Split (1)

train · 498k rows

meta dict	text stringlengths 0 55.8k
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7700 }	Medical Text: Admission Date: [2140-2-17] Discharge Date: Date of Birth: [2095-7-18] Sex: M Service: Bone marrow transplant HISTORY OF PRESENT ILLNESS: This is a 44 year old male with [Location (un) 5622] chromosome positive acute lymphocytic leukemia, presents for allo bone marrow transplant protocol. He was initially diagnosed with [Location (un) 5622] chromosome acute lymphocytic leukemia in [2139-6-7]. He initially presented in [2139-5-7] with nausea, abdominal pain, weight loss, and sweats. At that time he also noted decreased vision in his left eye and was diagnosed with possible central vein occlusion. On [2139-7-2], his white blood cell count was noted to be 21,000. A bone marrow biopsy confirmed pre-B cell acute lymphocytic leukemia positive for [Location (un) 5622] chromosome. A lumbar puncture was positive for lymphoblasts. He was treated with AP0 induction chemotherapy and received 2400 rads of spinal irradiation. His hospital course following diagnosis was prolonged and he developed adult respiratory distress syndrome requiring two week intubation in the Intensive Care Unit. He then received a cycle of hyper Cytoxan, Vincristine, Adriamycin and Dexamethasone followed by Gleevec at 400 mg p.o. b.i.d. He was admitted [2140-2-5] for dehydration, at which time he was diagnosed with a sinus infection. He was noted to have recurrence on blasts in his peripheral smear on [2140-2-5]. He received Vincristine [2-6], Cytoxan [2-7], and Prednisone for seven days and was continued on Gleevec. He developed blurry vision on [2140-2-8], a head magnetic resonance imaging scan at that time was without abnormalities. An lumbar puncture on [2140-2-9] showed recurrence of leukemia in his cerebrospinal fluid and he has received three doses of Methotrexate, Solu-Medrol, Ara-C intrathecal chemotherapy ([2-10], [2-12], and [2-15]). He returns for intrathecal chemotherapy and a planned allo bone marrow transplant. He current denies nausea, vomiting, abdominal pain, shortness of breath, chest pain, fevers or nightsweats. PAST MEDICAL HISTORY: 1. Acute lymphocytic leukemia [Location (un) 5622] chromosome positive as described in history of present illness. 2. Sleep apnea. MEDICATIONS ON ADMISSION: Nexium, Ativan, Gleevec (which has been discontinued), Hydromorphone prn and potassium. ALLERGIES: Acetaminophen (hypotension). FAMILY HISTORY: No family history of cancer. SOCIAL HISTORY: Lives with is wife, on leave from the Air Force, no tobacco or ethanol use. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.9, pulse 104, blood pressure 118/72. General: Clinically ill-appearing middle-aged male, alert and oriented times three in no acute distress in no respiratory distress. Head, eyes, ears, nose and throat: Oral mucosa moist, oropharynx clear. Neck supple, no lymphadenopathy. Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops. Pulmonary: Clear to auscultation bilaterally. Abdomen: Normoactive bowel sounds, soft, nontender, nondistended, no masses. Extremities: No cyanosis or edema. 2+ dorsalis pedis bilaterally. Neurological: Cranial nerves II through XII grossly intact and symmetric bilaterally. 5/5 Strength throughout. Skin: No rashes noted. Line: Left Hickman, clean, dry and intact. LABORATORY DATA: Laboratory studies on admission revealed white blood cell count 0.9, granulocyte count 510, hematocrit 30.4, platelets 74. MCV 92. Sodium 139, potassium 2.4, chloride 103, bicarbonate 26, BUN 11, creatinine 0.6, glucose 99. ALT 186, AST 64, LDH 228, alkaline phosphatase 59, total bilirubin 0.5, direct bilirubin 0.1. Total protein 5.4, albumin 2.6, calcium 9.1, phosphorus 3.8, magnesium 1.6, uric acid 5.3. [2140-2-15], cerebrospinal fluid, 5 white blood cells, 23 red blood cells, 5 mono, 91% lymphocytes, 86% blasts, total protein 29, glucose 58. Gram stain, no polys, no microorganisms, fluid culture negative, fungal culture pending, acid fast bacillus culture pending. [2140-2-5], echocardiogram, left ventricular ejection fraction greater than 55%, trivial mitral regurgitation. HOSPITAL COURSE: 1. Acute lymphocytic leukemia [Location (un) 5622] chromosome positive - The patient received intrathecal Hydrocortisone, Vincristine, and Ara-C, given history of positive cytology from cerebrospinal fluid on [2140-2-17] and [2140-2-23]. The cytology of the fluid from [2-17] was positive for acute lymphocytic leukemia. The cytology from [2-23], cerebrospinal fluid showed atypical lymphoid cells. Although the patient has evidence of persistent leukemia in his central nervous system, it is hoped that the allo bone marrow transplant will induce a graft for his leukemia response that will eliminate residual disease. The patient had a bone marrow biopsy on [2140-2-19]. The viability of the cells obtained was limited, however, blasts were reported. Initiation of bone marrow transplant protocol was initially held due to elevated liver enzymes. As they began to normalize the protocol was initialized. At the time of dictation the patient is currently on day +3 of Cytoxan, Busulfan, Etoposide transplant protocol. During the receipt of Cytoxan the patient's electrocardiogram and urinalysis was monitored. His electrocardiograms remained with no change from baseline throughout protocol. The patient's urinalysis was noted to be positive for blood on [2140-3-1]. Given concern that the drip represented cyclophosphamide induced interstitial nephritis, the patient was aggressively hydrated and repeat urinalyses were negative. The patient's bone marrow infusion was delayed from the planned day of [2140-3-1] to allow time for clearance of cyclophosphamide. The patient received his infusion on [2140-3-2] which he tolerated without complications. The patient received his first dose of Methotrexate on [2140-3-3]. This is the last dose he will receive given severe mucositis. The patient was started on Cyclosporin drip per protocol and levels monitored and adjusted to goal Cyclosporin level of 500. 2. Febrile neutropenia - The patient had fever to 101 on [2140-2-27] at which time he was started on Cefepime and Vancomycin for febrile neutropenia. On that same day his blood pressure dropped to 70/40 with a heart rate of 130s, (baseline systolic blood pressure 100 to 120, heart rate 70 to 90). The patient responded well to normal saline boluses, and since that time the patient's heart rate and blood pressure have remained stable. Given that the patient remained afebrile with a stable blood pressure his antibiotics were discontinued on [2140-2-29]. The patient's efferent hypotension was thought to be secondary to VP 16 infusion rather than sepsis. However, on [2140-3-2], the patient again had a fever. At that time he was started on Cefepime. Vancomycin was added on [3-3] for persistent fever and Ambazone was added on [2140-3-4] for a persistent fever in the setting of Grade 4 mucositis. In order to allow improved control of anaerobe the patient was started on Flagyl on [2140-3-5]. 3. Mucositis - Ulcers were noted over his lips at admission with progressive swelling. He was started on Acyclovir orally initially which was changed to topical Acyclovir while he was receiving his chemotherapy. However, following his chemotherapy he developed severe mucositis with minimal response to gel clear, and bicarbonate rinses. The patient has required a Dilaudid PCA for pain controls. Hydrocortisone was added given concern that a history of head radiation in [2139-10-7] may be contributing to mouth inflammation. 4. Gastrointestinal - The patient was noted to have a transaminitis on admission. Possible causes include medication-related (although the patient was on new medication), leukemia, viral hepatitis, liver or gallbladder pathology. The patient received three days of Leucovorin given the concern for intrathecal Methotrexate toxicity. Additional workup included an ultrasound of his liver which showed no evidence of abnormalities in the gallbladder or biliary ductal system but showed fatty infiltration of his liver. Since that time, the patient's liver function tests have normalized. 5. Eye swelling - Shortly after admission, the patient was noted to have right medial eye swelling and erythema. Ophthalmology was consulted on [2140-2-19] who felt that this was not inflammatory although it could be early presacral cellulitis. They recommended closely monitoring, particularly given the patient's history of herpes zoster on his face and warm compresses. This medial eye swelling and erythema gradually improved over the course of the hospital stay. 6. Hematology - The patient's blood counts were supported with transfusion for hematocrit less than 30 or platelet less than 30 given severe mucositis. 7. Fluids, electrolytes and nutrition - The patient was started on total parenteral nutrition on [2140-3-3] given poor p.o. intake. The patient's ins and outs were closely monitored while receiving chemotherapy, and he was given intermittent Lasix. 8. Access - Surgery placed a right triple lumen catheter on [2140-2-17]. On [2140-2-18], Surgery repositioned the catheter as it was curled as a chest x-ray had shown that it was improperly positioned. The patient had a left Hickman catheter at the time of admission. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4380], M.D. [MD Number(1) 10999] Dictated By:[Last Name (NamePattern1) 6008] MEDQUIST36 D: [2140-3-5] 16:13 T: [2140-3-5] 16:34 JOB#: [Job Number 50600] ICD9 Codes: 5070, 5845
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7701 }	Medical Text: Admission Date: [2169-4-8] Discharge Date: [2169-4-14] Date of Birth: [2106-10-22] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Percocet / Codeine / Zithromax Attending:[First Name3 (LF) 458] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: This is a 62 year old diabetic woman with CAD s/p [2157] CABG (LIMA to LAD, SVG to D1, SVG to D2, SVG to OM. SVG to PDA), s/p catheterization in [2162] with LAD stent in [2162] and revealing occluded SVG to D1, SVG to D2, SVG to OM and patent LIMA and patent SVG to rPDA. Also with systolic CHF with EF 40-45%, PPM in [8-/2168], carotid stenosis/TIAs, and s/p living-related renal transplant in [2161-9-13] with baseline Cr 1.6--2.0. . She presented to [Hospital6 5016] on [2169-3-28] with complaints of of shortness of breath. Per the patient, she had been feeling worsening shortness over the prior few days to the point she could only take a few steps. She was ruled out for myocardial infarction by cardiac enzymes. She had elevated CK's but low MB fraction and negative troponins. The patient was noted to be anemic and received two unit packed RBC's. The patient was also noted to be hyperkalemic and hyponatremic; she was presumed to have aldosterone insufficiency and was, was placed on florinef and salt tablets. The patient was diuresed on a day to day basis and her oxygenation and volume status would improve with diuresis. Her volume status, however, would worsen soon after the diuretic wore off Today was in respiratory distress and hypoxic. Chest X-ray revealed pulmonary edema. Placed on non-rebreather, ABG 7.31/46/113. Patient given lasix 80mg IV and zaroxylyn with improved oxygenation. Concern was raised for new ischemic event leading to L heart failure and pulmonary edema. For this reason, transfer to [Hospital1 18] was requested for possible cardiac catheterization. . On arrival, the patient reports her breathing is still uncomfortable. She denies having had any chest pain the past few weeks but does report continued epigastric pain and nausea (also reported at the outside hospital). No palpitations or lightheadedness Past Medical History: type I diabtes s/p renal transplant as above hypertension congestive heart failure with EF 45% coronary disease s/p cabg and PCI as above symptomatic bradycardia s/p PPM bilateral carotid stenosis Severe gastroparesis. Bilateral internal carotid stenosis. History of colonic polyps. History of erosive gastritis. Tertiary hyperthyroidism. History of transient ischemic attacks. Nephrotic syndrome. Depression with panic attacks. Diabetic retinopathy s/p laser surgery, due to undergo more laser surgery . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Cardiac History: CABG, in [2157] anatomy as follows: LIMA to LAD, SVG to D1, SVG to D2, SVG to OM. SVG to PDA . Percutaneous coronary intervention, in anatomy as follows: . Pacemaker, in [8-/2168] for symptomatic bradycardia . Social History: SOCIAL HISTORY: 60 pack year history of tobacco use. Quit in [2161-9-13]. No ethanol use. Lives with at [Hospital3 ]. * Family History: FAMILY HISTORY: Diabetes, hypertension, and coronary artery disease. * Physical Exam: VS - T 98.9 P 70-80 BP 172/82 RR 26 O2 100% on NRB Gen: Elderly female in NAD. Oriented x3. Anxious. Mood, affect appropriate. Head: NCAT. Eyes: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, Mouth: MM dry No xanthalesma. Neck: Supple with JVP of 9 cm. CV: RR, normal S1, S2. No thrills, lifts. No S3 or S4. Chest: Poor air movement. CTAB, no crackles, wheezes or rhonchi. Mildly decreased BS at bases bilaterally Abd: Soft, mild epigastric tenderness. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 1+ Femoral 1+ Popliteal 1+ DP 1+ Left: Carotid 1+ Femoral 1+ Popliteal 1+ DP 1_ Pertinent Results: [2169-4-8] 08:32PM BLOOD WBC-5.8 RBC-3.95* Hgb-10.5* Hct-32.8* MCV-83 MCH-26.6* MCHC-32.1 RDW-16.1* Plt Ct-187 [2169-4-9] 05:46AM BLOOD WBC-5.4 RBC-3.63* Hgb-9.7* Hct-31.0* MCV-85 MCH-26.7* MCHC-31.3 RDW-16.1* Plt Ct-161 [2169-4-8] 08:32PM BLOOD Neuts-79.7* Lymphs-10.8* Monos-8.2 Eos-0.9 Baso-0.5 [2169-4-8] 08:32PM BLOOD PT-13.5* PTT-27.0 INR(PT)-1.2* [2169-4-9] 05:46AM BLOOD PT-14.6* PTT-28.0 INR(PT)-1.3* [2169-4-8] 08:32PM BLOOD Glucose-212* UreaN-58* Creat-1.8* Na-130* K-4.6 Cl-99 HCO3-21* AnGap-15 [2169-4-9] 05:46AM BLOOD Glucose-218* UreaN-59* Creat-1.9* Na-133 K-4.6 Cl-100 HCO3-23 AnGap-15 [2169-4-8] 08:32PM BLOOD CK(CPK)-155* [2169-4-9] 05:46AM BLOOD CK(CPK)-114 [2169-4-8] 08:32PM BLOOD CK-MB-5 cTropnT-0.09* [2169-4-8] 08:32PM BLOOD Calcium-9.9 Phos-4.3 Mg-2.0 [2169-4-8] 08:55PM BLOOD Type-ART Temp-37.2 O2 Flow-5 pO2-246* pCO2-46* pH-7.32* calTCO2-25 Base XS--2 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] . CHEST (PORTABLE AP) [2169-4-8] 7:58 PM CHEST (PORTABLE AP) Reason: Please evaluate for pulmonary edema [Hospital 93] MEDICAL CONDITION: 62 year old woman with CHF, CABG, in resp distress REASON FOR THIS EXAMINATION: Please evaluate for pulmonary edema CLINICAL HISTORY: Respiratory distress status post CABG. CHEST The heart is enlarged. Bilateral pleural effusions present. There is a general pulmonary plethora consistent with cardiac failure. IMPRESSION: Acute cardiac failure. . EKG: NSR at rate 70-80, Axis 40, PR prolongation at 200 ms, QT prolongation 160 ms, STD in aVL v4-6 are old. No significant change from EKGs at OSH Brief Hospital Course: #) Acute exacerbation of CHF (EF 45%): This was likely secondary to excess Sodium load at OSH. We also believe that her hypertension also a likely contributer. Initially she was difficult to diurese and required a lasix drip. She improved with removing fluid as well as afterload reduction. She was maintained on a fluid restriction and her blood pressure medications were titrated. She was diuresed on lasix 80 mg [Hospital1 ] but her creatinine increased to 2.2 after a day in which she was negative about 1 [Last Name (LF) ], [First Name3 (LF) ] she was discharged on 40 mg [Hospital1 ]. She should have ins and outs monitored (with goal of running even +400 ccs for insensible losses), vs strict daily weights (goal to maintain current fluid status) to monitor fluid balance. A chest x-ray was performed on the day of discharge to establish her current pulmonary status, for the purposes of outpatient follow-up by her outpatient providers. . #) CAD s/p CABG: Cardiac cath in [2162] showed LIMA to LAD and SVG to R-PDA patent, SVGs to OM, D1, D2 occluded. She was continued on continued on ASA, plavix, lipitor and carvedilol. Her ACEi was stopped because of some mild renal failure, as recommended by the renal transplant team. Her repeat echo showed mild regional left ventricular systolic dysfunction with severe hypokinesis/near akinesis of the inferior and inferolateral walls, consistent with 1 vessel CAD. This seemed consistent with her previous P-MIBI study, showing a fixed wall defect. She was monitored on telemetry and had no major events; she does have periodic PVCs. . #) Chronic kidney disease/Hyponatremia: s/p LRRT in [2160] with baseline Cr 1.6-2. She was followed in house by the renal transplant team. Her ACEi was stopped as noted above because of mild renal failure. She was continued on her prograf and prednisone, and tacrolimus levels were followed in house. She was discharged on 3 mg of tacrolimus q12 hours. She will follow up with her transplant nephrologist on [4-24]. In terms of her hyponatremia, this was resolving at the time of discharge given correction for high glucose. The most likely explanation for her dip in sodium is CHF, given that urine lytes were not consistent with SIADH. However, because of this possible effect of citalopram, her dose was decreased as this may have been contributing. . Her creatinine rose to 2.2 on the day of discharge, likely secondary to aggressive diuresis as above. Her lasix dose was reduced to 40 mg a day [Hospital1 ] on the recommendation of the renal transplant team. Additionally, with concern that she could have a UTI, a U/A and urine culture were sent. The results of these tests should be available the day after discharge and should be followed up by her rehabilitation facility team. Additionally, CCU housestaff will track these results and endeavor to notify the receiving facility of abnormal results. . Laboratory tests (Electrolytes and tacrolimus level) need to be drawn on Tuesday and faxed to [Telephone/Fax (1) 697]. . #) Physical therapy: She was weak and did slip once, without injury or other sequelae. Physical therapy evaluated her and recommended physical therapy and rehabilitation services in an inpatient rehabilitation facility. A walker was recommended for ambulation. . #) HTN: Blood pressure was labile in house. Her imdur was stopped and she was started on amlodipine and carvedilol . #) DM: Continued lantus . #) Seizure disorder: continued phenytoin 100 qAM, 200 qPM . #) Gastroparesis: continued reglan . #) Depression, continued celexa, prn seroquel . #) Code: Full, confirmed with daughter . #) Communication: [First Name8 (NamePattern2) 803] [Last Name (NamePattern1) 92034]; relationship: Daughter. Phone: [Telephone/Fax (1) 92035]. . #) Disposition: to rehabilitation facility. Medications on Admission: 1. Clopidogrel 75 mg daily. 2. Aspirin 325 mg E.C.daily. 3. Atorvastatin 80 mg PO Daily. 4. Carvedilol 12.5 mg PO BID. 5. Isosorbide Mononitrate 60 mg Tablet SR daily. 6. Nitroglycerin 0.3 mg Tablet, PRN 7. Furosemide 20 mg PO Daily. 8. Lisinopril 5 mg PO Daily). 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Lantus 24 units SC qHS 11. Prednisone 5 mg PO daily. 12. Tacrolimus 1 mg PO Q12H 13. Phenytoin Sodium Extended 100 mg QAM, 200 mg qPM. 14. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 15. Gabapentin 300 mg PO TID. 16. Citalopram 40 mg PO daily 17. Pantoprazole 40 mg E.C. PO Q24H. 18. Metoclopramide 10 mg PO TID. 19. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID as needed. 20. Calcitriol 0.25 mcg PO every Other day 21. Iron 325 daily. . On transfer the patient was also on 1) NaCL tablet 1 g [Hospital1 ] 2) Florinef 0.1 mg PO daily 3) Nephrocaps she was not on lisinopril metoprolol 25 [Hospital1 ] carvedilol Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual PRN. 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24) units Subcutaneous at bedtime. 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 10. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)). 11. Quetiapine 25 mg Tablet Sig: 0.5-1 Tablet PO HS (at bedtime) as needed. 12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 17. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 20. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Location (un) ] House Nursing Home - [Location 9583] Discharge Diagnosis: acute on chronic systolic CHF EF 45% acute on chronic renal failure s/p transplant CAD DM2 with complications HTN Discharge Condition: Stable, comfortable on room air Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1L daily . You were admitted for fluid overload called congestive heart failure. You were given medications to help remove the fluid on your lungs. Please take your medications as prescribed. -We increased your dose of carvedilol -We stopped your Imdur -We stopped your lisinopril -Your prograf (tacrolimus) dose is 3 mg twice daily -Your dose of lasix is now 40 mg twice daily -We decreased your citalopram dosing . Please follow up as directed below. Please call your physician or go to the emergency room if you have fevers over 102, chest pains, trouble breathing, lightheadedness or any other symptoms which are concerning to you. Followup Instructions: Please schedule follow up with Dr. [Last Name (STitle) ] [Name (STitle) 4922], your cardiologist, within 1 month after hospital discharge . Please call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 12551] and schedule a follow up appointment in 2 weeks. . Please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 20417] on Monday [4-24] at 3:40PM. ICD9 Codes: 5849, 2761, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7702 }	Medical Text: Admission Date: [2128-7-31] Discharge Date: [2128-8-5] Date of Birth: [2101-4-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 358] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: [2128-7-31] EGD [2128-7-31] L PICC placement History of Present Illness: 27M with C5 quadripelegia, DVT s/p IVC filter not on anticoagulation, duodenal AVMs/PUD, with recent [Hospital1 18] admission for hematemesis on [7-10], found to have GDA pseudoaneurysm with communication to pacreatic duct s/p IR embolization, who presented with 3 days intermittent dark hematemesis. . Regarding the patient's recent admission, after 6 episodes of hematemesis, he underwent MRCP demonstrating a large GDA pseudoaneurysm with mass effect on the pancreatic head, as well as chronic pancreatitis. EGD on [7-13] showed 2 ulcers and hemobilia from the major papilla. He subsequently underwent successful IR guided embolization on [7-15]. Throughout his admission he required 3 units PRBCs for "autonomic instability." His Hct stabilized at 30 prior to discharge. . On admit, Mr. [Known lastname ] c/o 3 episodes of hematemesis, the first episode being 4 days PTA, and the last 2 episodes on the AM of admission. Could not quantify amount. Also of note, he reports "dark stool" for the last 3-4 days. The first episode of vomitting he describes as more coffee ground, with subsequent episodes darker. He also noted lightheadedness. . In the ED, VS T 100.6, HR 110, BP 123/84, RR 16, 100%RA . NGT lavage expressed dark red fluid which cleared with 500ml saline. 2 large bore PIV were placed and IV protonix was given. His Hct was 29.1 on transfer. He was given 2L NS, as well as morphine and ativan . MICU course: Endoscopy was performed on admission which showed [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tear without evidence of active bleeding. Repeat thrombin injection via IR-guidance into pseudoaneurysm, without evidence of active bleeding. Hct trended down to 19 after the procedure from admission hct of 29, and patient transfused two units pRBC with appropriate bump in hct to 27, and then up to 29 in 12 hours without further transfusion. Patient without further episodes of hematemesis. He was continued on protonix IV bid, and had a CTA performed to evaluate for presence of aneurysm, which showed resolution. He is transferred to the floor for further hct monitoring. Currently has no complaints. Denies abdominal pain, fevers, chills, hematemesis, BRPBR, melena. Past Medical History: -UGIB secondary to GDA pseudoaneurysm s/p IR embolization -PUD (gastric/duodenal) -Chronic Pancreatitis -C5 traumatic fracture sustained in diving accident with resultant quadriplegia -Autonomic Instability -s/p splenectomy for splenic rupture in [2124] -LE DVT s/p IVC filter which is now clotted -MRSA bacteremia in [6-19], finished course of Bactrim -Recurrent UTIs; pt has indwelling suprapubic catheter [1-16] quadriplegia Social History: Previous EtOH - none since 5/07 per patient Cocaine abuse - 2x/month. none since 5/07 per patient 1 pack per week cigarettes. denies IVDU Family History: Mother died of breast cancer. Grandmother with gastric cancer. Physical Exam: VS: AF, VSS Gen: Appears well. NAD. Skin: mildly diaphoretic. HEENT: MMM. no ulcers. Hrt: RRR. Lungs: CTAB no RRW Abd: Soft. Nontender. Multiple well healed scars. Ext: Bilateral ankle edema 2+. Pertinent Results: [2128-7-30] 10:45PM WBC-22.3# RBC-3.42 HGB-9.3* HCT-29.1* MCV-85 MCH-27.3 MCHC-32.1 RDW-18.5* [2128-7-30] 10:45PM LIPASE-89* [2128-7-30] 10:45PM ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-99 AMYLASE-79 TOT BILI-0.5 [2128-7-31] 03:37AM PT-15.7* PTT-31.5 INR(PT)-1.4* [2128-7-31] 04:49AM URINE BLOOD-LGE NITRITE-POS PROTEIN-100 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-MOD [2128-7-31] 01:13PM HCT-23.6* [2128-7-31] 07:17PM HCT-23.2* [2128-7-31] 08:05PM HCT-22.3* [2128-7-31] 10:53PM HCT-22.5* [2128-7-31] EGD: Esophagus: Excavated Lesions [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Doctor Last Name ] tear with stigmata of recent bleeding was seen in the cardia and gastroesophageal junction. It was well healed and would have little chance of rebleeding. Stomach: Normal stomach. Duodenum: Normal duodenum. Other findings: No blood in duodenum in the area of the ampulla. This area was observed closely. Impression: [Doctor First Name ]-[Doctor Last Name ] tear. No blood in duodenum in the area of the ampulla. This area was observed closely. Otherwise normal EGD to second part of the duodenum . [2128-8-1] CT abd/pelvis without contrast: This is a technically limited study due to the lack of oral and intravenous contrast material. There may possibly be a small hematoma near the site of pseudoaneurysm clipping although this is an indefinite finding. No large hematoma is identified nor is there evidence of large fluid collections or abscesses. . [2128-8-4]: CTA abdomen: 1. No evidence of previously identified GDA pseudoaneurysm status post thrombin injection. 2. Stable findings of pancreatic ductal dilatation and peripancreatic fluid collections. 3. Stable retroperitoneal lymphadenopathy as noted above. [2128-8-5] 06:40AM BLOOD WBC-10.1 RBC-3.31* Hgb-9.4* Hct-28.7* MCV-87 MCH-28.5 MCHC-33.0 RDW-17.2* Plt Ct-558* [2128-8-1] 04:28AM BLOOD PT-14.6* PTT-32.8 INR(PT)-1.3* [2128-8-5] 06:40AM BLOOD Glucose-92 UreaN-4* Creat-0.4* Na-134 K-3.8 Cl-97 HCO3-26 AnGap-15 [2128-8-1] 04:28AM BLOOD ALT-10 AST-13 LD(LDH)-119 AlkPhos-69 Amylase-23 TotBili-1.5 [2128-8-1] 04:28AM BLOOD Lipase-25 [2128-8-4] 04:19AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.9 [2128-8-2] 02:45AM BLOOD Hapto-217* URINE CULTURE (Final [2128-8-6]): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # [Numeric Identifier 73776] [2128-8-4]. URINE CULTURE (Final [2128-8-2]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. Brief Hospital Course: * Patient left AMA, although hematocrits were stable, no follow up was arranged prior to his departure. 27 M with C5 quadripelegia, splenectomy, DVT s/p IVC filter, and recent UGIB with PUD and a GDA pseudoaneurysm s/p IR embolization admitted with 3 days dark hematemesis. . #. Hematemesis: The patient was kept NPO and started on an IV PPI [Hospital1 ]. An NGT was placed with dark red blood which cleared with normal saline lavage. Patient had serial hcts q6 hour initially with admit hct of 29, down to 19 after procedure, which then responded appropriately to 2u pRBC. EGD showed a well-healing [Doctor First Name ]-[Doctor Last Name ] tear with stigmata of recent bleeding in the cardia and gastroesophageal junction. This was thought to have a low likelihood of rebleeding. CT of the abd/pelvis on [2128-8-2] showed evidence of persistent GDA ANR which was treated with repeat thrombin injection. CTA post-procedure showed resolution of the aneurysm. -Continue PPI [Hospital1 ] - change to po BID. . #. Leukocytosis: Admission value of 22.3, but trending down during hospital course. Has history of UTI and MRSA bacteremia and UA suspicious for infection, with culture growing CNSA. Received several doses of ciprofloxacin initially, but d/c'd in setting of culture results. Given that HD stable, felt to be colonizer, suprapubic cath changed. Also low grade temps over the past few days. . #. Scrotal tear. Patient noted scrotal tear to RN, but unable to examine currently because friends in room. Treated with wound care, dressing changes. . #. Chronic Pancreatitis: Diagnosed on prior imaging. Has significant EtOH history. LFTs unremarkable. Pancreatic enzymes slightly increased on admission, trended down throughout stay. No pain secondary to quadraplegia. . #. Quadripelegia/Autonomic dysfunction: Has prior record of diaphoresis and shaking chills due to autonomic instability, without significant symptoms during this stay. . #. DVT s/p IVC filter: Occurred in [2119*]. IVC filter currently clotted off. Not on anticoagulation given recent GIB. . Medications on Admission: Meds (on admission) Acetaminophen 325 mg PO Q6H Pantoprazole 40 mg PO Daily Docusate Sodium 100 mg PO BID Senna 1-2 Tablets PO BID Valium prn (unsure of dose) Ritalin prn (unsure of dose) . Meds (on transfer) Tylenol Bisacodyl Ativan prn Morphine prn Zofran prn Pantoprazole 40 mg IV q12h Reglan Senna Discharge Medications: Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 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 Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every [5-21] hours as needed for pain for 5 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: hematemesis Discharge Condition: stable Discharge Instructions: Pt left AMA Followup Instructions: Pt left AMA ICD9 Codes: 2851, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7703 }	Medical Text: Admission Date: [2116-6-1] Discharge Date: [2116-6-7] Date of Birth: [2049-10-12] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Lovastatin Attending:[First Name3 (LF) 922] Chief Complaint: CP & SOB Major Surgical or Invasive Procedure: CABG X 3, pericardial stripping on [2116-6-3] History of Present Illness: 66 y/o male s/p cardiac cath, presented to ED w/CP. Workup revealed possible constrictive pericarditis (and know CAD from cath). He was transferred to [Hospital1 18] for surgery. Past Medical History: HTN Gallstones Chronic sinusitis hypothyroid s/p melanoma excision prostate ca s/p surgery Social History: retired ETOH: few per week Denies tobacco Family History: father w/CAD Physical Exam: Unremarkable upon admission Pertinent Results: [2116-6-4] 02:31AM BLOOD WBC-10.9 RBC-3.97* Hgb-11.8* Hct-34.4* MCV-87 MCH-29.7 MCHC-34.4 RDW-13.3 Plt Ct-183 [2116-6-4] 02:31AM BLOOD PT-12.3 PTT-26.6 INR(PT)-1.0 [2116-6-4] 11:55PM BLOOD Glucose-125* UreaN-20 Creat-1.4* Na-141 K-4.4 Cl-104 HCO3-29 AnGap-12 [Last Name (LF) ], [First Name3 (LF) 177] [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2049-10-12] Age (years): 66 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: CABG ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.1, 424.0 Test Information Date/Time: [2116-6-3] at 11:58 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3318], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW3-: Machine: aw3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Aorta - Ascending: 2.8 cm <= 3.4 cm Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Mildly depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate ([2-5]+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is mildly depressed (LVEF= 40 - 45%). with mild global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([2-5]+) mitral regurgitation is seen. There is no pericardial effusion. Post- CPB: Patient is AV paced on no pressors or inotropes. Good biventricular systolic fxn. EF now 50 - 55%. AI unchanged. MR remains 1 - 2+. Aorta intact. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD, Interpreting physician [Last Name (NamePattern4) ] [2116-6-3] 13:55 Brief Hospital Course: Transferred to [Hospital1 18] from outside hospital. Underwent echo, cardiac MRI, and routine pre-operative evaluation. He was taken to the OR on [2116-6-3], and underwent CABG X 3, and pericardial stripping (please see operative report for details of procedure). Post-operatively, he was taken to the ICU on IV NTG gtt. He was extubated the evening of surgery, weaned off NTG, and was transferred to the telemetry floor on POD # 1. On POD # 2, his chest tubes and epicardial pacing wires were removed, and he began to progress with ambulation. POD # 3 Pt stable - could not move bowels, bowel regime given. Moved Bowels. POD # 4 pt stable for DC. Medications on Admission: ASA 81' Verapamil 240' Synthroid 0.1' Lasix 20' Claritin Viagra Lovenox NTG Ambien Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:40 Tablet(s) Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 ] care Discharge Diagnosis: CAD constrictive pericarditis HTN hyperlipidemia nephrolithiasis Discharge Condition: good Discharge Instructions: no creams, lotions or powders to any incisions no lifting > 10# for 10 weeks shower daily, no swimming or bathing for 1 month no driving for 1 month Followup Instructions: With Dr. [Last Name (STitle) 78249] in [3-8] weeks With Dr. [Last Name (STitle) 78250] in [3-8] weeks With Dr. [Last Name (STitle) 914] in 4 weeks Completed by:[2116-6-7] ICD9 Codes: 4111, 4019, 2449, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7704 }	Medical Text: Admission Date: [2117-4-8] Discharge Date: [2117-4-14] Date of Birth: [2058-8-26] Sex: M Service: CARDIOTHORACIC Allergies: Ampicillin / Typhoid Vaccine Attending:[First Name3 (LF) 1267] Chief Complaint: Worsening chest pain. Major Surgical or Invasive Procedure: Coronary artery bypass graft x 3 History of Present Illness: This is a 58 yo male patient with no history coronary artery disease who reports progressive chest pain. Cardiac catheterization revelaed EF 50%, RCA 100% occlusion, pLAD 80% occlusion, mLCx 100% occlusion, D1 60% occlusion, and D2 70% occlusion. He was then referred to Dr. [Last Name (STitle) ] for CABG. Past Medical History: Diabetes type 2. Hypertension. Silent MI. Depression. Anxiety. Migraines. Sleep apnea. Diverticulitis s/p GI bleed in [2116]. Hyperlipidemia. Strabismus, s/p many surgeries. Elbow surgery. Tonsillectomy. Penile implant. Social History: Lives with wife and three children in [Name (NI) 61358], MA. Works as credit collection manager. Tobacco: quit 12 years ago -- [3-4] ppd prior to that. ETOH: Never. Physical Exam: On presentation: Ht: 5'8" Wt: 250 pounds. VS: HR 66 BP 190/70 right 185/68 left General: Anxious, well appearing in NAD. Neuro: CN II -XII intact. Chest: CTA bilaterally. CV: RRR II/VI SEM. Abd: Obese, soft, NT, ND, + BS. No paplable masses. Extremities: Warm, well perfused. No edema, no varicosities. No carotid bruits noted. Pertinent Results: [2117-4-13] 06:15AM BLOOD WBC-4.3 RBC-3.64* Hgb-11.2* Hct-32.7* MCV-90 MCH-30.9 MCHC-34.4 RDW-13.0 Plt Ct-277# [2117-4-13] 06:15AM BLOOD Plt Ct-277# [2117-4-11] 05:30AM BLOOD Glucose-81 UreaN-27* Creat-1.3* Na-140 K-4.3 Cl-107 HCO3-27 AnGap-10 Brief Hospital Course: Mr [Known lastname 61359] was admitted on [2117-4-8]; the morning of his operative day. He proceeded directly the operating room. He underwent a coronary artery bypass graft x 3 with LIMA to the LAD, SVG to the RCA, and SVG to the Diag. He was transferred to the cardiac surgery recovery unit. He was weened and extubated on the evening of his operative day.On post-op day one he was transferred to the inpatinet floor for ongoing management and recovery. On the evening of post-op day two he had an acute episode of anxiety versus psychosis, thourgh metabolis cause could not be ruled-out. A thorough work-up revealed no obvious cause and by morning Mr. [Known lastname 61359] was alerat and oriented and significantly less anxious. On post-op day four, patient's blood pressure continued to be elevated iwth increase in his lopressor. He had no furtehr episodes of confusion or agitation. Post-op day five was significant for ongoing hypertension with increase in both his lopressor and valsartan. He also progressed with physical therapy and was cleared (from their standpoint) to be discharged home. On post-op day six ([4-14]) it was decided that he was safe for discharge home. Medications on Admission: Imdur 60 daily. Celexa 40 dialy. Atenolol 50 daily. Actos 45 daily. Lipitor 80 daily. Diovan 320 daily, Omeprazole 20 daily. Glyburide/metformin 2.5/500 [Hospital1 ]. Diclofenac 75 daily. Nitrostat PRN. 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. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 4. Pioglitazone HCl 45 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 6. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed. Disp:60 Tablet(s) Refills:0 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:28 Tab Sust.Rel. Particle/Crystal(s) Refills:0 9. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 10. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 11. Glyburide-Metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Coronary artery disease; s/p coronary artery bypass graft x 3. Discharge Condition: Stable Discharge Instructions: No heavy lifting -- greater tha 10 pounds. No driving x 6 weeks. No swimming or tub bathing. You should shower daily and wash incisions with soap and water; rinse well; pat dry. Do NOT apply any creams, lotions, powders, or ointments to incisions. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) 1112] [Name Initial (NameIs) ]. [Telephone/Fax (1) 170] Follow-up appointment should be in 1 month Provider: [Name10 (NameIs) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10984] [Telephone/Fax (1) 13254] Follow-up appointment should be in 1 week Completed by:[2117-4-14] ICD9 Codes: 4111, 4019, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7705 }	Medical Text: Admission Date: [2155-4-23] Discharge Date: [2155-4-23] Date of Birth: [2155-4-23] Sex: F Service: Neonatology DISPOSITION: Patient was transferred to [Hospital3 1810]. HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname 48419]-[Known lastname 22371] was admitted to the Newborn Intensive Care Unit at [Hospital6 1760] for a cardiac evaluation. She is a full term infant, birthweight 3,500 gm, delivered to a 32 year old gravida 3, para 1 mother. Prenatal screen: Blood type 0 positive, antibody screen negative, Rubella immune, RPR nonreactive, Hepatitis B surface antigen negative, Group B Streptococcus negative. Pregnancy was reported to be unremarkable except for a nonreactive nonstress test noted on the day prior to delivery, [4-22]. Delivery was unremarkable. Normal spontaneous vaginal delivery with Apgars of 7 and 9. On evaluation in the Newborn Nursery the baby was noted to have a cardiac murmur and was transferred to the Newborn Intensive Care Unit for evaluation. Oxygen saturation on admission to the Intensive Care Unit was 60% in room air. She also failed a hyperoxia test with an arterial blood gas, (post ductal) of 7.36, pCO2 of 43 and pO2 of 41 in 100% oxygen. Her chest x-ray revealed a normal cardiothymic silhouette. Electrocardiogram was unremarkable and oxygen saturation went up to 80 to 90% over the course of the admission. Supplemental O2 was not given because of concern regarding a possible duct dependant lesion. PHYSICAL EXAMINATION: The baby was noted to be pale, alert, in no respiratory distress. Color was pale pink with borderline perfusion noted. Oxygen saturations were in the mid 80s at the time of examination. Head, eyes, ears, nose and throat, anterior fontanelle was soft and flat. Sutures were mobile. Red reflexes were present bilaterally. Palate was intact. Respiratory examination was unremarkable. Cardiac examination was remarkable for a II/VI low pitched murmur at the lower sternal border, question of a gallop was noted. Pulses were 1+ with borderline perfusion. Abdominal examination was unremarkable with no organomegaly appreciated. Genitourinary examination, normal female. Neurological examination, tone was in the low normal range. The baby was responsive but not very active. HOSPITAL COURSE: As noted the Cardiology Consult Service from [Hospital3 1810] was consulted and recommended a cardiac echocardiogram. The echocardiogram revealed severe left ventricular dysfunction as well as mild mitral regurgitation, a patent ductus arteriosus, moderate right ventricular dysfunction, no pericardial effusion was noted, but pleural effusions was noted to be present bilaterally. The baby was transferred to [Hospital3 1810], Pavilion 6 for serial echocardiograsm to follow cardiac function. The baby also had a complete blood count performed, results revealed white blood cell count 21,800, platelet count 277,000. Hemoglobin 16.9, hematocrit 51.3%. A blood culture was performed, results were no growth, 12 nucleated red blood cells per [Pager number ] cells were also noted. The baby was started on ampicillin and gentamicin prior to transfer on intravenous fluid of D10/W 60 cc/kg. The baby was transferred to [Hospital3 1810]. The consulting cardiology attending was Dr. [Last Name (STitle) ] [Name (STitle) 48420]. CONDITION ON DISCHARGE: Critical. DISCHARGE DISPOSITION: Transfer to [Hospital3 1810], primary pediatrician is at [Hospital3 43089] Pediatrics. DISCHARGE DIAGNOSIS: 1. Term infant 2. Congenital heart disease with severe left ventricular dysfunction and moderate right ventricular dysfunction of unclear etiology 3. Rule out sepsis [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37237], M.D. [MD Number(1) 37238] Dictated By:[Last Name (NamePattern4) 41252] MEDQUIST36 D: [2155-4-30] 16:02 T: [2155-4-30] 18:00 JOB#: [Job Number 48421] ICD9 Codes: 5119, 4254, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7706 }	Medical Text: Admission Date: [2170-10-14] Discharge Date: [2170-10-18] Date of Birth: [2089-11-20] Sex: F Service: NEUROLOGY Allergies: Penicillins Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Headache Major Surgical or Invasive Procedure: None History of Present Illness: PER ADMITTING RESIDENT: 80 y/o RHF with PMH sig for HTN presenting with 2 day history of sudden global "leaking like" HA [9-13]. The HA started suddently on Friday PM and she took No HA meds taken at home. She went to bed early for her (11pm) on Friday night and still awoke with the same HA. She tried to lie down and keep still to relieve the pain. Pt was noted to have nausea this AM only dry heaving. She was taken to OSH in which her BP 180/90 she was given Labetalol 10mg per written note and Diuladid 0.5mg and was planned to start on a Labetalol drip. IVF were rendered. The HA subsided to [7-13] upon arrival to [Hospital1 18] ER. VS AF HR 59 BP 177/70 RR 16 O2 99% on RA. Pt has a known history of HTN since [2158]. She is complaint on her meds. Her meds were recently changed. She states that her atenolol was 25mg qday yet decreased to 12.5mg due to her low HR. Then while she was on 12.5mg she was noted to have epitaxis on several occasions. So her ASA 325mg was decreased to 81mg. her BP was "running high" so she was increased back to Atenolol 25mg qday. Per her daughter-in-law, she sometimes does not like to take her lasix due to the increased urination. Neurology consult was called. NO BP correction was done yet. She was started on a Nicardipine gtt due to her known low HR. No additional anagelesics were given. During the exam she had some additional nausea when standing her up during the physical exam and a STAT repeat HCT was obtained which showed an increase in size of the L frontal ICH3->4cm, intraparenchymal hemorrhage and + SAH without IVH spread or midline shift. ICU admission was arranged. Neurosurgery was consulted. No surgical intervention at this time. PERTINENT +: Nausea PERTINENT -: No head trauma, no visual changes, no photophobia, no phonophobia, no weakness, no changes in sensation, no coumadin usage, hx of migraines Past Medical History: - HTN since [2158] - Knee sx s/p MVA - "Had to have a spinal tap x1 to relieve HA pressure" - Epistaxis starting in [9-11]. Most recent episode of epistaxis was 7 days ago. - Bradycardia Social History: - Lives independently. - Had 2 sons. 1 died from HTN. Family History: - HTN - son who died in his 50s - MI - 65 y/o brother Physical Exam: ON ADMISSION: O: T: AF 97.8 BP: 177/770 HR: 59 R 16 99% on RA O2Sats Gen: WD/WN, comfortable,eyes closed in slight distress HEENT: No traumatic insults Pupils: EOMs Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. No murmurs, NO bruits Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Bilateral UE 3+ edema Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date with cues Recall: [1-6] objects at 5 minutes with cues Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Difficulty with 7qtrs calc yet she is normally able to handle her own finances. Pt also was delayed in answering questions. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-8] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 0 0 Left 2 2 2 0 0 Difficult to obtain LE reflexes due to edema Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin GAIT: Steady on feet yet became nauseous with standing and moving around CT noon repeat ~ 4hrs after the initial OSH HCT showing 3cm ICH in the L frontal area, IND inc nausea RESULTS- increase in size of the L frontal ICH3->4cm, intraparenchymal hemorrhage and + SAH without IVH spread or midline shift. LABS: Assessment/Plan: 80 y/o RHF with PMH sig for HTN pres with 2 day hx of sudden global HA with Nausea found to have a ICH - 3cm L frontal at an OSH with interval inc in ICH within 4hr with SBP 180-170. On PE, she is noted to have slightly diminished mentation and nml neuro exam otherwise. She took her meds yet doses were modified recently with and without her PCP. [Name10 (NameIs) ] her ASA, which have impaired her platelet fxn. She has a hypertensive intraparenchymal hemorrhage with mild increase in size in the setting of continue HTN. Admit to NeuroICU Attg: [Doctor Last Name ] Cont Nicardipine gtt goal SBP 120-160. Aim for 140s Repeat HCT in 12hrs ([2170-10-15] at MN) to compare ICH progression Neuro checks q1. If neuro exam changes obtain a stat HCT to eval for herniation. Neurosurgery consult completed and appreciated - plt transfusion rec. No neurosurgical intervention at this time. Will continue to follow. Platelet transfusion 1 packet x1 due to ASA adm yesterday Tylenol PRN HA NO narcotics for pain due to masking signs of Inc ICP NPO [2170-10-14] until HCT obtain and stable for possible neurosurgical intervention Zofran 4mg PRN N/V AM CBC, BMP, Coags Plan d/w ICU Resident, RN and family CODE STATUS - DNR ONLY PRESSORs NO intubation, NO cardioversion I have reviewed this case with Dr [Last Name (STitle) ], Neuro Attg, who reviewed the above formulated plan. [Name6 (MD) 84722] [Name8 (MD) ], MD Neurology Resident [Numeric Identifier ] Addendum by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD on [2170-10-14] at 7:59 pm: Patient was seen and examined. Agree with Dr.[Name (NI) 84723] note, exam, impression, and plan on [2170-10-14] with additions to the plan noted below. Patient is a 80 year old right handed woman hx of HTN and epistaxis who reports onset of severe headache on [10-13] at 11pm. The correct date was given by her son (patient said that the headache started on [10-12]. This headache was diffuse, and associated with nausea, and dry heaving, but not vomiting. She was unable to sleep during the night. At 5am on [10-14], her son took her to [Name (NI) ] Hospital. SBP was 180/90. She received Labetalol 10mg iv. CT brain showed a left frontal hematoma. She was transferred to [Hospital1 18]. Repeat CT brain showed left frontal hematoma measuring 4cm in diameter. Subarachnoid hemorrhage was present in the left cerebral convexity. There was no intraventricular extension. No midline shift. Neurosurgery was consulted but there was no neurosurgical intervention indicated. She was admitted to SICU. Additional PMH: She has a hx of epistaxis starting in [9-11]. Most recent episode of epistaxis was 7 days ago. Also has bradycardia. HTN since [2158]. On exam at 7:30pm on [10-14]: Neuro: MS: alert and oriented x3, intact naming, repetition, [Location (un) 1131], spelling house backwards, IR [3-6], SR [1-6], no apraxia, knows that [Last Name (un) 2753] is President CN: VFFTC, no visual extinction, PERRLA, EOMI, intact lt and facial strength, intact t/u/p Motor: no pronator drift, 5/5 Strength of deltoids, biceps, triceps, WE, WF. right iliopsoas is 5-/5 and left iliopsoas is [5-8]. [5-8] WE and WF. Sensory: intact light touch and pinprick of all four ext. intact proprioception of toes Reflexes: 2+ symmetric UE and LE, right toe upgoing, left toe downgoing Coord: intact fnf bilaterally Gait: deferred Pertinent Results: WBC-11.0 RBC-4.18* HGB-12.7 HCT-39.3 MCV-94 PLT-196 GLUCOSE-137* UREA N-15 CREAT-1.0 SODIUM-146* POTASSIUM-3.5 CHLORIDE-111* TOTAL CO2-21* ANION GAP-18 PT-12.3 PTT-24.8 INR(PT)-1.0 cTropnT-<0.01 . IMAGING . CT Head without Contrast ([2170-10-14]): Stable left inferior frontal lobe hemorrhage with SAH and mild mass effect on the left lateral ventricle from the study done 4 hrs. earlier. This is likely related to trauma given the location. To correlate with h/o trauma and further work up can be considered if there is no correlating h/o trauma. Early mild hydrocephalus is not excluded. . CT Head without Contrast ([2170-10-15]): IMPRESSIONS: Inferior left frontal lobe intraparenchymal hemorrhage with surrounding edema and local mass effect, diffuse left cerebral hemisphere subarachnoid hemorrhages, and intraventricular extension are not changed from 17 hours prior. No new focus of hemorrhage, shift of normally midline structures, or new enlargement of the ventricles. . MRI/MRA Head ([2170-10-15]): Areas of intraparenchymal hematoma in the left frontal lobe with mass effect on the frontal [Doctor Last Name 534], is redemonstrated. No obvious abnormal enhancement is noted compared to the precontrast images. Patent major intracranial arteries without focal flow limiting stenosis, occlusion, or aneurysm more than 3 mm within the resolution of MR angiogram. Followup assessment can be considered for any residual/obscured lesions. . CT Head without Contrast ([2170-10-16]): No change since [2170-10-15]. Left frontal intraparenchymal hematoma with scattered subarachnoid and intraventricular hemorrhage. No evidence of new bleeding. . CXR ([2170-10-16]): IMPRESSION: No evidence of pulmonary infectious process on single plain chest examination. Brief Hospital Course: Ms. [Known lastname 4680] is an 80 year-old right-handed woman with a history including HTN who initially presented to [Hospital 47] Hospital with headache and nausea. A non-contrast CT of the head demonstrated a left frontal intraparenchymal hemorrhage, and she was transferred to the [Hospital1 18] for further evaluation and care. At the time of arrival, the Neurosurgery Team was asked to evaluate the patient. No intervention was thought to be necessary. She was admitted to the stroke service from [2170-10-14] to [2170-10-18]. . # NEURO To evaluate for evolution of the lesion, several head CTs were performed over time. The neuroimaging documented a stable left inferior lobe intraparenchymal hemorrhage with surrounding edema and local mass effect in addition to diffuse left cerebral hemisphere subarachnoid hemorrhages. An MRI, performed to evaluate for evidence of ischemia, confirmed CT findings. Angiography studies showed that the major intracranial vessels were patent. . The etiology of the hemorrhage remains unclear; the patient denies preceding trauma, and the bleed is in a location uncharacteristic for hypertensive events. Furthermore, vessel imaging failed to suggest the presence of an AVM and other contributory abnormalities. It is possible that amyloid angiopathy is a contributing variable; for this reason aspirin has been discontinued. Keppra 500 mg po bid was started as seizure prophylaxis and should be continued until [2170-10-21]. . Particularly in the setting of intraparenchymal hemorrhage, blood pressure control with a target systolic blood pressure of 120 to 160 was an important focus of care. In addition to continuing the patient's pre-existing atenolol regimen, the lasix was continued. In the course of the hospitalization, the lisinopril dosing was increased from 25 mg po daily to 40 mg po daily. Norvasc (5 mg po daily) was also initiated prior to discharge. . # ID In the course of the hospitalization, the patient was found to have a urinary tract infection for which a three-day course of bactrim was started on [2170-10-17]. The last day of antibiotic treatment will be [2170-10-19]. . # REHABILITATION Following a PT evaluation, the patient was discharged to rehabilitation. . # CODE STATUS DNR/DNI, pressors acceptable Medications on Admission: Atenolol 25mg qday Lasix 40mg qday ASA 81mg qday Lisinopril 25mg qday . All: PCN - unknown Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days. Disp:10 Tablet(s) Refills:0 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for UTI for 3 days. Disp:4 Tablet(s) Refills:0 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital1 2670] & Rehab for [Location (un) 5871] Discharge Diagnosis: Left Frontal Hemorrhage, possibly due to amyloid angioathy Discharge Condition: Stable. The neurological condition is notable for a mild left pronator drift, left triceps weakness, and left finger extensor weakness in addition to a mild bilateral postural tremor. Discharge Instructions: You presented to the [Hospital 47] Hospital with headache. A CT scan revealed bleeding in the brain, and you were transferred to the [Hospital1 18] for further care. Repeat imaging demonstrated stability of the hemorrhage and surrounding swelling. It is thought that the bleeding could be related to a condition called amyloid angiopathy. For this reason, aspirin has been discontinued. . To help better control your blood pressure, the anti-hypertensive medication norvasc (5 mg by mouth daily) was started during the hospitalizations. The lisinopril dose was also increased to 40 mg by mouth daily. * Please note that aspirin has been discontinued. * The antibiotic bactrim was started to treat a urinary tract infection. Please finish the 3-day course prescribed on [2170-10-19]. * Please continue the keppra as seziure prevention until [2170-10-21]. * Please continue all medications as prescribed. * Please attend all follow-up appointments. * Please seek medical attention if you develop a severe headache, vision changes, trouble speaking, difficulty walking, weakness - especially on one side of the body, shaking of the limbs, chest discomfort, shortness of breath, or any other symptom you find concerning. Followup Instructions: Please attend the following appointments: * Primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] on [2170-10-26] at 11 am. * Stroke Specialist [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 640] [Last Name (NamePattern4) 3445], MD (Phone:[Telephone/Fax (1) 44]) on [2170-11-21] at 1:30 pm. * An MRI of the brain with and without contrast should be repeated in approximately one month to evaluate the frontal hemorrhage. ICD9 Codes: 431, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7707 }	Medical Text: Admission Date: [2103-1-22] Discharge Date: [2103-1-26] Date of Birth: [2045-6-4] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor First Name 2080] Chief Complaint: Lethargy and hypotension Major Surgical or Invasive Procedure: Tunneled line replacement [2103-1-25] History of Present Illness: 57M with h/o of dilated cardiomyopathy, afib on digoxin, COPD, ESRD, dyalisis who is admitted due to lethargy, hypotension, pulmonary congestion and hyperkalemia. . At baseline patient lives at home with sister and mother, is ADL independent and ambulates with cane. He gets dyalisis Q mon, wed, Fri. Previous admission to [Hospital1 ] in [9-/2102] for hyperkalemia which was treated with dyalisis. Most recent dyalisis session was [1-20] and was due for another session today. Yesterday he reported experiencing some generlized weakness and lack of apetite. Denies any recent fevers, chills or any focal symptoms. This morning in dyalisis unit prior to starting dyalisis was noted to be lethargic at with blood pressure in the 70s and was sent to the ED where he was found to have Afib with wide-complex RVR and hyperkalemia to 6.5. . In the ED, he claimed his BP's are usually low in the 80-90's but his previous chart showed SBP's in the 110's usually. initial VS in the ED were: 13:25 0 97 140 109/50 28 98% r/a . - ecg: Afib RVR: HR in the 100-140's in the ED. HD BP's in the high 90's low 100's occasionally dips down into the 80's, mentating well throughout. . labs: hyponatremia 130, hyperkalemia 6.5, bicarb 19, AG = 18, cr:BUN 10.1:79, WBC = 17,000 with neutrophil predominance, Hct 32.7 which is at baseline. Dig level 1.2. Lactate = 1.7. Blood cultures sent. - CXR: med-line sterotomy, dyalisis line in place left SC, cardiomegaly, mild congestion/edema, LLL is obscured by heart shadow, can't exclude infiltrate, sinus clear. - Got IV NS 250cc, 16:00 zosyn + vanco - 2X20G peripherals, tunneled HD line in left chest. - nephrologist: dialyse in ICU - got nebs for SOB. . On arrival to the MICU, patient says he feels a little week but other wise has no complaits. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies any worsening in hos chronic cough, sputum production, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Does not produce urine. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - ESRD on dyalisis - Afib - COPD - not on home O2 - h/o idiopathic constrictive pericarditis with 2nd right heart failure s/p percardial stripping [2083] - h/o congestive cirrhosis [2-22] to right heart failure c/b hepatic encephalopathy - recurrent LE cellulitis; recently on a course of IV vancomycin through [2100-11-17]. Had a hematoma evacuated on [2100-11-21]. - HTN - Morbid obesity - Lymphedema of lower extremities - Psoriasis - History of MRSA cellulitis Social History: Currently living with mother and sister in [Location ]. On disability. Mobilizes independently with cane, walks up 12 stairs at home, and can walk [1-24] a mile on flat surface before stopping d/t SOB. Smoker- 1/2-1 pack daily. denies EtOH/drug use for > 30 years. Family History: noncontributory Physical Exam: General: Alert, orientedX3, mild dyspnea at rest, no accessory muscles, RR 25 on RA. HEENT: Sclera anicteric, MMM, oral thrush, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Rapid Regular rate and rhythm, SM 1-2/6 in RUSB and LUSB, no rubs, gallops, no carotid bruits Lungs: bil air movement, some scattered [Hospital1 ]-basilar crackles, no wheezes or ronchi Abdomen: mild distension, non-tender, bowel sounds present, no palpable organomegaly GU: no foley Ext: severe bil stasis dermatitis and descoloration of LE with pre-tibial hyperkeratotic desquamating patches , bil edema of LE +2, no signs of cellulitis, bil onychomycosis and poor nail hygiene, warm, well perfused extremties, DP palpable, no clubbing or cyanosis Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Labs on admission: [2103-1-22] 01:40PM NEUTS-92.2* LYMPHS-4.9* MONOS-2.3 EOS-0.5 BASOS-0.2 [2103-1-22] 01:40PM WBC-17.0# RBC-3.37 HGB-10.6* HCT-32.7* MCV-97 MCH-31.6 MCHC-32.5 RDW-16.4* [2103-1-22] 01:40PM PLT COUNT-179# [2103-1-22] 01:40PM DIGOXIN-1.2 [2103-1-22] 01:40PM ALBUMIN-3.7 CALCIUM-9.4 PHOSPHATE-6.5* MAGNESIUM-2.0 [2103-1-22] 01:40PM cTropnT-0.23* [2103-1-22] 01:40PM CK-MB-2 [2103-1-22] 01:40PM ALT(SGPT)-11 AST(SGOT)-17 LD(LDH)-223 CK(CPK)-27* ALK PHOS-122 TOT BILI-0.6 [2103-1-22] 01:40PM GLUCOSE-117* UREA N-79* CREAT-10.1# SODIUM-130 POTASSIUM-6.5* CHLORIDE-93* TOTAL CO2-19* ANION GAP-25* [2103-1-22] 04:01PM LACTATE-1.7 [2103-1-22] 11:01PM PT-13.7* PTT-33.2 INR(PT)-1.3* MICROBIOLOGY: - Blood culture [2103-1-22]: 2/2 bottles positive for Enterococcus faecalis; 1/2 bottles positive for coagulase-negative staphylococcus - MRSA screen: No growth - Blood culture [2103-1-23]: Pending - Blood culture [2103-1-23]: Pending - Blood culture [2103-1-23]: Pending - Blood culture [2103-1-23]: Pending - Blood culture [2103-1-24]: Pending - Blood culture [2103-1-24]: Pending - Blood culture [2103-1-25]: Pending - Catheter tip culture [2103-1-25]: No growth - Blood culture [2103-1-26]: Pending SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS \| AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S PENICILLIN G---------- 2 S VANCOMYCIN------------ 1 S ECG [2103-1-22]: Atrial fibrillation with a mean ventricular rate of 122. Right bundle-branch block. Left axis deviation. Left anterior fascicular block. Possible left ventricular hypertrophy. Leftward precordial R wave transition point. Compared to the previous tracing of [2102-10-18] multiple abnormalities as described persist without major change. CXR [2103-1-22]: IMPRESSION: Stable massive cardiomegaly and mild pulmonary edema. Supervening left lower lobe infection cannot be excluded due to cardiac obscuration. ECHOCARDIOGRAM (TTE) [2103-1-24]: The left atrium is elongated. The right atrium is markedly dilated. 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 low normal (LVEF 50-55%). The right ventricular cavity is mildly dilated with depressed free wall contractility. There is abnormal septal motion/position. The number of aortic valve leaflets cannot be determined. The study is inadequate to exclude aortic valve stenosis as the aortic valve and the LVOT were not visualized and [First Name8 (NamePattern2) ] [Location (un) 109] could not be calculated. There was a slight increase of peak aortic valve velocity. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: poor technical quality study. With this limitation, no endocarditis or abscess was visualized. Left ventricular function is probably low normal, a focal wall motion abnormality cannot be fully excluded. No pathologic valvular abnormality seen. VEIN MAPPING [2103-1-25]: Performed [2103-1-25]. Results in OMR. Brief Hospital Course: HOSPITAL SUMMARY: 57M with h/o of dilated cardiomyopathy, afib, alcoholic cirrhosis, COPD, ESRD, dyalisis who was admitted to the MICU due to lethargy, hypotension, pulmonary congestion and hyperkalemia found to have enterococal bacteremia. MICU course: Patient never required pressors for his hypotension, but did require several small boluses (250 cc) to maintain pressure. Per patient, BPs run low though they have typically been in 100s-110s here in the past. He was initially treated empirically with vanco/zosyn, but changed over to ampicillin in the setting of enterococcus speciation. His existing tunneled line was exchanged, and he agreed to consider evaluation for graft placement so underwent vein mapping prior to discharge. ACTIVE ISSUES: # Sepsis due to ENTEROCOCCAL BACTEREMIA: Likely source was the patient's indwelling catheter, though culture of the catheter tip was unrevealing. The original ED culture also grew [1-22] bottles positive for coagulase-negative staph on hospital day 4, felt to be a contaminent. Surveillence cultures were negative and TTE did not show evidence of endocarditis. As the patient was clinically improving, TEE was not pursued. As above, he was initially treated empirically with vancomycin and Zosyn, then changed to ampicillin in-house once culture speciated as pan-sensitive Enterococcus. He was changed back to vancomycin at discharge so that he can complete a two-week course of antibiotics dosed per HD protocol (avoiding placement of a PICC). Of note, he was borderline hypotensive throughout this admission, with SBPs ranging upper 70s to 100s. Per recommendations of Dr. [Last Name (STitle) 4883] of the nephrology team, fluid boluses were avoided as long as he was mentating well. Surveillence cultures were obtained but had showed no growth at the time of discharge. # ATRIAL FIBRILLATION WITH RVR: The patient had a HR up to 140s at the time of presentation, but became hypotensive with administration of metoprolol. Once he came out of the ICU, heart rate was reasonably well-controlled in the range of 90s-100s at rest. As his blood pressures generally do not tolerate beta blocker or diltiazem, he has been controlled on digoxin 3 days per week. His level pre-HD was 1.2 and post-HD was 0.6. Therefore, his dose of digoxin was increased to 4 times per week (additional dose to be taken on Sunday) for improved rate control. He has not been anticoagulated in the past, but given CHADS2 score of (probable) 2 (for likely heart failure), he was started on aspirin in lieu of other anticoagulation. # ESRD: Patient was maintained on HD while inpatient on M/W/F schedule. His hyperkalemia corrected with HD. He was continued on nephrocaps and sevelamer. He agreed to pursue graft placement as an alternative and potentially lower-risk form of HD access, and underwent vein mapping prior to discharge. His existing tunneled line was changed out over a wire by IR on [2103-1-25]. He was started on nephrocaps during this admission. INACTIVE ISSUES: # ANEMIA: Secondary to ESRD and stable. He will continue Epogen with outpatient HD. # COPD: Continued on home Advair. Oxygen PRN during this admission (and will HD). # ALCOHOLIC CIRRHOSIS: LFTs normal. No active issues. # SMOKING: Patient was prescibed a nicotine patch while in-house. TRANSITION OF CARE: - Patient will need vancomycin dosed per HD protocol at HD through [2103-2-7] - F/U surveillence blood cultures - F/U vein mapping and arrange for graft placement with transplant surgery - Consider outpatient lipid panel to clarify CV risk status - Wound consult recommendations for legs with lymphedema and hyperkeratosis: Referral to podiatry, dermatology and/or vascular surgery as outpatient - Code: DNI, ok with cardioversion/shocks Medications on Admission: Medications (confirmed with patient): . Advair Diskus 250 mcg-50 mcg/dose for Inhalation Inhalation 1 puff Disk with Device(s) Twice Daily albuterol 90 mcg/Actuation HFA Aerosol Inhaler 1-2 Puffs Puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. metoprolol succinate 25 mg Tab Oral 1 Tablet(s) Once Daily Renvela 800 mg Tab Oral 2 Tablet(s) w/meals three times daily and 2 tabs with snacks twice daily digoxin 125 mcg Tab Oral 1 Tablet(s) Once Daily on M/W/F . Allergies: NKDA Discharge Medications: 1. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [1-22] puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 4x per week: M/W/F/[Doctor First Name ]. 5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Refills:2 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 8. vancomycin 1,000 mg Recon Soln Sig: As directed by HD protocol Intravenous QHD (by protocol) for 6 doses: Last dose [2103-2-7]. Will need vanco trough and Chem-7 monitored while on this medication. Discharge Disposition: Home Discharge Diagnosis: Primary: - Enterococcus bacteremia - Sepsis - Atrial fibrillation with rapid ventricular response Secondary: - ESRD on hemodialysis 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 [Hospital1 69] with lethargy and low blood pressure. You were found to have a rapid heart rate and bacteria in your blood. The blood infection is most likely the cause of your other symptoms, and most likely came from your tunneled dialysis line. Therefore, your tunneled line was exchanged for a clear catheter and you will require treatment with IV antibiotics (to take place at dialysis). We have made the following changes to your medication regimen: - BEGIN TAKING IV vancomycin at dialysis (last day [2103-2-7]) - BEGIN TAKING nephrocaps 1 tablet by mouth daily - BEGIN TAKING aspirin 81 mg by mouth daily - INCREASE FREQUENCY of digoxin to 4 days per week (M/W/F/[Doctor First Name ]) Please follow up with your doctors as recommended below. Followup Instructions: Department: HEMODIALYSIS When: FRIDAY [2103-1-26] at 7:30 AM Department: TRANSPLANT CENTER When: THURSDAY [2103-2-15] at 1:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Name: [Last Name (LF) ],[First Name8 (NamePattern2) 26] [Last Name (NamePattern1) ] Location: [Location (un) 2274]-[Location ] Address: 291 INDEPENDENCE DR, [Location ],[Numeric Identifier 1700] Phone: [Telephone/Fax (1) 43431] Appt: [1-31] at 2:40pm Completed by:[2103-1-27] ICD9 Codes: 5856, 4254, 2767, 496, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7708 }	Medical Text: Admission Date: [2149-9-5] Discharge Date: [2149-9-11] Date of Birth: [2076-8-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: Tx from OSH for weakness spells found to have 4vessel cerebrovasuclar disease. Major Surgical or Invasive Procedure: Carotid/vertebral angiogram History of Present Illness: 73 yo male with a history of DM2, a fib, carotid stenosis, hypercholest admitted to OSH on [2149-8-27] after presenting with [6-6] mo of weakness and LH. Pt was brought by family for transient episodes of disorientation and weakness in UE and LE. (Pt denies disorientation but endorses weak spells). The spells lasted 20-30s per family. He did drop things he was holding. The episodes began in [Month (only) 958] and have incr in freq. 4 episodes on day of admit to OSH. Pt notes one episode of 20 min of blurred vision 3 d ago that prevented him from [Location (un) 1131]. He denies any loss of vision. At OSH, found to have 2 acute infarcts in the L MCA territory. The patient was reported to have no neurologic defecits at the OSH and was tx here for further evaluation and potential carotid angiogram with Dr. [First Name (STitle) ]. The neurology service at the OSH started the pt on plavix and recommended a 4V arterogram to deliniate the vert/carotid dz better. Metformin and coumadin were held as of [9-5]. Neuro did not think these findings explained the UE and LE weakness that was the cheif complaint. Vitals on tx: vitals: afebrile, hr 70's afib, bp 154/80, rr 16-18, sat 97% ra glucose at 12noon 182. Past Medical History: DM II A Fib Carotid Stenosis - newly diagnosed CVA in [6-4] Hypercholesterolemia . Social History: Married, primarily russian speaking, lives with wife. [Telephone/Fax (1) 64360] Family History: Non-contributory Physical Exam: PE: V:98.0, 145/54, 74, 20, 99% RA Gen: NAD HEENT: anicteric, JVD not seen, supple, no LAD CV: irreg RR, no murmur appreciated, no JVD, Carotid bruits R>L, pulses 2+ bilat, no decreased hair on LE bilat, no RUQ pain, no [Location (un) ]. Lung: Clear Bilat Abd: Soft, NT, ND, BS present, no HSM Ext: no [Location (un) ] Neuro: MS:A and O x 3, calculation, repetition intact (pt is russian speaker) CN:II-XII intact bilat Motor: [6-5] throughout. Coordination: FNF with terminal ataxia bilaterally Sensation: intact to LT and cold bilat throughout Reflexes: Diminished bilat throughout x ankle jerk (absent) Gait: ataxic, romberg negative (stands without falling), toes downgoing, . Pertinent Results: [2149-9-6] 12:46AM BLOOD WBC-7.3 RBC-4.46* Hgb-12.0* Hct-35.4* MCV-80* MCH-27.0 MCHC-34.0 RDW-13.8 Plt Ct-222 [2149-9-6] 12:46AM BLOOD PT-13.1 PTT-27.6 INR(PT)-1.1 [2149-9-8] 07:30AM BLOOD PT-13.8* PTT-91.5* INR(PT)-1.3 [2149-9-6] 12:46AM BLOOD Glucose-250* UreaN-29* Creat-1.3* Na-133 K-4.3 Cl-99 HCO3-24 AnGap-14 [2149-9-8] 07:30AM BLOOD Glucose-201* UreaN-16 Creat-1.0 Na-137 K-4.2 Cl-103 HCO3-23 AnGap-15 [2149-9-6] 12:46AM BLOOD Calcium-9.6 Phos-4.7* Mg-1.8 [2149-9-8] 07:30AM BLOOD Calcium-9.2 Mg-1.8 [2149-9-6] 06:45AM BLOOD Calcium-9.6 Phos-4.4 Mg-1.9 Iron-72 Cholest-105 [2149-9-6] 06:45AM BLOOD calTIBC-436 Ferritn-29* TRF-335 [2149-9-6] 06:45AM BLOOD Triglyc-52 HDL-46 CHOL/HD-2.3 LDLcalc-49 . . Results from OSH: Imaging: CT ([8-27]): Mild atrophy. No acute findings. Ethmoid and maxillary chronic sinus disease. . CXR [8-27]: no acute process. . MRI/A: Severe stenosis of the intracranial [Country ] at the distal petrous segments with diminished caliber of the [Country ] distal to that point. Also, L MCA supplied by the ACA. Distal L vert with either small amount of retrograde or anterograde flow - originally the dominant vert. NO ACUTE INFARCTS ON READ AT [Hospital1 18] (though on OSH read of images, there were 2 areas of T2 shine through read incorrectly as acute/subacute infarcts) MRI C-spine: loss of flow void in the L vert. Normal cspine except DJD at C5 and C6. . Carotid duplex ([2149-8-12]): 60% [Country ] and a suspected totally occluded distal [Doctor First Name 3098] . Tilt Table Test - pt felt presyncopal without decrease in BP or HR. Read as "positive." I have not located report. . Tele: 6 beats VT last Sunday. EKG: afib, irreg rhythm, nml axis, narrow qrs, no TW changes, no ST changes. Brief Hospital Course: Brief Overiew: 73 yo male with a history of DM2, a fib, newly dx'd carotid stenosis, hypercholest admitted to OSH on [2149-8-27] after presenting with 5-6 mo of weakness and LH and spells of weakness. Dx'd with severe 4vessel cerebrovascular dz. Tx here for Dr. [First Name (STitle) ] to do arteriogram and consider intervention. The pt was evaluated by Dr. [First Name (STitle) ] and the stroke service. His images were reviewed. He was taken to the cath lab and his common carotid on R was stented. The stenosis at the petrous bone was not stented. Pt was HTN in cath and was started on Nipride. His BP decr to 50s and he was unresponsive for seconds. Pt was bagged and started on pressors with very fast recovery. Pressors weaned within hours in CCU. Neurointerventional was c/s'd regarding intervention for [Country ] at petrous - no intervention possible. Pt was discharged on coumadin and lovenox with BP goal at 140-160. Symptoms were not present at these BP's, but at lower, pt had sx of unsteadiness and occ. fluency probs with language. . Carotid Stenosis: Pt was tx to [Hospital1 18] for Dr. [First Name (STitle) ] to conduct 4 vessel arteriogram of Verts and Carotids. He was hydrated over the weekend and metformin was held. The pt's coumadin was held and he was continued on heparin (from OSH). Films were obtained from [Hospital3 ]. The films were reviewed by Dr. [First Name (STitle) ] and neuro and neuroradiology. They were felt to show occluded L vert, occluded L carotid, 60% common carotid on R and 60-80% [Country ] at petrous bone. There was a ? ostial lesion at R vert. There were NO subacute or acute infarcts (this was different than read at OSH that reported 2 subacute infarcts. . The pt was taken to the cath lab and a stent was placed in the R common carotid. The petrous was not amenable. The pt was hypertensive and was started on Nipride with BP drop and unresponsiveness. A code blue was called and the pt was bagged. His BP returned quickly on pressors. He was weaned from pressors over hours and was never intubated. In the CCU he recovered well but had one episode of word finding difficulty and non-fluent speech for roughly 10 minutes when his SBP was 105. His BP was increased with fluids, his atenolol was d/c'd and he was tx'd to [Hospital Unit Name 196]. Neurointerventional did not want to intervene on petrous ICA stenosis. Neuro agreed with plan. Pt was restarted on coumadin and metformin and d/c'd home on lovenox to bridge to coumadin at therapeutic INR. PCP was [Name (NI) 653], pt received training and was seen by PT svc. . DM: Held metformin for arteriogram of 4vessels. Cont'd glipizide. ISS was used to cover high BG's. Pt was well controlled on this regimen. Metformin was restarted on d/c home. Medications on Admission: Meds on admit to OSH: Atenolol 25 po qd Coumadin 4 mg po qd glipizide 10mg po qam/ 5mg qpm lipitor 20 po qd metformin 500 po bid . Meds on tx to [Hospital1 18]: Plavix 75mg po qd Heparin gtt per protocol Tylenol 650 mg po q4-6h prn fever Atenolol 25 po qd glipizide 10mg po qam/ 5mg qpm lipitor 40 po qd metformin 1000 po bid - holding Coumadin 4 mg po qd - holding . Discharge Medications: 1. Glipizide 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Tablet(s) 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous once a day for 5 days. Disp:5 syringes Refills:0 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Carotid Stenosis s/p stent to common corotid Discharge Condition: Stable Discharge Instructions: You have had a stent placed in the Right Carotid artery. Your symptoms of weakness seem to be better as long as your blood pressure is between 140 and 150 (top number should be 140-150). . We have stopped your blood pressure medication, Atenolol. DO NOT TAKE THIS MEDICATION. . You will need to take lovenox for the next 5-7 days while your coumadin has a chance to start working again (you were not receiving coumadin in the hospital). . We have started a medication called Plavix that prevents a clot from forming in the stent. Take it EVERY day. . If you develop new worrisome symptoms, high fever or chills, loss of consciousness, or neck pain, please seek immediate medical attention. . You should rest for the next two weeks - avoid strenuous activity. . You should have your INR checked at Dr.[Name (NI) 2633] office on Monday and establish a follow-up appointment within two weeks to see Dr. [Last Name (STitle) ] himself. . You should follow-up with Dr. [Last Name (STitle) 1693] within 2 weeks. His phone number is ([Telephone/Fax (1) 22692]. . You should follow up with Dr. [First Name (STitle) ] next week. His phone number is: ([Telephone/Fax (1) 7236]. Followup Instructions: Dr. [Name (NI) ] - pt to call for appointment within 2 weeks. Dr. [Last Name (STitle) ] on Monday for INR check. Dr. [Name (NI) 1693] - pt to call for appointment within 2 weeks. Dr. [Name (NI) ] - pt to call for appointment next week. Completed by:[2149-9-11] ICD9 Codes: 9971, 4275, 4271, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7709 }	Medical Text: Admission Date: [2197-2-12] Discharge Date: [2197-2-24] Date of Birth: [2128-5-10] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 297] Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 68 year-old female seen in ED for bilateral eye swelling yesterday and slit lamp exam revealed right keratitis. Ophthomology recommended Ciprofloxacin and Viroptic drops and follow up in clinic in the next 2 days. She was sent home and her PCP was called by daughter reporting ongoing weakness, fatigue and inability for patient to care for herself. She was referred back to ED for admission. Of note, her blood sugar was >300. At this time, she notes progressive weight loss over the past month, increased fatigue such that she spends > 50% of her day in bed, and decreased appetite. She denies any recent fevers, chills, chest pain, abdominal pain, changes in bowel and bladder habits. She does note occasional red blood on her stools that is unchanged from her usual hemorrhoids. She also notes loose watery stools since her colon surgery in [Month (only) ]. . Past Medical History: asthma s/p whipple procedure s/p ventral hernia repair Social History: The patient is widowed and is the mother of five healthy children. She lives in [Hospital1 189], [State 350]. She is a former high school teacher who retired in [2189]. She has never smoked tobacco and does not use alcohol. Family History: Family history includes a remarkable number of carcinomas on her maternal side. Her mother apparently died of cervical cancer and may have had a history of colon cancer as well. Her maternal grandmother died of breast cancer at the age of 36. Several maternal aunts, uncles, and [Name2 (NI) 12232] have been diagnosed with lung, pancreatic, and bone cancer. Physical Exam: PE: Vitals: Temperature:97.2 Pulse:104 Blood Pressure:103/76 Respiratory Rate:16 Oxygen Saturation:100% on room air General: Lying in bed in no acute distress with eyes closed HEENT: Erythematous eyelids with crusting on lashes. Patient is unable to open her eyes. Bilateral conjunctiva are injected. Pupils equal and reactive, dry mucouse membranes. Cardiac: Regular rate and rhythm without murmurs, rubs, or gallops. Pulmonary: Clear to auscultation bilaterally Abdomen: Normoactive bowel sounds, soft, nontender, nondistended, well-healed midline scar. Extremities: Warm and well perfused without edema or cyanosis, 2+ dorsalis pedis pulses bilaterally. . Pertinent Results: Imaging: 1. Orbit CT ([2-11]): Unremarkable exam 2. Head CT ([2-11]): No bleed or masses. Brief Hospital Course: INITIAL ASSESSEMENT AND PLAN ON ADMISSION: 68 year-old female with pancreatic cancer and colon cancer admitted with keratitis and hyperglycemia. 1. Keratitis: She was seen in the ED yesterday with blurry vision and eye swelling. A slit lap exam showed keratitis. Visual acuity was intact. She was sent home on ciporfloxacin ointments and viroptic. Continue ciprofloxacin and viroptic for now. 2. Hyperglycemia: She was noted to have sugars in the 300s yesterday. She had no evidence of DKA. Her blood surgars have been elevated above 180s for the past several years. Her hyperglycemia is likely secondary to pancreatic insufficiency after Whipple. Cover her with an insulin sliding scale for now. 3. Coagulopathy: She has elevate PT and PTT. Given her history of decreased appetite and poor po intake over the past several weeks, her coagulopathy could be secondary to vitamin K deficiency. Treat with 3 doses of vitamin K. 4. Colon cancer: She recently completed cycle 1 of FOLFOX. She is followed by Dr. [First Name (STitle) ] and Dr. [Last Name (STitle) 13933]. 5. Anemia: She has had recent hematocrits in the low 30s; however, on admission her hematocrit is 38. She may be hemoconcentrated. MICU COURSE: The patient was transferred to the MICU service with hypotension and gram negative sepsis. She was treated with IV fluid resuscitation and started on pressors, as well as antibiotics to cover the gram negative rods. Urine culture and blood cx eventually grew out E. coli, sesntitive to Cipro as well as meropenem, so the meropenem was discontinued and cipro was begun. She developed DIC and was transfused with pRBCs, platelets, and FFP. She was maintained on [1-20] pressors for several days. She also developed renal failure and renal team was consulted for dialysis. After a discussion with family goals of care were changed to comfort measures and patient expired [2197-2-24]. Medications on Admission: ... Discharge Medications: none Discharge Disposition: Home with Service Discharge Diagnosis: Bacteremia Sepsis Keratitis Diabetes mellitus Coagulopathy Mucositis Colon cancer Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[2197-2-27] ICD9 Codes: 5849, 5990, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7710 }	Medical Text: Admission Date: [2133-2-18] Discharge Date: [2133-2-26] Service: SURGERY Allergies: Morphine / Dilaudid Attending:[First Name3 (LF) 2597] Chief Complaint: ischemic rt. leg Major Surgical or Invasive Procedure: right AKA [2133-2-19] History of Present Illness: Patient with severe PVD s/p ax bifem, fem-[Doctor Last Name ] ,s/p thrombecomy of both grafts,now with ischemic rt. leg and line sepsis. Transfered from [Location (un) 745] [Hospital 3714] hospital to our hospital for further care. Past Medical History: hx of CAD hx HTN hx carotid disease s/p lt. CEA hx of CVA hx hyperthyroidism, s/p rx, now hypothyroid on supplement hx melenoma hx bladder cancer s/p excision [1-3] hx PVD, s/p rt. ax fem-femw 8mm ring gortex, rt. sfa-[Doctor Last Name ] w distaflo 7mm [11-1] hx renal insuffiency 1.6-1.8 renal artery stenosis rt. 70%,Lt. 50% ECHO: [2-4] EF 55%, mr, Ai lv basal wall hyppokenesis renal lithiasis hx MRSA hx yeast UTI rx fluconazole [2-4] Social History: unknown Family History: unknown Physical Exam: Vital signs: 100.1-95-21 111/32 oxygen saturation 98% on nonrebreather General: alert , oriented x3 in mild discomfort Lungs: rales bilaterally Heart: regular rate rythmn Abd: mild diffuse tenderness Extremity: Right groin with ecchmosis and fullness. rt. popliteal incision intact. rt. extremity cold ,mottled diminished sensation and motor Pulses: rt. femoral ?1+, absent pulses belaow femoral. ax fem graft no signal. left femoral palpable 2+, popliteal absent DP/PT biphasic signal Pertinent Results: [2133-2-18] 08:03PM WBC-14.1* RBC-2.84* HGB-8.5* HCT-25.1* MCV-88 MCH-30.0 MCHC-34.1 RDW-14.2 [2133-2-18] 08:03PM NEUTS-62 BANDS-22* LYMPHS-9* MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-3* MYELOS-0 [2133-2-18] 08:03PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2133-2-18] 08:03PM PLT COUNT-258 [2133-2-18] 08:03PM PT-13.7* PTT-36.4* INR(PT)-1.2 [2133-2-18] 08:03PM GLUCOSE-89 UREA N-42* CREAT-1.9* SODIUM-133 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-24 ANION GAP-13 [2133-2-18] 09:41PM LACTATE-1.2 [2133-2-18] 09:41PM TYPE-ART PO2-96 PCO2-32* PH-7.45 TOTAL CO2-23 BASE XS-0 [2133-2-18] 09:41PM LACTATE-1.2 [2133-2-18] 08:03PM VANCO-26.5* Brief Hospital Course: [2133-2-18] Transfered from [Location (un) 745] [Hospital ] hospital to SICU of [Doctor First Name ] [Hospital 59327] [Hospital ] Medical center.cultures blood and sputum obtained. cxr with LLL infiltrate. a-line placed and left subclavian triple lumen cath placed. Vancomycin, levofloxcin and flagyl continued fluconazole continued.IV heparinzation. serial coagulation paremeters monitered. [2133-2-19] DOS: rt. AKA [2133-2-20] POD#1 temperature 100.4 epidural catheter d/c'd.Extubated [2133-2-21] POD#2 temperature 101.3-99.3 urine culture sent.CVL changed over wire. [2133-2-22] POD#3 Transfered to VICU.Sputum and urine culture no growth. [2133-2-23] evaluated by Physical thearphy for agressive pulmonary care. Recommend rehab at d/c. social service followed patient for emotional support. AF intermittently postoperatively x 48 hrs. cardology consulted betablockade. Echo to asses LVF and valves. no anticoagulation since documented previoously during perioperative period. Check TSH , 19 [2133-2-24] POD#4 afebrile. WBC trending down [Hospital1 ] 20.2-18.0 required diuresis with IV laasix 20mgmx1. converted NRS x 24 hrs. [2133-2-25] POD#5 Expressing death wishes but not sucidal. Seen by our psychiatry department. adjustment disorder with depressed mood. Continue sertraline. have patient followed at rehab by psych. Consider followup with psychiarist or PCP at [Name Initial (PRE) ]/c from rehab if indicated.Levoxyl restarted. [2133-2-26] POD#6 afebrile. wounds clean dry and intact.d/c to rehabilitation for continued care and rehab. Medications on Admission: lopressor 5mgm IV q6h Vanco 1gm q24h moxiflex 400mgm q24 h flaglyol 500 q8h, fluconazole 200mgm qd Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. 10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 12. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln Intravenous Q48H (every 48 hours) for 5 days. 14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. lorezapam Sig: 0.5-1mgm mgm q6h prn. 16. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day: hold SBP <110, HR< 55. Discharge Disposition: Extended Care Facility: [Hospital3 ] Hospital - [Location (un) 701] Discharge Diagnosis: picc line infection ischemic right leg Discharge Condition: stable Followup Instructions: Dr. [Last Name (STitle) ] 2 weeks call for appointment. [Telephone/Fax (1) 3121] followup with psychiarty or PCP post discharge from [Last Name (un) ]. Completed by:[2133-2-26] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7711 }	Medical Text: Admission Date: [2144-4-15] Discharge Date: [2144-4-21] Date of Birth: [2078-8-28] Sex: M Service: SURGERY Allergies: Cymbalta / Robaxin Attending:[Known firstname 1481] Chief Complaint: recurrent stomach cancer Major Surgical or Invasive Procedure: Revisional gastrectomy with near total gastrectomy and Roux-en-Y reconstruction and feeding jejunostomy. History of Present Illness: Mr [Known lastname 45688] had gastric cancer (adenocarcinoma stage IIIA) resected in [2142-7-16] with adjuvant radiation. Biopsies of the anastomotic site in [2143-11-15] showed recurrent adenocarcinoma, confirmed by our pathologist. CT and PET scan were negative. However, there was concern this might be an extension from the external growth of the tumor inwards given the circumstance of excellent margins on the original [2142] specimen. He was given several courses of chemotherapy and a PET scan was again negative. He has been given his options and wishes to have surgical treatment. Past Medical History: PMH: gastric adenocarcinoma, asthma, arthritis PSH: subtotal gastrectomy [2142], two shoulder surgeries and arthroscopy, open meniscus repair, tonsillectomy Social History: The patient does not drink. He smoked one pack of cigarettes per day for 30 years and quit 2 years ago. He worked in realty but is presently on disability. Family History: There is a history of diabetes and coronary artery disease in his family. Physical Exam: Admission Exam Gen: AOx3, NAD, pleasant. HEENT: hair starting to return. Head, eyes, ears, nose, and throat are normal. The neck is supple, without mass, nodes, or thyromegaly. RESP: CTAB, no increased work of breating CV: RRR, no r/m/g; distal pulses palp Abd: S/NT/ND; well healed midline incision Ext: no cyanosis, no clubbing, no edema Neuro: intact Pertinent Results: Admission/Post-operative Labs: [2144-4-15] 06:43PM WBC-18.9# RBC-4.08 HGB-12.3* HCT-36.6* SODIUM-137 POTASSIUM-5.9* CHLORIDE-103 TOTAL CO2-23 UREA N-17 CREAT-1.1 GLUCOSE-117* CALCIUM-8.9 PHOSPHATE-4.6* MAGNESIUM-2.0 PT-12.8 PTT-22.8 INR(PT)-1.1 Surgical Specimen Pathology (see [2144-4-15] report for further details) 1. Extensive recurrent gastric adenocarcinoma present at proximal gastric resection margin. 2. Distal small intestinal margin free of tumor. 3. Two lymph nodes free of tumor. Brief Hospital Course: Mr [Known lastname 45688] was admitted to the General Surgical Service for evaluation and treatment. On [4-15] he underwent a revisional gastrectomy with near total gastrectomy and Roux-en-Y reconstruction and feeding jejunostomy. (Please see Dr [Name (NI) 45689] operative note of [2144-4-15] for further details) He was monitored in the ICU after the operation. He was NPO/IVF with NGT and dilaudid pca for pain. He was hemodynamically stable. He has a history of severe delirium on narcotics and after anesthesia, and he was closely monitored in the ICU until POD2. He did not have any episodes of delirium and was transferred to the floor in good condition on POD2 Neuro: He received dilaudid pca with good effect initially and adequate pain control. He was transitioned to liquid oxycodone via the Jtube with standing tylenol and intermittent IV dilaudid. He complained of back pain, which was bothering him more than his abdominal pain. By the day of discharge, his pain was well controlled on liquid roxicet. CV: He remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: He remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. CXR on POD5 was unremarkable. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. His NGT was kept in place until POD2 and then was dc'd. He started Bariatric stage I diet on POD3, which he tolerated well. He was slowly increased to Bariatric stage III when passing flatus. He was then advanced to Bariatric V POD5. Tube feeds were advanced as tolerated and we began cycling them on POD5. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. He had a foley for 3 days post-operatively to monitor urine output. Electrolytes were routinely followed, and repleted when necessary. He will require continued J-tube feeds to ensure adequate caloric intake. ID: The patient's white blood count and fever curves were closely watched for signs of infection. His wound remained clean, dry, and intact during his hospital course. He had a brief fever the evening of POD4; UA and CXR were negative and the fever did not recur. Endocrine: His blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. He was tolerating a Bariatric V diet, ambulating, voiding without assistance, and pain was well controlled. He received some discharge teaching and follow-up instructions but left prior to our nurse completing the task. See documented progress note from [4-21] for further details. Medications on Admission: oxycodone, carisoprodol 350', celebrex 200', gabapentin 600", buproprion 150", diazepam 2prn, reglan 5"", modafinil 200', tantoprazole 20, tylenol, Advair, Spiriva Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day): Hold for loose stool. Disp:600 mL Refills:2 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [2-16] Inhalation Q6H (every 6 hours) as needed for wheeze. 3. gabapentin 250 mg/5 mL Solution Sig: Ten (10) mL PO TID (3 times a day): 10mL in AM, 10mL with dinner, 15mL QHS. Disp:900 mL Refills:2 4. oxycodone 5 mg/5 mL Solution Sig: [6-23] mL PO Q4H (every 4 hours) as needed for pain. Disp:150 mL Refills:0 5. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) mL PO Q6H (every 6 hours) as needed for pain. Disp:1000 mL Refills:2 6. omeprazole magnesium 10 mg Susp,Delayed Release for Recon Sig: Twenty (20) mg PO twice a day. Disp:1000 mg Refills:2 7. diazepam 5 mg/5 mL Solution Sig: 2.5 mL PO at bedtime as needed. Disp:100 mL Refills:0 8. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: Two (2) puffs Inhalation once a day. 9. Reglan 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea: CRUSH ALL PILLS. 10. bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO twice a day: CRUSH ALL PILLS. DO NOT CRUSH EXTENDED RELEASE PILLS. Disp:120 Tablet(s) Refills:2 11. Isosource 1.5 Cal Liquid Sig: Seven [Age over 90 ]y (720) cc PO at bedtime: Infuse at 60cc/hour for 12 hours each night. Disp:14 bags Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Recurrent gastric adenocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your doctor or nurse practitioner if you experience the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [6-23] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Call Dr[Name (NI) 1482] office to schedule an appointment to be seen in two weeks: [Telephone/Fax (1) 2981] ICD9 Codes: 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7712 }	Medical Text: Admission Date: [2159-7-29] Discharge Date: [2159-7-31] Date of Birth: [2076-10-31] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 425] Chief Complaint: s/p PEA arrest/cardiac arrest Major Surgical or Invasive Procedure: cooling protocol History of Present Illness: 82M with h/o CABG 7 yrs ago, s/p ICD ([Hospital3 ]) for ?CHF (5yrs ago), afib on coumadin, COPD with baseline SOB, presented with acute dyspnea and found to be in respiratory distress overnight on Am on [7-29] around 1-1:30am with syncope/collapse onto soft couch. CPR started within 5-10 minutes of patient being found down. First rhythm was PEA, was in agonal breathing, regained pulse s/p epi, atropine, and intubation. Sent to OSH (arrived 2:55am), per OSH, had pulse but lost pulse around 3:15am, patient given epi, atropine, heparin bolus and gtt, then regained pulse with v-pacing so cooling protocol started (patient down to 30 degrees). Possible report that ICD fired twice - then was V-paced, got bolus/gtt of amiodarone, 20mcg of dopa, 2L IVF, CK and trop flat, INR therapeutic, sent to [Hospital1 18]. . Arrived at [Hospital1 18] ED around 5:20am, initial 31.4 R, 66, 80/37, 22, 88% of FiO2 100, PEEP 5, PiP 44. ECG showing wide right bundle with possible complete heart block. Found to have small R apical pneumothorax s/p R chest tube but not large enough to be culprit for causing . RIJ, PIVs placed. Bedside ECHO showed no pericardial effusion, ventricles beating. On cooling protocol. Kept on amio gtt, started max dopa (20mcg), levophed (0.12). K was high, given calcium, bicarb. Vitals on transfer were T30.8 (getting 1L warm saline fluid, warming blankets), 72, 132/56, 95% FiO2 60, RR18 - 60, PEEP 6, peak P 36, TV 400. CVP 17. ABG on transfer was 7/15/64/555 . On arrival to CCU, patient was unresponsive, not withdrawing to any noxious stimulation. Patient was transferred on amiodarone gtt at 1, levophed at 0.14, and dopamine at 20 weaned down to 10. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: 3V disease, CABG [2152] -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: (5 years prior) placed in [2154] 3. OTHER PAST MEDICAL HISTORY: Asthma, hyperlipidemia, hypertension Social History: SOCIAL HISTORY: No tobacco use, rare alcohol socially. Lives with wife, continues to be quite active golfing several times per week. Family History: non-contributory Physical Exam: VS: T= 88.7 BP= 129/45 HR=71 RR= 20 O2 sat= 100% Vt 550 /PEEP 8 GENERAL: WDWN, nonresponsive to verbal stimuli or sternal rub. HEENT: NCAT. Sclera anicteric, pupils fixed and dilated bilaterally. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. ET tube in place NECK: Supple 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. Ventilated. CTAB anteriorly without no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM. EXTREMITIES: No c/c/e. Cool. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: Minimal withdrawal to painful stimuli in LLE, no other purposeful movement, pupils nonreactive Pertinent Results: [2159-7-29] 05:40AM WBC-12.2* RBC-4.09* HGB-13.4* HCT-41.7 MCV-102* MCH-32.7* MCHC-32.1 RDW-13.6 [2159-7-29] 05:40AM PLT COUNT-185 [2159-7-29] 05:40AM CK-MB-12* MB INDX-4.3 cTropnT-0.10* [2159-7-29] 05:40AM CK(CPK)-277* [2159-7-29] 05:40AM GLUCOSE-406* UREA N-31* CREAT-1.6* SODIUM-134 POTASSIUM-8.8* CHLORIDE-106 TOTAL CO2-18* ANION GAP-19 [2159-7-29] 05:43AM GLUCOSE-376* LACTATE-3.3* NA+-135 K+-8.0* CL--103 TCO2-21 [2159-7-29] 05:55AM PT-28.9* PTT-150* INR(PT)-2.9* [2159-7-29] 06:21AM TYPE-ART TEMP-30 TIDAL VOL-370 PO2-555* PCO2-64* PH-7.15* TOTAL CO2-24 BASE XS--7 -ASSIST/CON INTUBATED-INTUBATED Brief Hospital Course: # s/p cardiac arrest: Unclear etiology which prompted initial PEA arrest. No anticedent illness. No e/o ischemia on EKG. Anticoagulated so unlikely to be PE & no e/o EKG. Small R-sided pneumothorax with no e/o tension prior to arrival. No e/o hypovolemia. With profound acidosis. Thus, unclear but potentially primary cardiac vs pulmonary source. Patient underwent cooling protocol. The cardiac arrest team, including neuro, was involved. Patient was monitored on continuous 48hr bedside EEG per protocol. EEG on [2159-7-30] showed some higher amplitude spikes, but since early morning of [2159-7-31], EEG was flatline. Neuro felt that there was very little hope of significant recovery of brain function. Patient also continued to require moderately high doses of levophed and dopamine to maintain blood pressure. Family meeting was held [2159-7-31] with CCU team, neurology consult, SW. Family agreed that CMO would be in line with patient's wishes. Patient was extubated and all medications stopped. Patient received morphine prn for comfort. . # Respiratory failure: s/p intubation initially difficult to ventilate with high auto PEEP, PIP. Patient with h/o asthma and concern for bronchospasm on exam. No h/o COPD per available records. Patient received Albuterol / Ipratroprium nebs prn, daily CXR were followed. . # CORONARIES: h/o CAD s/p CABG. No localized ischemia on ECGs, no elevation in enzymes. # PUMP: No prior records in our system, family cannot relay any clear details. . # RHYTHM: V-paced, pacer interrogated showing oversensitivity leading to 2 episodes of inappropriate ICD firing at OSH, none since. Patient therapeutic on prior coumadin. Patient was monitored on telemetry. . Medications on Admission: MEDICATIONS: Coumadin 2.5mg / 5mg alternating daily Carvedilol 12.5mg [Hospital1 ] Spironolactone 12.5 mg QHS Simvastatin 40mg QHS Aspirin 81 mg daily Albuterol inhaler PRN wheezing Aricept 5mg QHS Discharge Disposition: Expired Discharge Diagnosis: Patient passed on [2159-7-31]. Discharge Condition: Patient passed on [2159-7-31]. Discharge Instructions: Patient passed on [2159-7-31]. Followup Instructions: Patient passed on [2159-7-31]. ICD9 Codes: 4271, 5845, 4275, 4280, 2724, 5859, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7713 }	Medical Text: Admission Date: [2185-4-25] Discharge Date: [2185-4-28] Date of Birth: [2130-1-25] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: known murmur with mitral valve prolapse and dyspnea on exertion Major Surgical or Invasive Procedure: Minimally invasive MVR(27mm partial annuloplasty band) [2185-4-25] History of Present Illness: Mr. [Known lastname 60969] has had known mitral valve prolapse with mild dyspnea on exertion and was referred to Dr. [Last Name (STitle) ] for surgical repair. Past Medical History: mitral valve prolapse sleep apnea s/p herniorrhaphy s/p back surgery s/p L eye surgery Social History: he loves with his wife, has a remote tobacco history, [12-26] glasses of wine/day. Family History: non contributory Pertinent Results: [2185-4-28] 05:40AM BLOOD WBC-8.5 RBC-3.52* Hgb-11.2* Hct-31.4* MCV-89 MCH-31.8 MCHC-35.7* RDW-13.1 Plt Ct-135* [2185-4-28] 05:40AM BLOOD Plt Ct-135* [2185-4-27] 05:55AM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-135 K-4.1 Cl-99 HCO3-31* AnGap-9 Brief Hospital Course: Mr. [Name13 (STitle) ] was admitted on [4-25] and taken to the operating room with Dr. [Last Name (STitle) ] for a minimally invasive mitral valve repair with quadrangular resection of the posterior leaflet and a 27mm annuloplasty band. He was transferred to the intensive care unit in stable condition. He was weaned and extubated from mechanical ventilation on his first postoperative evening without difficulty. He was transferred to the regular floor on POD#1, began working with physical therapy and was cleared by POD#2. He developed muscle spasm in his back which was successfully treated with Valium and NSAIDS, and was cleared for discharge and discharged to home on POD#3. Medications on Admission: aspirin 81mg qd MVI Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:60 Tablet(s) Refills:0 6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 7. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:20 Tablet(s) Refills:0 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Mitral regurgitation Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 6 weeks. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 60965] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) 1290] for 4 weeks. Completed by:[2185-4-28] ICD9 Codes: 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7714 }	Medical Text: Admission Date: [2101-1-31] Discharge Date: [2101-2-7] Date of Birth: [2037-3-22] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: unstable angina Major Surgical or Invasive Procedure: coronary artery bypass grafts x4(LIMA-LAD,SVG-OM1,SVG-RI,SVG-DG)[2101-2-2] left heart catheterization, coronary angiogram [2101-1-31] History of Present Illness: This 63 year old male recently went to his internist's office with complaints of a few episodes of jaw and chest pain that occurred while he was sitting at work. He also reports dyspnea on exertion after walking up [Doctor Last Name ]. He was found to have an abnormal EKG and was referred for cardiology consultation. He was referred for a stress test on [2101-1-27]. He exercised for 7 minutes to greater than an 85% heart rate achieved. No EKG changes or ischemic symptoms. Test stopped r/t fatigue. Nuclear imaging revealed old inferior wall MI with peri-infarct ischemia and mild basal lateral wall ischemia. EF 59%. He was referred for a cardiac catheterization and was found to have three vessel coronary artery disease and is now being referred to cardiac surgery for revascularization. Past Medical History: benign prostatic hypertrophy hypertension hyperlipidemia colon polyp pilonidal cyst ankle fracture s/p surgery Kidney stones s/p left knee arthroscopy s/p right ankle surgery x3 s/p Back surgery Social History: Last Dental Exam:6 months ago Lives with:alone (daughters and sister involved in care) Contact:[Name (NI) ] (sister) [Telephone/Fax (1) 110202] Occupation:Works as a piping designer Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: 2 drinks/week Illicit drug use:denies Family History: Family History:Premature coronary artery disease- father died of an aneurysm at age 55 Race:Caucasian Physical Exam: Pulse:56 Resp:13 O2 sat:97/RA B/P Right:129/72 Left:130/68 Height:6'3" Weight:309 lbs General: NAD, AAOx3 Skin: Dry [x] intact [] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] obese Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: palp Left: palp DP Right: palp Left: palp PT [Name (NI) 167]: palp Left: palp Radial Right: palp Left: palp Carotid Bruit Right: none Left: none Pertinent Results: [2101-2-5] 05:15AM BLOOD WBC-8.9 RBC-3.37* Hgb-10.9* Hct-32.8* MCV-97 MCH-32.4* MCHC-33.3 RDW-13.7 Plt Ct-97* Findings LEFT ATRIUM: Moderate LA enlargement. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Mildly dilated ascending aorta. Mildly dilated descending aorta. Simple atheroma in descending aorta. No thoracic aortic dissection. AORTIC VALVE: Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. The patient appears to be in sinus rhythm. Resting bradycardia (HR<60bpm). Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: The left atrium is moderately dilated. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results at time of surgery. POST-BYPASS: The patient is A paced. The patient is on a phenylephrine infusion. Biventricular function is unchanged. Mitral regurgitation is unchanged. The aorta is intact post-decannulation. Brief Hospital Course: He tolerated the catheterization well and was kept in house for operation. The usual preoperative work up was done and on [2-2] he went to the Operating Room where revascularization was performed. He weaned from bypass on NeoSynephrine and Propfol. He was stable and transferred to the ICU. He awoke, weaned from the ventilator and was extubated, remaining stable and intact. He transferred to the floor. Beta blockade was started and he was diuresed towards his preoperative weight. CTs were removed on POD 2, wires on day 3. Physical Therapy worked with him for mobility. At discharge on POD 5 he was ambulating, wounds were healing well and follow up arrangements made. Diuretics were continued for a week after discharge.He has arranged for his girlfriend to stay at night and to have family check in during the day. Medications on Admission: ALLOPURINOL 150 mg Daily FINASTERIDE 5 mg Daily SIMVASTATIN 40 mg Daily DIOVAN 160 mg Daily ASPIRIN 325 mg Daily Vitamin D 50,000 capsule 1 tablet/week CALCIUM CARBONATE 500 mg tablet 3x/week MAGNESIUM 500mg Daily FISH OIL 1 capsule daily Multivitamin Daily Discharge Medications: 1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Protopic 0.1 % Ointment Sig: One (1) Topical [Hospital1 ] (). 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 6. hydrocortisone valerate 0.2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO ONCE (Once) for 1 doses. 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 11. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 10 days. Disp:40 Tablet(s) Refills:0 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 14. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:14 Tablet, ER Particles/Crystals(s) Refills:0 15. guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours) as needed for painful cough. Disp:1 240ML(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: unstable angina s/p coronary artery bypass grafts hyperlipidemia hypertension obesity benign prostatic hypertrophy s/p lumbar surgery s/p ankle surgery nephrolithiasis Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema : 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: Surgeon:Dr.[First Name (STitle) ]([Telephone/Fax (1) 170]) on [2101-3-15] at 1pm Cardiologist:Dr.[First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 1022] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 4475]) ON [2101-2-14] AT 4PM wound check at [Last Name (un) 6752] 2A on [2101-2-15] at 10:15am Please call to schedule appointments with: Primary Care: Dr.[First Name (STitle) ] [Name (STitle) 89247]([Telephone/Fax (1) 9489]in [2-17] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2101-2-7] ICD9 Codes: 4111, 412, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7715 }	Medical Text: Unit No: [Numeric Identifier 74423] Admission Date: [2176-8-22] Discharge Date: [2176-8-25] Date of Birth: [2176-8-22] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby boy [Known lastname ] is a 2.44 kg product of a 35-2/7-week gestation, born to a 19-year-old G4, P1 now 2 mother. MATERNAL HISTORY: Notable for asthma treated with albuterol, depression, anxiety, insomnia and posttraumatic stress disorder, not currently on any psychiatric medications. PRENATAL SCREENS: B positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, GBS unknown. Prenatal ultrasound at 17 weeks revealed very mild renal dilatation with no evidence of hydronephrosis - study was otherwise wnl. SOCIAL HISTORY: Notable for longstanding complex social issues. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ], LICSW has been providing mother with support. Please call [Telephone/Fax (1) 8717] if there are any questions. PREGNANCY: Complicated by progressive oligohydramnios. Decision made to deliver due to worsening oligo. The infant was deliver ed by cesarean section (repeat breech). Infant emerged vigorous w ith Apgars of 8 and 9. PHYSICAL EXAMINATION: At discharge: Swaddle, off radiant warmer. Anterior fontanel open and flat. Comfortable respirations on room air. Lungs clear and equal. Regular rate and rhythm, no murmur, pink and well-perfused. Abdomen soft, nontender, and nondistended. Active bowel sounds. Infant appropriate tone and activity for gestational age. HISTORY OF HOSPITAL COURSE: Respiratory: Infant is stable on room air without any issues. Cardiovascular: Stable. Fluid, electrolyte. Birth weight was 2.44 kg. Discharge weight is 2.325 kg. Infant was initially started on ad lib amounts of Enfamil 20 calorie with poor p.o. initially with increasing p.o. intake. Infant has been ad lib feeding, taking in adequate amounts of Enfamil 24 calorie, and is otherwise stable. He has remained euglycemic for the current hospital course. GI: Bilirubin on day of life 3 was 8.1/0.3 and 9.7/0.3 on day of life 5. Baby did not require phototherapy. Neurodevelopmental:Infant has been appropriate for gestational age, requiring warmer to support thermoregulation briefly and then had some mild temp instability on transfer the Newborn Nursery however he has maintained his temperature in a crib with out problem for the past 24 hours. Sensory: Hearing screen was performed with automated auditory brainstem responses on [2176-8-26] and passed in both ears. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To newborn nursery. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) 51097] [Name (STitle) 12332], [Hospital ] Health Center ([Telephone/Fax (1) 3581]). Appointment scheduled for [2176-8-29]. CARE RECOMMENDATIONS: Continue Enfamil 24 calories/oz. Medications: Not applicable. Car seat position screening was performed with a 90 minute screening on [2176-8-28] and the infant passed. State newborn screen was done on day of life number 3, and the infant's results are pending. Immunizations: Hepatitis B vaccine was given on [2176-8-26]. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants meeting 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 RC season, smoker in the household, neuromuscular disease, airway abnormalities, or school age sibling. 3. Chronic lung disease. 4. Hemodynamically significant congestive heart disease. Influenza immunization is recommended annually in the fall for all infants once they reached 6 months of age. Before this age and for the first 24 months of the child's life, immunizations 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 DIAGNOSIS: 1. Premature infant, born at 35-2/7 week gestation. 2. Mild immaturity of thermoregulation. 3. Mild hyperbilrubinemia. 4. Breech presentation - hip ultrasound screening needed at 3-6 weeks. 