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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7800 }	Medical Text: Admission Date: [2130-11-6] Discharge Date: [2130-11-13] Date of Birth: [2077-1-15] Sex: M Service: SURGERY Allergies: Ganciclovir / Acyclovir Attending:[First Name3 (LF) 695] Chief Complaint: The patient was admitted on [2130-11-6] for a liver transplant. Major Surgical or Invasive Procedure: Liver transplant [2130-11-7] History of Present Illness: Mr. [Known lastname ] is a 53M w/ Hx Hep C cirrhosis and HCC. He presented [11-6] for a liver transplant. He has not had any fevers, and chills. No diarrhea, nausea or vomiting. No urinary symptoms. No cough. No shortness of breath. He has night sweats at baseline but this has not increased and has actually improved. He ate at 1830. Past Medical History: HCV, HCC, HTN, Osteoporosis PSH: lap CCY, cervical laminectomy with fusion, tib/fib fx s/p fixation with steel rod. Social History: former smoker who has quit in [2130-2-16]. He smoked 2 packs per day for 40 years. He denies any alcohol or drug use. Family History: unremarkable Physical Exam: VS: T 97.4 HR 91 BP 135/73 RR 20 O2Sat 98% RA NAD, AAOx3, He is w/o asterixis. HEENT: NC/AT,and anicteric. Neck is supple w/o lymphadenopathy. CV: Regular Rate and Rhythm Pulm: CTA B/L Abd:Soft/Nontender/Distended/+BS. No splenomegaly. There is no guarding or rebound tenderness. Ext: no peripheral edema Pertinent Results: [2130-11-13] 05:05AM BLOOD WBC-8.5 RBC-2.86* Hgb-8.9* Hct-26.2* MCV-92 MCH-31.0 MCHC-33.8 RDW-15.9* Plt Ct-164 [2130-11-13] 05:05AM BLOOD Plt Ct-164 [2130-11-13] 05:05AM BLOOD PT-11.9 PTT-20.3* INR(PT)-1.0 [2130-11-10] 04:45AM BLOOD Fibrino-251 [2130-11-13] 05:05AM BLOOD Glucose-76 UreaN-29* Creat-1.0 Na-140 K-4.6 Cl-103 HCO3-31 AnGap-11 [2130-11-13] 05:05AM BLOOD ALT-941* AST-108* AlkPhos-83 TotBili-0.7 [2130-11-10] 04:45AM BLOOD Lipase-19 [2130-11-13] 05:05AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.8 Mg-2.4 [2130-11-13] 05:05AM BLOOD FK506-7.2 [2130-11-9] 01:34PM ASCITES TotBili-1.4 DUPLEX DOP ABD/PEL LIMITED [2130-11-7] 2:33 PM DUPLEX DOP ABD/PEL LIMITED Reason: FLOW/ FLUID COLLECTION. S/P LIVER TX [Hospital 93] MEDICAL CONDITION: 53 year old man with liver transplant REASON FOR THIS EXAMINATION: flow/fluid collcetion .INDICATION: 53-year-old man with liver transplant today, evaluate for fluid collection and flow in vessels. FINDINGS: The liver shows no focal abnormalities. There is a tiny trace of fluid in Morison's pouch but no other fluid collections are identified. There is no biliary dilatation seen. DOPPLER EXAMINATION: Hepatopetal flow is identified in the main portal vein, the right portal vein, and the left portal vein. Velocity of flow within the main portal vein is 52 cm/sec. Appropriate flow is identified in the hepatic veins. Arterial waveforms in the main hepatic artery, right hepatic artery, and left hepatic artery are appropriate with good upstrokes. Flow is identified within the IVC; however, this vessel is not well imaged on this exam. IMPRESSION: Tiny trace of fluid in Morison's pouch. Appropriate flow is identified in all of the hepatic vessels. DUPLEX DOPP ABD/PEL [2130-11-9] 11:58 AM LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL Reason: Need to look at arterial and venous flow of transplanted liv [Hospital 93] MEDICAL CONDITION: 53 year old man s/p liver transplant REASON FOR THIS EXAMINATION: Need to look at arterial and venous flow of transplanted liver. look for any fluid collections INDICATION: 53-year-old man status post liver transplant. [Doctor Last Name ]-SCALE AND DOPPLER ULTRASOUND OF THE LIVER: Comparison was made with the prior ultrasound dated [2130-11-7]. Again note is made of a small amount of fluid in [Location (un) 6813] pouch, as seen on the prior study. Otherwise, the appearance of the liver is unchanged on [Doctor Last Name 352]-scale images. Hepatopetal flow is identified in the main and right and left portal veins. The velocity of flow within the main portal vein is 56 cm/sec. Hepatic veins are patent with appropriate waveforms. Main and right and left hepatic arteries show appropriate arterial waveform with good stroke as noted previously. The proximal right hepatic artery is visualized with normal waveforrms, but peripherally assessment is somewhat limited. IMPRESSION: Small free fluid in Morison's pouch as noted previously. Patent vessels with appropriate waveforms as described above. Note that distal right hepatic artery is not fully visualized on this study--correlate clinically with lab values, and followup if indicated. CT ABD W&W/O C [2130-11-12] 1:33 PM CT ABD W&W/O C Reason: CTA of the liver. smaller cuts around the liver to evaluate Field of view: 39 [Hospital 93] MEDICAL CONDITION: 53 year old man s/p liver transplant. REASON FOR THIS EXAMINATION: CTA of the liver. smaller cuts around the liver to evaluate hepatic artery. Need to evaluation for hematoma and bleeding. only need IV contrast CONTRAINDICATIONS for IV CONTRAST: None. CT LIVER (MULTIPHASE) INDICATION: Status post liver transplant. TECHNIQUE: Non-contrast, arterial phase and portal venous phase CT liver performed. FINDINGS: The portal vein is patent. The donor hepatic artery has been surgically anastomosed to the recipient replaced hepatic artery which arises from the patient's celiac artery. The left and right hepatic arteries and the proper hepatic artery are patent. There is mild dilatation of the donor hepatic artery at the anastamosis. There is a focal wedge- shaped area of patchy hypoattenuation on portal venous and arterial phase in segment VII of the liver possibly representing a focal area of contusion related to recent surgery. There is some periportal edema in segment II and also in segment IVb. Remainder of the liver enhancement is normal on arterial and portal venous phases. The hepatic veins are patent. The spleen is enlarged measuring 14.6 cm in diameter. The pancreas, kidneys, and adrenal glands are normal. There is a small amount of intraperitoneal air. There is perihepatic fluid and some hematoma, consistent with recent surgery. There is mild right basilar collapse consolidation and a small right pleural effusion. IMPRESSION: 1. Patent hepatic vasculature. 2. Right basal collapse/consolidation. Brief Hospital Course: The patient was admitted on [2130-11-6] for a liver transplant. On admission, he was made NPO, and pre-op blood work, EKG and CXR were obtained. The patient tolerated the procedure well and was admitted to the ICU intubated following surgery for close monitoring. On [11-7] sedation was weaned, the patient was extubated. Ultrasound showed: Hepatopetal flow is identified in the main portal vein, the right portal vein, and the left portal vein. Velocity of flow within the main portal vein is 52 cm/sec. Appropriate flow is identified in the hepatic veins. Arterial waveforms in the main hepatic artery, right hepatic artery, and left hepatic artery are appropriate with good upstrokes. Flow is identified within the IVC; however, this vessel is not well imaged on this exam. On [11-9] the patient was transferred to [Hospital Ward Name 121] 10 for continued monitoring. He was encouraged to ambulate, started on a regular diet and his fluids were stopped. [11-10] - the patient's home medications were started and his foley catheter was removed. The patient continued to do well, a CT abdomen was performed on [11-12] showing patent hepatic vasculature. He is to be discharged home on [11-13]. Medications on Admission: [Last Name (un) 1724]: Actigall 300 mg q.i.d., Diovan 160 mg daily, Omeprazole 20 mg daily, Calcium with vitamin D twice a day, Multi-vit, B complex vitamin, Boniva 3 grams every 3 months, started on an antihistimine for itching. Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:60 Tablet(s) Refills:2 3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:60 Tablet(s) Refills:0 10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 12. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. Disp:180 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Liver transplant Discharge Condition: Good Discharge Instructions: Please return to the nearest emergency department or call the transplant coordinator ([Telephone/Fax (1) 673]) should you have a temperature greater than 101.5, abdominal pain, nausea, vomiting, shortness of breath, chest pain, excessive drainage or redness surrounding surgical incision. You will need labs (CBC, Chem 10, LFTs, Coags, FK levels) drawn on either Tuesday ([11-14]) or Wednesday ([11-15]). These results must be faxed to the transplant coordinator [Telephone/Fax (1) 697]. You have been prescribed a study drug - you have received an educational session by the transplant team. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2130-11-22] 3:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2130-11-29] 2:20 Provider: [Name10 (NameIs) 1248],CHAIR ONE [Name10 (NameIs) 1248] ROOMS Date/Time:[2130-12-5] 8:15 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] ICD9 Codes: 5715, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7801 }	Medical Text: Admission Date: [2117-8-27] Discharge Date: [2117-8-30] Date of Birth: [2089-10-25] Sex: F Service: MEDICINE Allergies: Guaifenesin / Robitussin A-C / Shellfish Attending:[First Name3 (LF) 2291] Chief Complaint: Status Asthmaticus Bilateral Sub-segmental PE Major Surgical or Invasive Procedure: - needle decompression & bilateral chest tubes placed at outside hospital, removed during stay at [Hospital1 18] History of Present Illness: 27 year old female with a pmh of asthma BIBMS for asthma attack. EMS attempted intubation in the field which failed. On arrival to OSH, she lost pulse and went into PEA arrest. She was resuscitated with CPR for 8 minutes with SROC. She was intubated, and had bilateral needle decompression with air return on the left (Per OSH ED report, US showed air on left, unclear why chesttube placed on right). Bilateral chest tubes were placed and the order of events is unclear. She was initiated with arctic sun protocol and paralyzed with rocuronium for the med flight to [Hospital1 18] for further evaluation and treatment. Upon arrival, post arrest team was consulted and recommended cooling, however the patient was awake and responsive in the ED responding to commands with normal vital signs. Cooling was stopped. . In the ED she received propofol gtt, fentanyl gtt and fentanyl bolus. IV access is 3 PIVs HR 79, BP 107/58, Sat 100% on 50% fio2 PEEP of 8 450 14. Lactate 2.5. She was admitted to MICU, was extubated the following day. IP removed chest tubes, but heard small leak on right side, portable film showed residual small PTX on right, but satting well (high 90s). Serum HCG was negative. Recieved nebs and steroids. Pred 40 (quick taper over 5-7 days given lungs clear right now), repeat CXR given concern for persistant right PTX. She underwent CT scan with ? bullae on imaging. . On floor, she is in good spirit, reports some pain b/l at her breast and back. Reports prior to her admission, she had worsening SOB, using albuterol inh 4-5x per day (baseline [1-17] per day), symbicort [Hospital1 ] (she was using this intermittently). She also had some steroid at home which she was taking prior to the event of asthema exacerbation. Otherwise, she report she smoked once this past week prior to her worsening respiratory condition. Past Medical History: Asthma since age [6-22] Psoriasis dx 1 month ago ongoing tobacco abuse Social History: Lives in [Location (un) 5503]. She has a 2 year old son. - Tobacco: social, with drinking, [2-18] cigarettes at a time - Alcohol: social, 1x/month - Illicits: none Family History: Mother: childhood asthma and DVT after trauma/multiple surgeries Father: psoriasis, h/o of DVT Paternal family: cancer (unknown types) Physical Exam: Admission Exam: T 98.2, HR 104, BP 129/107, RR 14, O2 98% (on CMV assist) General: Squeezing hands, opening eyes to command, intubated, restless, responding to commands, no acute distress HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated, no LAD Lungs: Some rhonchi bilaterally anteriorly, good airmovement, no wheezes, clear at posterior bases CV: Normal rate and regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema ============================ Discharge exam: Vitals 98/98 117/73 64 18 98%RA 182 lbs General: AOx3, NAD HEENT: NC/AT, Sclera anicteric, PERRLA, EOMI, MMM, OP clear, no JVD, neck supple CV: RRR, nl s1+s2, no M/R/G Lungs: CTAB, no r/r/w, good air movement, resp unlabored CV: Normal rate and regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, Soft, NT/ND, no rebound/guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: CBC: [2117-8-27] 05:25AM BLOOD WBC-15.6* RBC-3.86* Hgb-11.2* Hct-33.4* MCV-87 MCH-28.9 MCHC-33.4 RDW-13.7 Plt Ct-163 [2117-8-27] 05:25AM BLOOD Neuts-94.9* Lymphs-2.6* Monos-2.2 Eos-0.2 Baso-0.1 Blood Chemistry: [2117-8-27] 04:26AM BLOOD Glucose-146* Lactate-2.5* Na-140 K-5.2 Cl-110 freeCa-0.81* [2117-8-27] 05:25AM BLOOD Glucose-160* UreaN-15 Creat-0.9 Na-142 K-3.9 Cl-109* HCO3-23 AnGap-14 Calcium-7.7* Phos-4.0 Mg-1.7 [2117-8-27] 05:25AM BLOOD PT-12.4 PTT-26.1 INR(PT)-1.0 [2117-8-27] 11:21AM BLOOD CK(CPK)-710* Serum tox screen: [2117-8-27] 05:25AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [2117-8-27] 04:15AM URINE Color-Yellow Appear-Cloudy Sp [Last Name (un) ]-1.015 [2117-8-27] 04:15AM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [2117-8-27] 04:15AM URINE RBC-11* WBC-18* Bacteri-FEW Yeast-NONE Epi-1 [2117-8-27] 04:15AM URINE Mucous-RARE [2117-8-27] 04:15AM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [2117-8-27] 7:51 am MRSA SCREEN Source: Nasal swab. FINAL REPORT [2117-8-29] MRSA SCREEN (Final [2117-8-29]): No MRSA isolated. . ABG: [2117-8-27] 04:26AM BLOOD pO2-200* pCO2-24* pH-7.53* calTCO2-21 Base XS-0 Comment-GREEN TOP [2117-8-28] 04:27AM BLOOD WBC-13.9* RBC-3.85* Hgb-11.3* Hct-34.0* MCV-88 MCH-29.3 MCHC-33.2 RDW-14.0 Plt Ct-171 [2117-8-29] 06:40AM BLOOD WBC-11.0 RBC-3.49* Hgb-10.6* Hct-29.9* MCV-86 MCH-30.3 MCHC-35.3* RDW-13.9 Plt Ct-162 [2117-8-30] 05:35AM BLOOD WBC-8.8 RBC-3.73* Hgb-11.2* Hct-32.4* MCV-87 MCH-30.0 MCHC-34.5 RDW-14.0 Plt Ct-154 [2117-8-30] 05:35AM BLOOD Glucose-102* UreaN-18 Creat-0.7 Na-137 K-4.3 Cl-104 HCO3-28 AnGap-9 [2117-8-29] 06:40AM BLOOD ALT-45* AST-22 LD(LDH)-192 AlkPhos-43 TotBili-0.2 [2117-8-30] 05:35AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8 [2117-8-29] 09:30AM BLOOD D-Dimer-1891* [2117-8-27] 05:25AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2117-8-27] 08:11AM BLOOD Type-ART Rates-/15 Tidal V-500 PEEP-5 FiO2-30 pO2-100 pCO2-43 pH-7.37 calTCO2-26 Base XS-0 Intubat-INTUBATED . CXR [2117-8-29] As compared to the previous radiograph, there is no relevant change. No evidence of pneumothorax. The small retrosternal air collection documented on a CT from [8-28] is, with knowledge of this CT, visible on the lateral chest film. The air inclusions in the soft tissues are not apparent radiographically. Minimal left apical atelectasis. Unchanged band-like thickening along the right minor fissure. Unchanged size of the cardiac silhouette. No newly appeared focal parenchymal opacities. . . CTA Chest: 1.Pulmonary artery embolism involving bilateral segmental and subsegmental branches as described. Main pulmonary artery is free of filling defects and there is no heart strain or pulmonary infarct. 