
16. prednisone 10 mg Tablet [**Hospital1 **]: tapered dose as directed Tablet
PO once a day for 24 days: Please give 40mg/day for 3 days
([**Date range (1) 90717**]/12), then 30mg/day for 7 days ([**Date range (1) 43505**]/12), then
20mg/day for 7 days (1/11-17/12), then 10mg for 7 days
([**Date range (1) 91032**]) .
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Date range (1) **]: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. warfarin 1 mg Tablet [**Date range (1) **]: One (1) Tablet PO Once Daily at 4
PM: Please adjust dose as needed to attain goal INR of [**1-5**]. NOTE
that patient is very sensitive to Coumadin and has had
supratherapeutic INRs in the past with bleeding.
19. cholecalciferol (vitamin D3) 400 unit Tablet [**Date Range **]: Two (2)
Tablet PO DAILY (Daily).
20. Calcium 500 500 mg calcium (1,250 mg) Tablet [**Date Range **]: One (1)
Tablet PO twice a day: Please do not give with meals or with
other prescription medications as Ca can reduce absorption of
other medications.
21. Ganciclovir 300 mg IV Q12H
22. Morphine Sulfate 1-2 mg IV Q4H:PRN foot pain
23. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
24. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
25. heparin (porcine) 1,000 unit/mL Solution [**Date Range **]: as directed
units Injection continuous: Target PTT: 60 - 100 seconds
Sliding scale:
PTT <40: 2300 units Bolus then Increase infusion rate by 250
units/hr
PTT 40 - 59: 1100 units Bolus then Increase infusion rate by 100
units/hr
PTT 60 - 100*:
PTT 101 - 120: Reduce infusion rate by 100 units/hr
PTT >120: Hold 60 mins then Reduce infusion rate by 250 units/hr
.
26. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] rehab
Discharge Diagnosis:
Gastritis with probable gastrointestinal hemorrhage due to
supratherapeutic INR (11)
Colitis vs enteropathy
Resolving PCP pneumonia
[**Name9 (PRE) 2325**] foot dry gangrene
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with low blood pressures, low oxygen levels,
low blood counts, and an elevated INR (11). Your symptoms
improved with IV fluids and red blood cell transfusions and your
blood counts remained stable while on a heparin drip. It is
unclear the exact reason for your initial symptoms, but it is
likely that you had lung inflammation as a result of your
steroids being stopped and a bleed due to an elevated INR level.
To evaluate the source of your bleeding, you had an upper
endoscopy which showed inflammation of your stomach and you were
therefore started on a proton pump inhibitor (omeprazole) to
prevent further bleeding.
It is possible that you may have also had bleeding from your
colon and therefore it is very important that you have a full
colonoscopy in the next 4-6 weeks.
You were also noted to have malnutrition and diarrhea and were
seen by the Gastroenterology and Infectious Disease teams. You
were continued on your Gancyclovir as well as your other
previous Infectious Disease medications. You were also
restarted on your prednisone and this should be reduced slowly
over the next 4 weeks (to be reduced by 10mg each week).
With regards to your left leg clot, you are being continued on
anticoagulation and should follow up with your Surgeon as
previously scheduled.
Additionally, given that your recent hospitalization was likely
related to an elevated INR, your rehab facility should excercise
great care in titrating your Coumadin levels to make sure that
your INR does not get above 3. You also will need to follow up
with your PCP after discharge from rehab to have your INR levels
checked and your Coumadin dosing adjusted as needed.
Please call your doctor if you experience worsening abdominal
pain, fevers, severe worsening of your diarrhea, difficulty
breathing, or any other symptoms that concern you.
Followup Instructions:
1) Department: INFECTIOUS DISEASE
When: TUESDAY [**2102-12-5**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
2) Department: VASCULAR SURGERY
When: THURSDAY [**2102-12-7**] at 2:45 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
3)Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 14740**] or Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 798**]
to arrange a PCP fu appointment 3 days after discharge from
rehab.
4) Please call the GI Procedure scheduling to schedule a
colonoscopy in the next 4-6 weeks to evaluate for any potential
sources of bledding. (Ph: [**Telephone/Fax (1) 2233**]
ICD9 Codes: 2761, 5990, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7695
} | Medical Text: Admission Date: [**2197-11-9**] Discharge Date: [**2197-11-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Altered mental status, hypoxia
Major Surgical or Invasive Procedure:
Intubation x 2, central line insertion, tracheostomy [**11-23**], PEG
placement [**11-23**]
History of Present Illness:
Ms. [**Known lastname **] is an 89 yo female with PMH of Alzheimer's disease,
depression, hypernatremia, paroxysmal afib who presents from her
NH. Her son was called by the nursing home reporting a fever to
101 and O2 sat 84-86%. She was then sent to the ED.
.
In the ED, she was noted to have altered mental status. She was
nonverbal but responded to pain. Exam was reported as otherwise
unremarkable other than rhonchi. She was noted to be hypoxic to
89%. Her CXR was ok. Her ABG at that time was 7.37/58/178.
Subsequent ABG showed worsening hypercarbia at 66, so she was
intubated. She was transiently hypotensive after intubation.
This improved with fluid. Her HCT was in the 50s and her serum
sodium was 170. She received 2L NS in the ED with 2 more
hanging upon transport to the ICU. She was noted to have pyuria
and was givne vanc and zosyn. Lactate in the ED was 1.4. VS in
the ED: T 103.6 rectal 115/60 HR 52 RR 16 98% on 100%FiO2,
Peep 5 Tv 400.
Past Medical History:
Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b
Social History:
Permanent resident of [**Hospital3 **] Manor. Chinese speaking only,
Son and daughter active in her life and visit daily.
Family History:
N/A
Physical Exam:
Admission PE:
vitals: 97.3 89/49 99% on 100% FiO2
gen: resting, ill appearing
heent: ncat, mmd, pupils 2mm
neck: no elevated JVD
pulm: ctab, no w/r/r
cv: brady, 2/6 SEM, no r/g
abd: s/nt/nd/nabs
extr: no c/c/e, pulses thready
neuro: intubated, sedated. does not respond to voice.
withdrawals from pain.
Pertinent Results:
[**2197-11-9**] 10:30AM BLOOD WBC-9.1 RBC-5.03# Hgb-16.7*# Hct-52.6*#
MCV-105*# MCH-33.3* MCHC-31.8 RDW-15.3 Plt Ct-242
[**2197-11-9**] 10:30AM BLOOD Neuts-85.3* Bands-0 Lymphs-8.3* Monos-5.8
Eos-0.1 Baso-0.6
[**2197-11-9**] 03:00PM BLOOD PT-17.4* PTT-39.3* INR(PT)-1.6*
[**2197-11-9**] 10:21AM BLOOD Type-ART pO2-178* pCO2-58* pH-7.37
calTCO2-35* Base XS-6 Intubat-NOT INTUBA
[**2197-11-9**] 10:21AM BLOOD Lactate-2.0
[**2197-11-9**] 10:30AM BLOOD ESR-31*
[**2197-11-9**] 10:30AM BLOOD Glucose-128* UreaN-82* Creat-2.7* Na-170*
K-4.6 Cl-128* HCO3-33* AnGap-14
[**2197-11-9**] 10:30AM BLOOD ALT-30 AST-26 CK(CPK)-257* AlkPhos-55
Amylase-53 TotBili-1.3
[**2197-11-9**] 10:30AM BLOOD CK-MB-3 cTropnT-0.05*
[**2197-11-9**] 10:30AM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.1# Mg-3.7*
.
[**2197-11-12**] 10:10AM BLOOD FDP-0-10
[**2197-11-12**] 10:10AM BLOOD Fibrino-397 Thrombn-14.3*
.
[**2197-11-22**] 05:09PM BLOOD Type-ART Temp-37.2 Rates-18/0 Tidal V-380
PEEP-5 FiO2-40 pO2-128* pCO2-38 pH-7.45 calTCO2-27 Base XS-3
-ASSIST/CON
[**2197-11-22**] 05:09PM BLOOD Lactate-1.4
.
[**2197-11-23**] 03:16AM BLOOD Cortsol-20.1*
.