5. Mild fetal renal pelvic dilatation - FU renal ultrasound at 3-6 weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [MD Number(1) 37238] Dictated By:[Last Name (NamePattern4) 55751] MEDQUIST36 D: [2176-8-25] 03:44:16 T: [2176-8-25] 06:25:35 Job#: [Job Number 74424] ICD9 Codes: 7742, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7716 }	Medical Text: Admission Date: [2185-12-21] Discharge Date: [2186-1-6] Date of Birth: [2185-12-21] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname ] [Known lastname 46393] is a former 35 week gestation male, admitted to the newborn Intensive Care Unit with respiratory distress. MATERNAL HISTORY: 30 year old, Gravida II, Para 1 to 2 woman with the following antenatal screens: 0 positive. Antibody negative. Hepatitis B surface antigen negative. RPR nonreactive. Rubella immune. GBS negative. PREGNANCY HISTORY: [Last Name (un) ] [2186-1-23] for estimated gestational age of 35 and [4-29] week pregnancy, reportedly complicated by oligohydramnios, noted at 35 weeks, leading to induction. Progressed to spontaneous vaginal delivery under epidural anesthesia with reportedly precipitous second stage. Artificial rupture of membranes seven hours prior to delivery yielding clear amniotic fluid. No maternal fever or fetal tachycardia. No intrapartum antibiotics administered. NEONATAL COURSE: Infant well at delivery. Apgar scores eight at one minute and eight at five minutes. PHYSICAL EXAMINATION: On admission, heart rate was 154; respiratory rate of 74; saturations 95% in room air. Birth weight: 2,535 grams, 50th to 70th percentile. Discharge weight 2,465 grams. Head circumference 32.5, 50th percentile; length 47.5 cm, 75th percentile. HEAD, EYES, EARS, NOSE AND THROAT: Anterior fontanel, soft, flat, non dysmorphic. Palate intact. Mild nasal flaring. Neck and mouth normal. Chest: Mild retractions and grunting. Respirations: Good bilateral breath sounds, no crackles. CV: Well perfused, regular rate and rhythm. Femoral pulses normal. S1 and S2 normal. No murmur. Genitourinary: Normal male genitalia. Testes descended bilaterally. Active, alert, responsive to stimulation, good tone, appropriate for gestational age, moving all limbs symmetrically. Normal musculoskeletal, normal spine, limbs, hips and clavicle. HOSPITAL COURSE: Baby's grunting progressed. He had an initial blood gas of pH 7.29, CO2 51. He required intubation. He was on the conventional ventilator. He received one dose of Surfactant. He was weaned to extubatable setting. Repeat cap gas was pH 7.34, pCO2 46. Baby was ultimately extubated and demonstrated increased work of breathing after extubation and required reintubation. He was placed on the high frequency ventilator with a MAP of 8 and a delta-P of 18 and about 38 to 40% oxygen. Arterial blood gas was pH 7.39, pCO2 40 and pO2 164. Baby was noted to have increased work of breathing and transillumination suggested a right pneumothorax on day of life two, which was confirmed by chest x-ray. Chest was needled for 40 cc of air and ultimately, a chest tube was placed for continuous leak. This was placed to suction. This remained to suction and ultimately was transitioned to water seal and discontinued by day of life five. The baby remained on the high frequency ventilator until day of life five. After the chest tube was removed and it was demonstrated there was no reaccumulation of air, the baby was transitioned to continuous positive airway pressure. On day of life six, he was transitioned to nasal cannula oxygen. He ultimately received a total of three doses of Surfactant. By day of life eight, he was in room air. He did not demonstrate any apnea or bradycardia of prematurity. He did not require methylxanthine treatment. He did have a desaturation to 77 on day of life 15 with a feeding secondary to discoordination. He required blow-by oxygen. At the time of discharge, he has been feeding well with good coordination and free of desaturations for greater than 36 hours. The baby's baseline respiratory rate is 40's to 60's. His chest tube site is healing nicely. There is a small eschar at the site with no drainage. Cardiovascular: Baby initially required a normal saline bolus during transition for marginally low blood pressure. He did not require pressor support. He had an intermittent murmur which resolved and he has had no further cardiovascular issues. Baseline heart rate is 130s to 160s with blood pressures systolic in the 70s to 80s, diastolics 40s to 50s and means in the 60s. FLUIDS, ELECTROLYTES AND NUTRITION: The baby was initially started on peripheral intravenous fluid. He had initial dextrose stick of 46, subsequent ones greater than 70. He received parenteral nutrition. Enteral feedings were introduced as his respiratory status stabilized, by day of life six. He advanced on feedings of PE-20 to 120 cc per kg, requiring some gavage feeding. At the time of discharge, he is feeding Enfamil 24 calories per ounce, minimum of 100 cc per kg with a discharge weight as stated above of 2,465 grams. He is feeding well with good coordination. Electrolytes have been stable with the last ones being on day of life five. Sodium 141, potassium 3.5, chloride 108, bicarbonate 22. Baby is voiding and stooling. GASTROINTESTINAL: The baby demonstrated physiologic jaundice. He was started on phototherapy for a peak bilirubin of 15.8/0.8 on day of life six. He responded to the phototherapy. This was discontinued and he had a rebound bilirubin on day of life 8 of 6.0/0.5. HEMATOLOGY: Baby did not require any blood products during this admission. His initial hematocrit was 46.9. He had a repeat CBC on day of life two which had a hematocrit of 40.5. INFECTIOUS DISEASE: Baby had an initial sepsis evaluation with a white count of 70.2, 60 polys, 2 bands, platelets of 390,000. Hematocrit of 46.9. He was started on Ampicillin and Gentamycin. Blood cultures remained negative, however, because of his clinical course and respiratory status, he received seven days of Ampicillin and Gentamycin. He had Gentamycin levels of .5 and 7.3. Spinal tap was unremarkable. He has had no further issues with infection. NEUROLOGY: The baby has been appropriate for gestational age. He did not require a head ultrasound based on gestational age greater than 32 weeks. SENSORY: Audiology: passed hearing screen. Ophthalmology: eye examination not indicated based on gestational age of greater than 32 weeks. PSYCHOSOCIAL: Parents have been visiting frequently and look forward to transitioning [Known lastname ] home and are pleased with his progress. PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 46394], telephone #[Telephone/Fax (1) 38248]. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: Home with family. CARE RECOMMENDATIONS: Continue ad lib feeding, Enfamil 24 with iron. MEDICATIONS: None. Car seat position screening passed . State newborn screening status: He has had state newborn screen test on [12-26] and [1-4]. [12-26] results with low T4 (likely secondary to illness). [1-4] results are pending. IMMUNIZATIONS: Hepatitis B vaccine given on [2185-12-31]. Synagis not given secondary to gestational age greater than 35 weeks. IMMUNIZATIONS RECOMMENDED: Synagis-RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: 1.) Born at less than 32 weeks. 2.) Born between 32 and 35 weeks with plans for day care during the RSV season, with a smoker in the household or with preschool siblings. 3.) With chronic lung disease. Influenza immunization should be considered annually in the Fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. FOLLOW-UP: Appointment scheduled with primary care pediatrician on [1-9]. Visiting nurse referral. DISCHARGE DIAGNOSES: Former 35 [4-29] week preterm male. Respiratory distress syndrome, treated. Right pneumothorax, s/p chest tube. Rule out sepsis. Physiologic jaundice, treated. Feeding discoordination, resolved. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37233], M.D. [MD Number(1) 36463] Dictated By:[Last Name (NamePattern1) 38253] MEDQUIST36 D: [2186-1-5] 10:25 T: [2186-1-6] 04:19 JOB#: [Job Number 20386] ICD9 Codes: 769, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7717 }	Medical Text: Admission Date: [2115-5-1] Discharge Date: [2115-5-17] Date of Birth: [2066-6-14] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 165] Chief Complaint: Neck, jaw and chest pain Major Surgical or Invasive Procedure: [5-1] Ascending Aorta and Hemiarch Replacement with 28mm Gelweave Graft, Resuspension of Aortic Valve History of Present Illness: 48 y/o male who presented to OSH c/o left-sided neck and jaw pain, along with chest pain. Underwent a CTA which showed a Type A ascending aortic dissection. Was then transferred to [Hospital1 18] for surgical management. Past Medical History: Hypertension, Hemorrhoids, Ankylosing Spondylitis, Subarachnoid Hemrrhage (Rupture of cerebral aneurysm) s/p Craniotomy and clipping with VP shunt, Occasional Migraines, Hydrocephalus, Right Renal Cell Carcinoma Social History: Denies tobacco or ETOH use. Family History: Non-contributory Physical Exam: VS: 66 20 85/40 6'2" 163.5# Gen: NAD Skin: Unremarkable HEENT: EOMI, PERRL Neck: Supple, FROM, shunt noted right neck Chest: CTAB Heart: RRR Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, decreased pulse rt. arm Neuro: A&O x 3, MAE, non-focal Pertinent Results: [5-1] Echo: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Right ventricular chamber size and free wall motion are normal. The ascending aorta is markedly dilated There are three aortic valve leaflets. Moderate (2+) aortic regurgitation is seen. No mitral regurgitation is seen. There is no pericardial effusion. A large aneurysm of the ascending aorta is present with a dissection flap and entry point visible just above the STJ. The STJ is effaced. Epi-aortic done to view arch. Wire introduced into right femoral artery seen in descending aorta. Post- Bypass: Patient is not paced, on norepinephrine infusion. Procedure was an ascending aorta replacement and hemi-arch. Good biventricular systolic fxn. Trace MR. AI is now 1 - 2+. Descending aorta is intact. [5-2] CTA of Head/Neck: 1. Unchanged CT of the head with no acute intracranial process demonstrated. 2. Density abutting the brachiocephalic artery represents either a false luminal thrombosis or postoperative hematoma compressing the vessel, although the vessel distal to this is patent and opacified. [5-2] EEG: This is an abnormal portable EEG due to dimunition of voltages broadly over the right side suggestive either of a structural or destructive process of the cortical and subcortical structures on the right versus material interposed between the skull and cortex on the right side. In addition, there were intermittent bursts of mixed frequency slowing noted in the left anterior quadrant suggestive of an underlying area of subcortical dysfunction in that region as well. Transient sharp discharges were noted in the right frontal region but appeared most likely artifactual in nature given their narrow morphology and atypical field. On video, there was no clinical correlate for these. The background was disorganized and consisted mainly of a low voltage fast activity which may reflect medication effects from concomitant benzodiazepine administration. If clinically warranted, consideration could be given for a period of extended monitoring to further characterize the abnormalities noted above. [5-6] MRA of Head/Neack: 1) Multiple tiny scattered infarcts in both cerebral hemispheres, suggesting a central source of emboli. 2) Patent major intracranial arteries. 3) Very limited but grossly normal MRA of the neck, which excludes the origins of the carotid and vertebral arteries. [5-7] Abd X-ray: Single supine radiograph, which is limited by motion is presented for review. Upper abdomen is excluded from the field of view. Air and stool are present throughout the colon. Small bowel is not dilated. The liver appears to be enlarged. The evaluation for free intraperitoneal air is limited by technique, however, there is no supine evidence of free air. [5-10] CT of Spine: Alignment is within normal limits. No fracture is demonstrated. Multilevel degenerative changes are seen. There has been a recent median sternotomy. Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname 13551] was transferred from OSH with a Type A Aortic Dissection. He was emergently taken to the operating room where he underwent an Ascending Aorta and Hemiarch Replacement with Aortic Valve Resuspension. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later that night he was weaned from sedation and he was noted to have no left arm movement and onset of rhythmic movement of the right arm (epilepsia partialis continue per neuro). Neurology and Stroke service were consulted on the morning of post-op day one. He was started on Dilantin with continuous EEG monitoring. CT of the head was negative for stroke. Both services continued to follow pt. throughout hospital course. He required post-op [Known lastname ] transfusions for low HCT. He remained intubated over the next several days d/t lack of purposeful movements and not following commands. Chest tubes and epicardial pacing wires were removed per protocol. On post-op day five he underwent a head MRA which revealed multiple tiny scattered infarcts in both cerebral hemispheres, suggesting a central source of emboli. On post-op day six he was again weaned from sedation. Neurologically he was more alert and following commands with weaker right side along with tremors. He was then successfully extubated without incident. On post-op day seven he appeared stable and was transferred to the telemetry floor for further medical care. In the morning of post-op day eight he was found unresponsive and hypotensive (BP 50/30's w/ HR in 60's). This episode was felt related to hypotension d/t pt. recently receiving increased dose of beta blocker. Received appropriate treatment with increase in responsiveness and was transferred to the CVICU for closer monitoring. He was eventually found to be septic and was started on antibiotics. On post-op day nine he underwent CT of spine to evaluate for vertebral fracture d/t his h/o ankylosing spondylitis and current extremity weakness. Study was negative for fracture which reassured weakness not d/t cord compromise. Over the next several days patient became increasingly confused and delusional. He required a patient observer and was appropriately treated with Haldol, along with psychiatry consult. On post-op day twelve he was transferred back to the telemetry floor for further care. His haldol was weaned. By post-op day 16 he was ready to be transferred to rehab. Medications on Admission: Lisinopril , Iron, Percocet prn, Fentanyl patch Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 2. LeVETiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:10 Patch 72 hr(s) Refills:0 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:10 Tablet(s) Refills:0 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) bag Intravenous Q 12H (Every 12 Hours). Disp:60 bag Refills:0 12. Outpatient Lab Work weekly CBC/diff, BUN/cre, ESR, CRP, and vancomycin trough faxed to [Doctor First Name ] at infectious diseases ([Telephone/Fax (1) 16411] Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] [Hospital 1108] Rehab Unit at [Hospital6 1109] - [Location (un) 1110] Discharge Diagnosis: Type A Aortic Dissection s/p Ascending Aorta and Hemiarch Replacement Post-op Seizures PMH: Hypertension, Hemorrhoids, Ankylosing Spondylitis, Subarachnoid Hemrrhage (Rupture of cerebral aneurysm) s/p Craniotomy and clipping with VP shunt, Occasional Migraines, Hydrocephalus, Right Renal Cell Carcinoma Discharge Condition: stable/good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [First Name (STitle) ] in 4 weeks. Dr. [Last Name (STitle) 78487] in 2 weeks. Cardiologist in 2 weeks. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] (infectious diseases) in [1-2] weeks. Call ([Telephone/Fax (1) 6732] to make an appointment. Fax weekly CBC/diff, BUN/cre, ESR, CRP and vacomycin trough to [Doctor First Name ] at Infectious Diseases ([Telephone/Fax (1) 16411]. Obtain CTA of chest in 2 weeks. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2115-5-17] ICD9 Codes: 7907, 4241, 2930, 2859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7718 }	Medical Text: Admission Date: [2168-8-19] Discharge Date: Date of Birth: [2112-3-3] Sex: M Service: ORT DIAGNOSIS: Cervical spinal cord injury with C5 burst fracture. PROCEDURES PERFORMED: Anterior and posterior spinal fusion, cervical, tracheostomy, PEG placement, posterior spinal decompressive laminectomy and debridement, central line and then eventual PICC line placement. HOSPITAL COURSE: His 56 year old male was admitted to the Trauma Service on the [2168-8-19] after sustained a cervical spine injury during an intoxication event. The C5 burst fracture was associated with a central cord spinal cord syndrome. He was medically stabilized and underwent cervical spine stabilization procedure on the [8-21]. A C5 vertebrectomy and fusion was performed on the [2168-8-20]. In addition, a posterior spinous process wiring stabilization was also performed. The immediate postoperative course was unremarkable with extubation proceeding on the 29th. Due to difficulties with secretions, percutaneous tracheostomy was placed on [2168-9-1]. The anterior and posterior fixation was performed on [8-22]. On the [7-30], decreased movement to the lower extremities was noted and the MRI scan confirmed compression of the cervical spinal cord and emergent posterior decompression with removal of the hardware and laminectomy from levels C3 to C7 was performed. Findings at the time of surgery included hematoma in the epidural space and also purulent material in the subcutaneous space adjacent to the hardware and bone graft fixation. Eventually, this culture from intraoperatively grew out an Enterobacter species and he has been treated with piperacillin and ceftazidime intravenously. Perioperative cefazolin was the initial antibiotic coverage. Only low grade temperatures were documented. The antibiotics recommended included vancomycin, piperacillin and ceftazidime. MRSA screen was negative and on [8-24], Clostridium difficile toxin screen was negative. The culture from the [7-30] grew out the Enterobacter species. Zosyn was initiated along with vancomycin from the time of surgery and ciprofloxacin was also added for the acute perioperative coverage. The Zosyn, Cipro and vanco were continued until [9-1] where he received four days of Zosyn and two days of ciprofloxacin. The vancomycin was discontinued on the [8-3] and Cipro and Zosyn were also continued. Ciprofloxacin was changed to levofloxacin on the [8-3] and Zosyn was continued. He tolerated the trach procedure. The anterior wound healed and the suture was removed on postoperative day 10. Eventually, the posterior incision healed well and the staples were removed on postoperative day 10 after the posterior procedure. No signs of active wound sepsis occurred. Repeated transfusion for asymptomatic anemia were performed and multiple replacements of magnesium have been performed during his hospitalization. CURRENT MEDICATIONS: Current medications are metoprolol 100 mg po tid, lorazepam 1 mg IV tid, Atrovent MDI two puffs q6h, famotidine 20 mg IV q12h, olanzapine 5 mg po Q.D., Zosyn 4.5 g IV q8h and levofloxacin 500 mg IV q24h and now metronidazole 500 mg IV q8h. The metronidazole should be continued as long as the other antibiotics are continuing. The duration of antibiotics from the time of discharge is an additional four weeks of therapy via the PICC line. Tube feedings have been initiated for the last 48 hours. Diarrhea occurred and this was felt to be due to the strength of the tube feedings and they were cut in half and free water was added. However, in light of the C. difficile toxin positive screen, the tube feedings may be advanced per his nutritional requirements and tolerance up to the goal of 70 cc per hour with a 300 cc water flush every 12 hours. DISCHARGE INSTRUCTIONS: The care needs include trach care and this has been attended by the General Surgery team prior to his transfer, fitting a size 7 cuffed tube which they felt could be inflated or not inflated. Also, the PEG is the source of nutrition and for PO medications. A PICC line in the left brachium was inserted by the radiology interventionists and verified to be in position and has been successfully used for installation of intravenous medications and this will be continued for the four week duration of antibiotics. The cervical collar should be also used for an additional four weeks. After three to four weeks, follow-up with Infectious Disease should be performed with follow-up of CBC, sed. rate, C-reactive protein. Orthopedic follow-up with Dr. [Last Name (STitle) 363] will be performed in four weeks with AP and lateral x- ray of the cervical spine to assess healing. The cervical collar should remain in place full-time until this follow-up is completed. Mobility is important for pulmonary toilet and he has successfully been mobilized to the seated position out of the chair. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3191], [MD Number(1) 3192] Dictated By:[Last Name (NamePattern1) 3193] MEDQUIST36 D: [2168-9-12] 13:23:08 T: [2168-9-12] 14:00:15 Job#: [Job Number 45658] cc:[Name8 (MD) 57092] ICD9 Codes: 496, 2761, 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7719 }	Medical Text: Admission Date: [2184-3-15] Discharge Date: [2184-3-18] Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 2387] Chief Complaint: Transferred to cath Major Surgical or Invasive Procedure: Coronary angioplasty Bare metal stent to LAD History of Present Illness: 88 year old female with PMH of HTN, colon cancer s/p resection, presents from OSH for cardiac catheterization. Patient states she has been having left back/scapular pain intermittently for over 2 years. It occurs about once per week and lasts for up to an hour. She describes this pain as an ache that feels muscular. It worsens with movement but also comes on with exertion after walking for a block or two. She denies SOB, palpitations, N/V, chest pain, or radiating pain to neck or left arm. Ms. [Known lastname 1018] also describes DOE to one to two blocks. Because of her scapula pain, she was referred for a stress test in late [2184-2-3] which showed some 'changes'. Per note from NEBH, patient had inferolateral ischemia on ETT (4minutes) with reproduction of symptoms. Because of these changes she was sent for cardiac catheterization at [Hospital6 ] which showed 90% stenosis to the LAD and she is being transferred to [Hospital1 18] for intervention with cath in the AM. At NEBH, WBC 9.8, HCT 37.6, PLT 152, Na 141, K 5.0, Cl 102, CO2 32, Glucose 88, BUN 30, Cr 0.9, Ca 8.9. On arrival, the patient was sent to the cath lab holding area and had her cath sheath removed successfully. On arrival to [Hospital Unit Name 196] floor, patient was asymptomatic. She denied chest pain, back pain, scapular pain, SOB, palpitations, or N/V. She had no other complaints. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. 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, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Hypertension Colon Ca [2170] s/p resection Tonsillectomy at age 9 B/L Hip replacements Cardiac Risk Factors: - Diabetes, - Dyslipidemia, + Hypertension Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Patient drinks a glass or two of wine per week. She still works as a Dental Hygienist. Family History: Mother with MI, Father with Prostate Ca and MI. Physical Exam: VS - BP 122/65 HR 78 RR 12 O2ssat 98% RA Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. Normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Irregular rhythm Chest: No chest wall deformities, scoliosis or kyphosis. 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. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Popliteal 2+ DP 2+ PT 2+, Femoral not taken as pt is s/p cath sheath removal. Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2184-3-15*] 09:14PM BLOOD WBC-8.4 RBC-3.44 Hgb-11.1* Hct-32.6* MCV-95 MCH-32.3* MCHC-34.1 RDW-12.8 Plt Ct-130* [2184-3-15] 09:14PM BLOOD PT-12.2 PTT-26.3 INR(PT)-1.0 [2184-3-15] 09:14PM BLOOD Glucose-163* UreaN-23* Creat-1.0 Na-141 K-4.2 Cl-107 HCO3-26 AnGap-12 [2184-3-15] 09:14PM BLOOD Mg-2.1 MEDICAL DECISION MAKING EKG demonstrated . ETT performed on [2-/2184] demonstrated inferolateral ischemia on ETT (4minutes) with reproduction of symptoms. CARDIAC CATH performed on [2184-3-15] demonstrated: 90% stenosis of LAD. Brief Hospital Course: Patient is an 88 year old female with PMH of HTN, colon cancer s/p resection, presents from NEBH s/p cardiac catheterization which demonstrated 90% stenosis of [Hospital ] transferred to [Hospital1 18] for cardiac catheterization and intervention of LAD. CAD - Patient has no prior history of CAD. She describes intermittent left scapular/back pain which has been ongoing for 2 years. She also describes some DOE to one block. Stress test done 2-3 weeks ago showed inferolateral ischemia with reproduction of symptoms. Cardiac cath showed 90% occlusion of LAD. Patient transferred to our institution where intervention was performed with BMS to LAD. Patient experienced hypotensive episode after femoral sheath was pulled, and she developed a large groin hematoma and transiently lost lower extremity pulses, for details see below. Patient transfused one unit of pack red cells and medical regimen adjusted. She was closely monitored in the CCU. Patient remained hemodynamically stable overnight and did not require any further blood products. Follow up was arranged with her primary cardiologist. For discharge regimen, please see medications section. . # Groin hematoma: As above, catheterization complicated by groin bleed with estimated blood loss of approximately 1 liter. Serial hematocrits were obtained and no further drops were observed. Hematoma remained stable and no further intervention was necessary. . # Possible limb ischemia: loss of DP pulse most likely secondary to holding pressure on femoral artery. Vascular surgery evaluated and recommended checking serial pulses hourly. Patient remained with good pulses via doppler, no intervention was necessary. # Delerium: Likely in the setting of receieving sedation for catheterization. Patients mental status returned to baseline at time of discharge. . #. Hypertension: Regimen adjusted secondary to hypotension post procedure. Please refer to medication section for details. #. Colon Ca - Patient is s/p resection, no history of recurrence. . #. FEN - Cardiac heart healthy diet, replete lytes . #. Access: PIV . #. PPx: Heparin SQ, Bowel regimen . #. Code: Full Code . Medications on Admission: ASA 81mg daily Amlodipine 2.5mg daily Diovan 160mg daily Preserve Vision one tab daily Nasonex [Hospital1 ] Ocean spray nasal Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. 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 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary 1. Angina 2. Coronary artery disease Secondary 1. Hypertension Discharge Condition: Hemodynamically stable, afebrile, ambulatory Discharge Instructions: You were admitted to the hospital for a cardiac catheterization and received a stent to one of your arteries. The procedure was complicated by some bleeding. Your ultrasound did not show any further bleeding. Please take all of your medications as directed. The following changes have been made to your medications. 1. You are no longer taking your Amlodipine 2. You are now taking Metoprolol 12.5mg twice daily 3. Please take Aspirin and Plavix EVERY DAY. If you develop any chest pain, shortness of breath, pain in your groin or back, bleeding from your procedure site or any other concerning symptoms, you should call your doctor or come to the emergency room. Followup Instructions: You have a follow up appointment with Dr [Last Name (STitle) 14522], ([Telephone/Fax (1) 39803] [3-25] at 1 pm. At that time, you should have your hematocrit checked. ICD9 Codes: 4111, 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7720 }	Medical Text: Admission Date: [2102-3-13] Discharge Date: [2102-4-11] Date of Birth: [2027-4-28] Sex: F Service: NEUROLOGY Allergies: Oxycontin / Morphine Attending:[First Name3 (LF) 618] Chief Complaint: "swollen tongue" Major Surgical or Invasive Procedure: LP x2 History of Present Illness: 74 yo F with chronic low back pain s/p multiple procedures, urinary incontinence, and dementia who presented to the ED with tongue swelling after falling onto her face. Per report she was walking and fell forward. No apparent LOC or preceeding symptoms. She appeared to loose her balance. She sustained a right orbital hematoma and bit her tongue. She did not require sutures. She is being admitted to the [Hospital Unit Name 153] for airway monitoring given her swollen tongue. . She was seen at [Hospital3 ] today for a pre-op assessment prior to a urinary sling procedure. Her husband reports increasing confusion and frequent falls over the last two weeks. She was treated for a UTI with Amoxicillin 1 month ago. He reports she is forgetful at baseline. She has been on several different medications for urinary incontinence over the last 2 yrs including detrol and vesicare. Her recent confusion appears to correlate with starting Vesicare on [2102-2-21]. She also discontinued her fluphenazine on [2102-3-9] after 40 yrs of use. . In the ED a Head CT revealed chronic microvascular angiopathy without acute fracture or hemorrhage. Her UA was negative. . She is alert and oriented to self only. She denies pain, dysuria, or SOB. Husband reports her wt has been stable and she has a good appetite. Past Medical History: - ?dementia - urinary incontinence since [2099] - chronic low back pain/degenerative disk disease s/p failed back surgery, epidural steroid injections, nerve blocks, facet injections, trigger point injections - hyperlipidemia - hypertension - major depression Social History: She lives at home with her husband. She is independent of her ADL's. She quit smoking tob in [2049]; ~10 pack year history. Occasional EtOH. Denies illicit drug use. Husband, [Name (NI) 892] [Name (NI) 3647], is HCP ([Telephone/Fax (1) 36275]). Son [Telephone/Fax (1) 36276]. Family History: Mother died of [Name (NI) 11964]. Two sisters are healthy. Youngest child with mental retardation; lives in group home. Physical Exam: Admission: Tc 98.6 BP 170/100 HR 96 RR 18 Sat 95% RA Gen: appears comfortable, NAD HENNT: swollen tongue, multiple ecchymoses and abrasions over right orbit, lips, and cheeks. MMM, anicteric, PERRL Neck: no LAD, no JVD CV: RRR, nl S1S2, II-III/VI systolic murmer heard best at apex Lungs: CTAB Abd: soft, NT/ND, +BS, No HSM Ext: no peripheral edema, strong DP/PT pulses bilaterally Neuro: A&O to self, moving all extremities Pertinent Results: [2102-3-13] 09:25PM BLOOD WBC-10.5 RBC-4.27 Hgb-14.0 Hct-37.8 MCV-89 MCH-32.7* MCHC-36.9* RDW-13.7 Plt Ct-267 [2102-3-13] 09:25PM BLOOD Neuts-88.9* Bands-0 Lymphs-4.3* Monos-5.0 Eos-1.3 Baso-0.6 [2102-3-13] 09:25PM BLOOD PT-11.6 PTT-19.1* INR(PT)-1.0 [2102-3-13] 09:25PM BLOOD Glucose-116* UreaN-18 Creat-1.1 Na-139 K-3.7 Cl-102 HCO3-25 AnGap-16 [2102-3-13] 09:25PM BLOOD CK(CPK)-201* [2102-3-14] 05:55AM BLOOD ALT-23 AST-26 LD(LDH)-192 CK(CPK)-171* AlkPhos-95 Amylase-50 TotBili-0.4 [2102-3-13] 09:25PM BLOOD CK-MB-6 cTropnT-<0.01 [2102-3-14] 05:55AM BLOOD CK-MB-4 cTropnT-<0.01 [2102-3-14] 05:55AM BLOOD Lipase-22 [2102-3-13] 09:25PM BLOOD Calcium-9.5 Phos-3.5 Mg-1.7 [2102-3-14] 05:55AM BLOOD TSH-0.63 [2102-3-14] 05:55AM BLOOD VitB12-1012* Folate-GREATER TH . [3-13] ECG: Sinus rhythm Prior inferior myocardial infarction No previous tracing available for comparison . [3-13] CT Head: 1. No intracranial hemorrhage or mass effect. 2. Chronic microvascular angiopathy. 3. Right supraorbital facial swelling. 4. No fracture identified. . [3-13]: CT C-spine: No evidence of acute fracture or listhesis. Multilevel degenerative changes as described above. . [3-13] CT Orbits/face: 1. Soft tissue swelling over the right orbit. 2. No evidence of acute fracture. Note added at attending review: There is a fracture of the tip of the coronoid process of the right mandible. . [3-14] MRI Head: Significantly limited MRI of the brain due to motion artifact. Extensive chronic periventricular microvascular ischemic changes. Scattered old lacunar infarcts within the brainstem. No acute territorial infarcts are seen within the brain. . [3-30] Most recent head MRI: This study, slightly degraded by patient motion artifact, is compared with recent contrast-enhanced MR examination dated [2102-3-20]; the overall appearance is unchanged. There is mild-moderate cortical atrophy. There is severe, confluent FLAIR-hyperintensity in bihemispheric periventricular and subcortical white matter, representing extensive chronic microischemic change. However, there is no focus of restricted diffusion to indicate acute infarction. There is no evidence of acute hemorrhage. There are a few punctate foci of blooming susceptibility artifact, unchanged, likely representing hemosiderin from past petechial hemorrhage, related to small vessel infarction. Again noted is a prominent developmental venous anomaly ("venous angioma") in the right paramedian cerebellar vermis, with no associated cavernous angioma or hemorrhage. There is no other pathologic focus of parenchymal, leptomeningeal or dural enhancement. IMPRESSION: 1) No acute process and no significant interval change since the [3-20] examination. 2) Severe chronic micro-ischemic change in bihemispheric white matter. 3) Extensive fluid within bilateral mastoid air cells, significantly worse since the previous examination, and bilateral ethmoid mucosal thickening with small amount of fluid in the sphenoid sinus, some of which may relate to protracted supine positioning (is there clinical suspicion of either sinusitis or mastoiditis?). . CXR [2102-4-11]: The heart size is moderately enlarged, unchanged. There is a prominent mediastinal venous engorgement with no overt pulmonary edema. Bibasilar mild atelectasis are unchanged. The tracheostomy and the right subclavian venous line are in good position, stable. See OMR for further studies. Brief Hospital Course: Mrs [Known lastname 3647] was initially admitted to the medicine ICU for observation given her chronic tongue swelling and fall on her face with trauma. She was monitored overnight on standard ICU monitoring and a 1:1 sitter with no problems or events. Dementia work up was initiated, and she completed an MRI of the head. The dementia workup was negative and the MRI (limited study) was significant for no acute stroke. The pt was noted to have extensive chronic periventricular microvascular ischemic changes and scattered old lacunar infarcts within the brainstem. The pt's electrolytes were checked and repleted. She was disoriented throughout her stay, and agitated and somnolent at times. She was stable the day after admission morning, and transferred to the medical floor as she had a stable respiratory status, and did not require ICU level care any longer. On the morning of transfer to the floor the pt has a CT head that showed an isolated fracture of her mandible. The pt was evaluated by the oro-maxillofacial surgery service from the [Hospital1 756] and no intervention was recommended. The pt became increasingly somnolent on arrival to the floor and had decreased responsiveness. She became mildly rousable on her third day on the floor. The pt was noted to be hyperventilating. Due to concern for altered mental status secondary to meningitis/encephalitis, an LP was attempted by the Anesthesia team and house staff. Due to the pt's multiple back surgeries and spine fusions, an LP was not successful. The pt was empirically started on Vanc/Ceftriaxone/Acyclovir and Ampicillin. A day after initiation of these medications, there was an interval increase in creatinine from 0.9 to 2.2. Due to concern for Vancomycin or Acyclovir induced nephrotoxicity, these medications were held and Cr was rechecked; it normalized within days. . The [Hospital ] hospital course was significant for the following problems: . # Frequent falls/altered mental status: The pt was noted to have a progressive decline in mental status over the last few years with a significantly accelerated decline over the last 2-3 weeks. The pt's fall did not appear to be a syncopal event and her labs and urinalysis were unremarkable. Her head CT revealed chronic microvascular angiopathy likely representing dementia. A metabolic workup was negative. The pt was noted to have a waxing and [Doctor Last Name 688] mental status. During a neurology team evaluation the pt was noted to have ?mild myoclonus of toe. A STAT EEG showed markedly abnormal brain activity indicating severe encephalopathy. The pt was started on seizure prophylaxis with Phenytoin IV. In light of mental status changes, the pt was also empirically started on Ampicillin, Vancomycin, Acyclovir and Ceftriaxone after 4 failed attempts at LP (pt has spine fusions from L3 to S1). The Ampicillin was subsequently discontinued. [3-19] the patient was noted to have tonic extension of her arms thought to be a generalized seizure. Her dilantin level was found to be subtherapeutic at 2.5. She shortly after developed tachycardia, tachypnea, elevated BP, and acidemia. She was intubated and transferred to the ICU. She was then loaded with dilantin and transferred to the neuro ICU on the [Hospital Ward Name ]. Blood and urine cultures were ultimately unrevealing. A lumbar puncture was performed and found to be negative. All antibiotics were discontinued. In the neuro ICU the patient was placed on continuous EEG monitoring. Her EEG showed evidence of a deep encephalopathy. She was started on IV glycerine to treat brain edema related to her fall. She remained minimally responsive. A tracheostomy and g-tube were placed and the patient was transferred to the neurology step down unit. Thyroid function tests were repeated and were once again unremarkable; ammonia was sent and was normal. In the stepdown unit, her exam improved slightly - she began to open her eyes and keep them open to sternal rub, and then spontaneously opened her eyes on [3-31]. Initially, she had absent reflexes and no withdrawal to noxious stimuli; she began to regain reflexes and withdrew her lower limbs to nailbed pressure, raising the possibility of resolving critical illness polyneuropathy. Dilantin dosing was initially increased, then transitioned to Keppra. MRI was repeated and showed stable subcortical white matter changes. As she did not follow commands, further workup was pursued, including sending anti-TPO antibody to check for Hashimoto's encephalitis. Results of this were negative. LP was also repeated to look specifically for signs of limbic encephalitis (anti-[Doctor Last Name ]), intravascular lymphoma (LDH), and Creutzfield-[Doctor Last Name ] Disease (CSF for CJD). Results were pending at time of discharge for CJD. The LDH was normal as was the anti-[Doctor Last Name ]. By the end of her course, she had received 4 MRIs of the head which were all stable and unrevealing of a problem that would explain her encephalopathy. Multiple blood and urine cultures were sent which showed no signs of infection. She also had several days of EEG monitoring with no evidence of seizure, and only showing encephalopathy. She also had several routine EEGs with similar findings. . # Renal - the patient temporarily developed ARF on IV acyclovir. The medication was discontinued and the patient received aggressive IV hydration. Her creatinine eventually normalized. . # Swollen tongue: The pt was noted to have a swollen tongue on admission but this was not noted in admission to the floor; in fact the pt had had a large tongue (per husband) for the last 40 years secondary to chronic Fluphenazine use. The pt did not have any evidence of airway compromise. The pt was monitored in the [Hospital Unit Name 153] overnight. The pt's husband reported that the pt has h/o tongue angioedema scondary to chronic (>40y) fluphenazine use. She was given decadron 10 mg x1; this resolved. . # Thyroid mass Pt noted to have a 4.4-cm mass in the right lobe of the thyroid on ultrasound. Thyroid function was normal during the admission. She could be considered for ultrasound-guided biopsy of the mass in the future. . # Urinary incontinence. Appeared chronic. No evidence of acute infection or retention. Sling procedure was planned by urology prior to hospitalization. . # HTN. BP was elevated upon arrival to medical ICU; this was thought to be likely secondary to agitation. She was started on Metoprolol 50 [Hospital1 ] in ICU (home dose was atenolol 50 daily). Blood pressure stabilized after transfer to neuro ICU and finally to SDU. She had no further BP issues while on the floor and was stable on discharge. She did have a small amount of captopril added while she was here and was sent out on this. . # Psych. The patient had been on Fluphenazine x 40 yrs- initially, this was thought to be related to change in mental status; however, two weeks later when she remained in coma, this was thought less likely. Upon further questioning, her husband described a gait that resembled a Parkinsonian gait - she likely had an element of drug-induced Parkinsonism prior to hospitalization; it is possible that an unsteady gait contributed to her fall. #Pulm: The patient had a tracheostomy performed while here and then required oxygen through a trach mask for the remainder of her stay. She had to have frequent suctioning as she makes a significant amount of secretions. She oxygenated well throughout. She did develop a bilateral PNA which was successfully treated and subsequent CXRs were clear. She also had an element of mild fluid overload on some of the CXRs. Her most recent CXRs did not show this. Of note, the patient is tachypneic at times with no other instability with rates of ~30. This comes and goes over days. Most recent CXR [4-11] was normal. #In summary, the patient had a rapidly progressive encephalopathy while in the hospital. She had a fall, then became unresponsive fairly soon after. She was then likely in intermittent status for an unknown period of time. She also developed ARF likely due to med effect. She then had a tension pneumothorax requiring chest tube. She later developed a pneumonia which was treated. She recovered from all of this, but failed to wake up. A large work-up, including MRIx4, LPx2, and multiple blood tests yielded no reason for her symptoms. The theory as to what is causing her problems is that she has a large amount of small vessel disease at baseline. Then, she had these multiple medical problems, including likely several days of seizure. This has resulted in her current unresponsiveness. It may simply take a long time for her to recover in this setting. Her exam currently is that she opens her eyes to sternal rub and keeps them open, but only looks midline. She does not track at all or look around. Her brainstem reflexes are normal, with normal corneals, gag, cough, OCRs, nasal tickle, and pupils. She also withdraws her extremities to pain much of the time, but not always. She has no spontaneous movement or attempts at speech. Her toes are downgoing. Medications on Admission: Home Meds: - Fosamax 35 daily - niacin 500 daily - Atenolol 50 daily - Fluphenazine 5 [Hospital1 ] - MVI - Ca/VitD - VitE - Advil prn - Alleve prn - tylenol prn - HCTZ 25 daily (d/c'ed [2102-3-9] secondary to hypokalemia) - Vesicare ([2102-2-21] - [2102-3-9]) Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Alendronate 70 mg Tablet Sig: 0.5 Tablet PO QSUN (every Sunday). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Ranitidine HCl 15 mg/mL Syrup Sig: One [Age over 90 1230]y (150) mg PO BID (2 times a day). 7. Insulin Regular Human 100 unit/mL Solution Sig: as directed units Injection ASDIR (AS DIRECTED): Standard insulin sliding scale. 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): hold hr<60, SBP<100. 9. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): Hold for SBP < 100 . 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Persistent encephalopathy thought to be due to recent status epilepticus as well as severe small vessel cerebral disease. -- HTN Thyroid nodule Discharge Condition: Pt is unreponsive, but opens her eyes to sternal rub. She is flaccid otherwise. She has intact brainstem reflexes. Discharge Instructions: Please tell the doctors [First Name8 (NamePattern2) ] [Last Name (Titles) ] if there is any worsening of breathing, or apaprent change in her clinical status Followup Instructions: Please follow-up as the doctors [First Name8 (NamePattern2) ] [Last Name (Titles) ] arrange. -- You should follow-up with Dr [Last Name (STitle) ] in the stroke service at [Hospital1 18] after you are discharged. The staff at [Hospital1 ] can schedule this at discharge. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 5849, 2762, 486, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7721 }	Medical Text: Admission Date: [2115-1-22] Discharge Date: [2115-2-4] Date of Birth: [2115-1-22] Sex: F Service: NB DISCHARGE DIAGNOSIS: Premature female infant, 34 and 3/7 weeks gestation. Status post rule out sepsis. HISTORY OF PRESENT ILLNESS: [Known lastname ] is a 34 and [3-11] week premature female weighing 2.255 kg admitted to the Newborn Intensive Care Unit at [Hospital6 256] for management of prematurity. The infant was born to a 33-year-old, gravida 3, para 1, now 2, O positive female, whose remaining prenatal screens were noncontributory. The mother has a history of hypothyroidism of Levoxyl. Pregnancy was complicated by premature and prolong rupture of membranes since [2115-1-16]. Labor was induced on the day of delivery with no maternal fever. The mother had been on p.o. antibiotics since admission for unknown group B strep status. She delivered vaginally with Apgar scores of 9 and 9. The infant was admitted to the NICU for prematurity. Weight on admission was 2.255 kg, length 47 cm, head circumference 31 cm, all appropriate for gestational age. HOSPITAL COURSE: Respiratory: The infant remained in room air throughout her hospital course. Cardiovascular: Her pressures were stable, and there were no cardiovascular issues. No murmur was audible. Feeding and nutrition: The infant remained in the hospital because of immature feeding; however, at the time of discharge, she weighed 2.355 kg, was feeing ad lib demand of NeoSure 24 cal/oz and was gaining weight well. Hematologic: The mother is 0 positive. The baby had a peak bilirubin of 9.5, and a follow-up bilirubin on [1-28] was 8.3/0.4. Infectious disease: She was initially placed on Ampicillin and Gentamicin, and with 48 hours of a negative blood culture, the antibiotics were discontinued. Hematologic: Her initial hematocrit was 53.54. Immunizations: Hepatitis B immunization number 1 was administered on [1-28]. Hearing screening: Performed initially which showed a failed screen on the left ear. This was repeated prior to discharge, and both ears were normal. DISCHARGE PLAN: The patient is to be discharged home with a follow-up appointment within three days at [Hospital1 ] [Location (un) 8985] Center, Dr. [First Name (STitle) ] [Name (STitle) 59325]. DR.[Last Name (STitle) ],[First Name3 (LF) ] 50-393 Dictated By:[Last Name (NamePattern1) 56049] MEDQUIST36 D: [2115-2-4] 10:42:22 T: [2115-2-4] 11:03:52 Job#: [Job Number 59326] ICD9 Codes: V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7722 }	Medical Text: Admission Date: [2106-2-15] Discharge Date: [2106-2-23] Date of Birth: [2106-2-12] Sex: M Service: DISCHARGE DIAGNOSES: 1. Immature suck, swallow, and breathing pattern. 2. Premature male infant 36 weeks gestation. 3. Status post rule out sepsis. HISTORY OF PRESENT ILLNESS: [Doctor Last Name 518] is the former 2.490 kg male infant born at 35-1/7 weeks gestation to a 35-year-old A negative, gravida 2, para 1 now 2 female, whose pregnancy was unremarkable. Infant was born by repeat cesarean section with Apgars of nine and nine, and initially went to the Newborn Nursery. He was noted to have some dusky episodes and was sent to the Neonatal Intensive Care Unit at [Hospital3 ] Hospital for evaluation and car seat test. During the car seat evaluation, it was noted that he had some spontaneous desaturations followed by dusky episodes with bottle feeding. PHYSICAL EXAMINATION: Was entirely within normal limits. PROBLEMS DURING HOSPITAL STAY: 1. Respiratory: Infant was in room air throughout his hospital course. He had rare episode of desaturation at rest. These were unassociated with bradycardias. 2. Cardiovascular: No murmur was present. His blood pressures remained stable. 3. Feeding and nutrition: Infant was noted to have dusky episodes during feeding. It was felt that these were secondary to prematurity with immature suck, swallow, and breathing patterns. By the time of discharge, he had rare episodes, and the family knew to take the bottle out of his mouth if this occurred. Most often it was at the very beginning of a feeding. He had none of these episodes for at least 48 hours prior to discharge. 4. Infectious disease: Because the infant initially appeared somewhat low toned and sleepy, a complete sepsis evaluation was done including blood culture, LP, and spinal fluid culture. He was started on ampicillin and gentamicin and at 48 hours with all cultures negative, the antibiotics were discontinued. LP was normal. CBC was benign. 5. Hematology: Mother A negative, baby A positive, [Name (NI) 36243] negative. Peak bilirubin was 10.2. Infant required no treatment. His initial hematocrit was 50. 6. Infant passed his hearing screening on [2-12]. 7. Circumcision performed on [2-14]. 8. Hepatitis B immunization on [2-13]. 9. Neurologic: Because infant was quiet and somewhat low toned on admission, a screening head ultrasound was done on [2-16], which was entirely normal. Infant was discharged home weighing 2.465 kg. Feeding adlib demand of Enfamil 20 calories/ounce and taking up with 150 cc/kg. Patient is to be followed up by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] and has a follow-up appointment the day post discharge. Visiting nurse to come to home two days post discharge. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 37691] 50-393 Dictated By:[Last Name (NamePattern1) 38304] MEDQUIST36 D: [2106-2-23] 08:38 T: [2106-2-23] 08:36 JOB#: [Job Number 53102] ICD9 Codes: V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7723 }	Medical Text: Admission Date: [2182-4-24] Discharge Date: [2182-4-29] Date of Birth: [2126-2-28] Sex: FEMALE Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 56-year-old woman, with a history of tetralogy of Fallot status post a left- sided Blalock-Taussig shunt at age 19 months, with subsequent transannular repair at age 16. She had no documented sustained arrhythmias. She was a patient of [Location (un) 86] adult congenital heart service, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], at [Hospital3 18242]. She was referred to Dr. [First Name (STitle) ] [Last Name (Prefixes) ] for RV outflow repair and evaluation of her pulmonic valve. Sh[Last Name (STitle) ] originally by Dr. [Last Name (Prefixes) ] in the office on [2182-4-18]. She had increasing symptoms of dyspnea on exertion and recent cardiac MRA showed a severe pulmonic regurgitation, mild aortic insufficiency. Her previous tetralogy of Fallot repair dilated the ascending aorta 4.3 cm and RV dilatation. Please refer to the official report date [2182-3-5]. She had cardiac catheterization performed on [2182-3-28], which showed normal coronary arteries, and was referred for RV outflow tract reconstruction and pulmonic valve replacement versus repair. MEDICATIONS: Lo/Ovral birth control pill. ALLERGIES: Bactrim; Augmentin; ketorolac producing hives. PAST MEDICAL HISTORY: 1. Tetralogy of Fallot. 2. Chronic lower back and neck pain. 3. Bell palsy 10 years ago with mild paresis of the right side of her face. 4. Question of a bleeding episode, origin undetermined. PAST SURGICAL HISTORY: Repair of tetralogy of Fallot in [2126] and corrective repair again in [2142], and tonsillectomy and adenoidectomy in [2132] and [2139]. FAMILY HISTORY: Her father had a question of a myocardial infarction at age 53. SOCIAL HISTORY: She lives with her husband. [Name (NI) 1403] as emergency medical services. Had no tobacco or alcohol history. No use of IV drugs. EXAM: Her heart rate was regular in rate and rhythm, a rate of 84, blood pressure 198/90 on the right and 140/90 on the left, height 5'5" tall, weight 151 pounds. No obvious lesions. She appeared her stated age and was in no apparent distress. Her EOMs were intact. Pupils were equally round, reactive to light and accommodation. Neck was supple with no thyromegaly or obvious lymphadenopathy. Chest was clear to auscultation bilaterally with a well-healed midline sternal incision with no murmur, rub or gallop, with a regular rate and rhythm, S1, S2 tones with a grade III/VI diastolic murmur, and a grade II/VI systolic murmur. Abdomen was soft, round, nontender, nondistended, with positive bowel sounds. Extremities were warm and well-perfused with no clubbing, cyanosis or edema. Right lower extremity calf had some tenderness with a negative [Last Name (un) 4709] sign. The patient had bilateral spider veins in the lower extremities. Cranial nerves II through XII were grossly intact with a nonfocal neuro exam. NEUROLOGIC EXAM: The patient was moving all extremities. The patient had bilateral 2+ femoral, DP, PT and radial pulses, and no carotid bruit was present. PREOP LAB WORK: White count 6.8, hematocrit 41.8, platelet count 250,000. When the patient was admitted on the 24th, preoperatively PT 12, PTT 24.0, INR 1.1. Urinalysis was negative with a trace amount of blood present. ALT 15, AST 19, alkaline phosphatase 60, total bilirubin 0.9, total protein 7.1, albumin 4.4, globulin 2.7. Additional preop labs showed sodium 140, K 3.3, chloride 106, bicarbonate 21, BUN 13, creatinine 0.9, with a blood sugar of 102. HO[Last Name (STitle) ] COURSE: The patient obtained dental clearance prior to operation and was readmitted to our service on [4-23], the evening before her corrective repair. On the following morning, on [4-24], the patient underwent repair of a right ventricular outflow tract with reconstruction and pulmonic valve replacement with a 25 mm [Last Name (un) 3843]-[Doctor Last Name ] Magna ThermaFix pericardial valve. In addition, the patient also underwent right ventriculorrhaphy by Dr. [Last Name (Prefixes) ] and Dr. [Doctor Last Name 61313] of [Hospital3 1810] and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] of [Hospital3 1810]. The patient was transferred to cardiothoracic ICU in stable condition on a propofol drip of 20 mcg/kg/min and a Neo-Synephrine drip of 0.3 mcg/kg/min. On the day of operation, the patient had been extubated by 6:30 in the evening, and was awake and alert on a nitroglycerin drip. Gentle diuresis was begun. On postoperative day 1, the patient remained on nitroglycerin drip at 1.25 mcg/kg/min. Sternum was stable. Heart was regular in rate and rhythm. White count 11.0, hematocrit 32, platelet count 158,000, PT 14, PTT 31, INR 1.4, BUN 9, creatinine 0.7. The patient had decreased breath sounds at bilateral lung bases. Beta blockade was begun. The patient was seen by case management and evaluated, and seen everyday by the adult congenital service from [Hospital3 1810], with the patient's attending, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. On postoperative day 2, the patient began aspirin. Beta blockade was increased to metoprolol 50 b.i.d. The patient was received p.o. Percocet for pain management, and was satting 98% on room air, in sinus rhythm at 77, maintaining good blood pressure of 132/83. The patient continued to receive diuresis for a weight of 87.6 kg. Lopressor was increased to 75 b.i.d. Foley was removed later in the day. The patient was encouraged to increase her activity level and was transferred out to the floor on the 26th. She was seen and evaluated by physical therapy, and continued to make excellent progress. On postoperative day 3, she spiked a temp to 101.2. Blood cultures were drawn, but the patient continued to do extremely well. She had been pancultured. The following day, had a blood pressure of 146/66, remaining in sinus rhythm. Pacing wires were removed on postoperative day 3. K was repleted at 3.8, and Lopressor was increased the following morning operating table 100 mg p.o. b.i.d., and discharge planning was begun. On[Last Name (STitle) 14810]perative day 4, the patient was alert and oriented, nonfocal. Lungs were clear bilaterally. Heart was regular in rate and rhythm, with a blood pressure of 126/58, satting 97% on room air. Her sternal incision was clean, dry and intact with trace peripheral edema. Her central venous line had already been removed. She continued to work with the physical therapists, and continued to improve, and was cleared for discharge on the 30th, postoperative day 5, with an unremarkable exam, and was also seen by cardiology from [Hospital1 ] before discharge, was ambulating well, her volume status appeared stable, and she was discharged to home with visiting nurses on [4-29] with the following discharge instructions: To follow-up with Dr. [Last Name (STitle) 10747], her primary care physician, [Last Name (NamePattern4) ] [12-2] weeks post discharge; follow-up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 61710] in [1-3] weeks post discharge, and follow-up with Dr. [Last Name (Prefixes) ], her cardiac surgeon, for postop surgical visit in the office in [2-1] weeks. DISCHARGE MEDICATIONS: 1. Potassium chloride 20 mEq p.o. once a day for 10 days. 2. Lasix 20 mg p.o. once a day for 10 days. 3. Aspirin, enteric-coated, 81 mg p.o. once a day. 4. Percocet 5/325, 1-2 tablets p.o. p.r.n. q. 4 h. for pain. 5. Metoprolol 100 mg p.o. b.i.d. 6. Colace 100 mg p.o. t.i.d. 7. Ranitidine 150 mg p.o. b.i.d. DISCHARGE DIAGNOSES: 1. Status post right ventricular outflow tract repair with ventriculorrhaphy and pulmonic valve replacement with [Last Name (un) 3843]-[Doctor Last Name ] pericardial valve. 2. Status post tetralogy of Fallot with repair in [2126] and corrective repair again in [2142]. 3. Chronic low back and neck pain. 4. Bell palsy with mild paresis of the right side of her face. Again, the patient was discharged to home in stable condition with VNA service on [2182-4-29]. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2182-6-26] 11:17:04 T: [2182-6-26] 12:05:30 Job#: [Job Number 61711] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7724 }	Medical Text: Admission Date: [2147-6-25] Discharge Date: [2147-6-29] Date of Birth: [2083-2-4] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2836] Chief Complaint: RLQ Abdominal pain Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Known lastname 634] is a 64 year old man with a complex medical history including CHF and COPD, a poor surgical candidate, also with a history of medically managed appendicitis on 2 prior episodes. He presents with RLQ pain. In [4-/2146], he was admitted to the West 2A service in for ruptured appendicitis and was treated with an IR-placed drain. For the current admission, he presented on [2147-6-25] with 2 days of abdominal pain and poor urine output. He did not complain of nausea, vomiting, changes in bowel movements, fevers/chills. He was admitted for medical management for his likely recurrence of appendicitis. Past Medical History: Appendiceal abscess in [2140] treated with IR drain, recurrent appendicitis Insulin-dependent Diabetes Mellitus COPD Peripheral vascular disease Right fem-[Doctor Last Name ] bypass graft x 2 ([2115]'s) CVA ([2-/2139]) - mild dysarthria/mild left facial weakness Hepatomagaly Pulmonary hypertension History of DVT GERD Hypercholesterolemia Hypertension Obstructive Sleep Apnea Osteoporosis Depression Social History: -Tobacco history: Former smoker, quit 8-10 years ago. -ETOH: 2-3 beers/day. -Illicit drugs: None. Family History: Mother with lung carcinoma. No family history of heart disease, HTN, or DM. Physical Exam: VITALS: T 96.9 HR 81 BP 138/92 RR 20 O2sat 99%/1L GEN: Obese man, sitting comfortably, A&Ox3 HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. Poor dentition. Neck supple without lymphadenopathy. CVS: RRR, no murmurs, rubs or gallops. RESP: Expiratory wheezing. Labored breathing with increased O2 requirement with ambulation. ABD: Nontender, soft, obese abdomen. No pain with palpation. Small reducible umbilical hernia. EXTR: Warm, dry; small 0.3 cm ulcer on right 1st digit, DP and PT pulses palpable bilaterally. Pertinent Results: [2147-6-28] 08:45AM BLOOD WBC-8.7 RBC-3.51* Hgb-11.0* Hct-32.1* MCV-92 MCH-31.4 MCHC-34.3 RDW-12.6 Plt Ct-335 [2147-6-29] 08:00AM BLOOD PT-29.5* INR(PT)-2.9* [2147-6-28] 08:45AM BLOOD Glucose-338* UreaN-23* Creat-1.4* Na-143 K-3.3 Cl-97 HCO3-38* AnGap-11 [2147-6-28] 08:45AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.9 [2147-6-26] 03:26AM BLOOD ALT-19 AST-18 LD(LDH)-152 AlkPhos-34* TotBili-0.2 [2147-6-25] 10:50AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.006 [2147-6-25] 10:50AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG URINE CULTURE (Final [2147-6-26]): <10,000 organisms/ml. BLOOD CULTURE (taken [2147-6-25]): no growth to date CT ABD & PELVIS W/O CONTRAST Study Date of [2147-6-25] 1. Findings consistent with acute appendicitis with no evidence of abscess or free perforation. 2. A 1.3 cm exophytic liver lesion is stable since [2140] and of doubtful significance. CHEST (PA & LAT) Study Date of [2147-6-25] IMPRESSION: Lingular pneumonia. Brief Hospital Course: NEURO/PAIN: The patient was maintained on IV Dilaudid upon admission, and then transitioned to PO Dilaudid PRN on [2147-6-28]. The patient remained neurologically intact and without change from baseline during his stay. The patient remained alert and oriented to person, location and place. CARDIOVASCULAR: The patient remained hemodynamically stable. His vitals signs were closely monitored. He has a history of congestive heart failure, and was noted to have basilar crackles, and has been kept on his home doses of furosemide and metolazone. RESPIRATORY: The patient was maintained on his home COPD treatments. A CXR on [2147-6-25] demonstrated lingular pneumonia and he was started on a 10-day coure of azithromycin, and discharged with this medication. He is on 4L of oxygen at home and he was continued on this, maintaining adequate oxygenation with no acute desaturations. GASTROINTESTINAL: The patient was kept NPO and maintained on IV fluids for hydration. IV zosyn was used for antibiotic coverage until [2147-6-28]. The patient was transitioned to sips on [2147-6-27] and advanced to a regular diet on [2147-6-28]; he tolerated this well. He did not have any episodes of nausea or emesis. He was transitioned from iv zosyn to PO cipro/flagyl on [2147-6-28], and was discharged with these medications for a 2-week total course. GENITOURINARY: The patient presented with an elevated creatinine of 2.6 and BUN of 72. He was given IV fluids. A Foley catheter was placed on [2147-6-26] to monitor urine output. His creatinine eventually trended down to 1.4. His foley catheter was removed on [2147-6-28], at which time the patient was able to successfully void without issue. The patient's intake and output was closely monitored. HEME: The patient's hematocrit has been stable at around 32. The patient has a history of DVT, and takes coumadin, but on admission his INR was elevated (4.0; goal 2.5-3). His home coumadin was held until the day of discharge when the INR was 2.9, at which point the coumadin was restarted. He was instructed to follow up with his coumadin clinic as soon as possible after discharge. ID: The patient presented with an elevated WBC of 16.3, which trended to 8.7 by [2147-6-28]. He was treated for appendicitis and pneumonia with antibiotics as above. ENDOCRINE: The patient has insulin-dependent diabetes. His blood glucose was monitored with q6 fingersticks and maintained at a satisfactory level with insulin sliding scale per protocol. PROPHYLAXIS: The patient's anticoagulation was held secondary to supratherapeutic INR. He was encouraged to ambulate as tolerated. The patient also had sequential compression boot devices in place during immobilization to promote circulation. GI prophylaxis was sustained with omeprazole. The patient was encouraged to utilize incentive spirometry, ambulate, and was discharged in stable condition. Medications on Admission: Albuterol nebulizer 2 Puff Q6H Alendronate 70 mg PO QWeekly Budesonide 0.5/2ml [Hospital1 ] Citalopram 10mg PO QD Warfarin 12.5mg PO QD Furosemide 80mg PO QD Folic acid 800mcg PO QD Humalog 100 unit/mL PRN Humalin 45 units am, 15 units pm Lipitor 20mg PO QD Lisinopril 10 mg PO QD Metolazone 2.5 PO QD Omeprazole 40 mg PO QD Prednisone 5mg PO QD Proventil 2 Puff O2 4L Salsalate 750 mg PO BID, Spiriva inhaler daily ASA 81mg PO QD Vit B complex 300mg PO QD Vit B1 100mg PO QD Cal/vit D 1200mg PO QD Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 3. budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One (1) ML Inhalation [Hospital1 ] (2 times a day). 4. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. warfarin Oral 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Humalog 100 unit/mL Cartridge Sig: sliding scale units Subcutaneous lunch and dinner. 9. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig: 45 units Subcutaneous QAM. 10. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. metolazone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. salsalate 750 mg Tablet Sig: One (1) Tablet PO twice a day. 16. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 17. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 18. Vitamin B Complex Oral 19. Vitamin B-1 Oral 20. Calcium 500 + D Oral 21. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 11 days. Disp:22 Tablet(s) Refills:0 22. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 11 days. Disp:33 Tablet(s) Refills:0 23. azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day for 6 days. Disp:6 Tablet(s) Refills:0 24. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig: Fifteen (15) units Subcutaneous QPM. 25. Coumadin 10 mg Tablet Sig: One (1) Tablet PO once a day: Please fllow up with [Hospital 197] clinic on [2147-7-3] to check your INR. Follow [Hospital 197] clinic directions. Discharge Disposition: Home Discharge Diagnosis: Recurrent Appendicitis Lingular pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory Discharge Instructions: Discharge Instructions: You were admitted to Dr.[Name (NI) 5067] surgical service for evaluation and management of your recurrent appendicitis. You are now being discharged home. Please follow these instructions to aid in your recovery: Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. General Discharge Instructions: * Please resume all regular home medications, unless specifically advised not to take a particular medication. * Please take any new medications as prescribed. * Please take the prescribed analgesic medications as needed. You may not drive or operate heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. * Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. * Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. * Please also follow-up with your primary care physician. Please also follow up with your coumadin clinic as soon as possible following discharge. Followup Instructions: Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2147-8-15] 9:10 Provider: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2147-8-15] 9:30 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2147-8-15] 9:30 Provider: [First Name8 (NamePattern2) 1037] [First Name8 (NamePattern2) 3239] [Last Name (NamePattern1) 30891], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2147-7-14] 1:45 [Hospital Ward Name 23] 6, [Hospital Ward Name ] Please schedule an appointment with PODIATRY service at 1-2 weeks after discharge to continue monitoring your right great toe ulcer Please follow up with your coumadin clinic on or before Monday, [2147-7-3] Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3000], MD Phone:[Telephone/Fax (1) 274] Date/Time:[2147-7-28] 9:00 [Hospital Ward Name 23] 3, [Hospital Ward Name ]. You will have an abdominal CT scan prior your appointment with Dr. [First Name (STitle) ]. Dr.[Name (NI) 5067] office will inform you about time of the scan. Please arrive in Radiology Department 30 min before the scan, please do not eat/drink 4 hours before the CT scan. Completed by:[2147-6-29] ICD9 Codes: 486, 4280, 496, 4439, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7725 }	Medical Text: Admission Date: [2173-8-7] Discharge Date: [2173-8-12] Date of Birth: [2105-5-17] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 783] Chief Complaint: melena Major Surgical or Invasive Procedure: Endoscopy X 2 History of Present Illness: Mr. [Known lastname 25586] is a 68 year old man with a history of type II diabetes, CRI not yet on hemodialysis, ischemic CVA in [1-/2173], coronary disease s/p MI [2153] and well controlled crohns disease who presents to the [Hospital1 18] ED w/ cc of 1 day of fatigue and s/p black, dark stool X 1. Pt was in his USOH until day of admission when he awoke with profound fatigue, weakness with minimal exertion. He was unable to walk more than 10 steps w/o feeling tired, weak, and SOB which requirred him to sit and rest. Pt normally very functional, ADLs intact, walks around mall without problems. [Name (NI) ] was too weak to get out of bed all morning. Thought his BS was low so checked FS=200. Later that morning, pt had BM that was described as "stiff" dark in color-black. Has never had this before. The day prior to admission pt only notes that he had decrease in appetite. Pt was concerned about profound fatigue and called ambulance for transport to ED. . Denied N,V, denied hemoptysis, no abd pain/epigastric pain. Denied pain associated with eating, denied change in bowel habits, (no diarrhea/no constipation). Besides ASA 325mg X 17yrs, he denies any other recent NSAID use. . Of note, about a week ago when he experienced a severe unprovoked nose bleed. . He denies any fevers, chills, chest pain, or dyspnea on exertion. . In the ED, he was given aspirin and IV protonix. His SBP was 80-100, and his hct was noted to be low. His NGL x250cc was positive for coffee grounds and blood. hct noted to 21 from 38. NGL positive for coffee grounds and blood. . EGD in ED with lots of blood and clots, without any obvious source of bleeding aside from esophagitis, barrett's and hiatal hernia. Pt transferred to ICU. . While in MICU, given IV PPI, carafate, pt transfused X 7. Pt rescoped and noted to have no sig. changes. Pt c/o CP. EKG: mild ST depression in lateral leads. Trop pos from Trop 0.21-> to 0.17, however CK, MB negative. Cards consulted recommended outpt stress test. Repeat EGD nonactive bleed,consistent with first EGD. Pt Hct remained stable and pt transferred to floor. . . At time of transfer patient does not have any complaints. Denies any cp/sob. Denies any n/v/d. Denies lightheadedness, dizziness. Past Medical History: 1. CAD: s/p MI [2153], caths [2153], [2163], and [2166]: last w/ 30% LAD lesion after the second diagonal branch, 30% lesion at the origin of the second diagonal branch, 20% middle left circumflex lesion, 30% proximal RCA lesion w/ patent stent 2. systolic dysfxn: echo [1-25] w/ LVEF 35%, resting regional WMA include apical and mid and distal anterior and anteroseptal akinesis. 3. DM type 2: c/b nephropathy 4. HTN 5. Chronic kidney disease: [1-21] DM2, baseline creat 3.2-3.3 6. Crohn's dz 7. Anemia of chronic renal dz: baseline HCT 8. s/p ischemic CVA: [1-25], minimal residual left hemiparesis. CT/MRI with R basal ganglia ischemic infarct. MRA normal. Carotid US with 40% stenosis b/l. TTE without LV thrombus. Started on aggrenox. Coumadin entertained given EF 35%, areas of akinetic LV, but PCP decided against it for now. Social History: Pt is a retired church decorator. He quit smoking in [2153], but has ~75 pack-yr history. Social EtOH. Family History: NC Physical Exam: T 97.1 HR 65 BP 131/70 RR 18 Sat 98% RA Gen: Pleasant well-nourished in NAD HEENT: MMM, +conjunctival pallor, PERRL, sclerae anicteric Neck: Supple, non-tender, no masses, no LAD appreciated CV: Normal S1/S2, RRR, mild II/VI systolic murmur best heard at sternal border PUL: CTA b/l Abd: Soft, NT, ND Ext: No edema, no cyanosis, pulses 2+ throughout Neuro:CNII-XII intact. LUE: deltoid [2-21], biceps/triceps [2-21] RUE: [4-23] throughout LLE: [3-24] Q, [4-23] hamstrings/TA/Dorsifle/Plant flex RLE: [4-23] throughout 2+ reflexes throughout b/l cerebellar: FTN,HTS intact Pertinent Results: [2173-8-7] 08:26PM GLUCOSE-221* UREA N-167* CREAT-3.7* SODIUM-138 POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-14* ANION GAP-18 [2173-8-7] 08:26PM CALCIUM-7.8* PHOSPHATE-3.9 MAGNESIUM-2.2 [2173-8-7] 08:26PM WBC-10.9 RBC-3.04# HGB-9.3# HCT-27.0# MCV-89 MCH-30.7 MCHC-34.5 RDW-15.6 [2173-8-7] 08:26PM PLT COUNT-159 [2173-8-7] 02:10PM URINE HOURS-RANDOM [2173-8-7] 02:10PM URINE GR HOLD-HOLD [2173-8-7] 02:10PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.012 [2173-8-7] 02:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2173-8-7] 02:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [2173-8-7] 11:51AM LACTATE-1.4 [2173-8-7] 11:30AM GLUCOSE-289* UREA N-161* CREAT-3.7* SODIUM-135 POTASSIUM-5.3* CHLORIDE-108 TOTAL CO2-15* ANION GAP-17 [2173-8-7] 11:30AM CK(CPK)-41 [2173-8-7] 11:30AM cTropnT-<0.01 [2173-8-7] 11:30AM CK-MB-NotDone [2173-8-7] 11:30AM URINE HOURS-RANDOM [2173-8-7] 11:30AM URINE GR HOLD-HOLD [2173-8-7] 11:30AM WBC-11.1* RBC-2.31# HGB-7.2# HCT-21.5# MCV-93 MCH-31.3 MCHC-33.6 RDW-13.5 [2173-8-7] 11:30AM NEUTS-88.4 BANDS-0 LYMPHS-8.0* MONOS-2.1 EOS-0.7 BASOS-0.7 [2173-8-7] 11:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL [2173-8-7] 11:30AM PLT COUNT-195 [2173-8-7] 11:30AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.013 [2173-8-7] 11:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2173-8-7] 11:30AM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-NOTDONE . Studies: [2173-8-7] CXR: No evidence of pneumonia. loss of the soft tissue contour adjacent to the left clavicle, which may be suggestive of supraclavicular lymphadenopathy or soft tissue swelling in this location . [2173-8-7] EKG: Sinus rhythm Left axis deviation IV conduction defect Anteroseptal infarct - age undetermined Lateral ST-T changes may be due to myocardial ischemia Since previous tracing of [2173-4-23], anterior T wave inversion is resolving . [2173-8-9] EKG: Sinus rhythm. Intraventricular conduction delay. Probable old anterior myocardial infarction. Compared to the previous tracing of [2173-8-8] no change . Endoscopy: [8-7] - Grade 4 esophagitis; Mucosa suggestive of Barrett's esophagus; Blood in the whole stomach; Medium hiatal hernia . Endoscopy: [8-10]- Esophagitis in the lower third of the esophagus compatible with mild esophagitis; Esophageal ulcer; Mild erythema in the antrum, fundus and stomach body compatible with mild gastritis; Small hiatal hernia Otherwise normal EGD to second part of the duodenum Brief Hospital Course: 68 man with past medical history significant for CAD, CHF, DM, ESRD not yet on HD, presented with 1 day of fatigue, melena X 1 found to have anemia to 21. Transferred from MICU with stable hct in low 30's. . # Gastroenterology- Patient presented with 1 episode of melena in the setting of profound fatigue. In the ED, he was found to have hct 21 (down from basline of ~30)nasogastric lavage showed coffee grounds, blood. On Endoscopy he was found to have no active bleed, gastritis, esophagitis, esophagial nonbledding ulcer, [Last Name (un) ] esophagus,hiatal hernia, and repeat Endoscopy confirmed same thing. He was admitted to the Medical ICU and transfused approximately 6 units of packed RBC, IV PPI, and sucralfate was started. Because patient has history of CAD, he was maintained at a hematocrit to 30. Patient's hematocrit stabilized in the low 30's and he was transferred to the floor in stable condition. While on the floor, patient had one episode of melena, however, he was hemodynamically stable and hematocrit continued to be in low 30's, Patient did not require any more transfusions. Patient was scheduled for gastroenterology followup, along with followup with his primary care physician. . # Cardiovascular- Patient has history of CAD, CHF. While in the MICU, patient complained substernal chest pain, EKG was done which was consistent with old EKG. Troponins were 0.21-->0.l8-->0.17, however CK and MB negative X 3. Cardiology was made aware and the EKG seemed to implicate an area near his prior infarct in [2153]. Give the patient's chronic renal failure, the troponin clearing is was believed to be impaired accounting for the sustained high troponins, however given that the CK is not elevated, it does not appear that patient indeed sustained MI. Troponin levels along with CK would need to be elevated over time in order to support NSTEMI. Given the patient's GI bleed, anti-coagulation, plavix, and ASA 325mg was held. . However, while in MICU once GI bleed and hematocrit stabilized, ASA was restarted at 81mg. Plavix continued to be held. Blood pressure was controlled with metoprolol 100mg and hydralizine 25mg. Patient was discharged on ASA 81mg and plavix was held secondary to further outpatient assessment with gastroenterologist and cardiologist. . # Anemia: Likely due to both blood loss and chronic kidney disease. Stable, Hct=30. Procrit 4000U was continued. . # Renal- Patient has history of chronic kidney disease likely secondary to diabetes. Upon admission, creatinine was around baseline with an elevated BUN, likely due to upper GI source of bleeding. Electrolytes, in particular potassium was monitored and reamined within normal limits. Recommended patient continue to be closely followed as an outpatient in regard to chronic renal disease. . . #DM- Patient has history of diabetes type II, with secondary retinopathy, nephropathy. Blood sugars were maintained in the 150's-200's with regular insulin sliding scale while inpatient. Patient was discharged on home medications. Medications on Admission: ASA 325mg daily Plavix 75mg daily Lipitor 80mg daily Glipizide 5mg daily Isosorbide MN SR 30mg daily Toprol 100mg daily Hydralazine 25mg TID Doxercalciferol 0.5 mcg daily Cytra-2 5mg twice daily Folic Acid 1mg daily Florinef 0.1mg daily Lasix 20mg daily Procrit 4000u twice weekly Tums 500mg twice daily Vitamin B12 50mcg once daily Discharge Medications: 1. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times a day. Tablet(s) 2. Doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Procrit 4,000 unit/mL Solution Sig: One (1) Injection twice weekly. 5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 9. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day): Please make into slurry (crush tablet and add to water). Disp:120 Tablet(s) Refills:2 10. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Tablet Sustained Release 24HR(s) 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Tablet Sustained Release 24HR(s) 14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: 1.Upper GI bleed (Esophagitis, gastritis, esophageal ulcer) . Secondary: 1.CAD 2.DM, type II 3.ESRD Discharge Condition: Stable Discharge Instructions: IMPORTANT INFORMATON: . 1. Your aspirin was decreased from 325mg to 81mg because of your recent GI Bleed. Please take aspirin 81mg once a day. Your Plavix 75mg was stopped while you were in the hospital and we did not restart this on discharge because of your GI bleed. Please do not take Plavix 75mg. Given your history of heart disease and recent GI bleed, it is very important that you discuss whether or not you should restart your plavix and/or increase your aspirin dose with your gastroenterologist and/or your cardiologist. Please discuss this at your next appointments. Please also discuss your episode of chest pain with your cardiologist. He will decide whether you should have a stress test to reevaluate your heart. . 2.Please be sure to make your appointments listed below, if you are unable to attend, call to reschedule. . 3.Please return to primary care physician or emergency department if you have recurrent profound fatigue, dark tarry stools, blood per rectum, vomiting blood, or other concerns. Followup Instructions: 1. Cardiology: [Doctor First Name 900] [Name8 (MD) 901], M.D. Phone:[Telephone/Fax (1) 902] [2173-9-7] 11:00 . 2. Gastroenterology:.[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) ], M.D., [2173-9-9] 3:00PM.([Telephone/Fax (1) 2306] . 3. Primary care physician-[Name Initial (NameIs) 2169]: [Name10 (NameIs) 1576],[Name11 (NameIs) 2352], [2173-9-28] 8:50AM. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] ICD9 Codes: 5789, 4280, 5856, 2851, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7726 }	Medical Text: Admission Date: [2109-12-12] Discharge Date: [2109-12-16] Date of Birth: [2071-9-27] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: neck injury Major Surgical or Invasive Procedure: none History of Present Illness: 38 year old man was carrying a box over his head when the box fell and landed on him. He initially felt nothing below the neck. He did have loss of consciousness. He complained of neck and back pain. Past Medical History: Thoracic outlet syndrome Asthma Social History: ETOH: occasional Smoking: No Family History: mother healthy Physical Exam: 98.6 97 130/67 12 A&o perl RRR Chest: clear Abd: soft Decreased sensation radial & ulnar distributions Right hand Motor intact grossly throughout Pertinent Results: [2109-12-12] 05:00PM WBC-8.2 RBC-5.89 HGB-15.2 HCT-44.3 MCV-75* MCH-25.8* MCHC-34.4 RDW-15.3 [2109-12-12] 05:00PM NEUTS-91.7* LYMPHS-7.5* MONOS-0.7* EOS-0.1 BASOS-0 [2109-12-12] 05:00PM POIKILOCY-1+ MICROCYT-2+ [2109-12-12] 05:00PM PLT COUNT-333 [2109-12-12] 05:00PM PT-13.3 PTT-31.2 INR(PT)-1.1 [2109-12-12] 01:43PM GLUCOSE-90 LACTATE-2.6* NA+-143 K+-4.4 CL--107 TCO2-27 [2109-12-12] 01:16PM AMYLASE-36 [2109-12-12] 01:16PM URINE HOURS-RANDOM [2109-12-12] 01:16PM URINE HOURS-RANDOM [2109-12-12] 01:16PM URINE GR HOLD-HOLD [2109-12-12] 01:16PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 [2109-12-12] 01:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG [2109-12-12] 01:16PM URINE RBC-0-2 WBC-[3-8] BACTERIA-OCC YEAST-NONE EPI-<1 [2109-12-12] 01:16PM URINE COMMENT-SMALL WBC CLUMPS RADIOLOGY Final Report MR CERVICAL SPINE [2109-12-12] 5:05 PM MR CERVICAL SPINE; MR THORACIC SPINE Reason: TRAUMA DUE TO A FALL,WEAKNESS BELOW CLAVICLES [Hospital 93] MEDICAL CONDITION: 38 year old man with numbness, weakness below clavicles REASON FOR THIS EXAMINATION: spinal cord inj MRI CERVICAL SPINE CLINICAL HISTORY: Backwards fall, and decreased senstation inferior to the level of the clavicles. TECHNIQUE: Sagittal T1-weighted, T2-weighted, and STIR images, and axial T2- weighted images were obtained. The axial images are limited by motion. FINDINGS: The vertebral bodies are well-maintained. Alignment is normal. No STIR hyperintensity is seen to suggest a fracture or ligamentous injury. C2-3 and C3-4 level are unremarkable. At C4-5, there is a small central disc herniation. The axial images were quite limited, but this does not appear to affect the spinal cord on the sagittal images. Both the sagittal T2-weighted and STIR images show T2-hyperintensity in the anterior aspect of the spinal cord extending from the mid aspect of C5 to the superior aspect of C7. Given the history, perhaps this is a spinal cord contusion. The motion limited axial T2 weighted images suggest it extends to the ventral surface of the spinal cord, arguing against an incidental small hydromyelia. If it is a contusion it should evolve and a followup study after several days would be of use. No hemorrhage is seen. The C5-6 and C6-7 discs are normal. The C7- T1 level is normal. IMPRESSION 1. There is no evidence of a fracture or ligamentous injury. 2. There is T2 hyperintensity in the anterior midline aspect of the spinal cord at the level between the mid aspect of C5 and the superior aspect of C7, worrisome for a spinal cord contusion. No expansion of the spinal cord is seen. The finding was discussed with Dr. [First Name (STitle) 1022]. by telephone at 9pm. The patient is being treated with steroids empirically for a spinal cord injury. A followup study might be of use. 3. There is a small central disc herniation at C4-5 which does not appear to affect the spinal cord. MRI THORACIC SPINE Brief Hospital Course: He was admitted and his neurologic status improved. He continued to complain of right hand numbness.An ortho consult was obtained and steroid protocaol was followed. He was discharged to home. Discharge Medications: 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: do not drive or operate heavy machinery while on any percocet as it can cause marked drowsiness. Disp:30 Tablet(s) Refills:0 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: take while on any percocet to help prevent constipation. Discharge Disposition: Home Discharge Diagnosis: spinal cord contusion, transverse process of vertebral body T1 fracture, asthma, obesity Discharge Condition: stable Discharge Instructions: Patient to be discharged to home without services and to make MD aware or go to ER if having worse pains, weakness or numbness in the extremities, fevers, chills, nausea, vomiting, or if there are any questions or concerns. Patient to wear neck collar at all times until follow up with a neurosurgeon and neck flexion/extension x-rays are done. Followup Instructions: Patient to follow up with a neurosurgeon in [2-5] weeks and to arrange for an appointment throught his primary doctor. Patient must have flexion/extension x-rays at this time, having suffered a C5-6 spinal cord contusion and a T1 level transverse process fracture. Patient to follow up with neurologist through his primary doctor in one week and to have nerve conduction studies (EMG) on median and ulnar nerves for right hand numbness and to call to schedule an appointment. ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7727 }	Medical Text: Admission Date: [2128-8-17] Discharge Date: [2128-8-27] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 86 year male who was at home when he stood to walk across room and experienced acute dizziness associated with palpitations and right sided rib pain and then stumbled and fell. No reported LOC, he was able to call 911 for assistance. He was transported to an area hospital where upon CT imaging of his head wasfound to have a left frontal/parietal subarrachnoid bleed with intraparenchymal hematoma. He was then transferred via [Location (un) ] to [Hospital1 18] for further work-up and management. Past Medical History: CAD History MI Pacemaker s/p CABG s/p bovine aortic valve replacement TIA Atrial fibrillation Hypertension Bilateral knee replacements Kidney stones Social History: Lives at home alone, recently wife deceased. Supportive son who lives in [Name (NI) 6607]. Rare alcohol, rare tobacco. Family History: Non-contributory Physical Exam: Upon admission: PHYSICAL EXAM - O: T: 96.8 137/49 58 16 O2sat 100% on 2L Gen: NAD. HEENT: Pupils: PERRLA EOMs full Neck: on hard collar; non-tender Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: PERRLA 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. No dysarthria. Pertinent Results: On admission: . [2128-8-17] 09:40PM POTASSIUM-5.4* [2128-8-17] 08:15PM GLUCOSE-141* UREA N-60* CREAT-2.7* SODIUM-136 POTASSIUM-5.8* CHLORIDE-102 TOTAL CO2-22 ANION GAP-18 [2128-8-17] 08:15PM CALCIUM-10.9* PHOSPHATE-4.2 MAGNESIUM-2.1 [2128-8-17] 08:15PM WBC-9.3 RBC-2.91* HGB-9.1* HCT-26.6* MCV-92 MCH-31.1 MCHC-34.0 RDW-16.1* [2128-8-17] NEUTS-86.5* BANDS-0 LYMPHS-8.2* MONOS-4.6 EOS-0.5 BASOS-0.1 [2128-8-17] 08:15PM PLT SMR-NORMAL PLT COUNT-158 [2128-8-17] 08:15PM BLOOD PT-31.5* PTT-35.3* INR(PT)-3.3* . Diagnostics: CT HEAD [2128-8-17]: IMPRESSION: 1. Focal subarachnoid hemorrhage in the left frontal, parietal lobe sulci. Caudalmost hemorrhagic focus may represent small intraparenchymal hemorrhage. 2. Generalized atrophy, with symmetrically prominent extra-axial CSF spaces, which may represent chronic subdural hematomas. . CAROTID STUDY ([2128-8-19]): FINDINGS: Scattered areas of heterogeneous calcific plaque involving the common carotid arteries and extending into the ICA and ECA bilaterally. Peak systolic velocities on the right are 50, 86 and 75 cm from the proximal, mid and distal ICA. Similar values on the left are 140, 119 and 97 cm per second. Peak systolic velocities involving the right CCA and ECA are 62 and 116 cm respectively and similar values on the left are 77 and 67 cm respectively. There is antegrade flow involving both vertebral arteries. The ICA to CCA ratios are normal. IMPRESSION: 1. No significant right ICA stenosis (graded as less than 40%). 2. 40-59% left ICA stenosis. . ECHO ([2128-8-19]): Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: 7.4 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.2 m/s Left Atrium - Peak Pulm Vein D: 0.5 m/s Right Atrium - Four Chamber Length: 7.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 6.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.1 cm Left Ventricle - Fractional Shortening: 0.32 >= 0.29 Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Sinus Level: 2.7 cm <= 3.6 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aortic Valve - Peak Velocity: 3.6 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 51 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 27 mm Hg Mitral Valve - Peak Velocity: 2.1 m/sec Mitral Valve - Mean Gradient: 5 mm Hg Mitral Valve - Pressure Half Time: 86 ms Mitral Valve - MVA (P [1-20] T): 2.6 cm2 Mitral Valve - E Wave: 2.0 m/sec Mitral Valve - E Wave deceleration time: 316 ms 140-250 ms TR Gradient (+ RA = PASP): 41 mm Hg <= 25 mm Hg Findings: LEFT ATRIUM: Dilated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Low normal LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function. [Intrinsic RV systolic function likely more depressed given the severity of TR]. Paradoxic septal motion consistent with conduction abnormality/ventricular pacing. AORTA: Normal aortic diameter at sinus level. Nl ascending aorta diameter. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Normal AVR gradient. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Eccentric MR jet. [Month/Day (2) ] (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. [Month/Day (2) ] to severe [3+] TR. [Month/Day (2) ] PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. CONCLUSIONS: The left atrium is dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is low normal (LVEF 50-55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, [Month/Day (2) 1192] (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. [Month/Day (2) ] to severe [3+] tricuspid regurgitation is seen. There is [Month/Day (2) 1192] pulmonary artery systolic hypertension. There is no pericardial effusion. . Right upper extremity doppler ([2128-8-19]): IMPRESSION: Deep vein thrombosis in one of the two right brachial veins and clot identified in the right basilic and cephalic veins. . ECG: [2128-8-17] 20:05:02 Ventricular paced rhythm with capture. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 61 0 178 462/463 0 -72 96 . ECG: [2128-8-18] 12:19:30 Ventricular paced rhythm. Compared to tracing of [2128-8-17] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 60 0 176 482/482 0 -71 94 . CT head ([2128-8-22]): IMPRESSION: Unchanged appearance of blood products in the left frontal and parietal lobe sulci, most consistent with subarachnoid hemorrhage, although caudal-most focus again demonstrates features, which may be consistent with small intraparenchymal hemorrhage. Brief Hospital Course: He was admitted to the Trauma service. Neurosurgery was consulted given his subarachnoid hemorrhage. His injuries were nonoperative. He was loaded with Dilantin and will need to remain on this for a total of 10 days. Serial head CT scans were obtained and were stable. He will require follow up with Dr. [Last Name (STitle) ], Neurosurgery in [4-23] weeks for repeat head imaging. He was noted to have a significant cardiac history and recently had a pacemaker placed about 1 year ago. His pacer was interrogated by electrophysiology service who have recommended an EP study at some point to investigate ventricular arrythmias. He was on Coumadin for Afib and TIA's prior to this hospitalization; prescribed by his primary cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 73951]). His Coumadin was withheld initially and was restarted on [8-26] per request of his cardiologist. His goal INR is [2-21]; his INR today ([8-27]) is 2.2. He also underwent a dedicated carotid study which showed <40% right ICA stenosis and 40-59% left ICA stenosis. An ECHO was also performed which showed EF 55%; [Month/Year (2) 1192] MR [First Name (Titles) ] [Last Name (Titles) 1192] to severe TR. His primary cardiologist (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [Hospital1 ], MA) was contact[Name (NI) ] regarding his history and Coumadin. He had been started on Coumadin for chronic AF, bovine aortic valve and h/o TIA's. His Coumadin was eventually restarted once cleared by Neurosurgery. Because of his traumatic brain injury there were several episodes of psychotic behavior; he was initially placed on 1:1 sitters; Haldol was also recommended by Psychiatry who were consulted. He did eventually become less agitated and more cooperative with his care; the sitters were removed. He was evaluated by Physical and Occupational therapy and it was recommended that he go to a rehab facility after acute hospital stay. Medications on Admission: lasix, prilosec, norvasc, celexa, coumadin, zestril, lopressor, aspirin, aldactone, uroxatral Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for HR <60; SBP <110. 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for SBP<110. 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold fpr SBP< 110. 6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 4 days. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Goal INR [2-21]; adjust dose per INR. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stools. 10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime: hold for loose stools. 11. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for increased sedation. 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Location (un) 6594] Discharge Diagnosis: s/p Fall Left frontal & parietal subarachnoid hemorrhages Discharge Condition: Good Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ], Neurosurgery in [4-23] weeks. Please call [Telephone/Fax (1) 1669] to make an appointment. Inform the office that you will need a repeat head CT scan for this appointment. Follow up with your primary care doctor and your cardiologist after discharge from rehab. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] Completed by:[2128-8-27] ICD9 Codes: 4240, 4019, 3051, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7728 }	Medical Text: Admission Date: [2184-11-10] Discharge Date: [2184-11-18] Date of Birth: [2145-4-2] Sex: F Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old woman, with a long history of left temporal anaplastic oligodendroglioma, presenting with a questionable onset of new type of seizure. The patient was diagnosed with this tumor in [2170], at which time she had debulking of the tumor with irradiation. The patient also had 2 cycles of chemotherapy, one in [2182] with Temodar, and one in [2184] with PCV therapy. Over the past few years, the patient has had a characteristic seizure disorder associated with the tumor. Her atypical seizures consisted of drooling and fine arm and hand shaking for 1 minute bilaterally. The patient had been on Tegretol in the past, but her best seizure control has been Lamictal and Keppra which she has been on for 2 years. Normally, she gets seizures once a week. Five to six weeks prior to admission, the patient's decadron dose had decreased in half to 4 mg po bid. When her head imaging showed decreased edema after the decadron was lowered, the patient started to have language difficulties, with diminished comprehension and verbal output, and although she was totally ambulatory 1 month prior to admission, she had a fall 4 weeks prior to the day of admission with head trauma, and afterwards had increasing right-sided weakness. Her decadron was then increased shortly after these deficits were realized. On the day prior to admission, the patient had a 15 minute episode of a staring spell with glassy eyes and unresponsiveness after a near-fall. The staring spell was considered by her caretakers to be a new seizure type, and she was brought to the Emergency Room for further evaluation. According to the patient's father, the patient attempted to get out of the wheelchair and her father was helping her transfer from the wheelchair to the bed when he noticed that she had a staring spell, and there was a questionable loss of consciousness as she went to the floor. In the ED, emergent imaging showed large left temporal left mass with swelling and hemorrhage with a 2 cm midline shift to the left. Subsequent MRI did show the left lobe tumor with substantial edema and midline shift associated with subfalcine herniation. The patient was then transferred to the Intensive Care Unit for further monitoring. In the Intensive Care Unit, the patient's vital signs were stable. However, her mental status was poor, as she was unable to respond except to noxious stimulus, and she would open her eyes only to familial stimulus from close family members around her. She was kept NPO for 2-3 days, as the patient was considered an aspiration risk. The patient then was reimaged on MRI, and a new imaging showed a new large necrotic mass in the left frontal lobe with significant worsening of surrounding vasogenic edema with a midline shift to the right. She also demonstrated mass effect in the left lateral ventricle. PERTINENT PHYSICAL EXAMINATION FINDINGS: The patient's vital signs were stable in the ICU and throughout admission on the floor. Her lungs were clear to auscultation bilaterally. Her cardiac rhythm was regular rate with S1, S2, no murmurs, rubs or gallops. Her abdomen was soft, nondistended, good bowel sounds present. Extremities showed no edema. On neurologic examination, her mental status at the onset of her admission was poor. She opened eyes to sternal rub only, would repeat phrases such as "no English" and make neologisms when asked to perform mental status examination. The patient was intermittently able to follow simple midline commands, but could not follow complex commands. After the patient was transferred to the floor, the patient's mental status improved significantly. Subsequent PEG tube placement, and the patient was able to follow simple midline commands and interact with medical staff to follow along with the neurologic examination. Throughout the entire admission, the patient was inattentive and did not respond appropriately to the complex questions. However, she could respond appropriately to simple questions. On cranial nerve exam, the patient had equal pupils, 3 mm, 2 mm, throughout the admission, with extraocular movements that were full, symmetric face and sensation, and tongue that was midline. On motor examination, the patient had normal tone and bulk bilaterally. However, the patient did have a dense right hemiplegia. The left side in upper and lower extremities was [5-24] to power testing by the end of the admission. The patient on sensory exam was withdrawing on left upper and lower extremities at the onset of admission when her mental status was depressed, and then was intact to all modalities on the left side. However, the patient was unable to withdraw to painful stimulus on the right upper and lower extremities. Sensory examination at the onset of the admission - the patient was intact to all modalities in the left upper and lower extremities. Coordination exam - the patient was unable to follow finger-to-nose and heel-to-shin testing, but did have symmetric fine finger movements when cooperative. Gait was not tested throughout the admission. Reflexes - the patient was areflexic. PERTINENT LAB, X-RAY, EKG AND OTHER TESTS: The patient's CBC was followed vigorously throughout the admission. When the patient was admitted, she had a hemoglobin of [10-15] which decreased to [8-9]. The patient was transfused of 2 units of packed red blood cells in the ICU, and her hematocrit rebounded up to the mid-30s where it was stable prior to discharge. The patient also was thrombocytopenic on admission with a platelet count of 41. The patient afterward was transfused 2 units of platelets, and her platelets then stabilized in the low-100s prior to discharge. The CBC should be followed vigorously during the admission. The patient's chem-8 was normal and stable throughout the admission. The patient's coagulation were also normal and stable throughout the admission. The patient's UA did show evidence of a urinary tract infection which was confirmed by urine culture positive for E. coli. The patient's latest head CT on [2184-11-12] showed a slightly decreased degree of edema and mass effect, and a slight decrease in the size of the left temporal [Doctor Last Name 534] of the right lateral ventricle, but showed unchanged mass effect and substantial edema with surrounding hemorrhage. HOSPITAL COURSE: The patient was treated for her UTI with Levofloxacin 500 mg IV qd x 5 days in the Intensive Care Unit. She was also kept on her regular antiepileptic medications. The Keppra was kept at 1,250 mg po bid, and the Lamictal was kept at 150 mg po tid. The patient was kept NPO for 3 days because of her mental status and received a PEG tube on Friday, [11-12], while on the floor to help her with her nutritional intake. The patient was given her medications by mouth when she was alert enough to take them, and her mental status improved significantly after placement of the PEG tube, to the point where the patient was able to take the majority of her medications by mouth prior to discharge. The patient's neurologic exam remained unchanged while the patient was on the general medical floors, with a dense right-sided hemiplegia and full power on the left side. The patient's mental status improved to the point where she was able to interact and follow simple midline commands, and answer simple questions appropriately when asked. It should be noted that the patient was much more interactive when close family members asked her to perform such activities as sing, and remember events from the past. The patient's disposition was decided by the family, deciding that hospice was the best option for this patient with an extremely poor prognosis of her recurrent brain tumor. Palliative care consult met with the family and explained all of the rules that hospice would adhere to, including supportive treatment, but minimalizing diagnostic treatment and blood draws. The family was informed of the palliative care recommendations and agreed with them prior to discharge. The patient's prognosis remains extremely poor, and she met criteria for hospice admission. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSIS: Recurrent left anaplastic oligodendroglioma. DISCHARGE MEDICATIONS: 1. Dexamethasone 6 mg po q 6 h. 2. Bisacodyl 10 mg PO or per rectum qd. 3. Nystatin oral suspension 5 mg po qid prn. 4. Accutane 90 mg po bid. 5. Alendronate sodium 70 mg po q Monday. 6. Calcium carbonate 500 mg po qd. 7. Keppra 1,250 mg po bid. 8. Lamotrigine 150 mg po tid. 9. NOTE: It should be noted that the patient was treated with decadron 6 mg IV q 6 h during the admission, but this was changed to PO dose for hospice admission. FOLLOW-UP PLANS: The patient and her family have agreed to follow hospice rules regarding aggressiveness of treatment and the level of supportive treatment they will receive in the case that [Known firstname 3551] does decompensate from her left recurrent brain tumor. The patient's family was in agreement that the patient's prognosis was poor, and that supportive measures, although helpful, would eventually not change her diagnosis, or her prognosis. The patient also had oral thrush throughout the admission which was treated with nystatin and was continued in the hospice medications. The patient will follow-up as per recommendations from Dr. [Last Name (STitle) 724], her oncologist. [Doctor Last Name ] [Name8 (MD) 8346], M.D. [MD Number(1) 8347] Dictated By:[MD Number(1) 109685] MEDQUIST36 D: [2184-11-16] 12:09 T: [2184-11-16] 12:11 JOB#: [Job Number 109686] ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7729 }	Medical Text: Admission Date: [2129-12-13] Discharge Date: [2129-12-20] Date of Birth: [2066-7-12] Sex: F Service: [Hospital1 ] CHIEF COMPLAINT: Hypotension and melena. HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old woman with a complicated history who was well until [2129-7-31] until elective repair of a symptomatic 6.4 cm abdominal aortic aneurysm at [Hospital1 1474]. Postoperative course was complicated by deep venous thrombosis, pulmonary embolism, status post IVC filter placement and large retroperitoneal bleed, pancreatic cyst with growth of staph and Serratia, small bowel obstruction, diarrhea and ischemic colitis documented by sigmoidoscopy with severe malnutrition requiring total parenteral nutrition. She was discharged from the [Hospital1 69] on [11-28] after hospital course for enterococcal and Serratia bacteremia, multiple deep venous thromboses, severe malnutrition, improving pancreatic pseudocyst, ongoing ischemic colitis, paroxysmal atrial fibrillation, and depression. The patient was transferred to [Location (un) 511] Sanai on [11-28] at which time she continued to undergo total parenteral nutrition and had fair po intake. She remained afebrile while on Ampicillin for her bacteremia. Over the course of her rehabilitation stay she was noted to have increasing abdominal distention, lower quadrant pain bilaterally and KUB demonstrating persistent ileus. On the day of admission she was noted to be tachycardic in the 120s and irregularly irregular with a systolic blood pressure in the 110s, hematocrit was noted to be 22.9. She received intravenous fluids, Protonix, vitamin K for an INR of 2.6 and was transferred back to the [Hospital1 1444] for further evaluation. In the Emergency Department she was afebrile at 99, 100/56, 126, 97%, guaiac positive stool. Nasogastric lavage was positive for small amount of dried blood, received Vancomycin, Levaquin and Flagyl and was transferred to the Intensive Care Unit for further care. PHYSICAL EXAMINATION: Vital signs 99, 110, 108/60, 20, 97% on room air. General, she was awake, alert and oriented times three. HEENT pupils are equal, round and reactive to light and accommodation. Extraocular movements intact. Anicteric. Oral mucosa dry. Neck supple. No lymphadenopathy. Lungs clear to auscultation bilaterally. Cor tachycardic, but regular. Normal S1 and S2. Abdomen soft, mildly distended, nontender, positive bowel sounds. Stool guaiac negative in the Emergency Department. Extremities 2+, anasarca, warm, 2+ dorsalis pedis pulses and radial pulses bilaterally. Neurological Cranial nerves II through XII are intact, 4 out of 5 muscle strength in all four extremities. LABORATORY: White blood cell count 18.1, hematocrit 25, platelets 377, 74 neutrophils, 4 bands, 14 lymphocytes, INR 2.0, arterial blood gas 7.52/39/95 with a lactate of 1.1. Chest x-ray with low lung volumes and no signs of congestive heart failure or pneumonia. KUB with air filled loops of bowel consistent with an ileus. HOSPITAL COURSE: In the Emergency Department the patient received a CTA to rule out pulmonary embolism or aortic enteric fistula or ischemic colitis. The results of this was negative. The patient was admitted to the Intensive Care Unit for further management. She received blood transfusions for her anemia and continued to receive vitamin K for her elevated INR. She was maintained on Vancomycin, Levaquin and Flagyl and infectious disease was consulted. The patient then went into rapid atrial fibrillation with a heart rate in the 150s, blood pressure 110/50. She was started on an Esmolol drip due to her recent hypotension. During this her blood pressure decreased to 47 systolic and the drip was discontinued. Heart rate was maintained in the 90s. She tolerated the low blood pressure well. While in the Intensive Care Unit her PICC line was discontinued and a central line was placed. Blood cultures were performed. GI was consulted for ongoing bleeding and the patient had gastroscopy demonstrating only a hiatal hernia that was reduced with a scope. Sigmoidoscopy to 30 cm revealed the luminary with a possible stricture from old ischemic colitis versus a large diverticulum, status post surgical change. On hospital day number three the patient again went into rapid atrial fibrillation with a blood pressure decreased to 87/44 that responded with normal saline boluses. Also had a short run of supraventricular tachycardia. Right groin ultrasound and right upper extremity ultrasound revealed no evidence of deep venous thrombosis. The patient's blood cultures grew gram positive and gram negative organisms. Later that day the patient went to radiology for gastric graph to better characterize the nature of her stricture. The procedure was complicated by bradycardia to 37 likely a vasa vagal event. The patient then went into supraventricular tachycardia in the 160s, which lasted for less then one minute and spontaneously resolved. On hospital day number four the patient continued to have melanotic stools. She remained tachycardic in the 110s. She also grew out VRE in her blood cultures and was started on Linezolid. A transthoracic echocardiogram was performed on hospital day number five, which demonstrated a large vegetation on the posterior mitral leaflet, normal ejection fraction, 1+ mitral regurgitation. This was highly consistent with endocarditis likely VRE endocarditis given her positive blood cultures. The patient then proceeded to go back into atrial flutter with heart rate in the 160s, blood pressure again decreased to the 80s. The patient complained of a sore chest for several minutes, which resolved after she was treated with Diltiazem. A long discussion with the patient and her family resulted in the patient expressing that she did not wish to have any intensive treatment, but for her to have ventilation, but does not want ventilation or CPR performed if she became worse. Also she did not wish to have a painful procedures performed and would prefer leaning toward comfort care. This was a reasonable decision as the patient continued to have ongoing gastrointestinal bleeding, rapid atrial fibrillation that was difficult to control as well as new enterococcal endocarditis. The patient was transferred to the floor for additional management. On the floor she became minimally responsive. Discussions with the family was then readdressed and the patient's family wished to make the patient CMO. They felt this best represented her wishes. She was made comfort care only. Palliative care was consulted. The patient then passed on hospital day number eight. CONDITION ON DISCHARGE: Expired. DISCHARGE DIAGNOSES: 1. Enterococcal endocarditis. 2. Enterococcal and Serratia bacteremia. 3. Atrial fibrillation/atrial flutter. 4. Supraventricular tachycardia. 5. Gastrointestinal bleed. 6. Microischemic colitis. 7. Right femoral hematoma. 8. Malnutrition. 9. Hypotension. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2506] Dictated By:[Name8 (MD) 17420] MEDQUIST36 D: [2130-3-8] 12:14 T: [2130-3-8] 13:59 JOB#: [Job Number 47203] ICD9 Codes: 7907, 5789, 2859, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7730 }	Medical Text: Admission Date: [2158-3-31] Discharge Date: [2158-4-4] Date of Birth: [2102-1-24] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1042] Chief Complaint: BRBPR, anemia, chest pain Major Surgical or Invasive Procedure: EGD, flexible sigmoidoscopy History of Present Illness: Patient's H&P and hospital course reviewed. Briefly, this is a 56F w/ CAD, DM2, ESRD on PD sent to the ED for Hct of 15. She had LH for 5 days as well as chest tightness and dyspnea on exertion. She has had BRBPR for several days and has a prior diagnosis of hemorrhoids. She has not had abdominal pain, N/V, melena, diarrhea/constipation. In the ED she had a negative NG lavage, rectal exam was guaiac negative but external hemorrhoids were noted. Troponin was 0.07 and after discussion with cardiology in the ED, this was felt to be demand from severe anemia and not a primary cardiac process. She was transferred to the MICU for close monitoring and has so far received 4U PRBC. Hct was 20.6 after the first 2 units. She has remained hemodynamically stable. GI was consulted and felt that since this was likely a hemorrhoidal bleed, supportive care was warranted and that surgery should be consulted. Surgery consult recommended likely hemorrhoidectomy vs. banding but will staff with a colorectal surgeon on Monday. As she has been hemodynamically stable with no further bleeding, she was transferred to the floor. Past Medical History: 1) Type II diabetes mellitus 2) ESRD [1-21] diabetes, on hemodialysis since [2156-6-25] 3) HTN, benign essential 4) Anemia, chronic disease/iron deficiency 5) Diabetic Retinopathy, legally blind x 1 year 6) Eczema 7) s/p oophorectomy 8) CAD Social History: Patient is Cantonese and Mandarin speaking only, married, with husband at bedside. Denies alcohol, tobacco, or drug use. Family History: Strong family history of Type II DM. Brother deceased of renal failure. Physical Exam: Vitals- 96.8, 81, 125/58, 17, 100% RA Gen- NAD, appears fatigued but alert HEENT- sclerae anicteric, pale conjunctivae, MMM Neck- supple Pulm- CTAB CV- RR, 2/6 SEM heard throughout Abd- +BS, mildly distended with ?fluid wave, PD catheter in L lower abdomen, nontender Extrem- trace ankle edema Skin- scattered eczematous changes throughout Pertinent Results: [2158-3-31] 06:40PM GLUCOSE-80 UREA N-83* CREAT-13.7# SODIUM-133 POTASSIUM-4.2 CHLORIDE-94 TOTAL CO2-21* ANION GAP-22* [2158-3-31] 06:40PM POTASSIUM-4.0 [2158-3-31] 06:40PM ALT(SGPT)-26 AST(SGOT)-23 CK(CPK)-139 ALK PHOS-99 TOT BILI-0.1 [2158-3-31] 06:40PM LIPASE-111* [2158-3-31] 06:40PM cTropnT-0.07* [2158-3-31] 06:40PM CK-MB-3 [2158-3-31] 06:40PM CALCIUM-6.9* PHOSPHATE-6.7* MAGNESIUM-2.3 [2158-3-31] 06:40PM WBC-9.8 RBC-1.44# HGB-4.9# HCT-15.7# MCV-109# MCH-34.1* MCHC-31.3 RDW-19.1* [2158-3-31] 06:40PM NEUTS-75.9* LYMPHS-15.2* MONOS-4.9 EOS-3.5 BASOS-0.6 [2158-3-31] 06:40PM PLT COUNT-504* [2158-3-31] 06:40PM PT-12.3 PTT-26.4 INR(PT)-1.0 [4-3] EGD: Erosions in the antrum (biopsy) Normal mucosa in the duodenum (biopsy) Otherwise normal EGD to second part of the duodenum [4-3] flex sig: Grade 1 internal & external hemorrhoids Normal mucosa in the sigmoid colon Otherwise normal sigmoidoscopy to 25 from the anus in the sigmoid colon Brief Hospital Course: 1. Lower GI bleed: NG lavage negative so most likley lower GI bleed. Colonoscopy recently demonstrated normal colon except for internal hemorrhoids, which is thought to be most likely source of this subacute bleed. Patient presented reasonably stable from hemodynamic standpoint, and received 4 units PRBC with improvement in her symptoms. Her hematocrit remained stable at ~30-31 for the remainder of her hospital course. GI was consulted and performed EGD and flex sig that showed no clear source of bleeding other than hemorrhoids. Colorectal surgery was consulted and recommended outpatient banding as well as a high fiber diet, fiber supplements, and steroid suppositories. The patient is to follow up with Dr. [Last Name (STitle) 1120] of colorectal surgery for this procedure. 