2.Subcutaneous emphysema along the left axilla and chest wall as well as trace pneumomediastinum likely from recent chest tube removal or placement. Brief Hospital Course: 27 year old female with a pmh of poorly controlled asthma and frequent flares who presents s/p PEA arrest secondary to status asthmaticus +/- bilateral PTX. . # Respiratory distress: She presented from an OSH with bilateral chest tubes after needle decompression. She was intubated, and received solumedrol IV now on oral Prednisone taper. She is now s/p extubation and satting well on RA. Chest tubes d/ced by IP yesterday, some concern for small residual PTX on the right but recent CXR demonstrate no concerning PTX at this time. Dressings c/d/i. - History of asthma requiring 2 previous trips to the ED for treatment. Most recent exacerbation was "a few months ago." Lately, patient did say that there has been a construction site near her house and she has noticed her asthma worsening, using her inhalers during past week. She notes dust that covers everything in her house. - Patient also had bilateral subsegmental PE in RUL, RLL, LUL, L lingula demonstrated by CTA. Patient has reported allergic rxn to shellfish, gets anaphylaxis, so initiated pred/benedryl/cimetidine protocol prior to obtaining CTA. CTA went smoothly. Both of these processes could likely have caused her presentation and it is unclear if her PE could have set off an acute asthma exerbation or if her PE is subclinical. Currently, she is at RA, satting well and feeling well. Patient was guaic negative and started on anticoagulation (coumadin and lovenox bridge). - Patient was discharged on home medications (symbicort inhaler [Hospital1 ], albuterol q4-6h prn, as well as prednisone taper, to end on [2117-9-4]). For bilateral sub-segmental PE, patient was sent home on Lovenox to bridge, coumadin 5 po daily for 3 months. -Patient was set up with PCP and pulm appointments to f/u as outpatient. . # PEA arrest: 8 minutes of resuscitation, likely secondary to hypoxia from status asthmaticus but PE could have contributed to this picture as well. There is a possibility that the clot was bigger at one point and perhaps after 8 min of CPR, clot was dislodged and traveled more distally. Patient spon regained consciousness and then initiated cooling at OHS. This was d/c upon arrival to [Hospital1 18] ED. -see above for workup and tx for asthma/PE. . # Anxiety: Patient becomes teary when talking about her asthma attack. Family also concerned that patient's anxiety at home could trigger asthma attacks. - Recommended F/U with PCP for longterm anxiety treatment - Informed patient and family about how to set up Lifeline at their request . # Leukocytosis: Likely secondary to acute inflammatory process and steroids. Now normalized. . Ongoing tobacco abuse: patient was counseled extensively about smoking cessation. Patient was very adamant about quitting after leaving hospital and understands that smoking increases her risk of future asthma attacks as well as a hypercoag state that could lead to another PE. . # Code: Full . . Pending tests: none. . Transitional Issues: Patient will need to have INR checked at PCP's office for initiation of Coumadin. We have called her PCP to set this up for her. We have also set her up to see a pulmonologist as outpatient to evaluate PE/asthma. Medications on Admission: albuterol inhaler q4-6h prn Symbicort [Hospital1 ] OCP Discharge Medications: 1. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 1 doses. Disp:3 Tablet(s) Refills:0 2. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 doses. Disp:1 Tablet(s) Refills:0 3. prednisone 10 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. Disp:1 Tablet(s) Refills:0 4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 doses. Disp:2 Tablet(s) Refills:0 5. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). Disp:30 injection Refills:0 6. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:0 7. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain for 5 days. Disp:20 Tablet(s) Refills:0 8. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain for 7 days. Disp:60 Tablet(s) Refills:0 9. docusate sodium 50 mg Capsule Sig: Two (2) Capsule PO twice a day as needed for constipation. Disp:60 Capsule(s) Refills:0 10. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation twice a day. 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every 6-8 hours as needed for shortness of breath or wheezing. 12. oral contraceptives Sig: as directed PO as directed. 13. Outpatient Lab Work Please obtain INR on [2117-8-30] and fax to PCP [Name9 (PRE) ],[Name9 (PRE) 18356] Phone: [Telephone/Fax (1) 21473] Fax: [Telephone/Fax (1) 90804]. Discharge Disposition: Home Discharge Diagnosis: asthma exacerbation Bilateral pulmonary emboli Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at the [Hospital1 771]. You presented to the hospital with symptoms of shortness of breath and was urgently rescusitated and intubated. You were admitted for an acute asthma excerbation, which likely precipitated this event. We also found that you had sub-segmental pulmonary emboli in your lungs, on both sides. This means that you had small clots that traveled in the arteries that supply your lungs. Combination of smoking and using oral contraceptives increase this risk, especially in the setting of your family history. It is therefore critically important to your health to quit smoking. It is unclear if this pulmonary emboli event contributed to your asthma exacerbation or whether this triggered you to have shortness of breath and loss of pulse independently. We would like for you to follow up with a pulmonologist as an outpatient visit to assess your risk for future clots and exacerbations. . In the mean time, we are treating you with coumadin, an oral anticoagulant, which prevents future clots for building up in your legs and your lungs. This medication will need to be taken for at least 3 months, to be stopped by your pulmonologist or PCP. [Name10 (NameIs) ] medication requires frequent follow up and blood tests to make sure that you have the correct blood level. You will need to go to your PCP's office in the next 2-3 days to obtain an INR check, the blood test to check the levels of coumadin in your body. Also, you will need to use enoxaparin for roughly 1 week, a subcutaneous injection twice daily. We have started you on this and will teach you how to deliver the medicine yourself at home. . As for your severe asthma attack, we have started you on oral steroids, prednisone, which you will need to continue taking on a tapered regimen. Starting tomorrow ([8-31]), you will need to take 30mg, 20mg the day after ([9-1]), 10mg ([9-2]), 5([9-3]), 5([9-4]), then stop. . Please continue your home medications, including the symbicort twice daily, and albuterol as needed. You may discuss the possibility of switching your oral contraceptives to an alternative method, such as an IUD, with your PCP/gynecologist. . We also found that you were anxious, rightfully so, during this admission about your health. Please feel free to discuss your feelings with your PCP at your next visit. We have also given you information about "Lifeline" which you and your family requested. . Good luck and we wish you the best. Followup Instructions: Name: SKALITOSI, ARIS-PA Specialty: PULMONARY Location: [Hospital ] MEDICAL ASSOCIATES Address: [Last Name (un) 21477], [Location ],[Numeric Identifier ] Phone: [Telephone/Fax (1) 62464] Appointment: Friday [9-3] at 9AM Name: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 90805], NP Specialty: Internal Medicine When: Thursday [9-9] at 11:45am Location: [Hospital ] MEDICAL ASSOCIATES Address: [Location (un) 90806], [Location (un) ],[Numeric Identifier 90807] Phone: [Telephone/Fax (1) 21473] Dr. [Last Name (STitle) 47242] is not available so you will see her nurse practitioner for this visit. ICD9 Codes: 5185, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7802 }	Medical Text: Admission Date: [2145-6-16] Discharge Date: [2145-6-30] Date of Birth: [2072-3-4] Sex: F Service: SURGERY Allergies: Benadryl / Vancomycin Hcl Attending:[First Name3 (LF) 4748] Chief Complaint: left graft stenosis by graft survillance ,symptomatic Major Surgical or Invasive Procedure: angiogram with intervention cutting baloon angioplasty of left profunda femorus to DP bpg [2145-6-28] History of Present Illness: 73y/o female who was recently discharged from hospital after undergoing rt. groin exploration ,debreidment and washout for rt. groin infection with sinus tract.Surgery was complicated by NSTEMI with CHF requiring cardiac cath and angioplasty with stenting of LAD with metal eluding stentsx2 . Patient known vascularpathy s/p multiple, multipe [Month/Day/Year 1106] surgeries . underwent left graft survillance on [6-16] which demonstrated high grade stensois in the left fem-at proximal anastmosis. Patient was admitted to Dr.[Name (NI) 7446] service ( had appointmwent arraged by her PCP to be seen)for evaluation and treatment of her graft stenosis after resolution of her heart failure. Past Medical History: histroy of perpheral [Name (NI) 1106] disease,s/p rt. AKA ,s/p fem-fem bpg with rt. fem endart '[27],s/p ABF '[28],s/p bilat fem-pops91,removal of fem-fembpg'[28],redo left [Name (NI) 31642] ptfe+thrombectomy of left CFA'[38],s/p left temp bx'[40],rt. jump graft from rt. fem-[Doctor Last Name ] with ptfe to rt. distal pop'[42],s/p removal of lower extremiti gafts'[42],rt. BKA2/06,left [Name (NI) ] pta/stent12/06,left fem-atw rt. cephalic vein [12-21], left 1,4th toe amps [12-21] history of coronary artery disease s/p drug elutin sterca [2-18] histroy of chronic systolic (EF 37%) and diastolic CHF history of MR, mild with severe pulmonary hypertension histroy of hypertension histroy of hypercholestremia history of GI bleed secondary to ASA histroy of MRSA, VRE infections histroy of Dm1 with neuropathy history of carotid stenosis [Country ] 40-59%,[Doctor First Name 3098] 60-69% PICC line thrombosis treated with TPa [12-22] Social History: lives with husband former [Name2 (NI) 1818] 30 pkyrs d/c [2109] denies ETOH use Family History: noncontributory Physical Exam: Vital signs: 97.5-58-15 Os sat 92%, B/P 140/80 Gen: AAox3, no acute distress HEENT: ;eft carotid bruit Lungs clear to auscultation but diminished @ bases bilaterally Heart: RRR ABD: protuberant,soft, nonditended, nontender, BS+, no bruits or masses EXT: well healed rt.AKA. rubors skin changes/cellulitis form mid At to foot.toe 1 inch diamenter skin denuded . Pulses: rt. femoral pulse could not be accessed secondary to groin wound fibrosis.Left femorl 2+,[Doctor Last Name ] 1+ palpable, absent pedal pulses Neuro: nonfocal Pertinent Results: [2145-6-16] 05:49PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.014 [2145-6-16] 05:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2145-6-16] 05:49PM URINE RBC-0-2 WBC-[2-17] BACTERIA-FEW YEAST-NONE EPI-0-2 [2145-6-16] 05:17PM GLUCOSE-289* UREA N-32* CREAT-1.4* SODIUM-139 POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-21* ANION GAP-17 [2145-6-16] 05:17PM proBNP-[Numeric Identifier 31646]* [2145-6-16] 05:17PM CALCIUM-8.6 PHOSPHATE-4.0 MAGNESIUM-2.1 [2145-6-16] 05:17PM CALCIUM-8.6 PHOSPHATE-4.0 MAGNESIUM-2.1 [2145-6-16] 05:17PM CRP-24.6* [2145-6-16] 05:17PM WBC-10.1 RBC-3.90* HGB-11.1* HCT-36.3 MCV-93 MCH-28.4 MCHC-30.5* RDW-19.5* [2145-6-16] 05:17PM NEUTS-81.0* BANDS-0 LYMPHS-12.9* MONOS-3.2 EOS-2.3 BASOS-0.5 [2145-6-16] 05:17PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ SPHEROCYT-1+ BURR-OCCASIONAL FRAGMENT-1+ [2145-6-16] 05:17PM PLT SMR-NORMAL PLT COUNT-315 [2145-6-16] 05:17PM PT-14.1* PTT-23.0 INR(PT)-1.2* Brief Hospital Course: 7/2/08Admitted to Dr.[Name (NI) 7446] service. IV antibiotics instuted. Cardoloy:Dr.[Last Name (STitle) ] consulted for managment of patient's CHF excerbation.IV heparin began for left leg ischemic changes.Ciprofloxcin began [Date range (1) 31647]/08 ID consulted for antibiotics started on Daptomycin 4mg/kg q48hrs.,Cipro d/c'd and amxocillin started. [Last Name (un) ] consulted for her hyperglycemia and DM managment.Diuresis continued for her systolic CHF excerbation. [6-20] continues with antibiotics, mucomystand NaHCO3 gtt started for prepration for angio.Insulin adjustment required for improvement of continued glycemic control. [2145-6-21] Transfered to CIVCU for excerbation of CHF, secondary to lasix being held and fluid hydration for angio. angio cancelled IV Nitor gtt began, heparin gtt continued. Enzymes cycled. troponin 0.7. [2145-6-22] Improvement of cardiac and respiratory status. transfered to VICU for continued care.Diuresis continued.IV lasix dosing increase 80mgm [Hospital1 ]. Dr. [Last Name (STitle) ] recommends P mibi to asses for silent ischemia prior to any [Last Name (STitle) 1106] interventiion or surgery. [Last Name (un) ] and ID continue to follow patient. [2145-6-23] Dr. [Last Name (STitle) ] recommended patient be transfered to C-Med for continued managment of her CHF, patient's family declined recommendations. [2145-6-24] Patient transfered to Dr.[Name (NI) 1392] service per husband's request. P mibi fixed myocardial defect. No cardiac cath required. [2145-6-25] Patient transfered to floor. [2145-6-28] underwent angiogram with cutting balloonangioplpasty of left [Month/Day/Year ]-pr bpg. [2145-6-30] discharged to home in stable condition.Patient instructed to followup ;with PCP?cardologist, and endocrinologist upon d/c. followup with Dr. [Last Name (STitle) 1391] in 2 weeks. Will remain on long term suppression of amoxcillin 250mgm [Hospital1 ]. lasix 160mgm changed to lasix 40mgm [Hospital1 ] Isordil Dn 20mgm qam and 40mgm qpm changed to Isordil Mn 30mgm daily,lisinopril discontinued. uriinalysis and urin c/s sent prior to d/c. Medications on Admission: omeprazole 20mgm lasix 160mg norvasc 5mg atrovistatin 80mg celexa 40mg asa EC 325mg lisijnopril 40mg isordil 30mgm qam,20mgm qpm lopressor 50mg tid lantus 20 units qam HISS Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). Disp:30 Tablet, Sublingual(s) Refills:2 9. Isosorbide Mononitrate 30 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 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:60 Tablet(s) Refills:0 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:qs Refills:0 12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Insulin Glargine 100 unit/mL Solution Sig: as directed Subcutaneous twice a day: am 5 units HS 15 units. 14. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day. 15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 16. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:0 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 18. Insulin Glargine 100 unit/mL Solution Sig: as directed Subcutaneous at bedtime: 20 units. 19. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: AC: glucoses <100/no insulin 101-159/8u 160-199/10u 200-239/12u 240-279/14u 280-319/16u 320-359/18u 360-400/20u >400 [Name8 (MD) 138] MD u=units HS: glucoses <199/ no insulin 200-239/2u 240-279/4u 280-319/6u 320-359/8u 360-400/10u >400 [Name8 (MD) 138] Md. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Discharge Worksheet-Discharge Diagnosis-Finalized:[Last Name (LF) ],[First Name3 (LF) ], PA on [2145-6-30] @ 1011 left leg ischemia,symptomatic,s/p left fem-atbpg arm vein,graft stenosis by survillance [2145-6-16] history of PVD, s/p multiple bpg's,rt. aka,s/p fem-fembpg w rt. fem endartectomy'[27],s/p ABF'[28],s/p bilateral fem-pops''[27],s/p removal of fem-fem'[28],s/p redo left fem-bkpop wPTfeand thrombectomy of left CFA'[28],s/p rt. jumpgraft from rt.fem-[Doctor Last Name ] to distal [Doctor Last Name ] '[42],s/p removal of bilateral lower extremitiy grafts'[42], rt. BKA [1-20],s/p left PTAwstenting left [Month/Year (2) ] [11-20],s/p left fem-at w rt. cephalic vein [12-21] + left toe amps 1,4 [12-21] history of rt. groin infection,recurrentwith sinus tract-treated, on life long atbx suppresive tx w amoxcillin,s/p rt. groin exploration,debridment and wash out [2145-4-29] history of chronic systolic CHF with excerbation [6-22] history of coronary artery disease s/p drug eluding coronary stenting [2-18],NSTEMI [5-23] with baremetal stenting of lad history of MR, severe with pulmonary hypertension history of hypertension history of hypercholestremia historyof GI bleed [1-16] ASA history of MRSA,VRE wound infection history of acute oliguric renal failure [1-16] agressive diuresis for CHF [5-23] history of DM2,w neuropathy, insulin dependant history of carotid disease [Country ] 40-59%,[Doctor First Name 3098] 60-69% history of PICC Line thrombosis treated w TPa [12-22] history of chronic anemia, transfused 2 units PRBC's [5-23] postop NSTEMI [2145-6-24] Discharge Condition: stable Discharge Instructions: continue all medications as directed call if developes fever >101.5 or right groin wound developes erythema or drainage call if left foot circulation changes Followup Instructions: cardologist after d/c to home 2 weeks Dr. [Last Name (STitle) 1391], call for an appointment [Telephone/Fax (1) 1393] f/up with your endcrinologist: Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 31648] @ [Hospital3 ] Completed by:[2145-6-30] ICD9 Codes: 4280, 4168, 3572, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7803 }	Medical Text: Admission Date: [2152-4-10] Discharge Date: [2152-4-26] Date of Birth: [2078-11-4] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 477] Chief Complaint: HYPOXIA, HYPOTENSION Major Surgical or Invasive Procedure: None History of Present Illness: Mr [Known lastname ] is 73 yo M with metastatic prostate cancer on clinical trial drug a past history of CAD, CHF EF 45%. In clinic one week prior to admission, he appeared to be volume overloaded, so lasix was increased. The day of admission he was hypoxic in clinic today to 86%, and found to be anemic. Pt also endorsed light headedness and dizziness for several days since chemo. Denies any CP until morning of admit when he had episode of SSCP that lasted "seconds", relieved by nitro. . In the ED: 99.5 107/41 94 20 78% RA -> 94% 4L. BP transiently dropped to 70/41 but improved with 1L IVF and 1u pRBC. CXR showed worsening pulm congestion with possible right sided PNA. BNP 3000. Given ceftriaxone and azithro. No diuresis. EKG showed NSR, 1st degree AV block, NA w Q in III and aVF and STD I aVL and slight ST elevation in II and aVF, TWI V1-V3. Worse then prior. . He was initially admitted to the floor, where he was noted on arrival to be in mild repiratory distress. Given that the working diagnosis was volume overload, he was given 20 mg of IV lasix with a resulting drop in blood pressure to 80's systolic. Patient triggered for hypotension, ICU consult initiated. . At time of evaluation, BP 80/40, HR 100, RR 20, 87% on 5L NC, 96% on NRB. ABG obtained at that time revealed pH 7.45 pCO2 34 pO2 111 HCO3 24. He was admitted to the [Hospital Unit Name 153] for a lasix drip. Review of systems at the time of admisison was notable for increasing DOE x 1 week. Denies any blood in stool or dark tarry stools. Has not had any coughing, no nausea or vomiting, no fevers or chills. No orthopnea, sleeps with one pillow flat on his back. No dysuria or rashes. No abd pain. Poor PO intake. Review of systems is otherwise unremarkable. Past Medical History: CABG in [2130-8-29]: LIMA->LAD, SVG->PDA, SVG->ramus/OM, patent grafts [6-/2146] Prostate cancer DM II hypertension hyperlipidemia anxiety chronic systolic CHF w EF 45% hiatal hernia s/p L knee arthroscopy x 2 s/p R shouldar surgery for removal of bone spurs colonic polyps s/p hip replacement surgery, on coumadin after DVT/PE Social History: EtOH: prior, Tobacco: former heavy (35 pyh, quit 30 yrs ago), no illicits. Wife is HCP [Telephone/Fax (1) 10776] Family History: Father died of heart disease. Physical Exam: On admission: VITAL SIGNS: Tmax: 37.5 ??????C (99.5 ??????F) Tcurrent: 37.5 ??????C (99.5 ??????F) HR: 88 BP: 105/50(64) {105/50(64) - 110/52(68)} mmHg RR: 10 . PHYSICAL EXAM GENERAL: Pleasant, well appearing man, breathing comfortable on high flow mask HEENT: Normocephalic, atraumatic. Mild conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. II/VI systolic crescendo decrescendo murmur at RUSB, low pitched systolic murmur at heart base. JVP= 10cm LUNGS: Bibasilar crackles [1-15] way up. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [1-14]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant, anxious. Pertinent Results: Admission labs: [2152-4-10] 11:10AM WBC-8.8 RBC-3.09* HGB-8.4* HCT-25.2* MCV-81* MCH-27.1 MCHC-33.4 RDW-17.1* [2152-4-10] 11:10AM GLUCOSE-168* UREA N-56* CREAT-2.4* SODIUM-136 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-23 ANION GAP-18 [2152-4-10] 01:05PM PT-34.9* PTT-35.3* INR(PT)-3.7* Cardiac enzymes: [2152-4-10] 01:05PM BLOOD cTropnT-0.05* [2152-4-10] 08:35PM BLOOD CK-MB-6 cTropnT-0.03* [2152-4-10] 11:01PM BLOOD CK-MB-5 cTropnT-0.04* [2152-4-11] 05:26AM BLOOD CK-MB-4 cTropnT-0.05* Admission CXR: Cardiomegaly, worsening pulmonary congestion with increasing ground-glassopacity in the right lung likely pulmonary edema, though pneumonia cannot be excluded. Recommend post-diuresis. Brief Hospital Course: 73 yo M with metastatic prostate cancer on clinical trial drug a past history of CAD, CHF EF 45%, anemia, presenting with fatigue and DOE x 1 week, now with hypotension and hypoxia. . #. Hypoxia: His CXR showed volume overload. His fluid overload was thought to be secondary to the prednisone he was taking in conjunction of his study drug. He was agressively diuresed while in the ICU. He was placed on a lasix drip and also given boluses of lasix. His fluid balance in the ICU was 4.7 liters negative. His oxygen was weaned from a high flow mask to 4L NC. His cardiac enzymes were cycled and were negative thus making an ischemic event unlikely. An echo was done which showed EF of 50%, improved from prior. He was continued on his ASA and statin. On the OMED service gentle diuresis with IV lasix was continued for one day, O2 was weaned to 2L and then RA, and lung sounds improved. However, he subsequently developed increasing oxygen requirement, recurrent crackles, and hypoxia without elevated JVP or peripheral edema. CXR was again suggestive of pulmonary edema. However, there was doubt that this could fully explain his clinical situation. Given erratic hypoxia, pulmonary artery hypertension on echo, and recent use of taxotere, chest CT was done. This demonstrated likely pneumonitis. This was thought to be possibly secondary to taxotere. Pulse-dose steroids were begun and quickly tapered from IV to 60 mg PO prednisone. The pulmonary team followed the patient. He continued to have a 3L O2 requirement with desaturation into the 70s with exertion. Given this lack of improvement over a week, there was concern for PCP given his history of prednisone use. He was started on Bactrim at prophylactic doses. Induced sputum collection was attempted but unsuccessful. Thus, he was taken for bronchoscopy and BAL, which was negative for PCP. [Name10 (NameIs) ] oxygen requirement continued, so he was sent home with home O2 and plans to continue the prednisone and follow-up with his oncologist to arrange for PFTs, to attempt to taper prednisone, and for a possible referral to outpatient pulmonary and/or repeat CT if he didn't improve clinically. . #. Hypotension: SBP ranged high 70s to low 90s in the ICU. On the OMED service SBP initially ~100 but fell back into the 70s to 80s, limiting diuresis. The cause was unclear. [Name2 (NI) ] was afebrile, with negative blood cultures and no evidence of sepsis. CHF may have been contributory, although echo showed a nearly normal EF and only mild valve disease. The patient was persistently asymptomatic. In fact he was energetic and ambulatory through the hallway with this blood pressure. His beta blocker may need to be restarted as an outpatient given his history of coronary disease. . #. EKG changes: The patient had inferior ST changes on admission EKG. These were though to be secondary to demand ischemia in the setting of known CAD. Troponins were elevated in the setting of renal failure and increased demand. His CKs trended down and his CK-MB were flat. He was persistently without chest pain. He was continued on his ASA and ACE. Imdur was held for low blood pressure but may be restarted as an outpatient if needed for symptom control. . #. Metastatic prostate cancer: He had been on experimental drug therapy which was discontinued per the recommendations of oncology. He had been on prednisone 10mg daily, recently tapered to 7.5 mg daily, in conjunction with the drug. . #. Chronic pain: Outpatient opiate regimen was continued to treat bony metastases. Pain was well controlled on this regimen . #. Anemia: This was likely secondary to malignancy and recent chemotherapy. He was transfused one unit of pRBCs while in the [Hospital Unit Name 153] in order to maintain a HCT> 25. . #. DM 2: He was placed on a sliding scale for hyperglycemia in the setting of steroid use. . # Anxiety: He was continued on his home dose of Clonazepam. . # Elevated INR: Warfarin was held initially given subtherapeutic INR and restarted at home dose when INR fell within the therapeutic range. . Medications on Admission: clonazepam 1 mg twice daily furosemide 20 mg twice daily - recently increased. glyburide 1.25 mg daily Imdur 30 mg SR daily Lisinopril 5 mg daily Metoprolol 25 mg twice daily Nitroglycerin .4 mg SL PRN Oxycodone 15-30 mg q4h PRN Oxycontin 120 mg twice daily Prednisone 10 mg daily Prochlorperazine 5-10 mg PRN nausea Quetiapine 50 mg qhs Simvastatin 20 mg daily Warfarin 2mg every day except 4mg on Tuesday, Thursday, Saturday Discharge Medications: 1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): no driving on this medication. Disp:60 Tablet(s) Refills:0 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day. 4. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 6. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO SUN,MON,WED,FRI (). 9. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO TUES,THURS,SAT (). 10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 11. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: primary: pneumonitis, acute exacerbation of chronic systolic congestive heart failure secondary: prostate cancer, diabetes, hypertenion, coronary artery disease Discharge Condition: stable Discharge Instructions: You came to the hospital because you were short of breath. This was thought to be because of inflammation in your lungs that may have been related to your taxotere. Your prednisone was increased to 60 mg daily. This will be adjusted by Dr. [First Name (STitle) 1058] and Dr. [Last Name (STitle) 10777] next week. They may arrange for a repeat CT scan and pulmonary function tests. Other medication changes: - Bactrim was started - Omeprazole was started - Senna and colace were started - lasix was decreased - Metoprolol and imdur were stopped because of low blood pressure. These may need to be restarted by your primary care physician if your blood pressure is higher. Please call your doctor or return to the emergency room if you have wrosening shortness of breath, chest pain, fevers and chills, or other symptoms that are concerning to you. Followup Instructions: Please have your coumadin level checked on [Last Name (LF) 766], [5-1]. Please follow up with your oncologist and your primary care physician: Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2152-5-4] 11:00 Provider: [First Name11 (Name Pattern1) 2946] [Last Name (NamePattern4) 3217], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2152-5-4] 11:00 Provider: [Name10 (NameIs) 10778] [Name11 (NameIs) 10779], MD Phone:[Telephone/Fax (1) 1144] Date/Time:[2152-5-24] 9:20 [Name6 (MD) ] [Name8 (MD) 490] MD, [MD Number(3) 491] Completed by:[2152-5-2] ICD9 Codes: 5119, 4280, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7804 }	Medical Text: Admission Date: [2203-2-18] Discharge Date: [2203-2-24] Date of Birth: [2123-12-6] Sex: M Service: MEDICINE Allergies: Lisinopril / Macrobid / metformin Attending:[First Name3 (LF) 603] Chief Complaint: Flank pain Major Surgical or Invasive Procedure: [2203-2-18] - Left nephrostomy tube replacement [2203-2-18] - Mechanical ventilation during nephrostomy replacement [2203-2-18] - Central venous line placement in right internal jugular vein History of Present Illness: 79yo male w/ dCHF, COPD, OSA on CPAP and metastatic, castrate resistant prostate cancer who comes in with left-flank pain and fevers. Two days ago he was feeling well. Yesterday he developed fevers and left flank pain. Overnight he had nausea with a small amount of non-bloody emesis. No diarrhea, he has actually been constipated. He came into the ED. Of note, he had a nephrostomy tube placed [2-9] by interventional radiology because of hydronephrosis on CT scan. . In the ED, initial VS were: 102.0 109 145/71 24 96%. Triggered for tachycardia. Given 3L IV fluids. A CT scan his nephrostomy tube was out of place, with resultant hydronephrosis and surrounding fat-stranding concerning for pyelonephritis. He was given vanc/zosyn. A right IJ was placed. Is making urine, with negative UA. No foley in place. 