[**2197-11-24**] 03:26AM BLOOD WBC-7.8 RBC-2.55* Hgb-8.5* Hct-25.3*
MCV-99* MCH-33.4* MCHC-33.7 RDW-16.1* Plt Ct-354
[**2197-11-24**] 03:26AM BLOOD PT-13.7* PTT-35.3* INR(PT)-1.2*
[**2197-11-24**] 03:26AM BLOOD Glucose-99 UreaN-13 Creat-1.0 Na-139
K-4.3 Cl-104 HCO3-28 AnGap-11
[**2197-11-24**] 03:26AM BLOOD Calcium-8.2* Phos-3.6# Mg-2.2
.
Radiographic studies:
.
CXR [**11-12**]: Interstitial edema increased. Left retrocardiac
atelectasis also worsened. Small bilateral pleural effusions,
more marked on the left are unchanged. Calcifications of the
aortic arch and old right rib fractures are stable. Heart size
remains normal. Hilar contours are unchanged.
.
CXR [**11-20**]: FINDINGS: Endotracheal tube, right internal jugular
central venous catheter and nasogastric tube appear unchanged.
There has been an interval worsening of the bilateral perihilar
opacities and probable slight increase in the layering bilateral
large pleural effusions. This could reflect developing pulmonary
edema although multifocal infection cannot be entirely excluded.
.
ECHO [**11-22**]: The left atrium is normal in size. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. IMPRESSION: Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function. Pulmonary artery systolic
hypertension. Mild mitral regurgitation.
.
Micro Data:
[**11-9**]: UCx w/proteus, sputum w/MRSA
[**11-18**]: sputum w/stenotrophomonas
BCx [**11-12**] negative
BCx [**11-18**], [**11-19**], [**11-20**], [**11-21**] pending
R IJ tip [**11-22**] culture negative
UCx x2 [**11-19**] negative
3x CDiff negative ([**11-12**], [**11-13**], [**11-14**])
Brief Hospital Course:
A/P: 89 yo with PMH of Alzheimer's dementia, hypernatremia, UTI
presents with AMS, sepsis physiology, UTI, and impressive
hypernatremia
.
#1 Sepsis: Initially presenting with fever, hypotension,
hypoxia. Source was likely urine given pyuria, though may have
pneumonia as well given MRSA in sputum. UCx grew out pan
sensitive proteus mirabilis, initial sputum grew MRSA. BCx from
[**11-9**], [**11-12**] negative. BCx from [**11-18**], [**11-19**], [**11-20**], [**11-21**] all
pending. Patient had short additional time in MICU when
required pressors for approx 48 hours. Started on empiric zosyn
and gent for VAP. UCx during this time were negative and sputum
grew out Stenotrophomonas sensitive to Bactrim. IV Bactrim
started and zosyn/gent d/c. Although blood pressure is low at
baseline, patient always makes urine. Stool tests for C. diff
negative x 3 & flagyl stopped [**11-15**].
- completed 15d of vanco, was treated for 14d total for UTI
starting w/cipro/unasyn and switching to gent/zosyn (to double
cover for VAP)
- IV Bactrim 250mg Q8h for 14 days, starting [**11-24**] and finishing
on [**12-8**].
.
#2 Respiratory failure: Hypoxia and hypercarbia with spontaneous
breathing trials. [**Month (only) 116**] now be volume overloaded due to fluid
resuscitation. PNAs and deconditioning likely also contribute.
Patient failed SBTs due to RSBIs >130 and increasing acidosis.
Unclear why patient unable to be weaned off vent. Patient with
slightly hyperinflated [**Known lastname **]s and CO2 retention without acidosis
on admission. No Hx of COPD given but may be undiagnosed thus
far. NIF poor at 16 with large amount of dead space ventilation
(70% on PSV). Difficulty of weaning from the vent likely a mix
of decreased respiratory muscle strength combined with
underlying intrinsic [**Known lastname **] disease.
- Continue on Pressure support as tolerated and wean as
tolerated.
.
#3 Hypernatremia: likely from extreme dehydration. Now
resolved.
Patient is currently getting free water boluses 100ml every 6
hours with tube feeds. Continue to monitor sodium and adjust as
necessary.
.
#4 AMS: likely [**2-4**] toxic/metabolic, though other etiologies
could include stroke, and underlying dementia. Patient
increasingly alert as she is treated
.
#5 Hypotension: Resolved currently. Dopamine drip weaned off.
ECHO relatively unremarkable given patient??????s age and does not
explain hypotension or bradycardia. unclear etiology. Lactate
and mixed venous do not suggest infection. Pt did not respond
to fluid boluses and CVPs do not point to hypovolemia. Repeat
ECHO w/normal biventricular cavity sizes with preserved global
and regional biventricular systolic function. Pulmonary artery
systolic hypertension. Mild mitral regurgitation. [**Month (only) 116**] also be
unable to mount HR response with conduction disorder. EP
consulted twice and do not want to intervene given her hx of
sepsis. Adrenal insufficiency also a possibility but AM
cortisol was normal.
.
Fluid balance should be maintained. She has been both very
hypervolemic and exterienced flash pulmonary edema during her
stay, and fluid balance has been difficult. Any PRN IVF should
be given with caution and extubation was probably in part
limited [**2-4**] to pulm edema. Her sodium and other electrolytes
should be monitored every other day until stable and PO intake
of fluids encouraged.
.
Would reassess fluid status daily and give small doses of Lasix
as tolerated by blood pressure. The patient has been
hypotensive with Lasix in the past, therefore small doses should
be given.
.
#6 Bradycardia, HR consistently in 50's but asymptomatic: Not
new ?????? old records show ekg w/nsr at 65 w/1st degree AV block 3
years ago. Initially EP commented that her rhythm could be a
variation of normal or tied to her underlying illness and
recommended treating her sepsis and re-evaluating once she has
recovered or becomes unstable.
.
#7 Paroxysmal afib: not on anticoagulation on admission for
unclear reason (fall risk?) The reason for this should be
followed up with her PCP. [**Name10 (NameIs) **] was not investigated during this
stay.
.
#8 Alzheimer's: cont home meds of Namenda and Aricept.
.
#9 Anemia: hemoconcentrated upon admission, HCT trended to mid
to upper 20s during here stay. Further workup should be
initiated by her PCP. [**Name10 (NameIs) 357**] monitor her HCT every other day
until stable.
.
# PPx: H2 blocker, sc heparin, bowel regimen
.
# FEN: Tolerated TF at goal.
.
# Code: full code. Discussed with patient??????s son [**Name (NI) **] who
wants ??????everything done?????? including reintubation if patient fails
extubation.
Medications on Admission:
bisocodyl supp 10mg daily prn
albuterol q 6 prn
ipratropium q 6 prn
tylenol 500 q 6 prn
guiatuss q 6 prn
tylenol suppos 650mg q 6 prn
lactulose 15ml po daily
vit E 800 po daily
caltrate 600 + D [**Hospital1 **]
aricept 10mg po daily
colace 100 qday
zyprexa 5mg qday
namenda 10mg [**Hospital1 **]
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. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation q4hrs prn as needed.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
12. Trimethoprim-Sulfamethoxazole 80-400 mg/5 mL Solution Sig:
Two [**Age over 90 1230**]y (250) mg Intravenous q8hrs for 13 days:
through [**2197-12-7**].
13. Vitamin E 800 unit Capsule Sig: One (1) Capsule PO once a
day.
14. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
15. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
once a day.
16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Puff Inhalation PRN (as needed) as needed for shortness of
breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 86**]
Discharge Diagnosis:
Primary:
proteus mirabilis urosepsis
bradycardia
stenotrophomonas pneumonia
.
Secondary:
Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b
Discharge Condition:
good, afebrile
Discharge Instructions:
Ms. [**Known lastname **] was seen at [**Hospital1 18**] for urosepsis for which she finished
a course of vanc, gent, zosyn. She required pressors
intermittently for hypotension. She was also extremely
hypernatremic. She also was bradycardic with a mid-grade block.
She is receiving bactrim for stenotrophomonas pna. She will
need bactrim until [**2197-12-7**]. She will need ongoing nebulizers,
sc heparin, and bowel regimen per medication orders. Please see
discharge [**Last Name (un) 17576**] for full details.
.
Vital signs should be monitored daily. Fluid balance should be
maintained. She has been both very hypervolemic and exterienced
flash pulmonary edema during her stay, and fluid balance has
been difficult.
.
She has not been anticoagulated for her PAF in the past. The
reason for this should be followed up with her PCP as below.
This was not investigated during this stay.
.
She will need every other day electrolytes and CBC checked until
stable. Other discharge orders per medication sheet and page 1
referral.
.