2. CAD: Patient presented with chest tightness in setting of severe blood loss anemia, with negative CKs and elevated troponins. Symptoms resolved with correction of anemia. Medical therapy for coronary disease was continued, beta-blockers resumed, Aspirin and statin continued. 3. HTN: Metoprolol and valsartan were temporarily held and restarted after patient's tranfusions and hematocrits had remained stable. Metoprolol was changed to 100mg [Hospital1 ] and Lasix was changed to 80mg [Hospital1 ] in an effort to simplify her medication regimen. 4. ESRD on PD: Peritoneal dialysis per renal recommendations. Continued Sevelamer and lanthanum for phosphorus binding. Procrit dose was increased per renal and patient was started on iron. 5. DM2: Continued glargine + humalog sliding scale. Lantus was increased to 7 units daily due to increased blood sugars. 6. Prophylaxis: pneumoboots Medications on Admission: ASA 325mg daily Valsartan 40mg daily Lantus 5U QAM Humalog sliding scale Renagel 1600 TID w/ meals Simvastatin 40mg QHS Lasix 60mg [Hospital1 ] Metoprolol 75mg [Hospital1 ] Nephrocaps daily Fosrenol 1000mg QID Colace 100mg [Hospital1 ] Bisacodyl 10mg QHS Epogen Discharge Medications: 1. FiberCon 625 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 2. Insulin Glargine 100 unit/mL Solution Sig: Seven (7) Units Subcutaneous qam. 3. Humalog 100 unit/mL Solution Sig: per sliding scale Subcutaneous see sliding scale. 4. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO HS (at bedtime). 14. Hemorrhoidal Suppository 0.25 % Suppository Sig: One (1) suppository Rectal at bedtime. Disp:30 suppository Refills:2 15. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [Hospital1 ] PRN (). Disp:1 tube Refills:2 16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 17. Epogen 20,000 unit/mL Solution Sig: One (1) mL Injection once a week. Disp:1 month supply Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: hemorrhoidal bleeding Secondary: end-stage renal disease, diabetes mellitus Type II, coronary artery disease, hypertension Discharge Condition: good, stable, no abdominal pain, no shortness of breath, no lightheadedness, no chest pain Discharge Instructions: You were evaluated for chest discomfort and found to have very low blood levels, likely from chronic hemorrhoidal bleeding. There was no evidence of a primary cardiac problem to explain your chest discomfort, and this was likely from being severely anemic. An upper endoscopy and flexible sigmoidoscopy did not show any evidence of other concerning sources of bleeding. You were evaluated by colorectal surgery, and Dr. [Last Name (STitle) 1120] will perform banding of the hemorrhoids as an outpatient. You should eat a high fiber diet with fiber supplements (FiberCon), which you may also get over the counter. You should use Anusol suppositories at night until you see Dr. [Last Name (STitle) 1120]. We have adjusted some of your medications in an effort to achieve better blood pressure and blood sugar control and to make it a little easier for you to take your medications. Your Lantus dose has been increased to seven units in the morning. We have increased your metoprolol dose to 100mg twice a day and your Lasix dose to 80mg twice a day. We have also increased your Epogen dose to 20,000 Units once a week and started you on iron. Followup Instructions: You have an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1120] (colorectal surgery) on [4-19] at 9am. You may call her office at [Telephone/Fax (1) 17489] with any questions. She will discuss the procedure with you at that time and will get informed consent for the procedure if you agree. Follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) 714] [Doctor Last Name 29076]. You have an appointment with her this [Last Name (LF) 2974], [4-7] at 2:30pm. You may call [Hospital3 ] at [Telephone/Fax (1) 250] with any questions. ICD9 Codes: 5856, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7731 }	Medical Text: Admission Date: [2134-7-9] Discharge Date: [2134-7-14] Service: CCU REASON FOR ADMISSION: Substernal chest pain. HISTORY OF PRESENT ILLNESS: This is an 82-year-old gentleman with aortic valve replacement (St. [Male First Name (un) 923]), rheumatic heart disease and mitral stenosis with an ejection fraction of 50%, atrial fibrillation on Coumadin, who awoke on the day of admission with substernal chest pain approximately [7-8]. He presented to the emergency room at an outside hospital where an EKG showed 1-[Street Address(2) 1766] elevations laterally in 1, L, V5 through V6 with concomitant ST depressions in the inferior leads. The cardiology service was consulted and while evaluating the patient he was noted to go into polymorphic ventricular fibrillation. Cardiopulmonary resuscitation was begun and the patient was shocked at 360 joules. He then became bradycardic, was given atropine 1 mg and an amiodarone drip was started and the patient was taken emergently to the Cardiac Catheterization Laboratory. In the catheterization laboratory the patient was found to have normal left main, normal left anterior descending coronary artery, and a 20% proximal left circumflex coronary artery. Of note, there was also an obtuse marginal #1 with very distal thrombotic occlusion with TIMI 1 flow. The patient had a normal right coronary artery. He was taken to the coronary care unit for monitoring. REVIEW OF SYSTEMS: Negative for diaphoresis, nausea, vomiting or palpitations. PAST MEDICAL HISTORY: 1. Aortic valve replacement (St. [Male First Name (un) 923] placed in [2114]). 2. Rheumatic heart disease with moderate to severe mitral stenosis. 3. Echocardiogram of [2134-3-30] demonstrating an ejection fraction of 50%. 4. Atrial fibrillation on Coumadin with previous cardioversion attempts in 06/99 and [7-30]. The patient had been switched from sotalol to atenolol for the past year. 5. Asthma. 6. HCV, chronic. 7. Hypertension. 8. Hypercholesterolemia. 9. Prostate cancer recently diagnosed in [6-1]. 10. Eczema. 11. Transient ischemic attacks. ALLERGIES: The patient is allergic to amiodarone, reaction unknown. MEDICATIONS ON ADMISSION: 1. Atenolol 25 q.d. 2. Lisinopril 30 q.d. 3. Procardia XL 30 q.d. 4. Coumadin. 5. Albuterol two puffs b.i.d. 6. Flovent 10 mcg b.i.d. 7. Hydrochlorothiazide 25 q.d. SOCIAL HISTORY: Remote history of cigarette smoking. No alcohol use, no drug use. The patient is a [Street Address(1) 8901] clerk. FAMILY HISTORY: Significant for a brother with emphysema. PHYSICAL EXAMINATION: On admission temperature was 98, blood pressure 137/72, heart rate 68 and regular, respiratory rate 12, breathing at 95% on a shovel mask. General: No apparent distress, lying on back with shovel mask. HEENT: Five cm of jugular venous distension, pupils equal and reactive to light and accommodation. Oropharynx was negative. Cardiovascular: Regular rate with a 2/6 systolic murmur without radiation, nondisplaced point of maximal impulse, no carotid bruits auscultated. Pulmonary: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Extremities: No cyanosis, clubbing or edema, 2+ dorsalis pedis and radial pulses bilaterally. Neurological: Examination was nonfocal. Skin: Examination showed a groin incision which was clean, dry and intact without hematoma. LABORATORY DATA/STUDIES: Echocardiogram in [2133-3-30] shows an ejection fraction of 50-55% with moderate left ventricular hypertrophy, moderate to severe MS. The white count on admission was 9.1, hematocrit 38.1, platelet count 183, sodium 140, potassium 3.2, chloride 101, bicarbonate 25, BUN 31, creatinine 1.3, glucose 143, CK 210, MB 5, troponin less than .01. A repeat echocardiogram showed an ejection fraction of 20%, aortic valve normal, prosthetic mitral valve 1+ MR, left atrium was dilated, left ventricle showed severe hypokinesis, right ventricle was dilated. The catheterization report is as above. The chest x-ray showed congestive heart failure, mild. An EKG showed atrial fibrillation at 65 beats per minute with normal intervals, ST elevations in 1, L, V5 through V6, approximately 1-2 mm; ST depressions in leads 2 and 3. HOSPITAL COURSE: The patient was admitted to the coronary care unit for observation. His CKs were cycled. The patient was placed on telemetry and serial EKGs were performed. 1. Status post ventricular fibrillation arrest: The patient was continued on an amiodarone drip in the coronary care unit at 1 mg per minute, then decreased to 0.5 mg per minute due to bradycardia (heart rate in the 40s to 50s) and an episode of hypotension with systolic blood pressure in the 80s. On [2134-7-11] the patient was switched to p.o. amiodarone [Company 8902].i.d. On [2134-7-13] the patient's amiodarone was discontinued. 2. Distal obtuse marginal #1 lesion: The patient's distal obtuse marginal #1 lesion was thought to be embolic in origin secondary to being off of Coumadin in anticipation of a prostate biopsy. A transthoracic echocardiogram was performed on [2134-7-13] which demonstrated an ejection fraction of 35%, mildly dilated left atrium, decreased atrial velocity with a mechanical aortic valve, mitral stenosis, global left ventricular hypokinesis, rheumatic mitral disease with no thrombus. 3. Anticoagulation: The patient was anticoagulated in the setting of atrial fibrillation and left ventricular hypokinesis. His Coumadin dose was titrated to an INR of [2-1]. The heparin drip was overlapped with Coumadin and was discontinued on the day of discharge at which time the patient's INR was 2.5. 4. Post myocardial infarction: The patient was put on a post myocardial infarction regimen of aspirin, beta blockers, statin and ACE inhibitor. 5. Chronic obstructive pulmonary disease/asthma: The patient's clinical findings of wheezing gradually improved over the course of his hospital stay on metered dose inhalers and nebulizers. The patient's oxygen requirement decreased and on the day of discharge the patient was breathing at 98% on room air and his physical examination was remarkable for the absence of crackles or wheezing. 6. Bradycardia: The patient did have any episode of bradycardia to the 40s to 50s, during which time he was symptomatic and resolved spontaneously. 7. Cardiac enzymes: The patient's CK dropped from a maximum of 1,412 to 187. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: On the day of discharge the patient's blood pressure is 112/62 with a heart rate of 72, breathing at 98% on room air. The patient was asymptomatic with no events on telemetry. DISCHARGE DIAGNOSES: 1. Posterior/lateral myocardial infarction. 2. Atrial fibrillation. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg, one p.o. q.d. 2. Protonix 40 mg tablets, p.o. q.d. 3. Atorvastatin 10 mg, one p.o. q.d. 4. Fluticasone propionate 110 mcg aerosolized, two puffs b.i.d. 5. Ipratropium bromide 0.2 mg per mL inhalation q. 6. 6. Lisinopril 10 mg p.o. q.d. 7. Coumadin 2.5 mg alternating with 3.75 mg q.o.d. 8. Albuterol 90 mcg aerosolized, 1-2 puffs q. 4-6 hours p.r.n. 9. Atenolol 25 mg tablet, one-half of a tablet p.o. q.d. FOLLOW-UP PLANS: The patient was discharged home with a visiting nurse. He was advised to take his medications as prescribed and to return to the Emergency Department or call 911 with fevers, chills, nausea, vomiting, chest discomfort, shortness of breath, bloody stools, worsening cough, or any other concerning symptoms. The patient was advised to make a follow-up appointment with Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2207] within one week of discharge. The patient was advised to visit the [Hospital 263] clinic in the next two to three days. The patient had an appointment arranged with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4844] on [2134-8-9] at 10:50 at [Hospital6 733], phone number [Telephone/Fax (1) 250], and with Dr. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) ] at the [Hospital Ward Name 23] Center at [Telephone/Fax (1) 2207] on [2134-9-28] at 2:30 PM. The patient was also advised to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] regarding possible future electrophysiological testing for risk stratification, including a possible signal averaged ECG. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Last Name (NamePattern1) 1811] MEDQUIST36 D: [2134-7-19] 11:45 T: [2134-7-20] 07:12 JOB#: [Job Number 8903] cc:[Name8 (MD) 8904] ICD9 Codes: 4275, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7732 }	Medical Text: Admission Date: [2128-4-30] Discharge Date: [2128-5-23] Service: CARDIOTHORACIC Allergies: Adhesive Tape Attending:[First Name3 (LF) 1267] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2128-4-30] Cardiac Catheterization [2128-5-4] Thrombin Injection of Right Groin Pseudoaneurysm [2128-5-5] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending, with vein grafts to obtuse marginal and posterior descending artery [2128-5-17] Cardioversion History of Present Illness: This is an 85 yr old male with CRI (baseline creat 1.8-2.3) who was admitted to [Hospital 46] Hosp with a NSTEMI last month (medically managed) and was then readmitted to [Hospital 46] Hosp with chest pain on [2128-4-26]. He had squeezing sub-sternal CP intermittently for 2 weeks (both at rest and with exertion). The CP was associated with SOB. He ruled in again for MI with trop reportedly 0.15, ck??????s were negative. ETT reportedly revealed a reversible inferior posterior defect. He is on coumadin for hx of DVT, which has been on hold, and INR on [2128-4-29] was 1.5. He was pain free at rest but has had chest pain when getting oob to the BR, which has resolved with ntg SL and oxygen at [Hospital 46] Hosp. Creatinine was up to 2.3. He was hydrated just prior to transfer to the [Hospital1 18] for cardiac catheterization and further management of his coronary artery disease. On admission, he was pain free. Past Medical History: Coronary artery disease with Recent MI Chronic Renal Insuffiency History of Deep Vein Thrombosis Atrial Fibrillation Hypertension Hyperlipidemia Social History: Significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: Brother in 50's with CAD. Physical Exam: VS: T 97.8 BP 119/73 HR 73 RR 18 O2 96% RA Gen: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 6cm. CV: PMI located in 5th intercostal space, midclavicular line. Very distant heart sounds, irregular. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi anteriorly. Abd: Soft,nt, obse, +BS. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: 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+ Pertinent Results: [2128-4-30] 01:56PM BLOOD WBC-7.4 RBC-4.16* Hgb-13.9* Hct-40.4 MCV-97 MCH-33.4* MCHC-34.4 RDW-13.7 Plt Ct-149* [2128-4-30] 01:56PM BLOOD PT-16.4* INR(PT)-1.5* [2128-5-5] 01:18PM BLOOD Fibrino-332 [2128-4-30] 01:56PM BLOOD Glucose-141* UreaN-30* Creat-1.6* Na-136 K-4.4 Cl-104 HCO3-25 AnGap-11 [2128-4-30] 01:56PM BLOOD ALT-17 AST-21 AlkPhos-46 TotBili-0.7 [2128-4-30] 01:56PM BLOOD %HbA1c-5.8 [2128-5-2] 06:50AM BLOOD CK-MB-3 [2128-4-30] Cardiac catheterization: Selective coronary angiography of this right dominant system revealed three vessel disease. The LMCA had a distal 30% lesion. The LAD was moderately calcified with a 30% ostial stenosis and an 80% lesion in the mid-vessel just after the take off of a major D2 branch, which had diffuse plaquing. The D1 branch had a proximal 80% stenosis. The LCx had a 90% lesion in the proximal AV groove and a 40% lesion distally. The was a major OM3 branch with a proximal 70% stenosis. The RCA was diffusely diseased throughout with a 50% mid-vessel stenosis and 60-70% stenosis in the PDA. There was a major AM branch with a 60% lesion. Moderate diastolic left ventricular dysfunction. [2128-5-3] TTE: Preserved global left ventricular systolic function(LVEF approximately 55%). Right ventricular cavity enlargement but with good free wall function. No AI. Trivial MR. [First Name (Titles) ] [Last Name (Titles) ]. [2128-5-4] Carotid Ultrasound: Less than 40% stenosis involving the internal carotid arteries bilaterally. [2128-5-4] Groin Ultrasound: Right groin pseudoaneurysm measuring up to 2.8 cm at site of previous right femoral puncture. [2128-5-15] Abdominal CT Scan: Findings consistent with colonic ileus. Short segment of narrowed ileum with mild wall thickening. The appearance raises concern for a neoplastic process, for which further evaluation is recommended. Multiple bilateral cystic lesions in the kidneys, not fully characterized here. Although these most likely represents simple cysts, this appearance could be evaluated by ultrasound if clinically indicated. Brief Hospital Course: On admission, Mr. [Known lastname ] [Last Name (Titles) 1834] cardiac catheterization which revealed severe three vessel coronary artery disease. He was pretreated with Plavix. Given his chronic renal insufficiency, LV gram was deferred and echocardiogram was obtained which showed preserved global left ventricular systolic function. In anticipation for cardiac surgical intervention, Plavix was discontinued. Additional workup included cartoid ultrasond which found minimal disease of the internal carotid arteries. Cardiac catheterization was complicated by a right common femoral artery pseudoaneurysm which was successfully treated with thrombin injection on [5-4]. He otherwise remained pain free on medical therapy. He had bouts of paroxsymal atrial fibrillation preoperatively for which he was maintained on Amiodarone and Heparin. On [5-5], Dr. [Last Name (STitle) ] performed coronary artery bypass grafting surgery. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. He continued to experience periods of atrial fibrillation/flutter which was initially treated with beta blockade and Amiodarone. Given persistent atrial arrhythmias associated with hypotension, the EP service was consulted. Amiodarone was continued while Metoprolol was temporarily discontinued in hopes to improve hemodynamics. Warfarin was also resumed with a temporary Heparin bridge. Successful cardioversion was performed on [5-17], but he returned to atrial fibillation within several days. A second electrical cardioversion was attempted, but was also unsuccessful. It was recommended that he remain on Amiodarone at discharge with anticoagulation indefinitely. His renal function declined in the early postoperative period. His creatinine peaked to 3.8 on postoperative day ten. He did not experience oliguria. The renal service was consulted and attributed his acute on chronic renal failure to acute tubular necrosis secondary to hypotension. Despite significant rise in creatinine, there was no indication for dialysis. Over the remaineder of his hospital stay, his renal function slowly improved. He also experienced some hypernatremia which was treated with free water. His postoperative course was also complicated by an ileus/colonic pseudobstruction. He was temporarily made NPO and required placement of nasogastric and rectal tubes. With the above measures and aggressive bowel regimen, his pseudobstruction gradually resolved. His diet was slowly advanced and by discharge, he was tolerating a regular diet. He was also noted to have a sternal click associated with sternal drainage. He was placed on strict sternal precautions with close observation of his sternal incision. At discharge, his sternal drainage had resolved although he continued to have a click. By post-operative day seventeen he was ready for discharge to a rehabilitation facility. Medications on Admission: CURRENT MEDICATIONS (on transfer): Asa 81mg qd Ntg paste 1 inch Imdur 60mg qd Lopressor 100mg [Hospital1 ] Protonix 40mg qd Lipitor 5mg qd MVI qd Glucosamine 2000mg qd HCTZ 12.5mg qd, recently held due to rising creatinine Ambien 5mg qhs prn MEDS (home, [Last Name (un) 5487] doses): HCTZ Metoprolol Coumadin Glucosamine 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 Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 Tablet(s) Refills:0 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital 169] Center - [Location (un) 3320] Discharge Diagnosis: Coronary artery disease - s/p CABG Acute MI Postop Colonic Pseudo-obstruction(Olgilvie's syndrome) Postop Sternal Drainage Postop Acute on Chronic Renal Insuffiency Right Groin Pseudoaneurysm - s/p Thrombin Injection History of Deep Vein Thrombosis Atrial Fibrillation/Flutter - s/p Cardioversion Hypertension Hyperlipidemia Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Warfarin should be monitored closely and adjusted for goal INR between 2.0 - 3.0. Pre-admission his coumadin was followed by his cardiologist, [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [Location (un) 3320], Mass ([Telephone/Fax (1) 73314]. Followup Instructions: Dr. [Last Name (STitle) ] in [4-15] weeks, call for appt ([Telephone/Fax (1) 11763] Dr. [Last Name (STitle) 5310] in [2-14] weeks, call for appt ([Telephone/Fax (1) 73315] Dr. [Last Name (STitle) 12246] in [2-14] weeks, call for appt ([Telephone/Fax (1) 73316] Dr. [Last Name (STitle) ] from electrophysiology in 1 month, call for an appointment ([Telephone/Fax (1) 22784] ICD9 Codes: 4111, 5845, 9971, 496, 2760, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7733 }	Medical Text: Admission Date: [2172-2-26] Discharge Date: [2172-3-5] Date of Birth: [2086-11-14] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1481] Chief Complaint: splenomegaly, ?metastatic disease Major Surgical or Invasive Procedure: 1. Laparoscopically-assisted splenectomy. 2. Exploratory laparotomy, abdominal washout, crossclamp of the aorta. History of Present Illness: The patient is a 85y/o gentleman who has a history of mild splenomegaly that has been increasing slowly. He is thought to perhaps have some disorder of myelodysplastic syndrome. Of note is he also has had colon cancer and had a metastasis to his liver. He was noted on recent scanning to have some abnormalities in his spleen. The spleen is also somewhat increased in size. It is unclear whether this enlargement is due to his metastatic disease or progression of his myelodysplastic syndrome. Past Medical History: PMH: AAA with expansion after EVAR, HTN, COPD, hypercholesterolemia, metastatic colon CA s/p adjuvant chemotherapy, +ETOH, MDS anemia PSH: L colectomy, segment [3-17] liver resection for metastatic colon CA/open CCY '[63], EVAR [2163], redo EVAR [2166] Social History: Significant EToH use including [3-17] cocktails daily. Prior smoker, but quit 25 yrs ago. Family History: Non-contributory Physical Exam: On Discharge: AVSS GEN: NAD, more alert and oriented CV: RRR Lungs: CTAB, no r/w/r ABD: Soft, NT/ND. Staples in place. Wound is clean, dry, and intact. EXT: warm, well perfused. Pertinent Results: [2172-2-26] 06:51PM BLOOD WBC-15.6# RBC-3.45 Hgb-10.4* Hct-31.1* MCV-90 MCH-30.2 MCHC-33.5 RDW-17.9* Plt Ct-352 [2172-3-5] 09:25AM BLOOD WBC-12.3* RBC-3.03* Hgb-9.2* Hct-27.3* MCV-90 MCH-30.3 MCHC-33.5 RDW-15.4 Plt Ct-818* [2172-3-4] 07:15AM BLOOD Glucose-119* UreaN-19 Creat-1.1 Na-139 K-3.9 Cl-101 HCO3-31 AnGap-11 LUE duplex [2172-3-2]: No evidence of pseudoaneurysm LUE CTA [2172-3-3]: No evidence of pseudoaneurysm ABD U/S [2172-3-4]: No evidence of splenic/portal vein thrombosis ABD CT [2172-3-5]: No subdiaphragmatic collection. Small residual hematoma in LUQ. Brief Hospital Course: The patient was admitted to the General surgery service on [2172-2-26]. He underwent a laparoscopic assisted splenectomy. (Please see the operative report for further details.) The patient was extubated and taken to the recovery room in stable condition. Upon arrival to the recovery area, patient was noted to have a SBP in the 80s. His postoperative HCT was 23.1 down 8 units compared with pre-op. 2 units of PRBCs were given and patient was bolused with IVF to help improve urine output. The patient's epidural was split as well to improve vascular tone. His BP actually improved to 100 systolic after these interventions, but the patient soon became unresponsive. A central line was placed in the L femoral vein, and patient began to get hypotensive again to the 60s and was very pale and tachycardic. He was bolused aggressively, and then taken back to the OR emergently for re-exploration. (Please see operative note for further details). Post-operatively, the patient was managed in the ICU. He was HDS, but was still intubated and on pressors. A left subclavian line was attempted on [2-27], but was accidentally placed in the artery. This line was promptly removed and pressure held for 55 min, with no evidence of bleeding after. A Right SCL was subsequently placed successfully. The patient was weaned off of respiratory support and extubated on [2-28]. Epidural was restarted for pain control. He was ultimately transferred to the floor in good condition on [2172-3-2]. Neuro: The patient received epidural with good effect and adequate pain control. This was discontinued on [3-2], and patient was transitioned to oxycodone when tolerated oral intake. The patient has history of significant EToH use at baseline. As such, he was managed on CIWA scale during his hospital stay. He became intermittently agitated the first few days post-op and this was treated with small doses of ativan. However, once he was transferred to the floor, his mental status greatly improved. He was alert, oriented, and much less confused. He did show any signs of severe alcohol withdrawal. CV: Postoperatively, patient was initially on pressors, but this was quickly weaned off on POD1. Due to h/o AAA, Vascular was consulted and recommended keeping SBP between 100-140. As such, patient was maintained on lopressor during his hospital course. Pulmonary: The patient was weaned off of respiratory support and extubated on [2-28]. The patient's was stable from a respiratory standpoint after extubation. O2 was weaned as tolerated. Good pulmonary toilet, ambulation and incentive spirometry were encouraged throughout hospitalization. GI: Post-operatively, the patient was made NPO with IV fluids. Once extubated, the patient was started on sips and advanced to regular diet as tolerated. Due to intermittent confusion and agitation, patient did not take much po initially. However, this improved during his hospital course. His diet was supplement with ensure shakes. Prior to discharge, patient was eating larger amounts of food and tolerating it well. An abdominal ultrasound was performed on [2172-3-4] to rule out splenic/ portal vein thrombosis and it showed no evidence of thrombosis. On [2172-3-5] a CT scan was performed to evaluate for subdiaphragmatic collection due to persistent hiccups. No collection was seen on CT and patient's hiccups were improving upon discharge. GU/FEN: The patient suffered acute renal insufficiency during his hospital stay, likely from hypotension, possibly exacerbated by cross clamp of aorta during re-exploration. His Cr post-operatively was maximally elevated at 2.8. The patient was kept well hydrated and serial Cr levels were measured. His Cr came down appropriately and was 1.1 at time of discharge. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Post-operative, the patient was several Kg above his baseline weight and was started on lasix drip in the unit. Cxr's were followed that initially showed pulmonary edema, but this improved greatly with the lasix. Lasix was continued on the floor, but then discontinued when patient was clinically improved. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. The patient's wound remained clean, dry, and intact. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. HEME: The patient's complete blood count was examined routinely; After initial operation, the patient's HCT dropped to 23, down 8 units from pre-op. He was given 2 units of PRBCs at that time. He also received several more units of blood products when he was taken back to the OR for re-exploration. Serial HCTs were checked and on [2172-3-1], patient was noted to have a HCT of 22.3. He was given 1 unit of PRBCs and his HCT improved to 26.4. For the remainder his stay, the patient's HCT was stable. It was 27.3 at time of discharge. Patient was started on ASA 325 daily due to rising platelet count. The patient was also started on coumadin upon discharge for prophylaxis against splenic vein thrombosis. VASCULAR: The patient underwent a duplex of his L subclavian artery on [2172-2-28] that showed a 1.9 cm linear tract arising from the puncture site. Follow up duplex on [2172-3-2] showed no pseudoaneurysm. A CTA was performed on [2172-3-3] that again showed no evidence of pseudoaneurysm. The patient received mucomyst/bicarb before and after CTA for kidney protection. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. Physical therapy worked with the patient and recommended short term rehab until patient was back to baseline. He was begun on coumadin for prophylaxis against splenic/ portal vein thrombosis, which is relatively common followinf splenectomy in patients with myelodysplasia. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: amlodipine 5', atorvaststin 10', trandolapril 2', ASA 81', Vit D Discharge Medications: 1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. trandolapril 2 mg Tablet Sig: One (1) Tablet PO once a day. 5. Coumadin 5 mg Tablet Sig: Five (5) Tablet PO once a day: Please adjust dose for goal INR of [1-16]. 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 5176] Discharge Diagnosis: Splenomegaly- Myelodysplasia ? metastatic disease [Last Name (un) ] operative bleeding 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: Please call your doctor or nurse practitioner if you experience the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. . General Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-21] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 2359] Date/Time:[2172-3-12] 9:45 [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2172-3-23] 1:30 Please call your [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8049] (PCP) upon discharge from rehab to follow up on INR and coumadin dosing as well as BP measurement. ([Telephone/Fax (1) 14935] Completed by:[2172-3-5] ICD9 Codes: 5845, 4439, 4019, 2724, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7734 }	Medical Text: Admission Date: [2115-9-29] Discharge Date: [2115-10-7] Date of Birth: [2062-11-19] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 4219] Chief Complaint: tylenol overdose, suicide attempt Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Last Name (un) 62603] is a 52 yo woman with h/o bipolar disease and suicide attempts x 2 several years ago (with insulin and with a gun) who presented to [Hospital 62604] Medical Center [2115-9-28] s/p suicide attempt with large tylenol overdose (estimated 92 extra strength tylenols). At time of her presentation there her ALT was 419, her AST was 470 and her bili was 1.2 with INR of 1.4. Her tylenol level was 202 about 20 hours after ingestion. She had presented with nausea, vomiting, and abdominal cramping. She was started on mucomyst. On the following day her ALT was 16,010, AST 11,600 and INR 3.0. The pt was transferred to [Hospital1 18] for possible liver transplantation if it became necessary and was admitted to our SICU. On admission here she was found to have Creatinine of 2.4 as well as INR of 3.5. Urine sediment showed muddy brown casts c/w ATN cause d by tylenol overdose. LFTs have trended down slowly, but remain in the high thousands, and INR peaked at 4.1 for which the pt received FFP in the SICU. Now trending down as well. Currently the pt reports feeling nauseated but relatively well. Denies vomiting, abdominal pain. No other complaints. Past Medical History: bipolar suicide attemps years ago x 2 (insulin o/d and gun) Social History: pt is in midst of divorcing her husband. + tobacco [3-1] pack per day x 20 years. Denies EtOH. Family History: non-contributory Physical Exam: T 98.6 HR 69 BP 163/76 RR 22 O2 97% RA Gen: lying flat in bed in NAD, sleepy, answer questions although seems confused and requires much concentration, does not elaborate HEENT: NCAT, PERRL, no sinus tenderness, OP clear Neck: no LAD, no JVD Cor: RRR, s1s2, no R/G/M Pulm: CTAB anteriorly Abd: decreased BS, NTND, no HSM noted Ext: no c/c/e, w/w/p Neuro: grossly nl sensory and motor, no asterixis Pertinent Results: Labs on admission: WBC-8.0 RBC-4.02* Hgb-11.7* Hct-35.4* MCV-88 MCH-29.1 MCHC-33.1 RDW-14.5 Plt Ct-196 PT-15.9* PTT-28.3 INR(PT)-1.7 Glucose-116* UreaN-49* Creat-2.8* Na-142 K-8.3* Cl-110* HCO3-15* AnGap-25* ALT-3863* AST-554* AlkPhos-118* Amylase-79 TotBili-1.6* DirBili-0.6* IndBili-1.0 lipase-126* Ammonia-77* HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE HIV Ab-NEGATIVE CXR: no pna or CP disease Abd U/S: normal ultrasound Blood cx: no growth Urine culture: no growth At discharge: AST 22 ALT 315 T bili 0.8 INR 1.1 Cr 1.1 Brief Hospital Course: Ms. [Last Name (un) 62603] is a 52 yo woman with h/o bipolar disorder and 2 past suicide attempts who presented s/p third suicide attempt with large tylenol overdose (50g). The pt was transferred to floor from SICU, where she was transferred from an OSH after extreme elevation in LFTs and INR 4 for possible liver transplant as needed. 1. Acetominophen overdose: Ms. [Known lastname 62605] initially presented to an OSH with acetominophen level 202 at 20 hours after ingestion, which is c/w probable hepatic toxicity by the overdose nomogram. She was transferred to [Hospital1 18] SICU when her LFTs and INR were noted to be very elevated, as it was unknown whether she would be a liver transplant candidate. She was appropriately treated with N-acetylcysteine for 17 doses plus load dose. Her LFTs have consistently come down and continue to do so. She was once given FFP in SICU for elevated INR to 4.1, which was her peak. At the time of discharge her INR is normalized (1.1), her AST and bilirubin are normalized, and her ALT is 315, which is markedly decreased and continuing to trend downwards. She was followed by the liver team while in house. Her hepatotoxic psych medications (lamictal and trileptal) were held during her stay. 2. ARF and acidosis: Secondary to acetominphen overdose. The pt had an elevated creatinine and muddy brown casts c/w ATN in setting of tylenol overdose. She was followed by our renal team while inpatient and per renal, this typically resolves as liver damage and LFTs resolve. This has been the case with Ms. [Last Name (un) 62603], and her creatinine has been trending down daily and is normal on discharge at 1.1. 3. Psychiatric: Pt is s/p suicide attempt. She has a h/o bipolar disorder. She expresses a great deal of sadness, guilt and remorse. She states that her husband does not love her anymore and that she is not capable of taking care of herself as she has no job and no money. While here she was visited frequently by her brother and his family (wife and daughter), who cheered the patient greatly while they were here an dwere very concerned for her well being. On at least one occasion (and possibly more, although this is unknown to the writer) her husband joined them for these visits. Ms. [Last Name (un) 62603] is anxious about her condition and does not think that she will be able to be well. We are currently holding her lamictal and trileptal as above initially given possible hepatotoxicity, and they have not yet been added back on as patient had some changed mental status this weekend and we did not want to cloud the picture. She has been receiving Zyprexa 5mg qhs with good effect. She will be discharged to a psychiatric inpatient facility for further work-up and treatment of her h/o bipolar disorder and suicidality and to start an appropriate psychotropic med regimen. 4. Change in mental status: Four days prior to discharge the patient had a change in mental status consistent with delirium versus underlying psychiatric disorder. She had very poor eye contact and could not follow commands, although occasionally did follow commands. She was waxing and [Doctor Last Name 688] in being able to answer appropriately versuss only saying "oh my god," and referring to "[Doctor Last Name ]," who is her sister. She was seen by psychiatry, who believed this to possibly be her underlying psych disorder, but later that day she spiked a fever to 101.6, leukocytosis to 17, and became incontinent as well. Cultures were unrevealing, as were CXR and abdominal U/S. The patient was started on a course of levo/flagyl given concern for infection in compromised hepatic function. Her fever quickly resolved on this course and her mental status improved by the second day. It is unclear whether there is in fact a source of infection, however, given her improvement we will continue the antibiotics for a total of 7 days. 5. HTN: Ms. [Last Name (un) 62603] has had hypertension throughout her stay which was treated with betablocker and hydralazine. Nephrotoxins were initially avoided, and her beta blocker could not be increased further due to limitations of HR. On the morning of discharge she was started on lisinopril, as her renal function normalized, and hydralazine was discontinued. She continues on atenolol 50 qday. Her BP should be followed as an outpatient by her PCP upon ultimate discharge. 6. FEN: The patient ate a low salt diet during her stay. Potassium was repleted PO as needed. 7. dispo: The patient is now medically stable and is ready for discharge to a psychiatric inpatient facility. She prefers a facility near her home. Medications on Admission: atenolol 50 qday trileptal 450 [Hospital1 ] lamictal 150 [Hospital1 ] HCTZ 37.5 daily MVI Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Location (un) 45887] Retreat Discharge Diagnosis: acetominophen overdose suicide attempt bipolar disorder hypertension acute renal failure Discharge Condition: stable Discharge Instructions: Please continue to take all medications as directed. If you have fever, shortness of breath, prolonged diarrhea, or think about hurting yourself, please call your PCP or come to the emergency room. Followup Instructions: Please follow up with psychiatry after discharge from inpatient psych. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 4231] Completed by:[2115-10-7] ICD9 Codes: 5845, 2760, 2762, 3051, 4019, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7735 }	Medical Text: Admission Date: [2109-12-29] Discharge Date: [2110-1-1] Date of Birth: [2062-9-18] Sex: M Service: MEDICINE Allergies: Clindamycin Attending:[First Name3 (LF) 783] Chief Complaint: Hypertensive Crisis, Blurry Vision Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 47 yo male with HIV (last CD4 238, viral load 882 in [11-16]) on HAART, DM, ESRD on HD, h/o PE on coumadin (dx [6-16]), h/o medication noncompliance, h/o malignant hypertension, who awoke this morning with L eye monocular blurry vision and dysequilibrium with standing. When he first awoke, he was seeing double, worse with R gaze. He also felt as though he was losing his balance when standing, but thinks this is due to the double vision in his L eye. He does have some mild pain in his L eye. He deniess vertigo, pre-syncopal symptoms, syncope, lightheadedness, or LE weakness. He had one episode of n/v this AM. He also has had a R temporal HA over the past week which is not throbbing and fairly constant. He rates this HA as [9-19], but does not wish to take any pain medications for it. He denies slurred speech, CP, SOB, abd pain, new weakness or numbness in any of his extremities, BRBPR, diarrhea, constipation. He states he has been compliant with taking all of his medications. . In the ED, the pts vitals were: T 99.2, BP 159-204/88-106, HR 80s-90s, R 15-22, sat 93-98% RA. He was noted to have R eye disconjugate gaze and monocular blurry vision. He received lebatolol 5 mg IVx1/10 mg IVx1, valsartan 160 mg po x 1, Nifedipine CR 90mg po x1, Ativan, and heparin gtt. Code stroke was called. CT head and MRI head were negative for acute process. He was started on a labetolol gtt. He was seen by neuro and felt to have L 3rd nerve palsy with pupillary sparing. As soon as the pt arrived to the MICU, his lebatolol gtt was discontinued as his SBP was 140s. Past Medical History: - Type 1 diabetes - HIV (lamivudine, stavudine), dx'd [2096] VL 882, CD4 238 in [11-16]) - ESRD on HD, attempted on PD on transplant list (clinical study for HIV/solid organ transplant) - PE, on Coumadin, diagnosed [6-16] - Malignant Hypertension - hx Serratia bacteremia (presumed AV graft) tx 6 wks meropenem - Hx schistosomiasis - Restless leg syndrome - Peripheral neuropathy on gabapentin - S/p cholecystectomy - s/p R nephrectomy in [2092] secondary renal nephrolithiasis Social History: Moved from [Country 4812] in [2091]. Lives with wife in [Location (un) 538]. Works in support services for a law firm. Denies any alcohol or IV drug use. Quit smoking last year; previous 30 pack-year history. Family History: Non-contributory Physical Exam: Physical Exam on MICU admission: VS: Temp: 99.2 BP: 141/61 HR: 95 RR: 20 O2sat: 95% 2LNC GEN: pleasant, laying flat, comfortable, NAD HEENT: patch over R eye, PERRL, L eye unable to adduct or look up/down but able to abduct, anicteric, MMM, op without lesions, no diplopia, clear optic disc margins on left but unable to visualize on R, no hemorrhages on L or R fundoscopic exam NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: faint expiratory wheezing at the bilateral bases but no rales/ronchi CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, 1+dp/pt pulses BL SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact with the exception of the L 3rd CN. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. toes downgoing. Pertinent Results: Admission labs: [2109-12-29] 09:55AM WBC-5.9# RBC-4.03# HGB-14.1# HCT-40.2 MCV-100# MCH-34.9* MCHC-35.0 RDW-14.0 [2109-12-29] 09:55AM PLT COUNT-159 [2109-12-29] 09:55AM GLUCOSE-120* UREA N-54* CREAT-9.2* SODIUM-132* POTASSIUM-4.7 CHLORIDE-91* TOTAL CO2-27 ANION GAP-19 [2109-12-29] 07:54PM ALT(SGPT)-9 AST(SGOT)-11 CK(CPK)-136 ALK PHOS-71 AMYLASE-116* TOT BILI-0.3 [2109-12-29] 07:54PM LIPASE-46 [2109-12-29] 09:55AM PT-15.0* PTT-30.3 INR(PT)-1.3* . Pertinent labs: [2109-12-29] 09:55AM CK(CPK)-139 [2109-12-29] 09:55AM CK-MB-19* MB INDX-13.7* [2109-12-29] 09:55AM cTropnT-0.29* [2109-12-29] 07:54PM CK-MB-18* MB INDX-13.2* cTropnT-0.43* [2109-12-30] 03:56AM BLOOD CK(CPK)-98 [2109-12-30] 03:56AM BLOOD CK-MB-NotDone cTropnT-0.56* [2109-12-31] 03:35PM BLOOD %HbA1c-4.9 [2109-12-31] 06:10AM BLOOD Triglyc-87 HDL-35 CHOL/HD-3.7 LDLcalc-77 . EKG on admission: Sinus rhythm. Left atrial abnormality. Tall T waves in leads V2-V4. Consider acute ischemia or hyperkalemia. Compared to the previous tracing of [2109-7-18] T waves are now upright and more acute. . Imaging: CHEST (PORTABLE AP) [2109-12-29] IMPRESSION: No acute cardiopulmonary disease. . MRA BRAIN W/O CONTRAST [2109-12-29] IMPRESSION: 1. Normal MRA of the head. 2. Ventriculomegaly and low-lying cerebellar tonsils as before. 3. Minimal amount of chronic microangiopathic changes. . CTA HEAD W&W/O C & RECONS [2109-12-29] IMPRESSION: 1. Ventriculomegaly and low-lying cerebellar tonsils as before. 2. Normal CTP. 3. Normal CTA of the head and neck. Brief Hospital Course: 47 yo male with HIV (last CD4 238, viral load 882 in [11-16]) on HAART, DM, ESRD on HD, h/o PE on coumadin (dx [6-16]), h/o medication noncompliance, h/o malignant hypertension, who presents with hypertensive urgency and left 3rd nerve palsy. . # Hypertensive Crisis: Pt was admitted to the MICU. This is likely secondary to medication noncompliance given that pt's BP rapidly normalized after pt received his home BP meds. Pt has possible mild resultant cardiac ischemia from this event (positive MB index). He has prior h/o malignant HTN in the past, treated with nitro gtts and lebatolol gtts. Labetolol gtt was d/c'd once pt came into MICU. He was restarted on home medications with few modificaitons and his BP has been well-controlled. He was continued on his home diovan 160 mg po bid, nifedipine CR 60 mg daily, clonidine TTS 2 patch qSun, Toprol XL 25 mg daily. His lisinopril was increased from 10 mg tid to 20 mg [Hospital1 ]. . # Transient 3rd nerve palsy: Neurology was consulted and felt his vision changes were likely secondary to 3rd nerve palsy on the L, which is usually caused by DM or HTN. There was no pupillary defect nor papilledema or hemorrhages on fundoscopic exam. Ophthomology also evaluated the pt and reported resolution of the 3rd nerve palsy. His vision changes had resolved by discharge. Pt will follow up with outpatient ophthomology. . # Elevated cardiac enzymes: With his elevated cardiac enzymes, he was initially started on heparin gtt. This was likely due to leakage of enzymes from hypertensive emergency as opposed to ischemic event. His elevated Tpn is likely due to CRF. No had no EKG changes. CK plateaued at 139 and trended down. Heparin gtt was stopped given low suspicion and INR near therapeutic for distant DVT. He was continued on his aspirin. . # Hypoxia: On admission he was hypoxic wtih mild wheezing at lung bases, likely either [1-11] to atelectasis vs. volume overload from hypertensive crisis. CXR had no evidence of acute cardiopulmonary process. He was weaned to RA [12-30] without desaturation and remained on RA for the remainder of his hospitalization. . # N/V: This was likely related to hypertensive crisis as it resolved with BP control. Amylase/lipase, LFTs were not indicative of an acute processs. His known gastroparesis may have also contributed, and he was continued on his outpatient regimen of Reglan. . # ESRD: Pt cont. to have hemodialysis qMWF. He was continued on lanthanum. . # HIV: He follow ups poorly with both Dr. [Last Name (STitle) 724] (ID) and his PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ]. Per ID, given his history of medical noncompliance, his HAART medications were held. He will follow up with Dr. [Last Name (STitle) 724] as an outpatient regarding reinitiation of HAART. . # h/o PE: Pt was admitted with subtherapeutic INR of 1.3. His coumadin was increased to 5 mg daily and was therapeutic upon discharge. . # ?Depression: Per his nephrologist Dr. [Last Name (STitle) 1366] & PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ], there has been some concern for worsening depression/coping, which may be possibly contributing to his medical noncompliance. Psychiatry was consulted and felt that he did appear to be somewhat dysthymic but without overt depressive symptoms. Pt denies any medical noncompliance. . # Restless leg syndrome: Pt was continued on neurontin. . # DM: Pt was continued on home NPH and ISS with adqueate control of BS. . # Code Status: Full Medications on Admission: Lamivudine 25 mg QD Zerit 20 mg QD ?Ritonavir 100 mg daily ?Atazanavir 300 mg daily ?Tenofovir 100 mg weekly Diovan 160 mg [Hospital1 ] NPH 10 U QAM, 7 U QPM Insulin regular 5 U QPM Ativan 1 mg TID PRN Lisinopril 10 mg TID Ambien 10 mg QHS PRN Nifedipine SR 30 mg QD Coumadin 4 mg on non-HD days, 5 mg on HD days Neurontin 100 mg [Hospital1 ] to TID (depending on how bad restless legs are) Catapress 2 patch weekly Reglan 10 mg qachs fosrenol 1 gm tid Metoprolol Succinate 25 mg daily . Allergies: Clindamycin-rash Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly Transdermal QSUN (every Sunday). 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 7. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 12. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: [6-19] units Subcutaneous twice a day: Please take 10 units in the morning, 7 units in the evening. 16. Insulin Regular Human 100 unit/mL Solution Sig: 2-10 units Injection four times a day: Please take according to attached sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Emergency Cranial nerve palsy . Secondary: HIV Chronic renal failure, stage V Diabetes mellitus type 1 Pulmonary embolus Discharge Condition: Stable Discharge Instructions: You were admitted for dangerously high blood pressure with changes in vision. Your vision changes have resolved. Neurology and Ophthalmology have seen you and Ophthalmology recommends outpatient follow up. Your lisinopril has been changed from 10 mg three times a day to 20 mg twice a day. Your blood pressure has been well-controlled with these medications. . Please continue to take your medications except as above. In addition, please take coumadin (warfarin) 5 mg every evening as your INR was noted to be low. Please follow up with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 4026] to follow your INR and adjust your coumadin dose. In addition, the Infectious Diseases team recommends that you stop taking your HIV medications for now. Please follow up with Dr. [Last Name (STitle) 724] of Infectious Diseases regarding when to resume taking these drugs. . If you develop worsening headache, dizziness, lightheadedness, chest discomfort, palpitations, shortness of breath, or any other concerning symptoms, please call your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 4026] at [Telephone/Fax (1) 250] or go to the Emergency Department. Followup Instructions: Please follow up with Ophthalmology (Eye). You have an [Telephone/Fax (1) 648] for Tuesday, [2-25] at 1PM. Please confirm your [Month (only) 648] by calling the clinic at([Telephone/Fax (1) 5120]. . Please also follow up with Dr. [Last Name (STitle) 724] of Infectious Diseases regarding your medications for HIV. You have an [Last Name (STitle) 648] for Tuesday, [1-7] at 10AM. Please confirm your [Month (only) 648] by calling the clinic at ([Telephone/Fax (1) 4170]. . Please keep the following appointments as well: Provider: [First Name8 (NamePattern2) 1238] [Last Name (NamePattern1) 1239] [Name8 (MD) ], [MD Number(3) 1240]:[Telephone/Fax (1) 250] Date/Time:[2110-1-14] 9:40 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2110-2-11] 9:00 Provider: [First Name11 (Name Pattern1) 278] [Initial (NamePattern1) ] [Last Name (NamePattern4) 394], O.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2110-2-25] 1:00 [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] ICD9 Codes: 5856, 3572
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7736 }	Medical Text: Admission Date: [2156-8-25] Discharge Date: [2156-8-27] Service: CCU HISTORY OF PRESENT ILLNESS: This is a [Age over 90 ] year old female with a past medical history of CAD status post old MI who presented on [8-25] to the MICU with shortness of breath, ruled in for acute MI by enzymes. The patient is a long time resident of [Hospital 100] Rehab who was in her usual state of health until 2:00 a.m. on [8-25]. The patient claimed of "not being able to breathe." Initial MD evaluation was pale, alert, oxygen saturation 75% on 4 liters nasal cannula. Denied chest pain. Given nebulizer times one to no effect. In the emergency department afebrile, systolic blood pressure 80/palp, tachy to 98, respiratory rate 27, pulse ox 88% in room air increased to 99% on 100% nonrebreather. The patient was given 1 gm of ceftriaxone, started on dopamine for low SBP and given 125 mg IV Solu-Medrol for question of pneumonia/COPD exacerbation. In MICU the patient was alert and oriented times two, no complaints. Vital signs stable with systolic blood pressure of 90/50 on 10 mcg per kg per minute of dopamine. The patient was started on heparin, aspirin, started on prednisone, Dilantin. OB negative. The patient ruled in for MI with enzymes. On presentation to CCU team the patient was without complaints on 2 mcg per kg per minute of dopamine. PAST MEDICAL HISTORY: Dementia. CAD status post old IMI. COPD. History of alcohol and tobacco abuse. Seizure disorder. B-12 deficiency. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No children. Lives at [Hospital 100] Rehab. The patient has healthcare proxy, [Name (NI) 1193] [Name (NI) ], phone number [Telephone/Fax (1) 95661]. MEDICATIONS: B-12 shots, albuterol and Atrovent nebs p.r.n., thiamine, multivitamin, Dilantin, folate. PHYSICAL EXAMINATION: On admission, in general, pleasant, NAD. Vitals: T-current 98, pulse 77 to 80, blood pressure 107/49, pulse ox 98% on 4 liters nasal cannula, respiratory rate 18. HEENT anicteric. Neck no JVP appreciated, no LAD. CV: RRR, S1, S2, harsh SEM at LUSB radiating to carotids consistent with aortic stenosis. Lungs had mild wheezes bilaterally, bibasilar crackles half the way up. Abdomen was soft, nontender, nondistended, no hepatosplenomegaly, no CVA tenderness. Neuro: Alert and oriented times two. Mentating well. LABORATORY DATA: White count was 7.3, hematocrit 28.8, platelets 177. PT 15.3, PTT 67.9, INR 1.5. K 4.5. CK on [8-25] at 4:50 a.m. 377, MB 48, index 13. UA was negative. Blood cultures and urine cultures were sent. Chest x-ray right IJ catheter tip in SVC, no pneumothorax, possible left lower lobe consolidation with probable pleural effusion. Echo on [8-25] showed LA normal size. LV systolic function appeared depressed. Question LVEF 30%. Moderate pulmonary hypertension. At least moderate aortic stenosis, 1+ AR, 2+ TR, 1 to 2+ MR. LV cavity size normal. RV chamber size and free wall motion normal. EKG showed LBBB, NSR, difficult to interpret any ischemic changes. HOSPITAL COURSE: The patient was transferred to CCU team. 1. Cardiology. Coronary. The patient ruled in for MI with peak CK of 435, troponin greater than 50. The patient's CKs trended down throughout her stay. The patient did not complain of any chest pain while in the hospital. She was started on a beta blocker and ACE inhibitor as well as kept on aspirin. She was also started on Lipitor for LDL of 131. Heparin was turned off once her CKs trended down. 2. Pump. The patient had EF of approximately 30% per echo, ischemic cardiomyopathy. The patient was treated for mild CHF as the cause of her shortness of breath likely induced by her MI. She was gently diuresed, afterload reduced with an ACE inhibitor and started on low dose beta blocker before discharge. 3. Electricity. The patient remained on tele without event. 4. Pulmonary. The patient was not treated for specific COPD exacerbation. She was given albuterol and Atrovent nebs p.r.n. and put back on her standing dose of prednisone for COPD. Cause of COPD likely 60 pack year smoking history. The patient required less oxygen throughout the short course of her stay and O2 was turned down to 2 liters nasal cannula before discharge. 5. FEN. The patient was put on cardiac 2 gm sodium diet, started on outpatient thiamine and folate meds. 6. ID. The patient did not appear clinically infected throughout her stay. UA was negative as were cultures of urine and blood. 7. Heme. The patient had hematocrit of 28, hovering around 27 during her stay. The patient was not symptomatic from this and was not transfused. Unclear etiology. Iron studies were sent and pending at discharge. 8. Endocrine. The patient had elevated blood sugar on admission of 208 and was started on sliding scale insulin as an inpatient. Did not require any insulin toward end of stay. Hemoglobin A1C was sent and pending at discharge. 9. Neuro. The patient alert and oriented times two. Appears to be at baseline with dementia diagnosis. The patient had episodes of sundowning treated with low dose Haldol. 10. Lines. The patient had right IJ discontinued. Arterial line was taken out. Foley kept in, unclear if has it at [Hospital6 459]. 11. Prophylaxis. The patient was maintained on subcu heparin, Protonix as an inpatient, which were stopped at discharge. 12. Code. DNR/DNI, but can use pressors. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: No change. The patient is DNR/DNI, but may use pressors. DISCHARGE DIAGNOSES: 1. Acute MI. 2. CHF. 3. COPD. 4. Dementia. 5. Seizure disorder. 6. Anemia. DISCHARGE MEDICATIONS: 1. Zestril 10 p.o. q.d. 2. Metoprolol 12.5 p.o. b.i.d. 3. Aspirin 325 mg p.o. q.d. 4. Dilantin 200 mg p.o. q.d. 5. Thiamine 100 mg p.o. q.d. 6. Folate 1 mg p.o. q.d. 7. Prednisone 2.5 mg p.o. q.d. 8. Albuterol and Atrovent nebs p.r.n. 9. Lipitor 10 mg p.o. q.d. 10. Lasix 20 mg p.o. q.d. [First Name8 (NamePattern2) 1575] [Last Name (NamePattern1) 12203], MD [MD Number(1) 12204] Dictated By:[Last Name (NamePattern1) 1324] MEDQUIST36 D: [2156-8-27] 14:59 T: [2156-8-31] 11:11 JOB#: [Job Number 36966] ICD9 Codes: 4280, 496, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7737 }	Medical Text: Admission Date: [2191-10-10] Discharge Date: [2191-10-19] Date of Birth: [2116-7-3] Sex: F Service: Cardiothor HISTORY OF PRESENT ILLNESS: This is a 75 year old Spanish speaking female with a past medical history significant for poorly controlled diabetes mellitus, hypertension, and peripheral vascular disease, who presents with a two week history of intermittent chest pressure and pain radiating to the left arm. This pain began around two weeks prior to admission, which was [9-20], while she was watching the coverage of the World Trade Center attack. She describes the sensation as pressure in the chest, substernal, radiating to the arm where it becomes more crushing. The onset was unpredictable but more often with exertion; not associated with diaphoresis, nausea, vomiting or shortness of breath. She denies any prior history of chest pain or pressure as well as denying acid-reflux indigestion or any recent illnesses. ALLERGIES: The patient has no known drug allergies. HOSPITAL COURSE: She was ruled out for myocardial infarction with negative CPK times three. The patient was found to have a positive stress test. Cardiac catheterization was performed on [10-14] which revealed an ejection fraction of 60% with normal valves, 20% stenosis of the proximal right coronary artery, 20% stenosis of the mid- right coronary artery, 90% of the distal right coronary artery, 90% of the right PDA, 90% of the right PL, 80% of mid left anterior descending, 50% of the first diagonal and 100% of the obtuse marginal. Cardiothoracic Surgery was called to the Catheterization Laboratory to see the patient after stenting of her right coronary artery and diagonal and left anterior descending with a tamponade and cardiogenic shock, bleeding around 1300 cc in three to four hours, and a pH of 7.1, base access negative 17 on Dopamine. She was taken emergently to the Operating Room for exploration. Preoperative diagnosis was cardiac tamponade with percutaneous transluminal coronary angioplasty. Postoperative diagnosis was a cardiac perforation times two. The patient underwent a sternotomy and repair of cardiac perforations times two [2191-10-14]. A hole was found in the acute marginal pumping blood from the right ventricle, as well as a hole in the obtuse marginal in the V1 distribution which was bleeding. The holes were repaired and there was no other further intervention necessary. On postoperative day one status post repair of cardiac trauma, the patient was in atrial fibrillation on Pronestyl and Lopressor, temperature maximum of 101.5 F., to current of 101.5 F.; heart rate of 86; blood pressure of 106/82; respirations 11, saturating at 99%. PA pressures of 49/31, cardiac output 3.6, cardiac index of 2, CVP of 20 on vent settings of IMV of 600, 10, 0.5, and 5 PEEP. Last gas 7.46, 32, 112, 23, and zero. Chest tube outputs 475 over the last 24 hours. White count of 13.5, hematocrit of 32.5, platelet count of 151,000. Sodium 144, potassium 4.3, BUN 18, creatinine 1.1, glucose 139, calcium 8.5, magnesium 1.7, phosphate 4.3. On physical examination, the patient was alert. She was following commands. Lungs were clear to auscultation bilaterally. Heart: Regular rate and rhythm with the incision clean, dry and intact. Abdomen was soft and nontender. Extremities were warm. Plan was to decrease the Profadol, to continue Pronestyl, and to check the Procaine and Napa levels. The patient was to get an EKG this morning; discontinue the chest tubes and Lasix in the morning, wean to extubate and start p.o. medications after extubation. Continue to diurese and transfer to the floor. Postoperative day two, the patient on Amiodarone and Neo-Synephrine with temperature of 100.2 F., current of 100.0 F.; heart rate of 72 in normal sinus rhythm; blood pressure 112/70; respirations 23; saturating at 95%. Cardiac output 5.06, index of 2.92, PA pressures of 47/29; CVP of 19 with an SVR of 870. Vent settings: She is on C-PAP of 10, 5 and 60. Last arterial blood gas 7.43, 31, 10. Chest tubes put out 800 cc in the last 24 hours, 50 cc in the last hour. Neurologically, on physical examination, the patient opened her eyes and followed commands. Heart was regular rate and rhythm. Chest is clear to auscultation bilaterally with incision clean, dry and intact. Abdomen was soft. Extremities with mild trace edema. Hematocrit of 32.6, platelet count of 191,000, sodium of 143, potassium 4.3, BUN 30, creatinine 1.6 with glucose of 188, PT of 14.4. Plan was to continue Nitroglycerin drip and continue diuresis. Respiratory-wise the decrease of FIO2 to 50 and attempt extubation and to discontinue the chest tube. Postoperative day three, the patient was converted to normal sinus rhythm with Amiodarone from her atrial fibrillation. The temperature maximum of 100.6 F.; temperature current of 99.5 F.; the patient's heart rate is 75 in normal sinus rhythm; blood pressure 109/68; respirations 15, saturating at 96%. CVP of 16, cardiac output 4.2, index of 2.28 with an SVR of 1299, ventilator was on C-PAP and pressure support of 0.5, 8 and 5. The patient on an Amiodarone drip, Nitroglycerin, Coumadin, sliding scale insulin, Lasix, Ceptaz and Levofloxacin. On physical examination, the patient opens eyes to commands. Heart was regular rate and rhythm. Wounds were clean, dry and intact. Sternum stable. Lungs are clear to auscultation bilaterally. Abdomen was softly distended, but nontender. Extremities had one plus edema and they were warm. Plan was to check chest x-ray, consider bronchoscopy, continue vent settings with C-PAP, continue Lasix. Infectious Disease wise, continue Levofloxacin and Ceptaz and check cultures. Postoperative day four, the patient was found to have right lower lobe pneumonia with Gram negative rods. Temperature maximum 100.2 F., temperature current 99.9 F.; heart 74 in normal sinus rhythm; blood pressure 106/52; respirations 16, saturating at 98%. CVP of 9, output of 5.1, index of 2.95 with an SVR of 1114. The patient on C-PAP and pressure support, 0.5, 8 and 5; last gas 7.49, 40, 154, 31 and 7. The patient on Ceptaz, Levofloxacin, Amiodarone, Nitroglycerin and Lasix. White count of 13,000, hematocrit of 37, platelet count of 243,000. Sodium 141, potassium 3.3, BUN 27, creatinine 1.2. On physical examination, the patient was awake, following commands. Heart was regular rate and rhythm with wounds clean, dry and intact. Respirations: She had coarse breath sounds bilaterally. Abdomen was soft, nontender, nondistended. Extremities were warm with trace edema. Plan was to continue pain control, wean the Nitroglycerin, repeat the chest x-ray and continue pulmonary toilet. Continue the Ceptaz and Levofloxacin. On postoperative day five, the patient's temperature maximum 99.3 F.; heart rate 75 in sinus rhythm; blood pressure 124/61 on Nitroglycerin. Sodium 139, potassium 3.7, BUN 23, white count of 10,000, hematocrit 31, platelet count of 275,000. On physical examination, incisions were clean, dry and intact. The sternum was stable. Chest x-ray was improved. Plan is to extubate the patient and to transfer to the Floor. Cardiac Surgery addendum postoperative day five, the patient with complaints of chest pain that she described as incisional and different from her angina preoperatively. EKG showed less than 1 mm depressions in the lateral leads. Cardiac enzymes were sent. Troponin was 12.5. Pacing wires were discontinued. Plan was to transfer the patient to Cardiology for further management. Surgical clips were to be discontinued postoperative day number 14. The plan was discussed with Dr. [Last Name (STitle) ]. So the patient was transferred with the diagnoses of: 1. Cardiac perforation times two status post percutaneous transluminal coronary angioplasty. TRANSFER MEDICATIONS: The patient was transferred to the Cardiac Care Unit on the following medications: 1. Amiodarone 400 three times a day 2. Nitroglycerin drip. 3. Diamox 500 q. six. 4. Combivent four puffs q. six. 5. Levofloxacin 250 q. day. 6. Ceptaz two grams intravenously q. 12. 7. Protonix 40 mg intravenously q. day. 8. Sliding scale insulin. 9. Morphine, 8 mg in the last 24 hours. The patient was stable when transferred to the Cardiac Care Unit. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Doctor Last Name 2011] MEDQUIST36 D: [2192-1-11] 08:44 T: [2192-1-17] 10:57 JOB#: [Job Number 31730] ICD9 Codes: 9971, 4275, 486
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7738 }	Medical Text: Admission Date: [2124-8-14] Discharge Date: [2124-8-29] Date of Birth: [2051-7-31] Sex: M Service: Vascular Surgery CHIEF COMPLAINT: Right iliac artery aneurysm. HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old male with four days of history of right upper quadrant pain. He denied nausea or vomiting. The pain was worse with eating. There was no change in bowel activity. He also reported positive pain in the right calf after walking a couple of miles, also in the right buttock and right thigh area. Comorbidities include hypercholesterolemia, questionable diabetes, status post back surgery, and hypertension. PHYSICAL EXAMINATION: The patient was afebrile, pulse 55, blood pressure 199/87, breathing at a rate of 16, 98% oxygen saturation on room air. The patient was a tanned portly man in no apparent distress. Heart rate was regular. Lungs were clear to auscultation bilaterally. Abdomen was round with right upper quadrant and right midabdominal tenderness. Carotid examination revealed no bruits. There was no pulsatile mass in the abdomen. All lower extremity pulses were 2+ including femoral, popliteal, dorsalis pedis and posterior tibial pulses bilaterally. The patient was noted to have a small umbilical hernia, no inguinal hernias noted. On rectal examination no masses were palpated. The patient was guaiac negative. LABORATORY DATA: On admission the laboratory studies were all within normal limits. EKG revealed normal sinus rhythm. CT of the abdomen showed a 4.5 cm right iliac artery aneurysm without extravasation. Left common iliac was 2.7 cm. HOSPITAL COURSE: Post admission the patient received regular preoperative work-up including appropriate laboratory studies, chest x-ray, EKG, and in addition the patient received cardiology clearance, as well as a right upper quadrant ultrasound to rule out cholelithiasis and cholecystitis. After a positive stress test the patient received cardiac catheterization on [2124-8-16]. Upon pulling out of the sheath post cardiac catheterization, the patient experienced a vagal episode where his heart rate dropped to the 30s and blood pressure to systolic of 59. The patient received two amps of atropine as well as dopamine started at 20 cc per hour. Blood pressure increased to 111/63. The patient was also fluid resuscitated with three liters of normal saline. Cardiac catheterization analysis revealed a mild two-vessel coronary artery disease as well as a mild left ventricular systolic and diastolic dysfunction. Ejection fraction was 51%. Once the patient received clearance for the operating room, the patient was taken for aortobifemoral bypass on [2124-8-18]. For a detailed account of surgery, please see the operative report. Postoperatively the patient experienced abdominal distention as well as abdominal discomfort. KUB obtained on postoperative day number five revealed dilated loops of bowel, both small intestine and colon, positive air in the rectum. The picture was consistent with postoperative ileus as opposed to obstruction of some sort. The patient at that time received nasogastric tube put to low continuous wall suction with good results. Distention went down as well as the patient's discomfort. Repeat KUB on [2124-8-25] revealed resolution of dilated loops. The patient was started on TPN on [2124-8-27] due to prolonged course of n.p.o. In the early AM of [2124-8-28] the patient's nasogastric tube was discontinued with no resulting nausea, vomiting, or distention. The patient was started on a regular diet on [2124-8-28] starting with clears in the AM, general diet in the evening. On [2124-8-28] the patient's staples were discontinued. Steri-Strips were applied. The patient is stable on discharge. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: Right iliac artery aneurysm status post aortobifemoral bypass. DISCHARGE MEDICATIONS: 1. Metamucil. 2. Lipitor 40 mg p.o. q. day. 3. Aspirin 81 mg p.o. q. day. 4. Clorazepate 7.5 mg p.o. q. day. 5. Atenolol 50 mg p.o. q. day. 6. Tricor 160 mg p.o. q. day. 7. Verapamil 240 mg p.o. q. day. 8. Ultram p.r.n. FOLLOW-UP PLANS: The patient will follow up with Dr. [Last Name (STitle) ] in vascular surgery clinic at [Hospital1 346] in one to two weeks. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], M.D. [MD Number(1) 6223] Dictated By:[Name8 (MD) 7190] MEDQUIST36 D: [2124-8-28] 11:34 T: [2124-8-28] 11:53 JOB#: [Job Number 51204] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7739 }	Medical Text: Admission Date: [2124-7-11] Discharge Date: [2124-7-17] Date of Birth: [2052-8-6] Sex: M Service: CHIEF COMPLAINT: Shortness of breath, now with chest tightness HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 10220] is a 71-year-old gentleman with a history of aortic stenosis, now with increasing shortness of breath and dyspnea on exertion and chest pain. Cardiac catheterization was performed which showed a 90?????? discrete lesion of the RCA, 80% discrete lesion of the proximal diagonal, 70% discrete lesion of the LAD proximally, 50% mid LAD discrete lesion as well as moderately severe aortic stenosis. Mr. [Known lastname 10220] was taken to the Operating Room on [2124-7-11] for coronary artery bypass graft and aortic valve replacement. PAST MEDICAL HISTORY: 1. Hypertension 2. Status post abdominal aortic aneurysm repair 3. Questionable heart block from abdominal aortic aneurysm surgery for which pacemaker was placed 4. Chronic renal insufficiency 5. Gastroesophageal reflux disease 6. Kyphosis 7. Aortic stenosis 8. Unstable angina SOCIAL HISTORY: Mr. [Known lastname 10220] lives with his wife. MEDICATION: 1. Lotrel 1 pill q day REVIEW OF SYSTEMS: Negative unless otherwise stated above. PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 68, blood pressure 130/80, respirations 20, weight 180 pounds. GENERAL: Well developed, well nourished male. HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic, atraumatic. NECK: Supple. CHEST: Clear with decreased breath sounds. HEART: Regular rate and rhythm with a 4/6 systolic ejection murmur. ABDOMEN: Soft, nontender. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGIC: Nonfocal. HOSPITAL COURSE: Mr. [Known lastname 10220] was taken to the Operating Room on [2124-7-11] where coronary artery bypass graft x3 and aortic valve replacement were performed. Coronary artery bypass graft included left internal mammary artery to LAD, saphenous vein graft to ramus, saphenous vein graft to PDA. Aortic valve replacement was performed with a #27 pericardial tissue valve. Mr. [Known lastname 10220] [Last Name (Titles) 8337] the operation without incident. He was transferred to the Cardiac Intensive Care Unit where he was weaned off drips and hemodynamically monitored. He was extubated and stabilized. After adequate fluid resuscitation was performed and hemodynamic stability was assured, Mr. [Known lastname 10220] was then transferred to the floor on the evening of postoperative day #1. On postoperative day #2, his chest tubes were discontinued and on postoperative day his pacing wires were discontinued. While on the floor, Mr. [Known lastname 10220] had a high level oxygen requirement for which he was aggressively diuresed. His pulmonary status was gradually improved and oxygen was weaned. On postoperative day #4, Mr. [Known lastname 10220] had a nonsustained beat run of V-tach. He was monitored over the next 72 hours without any further incidents. By postoperative day #7, Mr. [Known lastname 10220] was doing well. His pulmonary status continued to improve. He was tolerating a po diet and was ambulating with a level 5 therapy status. He is now ready for discharge on [2124-7-17]. DISCHARGE MEDICATIONS: 1. Metoprolol 75 mg po bid 2. Lasix 20 mg po qd 3. Potassium chloride 20 milliequivalents po qd 4. Aspirin 325 mg po qd 5. Percocet 1 to 2 tablets po q 4 to 6 hours prn 6. Docusate 100 mg po bid while taking Percocet FO[Last Name (STitle) 996]P: 1. Please follow up with Dr. [Last Name (STitle) 43417] in three to four weeks. 2. Follow up with Dr. [Last Name (Prefixes) ] in four weeks DISCHARGE STATUS: Stable DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft x3 2. AVR [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Doctor First Name 24423] MEDQUIST36 D: [2124-7-17] 12:53 T: [2124-7-17] 13:02 JOB#: [Job Number 43418] ICD9 Codes: 4111, 4241, 4271, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7740 }	Medical Text: Unit No: [Numeric Identifier 75487] Admission Date: [2132-1-17] Discharge Date: [2132-1-22] Date of Birth: [2132-1-17] Sex: M Service: Neonatology IDENTIFICATION: Baby [Name (NI) ] [Known lastname 31473] #2 ("[Known lastname ]") is a 6 day old former 35 [3-21] week twin (twin #2) who is being transferred from [Hospital1 18] NICU to [Hospital3 3765] SCN. HISTORY: This patient is an 1860 gram product of a 35 week twin gestation born to a 40-year-old gravida 8 para 4 woman after a pregnancy that was complicated by insulin dependent diabetes mellitus and PIH. The infant was delivered by way of C. section for maternal reasons for worsening PIH. Prenatal screen: Blood type is O positive, antibody negative, hepatitis B negative, RPR nonreactive, rubella immune, GBS unknown. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Noncontributory. At delivery, the infant emerged vigorous, given blow-by and stim. Apgars were 8 and 8. The infant was brought to the NICU after visiting with parents. PHYSICAL EXAMINATION: At transfer to [Hospital3 3765]: The infant's current weight is 1725 grams with a length of 47 cm and a head circumference of 31 cm. On transfer, the infant is in an isolette and is in room air. Skin is warm and dry. Color pink with mild underlying jaundice. Head, ears, eyes, nose and throat: Anterior fontanel open, level sutures apposed. Chest is symmetric. Respiratory: Breath sounds were equal and clear. Cardiovascular: No audible murmur on exam. Regular rate and rhythm. Normal S1, S2. Pulses +2. Abdomen soft and round. No masses. Positive bowel sounds. Cord is on and drying. Extremities: Infant moves all extremities well. Neuro: Appropriate tone and reflexes on exam. HOSPITAL COURSE: 1. Respiratory: The infant has remained comfortable in room air since admission to the NICU. The infant does not have apnea and is not on caffeine. 2. Cardiovascular: The infant is cardiovascularly stable. No audible murmur. Regular rate and rhythm. Stable blood pressure. 3. Fluid, electrolyte and nutrition: Initially n.p.o. on admission to NICU with IV fluids of D10W at 60 per kilo per day. Enteral feeds of breast milk or PE20 began on day of life 1, advanced to full feeds without difficulty, given PO and PG. The infant is currently on total fluids of 140 per kilo per day of Enfamil 24 or breast milk 24 mixed with Enfamil powder, mostly p.o. feeding, requiring some p.g. feeds. 4. GI: Maximum bilirubin of 9.4/0.3 on day of life 3. The infant required phototherapy. Phototherapy was discontinued on day of life 5 for a bilirubin level of 7.7/0.3, with a rebound bilirubin on day of life 6 of 6.8/0.3. Jaundice can be followed clinically. 5. Hematology: The infant's blood type is A negative, coombs negative. Infant's hematocrit on admission to the NICU was 50.5 with a platelet count of 410,000. The infant did not require blood transfusion. 6. Infectious disease: CBC and blood culture on admission to the NICU were sent. Initial WBC was 9700 with 20 polys and 0 bands. The infant did not require antibiotics. 7. Neurology: The infant does not meet criteria for head ultrasound. Exam has been appropriate. 8. Audiology: The infant will need hearing screen prior to discharge to home. 9. Ophthalmology: The infant does not meet criteria for eye exam. 10.Psychosocial: [Hospital1 18] social worker involved with the family. The contact social worker can be reached at [Telephone/Fax (1) 73590]. CONDITION AT TRANSFER: Stable. DISPOSITION: To [Hospital3 3765]. PRIMARY CARE PHYSICIAN: [Last Name (NamePattern4) ]. [Last Name (STitle) 25270] at [Location (un) 25121] Air Fore Base. CARE AND RECOMMENDATIONS: 1. Feeds at discharge: Total fluids at 140 ml per kilo per day of Enfamil 24 calories or breast milk 24 calories made with Enfamil powder, PO, PG as needed. 2. Medications: None. 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 (may be provided as a multivitamin preparation) daily until 12 months corrected age. 4. The infant will need care seat position screening prior to discharge home. 5. State newborn screen has been sent per protocol and results are pending. 6. Immunizations: the infant has not received any immunizations. Immunizations recommended: Hepatitis B vaccine prior to discharge home. 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 two of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings. 3. Chronic lung disease. 4. Hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. This infant has not receive the rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. FOLLOWUP: Followup appointment schedule recommended with pediatrician, Dr. [Last Name (STitle) 25270], at [Location (un) 25121] Air Force Base 48 hours after discharge home. DISCHARGE DIAGNOSES: 1. Late preterm infant born at 35-2/7 weeks. 2. Rule out sepsis. 3. Hyperbilirubinemia. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Last Name (NamePattern4) 75413] MEDQUIST36 D: [2132-1-22] 10:13:57 T: [2132-1-22] 11:25:42 Job#: [Job Number 75488] ICD9 Codes: 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7741 }	Medical Text: Admission Date: [2147-5-2] Discharge Date: [2147-5-4] Date of Birth: [2085-9-12] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1115] Chief Complaint: Atrial fibrillation with RVR s/p bronchoscopy Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 61-year-old male with a history of nonsmall cell lung carcinoma (squamous cell), atrial fibrillation, AAA who developed atrial fibrillation with RVR and hypotension after bronchoscopy. . The patient presented for a bronchoscopy for increasing shortness of breath, weight loss and hemoptysis of the last 2 weeks duration. He states that he has a cough that has been progressing over the last three months. He developed scant hemoptysis which ranges from a pink color to frank blood over the last 2 weeks. The patient also endorses brownish sputum over that time. He also has been having increasing dyspnea and fatigue. He tried a four day steroid course without improvement in his symptoms. He also endorses a 13 pound weight loss over the last 2 weeks. . He has a history of atrial fibrillation that is hard to control tachycardia. He has been on coumadin but it was stopped Wed of last week prior to bronchoscopy. He is managed by a cardiologist on [Location (un) ]. . His oncologic history is significant for lobectomy of right lung and s/p radiation and chemotherapy. His last chemotherapy was in [2146-9-10]. . On presentation to the MICU, he was seen in clinic with HR in the 120s. He was stable and feeling well and given 5 mg IV lopressor prior to his bronchoscopy. During the procedure, his HRs were in the 100s and his BPs were stable in the 120s. He received fentanyl and versed during the procedure. Then, post-procedure he had tachycardia and hypotension with HRs in the 150s despite 2 doses of 5 mg IV lopressor and his home dose of 50 mg PO. His BP was in the 80s, but he was mentating. He denied chest pain, palpitations, shortness of breath. He felt tired and "loopy" from the sedation. He was appropriate as he answered questions and was easily arousable. Ten minutes prior to MICU transfer, he converted to NSR with a HR around 100. On arrival to the ICU, he was afebrile, BPs in 120s, HR in 100s and satting in mid 90s on 6L post-bronchoscopy. He had no current complaints and was more alert than on initial evaluation. . In the MICU, he was started on antibiotics. He was quickly weaned to room air and he remained in NRS. He was called out to the medicine floor. The patient feels well and states that his dyspnea is improved. He has had no further episodes of hemoptysis. . ROS: Denies fever, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Afib HTN Nonsmall cell lung cancer of squamous cell type, Stage IIIA Previous right inguinal hernia repair Intrarenal AAA Left hydronephrosis Peripheral Artery Disease Social History: -Tobacco history: Lifetime smoker now quit, ~45 pack year -ETOH: 1-2 beers per week -Illicit drugs: denies Married father of three and lives with family in [Location (un) 9101], MA. Is accompanied by his wife today who recently has undergone treatment for breast cancer. Family History: Father: Died from MI at age 42, Mother: Died of Leukemia, Brother: Died from pneumonia as sequelae of years of immobilization following MVC in [2112]., Sister: [Name (NI) ] and healthy, Uncle (paternal): Died from MI at age 41, Uncle (maternal): History of tuberculosis; however, died in [2097]. Physical Exam: VITALS: T afebrile, HR 88, BP 106/60, RR 28, SaO2 99% RA GENERAL: In chair, mildly tachypneic, no acute distress HEENT: Anicteric, MMM, OP without lesions, PERRL, EOMI CV: RR, nl rate, no rubs, gallops or murmurs LUNGS: coarse crackles at L base, decrease BS at R base, no wheezes, otherwise clear, no accessory muscles used ABD: soft, NT, ND, no hsm or masses, normoactive BS EXT: warm, well perfused, no edema NEURO: no deficits appreciated Pertinent Results: [2147-5-2] 02:00PM BLOOD WBC-10.3 RBC-4.36* Hgb-11.6* Hct-35.6* MCV-82 MCH-26.6* MCHC-32.5 RDW-14.6 Plt Ct-419 [2147-5-3] 02:17AM BLOOD WBC-14.2* RBC-4.33* Hgb-11.5* Hct-35.8* MCV-83 MCH-26.5* MCHC-32.0 RDW-14.8 Plt Ct-400 [2147-5-3] 02:17AM BLOOD Glucose-112* UreaN-16 Creat-1.0 Na-133 K-4.9 Cl-99 HCO3-26 AnGap-13 [2147-5-3] 02:17AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9 [2147-5-2] 02:00PM BLOOD TSH-1.9 [2147-5-2] 02:00PM BLOOD Digoxin-0.7* CXR: IMPRESSION: AP chest is read in conjunction with a chest CT scan performed earlier today prior to transbronchial biopsy: There is probably more consolidation in the left lower lung, now than prior to the biopsy suggesting some hemorrhage in addition to extensive pneumonia. Chronic atelectasis of the right upper lobe and distortion of both hila indicate tumor infiltration. Heart size is normal. There is no pneumothorax. CT Chest: IMPRESSION: 1. New multifocal pneumonia, most severe in the left lower lobe. The pattern of distribution could also represent aspiration pneumonitis. 2. Persistent subtotal collapse of RUL and RML, with tumor infiltration causing the persistent bronchial obstruction. 3. Unchanged marked left hilar lymphadenopathy with mild mass effect on adjacent left atrium. Bronchial Brushings: POSITIVE FOR MALIGNANT CELLS, consistent with non-small cell lung carcinoma. Bronchial Washings: POSITIVE FOR MALIGNANT CELLS. Consistent with non-small cell lung carcinoma. FNA, Lymph node station 11L: POSITIVE FOR MALIGNANT CELLS. Consistent with squamous cell carcinoma. FNA, Lymph node station 7: POSITIVE FOR MALIGNANT CELLS. Consistent with squamous cell carcinoma. Lung, left lower lobe, transbronchial biopsy: Alveolar tissue with increased intra-alveolar macrophages, fibrin deposition and organizing pneumonitis with features of bronchiolitis obliterans/organizing pneumonia (BOOP/COP). No malignancy identified, multiple levels are examined. Brief Hospital Course: 61-year-old male with a history of atrial fibrillation, squamous cell carcinoma of the lung and AAA was admitted to the MICU after AFib with RVR s/p bronchoscopy, which showed recurrence of nonsmall cell lung cancer. # Nonsmall cell lung cancer: The patient was found to have a recurrence of squamous cell carcinoma of the lung which was diagnosed by bronchoscopy. The patient was notified of his diagnosis by his interventional pulmonologist. The patient has a follow up appointment with is outpatient oncologist for the day after discharge. A CD of the imaging was given to the patient for use of his oncologist. # Atrial fibrillation: The patient was in atrial fibrillation with RVR and low blood pressure after the bronchoscopy. He was given IV and PO metoprolol tartrate and spontaneously converted into normal sinus rhythm. He was continued on his home medications and remained in normal sinus rhythm. He was observed on telemetry. He should follow up with his outpatient cardiologist as previously scheduled. # LLL infiltrate: The patient had a LLL infiltrate on CT scan. Bronchoscopy was done. The patient was initially started on antibiotics (vanc, levoflox) until biopsy results returned. The decision to continue to treat or not with antibiotics was addressed with his interventional pulmonologist who thought that they should be stopped as there was no evidence of infection during the bronchoscopy. Pathology, which returned following the patient's discharge, demonstrated features consistent with bronchiolitis obliterans/organizing pneumonia (BOOP/COP). The IP team contact[Name (NI) ] the patient to discuss this result and recommended a prolonged course of prednisone starting at 60mg tapering by 10mg every four weeks; as well as Bactrim DS 2 tabs, three times per week for PCP prophylaxis as well as Calcium and Vitamin D supplementation. # Hemoptysis: The patient was on anticoagulation and has metastatic cancer. His anticoagulation was held. The decision was made to continue to hold his anticoagulation in the setting of this hemoptysis. # Hypoxia: The patient became hypoxic with ambulation to the 80s when on room air. He was discharged with home oxygen to use with ambulation. # Diarrhea: The patient noted recent diarrhea. It resolved prior to admission and the etiology is unknown. # Hypertension: The patient was continued on metoprolol and lisinopril once he became hemodynamically stable. # PVD: Stable. No symptoms in the hospital. # AAA: Stable. Follow up as outpatient. Medications on Admission: # Codeine-Guaifenesin 10-100 mg/5 mL q 6hr PRN # Metoprolol 50 mg [Hospital1 ] # Digoxin 0.25 mg daily # Lisinopril 2.5 mg daily # cilostazol 100 mg daily # Coumadin being held currently Discharge Medications: 1. Home oxygen Oxygen at 2L NC continuous Pulse dose for portability Diagnosis: squamous cell carcinoma of the lung 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:1 bottle Refills:3 6. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for cough. Disp:120 Lozenge(s) Refills:3 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) inh Inhalation every six (6) hours as needed for shortness of breath or wheezing: Patient with Afib and does not tolerate albuterol [3-14] tachycardia. Disp:1 inh Refills:3 10. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) inhaler Inhalation every six (6) hours. Disp:1 inhaler Refills:2 11. Tessalon Perle 100 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for cough. Disp:90 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Squamous cell carcinoma of the lung 2. Atrial fibrillation with rapid ventricular rate (fast hear Secondary Diagnosis: 1. Hypertension 2. Intrarenal AAA 3. Left hydronephrosis 4. Peripheral artery disease Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted for a bronchoscopy. You had the bronchoscopy and it unfortunately showed squamous cell carcinoma of your lungs. You will need to follow up with your outpatient oncologist Dr. [Last Name (STitle) 10595] tomorrow. When you see her please bring the CDs of your images. You will also need to follow up with your primary care physician. [Name10 (NameIs) ] appointments are listed below. While you were an inpatient you were found to have low levels of oxygen when walking. You were prescribed oxygen which should be used when you feel short of breath or when ambulating. Pleaes wear this at 2 liters while walking and 2-3 liters while sleeping. You don't need to wear it when you are awake and resting. The following medications were added: 1. START: Oxygen as above 2. START: Aspirin 325mg once a day 3. HELD: Coumadin - we talked with you and Dr. [Last Name (STitle) ] and decided to hold your coumadin since you had been coughing up some blood. Please talk to your cardiologist about restarting the coumadin. If he feels strongly about restarting it, that is fine with Dr. [Last Name (STitle) ]. It was truly a pleasure meeting you and Barb and particiapting in your care. Followup Instructions: MD: Dr [First Name8 (NamePattern2) 1356] [Last Name (NamePattern1) 10595] Specialty: Oncology Date/ Time: Tomorrow, [5-5] at 10am Location: [Street Address(2) 83377], [Location (un) 9101] Phone number: [Telephone/Fax (1) 56014] Special instructions for patient: Please bring any disc of scans that they may have taken during your inpt stay here. Appointment #2 MD: Dr [First Name8 (NamePattern2) 487] [Last Name (NamePattern1) 17562] Specialty: Primary Care Date/ Time: [5-19] at 8:30am Location: [Street Address(2) 83378] , [Location (un) ] Phone number: [Telephone/Fax (1) 31979] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7742 }	Medical Text: Admission Date: [2106-5-31] Discharge Date: [2106-6-3] Date of Birth: [2037-12-26] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1271] Chief Complaint: Headache,nausea, emesis Major Surgical or Invasive Procedure: Left Burr holes for evacuation of L SDH [2106-5-31] History of Present Illness: This is a 68 year old Creole speaking Hatian female who started having a dull headache the morning before admission. This gradually worsened with progressive symptoms of nausea and vomiting by 1pm. She was taken to an outside facility where her head was not scanned and she was sent home on Motrin for headaches. He headache did not improve over night and she continued to have nausea and vomiting this morning at which point she returned to the outside facility and received a head CT which showed a acute on chronic SDH with 16mm of midline shift. She was subsequently transferred to [Hospital1 18] for further care. Past Medical History: HTN Osteoporosis Bilateral Cataract surgery Social History: Creole Speaking, Hatian female, lives with son who is present for translation. Has two other children and son and a daughter, [Name (NI) 4906] is deceased. Denies Tobacco and Alcohol use. Family History: NC Physical Exam: On Admission: O: T:99.1 BP: 142 / 77 HR86 R 18 O2Sats 100% 2L Gen: WD/WN, comfortable, NAD. HEENT: NCNT Pupils: PERRL EOMs: Intact Neck: Supple. Cardiac: RRR. Abd: Soft, NT, Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and president. Language: Speech fluent with good comprehension and repetition. Naming intact as observed and translated by her son. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,6 to 5mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-12] throughout. No pronator drift Sensation: Intact to light touch Toes up going on right , down on left On discharge: AOx3, PERRL, slight left facial [Last Name (LF) 85520], [First Name3 (LF) 2995] [5-12], no pronator. Incision C/D/I Pertinent Results: CT/CTA head [2106-5-31] 1. Left subdural hematoma with layering measuring up to 17 mm thickness. 2. Midline shift of up to 13 mm towards right. Left uncal and right-[Hospital1 ] subfalcine herniation. 3. Compression of left lateral ventricle and entrapment of right lateral ventricle. 4. CTA: No evidence of aneurysm. No site of active extravasation identified. CXR [2106-5-31] low lung volumes. rt basilar atelectasis. pannus obscures left lung base CT head 5/25/1am: 1. Status post left subdural evacuation with post-surgical changes and new left frontoparietal intraparenchymal and subarachnoid hemorrhage with surrounding edema. 2. Small right subdural hematoma. Slightly more conspicuous than prior exam. 3. Significantly decreased midline shift as compared to prior exam. CT head 5/25/10pm: Stable examination. Status post evacuation of left subdural hematoma with no new hemorrhage identified Brief Hospital Course: Ms. [Known lastname 4597] was admitted to the SICU under the care of Dr. [Last Name (STitle) 739] on [2106-5-31] for a Left SDH. She was neurologically intact. She was given 1 pakc of platelets due to her ASA use and one was ordered for the pre-op eval. On [2106-5-31] she was taken to the OR with Dr. [Last Name (STitle) 739] for a left burr holes for evacuation of SDH. Post operative head CT showed marked improvement of midline shift and decompression of L hemisphere of brain. Some pneumocephalus and acute blood also seen, but overall improved from previous scan. She had a subdural drain in place. This was removed on [2106-6-1]. The patient was neurologically intact. CT head performed that afternoon after drain removal showed no new hemorrhage. She remained stable overnight. She was transferred to the SDU on [2106-6-2]. Her Foley was DC'ed. She was discharged to home on [2106-6-3] Medications on Admission: ASA 81 mg', Ibuprofen 600mg prn, Amlodipine 10mg', Vi tamen D 50000u' week x 8 weeks, Oscal 500/200 '. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for constipation. 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [4-13] hours as needed for pain. Disp:30 Tablet(s) Refills:0 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left Subdural Hematoma Brain compression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [7-17] days for removal of your staples. ??????Please call ([Telephone/Fax (1) 4676] to schedule an appointment with Dr. [Last Name (STitle) 739], to be seen in [4-13] weeks. ??????You will need a CT scan of the brain without contrast. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2106-6-3] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7743 }	Medical Text: Admission Date: [2111-10-16] Discharge Date: [2111-10-24] Date of Birth: [2043-12-14] Sex: F Service: SURGERY Allergies: Heparin Agents Attending:[First Name3 (LF) 1556] Chief Complaint: hematemesis, bright red blood per rectum Major Surgical or Invasive Procedure: blood transfuions History of Present Illness: The patient is a 67 year-old female with coronary artery disease, history of MI, end stage renal disease on hemodialysis, diabetes mellitus, hypertension and known duodenal and gastric antral ulcers transferred from the Emergency Department of [Hospital 1562] Hospital for an upper GI bleed. She was admitted [10-7] - [2111-10-10] for an upper GI bleed. On the day of this current admission, she felt weak, had a non-bloody bowel movement, and went to the [Hospital1 1562] ED where she developed massive melena and hematochezia (1 liter). She received packed red blood cells at [Hospital 1562] Hospital (conflicting reports of how many - mostly likely 2) and was transferred via med flight to [Hospital1 ] emergency department. Past Medical History: Past Medical History: - Diabetes mellitus - End stage renal disease on hemodiaylsis - hypertension - coronary [Last Name (un) ] disease - peptic ulcer disease - congestive heart failure - diverticulitis Past surgical history: - appendectomy - cholecystectomy - c-section Physical Exam: (per surgery resident in the ED on admisson) VS HR 62 BP 120/74 intubated NG tube - frank blood Heart regular rate and rhythm Chest clear Abd obese, soft, non-distended Frank blood per rectum Pertinent Results: On admission: Hematocrit 28.0 (range 27.4 - 37.3) WBC 10.6 INR 1.4 PTT 34.1 CK 29 Trop 0.06 Electrolytes K 5.2, Creatinine 6.7, UreaN 34, Glucose 174 (others WNL) ABG 7.45/185/43/31 Angiography ([10-16]) No active contrast extravasation in the stomach or duodenum. Occlusion of SMA and proximal portion of the splenic artery and right hepatic artery. CXR ([10-16]) The ET tube tip terminates in the origin of the right main bronchus. The position was corrected and was demonstrated on the subsequent chest radiographs from 4:00 a.m. in the morning. The NG tube is coiled in the stomach with its tip most likely terminating in the mid or distal position of the stomach, not included on the field of view. There is new left lower lobe opacity which may represent either atelectasis or aspiration. No evidence of congestive heart failure is present. CXR ([10-16]) The patient is after median sternotomy and CABG. At least one of the mid sternal sutures is broken. The cardiac silhouette is mildly enlarged. The aorta is calcified. The right lung is essentially clear. The linear opacities in the mid area of the left lung most likely represent atelectasis. There is no sizable right pleural effusion. A left pleural effusion cannot be excluded due to the fact that the left costophrenic angle was not included in the field of view. EKG ([10-16]) normal sinus rhythm CXR([10-17]) Endotracheal tube remains in standard position, but nasogastric tube has been removed. Cardiomediastinal contours are stable in appearance. Worsening opacity in the left retrocardiac region probably represents a combination of atelectasis and effusion. Right lung is grossly clear except for minimal discoid atelectasis in the perihilar region. Echocardiography: Mild symmetric left ventricular hypertrophy with normal cavity sizes and regional/global biventricular systolic function. Mild pulmonary artery systolic hypertension. CXR (PICC placement): Interval improvement of aeration as noted above. The tip of the right subclavian line is in the right subclavian vein and requires advancement for standard positioning. Brief Hospital Course: ) GI bleed: The patient was intubated in the emergency department for airway protection given hematemesis. She had been transfused with packed red blood cells at the outside hospital (unclear number, likely 2) and on arrival her systolic blood pressure was in the 70s with a hematocrit of 28. She was transfued 4 units of packed red blood cells in the [Hospital1 18] emergency department with recovery of systolic blood pressure to the 120s. An initial EGD performed on [10-16] (night of admission) showed clot throughout the stomach and the scope could not be passed through the pylorus given that the clot covered the channel. An angiography demonstrated no active bleeding, as well as occlusions in the superior mesenteric artery and splenic artery, both which reconstituted. The patient was admitted to the surgical ICU. A second look EGD demonstrated a 1cm ulcer with a clean base in the antrum with evidence of recent bleeding which was treated with bicap and 4cc of epinephrine. Multiple shallow ulcers in the duodenum were treated with bicap. The plan, given high estimated risk of rebleed, was for angiography with attention to the left gastric artery. The patient had hematocrit checked every 8 hours. Between [10-16] and [10-18], the patient received a total of 12 units of packed red blood cells and 3 units of platelets with hematocrit ranging between 27.4 and 37.3. Since the last transfusion, her hematocrit has been stable between 27.4 and 31.0. Once she was taking clears, the patient was started on treatment for H. pylori: proton pump inhibitor (to be taken indefinitely), clarithromycin and amoxicillin (renally dosed - to be taken for a total of 2 weeks). The patient was extubated on [10-17] and did well from a respiratory standpoint for the rest of her admission. She was transfered from the intensive care unit to the floor on the evening of [10-20]. Her hematocrit remained stable, as did her vital signs for the rest of her admission. ) End stage renal disease: the patient was dialyzed on [9-24], [10-20], [10-21], [10-23]. ) FEN: The patient was advanced to sips then clears on [10-20], to full liquids on [10-21] and then to a regular, soft, diabetic diet on [10-22] which she tolerated well. She did complain of some loose/watery bowel movements on [10-21] that were light-medium brown with no blood. Stool was sent for C. difficile assay. The diarrhea resolved on the night of [10-21]. On dishcharge on hospital day #9, the patient's vital signs were stable, she was afebrile and she was able to tolerate a regular diet and ambulate well. She will follow up with her regular gastroenterologist and is aware that Dr. [Last Name (STitle) ] is available should she have any problems or questions. Medications on Admission: Lantus Humalog Nephrocap Toprol Diovan Vytorin Phoslo Felodipine Amoxicillin Clarithromycin Discharge Medications: 1. 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:5 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO once a day. 4. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO QTUTHSASU (). 5. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:20 Tablet(s) Refills:0 7. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 10 days. Disp:20 Capsule(s) Refills:0 8. Lantus 100 unit/mL Solution Sig: Sixty (60) Units Subcutaneous at bedtime. 9. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous sliding scale. 10. PhosLo 667 mg Tablet Sig: One (1) Tablet PO once a day. 11. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day. 12. Outpatient Physical Therapy Patient needs physical therapy for significant deconditioning after long hospitalization 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). Disp:qs qs Refills:2 Discharge Disposition: Home Discharge Diagnosis: upper GI bleed Discharge Condition: stable Discharge Instructions: Please call your doctor [First Name (Titles) ] [Last Name (Titles) ] > 101.5, severe pain, dizziness or lightheadedness, fainting, bleeding from the rectum or bloody/black bowel movements, vomiting blood, nausea or vomiting, or any other questions or concerns. Followup Instructions: Please follow up with your regular gastroenterologist. If needed, you can contact Dr.[Name (NI) ] office at ([Telephone/Fax (1) 2047] ICD9 Codes: 5856, 4280, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7744 }	Medical Text: Admission Date: [2113-11-3] Discharge Date: [2113-11-8] Date of Birth: [2061-12-3] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4393] Chief Complaint: tachypnea Major Surgical or Invasive Procedure: Therapeutic paracentesis x 2 History of Present Illness: 51-year-old male with past medical history of decompensated alcoholic cirrhosis still actively drinking complicated by portal hypertension with ascites and grade II esophageal varices admitted on [2113-11-3] with hyponatremia, new portal vein thrombosis, atrial fibrillation with RVR. He does have a history of an uncharacterized gastric mass in the pre-pyloric region with previous biopsies at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] during an EGD, which were inadequate. Another biopsy was attempted, but FNA deferred due to high INR of 1.9. Patient was admitted from [Hospital Ward Name 1950] 5 as was supposed to get scoped yesterday for same etiology but noticed to have worsening laboratory values/clinical status and sent to ED. Of note, the patient's liver disease has been worsening over the past 6 months to the point where he reuiqired therapeutic paracentesis (total of three taps with 4.5, 2, and 3.5 L removed). He also has a history of thoracentesis for effusions although specific data are not available. . During hospital course, diagnostic paracentesis with 60 mL serous fluid removed. Atrial fibrillation with RVR to 150s was noted and controlled with dilitazem. Patient was also managed for hyponatremia and continued management of decompensated alcoholic cirrhosis with likely vascular component given new portal vein thrombosis with poor collaterals. Surgery also consulted in setting of uncharacterized gastric mass. . On [2113-11-5] in AM, team concerned about increased labor of breathing and worsened altered MS with concern for airway protection. CXR showed L sided pleural effusion. ABG indicates good oxygenation on 2L NC. On exam pt appeared mildly tachypnic. He is alert and oriented x 3. ABG at time showed no hypoxemia or hypercarbia. Patient was subsequently transfered to the MICU. On floor, patient was AAOx2-3 and did not want to discuss his hospital course. Patient in no respiratory distress. Past Medical History: 1. Etoh Cirrhosis: - history of UGIB in [2111] at [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] which showed non-bleeding grade II esophageal varices, portal gastropathy, gastric mass - thrombocytopenia - anemia 2. Alcohol abuse/withdrawal - recently hospitalized at [Hospital ] hospital in [2113-8-25] and was placed on ativan gtt 3. Atrial fibrillation (long-standing) 4. Folate deficiency Social History: Tobacco: smokes 1PPD x "decades" EtOH: daily 6-pack after work for "many years", and "big bottles of SoCo" every night, unable to report last use Illicits: + marijuana (last use last week), denies IV or intranasal drug use Family History: Non-contributory. No GI or liver disease. Father had stroke. Physical Exam: Admission Exam Vitals: T 99.1 HR 100 BP 119/79 HR 88 RR 19 SaO2 94 % on 2 L NC GENERAL - ill-appearing man in no acute distress HEENT - NC/AT, EOMI, + scleral icterus, dry MM NECK - supple, no LAD or thyromegaly, no JVD LUNGS - CTA bilat, no r/rh/wh HEART - tachycardic, irreg irreg, no MRG ABDOMEN - +BS, soft/NT, + large ascites but not tense, + caput medusae, no palpable masses or HSM, no rebound / guarding EXTREM - WWP, 2+ BLE edema, 3+ scrotal edema SKIN - mild jaundice, no rashes or lesions NEURO - AAOx2-3, asterixis, poor insight . Discharge Exam 97.0 126-132/75-77 89-102 20-22 93%RA GENERAL - Male in no acute distress HEENT - Normocephalic. Nontraumatic. PERRLA. EOMI. Supple neck. LUNGS - Bibasilar crackles. HEART - Irregularly irregular. Not tachycardic. ABDOMEN - +BS, soft/NT, + large ascites but not tense, + caput medusae, no palpable masses or HSM, no rebound / guarding EXTREM - WWP, 2+ BLE edema, 3+ scrotal edema SKIN - mild jaundice, no rashes or lesions NEURO - Alert and oriented to person, place and time. Poor insight. Pertinent Results: [2113-11-3] 09:31AM BLOOD WBC-12.6* RBC-3.11* Hgb-11.3* Hct-33.1* MCV-106* MCH-36.4* MCHC-34.3 RDW-14.9 Plt Ct-64* [2113-11-5] 05:10AM BLOOD WBC-6.9 RBC-2.49* Hgb-8.9* Hct-27.4* MCV-110* MCH-35.8* MCHC-32.6 RDW-15.6* Plt Ct-47* [2113-11-8] 05:10AM BLOOD WBC-9.7 RBC-2.43* Hgb-8.9* Hct-27.1* MCV-111* MCH-36.6* MCHC-32.8 RDW-15.5 Plt Ct-64* [2113-11-3] 09:31AM BLOOD PT-18.2* PTT-36.7* INR(PT)-1.6* [2113-11-6] 05:54AM BLOOD PT-19.7* PTT-41.3* INR(PT)-1.8* [2113-11-8] 05:10AM BLOOD Plt Ct-64* [2113-11-3] 09:31AM BLOOD UreaN-14 Creat-0.7 Na-122* K-4.8 Cl-91* HCO3-22 AnGap-14 [2113-11-8] 05:10AM BLOOD Glucose-115* UreaN-14 Creat-0.7 Na-133 K-4.0 Cl-99 HCO3-26 AnGap-12 [2113-11-3] 09:31AM BLOOD ALT-34 AST-74* AlkPhos-206* Amylase-139* TotBili-5.7* DirBili-2.3* IndBili-3.4 [2113-11-5] 05:10AM BLOOD ALT-23 AST-44* LD(LDH)-265* AlkPhos-158* TotBili-4.0* [2113-11-8] 05:10AM BLOOD ALT-25 AST-40 LD(LDH)-276* AlkPhos-146* TotBili-4.1* [2113-11-3] 09:31AM BLOOD Albumin-2.9* Calcium-8.4 Phos-3.4 Mg-1.5* [2113-11-7] 04:45AM BLOOD Albumin-3.7 Calcium-9.2 Phos-3.3 Mg-1.5* [2113-11-6] 05:54AM BLOOD VitB12-1845* [2113-11-4] 02:46AM BLOOD Osmolal-280 [2113-11-4] 02:46AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE HAV Ab-POSITIVE [2113-11-3] 09:31AM BLOOD AFP-2.4 [2113-11-4] 02:46AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2113-11-4] 02:46AM BLOOD HCV Ab-NEGATIVE Test Result Reference Range/Units HCV AB, RIBA Negative Negative RUQ US ([2113-11-3]): Cirrhotic liver with large volume perihepatic ascites, and possible thrombosis of the main portal vein. Differential includes sluggish flow. Limited evaluation. CXR ([2113-11-3]): Subsegmental atelectasis in the left upper lobe, and patchy opacity in left lung base, also likely representing atelectasis. Probable small bilateral pleural effusions. CT Chest with contrast ([2113-11-4]): 1. Thrombosis of the portal venous system as described, with distal reconstition of right anterior and left branches due to cavernous transformation. However, it is noted that collateralization to the portal branches appears minimal in comparison with shunting of portal venous flow to massive esophageal varices. 2. Cirrhotic-appearing liver without arterially enhancing lesion. 3. Stigmata of portal hypertension including large gastroesophageal varices and splenomegaly. 4. Moderate left pleural effusion. 5. Abdominal ascites. Brief Hospital Course: 51 year old man with alcoholic cirrhosis complicated by portal hypertension with ascites and esophageal varices admitted for biopsy of known gastric mass and found to have hyponatremia, portal vein thrombus, and atrial fibrillation with RVR. 1. Portal vein thrombus: Ultrasound and CT abdomen consistent with portal vein thrombosis with some collaterals. Transplant surgery was consulted who suggested no anticoagulation in lieu of his esophageal varices 2. Hyponatremia: Improved with fluid restriction, discontinuing lasix/spironolactone and IV albumin 1g/kg daily x 3 days. Once his hyponatremia resolved, his spironolactone was started at increased dose of 100 mg po qdaily and lasix was started at decreased dose of 40 mg po qdaily. His serum sodium remained within normal range on latter doses of spironolactone and lasix. 3. Atrial fibrillation with RVR on admission: Rate controlled with diltiazem and nadolol. Likely due to not taking his regular medications on day of admission. He was not anticoagulated due to his Grade II nonbleeding esophageal varices and portal gastropathy. 4. Decompensated alcoholic cirrhosis: Known grade II esophageal varices and history of upper GI bleeding. Has large ascites and peripheral edema on admission. He reeceived two paracentesis (4L and 3L) during his hospital stay with IV albumin (25 g and 25 g respectively). He was encephalopathic during his hospital stay with negative diagnostic paracentesis, RUQ ultrasound, blood and urine culture, CXR and toxicology screen. His encephalopathy improved with lactulose and rifaximin. 5. Gastric mass: Pt has known pre-pyloric gastric mass. Initially noted on EGD, biopsies reportedly non-diagnostic. EUS [8-/2113] noted findings above, but biopsies not done due to his elevated INR at the time. Presented for repeat EUS for biopsies but unable to have this once as his labs returned markedly abnormal as above. Was not biopsied as he was not medically thought to be stable. Will follow up as outpatient. 6. Alcohol abuse with hx of withdrawal. Last drink day prior to admission. He was given ativen 2 mg po for CIWA > 8 on day of admission leading to worsening of his encephalopathy and ICU admission for a day. He was monitored for alcohol withdrawal with CIWA scale but not given ativan for rest of his admission stay. He was started on folic acid, thiamine and multivitamin for nutrition. Medications on Admission: Medications on Transfer: Lorazepam 1-2 mg PO/NG Q4H:PRN CIWA > 8 Albumin 25% (12.5g / 50mL) 37.5 g IV ONCE Duration: 1 Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze Metoclopramide 10 mg PO/NG QIDACHS CeftriaXONE 1 gm IV Q24H Duration: 4 Days Order date: [11-4] Nadolol 40 mg PO DAILY Diltiazem 30 mg PO/NG QID Nicotine Patch 14 mg TD DAILY FoLIC Acid 1 mg PO/NG DAILY Pantoprazole 40 mg PO Q12H Rifaximin 550 mg PO/NG [Hospital1 ] Heparin 5000 UNIT SC TID Thiamine 100 mg PO/NG DAILY Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze Tolterodine 2 mg PO DAILY Iron Polysaccharides Complex 150 mg PO DAILY Vancomycin 1000 mg IV Q 12H Lactulose 30 mL PO/NG QID Zinc Sulfate 220 mg PO/NG DAILY Lactulose Enema 1000 mL PR ONCE Duration Discharge Medications: 1. diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 2. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 3. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. tolterodine 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. polysaccharide iron complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 7. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO Q4H (every 4 hours). Disp:500 ML(s) Refills:2 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 8300] VNA and Hospice Discharge Diagnosis: Primary Diagnosis 1. Grade I encephalopathy 2. Alcoholic cirrhosis with esophageal varices and ascites 3. Alcohol abuse 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 because you were found to have low sodium level during your pre-EGD labs. It was thought to be due to your worsening liver function. Your sodium level improved with fluid restriction and change in your diuretics. You were noted to have worsening of your mental status and increase work of breathing thought to be due to fluid in your lung which led to admission to the intensive care unit. They aggressively removed fluid from your body which made your breathing better. . It is extremely essential you do not have another alcoholic beverage. . Following medication changes were made to your regimen INCREASE SPIRONOLACTONE to 100 mg once a day to help with low sodium level START RIFAXIMIN 550 mg by mouth twice a day for confusion START IRON 150 mg by mouth once a day for nutrition START THIAMINE 100 mg by mouth once a day for nutrition START FOLATE 1 mg by mouth once a day for nutrition DECREASE LASIX to 40 mg by mouth once a day to help with your low sodium level Followup Instructions: Name: [Known firstname ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD Specialty: Internal Medicine Address: 161 CORPORATE DR, [Location (un) ],[Numeric Identifier 62963] Phone: [Telephone/Fax (1) 87045] We are working on a follow up appointment for you with Dr. [Last Name (STitle) 40563] for the beginning of next week. You will be called at home with the appointment. If you have not heard or have questions, please call the number above. Name: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD Specialty: Gastroenterology Location: [Hospital1 18] LIVER CENTER Address: [Doctor First Name ], STE 8E, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2422] We are working on a follow up appointment with Dr. [Last Name (STitle) ] within the next 16-30 days. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call the number above. [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 4407] ICD9 Codes: 2761, 5119, 2875, 3051, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7745 }	Medical Text: Admission Date: [2188-6-15] Discharge Date: [2188-6-16] Date of Birth: [2132-10-16] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2817] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: 55yo F with h/o metastatic uterine CA with recurrent pleural effusions requiring QOD drainage via pleuravacs at home (last emptied on day of admission), pericardial effusion, and h/o upper extremity dvts on fondaparinux at home after failing lovenox therapy admitted with SOB. Patient initially presented to [Hospital6 ] with increased dyspnea, bedside TTE showed no pericardial eff, new ARF, with creatinine of 1.4 and k of 7. There she received kayexalate, insulin, glucose, lasix 40 mg IVX1. she was noted to be in Afib and received metporolol 25mg po x1, 5mg iv x1. She also complained of back pain and received one dose of dilaudid 2mg IV. . Initially here patient reported that she went to the OSH not for SOB but weakness and poor po intake. VS initially in our ED were: T 97.2 HR 83 BP 105/63 RR 20 O2sat 100% on 2L NC. Then , in our ED she felt acutely dizzy with BP 85/56 HR 106 AF and complained of SOB with RR 36 and O2 sat 100% on 4L NC. She was placed on NRB for her comfort although she did not need it based on her O2 sats. She did not tolerate the NIV. CXR showed bilateral basilar infiltrates/effusions and she received one dose of zosyn.K was 6.2 and she received insulin and dextrose as well as calcium. Lasix 40mg Iv was given with 200mL UOP. Repeat K was 5.9. A bedside TTE showed no pericardial effusion. She was given 0.5mg IV ativan for anxiety and a dose of dilaudid for pain. She also received 500mL NS. VS prior to transfer to the floor were T 98.2 HR 105 BP 96/54 RR 19 100% on NRB . . On the floor, the patient reported that she had been short of breath since leaving the hospital on [6-4]. It had not gotten any better. In addition her sister reported that she had been eating very little and getting weaker at home. She also had discomfort from being in bed all the time but denied back pain. She denied fevers, cough, sputum, sick contacts. She did endorse chest pain on inspiration. She also noted palpitations and tremulousness as well as increased anxiety. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Last BM day of admission. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Metastatic endometrial CA with lung metastases and recurrent pleural and pericardial effusions requiring QOD drainage via pleurex catheter - Upper extremity dvts on fondaparinux - Afib with RVR . ONC history (from OMR): Presented [3-/2187] with postmenopausal vaginal spotting. She had an endometrial biopsy which showed poorly differentiated cancer. She underwent on [2187-4-24] by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2028] an exploratory laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy, total pelvic lymphadenectomy, periaortic lymph node resection and infracolic omentectomy and biopsies. Pathology revealed serous adenocarcinoma with endometrioid adenocarcinoma with squamous metaplasia, it was a grade III tumor 7.5 cm in the greatest dimension with mets to the ovaries bilaterally. She had three out of the left pelvic lymph nodes involved with metastases and two out of seven right pelvic lymph nodes involved with metastases as well as a right periaortic lymph node. Omental biopsy was negative. The patient was treated for her stage IIIC papillary serous endometrial cancer with four cycles of carboplatinum and Taxol by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and treatment started on [2187-5-24] and completed on [2187-7-27]. She also started whole abdominal pelvic radiation. She began radiation on [2187-10-11] and completed in 12/[2186]. On the CT scan followup in [2-/2188], the patient had an interval development of multiple bilateral pulmonary nodules associated with significant mediastinal adenopathy and left axillary adenopathy. She also had diffuse, low-density hepatic lesions consistent with diffuse metastatic disease. -complicated by large pleural/pericardial effusions, s/p drainage of both with pleural drain in place Social History: Originally from martinique. She lives with her two daughters. no pets. Used to work as hostess. No smoking, ETOH, drug use. Family History: No history of cancer at young age. Physical Exam: Vitals: T: BP: 98/54 P: 105 irreg irreg R: 16 O2: 100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, Dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased air movement bilaterally with crackles at bilateral bases CV: Irregularly irregular and tachycardic, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ pitting edema bilateral lower extremities NEURO: Moves all four extremities. alert and oriented X 2. Not able to lift left leg off bed. Able to lift right leg off bed. Pertinent Results: Labs from OSH: Na 129 K 7.2 Cl 93 Co2 26 BUN 70 Cr 1.4 Ca 9.4 ALT 72 AST 76 APhos 606 TBili 0.4 albumin 3.2 WBC 12.4 Hct 38.3 PLT 232 80% N 1 band 12 lymph UA 1+ WBC, Pos nitrates, tr prot, tr bili, Few epis, 2+ bacteria, 30-49 hyaline casts, [12-28] granular casts . Labs on admission: [2188-6-14] 10:30PM BLOOD WBC-13.1# RBC-4.22# Hgb-12.3 Hct-39.8# MCV-94 MCH-29.1 MCHC-30.9 RDW-19.6* Plt Ct-288# [2188-6-14] 10:30PM BLOOD Neuts-87.0* Lymphs-8.1* Monos-4.0 Eos-0.6 Baso-0.2 [2188-6-14] 10:30PM BLOOD PT-14.5* PTT-24.4 INR(PT)-1.3* [2188-6-14] 10:30PM BLOOD Glucose-127* UreaN-73* Creat-1.7* Na-134 K-6.2* Cl-99 HCO3-22 AnGap-19 [2188-6-14] 10:30PM BLOOD Calcium-8.6 Phos-6.1# Mg-2.9 [2188-6-14] 10:30PM BLOOD CK(CPK)-25* CK-MB-NotDone cTropnT-<0.01 [2188-6-14] 11:21PM BLOOD Glucose-118* Lactate-2.6* Na-134* K-5.9* Cl-97* calHCO3-27 . Micro: Urine culture pending DFA influenza: inadequate sample. Respiratory viral cx pending.. Urine legionella Ag negative Brief Hospital Course: Assessment and Plan: 55yo F with h/o metastatic endometrial CA complicated by bilateral pleural effusions and pericardial effusion requiring intermittent drainage via pleuradex catheter and bilateral upper extremity DVTs on fondaparinux and O2 (1L NC) at home admitted with SOB, ARF, Afib with RVR. . #. SOB: Initially CXR showed right-sided infiltrates worse from prior and concerning for HCAP vs aspiration PNA. She was started on broad spectrum abx (Vanc/zosyn) on [2188-6-15] for presumed pneumonia. Legionella antigen neg. Influenza DFA neg. MI was ruled out with three sets of cardiac enzymes. Plan for drainage qod per home regimen but did not have large effussions at presentations and had been drained day of admit. . # Hypotension: SBP in 80s-110s range on admission. Patient likely with low-running BP at baseline with question of contribution from infection given CXR findings and leukocytosis despite remaining afebrile. Treated with broad abx as above. Unable to place a-line for closer monitoring of BP. Thought to be dehydrated but unable to place bedside RUE PICC successfully (LUE limited by DVT). Able to place one PIV. Femoral line discussed as an option but not pursued given goals of care and absence of emergent need. Pt maintained SBP in 110s overnight. On the AM of [6-16] - BP transiently decreased to 50s while mentating well, unclear if spurious, as subsequent cuff read back to 110s. However, about 9AM found to have 50/palp BP on doppler measurement by RN. HO notified. At this time, pt went into SVT which terminated in asystole. No resuscitative efforts as pt was made DNR/DNI day prior on discussion with family. . # ARF: Patient had had recent CTA and also had had poor po intake while taking lasix at home. Therefore it was thought her ARF was multifactorial including pre-renal azotemia, supported by urine lytes, and contrast nephropathy. Meds were renally dosed. A renal US also noted new right hdrynephrosis which was conerning to be related to pelvic massess and obstruction - it was unilateral #. Metastatic endometrial CA: Patient has poorly differentiated stage endometrial cancer with metastases to the lungs and liver. Patient did not start second cycle of carboplatin and Taxol in [5-3] and does not want further chemo. She continues alternative therapies. Had been in work-up for hospice the week prior to admission per Heme-Onc fellow. Continued here on lidocaine patch for pain and ativan for anxiety. Given her poor prognosis, family decision was to make pt DNR/DNI on [2188-6-15], and patient died the morning of [2188-6-16]. . #. Tachyarrhythmia: Pt with h/o afib as well as SVT on prior admission. Episodes seemed associated with anxiety, exacerbated by volume depletion. Terminated several times with lopressor and given low-dose anxiolytics with improvement but further IV fluid repletion limited by IV access. On AM of [6-16], pt went into SVT which terminated in asystolic arrest. . #. Hypercoagulability - Patient had been previously diagnosed with bilateral UE DVT. Left-sided DVT was spontaneous while the right-sided DVT was PICC associated. In late [4-3], she had a right-sided DVT occurred while on lovenox for which she was switched to fondaparinox. UENIs here showed persistent LUE DVT. Fondaparinox was held in setting of ARF and evidence of coagulopathy while trying to obtain IV access. . #. Back pain: Chronic and worsening over several months limiting patient's mobility. No point tenderness or neurologic deficits to suggest cord involvement. Continued on pain control with lidoderm patch and morphine prn. . # Code: DNR/DNI . # Communication: Patient, HCP/daughter [Name (NI) 77800] ([Telephone/Fax (1) 77801]), [Name2 (NI) ] [Name (NI) 77802] Sister ([Telephone/Fax (1) 77803]) Medications on Admission: 1. Metoprolol Tartrate 25 mg TID 2. Zolpidem 5 mg PO HS 3. Multivitamin PO DAILY 4. Cholecalciferol (Vitamin D3) 400 unit PO DAILY 5. oxygen home O2 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch DAILY 7. Fondaparinux 7.5 mg/0.6 mL Subcutaneous once a day. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: None Discharge Instructions: None Followup Instructions: None ICD9 Codes: 5849, 486, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7746 }	Medical Text: Admission Date: [2157-3-23] Discharge Date: [2157-4-5] Date of Birth: [2099-11-5] Sex: M Service: MEDICINE Allergies: Tetracyclines Attending:[First Name3 (LF) 898] Chief Complaint: Epistaxis Major Surgical or Invasive Procedure: Cardiac Catheterization, PTCA with stenting of LMCA/LCX History of Present Illness: Pt is a 57m with HTN, DM hyperlipidemia, CAD, CHF, ESRD on coumadin who presents to ED w/ R nare epistaxis x 12 hours. He reports that the epistaxis started at 1PM on day PTA when he was doing ??????gymnastics.?????? He denies any trauma to the nose, though states he may have picked at it. Despite applying pressure, it continued to bleed for a period of 12 hours, and he was brought to ED @ 1 AM on the day of admission. In the ED, his R nare was packed. Past Medical History: CAD s/p CABG in [2137](LIMA-LAD, SVG-RCA), s/p 2 stents RCA [6-/2155] with 3VD with occluded SVG grafts and patent LIMA, NSTEMI [11-20]. Last Cath 6/[2155]. CHF with EF 40% on [2156-12-21] echo with: Mod LV dysfunction, EF 40% with mildly dilated RV and mild pulm htn, global HK, 2+MR [First Name (Titles) ] [Last Name (Titles) ]R. Hypertension Hyperlipidemia Insulin-dependent diabetes mellitus morbid obesity hypothyroidism s/p Hartmann's procedure for diverticular bleed recurrent bilateral pleural effusions R>L-- last tapped under USG guidance [12-24] depression Social History: forty-five pack year history, quit 15 years ago. No EtOH in 3 years, never a heavy drinker. Family History: two brothers with DM. Mother died at age 5 of a stroke. Father died at 55 of an MI. Physical Exam: On physical exam, obese man, anxious, lying in bed, slightly tachypneic, but does not appear to be tiring. Vital signs: Temp: Pulse: BP: RR: O2 Sat: 98.4 97 81/65 25 97% RA Skin: Multiple scars on abdomen, legs, chest. No rash, petechiae, or ecchymoses. HEENT: Head NC/AT. Sclerae anicteric, conjunctiva pink. PERRLA, EOMs intact. Nasal mucosa pink. Oropharynx dry, nonerythematous. . Neck supple. No LAD. Cardiac: JVP difficult to assess. Carotid pulses 1+ bilat.; moderately brisk upstroke; without bruits. II-III/VI holosystolic ejection murmur, most prominent at LSB. Pulmonary: Decreased breath sounds at bases. Bibasilar crackles. Abdomen: Colostomy bag ?????? stump pink, non-erythematous. BS present in all 4 quadrants. Obese, soft. No tenderness No hepatosplenomegaly. -black stool, guiac positive. Extremities: Slightly cool extremities bilaterally. Symmetric 1+ radial and DP pulses. 1+ edema. Neuro: MMSE: AOx3. Rest of MMSE not performed. CNs: II-XII intact to direct testing. Pertinent Results: Admission Labs: BLOOD WBC-9.0 RBC-3.24* Hgb-10.2* Hct-32.4* MCV-100* MCH-31.3 MCHC-31.4 RDW-18.6* Plt Ct-473* PT-22.9* PTT-30.2 INR(PT)-2.3* Glucose-158* UreaN-41* Creat-2.0* Na-128* K-5.4* Cl-91* HCO3-26 AnGap-16 Calcium-8.2* Phos-3.5 Mg-1.5* Iron-31* Cholest-157 [2157-3-26] 06:19AM BLOOD WBC-9.4 RBC-2.69* Hgb-8.5* Hct-26.9* MCV-100* MCH-31.4 MCHC-31.4 RDW-18.1* Plt Ct-464* Cardiac Enzymes: CK(CPK)-30* CK-MB-3 cTropnT-0.35* CK(CPK)-25* cTropnT-0.32* CK(CPK)-27* CK-MB-NotDone cTropnT-0.29* CK(CPK)-31* CK-MB-NotDone cTropnT-0.35* Other Laboratory Studies: Triglyc-170* HDL-36 CHOL/HD-4.4 LDLcalc-87 calTIBC-280 Ferritn-945* TRF-215 PTH-99* Digoxin-0.6* PT-15.9* PTT-26.5 INR(PT)-1.4* [2157-3-26] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEGATIVE [2157-3-25] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEGATIVE [2157-3-24] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEGATIVE CHEST (PORTABLE AP) [2157-3-23] 10:22 AM IMPRESSION: Congestive heart failure with pulmonary edema and bilateral pleural effusions. Opacity at the right lung base may represent pneumonia versus atelectasis. ECG Study Date of [2157-3-23] 2:14:20 AM NOTE: patient on digoxin Sinus rhythm. First degree A-V delay. Left atrial abnormality. Modest non-specific intraventricular conduction delay. Probable infero-posterior myocardial infarction, age indeterminate. Diffuse ST-T wave abnormalities are non-specific but cannot exclude ischemia. Clinical correlation is suggested for possible right ventricular overload. Since the previous tracing of [2157-1-29] ST-T wave changes appear more prominent ECG Study Date of [2157-3-24] 10:50:40 AM Sinus rhythm Right axis deviation Inferolateral/posterior myocardial infarct Since previous tracing, no significant change ECHO Study Date of [2157-3-29] The left atrium is mildly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis (ejection fraction [11-4] percent). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2157-1-20], the left ventricular ejection fraction is further reduced. Cardiac Catheterization [2157-4-1]: COMMENTS: 1. Selective coronary angiography revealed a right dominant syetm with severe three vessel disease. RCA stents were patent but the distal vessel and the R-PDA were diffusely severely diseased. The LMCA was totally occluded as were the proximal LCX and the LAD. LIMA to the LAD graft was patent but did not backfill the LCX. SVG grafts were know occluded and were not engaged. 2. Left vetriculography was deferred. 3. Hemodynamic assessment showed markedly elevated left and right sided filling pressures (PCWP 29 mm Hg and RAp 34 mm Hg) consistent with severe volume overload. RA pressure tracing and LVEDP tracing had accentuated X and Y descents and square root sign configuration consistent with interventricular interdependence due to volume overload. Cardiac index was 2.0. 4. Successful PTCA and stenting of the LMCA and the LCX with two 2.5 mm Cypher drug-eluting stents, proximally post-dilated to 3.0 mm. 5. The right CFA arteriotomy site was closed with a 6 French Angioseal. Brief Hospital Course: In summary this is a 57 year old man with HTN, DM hyperlipidemia, CAD, CHF, ESRD on anticoagulation who presents to ED w/ epistaxis x 12 hours. Following transfer to the floor, the pt appeared volume overloaded on CXR. He subsequently [Month/Day/Year 1834] HD on [3-23] and had 2 kg ultrafiltration. During the next few days, the pt had several intermittent episodes of chest pain with EKGs showing deepened ST depression anterolaterally with peak troponins of 0.38 and CKs in 30s. The ST changes persisted even after resolution of the CP (relieved with metoprolol). He again received HD on [3-24] and [3-26] with 2L ultrafiltrated both times. The medicine team contact[Name (NI) ] the pt's outpatient cardiologist who stated that pt's last cath was in [6-19] at [Hospital1 18]. He had not had a cath at [Hospital1 2025] as was erronously stated in a prior discharge summary. The pt's outpt cardiologist agreed with continuing ASA and coumadin and discontinuing plavix since the taxol stent was placed over 19 months ago. The pt was also re-started on a statin. Given the episodes of chest pain with unclear etiology and EKG changes, the plan was made to proceed with P-MIBI on [3-29]. In further events, the pt was transfused 2 units of PRBCs over the hospital course for a goal Hct of 30 given concern for demand ischemia. . On [3-28], the pt [Month/Year (2) 1834] HD during which he had 2 L untrafiltrated. He tolerated this well but did receive 0.5 mg of IV ativan for anxiety. Following arrival back on the floor, the pt was found to be hypotensive at 78/doppler and was more lethargic then his baseline. At that time, the pt reported the presence of chest pain but stated that had been present for months. In addition, her reported mild SOB and nausea. No abdominal pain or vomiting. The pt received a total of 750 cc of NS (250 cc x3) but his SBP remained in the 80s and his mental status did not improve. VBG was significant for a lactate of 5.2. An ABG could not be obtained and it was difficult to maintain an oxygen sat per finger probe. EKG was essentially unchanged with ST depressions persistent in 1, V1-V3, and V5-V6 with RBBB pattern. CXR showed bilateral pleural effusions and ?RLL opacity essentially unchanged from prior. At that time, the pt was transferred to MICU for concern for sepsis and further management. . MICU course: For hypotension after dialysis, the patient was started on vanco and ceftriaxone initially as there was a concern for sepsis. Nasal packing was removed by ENT and PICC line was discontinued and sent for culture. When all cultures were negative x 48hours, antibiotics were discontinued. The patient did not have any further episodes of hypotension during his MICU stay and even after HD, he remained hemodynamically stable. His blood pressure ranged 90-100s. As a part of hypotension w/u, TTE was done which showed decreased EF of [11-4]% as compared to TTE done in [1-21] (EF of 25%). Given his ST depression and chest pain hx, it was felt that his worsening EF was secondary to ischemia. The patient was continued on ASA and lipitor, but given his hypotension, BB was not started in MICU but should be restarted once BP persistently stable. Dr. [Last Name (STitle) ] was made aware of the new findings on echo, and it was decided that patient should undergo cardiac cath for intervention. Dr. [Last Name (STitle) ] also recommended started carvedilol 3.125 [Hospital1 ], spironolactone 25 qday and Zestril 5 qday as BP tolerates. For afib, his anticoagulation was held for cardiac cath and digioxin was held per Dr. [Last Name (STitle) ] as it is unlikely improve his mortality. . Mr. [Known lastname ] [Last Name (Titles) 1834] cardiac catheterization on [2157-4-1] and found to have 3VD with complete occlusion of the LMCA, proximal LCX and the LAD. PTCA and stenting was performed for the LMCA and the LCX with two 2.5 mm Cypher drug-eluting stents. Hemodynamic assessment also showed elevated left and right sided filling pressures consistent with severe volume overload. . Consequently, Mr. [Known lastname ] [Last Name (Titles) 1834] 3 days of hemodialysis in order to make him more euvolemic. He was restarted on coumadin. . Following cardiac catheterization Mr. [Known lastname 55603] BP seemed to improve slightly (high 90s-110s SBP) and Coreg 3.125 mg [Hospital1 ] was re-initiated. He should be followed by Cardiology after discharge for further tailoring of his CHF regimen (titrating BB up and adding ACEI as tolerated). . . Additional hospital course by issues: 1. Epistaxis: Mr. [Known lastname 55603] nose was packed in the ED. On admission, his stool was notable for being guaic positive. His warfarin and coumadin were held on the day of admission, then restarted the following day when there was no evidence of continued epistaxis. His hematocrit was followed throughout his hospital stay and he periodically received transfusions of PRBCs during dialysis. Nasal packing was removed by ENT after 6 days. Keflex was prescribed to prophylax against toxic shock syndrome. 2. C.Difficile: Per [Hospital ] Rehab his stool was positive for C.Diff on [2157-2-24], [2157-3-14], and [2157-3-15]. On admission he was taking PO vancomycin (presumably for C.Diff failing to clear on metronidazole). PO vancomycin was continued during hospitalization until he was C.Diff negative x 3 and hand complated a 14 day course of PO vancomycin. Medications on Admission: 1. Lansoprazole 30 mg PO DAILY 2. Acetaminophen 325-650 mg PO Q4-6H:PRN 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Albuterol-Ipratropium [1-17] PUFF IH Q6H:PRN 5. Nephrocaps 1 CAP PO DAILY 6. Aspirin 325 mg PO DAILY 7. Quetiapine Fumarate 50 mg PO QHS 8. Clopidogrel Bisulfate 75 mg PO DAILY 9. Quetiapine Fumarate 25 mg PO Q12H:PRN 10. Digoxin 0.125 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Zofran 4 mg IV Q6H:PRN nausea 13. Senna 1 TAB PO BID:PRN 14. Docusate Sodium 100 mg PO BID 15. Sucralfate 1 gm PO BID 16. Epoetin Alfa 17. Vancomycin Oral Liquid 250 mg PO Q6H 18. Gabapentin 100 mg PO DAILY EXCEPT SUNDAY 19. Warfarin 6 mg PO DAILY 20. Insulin SC (per Insulin Flowsheet) Sliding 21. Toprol XL 50mg PO daily 22. Ocean 0.65% nose spray 2 sprays/nostril QID PRN 23. Glycerin suppository 24. Ducolax 25. lactulose 26. cepacol lozenges 27. robitussin AC syrup 28. Imodium 29. albuterol sulfate nebs Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [1-17] Puffs Inhalation Q6H (every 6 hours) as needed. 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed. 9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY EXCEPT SUNDAY (). 10. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID prn. 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 14. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 15. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 18. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-17] Sprays Nasal 5X/D (5 times a day) for 1 weeks. 19. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 21. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis: Coronary Artery Disease s/p PTCA and stent placement Congestive Heart Failure Secondary Diagnoses: Epistaxis Diabetes Mellitus ESRD on Hemodialysis Hypothyroidism Hypertension Hypercholestolemia s/p colostomy for diverticular bleed Discharge Condition: Stable, BP improved, without chest pain Discharge Instructions: You were admitted to [Hospital1 18] for uncontrolled bleeding from your right nostril. Packing was placed in your nostril and remained in place for 5 days, at which point it was removed. You received several transfusions of blood for decreased blood counts. On [3-28] following dialysis your blood pressure dropped low, and you were transferred to the Intensive Care Unit for close monitoring. An echocardiogram of your heart was performed, which demonstrated that the heart was not squeezing as effectively as prior. Accordingly, on [4-1] you were taken to cardiac catheterization where the blood vessels in your heart were imaged and stents (metal scaffolding) were placed to open up several vessels that were very narrow. After the cardiac catheterization and aggressive dialysis to remove excess fluid, your blood pressure improved slightly. 1. Please take all medications as prescribed. Please be aware that your medications have changed while you have been hospitalized. Some medications have been added, some have been changed, and some have been removed. 2. Please keep all appointments with medical care providers. You should follow-up with your Cardiologist, your kidney doctor, and your primary care doctor. 3. You should contact your doctor or return to the hospital if you experience: -chest pain that does not resolve (particularly if it is associated with shortness of breath, palpitations, sweating, N/V) -uncontrollable bleeding (if bleeding persists despite keeping pressure on the site of bleeding for 15-30 minutes) -for lightheadedness, confusion, decreased level of consciousness -for high fevers, uncontrollable shaking chills - shortness of breath - abdominal pain - or any other concerning symptoms Followup Instructions: Cardiology Follow-up: Dr. [First Name4 (NamePattern1) 2174] [Last Name (NamePattern1) 2912] on [4-25] @ 3PM. One [Location (un) ] Place, [Apartment Address(1) 19746]. ([Telephone/Fax (1) 47597] Nephrology (Kidney): Dr. [First Name (STitle) 4102] [Name (STitle) 4090], [4-12] @12:30 PM. [Hospital ] Clinic, [Location (un) 1385].([Telephone/Fax (1) 817] You should contact your Primary Care Physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 807] ([Telephone/Fax (1) 823]) and arrange to be seen by him approximately 2 weeks after you are discharged from the rehabilitation center. ICD9 Codes: 4280, 5856, 2761, 4111, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7747 }	Medical Text: Admission Date: [2197-1-3] Discharge Date: [2197-2-16] Date of Birth: [2170-6-17] Sex: F Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 4691] Chief Complaint: s/p ~80 ft jump off bridge Major Surgical or Invasive Procedure: Exploration perineal laceration Exploratory laparotomy with diverting sigmoid loop colostomy Pelvic external fixation Percutaneous drainage of abscesses History of Present Illness: 26 yo female with history of multiple sudicide attmepts who reportedly jumped off of an 80 ft bridge into water sustaining an open pelvic fracture. She was intubated at the scene and transported via [Location (un) 7622] to [Hospital1 18] for further care. Past Medical History: Depression Suicide attempts x 3 Social History: Has a daughter age 5 Very involved parents Family History: Noncontributory Pertinent Results: [2197-1-3] 08:19PM GLUCOSE-148* UREA N-14 CREAT-0.9 SODIUM-142 POTASSIUM-4.3 CHLORIDE-116* TOTAL CO2-17* ANION GAP-13 [2197-1-3] 08:19PM CALCIUM-6.5* PHOSPHATE-4.2 MAGNESIUM-1.8 [2197-1-3] 08:19PM WBC-10.5 RBC-3.89# HGB-11.8# HCT-33.0# MCV-85 MCH-30.2 MCHC-35.7 RDW-14.7 [2197-1-3] 08:19PM PLT COUNT-151 [2197-1-3] 08:19PM PT-14.2* PTT-25.4 INR(PT)-1.3* [2197-1-3] 10:32AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CT HEAD W/O CONTRAST Reason: assess [Hospital 93] MEDICAL CONDITION: 26 year old woman with mental status changes, decreased orientation REASON FOR THIS EXAMINATION: assess CONTRAINDICATIONS for IV CONTRAST: None. STUDY: Non-contrast head CT. INDICATION: Change in mental status. COMPARISON: None. TECHNIQUE: Non-contrast head CT. FINDINGS: No mass, hydrocephalus, shift of normally limited structures, or infarction is apparent. The density values of the brain parenchyma are within normal limits. The surrounding osseous and soft tissues structures as well as the paranasal sinuses are unremarkable. IMPRESSION: Normal study, including no sign of intracranial hemorrhage. Cardiology Report ECHO Study Date of [2197-1-31] PATIENT/TEST INFORMATION: Indication: Endocarditis. Height: (in) 66 Weight (lb): 220 BSA (m2): 2.08 m2 BP (mm Hg): 120/80 HR (bpm): 108 Status: Inpatient Date/Time: [2197-1-31] at 09:08 Test: TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W002-0:10 Test Location: West Echo Lab Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name11 (Name Pattern1) 900] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 2194] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.6 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 5.5 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: 4.9 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.4 cm Left Ventricle - Fractional Shortening: 0.31 (nl >= 0.29) Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%) Aorta - Valve Level: 2.7 cm (nl <= 3.6 cm) Aorta - Ascending: 2.7 cm (nl <= 3.4 cm) Aorta - Arch: 2.7 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.2 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A Ratio: 1.50 Mitral Valve - E Wave Deceleration Time: 237 msec TR Gradient (+ RA = PASP): 27 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Normal regional LV systolic function. TDI E/e' < 8, suggesting normal PCWP (<12mmHg). RIGHT VENTRICLE: RV not well seen. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or vegetations on aortic valve. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or vegetation on mitral valve. Normal LV inflow pattern for age. TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on tricuspid valve. Mild [1+] TR. Borderline PA systolic hypertension. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Resting tachycardia (HR>100bpm). Conclusions: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Preserved global and regional biventricular systolic function. No structural valve disease. No obvious vegetations seen. Borderline elevated pulmonary artery pressures. Resting tachycardia. CT GUIDANCE DRAINAGE; DRAINAGE HEMATOMA/FLUID Reason: Please [Last Name (NamePattern1) 19843] gluteal and paraspinous fluid collections, send [Hospital 93] MEDICAL CONDITION: 26 year old woman s/p hip fx, perineal injury, repair, now with GPC bacteremia, fluid collections seen on MRI REASON FOR THIS EXAMINATION: Please [Hospital 19843] gluteal and paraspinous fluid collections, send for gram stain, cultures HISTORY: 26-year-old woman with hip fractures and perineal injury with repair, now with Gram-positive bacteremia with fluid collection seen on recent MR. [First Name (Titles) 357] [Last Name (Titles) 19843] gluteal and paraspinous fluid collections and send for Gram stain and cultures. PROCEDURE: The risks and benefits of the procedure were explained to the patient, and written informed consent was obtained. A preprocedure CT was performed and compared to the patient's recent MR study of [2197-2-5]. Sedation included general anesthesia provided by the anesthesiology service. The patient was placed prone on the CT table. A preprocedure CT was performed, for localization and guidance. This CT as well as the prior MR demonstrates extensive communication between the paraspinous and gluteus maximus and minimus fluid collections. CT FLUOROSCOPY/PROCEDURE: Under CT fluoroscopic guidance, after the instillation of 5 cc of 1% lidocaine, a TLA catheter was advanced into the right gluteus collection. Location was confirmed under CT fluoroscopy. [Initials (NamePattern4) ] [Last Name (NamePattern4) 7648] wire was then advanced and the catheter was removed. The location was again confirmed with CT fluoroscopy. An 8 French pigtail catheter was advanced over the wire, and the wire removed and the location was confirmed. Approximately 100 cc of thick yellowish brown fluid was aspirated. The pigtail catheter secured to the skin with a StatLock. A drainage bag was attached via the three-way stopcock. Under CT fluoroscopic guidance, the second collection in the deep subcutaneous tissues in the right upper thigh was entered with a new TLA catheter after the instillation of 7cc of 1% lidocaine. A new [Last Name (un) 7648] wire was then advanced through the TLA catheter and the TLA catheter was removed and location was confirmed under CT fluoroscopy. A second 8 French pigtail catheter was then advanced and the wire was removed. Clear brownish fluid was aspirated. Approximately 250 cc was withdrawn. The pigtail catheter was secured to the skin with a StatLock, and a three-way stopcock was employed to attach the pigtail catheter to a drainage bag. The patient tolerated the procedure well, and there were no immediate post- procedure complications. General anesthesia was provided by the anesthesiology service. Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ], the attending radiologist, was present throughout and supervised the procedure. IMPRESSION: 1. Technically successful CT fluoroscopy-guided placement of an 8 French pigtail catheter into the right gluteus collection. 100 cc of purulent material was aspirated. Samples were sent for Gram stain and culture. 2. A second 8 French pigtail catheter was placed in the right lateral superior thigh fluid collection and the subcutaneous tissues of the right upper thigh laterally. Approximately 250 cc of clear brownish fluid was aspirated. This likely represents a seroma. Samples were, however, sent for Gram stain and culture from this location as well. Brief Hospital Course: She was admitted to the Trauma Service under the care of Dr. [Last Name (STitle) ]. Orthopedics was consulted because of her injuries and she was immediately taken to the operating room where she underwent examination under anesthesia of her perineal laceration, packing of the pelvic wound, repair of laceration of the perineal body and vulva, exploratory laparotomy and sigmoid loop colostomy. Her pelvic fracture was repaired by Orthopedics; a closed reduction of pelvic and application of multiplanar external fixator was performed. She was later taken back to the operating room by Orthopedics on [2-9] for removal of anterior ring hardware, placement of anterior pelvic external fixator, supplementation of posterior fixation with additional sacroiliac screw on the right side. She will remain non weight bearing on both lower extremities until follow up with Dr. [Last Name (STitle) 1005] in 4 weeks. Gynecology was also consulted because of the extent of her perineal injuries; her wounds were packed and on HD #3 she was taken back to the operating room for repair of anal sphincters and perineal body. They were also later re consulted because of + blood cultures ([4-26]) with [Name (NI) 8974], unclear source, with edematous, tender R labia majora, "question Bartholin's". No palpable abscess or fluid collection was noted; it was recommended to continue with her Cipro and to reconsult if no improvements. The swelling did eventually resolve. Psychiatry was also consulted because of the nature of her trauma; she was placed on 1:1 sitters initially and followed closely by Psychiatry. Her LFT's were checked and she was started on Valproic acid 250 mg [Hospital1 ]; her dose has since been increased (see medications); she was also started on an antipsychotic prn. Per family report she was diagnosed with Depression at age 16 and was started on an antidepressant at that time; she self discontinued the medication. During her stay here she was also followed by Social Work for coping and support; she has been cooperative with her care throughout her stay; there have been no expressed or observed suicidal thoughts/behaviors. The 1:1 sitters were eventually stopped a couple of weeks prior to her discharge. Wound Ostomy Nurse Specialists were consulted early on for care of her colostomy; she was instructed in caring for her appliance and is now independent with this. It is expected at some point in the next several months that she will have this reversed; this decision will be made by Dr. [Last Name (STitle) ] as she will need to follow up with him periodically after discharge to rehab. Infectious Disease was consulted because of a fever spike to 103; blood cultures were obtained and were positive for [Last Name (STitle) 8974]. She was started on Vanco and later Cipro was added. She continued to have fever spikes despite this. It was recommended that the Cipro be discontinued and to keep Vanco. She underwent MRI of her pelvis and lumbar spine region because of increased complaints of pain in that region on the right side; a fluid collection was noted. On the following day she underwent CT guided drainage x2 of the fluid collection. Nephrology was consulted because of hyponatremia and elevated renal function; she was initially fluid restricted; given normal saline intravenous boluses and started on salt tabs. Her Na did eventually improve, last level checked on [2-15] was 141; BUN 5 and Creatinine 0.7. She has had ongoing pain issues since her hospitalization; she was initially on PCA Dilaudid; this was later changed to long acting narcotics which made her very sleepy and noted changes in her mental status prompting a Neurology consult. Once these medications were weaned her mental status improved back to baseline, which is alert and oriented X3.Currently she is on prn Dilaudid for pain control which will likely require further adjustment. Use of long acting narcotics at a lower dose should also be reconsidered. Her hematocrit has run on low side throughout her hospital stay; her admission value was 33.0, but she has ranged between 22-26 steadily. She did have an EBL during her recent surgery of approximately 1 liter. Postoperatively her last Hct on [2-15] was 22.9. She was started on FeSo4 325 tid; it is expected that her hematocrit will equilibrate and will eventually rise. She is currently hemodynamically stable and does not show any signs of bleeding. The risks and benefits of transfusing otherwise young and healthy individuals have been discussed with the patient and her family. Because of her extensive pelvic injuries she has had a Foley catheter in place for the majority of her acute hospitalization. Initially she was having copious amounts of perineal leakage; a larger french Foley catheter was placed and the leakage did slow down to moderate amounts. Her Foley catheter was removed, post void residuals were checked; less than 50-75 cc's urine remained in her bladder. The leakage problem persisted along with causing excoriation to her perineum and so the Foley was again replaced; leakage slowed down considerably to smaller amounts, but still persisted. Her Foley was removed again on [2-15], she is still having leakage but much less than previously noted. Physical and Occupational therapy have been closely involved since her admission; prior to her most recent Orthopedic procedure she was ambulating and maintaining the previous non weight bearing on her right lower extremity. It is expected that her weight bearing status may be upgraded once she follows up with Dr. [Last Name (STitle) 1005] in 4 weeks. Until that time she is to remain non weight bearing. Medications on Admission: Zoloft Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) dose Subcutaneous Q12H (every 12 hours). 5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Must take with food. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation. 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain. 13. Valproic Acid 250 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 14. Valproic Acid 250 mg Capsule Sig: Four (4) Capsule PO HS (at bedtime). 15. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) GM Intravenous Q 12H (Every 12 Hours): Monitor Vanco peak and trough levels. 17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: s/p Jump from 80 ft Left C7/T1 transverse process fracture (non-operative) Perineal/rectal laceration Right superior/inferior pubic fracture Right sacral fracture Bacteremia Right gluteal abscess Right SI screw hardware failure Discharge Condition: Stable Discharge Instructions: DO NOT bear any weight on either of your lower extremities. Continue IV vancomycin until follow up with Infectious Disease on [2197-3-21]; this will be a total of 6 weeks from when the Vanco was originally started. Followup Instructions: Follow up with Trauma Clinic in [2-25] weeks, call [Telephone/Fax (1) 6429] for an appointment. Follow up in [Hospital 5498] Clinic with Dr. [Last Name (STitle) 1005] in 4 weeks, call [Telephone/Fax (1) 1228] for an appointment. Follow up in Infectious Disease (ID) clinic with Dr. [Last Name (STitle) ] on [2197-3-21] at 9:00 am. Call ([Telephone/Fax (1) 4170] if you need to reschedule or have any questions. You need to have weekly labs (CBC with diff, BUN, Creatinine, LFT's, Vancomycin trough) These results should be faxed to the [Hospital ] clinic at [Telephone/Fax (1) 17715]. Completed by:[2197-2-17*] ICD9 Codes: 7907, 2761
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7748 }	Medical Text: Admission Date: [2153-3-10] Discharge Date: [2153-4-5] Service: Plastics HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 40291] is an 86-year-old gentleman with a history of laryngeal cancer, status post laryngectomy, right radical neck dissection, with postoperative radiation therapy two years ago, with a second course of radiation therapy for question of a recurrence. The patient has since developed an orocutaneous fistula which has been resistant to local wound care and an advancement flap. The patient now presents with a large orocutaneous fistula anteriorly to the left neck measuring approximately 7 cm X 8 cm with saliva and purulent discharge. The patient was noted to have a large volume of bleeding from the wound earlier in the day, at which time the patient was transferred to the [Hospital1 ] for further evaluation. PAST MEDICAL HISTORY: 1. Laryngeal cancer. 2. Coronary artery disease. PAST SURGICAL HISTORY: 1. Laryngectomy. 2. Radical neck dissection. 3. G-tube placement. 4. Aortic valve replacement. MEDICATIONS ON ADMISSION: Coumadin 2.5 mg p.o. Monday through Friday and 5 mg p.o. on Saturday and Sunday, Roxicet elixir for pain PHYSICAL EXAMINATION ON PRESENTATION: At the time of admission, the patient was awake and alert, in no apparent distress. He was afebrile with stable vital signs. On head and neck, his cranial nerve examinations were all intact. There was a 7-cm X 8-cm orocutaneous fistula anteriorly over the left neck with saliva and purulent discharge extruding from the wound. The laryngeal stoma was intact. The airway was secured. His lungs were clear to auscultation bilaterally. His heart had a regular rate and rhythm. His abdomen was soft, nontender, and nondistended. A G-tube secured in place. HOSPITAL COURSE: Because of the nature of this wound, and near exposure of the left carotid artery, Neurosurgery was consulted for angiography to rule out any carotid bleeding given this patient's history of a large amount of blood extruding from the wound. The angiography was performed, and there was no sign of any pseudoaneurysm, dissection, or extravasation. An incidental finding was noted on CT. The patient had bilateral subdural hematomas. At the time of admission, the patient's INR was 2.9, and he was being anticoagulated for his prosthetic aortic valve. At this point, the patient began receiving blood products to reverse his INR in anticipation of the patient needing surgical correction for his neck as well as potential subdural hematomas. While this was being done, the patient developed congestive heart failure but rapidly responded to Lasix and did not require any ventilatory support. On hospital day five, the patient had been adequately reversed and was taken to the operating room by the Otolaryngology team where he underwent biopsies of the margins to insure there was no remaining cancer prior to placement of a flap for closure of this wound. Biopsy results of the wound were negative for any remaining signs of malignancy. At this point, it was decided by the Neurosurgery team that, despite the patient's subdural hematomas, the patient was suffering no neurologic compromise. There were no radiologic findings to suggest midline shift, and it was decided at this point that the patient would be of significant risk and of decreased benefit with the hematomas. Over the next several days the patient was seen by the Physical Therapy team and the Nutrition team as the patient was prepared for operative repair of his orocutaneous fistula. On [3-26], the patient was taken to the operating room where he underwent left pectoralis myocutaneous skin flap for closure of the orocutaneous fistula. The patient tolerated the procedure well, and there were no perioperative complications. The patient was taken to the Surgical Intensive Care Unit overnight for observation and monitoring of flap. The patient had no problems in the immediate perioperative period and was therefore transferred to the floor on postoperative day one. At this point, the patient's tube feeds were restarted, and the patient was begun on his home medications as well as restarted on heparin and Coumadin while waiting for the patient to become adequately anticoagulated in the setting of his prosthetic aortic valve. The patient was also treated with penicillin and Ancef postoperatively. The patient's pectoralis donor site was initially managed with a bulb suction drain. Over the next couple of days, the patient continued to do well. His rotational flap continued to thrive, with the only concern being that the level where his tracheostomy appeared to be causing some necrosis at the level of the right lateral inferior aspect of the flap. Otolaryngology was consulted, and it was decided the patient did not need a tracheostomy as the patient had a very mature stoma. After the tracheostomy was removed, the patient continued to do well; and, again, the flap continued to thrive. On postoperative day six, the patient developed a large left chest wall hematoma and had to be taken to the operating room for evacuation. The bulb suction drain which had been draining the chest wound had been discharged two days previously. The drainage output from the drain prior to it being removed had been less than 15 cc per day for the two previous days prior to it being removed. Again, the patient tolerated evacuation well with no perioperative complications. The patient did receive 2 units of packed red blood cells, as the patient's hematocrit during this bleeding episode had dropped to 26. The patient responded appropriately increasing his hematocrit to 30. Over the next two days, the patient continued to rapidly improve. He was seen by the Physical Therapy Department and began ambulating with assistance. From a nutritional standpoint he continued to do well on his tube feeds. On postoperative day nine, the patient had a barium swallow performed which revealed no signs of any leakage or persistent orocutaneous fistula. At this point, the patient was begun on soft solids, and swallow consultation was obtained. Also at this time, the patient's antibiotics were changed from penicillin and Ancef to clindamycin, and the patient was deemed medically stable and ready for discharge to a rehabilitation facility. CONDITION AT DISCHARGE: The patient was stable at the time of discharge. His orocutaneous skin flap was doing well. DISCHARGE STATUS: The patient was to be discharged to an acute rehabilitation facility. MEDICATIONS ON DISCHARGE: 1. Clindamycin 300 mg per G-tube q.i.d. 2. Acetaminophen 325 mg to 650 mg per G-tube q.4-6h. p.r.n. 3. Ascorbic acid 500 mg per G-tube b.i.d. 4. Tocopheryl 400 IU per G-tube q.d. 5. Zinc sulfate 220 mg per G-tube q.d. 6. Metoprolol 25 mg per G-tube b.i.d. 7. Albuterol 1 to 2 puffs per stoma q.4h. p.r.n. for wheezing. 8. Artificial Tears 1 to 2 drop OU p.r.n. 9. Coumadin 2.5 mg p.o. q.d. Monday through Friday and 5 mg p.o. q.d. on Saturday and Sunday. 10. Dulcolax per G-tube b.i.d. 11. Roxicet elixir 5 mL to 10 mL per G-tube q.4-6h. p.r.n. 12. G-tube feedings with ProMod fiber full strength at 80 cc per hour with a plan to wean the tube feeds as the patient's oral intake is gradually increased. DISCHARGE FOLLOWUP: The patient was to see Dr. [First Name (STitle) ] in clinic in one week for followup. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8332], M.D. [MD Number(1) 8333] Dictated By:[Last Name (NamePattern1) 40292] MEDQUIST36 D: [2153-4-4] 18:03 T: [2153-4-5] 09:12 JOB#: [Job Number 40293] RP [2153-4-5] ICD9 Codes: 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7749 }	Medical Text: Admission Date: [2108-3-11] Discharge Date: [2108-3-12] Date of Birth: [2039-6-15] Sex: M Service: MICU CHIEF COMPLAINT: Dyspnea, acute renal failure. HISTORY OF PRESENT ILLNESS: A 68-year-old ophthalmologist with no significant past medical history, who presents today with diffuse muscle pain and dyspnea on exertion times six days. Symptoms started when patient awoke six days prior to admission with lumbar lower back pain. Patient states that initially the pain was similar to lumbar back pain in the past, however, he usually notices this type of pain at the end of the day rather than first thing in the morning. Throughout the day his lower back pain worsened and patient began to note diffuse myalgias. Upon getting home from work that evening, he reports that the pain and myalgias were so severe that he was unable to walk. The weakness has worsened throughout the course of the week, and patient has been nonambulatory. His dyspnea on exertion began around the same time as the muscle weakness and prior to being unable to walk, he was only able to do three steps before he became tachypneic. He does not report any PND or orthopnea. The patient has also recently traveled to [State 108] approximately 10 days ago. While he was in [State 108], he had an acute diarrheal illness, which was described as watery and nonbloody. This resolved spontaneously and was self limited. He was unclear if this was associated with fevers. Five days prior to admission, he again had recurrence of symptoms and his diarrhea in addition to above symptoms of myalgias and weakness. His original episode of diarrhea was thought to be secondary to eating out at a restaurant with Cuban cuisine and possible beef exposure. He does not believe he had any fresh water exposure and he was not swimming in any pools. On presentation to the Emergency Department, he was noted to be in moderate respiratory distress with respiratory rates in the 30s and tachycardic with heart rates in the 100s. He was placed on nonrebreather face mask with initial oxygen saturation 88 percent, which improved to 95 percent on 3 liters without any intervention. Initial ABG showed 7.33/21/134 on unknown amount of oxygen. He received 2 liters of intravenous normal saline while in the Emergency Department and had development of bibasilar rales. He did not have any change in his oxygen saturation while lying supine. On review of systems, patient complains of mild oliguria, which he reports usually going 10 times per day, which decreased to one time per day over the last six days. He noted brown urine starting approximately four days ago. He has not had any dysuria or hematuria as far as he knows. He also reports a sore throat with a question of dysarthria at the onset of symptoms five to six days ago. He has had a headache and some blurry vision. The blurry vision was approximately two days prior to admission and lasted about 24 hours. One day prior to admission he believes he also had an episode of diplopia, which lasted approximately six hours. He has not had any abdominal pain, nausea, vomiting, chest pain, or palpitations. Of note, he and his wife, who is also a physician noted that his thighs were mottled. PAST MEDICAL HISTORY: 1. GERD. 2. Raynaud's phenomenon. 3. Adenomatous polyps x2 resected per colonoscopy in [2105]. 4. Osteopenia. 5. Status post inguinal hernia repair. 6. Hyperlipidemia. 7. History of lower back pain. MEDICATIONS AT HOME: 1. Aspirin 81 q.d. 2. Lipitor 20 mg q.d., which has been a stable dose over the last six to seven years. 3. Prilosec 20 q.d. 4. Aleve two tablets q.d. prn, however, patient has been taking approximately four tablets per day since the onset of symptoms six days ago. 5. Feldene 20 mg p.o. q.d. ALLERGIES: 1. Mice dander causes anaphylactic reaction. 2. Mussels (seafood) causes GI upset, however, other shellfish are okay. FAMILY MEDICAL HISTORY: Mother with [Name (NI) 2481]. Father died at age 89 years old of prostate cancer. SOCIAL HISTORY: Patient is an ophthalmologist/researcher in the area. He is married. His wife is also a physician. [Name10 (NameIs) ] denies any tobacco use. He drinks approximately one glass of wine per day. He has three children, most of whom live in the area. Vital signs in the Emergency Department: Temperature 94.6, blood pressure 129/90, which increased to 145/75 after 2 liters of intravenous fluid, heart rate went from 105 to 95, respiratory rate 20s, oxygen saturation 89 percentile on rebreather face mask, which improved to 95 percent on 3 liters nasal cannula. In general, patient was in mild respiratory distress, however, he was able to speak in full sentences. There was no accessory muscle use. HEENT exam: Pupils are equal, round, and reactive. Sclerae were anicteric. Extraocular muscles are intact. Mucous membranes were moist. His oropharynx was clear. He was normocephalic, atraumatic. Neck was supple without any jugular venous distention or thyromegaly. Chest demonstrated bilateral basilar rales without any wheezes. Cardiovascular: Regular rate, no murmurs, rubs, or gallops were appreciated. Abdomen was soft, nontender, nondistended, liver span percussed to approximately 3-4 cm above costal margin. There was no splenomegaly. There is a negative [Doctor Last Name 515] sign. On back exam, he had no midline spinal tenderness to palpation. He had no CVA tenderness bilaterally. Extremities demonstrated two plus peripheral pulses. There is trace bilateral edema. Skin exam: He had no rashes, however, there is evidence of livido reticularis on bilateral thighs. On neurologic exam, he was alert and oriented times four with cranial nerves II through XII intact. Deep tendon reflexes were symmetric. Motor strength was effort dependent, however, he had 3-4/5 weakness in his bilateral hip flexors, knee extensors, knee flexion with intact strength bilateral plantar flexion, dorsiflexion. His upper extremities were 4 plus bilaterally. He had a negative Babinski. His sensation was intact to light touch bilateral upper and lower extremities. LABORATORY VALUES ON PRESENTATION: White blood cells 6.5, hemoglobin 15.5, hematocrit 46.6, MCV 91, 67 percent neutrophils, 11 percent bands, 8 percent lymphocytes, 9 percent monocytes. PT 14.7, PTT 29.8, INR of 1.4. Urinalysis showed large blood, nitrite positive, 100 protein, trace ketones, negative for leukocytes, negative for RBCs, negative WBCs, few bacteria. Sodium was 140, potassium 3.5, chloride 97, bicarb 13, BUN 72, creatinine 4.0, which is up from a baseline of 1.0, glucose 200, anion gap was elevated at 30. ALT was 96, AST 164, CK 1654, alkaline phosphatase 310, total bilirubin 5.2, direct bilirubin 3.8. Lipase was 20. Troponin was less than 0.01. Calcium 9.8, phosphorus 3.3, magnesium 2.8, albumin 3.3. Serum and urine tox were both negative. DIAGNOSTIC IMAGING: 1. Chest x-ray showed linear atelectasis at the left base with a right lower lobe nodule. 2. CT head was negative for acute pathology. 3. Abdominal ultrasound showed normal liver, portal vein patent, right kidney 11.7 cm with 1.7 cm simple cyst, left kidney was 10.8 cm. No hydronephrosis and no ascites were present. 4. EKG showed a sinus tachycardia, rate 112, P-R of 150, normal axis, T-wave inversions in III and F, unchanged when compared with EKG dated [2104-5-29]. IMPRESSION: A 68-year-old gentleman with no significant past medical history, who presents with six days of lower back pain, myalgias with remote history of diarrheal illness and possible fevers at home. While in the Emergency Department, identified to have mild respiratory distress, which improved without significant intervention as well as acute renal failure and elevated CK. Also noted to be hypothermic with a left shift. HOSPITAL COURSE: Patient was admitted to the Medical Intensive Care Unit given his acute renal failure and respiratory distress. He arrived in the Medical Intensive Care Unit approximately 6 p.m. and he was noted to have cold and clammy extremities, and was now on 6 liters of oxygen per nasal cannula. Over the next two hours, the patient exhibited worsening tachypnea and altered mental status. He was noted to have worsening slurring of his speech as well. Neurology evaluated the patient approximately one hour after being admitted to the Intensive Care Unit, and although was not able to provide a coherent history at that point, provided a good exam, which was felt to be nonfocal except for mild tongue weakness. Around 8 p.m., patient's condition had deteriorated enough that he was extremely delirious and his respiratory rate had increased to approximately 40, and he was taking short and shallow breaths. He was intubated at that point without any complications. After intubation, an arterial blood gas was performed, which showed a pH of 7.14, pCO2 of 36, and a lactate of 8.0. Given his worsening clinical condition, he was started on empiric antibiotics at that point for presumed blood-born infection. Initial antibiotics were broad spectrum, and included Zosyn, Levaquin, doxycycline, Vancomycin, Flagyl. After intubation, a left subclavian line was attempted, however, was unsuccessful. A left internal jugular central venous catheter was placed without complications. Followup chest x-ray after central line placement showed a moderate sized pneumothorax on the left, which was decompressed with a chest tube placed by Cardiothoracic Surgery. Around midnight that evening, approximately six hours after admission to the Intensive Care Unit, patient's blood pressure had progressively fallen and now required intravenous pressors. He was initially started on Levophed and eventually Vasopressin followed by Neo-Synephrine were added. Laboratory values returned with values consistent with DIC. Likewise, his respiratory status declined throughout the evening, and cisastracurium was used for paralysis. ARDS Net ventilation strategy was employed, however, he was very difficult to oxygenate throughout the evening. Serial blood gases showed progressive worsening of his acidosis, and by 10 a.m. the next morning, 16 hours after admission, his blood gas showed a pH of 6.92 and a lactate of 11.8. He had been previously on a bicarb drip throughout the evening with no apparent effect. His potassium continued to rise throughout a few short hours in the Intensive Care Unit, and reached a level of 9.1 the following morning at 11 a.m. The Nephrology team, which had been following him from the night before given his acute renal failure, were contact[Name (NI) ] early in the morning and a CVVH was initiated. Around the time of initiation of CVVH, patient was noted to have a wide complex tachycardia and was eventually found to have evidence of complete heart block. Blood pressures despite maximum dose of three vasopressive medications remained with the systolics in the 80s to 90s and heart rate in the 50s to 60s. A discussion was had with his wife, who felt that resuscitation would not be consistent with patient's wishes, and he expired at 2:30 p.m. secondary to cardiac arrest. Blood cultures drawn from time of admission in the Emergency Department later grew out methicillin-sensitive Staph aureus in four blood culture bottles. Further investigation and discussion with wife revealed that patient had a dental procedure approximately three weeks prior to admission. It is unclear this was the source of his bacteremia or whether there was some infectious process, which was acquired while he was on [State 108] a week and a half prior to admission. After discussion with his wife, an autopsy was performed (which report is not available at this time), which was consistent with septic emboli to multiple organs including his kidneys. This was the most likely cause of his acute renal failure. There is also evidence of mitral valve involvement/endocarditis. DIAGNOSIS AT TIME OF DEATH: 1. Methicillin-sensitive Staphylococcus aureus high grade bacteremia. 2. Endocarditis. 3. Septic embolic involvement of bilateral kidneys. 4. DIC. 5. Acute respiratory distress syndrome. 6. Metabolic acidosis. 7. Hyperkalemia secondary to acute renal failure. 8. Myositis. 9. Respiratory failure requiring intubation. 10. Left tension pneumothorax. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-697 Dictated By:[Last Name (NamePattern1) 6829] MEDQUIST36 D: [2108-5-9] 15:16:34 T: [2108-5-10] 09:00:23 Job#: [Job Number 6830] ICD9 Codes: 4275, 5845, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7750 }	Medical Text: Admission Date: [2128-4-15] Discharge Date: [2128-4-20] Date of Birth: [2056-7-8] Sex: F Service: MEDICINE Allergies: Penicillins / Bee Pollens / Keflex Attending:[First Name3 (LF) 425] Chief Complaint: Transfer from [Hospital1 1474] with NSTEMI / acute SOB Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: 71 female with h/o CAD s/p CABG in [7-/2127] presents as a transfer from [Hospital1 1474] where she was evaluated for acute shortness of breath. Over the past two weeks (afer recovering from a viral gastroenteritis) she has had several episodes of throat tightness that appear to come on while she is bending forward, which is similar to how her MI was manifest in [2127-7-4]. The episodes last for about 5 minutes and get better with some rest and water. She had mentioned this to her PCP, [Name10 (NameIs) 1023] recommended an exercise stress test for this upcoming week. Then yesterday, she had an active day without any problems, and again experienced throat tightness and ear fullness when bending over to get the newspaper. When she got back inside, she developed acute shortness of breath, called her daughter and then 911. . [Hospital1 ] COURSE: Intubated on arrival. ABG 7.14/60/69 -> 7.28/40/77 on Fi02 100%. Shortly after intubation she became hypotensive and bradycardic, requiring neosynephrine. Her ECG showed ischemic changes in lateral precordial leads (ST depression >2mm); her cardiac enzymes were elevated (CK 600s, MB 35); she was started on heparin gtt, given aspirin, plavix, IV lopressor q 6h, continued on statin. She was also given nebs and IV solumedrol. . ROS: She had N/V/diarrhea with myalgias 2.5 weeks ago. Otherwise, denies recent fevers, chills, lightheadedness, palpitations, orthopnea, PND, claudication. She has chronic lower extremity edema, that gets worse during day. She denies rash, new medications, cough, sick contacts. Past Medical History: CAD s/p 4 vessel CABG [7-/2127] (LIMA->LAD, SVG->OM1, SVG->OM2, SVG->PDCA) Congestive Heart Failure, EF 40% Hypertension Right Carotid Disease DM2 Social History: Lives alone. Denies EtOH, tobacco Family History: Father with MI at age 65; mother with renal failure (unknown etiology). Physical Exam: PHYSICAL EXAM VS- 115/54 73 16 96% GEN- Intubated, not sedated, alert, oriented, conversing by writing HEENT- intubated, anicteric, face symmetric NECK- supple, thick, JVP flat CV- RRR, II/VI early systolic murmur along LSB, no S3 or S4 CHEST- Relatively clear anteriorlly ABD- obese, soft, NT, ND, pos BS x 4 EXT- no C/C; tr edema on right; 1+ edema on left; femoral arteries without bruit; 1+ dp pulses bilaterally; no calf tenderness NEURO- AAO x 3, MAEW, EOMI, PERRLA SKIN- Mult echymoses Pertinent Results: [2128-4-15] 06:45PM BLOOD WBC-22.8# RBC-3.86# Hgb-12.7# Hct-36.7# MCV-95 MCH-32.8* MCHC-34.5 RDW-13.1 Plt Ct-308 [2128-4-16] 05:32AM BLOOD WBC-19.7* RBC-3.51* Hgb-11.3* Hct-33.3* MCV-95 MCH-32.3* MCHC-34.0 RDW-13.0 Plt Ct-298 [2128-4-18] 05:35AM BLOOD WBC-8.6 RBC-3.14* Hgb-10.2* Hct-30.1* MCV-96 MCH-32.5* MCHC-33.9 RDW-12.8 Plt Ct-248 [2128-4-15] 06:45PM BLOOD Neuts-92.9* Bands-0 Lymphs-4.3* Monos-2.5 Eos-0.1 Baso-0 [2128-4-15] 06:45PM BLOOD PT-16.6* PTT-150* INR(PT)-1.5* [2128-4-17] 06:00AM BLOOD PT-11.6 PTT-23.5 INR(PT)-1.0 [2128-4-15] 06:45PM BLOOD Glucose-145* UreaN-36* Creat-1.3* Na-141 K-3.7 Cl-103 HCO3-26 AnGap-16 [2128-4-18] 05:35AM BLOOD Glucose-112* UreaN-26* Creat-1.0 Na-141 K-4.0 Cl-102 HCO3-32 AnGap-11 [2128-4-15] 06:45PM BLOOD ALT-40 AST-81* LD(LDH)-361* CK(CPK)-523* AlkPhos-70 Amylase-122* TotBili-0.5 [2128-4-15] 06:45PM BLOOD Lipase-18 [2128-4-15] 06:45PM BLOOD CK-MB-20* MB Indx-3.8 cTropnT-2.01* [2128-4-16] 05:32AM BLOOD CK-MB-11* MB Indx-3.7 cTropnT-1.70* [2128-4-16] 07:25PM BLOOD CK-MB-8 [2128-4-15] 06:45PM BLOOD Albumin-3.6 Calcium-8.5 Phos-4.5 Mg-1.9 [2128-4-18] 05:35AM BLOOD Albumin-3.2* Calcium-9.0 Phos-3.2 Mg-2.2 [2128-4-15] 06:45PM BLOOD TSH-1.8 [2128-4-15] 07:22PM BLOOD Type-ART Temp-36.7 Rates-10/ Tidal V-500 PEEP-8 FiO2-40 pO2-86 pCO2-39 pH-7.43 calHCO3-27 Base XS-1 -ASSIST/CON Intubat-INTUBATED [2128-4-16] 07:06AM BLOOD Type-ART Rates-10/ Tidal V-500 PEEP-8 FiO2-40 pO2-104 pCO2-42 pH-7.44 calHCO3-29 Base XS-3 -ASSIST/CON Intubat-INTUBATED [2128-4-15] 07:22PM BLOOD freeCa-1.15 . CATH: [4-16] . COMMENTS: 1. Selective coronary angiography of this right dominant system revealed native three vessel coronary artery disease. The LMCA had 70% ostial stenosis. The LAD had heavily calcified proximal 90% and 100% mid segment stenoses. The LCX had tubular 30-40% mid stenosis before the OM1. The RCA had 90% ostial and 70% rPDA stenoses. 2. Selective vein graft angiography demonstrated occluded SVG to RCA, OM1, and OM3. 3. Selective arterial conduit angiography revealed patent LIMA-LAD with diffuse 70% stenosis spanning anastomosis. 4. Resting hemodynamics demonstrated normal right and left sided pressures (mean RA pressure was 7mmHg, mean PCWP was 9mmHg, and LVEDP was 15mmHg). There was no evidence of pulmonary hypertension (mean PAP was 17mmHg). The cardiac index was elevated at 4.5 L/min/m2. There was no significant gradient across the aortic valve on pullback of the catheter from the left ventricle. 5. Left ventriculography demonstrated no mitral regurgitation. There was mild inferior wall hypokinesis. Calculated ejection fraction was 55%. 6. Succesful stenting of the ostial RCA with a 3.5 mm Cypher drug-eluting stent. 7. Successful stenting of the LMCA with a 3.0 mm Cypher drug-eluting stent, which was post-dilated to 3.5 mm. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Normal left ventricular systolic and diastolic function. 3. Patent LIMA to LAD. 4. Occluded SVG-OM1, SVG-OM2, and SVG-RCA. 5. Step-down oxygen saturation from SVC to PA. 6. Successful stenting of the RCA. 7. Successful stenting of the LMCA. . TTE: [4-16] . Conclusions: 1. The left atrium is mildly dilated. 2. 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 apical myocardium has focal a hyperechoic region. 3. Right ventricular systolic function is normal. 4 The aortic root is moderately dilated. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation seen. 6.The mitral valve leaflets are structurally normal. Trace mitral regurgitation seen. 7.There is no pericardial effusion. . CXR [4-18]: . Compared to the film from the prior day, there is no significant change in the mild cardiomegaly and blunting of the left CP angle. Continues to be bilateral lower lobe volume loss. There is no focal infiltrate. . Exercise-/Nuclear MIBI [4-19]: . SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB: Exercise protocol: modified [Last Name (un) 32495] Resting heart rate: 74 Resting blood pressure: 120/64 Exercise duration: six min. Peak heart rate: 106 Percent max predicted HR: 71% Peak blood pressure: 180/70 Symptoms during exercise: none. Reason exercise terminated: achieved target submaximal heart rate and double product ECG findings: no significant ST segment changes from baseline. . INTERPRETATION: Imaging Protocol: Gated SPECT Resting perfusion images were obtained with Tl-201. Tracer was injected 15 minutes prior to obtaining the resting images. Exercise images were obtained with Tc-[Age over 90 ]m sestamibi. . Resting and stress perfusion images reveal a moderate predominantly fixed perfusion defect of the distal anterior wall that extends to the apex . Gated images reveal normal hypokinesis of the distal anterior wall. The calculated left ventricular ejection fraction is 51%. . IMPRESSION: . Moderate, predominantly fixed perfusion defect of the distal anterior wall that extends to the apex (at the level of exercise achieved). Hypokinesis of the distal anterior wall with LVEF of 51%. . Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2128-4-20] 06:40AM 7.4 3.21* 10.3* 30.6* 95 32.0 33.6 13.0 307 . Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2128-4-20] 06:40AM 119* 20 0.9 143 3.8 104 26 17 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2128-4-16] 07:25PM 158* [2128-4-16] 05:32AM 294* OTHER ENZYMES & BILIRUBINS Lipase [2128-4-15] 06:45PM 18 CPK ISOENZYMES CK-MB MB Indx cTropnT [2128-4-16] 07:25PM 8 [2128-4-16] 05:32AM 11* 3.7 1.701 1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2128-4-20] 06:40AM 9.0 3.2 1.9 PITUITARY TSH [2128-4-15] 06:45PM 1.8 . Brief Hospital Course: IMPRESSION/PLAN: 71F with CAD, CABG x 3 on [7-7] who presented with atypical angina including throat pain, found to be in acute pulmonary edema thought to be related to ACS. Her cardiac enzymes were elevated and patient was subsequently intubated. She was taken to a cardiac catherization and was found to have her 3 grafts down. Patient's was subsequently extubated on [4-16] and remained symptoms free. Her stress test did not show any reversible ischemia and patient will be further managed as outpatient. . NSTEMI: Patient has atypical symptoms including throat tightness that are difficult to equate to her angina. Her peak CKs 523, MBs 3.7, Troponin 1.7. Her EKG initially showed LA enlargement with RBBB, ST depressions in inferior leads along with T wave fastening in II, III, and aVF. Her enzymes were already elevated at [Hospital 1474] hospital and she was started there on heparin gtt, and loaded with plavix, she was also started on integrillin gtt upon arrival to [Hospital1 18]. Patient on cath was found to have occluded SVG to OM and RCA, patent LIMA-LAD. She had cypher stents placed in RCA and LM, with good result. She was continued on ASA, plavix, beta blocker, statin and lisinopril. A limited stress test was done on [4-19] which showed moderate, predominantly fixed perfusion defect of the distal anterior wall that extended to the apex (at the level of exercise achieved). She also had Hypokinesis of the distal anterior wall with LVEF of 51%. Patient upon d/c had improvement in ST depressions inferiorly with persistence of RBBB. Patient was asymptomatic upon d/c and will follow up with Dr. [Last Name (STitle) ], her outpatient cardiologist. . RESPIRATORY FAILURE: Likely due to ACS / acute pulm edema. We also considered pulmonary embolism (no recent risk factors or suggestive history), infection (no cough, only one isolated fever at [Hospital1 1474]). She improved by the time she was transferred to [Hospital1 18], and remained intubated overnight for ease at catheterization. She was successfully extubated after the cath. Diuresis also helped her respiratory/oxygenation status. . CONGESTIVE HEART FAILURE: Patient had history of systolic (EF 30% in [Month (only) 205]) heart failure with presumed with diastolic dysfunction. After the acute event echo showed EF 55% on [4-18] Echo with trace MR, E:A 1.1 (Although her MIBI showed EF of 51%). Patient initially appeared to be volume overloaded and her diastolic heart failure was managed with lasix diuresis. Upon discharged patient was in no respiratory distress ambulating without dyspnea and no orthopnea was exhibited. Her leg edema was marked improved and only trace remained. She is to continue on her BB, her AceI and to monitory daily weights along with a low sodium diet. . RATE - NSR with RBBB, no tele events were observed. nl TSH. . HTN - long standing, well controlled with BB and Ace. . NECK MASS - patient's exam is concerning for a thyroid goiter. Patient's TSH was normal. Patient may benefit from an outpatient ultrasound for a cold goiter. . RENAL INSUFFICIENCY: Baseline Cr 0.9-1.0, presented at 1.3. Most likely due to poor perfusion in setting of relative hypotension. [Name2 (NI) ] urine output remained fine. She was given mucomyst peri-cath. Her Cr. eventually improved to a baseline level of 0.9. . DM2: NIDDM - while in house covered with Regular insulin sliding scale. Patient is to resume her metformin upon d/c. . FULL CODE . DISPO: patient to be d/c home. She will follow up with her cardiologist and her PCP. Medications on Admission: MEDS at HOME: Lasix 60 qam, Lopressor 75 [Hospital1 ], Lipitor 10 qd, Metformin 500 [Hospital1 ] Discharge Medications: 1. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s)* Refills:3 2. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:90 Tablet(s) Refills:3 3. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:3 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:3 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:3 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:3 7. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day. Disp:45 Tablet(s) Refills:3 Discharge Disposition: Home Discharge Diagnosis: Non ST elevation myocardial infarction Heart Failure - Diastolic Repiratory Failure Cardiogenic Shock Probable multinodular goiter Discharge Condition: Good, ambulating with symptoms. Discharge Instructions: Please come back to the hospital or see your primary care provider if you develop any chest discomfort, shortness of breath, palpitations, lightheadedness, nausea/vomiting, sweating or any other concerns. . Please take all of your medications as prescribed. You must take your aspirin and Plavix every day. Do not stop these medications without talking to your cardiologist first. . You should also take your lasix/furosemide daily because you have a mild heart failure and you should watch your weight daily. If you experience noticeable leg swelling, experiencing worsening shortness of breath especially on exertion or weight increase of >3 lbs please contact your doctor. Followup Instructions: Recommend evaluation of neck mass by ultrasound. Please follow up with Dr. [Last Name (STitle) ] on [2128-5-5] @ 1:30 pm. Completed by:[2128-4-21] ICD9 Codes: 4280, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7751 }	Medical Text: Admission Date: [2183-1-30] Discharge Date: [2183-2-20] Date of Birth: [2144-8-25] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2290] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: - Central line placement - A-line placement - Chest tube placement - PICC line placement - Thoacentesis - Transesophageal echocardiogram History of Present Illness: INITIAL HPI: 38yo M with h/o MRSA, recurrent boils, s/p hernia repair, s/p multiple I&D's, Hep C [1-8] stab wound(?per OSH note), and coccyx and neck pain [1-8] recent fall for past 3 days, who is transferred from [Hospital1 ] [Location (un) 620] unresponsive. He was recently given several Rx of dilaudid for the pain after fall doing roof work(28 doses of 2g dilaudid in bottle), refilled w/ add'l 12 tabs. Unclear how pt fell, if fell on head, or other details. Pt was found on ground this morning by his girlfriend, with emesis on floor next to the patient, unknown time he was down. Dilaudid bottle missing, and valium bottle empty. Pt given Narcan by EMS and awoke en route to ED. . In [Hospital1 ] [Location (un) 620] ED, less responsive, incomprehensible speech. Pt admitted to beer and cocaine use 5 days prior on Saturday. Pt has h/o heroin, cocaine IV use and skin popping. In ED there, VS 151/104 HR 149, Temp 100.8, 95% RA, RR 40-50s, small pupils on exam, dry MM, lungs w/decreased BS at bases, sinus tachy, lethargic on exam, but was following commands, 5/5 strength throughout, skin lesions on legs, arms due to skin popping. Labs remarkable for WBC 19.9 with 16 bands, Cr 1.1, Trop <0.01, CK 201 and repeat CK 193 with Trop 0.011. Serum Tox Alcohol <10, negative for salicylates and acetaminophen. UTox screen positive for Benzo's, cocaine, and opiates. Serum Tox EKG showed sinus tach at 150. CXR with L consolidation, unclear if true infiltrate due to penetration. Pt was intubated for airway protection after continued tachypnea remarked up to 60 and ill appearing, tachycardic to 160s. He received one dose of Vanc 1g q12h (1400), Flagyl 500mg IV q8hr (1800), and CTX 2g IV q24h planned but don't see order written; other places written all 3 given at 1900. Received Zofran, Clonidine 0.1mg po x1, Valium 2.5mg IV x3, Valium 5mg IV x1, Tylenol 650mg pr, Morphine 5mg IV x1, fentanyl and versed gtt, then switched to propofol. Increased propofol to 30mg/kg/min for increased RR and cont'd PIP 30-40. Given Nexium 40mg IV, and IVF running. . On transfer to MICU, pt intubated, sedated, not responsive to any commands. Initial VS 102.4, HR 134, BP 85/54, RR 25, 79%-->98% on vent. Vent settings AC RR 24, Tv 550, PEEP 5, FiO2 70%. ABG 7.34/45/194/25. Labs on admission remarkable for Cr 1.5, Trop 0.02 with flat CK and MB, INR 1.7, fibrinogen 352 (nl), plts 154. . Unable to obtain ROS given pt intubated and sedated. . Past Medical History: Heroin, Cocaine IV use, oral and skin popping Smoking history 1/2-1 ppd x25yrs (amt conflicting in various notes) Alcohol history History of MRSA with repeated Boils, s/p Multiple I&D's, s/p decolonization procedure in [8-/2182], unclear if pt completed protocol S/p hernia repair and lipoma removal [3-/2182] Social History: Lives at home with his girlfriend, and her children. He is employed as a tree-cutter. They are 12, 10, 3. None of them have had problems with MRSA infections. The three-year-old is in preschool; the other two are in elementary school. They have no pets at home. -Tobacco history: [12-8] ppd x25yrs -ETOH: amount known -Illicit drugs: IV cocaine, heroin, prescriptions narcotics Family History: Father - [Name (NI) 86183] died when patient aws 8 Maother - CVA and T2DM Sibs - well Physical Exam: ADMISSION VS: T=102.4 BP=85/54 HR=134 RR=25 O2 sat= 79%--> 98% on AC vent settingsGENERAL: intubated, sedated, not responsive to any commands, diaphoretic HEENT: NCAT. Sclera anicteric. pupils 2mm, mildly reactive Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP unable to appreciate given body habitus CARDIAC: Tachycardic, difficult to appreciate heart sounds over BS, +S1 S2, unable to appreciate a murmur LUNGS: Intubated, overbreathing vent, coarse BS diffusely ABDOMEN: +BS, obese, Soft, non-distended. No appreciable HSM. EXTREMITIES: Warm, diaphoretic, 2+ DP and PT pulses b/l NEURO: unresponsive, pupils symmetric, reactive, toes downgoing, no clonus . DISCHARGE: GEN: NAD, pleasant, in the chair VS: T 97.9 Tm 98.1 P 91 (79-100) BP 130/75 (124-148/60-83) R 20 96% 3L HEENT: MMM, no OP lesions, no LAD, JVP not elevated, tender in the Cspine and paraspinal muscles CV: RR, no MRG PULM: Diffusely poor air movement with bronchial BS at the L apex ABD: BS+, NTND, no HSM LIMBS: no LE edema, no tremors or asterixis NEURO: LEs are [4-10] bilaterally, toes are down bilat, RUE is 4+/5 strength and LUE is 4-/5 Pertinent Results: ADMISSION LABS: [2183-1-31] 02:48AM BLOOD WBC-9.8 RBC-4.14* Hgb-12.3* Hct-35.9* MCV-87 MCH-29.7 MCHC-34.2 RDW-13.2 Plt Ct-154 [2183-1-31] 02:48AM BLOOD PT-18.9* PTT-39.1* INR(PT)-1.7* [2183-1-31] 02:48AM BLOOD Glucose-105* UreaN-34* Creat-1.5* Na-137 K-4.2 Cl-102 HCO3-27 AnGap-12 [2183-1-31] 02:48AM BLOOD ALT-49* AST-37 LD(LDH)-217 CK(CPK)-191 AlkPhos-73 TotBili-0.7 [2183-1-31] 02:48AM BLOOD Calcium-7.7* Phos-3.7 Mg-1.7 DISCHARGE LABS; [2183-2-20] 06:36AM BLOOD WBC-9.2 RBC-3.07* Hgb-9.1* Hct-27.4* MCV-89 MCH-29.7 MCHC-33.2 RDW-17.1* Plt Ct-732* [2183-2-20] 06:36AM BLOOD Glucose-89 UreaN-10 Creat-0.7 Na-135 K-4.7 Cl-98 HCO3-29 AnGap-13 [2183-2-20] 06:36AM BLOOD ALT-65* AST-33 [2183-2-20] 06:36AM BLOOD Calcium-8.9 Phos-5.1* Mg-2.0 INFLAMMATORY MARKERS ON DISCHARGE: [2183-2-20] 06:36AM BLOOD ESR-24* [2183-2-20] 06:36AM BLOOD CRP-11.3* [2183-2-20] 06:37AM BLOOD Vanco-22.5* INFECTIOUS MARKERS: [2183-1-31] 05:03PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2183-2-13] 04:40AM BLOOD HIV Ab-NEGATIVE [2183-1-31] 05:03PM BLOOD HCV Ab-POSITIVE* MICROBIOLOGY: [2183-1-31] 2:48 am BLOOD CULTURE STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. SENSITIVE TO Daptomycin @ .38 MCG/ML TELAVANCIN = SENSITIVE AT 0.25 MCG/ML CLINDAMYCIN-----------<=0.25 S DAPTOMYCIN------------ S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S LINEZOLID------------- 1 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [2183-1-31] 8:05 am SPUTUM STAPH AUREUS COAG + CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [2183-2-11] 3:28 pm PLEURAL FLUID STAPH AUREUS COAG + CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S FIRST NEGATIVE BLOOD CULTURE [2183-2-7] 4:30 am BLOOD CULTURE Source: Line-TLC. FINAL REPORT [2183-2-13] Blood Culture, Routine (Final [2183-2-13]): NO GROWTH. IMAGING: TTE [2183-1-31] No thrombus/mass is seen in the body of the left atrium. No mass or thrombus is seen in the right atrium or right atrial appendage. There is moderate global left ventricular hypokinesis (LVEF = 30-35 %). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are free of atherosclerotic plaque to 45 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is a small pericardial effusion. IMPRESSION: No echocardiograpic evidence for endocarditis seen. There is moderate global ventricular hypokinesis. Head CT - [2183-2-1] IMPRESSION: No hemorrhage. Hypodensity in the right cerebellum consistent with acute infarct. Mild prominence of temporal horns. Consider MRI for further evaluation. CT Torso - [2183-2-1] IMPRESSION: 1. No evidence of intra-abdominal abscess. 2. Multiple diffuse pulmonary nodules, some of which are cavitary. Would strongly favor an embolis, infectious process; however, necrotic metastases could also give this appearance. 3. Bilateral pleural effusions with associated compressive atelectasis. 4. Eccentric thickening of the medial wall of the cecum without significant inflammatory changes. Normal ileocecal valve. Direct visualization should be considered with colonoscopy, or CT colonography. MRI Total Spine - [2183-2-1] IMPRESSION: 1. Extensive epidural abscess, predominantly in the thoracic and upper lumbar region posterior to the thecal sac with compression of the thecal sac, with a thin rim in the cervical region with diffuse meningeal enhancement throughout the spine. 2. Signal changes at C7-T1 vertebral bodies and in the C6-C7 and C7-T1 intervertebral discs are suspicious for early changes of discitis or osteomyelitis. 3. Compression of the thecal sac with some indentation on the spinal cord seen, but no definite abnormal signal within the spinal cord at this juncture, although evaluation is limited due to large field of view. 4. Extensive soft tissue changes predominantly at the posterior soft tissues of the cervical and upper thoracic region with small foci of fluid collections less than 1 cm indicating soft tissue abscesses. 5. Bilateral pulmonary changes, which can be better evaluated with correlation with chest CT. CT Head - [2183-2-3] IMPRESSION: 1. Bilateral posterior cerebellar infarcts, right greater than left. The left infarction is new compared to MR from [2183-2-1]. There is no associated hydrocephalus or compression of the fourth ventricle. 2. Mucosal thickening of the sphenoid sinuses and opacification of multiple mastoid air cells could represent an ongoing inflammatory process. CT Head - [2183-2-5] IMPRESSION: 1. Further evolution of the infarcts involving both cerebellar hemispheres, likely more acute on the left, with no significant mass effect or evidence of obstructive hydrocephalus. 2. Progressive fluid within the sphenoid and mastoid air cells, likely related to prolonged intubation and supine positioning. CT Chest - [2183-2-7] IMPRESSION: 1. Progression in size of multiple bilateral septic emboli with increased coalescence of these emboli in the right upper and middle lobes. 2. New air- and fluid-filled cavitary lesion within the anterior mediastinum, likely contiguous with cavitary lesions from the lingula. No pericardial effusion, although the anterior pericardium is somewhat displaced by this fluid- and air-filled cavity. 3. Moderate bilateral pleural effusions, larger on the left. Bibasilar atelectasis. 4. Mediastinal adenopathy. MRI Spine - [2183-2-9] IMPRESSION: 1. Persistent extensive epidural abscess formation identified from the posterior fossa throughout the lumbar spine, with a more organized fluid collection in the posterior fossa as described above, associated ischemic changes in the right cerebellar hemisphere. 2. Again, signal changes are demonstrated at C7/T1 vertebral bodies and intervertebral disc spaces concerning for discitis and osteomyelitis. 3. Extensive soft tissue changes involving the anterior and posterior compartments, with multiple foci of fluid collections, slightly larger at the level of C3 on the left, indicating soft tissue abscesses. 4. Bilateral lung changes, better depicted in the prior chest CT. TEE - [2183-2-11] No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. IMPRESSION: No vegetations or abscesses. MRI C-spine - [2183-2-13] IMPRESSION: 1. Widespread extensive ongoing infective process extending from the posterior fossa to the posterior cervical epidural space with multiple subcutaneous fluid collections. Slight interval reduction in the size of spinal epidural abcess in the upper cervical spine and minimal improvement in the prevertebral infective process. Stable small epidural collection in the posterior fossa. No new collections. 2. Bilateral cereballar infarctions, right more involved than left, could be related to spreading vascular inflammation along the distal vertebral arteries or their branches. 2. Extensive muscle enhancement in the neck and soft tissues suggest myositis. 3. Increased signal at C7-T1 vertebral bodies suggests osteomyelitis. Generalised low signal in the remaining vertebral bodies from marrow replacement, related to anemia or marrow infiltrative process. CT CHEST W/O CONTRAST - [2183-2-14] Again noted are numerous large and small cavitary lesions, most severely in the right upper lobe, but also seen in all other lobes, compatible with the known history of numerous septic pulmonary emboli. Many of the cavitary lesions have interval fluid filling. In addition to the existing nodular opacities of various size, there is evidence of new small nodular opacities, concerning for ongoing infectious process. There is interval placement of bilateral chest tubes, with tips in the lung bases. Overall improved aeration is most pronounced in the lung bases. The previously moderate-to-large bilateral pleural effusions have decreased to small-to-moderate. Potential loculation or empyema cannot be completely evaluated without IV contrast. No definite pneumothorax is noted. The heart remains normal in size without significant pericardial effusion. Numerous prominent mediastinal lymph nodes measure up to 10 mm in the precarinal station (4:84) and 9 mm in the left prevascular station (4:84), most likely reactive to the ongoing infection. Bihilar lymph nodes are noted, but incompletely assessed without IV contrast. The unopacified great mediastinal vessels are grossly unremarkable. A right-sided PICC line terminates in the lower SVC/cavoatrial junction. A left-sided IJ line terminates in the mid SVC. The study is not designed for subdiaphragmatic diagnosis, but no gross abnormality is noted. BONE WINDOW: There are no bone lesions suspicious for metastasis or infection. IMPRESSION: 1. Interval placement of bilateral chest tubes, with moderate decrease of bilateral pleural effusions. Interval improved aeration in the lung bases. 2. Interval fluid-filling of the cavitary lesions with evidence of new small nodular opacities. The lack of apparent CT improvement raises the concern for ongoing infection despite antibiotic treatments. CHEST (PA & LAT) - [2183-2-19] As compared to the prior radiograph, the pigtail catheter has been removed. Overall, multifocal consolidations and known cavitary lesions are re-demonstrated although there is slight improvement in the right lower lung involvement. The rest of the findings are unchanged. Cardiomediastinal silhouette is stable. There is a large basal opacity better appreciated on the lateral view which is consistent with known combination of pleural effusion and adjacent consolidation in the paraspinal location but overall appears to be slightly smaller than on the prior imaging. Brief Hospital Course: MEDICINE COURSE: 38M with a history of IVDU with cocaine, MRSA skin abscesses, and a recent fall treated with narcotics who was admitted after being found down. Ultimate etiology seems to have been narcotic OD and MRSA bacteremia. He was found to have septic emboli to the lungs, cerebellum, and cervical and throacic spines. His TEE was negative making endocarditis less likely; it is possible that his source of high grade bactermia was his extensive osteomyelitis. # MRSA endocarditis v high grade bacteremia. TEE negative but with bacteremia and various septic emboli (epidural abscess, pulmonic emboli, cerebellar infarct, epidural abscess and most likely C7-T1 osteomyelitis). Last blood culture positive [2183-2-6]. Neurosurgery has deferred debridement of the C and T spine and recommended prolonged antibiotics. Treated initially with linezolid then vancomycin plus daptomycin for better lung penetration. Now narrowed to vancomycin alone. Surveillance blood cultures have continued to be negative. Continue Vancomycin 1500 mg IV Q 8H with goal trough 20. Plan to continue to at least [2183-3-27]. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Hospital1 18] will manage troughs and determine ultimate length of treatment. The patient has follow up with Dr. [Last Name (STitle) ] on [2183-3-10]. The patient will need weekly screening blood cultures every Thursdays, inflammatory markers including CRP and ESR every Thursday, and vancomycin troughs twice weekly on Mondays and Thursdays. Results should be faxed to Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 17715]. # Cervical and thoracic spine osteomyelitis/ Neck pain: Osteomyelitis treated as above; followed by neurosurgery as well as infectious disease specialists. He continued to complain of neck and upper back pain during his admission, which was believed to be due to C-T spine osteo. Pain is relatively well controlled on methadone and nabumatone with dilaudid PO for breakthrough. Continue Methadone 20 mg PO/NG TID, increased from 10 mg PO TID on the PM of [2-19]. Continue nabumatone 750 mg PO BID as NSAID for pain control. Breakthrough pain control with Acetaminophen 325-650 mg NG/PR Q6H:PRN and HYDROmorphone (Dilaudid) 4 mg PO/NG Q3H:PRN. . # MRSA PNA and empyema: Of note, he required two weeks of intubation and mechanical ventillation for his severe pneumonia and sepsis. Extubated [2183-2-14]. Pleural fluid growing MRSA. Had b/l pigtail catheters in place which were DCed [2183-2-18]. CXR to evaluate for PTX s/p DC of chest tubes [2183-2-19] showed no PTX and stable lung infiltrates. Treat with vancomycin as above. Initially on daptomycin and linezolid. Linezolid was discontinued due to rising transaminases and vancomycin was started. Ultimately narrowed to vancomycin alone as above. Continue Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN and Ipratropium Bromide Neb 1 NEB IH Q6H:PRN. The patient was requiring oxygen at the time of discharge. This should be assessed with resting and ambulatory oxygen saturations prior to discharge from the rehabilitation facility. # Hypertension: Has labile pressures that are up and down based on fevers and withdraw symptoms. BP now well controlled with clonidine to 0.1 mg PO TID (started to treat withdrawal). # Elevated transaminases, ALT>AST. Not obstructive. Known HCV positive by viral load. HIV negative. Could have been related to linezolid which was discontinued. Transaminases normalized as of [2183-2-19]. # Neurologic status/myopathy: Weaker L >R in UE proximally. MRI shows some myositis. Likely multifactorial with some degree of myopathy likely present due to long ICU stay. Has persistent weakness and poor coordination of the left hand likely due to his right cerebellar infarct. This was believed to be due to his bacteremia and related to a septic infarct. # Atrial fibrillation with RVR: Now sinus rhythm. Was started on amiodarone in the ICU which was discontinued due to QTc prolongation. There were no further episodes after amiodarone discontinuation. # Anemia and thrombocytosis: HCT drop from 40 at presentation to 22 [2183-2-13] - stable since then. Most likely anemia of inflammation given reactive thrombocytosis. # Substance abuse. Pt admitted to recent cocaine and possibly heroin injection. Continue clonidine as above. Pt has been advised that he could die of he chooses to continue to use drugs. Medications on Admission: None By report, using Dilaudid Discharge Medications: 1. heparin lock flush 10 unit/mL Solution Sig: Two (2) mL Intravenous per lumen: Flush with 10mL normal saline followed by heparin daily and PRN. 2. Saline Solution Solution Sig: Ten (10) mL Miscellaneous per lumen: Flush with 10mL normal saline followed by heparin daily and PRN. 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing/sob. 4. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing/sob. 5. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. nabumetone 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): hold for sedation. 12. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for breakthrough pain. 13. vancomycin in 0.9% sodium Cl 1.5 gram/250 mL Solution Sig: 1500 (1500) mg Intravenous every eight (8) hours: continue until at least [2183-3-27] and do not DC until asked to do so by Dr. [Last Name (STitle) ] at [Hospital1 18]. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary: - High grade MRSA bacteremia - Possible MRSA endocarditis - MRSA pneumonia - MRSA empyema - MRSA osteomyelitis - Septic embolic cerebellar CVA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you at [Hospital1 827]. You were admitted after being found unrepsonsive. We found that you had a life threatening infection with MRSA, a drug resistant Staph bacteria. This infection came from injecting yourself. This infection spread to your lungs and caused a severe pneumonia as well as destruction of part of your lung tissue, your chest leading to a condition called empyema which was treated with chest tubes, your brain leading to an infected stroke, and to the bones of your spine leading to a condition called osteomyelitis. You may also have had an infection of your heart by MRSA. You will need 8 to 12 weeks of IV vancomycin, a potent antibiotic to treat this. You have a PICC line - or long term intravenous access line - to receive this therapy. Followup Instructions: Department: INFECTIOUS DISEASE When: MONDAY [2183-3-10] at 9:30 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: FRIDAY [2183-4-11] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 27625], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2183-2-20] ICD9 Codes: 5849, 5119, 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7752 }	Medical Text: Admission Date: [2139-9-13] Discharge Date: [2139-9-15] Date of Birth: [2063-11-18] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: sepsis, hypoxia Major Surgical or Invasive Procedure: 1. intubation 2. chest tube for pneumothorax 3. central line 4. arterial line History of Present Illness: HPI: 75yo woman with history of HTN, diverticulosis, squamous cell CA of skin, h/o expl. lap for appendicitis, "psychosis", presented from the [Hospital3 ] facility with respiratory distress. Per outside records, she had acute onset of respiratory distress today at 1pm. She has also had 2 days of non-productive cough and low grade fever. Chest film done there demonstrated bilateral pleural effusions and bibasilar infiltrates. She also had a WBC of 18.9 with 85% pmn's. She was started on Levaquin 500mg qD. Vitals at ALF were 99.3, 64, 100/60, 18, and 93% on RA -> 79% on RA with acute episode of respiratory distress. . On admission to the ED, she was in respiratory distress. Admission vitals were 104 (rectal), 117/80, 105, 32, 83% on NRB. After intubation, a chest film demonstrated a large right pneumothorax. She had a needle decompression, then placement of a right chest tube. . She also had evidence of sepsis with fever to 104.8, pulse in 120's, initial lactate of 6.5, and hypotension to 60's systolic despite NS boluses; she was started on peripheral dopamine. A sepsis-line TLC was placed in the ED. She was given 3L NS boluses. . She also had coffee grounds per NG tube, and was guaiac negative by rectal exam. Baseline Hct per outside records of 38.9. In ED, she had gastric lavage revealing coffee grounds that cleared with continued lavage. No known history of cirrhosis or varices. . Past Medical History: Past Medical History: Hypertension polyps on colonoscopy diverticulosis sqaumous cell CA on the face s/p [1-30] stage removal hx of exlporatory laparotomy for appendicitis cyst on her uterus "psychosis", SI Social History: The patient was born and raised in the [Location (un) 86] Area. She has 2 sisters ages 85, and 65. She is currently living with her 85 year old sister who is in a wheelchair and her brother-in-law who has multiple medical problems. The patient moved to New Jersey after finishing high school where she lived with a friend for 5 years. They then moved to [Last Name (un) 33963], FL and she recieved associates degree and began a BA in elementary education in [Location (un) 95454], but did not complete this degree. She worked as a medical secretary, transcriber for 20 years in [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) 1688] in Ft. [Last Name (un) ]. She retired in [2120] and moved back to [Location (un) 86]. She moved back into the family home with her sister before obtaining an apartment on her own. She moved back into the family home in [2133] to help care for her sister and her husband. The patient was never married, never had children. Reports that her only relationship was with her friend whom she lived with in FLA. She reports that this was not a lesbian relationship and that she was merely a "companion". Denies hx of sexual or physical abuse Family History: Denies. Physical Exam: Physical exam: T 104(rectal), 120's sinus tachy, 16, 117/80, 100% on AC (500 x 18, 100%, 8 peep). . gen: intubated, sedated heent: perrla neck: right IJ - sepsis line placed chest: right chest with subcutaneous air/crepitus cv: regular tachycardia with no m/r/g resp: coarse breath sounds bilaterally with basilar crackles; reduced breath sounds in right lung field abd: obese, midline surgical scar. Hypoactive bowel sounds. No appreciable tenderness. No peritoneal signs extr: 1+ pitting edema bilaterally. extremities cool, mottled . Admission data: ekg: sinus tachycardia at 121bpm, nl axis, intervals; 2mm ST depression in V3-V6. . cxr: right pneumothorax with some shift of midline structures to left; otherwise, lungs are clear. Pertinent Results: [2139-9-13] 01:50PM LACTATE-6.5* [2139-9-13] 02:01PM FIBRINOGE-796* [2139-9-13] 02:01PM PT-18.5* PTT-36.6* INR(PT)-2.4 [2139-9-13] 02:01PM PLT COUNT-556* [2139-9-13] 02:01PM WBC-24.6# RBC-3.90 HGB-11.9* HCT-35.7* MCV-91# MCH-30.5# MCHC-33.4 RDW-13.0 [2139-9-13] 02:01PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2139-9-13] 02:01PM ALBUMIN-2.3* CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-1.5* [2139-9-13] 02:01PM LIPASE-16 [2139-9-13] 02:01PM CK-MB-7 cTropnT-0.45* [2139-9-13] 02:01PM ALT(SGPT)-17 AST(SGOT)-39 CK(CPK)-49 ALK PHOS-55 AMYLASE-13 TOT BILI-0.8 [2139-9-13] 02:01PM GLUCOSE-193* UREA N-21* CREAT-1.0 SODIUM-147* POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-20* ANION GAP-23* [2139-9-13] 02:12PM URINE MUCOUS-MANY [2139-9-13] 02:12PM URINE HYALINE-0-2 [2139-9-13] 02:12PM URINE RBC-0 WBC-[1-31] BACTERIA-FEW YEAST-NONE EPI-[1-31] RENAL EPI-0-2 [2139-9-13] 02:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-5.5 LEUK-NEG [2139-9-13] 02:12PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.025 [2139-9-13] 02:12PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2139-9-13] 02:12PM URINE HOURS-RANDOM ct scan: . Large right hydropneumothorax with right lower lobe atelectasis. A traumatic cystic lesion is seen within the right lower lobe. There is a suggestion of possible bronchopulmonary fistula. 2. Nasogastric tube with tip at the gastroesophageal junction, and should be advanced. 3. Extensive subcutaneous emphysema within the chest wall. 4. Moderate sized left pleural effusion and compressive atelectasis. 5. Diffuse fatty infiltration of the liver without evidence of focal hepatic masses. 6. Wedge compression deformity of the T12 vertebral body, age indeterminate. echo: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is mild aortic valve stenosis. Trace 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. Compared with the findings of the prior report (tape unavailable for review) of [2138-11-10], the degree of tricuspid regurgitation and pulmonary hypertension detected have increased. [2139-9-13] 02:12PM URINE HOURS-RANDOM [2139-9-13] 05:54PM TYPE-[Last Name (un) ] PO2-42* PCO2-40 PH-7.36 TOTAL CO2-24 BASE XS--2 COMMENTS-GREEN TOP [2139-9-13] 07:29PM CORTISOL-67.5* [2139-9-13] 07:29PM CALCIUM-7.5* PHOSPHATE-2.9 MAGNESIUM-1.3* [2139-9-13] 07:29PM LD(LDH)-276* [2139-9-13] 07:29PM GLUCOSE-221* SODIUM-145 POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-22 ANION GAP-17 [2139-9-13] 09:00PM CORTISOL-58.0* [2139-9-13] 09:30PM CORTISOL-58.5* Brief Hospital Course: 75yo woman presented with sepsis, pneumonia complicated by DIC. She was treated with pressors, IVFs and antibiotics. She developed a pneumothorax and required chest tube placement. She had persistent subcutaneous emphysema. She had rapid atrial fibrillation and developed eveidence of a myocardial infarct. Her deteriorated clincally and the team was unable to maintain her BP despite pressors. In a discussion with her nephew [Name (NI) ] [Name (NI) ], it wa decided to make her comfort measure. She was extubated and placed on morhine for comfort. She expired on [2139-9-15] at 7:45pm. Medications on Admission: ASA 81mg celexxa 30mg diltiazem 180mg metoprolol 25mg [Hospital1 ] abilify 15mg HS Ativan 0.5mg HS Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: pneumothorax atrial fibrillation septic shock DIC pneumonia ischemia Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2139-12-18] ICD9 Codes: 0389, 486, 5119, 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7753 }	Medical Text: Admission Date: [2187-10-21] Discharge Date: [2187-10-23] Date of Birth: [2119-5-22] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: Irregular Heart Rate Major Surgical or Invasive Procedure: none History of Present Illness: 68 year old female with history of coronary artery disease s/p stent and diabetes that recently had a Coronary artery bypass grafting x4: Left internal mammary artery graft to left anterior descending, reverse saphenous vein of the marginal branch, diagonal branch and left-sided PDA. This was done on [2187-10-16]. Pt did well from the procedure was discharged to Rehab on BB 12.5 [Hospital1 ]. She now presents to the ER with Atrial Fibrillation. Was on IV Diltiazem. She lost venous access. She recieved one dose of PO Diltiazem. Past Medical History: Coronary artery disease s/p CABG [2187-10-16] Atrial Fibrillation (post-op) PMH: Myocardial infarction [2164] s/p stent Psoriasis Pneumonia Diabetes Mellitus type 2 Hypertension Depression Chronic bone on bone pain - Right ankle after fracture Anxiety Social History: Last Dental Exam: 6 months ago Lives with: Alone (separated from spouse) Contact: [Name (NI) ] [Last Name (NamePattern1) ] Phone # [Telephone/Fax (1) 91723] cell [Telephone/Fax (1) 91724] Occupation: Intake coordinator Cigarettes: Smoked yes [x] last cigarette 25 years ago Hx: 20 pyh ETOH: < 1 drink/week [] [1-22] drinks/week [x] >8 drinks/week [] Illicit drug use none Family History: Father deceased 39 MI and pneumonia Mother deceased 62 MI Sister deceased 75 amyloidosis Son [Name (NI) 3495] failure Physical Exam: Pulse: 116 Resp: 18 O2 sat: 98 % RA B/P Right: 150/64 Left: 150/68 General: no acute distress sitting laying in bed Skin: Dry [x] multiple areas of red scaly areas scalp, left flank buttock, left elbow, ecchymosis under bilateral eyes s/p door hitting her in face HEENT: Left pupil 3mm right 2mm reactive to light bilateral EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [x] grade [12-21] Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] obese no palpable masses Extremities: Warm [x], well-perfused [x] Edema none deformity right ankle d/e fx Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: +1 Left: +1 DP Right: +1 Left: +1 PT [Name (NI) 167]: +1 Left: +1 Radial Right: +1 Left: +1 Carotid Bruit Right: no bruit Left: no bruit Pertinent Results: [2187-10-21] Chest CT Final Report INDICATION: [Hospital 30608] transferred from [Hospital6 19155] for AFib and RVR status post CABG. TECHNIQUE: MDCT-acquired axial images were obtained through the lungs prior to and in arterial phase after the uneventful administration of 100 cc of Optiray contrast medium. Coronal and sagittal reformations were prepared. COMPARISONS: Chest radiograph [2187-10-20]. FINDINGS: Thyroid gland is normal in appearance. The patient is status post CABG with surgical clips and native coronary calcifications noted along with median sternotomy wires. In the anterior mediastinum, fluid and air are seen compatible with post-surgical state along with trace pericardial effusion. The heart is moderately enlarged. Small pericardial effusion is noted. Pulmonary arterial enlargement to 3.7 cm is noted and suggests pulmonary arterial hypertension. The pulmonary vascular tree is well opacified without evidence of embolus. Innumerable tiny pulmonary calcified nodules are seen which are likely granulomata given their appearance. Trace right and small to moderate left pleural effusions are seen with fluid layering along the major fissure on the left. Mild compression atelectasis is noted in the left lower lobe. The aorta and major branches are unremarkable with normal three-vessel branching arch. No mediastinal, axillary, hilar, supraclavicular, or pathologic adenopathy with non-enlarged nodes noted. Though this study is not tailored for subdiaphragmatic evaluation, the imaged upper abdomen is unremarkable. OSSEOUS STRUCTURES: Aside from median sternotomy there is no bony abnormality. IMPRESSION: 1. No pulmonary embolus or acute aortic pathology. 2. Changes compatible with recent CABG including fluid and air in the anterior mediastinum. 3. Small to moderate left and trace right pleural effusions. 4. Enlarged pulmonary artery up to 3.7 cm suggesting underlying pulmonary arterial hypertension. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Name (STitle) 815] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: SUN [2187-10-21] 10:40 PM Imaging Lab [2187-10-23] 05:45AM BLOOD WBC-11.4* RBC-3.02* Hgb-9.3* Hct-27.5* MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-337 [2187-10-22] 01:03AM BLOOD WBC-10.6 RBC-3.23* Hgb-9.4* Hct-29.3* MCV-91 MCH-29.2 MCHC-32.2 RDW-13.5 Plt Ct-344# [2187-10-23] 05:45AM BLOOD PT-14.8* INR(PT)-1.3* [2187-10-23] 05:45AM BLOOD Glucose-150* UreaN-18 Creat-0.7 Na-138 K-4.4 Cl-97 HCO3-33* AnGap-12 [2187-10-22] 01:03AM BLOOD Glucose-109* UreaN-17 Creat-0.8 Na-140 K-4.0 Cl-98 HCO3-29 AnGap-17 [2187-10-23] 05:45AM BLOOD Mg-2.1 Brief Hospital Course: The patient was re-admitted for management of Atrial Fibrillation. Rate control was achieved with Lopressor and Amiodarone, and she did convert to Sinus Rhythm. She was anticoagulated with Coumadin. She received two doses of 2.5mg on [10-22] and [10-23]. She will be discharged to [Location (un) 16493]Rehab. Medications on Admission: Simvastatin 20 QD Colace 100 [Hospital1 ] Zantac 150 QD Gluburide 2.5 QD Lopressor 12.5 [Hospital1 ] Lisinopril 2.5 QD Lasix 40 QD K Dur 20 meq TID ASA 81 QD Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR, Coumadin for a-fib Goal INR 2-2.5 First draw: [2187-10-24] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by MD 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. glyburide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [Hospital1 ] x 1 week, then 400mg daily x 1 week, then 200mg daily. 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. 7. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily) for 5 days. 8. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:20 Tablet(s) Refills:0 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: dose to change daily for goal INR 2-2.5, dx: AFib. Discharge Disposition: Extended Care Facility: [Location (un) 39857] - [Location 9583] Discharge Diagnosis: Coronary artery disease s/p CABG [2187-10-16] Atrial Fibrillation (post-op) PMH: Myocardial infarction [2164] s/p stent Psoriasis Pneumonia Diabetes Mellitus type 2 Hypertension Depression Chronic bone on bone pain - Right ankle after fracture Anxiety Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Incisional pain managed with Tylenol/Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. trace Edema Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] on Wed [11-7] at 1:30 PM in the [Hospital ] medical office building [Last Name (NamePattern1) ] [Hospital Unit Name ] Cardiologist: Dr. [Last Name (STitle) ] on [10-25] at 10:45am Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) 50167] in [3-20] weeks [Telephone/Fax (1) 72680] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR, Coumadin for a-fib Goal INR 2-2.5 First draw: [2187-10-24] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by MD Completed by:[2187-10-23] ICD9 Codes: 412, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7754 }	Medical Text: Admission Date: [2189-10-11] Discharge Date: [2189-10-24] Date of Birth: [2135-5-27] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11415] Chief Complaint: Moped vs [Doctor Last Name ] Major Surgical or Invasive Procedure: [2189-10-11]: External fixator placement left leg with left leg fasciotomies and VAC placement [2189-10-12]: ORIF left tibial plateau fracture with I&D and VAC change [2189-10-14]: I&D left leg with medial wound closure and VAC change to lateral wound [2189-10-16]: I&D left leg lateral wound with closure History of Present Illness: Mr. [Known lastname 79127] is a 54 year old man who was a driver of a moped that hit a [Doctor Last Name ]. He was taken to the [Hospital1 18] for further evaluation and care. Past Medical History: Cardiomyopathy (unclear etiology) Afib Social History: Patient moved from [Location (un) 41654] to [Location (un) 86] 5 years ago. He works as a cook in a restaurant. He lives with multiple friends ([3-2] people) in [Initials (NamePattern4) ] [Last Name (NamePattern4) ]. -Tobacco history: None -ETOH: Occasional -Illicit drugs: None Family History: Mother with DM2, died at the age of 42 of MI. Father died at 60 of unknown cause. No family history of early arrhythmia, cardiomyopathies; otherwise non-contributory. Physical Exam: Upon admission: General Evaluation Exam Sensorium: Awake (x) Awake impaired () Unconscious () Airway: Intubated () Not intubated (x) Breathing: Stable (x) Unstable () Circulation: Stable (x) Unstable () Musculoskeletal Exam Neck Normal (x) Abnormal () Comments: Spine Normal (x) Abnormal () Comments: Clavicle R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Shoulder R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: significant pain with passive ROM, no limits on ROM. Arm R Normal (x) Abnormal () Comments: L Normal () Abnormal (x) Comments: tender to palpation over medial and lateral epicondyles Elbow R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Forearm R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Wrist R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Hand R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Pelvis R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Hip R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Thigh R Normal (x) Abnormal () Comments: L Normal (x) Abnormal () Comments: Knee R Normal () Abnormal () Comments: L Normal () Abnormal () Comments: Leg R Normal () Abnormal () Comments: L Normal () Abnormal () Comments: Ankle R Normal () Abnormal () Comments: L Normal () Abnormal () Comments: Foot R Normal () Abnormal () Comments: L Normal () Abnormal () Comments: Pertinent Results: [2189-10-11] 11:26PM HCT-28.0* [2189-10-11] 11:26PM PT-14.2* PTT-34.5 INR(PT)-1.2* [2189-10-11] 07:21PM GLUCOSE-157* UREA N-15 CREAT-1.1 SODIUM-136 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-28 ANION GAP-9 [2189-10-11] 07:21PM CALCIUM-8.4 PHOSPHATE-1.9# MAGNESIUM-1.8 [2189-10-11] 07:21PM WBC-7.3 RBC-3.44 HGB-10.0* HCT-28.7* MCV-83 MCH-29.1 MCHC-35.0 RDW-13.5 Brief Hospital Course: Mr. [Known lastname 79127] presented to the [Hospital1 18] on [2189-10-11] after the moped he was driving struck a [Doctor Last Name ]. He was evaluated by the orthopaedic surgery service and found to have a left tibial plateau fracture with associated compartment syndrome. He was emergently taken to the operating room and underwent left leg fasciotomies with VAC placement and closed reduction and external fixator placement of his left tibia. He tolerated the procedure well, was extubated, transferred to the recovery room, and then to the floor. On [2189-10-12] he returned to the operating room and underwent an ORIF of his left tibial plateau fracture with I&D of his compartments and VAC changes. On [2189-10-13] he was transfused 2 units of packed red blood cells due to acute blood loss anemia. On [2189-10-14] he returned to the operating room and underwent an I&D of his compartments with VAC change to lateral wound and closure of his medial wound. He was also transfused with 2 units of packed red blood cells due to acute blood loss anemia. On [2189-10-16] he returned to the operating room and underwent an I&D of his lateral compartment and closure. He was seen by cardiology during his hospital stay to help with management of his tachycardia. His lopressor was increased per cardiology. Throughout his hospital stay he was seen by physical therapy to improve his strength and mobility. He had several episodes of tachycardia while walking during physical therapy sessions, but this improved after medication changes, and he was cleared for discharge by medicine and by physical therapy. The rest of his hospital stay was uneventful with his [Date Range ] data and vital signs within normal limits and his pain controlled. He is being discharged today in stable condition. His INR was therapeutic on discharge, and arrangements were made for INR followup with his outpatient provider. Medications on Admission: Coumadin Lisinopril Metoprolol Omeprazole Simvastatin Torsemide ASA Discharge Medications: 1. Outpatient [Name (NI) ] Work PT/INR draws To be done at the [Hospital3 33953] Community Health Center (Dr. [First Name (STitle) ] Goal INR [12-31] 2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 4. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: Target INR [12-31]. To be followed by Dr. [Last Name (STitle) ]. [Doctor Last Name ] [Telephone/Fax (1) 17826] at the [Hospital3 33953] Community Health Center. Disp:30 Tablet(s) Refills:2 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:30 Tablet(s) Refills:0 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain: Do not drive while taking this medication. Disp:50 Tablet(s) Refills:0 9. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 14. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Moped vs. [Doctor Last Name ] Left tibial plateau fracture Compartment syndrome left leg Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Continue to be touchdown weight bearing on your left leg Continue your coumadin dosing as you were prior to being admitted to the hospital. You need your next blood draw on [Doctor Last Name 766], [2189-10-26]. If you have any increased redness, drainge, or swelling, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. Followup Instructions: Please follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP in orthopaedics in 2 weeks, please call [Telephone/Fax (1) 1228] to schedule that appointment Please follow up with Dr. [First Name (STitle) ] at [Telephone/Fax (1) 17826] about your coumadin dosing. You should call on [Telephone/Fax (1) 766] to arrange this. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] ICD9 Codes: 4254, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7755 }	Medical Text: Admission Date: [2141-2-8] Discharge Date: [2141-2-14] Date of Birth: [2072-9-27] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1167] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Intubation History of Present Illness: 68 y/o F with no medical care x years, who called EMS tonight c/o shortness of breath. Upon their arrival, she was found to be agonal breathing, foaming at the nose/mouth, and an oxygen saturation of 80%. (Per report from ED resident, as there are no EMS records available.) She was intubated by EMS and brought to [Hospital3 3583]. At [Hospital1 46], she was hemodynamically stable (sbp 120s-140s, pulse 100s). She was given versed 2 mg, narcan 2 mg, morphine 4 mg, and ativan 1 mg. Per our ED resident, she was also given lasix 40 mg and had 800 cc UOP at [Hospital1 46] but this is not in their records. She had an EKG that demonstrated a LBBB, and so she was Medflighted to [Hospital1 ] for possible cardiac intervention. She also received vecuronium at some point. . In our ED, her vitals were: 99.4, 115/75, 113. Her inital vent settings were not recorded, but her oxygen saturation was between 94 and 98% on 100% FiO2. She required a PEEP of 15. She was noted to have a UTI on her UA and was given vanco, levofloxacin, and flagyl. She was also given sedation with versed. She had a bedside echo by the ED resident which reportedly showed a hyperdynamic state. . Upon discussion with her daughter, she reports that the pt is a [Doctor First Name ] Scientist and has not seen a doctor for over 20 years secondary to her religious preferences. Her daughter states the pt has been more short of breath lately and has been complaining of weakness and dizziness, as well as insomnia. This has been going on for a matter of months. Did not complain of chest pain, nausea, vomiting, abd pain per daughter. [Name (NI) ] daughter saw her yesterday [2141-2-7] and noted that her mom was able to get around the house, etc. Past Medical History: unknown as pt has not seen physician in over 20 years. Per daughter, she shattered her patella a few years ago and refused surgical intervention at that time. Social History: Lives by herself. Works as [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Science Practitioner. Used to smoke tobacco, daughter unsure how much, quit 20 years ago. No EtOH use. Divorced. Family History: noncontributory per daughter Physical Exam: T: 98.0 BP: 109/59 P: 86 AC 600x22 (23) FiO2 0.7 Peep 15 O2 sat 100% Gen: intubated/sedated but opens eyes to voice, follows commands in all four extremities HEENT: pupils 2 mm and nonreactive bilaterally, dried blood on face Neck: JVD difficult to visualize Lungs: inspiratory crackles at left base, good air movement, no wheezing CV: tachycardic, distant heart sounds, no murmur Abd: soft, nontender, nondistended, +bs. + Vaginal prolapse with some skin breakdown. Ext: trace to 1+ pitting lower extremity edema bilaterally to knees Pertinent Results: Hct 37.3 on admission, 30.2 currently Creatnine 2.2 on admission, baseline unknown [2141-2-10] 01:55AM BLOOD WBC-8.4 RBC-4.20 Hgb-10.5* Hct-30.2* MCV-72* MCH-24.9* MCHC-34.6 RDW-15.6* Plt Ct-257 [2141-2-10] 01:55AM BLOOD Glucose-106* UreaN-48* Creat-2.2* Na-142 K-3.8 Cl-106 HCO3-24 AnGap-16 [2141-2-10] 01:55AM BLOOD CK(CPK)-76 [2141-2-8] 05:56AM BLOOD ALT-25 AST-25 CK(CPK)-60 AlkPhos-118* TotBili-0.3 [2141-2-8] 02:30AM BLOOD ALT-29 AST-41* CK(CPK)-71 AlkPhos-142* Amylase-116* TotBili-0.2 [2141-2-8] 02:30AM BLOOD cTropnT-<0.01 [2141-2-8] 05:56AM BLOOD CK-MB-NotDone cTropnT-0.04* [2141-2-8] 12:30PM BLOOD CK-MB-4 cTropnT-0.03* [2141-2-8] 06:19PM BLOOD CK-MB-4 cTropnT-0.01 [2141-2-10] 01:55AM BLOOD CK-MB-NotDone cTropnT-0.01 ECHO on [2141-2-8]: Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed with global hypokinesis and akinesis of the septum and apex. The basal half oof the inferiuor wall is akinetic with an inferobasal left ventricular aneurysm. There is no ventricular septal defect. The right ventricular cavity is mildly dilated. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. CXR on [2141-2-8]: IMPRESSION: 1. High position of the endotracheal tube tip situated at the thoracic inlet. 2. Severe interstitial pulmonary edema. LENI on [2141-2-8]: Brief Hospital Course: 68 y/o F w/no medical care who called EMS today for respiratory distress. Currently requiring large amounts of support from the ventilator. . # Hypoxic Respiratory Failure: Given the clinical findings of pulmonary edema on CXR, peripheral edema on physical exam, this is likely due to congestive heart failure. It is unclear if this is flash pulmonary edema (due to myocardial ischemia, valvular dysfunction) vs. worsening of chronic pulmonary edema, as her daughter reports shortness of breath that has been going on x months. Also has BNP over 3000 but could be R heart strain in setting of hypoxic resp failure. Given clinical hx, the patient was treated as if she was in CHF. An echo was pefromed which revealed poor EF. Extubated without event, and no longer has oxygen requirement. The patient was able to be weaned off of oxygen and was doing well on room air upon discharge. . # CArdiac: LVEF = 20%. Slightly elevated troponins on admission likely due to CHF exacerbation. LBBB is concerning if it's new, but since we have nothing to compare and first set of enzymes are negative, it's likely old. The patient Diuresed well on furosemide. She was started aspirin given new left bundle. Also noted to have A. fib with RVR while in the MICU and started on metoprolol. The patient diuresed well on IV lasix and her lung exam improved. The patient underwent cardiac catheterization which showed non-occlusive disease, no interventions were done. The patient was started on po lasix, toprol xl and lisinopril. . # Hypotension: Likely due to CHF, as appears total body volume overloaded on initial exam. The patient had a normal lactate which is reassuring, and her mental status is also good as she can follow commands, etc. She did not require pressors and was called out of the unit. The patient's hypotension resolved while on the floor and was able to tolerate bp meds for cardiac protection. . # Renal Failure: Unknown baseline. UA has no protein in it, to suggest chronic nephropathy, ? due to diabetes. [Month (only) 116] be due to hypoperfusion from poor forward flow secondary to ATN. Sediment only showed WBCs, no casts. The patient's creatinine clearance had a nadir of 1.9 upon discharge. This should be her baseline creatinine function . # DM: FS in 300s upon arriving to ICU, so has diabetes. The pt was on insulin sliding scale, FS QID but did not require further insulin during her stay. The HgAIC was normal. This was likely as stress reponse. . # UTI: The patient was treated for a 7 day course of ciprofloxacin. She had no urinary symptoms upon discharge. . # Restless legs: The pt received ativan prn for restless leg syndrome. The patient was instructed to follow up with a pcp for further care. Medications on Admission: None Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Congestive Heart Failure Discharge Condition: Stable Discharge Instructions: You were diagnosed with coronary artery disease and congestive heart failure. You were started on a number of medications. Please take all medications as prescribed. Rest until you feel better * Be sure to take any prescribed medications as you were instructed. Continue your previously prescribed medications unless you were instructed to do otherwise. Warning Signs: Limit the amount of fluids you drink to about 2 liters. If you gain more than five pounds over two to three days, please call your primary care provider Call your doctor or return to the Emergency Department right away if any of the following problems develop: * You are not getting better in 24 hours, or you are getting worse in any way. * You experience new chest pain, pressure, squeezing or tightness. * You have shaking chills, or a fever greater than 102 degrees (F) * New or worsening cough or wheezing. * Abdominal (belly) pain, vomiting, severe headache. * Dizziness, confusion or change in behavior. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: You have been referred to Dr [Last Name (STitle) ] for your uterine prolapse. Please call [Telephone/Fax (1) ] to schedule an appointment. They will provide further instructions on where to go and what you need to bring. [2141-3-13] at 2:15. Please follow up in the Heart Failure Clinic in the next 3 weeks. Please call [Telephone/Fax (1) ] for more information about an appointment. You need to establish care with a primary care provider. [Name10 (NameIs) ] can call 1-[Telephone/Fax (1) 70946] or [Telephone/Fax (1) 250] to get a primary care provider. ICD9 Codes: 4280, 5849, 5990, 4589, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7756 }	Medical Text: Admission Date: [2124-4-27] Discharge Date: [2124-4-29] Date of Birth: [2049-2-1] Sex: M Service: MEDICINE Allergies: Ambien / Avodart Attending:[First Name3 (LF) 1881] Chief Complaint: epistaxis Major Surgical or Invasive Procedure: nasal packing by ENT History of Present Illness: 75 yo M with a history of mechanical AVR and MVR, afib on coumadin who complains of epistaxis. The patient was cleaning his nose this morning, and his nose started bleeding. He has never had issues with nose bleeds or GI bleeds before. Notably, the patient saw his PCP [Last Name (NamePattern4) ] [2124-4-18]. Routine labs showed BUN of 112 and Cr of 2.3. It was thought that his lasix dose of 80mg po bid was too much. He was told to hold the lasix and repeat his labs. Repeat labs from [4-26] showed BUN 130 and Cr of 2.1. . In the ED, Labs notable for INR 3.9, Hct 27 down from bl(32), but found to have ARF w K 6.2. Trop 0.05. ED course complicated by hypotension to SBP 50s, fluid responsive, now SBP 100s w 3L fluid, found to have UTI, ? urosepsis, with 18gauge IVx2. EKG: paced @60, no ST/Twave changes, no peaked Ts. ENT did Silver nitrate + affrin, found bleeding to be intermittent, requiring packing. Given D50, insulin, ca gluconate repeat 4.2->5.6 CXR no acute process. UA c/w UTI, Blood and urine culture and was started on zosyn. FS<70, likely [1-12] to poor clearance of insulin in setting of renal failure, continue D50 prn. 98.3 65 94/45 18 100% on RA. . In the ICU, patient without complaints. Denies CP, SOB, cough, fever, chills, N/V/D. His epistaxis stopped once being packed in ED. Denied dysuria. Reports being fatigued since coming in. He c/o itching throughout body. . REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies cough, shortness of breath, or wheezes. Denies diarrhea. No recent change in bowel or bladder habits. Denies rashes or skin breakdown. No numbness/tingling in extremities. No feelings of depression or anxiety. All other systems reviewed in detail with no significant findings. Past Medical History: # Mechanical MVR/AVR ([2098]) [1-12] rheumatic fever # Atrial fibrillation s/p AV node ablation, biventricular pacer ([2115]) on anticoagulation # s/pw ith a history of a rectosigmoid polyp resection and subsequent rectal bleeding with multiple sigmoidoscopies c/b perforation requiring a Hartmann procedure [2123-10-25] # Biventricular pacer # Dyslipidemia # HTN # COPD # Asthma # GERD # Osteoarthritis # Bilateral total knee replacements [1-12] OA # Gout # Hypothyroidism [1-12] amiodarone # Chronic Kidney Disease Stage II, baseline cr 1.6 # anemia # Melanoma # obesity # ETOH use # insomnia # hemorrhoids # h/o cellulitis # h/o MRSA PNA # osteopenia # # s/p Cholecystectomy # s/p Appendectomy Social History: Lives with wife. # Professional: Retired construction worker. # Tobacco: 1ppd x 15y, quit [2083]. # Alcohol: Former binge alcohol abuse x30y (hard liquor), quit mid [2102]. last drank 3 mo ago- 3 drinks at that time # Recreational drugs: Experimental mescaline in youth. Family History: # Mother d 85: Asthma # Father d 99 [10-21]: PAD, HTN # Siblings (5B, 2S): HTN, unknown, rheumatic fever Physical Exam: VS: 96.5 84 134/44 18 100%RA GEN: AOx3, NAD [Month/Year (2) 4459]: PERRLA. MMM. no LAD. JVP to 8cm. neck supple. Cards: RRR, mechanical S1/S2. 1-2/6 holosytolic murmur best heard at LLSB, no gallops/rubs. Pulm: No dullness to percussion, CTAB no crackles or wheezes Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [Doctor Last Name 515] sign. Colostomy in place in LLQ. Extremities: wwp,trace edema. DPs, PTs 2+. Skin: erythema in b/l LE, no rashes or bruising Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS). gait WNL. Pertinent Results: 1. Admission labs: [2124-4-26] 11:25AM BLOOD WBC-7.0 RBC-3.36* Hgb-9.7* Hct-28.9* MCV-86 MCH-28.9 MCHC-33.6 RDW-18.4* Plt Ct-188 [2124-4-26] 11:25AM BLOOD Neuts-62.4 Lymphs-21.9 Monos-7.0 Eos-8.1* Baso-0.5 [2124-4-26] 11:25AM BLOOD PT-35.6* INR(PT)-3.6* [2124-4-26] 11:25AM BLOOD UreaN-130* Creat-2.1* Na-140 K-5.6* Cl-110* HCO3-18* AnGap-18 [2124-4-27] 07:00PM BLOOD ALT-19 AST-22 AlkPhos-102 TotBili-0.7 [2124-4-27] 04:35PM BLOOD cTropnT-0.03* [2124-4-27] 09:30AM BLOOD cTropnT-0.04* [2124-4-27] 07:00PM BLOOD Calcium-8.8 Phos-3.2 Mg-1.7 [2124-4-26] 11:25AM BLOOD %HbA1c-5.6 eAG-114 . 2. Discharge labs: [2124-4-29] 06:20AM BLOOD WBC-6.4 RBC-2.94* Hgb-8.3* Hct-25.6* MCV-87 MCH-28.3 MCHC-32.4 RDW-19.0* Plt Ct-160 [2124-4-29] 06:20AM BLOOD PT-24.9* PTT-31.3 INR(PT)-2.4* [2124-4-29] 06:20AM BLOOD Glucose-89 UreaN-40* Creat-1.0 Na-139 K-5.2* Cl-111* HCO3-20* AnGap-13 . Imaging: - CXR ([2124-4-27]): No acute pulmonary process. Resolved pleural effusion. Otherwise, stable exam with no acute process. . - Renal ultrasound ([2124-4-28]): * Preliminary read * No hydronephrosis. Multiple simple renal cysts. . Brief Hospital Course: 75 yo M with a history of mechanical AVR and MVR, afib on Coumadin, who presents with epistaxis also found to have hypotension, hyperkalemia, and ARF. . #Hypotension: The patient had hypotension to the 50s in the emergency department, which was transient and fluid responsive. The etiology was thought to be hypovolemia. Lasix was held, and the patient was admitted to the MICU for hemodynamic monitoring. He had no further hypotension. . #Epistaxis: The patient presented with epistaxis, which was treated with Afrin, silver nitrate, and packing in the emergency department. . #Acute kidney injury: Differential diagnosis included pre-renal and obstructive etiology. A foley catheter was placed. Lasix was held. Renal ultrasound showed no hydronephrosis but some benign cysts which should be followed by primary care doctor. Renal function completely recovered. He will follow-up with outpatient urologist after discharge. . #Hyperkalemia: The patient presented with potassium 6.1 in the setting of acute renal failure. He was given calcium, insulin, and glucose in the emergency department. In the MICU, he received Kayexalate. Enalapril was held. Potassium level normalized prior to discharge. He never developed EKG changes. . #Urinary tract infection: Treated initially with ceftriaxone and switched to nitrofurantoin prior to discharge based on urine culture sensitivities to complete a 7-day course. . # Rash/peripheral eosinophilia: Rash on both arms started prior to admission. Suspected to be a drug reaction and offending [Doctor Last Name 360] (Avodart) was stopped. Patient treated symptomatically. . # Atrial fibrillation: Coumadin initially held given supratherapeutic INR. Re-started prior to discharge and patient instructed to follow-up closely with [Hospital 197] clinic. . #BPH: Held tamsulosin given foley. Foley removed and restarted tamsulosin prior to discharge. Medications on Admission: -allopurinol 300 mg po daily -colchicine-probenecid 0.5-500mg po daily --> held -ipratropium-albuterol inh q6h PRN SOB -Combivent inh [Hospital1 ] --> held -enalapril 20 mg po bid --> held -levothyroxine 88 mcg po daily -metoprolol succinate 50 mg po daily -pantoprazole 40 mg po q12h --> stopped -tamsulosin 0.4 mg po qhs --> held -tizanidine 4 mg po qhs --> held -warfarin 7.5 mg po daily --> held -ferrous sulfate 300 mg (60 mg Iron) po daily --> 325 mg pill - fluticasone-salmeterol 250-50 mcg/dose Disk inh [Hospital1 ] -furosemide 80 mg po bid on home --> held -fluticasone 50 mcg nasal daily -Ciclopirox- 0.77 % Gel - apply to abdomen folds twice a day -Clobetasol - 0.05 % Cream -Hydroxyzine 25mg po qhs PRN -Nystatin- 100,000 unit/gram Powder - as directed daily -Omeprazole 40mg po daily -Trazodone 25-50mg po qhs PRN -Docusate 100mg po daily Discharge Medications: 1. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 2. Combivent 18-103 mcg/Actuation Aerosol Sig: [12-12] puff Inhalation four times a day. 3. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) ampule Inhalation four times a day as needed for shortness of breath or wheezing: 1 ampule in nebulizer up to qid as needed for lung disease flare . 4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO at bedtime. 7. tizanidine 4 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO 5X/WEEK ([Doctor First Name ], TU, WE, TH, SA). 9. warfarin 5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,FR). 10. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 11. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1) whiff Inhalation twice a day. 12. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 13. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for itching. 14. ciclopirox 0.77 % Gel Sig: One (1) application Topical twice a day: Apply to abdomen folds. 15. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 16. docusate sodium 100 mg Tablet Sig: One (1) Capsule PO BID (2 times a day). 17. trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO HS (at bedtime) as needed for insomnia. 18. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 19. nitrofurantoin macrocrystal 100 mg Capsule Sig: One (1) Capsule PO four times a day for 5 days: Please take from [4-28] - [2124-5-4]. Disp:20 Capsule(s) Refills:0 20. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritis. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Epistaxis Atrial fibrillation Acute renal failure Hyperkalemia Hypotension Urinary tract infection Skin rash . SECONDARY DIAGNOSES: COPD Benign prostatic hypertrophy 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 [Hospital1 1170] because you were having a nosebleed. We also found that your kidneys were not working well and the level of potassium in your blood was very high. We put in a catheter to help drain the urine in your bladder and your kidney function improved. We did an ultrasound of your kidneys were showed that they were not swollen. You had an urinary tract infection and we gave you antibiotics to treat that which you should continue after your leave the hospital. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. . We found some small kidney cysts on ultrasound. Please ask your primary care doctor to follow-up on them. . MEDICATIONS: ADDED: - Nitrofurantoin 100 mg by mouth four times a day from [2124-4-28] - [2124-5-4] - Sarna cream as needed for rash CHANGED: none HELD (please speak to your primary care doctor [First Name (Titles) ] [Last Name (Titles) 9533] them): - Colchicine-probenecid 0.5-500 mg by mouth per day - Enalapril 20 mg by mouth twice a day - Furosemide 80 mg by mouth twice a day REMOVED: - pantoprazole 40 mg by mouth twice a day Followup Instructions: Please make an appointment and follow-up with your primary care doctor within the next week. . Please also make an appointment and follow-up with your urologist Dr. [Last Name (STitle) 770] within the next week. . Please make sure to go to [Hospital 197] clinic on [2124-5-1] to have your Coumadin level checked and dose adjusted accordingly. . Department: MEDICAL SPECIALTIES When: WEDNESDAY [2124-5-3] at 11:00 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 9316] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: [Hospital Ward Name ] [2124-5-22] at 9:00 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: [Hospital Ward Name ] [2124-5-22] at 10:00 AM With: [Year (4 digits) ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1882] MD, [MD Number(3) 1883] Completed by:[2124-4-29] ICD9 Codes: 5990, 2762, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7757 }	Medical Text: Admission Date: [2147-9-25] Discharge Date: [2147-9-29] Service: MEDICINE Allergies: Valium Attending:[First Name3 (LF) 594] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ]M h/o HTN, osteoperosis, and chronic resp failure [1-5] to parkinson's disease, trached and peged d/t multiple aspiration events, recent pneumonia and SIADH, who was brought to the ED from his NH with concern for AMS. Per my discussion with his wife, over the last 10 days he has been less interactive, and today has been moaning. At baseline the patient requires extensive pulmonary toilet, and today was noted to have worsening secretions. No fevers documented in the rehab facility. Additionally, she reports that he has new abdominal distension. In the ED, initial VS were: 62, 129/55, 20, 100%. He underwent CT head and CT abdomen. CT head did not show any acute process. CT abdomen shows a likely infectious process in the right lower lobe, concerning for necrotizine pneumonia. He also had a UA with 129 WBC's, few bacteria, and large leukesterase. In the ED he was started on vancomycin, cefepime, and flagyl. He was noted to be hypotensive, but was not responsive to IVF resusitation. As a result, he was placed on norepinepherine. Prior to transfer to the floor, his SBP was in the 120s. On arrival to the MICU, the patient was unresponsive, on ventilator. Additional history or review of systems were unobtainable. Past Medical History: 1. h/o aspiration PNA - Tx with levo, unasyn, vanco/zosyn in the past 2. h/o aspiration s/p swallow eval with swallowing difficulty, s/p [Month/Day (2) 282] placement on [10-10] - pt continues to feed for pleasure at HebReb 3. Parkinson disease 4. Osteoporosis 5. T11/12 compression fx 6. LLE osteomyelelitis as a child/Chronic osteomyelitis, quiescent. 7. granulomatous liver disease 8. LUE rotator cuff tear 9. Prostate cancer s/p orchiectomy in [2126] 10. s/p laminectomy L4-5 11. Cataracts s/p surgery [46]. Glaucoma 13. Hypertension 14. h/o of treatment for pseudomonas and aspiration PNA at heb reb 15. s/p Trach with night ventilator support. 16. s/p wrist fx 17. chronic constipation 18. Chronic abd pain- per Heb Reb notes 19. Recent admission following vasovagal event at heb/reb s/p chest compressions complicated by PTX s/p chest tube 20. L ant pubic rami fracture, L ant iliac fracture Social History: The patient has a sixty-pack-year history of tobacco. He quit in [12/2098]. He lives at [Hospital ] rehab MACU for last 3 hrs. He is a retired history professor. [First Name (Titles) ] [Last Name (Titles) ], no alcohol intake. - Tobacco: none currently - Alcohol: none currently - Illicits: none Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM General: unresponsive, trached, on ventilator HEENT: Sclera anicteric, MMM, left pupil 4mm, right pupul 2mm Neck: supple CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: diffuse wheezes and ronchi throughout the bilateral lung fields Abdomen: + BS, firm, distended, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis, 2+ non-pitting edema in the left arm Neuro: unresponsive Pertinent Results: ADMISSION LABS [2147-9-25] 04:50PM BLOOD WBC-26.1* RBC-3.23* Hgb-9.6* Hct-30.6* MCV-95 MCH-29.8 MCHC-31.5 RDW-15.5 Plt Ct-360 [2147-9-25] 04:50PM BLOOD Neuts-82* Bands-4 Lymphs-5* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-4* [2147-9-25] 04:50PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+ Stipple-1+ [2147-9-25] 04:50PM BLOOD Plt Ct-360 [2147-9-26] 01:45AM BLOOD PT-11.8 PTT-31.6 INR(PT)-1.1 [2147-9-25] 04:50PM BLOOD Glucose-157* UreaN-77* Creat-1.5* Na-115* K-5.0 Cl-73* HCO3-33* AnGap-14 [2147-9-25] 04:50PM BLOOD cTropnT-0.09* [2147-9-26] 01:45AM BLOOD Calcium-7.2* Phos-5.1# Mg-2.6 [2147-9-25] 04:50PM BLOOD Osmolal-274 [2147-9-25] 05:18PM BLOOD Type-ART pO2-232* pCO2-90* pH-7.18* calTCO2-35* Base XS-2 [2147-9-26] 12:31AM BLOOD freeCa-1.01* [2147-9-26] 01:45AM BLOOD Glucose-164* UreaN-74* Creat-1.5* Na-117* K-4.6 Cl-83* HCO3-29 AnGap-10 [2147-9-26] 02:42PM BLOOD Na-118* K-4.6 Cl-86* [2147-9-27] 02:15AM BLOOD Glucose-102* UreaN-77* Creat-1.9* Na-116* K-5.0 Cl-87* HCO3-17* AnGap-17 [2147-9-27] 08:44AM BLOOD Na-122* K-4.8 Cl-87* [2147-9-27] 09:00PM BLOOD Na-119* K-5.1 Cl-86* [2147-9-28] 03:55AM BLOOD Glucose-104* UreaN-84* Creat-2.4* Na-119* K-5.1 Cl-86* HCO3-21* AnGap-17 [2147-9-28] 04:06PM BLOOD Glucose-125* UreaN-84* Creat-2.6* Na-121* K-5.2* Cl-89* HCO3-20* AnGap-17 [2147-9-29] 03:03AM BLOOD Glucose-148* UreaN-98* Creat-2.9* Na-121* K-5.6* Cl-88* HCO3-20* AnGap-19 [2147-9-25] 05:21PM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.015 [2147-9-25] 05:21PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [2147-9-25] 05:21PM URINE RBC-68* WBC-129* Bacteri-FEW Yeast-NONE Epi-0 [2147-9-25] 06:14PM URINE Hours-RANDOM UreaN-416 Creat-66 Na-11 K-29 Cl-LESS THAN [2147-9-27] 06:40AM URINE Hours-RANDOM UreaN-450 Creat-42 Na-<10 K-22 Cl-<10 [2147-9-28] 11:48AM URINE Hours-RANDOM UreaN-245 Creat-37 Na-26 K-34 Cl-53 [2147-9-27] 06:40AM URINE Osmolal-318 [2147-9-28] 11:48AM URINE Osmolal-290 MICRO: [2147-9-25] 6:09 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. FINAL REPORT [2147-9-27] GRAM STAIN (Final [2147-9-25]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2147-9-27]): SPARSE GROWTH Commensal Respiratory Flora. ESCHERICHIA COLI. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R [2147-9-25] Blood cultures: No growth [2147-9-25] NCHCT; IMPRESSION: No acute intracranial process. Mastoid air cell and paranasal sinus opacification is likely related to tracheostomy. [2147-9-25] CT abd/pelvis: IMPRESSION: 1. Right lower lobe opacification with areas of non-enhancing pulmonary parenchyma concerning for necrotizing pneumonia. Bilateral moderate pleural effusions. 2. Evidence of right heart failure with congested liver, periportal edema, trace ascites, and gallbladder edema (no evidence to suggest cholecystitis). 3. Age-indeterminate T12 compression fracture [2147-9-27] CXR: CONCLUSION: New right PICC in standard position, terminating in the low SVC. Improved aeration of both upper lungs and improvement in previously seen right mid lung opacity. Otherwise, unchanged since the prior study. Brief Hospital Course: [Age over 90 ] yo M h/o parkinson's disease, chronic respiratory failure (s/p trach, ventilator dependent) admitted to the ICU with acute encephalopathy, UTI and pneumonia. # Oliguria / acute renal failure: The patient experienced progressive renal failure and oliguria throughout his ICU course. Despite large volume IVF resuscitation and urine electrolytes showing a pre-renal picture, the patient's creatinine continued to worsen. His urine output remained low despite high doses of furosemide, and he wa equally unresponsive to a furosemide drip. His potassium continued to worsen in light of this as well. A family meeting was held on HD#4 with the patient's wife, [Name (NI) ], to discuss the patient's poor overall clinical status as well as his progressive, likely irrevocable, renal failure and the decision was made to pursue comfort care options at that time in concert with his wife's understanding of his wishes given the clinical circumstances. The patient became progressively bradycardic during HD #3, and by 19:35 he progressed to asystole on telemetry monitoring. The patient's pupils were fixed and dilated, and he was noted to be without spontaneous respirations. All cranial and brainstem reflexes were non-reactive and the patient was pronounced dead and his wife was notified. # Respiratory acidosis: On admission the patient appeared to be retaining carbon dioxide in the setting of increased secretions and penumonia seen on CT. His exam was diffusely wheezy and ronchorus. His ventilator settings were optimized by increasing TV and PEEP in an effort to assist him with clearing his acidemia. RT was unable to titrate up RR based on auto-peep and further retention. Repeat ABG's are showed worsening of his acid-base status on HD#1, despite these interventions. Due to his extensive wheezing on examination, he was started on albuterol and ipratropium MDIs through the ventilator to aid with bronchidilation, as well as methylprednisolone to help reduce airway inflammation. His respiratory exam improved throughout his ICU course on this regimen, and his ventilator settings were weaned back to his baseline. # Hypotension: Initially in the ED he was responsive to IVF, but subsequently required the initiation of norepinephrine. Initially on transfer to the ICU he had SBP??????s in the 110-130 range. Norepinephrine was titrated to maintain MAPs > 60, and the patient recieved IVF boluses for BP support as well. # Pneumonia: CT abdomen on admission showed possible necrotizing pneumonia in the right lung bases, likely consistent with aspiration-associated pneumonia, given the presents of debris in the left bronchi. The patient was started initially on vancomycin, cefepime and flagyl for broad spectrum empiric coverage, which was titrated down to ceftriaxone in the setting of his sputum culture results. # Bacteriuria: UA concerning for UTI, with the culture pending. The patient is unable to communicate any symptoms of UTI. He was maintained on the antibiotic regimen stated above, and final urine cultures were negative. # Acute encephalopathy: Multifactorial etiology, with contributions from CO2 retention, hyponatremia, and infection. These various medical issues were managed as mentioned previously. # Hyponatremia: Likely from hypovolemic hyponatremia; although he appears volume up on exam, his circulating volume was likely low. In this setting, it was felt he would likely benefit from additional NS IVF. Just with IVF given in the ED his serum sodium began to slowly correct, although he subsequently deteriorated while in the ICU. Salt tabs were used in conjunction with volume resuscitation, however his hyponatremia did not improve on this regimen. After goals of care were discussed with the family, the patient was made CMO as mentioned previously. # Glaucoma: The patient was continued on his home regimen of Latanoprost, Artificial Tears # Parkinson's Disease: The patient was continued on his home regimen of sinemet, entacapone, mirapex Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Comtan NF (entacapone) 200 mg GT 7x/day 0500, 0800, 1100, 1400, 1700, [2134], 2300 2. Mirapex NF (pramipexole) 0.5 mg GT QHS 3. Artificial Tears Preserv. Free 2 DROP BOTH EYES QID 4. Acetylcysteine 20% Dose is Unknown NEB [Hospital1 ] 5. Calmoseptine NF (menthol-zinc oxide) 0.44-20.625 % Topical [Hospital1 ] 6. Albuterol-Ipratropium 2 PUFF IH Q6H 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 8. Mirapex NF (pramipexole) 0.125 mg Oral QID @ 0500, 0800, 1100, 1400 9. Ferrous Sulfate 325 mg PO DAILY 10. Miconazole 2% Cream 1 Appl TP [Hospital1 ] 11. Levothyroxine Sodium 50 mcg PO DAILY 12. Acetaminophen (Liquid) 650 mg PO Q4H:PRN pain 13. Racepinephrine 0.5 mL IH Q2H:PRN hemoptysis 14. Tobramycin-Dexamethasone Ophth Oint 1 Appl BOTH EYES QHS 15. Acetaminophen (Liquid) 650 mg PO Frequency is Unknown 16. Carbidopa-Levodopa (25-100) 1 TAB PO TID @0500, 0800, 1100 17. Carbidopa-Levodopa (25-100) 1 TAB PO QID @1400, 1700, [2134], 2300 18. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID swab 19. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES [Hospital1 ] 20. Simethicone 80 mg PO TID:PRN distension, gas 21. Omeprazole 20 mg PO DAILY 22. Vitamin D 1000 UNIT PO DAILY 23. Lorazepam 0.5 mg PO Q6H:PRN anxiety 24. OxycoDONE Liquid 5 mg PO Q3H:PRN severe pain 25. Sorbitol 15 mL GT [Hospital1 ] 26. Tobramycin-Dexamethasone Ophth Oint 1 Appl BOTH EYES QID 27. Sodium Chloride 1 gm PO BID Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Renal failure Respiratory failure Discharge Condition: Expired ICD9 Codes: 0389, 5849, 2762, 2767, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7758 }	Medical Text: Admission Date: [2145-10-30] Discharge Date: [2145-11-8] Date of Birth: [2095-7-22] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 695] Chief Complaint: HCV here for orthotopic liver [First Name3 (LF) ] Major Surgical or Invasive Procedure: [2145-10-31]: Orthotopic liver [Month/Day/Year ] History of Present Illness: 50 yo male w/hx HCV (genotype 1) cirrhosis c/b HCC with 2.7 cm mass s/p RFA ablation in [2144-7-25] with recent admit for RUQ pain concerning for cholecystits but with w/HIDA nl thus no operative rx performed being admitted tonight for liver [Year (4 digits) ]. ROS: Pt denies any fever/chills/recent infections/ sore throat/ sinus infections/chest pain/palpitations/difficulty breathing/ dysuria/nausea/vomiting/changes in bowel habits (last BM this morning)/rashes/jt pain. Does c/o long hx back pain, worse in am (w/recent bone scan and CT neg for mets), recent dull abd pain, similar to last admission, unchanged. Past Medical History: -HCV cirrhosis, genotype I. Followed by Dr. [Last Name (STitle) 497]. - known grade 2 varices, last scope [10-1] - HCC s/p RF ablation in [7-/2144] -Chronic abdominal pain -Chronic back pain, negative bone scan [9-1]. -Depression -Hemorrhoids -GERD Social History: From [Male First Name (un) 1056]. Lives with wife in [Location (un) 4398]. Quit tobacco and alcohol 12 years ago. Denies drug use. Family History: Sister with breast cancer Physical Exam: A and O NAD, well nourished 97.8 81 129/85 20 98% RA PERRL, Anicteric, no JVD, moist mucus membranes, no LAD RRR no m/r/g CTAB soft ND + BS no HSM + slight TTP RUQ neg [Doctor Last Name 515] sign, no rebound tenderness no CVA tenderness 2+ femoral pulses b/l no c/c/e 1+ DP b/l Neuro 1+ patellar L, unable to elicit on R, 1+ BR on R, unable to elicit on left, strength grossly intact Psych slightly slow but otherwise nl affect, thought process, content Derm: hyperpigmentation around back of arm, dorsal surfaces of arms, no petechiae slight TTP spine (lumbar), paraspinal Pertinent Results: On Admission: [2145-10-29] WBC-2.7* RBC-3.83* Hgb-13.0* Hct-35.7* MCV-93 MCH-34.0* MCHC-36.5* RDW-14.2 Plt Ct-32* PT-17.5* PTT-40.3* INR(PT)-1.6* Glucose-94 UreaN-13 Creat-0.7 Na-138 K-3.8 Cl-104 HCO3-27 AnGap-11 ALT-52* AST-70* LD(LDH)-205 AlkPhos-109 TotBili-2.1* Albumin-3.6 Calcium-8.7 Phos-2.6* Mg-1.6 At Discharge: [2145-11-8] WBC-6.6 RBC-3.55* Hgb-12.0* Hct-30.9* MCV-87 MCH-33.8* MCHC-38.9* RDW-16.4* Plt Ct-65* [2145-11-8] 05:50AM BLOOD Glucose-89 UreaN-17 Creat-0.8 Na-134 K-4.0 Cl-99 HCO3-27 AnGap-12 [2145-11-8] 05:50AM BLOOD ALT-94* AST-41* AlkPhos-57 TotBili-1.2 [2145-11-8] 05:50AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.9 [2145-11-8] 05:50AM BLOOD tacroFK-10.8 Brief Hospital Course: 50 y/o male with HCV who is deemed a suitable candidate for liver [Month/Day/Year ]. He was taken to the OR with Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. He received routine induction immunosuppression of Cellcept, solumedrol 500 mg intra-op with standard solumedrol /pred taper and Prograf initiated on the evening of POD 0. At the time of the surgery , he had a fibrotic hard nodular cirrhotic liver. He had moderate portal hypertension and moderate splenomegaly. He had no ascites. He had some omentum adherent to the anterior surface of the liver where the radiofrequency ablation was performed. He had normal anatomy. He received 4000 mL of crystalloid, 5 units of fresh frozen plasma, 4 units of platelets and urine output was 900 mL. EBL was [2136] mL. He was transferred to the SICU in stable condition, where he was extubated on POD 1. Ultrasound POD 1 showed patent hepatic vasculature with no biliary ductal dilatation. He was transferred to [Hospital Ward Name 121] 10 on POD 2 and followed the pathway in the post op period. His Hct was noted to be slowly trending down and on POD 4 he received 2 units pRBCs for a hct of 22.3%. His Hct remained stable at 30% for the rest of the hospitalization. His LFTs quickly normalized. Prograf level was therapeutic at time of discharge. He was ambulating and tolerating diet. He received training with insulin/blood glucose management and was sent home with scripts for supplies. Medications on Admission: omeprazole 20', spironolactone 25", nadolol 20', prozac 10', clonopin 0.5" prn, colace 100", senna' HS, psyllium''' Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous once a day: Morning Dose. Disp:1 bottle Refills:0 6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five (5) units Subcutaneous once a day: PM dose. 7. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 11. Insulin Syringe Ultrafine [11-25] mL 29 x [11-25] Syringe Sig: One (1) syringe Miscellaneous twice a day. Disp:1 box Refills:2 12. Lancets,Thin Misc Sig: One (1) Miscellaneous twice a day. Disp:2 bottles Refills:5 13. One Touch Ultra System Kit Kit Sig: One (1) kit Miscellaneous once. Disp:1 kit Refills:0 14. One Touch Ultra Test Strip Sig: One (1) In [Last Name (un) 5153] twice a day. Disp:2 bottles Refills:5 15. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. 16. Alcohol Prep Pads Pads, Medicated Sig: One (1) Topical twice a day. Disp:1 box Refills:5 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: HCV Cirrhosis now s/p Orthotopic liver [Hospital ] Discharge Condition: Stable/Good Discharge Instructions: Please call the [Hospital ] clinic at [Telephone/Fax (1) 673] for fever > 101, chills, nausea, vomiting, diarrhea, inability to take or keep down medications or other concerning symptoms. Monitor the incision for redness, drainage or bleeding Monitor the finger stick blood sugar twice daily and as needed for symptoms of low blood sugar to include sweating/weakness/irritability Labwork every Monday and Thursday, fax results to the [Telephone/Fax (1) ] clinic at [Telephone/Fax (1) 673]. When having labwork drawn, do not take your Prograf before the lab test. Bring Prograf with you so you can take it as soon as labs have been drawn. No heavy lifting No driving if taking narcotic pain medications [Month (only) 116] shower, pat incision dry, do not rub Followup Instructions: [Last Name (LF) ],[First Name3 (LF) 156] [First Name3 (LF) ] SOCIAL WORK Date/Time:[2145-11-11] 10:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2145-11-11] 10:40 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2145-11-24] 10:20 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2145-11-11] ICD9 Codes: 5715, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7759 }	Medical Text: Admission Date: [2112-8-22] Discharge Date: [2112-9-19] Date of Birth: [2050-3-27] Sex: M Service: MED Allergies: Remicade / Zosyn Attending:[First Name3 (LF) 398] Chief Complaint: RLE and LUE pain and edema Major Surgical or Invasive Procedure: EGD x2 TEE CT guided renal biopsy Skin biopsy History of Present Illness: 62 y/o male with h/o Crohn's disease on chronic steroids, recently admitted [7-13] to [7-22] for LLE cellulitis and new-onset jaundice thought to be due to recent EtOH use, who presented to the ED with increasing edema, RLE and LUE pain, worsening edema, and dark urine x 1 week. During his prior admission for jaundice, he had a liver biopsy that showed mild fibrosis, thought to be c/w toxic-metabolic injury from EtOH and Tylenol. His liver biopsy specifically did NOT show cirrhosis. Of note, the pt used to drink approx 6 beers/day x 30 yrs, and had stopped 9 years ago. 1 week prior to his admission in [Month (only) 205], he went on a cruise and began drinking EtOH again. After the [Month (only) 205] admission, he denies using any more alcohol, as he was specifically instructed not to do so upon discharge. He notes that he has never felt completely well since his discharge, and he has had worsening RLE and LUE pain and swelling. His skin was very fragile, and would break open easily. In [Month (only) 205] he had had a LLE infection that resolved with a course of Unasyn-->Augmetin-->Keflex. He also noted worsening shortness of breath and dyspnea on exertion (since d/c). He denies black or bloody stools, abdominal pain, or coffee ground emesis. In the ED, he had a RUQ u/s with dopplers that was unchanged from prior, demonstrating normal dopplers with a diffusely echogenic liver. He had ultrasounds of his 2 painful extremities (RLE, LUE) which were negative for DVT. He was sent to the [Hospital Unit Name 153] for further management of his cellulitis, as they were concerned that it would evolve to sepsis given his [Last Name (un) ] steroid use; as well as for management of his worsening liver fxn (INR 2.8 on adm). Past Medical History: Hepatitis thought [1-25] EtOH (see HPI) Crohn's disease on chronic prednisone,6-MP, and Remicade Osteoporosis Borderline hyperglycemia Glaucoma Low back pain Status post appendectomy Status post SBO Social History: Telemarketer, Lives alone in [Location (un) ], never married, no children. Has a niece who lives in the area and a brother (veterinarian) in NY. Etoh: drank 6 beers/night for about 30y per pt; stopped 9y ago. No EtOH since [Month (only) 205] when he drank on the cruise (see HPI). Family History: NC Physical Exam: None Pertinent Results: [2112-9-16] 10:44AM BLOOD WBC-11.0 RBC-2.87* Hgb-8.8* Hct-25.7* MCV-89 MCH-30.5 MCHC-34.1 RDW-17.6* Plt Ct-68* [2112-9-15] 04:07AM BLOOD WBC-11.7* RBC-2.83* Hgb-8.7* Hct-25.8* MCV-91 MCH-30.9 MCHC-33.9 RDW-17.1* Plt Ct-59* [2112-9-14] 03:50AM BLOOD WBC-11.4* RBC-2.98* Hgb-9.2* Hct-26.2* MCV-88 MCH-30.8 MCHC-35.0 RDW-17.7* Plt Ct-62* [2112-9-13] 05:23AM BLOOD WBC-19.3* RBC-3.24* Hgb-9.8* Hct-28.5* MCV-88 MCH-30.3 MCHC-34.5 RDW-17.1* Plt Ct-89* [2112-9-12] 02:11AM BLOOD WBC-23.4* RBC-2.91* Hgb-8.7* Hct-25.7* MCV-89 MCH-29.8 MCHC-33.7 RDW-17.8* Plt Ct-73* [2112-9-11] 05:48AM BLOOD WBC-21.8* RBC-3.43* Hgb-10.4* Hct-29.7* MCV-86 MCH-30.2 MCHC-35.0 RDW-17.8* Plt Ct-99* [2112-9-10] 04:18AM BLOOD WBC-16.4* RBC-3.71* Hgb-11.1* Hct-32.1* MCV-87 MCH-29.8 MCHC-34.4 RDW-17.0* Plt Ct-120* [2112-9-9] 11:52PM BLOOD Hct-32.2* [2112-9-9] 04:13PM BLOOD WBC-16.8# RBC-3.17 Hgb-9.6* Hct-27.3* MCV-86 MCH-30.4 MCHC-35.4* RDW-17.6* Plt Ct-138* [2112-9-9] 03:05AM BLOOD WBC-10.4 RBC-3.34* Hgb-10.0* Hct-29.1* MCV-87 MCH-30.0 MCHC-34.4 RDW-17.3* Plt Ct-140* [2112-9-8] 08:18PM BLOOD WBC-11.3* RBC-3.34* Hgb-10.1* Hct-29.5* MCV-89 MCH-30.3 MCHC-34.2 RDW-17.4* Plt Ct-136* [2112-9-8] 01:48AM BLOOD WBC-12.4* RBC-3.52* Hgb-10.5* Hct-31.3* MCV-89 MCH-29.9 MCHC-33.7 RDW-17.2* Plt Ct-142* [2112-9-7] 01:09PM BLOOD Hct-31.0* [2112-9-7] 03:54AM BLOOD WBC-12.1* RBC-3.52* Hgb-11.0* Hct-31.0* MCV-88 MCH-31.3 MCHC-35.5* RDW-17.6* Plt Ct-155 [2112-9-6] 02:09AM BLOOD WBC-9.3# RBC-3.72* Hgb-11.1* Hct-32.8* MCV-88 MCH-29.9 MCHC-33.9 RDW-16.9* Plt Ct-161 [2112-9-5] 02:28AM BLOOD WBC-6.1# RBC-3.84* Hgb-11.8* Hct-32.2* MCV-84 MCH-30.7 MCHC-36.6* RDW-17.1* Plt Ct-134* [2112-9-4] 03:15AM BLOOD WBC-3.0* RBC-3.48# Hgb-10.4# Hct-29.4# MCV-85 MCH-30.0 MCHC-35.4 RDW-16.9* Plt Ct-124* [2112-9-3] 10:36PM BLOOD WBC-3.0* RBC-2.65# Hgb-7.8# Hct-22.5* MCV-85 MCH-29.6 MCHC-34.7 RDW-17.7* Plt Ct-126* [2112-9-3] 10:00PM BLOOD Hct-22.8# [2112-9-3] 05:00AM BLOOD WBC-5.2# RBC-3.71 Hgb-11.0* Hct-31.7* MCV-86 MCH-29.6 MCHC-34.6 RDW-17.8* Plt Ct-112* [2112-9-2] 06:37PM BLOOD Hct-31.0* [2112-9-2] 08:17AM BLOOD Hct-28.0* [2112-9-2] 04:28AM BLOOD WBC-3.2* RBC-3.51* Hgb-10.7* Hct-30.4* MCV-87 MCH-30.3 MCHC-35.1* RDW-17.2* Plt Ct-96* [2112-9-1] 05:02AM BLOOD WBC-3.1* RBC-4.06* Hgb-12.2* Hct-35.5* MCV-88 MCH-30.1 MCHC-34.4 RDW-16.3* Plt Ct-74* [2112-8-31] 01:46PM BLOOD Hct-33.6* [2112-8-31] 05:01AM BLOOD WBC-2.5* RBC-3.70* Hgb-11.4* Hct-31.9* MCV-86 MCH-30.8 MCHC-35.7* RDW-16.9* Plt Ct-52* [2112-8-30] 04:45AM BLOOD WBC-3.9* RBC-4.27* Hgb-12.8* Hct-35.7* MCV-84 MCH-30.0 MCHC-35.9* RDW-16.3* Plt Ct-52# [2112-8-29] 03:57PM BLOOD Hct-34.5 Plt Ct-33* [2112-8-29] 04:00AM BLOOD WBC-3.1* RBC-3.96* Hgb-12.0* Hct-33.4* MCV-84 MCH-30.3 MCHC-36.0* RDW-17.1* Plt Ct-24* [2112-8-28] 10:56PM BLOOD Hct-35.6* Plt Ct-33* [2112-8-28] 03:56PM BLOOD Hct-33.5* Plt Ct-26* [2112-8-28] 04:15AM BLOOD WBC-2.6* RBC-4.05* Hgb-12.2* Hct-34.3* MCV-85 MCH-30.1 MCHC-35.5* RDW-16.8* Plt Ct-37* [2112-8-27] 02:15AM BLOOD WBC-3.4* RBC-4.29* Hgb-13.2* Hct-35.8# MCV-83 MCH-30.7 MCHC-36.9 RDW-17.2* Plt Ct-30* [2112-8-26] 05:45AM BLOOD WBC-4.3 RBC-3.52* Hgb-10.9* Hct-30.6* MCV-87 MCH-31.1 MCHC-35.8* RDW-16.9* Plt Ct-38* [2112-8-25] 04:30AM BLOOD WBC-3.0# RBC-2.86 Hgb-9.0* Hct-24.5* MCV-86 MCH-31.5 MCHC-36.8* RDW-18.8* Plt Ct-12# [2112-8-24] 10:24AM BLOOD WBC-1.6 RBC-3.12* Hgb-9.9* Hct-28.5* MCV-91 MCH-31.8 MCHC-34.8 RDW-19.8* Plt Ct-66* [2112-8-24] 03:00AM BLOOD WBC-1.8# RBC-3.26 Hgb-10.4* Hct-30.1* MCV-92 MCH-32.0 MCHC-34.7 RDW-18.6* Plt Ct-116# [2112-8-23] 09:23AM BLOOD WBC-5.1 RBC-3.12# Hgb-9.7# Hct-28.1 MCV-90# MCH-31.0# MCHC-34.4# RDW-19.5* Plt Ct-291# [2112-8-23] 12:52AM BLOOD WBC-7.2 RBC-2.07# Hgb-7.4# Hct-24.2* MCV-117# MCH-35.6 MCHC-30.4* RDW-17.9* Plt Ct-632* [2112-9-16] 10:44AM BLOOD PT-14.3* PTT-36.5* INR(PT)-1.3 [2112-9-14] 03:50AM BLOOD PT-14.4* PTT-37.3* INR(PT)-1.3 [2112-9-13] 05:23AM BLOOD PT-13.6 PTT-34.0 INR(PT)-1.2 [2112-9-12] 01:25PM BLOOD PT-13.6 PTT-37.4* INR(PT)-1.2 [2112-9-11] 05:48AM BLOOD PT-13.0 PTT-27.1 INR(PT)-1.1 [2112-9-10] 04:18AM BLOOD PT-13.0 PTT-27.3 INR(PT)-1.1 [2112-9-9] 03:05AM BLOOD PT-13.0 PTT-27.9 INR(PT)-1.1 [2112-9-7] 03:54AM BLOOD PT-12.7 PTT-29.7 INR(PT)-1.0 [2112-9-6] 02:09AM BLOOD PT-12.5 PTT-29.3 INR(PT)-1.0 [2112-9-5] 02:28AM BLOOD PT-12.7 PTT-31.7 INR(PT)-1.0 [2112-9-4] 03:15AM BLOOD PT-12.5 PTT-34.5 INR(PT)-1.0 [2112-9-3] 07:36AM BLOOD PT-12.0 PTT-27.8 INR(PT)-0.9 [2112-9-2] 02:39PM BLOOD PT-11.6 PTT-30.6 INR(PT)-0.9 [2112-9-1] 05:02AM BLOOD PT-11.4* PTT-25.2 INR(PT)-0.8 [2112-8-31] 05:01AM BLOOD PT-11.7 PTT-28.8 INR(PT)-0.9 [2112-8-30] 03:04PM BLOOD PT-12.1 PTT-28.7 INR(PT)-0.9 [2112-8-29] 04:00AM BLOOD PT-12.0 PTT-33.2 INR(PT)-0.9 [2112-8-28] 04:15AM BLOOD PT-12.0 PTT-35.2* INR(PT)-0.9 [2112-8-27] 02:15AM BLOOD PT-12.6 PTT-33.7 INR(PT)-1.0 [2112-8-26] 05:45AM BLOOD PT-12.9 PTT-38.5* INR(PT)-1.1 [2112-8-25] 09:00PM BLOOD PT-13.3 PTT-40.8* INR(PT)-1.1 [2112-8-25] 04:43PM BLOOD PT-13.1 PTT-42.5* INR(PT)-1.1 [2112-8-25] 10:49AM BLOOD PT-12.8 PTT-38.8* INR(PT)-1.0 [2112-8-25] 10:11AM BLOOD PT-13.0 PTT-37.7* INR(PT)-1.1 [2112-8-25] 04:30AM BLOOD PT-13.6 PTT-41.1* INR(PT)-1.2 [2112-8-24] 11:11PM BLOOD PT-13.6 PTT-42.1* INR(PT)-1.2 [2112-8-24] 05:29PM BLOOD PT-13.9* PTT-43.1* INR(PT)-1.2 [2112-8-24] 11:59AM BLOOD PT-13.1 PTT-41.8* INR(PT)-1.1 [2112-8-24] 03:00AM BLOOD PT-15.2* PTT-37.5* INR(PT)-1.5 [2112-8-23] 09:42PM BLOOD PT-15.7* PTT-35.2* INR(PT)-1.6 [2112-8-23] 02:43PM BLOOD PT-16.1* PTT-37.1* INR(PT)-1.6 [2112-8-23] 09:23AM BLOOD PT-17.1* PTT-41.7* INR(PT)-1.8 [2112-8-23] 12:45AM BLOOD PT-22.5* PTT-38.6* INR(PT)-3.2 [2112-8-22] 06:38PM BLOOD PT-21.2* PTT-33.4 INR(PT)-2.8 [2112-8-26] 05:45AM BLOOD Ret Aut-1.3 [2112-9-16] 10:44AM BLOOD Glucose-65* UreaN-102* Creat-3.6# Na-135 K-4.4 Cl-105 HCO3-19 AnGap-15 [2112-9-15] 04:07AM BLOOD Glucose-150* UreaN-82* Creat-2.1* Na-133 K-4.6 Cl-103 HCO3-16* AnGap-19 [2112-9-14] 03:50AM BLOOD Glucose-118* UreaN-70* Creat-2.1* Na-133 K-4.6 Cl-101 HCO3-21* AnGap-16 [2112-9-13] 05:23AM BLOOD Glucose-117* UreaN-52* Creat-1.2 Na-134 K-4.7 Cl-101 HCO3-24 AnGap-14 [2112-9-12] 02:11AM BLOOD Glucose-122* UreaN-36* Creat-1.0 Na-136 K-4.4 Cl-102 HCO3-27 AnGap-11 [2112-9-11] 09:45PM BLOOD Glucose-137* UreaN-37* Creat-1.0 Na-135 K-4.5 Cl-101 HCO3-27 AnGap-12 [2112-9-11] 05:48AM BLOOD Glucose-126* UreaN-48* Creat-0.9 Na-137 K-3.7 Cl-101 HCO3-28 AnGap-12 [2112-9-11] 01:00AM BLOOD Glucose-79 UreaN-55* Creat-1.6* Na-136 K-3.7 Cl-101 HCO3-27 AnGap-12 [2112-9-10] 08:30PM BLOOD Glucose-135* UreaN-60* Creat-1.7* Na-135 K-3.8 Cl-99 HCO3-27 AnGap-13 [2112-9-10] 04:18AM BLOOD Glucose-111* UreaN-83* Creat-2.3* Na-137 K-3.5 Cl-102 HCO3-26 AnGap-13 [2112-9-9] 04:13PM BLOOD Glucose-128* UreaN-113* Creat-2.6* Na-136 K-3.7 Cl-101 HCO3-22 AnGap-17 [2112-9-9] 03:05AM BLOOD Glucose-118* UreaN-115* Creat-2.6* Na-139 K-2.7* Cl-103 HCO3-21* AnGap-18 [2112-9-8] 08:18PM BLOOD Glucose-198* UreaN-145* Creat-3.6* Na-137 K-3.6 Cl-104 HCO3-17* AnGap-20 [2112-9-8] 01:48AM BLOOD Glucose-128* UreaN-162* Creat-3.6* Na-136 K-4.3 Cl-105 HCO3-16* AnGap-19 [2112-9-7] 03:54AM BLOOD Glucose-87 UreaN-154* Creat-3.3* Na-137 K-4.5 Cl-106 HCO3-17* AnGap-19 [2112-9-6] 02:09AM BLOOD Glucose-93 UreaN-141* Creat-3.3* Na-140 K-4.3 Cl-108 HCO3-18* AnGap-18 [2112-9-5] 02:28AM BLOOD Glucose-83 UreaN-133* Creat-3.3* Na-144 K-3.9 Cl-107 HCO3-23 AnGap-18 [2112-9-4] 03:15AM BLOOD Glucose-124* UreaN-131* Creat-2.7* Na-145 K-3.5 Cl-107 HCO3-25 AnGap-17 [2112-9-3] 05:00AM BLOOD Glucose-79 UreaN-118* Creat-2.2* Na-143 K-3.1* Cl-108 HCO3-25 AnGap-13 [2112-9-2] 04:28AM BLOOD Glucose-78 UreaN-120* Creat-2.4* Na-145 K-3.6 Cl-112* HCO3-22 AnGap-15 [2112-9-1] 05:02AM BLOOD Glucose-114* UreaN-116* Creat-2.7* Na-146* K-3.6 Cl-112* HCO3-22 AnGap-16 [2112-8-31] 05:01AM BLOOD Glucose-181* UreaN-103* Creat-2.4* Na-145 K-3.8 Cl-112* HCO3-24 AnGap-13 [2112-8-30] 04:45AM BLOOD Glucose-109* UreaN-100* Creat-2.4* Na-145 K-3.5 Cl-110* HCO3-24 AnGap-15 [2112-8-29] 04:00AM BLOOD Glucose-144* UreaN-96* Creat-2.4* Na-139 K-3.9 Cl-105 HCO3-23 AnGap-15 [2112-8-28] 04:15AM BLOOD Glucose-110* UreaN-92* Creat-3.0* Na-138 K-3.8 Cl-101 HCO3-25 AnGap-16 [2112-8-27] 02:15AM BLOOD Glucose-138* UreaN-69* Creat-2.4* Na-134 K-4.1 Cl-99 HCO3-25 AnGap-14 [2112-8-26] 05:45AM BLOOD Glucose-233* UreaN-55* Creat-2.4* Na-132* K-4.7 Cl-97 HCO3-24 AnGap-16 [2112-8-25] 09:30PM BLOOD Glucose-163* UreaN-50* Creat-2.6* Na-132* K-4.5 Cl-97 HCO3-21* AnGap-19 [2112-8-25] 01:44PM BLOOD Glucose-114* UreaN-46* Creat-3.0* Na-134 K-4.4 Cl-98 HCO3-21* AnGap-19 [2112-8-25] 04:30AM BLOOD Glucose-155* UreaN-44* Creat-2.6* Na-134 K-4.3 Cl-98 HCO3-17* AnGap-23 [2112-8-24] 05:29PM BLOOD Glucose-294* UreaN-41* Creat-2.1* Na-133 K-5.2* Cl-99 HCO3-9* AnGap-30* [2112-8-24] 03:00AM BLOOD Glucose-123* UreaN-38* Creat-1.5* Na-138 K-5.6* Cl-109* HCO3-8* AnGap-27* [2112-8-23] 09:42PM BLOOD Glucose-107* UreaN-37* Creat-1.6* Na-137 K-5.3* Cl-108 HCO3-8* AnGap-26* [2112-8-23] 08:06PM BLOOD Glucose-114* UreaN-34* Creat-1.4* Na-137 K-5.2* Cl-108 HCO3-9* AnGap-25* [2112-8-23] 09:27AM BLOOD Glucose-103 UreaN-33* Creat-1.4* Na-135 K-5.7* Cl-108 HCO3-12* AnGap-21* [2112-8-23] 12:52AM BLOOD Glucose-87 UreaN-34* Creat-2.1* Na-132* K-5.9* Cl-97 HCO3-18* AnGap-23* [2112-8-22] 06:38PM BLOOD Glucose-78 UreaN-30* Creat-1.7* Na-126* K-6.6* Cl-94* HCO3-14* AnGap-25* [2112-9-16] 10:44AM BLOOD ALT-125* AST-161* LD(LDH)-208 AlkPhos-669* Amylase-24 TotBili-28.6* [2112-9-12] 02:11AM BLOOD ALT-159* AST-137* LD(LDH)-265* AlkPhos-233* TotBili-20.1* [2112-9-11] 05:48AM BLOOD ALT-175* AST-146* LD(LDH)-323* AlkPhos-258* TotBili-23.9* [2112-9-9] 03:05AM BLOOD ALT-106* AST-90* AlkPhos-209* TotBili-19.9* [2112-9-8] 01:48AM BLOOD ALT-103* AST-88* AlkPhos-237* TotBili-20.9* [2112-9-6] 02:09AM BLOOD ALT-118* AST-80* AlkPhos-324* TotBili-25.6* [2112-9-5] 02:28AM BLOOD ALT-139* AST-99* LD(LDH)-214 AlkPhos-375* TotBili-27.9* [2112-9-4] 03:15AM BLOOD ALT-160* AST-119* CK(CPK)-17* AlkPhos-446* TotBili-26.3* [2112-9-3] 05:00AM BLOOD ALT-215* AST-156* AlkPhos-463* TotBili-29.5* [2112-9-2] 04:28AM BLOOD ALT-232* AST-197* LD(LDH)-257* AlkPhos-560* TotBili-26.4* DirBili-18.4* IndBili-8.0 [2112-9-1] 05:02AM BLOOD ALT-235* AST-213* AlkPhos-565* TotBili-29.3* [2112-8-31] 05:01AM BLOOD ALT-151* AST-160* AlkPhos-420* TotBili-26.5* [2112-8-30] 04:45AM BLOOD ALT-120* AST-142* LD(LDH)-289* CK(CPK)-43 AlkPhos-322* TotBili-28.7* [2112-8-29] 04:00AM BLOOD ALT-73* AST-90* AlkPhos-153* TotBili-25.1* [2112-8-28] 04:15AM BLOOD ALT-67* AST-91* LD(LDH)-252* AlkPhos-145* TotBili-27.8* [2112-8-27] 02:15AM BLOOD ALT-79* AST-89* AlkPhos-131* TotBili-27.0* [2112-8-26] 05:45AM BLOOD ALT-87* AST-94* LD(LDH)-212 AlkPhos-118* TotBili-23.4* DirBili-18.6* IndBili-4.8 [2112-8-25] 04:30AM BLOOD ALT-93* AST-147* LD(LDH)-211 AlkPhos-95 TotBili-18.8* [2112-8-24] 03:00AM BLOOD ALT-96* AST-138* AlkPhos-107 TotBili-18.7* [2112-8-23] 09:27AM BLOOD ALT-86* AST-79* AlkPhos-105 TotBili-11.1* [2112-8-23] 12:52AM BLOOD ALT-171* AST-111* LD(LDH)-218 AlkPhos-220* TotBili-15.8* [2112-8-22] 06:38PM BLOOD ALT-219* AST-134* LD(LDH)-312* CK(CPK)-52 AlkPhos-276* TotBili-18.3* DirBili-13.4* IndBili-4.9 [2112-8-31] 05:01AM BLOOD GGT-658* [2112-9-8] 08:18PM BLOOD CK-MB-3 cTropnT-0.02* [2112-9-5] 02:28AM BLOOD cTropnT-0.02* [2112-9-4] 01:24AM BLOOD CK-MB-3 cTropnT-0.03* [2112-9-3] 10:00PM BLOOD CK-MB-3 cTropnT-0.03* [2112-9-16] 10:44AM BLOOD Albumin-1.8* Calcium-7.9* Phos-5.6* Mg-2.0 [2112-9-12] 01:25PM BLOOD Hapto-58 [2112-9-3] 10:00PM BLOOD Hapto-100 [2112-8-26] 05:45AM BLOOD Hapto-59 [2112-9-7] 03:54AM BLOOD ANCA-NEGATIVE [2112-9-7] 03:54AM BLOOD [Doctor First Name ]-NEGATIVE [2112-8-29] 04:00AM BLOOD IgG-280* IgA-115 IgM-77 [2112-9-7] 03:54AM BLOOD C3-92 C4-12 [2112-8-23] 09:27AM BLOOD Ethanol-NEG [2112-8-22] 06:38PM BLOOD Acetmnp-8.8 [2112-9-4] 10:22AM BLOOD Gastrin-192* [2112-9-12] 08:21PM BLOOD Lactate-1.8 [2112-9-9] 08:53AM BLOOD Lactate-2.1* K-2.9* [2112-9-4] 05:01PM BLOOD Lactate-3.8* [2112-9-4] 03:10AM BLOOD Lactate-2.1* [2112-9-4] 02:10AM BLOOD Lactate-2.4* [2112-9-4] 12:39AM BLOOD Lactate-2.3* [2112-8-26] 05:55AM BLOOD Lactate-4.8* [2112-8-25] 04:33AM BLOOD Lactate-10.6* [2112-8-24] 11:35PM BLOOD Glucose-273* Lactate-12.6* [2112-8-24] 07:17PM BLOOD Glucose-286* Lactate-14.0* [2112-8-24] 05:50PM BLOOD Glucose-288* Lactate-14.2* [2112-8-24] 12:39PM BLOOD Glucose-247* Lactate-12.7* [2112-8-24] 06:51AM BLOOD Lactate-11.8* [2112-8-24] 04:59AM BLOOD Lactate-12.2* Na-132* K-5.1 Cl-106 [2112-8-24] 03:14AM BLOOD Lactate-11.9* [2112-8-23] 08:07PM BLOOD Lactate-11.3* [2112-8-23] 12:33PM BLOOD Glucose-95 Lactate-9.1* [2112-8-23] 06:45AM BLOOD Lactate-9.5* [2112-8-22] 09:43PM BLOOD Lactate-9.8* Brief Hospital Course: [Hospital Unit Name 153] course: (note: pt made CMO [9-17], so all treatments other than morphine were stopped at that time.) 1. GI Bleed: The night of admission, the patient became hypotensive to the 60s/40s unresponsive to fluid boluses. He remained alert and oriented throughout, and then a few hours later passed a large melenic stool and began having hematemesis. He was transfused numerous units of packed red cells and FFP, and GI was made aware. He was intubated for the endoscopy. When GI looked, he had a 2-cm duodenal ulcer covered by a clot, with a visable 4-5 mm vessel, which they injected with epi and cauterized. He had no other foci of bleeding, and so after his EGD he was maintained on Protonix 40 mg IV bid. An HPylori Ab was done, and was negative. In terms of his Crohn's meds, the 6-MP and Asacol were held per GI recs. He did well from an ulcer standpoint until the evening of [9-3], when he became tachycardic, hypotensive, and began having increasing bloody coffee-grounds output from his NGT. On lavage, he only became clear after 1 liter of lavage, then had increasing bloody output. His hematocrit was 22.5 down from 31.7 that AM. GI emergently scoped him overnight, and saw a >5 cm non-bleeding duodenal bulb ulcer, occupying almost the entire bulb, with ragged edges and a purulent blackish base. The ulcer was too large for them to intervene, and they recommended angio vs surgery if he bled again. He also had gastritis in his fundus. GI was unsure as to why his ulcer would have gotten so much larger on [Hospital1 ] Protonix and recommended checking a gastrin level to r/o Zollinger-[Doctor Last Name 9480] (gastrin was only mildly elevated, not in the [Telephone/Fax (1) 1999] range expected with Z-E). Per GI recs, the pt had a gastric pH monitor placed, and his protonix was titrated for a gastric pH greater than 7. This was accomplished on a dose of protonix 80 mg IV tid. The rest of their differential for an ulcer of this size was his Crohn's vs. lymphoma. At the time of this 2nd bleed, interventional radiology and surgery both became heavily involved in the case. IR did not want to take him down to angio if he was not actively bleeding, as they felt the risk of prophylactically embolizing this area (which would require the embolization of 2 arteries) outweighed the benefit of him possibly not bleeding again, when he had already stopped on his own for the 2nd time. Surgery felt he did not have an acute abdomen, and thought that he would be a poor surgical candidate regardless. Mr. [Known lastname 29666] hematocrit remained relatively stable throughout the rest of his admission, and he had no further catastrophic bleeding events. 2. Hepatitis: The etiology of his hepatitis remained unclear. His EtOH was negative on admission. He had negative viral and autoimmune serologies during his initial admission in [Month (only) 205], as well as a biopsy demonstrating mild sinusoidal fibrosis. The hepatology service was consulted, and although they were uncertain of the etiology of his liver disease, they felt it may be due to his 6-MP. There are reports in the literature of 6-MP causing hepatotoxicity. On admission, his liver tests were elevated to a higher extent than they had ever been during his prior admission. On admission, his transaminases were in the 100s and his bili was 15, rising to 29 ten days after admission. They fluctuated around that range throughout his stay, but interestingly his INR (2.8-->3.2 on adm.) improved with Vitamin K (which he was given after his initial GI bleed) and stayed in the 1.0 range throughout his course, signifying that his liver had some degree of synthetic fxn remaining. His albumin was poor, between 1.5 and 2.3. He had 6-MP metabolits sent off to an outside lab, which came back as: 6-TGN 101 (nl 230-400), units pmole/8x10(8) RBCs. The 6-MMPN was 6806 (nl <5700). In retrospect, this may have been the cause of his elevated bili and transaminases, but a clear etiology was never uncovered. 3. Cellulitis-->Skin Wounds-->Septicemia: He was originally begun on vancomycin and zosyn because he had skin infections that were worse after a course of Unasyn, Augmentin, and Keflex. He got so much fluid in his initial resuscitation that he developed 4+ pitting edema, and began weeping fluid out of all four extremities. The areas that had originally appeared to be cellulitis (warm, erythematous areas on his RLE and LUE) developed bullae due to all the fluid, and then eventually burst. Soon his RUE developed these same bullae. They all ruptured, and the ulcerations continued to worsen, with persistent sloughing of layer after layer of his skin on these 3 extremities (the LLE, which was where the initial infxn was during his stay in [Month (only) ], had 2 punched-out appearing chronic ulcers on his superior and inferior anterior lower extremity, but never looked as bad as the other 3 extremities.) The pain from these skin lesions required him to be on persistently higher doses of a fentanyl gtt. His RLE wound developed a greenish-looking necrotic area in the center which grew, and Plastics was consulted. They debrided his R leg on [8-29] in the area of this RLE necrosis, but did not feel he needed to go to the OR for debridement as they felt it was partial-thickness skin injury. The wounds were cultured on admission and grew MSSA. Derm was consulted as well, and they biopsied it given a concern for systemic vasculitis (with his multi-organ system dysfxn.) The biopsy demonstrated emboli in the vessels that grew gram-positive cocci (unable to obtain ID/[Last Name (un) 36]), but no vasculitis. After this info, he had a TEE done to r/o a source of the emboli, which showed no vegetations. He was continued on vancomycin for the MSSA until [9-18], as oxacillin has (rarely) been reported to cause hepatotoxicity. He also grew MSSA from 1/2 bottles of a blood cx from admission on [8-22]. His Zosyn was discontinued on [8-27] (due to concerns it was causing thrombocytopenia), and he had a five-day course of levaquin from [8-24] to [8-28] for empiric GNR coverage given his open skin wounds. [1-27] blood cx bottles from [8-25] grew [Female First Name (un) ] albicans (also had a urine from that date that grew >100K yeast), and line tip from [8-30] grew [Female First Name (un) ] albicans.. He was treated with a 14 day course of antifungals for this with first day counting as [8-30] (first day of negative blood cx). He was originally treated with caspofungin, but his liver tests worsened and so he was changed to fluconazole. (That also causes hepatotoxicity, but by a different mechanism, and his LFTs were more stable once he was switched to fluconazole.) Ophthalmology performed a retinal exam to r/o candidal endophthalmitis, which was negative. Given his positive candidal blood cx, he had a chest and abd CT scan looking for a fluid collection or increased areas of attenuation in his liver and spleen that would indicate he had seeded elsewhere with candidal emboli. The scan was negative for anything other than ascitse. During his stay, he also had negative CMV titers and viral load, negative urine histo ag, negative crypto ag, decrased IgG (280) with nl IgA and IgM, and CD4 count of 30 (expected, given his sepsis). His HIV status is unknown and we could not test him as he could not give consent. After his repeat bleed on [9-3], given the fear of aspiration while he was having increased bloody NG output to the point where it was leaking around his tube, he was begun on Clindamycin. That day he was also started on cipro, empirically for his Crohn's. For the next approx 2 weeks, his abx were: vanc (dosed by level), cipro, clinda, and fluconazole. He also grew VRE from a line tip (ID felt likely a contaminant and not something to treat, as it never grew from blood cx), and lactobacillus from one bottle of a blood cx (ID also felt this was a contaminant.) He grew klebsiella from his sputum as well, but at this point it was felt any further treatment was futile. His antibiotics were continued until he was made CMO. 4. EKG changes: On the night of his 2nd bleed ([9-3]), while he was tachycardic and appearing generally uncomfortable, we obtained an EKG. It showed TWI in his inf and lat leads, with ST depression in V3. CKs were negative, and his troponin was 0.03 which decreased to 0.02 on serial labs. It was felt this was related to demand ischemia. He had a TEE which demonstrated an EF of 60-65%. 5. ARF: Mr. [Known lastname 29666] creatinine was elevated initially at 1.7, with a FeNa of less than 1% and granular casts on UA. It was felt he had renal failure [1-25] prerenal physiology initially, which was worsened by his hypotension creating an ATN picture. Hepatorenal was much further down on the differential given that his liver fxn (INR) improved so dramatically while his renal fxn worsened. His creatinine initially peaked at 3.0 one week after admission, then slowly improved to the 2.4 range. After his 2nd bleed with concomitant hypotension, it worsened again, peaking at 3.6. With this he also had a worsening acidosis and uremia. Renal evaluated him, and he was begun on CVVH with resulting improvement in the acidosis and uremia. He continued to make small amounts of urine. He had a CT-guided renal biopsy on [9-9], given the thought that maybe a vasculitis would tie his systemic illness together. The renal biopsy demonstrated ATN, no vasculitis. After discussion with his brother, it was decided to stop the dialysis and monitor his renal fxn. His creatinine slowly rose and his urine output dropped. His brother did not wish to restart dialysis given his poor prognosis, and he became progressively more oliguric. 6. Thrombocytopenia and leukopenia: On admission, his platelets were elevated in the 600-700s, but they quickly fell. Throughout his admission they were basically in the 10-50 range, and because of his bleeding we attempted to keep him greater than 50K, which was difficult at times. Originally it was felt that his thrombocytopenia was [1-25] the Zosyn, and it did improve (to the low 100s) after the zosyn was stopped. However, he began to trend back down to the levels he was at before. It was felt that this, and his initial leukopenia, were due to relative [Name (NI) 28729] from severe sepsis. His WBC count was initially very low, around [1-26]. It eventually rose to 23 3 weeks later, and it was unclear if this was due to a new infxn or to an appropriate response to his ongoing illness. His chronic steroid use did not seem to be a sufficient explanation for his degree of immunosuppression, and we were unsure if it was due to sepsis vs. an underlying immune system dysfunction that remained undiagnosed. 7. Chronic steroid use: Mr. [Known lastname 8494] was placed on an insulin drip, as his glucose was likely going to be difficult to control given the higher-dose steroids we were using. We didn't feel we could use subQ insulin due to his overwhelming skin wounds. Per OMR notes, the pt often self-dosed his prednisone, and in his bag of pills he had at least 7 different bottles of prednisone of varying doses (between 5-40 mg). We did speak with his pharmacist in [Location (un) ], however, who assured us that Mr. [Known lastname 8494] was extremely conscientious about his medications. Given his chronic and unclear prednisone use, he was initially placed on hydrocortisone 100 mg IV q8h for stress dose. This was tapered beginning after his 2nd bleed, as he likely no longer needed stress-dose and the dose we were giving him was insufficient to treat his Crohn's. The steroids at this point were only worsening his wound healing (both skin and duodenal ulcer). He was eventually maintained on a level of hydrocortisone 10 mg IV q8h, which was felt to be a physiologic dose for him. 8. Mental status: Mr. [Known lastname 8494] was initially sedated on fentanyl and versed for pain control due to his skin lesions. He required large doses of fentanyl for pain control as he frequently appeared uncomfortable, becoming tachycardic and hypertensive, especially with dressing changes. Throughout the month, he was intermittently able to follow commands. It was hoped that when he was extubated on [9-15], he would wake up slightly and be able to interact. At this point his Versed was weaned to off and his fentanyl was turned down, with morphine boluses when he appeared in pain. Unfortunately, after extubation, he was only able to open his eyes to voice. He never followed commands, tracked with his eyes, or responded to questions. This may have been due to his uremia or simply the effect of being sedated for 30 days. 9. Intubation: He was initially intubated for his endoscopy, and after that he was kept intubated because he was requiring such heavy amounts of fentanyl for pain control. For most of his course, he was maintained on pressure support ventilation and had excellent RSBI's every morning. He was evaluated by the Interventional Pulmonary Service for trach, but they felt he was too sick for that indication. He also had a component of pulmonary edema going on. As he had received an aggressive fluid resuscitation when he bled, and although it was impossible to measures his I/O's (given that he constantly wept fluid out of all 4 extremities) he was massively total body volume overloaded. He initially responded to diuresis with Lasix, but his creatinine began rising steadily after his 2nd ulcer bleed and we felt it was not indicated to diurese with lasix. We took fluid off with his CVVH, in order to optimize his lungs for extubation. His breathing was comfortable-appearing after extubation although he had copious secretions that he was unable to cough up. 10. Hypotension/Hypertension: His blood pressure was difficult to control throughout his stay. At the time of his 2 bleeds, he was hypotensive, but at other points he was hypertensive, requiring afterload reduction with hydralazine. Later on in his course, he became progressively hypotensive to the 60s, unresponsive to fluid boluses. This occurred around the weekend of [9-25], and it was felt that he was likely septic. At this point all antibiotics were discontinued as part of his CMO status (with the family's consent). He became progressively hypotensive until he died of cardiac arrest on [Last Name (LF) 766], [9-19], [2111]. Medications on Admission: Prednisone 35 mg qd Asacol 1600 mg po tid 6-MP 125 mg qd Vitamin E Calcium Centrum Fosamax 35 mg q Wednesday Vitamin D Discharge Disposition: Home Discharge Diagnosis: Sepsis Discharge Condition: none Discharge Instructions: none Followup Instructions: none ICD9 Codes: 5845, 4275
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7760 }	Medical Text: Admission Date: [2112-11-8] Discharge Date: [2112-11-15] Date of Birth: [2056-8-15] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: confusion, decreased verbalization Major Surgical or Invasive Procedure: Left Craniotomy for Mass [11-11] Bronchoscopy History of Present Illness: Patient is a 56 yo man with PMH of recently diagnosed metastatic small cell lung CA. Diagnosed 1.5 weeks ago with BX after prolonged cough. Following Bx was noted to be more confused and less verbal. had some lowgrade temps. Then thursday last week stopped speaking and was noted to have a right hemiparesis. On thursday last week had a PET scan which showed mets to left skull base and lymph nodes. Was to have an outpatient CT of head for headaches, but PCP asked family to take him to ED for more urgent imaging. Past Medical History: small cell CA as above, depression Social History: Married, resides at home with wife Family History: Non-contributory Physical Exam: On Admission: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [4-27] left and 4-2.5 left and slightly sluggish EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Follows commands moderately well but aphemic. Cranial Nerves: I: Not tested II: Pupils: [4-27] left and 4-2.5 left and slightly sluggish III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-30] on left and right side is 5- at tircep, finger extensors, HS and DF. Mild right pronator drift Sensation: Difficult to assess. Reflexes: B T Br Pa Ac Right 2+ throughout Left Toes downgoing bilaterally Coordination: normal on finger-nose-finger On Discharge: Alert, oriented x2, slight RUE motor deficit of 5-/5, otherwise full strength, ambulating in hallway with nursing without difficulty. Pertinent Results: Labs on Admission: [2112-11-8] 08:13PM BLOOD WBC-11.7* RBC-4.02* Hgb-11.1* Hct-33.6* MCV-84 MCH-27.6 MCHC-32.9 RDW-13.3 Plt Ct-467* [2112-11-8] 08:13PM BLOOD Neuts-90* Bands-2 Lymphs-7* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2112-11-8] 08:13PM BLOOD PT-12.8 PTT-25.3 INR(PT)-1.1 [2112-11-8] 08:13PM BLOOD Glucose-118* UreaN-5* Creat-0.6 Na-139 K-4.3 Cl-101 HCO3-27 AnGap-15 [2112-11-9] 03:00AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.2 Labs on Dishcarge: XXXXXXXXXXXXXXX Imaging: MRI Head ([11-9]): IMPRESSION: 1. Multiple intra-axial enhancing lesions, consistent with metastases. 2. The largest lesion is within the left frontal lobe, has a bilobed appearance, and demonstrates extensive edema, with mass effect on the ipsilateral ventricle, rightward midline shift of at least 1 cm, early uncal herniation. Some of the above-described lesions demonstrate diffusion restriction, which has been reported in small cell carcinoma of the lung. 3. The reported skull base lesion identified on an outside PET study is not definitively identified on this study. If available, the PET could be digitized into PACS for more detailed comparison.\ CT Torso [11-10]: IMPRESSIONS: 1. Large neoplastic right lung mass with extensive right hilar and mediastinal adenopathy causing narrowing of adjacent airways and pulmonary arteries, as described above. 2. Lucent lesion in the T7 vertebral body with ill-defined borders and without typical findings of hemangioma is concerning for metastatic disease in this patient with a reported history of skull metastasis. Correlation with prior PET study is recommended. 3. Tiny left pleural effusion, without evidence of left lung mass. Head CT [11-11]-post-resection: IMPRESSION: 1. Status post resection of large left frontal mass with no large postoperative hemorrhage identified. Decreased rightward subfalcine herniation as described. 2. Other scattered smaller intracranial mass is identified as described. EKG [11-8]: Sinus rhythm. Normal tracing. No previous tracing available for comparison. CXR [11-8]: IMPRESSION: Right perihilar mass with right upper and mid lung field opacification worrisome for post-obstructive pneumonia. Brief Hospital Course: Mr. [Known lastname ] was admitted to the ICU where he was closley monitored. He was found to have a LLL pleural effusion and had a bronchoscopy to better evaluate prior to going to the OR for resection of his brain mass. On [11-11] he had a Left craniotomy and mass resection in which post-op imaging was stable. After the OR the pt was sent back to the ICU where he did however continued to have expressive aphasia and 5-/5 R side hemiparesis. He tolerated reg. diet, foley was d/c'd and pt was OOB and ambulating. On [11-14] he was transferred to the floor and ambulated well with nursing. On [11-15] he had improved aphasia, however continued to have very sl. R side weakness however ambulating w/o difficulty. Medications on Admission: Paxil Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. 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 3. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for as below: continue to take daily as long as you require narcotic pain medication to avoid constipation. Disp:60 Capsule(s) Refills:0 5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed: Caution not to exceed more than 4gm of tylenol in 24h period. Disp:40 Tablet(s) Refills:0 7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: VNA care networks Discharge Diagnosis: Left Frontal Brain Mass Right Upper Lung Mass Small LLL Pleural effusion Mild R hemiparesis Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. Please have results faxed to [Telephone/Fax (1) 87]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office on [11-21] for removal of your staples or sutures. ??????You have an appointment scheduled with the brain tumor clinic, located on the [Hospital Ward Name ] for [12-5] @4pm. They are located in the [Hospital Ward Name 23] building, [Location (un) ]. Speech Language Follow-up: please call [Telephone/Fax (1) 3731] to schedule an appointment Completed by:[2112-11-15*] ICD9 Codes: 5119
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7761 }	Medical Text: Admission Date: [2187-3-19] Discharge Date: [2187-4-6] Date of Birth: Sex: Service: ADDENDUM: This is an addendum to the previous discharge summary. DISCHARGE STATUS: Discharged to extended care facility. DISCHARGE INSTRUCTIONS: Nasogastric tube replaced; tube feedings Lovenox full strength, ProMod 20 grams per day, starting at 10 mls per hour, advance by 20 mls q. six with a goal rate of 80 mls per hour. Therapeutic paracentesis prn. Give albumin with each tap. Transfuse red blood cells as needed for hematocrit less than 25. Neutropenic precautions for ANC less than 500. Consider initiating cyclophosphamide and tapering high dose steroids for [Doctor Last Name 11586]-[Doctor First Name ] syndrome once nutritional status is improved. Monitor pancreatic enzymes while on tube feeds. Consider starting Disphosphinate such as LNGE, given high dose steroids. Consider bone mineral density examination with high dose steroids. Continue checking platelet antibodies to 2B, 3A and factor 9. If positive, would argue for ITP and possible treatment with Rotoxamine. FINAL DIAGNOSES: Probable [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 11586] syndrome, no unifying diagnosis possible at this time. Catalyst ascites. Pancreatitis. Ileus. Pancreatic/splenic infarct. Pulmonary edema. Thrombocytopenia. Anemia. Leukopenia. Malnutrition. Adrenal insufficiency. Steroid induced diabetes mellitus. Depression. DISCHARGE CONDITION: Fair. The patient remained in the hospital until [2187-4-6] when she was transferred, by plane, to a hospital in [Country ]. MEDICATIONS ON DISCHARGE: Phyllglastin 1 mls of 300 mcg q. 24 hours. Epoetin 4,000 mg q. Thursday. Lorazepam 0.5 to 2 mls intravenous q. four to six hours prn. Hydromorphone 4 mg p.o. every four to six hours prn. Lorazepam 0.5 mg one to two tablets p.o. every four to six hours prn. Methylprednisolone 100 mg intravenous q. day. Hydromorphone 0.5 mg intravenous every three to four hours prn. Serchilene 50 mg p.o. q. day. Furosemide 40 mg p.o. q. day. Ferrous gluconate 300 mg p.o. q. day. Sopra 30 mg p.o. q. day. Multi-vitamin liquid, 5 mls p.o. q. day. Regular insulin sliding scale. Calcium 500 mg p.o. three times a day. Vitamin D 400 mg p.o. twice a day. [Doctor Last Name ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD [MD Number(1) 5708] Dictated By:[Last Name (NamePattern1) 2918] MEDQUIST36 D: [2187-6-11] 06:13 T: [2187-6-12] 03:37 JOB#: [Job Number 49456] ICD9 Codes: 5845, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7762 }	Medical Text: Admission Date: [2196-2-29] Discharge Date: [2196-3-4] Date of Birth: [2132-5-26] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 922] Chief Complaint: Shortness of breath, Dyspnea on exertion Major Surgical or Invasive Procedure: [2196-2-29] Pericardiectomy [3-3] Paracentesis by Hepatology service History of Present Illness: This is a 63 yo male with cirrhotic liver disease, atrial fibrillation and known pericardial calcification/constriction referred for evaluation for pericardial stripping and possible Maze procedure. Denies orthopnea and PND. No history of chest pain. His shortness of breath does improve following paracentesis. Past Medical History: - Liver Cirrhosis, complicated by Ascites. Liver bx [10-29] showed chronic venous outflow obstruction/constrictive pericarditis. - Alcoholism, quit [2187] - Hypertension - Chronic Atrial Fibrillation - Chronic Venous Insufficiency - History of Gout(resolved when quit ETOH) - External Hemorrhoids Past Surgical History: - s/p Paracentesis on frequent basis, currently Q3-4 weeks - s/p Bilateral Inguinal Hernia - s/p Umbilical Hernia - Polypectomy(complicated by GI Bleed) Social History: Race: Caucasian Lives with: Alone in [Location (un) 39908]. Partner is [Name2 (NI) ]. Occupation: Retired Machinist Tobacco: Denies ETOH: None since [2187]. History of heavy use. Family History: Father died of liver disease at age 69. Mother died of stroke at age 83. No premature CAD. Physical Exam: Pulse: 87 Resp: 20 O2 sat: 99% B/P Right: 115/81 Left: 115/84 Height:6'0" Weight:175 lbs General: Non-toxic, No acute distress middle aged male Skin: Dry [x] intact [x] ?jaundice HEENT: PERRLA [x] EOMI [x] - sclera anicteric Neck: Supple [x] Full ROM [x] - no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur - none Abdomen: +distended, very firm - significant ascites noted, large ventral hernia noted Extremities: Warm [x], well-perfused [x] Edema 1+ pitting edema bilaterally, chronic venous changes Varicosities: GSV without varicosities Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 DP Right: 1 Left: 1 PT [Name (NI) 167]: 1 Left: 1 Radial Right: 2 Left: 2 Carotid Bruit -- none Pertinent Results: [2196-2-29] Echo: PREBYPASS: The left atrium is dilated. 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%). Transgastric view could not be obtained. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The pericardium appears thickened. There are pericardial calcifications. The echo findings are suggestive but not diagnostic of pericardial constriction. POST BYPASS: Biventricular systolic function remains preserved. Pre-op [2196-2-29] 12:10PM BLOOD WBC-17.8# RBC-3.99# Hgb-11.5# Hct-34.4# MCV-86 MCH-28.7 MCHC-33.3 RDW-15.6* Plt Ct-353 [2196-2-29] 01:45PM BLOOD UreaN-31* Creat-1.1 Cl-99 HCO3-25 [2196-3-2] 11:55AM BLOOD ALT-18 AST-38 LD(LDH)-221 AlkPhos-114 TotBili-0.9 Post-op [2196-3-3] 05:45AM BLOOD WBC-7.8 RBC-3.05* Hgb-8.6* Hct-26.3* MCV-86 MCH-28.4 MCHC-32.8 RDW-16.2* Plt Ct-200 [2196-3-3] 05:45AM BLOOD Plt Ct-200 [2196-3-3] 05:45AM BLOOD PT-12.2 INR(PT)-1.0 ASCITES ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Mesothe Macroph [2196-3-3] 06:12PM 400* 3750* 48* 36* 0 3* 13* PERITONEAL ASCITES CHEMISTRY TotPro Albumin Triglyc [2196-3-3] 06:12PM 3.9 2.2 169 [2196-3-3] 05:45AM BLOOD Glucose-91 UreaN-25* Creat-1.0 Na-127* K-4.9 Cl-92* HCO3-28 AnGap-12 [2196-3-2] 11:55AM BLOOD ALT-18 AST-38 LD(LDH)-221 AlkPhos-114 TotBili-0.9 Radiology Report CHEST (PORTABLE AP) Study Date of [2196-3-2] 11:55 AM Final Report HISTORY: Chest tubes removed. Rule out pneumothorax. IMPRESSION: AP chest compared to [3-2]: Since [3-2], major cardiopulmonary support devices have all been removed, left lower lobe atelectasis has worsened, though the small overall lung volumes are unchanged. A slight interval increase in the cardiomediastinal diameter is a common finding after cardiac surgery. No pneumothorax. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Approved: WED [2196-3-2] 7:47 PM Chest CT [2196-3-4]: Preliminary Report !! WET READ !! A 9.6 x 8 cm loculated left pleural high density collection represents hematoma, possibly with moderate mass effect on the left ventricle - Dr [Last Name (STitle) 914] reviewed and spoke with radiologist - left pleural hematoma noted -patient cleared for discharge [2196-3-4]: Right femoral US: small hematoma at cannulation site with no vessel compression - WET REAS Brief Hospital Course: Mr. [Known lastname 50343] was a same day admit after undergoing pre-operative work-up as an outpatient. On day of admission he was brought directly to the operating room where he underwent a pericardiectomy with a bypass time of 105 minutes. Please see operative report 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-operative day one he remained hemodynamically stable and was transferred to the step-down floor for further care. Coumadin was restarted for atrial fibrillation. Chest tubes and epicardial pacing wires were removed per cardiac surgery protocols. He was seen by the hepatology service and had a paracentesis for 3500 cc's during his hospital stay. He complained post operatively of right leg stabbing pain and right thigh paresthesia. He was started on Neurontin. Neurology was consulted and it was thought that the paresthesia was a direct result of the femoral vein cannulation. A right femoral ultrasound was performed which revealed only a small hematoma with no pseudoaneurysm or fistula noted. The pain was improving at the time of discharge. Neurology recommended continuing Neurontin with follow up in clinic in 4 weeks if symptoms persist. He continued to progress with activity level and was discharged home with visiting nurses on [3-4]. He is to have his INR checked by VNA on [3-6] with results called to Dr[Name (NI) 670] office. Follow up with Dr [Last Name (STitle) 914] in 1 month. Medications on Admission: Ciprofloxacin 250mg po daily since [4-29] Furosemide 20mg po TID Spironolactone 100mg po BID Warfarin 7.5mg po daily STOPPED [2196-2-23] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): resume preop schedule. 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for dermititis. Disp:1 bottle Refills:0 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4 hrs as needed for pain. Disp:50 Tablet(s) Refills:0 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:45 Tablet(s) Refills:2 8. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day as needed for a-fib: for target INR 2-2.5. resume preop schedule. 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. 10. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:30 Tablet(s) Refills:0 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a day for 1 months. Disp:60 Tablet(s) Refills:0 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:30 Tablet(s) Refills:0 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 14. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:180 Capsule(s) Refills:1 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Constrictive Pericarditis s/p Pericardiectomy Past Medical History: - Liver Cirrhosis, complicated by Ascites. Liver bx [10-29] showed chronic venous outflow obstruction/constrictive pericarditis. - Alcoholism, quit [2187] - Hypertension - Chronic Atrial Fibrillation - Chronic Venous Insufficiency - History of Gout(resolved when quit ETOH) - External Hemorrhoids Past Surgical History: - s/p Paracentesis on frequent basis, currently Q3-4 weeks - s/p Bilateral Inguinal Hernia - s/p Umbilical Hernia - Polypectomy(complicated by GI Bleed) Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Sternal wound healing well, no drainage or erythema 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] Coumadin to be followed by [Hospital 197] Clinic at PCP's office (Dr. [First Name (STitle) ] Followup Instructions: Surgeon Dr. [Last Name (STitle) 914] on [3-29] @ 1:00 PM [Telephone/Fax (1) 170] Please call to schedule appointments Primary Care Dr. [First Name (STitle) ] in [1-23] weeks Cardiologist Dr.[Name (NI) 3733] in [1-23] weeks [Hospital 878] Clinic in 4 weeks if right leg pain persists Wound check appointment -[Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse [First Name (Titles) ] [Last Name (Titles) 10542]e prior to discharge Coumadin to be followed by [Hospital 197] Clinic at PCP's office (Dr. [First Name (STitle) ] - phone #[Telephone/Fax (1) 24713] Completed by:[2196-3-4] ICD9 Codes: 2761, 5715, 4019, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7763 }	Medical Text: Admission Date: [2178-5-28] Discharge Date: [2178-6-3] Date of Birth: [2114-2-8] Sex: M Service: MED Allergies: Doxepin / Levofloxacin / Oxycontin Attending:[First Name3 (LF) 242] Chief Complaint: SOB x 2d Major Surgical or Invasive Procedure: none History of Present Illness: 64 yo M w/ PMHx as below presented to ED on [5-29] w/ hypercarbic respiratory failure (initial ABG [5-28]: 7/29/92/~200 on NRB; baseline pco2 ~50-60); - CXR (? LLL opacity on [5-28] not well visualized on [5-29] CXR) in ED where he received 1 dose ctx and azithro. Likely [12-29] tracheobronchitis. Placed on AC 400/20/5/0.6--> improved ventilation (PC02 70). Hemodynamically stable throughout. Transferred to MICU for further management. Pt extubated on [5-29]. Past Medical History: Lung carcinoma, status post right pneumonectomy. Prostate cancer, status post resection. History of perioperative PE, on anticoagulation. Atrial fibrillation, on anticoagulation. Hypertension. Diabetes, type II. Obstructive sleep apnea. Hypercholesterolemia. B12 deficiency. Cataracts. Status post trach placement Social History: He lives with his wife. [Name (NI) ] has a 3-pack-per- day tobacco history but quit in [2174] and an overall 160-pack- per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: In general, the patient was lying in bed, in no acute distress. His pupils were equal, round, and reactive to light. He had moist mucous membranes. His neck was supple. He had no JVD. He had no breath sounds on chest exam on the right. Positive rhonchi on the left with some upper airway noise that was transmitted downward. Cardiac exam showed regular, rate, and rhythm nl S1 S2 no m/r/g. His abdomen was soft and nontender. Bowel sounds were present. Extremities were warm without edema. Neurological, he was alert and oriented x 3. Pertinent Results: [2178-5-28] 06:20PM PLT SMR-NORMAL PLT COUNT-330 [2178-5-28] 06:20PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2178-5-28] 06:20PM NEUTS-76* BANDS-22* LYMPHS-1* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2178-5-28] 06:20PM WBC-33.7# RBC-4.55 HGB-13.9* HCT-41.8 MCV-92 MCH-30.6 MCHC-33.3 RDW-14.0 [2178-5-28] 06:20PM GLUCOSE-137* UREA N-21* CREAT-1.2 SODIUM-139 POTASSIUM-6.0* CHLORIDE-90* TOTAL CO2-39* ANION GAP-16 [2178-5-28] 06:29PM LACTATE-2.7* [2178-5-28] 08:01PM K+-3.9 [2178-5-28] 08:01PM TYPE-ART PO2-224* PCO2-92* PH-7.29* TOTAL CO2-46* BASE XS-13 [2178-5-28] 10:00PM URINE MUCOUS-FEW [2178-5-28] 10:00PM URINE HYALINE-0-2 [2178-5-28] 10:00PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [2178-5-28] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2178-5-28] 10:00PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.015 [2178-5-28] 10:00PM URINE GR HOLD-HOLD [2178-5-28] 10:00PM URINE HOURS-RANDOM Brief Hospital Course: The patient was intubated in the ER with hypercarbic respiratory. He was given antibiotics, steroids, and bronchodilators, transferred to the MICU A mini-trach was placed on [5-28]. Pt was extubated on in the MICU [5-29] as his respiratory status stabilized. He was eventually transferred to the floor where he continued to improve. He received physical therapy until he was satisfacorily ambulatory and was d/c'd to home. Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) [Month/Day (2) ]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule [Month/Day (2) ]: One (1) Capsule PO TID (3 times a day). 3. Senna 8.6 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day) as needed. 4. Amiodarone HCl 200 mg Tablet [Month/Day (2) ]: One (1) Tablet PO QD (once a day). 5. Atorvastatin Calcium 10 mg Tablet [Month/Day (2) ]: One (1) Tablet PO QHS (once a day (at bedtime)). 6. Gabapentin 100 mg Capsule [Month/Day (2) ]: One (1) Capsule PO HS (at bedtime). 7. Multivitamin Capsule [Month/Day (2) ]: One (1) Cap PO QD (once a day). 8. Cyanocobalamin 100 mcg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 9. Ferrous Sulfate 325 (65) mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 10. Paroxetine HCl 20 mg Tablet [Month/Day (2) ]: One (1) Tablet PO QD (once a day). 11. Bupropion HCl 150 mg Tablet Sustained Release [Month/Day (2) ]: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 12. Doxycycline Hyclate 100 mg Capsule [Month/Day (2) ]: One (1) Capsule PO Q12H (every 12 hours) for 7 days. Disp:14 Capsule(s) Refills:0 13. Theophylline 400 mg Tablet Sustained Release [Month/Day (2) ]: 0.5 Tablet Sustained Release PO QD (once a day). 14. Glyburide 5 mg Tablet [Month/Day (2) ]: One (1) Tablet PO QD (once a day). 15. Furosemide 80 mg Tablet [Month/Day (2) ]: One (1) Tablet PO BID (2 times a day). 16. Lactulose 10 g/15 mL Syrup [Month/Day (2) ]: Thirty (30) ML PO TID (3 times a day). 17. Advair Diskus 500-50 mcg/DOSE Disk with Device [Month/Day (2) ]: One (1) Inhalation twice a day. 18. Coumadin 3 mg Tablet [Month/Day (2) ]: One (1) Tablet PO q Mon, [Initials (NamePattern4) ] [Last Name (NamePattern4) ]. 19. Coumadin 5 mg Tablet [Last Name (NamePattern4) ]: One (1) Tablet PO on Tues, Wed, Fri, Sat, and Sun. 20. Prednisone 10 mg Tablet [Last Name (NamePattern4) ]: One (1) Tablet PO taper: Please take 4 tabs x 4 days, 2 tabs x 4 days, and 1 tab x 4 days. Disp:30 Tablet(s) Refills:0 21. Lovenox 80 mg/0.8 mL Syringe [Last Name (NamePattern4) ]: One (1) Subcutaneous twice a day for 10 days. Disp:10 syringes Refills:0 22. Percocet 5-325 mg Tablet [Last Name (NamePattern4) ]: One (1) Tablet PO every [3-3] hours as needed for fever or pain. Disp:80 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 269] Hospice [Location (un) 270] East Discharge Diagnosis: Hypercarbic respiratory failure COPD Tracheobronchitis DM II A fib OSA Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1.5 L/d Please continue with [Hospital1 ] Lovenox until you have your INR re-checked by [Hospital3 271]. Followup Instructions: Provider: [Name Initial (NameIs) 272]/UROLOGY UROLOGY CC3 (NHB) Where: [Hospital 273] SURGICAL SPECIALTIES Phone:[Telephone/Fax (1) 274] Date/Time:[2178-7-1] 11:30 Provider: [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 276], M.D. Where: [Hospital6 29] SURGICAL SPECIALTIES Phone:[Telephone/Fax (1) 277] Date/Time:[2178-7-1] 10:30 Provider: [First Name8 (NamePattern2) 278] [Last Name (NamePattern1) 279], [Name12 (NameIs) 280] Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2178-6-19] 1:20 ICD9 Codes: 2765, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7764 }	Medical Text: Admission Date: [2158-9-11] Discharge Date: [2158-9-15] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 689] Chief Complaint: Failure to thrive, acute renal failure, mental status change, tremor Major Surgical or Invasive Procedure: G-tube placement History of Present Illness: 86 yo F with dementia, HTN, CKD with recent discharges from [Hospital1 18] for FTT, ARF and UTI admitted today from rehab due to poor PO intake and concern of new body tremors/neck spasm; found to have acute on chronic renal failure. The pt has had two recent admissions for similar complaints. Today, the pt was referred to her PCP's office and was found to have cogwheel rigidity and neck spasm. Additionally, HCT was found to be slightly below baseline and LFTs were abnormal by report, although not yet available here. Unfortuantely, at the time of the interview the pt was minimally oriented and thus could not provide much history. Past Medical History: Auditory Hallucinations- not a seizure Disorder Dementia Hypertension Depression h/o falls Chronic Renal Insufficiency (Cr 2.2-2.9) Osteoporosis Renal Medullary Necrosis Organic Brain Syndrome Recent L rib fx Social History: Retired garment industry worker. Unmarried. No Tob, EtOH or drug history. Recently moved to a nursing home. Family History: Negative for seizures or stroke, otherwise NC. Physical Exam: VS: T 96, BP 136/52, HR 71, RR 20, 97%RA Gen: Elderly female, lying in bed, awake and responsive but otherwise disoriented. HEENT: EOMI, anicteric slera, MM dry, OP clear Neck: supple, no LAD CV: RRR, soft heart sounds, soft 3/6 SEM at RUSB Pulm: CTAB with decent effort, no wheeze or crackles aprpeciated Abd: thin, soft, + BS Ext: warm, 2+ DP pulses, no pitting edema, no calf tenderness Neuro: Awake and alert, not oriented. Intermittently able to follow one step commands. CNII-XII intact, motor and gross sensation intact throughout. Pertinent Results: [2158-9-11] WBC-9.6 Hgb-8.2* Hct-26.2* MCV-84 RDW-15.8* Plt Ct-245 Neuts-78.2* Lymphs-16.9* Monos-3.9 Eos-0.8 Baso-0.2 PT-12.4 PTT-18.3* INR(PT)-1.0 Glucose-74 UreaN-54* Creat-3.4* Na-141 K-5.9* Cl-109* HCO3-21* AnGap-17 ALT-346* AST-59* LD(LDH)-280* AlkPhos-174* TotBili-0.3 Albumin-3.5 . CXR [2158-9-11]: Stable atelectasis in the left lower lobe with no evidence of focal consolidations. Brief Hospital Course: HOSPITAL COURSE BY PROBLEM # Failure to Thrive: Thought to be [3-11] dementia and poor PO intake; has had multiple similar admissions in the past for the same reason. After discussion with [Hospital 228] health care proxy, IR was consulted and agreed to place a G-tube because of her persistent FTT related to poor PO intake even in the setting of monitoring at rehab. This was placed on [2158-9-13]. . Following the procedure, the patient developed chest/abdominal pain and leakage was noted around the G-tube. Pt was started on Zosyn and Flagyl overnight given the possibility of a perforation. Overnight the patient was noted to be hypotensive with SBP's in the 90's, which was well below her baseline BP as well as low urine output. Later the patient was also noted to have a moderate amount of hematemesis. Surgery was consulted and CT abdomen was suspicious for for extravasation of contrast. Given clinical changes, she required transfer to ICU for further management. After discussion with family regarding grave prognosis, decision was made to provide aggressive comfort measures. Pain medications were administered and she passed away at 11:03 pm on [2158-9-15]. Autopsy will be pursued given clinical circumstances. . Medications on Admission: Lisinopril 20 mg daily Atenolol 25 mg daily HCTZ 25 mg daily Norvac 5 mg daily ASA 81 mg daily Aricept 10 mg daily Lipitor 10 mg daily Risperdal 0.25 mg [Hospital1 ] Fosamax 70 mg weekly Mirtazapine 15 mg QHS Senna Colace Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Septic shock Possible gastric perforation Failure to thrive Acute on chronic renal failure Mental status change Discharge Condition: Expired Discharge Instructions: NA Followup Instructions: NA ICD9 Codes: 5849, 0389, 2762, 5859, 2767, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7765 }	Medical Text: Admission Date: [2148-6-11] Discharge Date: [2148-6-15] Date of Birth: [2096-10-22] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3151] Chief Complaint: Hypoxia. Major Surgical or Invasive Procedure: Right femoral central venous line placement ([6-11]). PICC line placement ([6-13]). History of Present Illness: Patient is a 51 y/o woman with PMHx of T1-T2 paraplegia following MVC [1-4], COPD and recent admission for PNA on [5-29]-4/30 who presented to her PCP today with hypoxia, lethargy, cough and increased work of breathing. Of note, she was discharged on [5-31] after a two day hospital stay for PNA and COPD exacerbation. She was treated with a short course of Levofloxacin and steroid taper. Per husband, pt has been doing well for the last week and has been out socializing and feeling well. However, she was notably tachypneic, satting in the 80s and requiring increased NC oxygen this morning. He brought her in for evaluation in [Company 191] and they referred her into the ED for further evaluation. In the ED, initial vs were: T 97.9 P 110 BP 109/84 R 24 O2 sat 97% on NRB. Pt underwent CXR which showed bilateral hazy opacities at bases, essentially unchanged from prior film on [5-30]. CTA was performed for hypoxia but did not show any PE, there was bilateral atelectasis with RLL consolidations. Blood & Urine Cx were sent and pt had right femoral line placed before she was given 1L NS, Vanc and Zosyn for possible PNA. Per [Name (NI) ], pt became more somnolent with ABG showing pH 7.34 pCO2 64 pO2 62. She was given Solumedrol 125mg IV, alb/atrovent and was placed on BIPAP to treat a component of COPD exacerbation and CO2 retention. On arrival to the ICU, pt was wearing BIPAP and complaining about the discomfort of the mask. Overall, she was still somnolent and husband provided most of the history. Review of systems: as above, provided by husband. Denies fevers, chills, nausea, vomiting, diarrhea, chest pain, med changes, rash, cough. Husband did note increased somnolence while eating and snoring while asleep. Past Medical History: 1. T1-T2 paraplegia following MVC [1-4] 2. Recurrent UTIs: [Month/Year (2) 40097] klebsiella 3. HCV, viral load suppressed 4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb 5. Anxiety 6. DVT in [2142] -IVC filter placed in [2142] 7. Pulmonary nodules 8. Hypothyroidism 9. Chronic pain 10. Chronic gastritis 11. H/o obstructive lung disease 12. Anemia of chronic disease 13. S/p PEA arrest during last hospitalization in [2147-10-3] Social History: - Lives at home with her husband and 2 adolescent children - Tobacco: 35 pack years, quit smoking after last hospitalization - etOH: Denies - Illicits: Denies Family History: No history of lung disease. Physical Exam: Vitals: BP 114/70 HR 80 Sats 99% on Face tent and 2L NC General: NAD, sleepy but easily arousable HEENT: Sclera anicteric, MMM, PERRLA Lungs: CTAB, no wheezes, occaisional RLL rhonchi CV: RRR no murmurs, rubs, gallops Abdomen: soft, NT/ND/NABS, no rebound tenderness or guarding Ext: warm, 2+ pulses, trace edema bilaterally Neuro: following commands, symmetric facial movement, squeezing hands bilaterally Pertinent Results: Labs at Admission: [2148-6-11] 02:45PM BLOOD WBC-18.3# RBC-4.00 Hgb-10.7* Hct-35.0* MCV-88 MCH-26.7* MCHC-30.4* RDW-15.5 Plt Ct-223 [2148-6-11] 02:45PM BLOOD Neuts-93.6* Lymphs-3.5* Monos-1.7* Eos-1.0 Baso-0.3 [2148-6-11] 02:45PM BLOOD PT-12.2 PTT-27.4 INR(PT)-1.0 [2148-6-11] 02:45PM BLOOD Glucose-123* UreaN-11 Creat-0.3* Na-142 K-4.9 Cl-101 HCO3-32 AnGap-14 [2148-6-11] 02:45PM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9 Lactate: [2148-6-11] 03:10PM BLOOD Lactate-2.1* K-4.1 [2148-6-11] 11:40PM BLOOD Lactate-1.9 [2148-6-12] 02:47PM BLOOD Lactate-3.0* Micro Data: [2148-6-12] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE- negative [2148-6-11] URINE URINE CULTURE- negative [2148-6-11] BLOOD CULTURE Blood Culture, Routine- negative [2148-6-11] BLOOD CULTURE Blood Culture, Routine- negative CTA chest ([2148-6-11]): 1. Assessment for pulmonary embolism within the segmental and subsegmental pulmonary arterial branches is limited due to suboptimal bolus timing. No evidence of pulmonary embolism in the main pulmonary arteries. 2. Moderate-to-severe bibasilar atelectasis, predominately within the right lower lobe. A more consolidative element within the right lower lobe along with a new lingular patchy opacity may reflect an infectious process. 3. Paraseptal emphysema. 4. Unchanged chronic rib cage deformities. Brief Hospital Course: 51 y/o woman with PMHx of T1-T2 paraplegia, COPD and recurrent PNAs who presents after recent discharge with respiratory distress and somnolence, concern for new RLL infiltrate. # Respiratory Distress: Mixed hypoxic/hypercarbic resp failure. Pt with COPD and recurrent PNAs who developped tachypnea, increased O2 requirement, cough and lethargy acutely this morning. She was referred into the ED by her PCP and underwent [Name Initial (PRE) ] CTA that was negative for PE but revealed RLL consolidation, unclear if new or resolving from prior admission. Pt became increasingly somnolent in the ED with pCO2 in 60s. In the ED she got steroids, alb/atrov and BIPAP, with improved mental status and minimal O2 requirement. Given increased WBC and possible consolidation and recent hospital admission, she was treated for HAP with cefepime and vancomycin. A PICC line was placed so that she could complete a 7-day course of antibiotics. There was concern of recurrent aspiration. Patient underwent a speech and swallow eval and passed. Her diet was restarted. Her initial PICC placed at the bedside went up the right IJ, so it was removed and replaced by interventional radiology. [2148-6-12] she had hypotension and a low-grade fever to 100.7 at 1am. She was given fluids and looked well clinically. Her CXR was unchanged, U/A was negative and blood cultures had no growth at the time of discharge. Her vancomycin was originally dosed 1250mg Q24 hours, but a trough level was 3.8, so the dosing was changed to 1000mg Q12 hours for the remainder of the course. # T1-T2 Paraplegia with chronic pain: pt is maintained on multiple sedating drugs for spasms and pain. She presented with respiratory distress and progressive somnolence and hypercarbia. Suspect a component of obesity hypoventilation with possible aspiration PNA. During this admission, her clonazpeam, pregabalin, and trazodone were initially held. Baclofen was decreased to 5 mg tid. Methadone and oxybutynin were continued at outpatient doses. Her pregabalin and trazodone were added back on, but her Baclofen was continued at 5mg TID with some minor leg spasticity, but adequate pain control. She was switched to Ultram for breakthrough pain, but did not find this effective, so she was switched back to Oxycodone. She was discharged, finally, on the same doses of methadone and oxycodone, a reduced dose of baclofen, and off of Klonopin. She was given 2 weeks of methadone and oxycodone to last until she can see Dr. [Last Name (STitle) 665] because she was supposed to get refills the day of her admission but ended up being transferred to the ED. . # Possible UTI: Urine Cx from [5-29] grew out +enterococcus >100,000 and this was not treated, possibly thought to be contaminant. Repeat UAs appeared bland without WBCs and she remained asymptomatic, so any possible UTI was probably treated with vanco/cefepime. . # Access: She originally had a right femoral CVL, which was pulled once she was stabilized. Medications on Admission: - albuterol nebs q4-6h prn - baclofen 10 mg up to 5 tabs daily - citalopram 40 mg daily - clonazepam 2mg qhs (occaisionally during the day for pain) - Combivent 2 puffs tid - levothyroxine 75 mcg qday - lidocaine patch qday - methadone 5 mg tid - omeprazole 20 mg prn - oxybutynin 5 mg up to five tabs daily - pregabalin 150 mg tid - sucralfate 1 g qid - trazodone 200 mg qhs - calcium carbonate 500 mg [Hospital1 ] - loratadine 10 mg daily prn - nicotine patch 21 mg daily - polyethylene glycol prn Discharge Medications: 1. Cefepime 2 gram Recon Soln [Hospital1 ]: Two (2) grams Intravenous every twelve (12) hours for 3 days. Disp:12 grams Refills:0 2. Vancomycin in D5W 1 gram/200 mL Piggyback [Hospital1 ]: One (1) gram Intravenous Q 12H (Every 12 Hours). Disp:6 gram Refills:0 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Hospital1 ]: One (1) treatment Inhalation Q6H (every 6 hours) as needed for wheeze. 4. Baclofen 10 mg Tablet [Hospital1 ]: 0.5 Tablet PO TID (3 times a day). 5. Citalopram 20 mg Tablet [Hospital1 ]: Two (2) Tablet PO DAILY (Daily). 6. Combivent 18-103 mcg/Actuation Aerosol [Hospital1 ]: Two (2) puffs Inhalation three times a day. 7. Levothyroxine 75 mcg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [Hospital1 ]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 9. Methadone 5 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). 10. Oxybutynin Chloride 5 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). 11. Pregabalin 150 mg Capsule [Hospital1 ]: One (1) Capsule PO once a day. 12. Trazodone 100 mg Tablet [Hospital1 ]: Two (2) Tablet PO HS (at bedtime). 13. Calcium Carbonate 500 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO BID (2 times a day). 14. Loratadine 10 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 15. Nicotine 7 mg/24 hr Patch 24 hr [Hospital1 ]: One (1) Patch 24 hr Transdermal DAILY (Daily). 16. Polyethylene Glycol 3350 17 gram/dose Powder [Hospital1 ]: One (1) packet PO DAILY (Daily). 17. Ranitidine HCl 150 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily) as needed for heartburn. 18. Colace 100 mg Capsule [Hospital1 ]: One (1) Capsule PO twice a day. 19. Percocet 5-325 mg Tablet [Hospital1 ]: One (1) Tablet PO every six (6) hours as needed for pain: For breakthrough pain. Take methadone as prescriped. Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Aspiration pneumonia Respiratory failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted because you were having difficulty breathing. We think that you had some contents from your stomach go into your lungs because you were oversedated by your medications. You went to the intensive care unit overnight, but your breathing has now improved and we think you are safe to go home. We cut back on your medications to try to avoid having this happen again. . - You should get 3 more days of antibiotics. A visiting nurse will come to give you the antibiotics through your PICC line. - Please STOP taking Klonopin for at this time. - Please DECREASE your Baclofen dose to 5mg every 8 hours. 5mg is half of a 10mg dose. - Please continue using methadone for pain control and percocet for breakthrough pain. - Please use ranitidine instead of omeprazole as needed for heartburn. - You can use colace and Miralax for constipation. You should take them every day unless you are having diarrhea. Followup Instructions: Please call Dr.[Name (NI) 666] office at [Telephone/Fax (1) 250] on Monday morning to make an appointment for later next week or the week after. You had this appointment already made for you: Department: SURGICAL SPECIALTIES When: MONDAY [2148-9-2] at 3:30 PM With: [Name6 (MD) 161] [Name8 (MD) 6476], MD [Telephone/Fax (1) 921] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2148-6-16] ICD9 Codes: 5070, 2762, 5180, 2449, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7766 }	Medical Text: Admission Date: [2126-8-11] Discharge Date: [2126-8-21] Date of Birth: [2041-4-30] Sex: M Service: CARDIOTHORACIC Allergies: Ciprofloxacin Hcl / Lisinopril Attending:[First Name3 (LF) 1406] Chief Complaint: Left arm numbness and +ETT after Coronary stenting(BMS) Major Surgical or Invasive Procedure: [2126-8-13] Coronary artery bypass grafting x4 with a left internal mammary artery to the left anterior descending artery and reverse saphenous vein grafts to the posterior descending artery, the right posterior left ventricular branch artery, second diagonal artery. History of Present Illness: s/p Inferior Myocardial Infarction([6-/2126]) during which he presented with syncope and high grade AV block. Had cardiac cath and angioplasty(BMS) of RCA at that time. Complained again during ETT of arm numbness and chest discomfort and was referred for bypass grafting. Past Medical History: Coronary Artery Disease s/p AMI/angioplasty(BMS)[6-/2126], Hypertension, Dyslipidemia, Right Bundle branch block, ? Seizure disorder([2125]), Rectal prolapse, Benign prostatic hypertrophy Social History: Lives with: wife Occupation: semi retired engineer/former missioary minister Tobacco: quit 40 yrs ago ETOH: none Family History: no cardiac disease- father CVA Physical Exam: On Admission Temp 98 Pulse: 66 Resp: 16 O2 sat: 95%-RA B/P Right: 127/68 Left: Height: 5'6" Weight:144 lbs General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact, non-focal exam 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 no Right: 2+ Left: 2+ Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [2126-8-13] at 12:01:48 PM Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. Mild (1+) AR. Eccentric AR jet directed toward the anterior mitral leaflet. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-bypass: The left atrium is mildly dilated. 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. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is a trivial/physiologic 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. PRELIMINARY REPORT developed by a Cardiology Fellow. Not reviewed/approved by the Attending Echo Physician. [Name10 (NameIs) 55496] assigned to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, Interpreting physician [Name Initial (PRE) ]: [2126-8-11] 12:35PM PT-13.9* PTT-32.4 INR(PT)-1.2* [2126-8-11] 12:35PM PLT COUNT-255 [2126-8-11] 12:35PM WBC-6.2 RBC-2.98* HGB-9.3* HCT-26.5* MCV-89 MCH-31.1 MCHC-34.9 RDW-13.8 [2126-8-11] 12:35PM %HbA1c-6.1* eAG-128* [2126-8-11] 12:35PM ALBUMIN-3.6 CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-1.9 IRON-66 [2126-8-11] 12:35PM CK-MB-2 cTropnT-<0.01 [2126-8-11] 12:35PM LIPASE-28 [2126-8-11] 12:35PM ALT(SGPT)-32 AST(SGOT)-26 LD(LDH)-128 CK(CPK)-51 ALK PHOS-103 AMYLASE-60 TOT BILI-0.4 [2126-8-11] 12:35PM GLUCOSE-112* UREA N-18 CREAT-0.6 SODIUM-128* POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-27 ANION GAP-11 [2126-8-11] 12:53PM freeCa-1.09* [2126-8-11] 05:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-NEG [2126-8-11] 05:12PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.014 [2126-8-11] 06:27PM HCT-32.3* Discharge: [2126-8-20] 04:15AM BLOOD WBC-9.3 RBC-2.86* Hgb-8.6* Hct-24.9* MCV-87 MCH-30.2 MCHC-34.6 RDW-14.9 Plt Ct-340 [2126-8-20] 04:15AM BLOOD Plt Ct-340 [2126-8-15] 03:05AM BLOOD PT-13.3 PTT-37.2* INR(PT)-1.1 [2126-8-20] 04:15AM BLOOD Glucose-96 UreaN-20 Creat-0.5 Na-127* K-4.5 Cl-94* HCO3-27 AnGap-11 Radiology Report CHEST (PA & LAT) Study Date of [2126-8-18] 9:58 AM [Hospital 93] MEDICAL CONDITION: 85 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pleural effusions Final Report In comparison with the study of [8-16], moderate enlargement of the cardiac silhouette persists in this patient with intact sternal sutures following CABG procedure. Left pleural effusion is again seen and may be slightly more prominent. Mild basilar atelectatic changes are again seen. No definite vascular congestion or acute pneumonia. DR. [First Name11 (Name Pattern1) 1569] [Initial (NamePattern1) ] [Last Name (NamePattern4) 11006] Brief Hospital Course: 85yo man s/p IMI wBMS of RCA in [2126-6-15], admitted to MWMC [8-9] after episode of arm tingling(anginal equivelant)during ETT. He was placed on Heparin and Integrillin infusion. Did well over next 2 days however had guiac + stool and recurrance of arm tingling on [8-11]. He was transferred to [Hospital1 18] for further treatment including planned coronary bypass grafting after preoperative admission testing was completed. On [8-13] Mr.[Known lastname 85600] was taken urgently to the operating room and underwent coronary artery bypass grafting x4. Please refer to Dr[Doctor Last Name ] operative report for details, in summary he had: Coronary artery bypass grafting x4 with a left internal mammary artery to the left anterior descending artery and reverse saphenous vein grafts to the posterior descending artery, the right posterior left ventricular branch artery, second diagonal artery. His bypass time was 83 minutes with a crossclamp of 76 minutes. He tolerated the procedure well and was transferred to the CVICU in stable but critical condition. He awoke neurologically intact and was extubated without incident. He was weaned off cardiac drips and Beta-blocker/Statin/Aspirin and diuresis was initiated. All lines and drains were discontinued according to cardiac surgery protocol. On POD# 2 he was transferred to the step down unit for further monitoring. Physical therapy was consulted for evaluation of strength and mobility. The remainder of his hospital course was uneventful. He continued to progress and on POD#8 he was cleared by Dr.[Last Name (STitle) ] for discharge to rehabilitation atSudbury Pines in [Location (un) 5176], MA Medications on Admission: Diovan 80', Metoprolol SR 200', Lipitor 80', Plavix 75'(last dose 6/25), Aspirin 325', Keppra 500"-stopped, Omeprazole 20', Colace 100" On transfer add Maxair Inhaler 2 puffs TID, Nitropaste [2-16]" Q6hrs, Zofran 4mg Q8hrs Plavix - last dose:[8-9] Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): [Hospital1 ] x 10days then QD until at pre-op weight(144lbs). 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). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Atorvastatin 80 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 DAILY (Daily). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for sob wheezing. 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection twice a day: IV BID x7 days then convert to PO and continue until at preop weight(144lbs). 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three (3) ML Intravenous DAILY (Daily) as needed for line flush: 0.9% Flush 3 ml IV DAILY:PRN line flush Peripheral IV - Inspect site every shift . Discharge Disposition: Extended Care Facility: TBD Discharge Diagnosis: Coronary Artery Disease s/p AMI/angioplasty(BMS)[6-/2126], [2126-8-13] Coronary artery bypass grafting x4 Hypertension, Dyslipidemia, Right Bundle branch block, Seizure disorder([2125]), Rectal prolapse, Benign prostatic hypertrophy Discharge Condition: Alert and oriented x3, nonfocal. Ambulating with steady gait. Incisional pain managed with ** Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 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: are scheduled for the following appointments: Surgeon:Dr.[Last Name (STitle) ] #[Telephone/Fax (1) 170] appointment arranged for [2126-9-11] at 1:30 pm Please call to schedule appointments with your Primary Care: Dr.[Last Name (STitle) ],[First Name3 (LF) ] P. [Telephone/Fax (1) 83273] in [2-16] weeks Cardiologist: Dr.[First Name4 (NamePattern1) 449] [Last Name (NamePattern1) 1295] in [2-16] 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:[2126-8-21**] ICD9 Codes: 2761, 5119, 4019, 2724, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7767 }	Medical Text: Admission Date: [2168-9-22] Discharge Date: [2168-9-26] Date of Birth: [2112-9-20] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 64] Chief Complaint: Intraoperative blood loss. I&D right hip THA Major Surgical or Invasive Procedure: Intubation; Attempted Total hip replacement History of Present Illness: This 56 year male unilingual russian speaker w/ a hx of hep B/C, cirrhosis, hypersplenism and pancytopenia was taken to the OR today for complex revision total right hip replacement because of debilitating right hip pain. The surgery was intended to be exploratory to see if there were any loose parts from previous surgeries that might be causing pain and could be removed. The patient's hip was opened and no such loose parts were found. Orthopedics feels the patient is not a candidate for any further surgical intervention. The procedure could not be completed due to heavy bleeding from the surgical site in the context of platlets of 34 and an INR 1.6. He lost an estimated 4L of blood, but got most of this back as cell [Doctor Last Name 10105]. He was also transfused 3 units PRBC, 6 units FFP and 5 units of platlets. He remained hemodynamically stable throughout the OR and never became hypoxic. Vanc and ancef were given intra-op and a drain was placed in the operative site before closing the hip. Post-op, he is admitted to [Hospital Unit Name 153] for resuscitation and monitoring in the context of heavy bleeding intra-op. . On the floor, he is intubated and sedated w/ pressure wrappings over his right hip and a drain in place. He remained stable in the [Hospital Unit Name 153] and was tranferred to the general orthopedic floor. Remainder of his hospital stay was unremarkable. He progressed with PT and was discharged to home with services in stable condition. Past Medical History: -Motor vehicle accident: failed ORIF acetabulum in [2160] requiring complex right total hip replacement in [2160]. -Hep B serology pos, DNA neg -Hep C presumed [1-5] transfusion after MVA in [2160]. s/p 6mo Interferon and Ribavirin tx, but hep C recurred -Liver cirrhosis: followed by GI. no focal lesions on U/S in [2168-6-2] -Cholelithiasis, no acute cholecystitis -hypersplenism -pancytopenia: felt to be secondary to marrow suppression from HCV and hypersplenism, not considered a candidate for epo tx per report -s/p appendectomy -s/p right hand surgery -s/p left shoulder surgery Social History: Originally from [Country 532]. - Tobacco: None per anesthesia report - Alcohol: None per anesthesia report - Illicits: None per anesthesia report Family History: Unknown Physical Exam: On arrival to ICU, Vitals: stable General: Intubated and sedated HEENT: Sclera anicteric. Right eye with cataract. Left pupil 1mm Neck: supple, 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, distended, bowel sounds present GU: foley draining clear fluid Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Skin over feet is darker brown bilaterally. incision C/D/I Skin: diffuse macular papular [Country ] over shoulder, neck legs and abdomen. Chest is spared. Brief Hospital Course: 56 year male with hep B/C, cirrhosis, hypersplenism and pancytopenia s/p unsuccessful complex revision total right hip replacement today, now admitted to [Hospital Unit Name 153] for resuscitation in the context of extensive intraoperative blood loss. # Hemorrhage: Patient had bleeding secondary to surgery with high intraop blood loss in context of thrombocytopenia and cirrhosis with elevated INR. He was transfused a total of 4 units PRBCs, 5U of platelets, and 5U FFP, and was bolused with IVF to maintain hemodynamic stability. He remained intubated overnight after surgery while he was being bolused and transfused repeatedly but was extubated to 2L NC the following morning on [9-23] without difficulty. DIC labs were wnl, and platelets were 40-70s. . # Post-op attemtpted total hip replacement: He received 2 g ancef Q8H x 48H for infection ppx. As above, he intitially remained intubated overnight due to fluid shifts and was kept on ARDSnet ventilation as pt at risk for TRALI. Pain was treated with dilaudid PCA when extubated. He spiked a fever to 100.7 on [9-23] and was pan cultured but has been afebrile since . # [Name (NI) ] - Unclear etiology but resolved by following day. [Month (only) 116] have been secondary to transfusion or anesthesia as he continued on abx without further reaction. . # Cirrhosis - Stable. Management as above. Gastroenterologist is Dr. [First Name (STitle) 679] if questions arise. He progressed well with PT while on the general orthopedic floor and was stable for discharge to home with physical therapy. Medications on Admission: Oxycodone-acetaminophen 5/325 mg 1 tab up to TID prn pain Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. Disp:80 Tablet(s) Refills:0 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: painful R THA 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may shower starting five days after surgery, but no tub baths or swimming for at least four weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. 10. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: wbat rle post hip precautions Treatments Frequency: daily dressing changes as needed ice as tolerated wbat Followup Instructions: Provider: [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3260], [MD Number(3) 3261]:[Telephone/Fax (1) 1228] Date/Time:[2168-10-21] 10:00 Completed by:[2168-9-26] ICD9 Codes: 2851, 5715, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7768 }	Medical Text: Admission Date: [2186-5-2] Discharge Date: [2186-5-10] Date of Birth: [2120-1-2] Sex: M Service: MEDICINE Allergies: Pneumovax 23 Attending:[First Name3 (LF) 689] Chief Complaint: Diarrhea, Weakness, Pneumonia Major Surgical or Invasive Procedure: None History of Present Illness: 66M hx pAF, C diff, recent at St E for PNA, home from rehab x few days, wife noted sats down (95-96 on 2 L NC up to 3-4 L this AM), more letharagic, poor POs, today 102F, recent tx for C diff, now increased volume diarrhea. . Per records from [Hospital 2940] admission [2186-3-29], treated for C diff with Flagyl, in addition to Vanc/Zosyn for PNA. Blood cx positive for VRE, started on Linezolid. BAL grew Enterobacter cloacae (treated with Zosyn). Pt also had pancytopenia, had marrow bx, penia attributed to infection vs fecainide, which was discontinued. . In [Name (NI) ], pt noted to have a cough, crackles R base, BP 160s down to 80s, abd soft, bilat LE edema. Vitals: 103.8R, HR 90s, 160/90, sat 94 on 5L. BP mid 80s, given 3 L NS. Tylenol brought temp down to 101.8. Pt noted to be confused at times. Lactate 2.4. CXR with RLL infilrate. UA neg. Antibiotics given: CTX/Vanc/Levaquin/Flagyl. FULL Code. . On arrival to the ICU, pt was in NAD, speaking in full sentences, A&Ox3. . Review of sytems: (+) Per HPI (-) Denies abd pain, vomiting, headache Past Medical History: - pAF - C diff - Bipolar - Hx EtOH in past - Hx Hep C - Hx rheumatic heart dz - hx R MCA aneurysm clipping in [2167] - hx pernicious anemia - GERD Social History: Hx EtOH, quit months ago; 40 pack year smoking hx, quit 1 month ago. Lives with wife Family History: NC Physical Exam: Vitals: T: 100.7 BP: 102/53 P: 80 R: 17 O2: 99% on 5L NC General: NAD HEENT: PERRL, MM dry Neck: Supple, no meningismus Lungs: Crcakles R base CV: s1s2 sinus with ectopy, 2/6 systolic murmur Abdomen: +BS, soft to firm, distended, NON-tender, no rebound or guarding Ext: [2-17]+ pitting edema bilaterally Skin: No rashes Pertinent Results: [2186-5-2] 07:55PM LACTATE-1.0 [2186-5-2] 11:22AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.014 [2186-5-2] 11:22AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG [2186-5-2] 11:02AM COMMENTS-GREEN TOP [2186-5-2] 11:02AM LACTATE-2.4* [2186-5-2] 10:49AM GLUCOSE-97 UREA N-6 CREAT-1.0 SODIUM-140 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-29 ANION GAP-15 [2186-5-2] 10:49AM estGFR-Using this [2186-5-2] 10:49AM proBNP-1005* [2186-5-2] 10:49AM DIGOXIN-0.3* [2186-5-2] 10:49AM VALPROATE-106* [2186-5-2] 10:49AM WBC-5.8 RBC-3.48* HGB-11.7* HCT-33.9* MCV-97 MCH-33.5* MCHC-34.4 RDW-16.2* [2186-5-2] 10:49AM NEUTS-71.6* LYMPHS-20.7 MONOS-6.3 EOS-1.0 BASOS-0.3 [2186-5-2] 10:49AM PLT COUNT-217 Brief Hospital Course: # Sepsis: Elevated lactate on admission with fever and hypotension responsive to fluids. Sources Id'd as PNA and C diff colitis. Initially pt was on Levaquin/Zosyn/Vancomycin. Transitioned to Levaquin, Zosyn and PO Vanc and Flagyl. Pt's sepsis picture resolved prior to tx'fr to hospital floor. On floor afebrile with decreased WBC. Fluids and lytes PRN. . # PNA - RML/RLL infiltrate - tx'd for HAP PNA with levaquin, vancomycin, zosyn. Finished course of levaquin in hospital, finishing course of zosyn in rehab. PO Vanc cont'd with flagyl for C. diff. Still requiring 2L NC on d/c - can be weaned as tolerated. . # Diarrhea: C-diff positive on [5-2]. Diarrhea persistent until [5-7] when stooling became more formed and less frequent. Will cont tinue on month long abx course for persistent C diff. Fluid and lyte repletion PRN. . # Anasarca/Hypoproteinemia: Hyoalbuminemia on admission, poor PO during heavy diarrhea periods. Now tolerating POs and TPN for nutritional support. Gave lasix to help mobilize fluids. Urine production c/w mobilizing fluids with improving albumin on d/c. . # pAF: Was on flecainide and digoxin as outpt. Both meds initially held. Pt was noted to be in Afib on HD 2 and started on Lopressor. Initially rate control was achieved, but pt's HR was noted to be approx 50 when in sinus rhythm. Discussed with pt's cardiologist. Pt restarted on flecainide and digoxin. In normal sinus on discharge. Lytes, fluids repleted prn. . # Bipolar D/o: Mood stable t/o hospitalization. Cont'd on home meds. . # FEN: tolerating POs and TPN on d/c. Medications on Admission: - Depakote 500 q AM - Depaokte 1000 q HS - Iron - Zyprexa 5 qd - Celexa 20 qd - Digoxin 0.125 qd - MVI Discharge Medications: 1. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO Q AM (). 3. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO Q PM (). 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 5. Vancomycin 125 mg Capsule Sig: One (1) dose per dosing schedlue PO once a day: Week 1 - 125mg QID Week 2 - 125mg [Hospital1 ] Week 3 - 125mg QD Week 4 - 125mg QOD Weeks 5 and 6 - 125mg ever third day. 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Flecainide 50 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours). 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 10. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Piperacillin-Tazobactam 4.5 gram Recon Soln Sig: One (1) dose Intravenous every eight (8) hours for 3 days. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection [Hospital1 ] (2 times a day): For DVT prophylaxis while pt is less active, may d/c once ambulating regularly. 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 15. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) inj Injection QACHS: Per sliding scale. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: PNA C Diff Colitis Paroxysmal A Fib Secondary: Pancytopenia Bipolar Disorder Discharge Condition: Improved, decreased diarrhea, tolerating POs, hemodynaically stable, sinus rhythm Discharge Instructions: You were treated and evaluated for pneumonia and an infection of your colon. Because you had substantial diarrhea and were unable to tolerate food your nutritional status declined. In response to that we placed you on supplemental nutrition through your veins in addition to geting you back to regular foods which you tolerated well. You will on antibotics to treat your pneumonia and infection in your colon. You will also be getting supplemental nutrion through your veins to help with improving your nutrional status. Please call your primary care doctor or return to the ER with: * Worsening diarrhea or blood in your stool * Inability to take foods, nausea, vomiting, fevers > 101, or chills * Abdominal pain * Worsening abdominal distention * Shortness of breath, chest pain * Worsening oxygen requirement * With any new concerns or symtpoms Followup Instructions: Please call Dr. [Last Name (STitle) 2204] to arrange for follow-up prior to discharge from rehab at ([Telephone/Fax (1) 2941]. ICD9 Codes: 0389, 486
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7769 }	Medical Text: Admission Date: [2106-2-24] Discharge Date: [2106-3-12] Service: MEDICINE Allergies: Penicillins / Quinine / Sulfonamides Attending:[First Name3 (LF) 317] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right hip replacement [2106-2-24] intubation hemodialysis cardiac catheterization History of Present Illness: The patient is an 84 year-old female with a history of CHF (EF 20-25% in [11-28]), CAD (s/p CABG '[81]( SVG->LAD) with multiple stents most recent NSTEMI in [11-28]), HOCM and severe MR who was originally admitted to the orthopedic service on [2106-2-24] for removal of a sliding screw and plate, removal of the femoral head and neck and reconstructive bipolar hemiarthroplasty on [2106-2-24]. In short, the patient had bilateral hip fractures in [2103] and is s/p repair complicated by CHF exacerbation. She has since had persistent right hip pain, and was walker- dependent. The patient received 2900 cc IVF intraoperatively and lost 750 cc of blood and was transfused 1 unit PRBC. She received 2 mg morphine x 5 in PACU for hip pain. She developed an episode of shortness of breath in the PACU where her O2 saturation dropped to 80% and was placed on 3 liters of O2, then saturating 97%. Her CXR showed no evidence of CHF or infiltrate. Hours later, her systolic blood pressure dropped to 75/40 and she was started on neosynephrine which was subsequently switched to levophed. The patient then received one 250 cc bolus of NS and then another 250 cc 1/2 NS with an increase in her SBP to 90s-100. She was given another bolus of 250 cc NS and her SBP was stable at 101 on levophed which was subsequently weaned off. Her hypotension as felt to be secondary to dehydration given her volume loss. She lost an additional 350 cc blood in her hemovac. She was transferred to the CCU from the PACU for further care. In the CCU, the pt. was observed overnight and her cardiac enzymes were cycled. On transfer, the patient offered no complaints. She is concerned over her low blood pressure. She also complained of residual "numbness" over her right hip. She denied fever, chills, cough, N/V/D, chest pain, shortness of breath. She r/o for MI. 24 hrs later she was transfered to MICU for hypotension on the medical floor. During transfer she had a respiratory arrest requiring intubation. She suffered a inferiolateral NSTEMI and underwent cath [2-27] with LCX taxus stent to LCX instent restenosis. She was re-admitted to the CCU post cath. The EKG showed LBBB. The echocardiogram showed new akinesis of in the posterolateral wall. Past Medical History: 1. CAD - s/p CABG '[81], multiple stents total of 9 (SVG-LAD [10/2096], [Doctor First Name 10788] [8-/2099], [2105-9-18] 2 stents, [11-28] 1 stent) 2. HOCM 3. CRF (creatinine 3.0) s/p fistula placement rt. arm 4. HTN 5. CHF/ischemic cardiomyopathy - EF 20-25% in [11-28] 6. HTN 7. Gout 8. LLL lung resection for carcinoid 9. s/p cholecystectomy [10]. s/p abdominal hysterectomy 11. s/p rt ant tib surgery [12]. rt. hip fracture [10-28], now with artificial hip and reconstruction as discussed in HPI Social History: Pt is a nonsmoker, does not use alcohol, is retired and lives with her husband. Family History: Remarkable for an extensive history of CAD. Physical Exam: Vitals: T: 98.3F P: 80 R: 18 BP: 120/48 SaO2: 99% on 2L via NC General: Awake, alert, NAD. HEENT: NC/AT, [Month/Year (2) 2994], EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP, NC in place Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, III/VI blowing HSM at mitral area radiating to apex Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Dressing in place over R hip, hemovac in place draining serosanguinous fluid Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout with exception of RLE which was not tested [1-27] to recent surgery. Pt noted to be somewhat tremulous. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, intention or action tremor, dysdiadochokinesia noted. FNF and HKS WNL bilaterally. -DTRs: 2+ biceps, triceps, brachioradialis, patellar and ankle jerks bilaterally with exception of RLE which was not tested. Plantar response was flexor bilaterally. Pertinent Results: Labs on admission: [2106-2-24] 05:45PM BLOOD WBC-13.4# RBC-4.37 Hgb-13.1 Hct-40.1 MCV-92 MCH-30.0 MCHC-32.7 RDW-15.7 Plt Ct-177 [2106-2-24] 05:45PM BLOOD Neuts-82.6* Lymphs-13.0* Monos-4.0 Eos-0.2 Baso-0.2 [2106-2-24] 05:45PM BLOOD Glucose-118* UreaN-36* Creat-4.4* Na-139 K-4.9 Cl-104 HCO3-23 AnGap-17 [2106-2-24] 05:45PM BLOOD Calcium-9.7 Phos-5.4* Mg-1.5* [2106-2-24] 05:45PM BLOOD CK(CPK)-356* [2106-2-24] 05:45PM BLOOD CK-MB-6 cTropnT-0.2* [2106-2-24] 11:54PM BLOOD CK(CPK)-393* [2106-2-24] 11:54PM BLOOD CK-MB-5 cTropnT-0.25* Labs on transfer: [2106-2-25] 12:15PM BLOOD Glucose-97 UreaN-45* Creat-5.7# Na-136 K-5.2 Cl-102 HCO3-24 AnGap-15 [2106-2-25] 12:15PM BLOOD ALT-70* AST-147* AlkPhos-165* TotBili-0.8 [2106-2-25] 12:15PM BLOOD Albumin-3.1* Calcium-9.4 Phos-6.3* Mg-1.4* EKG: NSR at 84bpm, LBBB (old) PA and lateral radiographs of the chest. The previously identified congestive heart failure has been slightly improving. This continued mild congestive heart failure with cardiomegaly and bilateral pleural effusions. There is continued bibasilar patchy atelectasis. Echo: Left Ventricle - Ejection Fraction: 20% to 25% (nl >=55%) Conclusions: 1. The left atrium is moderately dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is severely depressed with EF 20-25%. Resting regional wall motion abnormalities include mid and apical septal, anterior, lateral and inferolateral akinesis. The remaining left ventricular segments are hypokinetic. 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) appear structurally mildly thickened with good leaflet excursion and no aortic regurgitation. 5.The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Moderate to severe (3+) mitral regurgitation is seen. 6.There is no pericardial effusion. 7. The aorta was not well seen. Compared to the previous study of [2105-9-30], the mid and basal portion of the inferolateral wall which had been previously normal is now akinetic in the mid portion and hypokinetic at the base. Cardiac catheterization results: 1. Selective coronary angiography revealed a right dominant system and two vessel CAD. The LMCA was diffusely diseased without flow limiting stenoses. The LAD was proximally occluded and filled retrogradely via the SVG-LAD. The LCX was proximally diffusely diseased. There was a 90% stenosis just proximally to the recent stent as well as a 60% in-stent stenosis. The RCA was diffusely diseased without flow limiting stenoses angiographically. 2. Selective vein graft angiography showed a patent SCG-LAD with a 30% in-stent stenosis. 3. Limited resting hemodynamics showed a normal cardiac output and index (CO 4.3 l/min, CI 3.1 l/min/m2) obtained on Dopamine. 4. Successful PTCA and stenting of the LCX with a 3.0 x 28 mm Taxus DES. Final angiography revealed no residual stenosis, no apparent dissection, and normal flow (see PTCA comments). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. LCX in-stent restenosis treated with placement of a drug-eluting stent. Brief Hospital Course: The patient is an 84 year old female with an extensive cardiac history who developed hypotension post-operatively (S/P right hip hemiarthroplasty) likely related to a combination of hypovolemia and sedation with narcotic analgesics. Ms. [Known lastname 23] was hypotensive, requiring pressor support and this was initially thought to be secondary to blood loss vs. peri-op sedation. The increased troponin was likely demand related. Her cardiac markers were cycled and her BB and ACEI were held. Her cultures were negative, suggesting that her hypotension was not secondary to sepsis. Her markers increased and EKG was consistent with NSTEMI so she was taken to the catheterization lab, where she was restented. For her CAD, Ms. [Known lastname 23] was continued on [Known lastname ], aspirin, and Lipitor. Her beta-blocker and ACE I were initially held but restarted once she stabilized. Ms. [Known lastname 23] did develop evidence of pulmonary edema, and her TTE revealed a grossly reduced EF of 20%. Of note, she had an akinetic ventricle and so she was started on both digoxin and warfarin. These levels were in the therapeutic range at discharge. Ms. [Known lastname 23] has chronic renal insufficiency on hemodialysis. The renal team followed her and determined that her sevelamer should be discontinued as her phosphate was low enough. Her creatinine stablized around 4.4. Her dry weight appears to be 52 kilograms. Ms. [Known lastname 23] developed an ulcer on her coccyx that was likely secondary to prolonged bed rest during intubation and poor nutrition. She was followed by the skin care team and started on nepro supplements in addition to vitamin C and zinc. The ulcer improved as soon as she mobilized. The patient was s/p right hip hemiarthroplasty. The Ortho service intially followed her and once she stabilized, she worked with the physical therapy to improve her mobilization. Her staples were removed the day prior to discharge. During her course, Ms. [Known lastname 23] was given empiric broad spectrum antibiotics for fevers while she was intubated. Cultures were negative. She eventually developed c.diff colitis and was started on flagyl. Her diarrhea resolved prior to discharge. On the day of discharge, the patient was transfused one unit of PRBC for a Hct of 28 (her baseline is 30) and she received dialysis shortly thereafter to remove excess fluid. Medications on Admission: 1. Aspirin 325 mg PO DAILY 2. Clopidogrel Bisulfate 75 mg PO DAILY 3. Atorvastatin Calcium 40 mg PO DAILY 4. Pantoprazole Sodium 40 mg PO Q24H 5. Sevelamer HCl 1600 mg TID 6. Gabapentin 100 mg PO HS 7. Metoprolol Tartrate 12.5mg po bid 8. Digoxin 125 mcg Tablet 0.5 Tablet PO DAILY 9. Lisinopril 2.5 mg Tablet PO DAILY 10. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Witch [Female First Name (un) ]-Glycerin (Hamamel) Pads, Medicated Sig: One (1) Pads, Medicated Topical QD PRN (). 14. Starch 51 % Suppository Sig: One (1) Suppository Rectal [Hospital1 ] PRN (). 15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 16. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 17. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 18. Warfarin Sodium 1 mg Tablet Sig: 0.5 Tablet PO QOD (). 19. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 20. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO Q3 DAYS (). 21. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 22. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital 36730] [Hospital 4094] Hospital - [Hospital1 ] Discharge Diagnosis: Non ST segment MI Clostridium difficile colitis CAD s/p CABG in [2081] and in [2095], 98, 99, [2104] PTCA stents respiratory arrest, requiring intubation HOCM hypertension CHF hyperparathryroidism Gout ischemic cardiomyopathy Chronic renal insufficiency Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 Call your doctor for increased chest pain, leg swelling, shortness of breath, dizziness, nausea or vomitting. You will continue hemodialysis 3 days per week. Followup Instructions: Please call Dr. [Last Name (STitle) ],[First Name3 (LF) ] C [Telephone/Fax (1) 44354] for an appointment in the next 2 weeks. ICD9 Codes: 2765, 2851, 4240, 4280, 5849, 2749, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7770 }	Medical Text: Admission Date: [2110-10-2] Discharge Date: [2110-11-1] Date of Birth: [2053-12-9] Sex: M Service: SURGERY Allergies: Keflex / Oxycodone Attending:[Doctor First Name 5188] Chief Complaint: Toxic megacolon s/p TAC/end ileostomy, septic shock, ARDS, ARF Major Surgical or Invasive Procedure: TAC/end ileostomy at [Hospital3 3583] US guided paracentesis Post-pyloric Dobhoff Thoracostomy tube palcement History of Present Illness: 56 M presented to [Hospital3 3583] on [2110-10-1] hypotensive to systolic of 50s, tachycardia to 140s and with a firm & distended abdomen. CT scan was perfomred and showed distended colon and small bowel with cecum & transverse colon measuring up to 9 cm id diameter. Distention extended to rectosigmoid area wihtout obvious obstruction. Patient taken emergently to OR this AM at OSH - diffusely gangrenous colon identified without perforation. Patient is s/p TAC/end ileostomy/Hartmann's pouch at [Hospital3 3583]. He remained intubated on pressors postop with maximal vent suppport. He has been transferred to [Hospital1 18] for SICU-level care. On arrival to SICU, patient was on Levophed at 0.25 mcg/kg/min. He had been on Pitressin at OSH, but this was d/c'd upon transfer. He is on, vanc, [Last Name (un) 2830], flagyl for Abx covergae. Past Medical History: GERD, HTN, fibromyalgia, nephrolithiasis s/p appendectomy, L ureteral stent Social History: No tobacco, no ETOH, no IVDA Family History: Parents with HTN Physical Exam: A and O x 2 person/place V.S.S RRR no mrg LSCTA with coarse lung sounds at bases, productive cough. Soft, NT, ND, abd wound pink, granulation no s/s of infection, ostomy with loose stool no c/c/e Pertinent Results: CT Torso [10-7]: Diffusely dilated fluid-filled small bowel loops down to the rectus sheath tunnel may reflect postoperative ileus, though stenosis at the level of the tunnel is another diagnostic consideration. Apparent flattening of SMV mesenteric branches is of unknown etiology, but concerning in the setting of recent colectomy for gangrenous colon. Bilateral predominantly upper lobe confluent lung consolidation is most consistent with the radiographic sequela of acute respiratory distress syndrome. Enhancing small right hepatic lesions may represent hemangiomas, though MRI should be pursued to further evaluate on a nonurgent basis once the patients acute clinical issues have resolved. LENI's [10-8]: no DVT UE U/S [10-10]: L brachial vein thrombus RUQ US [10-10]: Three hepatic lesions, two of which have a typical appearance for hemangiomas. The third has an atypical appearance, but may also represent a hemangioma. Tiny gallbladder polyp. No gallstones and no signs of cholecystitis and no biliary dilatation. CT A/P [10-14]: Bilateral pleural effusions, right greater than left and ARDS. Two nonspecific hypodense liver lesions as described on previous study. Large stable renal cysts without evidence of hydronephrosis or pyelonephritis. Status post total colectomy and ileostomy without evidence of suture line leak or upstream obstruction CT torso [10-28]: Diffuse multifocal bilateral airspace disease, worse in the superior segment of the left lower lobe since the prior consistent with pneumonia. Circumferential bowel wall thickening involving the Hartmann's pouch. Moderate ascites throughout the abdomen. Mild left-side hydronephrosis likely due to compression of the ureter between a focal area of fluid and the left psoas muscle. Two probable hemangiomas in the right hepatic lobe. Indeterminate 1.2 cm hypodensity in the lower pole of the left kidney. MRI head [10-20]: Numerous T2 hyperintense lesions in the supratentorial white matter, without associated contrast enhancement, blood products, or diffusion abnormalities, which are nonspecific. Diagnostic considerations include advanced chronic small vessel ischemic disease if the patient has longstanding diabetes or hypertension, demyelinating disease, other inflammatory/infectious etiologies, and vasculitis. No specific evidence of septic emboli. Questionable signal abnormality in some of the superior cerebral sulci on FLAIR images, which could be an artifact of technique, since the flare images have been acquired following intravenous gadolinium administration. UE US [10-24]: no DVT [2110-10-29] 05:30AM BLOOD WBC-15.8* RBC-3.65* Hgb-10.7* Hct-33.3* MCV-91 MCH-29.2 MCHC-32.0 RDW-16.2* Plt Ct-583* [2110-10-28] 02:56AM BLOOD WBC-16.7* RBC-3.61* Hgb-10.5* Hct-32.3* MCV-90 MCH-29.2 MCHC-32.6 RDW-16.4* Plt Ct-627* [2110-10-2] 07:19PM BLOOD WBC-1.6* RBC-4.31* Hgb-13.0* Hct-40.5 MCV-94 MCH-30.1 MCHC-32.0 RDW-15.4 Plt Ct-160 [2110-10-3] 02:13AM BLOOD WBC-2.7# RBC-3.74 Hgb-11.9* Hct-34.6* MCV-92 MCH-31.7 MCHC-34.3 RDW-15.6* Plt Ct-128* [2110-10-28] 02:56AM BLOOD Neuts-79.2* Lymphs-11.7* Monos-4.6 Eos-4.2* Baso-0.3 [2110-10-25] 02:34AM BLOOD Neuts-80.9* Lymphs-9.4* Monos-5.4 Eos-4.1* Baso-0.3 [2110-10-2] 07:19PM BLOOD Neuts-20* Bands-24* Lymphs-56* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2110-10-3] 02:13AM BLOOD Neuts-47* Bands-15* Lymphs-26 Monos-9 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0 [2110-10-23] 03:23AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Stipple-OCCASIONAL [2110-10-2] 07:19PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Burr-2+ Tear Dr[Last Name (STitle) 833] [2110-10-29] 05:30AM BLOOD Plt Ct-583* [2110-10-22] 02:12AM BLOOD Plt Smr-HIGH Plt Ct-678* [2110-10-16] 02:12AM BLOOD PT-13.7* PTT-31.0 INR(PT)-1.2* [2110-10-2] 07:19PM BLOOD PT-22.7* PTT-61.5* INR(PT)-2.1* [2110-10-3] 02:13AM BLOOD PT-21.5* PTT-61.2* INR(PT)-2.0* [2110-10-2] 07:19PM BLOOD Fibrino-457* [2110-10-20] 12:46PM BLOOD ESR-38* [2110-10-29] 05:30AM BLOOD Glucose-118* UreaN-34* Creat-0.9 Na-142 K-4.6 Cl-102 HCO3-33* AnGap-12 [2110-10-28] 02:56AM BLOOD Glucose-83 UreaN-29* Creat-0.8 Na-141 K-4.1 Cl-102 HCO3-32 AnGap-11 [2110-10-2] 07:19PM BLOOD Glucose-158* UreaN-49* Creat-1.6* Na-149* K-3.9 Cl-119* HCO3-21* AnGap-13 [2110-10-3] 02:13AM BLOOD Glucose-106* UreaN-52* Creat-2.0* Na-148* K-4.0 Cl-117* HCO3-22 AnGap-13 [2110-10-27] 02:44AM BLOOD ALT-42* AST-22 AlkPhos-171* TotBili-0.4 [2110-10-2] 07:19PM BLOOD ALT-62* AST-146* LD(LDH)-339* CK(CPK)-5091* AlkPhos-25* Amylase-48 TotBili-0.6 [2110-10-20] 03:09PM BLOOD Lipase-33 [2110-10-14] 02:02AM BLOOD GGT-134* [2110-10-3] 02:13AM BLOOD CK-MB-86* MB Indx-2.0 cTropnT-0.01 [2110-10-2] 07:19PM BLOOD CK-MB-124* MB Indx-2.4 cTropnT-<0.01 [2110-10-29] 05:30AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.2 [2110-10-27] 02:44AM BLOOD Albumin-2.9* [2110-10-2] 07:19PM BLOOD Albumin-1.0* Calcium-6.1* Phos-5.7* Mg-2.0 [2110-10-3] 02:13AM BLOOD Albumin-1.9* Calcium-7.1* Phos-4.9* Mg-2.0 [2110-10-12] 03:55AM BLOOD calTIBC-88* Ferritn-695* TRF-68* [2110-10-15] 02:02AM BLOOD Triglyc-99 [2110-10-20] 03:09PM BLOOD Ammonia-19 [2110-10-7] 04:18AM BLOOD Osmolal-332* [2110-10-20] 03:09PM BLOOD TSH-5.4* [2110-10-26] 07:09AM BLOOD Cortsol-30.1* . MRSA SCREEN (Final [2110-10-31]): No MRSA isolated . OVA + PARASITES (Final [2110-10-24]): NO OVA AND PARASITES SEEN. Brief Hospital Course: 10 /22 -[10-11] Mr. [Known lastname 174] was admitted to the [Hospital1 18] SICU on [2110-10-2] after being transferred from [Hospital3 3583] with multi organ system failure after total abdominal colectomy. He remained in critical condition with sepsis and ARDS for the first week in the ICU. He was placed on broad spectrum IV antibiotics and was gradually weaned off vasopressors. He continued to spike high fevers despite no positive cultures (aside from yeast in sputum). Wound treated with wound vac. [10-12] Pt was treated with fluconazole for yeast Pt was also started on TPN [10-13] pt with brachial thrombosis on UE u/s. until [10-15] . [10-15] Paracentesis of abdominal ascites, TTE without vegetations, continued fevers to 103.8. wound vac dc'd. Coag negative bacteremia secondary to + cathter tip. [10-17] Enteral feeds started , continued fevers to 105 requiring aggressive cooling. [10-18] percutaneous tracheostomy placed [10-19] urology consulted for hydronephrosis of the left ureter- no indication for intervention. Ct scan showed worsening LLL PNA. [10-20] Thoracostomy tube placement for pleural effusion drainage. Cont fever, agitation. NGT . LP performed with elevated opening pressure. [10-21] TEE performed, no vegetations noted. [10-22] Trach collar tolerated Mental status improving as patient weaned off sedatives and started on Precedex and fentanyl. MRI performed showing diffuse parenchymal changes. Tagged WBC scan with ? loculated ascites in RLQ. Anca negative. [10-23]: Us of renal artery without RAS, CT abd pelvis, with ? Right kidney mass and renal calculus [10-25] GI consulted for ? sigmoidoscopy/ ileoscopy. Fevers improved. [10-26] afebrile Deferred scope , ABX dcd tolerated trach collar x 24 hours. Doboff replaced. Intermittent agitation. Speech and swallow eval for passy muir valve. [10-27] pt transferred to the floor. . General surgery Mr. [Known lastname 174] returned to the floor. Physical therapy continued to work the the patient. Pt's dobboff was self d/c'd. Speech and swallow evalutated the pt and he failed video swallow. A new dobboff was placed and tube feeds were restarted at goal. Trach care was continued per protocol. . He will be d/c'd to rehab. Pt again discontinued his Doboff tube and refused replacement. A bedside swallow demonstatrated no choking or evidence of aspiration with ensure. As discussed with Dr. [Name (NI) 5182] pt may use ensure supplementation and take nectar thickened liquids. The patient was confused at times but oriented x 2 person, place. Easily reoriented. He will follow up with Dr. [Last Name (STitle) 5182] in 1 week. Medications on Admission: Home meds: Zocor 10 mg daily, Prilosec 20 mg daily, Amitriptyline 100 mg daily, Cymbalta 60 mg daily, Lisinopril 10 mg daily, Toprol XL 25 mg daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic Q2H (every 2 hours) as needed for dry eyes. 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for orsal hygeine. 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily) as needed for depression. 8. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Methadone 5 mg Tablet Sig: One (1) Tablet PO once a day: please titrate down as needed. 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 11. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 12. HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN pain 13. Saline Flush 0.9 % Syringe Sig: One (1) Injection twice a day. Discharge Disposition: Extended Care Facility: [Hospital1 700] Discharge Diagnosis: septic shock, ARF, ARDS s/p TAC for C Diff colitis Discharge Condition: Stable. Tolerating tube feed at goal rate. Pain well controlled. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: Please continue to apply wet to dry dressings twice a day and as needed to abd wound. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours Followup Instructions: 1. Please call Dr.[Name (NI) 6045] office, [Telephone/Fax (1) 5189], to make a follow up appointment in [12-13] weeks. [Name6 (MD) ] [Last Name (NamePattern4) ] MD, [MD Number(3) 5190] Completed by:[2110-11-1] ICD9 Codes: 0389, 5849, 5070, 5119, 2760, 7907, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7771 }	Medical Text: Admission Date: [2154-10-25] Discharge Date: [2154-10-30] Service: CCU HISTORY OF PRESENT ILLNESS: This is an 84-year-old gentleman with a history of severe coronary artery disease status post coronary artery bypass graft x2, recent admission to [Hospital1 1444] for ST elevation myocardial infarction on [2154-10-12], moderate aortic stenosis, congestive heart failure, and chronic renal insufficiency, admitted again on [2154-10-25] for failure to thrive secondary to decompensated congestive heart failure. On admission, patient appeared very cachectic and fluid overloaded. Swan Ganz catheter revealed CVP pressure of 22, PA systolic and diastolic pressures of 68/26, with capillary wedge pressure of 30. He was started on dobutamine and dopamine drip and was aggressive diuresed with Lasix. After a long discussion with patient and his family, decision was made to continue medical management, but not to pursue any invasive interventions including valvuloplasty for the aortic stenosis. His code status was changed to DNR/DNI. However, despite aggressive medical management, the patient arrested around 10 pm on [2154-10-30] after a run of V-T which turned into torsade V-fib. When on the on-call house staff was called to examine the patient, the patient had already been in cardiopulmonary arrest. Death was pronounced and family was informed. The family declined a postmortem examination. DIAGNOSES: Cardiac arrest, coronary artery disease, aortic stenosis, congestive heart failure, chronic renal insufficiency. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 4786] Dictated By:[Last Name (NamePattern1) 225] MEDQUIST36 D: [2154-11-5] 15:20 T: [2154-11-11] 08:57 JOB#: [Job Number ] ICD9 Codes: 4280, 4240, 4241
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7772 }	Medical Text: Admission Date: [2120-1-16] Discharge Date: [2120-1-22] Date of Birth: [2120-1-16] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname 60459] is a 33 to 34 week female infant admitted with issues of prematurity. Infant born to a 30 year old gravida 6, para 1 mother with [Name2 (NI) ] type A positive, hepatitis B surface antigen negative, RPR nonreactive, antibody negative and Rubella immune. EDC uncertain, question [2119-3-10]. Pregnancy is significant for: Limited prenatal care; history of drug abuse, reportedly none during pregnancy and currently on methadone 10 mg number 3, tobacco use during pregnancy. Maternal history is also significant for hepatitis C and mother taking Paxil during this pregnancy. Mother presented on the day of delivery with vaginal bleeding from [Hospital3 ] Hospital. The fetus was noted to have decreased activity and biophysical profile 6 out of 8 prompting delivery. Infant delivered by cesarean section on [2120-1-16], at 2:58 with Apgars of 8 at one minute and 8 at five minutes. Emerged active, central cyanosis requiring blow-by oxygen, noted to have intermittent apnea and mild respiratory distress, and thus placed on CPAP in the Newborn Intensive Care Unit. Group B Streptococcus unknown. No maternal fever. No intrapartum antibiotics, no history of ruptured membranes. PHYSICAL EXAMINATION ON ADMISSION: Heart rate 166, respiratory rate 30s, [Year (4 digits) ] pressure 74/32 with a mean of 43. Birth weight 1630 gm, 10 to 25th percentile for infant at 33 weeks gestation. Discharge weight on [2120-1-22], 1500 gm. Head circumference 29.5 cm, 25th percentile for infant at 33 weeks gestation. Length 39.5 cm 10th to 25th percentile for infant at 33 weeks gestational age. On admission infant on CPAP without respiratory distress. Anterior fontanelle, soft and flat. Overriding sutures. Large caput. Palate intact. Mild intercostal, subcostal retractions. Breath sounds slightly decreased. Normal S1 and S2. No murmur. Abdomen, soft, nontender, nondistended. Extremities, well perfused tone, appropriate for gestational age. Initially with decreased activity but during examination responsive and appropriate. Intact spine. [Doctor Last Name 36450] examination demonstrated a score of 24, between 32 with score of 24 in 34 weeks and a score of 25, thus most likely 33 to 34 weeks by examination. Admission D-stick 71. REVIEW OF HOSPITAL COURSE BY SYSTEMS: Respiratory - The baby remained on CPAP. By day of life number 1, she transitioned to room air with a baseline respiratory rate of 30s to 40s, intermittent mild retractions with saturations greater than 95. The baby has not exhibited any apnea or bradycardia of prematurity. She has not required any methylxanthine treatment. Cardiovascular - The patient has had no cardiovascular issues. Baseline heart rate 120s to 160s. No murmur. [Doctor Last Name ] pressure is systolic in the 50s to 60s, diastolic 30s to 40s, means in the 40s to 50s. Fluids, electrolytes and nutrition - The baby initially was NPO with peripheral IV, maintenance intravenous fluids. Introduced enteral feedings on day of life number 2 and she has advanced to Special Care 20 of 150 ml/kg/day without incident. She is voiding and stooling. Abdominal girth has been stable. Electrolytes, initial electrolytes on day of life number 1, sodium 133, potassium 4.7, chloride 103, carbon dioxide 20. Last electrolytes on [1-21], sodium 140, potassium 6.0, hemolyzed, chloride 110 and carbon dioxide of 18. The baby's initial D-stick was 71. She has had subsequent D-sticks, all greater than 55 and has not had any hypoglycemia or hyperglycemia. Gastrointestinal - The baby had peak bilirubin on day of life number 3, 14.3, 0.3, 13.7. She received triple phototherapy, transitioned to double phototherapy and ultimately had phototherapy discontinued on [2120-1-22]. The plan would be to repeat a repeat bilirubin on [1-23]. Hematology - The baby has not required any [Month (only) ] products during this admission. Infectious disease - Because of prematurity and mild respiratory distress, the baby had a sepsis evaluation on admission and had a white count of 11.3 with 38 polys, 0 bands, platelets of 254,000, hematocrit of 49.7. [Month (only) ] culture was sent and the baby was started on 48 hours of ampicillin and gentamicin. At 48 hours the cultures remained negative, the baby looked clinically well and the antibiotics were discontinued. There have been no further issues with infection. Neurology - The baby's neurological examination is consistent with a baby in the gestational range of 33/34 weeks gestation. She has had neonatal abstinence scores of 1 to 2 and has not required any treatment for withdrawal. The plan would be to continue to score. Sensory - Audiology screening has not been done at the time of this dictation. Ophthalmology examination not done due to gestational age of greater than 32 weeks. Psychosocial - Mother has had difficulty visiting because of distance, she lives on [Hospital3 ]. [Doctor First Name 36130] [Doctor Last Name 36527], beeper number [Serial Number 36451], has met with mother at length during this admission to discuss social situation, supports at home, mother's drug history, necessity of filing a 51A secondary to the current methadone maintenance regime. Mother has stated she is a former heroin user. She began her maintenance program in [2119-1-23] and is seen at [Location (un) 3610] Habit Management Institute [Telephone/Fax (1) 60460]. Her counselor is [Doctor First Name ]. The patient states that all of her drug screening has been negative. She is employed as is her current partner, [Name (NI) ] [Name (NI) 51286], with whom she lives. They have prepared a nursery for the baby, have supplies and plan to take the infant to [Hospital 3610] Pediatrics. The patient has a history with DSS. She has partial custody of her 12 and 9 year old sons, her 6 year old son was adopted by her former mother-in-law and now the children live in the mother-in-law's home. Her son visits with her on the weekend. The patient is aware that DSS will be contact[Name (NI) ] and a 51A will be filed. She is eager to meet with DSS and it is quite hopeful that she will retain custody of this infant based on her year-long compliance. She denied other questions and concerns during our meeting and knows that Social Service will continue to follow her. If you have any questions regarding the social situation, please feel free to contact [Name (NI) 36130] [Name2 (NI) 36527]. CONDITION ON TRANSFER: Stable. DISCHARGE DISPOSITION: To [Hospital6 33]. PRIMARY CARE PEDIATRICIAN: Name unknown, [Hospital 3610] Pediatrics. CARE/RECOMMENDATIONS: Feedings - Continue Special Care 20 calories/ounce at 150 ml/kg/day. Continue to work on oral skills. Consider increase in calories based on weight gain requirements. Medications - None at the time of transfer. Car seat position screening - Not done at the time of transfer. State newborn screen - Initial was sent on [1-19], repeat is due on day of life number 14. Immunizations received - None at the time of transfer. Immunizations recommended - Synagis respiratory syncytial virus prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria: Born at less than 32 weeks; Born between 32 and 35 weeks with two of the following: daycare during respiratory syncytial virus season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or With chronic lung disease. Influenza Immunization is recommended annually in the fall for all infants once they reach six months of age. Before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contacts and out of home caregivers. Follow up appointments - With primary care physician per routine. Consider Early Intervention and/or [Hospital6 1587]. DISCHARGE DIAGNOSIS: 1. Former probable 33 week premature female. 2. Mild transitional respiratory distress. 3. Rule out sepsis. 4. Hyperbilirubinemia, treated. 5. Ongoing narcotic withdrawal surveillance. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 54936] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2120-1-22] 16:52:11 T: [2120-1-22] 17:30:26 Job#: [Job Number 60461] ICD9 Codes: 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7773 }	Medical Text: Admission Date: [2151-1-14] Discharge Date: [2151-2-25] Date of Birth: [2105-10-14] Sex: M Service: SURGERY Allergies: Penicillins / Quinolones Attending:[First Name3 (LF) 148] Chief Complaint: Acute Pancreatitis Major Surgical or Invasive Procedure: #Retrograde SMA stenting with vein patch angioplasty using right greater saphenous vein. #Second look exploratory laparotomy and small bowel resections x 2. #Third look exploratory laparotomy. Ileocecectomy with hand-sewn two-layer side-to-side ileocolostomy. Small bowel resections x 2 with hand-sewn two-layer anastomoses x 2. Gastrostomy tube placement. History of Present Illness: This is 45 year old male who presented to [Hospital1 18] on [2151-1-14] with a complaint of severe mid-epigastric pain, diarrhea, nausea, malaise and a 7 lb weight loss. Having a know history of pancreatitis thought to be induced by HIV meds. An MRCP was performed and this revealed pancreatitis with pseudocyst formation and extrahepatic biliary ductal dilation. He had acutely worsening of pain earlier on [1-18], and underwent CTA of his abdomen. He also had one episode of nausea and vomitting. The CT revealed SMA throbosis and extensive small and large bowel pneumotosis and pneumobilia. He underwent emergent exploratory laparotomy. Past Medical History: . Pancreatitis . HIV diagnosed in [2137] (MSM unprotected sex) (CD4 528 [10-5]; VL = 0) . Herpes zoster . Condylomata accuminata (surgery scheduled for [8-9]) . Thyroid cyst (childhood) Social History: Lives alone in [Location (un) 86]. Workes in ed. adminstration at [University/College 5130]. Smokes 1 ppd for several yrs. Planned on quitting in [Month (only) ]. EtOH: 2 martinins/day Drugs: occ. marajuana, cocaine (snorted) in past Family History: Non-contributory Physical Exam: 100.2, 111, 194/115, 22, 99 RA Gen: confused, lethargic HEENT: AT, NC. EOMI, PERRLA, [3-2] bilat. Neck: 2+ carotid bilat., no JVD Chest: CTA bilat., RRR, no M/R/G Abd: diffusely severe tenderness, rigid, +rebound, + guarding Rectal: deferred Ext: no C/C/E x 4; +2 radial DT/PT bilat. Pertinent Results: MRCP (MR ABD W&W/OC) [2151-1-15] 9:25 AM IMPRESSION: 1. Interval development of pseudocyst within the pancreatic body as described which communicates with the pancreatic duct as well as irregular pancreatic duct within the distal body and tail of the pancreas, however, less prominent than prior examination. These findings favor the sequela of pancreatitis. There is no evidence of pancreatic mass. 2. Extrahepatic biliary ductal dilatation which tapers down to the level of the ampulla where there is prominence of the ampulla, this constellation of findings may be seen in HIV cholangiopathy, however, ampullary mass cannot be excluded. . CT ABD W&W/O C [2151-1-18] 6:25 PM IMPRESSION: 1. Occlusion of the proximal SMA and extensive ischemic changes of bowel in the SMA distribution is new from MR [2151-1-15]. 2. Origin of the celiac axis is attenuated and may be occluded with reconstitution by distal collaterals. 3. Interval decrease in size of cystic areas of the pancreas consistent with sequela of pancreatitis and possible early pseudocyst formation. 4. Esophagus filled with contrast and other ingested material places patient at risk for aspiration. . CT PELVIS W/CONTRAST [2151-1-29] 12:16 PM IMPRESSION: 1. Patent SMA status post stenting of proximal portion. Plaque identified in the SMA just distal to the stent. Distal SMA and branches are widely patent. 2. Hypoattenuation at the origin of the celiac artery consistent with given history of celiac stenosis. The branches of the celiac artery distal to the stenosis remain widely patent. It is unclear if this represents reterograde or anterograde filling. There are significant collateral formation within the abdomen, unchanged. 3. Unchanged size of cystic areas of the pancreas which is inseparable from the duct consistent with either pseudocyst formation vs. IPMT depending on clinical context and chronology in respect to pancreatitis. 4. Small bilateral pleural effusions with adjacent compressive atelectasis. 5. Large areas of nonperfusion in the spleen extending to the periphery consistent with infarction. In the inferior portionof the spleen only a small area in the hilum remains perfused. 6. Status post resection of a large amount of small bowel and portion of ascending colon. The remaining bowel demonstrates wall thickening and enhancing mucosa. No evidence of pneumatosis. Lack of oral contrast precludes evaluation of anastomotic leak. . CT ABDOMEN W/CONTRAST [2151-2-2] 6:23 PM IMPRESSION: 1. Large fluid collection within the right abdomen extending down into the pelvis with multiple foci of air and wall enhancement, likely consistent with peritonitis. Hyperdense foci within this fluid collection may represent hemorrhage or spillage of intraluminal bowel contents. There is increased intraperitoneal free air. 2. Markedly abnormal loops of small bowel with dilatation at the small bowel to small bowel anastomotic site. Ischemic bowel cannot be excluded. 3. Unchanged size of cystic areas of the pancreas, which is inseparable from the duct which may represent pseudocyst formation or IPMT. 4. Decreasing small bilateral pleural effusions. 5. Large splenic infarct not changed compared to prior examination. . CT ABDOMEN W/CONTRAST [2151-2-3] 12:44 PM IMPRESSION: 1. Dilated contrast-filled duodenum with no contrast passing the proximal duodenojejunal anastomosis, concerning for obstruction. 2. Large enhancing fluid collection within the abdomen extending down to the pelvis with areas of hyperdense attenuation, consistent with hemorrhage. 3. Small bilateral pleural effusion and bibasilar atelectasis. 4. Splenic infarct, unchanged. 5. Widely patent SMA status post stent. Severe narrowing at the origin of the celiac artery. 6. Unchanged size of cystic areas of the pancreas, which is inseparable from the duct may represent pseudocyst formation or IPMT. 7. Markedly abnormal loops of small bowel. Ischemic bowel cannot be excluded. . Brief Hospital Course: He was admitted on [2151-1-14] for pancreatitis with pseudocyst formation and failure to thrive. The GI service and Gold Surgery service were consulted and following along. On [2151-1-18],he reported acute abdominal pain, nausea and vomiting. A CT revealed occlusion of the proximal SMA and extensive ischemic changes of bowel in the SMA distribution. He emergently went to the OR on [2151-1-18] with help from the vascular service. On [1-18] he had Retrograde SMA stenting with vein patch angioplasty using right greater saphenous vein. On [1-20], Second look exploratory laparotomy and small bowel resections x 2. On [1-21], Third look exploratory laparotomy. Ileocecectomy with hand-sewn two-layer side-to-side ileocolostomy. Small bowel resections x 2 with hand-sewn two-layer anastomoses x 2. Gastrostomy tube placement. GI: He was NPO with a NGT. He remained NPO and the G-tube was to gravity. Abd: His abdomen was left open between cases. His abd was closed on [1-21] with staples and a dressing in place. FEN: He was ordered for daily TPN and was NPO. On POD 13, his PO diet was slowly advanced. We monitored his Amylase and Lipase and these continued to trend down. ID: He was on Vanco/Cipro/Flagyl. ID was consulted and following along. They said to continue broad spectrum antibiotics. On [2-1] all abx were d/c'd. We then noticed a bump in his WBC from 11,000 to 24,000. He was then restarted on Vanc/Cefepime/Flagyl/Fluconazole. Per ID recs, his HAART therapy was held as his CD4 was 381. The other issue was whether his HAART meds would be absorbed due to his short gut. Heme: Heme was consulted for a question regarding anticoagulation. They did not feel it was necessary to anticoagulate at this time and he did not have a coagulation disorder based on lab results (ACA IgG 11.5; ACA IgM13.6). His HCT was stable post-operatively. On [2-1] ASA and plavix were restarted. A surveillance CT was done on [2151-1-29] and showed a splenic infarction. He was started on a Heparin gtt on [2151-1-29]. CV: He was tachycardic post-operatively, up to 130's. He received several IV fluid boluses while in the ICU and helped with UOP and to decreased HR. Resp: He remained intubated after going to the OR on [1-18]. He was extubated on [2151-1-22] and doing well. Neuro: He had post-op confusion and was found talking to himself at times. He was easily reoriented and his confusion cleared as he continued to recover. Psych: Psych was consulted for bazaar behavior. He reportedly said his name was [Female First Name (un) 77233] and that he lived on a farm. It was not clear if he was having post-op confusion or another form of psychosis... Opthomolgy: Patient had bilateral eye erythema and conjunctival infection. They recommended ointment for corneal dryness. On [2-2], he had bleeding and blood coming from the J-tube. His HCT dropped as low as 18.6. His Heparin was stopped and he was transfused 3 units PRBC. His Hct rose to 26 the next day. He had a CT on [2-2] and showed a Large fluid collection within the right abdomen extending down into the pelvis with multiple foci of air and wall enhancement, likely consistent with peritonitis. Hyperdense foci within this fluid collection may represent hemorrhage or spillage of intraluminal bowel contents. There is increased intraperitoneal free air. Markedly abnormal loops of small bowel with dilatation at the small bowel to small bowel anastomotic site. Ischemic bowel cannot be excluded. Unchanged size of cystic areas of the pancreas, which is inseparable from the duct which may represent pseudocyst formation or IPMT. Decreasing small bilateral pleural effusions. Large splenic infarct not changed compared to prior examination. He then went to IR for CT guided drainage of this collection. . A repeat CT on [2-3] showed Dilated contrast-filled duodenum with no contrast passing the proximal duodenojejunal anastomosis, concerning for obstruction. 2. Large enhancing fluid collection within the abdomen extending down to the pelvis with areas of hyperdense attenuation, consistent with hemorrhage. 3. Markedly abnormal loops of small bowel. Ischemic bowel cannot be excluded. He went to the OR on [2151-2-4] for his: 1. Infected intra-abdominal hematoma. 2. Status post small-bowel resection for intestinal ischemia. 3. Human immunodeficiency virus. 4. Enterocutaneous fistula from disintegrated anastomosis, and had a 1. Exploratory laparotomy with washout of infected intra-abdominal hematoma. 2. Externalization of bowel for enteric fistula with tube decompression technique. In the OR there was a huge, bloody, gelatinous hematoma. There was no evidence of overt pus. At the anastomosis the lower catheter into what I felt was the proximal end of this bowel and advanced it upwards of 10 cm into the bowel. I then placed the upper catheter on the abdominal wall into what I felt would be the distal aspect going towards the colon. It was pretty clear that this was the layout in my mind. I then closed over as much of this weak, disintegrated anastomosis with 3-0 Vicryl sutures in multiple places. This allowed us to then funnel omentum around the 2 tubes as they exited the top of this anastomosis. The patient has less than 60 cm of bowel left. Abd/GI: Post-op he had a G-tube, 2 J-tubes, 2 JP drains. He remained NPO with TPN. His midline incision had staples with wicks in place. The wicks were removed on POD 4. His incision was intact and dry. The JP drains were in place and draining bilious fluid. He was having high volume output from the J-tube and JP drains. We were repleating this fluid loss with IV fluid in order to maintain hydration. The JP drains decreased in output with time. His Amylase and Lipase trended down to 138 and 77 on [2151-2-5], but then started a slow climb to 544 and 582 on [2151-2-15]. On [2151-2-24] his G-tube was clamped and his drain output was monitored. His midline incision was healing nicely and his drains remained secure with his skin intact without redness or drainage from around the insertion sites. The staples were removed and steri strips place. ID: He continued on ABX: VANCO/Flagyl, Meropenem ([2-2]), Caspofungin for peritoneal fluid cult: [Female First Name (un) 564]. The Caspo was then switched to Fluconazole on [2151-2-9]. He was clinically stable, afebrile. CD4 209- right on border of needing PCP [Name Initial (PRE) 1102]. ID was holding on restarting HAART back up, due to his short gut and the inability to absorb food or medication. His ABX were continued. Next, his antibiotics were slowly stopped, one by one, and he tolerated this fine without fevers or increase in WBC. Heme: His Heparin was stopped due to the bleeding risk and he continued on ASA. Activity: He was being seen by PT and getting up and walking the halls. Pain: pain was controlled with a PCA. FEN: He continued on TPN and will be TPN dependent. Due to the weak anastomosis, short bowel, and his small bowel is not connected and all PO contents would come out the superior J-tube, he will have to remain NPO and on TPN. He is thin and malnurished. Medications on Admission: Remeron 15', ativan 1 PRN, truvada T', Kaletra TT", Bentyl, Lomotil Discharge Medications: 1. Bed KINAIR BED 2. IV Fluid please replace J-tube and G-tube output 1cc:1cc with 1/2NS q8h 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Tablet, Chewable(s) 4. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 5. Hydromorphone 4 mg/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED): see sliding Scale. 7. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): On intact skin only. Leave in place for 12 hours, then off for 12 hours. 9. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q4H (every 4 hours). 10. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 11. Diphenhydramine HCl 50 mg/mL Solution Sig: One (1) Injection HS (at bedtime) as needed. 12. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Ischemic Bowel Superior Mesenteric Artery Thrombosis SMA stenting and small bowel resections. HIV Post-op Hypovolemia Deconditioning MalNutrition Discharge Condition: Good Discharge Instructions: Increasing pain * Fever (>101.5 F) * Persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain . Please take all your medications as ordered. . Continue to ambulate several times per day. Followup Instructions: Please follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Call ([Telephone/Fax (1) 15807] to schedule an appointment. Please follow-up with Dr. [Last Name (STitle) 174] in 1 month. Call ([Telephone/Fax (1) 22346] to schedule an appointment. Please follow-up with Infectious Disease on [2151-3-25] at 9:00. Call [Telephone/Fax (1) 457] with questions. Completed by:[2151-2-25] ICD9 Codes: 3051, 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7774 }	Medical Text: Admission Date: [2176-8-17] Discharge Date: [2176-8-26] Date of Birth: [2122-10-9] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2145] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Bronchoscopy ([2176-8-15]) Intubation ([2176-8-15]) History of Present Illness: Ms. [Known lastname 111907] is a 53 year old female with no signifcant past medical history who presented to [Hospital6 ] on [2176-8-14] with shortness of [Date Range 1440]. The patient was in her usual state of health one month ago. About 3 weeks prior to presentation, she went on a trip to [Country 5881] and returned to America on [2176-8-12]. On [2176-8-13], she had a LGT of 100.9 and also started developing shortness of [Date Range 1440] without a cough. She saw her PCP, [Name10 (NameIs) ] which time she was noted to be saturating 90% on RA. She received nebulizer treatments with modest improvement. She had a chest xray that showed diffuse infiltrates, prompting evaluation in the emergency room. A CT scan of the chest at that time reportedly did not show evidence of a pulmonary embolism. What was seen was moderately severe diffuse interstitial penumonitis versus atypical bacterial pneumonia or other interstitial pneumonia. Given persistent shortness of [Name10 (NameIs) 1440] and hypoxemia, she was admitted. At the OSH, her WBC increased from [Numeric Identifier 6085] to 29.8k with left shift. Her HCT was 41, and platelets were [Numeric Identifier 111908]. Legionella pneumoniae antigen was negative as well as rapid influenza antigen. She had blood cultures drawn that were negative x 2days. She had C. Difficile PCR checked that was negative. Troponins were also checked that were negative for ACS. EKG showed sinus tachycardia with inverted P waves in V1/ flat in V2, with rightward axis deviation. No ST changes were noted. She was started on ceftriaxone, azitghromycin, and doxycylcine for empiric coverage for pneumonia. Pulmonary consult was obtained and also considered ARDS as a potential etiology of her lung disease. She was transferred to [Hospital1 18] MICU for further workup. On arrival to the MICU, patient was tachypnic to the 30's satting 95% on 5L. She was intubated. Past Medical History: Osteopenia Cesarean section Tonsillectomy Laparoscoopy for infertility issues. Social History: From [Country 5881] originally, but moved to the US about 20 years ago. Lives in [Location 9583] with her husband and 14 [Name2 (NI) ] son. Quit smoking in the late [2154]'s. Has occassional alcohol use daily. No illicit drug use. Worked as a lawyer in [Country 5881] and currently works as a substitute teacher. Family History: No family history of pulmonary disease or cardiovascular disease. Physical Exam: ADMISSION EXAM Vitals: T:98.1 BP: 102/79 P: 84 R:34 O2: 96% 5L General: Moderate respiratory distress and diaphoretic. Alert, oriented. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, bilateral shoddy anterior cervical LAD CV: Tachycardic otherwise normal S1 + S2, no murmurs, rubs, gallops Lungs: Low volume [Country 1440] sounds with dry crackles auscultated in the mid lung fields R>L. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: clear urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact DISCHARGE EXAM VS: 98.5 130/70 75 20 96%RA Gen: stable-appearing female of stated age Neck: Supple without LAD Pulm: clear in all lung fields without wheeze or rhonchi Cor: RRR (+)S2/S2 without m/r/g Abd: soft, non-distended, non-TTP, NABS LE: trace LE edema b/l Neuro: AOx3, mentating well, asking appropriate questions Pertinent Results: IMAGING: CXR [2176-8-17] FINDINGS: There are bilateral confluent parenchymal opacities, most dense in the right lower lobe and bilateral upper lobes with some sparing of the APCs.The heart size is normal. Due to the parenchymal opacities, it is difficult to tell if effusion is present. This could be pneumonitis or infection.Compared to the reference exam, the appearance is much worse. TTE [2176-8-19] IMPRESSION: Normal biventricular size and systolic function. Probably normal diastolic function. Mild mitral regurgitation. Mild tricuspid regurgitation. Normal pulmonary arterial systolic pressures. CXR [2176-8-21] FINDINGS: In comparison with the study of [8-20], the monitoring and support devices are essentially unchanged. There has been some improvement in the diffuse bilateral pulmonary opacifications, though a substantial residual persists. This suggests that much of the previous appearance was due to pulmonary vascular congestion. [2176-8-20] Bronchial lavage, right middle lobe: ATYPICAL. Occasional clusters of atypical degenerated epithelial cells. Abundant macrophages, neutrophils, eosinophils and lympho- cytes. [2176-8-20] Bronchial lavage, left lower lobe: NEGATIVE FOR MALIGNANT CELLS. Abundant macrophages, neutrophils, eosinophils and some lymphocytes. ADMISSION LABS [2176-8-17] 08:50PM PT-12.5 PTT-30.9 INR(PT)-1.2* [2176-8-17] 08:50PM PLT COUNT-294 [2176-8-17] 08:50PM NEUTS-83.1* LYMPHS-8.7* MONOS-4.4 EOS-3.5 BASOS-0.2 [2176-8-17] 08:50PM WBC-18.6* RBC-4.09* HGB-12.5 HCT-38.3 MCV-94 MCH-30.5 MCHC-32.5 RDW-13.4 [2176-8-17] 08:50PM CALCIUM-8.7 PHOSPHATE-1.9* MAGNESIUM-1.9 [2176-8-17] 08:50PM ALT(SGPT)-24 AST(SGOT)-11 LD(LDH)-215 ALK PHOS-67 TOT BILI-0.5 [2176-8-17] 08:50PM estGFR-Using this [2176-8-17] 08:50PM GLUCOSE-100 UREA N-8 CREAT-0.5 SODIUM-143 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-29 ANION GAP-13 [2176-8-17] 08:59PM LACTATE-1.2 [2176-8-17] 08:59PM TYPE-[Last Name (un) ] TEMP-37.1 RATES-/34 O2-5 PO2-32* PCO2-44 PH-7.43 TOTAL CO2-30 BASE XS-3 INTUBATED-NOT INTUBA COMMENTS-NASAL [Last Name (un) 154] [2176-8-18] 05:45AM BLOOD [Doctor First Name ]-NEGATIVE [2176-8-18] 05:45AM BLOOD RheuFac-15* RELEVENT LABS [2176-8-20] 04:26AM BLOOD WBC-15.8# RBC-3.55 Hgb-10.8* Hct-33.5* MCV-94 MCH-30.4 MCHC-32.2 RDW-14.1 Plt Ct-391 [2176-8-21] 03:37AM BLOOD WBC-23.3* RBC-3.53* Hgb-10.9* Hct-33.2* MCV-94 MCH-30.8 MCHC-32.8 RDW-14.1 Plt Ct-460* [2176-8-22] 04:08AM BLOOD WBC-22.9* RBC-3.47* Hgb-10.4* Hct-32.3* MCV-93 MCH-30.1 MCHC-32.3 RDW-13.7 Plt Ct-499* [2176-8-19] 02:31AM BLOOD Neuts-80.1* Lymphs-14.1* Monos-2.5 Eos-3.1 Baso-0.2 [2176-8-21] 03:37AM BLOOD Neuts-82.7* Lymphs-8.1* Monos-7.8 Eos-1.0 Baso-0.4 [2176-8-22] 04:08AM BLOOD Neuts-57 Bands-0 Lymphs-14* Monos-7 Eos-17* Baso-0 Atyps-0 Metas-1* Myelos-4* [2176-8-20] 04:26AM BLOOD Glucose-203* UreaN-18 Creat-0.5 Na-141 K-4.2 Cl-104 HCO3-33* AnGap-8 [2176-8-21] 03:37AM BLOOD Glucose-167* UreaN-23* Creat-0.5 Na-143 K-3.8 Cl-102 HCO3-33* AnGap-12 [2176-8-22] 12:06PM BLOOD Glucose-117* UreaN-19 Creat-0.5 Na-142 K-4.7 Cl-104 HCO3-30 AnGap-13 [2176-8-21] 03:37AM BLOOD ALT-40 AST-16 LD(LDH)-276* AlkPhos-76 TotBili-0.2 [2176-8-22] 04:08AM BLOOD Calcium-7.7* Phos-3.1 Mg-2.3 [2176-8-22] 12:06PM BLOOD Calcium-8.1* Phos-2.8 Mg-2.4 [2176-8-18] 05:45AM BLOOD [Doctor First Name ]-NEGATIVE [2176-8-18] 05:45AM BLOOD RheuFac-15* [2176-8-21] 10:15AM BLOOD Type-ART Temp-37.3 pO2-97 pCO2-46* pH-7.48* calTCO2-35* Base XS-9 [2176-8-21] 06:03PM BLOOD Type-ART Temp-38.3 pO2-65* pCO2-43 pH-7.50* calTCO2-35* Base XS-8 Intubat-NOT INTUBA [2176-8-22] 08:14AM BLOOD Type-ART Temp-37.2 pO2-82* pCO2-39 pH-7.54* calTCO2-34* Base XS-9 [2176-8-19] 02:52AM BLOOD Lactate-1.0 [2176-8-20] 02:30PM BLOOD Lactate-2.2* [2176-8-21] 04:05AM BLOOD Lactate-2.0 DISCHARGE LABS [2176-8-26] 07:20AM BLOOD WBC-24.8* RBC-3.50* Hgb-10.6* Hct-32.6* MCV-93 MCH-30.4 MCHC-32.6 RDW-14.0 Plt Ct-477* [2176-8-26] 07:20AM BLOOD Neuts-51 Bands-1 Lymphs-8* Monos-6 Eos-30* Baso-0 Atyps-0 Metas-0 Myelos-3* Promyel-1* [2176-8-26] 07:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2176-8-26] 07:20AM BLOOD Glucose-80 UreaN-13 Creat-0.5 Na-140 K-3.6 Cl-104 HCO3-28 AnGap-12 [2176-8-21] 03:37AM BLOOD ALT-40 AST-16 LD(LDH)-276* AlkPhos-76 TotBili-0.2 Brief Hospital Course: The patient was a 53 yo female presenting from OSH with hypoxemia, found to have an interstitial pulmonary process on imaging, and further characterized to be eosinophilic pneumonia on bronchoscopy. . #Acute eosinophilic pneumonia: The patient arrived in the MICU and was intubated for concern of ARDS. A bronchoscopy was performed and elevated eosinophils were found from the BAL in the RML. This was consistent with acute eosinophilic pneumonia. She was started on empiric treatment for CAP with ceftriaxone and azithromycin and was started on solumedrol for the eosinophilic pneumonia. Collagen-vascular processes, HIV, and acute cardiac processes were considered, but were ruled out. The patient was extubated on [2176-8-21] and did very well with decreasing oxygen requirements. On [2176-8-22] her foley and arterial line were discontinued and she was transfered to the general medicine floor. Upon transfer to the floor, the patient was on 4L of oxygen by nasal canula, but over the next 3 days, the patient was completely weaned off. The patient was transitioned to prednisone by mouth and a taper schedule was implemented. The patient was seen by physical therapy, and within 3 days, the patient was able to ambulate on the floor and on stairs without oxygen or assistance. . #Leukocytosis: Patient found to have a low grade fever (in the setting of steroid use that may blunt a fever), leukocytosis of ~23.0 (beyond a leukocytosis of ~15.0 that was ascribed to steroids and demarginlization) while in the MICU. A consolidation on the right base that remained despite the resolution of her eosinophilic pnemonia was concerning for a ventilator aquired pneumonia. A Mini bronchioalveolar lavage gram stain was negative. She was started on empiric antibiotics on [2176-8-21]. Given the patient's improving clinical condition on the floor without fevers, it was decided in conjunction with the pulmonary team that a VAP was unlikely. The antibiotics were discontinued. . #Anemia: The patient's H/H had trended down over the course of her brief hospitalization. There was no evidence of acute blood loss and her progressive anemia was likely due to critical illness and phlebotomy. Her H/H was trended. . #Hyperglycemia: The patient had elevated blood sugars while inpatient. There were likely elevated in the setting of high dose steroids. As her steroid dose was tapered, her blood glucoses trended down. . #Transitional Issues: [Hospital ] clinic was contact[Name (NI) ] for an appointment, patient was tentatively scheduled for [10-7], but will be contact[Name (NI) ] for a sooner appointment as it becomes available. Patient was instructed to continue 10mg of prednisone daily (after the taper) until the time of appointment. SHe will need a follow-up CXR before the office visit. -Patient was started on a steroid taper while hospitalized, and discharged with explicit instructions for taper. These instructions can be found at the end of this document. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. PredniSONE 10 mg po daily Duration: 35 Days Start: After 20 mg tapered dose. Please continue taking until you see the pulmonologist. RX prednisone 20 mg [1-8] tablet(s) by mouth daily Disp #10 Tablet Refills:0 RX prednisone 10 mg 1 tablet(s) by mouth daily Disp #35 Tablet Refills:0 2. Multivitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Acute Eosinophilc pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname 111907], You were admitted with "eosinophilic pneumonia". While in the ICU, you were on a ventilator to support your breathing and were started on steroids. While in the ICU, there was concern that you had a bacterial infection and were started on antibiotics. Once your breathing was better, you came off the ventilator and your antibiotics were stopped. Please TAPER your steroids as follows: 60mg daily for 4 days ([2176-8-21] through [2176-8-24]) 40mg daily for 4 days ([2176-8-25] through [2176-8-28]) 20mg daily for 4 days ([2176-8-29] through [2176-9-1]) 10mg daily until you see Pulmonology Please make sure you get a chest xray (xray will be setup by Pulmonology) before you see the doctor. If you are feeling increased shortness of [Last Name (LF) 1440], [First Name3 (LF) ] not hesitate to contact your primary care doctor [First Name (Titles) ] [Last Name (Titles) 10836] to the ER. It has been a pleasure taking care of you, best of luck. Thank you for choosing [Hospital1 18]. Followup Instructions: *Our Pulmonary Dept. is working on a sooner follow up appt for you and will call you at home with the appt change. IF you dont hear from the office by Tuesday, please call them direcdtly to book at [Telephone/Fax (1) 612] Department: PULMONARY FUNCTION LAB When: MONDAY [2176-10-7] at 1:10 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PFT When: MONDAY [2176-10-7] at 1:30 PM Department: MEDICAL SPECIALTIES When: MONDAY [2176-10-7] at 1:30 PM With: DR. [Last Name (STitle) 5528]/DR. [Last Name (STitle) ] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Last Name (un) ],SUETTA M. Location: [Hospital 111909] MEDICAL ASSOCIATES Address: [Location (un) 111910], [Location (un) ],[Numeric Identifier 73741] Phone: [Telephone/Fax (1) 70172] Please call Dr [Last Name (STitle) 111911] office on Monday morning to book a follow up appt within one week of discharge. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158*] ICD9 Codes: 2762, 2768, 4240, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7775 }	Medical Text: Admission Date: [2124-12-21] Discharge Date: [2124-12-24] Date of Birth: [2078-6-17] Sex: F HISTORY OF PRESENT ILLNESS: Ms. [Known lastname ] is a 46-year-old woman with a history of deep venous thrombosis times two, not on anticoagulation, who also has a significant family history for coronary artery disease. She was in her usual state of health until 10 p.m. on the night prior to admission when she developed the acute onset of infrascapular pressure at rest. She went to bed but was unable to fall asleep for several hours due to this discomfort. She finally fell asleep, but awoke at 7 a.m. on the morning of admission with identical back pressure. some numbness and tingling in both hands and diaphoresis and dizziness upon rising. She awoke her daughter who brought her into the [Hospital3 417] Hospital Emergency Department. In the [Hospital3 417] Hospital Emergency Department, the patient was found to have 1-mm ST elevations in lead III along with ST depressions in I and aVL. She was given sublingual nitroglycerin, started on heparin and Integrilin drip and made pain free in the [Hospital3 417] Hospital Emergency Department. She was then Med-Flighted over to [Hospital1 190] for cardiac catheterization. En route, the patient had the onset of chest pain and was known to have a possible ST elevations in right-sided V4 leads. In the cardiac catheterization laboratory here at [Hospital1 346], the patient was found to have a cardiac output of 7.42, a cardiac index of 3.93, a pulmonary capillary wedge pressure of 17, and a proximally occluded right coronary artery. The right coronary artery lesion was stented, but her course was complicated by temporary complete heart block after a ballooning of the lesion with associated hypotension. She necessitated temporary pacing and a dopamine infusion. The patient was then transported to the Cardiothoracic Intensive Care Unit for further monitoring. PAST MEDICAL HISTORY: 1. Pulmonary embolism times one. 2. Deep venous thrombosis times one. 3. Hypercholesterolemia. 4. Knee surgery. 5. Gastroesophageal reflux disease. MEDICATIONS ON ADMISSION: Protonix. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She lives with two daughters. [Name (NI) 1403] in insurance litigation office. She has a 15-pack-year history of tobacco but quit 15 years ago. She denies any alcohol or drug use. FAMILY HISTORY: Her mother had a coronary artery bypass graft at the age of 50. Father had a myocardial infarction at the age of 47. REVIEW OF SYSTEMS: The patient reports six months of postprandial epigastric pain with a sour taste rising in her throat that has not been relieved by a proton pump inhibitor. She also notes several weeks of weakness in both hands; worse upon awakening. At baseline, the patient reports getting short of breath when climbing one flight of stairs and occasional left ankle swelling. She denies any orthopnea, paroxysmal nocturnal dyspnea, or palpitations. PHYSICAL EXAMINATION ON PRESENTATION: Upon arrival to the Unit, the patient had the following vital signs. Her weight was 77 kg, her temperature was 95, her blood pressure was 99/60, she was on 3 mcg/kg per minute of dopamine. Her heart rate was 73, in a normal sinus rhythm. She was breathing 19 and oxygen saturation was 98% on 2 liters. In general, she was lying in bed. She was nauseous but in no acute distress. She was speaking in full sentences. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. The oropharynx was moist with specks of blood of in the mouth; but otherwise clear. The neck was supple. No bruits. Jugular venous distention was roughly 8 cm to 9 cm. Cardiovascular examination revealed a regular rate and rhythm, normal first heart sound and second heart sound, no murmurs, rubs, or gallops. The lungs revealed decreased breath sounds at the right lower lobe; but otherwise clear to auscultation. The abdomen was obese, soft, nontender, and nondistended. Normal active bowel sounds. Extremities revealed she had a right groin site without a hematoma with the sheath still in. She had good distal pulses bilaterally. Neurologically, alert and oriented times three. She moved all extremities. She had 4/5 strength in the left hand and left foot with normal 3+ reflexes bilaterally and symmetrically. PERTINENT LABORATORY DATA FROM THE OUTSIDE HOSPITAL: At the outside hospital she had the following laboratories; white blood cell count was 4.6, hematocrit was 43.5, and platelets were 204. PT was 12.2, PTT was 22, and INR was 1. Sodium was 140, potassium was 4, chloride was 107, bicarbonate was 25, blood urea nitrogen was 16, creatinine was 0.8, and blood glucose was 137. Her LDH was 161. Creatine kinase was 33. MB was 1.5. Index was 4.5. Troponin was 0.10. She had creatine kinases which peaked at 1068 and subsequently declined to 759, and a MB which peaked at 145 and subsequently declined to 196. Her total cholesterol was 211, low-density lipoprotein was 127, high-density lipoprotein was 39, triglycerides were 227. Protein culture and sensitivity studies were pending at the time of discharge. Hemoglobin A1c was pending at the time of discharge as well. RADIOLOGY/IMAGING: The initial electrocardiogram at the outside hospital showed a normal sinus rhythm at 75, normal axis, normal intervals, 0.5-mm asymmetric ST depressions in aVL and I and 1-mm ST elevations in III. Here, as previously mentioned, the patient underwent cardiac catheterization with the previously mentioned results. She also had subsequent laboratory values. She had an electrocardiogram on the day after admission which showed a normal sinus rhythm at 68, normal axis, and intervals. She had Q waves in II, III, and aVF with flipped T waves in III and aVF; and she had resolution of the ST elevations in III and the ST depressions in I and aVL. She had a chest x-ray here at [Hospital1 188] which showed a heart size at the upper limit of normal, bilateral interstitial opacities consistent with mild congestive heart failure. PERTINENT LABORATORY VALUES ON DISCHARGE: Her laboratories on the day of discharge were as follows; her sodium was 140, potassium was 3.9, chloride was 107, bicarbonate was 23, blood urea nitrogen was 11, creatinine was 0.6, and blood glucose was 110. HOSPITAL COURSE: 1. CARDIOVASCULAR SYSTEM: As previously mentioned, the patient had a likely inferior myocardial infarction with possible right ventricular involvement. She was taken to the cardiac catheterization laboratory where a proximal right coronary artery lesion had a stent placed and was subsequently treated with Integrilin, heparin, aspirin, and Plavix. She was also started on a beta blocker and ACE inhibitor in house. She did well and was pain free throughout the duration of her hospital stay with the exception of the day following catheterization when she experienced mild infrascapular back pain lasting 20 minutes which spontaneously resolved without any change in her electrocardiogram. Her blood pressure remained between 90 and 100 systolic, and she tolerated the ACE inhibitor and beta blocker well. She did have some persistent nausea and some vomiting for the 24 hours status post catheterization which was treated successfully with Zofran. From a rhythm standpoint, she remained in a normal sinus rhythm throughout the duration of her hospital stay with occasional premature ventricular contractions. For her coronary artery disease; as previously mentioned, she had right coronary artery lesion that was stented. She was to remain on Plavix for one year, aspirin, beta blocker, ACE inhibitor, and Lipitor. 2. ENDOCRINE SYSTEM: The patient had some mildly elevated blood sugars of slightly greater than 120 during her hospital stay. She has no previous past medical history, and her hemoglobin A1c was pending. On discharge, she should follow up with this with her primary care physician to ensure she does not have diabetes which is contributing to her coronary artery disease. CONDITION AT DISCHARGE: The patient was in good condition at the time of discharge. DISCHARGE STATUS: The patient was to be discharged to her sister's home. Her sister is a Cardiac Intensive Care Unit nurse. DISCHARGE DIAGNOSES: 1. Coronary artery disease; right coronary artery stenosis, status post stent placement, and inferior myocardial infarction (with a peak creatine kinase of roughly 1100). 2. Hyperlipidemia. 3. Gastroesophageal reflux disease. MEDICATIONS ON DISCHARGE: (Her medications on discharge were as follows) 1. Lisinopril 2.5 mg p.o. q.d. 2. Atenolol 50 mg p.o. q.d. 3. Lipitor 10 mg p.o. q.d. 4. Plavix 75 mg p.o. q.d. (times one year). 5. Enteric-coated aspirin 325 mg p.o. q.d. 6. Colace 100 mg p.o. b.i.d. 7. Ambien 10 mg p.o. q.h.s. as needed (for insomnia). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to call Dr. [Last Name (STitle) ] and schedule a follow-up appointment as a cardiologist within two weeks of discharge. 2. The patient was also to call her primary care physician within one week for an appointment for followup. 3. The patient was to be arranged for cardiac rehabilitation. [First Name4 (NamePattern1) 610] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3812] Dictated By:[Last Name (NamePattern1) 11801] MEDQUIST36 D: [2124-12-24] 13:15 T: [2124-12-28] 19:46 JOB#: [Job Number 25875] ICD9 Codes: 9971, 4280, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7776 }	Medical Text: Admission Date: [2130-6-28] Discharge Date: [2130-7-3] Date of Birth: [2102-6-6] Sex: M Service: [Year (4 digits) 662] Allergies: Fentanyl Attending:[First Name3 (LF) 338] Chief Complaint: Uncontrolled pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 28-year-old gentleman with a past medical history significant for Hajdu-[Location (un) 2987] Syndrome (genetic disorder with excessive bone resorption leading to osteoporosis), restrictive lung disease from kyphoscoliosis, COPD/asthma, chronic ventilatory insufficiency with hypercarbia and trach for nocturnal ventilation and home supplemental O2, multiple admissions for pseudomonal pneumonia now admitted for pain control and failure to thrive at home with extensive services. He is already on Morphine SR 200mg PO BID, MS IR 30-60mg q4 hours PRN, methadone 50mg TID, and baclofen TID for pain related to a right femur fracture he [Location (un) 18095] following a fall in [Month (only) 958] [2130] and has been followed by the pain service during his past hospitalization. He feels as though he is decompensating at home secondary to the pain and is unable to transfer himself as he usually can. There is no clear precipitant to his increased pain as he does not report any new falls. . In the ED, initial vs were: T=98, HR=96, BP=92/56, RR=18, POx=98% RA. Plain films were performed of his left forearm and elbow showing baseline severe osteopenia from with no definite acute fracture noted, although there is gross deformity and pseudoarthrosis of the radius with the humerus with marked soft tissue swelling. Plain films of his knees bilaterally showed a known old oblique fracture through the right distal femoral condyle and the left knee showed severe obliteration of the joint space with degenerative change, but no discrete fracture or effusion identified. A CXR was markedly limited due to baseline chest wall deformity and scoliosis, but the overall appearance was relatively stable with slight improved aeration and no definite single focal consolidation identified. The patient was given 195mg of morphine SR and 75mg of morphine IR in the ED and was admitted to the ICU for further pain control, chronic overnight vent dependency, and will likely require placement to rehab directly from the ICU given his inability to function optimally at home despite high level of home services. His vitals were stable and he was satting 98% on RA prior to transfer. . On the floor, the patient is complaining of pain that is most intense throughout his right leg and around his left knee. He has also noted thicker, opaque white secretions from his trach consistent with past infections as well as low grade fevers over the last 2 days. He is reluctant to go to rehab as he did not have a good experience at a rehab his last month long stay following his last admission. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: 1. Hajdu-[Location (un) 2987] Syndrome (rare autosomal dominant congenital connective tissue disorder characterized by severe and excessive bone resorption leading to osteoporosis, also known as type VI idiopathic osteolysis) 2. Osteomyelitis, right olecranon (pressure-related) 3. Chronic obstructive/restrictive lung disease on home O2 during day and SIMV during the night 4. H/o multiple pneumonias, including Pseudomonas PNA and VAP 5. Right heart strain and pulmonary hypertension Social History: Patient lives at home with his grandparents and brother. [Name (NI) ] a Home Health Aide from 8am to 5pm daily. His Mother died in [Name (NI) 404]. Has been smoking [5-16] cigarettes per day. Rare EtOH use. Denies illicit drug use. Family History: Mother and brother with [Location (un) 86059] syndrome. Physical Exam: On admission: General: Alert, oriented, no acute distress, appears comfortable with several congenital abnormalities noted such as clubbed feet, broad stubby fingers, and facial characteristics of Hajdu-[Location (un) 2987] Syndrome HEENT: Sclera anicteric, MMM, trach in place Neck: supple, JVP not elevated, no LAD Lungs: Poor inspiratory effort, scattered rhonchorous sounds especially noted on end expiration 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 cyanosis or edema; exam limited secondary to pain with any movement On discharge: General: Alert, oriented, no acute distress, appears comfortable with several congenital abnormalities noted such as clubbed feet, broad stubby fingers, and facial characteristics of Hajdu-[Location (un) 2987] Syndrome HEENT: Sclera anicteric, MMM, trach in place Neck: supple, JVP not elevated, no LAD Lungs: Poor inspiratory effort, scattered rhonchorous sounds especially noted on end expiration 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 cyanosis or edema; exam limited secondary to pain with any movement Pertinent Results: ADMISSION LABS -------------- [2130-6-27] 02:40PM BLOOD WBC-6.6 RBC-3.84* Hgb-10.8* Hct-30.6* MCV-80* MCH-28.2 MCHC-35.3* RDW-13.1 Plt Ct-171 [2130-6-27] 02:40PM BLOOD Neuts-76.1* Lymphs-17.6* Monos-4.0 Eos-2.2 Baso-0.2 [2130-6-27] 02:40PM BLOOD Glucose-140* UreaN-21* Creat-0.4* Na-139 K-3.6 Cl-96 HCO3-36* AnGap-11 [2130-6-27] 02:40PM BLOOD cTropnT-<0.01 IMAGING ------- CXR on admission: Markedly limited study due to baseline chest wall deformity and scoliosis. However, the overall appearance is relatively stable with slight improved aeration and no definite single focal consolidation identified. Left elbow/forearm X-ray [6-27]: Baseline severe osteopenia from Hajdu-[Location (un) 2987] syndrome. No definite acute fracture noted, although there is gross deformity and pseudoarthrosis of the radius with the humerus, both of which are unclear in chronicity given the lack of comparison study. Bilateral knee X-ray [6-27]: Very limited exam due to multiple factors. On the right, in particular, there is an overlying brace, which obscures visualization of the underlying osseous structures. Grossly, there is an apparent fracture obliquely through a distal femoral condyle, which is similar to prior exams as best can be compared. On the left, there is severe obliteration of the joint space with degenerative change, but no discrete fracture or effusion identified. Right femur/tibia/fibula X-ray [6-27]: Markedly limited study as above. The known fracture of the distal right femur is again redemonstrated and the fracture fragments are grossly stably aligned. Brief Hospital Course: This is a 28-year-old gentleman with a past medical history significant for Hajdu-[Location (un) 2987] Syndrome (genetic disorder with excessive bone resorption leading to osteoporosis), restrictive lung disease from kyphoscoliosis, COPD/asthma, chronic ventilatory insufficiency with hypercarbia and trach for nocturnal ventilation and home supplemental O2, multiple admissions for pseudomonal pneumonias now admitted for pain control and failure to thrive at home with extensive services. #. Pain control. Pain service was consulted for recommendations, considering his disease process and history of chronic pain. Gabapentin was uptitrated, started nortryptiline, methadone was uptitrated to QID, and tizanidine was started. Pain regimen now: nortryptiline 25 mg PO QHS, gabapentin 800 mg PO QID, combined acetaminophen and ibuprofen for bone pain, methadone 50 mg QID, tizanidine 2 mg TID. He is also on his home Morphine SR 200 mg PO BID, MSIR 30-60 mg q4H PRN, baclofen TID. The option of an epidural or intrathecal pump was discussed but not recommended by the pain service considering his underlying disease. Ortho was consulted for bracing to decrease fracture pain but a new brace was not felt to benefit patient. Palliative care was also involved during this admission, and team has been involved as an outpatient, given his end stage disease and chronic pain issues. The patient said his primary goal was pain control, despite hypotension, difficulty breathing or other issues that may arise with increasing doses of opiates or other medications. Pt has planned pain clinic follow-up at [Hospital3 ], and his pain management physician was informed of changes made to his pain regimen. #. Chronic respiratory failure: He remained on room air during the day and on his home vent settings overnight during course of stay. Wound care was consulted for neck pressure ulcer, recommended topical therapy to wound with cleansing would with wound cleanser or normal saline, apply aquacel Ag Rope to wound bed, cover with 4x4 drain sponges, secure dressing with trach holder, daily dressing changes. Once wound is healed, continue with 4x4 drain sponge to right lateral neck in between skin folds to decrease pressure to area, and prevent increase moisture and erosion of tissue. #. Hajdu-[Location (un) 2987] Syndrome: Pain management and calcium/vitamin D. See above. #. Anemia: Hct is at its baseline of 30 and he will continue home iron supplementation. #. Constipation: Continue home dulcolax, colace, senna, and Miralax. Agressive bowel regimen given pain medication. #. Depression/anxiety: Continue home buproprion and ativan. Medications on Admission: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. methadone 10 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing or sob. 10. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 13. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 14. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 15. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 17. baclofen 40 mg QAM, 20mg Qnoon, and 40mg HS 18. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 19. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB while on vent. 20. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB while on vent. 21. morphine 100 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 22. morphine 30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 23. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Try to wean as pain will allow. 24. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 25. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Last day [2130-5-22]. 26. morphine 30 mg Tablet Sig: One (1) Tablet PO DAILY PRN () as needed for 30 minutes prior to PT. 27. 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. Discharge Medications: 1. morphine 100 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours): Take 200mg PO Q12H. 2. morphine 30 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 9. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO Q8H (every 8 hours). 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 14. baclofen 10 mg Tablet Sig: Four (4) Tablet PO QAM (once a day (in the morning)): 40 mg QAM, 20mg Qnoon, and 40mg HS . 15. baclofen 10 mg Tablet Sig: Two (2) Tablet PO NOON (At Noon): 40 mg QAM, 20mg Qnoon, and 40mg HS . 16. baclofen 10 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime): 40 mg QAM, 20mg Qnoon, and 40mg HS . 17. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 18. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). Disp:240 Capsule(s) Refills:2 19. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:2 20. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 21. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 22. methadone 10 mg Tablet Sig: Five (5) Tablet PO QID (4 times a day): 50 mg PO/NG QID . 23. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 24. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 25. tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: vna Discharge Diagnosis: Uncontrolled pain due to Hajdu-[Location (un) 2987] Syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital because of uncontrolled pain related to your chronic Hajdu-[Location (un) 2987] Syndrome. Both the pain and palliative care teams were consulted to help better manage your pain. Your symptoms improved with changes in your medications and you were discharged home with services and planned follow-up with your pain clinic at [Hospital3 ]. The following changes were made you your medications: - Please START taking nortryptiline 25 mg at night - Please INCREASE gabapentin to 800 mg four times per day - Please START taking tizanidine 2 mg three times per day (this may be potentially adjusted in the future but speak with your doctors about this) - Please INCREASE methadone to 50 mg four times per day - Please continue to take both acetaminophen and ibuprofen for bony pain - You also informed us that you are no longer taking omeprazole. Please discuss this with your doctor as he may wish to resume this medication or start you on a different medication to protect your stomach given that you are taking ibuprofen long term. - Please continue to take all of your other home medications as prescribed Followup Instructions: Please follow up with your pain management specialist at [Hospital 2586] as planned Name: [Last Name (LF) ],[First Name3 (LF) 275] L. Location: [Hospital1 ] [First Name (Titles) 3860] [Last Name (Titles) 662] CENTER Address: [Street Address(2) 3861], [Location (un) ],[Numeric Identifier 3862] Phone: [Telephone/Fax (1) 3858] Appt: [7-6] at 3:15pm Department: ORTHOPEDICS When: THURSDAY [2130-7-13] at 9:30 AM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: THURSDAY [2130-7-13] at 9:50 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1984], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2130-7-3] ICD9 Codes: 3051, 4168, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7777 }	Medical Text: Admission Date: [2177-2-18] Discharge Date: [2177-2-26] Date of Birth: [2177-2-18] Sex: M Service: Neonatology HISTORY: [Known lastname ] is a former 34 week infant born to a 40 year-old G4, P0 now 1 mother [Name (NI) ] times two, SAB times one with D&C). Prenatal screens were significant for blood type A+, hepatitis B surface antigen which was negative, RPR which was nonreactive, antibody negative, rubella immune and GBS was unknown. The estimated date of confinement was [2177-3-31]. This pregnancy was complicated by premature, spontaneous rupture of membranes on [2177-2-12]. Intrapartum antibiotics were administered with the initial dose on [2177-2-13]. The infant was born vaginally at 11:55 A.M. on [2177-2-18] with both initial grimace and cry. The infant was stimulated with bulb suction and dried. He did require blow by O2 at approximately five minutes and the APGARs were 8 and 8 at one and five minutes respectively. The infant was shown to the parents and then transported to the Neonatal Intensive Care Unit where grunting, flaring and mild retractions were noted. PHYSICAL EXAMINATION ON ADMISSION: Baby's admission weight was 2.35 kilograms which is the 50 to 75th percentile. The frontal occipital circumference was 32.5 cm in the 75th percentile. The length was 49.5 cm which was greater than the 90th percentile. The infant was in mild to moderate respiratory distress with some molding on the head and anterior fontanelle which was soft and flat. There was some bruising over the occiput. The nasal pharyngeal CPAP was in place and started at +6 and quickly weaned down to room air. The lungs had coarse breath sounds initially but then cleared. The cardiovascular exam showed a regular rate and rhythm with a soft, I/VI systolic murmur initially and has not been heard since in the last five days. There were 2+ femoral pulses. The abdomen was soft, nontender with normoactive bowel sounds. The GU showed normal phallus with testes down bilaterally. The anus was patent with meconium present in his diaper. The skin was pink. Extremities were warm and well perfused. HOSPITAL COURSE BY SYSTEMS: 1. Respiratory - The patient developed initial respiratory distress, had a chest x-ray which was significant for likely retained lung fluid. The patient was given blow by in the delivery room and then started on a CPAP of 6, weaned down to a CPAP of 5 and eventually a CPAP of 5 room air all within the first four or five hours of life. The patient was then taken off CPAP to room air and has remained stable in room air since. The patient has had no apnea or bradycardia. 2. Cardiovascular - The patient did have a soft murmur noted on day of live zero but that murmur resolved within the second day of life and has not been heard to date. 3. Fluids, Electrolytes and Nutrition - The patient was initially started off on D10 water but after coming off of CPAP he started breast feeding and with supplemental of pumped breastmilk. The patient has consistently fed well. Last electrolytes: Na 140, K 4.5, CL 103, CO2 24. Discharge weight is 2.225 kilograms. 4. Gastrointestinal - The patient did develop hyperbilirubinemia and was started on phototherapy. Mother's blood type is A+, baby's blood type is A+, Coombs negative. He was on double phototherapy from the 23rd to the 25th and was then changed to single phototherapy on [2-24] and then to a bili blanket on [2-25]. He remains currently on a bili blanket. The patient will be going home on a bili blanket and visiting nurse will be drawing a bili at home tomorrow, Thursday, [2177-2-27]. The blood will be taken to the lab at [Hospital ] Hospital and results will be reported to Dr. [First Name (STitle) ] office. Last bilirubin level is 12.0/0.3 on [2177-2-26]. Peak bilirubin was 15.0/0.4 on [2177-2-20]. 5. Hematology - The patient did have an initial CBC performed in the context of a rule out sepsis. The initial CBC had a white count of 17.9, hematocrit of 45.0, platelet count 198,000. There was 32 polys, 0 bands, 57 lymphs. 6. Infectious Disease - A blood culture was drawn on admission. The patient was started on antibiotics of Ampicillin and Gentamycin and continued for 48 hours at which time the blood culture was no growth to date. 7. Neurologic - The patient has had a normal neurologic exam and does not qualify for a routine screening head ultrasound. 8. Sensory/Audiology - A hearing screen was performed with an automated, auditory brain stem response. The result was pass in both ears. 9. Ophthalmologic - The patient did not qualify for routine ophthalmology examination. 10. Psychosocial - Social Work was involved with the family providing support to this preterm infant born to a first time mother. DISCHARGE CONDITION: The patient's condition at discharge is good. DISCHARGE DISPOSITION: Home. The name of the primary pediatrician is Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. The phone number at the office is [Telephone/Fax (1) 37376], fax number is [Telephone/Fax (1) 37377]. CARE AND RECOMMENDATIONS: (1) Feeds at discharge - PO/at breast, ad lib. (2) Medications - none. (3) State newborn screen has been sent and is pending. (4) Immunizations received - hepatitis B dose #1. IMMUNIZATIONS RECOMMENDED: I. Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 958] for infants who meet any of the following three criteria: 1. Born at less than 32 weeks. 2. Born between 32 and 35 weeks with plans for daycare during RSV season, with a smoker in the household or with preschool siblings. 3. Chronic lung disease. II. Influenza immunization should be considered annually in the fall for pre-term infants with chronic lung disease once they have reached six months of age. Before this age the family and other caregivers should be considered for immunization against influenza to protect the infant. FOLLOW UP APPOINTMENTS SCHEDULED: The patient will be followed up by a visiting nurse tomorrow in the home at which time a bilirubin will be obtained sent to [Hospital3 1280] and Dr. [Last Name (STitle) 38010] office will be notified. Dr. [Last Name (STitle) 38010] office will contact the family. Also the family was asked by Dr. [First Name (STitle) ] to follow up in the office on this Friday, [2177-2-28]. DISCHARGE DIAGNOSIS: 1. Appropriate for gestational age preterm male infant at 34 weeks. 2. Sepsis rule out (resolved). 3. Respiratory distress, transient (resolved). 4. Indirect hyperbilirubinemia. 5. Status post circumcision. [First Name8 (NamePattern2) 36400] [Name8 (MD) ], M.D. [MD Number(1) 37201] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2177-2-26] 12:16 T: [2177-2-26] 12:52 JOB#: [Job Number 38011] ICD9 Codes: V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7778 }	Medical Text: Admission Date: [2137-12-31] Discharge Date: [2138-2-24] Date of Birth: [2137-12-31] Sex: M Service: Neonatology HISTORY: Baby [Name (NI) ] [Known lastname 19419] is the 1520 gram product of a 31 [3-17] week twin gestation born to a 31 year old gravida I, para now II mother. Prenatal screens: A positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, GBS status unknown. Pregnancy notable for in [Last Name (un) 5153] fertilization twins and concerns for maternal preeclampsia HELLP syndrome. Infant delivered for worsening maternal liver function tests and declining platelet counts. Betamethasone complete on [2137-12-26]. The infant was delivered by cesarean section. Apgars were 8 and 8. PHYSICAL EXAMINATION: On admission birth weight was 1520 grams, 50th percentile, length was 42 cm, 50th percentile, head circumference was 29.5 cm, 50th percentile. Anterior fontanelle was open and flat. Bilateral red reflex was present. Palate intact. Breath sounds symmetric with mild respiratory distress with retractions, fair aeration, normal S1, S2, no murmur. Pulses 2 plus. Abdomen soft, no hepatosplenomegaly. Normal external male genitalia. Testes descended bilaterally. Anus patent. Hips stable. HISTORY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Infant admitted to the Newborn Intensive Care Unit with mild respiratory distress syndrome. Placed on CPAP. Remained on CPAP for a total of five days at which time he transitioned to room air. He has been stable on room air throughout the remainder of his hospital course. He has not received methylxanthine therapy for mild apnea and bradycardia of prematurity. His most recent episode of apnea and bradycardia unassociated with feeding was on [2138-2-16]. CARDIOVASCULAR: Has been stable throughout the hospital course. Did receive indomethacin for confirmed patent ductus arteriosus by echocardiogram that was given on [1-3]. Has had no further cardiovascular issues. FLUID AND ELECTROLYTES: Birth weight was 1520 grams. Discharge weight is 2600 gms. The infant was initially was started on 80 cc per kilo per day of D10W. Enteral feedings were started on day of life and restarted following indomethacin therapy on day of life number five. Achieved full enteral feedings by day of life 13 and is currently ad lib feeding in excess of 150 cc per kilo per day of Nutramigen 28 calorie for growth. GASTROINTESTINAL: Peak bilirubin was on day of life number 3 of 8.2, received phototherapy for a total of four days at which time phototherapy was discontinued and he has had no further issues. The infant was noted to have guaiac positive stools on day of life number 22 receiving breast milk 28 calories. Abdomen continued to be within normal limits. KUBs were normal. On day of life number 24 infant noted to have frankly bloody stool, was made NPO at that time. KUBs continued to be stable. It was thought to be a milk protein allergy. Infant was restarted on Nutramigen two days later and is currently on Nutramigen 28 calories, tolerating fine with occasional trace positive stools likely related to rectal fissures. Is also receiving Zantac and Reglan. HEMATOLOGY: The most recent hematocrit on [2-20] was 22.7, received 20 cc per kilo per day of packed red blood cells. That was his first blood transfusion during this hospital course. INFECTIOUS DISEASE: CBC and blood culture were obtained on admission. CBC was benign. Blood culture remained negative at 48 hours at which time Ampicillin and Gentamicin were discontinued. The infant had another episode of sepsis rule out in which he received 48 hours of Vancomycin and Gentamicin and received Ampicillin and Gentamicin around his hemoccult positive stools. NEUROLOGY: Head ultrasound performed on day of life seven and day of life 30 were within normal limits. Infant has been appropriate for gestational age. SENSORY: Audiology was performed with automated auditory brain stem responses and the infant passed both ears. Ophthalmology: The infant was most recently examined on [2138-2-11] with immature retina in zone three. Follow up in three weeks with Dr. [Last Name (STitle) ] at [Hospital3 ]. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. Name of primary pediatrician is Dr. [First Name8 (NamePattern2) 1154] [Last Name (NamePattern1) 33645], [Hospital 1411] Medical Group, telephone number is [Telephone/Fax (1) 8506]. CARE RECOMMENDATIONS: Continue ad lib feeding Nutramigen 28 calorie. Medications: Zantac and Reglan, ferrous sulfate supplement and TriViSol. Care seat position screening has been performed and infant passed. State Newborn Screens have been performed and have been within normal limits. IMMUNIZATIONS RECEIVED: Synagis on [2138-1-27]. Has not yet received hepatitis B vaccine. IMMUNIZATIONS RECOMMENDATIONS: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria: 1) born at less than 32 weeks, 2) born between 32 an 35 weeks with two of the following - day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings, or 3) with chronic lung disease. Influenza immunization is recommended in the fall for all infants once they reach six months of age. Before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contacts and other home care givers. DISCHARGE DIAGNOSES: Premature male born at 31 3/7 weeks. Status post respiratory distress syndrome. Status post rule out sepsis with antibiotics. Patent ductus arteriosus. Mild protein allergy. Gastroesophageal reflux. Apnea and bradycardia of prematurity. Anemia of prematurity. Hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Last Name (NamePattern1) 58700] MEDQUIST36 D: [2138-2-22] 21:03:44 T: [2138-2-22] 22:11:52 Job#: [Job Number 60032] ICD9 Codes: 769, 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7779 }	Medical Text: Admission Date: [2123-2-11] Discharge Date: [2123-3-5] Date of Birth: [2049-10-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: Hypoxic respiratory failure and hypotension Major Surgical or Invasive Procedure: 1. s/p Intubation 2. s/p Tracheostomy History of Present Illness: 73 y.o. man who presents for respiratory distress. History is limited and is from son and [Name (NI) ] notes. He was apparently feeling ok yesterday. This morning, per his living facility, he was less responsive and in respiratory distress. O2 sat was in the 50s. He may have had a mild cough over the last few days. He was brought to the ED. He was intubated on arrival for unresponsiveness, cyanosis. Subsequently, he was hypotensive with SBP to 60s. A CVL was placed, he was given 2.25 L NS and started on levophed with response in SBP up to 110s. He was started on vanco, levo, flagyl for pneumonia after infiltrate was seen on CXR. Then transported to [Hospital Unit Name 153]. Pt had CXR on [2-4] which showed bibasilar infiltrates. He was started on levaquin and flagyl. Past Medical History: 1) AAA repair--R common iliac aneursym repair in [7-12] with endovascular stent 2) COPD--on home O2 3) CAD with cardiomyopathy: last TTE in [7-12] showed nml EF, impaired relaxation. 4) HTN 5) CRI (bl Cr=1.2) 6) Anemia 7) chronic UTI 8) dementia 9) depression Social History: Spanish speaking, lives in a nursing home, ex-smoker and alcohol user. Family History: noncontributory Physical Exam: VS: Tm 102 (Tc 101.3) -- BP 110/80 --- HR 90-100s -- RR 20 (set) --- 100% on AC 500 x 20 FiO2 0.6 PEEP 5 PIP 37. GEN: intubated, but opens eyes and follows simple commands. HEENT: NCAT, Pupils 3mm and min reactive but equal. Anicteric. OP with ETT, dry MM. Neck: supple, JVP not appreciated due to habitus. Lungs: coarse BS b/l with anterior rhonchi and left sided expiratory wheezing. CV: distant HS, RRR, nml S1S2, no m/r/g appreaciated ABD: soft, mod distended, NT, naBS, no masses. EXT: no c/c/e. NEURO: resting cogwheel tremor of hands R>L. SKIN: no wounds or ulcers. Pertinent Results: [2123-2-11] 07:56AM WBC-15.2* RBC-3.67* HGB-10.9* HCT-33.7* MCV-92 PLT COUNT-215 . [2123-2-11] 08:27AM GLUCOSE-291* LACTATE-3.4* NA+-146 K+-4.3 CL--106 [2123-2-11] 08:27AM freeCa-1.11* [2123-2-11] 09:10AM CALCIUM-7.8* PHOSPHATE-4.6* MAGNESIUM-2.2 . [2123-2-11] 09:51AM LACTATE-3.9* [2123-2-11] 10:47AM LACTATE-2.4* . [2123-2-11] 08:30AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.009 [2123-2-11] 08:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2123-2-11] 08:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 . [2123-2-11] 08:27AM ABG#1: O2-100 PO2-277* PCO2-94* PH-7.21* [2123-2-11] ABG#2: RATES-/16 O2-100 PO2-253* PCO2-64* PH-7.29* . CXR: RLL patchy opacity ECG: porr baseline but appears SR at 96bpm, nml axis, ints. PRWP. TWI in V2, no acute ST-T changes (c/w [7-12]) . [2123-2-11]- abdominal x-ray - No evidence of bowel obstruction. Nasogastric tube in satisfactory position. . Echo [2123-2-15] - Suboptimal image quality. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is probably mildly depressed. The basal septum appears hypokinetic. Right ventricular chamber size and free wall motion appear 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. No mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of [2122-8-5], the degree of pulmonary hypertension detected has increased. A mildly depressed LVEF is now suggested, but not conclusive (poor image quality). If clinically indicated, a repeat TTE with echo contrast (Definity) may better define regional/global LV systolic function. . CT abdomen - [2123-2-22] - IMPRESSION: 1. No findings to explain patient's bacteremia within the chest, abdomen, or pelvis. No abscesses. 2. Extensive bullous emphysema within the lungs. Bilateral pleural effusions, findings to suggest loculation. Bibasilar consolidation has the appearance of more of atelectasis. Nodules within the lungs should be followed up by CT in [4-12] months after the patient's current condition has resolved. 3. The pancreatic head cystic lesion and small pancreatic neck cystic lesion are unchanged in appearance from [2122-5-14]. These likely represent cysts, however IPMT cannot be excluded, and attention should be paid to this on follow-up. 4. Decreased size of right common iliac artery aneurysm after graft placement. No evidence of superinfection of this aneurysm. No change in the aortic, left common iliac, or bilateral common femoral aneurysms. No evidence of infection of these aneurysms. 5. Gastrostomy tube tip is within the second/third portion of the duodenum. 6. Persistent atrophic left kidney. . CXR [2123-3-4]- No change in comparison to the prior study. No evidence for new infiltrate Brief Hospital Course: 73 y.o. man with h/o severe COPD, pneumonias, HTN who presents with hypoxic respiratory failure, unresponsiveness, and hypotension. Given fevers, infiltrate on CXR, most likely etiology of respiratory failure is pneumonia, and this is also the most likely cause of his hypotension/septic shock. There is no evidence of ACS or CHF. .. .. ## Hypoxic respiratory failure: Intuabated on AC mode on admission. Given his history of recurrent aspiration pneumonias with MRSA and Pseudomonas he was started on broad comverate antibiotics with vanc, zosyn and azithromycin. Urine legionella was negative. DFA for influenza also negative. Sputum cultures returned with MSSA and pesudeomonas ([Last Name (un) 36] to zosyn). He was treated with Vanc, Zosyn and azithro for 14 day course. He was also given albuterol/atrovent nebs given history of COPD. He did not have much improvement in lung mechanics with 20 puffs of bronchodilator trial and was given burst of IV steroids (methylpred 80 IV for 7 days). Daily RSBIs were checked with not much improvement in his respiratory status. With attempts of weaning pt became tachycardic and tachypneic and pressure support was unable to be weaned off. He was evaluated by Interventional pulmonary who planned on placing a trach, this was delayed given positive blood culture with klebsiella, see below. After cultures were negative for 6 days, IP placed a bedside trach. He will need to have continued mechanical ventilation for now which should be weaned at a vent facility as tolerated. The trach should also help pt with preventing aspiration as he's had multiple admissions for aspiration pneumonias. . ## Septic shock: Likely due to pneumonia. Treated with abx as above. Given IVF and levophed initially, with goals of CVP 10-12 corrected for PEEP, MAP>60, and UOP>30 cc/hr. [Last Name (un) ] stim showed appropriate response. Levophed was weaned off and he did not require pressors thereafter. . ## CAD/CHF: No indication of acute process. Held antihypertensives on admission. His blood pressure remained stable and he was not restarted on his anithypertensives. Given his CAD, inquired with PCP and started him asa, statin. .. ## Bacteremia: Few days after admission pt had temp spike and had blood cultures done which later grew Klebsiella. There was no clear source of infection. So CT scan of abdomen was done without clear source. His central line was changed and cultures were negative thereafter. he should be treated for total 2 week course with levofloxacin (start date [2123-2-24]). ## [Doctor First Name 48]/CRI: Likely pre-renal from sepsis and hypotension. This resolved with initial ivf. Creatinine remained around 1.4-1.7 during the rest of the admission. .. ## Abd distention: nontender, LFTs were checked on admission and several times during the admission and were unremakable. KUB was done which showed no evidence of obstuction only stool in colon. Given persistent distension he also had a CT scan of abdomen, results above. His distention improved with prn Lactulose during the admission. .. ## F/E/N: He was continued on TFs during the hospitilization. Nutrition also followed pt while he was in the ICU. He was placed on insulin gtt initially and was changed over to basal insulin + RISS. .. ## PPx: Maintained on SC heparin, PPI. bowel regimen. Medications on Admission: Trazadone 25mg q6h prn APAP prn Flovent 110mcg 2puffs [Hospital1 ] Combivent 2 puffs q4h Lopressor 25mg tid Levaquin 500mg daily (since [2-4]) Flagyl 500mg tid (since [2-4]) Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection Q8H (every 8 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) ml PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Eight (8) Puff Inhalation Q4H (every 4 hours). 8. Albuterol 90 mcg/Actuation Aerosol Sig: Eight (8) Puff Inhalation Q4H (every 4 hours). 9. Albuterol 90 mcg/Actuation Aerosol Sig: Eight (8) Puff Inhalation Q4H (every 4 hours) as needed. 10. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Two Hundred Fifty (250) mg Intravenous Q24H (every 24 hours) for 8 days: Please continue until [2123-3-10]. thank you. 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 12. Acetaminophen 160 mg/5 mL Solution Sig: [6-16] ml PO Q4-6H (every 4 to 6 hours) as needed. 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 15. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Please see attached list for details Injection four times a day: Please see attached list for details. 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary: 1. Sepsis due to PNA 2. COPD 3. Acute renal failure on baseline chronic renal failure Secondary: 1. CAD 2. CHF 3. AAA repair 4. HTN 5. Dementia Discharge Condition: Stable Discharge Instructions: Please follow up with all of your doctors. Please take all of your medications as instructed. Please note, several changes have been made in your medications including antibiotics which should be continued for two weeks. See below for details: 1. Please continue the antibiotic Levofloxacin until [2123-3-10] 2. Please continue the albuterol and atrovent nebulizers 8 puffs Q 4hours. Your flovent and combivent has been discontinued and replaced with the albuterol and atrovent IH. 3. Please continue to hold the antihypertensive medications until his blood pressure shows signs of hypertension. At this point, the pt can be started on metoprolol 12.5mg three times a day and titrated up to 25mg three times a day. Followup Instructions: Please follow up with your PCP [Last Name (NamePattern4) ] 2 weeks after discharge. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2123-3-7] ICD9 Codes: 0389, 5070, 496, 4280, 5849, 4254, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7780 }	Medical Text: Admission Date: [2120-8-12] Discharge Date: [2120-8-16] Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 602] Chief Complaint: Pulmonary embolus Major Surgical or Invasive Procedure: CT angiogram History of Present Illness: [Age over 90 ]F history of dementia, oriented x1 CRI, multiple recent admissions, was reportedly hypoxic to 69% on room air during physical therapy earlier today, and appeared lethargic. she is not able to provide any helpful history. She is DNR/DNI. recent admission for anemia, altered mental status, and acute renal failure. Work-up that admission found that renal insufficiency improved with IVF and anemia was likely chronic in nature. . In ED intial VS: 97.1, 63, 106/80, 20, 95% on NRB. EKG showed av paced @ 61. continues to be hypoxic here, on room air it went to 88%, nasal cannula applied only went to 91%, nonrebreather be applied, with O2 sat 97%. Guaiac-negative. Discussed in detail with healthcare proxy [Name (NI) ] [Name (NI) 103058] (nephew) [Telephone/Fax (1) 103059] confirmed DNR, DNI, but otherwise would like treatment including heparin drip. . Labs showed WBC 10.6, Hct 29.9 (baseline at discharge), 277. Electrolyte with creatinine 1.6 (baseline 1.1-1.6 last admission), trop .22 (baseline normal), D-dimer [Numeric Identifier ], lactate 1.5. UA with few bact, 2 RBC, 1 WBC, neg leuk/nit. . CT showed 1. bilateral PE affecting RUL, RML, RLL, LLL, and to a lesser extent LUL. 2. straightening to mild bulging of intraventricular septum into the LV cavity, concerning for early R heart strain. . CXR showed low lung volumes but similar to prior with PPM in place. Urine and blood cultures sent. She was started on a heparin drip with bolus of 6100, currently at 1350 units/hr. . Prior to transfer she was placed on ventimask. VS were 62 109/50 20 97% 12L venti mask Two 20G IVs were in. OX 1 at baseline. . On the floor, the patient is orienged to person. She is sleepy but arousable. . Review of systems: Unable to obtain. Past Medical History: hypertension hypercholesterolemia osteoporosis depression chronic kidney disease, stage 3 macular degeneration carpal tunnel syndrome 3rd degree AV block s/p pacemaker lumbar spinal stenosis and leg pain syncope sensorineural hearing loss skin cancer right leg s/p excision Social History: Lives alone in nursing home which was her choice for the past 2 months. Nephew notes that has had decline/dementia for the past 3 months. Tobacco: Former smoker. Smoked 2 cigarettes/day for a few years, never was a heavy smoker. EtOH: none. Drugs: none Family History: Has no children. Father had cancer (unknown type) in 70s. Mother had heart disease in 70s. Has sister. Physical Exam: Admission physical exam Vitals: 97.4 62, 108/59, 94%/ General: Sleepy, easily aroused HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated 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 PE: VS: 96.5 130/70 61 20 98 on 2L Gen: elderly female sleeping comfortably in bed, NAD CV: faint heart sounds; RRR, S1, S2 lungs: anterior lung fields clear to ausculation b/l abdomen: soft, nontender, nondistended, +BS extremities: pedal edema b/l L>R, warm, well perfused, no LE edema b/l hand swollen b/l, L>R, improved from yesterday Pertinent Results: Admission labs: [2120-8-12] 02:30PM BLOOD WBC-10.6 RBC-3.47* Hgb-10.0* Hct-29.9* MCV-86 MCH-28.7 MCHC-33.3 RDW-14.6 Plt Ct-277 [2120-8-12] 02:30PM BLOOD Neuts-79.8* Lymphs-14.6* Monos-3.6 Eos-1.7 Baso-0.4 [2120-8-12] 02:30PM BLOOD Glucose-95 UreaN-53* Creat-1.6* Na-145 K-4.5 Cl-110* HCO3-22 AnGap-18 [2120-8-12] 09:35PM BLOOD ALT-67* AST-42* CK(CPK)-164 AlkPhos-113* TotBili-0.4 [2120-8-12] 02:30PM BLOOD cTropnT-0.22* [2120-8-12] 08:21PM BLOOD cTropnT-0.21* [2120-8-12] 09:35PM BLOOD CK-MB-11* MB Indx-6.7* cTropnT-0.19* [2120-8-13] 04:33AM BLOOD CK-MB-9 cTropnT-0.18* [2120-8-14] 04:35AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.3 [2120-8-12] 02:30PM BLOOD D-Dimer-[Numeric Identifier ]* [2120-8-14] 04:35AM BLOOD TSH-2.4 [2120-8-14] 04:35AM BLOOD T4-6.3 Discharge labs: [2120-8-16] 05:15AM BLOOD WBC-7.2 RBC-3.16* Hgb-9.2* Hct-27.1* MCV-86 MCH-29.0 MCHC-33.8 RDW-16.4* Plt Ct-267 [2120-8-14] 04:35AM BLOOD Neuts-76.4* Lymphs-18.1 Monos-3.5 Eos-1.5 Baso-0.5 [2120-8-16] 05:15AM BLOOD PT-34.1* PTT-94.9* INR(PT)-3.4* [2120-8-16] 05:15AM BLOOD Glucose-83 UreaN-20 Creat-1.0 Na-143 K-4.0 Cl-110* HCO3-25 AnGap-12 [2120-8-16] 05:15AM BLOOD ALT-33 AST-23 [2120-8-16] 05:15AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.3 CTA: FINDINGS: Again, a hypodense nodule in the left lobe of the thyroid is seen measuring 15 x 13 mm, similar in appearance to prior study. The aorta shows no evidence of dissection or intramural hematoma. Extensive filling defects are seen within the pulmonary arterial tree involving both right and left branches and nearly all pulmonary lobes and segments. There is relative sparing of the left upper lobe. There is enlargement of the right ventricle with leftward bowing of the interventricular septum, concerning for right heart strain. The lungs are clear aside from mild bibasilar atelectasis. There is no pleural or pericardial effusion. Calcified atherosclerotic disease in the coronary arteries bilaterally. The visualized portion of the upper abdomen appears unremarkable. The bones demonstrate degenerative changes in the thoracic spine but no aggressive-appearing lytic or sclerotic lesions. IMPRESSION: 1. Massive pulmonary emboli with CT signs of right heart strain. These findings were communicated to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at 18:45 on [2120-8-12] by [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 11623] over the phone. 2. Left thyroid nodule - nonemergent ultrasound may be considered if clinically indicated. Brief Hospital Course: [Age over 90 ]F with chronic kidney disease, dementia, HTN and recent admission for rising BUN and reduction in hematocrit admitted with hypoxia and found to have large bilateral pulmonary emboli . #Acute pulmonary embolism: CTA showed massive pulmonary embolus with evidence of right heart strain. She also had a troponin leak (peak 0.22), as well as an elevated BNP. In addition, she was also hypoxic on presentation, and the patient was admitted to the MICU. She was started on a heparin drip. Her Hct were monitored and stable. Based on her impaired renal function, she was not candidate for lovenox and she was transitioned to coumadin via heparin drip. On transition to the floor, the patient was satting mid-90s on 2L NC. She was therapeutic on her coumadin with INR peaking at 3.8 and heparin drip was discontinued after two days of therapeutic INR. Coumadin was held when INR > 3 with instructions for her to restart coumadin when INR <3. She was weaned down on her oxygen to 1-2 L by time of discharge with instructions to increase nasal cannula if oxygen levels fall below 92%. . # Acute on chronic renal failure: Cr on admission was 1.6. She improved with IVF last admission. She was given gentle hydration creatinine improved. On transition to the floor, her creat has stablized, on discharge it is 1.0. . #Anemia: Stable on last admission at which point this was felt to be anemia of chronic inflammation. During hospitalization, patient had no signs or symptoms of occult bleed and was guiac negative. Her HCT remained stable in the high 20s and upon discharge her Hct was 31.0. Iron studies were consistent with anemia of chronic inflammation. . #Dementia: Patient has dementia at baseline, oriented to person. Rapidly deteriorating course per family and documentation. She was continued on home haldol for agitation - QTc noted to be prolonged at baseline (peaking in the 490s) and rechecked during stay. Home trazodone was held initially for hypotension. Home depakote was continued. On transition to the flor, the patient was continued on her home Haldol regimen, with daily EKGs to check her QTc. . #Hypertension: Home diltiazem was held on admission for SBP in 100s while in the MICU, but after transition to the floor, her pressures increased that patient was restarted on her Diltiazem, with pressures stable in the 130s systolic. . Transitional Issues: # goals of care: The patient is DNR/DNI, but issues such as do not hospitalize and goals of care should be addressed as an outpatient. . #Thyroid nodule: CTA chest showed incidiental left thyroid nodule. Thyroid function tests were within normal limits. She should follow-up with an ultrasound as outpatient. Medications on Admission: per nursing home paperwork 500cc fluids daily Tylenol 650 mg daily Bisacodyl 10mg daily prn constipation Senna 2 tabs daily Trazodone 50mg QHS Haldol 0.5mg Qam and Qpm Haldol 0.5mg [Hospital1 ] prn agitation Milk of Magnesia prn Mutlivitamin with minerals daily House supplement twice a day Vitamin D 1000 U daily Miralax 17 gm daily Depakote 125mg Qam, 1pm and QHS Diltiazem 120mg daily Docusate 100mg [Hospital1 ] Ground nectar prethickened liquid diet Discharge Medications: 1. fluids Sig: 500 cc cc once a day: 500 cc fluids daily. 2. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO qdayPRN as needed for constipation. 3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day. 4. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN as needed for agitation. 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q12H (every 12 hours) as needed for constipation. 8. house supplement Sig: One (1) twice a day. 9. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 10. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day. 11. Depakote 125 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: please take qam, 1pm, and qhs. 12. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. 13. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 14. ground nectar prethickened liquid diet Sig: as directed once a day. 15. Coumadin 1 mg Tablet Sig: as directed Tablet PO once a day: please check your blood levels and take coumadin accordingly. 16. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO once a day. 17. Outpatient Lab Work Please check INR every other day starting [2120-8-17]; if level is between 2 and 3, please start coumadin at 2mg daily and continue checking levels every other day until stable with dose adjustments as needed. [Month (only) 116] check INR twice weekly when levels and dosing more stable 18. Multiple Vitamin-Minerals Tablet Sig: One (1) Tablet PO once a day. 19. Outpatient Lab Work Please check CBC on [2120-8-19] (patient with history of anemia) Discharge Disposition: Extended Care Facility: [Hospital1 599] Senior Healthcare of [Location (un) 55] Discharge Diagnosis: primary diagnosis: pulmonary embolism secondary diagnosis: dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname 103057], It was a pleasure taking care of you while you were hospitalized at [Hospital1 18]. You were hospitalized because your oxygen levels were low at the nursing home. When you got to the hospital we did some imaging of your lungs and found a blood clot in your lungs that was causing your decreased oxygen levels. We started you on medications that will thin your blood, and your breathing and oxygenation levels have been improving. While you are on this medication, it is very important that you check your blood levels of this medication. For the first week, please get your blood checked every other day starting tomorrow, and the doctor at your facility will change your coumadin dose depending on your blood level. After the first two weeks, you can start checking your blood levels 2 times per week when your levels become stable. You will need to be on this medication for at least six months; the duration of therapy should be discussed with your doctor. The CAT scan of your lungs showed an incidental nodule in the thyroid. Your thyroid function tests were normal. You should follow up as outpatient regarding further evaluation, including a thyroid ultrasound. We made some changes to your medications: START Coumadin; your dosage and schedule for taking the medication will depend on the blood level. Hold coumadin until INR<3; start coumadin at 2mg daily when INR is between 2 and 3 Followup Instructions: You will be seen by a doctor at your nursing facility Completed by:[2120-8-18] ICD9 Codes: 5849, 2720, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7781 }	Medical Text: Admission Date: [2125-11-3] Discharge Date: [2125-11-12] Date of Birth: [2064-4-22] Sex: F Service: MEDICINE Allergies: Demerol / Codeine / Zocor / Crestor / Lescol / Fosamax / Percocet / Advair Diskus / Azulfidine / Celexa / Cymbalta Attending:[First Name3 (LF) 2387] Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: [2125-11-3] - Central venous line insertion [2125-11-8] - Cardiac catheterization with four stents placed [2125-11-11] - PICC line placement History of Present Illness: Ms. [Known lastname 8529] is a 61 y/o f with h/o of CAD s/p multiple stents, most recently [2125-7-19] ostial RCA Promus and RPDA promus, LCX Taxus, PCI ostial LAD promus for instent restenosis of the RCA, RPDA, LCX and LAD, HTN, hyperlipidemia, rheumatoid arthritis, restrictive lung disease who was transferred from OSH for possible cholangitis. Patient complained of some chest discomfort on the night of [11-2] while eating dinner and was noted to have elevated cardiac biomarkers. . Patient reports on [11-2] she was eating dinner when she developed sudden onset of head ache [10-29] which radiated to her back. She became anxious and then developed throat "heaviness" that subsequently radiated to her chest, which pt states is consistent with her previous anginal and heart attack symptoms. She took NTG and after 5 minutes the pain did not subside so she took another nitroglycerine and then a third which improved the CP slightly. She said the entire episode lasted about 20 minutes. The chest pressure was associated with diaphoresis and SOB but pt denied palpitations, dizziness, nause, vomiting. She was taken to the hospital by her husband and by the time she reached [Name (NI) 8530] her chest pressure had subsided completely but she did have some abdominal discomfort. In [Location (un) ], she was hypotensive and central line was placed. No EKG shown. She was given stress dose steroids and put on pressors. Per report, there were some gallbladder thickening and the initial thought was hypotension/sepsis from a gallbladder source prompting her transfer to [Hospital1 18] with for management of possible cholangitis. The week prior she endorsed increasing orthopnea having to sleep upright and also noticed some increase LE swelling for which she was taking [2-22] additional lasix 20 mg pills on top of her morning 20 mg lasix. . On presentation to [Hospital1 1516], she denies any chest pain or shortness of breath. She also denied abdominal pain. She was also finishing her last day of azithromycin for an upper respiratory infection. She reports that over the last 6 days, she has also noticed increasing LE edema for which she has been taking increasing doses of Lasix. She also complains of worsening orthopnea. She is able to walk [1-21] blocks with no chest pain. She can go up 1 flight of stairs but sometime has to stop for SOB. On cardiac review of symptoms as stated above. All other ROS negative. Past Medical History: CAD: [2125-7-19]: 4 [Name Prefix (Prefixes) ] [Last Name (Prefixes) 8531] RCA, PDA- ISR, CX- ISR and LAD. Cath [6-27] w/ PCI/[Name Prefix (Prefixes) ] [Last Name (Prefixes) 8532] RCA. Cath [7-26] PTCA/[Name Prefix (Prefixes) ] [Last Name (Prefixes) ] circumflex. [10-23] stenting of the LAD and RCA. - Carotid stenosis s/p CEA - HTN - Hyperlipidemia - h/o pericarditis x 1 - Rheumatoid arthritis on DMARDs - s/p wrist fusion - s/p multiple joint replacements - C4-5 neck fusion - Restrictive lung disease (rheumatoid lung) - Asthma questionable - s/p TAH for precancerous uterine lesion . PAST SURGICAL HISTORY: - s/p wrist fusion - s/p multiple joint replacements - carotid endardectomy Social History: Lives with husband. Denies etoh or tobacco use. No illicits, disabled since [2092]. Family History: Dad- MI in 40s. Mom MI in 50s. Physical Exam: ADMISSION PHYSICAL EXAMINATION: Vitals: T: 98.2, BP: 117/69 (yesterday 110-130/50-60) HR 80 RR 18 93/RA Gen: Awake, alert NAD HEENT: Pale. No icterus. moist mucus membranes. OP clear. NECK: Supple, JVP ~ 9 cm. Normal carotid upstroke without bruits. R IJ central line, dressing c/d/i. CV: PMI in 5th intercostal space, mid clavicular line. RRR. normal S1,S2. II/Vi holosystolic murmur apex LUNGS: Crackles bilaterally 2/3 up the back. No wheezes, rales, rhonchi. ABD: Soft, NT, ND. No HSM. Central abdominal bruit heard. EXT: [1-21]+ lower extremity edema below the knees. Left leg erythematous, warm and tender half way up the shin. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [1-21]+ reflexes, equal BL. Normal coordination. . DISCHARGE PHYSICAL EXAMINATION Gen: Awake, alert NAD HEENT: Pale. No icterus. moist mucus membranes. OP clear. NECK: Supple, JVP low. Normal carotid upstroke without bruits. CV: PMI in 5th intercostal space, mid clavicular line. RRR. S1,S2 clear and of good quality. [2-25] holosystolic murmur best over apex LUNGS: Lungs CTAB, No wheezes, rales, rhonchi. ABD: Soft, NT, ND. No HSM. EXT: Left leg erythema, warm and tenderness vastly improved though still present. LLEE no RLEE NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [1-21]+ reflexes, equal BL. Normal coordination. Pertinent Results: ADMISSION LABS: [2125-11-3] 03:47PM BLOOD WBC-42.4# RBC-2.59 Hgb-7.9* Hct-25.3* MCV-98 MCH-30.7 MCHC-31.4 RDW-14.6 Plt Ct-236 [2125-11-4] 02:21PM BLOOD Neuts-96.8* Bands-0 Lymphs-2.2* Monos-0.6* Eos-0.4 Baso-0 [2125-11-6] 07:52AM BLOOD WBC-12.1* RBC-3.61* Hgb-11.1* Hct-34.5* MCV-96 MCH-30.7 MCHC-32.1 RDW-15.3 Plt Ct-216 [2125-11-3] 03:47PM BLOOD PT-13.8* PTT-29.3 INR(PT)-1.2* [2125-11-3] 03:47PM BLOOD Glucose-101* UreaN-27* Creat-1.3* Na-137 K-4.3 Cl-108 HCO3-19* AnGap-14 [2125-11-3] 03:47PM BLOOD ALT-52* AST-123* CK(CPK)-606* AlkPhos-90 Amylase-31 TotBili-0.2 [2125-11-4] 02:21PM BLOOD CK(CPK)-485* [2125-11-3] 03:47PM BLOOD CK-MB-64* MB Indx-10.6* cTropnT-1.33* proBNP-[Numeric Identifier 8533]* [2125-11-3] 03:47PM BLOOD Albumin-2.8* Calcium-7.4* Phos-2.9 Mg-1.1* [2125-11-4] 02:21PM BLOOD calTIBC-185* VitB12-1266* Folate-14.4 Ferritn-801* TRF-142* [2125-11-4] 02:21PM BLOOD Triglyc-174* HDL-25 CHOL/HD-6.2 LDLcalc-96 [2125-11-4] 02:21PM BLOOD TSH-2.7 . MICROBIOLOGY: -[2125-11-3] 4:14 pm MRSA SCREEN Source: Rectal swab. FINAL REPORT [2125-11-6] MRSA SCREEN (Final [2125-11-6]): No MRSA isolated. -[2125-11-3] 4:14 pm SWAB Source: Rectal swab. FINAL REPORT [2125-11-5] R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [2125-11-5]): No VRE isolated. -[2125-11-3] 4:45 pm URINE Source: Catheter. FINAL REPORT [2125-11-5] URINE CULTURE (Final [2125-11-5]): NO GROWTH. -[2125-11-5] 12:22 am STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT [2125-11-8] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2125-11-5]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). -[2125-11-6] 11:45 am THROAT CULTURE VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): No Herpes simplex (HSV) virus isolated. -[2125-11-7] 10:04 am URINE Source: Catheter. FINAL REPORT [2125-11-8] URINE CULTURE (Final [2125-11-8]): NO GROWTH. . Blood Cx: Negative x3 Discharge Labs: [2125-11-12] 06:21AM BLOOD WBC-8.8 RBC-2.92* Hgb-8.7* Hct-28.0* MCV-96 MCH-29.8 MCHC-31.1 RDW-14.1 Plt Ct-250 [2125-11-12] 06:21AM BLOOD Creat-0.9 Na-140 K-3.9 Cl-102 [2125-11-12] 06:21AM BLOOD Mg-1.7 IMAGING: -[11-3] RUQ US: IMPRESSION: Collapsed gallbladder, with pericholecystic fluid and gallbladder wall edema but no distention or son[Name (NI) 493] [Name2 (NI) 515] sign, decreasing the likelihood of acute cholecystitis. The gallbladder findings may be secondary to third-spacing from volume overload. There is no intra- or extra-hepatic bile duct dilation. Trace ascites. . -[11-4] CTA Chest: IMPRESSION: 1. No evidence of aortic dissection or aneurysm as questioned. Atherosclerotic change and ulcerated plaque throughout the imaged aorta. 2. Dilated air and fluid-containing esophagus which is unchanged. The appearance could be seen with a connective tissue disorder such as scleroderma. 3. New, extensive and diffuse peribronchovascular, ground-glass and nodular bilateral lung opacities which likely represent pulmonary edema and/or superimposed atypical infectious or inflammatory process. Bibasilar fibrosis that was demonstrated on prior chest CT is largely obscured by this process. 4. 1.3-cm hyperdense left renal lesion which is slightly larger than in [2121] and does not clearly enhance. Features are most suggestive of a hemorrhagic cyst, however, as some types of renal cell carcinoma could have a similar appearance, further follow up is recommended. Renal ultrasound could provide additional information or MRI could be obtained in [3-25] months. 5. Mild stenosis of the left subclavian artery at its origin. . -[11-5] TTE: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal 2/3rds of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 40-45 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([1-21]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w CAD (PDA distribution). Mild-moderate mitral regurgitation most likely due to papillary muscle dysfunction. Compared with the prior report (images unavailable for review) of [2119-1-10], the left ventricular regional dysfunction is new and c/w interim ischemia/infarction. . -[11-7] LLE Doppler: IMPRESSION: No evidence of deep vein thrombosis in the left leg. . -[11-7] ABI: IMPRESSION: Mild left common iliac arterial inflow insufficiency and mild right popliteal outflow arterial disease. Brief Hospital Course: Ms. [Known lastname 8529] is a 61F with significant history of CAD with multiple stents presenting from OSH with abdominal pain initially concerning for cholangitis and hypotensive episode requiring pressors, transferred from [Hospital1 18] SICU for NSTEMI. . ACTIVE ISSUES: . #. NSTEMI: After transfer to [Hospital1 18], she was found to have troponin elevated to 1.33->.1.23-> 1.24, likely ACS vs demand ischemia in the setting of the hypotensive episode at the OSH. EKGs remained normal and unchanged from previous, and pt was chest pain free. She was kept on a heparin gtt for 48hrs, and was continued on ASA, Plavix, pravastatin. TTE showed new left ventricular regional dysfunction c/w interim ischemia/infarction. Pt does have a history of in-stent restenosis, and she received cath on [11-8] (DES -> mid RCA, DES -> distal RCA, DES x2 -> mid LAD, POBA -> mid LCx). Her enalapril and nifidipine were held during admission given recent hypotensive episode and multiple doses of contrast. #. CHF- echo [2118] showed EF> 55 percent but exam notable for bilateral crackles, elevated JVP, and lower extremity edema. She also had an elevated BNP. She was diuresed with PO and IV lasix. . # New onset atrial fibrillation at OSH - etiology may be secondary to infectious process (UTI or pneumonia) vs. secondary to ischemia from NSTEMI. We continued metoprolol tartrate 25 mg TID for rate control. Her CHADS2 score is 2, but because she is already on ASA and Plavix, warfarin was not indicated at this time. Furthermore, she remained in sinus throughout the remaineder of admission and the afib was likely paroxysmal. . #. Widened mediastinum on xray [11-3]: CTA was obtained and aortic dissection was ruled out. . #. Leukocytosis: on admission to [Location (un) ], she received stress dose steroids and had a WBC of 44K on admission to [Hospital1 18], likely secondary to stress dose of steroids. The outside hospital noted gall bladder thickening but US done at [Hospital1 18] on [11-3] did not show evidence of acute cholecystitis and abdominal exam is benign so evolving cholangitis was unlikely (see below). . # UTI- Ucx were negative, but initial UA showed UTI. Vanc and unasyn were switched on the cardiology floor to PO bactrim and ampicillin, but the pt spiked fevers and her cellulitis worsened (see below). Thus, she was switched back to vanc and zosyn. . # left leg cellulitis: erythematous and warm upon admission. Vanc and unasyn were switched on the cardiology floor to PO bactrim and ampicillin, but the pt spiked fevers and her cellulitis worsened. Thus, she was switched back to vanc and zosyn. Discharged on Vancomycin/Cefepime for 3 more days to switch to PO Doxycyline for 5 days. . # anemia- hct was 30.0 after being transfused 2 units prbcs after admission. stool guaic in icu was negative. Fe studies were c/w anemia of chronic dz. . CHRONIC ISSUES: . #RA: Continued prednisone taper; in the context of possible infection leflunomide and simponi were held. . #GERD: cont pantoprazole. . TRANSITIONS OF CARE: -Pt had PICC line placed [2125-11-11]. -Vanc/Cefepime to continue for 3 more days -Doxycyline to start after IV Abx, complete 5 day course Medications on Admission: Atenolol 25 mg qam and 12.5 mg qpm Plavix 75 mg/day Enalapril 2.5 daily Montelukast 10 mg daily Nifedipine 30 mg daily Niacin 500 [Hospital1 ] Pantoprazol 40 mg daily Prednisone 5 mg daily Asa 325 mg daily bupropion 300 mg daily Leflunomide 20 mg daily Simponi (golimubab injections) Lasix 20mg PO daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:120 Tablet(s) Refills:2 2. enalapril maleate 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. niacin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. bupropion HCl 300 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 9. Simponi 50 mg/0.5 mL Pen Injector Sig: One (1) Subcutaneous once a month: Use as directed by your rheumatologist. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. [Hospital1 ]:30 Tablet(s) Refills:2 11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once a day: 1 Tablet(s) sublingually every five minutes for chest discomfort. Take up to a total of 3 pills. Call 911 if pain persists longer than 15 minutes. 12. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 14. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 6 doses: End Date:[2125-11-15]. [Month/Day/Year ]:6 gram Refills:0 15. leflunomide 20 mg Tablet Sig: One (1) Tablet PO once a day. 16. doxycycline hyclate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: Please start [11-16] End Date: Per your outpatient PCP. [Name Initial (NameIs) ]:14 Tablet(s) Refills:0 17. cefepime in D5W 2 gram/50 mL Piggyback Sig: Two (2) grams Intravenous every twelve (12) hours for 6 doses: End Date: [2125-11-15]. [Month/Day/Year ]:12 grams Refills:0 18. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: 1.5 (75 mg) Tablet Extended Release 24 hrs PO once a day. [Month/Day/Year ]:45 Tablet Extended Release 24 hr(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 6136] VNA Discharge Diagnosis: Primary diagnosis: Non ST-elevation myocardial infarction Lower extremity cellulitis New onset paroxysmal atrial fibrillation Secondary diagnoses: Coronary artery disease Carotid stenosis Hypertension Hyperlipidemia Rheumatoid arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 8529], It was a privilege to provide care for you here at the [Hospital 61] Hospital. You were transferred to [Hospital1 18] because you were sick with very low blood pressures. You were treated in the intensive care unit, and were then moved to the cardiology floor because you were found to have blood tests suggestive of a type of heart attack called an NSTEMI (non ST-elevation myocardial infarction). You were treated with a blood thinner (heparin), and also received cardiac catheterization with four stents placed on [11-8]. You also continued to receive antibiotics for your left leg skin infection and a urinary tract infection. Your condition has improved and you can be discharged to home. The following changes were made to your medications: NEW: 1. START Metoprolol Succinate 75 mg PO/NG daily 2. START Vancomycin 1000 mg IV Q 12Hrs x3days -[Date range (1) 8534] 3. START Cefepime 2gm IV Q12Hrs x3days - [Date range (1) 8534] STOPPED: 1. Atenolol 2. Nifedipine Please keep your follow-up appointments as scheduled below. Followup Instructions: Name: [Last Name (LF) 8535],[First Name8 (NamePattern2) 768] [Doctor Last Name 162] Location: ASSOCIATES IN INTERNAL MEDICINE Address: [State 8536], [Apartment Address(1) 8537], [Location (un) ],[Numeric Identifier 8538] Phone: [Telephone/Fax (1) 8539] Appointment: Monday [2125-11-26] 11:00am You have any issues or concerns before your appointment please call the office. Name: [Last Name (LF) 2912], [First Name7 (NamePattern1) 2174] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Hospital1 ] BLDG, [Apartment Address(1) 8540] Address: [Last Name (NamePattern1) 8541], [Location (un) ],[Numeric Identifier 8542] Phone: [Telephone/Fax (1) 8543] Appointment: Thursday [2125-12-6] 3:30pm You already have a scheduled appointment with Dr. [Last Name (STitle) 2912*], please keep that appointment as previously scheduled. ICD9 Codes: 5990, 4280, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7782 }	Medical Text: Admission Date: [2169-7-21] Discharge Date: [2169-7-22] Service: MEDICINE Allergies: Crestor / Ciprofloxacin Attending:[First Name3 (LF) 3984] Chief Complaint: Lower GI bleed Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ] yom h/o FTT, mild Dementia, pernicious anemia, ischemic heart dz (CATH in [2154] with LAD stent), Mobitz I block s/p pacemaker, recent prior lower gi bleed, and on home hospice, DNR/DNI who presents w/ BRBPR today. Bleeding started this evening per nursing home report prompting transfer. Pt denies SOB, palpitations, CP, fatigue on admission. He is A+O x2 (not to year). Of note, hospitalized in [2-27] for similar passing clot. Given IVF w/ stable hct and resolution of bleed. He is able to articulate that he would not like a blood transfusion if possible. He confirms DNR/I. Discussed admission w/ wife [Name (NI) 382] and daughter at 2:45AM. Confirmed DNR/I, no invasive measures, no colonoscopy, cxr, pressors, prefer IVF only, and blood transfusions only if absolutely necessary. Physical Exam is significant for grapefood sized clot of red/maroon blood. . In ED, initial vitals: 97.3 72 102/60 20 99%. Exam was significant for grapefruit sized clot in the rectum, guaiac positive. Labs were significant for HCT of 31. He was given IVF down in the ED (600cc downstair). EKG was V-paced. Patient stated to be DNR/DNI, no aggressive intervention, no colonscopy, no pressors. He was presistently hypotenisve in the ED. This was the reason for MICU admission. . In MICU, appears to be comfortable. Past Medical History: Parkinson's Disease (rigidity not responsive to meds) CAD s/p cath in [2154] with LAD stent Mobitz Type I block s/p PPM placement AF s/p successful cardioversion in [2164-1-18] Prostate Cancer s/p XRT ([2152]) Pernicious Anemia HTN Hyperlipidemia Glaucoma Bradycardia Basal Cell Carcinoma GERD Hematuria Left nephrolithotomy ([2127]) Social History: Pt is a retired physician (Family Practice), currently lives at [Hospital3 41599] Home since [Month (only) 404]; previously was living with his wife. [Name (NI) ] does have a history of tobacco use 2ppd x ~30 years, but he quit 44 years ago. Denies any Etoh use or IVDU. Family History: Mother had [Name (NI) 5895] disease. Father had prostate cancer. He has one sister who is healthy. Physical Exam: Admission Physical Exam Vitals: T:97.8 BP:125/52 P:70 R: 18 O2:100% General: Alert, oriented x1, stiff, no acute distress HEENT: Sclera anicteric, dMM, 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 Pertinent Results: [2169-7-21] 02:25AM BLOOD WBC-6.1 RBC-4.04* Hgb-11.6* Hct-33.7* MCV-83 MCH-28.8 MCHC-34.5 RDW-14.3 Plt Ct-243 [2169-7-21] 02:25AM BLOOD Neuts-65.2 Lymphs-27.1 Monos-4.4 Eos-2.7 Baso-0.4 [2169-7-21] 02:25AM BLOOD PT-13.1 PTT-29.1 INR(PT)-1.2* [2169-7-21] 02:25AM BLOOD Glucose-101* UreaN-17 Creat-0.9 Na-135 K-4.5 Cl-100 HCO3-26 AnGap-14 [2169-7-21] 09:54AM BLOOD Calcium-9.0 Phos-2.4* Mg-1.7 [2169-7-21] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2169-7-21] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [Known lastname ],[Known firstname ] MD [Medical Record Number 98927] M 90 [2079-4-28] Radiology Report CHEST (PORTABLE AP) Study Date of [2169-7-21] 9:18 AM [Last Name (LF) 2437],[First Name3 (LF) ] MED MICU-7 [2169-7-21] 9:18 AM CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 98928] Reason: eval pulmonary process [Known lastname ],[Known firstname ] MD [Medical Record Number 98927] M 90 [2079-4-28] Cardiology Report ECG Study Date of [2169-7-21] 3:15:40 AM A-V sequential pacing at a rate of 70 beats per minute. TRACING #1 Read by: [Last Name (un) ],ELAD [Hospital 93] MEDICAL CONDITION: [Age over 90 ] year old man with hypotension, brbpr, like to r/o pulmonary process. REASON FOR THIS EXAMINATION: eval pulmonary process Final Report SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Hypertension. Comparison is made with prior study [2169-2-21]. Left transvenous pacemaker leads are in standard position in the right atrium and right ventricle. Cardiac size is top normal, unchanged. If any, there is a small right pleural effusion. There is no evidence of pulmonary edema or pneumonia. Bibasilar atelectases are minimal, larger on the left retrocardiac area. Brief Hospital Course: [Age over 90 ] yom h/o FTT, anemia, ischemic heart dz, recent prior lower gi bleed, and on home hospice, DNR/DNI who presents w/ BRBPR today. . # Hypotension: Attributed to hypovolemia [12-21] acute lower GI bleed now HD stable. Etiology of rectal bleed is unknown - Held home antihypertensive yesterday. Family agreeable for pressors, IVF, picc line if needed, and abx. A PICC line was placed but he never required pressors. He was transfused two units PRBC during his admission and his Hct was 28.7 at discharge. . # BRBPR: Resolved on its own. No aggressive intervention, on home hospice. . # Anemia: The patient had a normocytic, normochromic anemia. Multifactorial - GIB, chronic disease, b12/iron deficiency. We continued B12 supplementation. . # CAD, PPM: Regarding his multiple cardiac issues, he was continued on his home amiodarone. Initially imdur was held but was restarted on [7-22]. His aspirin can be restarted as an outpatient. # Code: DNR/DNI on home hospice. # Disposition: Family meeting was held to review goals of care. Wife and daughter both endorsed that patient comfort was a priority, and that they were pleased with the current nursing home care with hospice arrangements. BOth family members agreed that transfer back to the nursing home was a priority for the patient. The family members were encouraged to continue discussions on goals of care as medical problems evolve. [Name2 (NI) ] the family wishes, plan to arrange transport back to nursing home. Medications on Admission: Medications: (per nursing home) - citalopram 30 mg PO DAILY - isosorbide mononitrate 60 mg once a day - travoprost 0.004 % Drops Ophthalmic once a day. - amiodarone 50 mg PO at bedtime: hold for HR < 60 or SBP < 90. - carbidopa-levodopa 50-200 mg Tablet ER PO QHS - omeprazole 20 mg PO BID - ipratropium-albuterol Nebulization Q6H PRN cough. - acetaminophen 650 mg PO TID - acetaminophen 325 mg Sig: 1-2 Tablets PO Q4H prn . Downers: - trazodone 50 mg PO at bedtime PRN insomnia - trazodone 25mg Q4H PRN anxiety - ativan 0.25mg Q6H PRN anxiety - Morphine 2.5mg sl Q8H - Morphine 2.5mg sl q3H prn pain . BM meds: - docusate sodium 100 mg Capsule PO twice a day. - MOM 30ml daily PRN constipation - Polyethylene glycol daily prn constipation - Senokot 8.6 mg 2 Tablet PO at bedtime - magnesium hydroxide 400 mg/5 mL 30ML PO DAILY PRN constipation. - bisacodyl 10 mg Suppository once a day PRN constipation - Fleet Enema 19-7 gram/118 mL Enema once a day PRN constipation . MISC: - polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [Hospital1 ] - multivitamin PO DAILY (Daily). - dextromethorphan-guaifenesin 10-100 mg/5 mL PO Q4H PRN cough. - Calcium 500 500 mg (1,250 mg) Tablet PO twice a day. - cholecalciferol 1000 unit PO DAILY - cyanocobalamin (vitamin B-12) Injection Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 3. trazodone 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for anxiety. 4. carbidopa-levodopa 50-200 mg Tablet Extended Release Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [11-20] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 9. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for agitiation. 11. morphine 10 mg/5 mL Solution Sig: 2.5 mg PO Q 8H (Every 8 Hours). 12. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 13. citalopram 20 mg Tablet Sig: 1.5 Tablets PO once a day. 14. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 15. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for cough. 16. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 2.5 mg PO Q3H as needed for pain. 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 18. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO once a day as needed for constipation. 19. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. 20. Senna Laxative 8.6 mg Tablet Sig: Two (2) Tablet PO QHS as needed for constipation. 21. polyvinyl alcohol 1.4 % Drops Sig: One (1) drop Ophthalmic twice a day. 22. dextromethorphan-guaifenesin Oral 23. cyanocobalamin (vitamin B-12) Injection 24. amiodarone 100 mg Tablet Sig: 0.5 Tablet PO QHS. Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] & [Hospital ] Care Center - [Location 1268] Discharge Diagnosis: lower GI bleed, unknown causes Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted to the intensive care unit at [Hospital1 771] because of a lower GI bleed. While you were here, you had low blood pressures and bleeding from your rectum which resolved on its own. Your family decided that because of your goals of care we would not persue invasive measures like colonoscopy. You were transfused two units of blood and your bleeding stopped on its own. While you were here some of your laxatives were held. You should hold your rectal laxatives unless you have severe constipation. You should continue all of your other medications as they previously were given. Followup Instructions: You should follow-up with your doctors at your nursing facility and with your hospice team. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] ICD9 Codes: 5789, 4589, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7783 }	Medical Text: Admission Date: [2153-1-24] Discharge Date: [2153-2-1] Date of Birth: [2108-3-6] Sex: M Service: HISTORY OF PRESENT ILLNESS: This gentleman had progressed to shortness of breath and chest tightness over a 2-month period with left arm numbness for which the patient visited his cardiologist. He had a cardiac catheterization and echocardiogram, and the patient was referred to Dr. [First Name (STitle) ] [Last Name (Prefixes) ] for aortic valve replacement and coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Hodgkin's disease at the age of 29. 2. Status post splenectomy with radiation therapy for Hodgkin's disease in [2135] and [2136]. 3. Left ankle injury with repair. 4. Question herniorrhaphy as a child. MEDICATIONS ON ADMISSION: He was on no medications on admission. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: On examination, his heart was in a sinus rhythm at 108 and blood pressure was 133/89. He had no jugular venous distention or thyromegaly. His neurologic examination was grossly intact with no motor or sensory deficits. His lungs were clear bilaterally. No wheezes or rhonchi. His heart was regular in rate and rhythm with a grade 3/6 systolic ejection murmur radiating to both carotids. He also had a well-healed midline scar. His extremities were warm with no edema. He had some mild varicosities bilaterally with left greater than right. He had good femoral, dorsalis pedis, and posterior tibialis, and radial pulses. PERTINENT LABORATORY VALUES ON PRESENTATION: Preoperative laboratory work revealed white blood cell count was 11.6 and hematocrit was 40.1. Prothrombin time was 12.5, partial thromboplastin time was 29, and platelet count was 371,000. INR was 1. Sodium was 141, potassium was 4.1, chloride was 103, bicarbonate was 23, blood urea nitrogen was 17, creatinine was 1, and blood glucose was 86. ALT was 18, AST was 20, LDH was 211, alkaline phosphatase was 59, and total bilirubin was 0.3. PERTINENT RADIOLOGY/IMAGING: His preoperative chest x-ray showed no evidence of pulmonary masses or nodules. No consolidations or pneumothoraces or effusions. Please refer to the chest x-ray report done on [2153-1-11]. His preoperative electrocardiogram from [2153-1-11] also revealed a sinus rhythm with left ventricular hypertrophy and secondary ST-T wave changes. HOSPITAL COURSE: He was referred to Dr. [First Name (STitle) ] [Last Name (Prefixes) ] for aortic valve replacement. On [1-24], he underwent a coronary artery bypass graft times two with a right internal mammary artery to the posterior descending artery a left radial artery to the obtuse marginal. He had an aortic valve replacement with a 20-mm Homograft, and he had repair of his atrial septal defect. Please refer to the Operative Report. He was transferred to the Cardiothoracic Intensive Care Unit in stable condition. On postoperative day one, he was in a sinus rhythm with a blood pressure of 94/54. He was on a propofol drip, and nitroglycerin at 0.5 for his radial artery coverage, Fentanyl, and Neo-Synephrine at 0.5. He remained intubated with coarse breath sounds. He extremities had trace edema. The plan was to wean his sedation. His postoperative laboratories revealed white blood cell count was 9.3, hematocrit was 27.1, and platelets were 242,000. Sodium was 141, potassium was 4, chloride was 107, bicarbonate was 22, blood urea nitrogen was 11, creatinine was 0.8, and blood glucose was 119. His chest x-ray showed decreased lung volumes with no effusions of pneumothorax, and no congestive heart failure. An aggressive pulmonary toilet was started. The patient remained stable on his perioperative antibiotics. He had a bronchoscopy done; also done on [1-25], on postoperative day one, which showed clean airways by Dr. [Last Name (STitle) 952]. He was seen by Case Management and Physical Therapy when he was transferred out to the floor. He also had an Electrophysiology consultation on postoperative day two. He had already been started on Lopressor and amiodarone for runs of tachycardia. He also had some late night episodes which were asymptomatic but responded to 5 mg of intravenous Lopressor. Some were self-limiting. His tracing showed atrial fibrillation. They recommended continuing his Lopressor and amiodarone and starting him on a intravenous heparin, off anticoagulation without a bolus if he could tolerate that. This was confirmed and reviewed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 73]. A-wire tracing did confirm atrial fibrillation and atrial flutter. On postoperative day two, he was in a sinus rhythm in the 80s with a blood pressure of 101/56. His oxygen saturations were 97% on face mask and nasal cannula. He was continued on amiodarone, Imdur for his radial artery, albuterol, Colace, Zantac, and aspirin, as well as Percocet for pain. His hematocrit was stable at 28.7. Blood urea nitrogen was 11 and creatinine was 0.9. He was comfortable. His incision was clean, dry, and intact. Amiodarone was increased to 400 mg three times per day as per recommendations, and he began to auto diurese; putting out 3.5 liters of urine in a 24-hour period. He was alert, awake, and oriented. He started his rehabilitation with Physical Therapy on the floor on postoperative day two. He continued to diurese on the floor. He received an amiodarone bolus in addition to his routine dosing for supraventricular tachycardia which converted him back to a sinus rhythm. On postoperative day three, his blood pressure was 107/70; in a normal sinus rhythm at 67. His diet was advanced. He also started his Zantac. His creatinine rose slightly to 0.9. On postoperative day three, his chest tubes were removed. He remained on Lopressor, amiodarone, and Imdur, as well as his aspirin. He was comfortable. His lungs were clear bilaterally. His hematocrit rose to 30.5, and his creatinine dropped back down to 0.7. He had some trace peripheral edema and was continued with a pulmonary toilet and diuresis. His heparin drip continued. The decision was made to hold the Coumadin for now, and the patient was transferred out to the floor. He continued to receive Percocet for his incisional pain. He was followed by Electrophysiology who suggested possibly getting an Endocrine consultation given his radiation therapy and elevated thyroid-stimulating hormone with amiodarone. He was continued on his Lopressor and insulin sliding-scale. His creatinine remained stable at 0.8. He was started on 3 mg of Coumadin on postoperative day five while he continued his baseline intravenous heparin for anticoagulation for atrial fibrillation and atrial flutter, in addition to amiodarone boluses. Endocrine recommended starting him on Levoxyl 50 mcg p.o. once per day and following up with Dr. [First Name (STitle) 16901] as an outpatient. They also recommended that he get a yearly thyroid examination and to recheck his thyroid function tests is approximately eight weeks given his history of radiation therapy. He was seen again by Case Management. On postoperative day five, he continued with his anticoagulation with heparin and Coumadin. His pacing wires were discontinued. He remained in atrial flutter and atrial fibrillation. His lungs were clear. His heart was regular in rate and rhythm. He had trace peripheral edema. He was in a sinus rhythm at 89 at the time of examination in the morning with a blood pressure of 126/75. On postoperative day six, he had some more bursts of atrial fibrillation in the evening and rapid atrial fibrillation in the morning which was rate controlled with Lopressor. The patient was totally asymptomatic. He had a blood pressure of 134/81. Temperature maximum was 100.6. His lungs were clear. He continued his anticoagulation and continued to ambulate with Physical Therapy. Since all of the recommendations had been followed, over the next day, the patient continued to ambulate on the floor awaiting therapeutic anticoagulation. His creatinine remained stable at 0.9. His INR on postoperative day six rose to 1.2. He continued to receive Percocet for pain and occasional Ambien for sleep with good effect. The patient remained in house awaiting a therapeutic INR. On postoperative day seven, the patient had no events overnight. He was in a sinus rhythm at a rate of 77. His blood pressure was 94/53. Oxygen saturation was 94% on room air. His heart was regular in rate and rhythm. His lungs were clear. He had trace pedal edema. His INR was 1.3, and he continued to ambulate. On postoperative day eight, the patient went back into intermittent atrial fibrillation and atrial flutter alternating with his sinus rhythm but with no complaints. His examination was unremarkable. On the day of discharge, his INR rose to 1.6. His prothrombin time was 15.8, and his partial thromboplastin time was 81.8 on heparin. DISCHARGE STATUS: The patient was discharged to home. DISCHARGE DIAGNOSES: 1. Status post aortic valve replacement with a 20-mm Homograft, and coronary artery bypass graft times two, atrial septal defect repair. 2. Status post Hodgkin's disease with splenectomy and radiation therapy. 3. Status post left ankle surgery. 4. Status post herniorrhaphy as a child. MEDICATIONS ON DISCHARGE: (Discharge medications were as follows) 1. Lovenox 100 mg subcutaneously q.12h. 2. Coumadin 3 mg p.o. once per day (with instructions for blood draws and dosing by the patient's cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 46008] at [Hospital3 1280] Hospital). 3. Amiodarone 400 mg p.o. three times per day. 4. Isosorbide 60 mg p.o. once per day. 5. Lopressor 75 mg p.o. once per day. 6. Aspirin 325 mg p.o. every day. 7. Albuterol nebulizers as needed. 8. Percocet 5/325 one to two tablets p.o. q.4h. as needed. 9. Colace 100 mg p.o. twice per day. 10. Levothyroxine 50 mcg p.o. once per day. DI[Last Name (STitle) 408]E INSTRUCTIONS/FOLLOWUP: 1. The patient was discharged with instructions to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 46008] for [Initials (NamePattern4) ] [Last Name (NamePattern4) ] of Hearts Holter monitor which was placed on [2-1] as well as blood draws via the [Hospital6 407] with results called in to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 46009] office for dosing to get the patient to a therapeutic INR for his atrial fibrillation. 2. The patient was also instructed to see Dr. [Last Name (Prefixes) ] in the office in approximately four weeks. 3. The patient was to follow up with his primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 76] MEDQUIST36 D: [2153-4-10] 08:54 T: [2153-4-10] 08:59 JOB#: [Job Number 46010] ICD9 Codes: 4241, 9971
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7784 }	Medical Text: Admission Date: [2134-9-1] Discharge Date: [2134-9-15] HISTORY OF PRESENT ILLNESS: This is an 82-year-old female with an extensive past medical history including atrial fibrillation, coronary artery disease, status post coronary artery bypass graft, hypertension, peptic ulcer disease, and came to the hospital on [2134-9-1]. HOSPITAL COURSE: At that time she was admitted for an elective procedure for lumbar decompression. The patient had been confined to a wheelchair, and therefore, it was felt that despite her advanced age she was an acceptable surgical risk for surgery to correct the spinal stenosis. Following surgery, she was in severe pain treated with very high doses of morphine and was noted to be very lethargic with a decreased right arm and incoherent speech. CT of the brain was done on [9-2] that was normal, but she continued to not be able to arouse. MRI was done on [9-3] which showed a left occipital 1 X 1 hemorrhage on susceptibility weighted imaging with blood layering out posteriorly in both lateral ventricles. There were no areas of restricted diffusion, no mass affect or shift was noted. The patient was then evaluated by Neurology, that noted the patient to be quite lethargic, but able to open her eyes and answer questions. She did indeed appear to be weaker on the right and very weak in both legs bilaterally. A test dose of Narcan managed to improved her symptoms suggesting that most of her symptoms were due to the high dose of morphine that she received post-op. During the next few days she did improve especially in her mental status and strenght in her upper extremities. On [9-4], due to the decreased mental status a repeat head CT was obtained which now showed the blood seen in the ventricles and in the left occipital lobe, but no other acute changes. Becaouse of concern that she may not be able to protect her airways due to sedation, the patient was kept in the Intensive Care Unit during this entire time. During her ICU stay as she was noted to develop decreasing strength in her legs bilaterally both proximally and distally, and it was noted that her reflexes which had previously been intact were now decreased. It was therefore decided to emergently obtain a MRI of the lumbar spine which demonstrated an L3-L4 and L4-L5 epidural hematoma. She was taken back to the operating room on [9-7], where the epidural hematoma was evacuated and a drain was left in place. Following the surgery she did much better. Her strength began to return to her legs, and her reflexes were also noted to be better. Postoperatively, the question was whether or not to restart her on her anticoagulation because of her atrial fibrillation which had been held due to her recent surgery and also to the fact that she had a hemorrhage in the surgical site. Cardiology was consulted, and they felt that anticoagulation she should be restarted on Coumadin. She was started on Occupational Therapy and Physical Therapy, who worked initially with her with passive range of motion but later in the course was able to sit up in a chair, able to stand for brief period; although, she was not yet able to walk. From a mental status point of view, she did better upon transfer out of the unit and appeared to be doing well. However, a few days later she was noted again to have a waxing and [Doctor Last Name 688] course. Further investigation revealed that she was sleeping poorly at night and more during the day, and it was felt that this may have represented a derangement of her sleep/awake cycle, and she was placed on trazodone for sleep prophylaxis. It was noted that certain times during the day she was very alert and seemed to be doing very well, so further imaging was held off on. She continued to have difficulties with poor swallowing, and it was felt that no neurological abnormality could be found for this. She had a number of video swallow studies which all demonstrated a weak swallow mechanism. She was fed via nasogastric tube during this time. An ENT consultation was obtained which is still pending at this time, but the suspicion was that this may be due to vocal cord injury secondary to intubation during the surgery. PHYSICAL EXAMINATION ON DISCHARGE: Prior to discharge, the patient was alert and oriented. Her physical examination was significant for a 2/6 systolic ejection murmur. Heart otherwise had a regular rate and rhythm. Lungs were clear to auscultation. Abdomen was benign. Her back examination revealed a healing surgical site; although, there was some wound breakdown along the edge of the site felt by Surgery to be due to incomplete nutritional status. On neurologic examination she alert and oriented. Her motor testing was as follows on the left: Deltoids were [6-5], biceps [6-5], triceps 4+/5, wrist extensors [6-5], finger extensors [6-5], hip flexor was 4-/5, knee flexor 4+/5, knee extensor 4+/5, plantar extension was 4-/5, plantar flexion was 3+/5. On the right: Deltoids were 4+/5, biceps [6-5], triceps 4+/5, wrist extensors [6-5], finger extensors [6-5], hip flexor was [5-6], knee flexor 4-/5, knee extensor [5-6], plantar extension was 3+/5, plantar flexion was [4-5]. Deep tendon reflexes were 2+ and symmetric in the upper extremities and at the knees. They were absent at the ankles, and the toes were mute bilaterally. CONDITION AT DISCHARGE: The patient was afebrile. She was hemodynamically stable. She was not able to ambulate independently. DISCHARGE STATUS: The patient was to be discharged to rehabilitation facility for acute postoperative rehabilitation. The final decision as to which institution will be decided by the patient and her family and appended to this report. DISCHARGE DIAGNOSES: 1. Lumbar stenosis. 2. Status post lumbar decompression with multiple complications including intracranial bleed and epidural hematoma. 3. Coronary artery disease, status post coronary artery bypass graft. 4. Atrial fibrillation. 5. Hypertension. 6. Peptic ulcer disease by history. 7. Polymyalgia rheumatica. MEDICATIONS ON DISCHARGE: 1. Trazodone 50 mg p.o. q.h.s. 2. Maalox p.r.n. 3. Coumadin 5 mg p.o. q.h.s. 4. Dulcolax p.r.n. 5. K-Phos 2 tablets per G-tube p.r.n. 6. Percocet p.r.n. for pain. 7. Atenolol 50 mg per G-tube b.i.d. 8. Prevacid 30 mg per nasogastric tube q.12h. 9. Prednisone 5 mg per nasogastric tube q.d. 10. Cardizem 30 mg per nasogastric tube q.6h. 11. Accupril 40 mg per nasogastric tube q.d. 12. Lasix 40 mg per nasogastric tube q.d. 13. Synthroid 0.125 per nasogastric tube q.d. 14. Neurontin 800 mg per nasogastric tube t.i.d. [Name6 (MD) 725] [Name8 (MD) 726], M.D. [MD Number(1) 727] Dictated By:[Last Name (NamePattern1) 20736] MEDQUIST36 D: [2134-9-14] 13:16 T: [2134-9-14] 13:23 JOB#: [Job Number 32762] ICD9 Codes: 431, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7785 }	Medical Text: Admission Date: [2116-6-20] Discharge Date: [2116-7-8] Date of Birth: [2062-10-17] Sex: M Service: MEDICINE Allergies: Bactrim / Sulfa (Sulfonamide Antibiotics) / Seroquel / Heparin Agents Attending:[First Name3 (LF) 2186] Chief Complaint: dyspnea/hypoxia Major Surgical or Invasive Procedure: [6-21]: Chest tube placement on left [6-24]: IR fluoroscopy guided pigtail drain placement into loculated left pleural effusion History of Present Illness: Mr. [Known lastname 449] [Last Name (Titles) ] 53-year-old male with history of CAD status post MI in '[12] with bypass, chronic systolic CHF, EF of 30%-35%, hep C untreated with thrombocytopenia, history of IVDU, chronic pain on chronic methadone, status post history of laryngeal nerve injury, status post a history of multiple lower extremity orthopedic surgeries who presents with L-sided pleuritic chest pain and cough for 4 days. Patient denies fevers but has been fatigues for the past week, coughing up "pus like" sputum that is occasionally streaked with blood. He has lost 14 lbs in 3 weeks with decrease in appetite. He denies night sweats but reports significant left sided pleuritic CP which has been progressing. . In the ED 100.0 134 113/56 20 95%. CXR: large L pleural effusion. Given [Last Name (un) ]/ceftriax and morphine. Labs notable for Cr 1.3 and WBC 19 and lactate normal. 100.6 126 115/92 30 96% on 4L. Given 1L fluids. . Upon arrival to the ICU, patient was endorsing [11-2] sharp, left sided pleuritic CP with radiation to left shoulder and neck and to left side of abdomen. He took 2 nitros for this 5 days ago which did not provide relief of his pain. He endorses cough productive of yellow mucus but that is hurt to cough or move at all the left side. Denied shortness of breath or palpitations. Also endorsed chronic aspiration given previous C2 injury. He was febrile but denied feeling chilled on admission or at home. He also endorses right hip pain that has been progessing and limiting his walking. Orthopedics had told him this was likely arthritis. . ROS: (+) Per HPI (-) Denies night sweats, recent weight gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. Denied chest tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: -CAD status post STEMI in 07, LIMA to LAD -chronic systolic CHF, EF 30%-35%. Most recent echo was from [7-2] -HCV with possible cirrhosis, never treated -COPD -HTN -HL -Hepatitis B with reported cleared infection -Depression/Anxiety/PTSD -Chronic back pain -Psoriasis -L3 spinal fusion -[2083]: L knee gun shot wound; [2104]: L knee total arthroplasty; -[2105]: L knee fusion -DM2, diet controlled -hep C genotype 1 cirrhosis -thrombocytopenia -history of CVA with small left thalamic infarction -GERD/Barrett's -history of question BPH, -PTSD status post C2 injury with fall with subsequent surgery complicated by laryngeal nerve injury -recurrent aspiration pneumonitis -history of isolated MAC in his sputum -history of MSSA plus GBS tibial osteomyelitis [Date range (1) 12917]/11 Social History: Recently noncompliant with medications. He lives at [Location 12918] St [Company 3596] has VNA QD. Smoking five cigarettes per day down from onepack, history of IV drug use, none in the last 16 years. Denies alcohol. Family History: Mother died of lung cancer when he was three years old. Father was murdered when he was 7. Physical Exam: VS: Temp: 100.7 BP: 133/78 HR:124 RR:27 O2sat96%4L GEN: pleasant but uncomfortable, in obvious distress in pain from left sided pain with rapid shallow breaths HEENT: PERRL, EOMI, anicteric, dryMM, op without lesions, no supraclavicular or cervical lymphadenopathy, JVP to 8mmHg, no carotid bruits, no thyromegaly or thyroid nodules RESP: Poor inspiratory effort [2-26] pain, but coarse BS at right base and decreased BS at left base anteriorly CV: tahcy regular, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, TTP in lower upper and lower quadrants, with involuntary guarding, no rebound, no masses or hepatosplenomegaly EXT: no c/c/e, left knee is reconstructed and fused SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength in upper extremites, LLE 4+/5, RLE [3-28]. LLE decreased sensation, otherwise intact. No pass-pointing on finger to nose. 2+DTR's biceps unble to elicit in lower ext . Discharge Exam: Vitals: VSS, breathing at 20 94 RA . Gen: NAD HEENT: NCAT PERRL MMMs Neck: No LAD supple Pulm: No accessory muscle use, Right lung field CTA with basilar expiratory crackles, no wheezes or rhonci; Left lung improving, still with bronchial BS and crackles Chest Wall: Chest tube draining from left chest; chest tube draining yellow fluid CV: RRR nml S1/2 no m/r/g Ab: +BS. Non-tense distended abdomen, mildly TTP. FOS. Ext: No edema Left knee: Well healed scar Skin: No lesions, no rashes Neuro: grossly non-focal. Pertinent Results: Admission Labs: [2116-6-20] 10:10PM URINE HOURS-RANDOM CREAT-48 SODIUM-44 POTASSIUM-17 CHLORIDE-35 [2116-6-20] 10:10PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155*]-1.046 [2116-6-20] 10:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG [2116-6-20] 07:22PM PT-18.5* PTT-29.2 INR(PT)-1.7* [2116-6-20] 03:25PM GLUCOSE-85 UREA N-23* CREAT-1.3* SODIUM-134 POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-28 ANION GAP-15 [2116-6-20] 03:25PM estGFR-Using this [2116-6-20] 03:25PM ALT(SGPT)-18 AST(SGOT)-28 LD(LDH)-171 ALK PHOS-84 TOT BILI-1.0 [2116-6-20] 03:25PM TOT PROT-7.8 [2116-6-20] 03:16PM COMMENTS-GREEN TOP [2116-6-20] 03:16PM LACTATE-1.6 [2116-6-20] 03:00PM cTropnT-<0.01 [2116-6-20] 03:00PM WBC-19.7# RBC-3.88 HGB-12.1* HCT-34.6* MCV-89 MCH-31.0 MCHC-34.9 RDW-15.5 [2116-6-20] 03:00PM NEUTS-91.4* LYMPHS-4.6* MONOS-3.4 EOS-0.4 BASOS-0.2 [2116-6-20] 03:00PM PLT COUNT-147# . EKG: NSR at 129 bpm, LAD, NI, Q in AVF, V1, V2, upsloping 1mm STE in V2, 2mm STE V3 with poor baseline, compared to prior elevated in V3 on new but may be related to lead placement. Ischemic cannot be excluded. . Imaging: CXR [6-20] : prelim, left sided white out . Bedside U/S: loculated pleural effusion . [6-20] CT Ab/P/Ch c Contrast: IMPRESSION: 1. Multiloculated large left pleural effusion with visceral and parietal pleural enhancement concerning for empyema. 2. Mediastinal adenopathy, likely reactive. 3. Cirrhosis. Splenomegaly and evidence of umbilical vein recanalization, suggestive of portal hypertension. 4. Left renal cyst. . [6-24] CT-Guided Pigtail IMPRESSION: Moderate to large residual loculated left upper effusion now status post successful 8 French modified pigtail drain catheter placement into the pleural space. 165 mL of serosanguineous fluid was aspirated. The findings were discussed with caring resident, Dr. [Last Name (STitle) ], shortly after exam completion at approximately 5:15 p.m. via phone by Dr. [Last Name (STitle) 12919]. System should be placed to suction overnight. . [6-25] CXR: IMPRESSION: AP chest compared to [6-23] through [2116-6-25]:34 a.m.: The volume of residual left pleural effusion is smaller today than it was yesterday and a closer apposition of pleural surfaces may account for increase in pain. The pigtail catheter ends at the level of the carina. Left lower lobe is essentially collapsed. Less severe atelectasis at the right lung base is unchanged. No right pneumothorax. Small volume of left apical pleural air is decreasing as that compartment fills with fluid. Basal pleural tube also unchanged in position but difficult to localize on the single frontal view. . [6-28] CXR PA-L: FINDINGS: In comparison with the study of [6-27], there again are areas of air-fluid levels in the lateral aspect of the left hemithorax, consistent with a complex hydropneumothorax. Chest tubes remain in place. Right lung remains essentially clear. . [6-30] CT-Ab/P/C Wet Read: JBRe TUE [2116-6-30] 3:18 AM 1. No acute process of the abdomen or pelvis including no ascites, splenic infarct, abd abscess or diverticulitis. 2. Significant fecal loading of the entire colon, increased from prior exams. 3. Unchanged splenomegaly and left renal cyst. 4. Since [6-24], significant interval decrease in size of the left empyema, but remaining LLL opacity (atelectasis vs. PNA). 5. Stable RML opacity, likely atelectasis. 6. Unchanged reactive mediastinal LAP. . FINAL Read: 1. Significant interval decrease in the size of the left-sided complex pleural effusion / empyema with thoracostomy tube placement. Residual tethering of the left lower lobe is noted; however, there has been reasonable reexpansion of the left lung. 2. Unchanged splenomegaly. The study and the report were reviewed by the staff radiologist. . [7-3] CT-Chest c contrast: IMPRESSION: 1. Interval marked decrease in size of loculated pleural collections, with no new fluid collections seen. A left pleural pigtail catheter and left thoracostomy tube are unchanged in position. There is residual moderate atelectasis at the left lung base. . [7-7] CXR FINDINGS: Low lung volumes result in bronchovascular crowding. The small left pleural effusion and left basilar atelectasis are unchanged from [2116-7-6]. The right lung is clear. A chest tube projects over the left hemithorax. A right PICC ends in the mid SVC. There is no pneumothorax. Cervical spinal hardware is incompletely evaluated. IMPRESSION: No change from [2116-7-6]. No pneumothorax. Discharge Labs: . [2116-7-6] 05:44AM BLOOD WBC-5.3 RBC-2.99 Hgb-8.9* Hct-26.8* MCV-90 MCH-29.6 MCHC-33.1 RDW-15.7* Plt Ct-145* [2116-7-7] 09:08AM BLOOD Glucose-99 UreaN-11 Creat-1.0 Na-136 K-4.2 Cl-101 HCO3-30 AnGap-9 [2116-7-7] 09:08AM BLOOD Calcium-7.4* Phos-3.6 Mg-2.1 Brief Hospital Course: 53 yoM admitted to the ICU with hypoxia due to aspiration PNA associated empyema, now s/p chest tube and pigtail drain (removed) on ceftriaxone, who has a history of recurrent aspiration pneumonitis, MAC isolated from his sputum, and COPD in the setting thrombcytopenia, HCV, and chronic pain/heroine abuse on methadone. . ACTIVE ISSUES: . #Empyema: Patient presented with large located left-sided pleural effusion. Thoracic surgery was consulted and placed a left-sided chest tube. Pleural fluid studies were consistent with empyema. IR was consulted for drainage of a loculated effusion not drained by chest tube, with a pigtail catheter placed on [6-24]. Cultures of the pleural fluid showed Strep Anginosis. Was treated initially with Levofloxacin, then broadened to Vanc/Zosyn, then narrowed to ceftriaxone for a planned course of [4-29] weeks. Serial imaging as detailed above showed interval improvement in the empyema with serial injections of TPA and drainage by wall suction. VATS was considered, with both Liver and Cardiology clearing the patient for surgery, but ultimately deferred due to the improvement with conservative management and with the patient's comorbidities making the risk to benefit ratio unfavorable. The pigtail was pulled before discharge. The patient was discharged on Ceftriaxone with one chest tube in place and plans to follow-up with cardiothoracic surgery. . #Pleuritic Chest Pain: The pain service consulted. The patient was initially managed on a Dilaudid PCA, which was transitioned to dilaudid PO before transfer to the floor from the ICU. Breakthrough was managed with PO Dilaudid then transitioned to Percocet the day before discharge. Longacting pain control was provided by convertin the patient's daily methadone to q6h with an increase to 200mg total daily before being decreased back to once daily 155mg, the patient's baseline, before discharge. A fentanyl patch was started and uptitrated to 50mg. The patient was discharged with follow-up with the pain clinic. Adjunctive pain management was provided with lidocaine patches, gel, and tizanidine, with little effect. . #Constipation: The patient had marked abdominal pain on transfer to the floor from the ICU. CT-Abd showed no acute pathology other than constipation. The patient's symptoms improved with an aggressive bowel regimen, which included mag-citrate and methylnaltrexone every other day. . #Acute renal failure: The patient presented with creatinine 1.3. His acute renal failure was felt to be secondary to volume depletion, and he was treated with IV fluids, bicarb and mucomyst after contrast study. Lisinopril was held. The patient's urine output increased, and his renal function rapidly returned to [Location 213]. On [2116-6-25], the patient's renal function worsened again, which was attributed to contrast nephropathy. Cr returned to [Location 213] with supportive measures. . #Methadone overdose: [7-7] the patient was given his home dose of methadone 155mg daily twice; he was only prescribed for once daily dosing as documented in POE. Fentanyl and percocet were stopped. He was ordered for naloxone but this was never given because he remained AO x 3 and sats remained stable. Serial EKGs showed stable QTc peaking in 470s. He was discharged on his home dose of methadone, fentanyl patch, and percocet. The patient said that he did not refuse the second dose because he forgot receiving the first dose; he also noted that the morning prior he was almost given a second dose but refused it. . INACTIVE ISSUES: . #DM2: Diet controlled at home. While inpatient, the patient was managed with an insulin sliding scale. Insulin sliding scale was stopped on [6-24] given lack of significant hyperglycemia. Remained euglycemic. . #Chronic Pain: Methadone was continued at the patient's home dose. The patient's acute left-sided pleuritic chest pain was managed as above. Chronic Pain Service followed patient in-house. QTC remained ~ 460. . # COPD: No e/o flare. Was managed on Ipratropium Bromide Neb 1 NEB IH Q6H and Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN. . # Hep C Cirrhosis: Was never encephalopathic this admission. Maintained on Lactulose TID. . # Anemia: Remained Stable. . # Thrombocytopenia, Coagulopathy: Working Dx = Cirrhosis related. Remained stable. Coagulopathy was corrected with Vitamin K when the patient was under consideration for VATS. . # CHF: Clinically euvolemic throughout admission. Discharged in euvolemic condition. . # CAD, HTN: Continued home regimen as detailed below. -Metoprolol Tartrate 25 mg PO/NG [Hospital1 ] (home dose 25mg succinate daily) -CloniDINE 0.3 mg PO DAILY -Aspirin 81 mg PO/NG DAILY -Simvastatin 40 mg PO/NG DAILY -Lisinopril 5mg DAILY . # Psych issues: Anxiety, PTSD, Depression. Continued home regimen as below. -Clonazepam 1 mg PO/NG TID:PRN anxiety -Doxepin HCl 300 mg PO/NG HS . # GERD: Stable. Continued home regimen as below. -Omeprazole 40 mg PO DAILY . TRANSITIONAL ISSUES: # Chest Tube: Will be managed by the cardiothoracic surgical service with outpatient follow-up. # Chronic pain: Will be managed by the pain service with outaptietn follow-up. # Methadone: Will be overseen by new PCP [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 401] [Last Name (NamePattern1) 9434]. Medications on Admission: CLONAZEPAM - (Prescribed by Other Provider) - Dosage uncertain CLONIDINE [CATAPRES-TTS-1] - (Prescribed by Other Provider) - Dosage uncertain DOXEPIN - (Prescribed by Other Provider) - Dosage uncertain LACTULOSE - (Prescribed by Other Provider) - 10 gram/15 mL Solution - 30 ml by mouth daily as needed for prn for constipation LISINOPRIL - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day METHADONE - (Prescribed by Other Provider) - 40 mg Tablet, Soluble - 5 Tablet(s) by mouth once a day Total dose 170 mg daily METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually every 5 mins as needed for angina call 911 if no relief after 3rd pill. NITROGLYCERIN [NITROSTAT] - (Prescribed by Other Provider) - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually Q5 min X3 for chest pain as needed for PRN OMEPRAZOLE - (Prescribed by Other Provider) - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily OXYCODONE - 30 mg Tablet - 1 Capsule(s) by mouth once a day as needed for pain do note drink or drive under the influence of this medicaion. Do not operate dangerous equipement. POTASSIUM CHLORIDE - (Prescribed by Other Provider) - Dosage uncertain PROMETHAZINE - 50 mg Tablet - 1 Tablet(s) by mouth daily at bedtime for nausea SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth daily TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - (Prescribed by Other Provider) - 18 mcg Capsule, w/Inhalation Device - 1 puff daily Discharge Medications: 1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety . 2. clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. doxepin 150 mg Capsule Sig: Two (2) Capsule PO once a day. 4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for Cirrhosis patient, prevent encephalopathy. 5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. methadone 10 mg Tablet Sig: 15.5 Tablets PO DAILY (Daily). 7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab Sublingual once a day as needed for chest pain. 9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) puff Inhalation once a day. 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 16. magnesium citrate Solution Sig: Three Hundred (300) ML PO DAILY (Daily). 17. methylnaltrexone 12 mg/0.6 mL Solution Sig: Twelve (12) mg Subcutaneous every other day as needed for constipation for 2 weeks. 18. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 19. oxycodone-acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 20. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) g Intravenous Q24H (every 24 hours) for 3 weeks: Last day [2116-7-27] for total course of 5 weeks (day 1 [6-22]). 21. sodium chloride 0.9 % 0.9 % Solution Sig: One (1) Flush Injection PRN (as needed) as needed for line flush: PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 22. Chest tube to suction Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Hospital1 8] Discharge Diagnosis: PRIMARY: -Empyema SECONDARY: -Chronic pain -Opiate dependence on Methadone maintenance Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance. Discharge Instructions: It has been a privilege to take care of you at [Hospital1 18]. . You were hospitalized for a puss collection in your left chest called an empyema; the empyema was probably caused by aspiration pneumonia, which you have had in the past due to your vocal cord paralysis. The cardiothoracic surgeons saw you during this hospitalization, and placed a chest tube as well as a pigtail catheter; they injected enzymes into your chest to dissolve the pus. Overtime the pus has drained from the chest cavity as seen by serial x-rays. The pigtail catheter was removed, but you are being discharged with the chest-tube in place; it will remain in place until you see your cardiothoracic surgeons in [Hospital 702] clinic after discharge. You are being discharged on intravenous antibiotics, which you will need to continue for several weeks. . The pain service saw you during this hospitalization. They started a number of new medications for your pain, but you are being discharged on your home dose of methadone, which is 155mg daily. . Abdominal imaging was performed because you were experiencing abdominal pain. The imaging showed that you were very constipated. You are being discharged on anti-constipation medications. . No changes were made to your medications other than as detailed below. START: -Ceftriaxone antibiotics until the prescription is complete. -Fentanyl patch for pain -Percocet as needed for pain -Duonebs for shortness of breath, wheeze -MagCitrate daily to prevent constipation -Miralax to prevent constipation -Colace to prevent constipation -Compazine for nausea -Methylnaltrexone to prevent constipation - this medication acts only on the intestine - it does not cause withdrawal, and you have been receiving it this hospitalization without any problems -Aspirin to prevent heart disease . STOP: -Promethazine -Potassium chloride Followup Instructions: Department: Thoracic Surgery (in HEMATOLOGY/ONCOLOGY suite) When: THURSDAY [2116-7-16] at 4:00 PM With: [Name6 (MD) 1532] [Name8 (MD) 1533], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PAIN MANAGEMENT CENTER When: FRIDAY [2116-7-24] at 10:30 AM With: [Name6 (MD) 10720] [Last Name (NamePattern4) 10721], MD [Telephone/Fax (1) 1652] Building: One [Location (un) ] Place ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Parking on Site Your new PCP will be Dr. [First Name8 (NamePattern2) 401] [Last Name (NamePattern1) 9434]. Call the [Hospital ] Clinic at [Telephone/Fax (1) 250] to make this appointment once you leave rehab. ICD9 Codes: 5070, 5119, 5849, 4280, 496, 412, 4019, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7786 }	Medical Text: Unit No: [Numeric Identifier 73223] Admission Date: [2164-5-19] Discharge Date: [2164-5-21] Date of Birth: [2164-5-19] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname 73224] is the former 4.035 kg product of a 39 and [12-25] week gestation pregnancy, born to a 33 year-old, G4, P1 now 2 woman. Prenatal screens: [Month/Day (4) ] type A negative, antibody negative, Rubella immune, RPR nonreactive, hepatitis B surface antigen negative. Group beta strep status positive. The mother's medical history is notable for anxiety and treated with Clonazepam, Fluoxetine. She also has a history of herpes simplex virus infection. She has no current lesions and was maintained on Valtrex suppressive therapy during pregnancy. She also has recurring abdominal and back pain, treated with Oxycodone and acetaminophen/codeine. She presented in labor and progressed to spontaneous vaginal delivery. There was no intrapartum fever or other clinical evidence of chorioamnionitis. Antepartum antibacterial prophylaxis was administered begriming 2-1/2 hours prior to delivery. Rupture of membranes occurred 1 hour prior to delivery and yielded meconium stained fluid. The infant initially emerged apneic and hypotonic. She received bagged mask positive pressure ventilation, bulb and orogastric suctioning. Heart rate was well maintained. Apgars were 4 at 1 minute and 8 at 5 minutes. The infant was pink and in no distress in room air following resuscitation but was noted to be apneic again at approximately 20 minutes of life. She was transferred to the NICU for further evaluation. Measurements at birth: Weight 4.035 kg, greater than 90th percentile. Length 51 cm. Head circumference 36.5 cm. PHYSICAL EXAMINATION: At the time of transfer to the newborn nursery, general revealed a nondysmorphic, pink, well perfused infant in room air. HEENT: Anterior fontanel open and level. Sutures approximated. Normal facies. Chest: Breath sounds clear and equal. Good air entry. No retractions. Cardiovascular: Regular rate and rhythm, no murmur. Pulses +2. Abdomen soft. Positive bowel sounds. Cord drying. Extremities: Moving all. Genitourinary: Term normal female. Neuro: Appropriate tone and reflexes. HOSPITAL COURSE: 1. Respiratory: This baby required nasal cannula oxygen to maintain her oxygen saturations. She weaned to room air at 01:00 hours on [2164-5-20]. She was monitored for an additional 24 hours in the Neonatal Intensive Care Unit in room air without any episodes of apnea or oxygen desaturation. At the time of transfer, she is breathing comfortably with a respiratory rate of 40 to 60 breaths per minute. 2. Cardiovascular: This infant maintained normal heart rates and [Year (4 digits) ] pressures. No murmurs have been noted. Recent [Year (4 digits) ] pressure is 73/43 mmHg with a mean arterial pressure of 54 mmHg. 3. Fluids, electrolytes and nutrition: This infant has been ad lib p.o. feeding, taking Similac with iron. She has maintained good urine output. Most recent weight is 3.955 kg. 4. Infectious disease: Due to the presentation at delivery and the inadequate intrapartum prophylaxis during labor, this infant was evaluated for sepsis upon admission to the NICU. A white [Year (4 digits) ] cell count was 13,100 with a differential of 51% polymorphonuclear cells, 5% band neutrophils, 1 metamyelocyte. A [Year (4 digits) ] culture was obtained prior to starting IV ampicillin and gentamycin. The [Year (4 digits) ] culture remained no growth at the time of transfer to the newborn nursery. Intended course was for 48 hours pending the [Year (4 digits) ] culture which will be 48 hours at 09:00 on [2164-5-21]. 5. Hematologic: Hematocrit at birth was 58.9%. This baby is [Name2 (NI) ] type A positive and is direct antibody test negative. 6. Gastrointestinal: Serum bilirubin is to be obtained with the newborn screen on the morning of [2164-5-21]. 7. Neurology: This baby has maintained a normal neurologic exam during admission in the Neonatal Intensive Care Unit. She has been monitored closely for any evidence of narcotic abstinence syndrome and has shown no symptoms. 8. Sensory: Audiology hearing screening is recommended prior to discharge. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Transfer to the newborn nursery. PRIMARY PEDIATRICIAN: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 73225], [Country 73226]., [Location (un) ], [Numeric Identifier 56937]. Telephone number [Telephone/Fax (1) 73227]. CARE AND RECOMMENDATIONS: 1. Feeding ad lib Similac 20 calorie per ounce with iron formula. 2. Medications: Ampicillin 500 mg IV q. 12 hours. Gentamycin 60 mg IV q. 24 hours. Antibiotics due to be discontinued at 09:00 on [2164-5-21] if [Year (4 digits) ] culture is negative. 3. Car seat position screening is not indicated. 4. State newborn screen to be drawn on the morning of [2164-5-21]. 5. Hepatitis B vaccine to be administered prior to discharge. DISCHARGE DIAGNOSES: 1. Term female. 2. Large for gestational age. 3. Transitional respiratory distress. 4. Suspicion for sepsis. 5. In-utero narcotic exposure. [Name6 (MD) ] [Last Name (NamePattern4) ], [MD Number(1) 55472] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2164-5-21] 00:00:08 T: [2164-5-21] 04:53:41 Job#: [Job Number 73228] ICD9 Codes: V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7787 }	Medical Text: Admission Date: [2131-7-24] Discharge Date: [2131-7-29] Date of Birth: [2079-8-25] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: asymptomatic Major Surgical or Invasive Procedure: AVR, ascending aorta/hemiarch replacement [7-24] ( 27 mm Magna CE pericardial valve, 26 mm Gelweave graft) History of Present Illness: 51 yo male with bicuspid aortic valve and dilated asc. aorta has been asymptomatic. Cardiac cath performed [7-13] showed no MR, EF 65%, no CAD, mild AI, dilated asc. aorta. On MRI [2-9], root 4.4cm, prox asc. 4.5-4.6cm, effective forward LVEF 47%, mod. dil. LV, bicuspid AV, mild AI, no AS, mod. MR, mild-mod TR. CT with contrast [6-9] showed root 5.0cm with aortic calcification, significant AS unable to be excluded.Referred to Dr. [Last Name (STitle) 1290] for surgical repair. Past Medical History: bicuspid AV asc. aortic aneurysm HTN elev. lipids fx clavicle NIDDM appendectomy left arthroscopic ACL [Doctor First Name ]. Social History: lives with wife and 2 children [Last Name (un) ] socially no tobacco last dental exam 1.5 years ago owns consulting business Family History: mother with PCI in 70's Physical Exam: HR 68 RR 20 143/86 5'[36]" 97.5 kg NAD skin/HEENT unremarkable neck supple with full ROM and no carotid bruits CTAB RRR no murmur abd soft, Nt, ND extrems warm and well-perfused with no edema or varicosities neuro grossly intact 2+ bilat fems/DP/PT/radials Pertinent Results: [2131-7-29] 05:19AM BLOOD WBC-7.7 RBC-3.33* Hgb-10.4* Hct-29.4* MCV-88 MCH-31.1 MCHC-35.2* RDW-13.7 Plt Ct-312# [2131-7-29] 05:19AM BLOOD Plt Ct-312# [2131-7-29] 05:19AM BLOOD Glucose-137* UreaN-15 Creat-0.9 Na-137 K-4.6 Cl-100 HCO3-27 AnGap-15 [2131-7-27] 10:55AM BLOOD Mg-2.3 [2131-7-26] 07:15AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.8 FINAL REPORT HISTORY: Effusion. PA and lateral radiographs of the chest demonstrate resolution of the previously seen bilateral pleural effusions. Cardiomediastinal contours are unchanged. Lungs are clear. Trachea is midline. IMPRESSION: Resolution of bilateral pleural effusions. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 6892] Approved: [Doctor First Name ] [2131-8-9] 8:03 AM Procedure Date:[2131-7-28] PRE-CPB No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. There is commisural fusion of the left and right coronary cusps leading to a functionally bicuspid aortic valve. There is no aortic valve stenosis. Mild to moderate ([2-5]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. POST-CPB Normal biventricular systolic function. Aortic valve bioprosthesis in situ. The valve is well seated and displays normal leaflet function. There are two jets of trace aortic regurgitation - one appears valvular and the other perivalvular. No aortic stenosis. Ascending aortic graft in situ. No new aortic pathology noted. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4901], MD, Interpreting physician Brief Hospital Course: Admitted on [7-24] and underwent AVR/ replacement of asc. and hemi-arch aorta with Dr. [Last Name (STitle) 1290]. Transferred to the CSRU in stable condition on insulin and propofol drips. Extubated that evening and off all drips on POD #1. Swan removed, and transferred to the floor to begin increasing his activity level. C/O bilat. hand paresthesias with significant edema which slightly improved on POD #2. Chest tubes, pacing wires and foley removed. Beta blockade titrated for better HR and BP management, and gentle diuresis continued. Went into AFib on POD #3, converted to SR on lopressor, and then had another eipsode. Lytes were repleted and converted to SR again. Remained in SR and was cleared for discharge to home with VNA services on POD #5. Pt. is to follow up as per discharge instructions. Medications on Admission: glyburide 2.5 mg [Hospital1 ] atenolol 25 mg [Hospital1 ] benicar 20 mg daily vits. suppl. fiber suppl. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:10 Tablet(s) Refills:0 8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5 days. Disp:20 Capsule, Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Aortic valve replacement (tissue valve), ascending aorta/hemiarch replacement for bicuspid AV with mild AI. DM Type 2. HTN. Hypercholesterolemia. 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. No lifting more than 10 pounds or driving until follow up with surgeon. Shower, no baths, no lotions, creams or powders to incisions. Followup Instructions: Surgeon Dr. [Last Name (STitle) 1290] 3-4 weeks Cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5874] 2-3 weeks PCP [Last Name (NamePattern4) ]. [First Name (STitle) ] 2-3 weeks Completed by:[2131-8-16] ICD9 Codes: 4241, 9971, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7788 }	Medical Text: Admission Date: [2124-1-16] Discharge Date: [2124-1-28] Date of Birth: [2040-3-28] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7015] Chief Complaint: seizures, confusion Major Surgical or Invasive Procedure: [1-16]: Intubation for airway protection [1-17]: Failed extubation, then re-intubation [1-20]: Successful extubation History of Present Illness: In summary, Mr. [Known lastname 4640] is an 83 year old male with past medical history significant for HTN, HL, MI s/p CABG, atrial fibrillation, dCHF (EF>55%), borderline DM, and mild COPD who was transferred to [Hospital1 18] TICU after onset of seizures of unclear etiology. . Per TICU summary, patient had been in his usual state of health up until the early morning of [1-16] when he fell trying to walk to bathroom around 3am. Per reports, wife witnessed patient fumbling at the doorknob and subsequently fell to the floor "like a log". He then had sudden stiffening, tremors and residual right sided weakness, confusion and somnolence. EMS took patient to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] where code stroke called and patient had a brief second repeat seizure that was effectively treated with IV Ativan. He had right hemiparesis that persisted and needed intubation for airway protection. Initial OSH head CT negative. [1-16] MRI head also showed no acute infarcts but evidence of chronic small vessel ischemic disease and volume loss noted. OSH ED Labs notable for K of 7.8 (unclear if hemolyzed) and he received calcium gluconate, dextrose/insulin and K recovered. at initial ED evaluation, tPA was not pursued. . On [1-16] he was then transferred to [Hospital1 18] TICU for further evaluation. In the ED, CT/CTA performed which were unremarkable. Infectious workup showed negative LP, CXR, and urine. Neurology team felt that patient's history and exam was most consistent with a post-ictal [Doctor Last Name 555] paralysis verus CVA or infection. Since patient was admitted he has been stable on Keppra therapy with no repeat seizures thus far. . He initially remained intubated in TICU after admission for airway protection and extubated on [1-17] but then required repeat intubation after he had notable dyspnea, generous yellowish sputum production and desaturations to high 80s range. Extubated successfully on [1-20] and now comfortable at 93% O2 Saturations but continues to have mild cough and fevers. . Mr. [Known lastname 4640] was transferred to the neurology service on [1-20] and additional workup has been limited from a neurological standpoint with no clear cause for his seizures to date. As above, he has been seizure free on Keppra management. On [1-21] he had episode of atrial fibrillation with RVR to 120s per neuro team but this resolved after IV metoprolol and he has since been well controlled on higher oral metoprolol dose of 75mg TID ; up from his usual home atenolol dosing. . He is being transferred to medicine service now for further management due to more complicated hospital course which has evolved and includes complicated HAP/VAP, intermittent atrial fibrillation with RVR, hyponatremia, worse anemia and ongoing fevers. [1-17] Sputum Culture grew out Moraxella catarrhalis and he has been continued on IV ceftriaxone and Azithromycin (started [1-18]) and . Vancomycin had been started but was recently discontinued on [1-23]. . He appears to be in no apparent distress at rest and is fully alert and oriented now. Current vitals at time of transfer: T:97.9F, BP: 143/72, HR: 88, RR: 24, O2: 97% 2L. Past Medical History: -Hypertension -Hyperlipidemia -s/p MI and 5 vessel CABG in [2114] -paroxysmal atrial fibrillation -diastolic CHF -borderline DM -BPH -mild COPD Social History: Lives at home with his wife in [Name (NI) 1727]. He was very independent with all ADLs at baseline prior to this event with seizure. Stopped smoking about 40 years ago but had smoked 2PPD x 15-20 years. Drinks a glass of wine daily about 5 days week. No illicits. . Family History: Father died of an MI and his mother had mild dementia. Physical Exam: Vitals: T:97.9F, BP: 143/72, HR: 88, RR: 24, O2: 97% 2L General: Fully alert and oriented, no acute distress HEENT: PERRL, sclera anicteric,EOMI, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Mild crackles at bases bilaterally ( right >left), no wheezes CV: Regular rate and rhythm, mild 2-3/6 systolic murmur at base(?MR), no other rubs or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs [3-12] in tact, face symmetric, normal speech. PERRL. Slight weakness 4/5 in right UE, otherwise [6-2] LE strength. Sensation to light touch in tact. Gait assessment deferred. Pertinent Results: ADMISSION LABS: [2124-1-16] 07:03AM CALCIUM-10.4* PHOSPHATE-2.6* MAGNESIUM-1.8 [2124-1-16] 07:03AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2124-1-16] 07:03AM GLUCOSE-63* LACTATE-2.5* K+-3.8, SODIUM-134 POTASSIUM-3.9 CHLORIDE-100 [2124-1-16] 07:03AM WBC-8.8 RBC-3.94* HGB-12.3* HCT-35.0* MCV-89 MCH-31.3 MCHC-35.3* RDW-13.3, PLT COUNT-173 [2124-1-16] 07:03AM PT-12.3 PTT-28.2 INR(PT)-1.0 [2124-1-16] 07:03AM ALT-17, AST-29, ALP-59 TOT BILI-0.6, LIPASE-75* Labs on discharge [2124-1-27]: WBC 10.5 HCT 27.9 Plts 358 Na 129 (nadir earlier in admission 126. K 4.1 Cl 94 bicarb 26 BUN 18 creatinine 0.8 ca 9.1 mg 1.7 ph 2.7 glc 112 MICROBIOLOGY DATA: [2124-1-17] 8:59 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [2124-1-17]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2124-1-19]): SPARSE GROWTH Commensal Respiratory Flora. MORAXELLA CATARRHALIS. HEAVY GROWTH. [2124-1-17] 5:11 pm BLOOD CULTURE Source: Line-arterial. Blood Culture, Routine (Final [2124-1-23]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [2124-1-18]): GRAM POSITIVE COCCI IN CLUSTERS. REPORTED BY PHONE TO [Last Name (LF) 87764], [First Name3 (LF) 2191] AT [2124-1-18] ON 18:30. [2124-1-17] 4:55 pm BLOOD CULTURE Routine (Final [2124-1-23]): NO GROWTH. [2124-1-16] 12:53 pm BLOOD CULTURE Routine (Final [2124-1-22]): NO GROWTH. Blood cx pending from [2124-1-25], [2124-1-24], [2124-1-21] [2124-1-17] 4:56 pm URINE URINE CULTURE (Final [2124-1-18]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. Urine cx [2124-1-24] grew mixed bacteria flora final Urine cx [2124-1-21] no growth final Mini BAL [2124-1-18]: GRAM STAIN (Final [2124-1-18]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2124-1-20]): NO GROWTH, <1000 CFU/ml. CSF Fluid Data : [2124-1-16] 09:27AM CEREBROSPINAL FLUID (CSF) PROTEIN-76* GLUCOSE-67 [2124-1-16] 09:27AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-17* POLYS-29 BANDS-5 LYMPHS-40 MONOS-14 NUC RBCS-9 MACROPHAG-3 [2124-1-16] 09:27AM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-367* POLYS-28 BANDS-14 LYMPHS-20 MONOS-2 ATYPS-2 METAS-3 MYELOS-4 NUC RBCS-25 [2124-1-16] 9:27 am CSF;SPINAL FLUID #3. GRAM STAIN (Final [2124-1-16]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2124-1-19]): NO GROWTH. OTHER STUDIES: ABG at admission -> [2124-1-16] 11:28AM TYPE-ART PO2-503* PCO2-36 PH-7.49* TOTAL CO2-28 BASE XS-5 INTUBATED-INTUBATED VENT-CONTROLLED URINE STUDIES: [2124-1-16] 07:58AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2124-1-16] 07:57AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.014 [2124-1-16] 07:57AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-25 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2124-1-16] 07:57AM URINE RBC-0-2 WBC-0 BACTERIA-FEW YEAST-NONE EPI-0 [2124-1-16] 07:03AM UREA N-20 CREAT-1.3* SODIUM-138 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-30 ANION GAP-11 CARDIAC MARKERS: [2124-1-16] 03:03PM CK(CPK)-348* [2124-1-16] 03:03PM CK-MB-9 cTropnT-0.01 [2124-1-16] 07:03AM CK-MB-6 cTropnT-<0.01 CXR PA/lat [2124-1-26]: FINDINGS: The left PICC ends in the mid SVC. The bibasilar atelectasis has improved. There are unchanged small bilateral pleural effusions. Cardiac and mediastinal contours are normal. No pneumothorax is identified. IMPRESSION: 1. Left PICC ending in mid SVC. 2. Improvement in bibasilar atelectasis. 3. Small bilateral pleural effusions, unchanged. CXR [2124-1-26]: FINDINGS: Retrocardiac opacity has slightly worsened since [2124-1-24] and likely reflects left lower lobe collapse. Blunting of the left costodiaphragmatic angle and is most likely a small left pleural effusion. New right lower lobe hazy opacity in the right lower lobe is new and may represent an acute pneumonia. Midline sternotomy wires are and healed left posterior rib fractures are also stable, the cardiac size is normal. IMPRESSION: 1. New right lower lobe opacity, which could reflect aspiration or developing pneumonia in the appropriate clinical setting. Possible small right effusion. 2. Left lower lobe atelectasis and small left pleural effusion have worsened since [2124-1-24]. Multiple other CXRs done these were just the most recent. [2124-1-18] MR cervical spine: FINDINGS: There is no evidence of fracture or compression deformity. There is elevated STIR signal within the C5-6 intervertebral disc. There is no prevertebral edema, there is no high STIR signal in the ligamentous structures. The cervical cord is normal in signal. The craniocervical junction is unremarkable. There is fluid in the oral cavity and nasopharynx through hypopharynx in the setting of intubation and nasogastric tube. Partially imaged is mucosal disease in the maxillary sinuses with air-fluid levels and mastoid effusions. There is no thyroid focal lesion. There is multilevel cervical spondylosis. At C3-4, disc bulge, endplate and facet arthropathy cause moderate canal stenosis, remodeling the ventral cord and moderate bilateral neural foraminal stenosis. At C4-5, disc bulge and uncovertebral and facet arthropathy cause moderate canal stenosis and moderate-to-severe bilateral neural foraminal stenosis. At C5-6, the same factors cause severe canal stenosis, remodeling the cord and severe bilateral neural foraminal stenosis. At C6-7, the same factors cause moderate canal stenosis and moderate left and mild right neural foraminal stenosis. There is grade 1 anterolisthesis of C7 on T1 with mild uncovering of the disc. There is mild canal and neural foraminal stenosis. IMPRESSION: 1. No evidence of ligamentous injury or cord contusion. 2. Multilevel cervical spondylosis as described above, worst at C5-6. 3. High signal within the C5-6 intervertebral disc is probably related to degenerative change. Traumatic disc injury and/or infection/inflammation could also have a similar appearance, and clinical correlation is recommended. [2124-1-18] CT head without contrast: FINDINGS: There is no evidence for acute intracranial hemorrhage, mass effect, edema, or hydrocephalus. Unchanged moderate enlargement of the ventricles and sulci indicates moderate cerebral atrophy. Extensive periventricular, deep and subcortical white matter hypodensity is likely secondary to chronic small vessel ischemic disease, similar to prior. A tiny focal hypodensity in the left head of the caudate is better seen on the current study due to differences in positioning, consistent with a chronic lacunar infarct. Visualized bony structures are grossly unremarkable. There is evidence of bilateral cataract surgery. There is increased fluid in the paranasal sinuses, and persistent nasopharyngeal fluid, likely secondary to endotracheal and nasogastric intubation, as well as prolonged supine positioning. Underpneumatization of the right mastoid air cells is again seen, likely secondary to prior chronic infections. IMPRESSION: 1. Unchanged appearance of the brain without evidence for an acute intracranial process. 2. Increased fluid in the paranasal sinuses, which could be secondary to endotracheal and nasogastric intubation, as well as prolonged supine positioning. Echo [2124-1-17]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size is normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No systolic prolapse or discrete vegetation is seen (does not exclude as images are suboptimal). Moderate to severe (3+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Moderate to severe mitral regurgitation with mildly thickened leaflets. Pulmonary artery systolic hypertension. EEG [2124-1-17]: IMPRESSION: This is an abnormal portable routine EEG due to the presence of a disorganized background composed of generally slow frequencies. This is consistent with a mild diffuse encephalopathy possibly caused by medications, infection, toxic/metabolic disturbances, or other causes. There were no focal or epileptiform features during this recording. MRI head with and without contrast [2124-1-16]: FINDINGS: There is no acute intracranial hemorrhage or infarct. The major intracranial vascular flow-voids are maintained (please see the recent CTA for additional details regarding the vessels). There is extensive, confluent white matter FLAIR-signal abnormality, compatible with sequelae of chronic small vessel ischemic disease. There is moderate prominence of the ventricles and sulci, representing global atrophy. There is diffuse thickening, signal abnormality, and enhancement within the dura raising the possibility of intracranial hypotension. There is no abnormal parenchymal enhancement after gadolinium. There are maxillary sinus and sphenoid air cell fluid levels and opacification of nearly all the ethmoidal air cells. There is also a right mastoid effusion. IMPRESSION: 1. No acute infarct. 2. Evidence of chronic small vessel ischemic disease and atrophy. 3. Paranasal sinus and right mastoid fluid-opacification, likely related to intubation, possibly superimposed on pre-existent inflammatory disease. 