110, 132/64, 30, 97% on RA. . On arrival to the MICU, patient alert, oriented, but tachypneic. He confirmed that he had been feeling unwell since yesterday, with left flank pain that is much worse with movement, but no pain elsewhere. He was unable to lie flat. He was intubated for nephrostomy replacement. He was unable to provide further ROS. Past Medical History: Adenocarcinoma of the prostate - metastatic, androgen resistant Benign Prostatic Hypertrophy s/p TURP with GreenLight [10-9] COPD - FEV1 67% predicted in [2198] Low back pain Type II Diabetes Diastolic Congestive Heart Failure Coronary Artery Disease: Mild, reversible inferior wall defect on stress MIBI [6-6]; [9-11] cath showed microvascular disease Hypertension GERD Obstructive Sleep Apnea on CPAP (intermittently) Migraine Headaches Hypercholesterolemia s/p CCY [12-11] Social History: The patient has never smoked. He previously used alcohol but quit many years ago. He is married and lives with his wife. From the [Country 13622] Republic with 9 children. He previously worked in agriculture but is now retired. Family History: His mother is deceased and had heart disease. His father is also deceased but had no health problems to the patient's knowledge. Physical Exam: Admission exam: Vitals: T: 101 BP: 130/60 P: 83 R: 22 O2: 94%RA General: Alert, oriented, moderate respiratory distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, JVP difficult to appreciate, no LAD CV: Regular rate, tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, basilar crackles posteriorly. Abdomen: soft, left flank very tender. Obese with mild abdominal distention. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. Trace L>R edema. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation. Discharge exam - unchanged from above, except as below: General: Alert, comfortable, no resp distress CV: RRR, no m/r/g Back: left sided nephrostomy tube in place Pertinent Results: Admission labs: [2203-2-18] 10:40AM BLOOD WBC-11.8* RBC-3.83* Hgb-10.6* Hct-31.0* MCV-81* MCH-27.7 MCHC-34.1 RDW-14.1 Plt Ct-276 [2203-2-19] 04:39AM BLOOD PT-12.6* PTT-33.5 INR(PT)-1.2* [2203-2-18] 10:40AM BLOOD Glucose-153* UreaN-35* Creat-1.8* Na-131* K-5.3* Cl-94* HCO3-23 AnGap-19 [2203-2-18] 10:40AM BLOOD ALT-38 AST-74* AlkPhos-113 TotBili-0.9 [2203-2-19] 04:39AM BLOOD Calcium-8.0* Phos-6.5* Mg-2.2 [2203-2-18] 10:20AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.007 [2203-2-18] 10:20AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG Discharge labs: [2203-2-24] 07:38AM BLOOD WBC-7.3 RBC-3.18* Hgb-8.6* Hct-25.9* MCV-82 MCH-27.1 MCHC-33.2 RDW-14.3 Plt Ct-334 [2203-2-24] 07:38AM BLOOD Glucose-93 UreaN-31* Creat-1.5* Na-140 K-3.4 Cl-103 HCO3-26 AnGap-14 [2203-2-24] 07:38AM BLOOD Calcium-7.2* Phos-3.4 Mg-2.1 Micro: -UCx ([2203-2-18]): URINE CULTURE (Final [2203-2-22]): MORGANELLA MORGANII. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ MORGANELLA MORGANII \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- <=1 S 2 S CEFTAZIDIME----------- <=1 S 4 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 1 S <=0.25 S GENTAMICIN------------ =>16 R 2 S MEROPENEM-------------<=0.25 S 0.5 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R -UCx ([2203-2-18]), from nephrostomy tube: (L) PARCUTANEOUS NEPHROSTOMY TUBE. FINAL REPORT [2203-2-21] URINE CULTURE (Final [2203-2-21]): PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S -BCx ([2203-2-18]): No growth final Imaging: -CT Abd/Pelvis ([2203-2-18]): IMPRESSION: Misplaced left percutaneous nephrostomy catheter with the pigtail coiled in the lateral perinephric fat. 2. Moderate-to-severe left hydroureteronephrosis with extensive perinephric fat stranding and pararenal fascial thickening. This could represent pyelonephritis in a closed urinary collecting system, or post-surgical changes from the recent procedure and displacement of the catheter. 3. Stable thickening of the soft tissues adjacent to the prostate, likely representing prostate cancer, with unchanged paraaortic mass causing left reteric malignant obstruction. 4. Sclerotic appearance of right posterior 10th rib and adjacent pedicle of the T10 vertebra, with increased uptake seen on bone scan in [2201], which may represent an old traumatic injury, however, is also concerning for metastatic disease given the patient's history of metastatic prostate cancer. Routine followup with bone scan is recommended. -AP CXR ([2203-2-18]): enlarged heart. Bibasilar opacities, likely atelectasis. Worsening congestion. -KUB ([2203-2-19]): There is some overlying artifact and motion on the study. A percutaneous nephrostomy tube appears to be projecting over the left mid abdomen. No nasogastric tube or Foley catheter is visualized. Calcification in the right hemipelvis is felt to most likely represent a phlebolith. Degenerative changes are seen in the spine. No acute bony abnormality. There is scattered air in nondistended loops of colon. -KUB ([2203-2-22]): Unchanged left nephrostomy tube position. Brief Hospital Course: 79yo male with dCHF, COPD, OSA on home CPAP and metastatic prostate cancer causing left-sided hydronephrosis who presents with displacement of his nephrostomy tube and pyelonephritis with sepsis. # Pyelonephritis with sepsis: At admission, the patient was started on broad spectrum antibiotics with vanc/zosyn and his nephrostomy tube was replaced by IR. A foley was placed which required a guidewire and assistance by [Month/Day/Year ] given his prostate cancer and large prostate. His urine culture (from the replaced nephrostomy tube) showed pansensitive Pseudomonas. Antibiotics were narrowed to cipro which he will receive for a total of 14 days, course to be finished after discharge. Given his sepsis and chronic steroid use at home he was given stress dose steroids which were eventually tapered back to his home dose of hydrocortisone. At discharge, he still has a 3-way Foley in place and will follow-up with his urologist as an outpatient for a voiding trial. # Leaking nephrostomy tube: IR was [Month/Day/Year 653] prior to discharge regarding leaking of urine from around the nephrostomy tube. This was not improved after flushing the tube with 15cc of NS. We considered a nephrostogram to ensure proper placement of the tube, however IR felt the tube was correctly placed based on a KUB that was obtained. They did not want to perform the nephrostogram given that he would have to lie prone and required intubation for this last time. The nephrostomy tube continued to drain urine into the collection bag at the time of discharge. # Tachypnea/respiratory failure: The patient was intubated upon arrival to the MICU for his nephrostomy tube change, which required him to lie prone. His tachypnea was thought to be due to primarily CHF. Also may have a component of baseline COPD. He was started back on his home lasix once his sepsis improved and continued on his home combivent, advair, montelukast. He was extubated soon after the nephrostomy tube was replaced and remained on room air at the time of discharge. # Acute on chronic diastolic CHF: The patient was found to be congested on CXR and exam, he was also significantly orthopneic. He was intubated for his procedure as above. He was restarted on his home dose of Lasix after his sepsis improved and continued on his home metoprolol. # Metastatic prostate cancer: Currently on ketoconazole and hydrocortisone at the time of admission. Despite this therapy, his PSA was found to have doubled over the past month. His outpatient oncologist, Dr. [Last Name (STitle) 1365], was [Last Name (STitle) 653] during this admission. He continued to receive palliative radiation during his admission. After his renal function improved, he was restarted on his home dose of gabapentin. # Diabetes: His metformin was held and he was covered with an insulin sliding scale. Ta discharge, he was restarted on metformin. # Coronary artery disease: Continued home aspirin, rosuvastatin, beta blocker. # Depression: Continued home dose of fluoxetine # Transitional issues: -Will follow-up with his urologist regarding removal of his Foley catheter -Will follow-up with his oncologist regarding his metastatic prostate cancer and alternative treatment options given that his PSA continued to rise on the current regimen -Amlodipine was held at discharge given SBP of 110-120, BP control should be re-evaluated as an outpatient -He will continue Cipro PO after discharge for a total 14 day course Medications on Admission: - albuterol 90mcg 2puffs QID - albuterol nebs - amlodipine 5mg daily - finasteride 5mg daily - fluoxetine 20mg daily - fluticasone 100 mcg nasal daily - Advair 500/50mcg 1 puff [Hospital1 ] - furosemide 80mg daily - gabapentin 300mg QHS - hydrocortisone 20mg QAM, 10mgQPM - ketoconazole 400mg [Hospital1 ] - loratadine 10mg daily - lorazepam 0.5mg 1-2 tabs QHS - metformin 500mg [Hospital1 ] - metoprolol succinate 50mg Q24hr - montelukast 10mg daily - omeprazole 40mg daily - rosuvastatin 20mg daily - tiotropium 18mcg daily - tramadolol 50mg 1-2 tabs QID - Aspirin 81mg daily - ferrous sulfate 325mg [Hospital1 ] - senna 8.6mg 2 tabs daily Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) sprays Nasal once a day: Each nostril. 5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime. 8. hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 9. hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO Each afternoon. 10. ketoconazole 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime. 13. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 14. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 15. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 17. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 19. tramadol 50 mg Tablet Sig: 1-2 Tablets PO four times a day. 20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 21. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 22. senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day. 23. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation four times a day as needed for shortness of breath or wheezing. 24. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 25. ammonium lactate 12 % Cream Sig: One (1) application Topical twice a day. 26. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 27. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days: Last dose on [2203-3-4]. Disp:16 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary diagnoses: Sepsis Pyelonephritis Urinary tract infection Secondary diagnoses: Metastatic prostate cancer Chronic obstructive pulmonary disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or [Hospital ]). Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you during your admission to [Hospital1 18] for left flank pain and displaced nephrostomy tube. You were found to have sepsis from an infection in your kidney. Your left nephrostomy tube was replaced and you were treated with IV antibiotics. You were initially admitted to the ICU and were then transferred to the floor after your condition improved. A Foley catheter was placed at admission. This will remain in place until you see your urologist on Monday [2203-2-28], at which time they will attempt to remove it. You also continued to receive radiation treatments during your admission. We stopped your amlodipine because your blood pressure was normal without it. Please discuss this your PCP at [Name9 (PRE) 702]. The following changes were made to your medications: START Cipro 500mg twice daily for 9 more days (last dose on [2203-3-4]) STOP amlodipine until you are seen by your PCP in [Name9 (PRE) 702] Followup Instructions: Department: [Hospital3 249] When: FRIDAY [2203-2-25] at 3:25 PM With:DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] (works on Dr. [Last Name (STitle) 52249] team) Phone:[Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SURGICAL SPECIALTIES When: MONDAY [2203-2-28] at 4:30 PM With: [First Name8 (NamePattern2) 161] [Name6 (MD) 162] [Name8 (MD) 163], MD [Telephone/Fax (1) 164] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/[Hospital Ward Name ] When: TUESDAY [2203-3-8] at 1:30 PM With: [First Name11 (Name Pattern1) 2946] [Last Name (NamePattern4) 3217], MD [Telephone/Fax (1) 10784] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage We are working on a sooner follow up appointment with Dr. [Last Name (STitle) ] than the scheduled appointment of [3-8] as seen above. You will be called at home with that appointment. If you have not heard within 2 business days or have questions, please call [Telephone/Fax (1) 10784**]. ICD9 Codes: 4280, 496, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7805 }	Medical Text: Admission Date: [2181-4-24] Discharge Date: [2181-5-24] Date of Birth: [2104-9-3] Sex: M Service: ADMISSION DIAGNOSIS: Esophageal carcinoma. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 7635] is a 76-year-old male who was noted to adenocarcinoma of the esophagus on routine surveillance esophagoscopy for known [Doctor Last Name 15532] esophagus. At the time of the discovery, the patient was asymptomatic; not having experienced any weight loss or any dysphagia. PAST MEDICAL HISTORY: 1. Hypertension. 2. Gout. 3. Mild aortic stenosis. 4. Seizures secondary to medications. 5. Gastroesophageal reflux disease. PAST SURGICAL HISTORY: Past surgical history is significant for Nissen fundoplication in [2163]. MEDICATIONS ON ADMISSION: 1. Norvasc 10 mg p.o. once per day. 2. Lipitor 20 mg p.o. once per day. 3. Prevacid 30 mg p.o. once per day. 4. Allopurinol 300 mg p.o. once per day. 5. Hydrochlorothiazide 25 mg p.o. once per day. 6. Glucosamine. 