She should return to the ED if she develops altered mental
status, fever, hypotension, bradycardia.
Followup Instructions:
she should follow-up with her Primary Care Provider, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 10145**], in the next 1-2 weeks. His office number is
[**Telephone/Fax (1) 10573**].
ICD9 Codes: 0389, 2760, 5849, 5990, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7696
} | Medical Text: Admission Date: [**2166-11-15**] Discharge Date: [**2166-11-21**]
Date of Birth: [**2144-4-15**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 20506**]
Chief Complaint:
episode of confusion
Major Surgical or Invasive Procedure:
LP - [**2166-11-14**]
History of Present Illness:
22 year old right handed woman who was transferred from
[**Location (un) 47**], for assessment for an acute change in mental status
around 2 pm this afternoon. She had recently been discharged
from
[**Hospital1 **] [**Location (un) 21601**] after treatment for a viral meningitis, her main
symptoms were bitemporal pulsatile headaches with photophobia.
Notably, her work-up in [**Hospital1 **] [**Location (un) 21601**] was negative for HIV, Lyme,
Ehrlichia, Syphilis, but she was EBV positive. Her initial LP
on
[**10-29**] when she was admitted over there showed 400 white cells
with
a 95% lymphocytic predominance, 0 red cells, 45 glucose, and 106
total protein. Two days before she was discharged on [**11-3**], her
LP
showed the following: 571 white cells, 14 red cells, 1
neutrophil, 91 lymphocytes. She was treated empirically with
Rocephin+Vanc+Acyclovir, and the Acyclovir was discontinued when
the HSV PCR came back negative, on the initial CSF tap on [**10-29**].
She was seen by neurologist Dr [**Last Name (STitle) **] at the OSH. She was febrile
up to 104 during her hospital stay, until about two days before
her discharge. Since her discharge home, she has been staying
with her mother in [**Name (NI) 1411**] who mentioned that her daughter barely
drank much in terms of fluids, and would eat a few fruit loops.
At 2pm today she started acting extremely confused, not
agitated,
but not knowing where she was, what date it was, or being able
to
identify various family members. She had a CT head at
[**Location (un) 47**],
which was unremarkable (apart from movement artifact) and she
received a dose of Acyclovir, and was transferred to [**Hospital1 18**] for
neurological care. Her mother mentioned that she had urinary
retention, and had left lower quadrant abdominal pain.
Past Medical History:
HUS age 5
Recurrent PNA
HPV
Social History:
No tobacco, rare ETOH, no IVDU. Boyfriend.
Unprotected sexual contacts with single male partner x several
years. No tick bites, rash, joint pain. No h/o HSV known. Cat.
No travel. No contacts who are ill. Intern for magazine.
Family History:
NC
Physical Exam:
initial exam:
T-98.4 BP-130/89 HR-86 RR-16 O2Sat-99%
Gen: Lying in bed, complaining of not being able to pass urine,
when the Foley was inserted she voided>300 ml of urine
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, suprapubic fullness
Skin: no rashes
ext: no edema
Neurologic examination:
Mental status: Confused, inattentive. Is calling her family
members incorrect rooms. Thinks her cat is blue in color, and
thinks that her boyfriend in her cat. Looking around the room,
and sees multiple images of everything. Uses neologisms. Her
speech is fluent, and she is intermittently following commands.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Not allowing me to do fundoscopy. Keeps
perseverating on the number of fingers in each quadrant. Tracks
normally, with nystagmus. Corneal reflexes in tact bilaterally.
Facial excursion is symmetric. Gag is intact.
Motor:
Her calves seemed deconditioned. Tone normal. No observed
myoclonus or tremor
Can hold each limb up for 1 minute without fatiguing, but she
cannot comply with formal strength testing.
Sensation: moves all 4 limbs away from tickle or noxious stimuli
Reflexes:
2 and symmetric throughout.
Toes downgoing bilaterally
Coordination and Gait could not be assessed
follow up exam (next day):
Neuro: MS: alert and oriented x3, intact naming, repetition,
knowledge, fluency, comprehension, follows crossed body
commands,
able to say world backwards, no apraxia, [**4-8**] IR and [**4-8**] SR
CN: PERRLA, EOMI, intact light touch and facial strength
bilaterally, intact t/u/p, [**6-10**] SCM, VFFTC, no extinction to DSS
stimuli
Motor: normal tone and bulk of all four ext. 5/5 Strength of all
four ext
Sensory: intact lt of all four ext
Reflexes: 2+ symmetric of UE and LE, toes are downgoing
bilaterally
Coord: Intact fnf and hs bilaterally
Gait: deferred
Pertinent Results:
[**2166-11-14**] 09:00PM PT-12.5 PTT-26.4 INR(PT)-1.1
[**2166-11-14**] 09:00PM PLT COUNT-420
[**2166-11-14**] 09:00PM WBC-16.2* RBC-4.49 HGB-12.9 HCT-37.1 MCV-83
MCH-28.8 MCHC-34.9 RDW-13.4
[**2166-11-14**] 09:00PM CALCIUM-10.0 PHOSPHATE-4.0 MAGNESIUM-2.0
[**2166-11-14**] 09:00PM LIPASE-115*
[**2166-11-14**] 09:00PM ALT(SGPT)-15 AST(SGOT)-13 CK(CPK)-43 ALK
PHOS-39 TOT BILI-0.5
[**2166-11-14**] 09:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2166-11-14**] 11:50PM CEREBROSPINAL FLUID (CSF) WBC-73 RBC-1*
POLYS-0 LYMPHS-91 MONOS-4 EOS-3 BASOS-1 ATYPS-1
[**2166-11-14**] 11:50PM CEREBROSPINAL FLUID (CSF) WBC-101 RBC-1*
POLYS-0 LYMPHS-90 MONOS-4 EOS-2 BASOS-1 ATYPS-3
[**2166-11-14**] 11:50PM CEREBROSPINAL FLUID (CSF) PROTEIN-105*
GLUCOSE-43
[**2166-11-15**] 03:11AM WBC-10.7 RBC-4.25 HGB-11.8* HCT-34.8* MCV-82
MCH-27.7 MCHC-33.8 RDW-13.9
[**2166-11-15**] 03:11AM RHEU FACT-<3
[**2166-11-15**] 03:11AM dsDNA-NEGATIVE
[**2166-11-15**] 03:11AM ANCA-NEGATIVE B
[**2166-11-15**] 03:11AM TSH-0.77
[**2166-11-15**] 11:02AM URINE UCG-NEGATIVE
From OSH:
SH:nml, dsDNA:- RF<3, ANCA:- [**Doctor First Name **]:- RPR: - CSF syph:- CSF Cx:-
HSV PCR:-, CSF Cx:-, CSF [**Country **] ink:- AFB: - cocksackie:- viral
cx:-
from blood: HIV:- Babesia:- Erlichia:- Ricketsia: - Adenosine
deaminase(from CSF):1.7 CMV:-, viral throat swap:- flu:-
CT C/A/P: Normal study, gallstones noted
MRI ([**2166-11-16**])
1. Redemonstration of the restricted diffusion in the genu of
the corpus
callosum, the significance of this finding is uncertain, given
the lack of
corresponding abnormality on the color maps of fractional
anisotropy.
2. Faint foci of increased FLAIR hyperintensity in the posterior
parts of the
thalami on both sides, again of uncertain significance.
3. Very subtle possible enhancement in the optic nerves, without
obvious
increased signal on the STIR sequence. Hence, the significance
of these
subtle findings is uncertain, ? related to fat suppression of
the adjacent fat
than an abnormality, being bilateral and symmetric, thin and
linear.
Followup evaluation in a few days/weeks can be considered based
on the
patient's condition/progression to evaluate the
stability/progression of the
above-mentioned equivocal abnormalities.
MRI ([**2166-11-14**]):
1. Restricted diffusion is seen within the genu of corpus
callosum which
can be seen in ischemia or demyelination.
2. Subtle signal abnormalities in medulla, pons and thalami need
further
confirmation with repeat sagittal FLAIR and T2 and axial FLAIR
(without
gadolinium).
3. FLAIR signal abnormalities along sulci and along the surface
of the
brain are consistent with meningeal inflammation.
4. Subtle signal changes are seen on diffusion images within
both optic nerves
and subtle enhancement is suspected on post- gadolinium images.
However, this
could not be confirmed, and if clinically indicated, a dedicated
MRI of the
orbit can help for further assessment.