4. Diffuse dural thickening and enhancement, most suggestive of intracranial hypotension, which may relate to LP performed earlier in the day. CTA head with and without contrast with perfusion analysis [2124-1-16]: CONCLUSION: Extensive atherosclerotic calcifications of the intra- and extra-cranial vasculature. No perfusion abnormalities to raise the question of acute brain ischemia. However, if feasible, an MRI scan may be more sensitive in detecting a so-called ischemic core. COMMENT: There is moderately prominent spinal stenosis identified due to a posterior spondylytic ridge at the C5-6 level, with associated uncovertebral spurring causing prominent bilateral foraminal stenosis. A more shallow posterior spondylytic ridge and uncovertebral spurring is noted at C6-7. Brief Hospital Course: In summary, this is an 83yo male with history of HTN, MI, dCHF, mild COPD who was transferred for acute onset seizures of unclear etiology despite extensive neurological and infectious workup to date who has had complicated hospital course with new PNA, hyponatremia, anemia, atrial fibrillation, and COPD exacerbation. . #Seizures: Patient without prior history of any seizure disorders prior to admission. Imaging with head CT/CTA and MRI show no evidence of any bleeds, traumas, new infarcts to blame CVA event for his seizure activity. EEG done [1-17] showed mild diffuse encephalopathy but no focal or epileptiform features. He initially had a right sided weakness in the shoulder which has been attributed to post-ictal Todds Paralysis effects which improved to just some mild right shoulder weakness. He is on Keppra 1000mg [Hospital1 ] and has neuro follow up at [Hospital1 ] on [2-3]. He will likely need to be on the Keppra for atleast one year. I have discussed with him that he cannot drive given his seizure. . #PNA: Patient had [1-17] fevers to 102F and new sputum production with sputum growing out Moraxella. Originally started on CTX/Azithromycin and Vancomycin for PNA and tapered to CTX/Azithromycin. Given that he grew moraxella PNA his antibiotics were tapered to cetriaxone alone. On [2123-03-28] when he had only 2 days of Ceftriaxone treatment left he became tachypnic and his CXR showed a new RLL. He was not febrile and had a normal WBC at this time but a persistent cough. His abx were changed to vancomycin and cefepime with a plan for a 10 day course with day 1 being [2124-1-26]. Trend daily goal 15-20. His vanco trough was 29 on [2124-1-28] and he did get a dose of 1250mg so he will need daily vanco trough and do not restart vanco until level <20. Maximum WBC while he was here was up to 11.9 and was normal for several days. It increased from 6.9 to 10.5 on the day of discharge but steroids had been started. He is currently on RA to 2L of oxygen. He is on both albuterol nebs and advair. A bed side speech and swallow evaluation was negative for aspiration. . # Mild COPD exacerbation: Pt's breathing has appeared somewhat labored during entire hospitalization but better on the day of discharge. Pt with decreased breath sounds and wheeze on exam. He was receiving advair and prn albuterol while here. Started prednisone 40mg on [2124-1-27] with plan for a 5 day course. . #Fevers: His last was on [1-17] to 102F range was [1-17]. Prior fevers likely from PNA vs. UTI source. He had a UA on [1-17] that grew coag negative staph but repeat UA on [2124-1-24] showed no pyuria and his urine cx returned with mixed bacterial flora. On [2124-1-17] he had a single bottle blood cx + for coag negative staph on [1-17] that was thought to be a contaminant. He has multiple days of blood cultures pending since. . #Hyponatremia: He became hyponatremic to as low as 126. This was thought to be secondary to hypovolemia given FENA of 0.9% and contracted labs with elevated BUN. A mild SIADH or other pre-renal causes is also a possibility. He was a given several 500cc boluses for several days with slow improvement in his hyponatremia. His HCTZ was discontinued indefinately. His Na was 129 on the day of discharge. He should have his sodium followed daily at rehab. He needs to be encouraged to drink up to 2L of fluid a day until he is better hydrated. . #Atrial fibrillation: He had a know history of paroxysmal atrial fibrillation with recent A fib with RVR episode on [1-21]. His atenolol 25mg was changed to metoprolol and ultimately increased to toprol XL 300mg on [1-26]. His HRs were stable in 80s-90s on discharge. His toprolol XL can be titrated up as needed for tighter heart rate control. His aspirin was increased to 325mg daily from 81mg daily. He is currently at a high fall risk given his deconditioning/[Doctor Last Name 555] hemiparesis (per PT) and given the recent seizure. He should discuss with his PCP at [Name Initial (PRE) ] later date whether to start coumadin for stroke prevention given his CHADS 3 score. . #Anemia: HCT levels have been slowly drifting down over hospital course with drop from 35-> 29-> 26 and then stable after this. His HCT was 29 on the day of discharge. He was found to be guaiac + and will need a colonoscopy as an outpatient. He was iron deficient and iron supplementation was started. . #HTN: His atenolol was discontinued and his metoprolol was uptitrated as above for A fib rate control. His HCTZ was stopped indefinately for hyponatremia. Amlodipine 5mg daily was started and the dose was increased to 7.5mg daily on the day of discharge. Once his amlodipine new dose has taken effect he can be restarted on his home tamsulosin 0.4mg daily. . #CAD/hyperliidemia: No evidence of any new ischemic changes on recent EKG. Old infarct seen on EKG. Cardiac enzymes were cycled and negative. His statin was continued. His Beta blocker and aspirin were both uptitrated as above. . #Diastolic CHF: Most recent TTE on this admission with continued preserved systolic function and EF 55%. Longstanding HTN is likely cause for his mild diastolic congestion. His HCTZ was stopped as explained above. . #Nutrition: cardiac healthy regular diet. Please encourage po intake of fluids up to 2L daily until patient better hydrated . #Prophylaxis: Subcutaneous heparin, continue on Famotidine PPx, bowel regimen prn . #Access: midline in place . #Communication: Patient, daughter [Name (NI) ] [Telephone/Fax (1) 87765] and his wife [Name (NI) 1743] [Telephone/Fax (1) 87766]. . #Code: Full code confirmed with patient on [2124-1-25]. Medications on Admission: Home Medications: -Simvastatin 20mg daily -HCTZ 25mg daily -Atenolol 25mg daily -Aspirin 81mg daily -Tamsulosin .4mg daily Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:2 Disk with Device(s) Refills:2 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO once a day. 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Insulin sliding scale Blood sugars controlled here but will need generic insulin sliding scale as we just started prednisone 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 12. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily): give 1 hr after dinner. 13. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily): hold for SBP< 100 or HR<60. 14. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3 days: last dose on [2123-2-1], total 5 day course. 15. 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. 16. 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. 17. cefepime 2 gram Recon Soln Sig: One (1) dose Intravenous q 24 at 1600 for 6 days: total 8 day course, day 1 [2124-1-26]. 18. vancomycin 500 mg Recon Soln Sig: 1000mg total dose Recon Solns Intravenous Q 12H (Every 12 Hours) for 6 days: total 8 day course, day 1 [2124-1-26]. Trough supertherapeutic to 29 on [2124-1-28] and got AM dose. Trend trough daily and restart vanco when <20. Goal 15-20. 19. Vanco trough Trend daily goal 15-20. Was supratherapeutic on [2124-1-28] so do not restart vanco until level <20. 20. Constipation Pls ensure pt has good BM in next 2 days 21. Lab work follow sodium level daily Discharge Disposition: Extended Care Facility: [Hospital ] Hospital for Continuing Medical Care - [Location (un) 1121] ([Hospital3 1122] Center) Discharge Diagnosis: Primary: 1. New onset seizures 2. [Doctor Last Name 555] Paralysis (partial right sided hemiparesis) 3. Pneumonia (Bacterial) 4. Atrial fibrillation 5. Anemia 6. Hyponatremia 7. COPD exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance very deconditioned. Heavy breather/mouth breather at baseline. Discharge Instructions: Dear Mr. [Known lastname 4640], It was a pleasure taking care of you here at [Hospital1 771]. You were transferred from an outside hospital after sudden onset of new seizures. You required intubation or a breathing tube for a few days to protect your airway. . You were initially taken care of and managed in the Trauma ICU and were then transferred to the general neurology and medicine teams once you were stable enough to be outside of the intensive care setting. You had a very thorough workup with the neurology service which included MRI imaging of your brain, CT/CTA scans of your head and neck, electrical studies of the brain (EEG), and a lumbar tap of your spine was done to examine cerebral spinal fluid (CSF) for any concerning malignancies, meningitis or other infections. All of these studies were unrevealing for a clear cause of your seizures. You were started on a new anti-seizure medication called Keppra which needs to be continued for at least a year following discharge. A follow-up appointment with your new [Hospital1 18] neurologist has been made for you so that you will continue to be monitored and managed closely as an outpatient. Appointment details listed below. [Street Address(1) 87767] BECAUSE YOU HAD AN UNEXPLAINED SEIZURE. . During your hospital course you also developed fevers, shortness of breath and a productive cough which was attributed to new pneumonias which can sometimes occur following intubation. You will finish your antibiotics at rehab. It is important that you discuss the need for a repeat chest x-ray in a few weeks with your primary care M.D. (Dr. [First Name (STitle) 87768] as an outpatient to ensure your pneumonia has fully resolved. We also started you on steroids as we feel you have a mild COPD exacerbation. . Your hospital stay was also significant for an episode of rapid atrial fibrillation which is a rapid irregular heart rate which you have had in the past as well. You were placed on higher dose heart rate medications for better control. Heart rates are now in normal ranges but you were asked to increase your usual aspirin to higher dose of 325mg daily because atrial fibrillation is a risk for stroke and aspirin will be protective for this risk. . MEDICATION INSTRUCTIONS/CHANGES: The following medications were discontinued: -tamsulosin (will likely be restarted at rehab) -atenolol -Hydrochlorothiazide (this should not be restarted in the future given your low sodium) . The following medications were changed in dose: -Aspirin increased to 325mg daily . The following medications were started: -Cefepime 2g IV q24hrs for 6 days for pneumonia -Vancomycin 1250mg IV every 12 hrs for 6 days for pneumonia -Amlodipine 7.5mg daily for blood pressure control -Albuterol nebs q4hr prn shortness of breath or wheeze -Ferrous sulfate 325mg after dinner for iron deficiency -keppra 1000mg po twice a day for seizure prevention -Metoprolol succinate XL 300mg daily for heart rate control -senna, colace, miralax for constipation -prednisone 40mg daily for 3 more days -heparin sc 5000 units TID . Please continue the following medication at it's previous dose: -simvastatin 20mg daily Followup Instructions: Primary: 1. New onset seizures 2. [Doctor Last Name 555] Paralysis (partial right sided hemiparesis) 3. Pneumonia (Bacterial) 4. Atrial fibrillation 5. Anemia 6. Hyponatremia 7. COPD exacerbation Completed by:[2124-1-28] ICD9 Codes: 2859, 4019, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7789 }	Medical Text: Admission Date: [2114-6-2] Discharge Date: [2114-6-5] Service: MEDICINE Allergies: Penicillins / Diflucan Attending:[First Name3 (LF) 2704] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Cardiac Catheterization - Stent placed in RCA and LAD History of Present Illness: 83 year old female with history of HTN, Type 2 DM and h/o AAA repair, who presented to the ED of OSH with 9/10 substernal chest pain. She woke up this morning feeling weak, and when she arrived at her physical therapy appt she developed pain that spread across her chest, around her neck, and down her left arm to her elbow. She had associated nausea but no diaphoresis. Her pain lasted for 10+ minutes. Her BP was 80/40 and HR was in the 50's. A 12 lead EKG showed ST elevation in leads 2, 3, and aVF. She had been feeling weak for the last month or so, and during the last week she had three episodes of chest pain which lasted for about 30 minutes. This pain would come on with rest, would be associated with diaphoresis and lightheadedness, and would resolve after she would lay down. No prior hx of CAD or MI. Denies PND or orthopnea. Does admit to SOB on exertion. She was transferred to [Hospital1 18] for emergent cardiac catheterization. Past Medical History: HTN Type 2 DM s/p repair of aortic aneurysm glaucoma colon carcinoma right hip bursitis osteoarthritis Social History: No alcohol or drugs of abuse Family History: non-contributory Physical Exam: Vitals: 92.6 84 107/53 18 100%RA Gen: thin, pale, elderly woman, resting in bed, in NAD HEENT: MM dry, PERRLA, EOMI Neck: soft, no JVD CV: RR, nl S1, S2, no MGR Pulm: CTAB, no w/c/r Abd: + BS, soft, NT, ND Ext: no peripheral edema, arterial and venous lines in right groin, oozing blood Skin: dry, warm, without lesions Neuro: CN II-XII grossly intact, moving all extremities Pertinent Results: ADMISSION LABS: WBC-9.7 RBC-3.29* Hgb-10.0* Hct-28.9* MCV-88 MCH-30.4 RDW-15.5 Plt Ct-166 Glucose-162* UreaN-22* Creat-1.0 Na-136 K-4.7 Cl-116* HCO3-13* AnGap-12 ALT-8 AST-2 CK(CPK)-498CK-MB-63 MB Indx-12.7* cTropnT-1.61* Calcium-8.4 Phos-3.1 Mg-1.5* Type-ART Temp-35.6 pO2-180* pCO2-31* pH-7.24* calHCO3-14* Type-ART Temp-35.3 pO2-117* pCO2-26* pH-7.30* calHCO3-13* Lactate-0.8 . Discharge HCT: 34.4 . CARDIAC CATHETERIZATION . FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Acute inferior myocardial infarction, treated with primary PCI of the RCA. 3. Successful PCI of the LAD. COMMENTS: 1. Coronary angiography of this right dominant circulation demonstrated three vessel disease. The LMCA had mild calcification. The LAD had proximal 70% tubular lesion to the mid segment with a focal 95% lesion. The LCX had a 60% tubular lesion. There were four OM branches without significant disease. The RCA was a dominant vessel with a 99% mid vessel hazy lesion with TIMI II flow down the RPL and PDA. This was the cuprit vessel. 2. Resting hemodynamics demonstrated normal filling pressures with mean RA pressure of 3 mmHg and mPCWP of 8 mmHg. There was no pulmonary hypertension. Fick calculated cardiac output (using oxygen consumption index of 110 ml/M2) was preserved at 4.8 L/min and cardiac index was 3.3 L/min/M2. 3. Successful PCI of the RCA with a 3.0 x 18 mm Cypher DES, post-dilated with a 3.5 mm balloon. 4. Successful PCI of the LAD with two overlapping Cypher DES (2.5 x 13 mm and 2.5 x 28 mm). . ECHO: Conclusions: The left atrium is normal in size. 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 inferior and inferolateral walls. The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. . IMPRESSION: Mild regional left ventricular systolic dysfunction c/w CAD. . EKG: Normal sinus rhythm, rate 70. Possible acute inferolateral myocardial infarction. Cannot exclude a component of focal inferolateral pericarditis (though unlikely). TRACING #1 Read by: [Last Name (LF) ],[First Name3 (LF) ] S. Brief Hospital Course: # IMI - Patient had elevated ST segments in II, III, and aVF which correlated with the RCA stenosis seen on cath. She was also found to have flow limiting stenosis in the LAD. Both the RCA and LAD were stented with Cypher stents. Patient continued to have ST elevations post cath. Patient's cardiac enzymes peaked on [6-2] and continued to trend down. Her Lipid panel was as follows: LDL 16, HDL 12, TG 144 and thought to be due to lab error, will recommend follow up as outpatient. She was discharged on ASA 325, Toprol XL 25, lisinopril 2.5, atorvastatin 80, plavix 75. She was kept on an insulin sliding scale during her hospitalization. She will follow up with Dr. [First Name (STitle) ] as an outpatient. . # Pump - Previous EF unknown, post cath ECHO showed EF 45%. No AS, trace AR, trivial MR. [First Name (Titles) ] [Last Name (Titles) 10225] with mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal inferior and inferolateral walls. Pt was hypotensive after arriving in the CCU post cath, and required dopamine initially. She was weaned from the dopamine after NS bolus and one unit PRBCs and was able to be started on low dose antihypertensives as listed above. . # Rhythm - normal sinus rhythm. . # Anemia - Patient received a total of 3 units of blood this admission. Hct stabilized and was felt to be due to blood loss during placement of lines. . # Thrombocytopenia - Plts decreased during admission, all heparin flushes were stopped. Pt was HIT negative and platelets stabilized prior to discharge. Patient will have follow up blood work sent to her PCP. . # Diabetes - Patient's oral hypoglycemics were held and she was kept on an insulin sliding scale and a Diabetic diet. Will restart oral hypoglycemics as outpatient. . # FEN - Electrolytes repleted to maintain K >4 and Mg >2. Start pt on heart healthy/diabetic diet. . # Hypothyroidism - pt's TSH of 4.6 is slightly elevated. At OSH had TSH of 10.4. Pt does not have any sxs of low thyroid at this time. Will F/U with PCP for further work up as outpt to see if medications are indicated. . # Prophylaxis - pneumoboots, PPI . # Dispo - patient was discharged to home with: home PT, [Name (NI) 269] services and follow up blood work that will be checked by her PCP. Medications on Admission: Cosopt Metformin Tricor Ultracet Discharge Medications: 1. Outpatient Physical Therapy 2. 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 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 6. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 8. Outpatient Lab Work Please check CBC and Chem 7 on Thursday [6-7] and fax results to Dr. [First Name8 (NamePattern2) 1154] [Last Name (NamePattern1) ] at 1-[Telephone/Fax (1) 63453]. 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 10. Alphagan P 0.15 % Drops Sig: One (1) drop Ophthalmic twice a day: For right eye. 11. Lumigan 0.03 % Drops Sig: One (1) drop Ophthalmic at bedtime: Both eyes. 12. Cosopt 2-0.5 % Drops Sig: One (1) drop Ophthalmic twice a day: Right eye. Discharge Disposition: Home With Service Facility: [Hospital1 1474] [Hospital1 269] Discharge Diagnosis: Inferior Myocardial Infarction Coronary Artery Disease Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Call your doctor if you have chest pain, pressure, or shortness of breath. Followup Instructions: Provider: [First Name8 (NamePattern2) 1154] [Last Name (NamePattern1) ] [Name Initial (NameIs) ].D. [2114-6-8] at 11:00 AM to follow up on new labs drawn on [6-7], further workup of hypothyroidism, and vitamin D deficiency. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 920] Date/Time:[2114-6-27] 2:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4851], M.D. Where: [Hospital6 29] ORTHOPEDICS Phone:[Telephone/Fax (1) 1228] Date/Time:[2114-6-21] 2:30 Completed by:[2114-6-26] ICD9 Codes: 2851, 2762, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7790 }	Medical Text: Admission Date: [2121-12-1] Discharge Date: [2121-12-8] Date of Birth: [2066-12-15] Sex: F Service: MEDICINE Allergies: Penicillins / Ciprofloxacin / Benzodiazepines Attending:[Male First Name (un) 5282] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: 1. Diagnostic paracentesis [2121-12-1] 2. Hemodialysis M/W/F during this admission 3. Cardiac catheterization [2121-12-5] History of Present Illness: This is a 54 year old female with a history of ESLD [12-23] HCV complicated by HRS and SBP in past, HTN, DM who presents with one day of worsening mental status. Per husband patient was in usual state of health one day prior to admit. Over course of day her mental status decreased until she was answering one word answers. She has not been oriented to person, place or time and has been having increasing agitation over the past 24 hours. Per husband who spoke to renal fellow, no N/V/C/D, no F/C. Last HD was on Friday. Of note patient recently admitted and D/Ced for AMS, at that time no etiology could be found but patient improved with lactulose. Durring last admit patient started on cefpodoxime for SBP proph. In the ED initial vitals were: 98.0 78 117/101 20 100 on RA. Labs were significant for a UA which appeared infected. A CT head was done, the prelim read was no acute process. The patient was given 2mg of ativan for agitation after which she became minimally responsive. A diagnostic para was performed which was negative for SBP, Cx pending. On the floor, patient was somnolent and was not able to answer questions. 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: Hep C cirrhosis c/b ascites and encephalopathy, known grade I varices last EGD in [3-/2120], active on [Year (4 digits) ] list ESRD on HD started [5-/2121] schedule MWF Cerebral Infarction - multifocal, thought to be embolic [5-/2121] Patent foramen ovale - open, not repairable per cards Diabetes on Insulin Hypertension Mitral Regurgitation (2+) S/p [Year (4 digits) 105777] [Year (4 digits) 32050] hernia repair [5-11] by Dr. [Last Name (STitle) ] H/o sub-segmental PE in [5-/2121] not on anticoagulation Social History: Worked as staff accountant at Sound life financial. Lives in [Hospital1 392] with husband who is primary caretaker. [Name (NI) ] children. Nonsmoker. No etoh. No ivdu Family History: No history of liver disease. Father with CVA in 50s. Mother with DM and CHF Sister with DM. Physical Exam: General: somnolent HEENT: Sclera anicteric, MMM, oropharynx clear, Pupils 4-5mm, reactive to light 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: midline abdominal inscision. Soft, non-tender, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Ascities present. GU: foley, Reducible mass palpated. Ext: warm, well perfused, no clubbing, cyanosis, + pitting edema in LE b/l Neuro: Patient withdraws to pain, occasional movement of all four limbs. Pertinent Results: Labs on Admission: [2121-12-1] 11:08PM TYPE-ART TEMP-35.7 PO2-108* PCO2-34* PH-7.53* TOTAL CO2-29 BASE XS-6 [2121-12-1] 07:00PM ASCITES WBC-155* RBC-216* POLYS-0 LYMPHS-4* MONOS-12* MACROPHAG-84* [2121-12-1] 03:20PM GLUCOSE-151* UREA N-27* CREAT-7.4# SODIUM-136 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14 [2121-12-1] 03:20PM estGFR-Using this [2121-12-1] 03:20PM URINE HOURS-RANDOM [2121-12-1] 03:20PM URINE GR HOLD-HOLD [2121-12-1] 03:20PM PT-18.5 PTT-40.2* INR(PT)-1.7* [2121-12-1] 03:20PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.016 [2121-12-1] 03:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-TR [2121-12-1] 03:20PM URINE RBC-[1-23]* WBC-[10-10]* BACTERIA-FEW YEAST-NONE EPI-[10-10] TRANS EPI-0-2 RENAL EPI-0-2 [2121-12-1] 03:20PM URINE WBCCLUMP-MANY [2121-12-1] 02:45PM GLUCOSE-162* LACTATE-1.9 NA+-137 K+-4.8 CL--95* TCO2-29 [2121-12-1] 02:45PM WBC-4.4 RBC-3.39# HGB-10.6# HCT-34.7# MCV-102 MCH-31.2 MCHC-30.5* RDW-17.5* [2121-12-1] 02:45PM NEUTS-64.5 LYMPHS-21.4 MONOS-11.2* EOS-1.4 BASOS-1.5 [2121-12-1] 02:30PM AMMONIA-158* [2121-12-1] 12:18PM CREAT-6.9# SODIUM-132 POTASSIUM-5.0 CHLORIDE-96 [2121-12-1] 12:18PM estGFR-Using this [2121-12-1] 12:18PM TOT BILI-4.2* [2121-12-1] 12:18PM ALBUMIN-2.5* [2121-12-1] 12:18PM PT-18.6* INR(PT)-1.7* Labs on Discharge: [2121-12-8] 07:00AM BLOOD WBC-5.7 RBC-2.56* Hgb-8.1* Hct-26.9* MCV-105* MCH-31.8 MCHC-30.2* RDW-18.0* Plt Ct-45* [2121-12-8] 07:00AM BLOOD PT-21.8* PTT-49.3* INR(PT)-2.0* [2121-12-8] 07:00AM BLOOD Glucose-161* UreaN-23* Creat-6.6# Na-135 K-4.5 Cl-100 HCO3-27 AnGap-13 [2121-12-8] 07:00AM BLOOD ALT-17 AST-45 AlkPhos-155* TotBili-3.9* [2121-12-8] 07:00AM BLOOD Calcium-9.4 Phos-4.4 Mg-1.9 Micro: Studies: [2121-12-1] ECG - Sinus rhythm. Borderline Q-T interval prolongation. Since the previous tracing of [2121-11-22] probably no signifiant change. [2121-12-1] CXR (port AP) - Low lung volumes, but no focal consolidations. [2121-12-1] NCHCT - Suboptimal exam due to patient motion. No acute intracranial pathology seen. [2121-12-1] CXR (port AP) - No pneumothorax is identified. Allowing for low lung volumes, no definite lung infiltrate is seen. [2121-12-2] TTE - The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The right ventricular cavity is borderline dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are elongated. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic left ventricular systolic function. Mild resting outflow tract [Year (4 digits) ]. Minimal aortic stenosis. Moderate pulmonary hypertension. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of [2121-7-2], the severity of mitral regurgitation has increased while the severity of tricuspid regurgitation has decreased. Right ventricular size is smaller. Estimated pulmonary artery pressures are higher. The heart rate is faster. [2121-12-2] ECG - Normal sinus rhythm. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [2121-12-1] there is no diagnostic interim change. [2121-12-2] RUQ U/S 1. Patent portal vein and hepatic veins. 2. The portal vein has normal hepatopetal flow; however, the splenic vein demonstrates a hepatofugal flow. This appearance suggest underlying spontaneous porto-systemic shunt, most likely splenorenal. 3. Unchanged cholelithiasis with no signs of cholecystitis. 4. Findings compatible with cirrhosis. Increasing ascites. [2121-12-4] CXR (port AP) - low lung volumes which is unchanged. Nasogastric tube ends in the stomach. A right central venous catheter ends in the right atrium, unchanged from the previous study. There is no pneumothorax. Cardiac, mediastinal, and hilar contours are unchanged. [2121-12-5] Cardiac catheterization (right heart) COMMENTS: 1. Resting hemodynamics revealed normal right sided filling pressures with RVEDP 13mmHg and mildly elevated pulmonary capillary wedge pressure with PCWP 14mmHg. The pulmonary arterial pressure was normal with PASP 33mmHg. The cardiac index was preserved at 3.4 L/min/m2. The pulmonary vascular resistance was normal at 147 dynes-sec/cm5. FINAL DIAGNOSIS: 1. Normal filling pressures. 2. Pulmonary pressures consistent with those seen on echocardiogram. [2121-12-5] ECG Sinus rhythm. Non-specific inferolateral ST-T wave changes. Q-T interval prolongation and slowing of the rate as compared with prior tracing of [2121-12-4]. The ST-T wave changes have improved. Otherwise, no diagnostic interim change. [2121-12-5] Chest x-ray IMPRESSION: AP chest compared to [12-4]: There is no pneumothorax, pleural effusion or mediastinal widening. Bronchial cuffing both hila is new which could be the earliest indication of cardiac decompensation though heart size is stable. There is no edema manifested elsewhere in the lungs and pleural effusion if any is minimal. A dual-channel right-sided central venous line ends close to the anticipated location of the tricuspid valve. [2121-12-5] US vein study FINDINGS: Focus color and Doppler son[Name (NI) 493] evaluation of bilateral subclavian and internal jugular veins demonstrated normal flow and compressibility. Wall-to-wall flow is demonstrated within the internal jugular veins. There was no hematoma in the surrounding soft tissue. IMPRESSION: Normal flow and compressibility of bilateral internal jugular veins without evidence of internal jugular vein thrombus. Brief Hospital Course: MICU COURSE: [12-1] - Episode of hypertension to 190/82 overnight treated with an extra home dose Nadolol - Obtained ABG due to concern regarding tachypnea although saturating well, 7.53/34/108/29 BaseXS . [12-2] - Renal: HD last night, 1.5 liters removed. - [Month/Year (2) 1326]: - as noted by hepatology team, rifaximin, lactulose, cultures,f/u head ct; [Month/Year (2) 1326] surgery will follow. F/U peritoneal cultures, blood cultures, stool cultures. Monitor mental status exam - Abd US with Doppler: Cirrhotic liver, ascites, gallstone, reverse flow in her splenic vein (some type of shunt), portal vein is patent. - ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The right ventricular cavity is borderline dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are elongated. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic left ventricular systolic function. Mild resting outflow tract [Month/Year (2) ]. Minimal aortic stenosis. Moderate pulmonary hypertension. Moderate mitral regurgitation. Compared with the prior study (images reviewed) of [2121-7-2], the severity of mitral regurgitation has increased while the severity of tricuspid regurgitation has decreased. Right ventricular size is smaller. Estimated pulmonary artery pressures are higher. The heart rate is faster. - Tox Screen: Negative - Mental Status/Bowel Movement: Increased lactulose to Q4Hrs moving bowels, Flexiseal placed. Decreased back to Q6Hrs given copius bowel movements. Patient slightly more arrousable to pain. -Tachycardic during HD. EKG with Sinus Tachycardia. Resolved after HD. [12-3] - Mental status clearing. - Had [Month/Year (2) 2286] in early afternoon, with 1.2 L taken off. Was tachycardic at times during [Month/Year (2) 2286], but maintained pressure. - Stated was thirsty in the evening so started sponge sticks and ice chips. - Several runs of VT, often around 20 beats. On 20 mg QD nadolol. Did not increase overnight, but would consider this in the a.m. - Sustained SVT at 115 later with maintained pressures, SBP ~ 100s. Distinct from runs of VT. - EKG 115 bmp, Normal intervals and axis. Sinus tachycardia. - Very dry on physical exam with flat JVP, dry mouth and thirsty. Gave 500 mL LR. - Reduced lactulose from 45 mg q6 to q8 given loose stool. ===== FLOOR COURSE: The following issues were addressed during this admission after the patient was transferred to the floor: # Altered mental status. The patient continued to improve while on the floor and became progressively more alert. She was initially only partially oriented (confusion over date, place), but was fully oriented at the time of discharge. Her confusion was attributed to hepatic encephalopathy. There was no clear precipitating factor - diagnostic tap was negative for SBP, no evidence of GIB, per husband patient had been medication-compliant and was having 3 bowel movements daily. Worsening cirrhosis is a possibility. She was continued on her home medications and lactulose was titrated to [1-22] BM daily. # Pulmonary hypertension. Patient had no further arrhythmia after arrival to the floor. However, echocardiogram raised concern for possible pulmonary hypertension that could represent a contraindication to [Month/Day (3) ]. An attempt was made to place a Swan [Last Name (un) 26645] catheter, but it could not be advanced. The patient was evaluated by cardiology and referred for right heart catheterization. She tolerated the procedure well. Mean pulmonary artery pressure was 23 mmHg, compatible with [Last Name (un) ]. # Wheeze, shortness of breath. Once transferred to the floor, the patient experienced no further symptoms. Repeat CXR showed no evidence of worsening infiltrate. # UE venous study. As Swan [Last Name (un) 26645] catheter was not possible to place, there was concern for possible venous occlusion in the upper extremity. Patient underwent an ultrasound study which showed patent vessels. # UTI. Patient was treated with ceftriaxone for a possible UTI, but culture showed no growth, so this medication was discontinued. # ESLD, ESRD. Patient is on the liver-kidney [Last Name (un) ] list. The patient was continued on hemodialysis per renal consult team throughout this admission. She was clinically volume-overloaded, with abdominal exam pertinent for full but not tense abdomen. She considered this degree of ascites consistent with her baseline and had no pain or shortness of breath so therapeutic tap was deferred. Her MELD score remained in the low 30s throughout this admission. # Diabetes mellitus type II. Patient was maintained on an insulin sliding scale. # FEN: No IVF, replete electrolytes, regular diet # Prophylaxis: Pneumoboots # Access: PIVs # Communication: Patient, husband [Name (NI) 9261] # [Name2 (NI) 7092]: Full Medications on Admission: Lactulose 30ml PO QID titrate to [1-22] BMs daily Lansoprazole 30mg PO daily Rifaximin 400mg PO TID Cefpodoxime 200mg PO QHD Insulin SS Aranesp 300mcg/ml with HD B-complex vitamins 1capsule PO daily Caltrate 600mg (1500mg) PO daily Ferrous sulfate 325mg (65mg Iron) PO TID Nephplex Rx 1-60-300-12.5 mg-mg-mcg-mg Tablet PO daily Miconazole nitrate 2% cream topical daily Nadolol 20mg PO daily Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 2. Lactulose 10 gram/15 mL Syrup [Last Name (STitle) ]: 15-30 MLs PO three times a day: Increase dose until you are having at least 3 bowel movements a day. 3. Rifaximin 200 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO TID (3 times a day). 4. Cefpodoxime 100 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO QHD (each hemodialysis). 5. Aranesp (Polysorbate) 300 mcg/mL Solution [Last Name (STitle) ]: One (1) injection Injection QHD (on hemodialysis days). 6. B Complex Vitamins Capsule [Last Name (STitle) ]: One (1) Capsule PO once a day. 7. Caltrate 600 600 mg (1,500 mg) Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 9. Nephplex Rx 1-60-300-12.5 mg-mg-mcg-mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 10. Miconazole Nitrate 2 % Cream [Last Name (STitle) ]: One (1) application Topical once a day: Apply to affected area. 11. Insulin Please continue your insulin sliding scale according to your home regimen. 12. Nadolol 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary: - Hepatic encephalopathy - Cirrhosis of the liver secondary to hepatitis C virus Secondary: - Diabetes mellitus type II - End stage renal disease, on hemodialysis 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 [Hospital1 69] with confusion. You were unable to take medication by mouth, so you were admitted to the medical intensive care unit and a feeding tube was placed. Two days later, you appeared improved so you were transferred to the liver floor service. You were taken for a cardiac catheterization procedure to make sure that the vessels supplying blood to your lungs are healthy enough for you to undergo a [Hospital1 ] surgery - it appears that they are. You tolerated this procedure very well. The following day, your feeding tube was removed and you were able to walk with physical therapy. Your confusion improved, and you were discharged home. We have made no changes to your medication regimen. Please remember to take your lactulose regularly and increase the dose until you are having at least 3 bowel movements daily. This will help to prevent confusion in the future. Please schedule follow up with the liver clinic as directed below. Followup Instructions: Please call the liver clinic at [Telephone/Fax (1) 673] to schedule an appointment for 1-2 weeks from the time of discharge to discuss this admission. Completed by:[2121-12-11] ICD9 Codes: 5856, 4271, 5715, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7791 }	Medical Text: Admission Date: [2205-5-2] Discharge Date: [2205-5-15] Date of Birth: [2150-7-11] Sex: F Service: CARDIOTHORACIC Allergies: Latex / Morphine / bee sting Attending:[First Name3 (LF) 1406] Chief Complaint: Angina, Shortness of breath Major Surgical or Invasive Procedure: [2205-5-8] Re-do sternotomy. Coronary artery bypass grafting x1 with saphenous vein graft to the right coronary artery. Mitral valve replacement with a 25/33 On-X mechanical valve, serial #[Serial Number 107678], reference #[Serial Number 101277]. Aortic valve replacement with a 19 mm On-X mechanical valve, serial #[Serial Number 107679], reference #[Serial Number 42227]. History of Present Illness: 54F with hx of CAD s/p CABG x 2, prior stents, CHF, and severe MR referred here by her primary cardiologist for one month of intermittent chest pain and increasing shortness of breath. Patient states that for the past month she has had increasingly severe DOE with occasional pre-syncopal symptoms and light-headedness. She also describes experiencing a dull, squeezing sensation in her chest about a month ago and since has had intermittent sharp central chest pain that has crescendo quality with exertion and resolves after seconds with rest. She also describes occasional onset of chills without fevers, 3-pillow orthopnea, PND, frequent bedtime urination, and waxing and [Doctor Last Name 688] LE swelling. She was to undergo coronary cath today for evaluation primarily of her MV as she has been undergoing outpatient planning for possible MVR but is thought to be higher risk given her past history of bleeding (nose bleeds requiring ED visit and cautery) and prior CABG prompting a trial of medical management. Of note, she does not take aspirin or plavix currently due to her history of bleeding. Her baseline creatinine is in the high 1.0's per report but was 2.0 this AM so his cath was deferred and she was transferred. Goal of transfer also include coronary cath, C-[Doctor First Name ] evaluation, diuresis, and ACS rule-out. In the ED, initial vitals were 98.5 71 130/66 18 100% Labs and imaging significant for negative troponin, creatinine 2.0, BNP of 2374, HCT of 33.7, UA negative, CXR c/w mild fluid overload ECG showed SR @ 70, NA, NI, TWI in V1-V2 Patient given Aspirin 325mg PO x 1, Hydromorphone 0.5 mg IV x 1, humalog 14units x 1 for fingerstick of 300. Vitals on transfer were P 66, BP: 114/93, RR: 12, 95% on RA On arrival to the floor, patient initially feeling well and recounting her history as above but became acutely diaphoretic, anxious, described chest pressure and shortness of breath. Vital signs unchanged, satting 100%RA, EKG unchanged, FSBS 54 following 1 glass of juice 10 minutes prior. REVIEW OF SYSTEMS: Cardiac review of systems is notable for intermittent chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, but no palpitations, Also denies fevers, abdominal pain, N/V/D, urinary symptoms, or localized numbness, weakness, or tingling. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: CABG x2 [2199-7-26] (LIMA-LAD, SVG-OM) -PERCUTANEOUS CORONARY INTERVENTIONS: Prior stenting (anatomy not presently known) -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -Non-Hodgkin's lymphoma dx [2175] s/p splenectomy/partial pancreatectomy along with XRT/chemotherapy -COPD/asthma -Heliohepatitis -Hyperlipidemia -NIDDM -GERD c/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] esophagus -Bipolar disorder, depression/anxiety -Retinal artery stenoses -Hypothyroidism -Prior shoulder injury -3+ Mitral valve regurgitation Past Surgical History: -CABG -shoulder surgery -splenectomy -distal pancreatectomy '[94] for duct stricture Social History: Lives with boyfriend, 20 pack-year smoking history, quit a few years ago, prior modest ETOH but none now, no illicts. Family History: Father died of MI at 47 Brother with PTCA at 50 Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS- T= 97.8 BP= 132/76 HR= 67 RR= 16 O2 sat= 99RA GENERAL- WDWN woman in NAD, AOx3, tearful when recounting PMHx HEENT- NCAT. Sclera anicteric. PERRL, EOMI. NECK- Supple without JVD. CARDIAC- RRR, normal S1, S2. [1-29] holosystolic mumur loudest lower left sternal border. No thrills, lifts. No S3 or S4. Some tenderness to palpation of her sternum which she describes as reproducing her sharp chest pain LUNGS- Soft expiratory wheezes diffusely, no rales appreciated on exam ABDOMEN- Soft, obese, ND, mildly tender to palpation in epigastrium. EXTREMITIES- 1+ pitting in BLE's. Non-tender. 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: Pertinent Results: ADMISSION LABS: --------------- [2205-5-2] 10:15AM BLOOD WBC-9.3 RBC-3.58* Hgb-10.9* Hct-33.7* MCV-94# MCH-30.3# MCHC-32.2 RDW-14.7 Plt Ct-354 [2205-5-2] 10:15AM BLOOD Neuts-74.0* Lymphs-14.0* Monos-5.1 Eos-5.9* Baso-1.1 [2205-5-2] 10:15AM BLOOD PT-11.3 PTT-34.8 INR(PT)-1.0 [2205-5-2] 10:15AM BLOOD Glucose-252* UreaN-64* Creat-2.0* Na-138 K-5.1 Cl-101 HCO3-24 AnGap-18 [2205-5-2] 10:15AM BLOOD CK-MB-2 proBNP-2374* [2205-5-2] 10:15AM BLOOD Calcium-9.3 Phos-4.8* Mg-2.6 [2205-5-2] 10:45AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.009 [2205-5-2] 10:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2205-5-2] 10:45AM URINE Hours-RANDOM UreaN-557 Creat-49 Na-45 K-51 Cl-39 [2205-5-2] 10:45AM URINE Osmolal-392 DISCHARGE LABS: --------------- MICRO/PATH: ----------- -MRSA SCREEN (Final [2205-5-6]): No MRSA isolated. -URINE CULTURE (Final [2205-5-4]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING/STUDIES: ---------------- ECG [2205-5-2]: Sinus rhythm. Mild P-R interval pro0longation. RSR' pattern in leads VI-V2 is likely a normal variant. Minor non-specific ST-T wave abnormalities. Compared to the previous tracing of [2202-6-5] no significant changes. . CXR PA/LAT [2205-5-2]: IMPRESSION: Unchanged, small right pleural effusion with mild pulmonary edema. . TTE [2205-5-3]: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild to moderate ([11-26]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened and mildly retracted. There is no mitral valve prolapse. There is moderate thickening of the mitral valve chordae. There is a minimally increased gradient consistent with trivial mitral stenosis. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened and mildly retracted. Moderate [2+] tricuspid regurgitation is seen (may be significantly underestimated due to the technically suboptimal nature of this study). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2202-4-26], the pulmonary artery pressure is increased. IMPRESSION: Suboptimal image quality. The multiplicity and morphology of valve lesions suggests radiation-induced or, less likely, rheumatic valve disease . L-Spine XR AP/LAT [2205-5-3]: FINDINGS: Comparison is made to the CT scan of the abdomen and pelvis from [2199-8-1]. There is slight scoliosis of lumbar spine convexity to the left side centered at L3-L4. There are no compression deformities. There are degenerative changes of the lower facet joints. No compression deformities or antero- or retrolisthesis is seen. There are abdominal aortic calcifications. The sacroiliac joints and bilateral hip joints are grossly preserved. . CT CHEST Non-Con [2205-5-4]: IMPRESSION: 1. Status post CABG and median sternotomy with intact sternotomy wires. 2. Several stable pulmonary nodules, some of which are calcified. 3. Hepatomegaly, similar to prior. 4. Status post splenectomy with splenules. . TEE [2205-5-6]: Conclusions The left atrium is minimally enlarged. 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. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic function may be depressed given the severity of mitral regurgitation and aortic regurgitation.] Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) are moderately thickened. No masses or vegetations are seen on the aortic valve. At least moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse or mass/vegetation Systolic flow reversal is seen in the pulmonary veins. Moderate to severe (3+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Moderate to severe mitral regurgitation without discrete vegetation or systolic prolapse. At least moderate aortic regurgitation. Preserved global left ventricular systolic function. If clinically indicated, cardiac MR would be better able to quantify the severity of valvular regurgitation and to assess effective left ventricular ejection fraction. . C. Cath [2205-5-6]: COMMENTS: 1. Selective angiography of this right dominant system demonstrated native LMCA and three-vessel coronary artery disease. The LMCA is diffusely diseased with distal haziness; caliber of LMCA similar to LCx so likely 70% ostial lesion with diffuse disease throughout. The LAD had a mid total occlusion after S1 and branching D2; D2 proximal 50%. The LCx had a mid AV groove CX lesion of 80% supplying grafted tortuous LPL. The RCA had stent(s) ostially and proximally; difficult to engage RCA selectively, likely severe ostial in-stent restenosis with unequivocal diffuse 60% in-stent restenosis with diffuse mid 60% stenosis beyond with TIMI 2 flow. 2. Selective arterial conduit angiography demonstrated a patent LIMA to LAD graft. 3. Selective venous conduit angiography demonstrated patent SVG to OM graft with tapering at the distal anastamosis (but taper approximates the caliber of the grafted LPL/OM). 4. Subclavian artery angiography showed no obvious proximal subclavian artery stenosis. 5. Although not imaged in detail, the left vertebral artery is tortuous at its origin and significant stenosis cannot be excluded. FINAL DIAGNOSIS: 1. Native LMCA and three vessel coronary artery disease with severe in-stent restenois. 2. Prominent PCW v waves consistent with significant mitral regurgitation. 3. Moderate to severe pulmonary arterial hypertension. 4. Moderate to severe left and severe right ventricular diastolic heart failure. 5. Sheaths to be removed in holding. 6. Additional plans per Dr. [Last Name (STitle) ], Dr. [Last Name (STitle) ], and Dr. [Last Name (STitle) ]; likely benefit from MVR+CABG (SVG-RPDA). 7. Reinforce secondary preventative measures against CAD. Brief Hospital Course: 54F with hx of CAD s/p CABG x 2, prior stents, dCHF, and severe MR referred here by her primary cardiologist for one month of intermittent chest pain and increasing shortness of breath concerning for ACS overlying diastolic CHF exacerbation. ACTIVE DIAGNOSES: ----------------- # Subacute Diastolic CHF Exacerbation/Severe Aortic and Mitral Regurg: Patient was admitted following a month of severe CHF symptoms such as orthopnea, PND, frequent night time urination and was found to have an elevated BNP and evidence of fluid overload on admission CXR concerning for worsening CHF likely related to her severe known MR. [First Name (Titles) ] [Last Name (Titles) 1834] TTE and then TEE which showed moderate to severe mitral regurgitation without discrete vegetation or systolic prolapse and at least moderate aortic regurgitation with preserved global left ventricular systolic function. She was diuresed with IV lasix and maintained on metoprolol (lisnipril initially held given need for contrast with C. cath and fear of precipitating CIN). She had a coronary catheterization which showed in-stent restenosis with a 60% ostial RCA lesions. She was evaluated by cardiac surgery who felt she would benefit from AVR/MVR/RCA CABG. On [5-8] she [Month/Year (2) 1834] a redo sternotomy, aortic valve replacement, mitral valve replacement, and coronary artery bypass grafting times one. This procedure was performed by Dr. [Last Name (STitle) ], please see the operative note for details. She tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. She was extubated by the following day and weaned from vasopressor and inotropic support over the next two days. Her chest tubes were removed. On post-operative day three she transferred to the step down unit and coumadin was begun for her double mechanical valves. She quickly became supertherapeutic so her epicardial wires were cut at the skin and several doses of coumadin were held. She was discharged to home on post-operative day seven with low dose coumadin and INR/CBC follow-up arranged with VNA and Dr. [Last Name (STitle) 29478], her PCP. . # Unstable Angina/CAD/HTN/HLD: Patient with increasing anginal symptoms at home over the past month. Chest pain has features of classic angina but also has aytpical features including reproducibility on palpation and sharp nature. EKG with TWI in V1-V2 which are minimally changed from her prior EKG's in our system 3 years ago. She ruled-out for MI with CE's x 3 which were negative. CXR without significant thoracic process other than mild fluid overload. CT chest non-con without significant findings that may explain cause. Cardiac cath showing 60% ostial RCA in-stent restenosis. She was initially treated with aspirin 325mg daily but then switched to 81mg daily following rule-out. She was continued on her crestor and metoprolol (switched to tartrate in-house) with holding of her lisinopril prior to and following catheterization given concerns for [Last Name (un) ] and CIN. . # Acute on Chronic Kidney Injury: Patient with CKD Stage III at baseline. She was admitted with a Cr of 2.0 with FENa and FEUrea in indeterminant ranges. Her Cr improved to 1.5 with initial diuresis and witholding her lisinopril. Following surgery her creatinine stabilized and lisinopril was restarted. . # Low Back Pain: Patient with a couple weeks of low back pain localized mostly to the low lumber paraspinal muscles but also including the central back. No radiculopathy, localized weakness, or other concerning symptoms. She recounts history of falling when getting out of bath tub which may correlate. L-spine XR 2 views was without significant pathology. Her pain was managed with tylenol and dilaudid PO PRN. Post operatively her pain was adequately managed with percocet. . CHRONIC DIAGNOSES: ------------------ # COPD/Radiation-related Lung Disease: Patient with history of COPD related to smoking and radiation relatd lung disease from non-hodgkins lymphoma treatment 30 years ago. She had intermittent diffuse expiratory wheezes on exam which improved with nebs. Her CT non-con of her chest showed parenchymal scarring and volume loss within the medial portion of both lungs, likely related to previous radiation therapy as well as post-CABG, post-sternotomy, and post-splenectomy changes. She was maintained on nebs PRN as well as her home montelukast, inhaled steroid, and [Last Name (un) ] regimen. # DM2: A1c 7.5. She was hyperglycemic on admission to 300's for which she recieved 14 units of humalog which percipitated a hypoglycemic episode with significant symptoms at a BSL of 49. She was started on her home regimen of humalog 75/25 with improved control in her BSL's. Her home glipizide was held while in-house given [Last Name (un) ]. It was restarted at discharge with stablilization of her creatinine. # Anemia: Chronic anemia with prior workup 4 years ago with normal iron studies and B12/folate. Likely related to CKD and stable. Further workup was deferred to the outpatient setting. Her hematocrit was 27 on the day of discharge, she will have a CBC drawn the day after discharge. # Bipolar Disorder: Stable. She was continued on her home sertraline 150mg PO daily, seroquel 25 mg PO bid, and 50mg PO QHS. She was followed by social work in-house. Medications on Admission: - Albuterol Neb Q4-6hrs PRN - Clonazepam 1mg TID - Rosuvastatin 5 mg PO DAILY - Fluticasone 220 mcg inhaler 2 puffs [Hospital1 ] - Furosemide 80mg PO daily - Lamotrigine 100mg Tab PO DAILY - Lamotrigine 100mg Tab x 2 PO QHS - Levothyroxine 88 mcg PO DAILY - Lisinopril 20mg PO daily - Metoprolol Succinate 25mg PO BID - Protonix 40mg PO BID - Albuterol Inhaler 2 puffs Q4hrs PRN - Serevent Diskus 50mcg 1 puff [Hospital1 ] - Singulair 10mg PO daily - Colace 100mg PO daily - Ascorbic Acid 1000mg PO DAILY - Sertraline 150mg PO daily - Glipizide 10mg PO daily - Quetiapine 25 mg PO BID - Quetiapine 50 mg PO QHS - Insulin (Humalog) 75/25 15units [Hospital1 ] Discharge Medications: 1. Furosemide 80 mg PO DAILY 2. Rosuvastatin Calcium 5 mg PO DAILY 3. Levothyroxine Sodium 88 mcg PO DAILY 4. Quetiapine Fumarate 25 mg PO BID 5. GlipiZIDE 10 mg PO DAILY 6. fluticasone NF 220 mcg Inhalation 2 puffs [Hospital1 ] 7. Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H PRN wheezing/dyspnea 8. Clonazepam 1 mg PO TID 9. LaMOTrigine 100 mg PO DAILY 10. LaMOTrigine 200 mg PO QHS 11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing/dyspnea 12. Docusate Sodium 100 mg PO DAILY 13. Ascorbic Acid 1000 mg PO DAILY 14. Montelukast Sodium 10 mg PO DAILY 15. Pantoprazole 40 mg PO Q12H 16. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H 17. Sertraline 150 mg PO DAILY 18. Aspirin EC 81 mg PO DAILY RX Adult Low Dose Aspirin 81 mg daily Disp #30 Tablet Refills:2 19. Metoprolol Tartrate 6.25 mg PO BID Hold for HR <60 or SBP <95 RX metoprolol tartrate 25 mg two times daily Disp #30 Tablet Refills:2 20. Oxycodone-Acetaminophen (5mg-325mg) [11-26] TAB PO Q4H:PRN pain RX Percocet 5 mg-325 mg every four hours Disp #40 Tablet Refills:0 21. Warfarin 0.5 mg PO ONCE Duration: 1 Doses do not take until as directed by the office of Dr. [Last Name (STitle) 29478] RX Coumadin 1 mg once Disp #30 Tablet Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: mitral regurgitation coronary artery disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound check [2205-5-23] at 10:00am at Cardiac Surgery Office [Telephone/Fax (1) 170] Surgeon Dr. [Last Name (STitle) ] [2205-6-20] at 1:00pm [Telephone/Fax (1) 170] Cardiologist Dr. [Last Name (STitle) ] [2205-6-3] 2:20p Please call to schedule the following: Primary Care Dr. [Last Name (STitle) 29478] in [2-28] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR/CBC Coumadin for mechanical aortic and mitral valves Goal INR 2.5-3.5 First draw day after discharge Thursday [2205-5-16] Then please do INR checks daily until stablized and then Monday, Wednesday, and Friday for 2 weeks then decrease frequency as directed by Dr. [Last Name (STitle) 29478] ([Telephone/Fax (1) 35953]. Check a CBC during the first INR check. Plan confirmed with Dr. [Last Name (STitle) 29478] on [2205-5-15]. Results to phone fax ([Telephone/Fax (1) 107680] Completed by:[2205-5-15] ICD9 Codes: 5849, 4280, 4168, 2449, 4111
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7792 }	Medical Text: Admission Date: [2188-2-4] Discharge Date: [2188-2-11] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 12] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Endoscopy with clips, epinephrine injection, and Bicap thermal therapy to site of bleeding gastric ulcers. History of Present Illness: 84M with lymphoma s/p CHOP last week, h/o GIB, dilated CMP, who originally presented from home with hematemesis x2, after taking high dose prednisone during chemotherapy as well as Bufrin for arthritis. Patient denied melena, abdominal pain, hematochezia, chest pain, shortness of breath, fever, chills or chest pain. Patient has had UGIB in past with NSAID use. Patient came to ED, with VS 96.8, 100, 119/65, 18, 100%RA and A and O times 3. At home, patient is functional in his ADLs, grocery shopping and driving on his own, and taking care of his wife with [Name (NI) 2481] disease. Patient is very noncompliant at home. He was given PPI, received NGT lavage, which did not clear after 1L, and patient was fluid resuscitated prior to transfer to the MICU for emergent endoscopy. In the MICU, patient had endoscopy showing multiple gastric ulcers, which were clipped, injected with epinephrine, and Bicapped. He remained hemodynamically stable. Patient was also found to have an evolving STEMI, with isolated ST elevation in V3, as well as CE with peak troponin of 1.48 on [2188-2-6]. Patient remained chest pain free. Cardiology was consulted, and patient was medically managed with a beta blocker, ACE inhibitor, and advised to follow up for an outpatient stress test. Patient was taken off his home digoxin and amlodipine. Patient is transferred to OMED. Past Medical History: 1. Lymphoma - Biopsy [2-24] showing B-cell non Hodgkins lymphoma c difficult subclassification. Originally felt to be a small lymphocytic lymphoma but new, more aggressive behavior is suggestive of NHL. Tx c XRT [8-26]-on CHOP-R- last chemo last Friday 2. Dilated cardiomyopathy, EF 20% 3. Chronic afib, has refused coumadin in past for side effects 4. HTN 5. Migraines 6. Arthritis 7. question OSA 8. GI bleed - [2184] c hgb 7.7 [1-24] NSAID/aspirin use, EGD showing gastritis/ulcers in fundus. 9. Hearing loss 10. ARF from hydronephrosis due to lymphoma Social History: No smoking, rare ETOH, married, lives in [Location ], former prof. chemistry c hx exposure to organic compounds. Lives at home with his wife who has [Name (NI) 2481] disease. Family History: Mother c asthma, CHF, daughter died in childhood [1-24] neuroblastoma Physical Exam: Tc 97.5 BP 120/70 HR 73 O2sat 99%RA. Gen: NAD. HEENT: NCAT, EOMI. No cervical LAD. No oral ulcers or exudates. CV: Irregularly irregular. 2/6 SEM. Lungs: CTAB. Decreased BS at bases/ Abd:+BS, soft, NT, ND. Guaiac positive in the ED. Ext: WWP. No CCE. Neuro:CN II-XII intact, strength 5/5 bilat Pertinent Results: 132 97 52 / 186 AGap=14 ------------ 4.4 25 1.0 . CK: 38 MB: Notdone Trop-T: 0.02 Ca: 8.3 Mg: 2.0 P: 4.1 ALT: 10 AP: 98 Tbili: 0.5 Alb: 3.1 AST: 12 LDH: 151 [Doctor First Name ]: 33 Lip: 18 Dig: 0.3 . 86 10.5 \ 7.1 / 339 ------- 20.8 D N:96.9 Band:0 L:2.0 M:0.9 E:0.2 Bas:0.1 . Conclusions: The left atrium is dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed. Resting regional wall motion abnormalities include mid to distal anteroseptal and anterior akinesis/hypokinesis and basal to mid inferior/inferolateral hypokinesis akinesis. The apex is not fully visualized but appears hypokinetic/akinetic. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2187-12-21], left ventricular systolic function is now significantly worse with new anteroseptal and anterior akinesis/hypokinesis. . EKG [2188-2-6]: Atrial fibrillation Ventricular premature complex Modest nonspecific intraventricular conduction delay Left ventricular hypertrophy with ST-T abnormalities Anteroseptal myocardial infarct, age indeterminate - possible acute/recent/in evolution Diffuse ST-T wave abnormalities Since previous tracing of [2188-2-5], further ST-T wave abnormalities present . Endoscopy: Findings: Esophagus: Lumen: A sliding small size hiatal hernia was seen. Mucosa: A salmon colored mucosa suggestive of Barrett's Esophagus was found. Biopsy not performed due to bleeding. Stomach: Excavated Lesions Multiple ulcers were found in the antrum and stomach body. A large 3-4 cm cratered ulcer with a necrotic center and adherent clot on the incisura was seen. There was a pulsating vessel seen after the clot was removed. Two resolution clips were applied to the vessel with persistent oozing. 9cc of 1:10,000 epinephrine was injected with successful hemostasis. Bicap thermal therapy was then applied to the area at the setting of 28. No bleeding was seen at the completion of therapy. Much of the body and fundus was not well-visualized due to blood and clot obscuring the view. Duodenum: Other lymphoid hyperplasia in the duodenal bulb. Other findings: An opening that is either a diverticulum or accessory duct was seen in the second portion of the duodenum. Impression: Ulcers in the antrum and stomach body Lymphoid hyperplasia in the duodenal bulb. Small hiatal hernia An opening that is either a diverticulum or accessory duct was seen in the second portion of the duodenum. Mucosa suggestive of Barrett's esophagus Brief Hospital Course: 84 yo male with PMHx sx for lymphoma, upper GIB, cardiomyopathy, who presented with an upper GI bleed with multiple gastric ulcers seen on endoscopy, likely secondary to NSAID use and recent high dose prednisone with CHOP therapy for lymphoma. Patient was also found to have a silent STEMI, with V3 elevation and elevated CE. . Upper GI bleed: Patient's UGI bleed was likely [1-24] NSAID use combined with recent prednisone for CHOP. Patient was transfused several units while in the MICU for hematocrit drop from 29.9 to 20.8 on presentation. Patient had an NG lavage performed, which did not clear after 1000cc NS were infused. An emergent upper endoscopy demonstrated ulcers in the antrum and stomach body, lymphoid hyperplasia in the duodenal bulb, and mucosa suggestive of Barrett's esophagus. Patient's ulcers were clipped, injected with epinephrine, and had thermal therapy which stopped the bleeding. Biopsy wasn't performed at the time due to concern for increased bleeding. On transfer to OMED, patient was hemodynamically stable, but then began to have drop in hematocrit. He received three units of blood, without an appropriate increase in hematocrit. He remained guaiac positive, had two large bore pIVs for access, and continued on [Hospital1 ] pantoprazole. He had serial hematocrits checked, and was stable for 48 hours prior to discharge. Patient was scheduled for outpatient endoscopy to reassess the ulcers, and for biopsy of the lymphoid hyperplasia. Patient was advised to avoid all NSAIDs. He will have serial hematocrits checked by home VNA. . STEMI: Patient was admitted with initial STE in V3, but with a progressive rise in cardiac enzymes. He was noted to have evolving ST changes since admission with peak troponin, and was diagnosed as having a STEMI. A cardiology consult was obtained, and recommended stopping patient's amlodipine and digoxin, and starting atorvastatin, lisinopril and metoprolol, which were started when patient was hemodynamically stable from a GI bleed perspective. Patient's cardiac enzymes were trended, and he was found to have continued upward trend in troponin to peak 2.24, with gradual decrease in CK and CKMB. Cardiology was reconsulted, and felt that elevation in troponin was not an indication for cardiac catheterization, and opted for medical management. Patient was not placed on heparin due to bleeding risk. He was not anticoagulated for his atrial fibrillation due to bleeding risk, and due to concern for poor compliance as an outpatient. A repeat echocardiogram was performed, which showed global hypokinesis and a depressed EF from 40% to 30-35%, possibly from stunned myocardium. He will need to have follow up with his outpatient cardiologist. He remained on telemetry with no events. He will need a stress test as an outpatient. He remained chest pain free through his admission. . Lymphoma: Patient's lymphoma was stable. He received one dose of neupogen as an inpatient, but had a leukocytosis. He will be seen in [Hospital 20722] clinic for consideration of further chemotherapy. Patient will be seen by Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) 5565] as an outpatient. . Patient remained full code. His diet was advanced as tolerated. His electrolytes were monitored carefully and repleted. Communication was with patient, and son Dr. [Last Name (STitle) 2578] [Known lastname ]. C: [Telephone/Fax (1) 21950] H: [Telephone/Fax (1) 21951]. Patient was seen by physical and occupational therapy. He will be seen by physical therapy at home for services. Medications on Admission: Amlodipine Digoxin Bufferin Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:56 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:28 Tablet(s) Refills:2 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:28 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: 1. Upper gastrointestinal bleeding 2. Gastric ulcers 3. ST elevation MI 4. Lymphoma s/p R-CHOP 5. Leukopenia 6. Lymphoid hyperplasia in duodenal bulb Discharge Condition: Stable Discharge Instructions: If you develop nausea, vomiting, shortness of breath, blood in your stool, vomiting blood, dizziness on standing, black stools, chest pain, please call your primary care doctor or go to the emergency room. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) 5566] [Name Initial (NameIs) ]. HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[2188-3-6] 2:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 647], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2188-3-6] 2:30 Provider: [Name10 (NameIs) ],[First Name3 (LF) ] [Location (un) 2788] CARDIOLOGY-PRIVATE Date/Time:[2188-5-6] 11:30 Please follow up with Dr. [Last Name (STitle) 21952], your primary care doctor, in the next 1-2 weeks. The number to call is [Telephone/Fax (1) 4775]. ICD9 Codes: 4254, 4240, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7793 }	Medical Text: Admission Date: [2155-2-8] Discharge Date: [2155-2-24] Date of Birth: [2072-10-24] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[First Name3 (LF) 2518] Chief Complaint: Sudden fall and aphasia Major Surgical or Invasive Procedure: None History of Present Illness: 82y/o gentleman with history of prostate cancer, presented with sudden fall and aphasia. He was dressing. Wife witnessed in the same room. He suddenly fell onto the bed and became aphasic. He was not able to stand up. The wife saw that his left (right?) leg was not moving. EMT was called and brought him to [Hospital1 18] ED. Neurology was called for code stroke. Past Medical History: Prostate cancer: surgically resected and seeding implant placed 10y ago. Hypertension? (on Atnenolol) Social History: Unknown. Family History: Unknown. Physical Exam: T 98.2 HR 106, reg BP 134/59 RR 21 SO2 98% r/a Gen:NAD. HEENT:MMM. Sclera clear. OP clear. Extra ear canals, ear drums clear. Neck: No Carotid bruits CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, flat, no tenderness Ext: No arthralgia, no deformities, no edema Neurologic examination: Mental status: Keeps eyes opening. Non verbal. No following commands. Cranial Nerves: No blink to the right sided visual stimuli. Conjugated left gaze deviation, which did not break with OCR. Pupils reactive and equal. Slightly shallower Right NLF. ? R mouth angle droop. Gag positive. Motor: Able to lift Left arm for 10 secs, Left leg [4-12] secs with drift. Right arm showed posturing for noxious stimuli. Right leg showed extension of knee to the noxious stimuli (posturation). Sensation: Withdrawal x4 as above. Reflexes: B T Br Pa Ankle Right 2 2 2 2 2 Left 2 2 2 2 2 Toes were upgoing bilaterally Coordination: Unable to perform FNF due to limited comprehension. Meningeal sign: Negative Brudzinski sign. No nucal rigidity. Pertinent Results: [2155-2-8] 11:00AM BLOOD WBC-8.4 RBC-3.84* Hgb-13.0* Hct-36.7* MCV-96 MCH-34.0* MCHC-35.5* RDW-12.0 Plt Ct-228 [2155-2-9] 01:56AM BLOOD WBC-11.0 RBC-4.07* Hgb-13.4* Hct-38.3* MCV-94 MCH-33.0* MCHC-35.0 RDW-12.0 Plt Ct-248 [2155-2-10] 02:19AM BLOOD WBC-14.1* RBC-3.75* Hgb-12.5* Hct-35.7* MCV-95 MCH-33.2* MCHC-34.9 RDW-12.0 Plt Ct-251 [2155-2-11] 03:47AM BLOOD WBC-14.7* RBC-3.54* Hgb-12.3* Hct-34.3* MCV-97 MCH-34.8* MCHC-35.9* RDW-12.1 Plt Ct-249 [2155-2-12] 03:10AM BLOOD WBC-11.8* RBC-3.22* Hgb-11.3* Hct-31.4* MCV-98 MCH-35.2* MCHC-36.1* RDW-12.1 Plt Ct-215 [2155-2-13] 03:55AM BLOOD WBC-12.3* RBC-3.38* Hgb-11.2* Hct-32.9* MCV-97 MCH-33.1* MCHC-34.1 RDW-12.1 Plt Ct-265 [2155-2-14] 04:24AM BLOOD WBC-13.0* RBC-3.14* Hgb-10.4* Hct-30.5* MCV-97 MCH-33.2* MCHC-34.2 RDW-12.1 Plt Ct-266 [2155-2-15] 03:00AM BLOOD WBC-15.2* RBC-3.07* Hgb-10.1* Hct-29.8* MCV-97 MCH-32.8* MCHC-33.9 RDW-12.0 Plt Ct-272 [2155-2-16] 03:47AM BLOOD WBC-12.8* RBC-3.10* Hgb-10.2* Hct-29.9* MCV-97 MCH-33.0* MCHC-34.1 RDW-12.0 Plt Ct-310 [2155-2-17] 03:14AM BLOOD WBC-12.1* RBC-3.08* Hgb-10.2* Hct-29.5* MCV-96 MCH-33.0* MCHC-34.4 RDW-12.0 Plt Ct-314 [2155-2-18] 01:59AM BLOOD WBC-11.2* RBC-3.08* Hgb-10.0* Hct-29.9* MCV-97 MCH-32.4* MCHC-33.4 RDW-12.1 Plt Ct-340 [2155-2-19] 01:51AM BLOOD WBC-12.0* RBC-3.03* Hgb-9.7* Hct-29.3* MCV-97 MCH-31.9 MCHC-32.9 RDW-12.0 Plt Ct-349 [2155-2-22] 02:12AM BLOOD WBC-12.9* RBC-2.99* Hgb-9.9* Hct-28.7* MCV-96 MCH-33.2* MCHC-34.5 RDW-12.3 Plt Ct-464* [2155-2-22] 02:12AM BLOOD PT-16.4* PTT-29.9 INR(PT)-1.5* [2155-2-19] 01:51AM BLOOD PT-14.4* PTT-30.6 INR(PT)-1.3* [2155-2-18] 01:59AM BLOOD PT-14.5* PTT-30.5 INR(PT)-1.3* [2155-2-14] 04:24AM BLOOD PT-14.1* PTT-31.3 INR(PT)-1.2* [2155-2-11] 03:47AM BLOOD PT-13.2 PTT-27.6 INR(PT)-1.1 [2155-2-8] 11:00AM BLOOD Fibrino-462* [2155-2-22] 02:12AM BLOOD Glucose-121* UreaN-25* Creat-1.1 Na-133 K-4.8 Cl-98 HCO3-28 AnGap-12 [2155-2-20] 02:40AM BLOOD Glucose-75 UreaN-29* Creat-1.2 Na-139 K-5.0 Cl-105 HCO3-29 AnGap-10 [2155-2-18] 01:59AM BLOOD Glucose-192* UreaN-34* Creat-1.3* Na-138 K-4.2 Cl-104 HCO3-27 AnGap-11 [2155-2-16] 05:17PM BLOOD Creat-1.3* K-4.0 [2155-2-16] 03:47AM BLOOD Glucose-163* UreaN-36* Creat-1.3* Na-139 K-4.2 Cl-106 HCO3-26 AnGap-11 [2155-2-15] 03:00AM BLOOD Glucose-176* UreaN-29* Creat-1.2 Na-139 K-4.1 Cl-107 HCO3-25 AnGap-11 [2155-2-14] 04:24AM BLOOD Glucose-196* UreaN-29* Creat-1.1 Na-142 K-3.9 Cl-109* HCO3-25 AnGap-12 [2155-2-13] 03:55AM BLOOD Glucose-186* UreaN-26* Creat-1.0 Na-139 K-3.9 Cl-109* HCO3-24 AnGap-10 [2155-2-12] 03:10AM BLOOD Glucose-187* UreaN-32* Creat-1.0 Na-136 K-3.9 Cl-106 HCO3-25 AnGap-9 [2155-2-11] 03:19PM BLOOD Glucose-155* UreaN-29* Creat-1.1 Na-141 K-4.2 Cl-107 HCO3-24 AnGap-14 [2155-2-11] 03:47AM BLOOD Glucose-125* UreaN-27* Creat-1.0 Na-139 K-4.2 Cl-108 HCO3-23 AnGap-12 [2155-2-10] 04:02PM BLOOD Glucose-168* UreaN-26* Creat-1.0 Na-138 K-4.7 Cl-106 HCO3-24 AnGap-13 [2155-2-9] 01:56AM BLOOD Glucose-118* UreaN-22* Creat-1.0 Na-137 K-4.0 Cl-102 HCO3-27 AnGap-12 [2155-2-8] 11:00AM BLOOD UreaN-31* Creat-1.4* [2155-2-10] 02:19AM BLOOD CK(CPK)-474* [2155-2-9] 01:56AM BLOOD CK(CPK)-589* [2155-2-8] 06:34PM BLOOD ALT-27 AST-54* LD(LDH)-476* CK(CPK)-409* AlkPhos-78 Amylase-38 TotBili-0.4 [2155-2-9] 10:15AM BLOOD CK-MB-16* MB Indx-2.3 cTropnT-<0.01 [2155-2-9] 01:56AM BLOOD CK-MB-15* MB Indx-2.5 cTropnT-<0.01 [2155-2-8] 06:34PM BLOOD CK-MB-10 MB Indx-2.4 cTropnT-<0.01 [2155-2-8] 11:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2155-2-22] 02:12AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.0 [2155-2-11] 03:47AM BLOOD %HbA1c-5.8 [2155-2-11] 03:47AM BLOOD Triglyc-53 HDL-34 CHOL/HD-3.6 LDLcalc-77 [2155-2-11] 03:47AM BLOOD TSH-0.91 [2155-2-16] 07:26AM BLOOD Vanco-26.2* [2155-2-16] 03:47AM BLOOD Vanco-30.0* [2155-2-15] 07:45PM BLOOD Vanco-19.9 [2155-2-8] 11:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2155-2-19] 12:25PM BLOOD Type-ART pO2-114* pCO2-37 pH-7.49* calTCO2-29 Base XS-4 [2155-2-8] 11:15AM BLOOD Glucose-98 Lactate-2.1* Na-135 K-4.4 Cl-99* calHCO3-28 [2155-2-8] CT-head IMPRESSION: 4.0 x 2.4 cm left posterior limb internal capsule intraparenchymal hemorrhage with very mild mass effect and minimal rightward shift of the midline. No evidence of hydrocephalus. No evidence of intraventricular hemorrhage. [2155-2-8] CT-head IMPRESSION: Acute 29-mm left basal ganglion intracranial hemorrhage with mild mass effect as described. Brief Hospital Course: The patient had a devastating hemorrhage from which his neurological condition was severely impaired. He recieved life support here, but was certain to at least require a PEG tube and possibly a tracheostomy for further support. Numerous family meetings with social work, the ICU physicians, and the Neurology service were held. There was considerable disagreement about how aggressively to pursue care, especially between the patients son and the patients daughter and wife. In the end the family came to a concensuss that he should be made CMO. He passed away on [2155-2-24]. Medications on Admission: ASA "2 pills" QPM per wife Atenolol 25mg [Name2 (NI) 244] Prevacid Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Intracerebral hemorrhage. Discharge Condition: deceased. Discharge Instructions: x Followup Instructions: x [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2533] Completed by:[2155-3-13] ICD9 Codes: 431, 5070, 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7794 }	Medical Text: Unit No: [Numeric Identifier 77124] Admission Date: [2152-1-21] Discharge Date: [2152-1-25] Date of Birth: [2152-1-21] Sex: M Service: NB DISCHARGE DIAGNOSES: 1. Term male infant post dates (41 weeks). 2. Status post tachypnea. 3. Pneumomediastinum. HISTORY: [Location (un) ] is a full-term male infant born weighing 3.825 kg to a 39-year-old gravida 4, para 0, now 1 female via cesarean section secondary to a nonreactive fetal heart rate tracing. Maternal labs reveal she is hepatitis B negative, RPR nonreactive, antibody negative, rubella immune, group B Strep negative, and blood type A-. The pregnancy was complicated by maternal fibroids. The mom received RhoGAM during the pregnancy. The newborn intensive care unit was called to delivery of this infant when meconium was noted in the amniotic fluid. He cried at the perineum, but then required vigorous stimulation by the team, with poor initial respiratory effort. He had Apgars of 3 and 8 at 1 and 5 minutes, and the infant was initially briefly admitted to the newborn intensive care unit, and then transferred to the newborn nursery. The infant developed tachypnea into the 70s and 80s in the newborn nursery, and retrotransfer to the NICU was made. PROBLEMS DURING STAY IN NEWBORN NURSERY: On admission, he was noted to have peeling skin, with postdates appearance and tachypnea with coarse breath sounds and occasional grunting. 1. Respiratory. The infant was initially placed on continuous positive airway pressure, which he remained on for 24 hours. An initial chest x-ray was done. X-ray revealed an unusual opacity in the left lateral aspect of the left upper lobe and lucency medially. This was thought to represent some lung collapse and a medial pneumothorax. Cardiac contour was normal, and the right lung was clear. A follow-up film was recommended by radiology, and at that time, this unusual air collection was once again noted in the left upper chest. At this point, it was thought to be a pneumomediastinum, but the radiologist was not certain. Follow-up lateral and left lateral decubitus films were performed on the day of discharge and read as pneumomediastinum. On the day of discharge, although there was the ongoing presence of the pneumomediastinum, the infant was clinically well, not tachypneic, and breathing in the 40s and at most up to the 60s. 2. Cardiac. There were no cardiac issues. 3. Feeding and Nutrition. The infant was initially n.p.o. while he was on CPAP. He was then started on both IV and slow p.o. feedings. He was placed on the breast, and by the day of discharge, he was feeding well at the breast. His discharge weight was 3.800 kg. 4. Infectious Diseases. An initial CBC was obtained and was benign. Antibiotics were discontinued at 48 hours. 5. Hematologic. The mom was [Name (NI) ] and the baby A+, [Name2 (NI) 36243] negative. The infant had a bilirubin obtained on the day of discharge and it was 4.1/0.3. His initial hematocrit was 49.9. 6. Immunizations. Hepatitis B immunization was given on [2152-1-24]. 7. Hearing screen passed on [1-25]. DISCHARGE PLANS: 1. The patient is to be followed up at [Hospital1 ] Center, [Location (un) 1468] by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [1-28]. 2. Visiting nurse to come to home the day post discharge. 3. Follow-up AP and lateral films to be obtained as an outpatient in a week to f/u on pneumomediastinum. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Last Name (NamePattern1) 56049] MEDQUIST36 D: [2152-1-25] 09:55:48 T: [2152-1-25] 10:54:52 Job#: [Job Number 77125] ICD9 Codes: V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7795 }	Medical Text: Admission Date: [2177-12-20] Discharge Date: [2178-1-13] Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 5790] Chief Complaint: Esophageal food impaction and esophageal perforation. Major Surgical or Invasive Procedure: Rigid and flexible esophagoscopy and retrieval of esophageal foreign body, right thoracotomy and repair of distal esophageal perforation, intercostal muscle pedicle flap. History of Present Illness: 88 y F h/o dementia and AF who presents upon transfer from [Hospital3 ] with a esophageal food impaction. She presents today with a copied chart but no formal discharge summary. History is as best obtained with these sources and the help of her son. Pt originally presented [12-18] with a chocking episode and hypoxia. Family noticed some worsening shortness of breath on the day the patient had a episode of choking on her meal. During this episode she appeared to choke, then coughed up some food and developed some respiratory distress. In the ED, she was found to be hypoxic with sat 75%. Pt was w/o symptomatic complaint at that time. Pt admitted to ICU with diagnosis of aspiration pnuemonitis and possible CHF. Treated with ABx(levofloxacin/clinda) and diuresis. Diuresis complicated by episodes of hypotension. AFib management unclear. Underwent 2 subsequent EGDs both of which unsuccessful in clearing a large food bolus impacted in her esophagus. Pt transferred to [Hospital1 18] for further management. Upon arrival, pt confused and tachycardic, hemodynamically stable. Pt unable to give history and denies any symptomatic complaints. Past Medical History: osteoporosis afib dementia Social History: Pt lives alone. No alcohol or tobacco use. Family History: Non-contributory. Physical Exam: T 98.4 P 121 BP 131/78 R 28 SaO2 95% FM gen- agitated, tachypneic but comfortable appearing heent- perrl, op wnl, mmm neck- supple, JVP not visible at 45 deg cvs- tachycardic and [Last Name (un) 3526], no murmurs obvious pulm- decreased BS right base with bibasilar rales abd- soft, ND, no apparent tenderness, +BS ext- WWP, no edema neuro- alert and oriented times self, moving all extremities, no obvious motor deficit, answers questions but not appropriately, not following commands Pertinent Results: [2177-12-20] 10:12PM BLOOD WBC-10.6 RBC-3.65* Hgb-11.3* Hct-33.8* MCV-92 MCH-30.8 MCHC-33.4 RDW-12.9 Plt Ct-170 [2177-12-20] 10:12PM BLOOD PT-16.1* PTT-34.1 INR(PT)-1.5* [2177-12-20] 10:12PM BLOOD Glucose-105 UreaN-31* Creat-1.0 Na-144 K-3.2* Cl-106 HCO3-29 AnGap-12 [2177-12-21] 8:31 am SPUTUM FINAL REPORT [2177-12-23] GRAM STAIN (Final [2177-12-21]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [2177-12-23]): OROPHARYNGEAL FLORA ABSENT. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. 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 PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S Brief Hospital Course: Patient was admitted to the ICU and was intubated for her respiratory distress which was thought to be due to either aspiration pneumonia or pneumonitis. The patient's DNR/DNI status was reversed. She had an EGD on the evening of admission and found to have broccoli impaction. Large amounts of food was able to be extracted. An attempt was made to wean the sedation and extubate the patient the following day. As the propofol sedation was weaned off, the patient became increasingly agitated and self extubated herself. She had an adequate oxygen saturation on 100% face tent and did not require intubation. The patient was made strict NPO and the plan was to have a second EGD to reassess for retained food. On [2177-12-23], the patient had another EGD which demonstrated food in the middle and lower third of the esophagus. The scope was able to be passed through the site of retained food to the stomach with moderate difficulty. An attempt was made to push the retained food particles into the stomach, however this was done without success. The following day, the decision was made to electively intubate the patient and re-attempt EGD to try to remove the food particles with an overtube. However, this attempt was again unsuccessful and the procedure was aborted. Thoracic surgery was consulted and the patient went to the OR on [2177-12-25] for a rigid and flexible esophagoscopy in an attempt to clear the food. During the rigid esophagoscopy, a full thickness tear was noted in the esophagus at approximatedly 30cm from the incisors. Informed consent was obtained from the patient's son for an open repair of her esophageal perforation which the patient tolerated well and was transferred to the ICU in stable condition. Post-operatively, the patient was placed on broad spectrum empiric antibiotics. She was started on TPN for nutrition. The patient was able to be extubated on post-op day 1. However, she required reintubation for repiratory decompensation and hypotension on post-op day 2. The patient received frequent bronchoscopies to suction her copious airway secretions and was started on stress dose steroids for her hypotension. To evaluate for possible pulmonary embolism, the patient had a CT scan which showed a 8 x 12 mm thrombus in the left atrial appendage. The patient was started on a heparin drip for this. On [2177-12-30], the patient was taken to the OR for a tracheostomy and G tube and J tube placement which she tolerated well. The G tube was left to gravity and tube feeds via the J tube were slowly advanced to goal and the TPN was discontinued. The patient was able to be weaned off the vent and was able to tolerating breathing via trach collar. Frequent suctionings of the patient's tracheostomy were done to clear her airway secretions. The patient finished a 2 week course of ceftriaxone for Klebsiella that grew from her sputum. The patient also developed a MRSA pneumonia and was started on Vancomycin for this. From a neurologic standpoint, the patient continued to have delirium throughout her hospital course, being unresponsive to commands and minimally active. Neurology was consulted to provide recommendations. EEG showed encephalopathy and MRI/MRA of the head was essentially normal with no infarctions shown. If there is improvement in the patient's decreased mental status, progression would likely be very slow and the hope is having the patient placed in a rehab facility would help with her mental status. The patient's chronic atrial fibrillation was managed with beta blockers and anticoagulation. She was transitioned to coumadin from her heparin drip and her INR was monitored closely. From a fluid/electrolyte standpoint, the patient was diuresed aggressively for fluid overload and she developed hyponatremia. Her tube feeds were switched to full strength and her sodium trended up into the normal range. The patient was discharged on [2178-1-13] in stable condition. This d/c summary was completed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3636] and signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4129] NP Medications on Admission: 1. risperidal 0.25 [Hospital1 ] 2. cardia 120 3. benadryl qhs Discharge Medications: 1. Vancomycin in Dextrose 1 g/200 mL Piggyback [Hospital1 ]: One (1) gram Intravenous Q 12H (Every 12 Hours) for 3 weeks. 2. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: 0.5 Tablet PO BID (2 times a day). 3. Albuterol Sulfate 0.083 % Solution [Hospital1 ]: One (1) nebule Inhalation Q6H (every 6 hours) as needed. 4. Warfarin 2 mg Tablet [Hospital1 ]: One (1) Tablet PO at bedtime. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 6. Acetaminophen 160 mg/5 mL Solution [Last Name (STitle) ]: Six [Age over 90 1230]y (650) mg PO Q4-6H (every 4 to 6 hours) as needed. 7. Haloperidol Lactate 5 mg/mL Solution [Age over 90 ]: 0.5 mg Injection [Hospital1 ] (2 times a day) as needed. 8. Insulin per sliding scale Discharge Disposition: Extended Care Facility: [Hospital1 ] Northeast-[Location (un) 38] Discharge Diagnosis: Esophageal food impaction Esophageal perforation Atrial fibrillation Atrial thrombus Pneumonia Delirium Discharge Condition: Stable Discharge Instructions: Call your doctor or seek immediate medical attention if you experience fever, chills, lightheadedness, dizziness, cough productive of increased amount of sputum, chest pain, shortness of breath, palpitations, severe abdominal pain, nausea/vomiting, or increased drainage, redness, or bleeding from surgical wound. Let the steri-strips fall off on their own. You may pat the wound dry and cover with dry dressing. Activity as tolerated. Nothing by mouth. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] after you leave your rehab facility. Please call [Telephone/Fax (1) 170] for appointment. Completed by:[2178-1-13] ICD9 Codes: 4280, 2760
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7796 }	Medical Text: Admission Date: [2131-9-4] Discharge Date: [2131-9-8] Date of Birth: [2055-3-11] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old female with a past medical history of coronary artery disease (status post cardiac catheterization in [2130-12-1] with stent placement to the circumflex artery and a questionable history of myocardial infarction 25 years ago), hypertension, and chronic atrial fibrillation who was admitted to the CMI Service after and elective catheterization was performed on [2131-9-4] due to increasing dyspnea on exertion times one to two weeks and increasing frequency of chest pain. The cardiac catheterization was complicated by bradycardia which required 0.5 mg of atropine. The first obtuse marginal was opened by angioplasty, but stent was unable to be deployed. Status post catheterization, she was noted to be stable with an initial blood pressure of 144/65 and a heart rate of 60. Three hours status post catheterization, she was noted to have a decreased blood pressure to 60/40 with a heart rate still in the 60s. Her hematocrit was found to be 29 (down from 36). She was given atropine with an increase in heart rate to the 100s. She was started on a dopamine drip with an increase in blood pressure to the 90s to 110s/60s to 70s. Her right groin was stable and without hematoma. The Integrilin was discontinued. She was transferred to the Coronary Care Unit for further management. On transfer, she denied any chest pain or shortness of breath. No leg pain. No new low back pain. She has chronic midback pain. She did complain of diffuse abdominal pain. PAST MEDICAL HISTORY: (The patient has a history of) 1. Coronary artery disease; status post myocardial infarction approximately 25 years ago. 2. Hypertension. 3. No history of diabetes or hypercholesterolemia. 4. Probable chronic obstructive pulmonary disease; she is on 2 liters nasal cannula at home at night. 5. Chronic atrial fibrillation. 6. Congestive heart failure. 7. Osteoarthritis. 8. History of gastrointestinal bleed three years ago on Coumadin. 9. Gastroesophageal reflux disease. MEDICATIONS ON ADMISSION: (Home medications included) 1. Aspirin 325 mg by mouth once per day. 2. Nitroglycerin patch 0.4 mg transdermally. 3. Digoxin 0.125 mg by mouth once per day. 4. Vasotec 10 mg by mouth once per day. 5. Lasix 80 mg by mouth once per day. 6. Imdur 30 mg by mouth once per day. 7. Protonix 40 mg by mouth once per day. 8. Coumadin 4 mg to 5 mg by mouth once per day. 9. Singulair 10 mg by mouth once per day. 10. Zoloft 50 mg by mouth once per day. 11. Combivent 2 puffs inhaled four times per day. 12. Ditropan 2 mg by mouth twice per day. 13. Lopressor 12.5 mg by mouth twice per day. 14. Ativan by mouth as needed. 15. Celebrex 200 mg by mouth as needed. ALLERGIES: SOCIAL HISTORY: The patient was a former heavy tobacco smoker. She had over a 50-pack-year history. She recently quit. Social alcohol. She currently lives in a nursing home. FAMILY HISTORY: Her mother died of a myocardial infarction at the age of 70. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed the patient's vital signs in the Coronary Care Unit revealed initial blood pressure of 77/48, increased to 122/40, heart rate was 96 (in atrial fibrillation), and she was saturating 100% on 2 liters nasal cannula. Generally, she was a pale elderly female in no apparent distress. She appeared comfortable. Head, eyes, ears, nose, and throat examination revealed sclerae were anicteric and pale. Pupils were equal, round, and reactive to light. The mucous membranes were moist. No thrush. Neck examination revealed jugular venous pulsation not appreciated at 30 degrees. Chest examination revealed the lungs were clear to auscultation bilaterally except for coarse upper airway sounds. Cardiovascular examination revealed a irregular rate and rhythm. A 2/6 systolic murmur at the left upper sternal border. No radiation. The abdomen revealed mild diffuse tenderness to palpation. No rebound or guarding. Bowel sounds were present. There was no [Doctor Last Name ] sign. Extremity examination revealed the right groin was without hematoma or bruits. Fingers and toes were cold and clammy. Dorsalis pedis and posterior tibialis pulses were dopplerable bilaterally. Neurologic examination revealed she was alert and oriented times three, enunciating effectively. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories of significance on admission revealed hematocrit fell from 36 to 29 and increased to 32 after 2 units of packed red blood cells. Complete blood count was within normal limits. PERTINENT RADIOLOGY/IMAGING: Catheterization in [2130-8-31] revealed right coronary artery with 80% proximal circumflex, mild left axis deviation, left circumflex was stented, left middle cerebral artery was normal, pulmonary artery pressures were 31/16, left ventricular end-diastolic pressure was 17. Catheterization on [2131-9-4] showed first obtuse marginal with 99% which received percutaneous transluminal coronary angioplasty with 20% residual stenosis. They were unable to pass a stent at that time. Left main coronary artery was within normal limits. Left anterior descending artery with mild disease. Right coronary artery with 100% stenosis which filled with collaterals. A transthoracic echocardiogram in [2130-12-1] showed an ejection fraction of 50% to 60%. Her left anterior descending artery was dilated. Mitral regurgitation of 1+. Mild tricuspid regurgitation. Persantine MIBI in [2131-5-1] revealed an ejection fraction of 60% with an apical ischemia, some fixed inferoseptal defects. Electrocardiogram prior to catheterization revealed atrial fibrillation, heart rate of 54, a Q wave in lead III, early R wave transition. Electrocardiogram status post catheterization revealed a right bundle-branch block and 1-mm to 2-mm ST depressions in leads V3 to V6, atrial fibrillation at a rate of 125. Electrocardiogram at [Street Address(2) 104875] depressions (less than 1 mm) in leads V3 to V6. An electrocardiogram at [Street Address(2) 104876] changes had resolved. HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the Coronary Care Unit. 1. CARDIOVASCULAR SYSTEM: The patient was felt to be at an increased risk of bleed given that she had just had cardiac catheterization, and her hematocrit had dropped. Her aspirin and Plavix were held. The Integrilin was discontinued. The patient had a computed tomography scan of the abdomen and pelvis on the morning after admission which showed that she had a right retroperitoneal 5 X 6 hematoma. A follow-up computed tomography on [2131-9-6] showed that the hematoma was stable, so no further action was taken at that time. Vascular Surgery was consulted and did not feel that intervention was necessary. Of note, on the computed tomography, the patient was noted to have a 5-cm abdominal aortic aneurysm which was asymptomatic. Vascular Surgery said that they would follow that as an outpatient. The patient had serial hematocrit levels checked. Throughout her hospital stay, her only required 3 units of packed red blood cells. Her hematocrit levels remained stable afterwards, and she had no signs of further bleeding or infection at her groin site. (a) Coronary artery disease: She was continued on her Lipitor. Enalapril and beta blocker were started after her blood pressure had stabilized. Cardiac enzymes were cycled and remained negative. The patient did require pressor support during the first 24 hours of her hospital admission. She was initially on dopamine which was discontinued due to tachycardia which was causing some demand ischemia. She was placed on Neo-Synephrine and weaned off as her blood pressure tolerated. Her ejection fraction was 60% (per echocardiogram in [2130-12-1]). She had no signs or symptoms of congestive heart failure throughout her hospital course. A repeat echocardiogram was not done at this time as it was not clinically indicated. (b) Rhythm: The patient has a history of chronic atrial fibrillation with occlusion bursts of rapid ventricular response. She was rate controlled on digoxin and beta blockers. Amiodarone was not started due to her baseline chronic obstructive pulmonary disease. During the hospital course due to the risk of increased bleeding, her Coumadin was held. Coumadin was to be restarted on Monday morning at the nursing home. 2. HEMATOLOGIC ISSUES: Her hematocrit had fallen due to an unknown etiology. A computed tomography of the abdomen and pelvis showed a retroperitoneal hematoma which was stable by follow-up computed tomography. Vascular Surgery said to follow up with serial hematocrit checks, which stabilized. No further action was taken at this time. 3. GASTROENTEROLOGY ISSUES: For nausea and retching the patient was given antiemetics. She had no response to Phenergan. She did respond to Ativan. The nausea and vomiting resolved after the first night of admission. 4. PULMONARY ISSUES: The patient has a history of chronic obstructive pulmonary disease with a significant tobacco history. She was continued on her Combivent and Singulair inhalers and given albuterol nebulizers as needed. 5. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: She was started on a cardiac diet, and her electrolytes were repleted as needed. 6. CODE STATUS: She was do not resuscitate/do not intubate. 7. OTHER ISSUES: The patient remained stable throughout her hospital course. Her hemoglobin and hematocrit remained stable. She had no further episodes of chest pain or other problems. The patient was discharged to the nursing home on [9-8]. Of note, the patient was seen by Physical Therapy. Physical Therapy recommended physical therapy training two to five times per week for gait balance and endurance training. Lastly, the patient was noted to have several loose stools on the evening of [9-6]. Stool studies were sent. The patient was taken off her bowel regimen. The patient had no further complaints. DISCHARGE DISPOSITION: The patient was discharged to the nursing home in stable condition on [9-8]. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. If she had any recurrence of her chest pain, shortness of breath, diaphoresis, or any other concerning symptoms please call medical doctor or return to the hospital. 2. Follow the post interventional guidelines that have been provided for her. 3. The patient was to follow up with Dr. [Last Name (STitle) ] in two weeks. 4. The patient was also to follow up with Vascular Surgery as an outpatient in one to two weeks. 5. The patient was to see Dr. [Last Name (STitle) 1476] in the [Hospital ] Clinic to follow up the abdominal aortic aneurysm. 6. The patient was to have outpatient physical therapy at her nursing home. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Chronic obstructive pulmonary disease. 3. Congestive heart failure. 4. Gastroesophageal reflux disease. 5. Atrial fibrillation. 6. Anemia secondary to blood loss. 7. Arthritis. 8. Hypertension. 9. Gastrointestinal bleed. 10. Gastroesophageal reflux disease. MAJOR SURGICAL OR INVASIVE PROCEDURES: The patient had percutaneous transluminal coronary angioplasty for 90% obtuse marginal stenosis. CONDITION AT DISCHARGE: Right groin was without hematoma or bruits. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg by mouth once per day. 2. Plavix 75 mg by mouth every day. 3. Nitroglycerin 0.3-mg tablets sublingually q.5min. as needed (for chest pain). 4. Enalapril 10 mg by mouth once per day. 5. Digoxin 0.125 mg by mouth once per day. 6. Furosemide 80 mg by mouth once per day. 7. Isosorbide dinitrate 30 mg by mouth q.24h. 8. Protonix 40 mg by mouth once per day. 9. Montelukast sodium 10 mg by mouth once per day. 10. Sertraline 50 mg by mouth once per day. 11. Albuterol/ipratropium inhalers as needed. 12. Tolterodine tartrate 2 mg by mouth q.24h. 13. Nitroglycerin patch 0.4 mg transdermally q.24h. 14. Toprol-XL 25 mg by mouth once per day. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-641 Dictated By:[Name8 (MD) 8736] MEDQUIST36 D: [2131-9-8] 00:57 T: [2131-9-8] 03:43 JOB#: [Job Number 104877] ICD9 Codes: 4111, 496, 4280, 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7797 }	Medical Text: Admission Date: [2133-10-2] Discharge Date: [2133-10-4] Date of Birth: [2066-4-15] Sex: M Service: MEDICINE Allergies: Pneumococcal Vaccine Attending:[First Name3 (LF) 2387] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 67 year old man with a history of kidney/liver transplant on immunosupression, DM2, PVD s/p right [Doctor Last Name ]-AT and atrial fibrillation s/p DCCV on [2133-10-1] who presents with shortness of breath. Around [6-3] pm on the night prior to admission he developed insidius shortness of breath associated with chest pressure. He describes the pressures as constant, [2134-6-3] in severity. He had a hard time laying flat overnight and did not get much sleep. He also reported fatigue with minimal activity. He denied fever, chills, palpitations, LE edema, cough or sputum production. He denied radiation of the pain to his jaw or arm and denied diaphoresis or lightheadedness. He has had similar symtoms in the past, most recently in [March 2133], when they were associated with LE edema. His symptoms persisted untill the morning and he presented to the ED. Apparently he had been on asymtomatic atrial fibrillation since [March 2133]. An echocardiogram in [July 2133] showed mild symmetric left ventricular hypertrophy (LVEF >55%) with preserved global and regional biventricular systolic function. Also notable were mild diastolic LV dysfunction and mild moderate mitral regurgitation. Yesterday, [2133-10-1], he underwent succesfull DCCV. He was feeling well after the procedure. He reports however, that he missed his dose of lasix for the day. He had been taking his antihypertensive medications and blood thiners. In the ED, he was noted to be hypertensive with BP 180/87, tachypneic with RR 40 and had a SaO2 of 76% RA. He was placed on NRB and subsequently on BiPAP. His respirations decreased to 20 and was subsequently placed on NC. His CXR showed worsening of his pleural effusions. He received nitro ggt, lasix 60 mg IV and Lovenox (given a subtherapeutic INR). Prior to transfer his vitals were 98 74 119/66 23 97%4Lt. On review of systems, he denies ankle edema, palpitations, syncope or presyncope, any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: - Renal and Liver transplant in [2123]; ESLD [12-29] EtOH use, ESRD thought [12-29] DM2 - DM type II - Hypertension - Bilateral lower extremity neuropathy - Peripheral Vascular Disease - Right foot BKA [7-/2133] - MRSA - Osteomyelitis - s/p R [Doctor Last Name ]-AT bypass [2129] - Hernia Repair X2 - Arthritis - Tonsillectomy - Cholecystectomy Social History: No tobacco h/o significant EtOH abuse, stopped before transplant lives with wife Family History: Father:CM, asbestos poisoning, lung cancer, DM. Mother: died of natural causes, had DM Physical Exam: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD or HJR CARDIAC: Pectus excavatum. 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: RUQ surgical scar. Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: R BKA. 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+ Pertinent Results: [2133-10-2] 10:55AM BLOOD WBC-9.5# RBC-4.98 Hgb-10.8* Hct-34.8* MCV-70* MCH-21.7* MCHC-31.0 RDW-18.5* Plt Ct-254 [2133-10-4] 06:05AM BLOOD WBC-5.4 RBC-4.71 Hgb-10.3* Hct-33.0* MCV-70* MCH-21.8* MCHC-31.1 RDW-18.1* Plt Ct-219 [2133-10-1] 09:00AM BLOOD PT-20.3* INR(PT)-1.9* [2133-10-4] 06:05AM BLOOD PT-22.4* PTT-35.9* INR(PT)-2.1* [2133-10-4] 06:05AM BLOOD Glucose-157* UreaN-41* Creat-1.4* Na-136 K-4.8 Cl-102 HCO3-24 AnGap-15 [2133-10-2] 10:55AM BLOOD CK-MB-NotDone proBNP-9331* [2133-10-2] 10:55AM BLOOD CK(CPK)-62 [2133-10-2] 10:55AM BLOOD cTropnT-0.02* [2133-10-2] 08:04PM BLOOD CK(CPK)-58 [2133-10-2] 08:04PM BLOOD CK-MB-NotDone cTropnT-0.04* [2133-10-3] 04:50AM BLOOD CK(CPK)-51 [2133-10-3] 04:50AM BLOOD CK-MB-NotDone cTropnT-0.06* [2133-10-4] 06:05AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.6 [2133-10-3] 04:50AM BLOOD tacroFK-15.3 [2133-10-2] 10:55AM URINE Blood-LG Nitrite-NEG Protein->300 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2133-10-2] 10:55AM URINE RBC-[10-16]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0 EKG [10-1]: Normal sinus rhythm with occasional ventricular premature beats. No other diagnostic abnormality. Since the previous tracing [2133-8-5] no diagnostic interim change. . CXR [10-2]: Interval increase in size of small bilateral pleural effusions. No evidence of CHF. Brief Hospital Course: # SOB - Likely [12-29] LV dysfunction in setting of elevated BP, BNP. Patient in NSR on initial presentation. Ruled out for MI. Pt's SOB resolved after IV lasix and was placed back on his home PO lasix dose, on which he continued to diurese well. . # AF s/p DCCV - was in NSR throughout hospitalization until AM of [10-4], at which time he converted back to atrial fibrillation at a rate between 80s-100s. Currently rate-controlled, asymptomatic. - uptitrate home metoprolol dose to 100 mg po bid - continue warfarin, goal INR 2.0 - 3.0. Pt was found to be slightly subtherapeutic on admission, home dose was slightly uptitrated to 6 mg/d from 5 mg/d. - patient remained well rate-controlled and asymptomatic after converting to atrial fibrillation. It was discussed that he should follow up closely with his cardiologist (Dr. [Last Name (STitle) ] and discuss further management options, including repeat attempt at cardioversion. . # HTN - Increased nifedipine, metoprolol doses. . # s/p kidney, liver transplant - Found to have significantly elevated tacrolimus level on admission. Decreased dose during admission with plans for repeat check at home this coming Thursday following discharge. Nephrology follows patient closely as an outpatient and will f/u on repeat drug level. - continue mycophenolate, tacrolimus - f/u tacro level Medications on Admission: Furosemide 20mg three tablets once daily Metoprolol Succinate 100mg one tablet by mouth daily Mycophenolate Mofetil 500mg one tablet by mouth twice daily Pregabalin (lyrica) 100mg once daily Tacrolimus (prograf) 1mg three capsules twice daily Warfarin 5.0mg once daily Insulin NPH and Regular Human (Humulin 70/30) Ranitidine HCL 75mg tablet twice daily Nifedipine 30mg once daily Discharge Medications: 1. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 2. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Mycophenolate Mofetil 250 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: AS DIRECTED Subcutaneous . 7. Outpatient Lab Work Please draw serum tacrolimus level, PT/INR, blood urea nitrogen, serum creatinine, serum potassium on [2133-10-8]. Results showed be faxed to Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 17382]) and Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 21335]). 8. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day. Disp:120 Capsule(s) Refills:1 9. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 10. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Disp:30 Tablet Sustained Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary Diagnosis: acute diastolic heart failure, paroxysmal atrial fibrillation Secondary Diagnoses: 1. hypertension 2. end-stage liver disease s/p liver transplant 3. end-stage renal disease s/p renal transplant 4. peripheral vascular disease s/p below-knee amputation 5. anemia Discharge Condition: Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Mental Status:Clear and coherent Discharge Instructions: You were seen at [Hospital1 18] for shortness of breath. You were found to have excess fluid in your body which was likely causing your symptoms. You received intravenous diuretics which removed the extra fluid from your body and improved your symptoms. During your hospitalization, it was discovered that you returned to a rhythm of atrial fibrillation. It is currently at a reasonable rate, controlled with medication. You should discuss long-term management of this rhythm with your cardiologist, Dr. [Last Name (STitle) ]. The following medications were changed during your hospitalization: INCREASED metoprolol from 100 mg daily (succinate) to 100 mg twice daily (tartrate) to better control heart rate INCREASED nifedipine to better control blood pressure INCREASED warfarin to ensure adequate thinning of blood DECREASED tacrolimus to 2mg twice daily, as you were found to have a blood level of this medication that was too high during your hospitalization Please weigh yourself daily if possible and notify your physician if you notice a weight change > 3 lbs. Adhere to a low-salt, low-cholesterol diet. You will need your blood checked this Thursday, [10-8], to recheck your tacrolimus level, as well as to monitor your kidney function and warfarin dosage. If you experience worsened shortness of breath, chest pain, fevers, or any other symptoms that worry you, please contact your PCP or go to the Emergency Department. Followup Instructions: Please contact your cardiologist, Dr. [Last Name (STitle) ], to schedule an appointment within the next 1-2 weeks to discuss a plan for managing your atrial fibrillation, which recurred during this hospitalization. You can contact his office at [Telephone/Fax (1) 7960]. Provider: [Name10 (NameIs) 13953] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 2977] Date/Time:[2133-10-7] 9:30 Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2133-10-16] 10:50 Completed by:[2133-10-4] ICD9 Codes: 4280, 3572, 5859, 2859, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7798 }	Medical Text: Admission Date: [2109-8-11] Discharge Date: [2109-8-13] Date of Birth: [2083-9-5] Sex: M Service: MEDICAL ICU CHIEF COMPLAINT: Confusion. HISTORY OF PRESENT ILLNESS: This is a 25-year-old man who was originally admitted from the Emergency Room under [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 24320] [Numeric Identifier 24321], who initially stated that his name was [Doctor Last Name 6382] and reportedly drank three bottles of Dextromethrophan to get high after dinner on the night of presentation. He denied that the overingestion represented a suicide attempt. The patient has a previous history of overdose on Dextromethorphan requiring hospitalization. He denied homicidal ideation or previous suicide attempts. He was unable to explain what led him to come to the Emergency Room. He denied chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting, visual or auditory hallucinations. According to notes from the Emergency Room, the patient presented to the [Hospital6 256] by police who found him wandering confusedly in the street. Upon further record evaluation, the patient is reported to have had schizophreniform disorder, for which he had been taking medications at home. He stated that he drinks Robitussin (Dextromethorphan) almost daily. Initially he was combative, made sexually inappropriate comments to the nursing staff, and was intermittently oriented and cooperative. He had been tachycardiac to the 160s, hypertensive to the SBPs of 180s and somewhat responsive to Ativan. In the Emergency Room, the patient was given approximately 2 L normal saline. He also received 8 mg Lorazepam and was placed in restraints. Toxicology Staff was consulted in the Emergency Room and reported that the patient should be followed with close hemodynamic monitoring and required an ICU stay but did not at the present time require any specific medications other than relief of his agitation. PAST MEDICAL HISTORY: Schizophreniform disorder. MEDICATIONS: Schizophrenia medication, the patient was unsure of name but later disclosed during the hospitalization that he was taking Abilify 10 mg p.o. q.d., Tegretol 200 mg p.o. b.i.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient lives alone. He denied alcohol, tobacco or other drug use at this time. PHYSICAL EXAMINATION: Vital signs: Temperature 100.9??????, heart rate 131, blood pressure 166/102, respirations 16, oxygen saturation 98% on room air. General: The patient was severely agitated and was in four-point leather restraints. He followed some vocal commands. Speech was intermittently intelligible and slow, and he was diaphoretic at the time. HEENT: Pupils approximately 5 mm reactive bilaterally. Extraocular movements intact. Dry mucous membranes. No lymphadenopathy. Chest: Clear to auscultation anteriorly. Cardiovascular: Sinus tachycardia. No murmurs, rubs, or gallops. Abdomen: Positive bowel sounds. Nontender and nondistended. No organomegaly. Extremities: Warm and well perfused. No edema or cyanosis. He had a peripheral IV times one in place. Neurological: The patient reported that this name was [Doctor Last Name 6382]. He was oriented to the hospital. He moved all of limbs spontaneously. He was significantly agitated. He was unable to relax for reflex check. LABORATORY DATA: INR 1.2; white count 6.7, hematocrit 45.8; potassium 3.1, creatinine 0.9, CK 377; urinalysis negative for nitrites and leukocytes; serum toxicology screen negative for Aspirin, alcohol, acetaminophen, benzodiazepines, barbiturates, tricyclics and antidepressants; urine toxicology screen was negative for benzodiazepines, barbiturates, opiates, cocaine, amphetamines, methamphetamines. Electrocardiogram was normal sinus rhythm at 150 with normal axis, normal intervals, no hypertrophy, inferior T-waves, no ST/T wave changes. HOSPITAL COURSE: 1. Dextromethorphan overdose: Toxicology was involved in the care of this patient. They recommended overnight monitoring in the Intensive Care Unit with stabilization of his anxiety which was normal and accompanied with the Dextromethorphan overdose but did not require any specific antidote besides hemodynamic monitoring. The patient was aggressively hydrated and was placed on standing dose of Ativan q.4 hours 2 mg with improvement of his agitation and sedation, and he was maintained on leather restraints. The patient improved in terms of his mental status, and his agitation also improved. Within a few hours of starting the Ativan, the patient's hypertension and tachycardia had resolved and did not increase for the remainder of his stay in the Intensive Care Unit. 2. Psychiatry: The patient has a history of schizophrenia and reportedly had been compliant with his medications at home. Psychiatry was consulted on this patient for further evaluation. Upon further evaluation, the patient felt that this was not a suicide attempt or suicidal ideation. Psychiatry recommended slowly discontinuing the four-point leather restraints and discontinuing the 1:1 sitter. They recommended checking a Tegretol level for which the patient had been on at home and redosing his medication to appropriate levels. There was concern that the patient did not meet acute criteria for inpatient psychiatric hospitalization. The patient was changed from a standing dose of Ativan p.r.n. for improvement of his mental status, as he had become more somnolent throughout the day with further sedation. On hospital day #3, the patient was full mental status clearance, with stable blood pressure and heart rate. Throughout the night, he actually had been running in the 40s. Electrocardiograms were done that showed no acute arrhythmias. The patient thought to be just sinus bradycardia without change in mental status. He was completely hemodynamically stable. As such, the patient had requested to leave against medical advice on hospital day #3. He was evaluated by the House Staff who felt that he was medically cleared from his admission, given his stable vital signs and improvement of his mental status. Psychiatry was called to consult again, and the patient refused to stay for further evaluation. The benefits and consequences of his leaving were fully discussed with him. The patient signed out against medical advice without further evaluation from Psychiatry. It was felt that the patient should go home and follow-up with his primary outpatient psychiatrist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], as well as take his home medications. The patient left against medical advice. The patient was maintained on NPO until his mental status improved. On the day of discharge, the patient was off intravenous fluids. His electrolytes were aggressively repleted. His hypokalemia resolved with repletion of 4.0 without further events. DISCHARGE MEDICATIONS: None. FOLLOW-UP: The patient is to go home and continue his home doses of Abilify and Tegretol as outlined previously above. COMMUNICATION: The patient's mother, who was reportedly in a nursing home was contact[Name (NI) ] by the House Staff and was updated on the patient's condition. At that time, the House Staff was informed that the patient had recently been in the [Hospital6 1708] for previous Dextromethorphan overdose. DISPOSITION: The patient requested to leave against medical advice, and he signed off on a form after discussion of the consequences of his actions. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4561] Dictated By:[Last Name (NamePattern1) 24322] MEDQUIST36 D: [2109-8-13] 13:37 T: [2109-8-13] 15:04 JOB#: [Job Number 24323] ICD9 Codes: 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7799 }	Medical Text: Admission Date: [2193-5-18] Discharge Date: [2193-5-27] Date of Birth: [2193-5-18] Sex: M Service: NEONATOLOGY Allergies: No Drug Allergy Information on File Attending:[Doctor First Name 61879] Chief Complaint: Prematurity Major Surgical or Invasive Procedure: None History of Present Illness: Infant is a 33 0/7 week, 1830 gram male newborn who was admitted to the NICU for management of prematurity. Infant was born to a 30 y.o. G2P0 now 2 mother. Prenatal screens: O+, antibody negative, HBsAg negative, RPR NR, RI, GBS negative. Pregnancy complicated by IDDM, chronic hypertension, and severe pre-eclampsia. On day of delivery, labor induced for above reasons. Due to fetal decelerations, delivery by Cesarean section. Maternal meds: insulin pump, zestril (lisinopril - ace-inhibitor). Pregnancy class D. Lactation class L3 - not reviewed by AAP, [Doctor Last Name ]: observe for hypotension, moderately safe, no reported incidents. No perinatal sepsis risk factors (except prematurity): no maternal fever, no PROM, GBS negative, no fetal tachycardia. Infant emerged with good tone, activity and spontaneous respirations. Routine bulb suctioning, drying, and stimulation. +BBO2. Nuchal cord x 1. Apgars 8,8. Infant shown to parents then transported to NICU. Exam: VS per CareView Growth measurements: Wt 1830 gms = 50%, L 42 cm = 25%, HC 28 cm = 10% Pink, active, alert and in no distress. +molding. non-dysmorphic. AFSF. RR x 2. Palate, clavicles intact. Lungs CTA, =. No GFR. CV RRR, no murmur, 2+FP. Abd soft, +BS. GU nl male. testes down bilat. Patent anus. +sacral dimple, shallow, closed. Hips stable. Ext pink and well perfused. Neuro: Nl tone/strength, MAEW, +suck, grasp, moro. Past Medical History: See above Social History: Parents are an intact couple, live in [Hospital1 1474]. Family History: See Above Physical Exam: See above section Pertinent Results: [2193-5-18] 04:30PM WBC-9.1 RBC-4.92 HGB-18.5* HCT-55.7* MCV-113* MCH-37.7* MCHC-33.3 RDW-16.5* [2193-5-18] 04:30PM NEUTS-40 BANDS-0 LYMPHS-51 MONOS-8 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 Brief Hospital Course: Hospital Course by systems: Resp: Initially on CPAP, weaned to nasal canula O2 on dol 3, then to room air by dol 5. No apnea or bradycardia. He had been on room air for greater than 72 hrs at the time of transfer. CV: He has been hemodynamically stable throughout his stay. Normal BPs and perfusion. Fluids and nutrition: Initially npo, on IVF. Enteral feed begun on dol 3, slowly advanced by 15 mL/kg/day to reach full enteral volume of 150 mL/kg/day on dol 6. He is currently taking MBM/SSC 24 cal at full volume, and has begun to take small po volumes. Mom is hoping to breast feed. Discharge weight 1875g. GI: Maximum bilirubin on dol 3 of 12.7. He had started phototherapy the day prior. Phototherapy was discontinued on dol 6 for a bili of 4.6. Rebound bili on dol 8 was 5.3. ID: CBC on admission with wbc 9.1, 40 pmns, no bands. He was on ampicillin and gentamicin for 48 hrs. Antibiotics discontinued when blood culture negative at 48 hrs. Heme: Admission Hct 55.7%. Neurologic: He did not meet criteria for screeing head ultrasound Sensory: Hearing screening has not been performed. Immunizations: He has not received any immunizations Condition at transfer: good Parents have not yet identified pediatrician State newborn screeing is pending Discharge Medications: None Discharge Disposition: Extended Care Facility: [Hospital 1474] Hospital Discharge Diagnosis: Prematurity 33 weeks Transient tachypnea of the newborn Presumed sepsis-ruled out Hyperbilirubinemia Discharge Condition: good Discharge Instructions: Transfer to [Hospital 1474] Hospital ICD9 Codes: 7742, V290

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.