7. Potassium chloride. ALLERGIES: Allergies included ATENOLOL. SOCIAL HISTORY: Social history was significant for social alcohol use, and no tobacco use. FAMILY HISTORY: There is no family history of cancer. Mr. [Known lastname ] father passed away at the age of 42 years of a stroke. PHYSICAL EXAMINATION ON PRESENTATION: Initial physical examination revealed Mr. [Known lastname 7635] was a well-appearing gentleman in no acute distress. His sclerae were anicteric. Pupils were equally reactive to light and accommodation. His extraocular muscles were intact. His oropharynx was pink and moist with no lesions. His neck was supple with no thyromegaly or lymphadenopathy. His chest was symmetric with no palpable masses. His lungs were clear to auscultation bilaterally. His heart showed a regular rate and rhythm with a grade 2/6 systolic ejection murmur; consistent with aortic stenosis. His abdomen was soft, nontender, and nondistended. No palpable masses. No guarding. No rebound. No hepatosplenomegaly. Cranial nerves II through XII were intact as was his gross neurologic status. He was alert and oriented to person, place, and time. His range of motion and strength in both the upper and lower extremities were normal. His skin showed no pathology. HOSPITAL COURSE: Mr. [Known lastname 7635] was admitted to the operating room on [2181-4-24] where he [Year (4 digits) 1834] an Ivor-[Doctor Last Name ] esophagectomy. Please refer to the dictated Operative Note for full details of this procedure. The patient was transferred postoperatively to the Surgical Intensive Care Unit intubated and on Levophed for support of his blood pressure. He had a preoperatively placed epidural for pain control; which at the time contained only narcotic medications. He was transfused 2 units of packed red blood cells intraoperatively and proceeded to receive multiple fluid boluses postoperatively for decreases in urine output. On postoperative day one, he continued to have labile blood pressures and the requirement of pressors (namely Levophed) to help maintain this. On postoperative day two, he was found to have some degree of pulmonary deterioration as his PCO2 continued to rise. However, his urine output did improve. At this time, Mr. [Known lastname 7635] also had episodes of atrial fibrillation. On postoperative day three, the Levophed drip was turned off as the patient's blood pressure stabilized. With the discontinuation of the Levophed, the patient's oxygenation also improved. On postoperative day four, the patient continued to be intubated and sedated but showing improvement in cardiac index as well as improvement in urine output. He continued with his Dilaudid epidural at this time. Tube feeds were started on postoperative day five by jejunostomy tube with the patient receiving Impact with fiber at 30 cc per hour. Later on postoperative day five, the patient was found to have a worsening PO2, for which Lasix was given. The patient's blood pressure remained stable, and with diuresis the patient's oxygenation improved. On postoperative day six, the patient continued to require further diuresis as he would occasionally have oxygen desaturations on turning. His tube feeds were raised to 40 cc per hour on this day. Also during this time, the patient was found to have a pneumonia by chest x-ray, and a sputum culture was positive for Klebsiella which was pan-sensitive. He remained intubated and stable over the next number of days. Mr. [Known lastname 7635] continued to be intubated and sedated with active diuresis and was started on levofloxacin for his pneumonia. He did require occasional suctioning for desaturations as he respiratory status continued to fluctuate. The patient was concurrently followed in consultation by the Cardiology Service due to his atrial fibrillation and previously existing aortic stenosis. The patient remained intubated and sedated on postoperative day 17. At this time, he was continuing on his tube feeds as well as Levaquin for pneumonia. At this time, he was not following commands. Due to the prolonged course of intubation, on postoperative day 17, a tracheostomy was performed on the patient. He tolerated the procedure well. He was started on Coumadin on postoperative day 19 due to his prolonged atrial fibrillation. At this time, his tube feeds were running at his goal nutritional rate. Over the ensuing days, the patient began to slowly follow commands as given to him by the surgical team and Physical Therapy. His respiratory status remained stable via tracheostomy tube, and the patient was continued on Levaquin. On postoperative day 27, Mr. [Known lastname 7635] [Last Name (Titles) 1834] a bedside swallowing evaluation; however, this study could not be evaluated as the patient refused to swallow liquids given to him. He was elevated by Physical Therapy on multiple occasions who deemed him to require a stay in an acute rehabilitation facility in order to build strength and mobility and to gain independence with activities of daily living. By on postoperative day 29, his respectively and hemodynamic status were stable and improved enough for transfer to the regular patient floor. The patient was tolerating his tube feeds without nausea or vomiting, and return of bowel function was indicated by bowel movements. At this time, the patient continued to receive daily doses of Coumadin with intravenous heparin for anticoagulation due to his atrial fibrillation. By postoperative day 30, the patient was deemed stable and ready for transfer to an acute care rehabilitation facility where he could continue to receive tracheostomy care as well as tube feeds. The patient will require remaining nothing by mouth at this time and will require daily INR checks as he is receiving daily Coumadin until his INR has reached a therapeutic level; per his prolonged and continued atrial fibrillation. At this time, the heparin drip may be discontinued. DISCHARGE DISPOSITION: The patient was to go to an acute care rehabilitation facility. DISCHARGE DIET: The patient is nothing by mouth at this time and is receiving Impact with fiber (full strength) at 80 cc per hour. DISCHARGE ACTIVITY: The patient's activity is to be restricted, and he require extensive help with Physical Therapy and Occupational Therapy to regain strength and mobility as well as independence with his activities of daily living. MEDICATIONS ON DISCHARGE: 1. Levofloxacin 500 mg via jejunostomy tube once per day. 2. Reglan 10 mg via jejunostomy tube three times per day. 3. Zantac 150 mg via jejunostomy tube once per day. 4. Lopressor 12.5 mg via jejunostomy tube twice per day. 5. Regular insulin sliding-scale. 6. Acetaminophen liquid 650 mg jejunostomy tube q.4-6h. as needed. 7. NPH insulin 20 units subcutaneously q.12h. 8. Coumadin (dose to be adjusted per the patient's INR which need to be continually checked on a daily basis). DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with Dr. [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) ]. The physician should be called in order to schedule an appointment (date and time). [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 6066] Dictated By:[Name8 (MD) ] MEDQUIST36 D: [2181-5-24] 13:50 T: [2181-5-24] 14:48 JOB#: [Job Number 49350] ICD9 Codes: 5185, 4241, 4019, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7806 }	Medical Text: Admission Date: [2134-10-25] Discharge Date: [2134-10-25] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: dyspnea, hypotension Major Surgical or Invasive Procedure: attempted subclavian triple lumen catheter History of Present Illness: 83yo woman with medical history significant for HTN, IDDM, CAD s/p MI and peripheral vascular disease with recent bilateral toe amputations presented from nursing home with complaints of dyspnea. She was noted there to have oxygen saturation of 58-66% on room air. She was given albuterol. . Initial vitals in [Hospital1 18] ED were 99.8, 67, 68/22, 14, and 100% on 2Lnc. Initial potassium was 6.4, and she was given calcium gluconate, insulin/d50, one amp of bicarbonate, and keyexalate 30cc po once. She was also given decadron 6mg once IV given hypotension and recent history of steroid taper at nursing home. Also given ASA 81mg po x 4. Given vanco 1g/levaquin 500mg/flagyl 500mg. BP increased to 100's systolic after 1.5L in NS bolus. Bedside TTE was done, and demonstrated global hypokinesis with an EF of 20-25%. Trop was elevated at 1.45 with flat CK. Also noted transaminitis. . On limited review of systems here in [Hospital Unit Name 153], she does endorse dyspnea, but does not elaborate on this. Denies any chest pain. Denies any recent fevers/chills or other infectious symptoms. Her daughters are present for interview, and they report that she has had progressive dementia with recent placement in a nursing home. Past Medical History: 1. IDDM 2. Hypertension 3. CAD, s/p MI 4. h/o CVA 5. peripheral vascular disease with recent toe amputations ([8-18]) 6. h/o UTI's 7. Neuropathy 8. h/o osteomyelitis 9. h/o cord compression Social History: Details obtained from daughters. They report that she has had progressive dementia and has been living in nursing home for this reason with minimal self-care. Family History: - Physical Exam: vitals: (in [Hospital Unit Name 153]) 97.2, 69, 138/73, 16, 100% on 50% cool neb mask . gen: alert; minimally oriented. No acute distress. No respiratory distress. heent: sclera anicteric neck: no JVD appreciated; full neck habitus cv: regular rate, rhythm. No m/r/g resp: bibasilar decreased breath sounds with inspiratory crackles abd: obese, NABS, soft, NT extr: 1+ symmetric edema bilaterally; bilateral toe amputations; extremities are warm with no mottling. neuro: no focal deficits. Pertinent Results: Admit data/imaging: AP SEMI-ERECT PORTABLE CHEST X-RAY: The cardiac silhouette is grossly enlarged with left ventricular and right atrial prominence. The aorta contains intramural calcifications. There is mild pulmonary vascular redistribution with layering peural effusions bilaterally. The surrounding soft tissue and osseous structures are unremarkable. IMPRESSION: CHF. Cardiomegaly. An underlying pneumonia cannot be excluded. . Admission EKG: Sinus rhythm at 67bpm with normal axis, intervals. Notable for 1mm ST depression in I and aVL; also with TWI in V1, V2; also minimal 1mm upsloping ST elevation in III and aVF. Brief Hospital Course: Impression/Plan: 83yo woman with h/o IDDM, HTN, CAD s/p MI admitted with complaints of dyspnea and hypotension. . 1. Hypotension - Differential includes cardiogenic (with ischemia history and evidence of global hypokinesis), hypovolemic, neurogenic, septic (supported by evidence of UTI, elevated WBC count with neutrophilic predominance, tachypnea, elevated lactate), and adrenal insufficiency (given recent steroid taper). - Overall, clinical exam not consistent with cardiogenic shock; no JVD appreciated, and extremities are warm and well perfused. - Suspect rather distributive shock with contributions from likely urosepsis and consideration of adrenal insufficiency. . - will place central venous access - bolus for CVP goal [8-25] - pressors as needed for MAP > 65 - will continue broad spectrum antibiotics - most likely source is urinary tract; consider toe amputation site/wound infection as potential source. - follow pan-cultures and tailor accordingly - check [Last Name (un) 104]-stim, then start stress dose steroids . 2. Dyspnea - Given h/o likely ischemic cardiomyopathy and bedside echo showing very significant global hypokinesis with EF of 20% and CXR findings consistent with pulmonary edema, most likely etiology of initial dyspnea and ongoing hypoxia is congestive heart failure. - question whether elevated troponin may represent recent ischmic event or events that may explain her worsening congestive heart failure. - unclear as to whether she has been following sodium restriction and being adherent to her medication regimen. . 3. Troponin elevation - With no active ischemic symptoms, non-diagnostic EKG changes (no baseline ekg for comparison), and flat CK, suggests that this is not an Acute coronary syndrome. - [Month (only) 116] rather represent troponin leak in setting of hypotension or residual troponin elevation after distant event with renal insufficiency. - Cardiology has been involved; not planning on any intervention for present time. - will cycle cardiac enzymes . 4. Renal failure - uncertain chronicity/acuity - check urine lytes, calculate FeNa - get renal US to evaluate for obstruction/hydronephrosis - r/o active urine sediment - try to obtain baseline labs . 5. Hyperkalemia - likely secondary to renal insufficiency in combination with ace-inhibitor - no acute EKG changes from hyperkalemia - s/p acute intervention with calcium, insulin/d50, bicarbonate, and kayexalate - persistent hyperkalemia; will continue kayexalate and monitor for any further EKG changes - hold ace-i . 6. Transaminitis/shock liver - progressive increase in transaminitis; with levels > 1000, likely secondary to hypoperfusion/shock liver with hypotensive episode. - likely some component of congestive hepatopathy as well. - will consider differential of extreme transaminitis and check for toxic injury/tylenol and acute viral hepatitis. . 7. Coagulopathy/? DIC - elevated INR; does not take coumadin - per med list from nursing home. - consider Disseminated intravascular coagulopathy vs. coagulopathy from liver synthetic dysfunction - low fibrinogen suggests DIC, but can be seen with hepatic synthetic dysfunction as well. - need to check hemolysis labs and peripheral smear for signs of intravascular hemolysis. - treat infectious process - give FFP prior to central line . 8. IDDM - marked hyperglycemia with high-normal anion gap - monitor FS and manage with sliding scale coverage; will consider Insulin gtt. . 9. Urinary tract infection/leukocytosis - follow up urine cultures, blood cultures - continue broad spectrum abx coverage . 10. Increased anion gap metabolic acidosis - likely contribution from lactic acidosis (lactate of 7.0 trending down to 4.0) as well as azotemia - will check ABG to further characterize acid/base status . 11. DNR/DNI - confirmed with daughter (who is health care proxy). . 12. Access: - Only peripheral IV for now; will need central access for transducing CVP, consideration of swan-ganz, and potential for pressors. - reverse coagulopathy with FFP for placement of central line. . 