5. Findings discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
MRV:
The head MRV demonstrates normal flow in the superior sagittal
and transverse
sinuses as well as in the deep venous system.
IMPRESSION: Normal MRV of the head.
EEG ([**2166-11-18**])
Normal EEG in wakefulness and sleep. There were no focal
abnormalities or epileptiform features.
EEG ([**2166-11-15**]):
Abnormal EEG due to bursts of focal slowing from the left
temporal and central regions with secondary generalization
indicative of
some degree of focal irritation involving primarily the left
hemisphere
and primarily the left temporal and central structures
independently
and, at times, synchronously with secondary spread. No frank
epileptiform discharges were, however, seen. A focal infectious
etiology cannot be absolutely excluded and this pattern can be
seen in
the early stages of a typical viral encephalitis or
encephalopathy.
Echo: ([**2166-11-18**]):
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Transmitral
Doppler and tissue velocity imaging are consistent with normal
LV diastolic function. Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Brief Hospital Course:
The patient was admitted with an episode of confusion after a
diagnosis of viral meningitis that was made at a hospital in [**Location (un) 7349**]
([**Hospital1 **] [**Location (un) 21601**]). This confusion was short (less than 6 hours)
but was concerning enough given the recent history to warrant an
ICU admission and a repeat spinal tap was done (as well as
obtaining the records from the prior hospitalization. The LP
still showed a lymphocytic pleocytosis but it was improving from
the last hospitalization.
The confusion rapidly resolved and the patient was at baseline
the next morning after admission and she was transferred out of
the ICU. She was initially placed on antibiotics for empiric
treatment of meningitis, however these were discontinued after a
day with the results of the gram stain and culture of the LP.
She was maintained on Acylovir for the time period before
another HSV PCR could be obtained. Imaging showed some mild
FLAIR hyperintensity in the thalamus b/l, that was thought to be
consistent with the patients recent viral meningo/encephalitis.
It was thought that this breif episode of confusion could have
been a result of a seizure brought about by the patient's
underlying illness. An EEG was obtained that was abnormal
showing: focal slowing from the left temporal and central
regions with secondary generalization indicative of some degree
of focal irritation involving primarily the left hemisphere and
primarily the left temporal and central structures independently
and the patient was started on Keppra. The HSV PCR was negative
and acyclovir was discontinued. The patient had persistent
headaches throughout the admission but these improved with
Toradol, and appeared to improve as the hospital course went on.
The patient was also had some brief hypertension and
tachycardia, that were likely secondary to pain, and resolved
with pain treatment, and were at baseline on d/c. She was
briefly treated with a beta blocker but this was discontinued.
Medications on Admission:
OCP stopped in her recent hospital admission at [**Hospital1 **], [**Location (un) 21601**]
Ibuprofen 600 mg Q6h, prn
Tylenol prn
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Possible seizure after viral meningitis.
Discharge Condition:
Good: MS: intact CN: intact, no deficits, Motor/Sensory: no
deficits Reflexes: 2+ throughout Gait: normal
Discharge Instructions:
You were admitted with an episode of confusion after you were
given a diagnosis of viral meningitis at an outside hospital in
[**Location (un) **]. You had been improving over a week that you were
discharged from the other hospital but had another breif episode
of confusion. You were brought to [**Hospital1 18**] where you were placed
in the ICU and another workup was done, including LP and blood
work and imaging. Your confusion rapidly resolved. You were
transferred out of the ICU. The workup at the [**Hospital 8050**] hospital
was negative, as well as the workup here. You had another HSV
PCR which was shown to be negative. There is a Bartonella test
still pending which you will follow up with infectious disease
in about 3 weeks. At this time please also follow-up on results
pending from [**Hospital3 **] in [**Location (un) **] including EEE and WNV.
You had an EEG which showed some abnormailites, and based on
your recent infection and episode of confusion you were started
on an anti-epileptic medication Keppra. You tolerated the
medication well.
Please take all medicine as prescribed
Please ensure you keep all follow up appointments
If you have any worsening of your symptoms, such as new
confusion, please call your doctor or return to the nearst ER.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13896**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2166-12-16**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**], MD Please call
for an appointment within 1 month [**Telephone/Fax (1) 2100**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7697
} | Medical Text: Admission Date: [**2112-11-30**] Discharge Date: [**2112-12-7**]
Date of Birth: [**2078-1-21**] Sex: M
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Fall, nausea and vomiting secondary to alcohol use.
Major Surgical or Invasive Procedure:
Flexible bronchosopy ([**2112-12-1**]).
History of Present Illness:
34 y/o gentleman with known alcohol abuse was found down in his
bathroom with vomit and blood around him. His landlord called
police after a water leak from his apartment. Patient was
transfered to [**Hospital3 **] and was found to have two
seizure episodes en route. Patient received IVF greater than 1 L
NS (unclear amount), thiamine 100 mg and 1 mg folate. Patient
also received 10 mEq KCl, 40 mg IV pantoprazole and Zosyn 3.375
gm IV once. CXR there showed pneumomediastimum without
pneumothorax and he was transfered to [**Hospital1 18**] ED.
.
In [**Hospital1 18**] ED his vitals were T 98.2 HR 92 BP 124/50 RR 16 O2 sat
98%. Patient was alert and oriented times three but was a poor
historian. His family saw him and thought that he was at
baseline. He has had trouble giving history and recalling events
at baseline per family. Patient was given metronidazole 500 mg
IV, Fluconazole 200 mg IV and vancomycin 1 gram IV. He also
received 1 unit of PRBC. His urine output was greater than 700
ml in ED over approx 4 hours. Thoracics was consulted who
recommended a barium swallow study. Preliminary read was some
distal filling defect without any extravasation. Recommended GI
consult.
.
On arrival to the MICU his vitals were T 95.9 HR 89 BP 156/53 RR
15 100% 4LNC. Patient denies any acute distress. He states that
he was aware of EMS coming into his house. He states that he
might have had a seizure this morning. He also had a seizure one
week ago. He has had episodes of binge drinking. His last drink
was three days ago per patient. He drank greater than 1 bottle
of Vodka that night but unable to quantify. He denies any fever,
chills, chest pain, shortness of breath, nausea, abdoinal pain,
dysuria, diarrhea, constipation, focal numbness or weakness. He
has noticed dark urine and dark colored stool in the last two
days. He has depressed mood per family history after losing his
job recently. Patient denies any suicidal ideation.
Past Medical History:
Alcohol abuse
SDH in [**2109**] secondary to fall
Known alcohol withdrawl seizures
Otherwise denies any medical problems
Social History:
Works in construction.
20 pack/year tobacco.
Drinks ETOH in binges.
Family History:
Noncontributory.
Physical Exam:
Vitals: T 95.9 HR 89 BP 156/53 RR 15 100% 4LNC
Gen: Alert and oriented x 3 (not date but month/year). Poor
historian. NAD
HEENT: PEERL, EOM-I, Mucous membranes are dry, bruise in lower
lip, JVP not elevated
Lungs: Clear to auscultate bilaterally
Heart: Tender to palpate in left chest wall, S1S2 RRR, no MRG
Abdomen: BS present, soft NTND
Ext: WWP, DP 2+
Neuro: CN II-XII grossly intact, strength 5/5, sensation is
intact, normal muscle tone.
Pertinent Results:
Complete blood count
[**2112-11-30**] 10:01PM BLOOD WBC-10.0 RBC-2.96*# Hgb-10.2*# Hct-26.0*#
MCV-88 MCH-34.4* MCHC-39.1* RDW-13.0 Plt Ct-145*
[**2112-12-1**] 03:07AM BLOOD WBC-9.5 RBC-3.02* Hgb-10.2* Hct-26.1*
MCV-87 MCH-33.7* MCHC-38.9* RDW-13.8 Plt Ct-155
[**2112-12-2**] 05:15AM BLOOD WBC-9.2 RBC-3.05* Hgb-10.1* Hct-28.0*
MCV-92 MCH-33.1* MCHC-36.0* RDW-13.4 Plt Ct-200
[**2112-12-3**] 06:05AM BLOOD WBC-6.9 RBC-2.98* Hgb-10.0* Hct-27.3*
MCV-92 MCH-33.5* MCHC-36.5* RDW-13.9 Plt Ct-199
[**2112-12-4**] 05:10AM BLOOD WBC-7.2 RBC-2.99* Hgb-10.3* Hct-28.1*
MCV-94 MCH-34.6* MCHC-36.8* RDW-14.0 Plt Ct-267
.
Liver function and coags
[**2112-11-30**] 04:25PM BLOOD ALT-52* AST-131* CK(CPK)-8404* AlkPhos-41
TotBili-1.6*
[**2112-12-1**] 12:44PM BLOOD ALT-54* AST-115* AlkPhos-33* TotBili-1.0
[**2112-12-2**] 05:15AM BLOOD ALT-56* AST-130* LD(LDH)-372*
CK(CPK)-2634* AlkPhos-36* TotBili-1.0
[**2112-12-4**] 05:10AM BLOOD ALT-49* AST-66* CK(CPK)-615* AlkPhos-33*
TotBili-0.3
[**2112-11-30**] 04:25PM BLOOD PT-13.5* PTT-22.2 INR(PT)-1.2*
[**2112-12-1**] 03:07AM BLOOD PT-12.6 PTT-20.7* INR(PT)-1.1
[**2112-12-2**] 05:15AM BLOOD PT-12.1 PTT-22.1 INR(PT)-1.0
.
Renal function and electrolytes
[**2112-11-30**] 04:25PM BLOOD Glucose-102 UreaN-149* Creat-3.1*#
Na-126* K-2.6* Cl-72* HCO3-41* AnGap-16
[**2112-11-30**] 10:01PM BLOOD Glucose-93 UreaN-110* Creat-2.3* Na-135
K-2.8* Cl-89* HCO3-36* AnGap-13
[**2112-12-1**] 03:07AM BLOOD Glucose-93 UreaN-86* Creat-2.0* Na-140
K-3.0* Cl-95* HCO3-37* AnGap-11
[**2112-12-1**] 12:44PM BLOOD Glucose-82 UreaN-59* Creat-1.6* Na-143
K-3.0* Cl-99 HCO3-35* AnGap-12
[**2112-12-1**] 11:50PM BLOOD Glucose-80 UreaN-36* Creat-1.2 Na-139
K-2.7* Cl-97 HCO3-33* AnGap-12
[**2112-12-2**] 05:15AM BLOOD Glucose-75 UreaN-27* Creat-1.2 Na-138
K-2.9* Cl-98 HCO3-32 AnGap-11
[**2112-12-2**] 12:48PM BLOOD Glucose-87 UreaN-19 Creat-1.0 Na-134
K-3.4 Cl-98 HCO3-29 AnGap-10
[**2112-12-3**] 06:05AM BLOOD Glucose-92 UreaN-10 Creat-1.1 Na-137
K-3.0* Cl-101 HCO3-30 AnGap-9
[**2112-12-4**] 05:10AM BLOOD Glucose-134* UreaN-6 Creat-1.0 Na-137
K-3.9 Cl-107 HCO3-25 AnGap-9
[**2112-11-30**] 10:01PM BLOOD Albumin-2.8* Calcium-6.6* Phos-2.5*#
Mg-3.1*
[**2112-12-1**] 03:07AM BLOOD Albumin-3.0* Calcium-7.2* Phos-1.8*
Mg-3.3*
[**2112-12-4**] 05:10AM BLOOD Calcium-7.9* Phos-1.6* Mg-1.8
.
Cardiac enzymes
[**2112-11-30**] 04:25PM BLOOD CK-MB-19* MB Indx-0.2
[**2112-11-30**] 04:25PM BLOOD cTropnT-0.05*
[**2112-11-30**] 10:01PM BLOOD CK-MB-14* MB Indx-0.2 cTropnT-0.04*
.
Anemia studies
[**2112-12-1**] 03:07AM BLOOD calTIBC-291 VitB12-878 Folate-12.0
Ferritn-377 TRF-224 Iron-42*
.
Serum toxicology
[**2112-11-30**] 04:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Electrocardiogram ([**2112-11-30**])
Sinus rhythm. Non-specific ST-T wave changes. Compared to the
previous tracing ST-T wave changes are new.
.
Imaging
Barium swallow ([**2112-11-30**])
IMPRESSION:
1. No extraluminal contrast appreciated. No evidence for
esophageal
perforation.
2. Filling defect in the distal esophagus persistent on all
images and
associated with a delay in clearance of the esophagus. This is
concerning for food/other impacted material, and endoscopic
evaluation is recommended.
.
Abdominal ultrasound ([**2112-12-1**])
IMPRESSION: No evidence of fluid or hemorrhage.
.
CXR pa and lateral ([**2112-12-1**])
IMPRESSION: Slight improvement in pneumomediastinum. Left lower
lobe
opacification remains the same and is most likely atelectasis
versus
aspiration.
.
CT chest with po contrast ([**2112-12-2**])
IMPRESSION:
1. Findings do not suggest active esophageal perforation or
mediastinal
infection: interval decrease in pneumomediastinum, no
extravasation of oral
contrast or dominant periesophageal gas collection, no
mediastinal fluid
collection. The presence of a small esophageal tear is better
evaluated
endoscopically.
2. Normal esophagus. Small hiatal hernia.
3. New bibasilar peribronchial infiltrates may represent
aspiration versus
atelectasis. Minimal right pleural effusion.
Brief Hospital Course:
A 34 year-old gentleman with alcohol abuse presents with
seizure, pneumomediastinum, acute renal failure and
rhabdomyolysis.
.
1. Pneumomediastium / ?esophageal tear / ?mediastinitis
Possibly secondary to alcohol withdrawal seizure versus
esophageal tear during emesis. Distal barium filling defect on
barium swallow raised concern of distal esophageal origin.
.
On admission to the ICU, the patient was afebrile and
hemodynamically stable. Thoracic surgery was consulted in the ED
and felt surgery was not indicated. Vancomycin, Zosyn and
fluconazole were initiated. Interventional pulmonary performed a
bronchoscopy showing normal anatomy and no evidence of tear or
rupture. GI was also consulted and recommended NPO and
intravenous PPI. Endoscopy was deferred in order to avoid risk
of any further damage to the esophagus. A repeat CXR showed a
stable pneumomediastinum. Fluconazole was discontinued after
discussion with ID.
.
Patient spent one night in the ICU after which he underwent CT
chest with po contrast showing no esophageal leak and resolving
pneumomediastinum. He was then transferred to the medical
floors with stable vitals. Per GI recommendations, his diet was
progressed slowly to cold clears, then full clears, then solids.
His antibiotics were switched to Augmentin and Flagyl for
presumptive treatment of mediastinitis eventhough there was no
radiographic evidence to suggest inflammation to the
mediastinum. He will complete a ten day course of antibiotics.
.
GI has recommended that patient undergo upper endoscopy as
outpatient, once stabilized, for close evaluation for esophageal
tear.
.
2. Rhabdomyolysis.
This was felt to be secondary to his fall and seizures. He was
treated with IV fluids and his CK normalized.
.
3. Acute renal failure.
This was felt to be secondary to dehydration and rhabdomyolysis;
his admission FeNa was c/w prerenal azotemia. His creatinine
normalized with IV hydration. He maintained a good urine
output.
.
4. Alcohol dependence and withdrawal.
Per OSH report, he had seizures en route to the ED from his
apartment, most likely due to alcohol withdrawl. On admission
to this hospital CIWA protocol was instituted and he was
monitored on telemetry. His serum toxicology was negative on
admission.
.
Upon transfer to the floors, his CIWA scores were consistently
less than 10. However, he was intermittently tachycardic and as
he was 48-72 hours after his last drink, with a history of DTs
and withdrawal seizures, he was started on standing Valium with
a slow taper. He was monitored on telemetry and there was no
seizure activity. There were no hallucinations.
.
He was treated with IV hydration, multivitamin, thiamine, and
folate from time of admission. Social work was consulted and
provided information regarding detox programs.
.
5. Anemia.
His hematocrit was stable in the high 20s during this admission.
He was guiaic positive stool in ED and noted to have tarry
stools by GI service. An abdominal ultrasound was negative for
intra-abdominal bleed. His iron was 42 with a TIBC of 291 and
ferritin of 277, suggestive of mild iron deficiency. B12 an
folate were normal. He will need to have endoscopy and
colonoscopy as outpatient to work-up GI bleed.
.
6. Depression.
Patient may benefit from psychiatric consult as outpatient.
.
7. Dizziness.
He developed dizziness after transfer to the floors from the
intensive care unit. His description was consistent with BPPV,
brought on with rapid head movements, position changes in bed,
or shifts from supine to standing. [**Last Name (un) **]-hallpike maneuver
demonstrated lateral nystagmus and reproducibility of dizziness.