13. dispo - ICU - Several hours after admission to [Hospital Unit Name 153] (same day of admission via Emergency department), she became progressively bradycardic, hypotensive, and hypoxemic acutely. Central access was attempted, but she coded (pulseless and unresponsive) at this time. In total, she was given atropine 1mg x 2 for bradycardia. - No further intervention/resuscitation was done, as (discussed in depth with patient's two daughters/health care proxy on admission to [Name (NI) 153]) she was DNR/DNI. - She passed away at 4pm on [2134-10-25]. Family was notified, death paperwork was done, and medical examiner was notified (as death occurred within 24hrs of admission to hospital). Medical examiner heard case and denied any further investigation. - Family denied any post-mortem examination. Medications on Admission: ipratopium neb q4h prn albuterol neb q4h prn benadryl 25mg HS prn Zantac 150mg [Hospital1 ] Sudafed 30 TID x 48h Prednisone taper 30mg ([10-15] x 3 days), then 20qD x 3 days, then 10qD x 3 days, then 5qD x 3 days plavix 75mg qD Ritalin 2.5mg po BID Aricept 10mg HS Neurontin 300mg HS Lipitor 10mg HS senna xalatan opth 0.005% OU at HS Colace 100mg [Hospital1 ] ASA 81 daily Lisinopril 30mg qD Paroxetine 20mg qD Prilosec 20mg qD Prandin 1mg [Hospital1 ] Atenolol 75mg TID Heparin 5000 U SC TID Insulin - lantus d/c'd - regular insulin s/s coverage Discharge Medications: - Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: - Discharge Instructions: - Followup Instructions: - ICD9 Codes: 0389, 5990, 4280, 2762, 2767, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7807 }	Medical Text: Admission Date: [2138-2-7] Discharge Date: [2138-2-11] Date of Birth: [2091-2-17] Sex: M Service: ICU CHIEF COMPLAINT: Change in mental status. HISTORY OF PRESENT ILLNESS: A 46-year-old male with a history of hepatitis-C cirrhosis on the transplant list, now admitted with change in mental status. Per the family, the patient has been in his usual state of health, until two days prior to admission, when he became profoundly confused and somnolent after his lactulose was held prior to an elective cardiac catheterization on [2-4] for his liver transplant evaluation. Per his wife, the patient did not get lactulose on three consecutive days and started developing confusion two days prior to admission. He, also, had decreased PO intake at the time, but apparently no fever, chills, nausea or vomiting. He has been having no bright red blood per rectum, no black stools, and no hematemesis. He also has no chest pain, shortness of breath. There were no sick contacts at home. In the Emergency Department, despite multiple doses of Ativan and Haldol and PO lactulose, the patient's mental status did not improve. A nasogastric tube was not placed secondary to the patient's mental status and non-cooperation. The patient was admitted to the Medical ICU for management of encephalopathy, given the risk of self-harm and question of airway protection, as well as continued administration of lactulose. PAST MEDICAL HISTORY: 1. Hepatitis-C cirrhosis. The patient is on the transplant list status post interferon and ribavirin. His previous EGD's have shown no varices. 2. Hypertension. 3. History of nephrolithiasis. 4. Cryoglobulinemia. MEDICATIONS: 1. Diovan, 80 PO q d. 2. Magnesium oxide, 100 PO b.i.d. 3. Lactulose, two tablespoons PO q a.m. 4. Nexium, 40 mg PO q d. 5. Oxycodone, 5 mg PO b.i.d. p.r.n. 6. Ambien, 10 mg q h.s. 7. Lasix, 20 mg PO q d. 8. Aldactone, 50 mg PO q d. 9. Multivitamins. ALLERGIES: Codeine which gives him nausea and vomiting. SOCIAL HISTORY: He works as a substance abuse counselor. He is married. He has a history of heavy alcohol use in the past. PHYSICAL EXAMINATION: Temperature 98.8, heart rate 100, blood pressure 118/66, respiratory rate 20, saturation 100 on room air. General: An agitated male, struggling in bed. HEENT: Anicteric sclerae. Dry mucous membranes. Nose mildly bloody. Cardiovascular: S1, S2. Tachycardiac. No murmurs. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender. There is no evidence of caput medusae. Liver is palpated about 2 cm below the costal margin. Extremities: Palm erythema and asterixis. There is no edema. Skin: Telangiectasias. Neuro: Alert and agitated and not oriented to place and time. Uncooperative with neuro exam. LABORATORY/DIAGNOSTICS: Laboratories on admission reveal a white count of 6.5, hematocrit 35, platelets 114. Initial electrolytes: Sodium of 130, potassium of 6, chloride 104, bicarbonate 20, BUN 31, creatinine 1.4. Initial ammonia level was 240. BRIEF HOSPITAL COURSE: 1. Hepatic encephalopathy: Upon arrival in the ICU, NG tube was placed and the patient was started on aggressive lactulose regimen. After about two days, his mental status significantly improved. The patient was oriented to time and place, recognized family members, and was cooperative and conversant with the ICU staff. 2. Acute renal failure: Creatinine was 1.4 up from 0.8, most likely secondary to prerenal azotemia. Urine electrolytes confirmed that. His ............ were being withheld and he received some IV fluids which led to eventual improvement in his renal function. 3. Nephrolithiasis: During his ICU stay, the patient developed acute onset of groin pain which he said resembles his previous episodes of nephrolithiasis. A KUB was obtained, but that was nondiagnostic. An abdominal ultrasound revealed two stones, one a 5 mm stone in the right inferior kidney which showed no evidence of hydronephrosis and was consistent with old stone in that same area. He, also, had a second new stone in his bladder with no evidence of hydroureter. The second stone was 3 mm. Given the patient had a mild amount of pain, it was felt he could manage his condition at home. He was advised to drink plenty of fluids and strain his urine with the hope of obtaining the stone and submitting it to chemical analysis as an outpatient. 4. Hypertension: His antihypertensives were being held, given he was dehydrated upon arrival. He is discharged on his outpatient regimen. 5. Hepatitis-C cirrhosis: The patient is on the transplant list. LFT's remained stable during this admission. Coags remained stable. DISCHARGE MEDICATIONS: 1. Diovan, 80 PO q d. 2. Mag-Ox, 400 PO q d. 3. Lactulose, two tablespoons b.i.d. and titrate to two to three bowel movements a day. 4. Nexium, 40 PO q d. 5. Oxycodone, p.r.n. 6. Ambien, 10 mg q h.s. 7. Lasix, 20 mg PO q o.d. 8. Aldactone, 50 mg PO q o.d. 9. Flagyl, 250 mg PO q d. DISPOSITION: Discharged to home. DISCHARGE CONDITION: Dramatically improved since arrival with clearing in mental status. DISCHARGE DIAGNOSES: 1. Hepatic encephalopathy. 2. Cirrhosis secondary to hepatitis-C. 3. Hypertension. 4. Acute renal failure. 5. Nephrolithiasis. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. Dictated By:[Name8 (MD) 5094] MEDQUIST36 D: [2138-2-11] 19:39 T: [2138-2-11] 20:18 JOB#: [Job Number 25447] ICD9 Codes: 5849, 5715, 2875, 2761, 2765
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7808 }	Medical Text: Admission Date: [2133-9-7] Discharge Date: [2133-9-14] Date of Birth: [2058-3-25] Sex: F Service: ORTHOPAEDICS Allergies: Demerol / Epinephrine / Fosamax / Latex / Dilaudid Attending:[First Name3 (LF) 3190] Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: Anterior fusion [9-7] T11-L1 Posterior fusion T4-L5 History of Present Illness: Ms. [Name14 (STitle) ] has a long history of back and leg pain. She has attempted conservative therapy including physical therapy and has failed. She now presents for surgical intervention. Past Medical History: Multiple compression fractures, not surgical candidate b/l hip and ankle ulcers Chronic diarrhea Colonic polyps Hx of GIB [3-7] ulcers HTN Fibromyalgia Hypothyroidism Glaucoma Cataracts "Irregular heartbeat" h/o benign fallopian tumor, removed [2085] SBO [3-7] adhesions [2117] IBS Gastritis Social History: Was living at [Doctor Last Name ], now in rehab after recent hospitalization. Smoked for 50 years, currently smoking 3 cigaretts/day. Denies alcohol/illicit drug use. Family History: [Name (NI) 74312] [Name (NI) 74313] Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [Doctor Last Name 937], reflexes symmetric at biceps, triceps and brachioradialis BLE- good strength at hip flexion/extension, knee flexion/extension, decreased strength ankle dorsiflexion and plantar flexion, [Last Name (un) 938]/FHL; sensation diminished; - clonus, reflexes symmetric at quads and Achilles Pertinent Results: [2133-9-14] 09:30AM BLOOD WBC-8.9 RBC-3.71* Hgb-11.3* Hct-32.9* MCV-89 MCH-30.4 MCHC-34.3 RDW-14.5 Plt Ct-284 [2133-9-13] 09:30AM BLOOD WBC-11.9* RBC-3.99* Hgb-12.2 Hct-35.0* MCV-88 MCH-30.5 MCHC-34.8 RDW-14.6 Plt Ct-218# [2133-9-11] 02:48AM BLOOD WBC-10.0 RBC-3.50* Hgb-10.9* Hct-30.9* MCV-88 MCH-31.1 MCHC-35.3* RDW-15.0 Plt Ct-99# [2133-9-10] 02:11AM BLOOD WBC-8.2 RBC-3.61 Hgb-11.1* Hct-31.5* MCV-87 MCH-30.7 MCHC-35.2* RDW-15.2 Plt Ct-58* [2133-9-14] 09:30AM BLOOD Glucose-175* UreaN-9 Creat-0.3* Na-135 K-3.4 Cl-99 HCO3-26 AnGap-13 [2133-9-13] 09:30AM BLOOD Glucose-200* UreaN-6 Creat-0.4 Na-135 K-3.3 Cl-99 HCO3-26 AnGap-13 [2133-9-11] 02:48AM BLOOD Glucose-99 UreaN-6 Creat-0.4 Na-139 K-3.6 Cl-102 HCO3-32 AnGap-9 Brief Hospital Course: Ms. [Known lastname 33172] was admitted to the service of Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 363] for a thoracolumbar fusion. She was informed and consented and elected to proceed. Please see Operative Note for procedure in detail. Post-operatively she was given antibiotics and pain medication. She was transfer3d to the T/SICU for blood loss anemia and neuro checks. She was extubated POD 2 and had no further difficulty. A hemovac drain was placed intra-operatively and this was removed POD 3. Her bladder catheter was removed POD 3 and her diet was advanced without difficulty. She was able to work with physical therapy for strength and balance. She was discharged in good condition and will follow up in the Orthopaedic Spine clinic. Medications on Admission: Protonix 40mg', Levoxyl 100mcg', lovastatin 20mg', clonazepam 2mg', zyprexa 10mg', Amitryptilne 50mg', Asacol 800mg''', Lidoderm patch, Fentanyl patch 100mcg q72, Celebrex 200mg" Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed. 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 8. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 11. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for insomnia. 15. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for HTN. 18. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Thoracic kyphosis Post-op anemia Discharge Condition: Good Discharge Instructions: Please continue to take your pain medication with an over the counter laxative. Call the clinic should you experience any redness, swelling or discharge at the incision site. Call the clinic if you experience a temperature greater than 101 degrees. Do not smoke. Do not lifting anything greater than a gallon of milk. Call the clinic for any additional concerns. Physical Therapy: Activity: Out of bed w/ assist Thoracic lumbar spine: when OOB Treatments Frequency: Please continue to change the dressings daily with dry, sterile gauze. Followup Instructions: Please follow up in the Orthopaedic Spine clinic during your previously scheduled appointments. Call [Telephone/Fax (1) 11061] to confirm your post-operative appointments. Completed by:[2133-9-14] ICD9 Codes: 2851, 2449, 4019, 2875, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7809 }	Medical Text: Admission Date: [2153-5-14] [Year/Month/Day ] Date: [2153-5-16] Date of Birth: [2089-12-13] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Indomethacin / Actonel / Reglan Attending:[First Name3 (LF) 3561] Chief Complaint: Hypoxia and hypotension s/p thoracentesis Major Surgical or Invasive Procedure: None History of Present Illness: 63 F with NASH cirrhosis, recurrent pleural effusions, DM, ESRD on TTS schedule who was sent to the ER after 2 liter thoracentesis done by radiology. Her oxygen saturation dropped to the high 80s and she was transiently hypotensive to 80s systolic. She denied lightheadedness, dizziness, chest pain, nausea, diaphoresis, her only complaint was of pleurisy on inspiration. In the ER her blood pressure was stable in the 90s systolic (b/l 90-100s), CXR with no PTX, 99% 4L/NC. Clinically without complaints, asking for food. Guiaic negative. No other complaints. No fluids given. Admitted to MICU for close observation of hemodynamics. . Review of systems is otherwise negative other than HPI. In the ICU she had no complaints other than pleurisy. Past Medical History: NASH cirrhosis: Liver bx [2152-9-6] = Stage IV cirrhosis, Grade 2 inflammation, complicated by portal HTN --Esophageal varicies (grade I and II, s/p banding), s/p TIPS in [9-15] --History of encephalopathy --History of ascites - Anemia - Thrombocytopenia - ESRD on HD due to diabetes and contrast-induced nephropathy - Type 2 diabetes with retinopathy, nephropathy, and neuropathy - History of C. difficile infection - History of seizures - Small left frontal meningioma - Hypertension - GERD - OSA - Leg cramps/? RLS - DJD of neck - History of dermoid cyst - Right adrenal mass . Past Surgical History: - Status post cholecystectomy followed by tubal ligation - Status post left oopherectomy - Status post appendectomy . Past Psychiatric History: Depression first experienced in high school. First hospitalization in [2131] (after husband's death). History of cutting and burning self. History of overdose. One course of ECT in past that was helpful. Social History: Social History: Widowed, lived in [Hospital3 ] although most recently has been at rehab. Has 4 children, several in MA. Smoking: None EtOH: Never Illicits: None Family History: Family History: Mom: CAD, stroke Dad: HTN, DM Physical Exam: Tmax: 36.7 ??????C (98 ??????F) Tcurrent: 36.7 ??????C (98 ??????F) HR: 58 (56 - 62) bpm BP: 98/34(49) {76/34(47) - 100/47(59)} mmHg RR: 15 (11 - 15) insp/min SpO2: 97% General Appearance: No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : RLL), (Breath Sounds: Diminished: RLL) Abdominal: Soft, Non-tender, Bowel sounds present, Distended, ascites present Extremities: Right: 1+, Left: 1+ Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed Pertinent Results: COMPARISON: [2153-4-29]. FINDINGS: There is no pneumothorax. There is small residual pleural effusion on the right. Left lung is clear. There is no left effusion. Heart and mediastinal contours are stable. Right-sided tunneled catheter is again noted, and the tip is situated within the right atrium. A tip is noted, and projects over the expected location within the liver. Osseous structures are stable. IMPRESSION: No pneumothorax. ------------ [5-15] CHEST PORTABLE AP REASON FOR EXAM: 63-year-old woman with re-expansion pulmonary edema, assess change. Since yesterday, right middle lobe and right lower lobe alveolar opacity decreased. Bilateral pleural effusions are unchanged, still small, more marked on the right. Right hemodialysis catheter still ends in the right atrium. Clips in the upper abdomen are unchanged. There is no other change. Brief Hospital Course: 63 F with cirrhosis, ESRD s/p thoracentesis who presents with hypoxia and hypotension in setting likely re-expansion pulmonary edema . #. Hypoxia- patient currently 99% on 2L and comfortable. Suspect she had some desaturation in setting of re- expansion edema which has stabilized. No evidence of pneumothorax on multiple CXR, there is re-accumulation of fluid in the right lung. She was monitored for 48 hours in the ICU and had stable blood pressure and oxygen saturation on 2 liters of oxygen. She was discharged to rehab facility. She should have future thoracentesis by interventional pulmonary in order to follow trans pulmonary pressures to avoid re-expansion pulmonary edema. . # Hypotension- patient back to baseline, suspect transient hypotension in setting volume shifts after thoracentesis. Baseline systolic pressure 90s. . # ESRD- [3-12] diabetes, continue phos binder, was dialyzed on [5-15] with 3 liters removed. - call renal in AM, due for HD - continued midodrine with HD . # Cirrhosis- on transplant list - Encephalopathy- continued lactulose and rifaximin - SBP- h/o prior SBP, continued Bactrim DS ppx - ascites- off diuretics, intermittent PC as indicated, none this hospitalization - varices- nadolol - anemia- cont PPI . # Diabetes- continued lantus and humalog SS . # Seizures- continued lamictal . # Depression- continued celexa CODE STATUS: confimred FULL CODE Medications on Admission: Acetaminophen prn Lactulose 30cc qid Lamotrigine 100 mg qhs Pantoprazole 40 mg daily Allopurinol 100 mg qod Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q8H prn Lorazepam 0.5 mg q8h prn Gabapentin 300 mg daily Sevelamer HCl 800mg po tid Cholecalciferol 800 units daily Rifaximin 200 mg po tid Albuterol prn Ipratropium prn B-Complex with Vitamin C po daily Insulin Glargine 20 units QHS Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY Keppra 1,000 mg Tablet Sig: One (1) Tablet PO once a day Docusate Sodium 100 mg PO BID Bactrim DS 1 tab daily Midodrine 5 mg Tablet Sig: One (1) Tablet PO QTUTHSA Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS Insulin Lispro Subcutaneous [Month/Day (4) ] Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 2. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 10. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed. 12. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 17. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) Subcutaneous at bedtime. 19. Insulin Lispro 100 unit/mL Cartridge Sig: as directed Subcutaneous four times a day: per sliding scale. 20. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 22. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Midodrine 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 24. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. [Month/Day (4) ] Disposition: Extended Care Facility: [Last Name (LF) 2670] , [First Name3 (LF) 5871] [First Name3 (LF) ] Diagnosis: Re-expansion pulmonary edema [First Name3 (LF) ] Condition: Stable [First Name3 (LF) ] Instructions: You were in the ICU for monitoring after fluid removal of your lung. Your vitals were stable. Follow up with the liver doctors [First Name (Titles) ] [Last Name (Titles) ]. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2153-6-22] 11:30 ICD9 Codes: 5119, 5856, 5715, 3572
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7810 }	Medical Text: Admission Date: [2129-12-29] Discharge Date: [2130-1-3] Date of Birth: [2085-7-9] Sex: M Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 1646] Chief Complaint: OSH transfer for alcoholic pancreatitis Major Surgical or Invasive Procedure: PICC placement NGT placement post pyloric by floroscopy History of Present Illness: Mr. [Known lastname 12130] is a 44 year old man with ETOH abuse and Crohns' disease initially admitted to OSH [12-23] with abdominal pain radiating to back, nausea and vomiting x 1 week, which became progressively worse over 24 hours PTA found to have acute pancreatitis with initial amylase>3000 and CT with evidence of necrotizing pancreatitis. At OSH, he was treated with bowel rest, IVF and started on primaxin. Course was complicated by ETOH withdrawal and DTs so he was transferred to ICU there and started on an ativan drip which was uptitrated to 15mg/hr. He is being transferred to [Hospital Unit Name 153] for further management, ? need for surgical intervention. Course also c/b fevers to 101 and positive blood cx with GPCs in clusters on [2129-12-28] (2 bottles of coag neg staph, sensitive to cefazolin, CTX, cipro/levo, clinda, azithro, oxacillin, bactrim, tetra, and vanc). He reportedly had been started on TPN day prior to transfer via PICC. . VS prior to transfer: T:101 rectal HR: 110s BP:120-130/70-80 RR:30s O2 sat: 99-100%2L . Upon arrival to the ICU a complete ROS could not be obtained. Prior to transfer to the medical floor the patient was able to state that he did not have CP, SOB, dysuria, headache, neurologic changes, visual changes prior to presentation. He had pain in his abdomen with defecation which is consistent with his Crohn's disease. . Per discussion with family, patient had denied any other complaints prior to admission other than right shoulder pain which was attributed to rotator cuff tear and was recently being worked up with MRI. He had approximately 1 episode of emesis per week for 3 weeks PTA and had multiple episodes nonbloody bilious emesis on day of admission with epigastric abdominal pain as above. Had denied fevers, chills, diarrhea, joint pains, headache or any other complaints. Denies recent weight loss or gain. . While in the [Hospital Unit Name 153] a rectal tube placed for frequent stooling. Two cidffs have been negative. A post pyloric feeding tube placed and he started tube feeds. His PICCL was d/c'ed and cultured. On [2129-12-31] he developed thrush and was started on nystatin. While in the ICU his mental status slowly cleared. . ROS: Currently reports [12-28] pain in his R shoulder c/w rotator cuff tear. He does not have any abdominal pain. No cp/sob/n/v. + Diarrhea. He is unclear if it is worse than his usual Crohn's but his family does. [2130-1-26] back pain. He reports decreased dexterity of his fingers in that he keeps dropping things. No slurred speech or other focal weakness. All other ROS negative. Past Medical History: Crohn's Disease ETOH abuse Marijuana abuse Right shoulder pain/rotator cuff tear Social History: Lives with girlfriend. Divorced. [Name2 (NI) ] 3 children (2 sons, one 10 year old daughter). Per friends and [Name2 (NI) 40764], drinks 1 pint of vodka/hard liquor per day and 2 glasses-1 bottle of wine daily. No prior h/o withdrawal. Also reprots daily marijuana use. No other drug use. Occ cigarettes. No regular tobacco abuse. He works as an electrician. Family History: Father died of a cerebral anneurysm. Mother is good health. MGF had DM. His second cousin has [Name (NI) 4522] disease. No family h/o pancreatitis. . Physical Exam: Vitals: Tm=101, Tc=99.2 HRm = 91-105: BP: Pc =105 : R: 18 O2: 100% RA Fluid balance: I/O = [Telephone/Fax (1) 86327] LOS = + 3.4 L . General: Alert, oriented, no acute distress HEENT: Sclera anicteric, moist MM, 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, mildly distended, decreased bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + foley draining clear yellow urine Rectal: rectal tube draining dark liquid stool. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema R shoulder without erythema or wamth. No pain with active and passive ROM. Neuro: A & O x3. Able to DOW backwards. 5/5 strength in upper and lower extremities b/l. 2+ biceps and patella DTRs. ************ at discharge: patient awake, alert, mental status clear. still generally weak and walking with a walker. NGT in place. Not tremulous or with any s/s of etoh w/d. abd tender in epigastrim with some firmness, but no r/g. Pertinent Results: OSH Labs: WBC 15.2 HCT 50.4 Lipase>3000, AST 2 ALT 249 T Bili 1.4 Na 145 K 3.4 BUN 5 Cr 0.8 Phos 1.9 ca 7.8 WBC 30.6 HGB 12.8 PLT 168. LDL 42 TG 202 Micro: OSH: Blood cx as above. Blood cultures at [Hospital1 18] are pending. ADMISSION LABS: [2129-12-29*] 04:57PM BLOOD WBC-16.8 RBC-4.43* Hgb-13.6* Hct-38.8* MCV-88 MCH-30.7 MCHC-35.0 RDW-13.1 Plt Ct-283 [2129-12-29] 04:57PM BLOOD Neuts-88.5* Lymphs-6.0* Monos-3.3 Eos-2.0 Baso-0.2 [2129-12-29] 04:57PM BLOOD PT-14.0* PTT-30.5 INR(PT)-1.2* [2129-12-29] 04:57PM BLOOD Glucose-144* UreaN-9 Creat-0.7 Na-139 K-4.4 Cl-106 HCO3-19* AnGap-18 [2129-12-29] 04:57PM BLOOD ALT-35 AST-31 LD(LDH)-480* AlkPhos-97 TotBili-0.8 [2129-12-29] 04:57PM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.6 Mg-2.2 [2129-12-29] 04:57PM BLOOD Osmolal-293 [2129-12-29] 04:57PM BLOOD Vanco-4.6* [2129-12-29] 05:42PM BLOOD Type-[Last Name (un) ] pO2-64* pCO2-30* pH-7.47* calTCO2-22 Base XS-0 [2129-12-29] 05:42PM BLOOD Lactate-1.6 REPORTS: CXR [2129-12-29]: Lung volumes are extremely low exaggerating vascular congestion in the lungs and mediastinum though there may be volume overload. Discrete opacification at the left lung base is probably atelectasis. Pleural effusions are small if any. Cardiac silhouette is largely obscured by the high diaphragm but not grossly dilated. No pneumothorax. Left PIC catheter passes at least as far as the upper right atrium, obscured beyond that by overlying EKG leads. CXR [2130-1-1]: FINDINGS: Radiodense tip of feeding tube is visualized in the upper to mid cervical region as communicated by telephone to Dr. [Last Name (STitle) ]. Exam is otherwise similar to recent radiograph of two days earlier. CT head [2130-1-1]: FINDINGS: There is no intracranial hemorrhage, edema, mass effect, shift of normally midline structures, or acute major vascular territorial infarction. The ventricles and sulci are prominent, likely reflective of atrophy. Minimal mucosal thickening of the ethmoid air cells are noted bilaterally. Osseous structures reveal no evidence of fracture. IMPRESSION: No acute intracranial process. CXR PA/LAT [2130-1-1]: IMPRESSION: Small left pleural effusion with adjacent opacity favoring atelectasis over infectious pneumonia. [2129-12-29] ECG Baseline artifact. The rhythm is most likely sinus tachycardia. Non-specific ST-T wave changes. Repeat tracing is recommended. No previous tracing available for comparison. Brief Hospital Course: Assessment and Plan: 44 year old man with ETOH abuse transferred from OSH with necrotizing pancreatitis, ETOH withdrawal and DTs, fever and GPC bacteremia. . #. Necrotizing Pancreatitis: Patient initially presented with abdominal pain and nausea and vomiting with lipase>3000 and evidence of pancreatic 20-30% necrosis on CT scan. US without stones. Surgery evaluated him and elected for conservative management. With high fever and level of necrosis, meropenim was started at the OSH. A 7 day course of this was completed. His abd pain is now mostly resolved. He has developed an appetite, but given the level of necrosis seen on the CT scan the mild DM that he has developed it was recommended by surgery that he get jejunal tube feedings for at least another week. After that time, clears should be introduced and diet advanced, and if not tolerated, TF resumed. He is followed by gastroenterology, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2523] MD [Telephone/Fax (1) 86328] for his crohn's disease and she will follow him for his pancreatitis as well. Of note, at the time of discharge his LFT's had returned to [Location 213] and his WBC's had come down to 14 from a high of 22. . # ETOH Withdrawal/abuse: Patient reportedly agitated at OSH secondary to ETOH withdrawal and has reported heavy daily ETOH intake. No prior h/o withdrawal but has been in active withdrawal there on ativan drip and also getting haldol for agitation. Last ETOH [12-22] or [12-23]. Pt arrived to the ICU with significance somnolence, minimally responsive but protecting his airway. We d/c'd ativan drip and changed to valium PO as tolerated. Pt's mental status significantly improved and patient became more coherent. CT head without acute changes. Continued MVI, thiamine, folic acid. Strongly encouraged ETOH cessation. At the time of discharge he was AAO x 3, awake, alert, and w/o any s/s of withdrawal. . # GPC bacteremia: Most likely sources include catheter related bloodstream infection given PICC line given TPN. Treated with vanco and [Last Name (un) 2830] for now while awaiting speciation and sensitivities, that returned as pansensative coag neg staph. He was given ceftriaxone to complete a 2 week course to end [1-10]. A midline was placed for this which should be removed after abx therapy is complete. . # Fever/leukocytosis: Likely multifactorial secondary to pancreatitis and bacteremia. last check 14. . #B12 deficiency: The patient arrived to our institution on daily B12 injections, presumably from a newly diagnosed B12 deficiency. he received 1 week of daily injections, planning for 1 month of qweek followed by qmonth afterwards. . #Diarrhea:while on zosyn, the patient had severe diarrhea. infectious w/u neg. diarrhea stopped. . #crohn's disease:No issues. His mesalamine was held while sick, but was restarted. . #Fe deficiency anemia:was also noticed to have low Tsat with fe 17 TIBC 190. Ferritin high from inflammation. did not start on iron tabs given GI issues, but when stable should resume this. Guaic was negative. . #diabetes:likely pancreatitis related. q6 FS while on TF with insulin SS. Hopefully with not require DM therapy after discharge. Medications on Admission: Home medications: Lialda 1.2g 2 tablets daily Percocet prn Medications prior to Transfer: Clonidine patch 0.3mg transdermal q week TPN with fat emulsion Heparin 5000 units SQ TID Primaxin 500mg IV q day Ativan drip at 15mg/hr Lopressor 5mg IV q6 hours Protonix 40mg IV BID Vanco 1g IV q12 day 1 [2129-12-28] B12 1000mcg IM q24 hours tylenol, benadryl, haldol, dilaudid, ativan, reglan, zofran prn Discharge Medications: 1. Lialda 1.2 g Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day. 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 3. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) dose Injection once a week for 4 weeks: then 1 q month. 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) regular insulin SS q6 while on Tube feedings Injection every six (6) hours. 5. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) GM Intravenous Q24H (every 24 hours) for 7 days. 6. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 7. Hydromorphone (PF) 1 mg/mL Syringe Sig: 0.25-0.5 mg Injection Q3H (every 3 hours) as needed for pain: (patient has not required this medication in>48hrs). 8. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: patient was taking prior to admission to shoulder injury. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Discharge Worksheet-Discharge Diagnosis-Finalized:[Last Name (LF) ],[Name8 (MD) ], MD on [2130-1-3] @ 1351 Primary Diagnosis: 577.0 PANCREATITIS, ACUTE Secondary Diagnosis: 291.81 DRUG WITHDRAWAL, ALCOHOL Secondary Diagnosis: 303.90 DRUG USE/DEPENDENCE, ALCOHOL Secondary Diagnosis: 555.9 CROHN'S DISEASE Secondary Diagnosis: 790.7 BACTEREMIA Secondary Diagnosis: 787.91 DIARRHEA, NOS Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Patient being transferred to a facility for tube feedings and to complete antibiotic course. Followup Instructions: with PCP at the time of discharge from rehab Name: [Last Name (LF) ],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Address: [Location (un) 35619], [Apartment Address(1) ], [Hospital1 ],[Numeric Identifier 23661] Phone: [Telephone/Fax (1) 35614] Fax: [Telephone/Fax (1) 35625] * Also needs f/u with his gastroenterologist. We believe he should be seen within next 2-4 weeks, but she had no appts during that time. She was not availible for contact today, but will be in the office tomorrow to schedule f/u. please call their office tomorrow. MD: Dr [Last Name (STitle) ] [Name (STitle) 2523] Specialty: Gastroenterology Phone number: [Telephone/Fax (1) 86328] ICD9 Codes: 7907