Epley meneuver was moderatly thereapeutic, although this did
not entirely cure his symptoms. We believe he may have BPPV
secondary to head trauma prior to admission. As there were no
other neuorologic symptoms and CT at OSH was negative, we did
not feel follow-up imaging was warranted. His dizziness quickly
resolves after head movement ceases, he is able to ambulate, and
overall his symptoms have been improving gradually since onset
about five days prior to discharge. He has been cleared by
physical therapy.
.
He was NPO initially and his diet progressed slowly as
tolerated. Electrolytes were repleted as needed. Subcutaneous
heparin was used for venous thrombosis prophylaxis. His code
status is full code.
Medications on Admission:
None
Denies any OTC/herbal
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days: last day [**12-17**].
Disp:*20 Tablet(s)* Refills:*0*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days: last day [**12-17**].
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
Alcohol withdrawal
Pneumomediastinum likely secondary to small esophageal tear
Rhabdomyolysis
Acute renal failure
.
Secondary Diagnoses
Alcohol dependence
Discharge Condition:
Vital signs stable. Afebrile.
Discharge Instructions:
You were hospitalized for treatment of nausea and vomiting.
There was air in the space surrounding the heart, which may be
due to leak from the esophagus while you were vomiting. Recent
imaging shows that the air has almost entirely gone away.
Furthermore, there is no leak in the esophagus seen on recent
imaging. It is possible that this leak has healed.
Bronchoscopy was performed while you were in the intensive care
unit to look at the airways. There were no abnormalities
detected.
.
We have started you on antibiotics to treat infection from the
esophageal leak. In order to complete a ten-day course, please
take clindamycin and Augmentin for 10 more days. We have also
given you prescriptions for vitamins and a medicine called
pantoprazole to help decrease acid secretion in the stomach.
.
You met with our social worker while you were in the hospital
and she helped you arrange for a place to stay. You planned to
go to Place of Promise on the day after leaving the hospital.
.
Please follow-up with your primary care provider. [**Name10 (NameIs) **] should
have an upper endoscopy performed as an outpatient to look at
the esophagus, stomach, and first part of the small intestine.
.
Please call your doctor or return to the emergency room if you
have any bleeding, belly pain, or any other symptoms that are
concerning to you.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in the next two weeks
[**0-0-**]. You need to have upper endoscopy performed as
outpatient.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2112-12-7**]
ICD9 Codes: 5849, 2761, 2859, 2768, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7698
} | Medical Text: Admission Date: [**2136-9-1**] Discharge Date: [**2136-9-15**]
Date of Birth: [**2053-12-8**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Tramadol Hcl / Hydrocodone
Attending:[**Doctor Last Name 69321**]
Chief Complaint:
Transfer from OSH for obtundation
Major Surgical or Invasive Procedure:
lumbar puncture [**2136-9-3**]
History of Present Illness:
82 yo F with h/o dementia, HTN, AS s/p AVR ([**Hospital1 18**]), vasculitis
on mycophenolate (Cellcept), admitted [**2136-8-20**] to [**Hospital3 2737**]
with VZV encephalitis (1.8 million copies on PCR) with course
c/b ARF and worsening obtundation.
Pt presented to OSH on [**8-20**] with increasing confusion and
weakness over 48 hours. On presentation she was nonverbal after
being able to speak earlier in the morning, and zoster rash was
noted on her right hip. She was started on acyclovir on
empirically on [**8-21**] and LP on [**8-22**] reportedly was postive for
VZV PCR, although report is not included. Patient apparently
improved initially, and MRI on [**8-27**] showed scattered lacunar
infarcts but was otherwise unremarkable. However, she developed
increased confusion on [**8-28**]. Repeat NCHCT on [**8-29**] was
unremarkable, and repeat LP was performed on [**8-30**], but again, I
have no records of the result. Patient's course was also c/b
ARF, with Cr increasing from 0.72 on [**8-26**] to 1.5 on [**8-30**]. Renal
US showed no hydronephrosis, and acyclovir was DC'd on [**8-30**].
However, Cr improved to 1.1 on [**8-31**] and acyclovir was restarted.
Unfortunately patient remained obtunded and was transferred to
[**Hospital1 18**] for further management.
On the floor, patient is minimally responsive. She does open her
eyes to voice and intermittently attempts to vocalize, but ROS
is unable to be obtained.
Past Medical History:
-Hypertension
-Hyperlipidemia
-Aortic stenosis s/p AVR (21mm [**Company 1543**] Mosaic Ultra Porcine
Valve) [**2133-2-4**]
-Osteoarthritis
-Pending bilateral knee replacements
-Colectomy with h/o colostomy for bowel
obstruction/?diverticulitis
Social History:
She is a widow with 5 grown children. Lives with her son. She
does not smoke or drink.
Family History:
Her brother with a cardiac stent in his 60??????s
Physical Exam:
Admission Physical Exam:
Vitals: T:97.8 BP:136/78 P:60 R: 20 O2:96%RA
General: Opens eyes briefly to command, attempts to vocalize but
unable. Minimally attentive to examiner
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Nonlabored, mildly decreased BS on right with expiratory
wheeze, although patient intermittently vocalizing
CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM c/w prior
AVR
Abdomen: soft, non-distended, bowel sounds present, grimaces
diffusely to palapation. No HSM noted.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: 2-3mm scab over right hip with a few surrounding
erythematous macules distriubuted in a linear fashion
Exam on transfer [**2136-9-7**]:
VS: afebrile, BP 110s/70s HR in 80-100s, RR 20-30s O2 96% on
nonrebreather
CV: tachycardic, normal S1/S2 and 2/6 systolic murmur
PULM: tachypneic, poor air movements throughout, decreased
breath sounds in LLL and bibasilar crackles
NEURO: obtunded, opens eyes only to loud voice and noxious
stimuli (such as sternal rub and nailbed pressure on
extremities). Does not follow midline or appendicular commands.
With nailbed pressure, withdraws all extremities and grimaces.
Tone increased in upper extremities, RUE>LUE. Right toe upgoing,
left toe mute.
Pertinent Results:
Admission Labs:
[**2136-9-1**] 07:10AM BLOOD WBC-7.5# RBC-3.87* Hgb-11.3*# Hct-35.3*#
MCV-91 MCH-29.3 MCHC-32.1 RDW-15.3 Plt Ct-253#
[**2136-9-1**] 07:10AM BLOOD Neuts-72.4* Lymphs-18.2 Monos-6.0 Eos-2.3
Baso-1.1
[**2136-9-1**] 07:10AM BLOOD PT-12.6* PTT-28.6 INR(PT)-1.2*
[**2136-9-1**] 03:01PM BLOOD Glucose-160* UreaN-21* Creat-0.8 Na-142
K-3.2* Cl-104 HCO3-29 AnGap-12
[**2136-9-1**] 07:10AM BLOOD ALT-13 AST-20 AlkPhos-56 TotBili-0.4
[**2136-9-1**] 07:10AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9
[**2136-9-1**] 02:00PM BLOOD Type-ART Temp-37 pO2-85 pCO2-33* pH-7.54*
calTCO2-29 Base XS-5
[**2136-9-1**] 02:00PM BLOOD Lactate-0.8
[**2136-9-1**] 05:18AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2136-9-1**] 05:18AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2136-9-1**] 05:18AM URINE Eos-NEGATIVE
[**2136-9-1**] 05:18AM URINE Hours-RANDOM UreaN-234 Creat-25 Na-86
K-21 Cl-91
[**2136-9-1**] 05:18AM URINE Osmolal-300
Discharge Labs:
Imaging:
CXR [**2136-9-1**]: Left PICC line terminates in mid SVC. Nasogastric
tube
terminates in the stomach.
MRI [**2136-9-2**]:
1. No definite acute intracranial abnormality; specifically,
there is no evidence of edema, slow diffusion or abnormal
enhancement to specifically support the apparently established
diagnosis of varicella zoster encephalitis.
2. No pathologic focus of enhancement, though sensitivity for
subtle cranial nerve enhancement (as may be seen with varicella
zoster infection) is severely limited.
3. Global, particularly central atrophy and extensive sequelae
of chronic small vessel ischemic disease with right basal
ganglionic chronic lacunes.
4. Unremarkable cranial MRA with no flow-limiting stenosis.
5. Fluid-opacification of the mastoid air cells, bilaterally, as
on the OSH CT dated [**2136-8-29**]; this should be correlated
clinically.
LENI [**2136-9-4**]: Deep vein thrombosis of both left posterior tibial
veins.
CTA chest [**2136-9-4**]:
1. Left lower lobe pulmonary embolus. Small left pleural
effusion with adjacent atelectasis.
2. Esophageal catheter with retained fluid and aeroselized
material in the proximal and mid esophagus. When clinically
feasible, upper GI study may be helpful.
3. Sequelae of aortic stenosis (now status post valve
replacement), including 4.1 cm ascending aortic dilation and
severe left ventricular hypertrophy. Extensive arterial
atherosclerotic
calcifications, including the coronary arteries.
4. Left PICC terminates at the top of the superior vena cava.
MRI head [**2136-9-11**]:
1. New subarachnoid and intraventricular hemorrhage with
associated enhancement in the subarachnoid space, in the
interpeduncular cistern and right ambient cistern, as well as
areas of scattered enhancement in the leptomeninges in the
vermis and right frontal lobe. Abnormal signal in the pons and
left medulla with intraparenchymal hemorrhage in the left
medulla. These findings could represent a combination of
hemorrhage as well as meningitis and encephalitis.
2. Slightly larger ventricular size when compared to the prior
examination of [**2133-2-7**]. While this could be due to global
cerebral volume loss, the possibility of communicating
hydrocephalus should be considered.
Microbiology:
+Varicella PCR on CSF at OSH (1.8 million copies -> <3000
copies)
[**2136-9-4**]: VZV PCR <500 copies, negative for HSV, negative [**Male First Name (un) 2326**]
Brief Hospital Course:
A/P:82 yo F with h/o dementia, HTN, AS s/p AVR ([**Hospital1 18**]),
vasculitis on mycophenolate (Cellcept), admitted [**2136-8-20**] to
[**Hospital3 2737**] with VZV encephalitis (1.8 million copies on
PCR) with course c/b ARF and worsening obtundation. Her repeat
LP here showed increased WBC in CSF, so she was started on IV
bactrim given concern for listeria meningitis by the ID team.
Patient also developed DVT/PE during this hospitalization likely
due to her immobility. Her respiratory status worsened with
desaturation to 70s on room air, requiring a nonrebreather and
transfer to ICU. Patient was also found to have new subarachnoid
hemorrhage and decision was made to transition her to comfort
care. Her pain was managed with morphine and her secretion was
managed with scopolamine patch and prn
hyocyamine/glycopyrrolate.
# Obtundation: Unclear if this was related to the patient's VZV
meningoencephalitis, as she reportedly improved with tx at OSH,
but became and remained obtunded throughout this hospital stay.
Review of reports from OSH showed imaging without signficant
acute new process and labs relatively unremarkable. Patient was
continued on acyclovir for treatment of VZV meningoencephalitis
and EEG was obtained to evaluate for seizures, which showed
slowing and PLEDs but no actual seizure activity. She was
started on Keppra and lacosamide was added to improve the EEG
without clinical improvement. Her initial MRI/MRA of head did
not show any evidence of CVA or enhancing area and no evidence
of vasculitis on MRI/MRA. Her repeat MRI on [**2136-9-11**] showed new
subarachnoid hemorrhage, and her anticoagulation for DVT/PE were
reversed, but upon discussion with her family, decision was made
to focus on comfort care given the poor prognosis.
# Pulmonary Embolus: patient developed worsening tachypnea on
[**2136-9-4**], doppler of legs showed DVT in left calf. Patient was
started on heparin and CTA was obtained, which showed left lower
lobe segmental pulmonary embolus. She was continued on heparin
gtt with bridge to coumadin. Her anticoagulation was reversed
when she was found to have subarachnoid hemorrhage.
# VZV meningoencephalitis: Patient received at least 7 days
acyclovir tx at OSH with reported initial improvement. At OSH,
acyclovir was discontinued due to ARF, but restarted a day later
when ARF resolved. Her CSF showed 1.8 million copies of VZV on
the initial LP, and subsequent LPs showed decreasing copies of
VZV (~2900 copies on LP from [**2136-8-30**], and <500 copies on
[**2136-9-3**]). Acyclovir was continued per ID recommendations.
Acyclovir was discontinued when decision was made to focus on
comfort care.
# ARF: Baseline 0.9 back in [**2132**]. Currently 1.1 per OSH reports,
but was up to 1.5 and attributed to acyclovir tx. Should be
noted patient was continued on celebrex daily as well. Also
possibly due to urinary retention, foley placed after retention
x2. Her creatinine remained stable around 0.7-0.8.
# History of PAN: Per her outpatient rheumatologist, patient had
a history of muscle biopsy proven polyarteritis nodosa 5-6 years
ago. Presented with abdominal/leg pains. Initially treated with
prednisone and methotrexate, but has been on cellcept for years
and doing very well, so dose has been weaned off. Cellcept was
held during this hospitalization given ongoing infections.
# HTN: Amlodipine increased to 10mg at OSH, but
antihypertensives held in house given ongoing infectious issues
and concern for sepsis.
# HLD: continued on home pravastatin 20mg, and discontinued when
decision was made to focus on comfort care.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from OSH.
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Amlodipine 2.5 mg PO DAILY
5. Bumetanide 0.5 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Psyllium 1 PKT PO Frequency is Unknown
8. CeleBREX *NF* (celecoxib) 200 mg Oral daily
9. Pravastatin 20 mg PO DAILY
10. Ditropan XL *NF* (oxybutynin chloride) 10 mg Oral daily
11. Fish Oil (Omega 3) 1000 mg PO BID
12. Timolol Maleate 0.25% 1 DROP BOTH EYES Frequency is Unknown
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES
Frequency is Unknown
14. Gentamicin 0.3% Ophth. Ointment Dose is Unknown BOTH EYES
Frequency is Unknown
15. Multivitamins 1 TAB PO DAILY
16. Vitamin E 400 UNIT PO DAILY
17. Ascorbic Acid 250 mg PO DAILY
18. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) unknown
Oral unknown
19. Mycophenolate Mofetil Dose is Unknown PO Frequency is
Unknown
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis: VZV encephalitis, deep vein thrombosis,
hospital acquired pneumonia
Secondary Diagnosis: dementia, aortic stenosis s/p tissue aortic
valve replacement, hypertension, polyarteritis nodosum
Discharge Condition:
expired
Discharge Instructions:
The patient was transferred from [**Hospital3 **] where she was
found to have VZV encephalitis (infection of the brain) because
she had worsening level of awakefulness. Repeat lumbar puncture
was done and showed that she still had a lot of white blood
cells, suspicious for infection. She were treated with acyclovir
and Bactrim was also added to treat possible infection with
listeria. Her course was also complicated by a pulmonary
embolism and then bleeding into the brain. After discussion with
family it was decided that given the grave medical issues
comfort measures would be more appropriate.
Time of death 5pm [**2136-9-15**]
Followup Instructions:
Expired.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 69324**]
ICD9 Codes: 486, 2761, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7699
} | Medical Text: Admission Date: [**2144-6-28**] Discharge Date: [**2144-7-2**]
Date of Birth: [**2060-9-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Cardiac tamponade
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
Ms. [**Known lastname 83057**] is an 83 yo female with IDDM, HTN, dyslipidemia and
h/o lung cancer s/p XRT and RLL resection who was taken to an
OSH by her family for increased SOB and found to be hypotensive
with a large pericardial effusion and RUL opacity on CT. She was
transferred to [**Hospital1 18**] for further workup and management of the
pericardial effusion.
.
Per family, she has had progressive SOB over the past month. At
baseline, she is a "couch potato" and does not leave the house
or exert herself much, but on the morning of admission stayed in
bed due to fatigue and told her family that she wanted to be
taken to the hospital. She has had a cough for several weeks,
which has sounded wet but not been productive of sputum or
blood. She has been clammy but the family denies F/C, N/V. She
has had decreased appetite but no weight loss.
.
On further review of systems, the family denies any prior
history of MI, syncope, stroke or TIA. Her husband does note
black stools recently, but in the setting of iron pills. She is
incontinent of urine at baseline. She is also occasionally
lightheaded at home.
.
At the OSH, she had negative LENIs and no PE on CTA. She was
started on ceftriaxone and azithromycin for ? RUL PNA.
.
In our ED, initial vitals were T 97.3, HR 103, BP 111/67, POs
100%. She was given 1.5L fluid, ondansetron, albuterol and
ipratroprium nebulizers. Bedside U/S showed a large effusion
with RV collapse and tamponade physiology. Pulsus paradoxus was
30-40. She was taken to the cath lab for pericardiocentesis.
.
In the cath lab, she was initially hypotensive. An arterial
groin line and venous groin line were place along with swan-ganz
catheter. Initial PCWP was 30mmHg. Pericardicentesis showed
initial pericardial pressure 30mmHg. 600cc of bloody fluid were
drained and the pericardial pressure decreased to zero. PCWP
post-procedure declined to 20mmHg. She was intubated due to
increased agitation and progression of her acidosis which was
thought to represent lactic acidosis. She received 2g zosyn in
the cath lab.
.
On arrival to the unit, she was sedated and intubated, with
stable blood pressures of SBP 130s.
Past Medical History:
CARDIAC RISK FACTORS: IDDM, Hypertension, Dyslipidemia
No past cardiac history
OTHER PAST MEDICAL HISTORY:
-h/o lung cancer (patient declined treatment upon diagnosis)
-Depression (no current meds)
-Parkinson's Disease with dementia
-hypothyroidism
-Anxiety
-s/p shoulder fracture [**2138**]
-s/p arm fracture [**2139**]
.
Social History:
Worked in a light bulb soldering and packaging factory for many
years.
-Tobacco history: Heavy smoker, quit [**2134**].
-ETOH: Family denies.
Family History:
No family history of lung cancer
Physical Exam:
VS: T= 97.1 BP= 139/76 HR= 94 RR= O2 sat= 100% on 40% FiO2
GENERAL: Sedated, Intubated.
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink.
NECK: Exam limited by large neck. JVD could not be appreciated.
CARDIAC: Exam limited by continuous rhonchi and soft heart
sounds but RRR appreciated. No thrill was appreciated.
LUNGS: Resp appear unlabored on vent, no visible accessory
muscle use. Diffuse, loud rhonchi and wheezes throughout. No
crackles appreciated on left lat decubitus exam.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abd bruits. +BS.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+
Left: Carotid 2+ Femoral 2+ DP 1+
Pertinent Results:
[**2144-6-28**] 06:05PM
8.4
10.8>----< 509
26.8
NEUTS-89.6* LYMPHS-6.1* MONOS-3.8 EOS-0.4 BASOS-0.2
PT-16.8* PTT-28.8 INR(PT)-1.5*
141 / 108 / 66
--------------
5.2 / 18 / 1.4
ANION GAP-20
CALCIUM-9.6 MAGNESIUM-2.9*
LACTATE-2.0
URINE RBC-0-2 WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0
BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15
BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-MOD
ABG: PO2-247* PCO2-38 PH-7.34* TOTAL CO2-21 BASE XS--4
TSH-1.5
%HbA1c-7.7*
Brief Hospital Course:
1. Cardiac tamponade-
On arrival, the patient was noted to have a large pericardial
effusion on bedside echo. She underwent pericardiocentesis in
the cath lab, with 600 cc bloody fluid drained, resulting in
normalization of systemic and pulmonary wedge pressures. Fluid
was sent for chemical and cytological analysis, and showed no
malignant cells. However, etiology of pericardial effusion is
most likely malignant, as patient has lung cancer diagnosed over
1 year ago for which she preferred no treatment. She remained
hemodynamically stable throughout course. Home BP meds (ACE)
were held for borderline blood pressures. A repeat echo on [**6-30**]
showed no evidence of pericardial fluid reaccumulation, with
normal RV chamber size and wall motion. LVEF was >75%.
2. RUL PNA-
CXR at admission showed right upper lobe pneumonia, likely
post-obstructive due to right upper lobe mass, and small right
pleural effusion. WBC was 12.5 at admission. The patient was
started on Levo/Flagyl for a 10 day course which will be
completed on [**7-7**]. Blood cultures were pending, sputum cultures
showed rare yeast and urine Legionella antigen was negative.
Patient remained afebrile throughout course and WBC trended down
to normal range. She was initially intubated
post-pericardiocentesis for agitation and increasing anion gap
metabolic acidosis, thought to be lactic acidosis. She was
successfully extubated, but continued to require high flow
oxygen and nebs prn. Family and patient were consulted regarding
possible pulmonary intervention (bronchoscopy +/- stenting) but
they declined in favor of non-invasive care moving towards
palliative care.
3. R pleural effusion-
Etiology may be malignant or infectious. Unlikely to be cardiac
etiology since echo showed normal EF and effusion was
right-sided only. Therefore, diuretics would likely not be
helpful, and were held in light of tenuous blood pressure.
4. UTI-
Urinalysis on admission showed 21-50 WBCs and moderate bacteria.
Patient was already on Levofloxacin for [**Last Name (LF) **], [**First Name3 (LF) **] no additional
antibiotics were started. Urine culture was negative.
5. Respiratory distress-
Patient was extubated successfully but required high Fi02 face
mask and nebs prn. Likely due to underlying COPD and lung
pathology, as well as post-obstructive PNA. Will continue to
oxygenate as needed and complete course of Levo/Flagyl as above.
6. Acid/base disturbance-
ABG post cath showed pH 7.26, down from 7.34 in ED with a
lactate of 1.3 and normal PCO2. Given hypotension in the setting
of cardiac tamponade, this likely reflected lactic acidosis
along with respiratory alkalosis in the setting of respiratory
distress. Acid-base status improved as vent settings were
adjusted accordingly. Her most recent ABG was from [**6-29**]- pH 7.34
CO2 41 O2 87.
7. CAD/HL-
No prior history of CAD and no CP during this episode. Cardiac
enzymes negative for ACS. Off simvastatin given comfort focus
of care.
8. Presumed ARF-
Baseline Cre unknown but was 1.4 at admission. A component of
prerenal ARF was likely given hypotension in setting of
tamponade. Creatinine trended down to 0.8 by discharge.
9.DM-2: Home basal lantus dose was continued with SSI coverage.
10. Speech/swallow- Patient is approved for thin liquids and
crushed or whole medications as tolerated.
Medications on Admission:
Lisinopril 20 mg PO daily
Carbidopa/Levodopa 25/100 mg PO qid
Vitamin B12 SR 1,000 mcg PO daily
Hydroxyzine 25 mg/mL IM syringe qhs
Lantus 45U SC daily at supper
Regular Insulin 20U SC daily at noon
Simvastatin 40mg daily
Synthroid 88mcg daily qam
Ferrous sulfate PO daily
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheeze, cough, SOB.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for wheezing.
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 6 days.
7. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 6 days.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
11. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
15. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
16. Insulin Lispro 100 unit/mL Solution Sig: SLIDING SCALE
Subcutaneous QACHS: see attached SLIDING SCALE.
17. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Tablet, Rapid Dissolve(s)
18. Promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for nausea.
19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5682**] Rehab & Nursing Center
Discharge Diagnosis:
Primary diagnosis: Pericardial tamponade
.
Secondary diagnoses:
- Primary lung cancer
- Pneumonia
- Pleural effusion
- Anemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because you were having
difficulty breathing. You were found to have a build-up of
fluid around your heart, so this fluid was drained. You also
had pneumonia which was treated with antibiotics, and fluid in
your lungs. All of these problems were most likely caused by
the cancer in your lungs.
.
You were started on two antibiotics, Levofloxacin and Flagyl.
You should keep taking these antibiotics for 6 more days. You
were also started on some medications to make you more
comfortable, including percocet for pain, Zofran and Phenergan
to help with nausea, trazodone to help you sleep and ipratropium
and albuterol to help with your breathing. You can keep taking
these medications as needed to make you more comfortable. We
stopped your lisinopril because your blood pressure has been
low, and stopped your simvastatin because it is no longer
necessary. We lowered your dose of Lantus insulin to 40 Units
because you are not eating as much. You should keep taking
carbidopa/levodopa, synthroid, Iron and Vitamin B12 because they
will help you feel better.
.
You are being discharged to a nursing facility.
Followup Instructions:
Please follow-up your primary care physician in about two weeks.
You can contact his office Dr. [**Last Name (STitle) 75078**] [**0-0-**]
Completed by:[**2144-7-2**]
ICD9 Codes: 486, 5119, 5990, 5849, 496, 4019, 2724, 2449 |
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