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7811 }	Medical Text: Admission Date: [2131-2-16] Discharge Date: [2131-2-20] Date of Birth: [2068-8-1] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old female with a history of left total knee replacement on [2130-12-21] on Coumadin who presented to the Emergency Department on [2131-2-16] with complaints of multiple episodes of bright red blood per rectum, crampy abdominal pain and lightheadedness. EMERGENCY DEPARTMENT COURSE: INR on admission was 3.1. Initial blood pressure in the Emergency Department was 60/palpable. A cordis was placed in addition to large bore IV. The patient was given 4 units of blood, 10 of subcutaneous vitamin K and 4 units of fresh frozen platelets as well as 6.25 liters of normal saline. Nasogastric lavage was negative for blood. Hematocrit in the Emergency Department was 21.3. Interventional radiology consulted, but no source of bleed. The patient was stabilized and transferred to the MICU. PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease. 2. Echocardiogram in [7-12] demonstrating ejection fraction of 55% and moderate concentric left ventricular hypertrophy. 3. Psoriasis since [2116] treated with Puva. 4. Left breast cancer grade 1 invasive status post left mastectomy in [2127]. ER positive. Treated with Tamoxifen. 5. Osteoarthritis of the knee. 6. Remove history of diabetes mellitus. Hemoglobin A1C [9-14] 6.5. PAST SURGICAL HISTORY: 1. Total knee replacement [2130-12-21] of left knee. 2. Total abdominal hysterectomy and bilateral salpingo-oophorectomy [12-13]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Coumadin. 2. Oxycodone. 3. Tamoxifen. 4. Protonix. SOCIAL HISTORY: The patient is widowed, currently works as a middle school teacher. Before admission ambulating with walker. Minimal alcohol use. No tobacco use. Has two daughters who currently live in [Name (NI) 3908]. FAMILY HISTORY: Remote history of pancreatic cancer and lung cancer in two uncles. Mother with diabetes mellitus. REVIEW OF SYSTEMS: Positive only for a history of hemorrhoids, however, the patient denied ever having bleeding episodes as the current one. PHYSICAL EXAMINATION: Pulse 93. Blood pressure 153/38. Respiratory rate 18. O2 sat 98% on room air. The patient is in no acute distress, obese woman sitting upright in bed. The rest of the physical examination was normal including chest, cardiovascular, abdomen and neurological examination. There was a right femoral wound from the cordis removal in the right thigh. There was no sign of active bleeding, infection or hematoma. LABORATORY: Hematocrit of 29, PT 14.4, PTT 27.4, INR of 1.4. Chem 7 was normal. HOSPITAL COURSE: Chest x-ray on [2131-2-16] demonstrated no acute cardiopulmonary abnormality. A mesenteric angiography performed on [2131-2-16] showed no sign of active gastrointestinal bleeding. A colonoscopy performed on [2131-2-17] demonstrated bleeding vessel in the transverse colon, which was clipped with a surgical clip. As well a colonoscopy demonstrated two small polyps and signs of diverticuli. A follow up colonoscopy was recommended for the next Monday and the patient's hematocrit was actively monitored. The patient needed one more unit of packed red blood cells in the MICU and one more unit on the floor. Hematocrit stabilized around 29 and on discharge hematocrit was 28.2. The patient's baseline hematocrit runs between 24 and 34. A colonoscopy was performed on [2131-2-19] and two polyps were removed. However, the colonoscopy could only go as far as the hepatic flexure and a virtual colonoscopy is scheduled for an outpatient on [2131-2-27]. DISCHARGE MEDICATIONS: Same as admission except Coumadin has been discontinued. DISPOSITION: To home. DISCHARGE STATUS: Ambulating comfortably and stable. DISCHARGE DIAGNOSIS: Large lower gastrointestinal bleed. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[Doctor First Name 103737] MEDQUIST36 D: [2131-2-21] 09:06 T: [2131-2-21] 09:19 JOB#: [Job Number 103738] ICD9 Codes: 5789, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7812 }	Medical Text: Admission Date: [2171-3-2] Discharge Date: [2171-3-11] Date of Birth: [2102-7-31] Sex: M Service: EMERGENCY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2565] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Intubation PICC placement G/J replaced G tube History of Present Illness: A 68 year old gentleman was transferred to [Hospital1 18] (scheduled for floor admission) from [Hospital 60966] Community Hospital at the request of his family for ongoing pneumonia. During the Medivac (per flow sheet): patient ambulatory prior to flight. During the flight he was in Afib, satting 96-100% on 3L NC. Never hypotensive or tachycardic. BS varied from 81-441 (pre/post dextrose administration). Patient became confused ~1615. His rate increased to 110 ~ 1700, labelled as ? for which he received 100mg Lidocaine, presumably IV just prior to arrival at [Hospital1 18]. After deplaning from a medivac flight, the patient became unresponsive and was transferred to the [Hospital1 18] emergency room. . In the ED, vital signs were initially: 96.9 69 180/84 12 100% NRB. Patient was intubated for airway protection given unresponsiveness (Etomidate & Succ for intubation; Propofol for sedation). He was given Vanc/Zosyn for HAP vs. abdominal process. BS in the 70s, given D50 without change in mental status. Transferred to the MICU: 96.4 120/59 14 100% 500/14/10/1.0. . On arrival to the floor, the patient is not responsive to voice or sternal rub. His family is present and confirm the hospital course. Per all reports, he was independent at home and still working but "slowing down" recently with weight loss, several recent hospitalizations for pneumonia. His rapid change in status today was unexpected and not at all resembling his recent hospital course. REVIEW OF SYSTEMS: Unable to obtain. . Brief Hospital Course per included records: The patient was seen in the [Hospital 60966] Community Hospital ED on [2-20] for confusion. He was started on levaquin and ceftriaxone then admitted to the floor for PNA. Never hypotensive in their ED. Some confusion but no unresponsiveness for which an LP was performed. Cards, ID, Endocrine consulted with the major change being abx switced to Zosyn for PNA. . Progress notes are only available after [2-25], but the patent failed a video swallow and was thought to have erosive esophagitis and a G-tube was placed on ?[2-26]. The patient was awake and oriented during the hospital course. He was started on metoprolol--> diltiazem and coumadin for Afib. On [2-28], he was found to be in heart failure based on CXR findings and started on bolus lasix, but exam not consistent with CHF. Digoxin was added for rate control. On [3-2], a ? of LUE DVT was raised as was a tricuspid valve vegitation. . Significant Labs (No CSF): BNP 1773 Trop <0.01 Albumin 3.1 . Micro: C diff (-) . Imaging: CXR (summary): ? CHF, LUL consolidation Head CT: No intracranial process . CT Chest: RUL Consolidation, bilateral effusions, mediastinal lymphadenopathy . EF 55-60%, LVH, Mod MS, ?veg Tricuspid valve, mod TR, mod, Pulm htn Past Medical History: -Hodgkin's Lymphoma s/p mental & periaortic radiation in [2132]; 6 cycles of MOPP: recurrence, skin Ca - Splenectomy [2135] - s/p CCY - Pacer placement [2167] for sick sinus syndrome - DM [1-29] pancreatic Radiation, on Insulin - Chronic Pancreatitis - Hypothyroidism - Hyperlipidemia - CAD s/p CABG [2154] - Degenerative Joint Disease - GERD - Zenker's Diverticulum Social History: Lives in [Location ], works as an attorney. Married with 2 children. Lifetime non smoker, occasional EtOH Family History: Father with dementia Physical Exam: VS: 94.6 144/99 65 14 100% FI02 1.0 GEN: Intubated, sedated and unresponsive SKIN: Stage 1 pressure ulcer on back HEENT: Prominent JVP at 30 degrees, neck supple, No lymphadenopathy noted. CHEST: Diffuse Rhonchi in all lung fields CARDIAC: S1 & S2 regular without murmur appreciated ABDOMEN: G tube in place, no erythema around site. Nontender or rigid EXTREMITIES: trace peripheral edema, warm without cyanosis NEUROLOGIC: Sedated, not responsive to commands, pinpoint pupils Pertinent Results: Admission labs: [2171-3-2] 05:38PM GLUCOSE-185* LACTATE-1.4 NA+-139 K+-3.8 CL--90* TCO2-35* [2171-3-2] 05:39PM PT-29.5* PTT-40.7* INR(PT)-2.9* [2171-3-2] 05:39PM WBC-9.6 RBC-3.35* HGB-9.9* HCT-30.2* MCV-90 MCH-29.6 MCHC-32.9 RDW-16.6* [2171-3-2] 05:39PM HYPOCHROM-1+ ANISOCYT-OCCASIONAL POIKILOCY-2+ MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-OCCASIONAL TARGET-1+ SCHISTOCY-OCCASIONAL BURR-OCCASIONAL HOW-JOL-OCCASIONAL ACANTHOCY-2+ [2171-3-2] 05:39PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2171-3-2] 05:39PM TSH-1.3 CT head: 1. Chronic small vessel infarcts, without acute hemorrhage or territorial infarction. 2. Sulcal and ventricular prominence may represent global atrophy, though given the prominence of the temporal horns, NPH should be considered in the proper clinical setting. CT torso: Preliminary Report !! PFI !! 1. No PE or acute aortic abnormality. 2. Left upper lobe pneumonia. Bilateral pleural effusions, small on left and moderate on right. 3. Left hepatic lobe atrophy and segmental biliary duct dilatation, with suggestion of hypodense perihilar lesion, concerning for biliary or hepatic neoplasm. Numerous enhancing lesions are noted throughout the liver. This can be further assessed with MRI or multiphase CT. Brief Hospital Course: A 68 yo gentleman with progressive decline transferred from [Location (un) 95454] after PNA/AMS with an acute change in mental status during/after [Location (un) ]. The patient has underlying dementia as evidenced by family & recent notes. His acute decline during [Location (un) ] appears to correspond roughly to a rapid ventricular rate and lidocaine administration. He was unresponsive and intubated on arrival to the MICU but improved over the first hospital day. EEG was negative for seizure activity, but seizure was thought to be most likely cause given improvement over a day and seizure-lowering properties of lidocaine and alkalosis. Head CT showed nothing concerning for an acute intracranial process. Mental status improved to baseline within the first hospital day, he was extubated without difficulty on [3-4], and he was alert and communicative at the time of extubation. He was called out to the general medicine service. . The day after call-out to the medical service, the patient was found unresponsive and pulseless, ~15 minutes after having been seen well. This was a PEA arrest, with rapid atrial fibrillation on the monitor. After 1 round of CPR and 1 mg epinephrine, atropine, and bicarbonate patient regained a pulse. He was intubated and transferred to the MICU. . Arrest was thought to be secondary to an aspiration event. The patient was initially agitated but then became unresponsive despite no sedation. Continuous EEG monitorring revealed no epileptiform activity. Mental status improved over several days, and patient was able to follow commands. However, he became intermittently quite agitated requiring anti-psychotics and eventually resumption of sedation. He was difficult to wean from the ventilator, becoming uncomfortable after a few hours on pressure support, and it was clear that he had substantial respiratory muscle weakness. Meanwhile, his family re-addressed goals of care. They felt that he would not want any life short of the full quality he had experienced prior to hospitalization. Given that this was unlikely after such a dramatic course, they chose to change his code status to DNR/DNI and eventually was transitioned to comfort measures. Family wished for patient to be extubated with knowledge that he likely would not survive for long. Patient extubated on [2171-3-11] and expired at 1812. Family was at bedside. An autopsy was declined by patient's wife. Medications on Admission: TRANSFER MEDS (All meds prescribed at OSH): Levaquin Ceftriaxone Zosyn Augmentin Diltiazem Metoprolol Digoxin Aspirin Lidocaine ([Location (un) 7622]) Lasix Insulin Coumadin Heparin Lovenox Xopenex Albuterol Guaifenesin Pancreatic Enzymes Vit D B12 Folate Iron Neutraphos Lansoprazole . MEDICATIONS AT HOME (prior to [Location (un) ] admission, meds confirmed with wife, dosages per [Name (NI) 60966] notes): Aspirin 81mg PO daily Levothyroxine 150mcg PO Daily Lisinopril 10mg PO daily Metoprolol 25mg PO BID Pancrease 2 tabs PO TID Lantus 16 units QHS & Novolog 8 units prior to each meal Vitamin D 50,000 International Units Weekly Levitra 20mg PO daily prn Prilosec 40mg PO BID Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Chronic Aspiration Pneumonia Hypothyroidism History of Hodgkin's Lymphoma Sick Sinus Syndrome Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired Completed by:[2171-3-12] ICD9 Codes: 2859, 2449, 5070, 5849, 5119, 4275, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7813 }	Medical Text: Admission Date: [2189-7-27] Discharge Date: [2189-8-12] Date of Birth: [2116-9-14] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 473] Chief Complaint: Jaundice and pruritis Major Surgical or Invasive Procedure: Whipple procedure [2189-7-28] Evacuation of retroperitoneal hematoma [2189-8-1] History of Present Illness: 72 year old female with 10 day history of pruritis and jaundice. Seen by her primary care physician where labs revealed increased bilirubin. A CT was then performed which showed a mass in the pancreas. The patient then underwent two ERCPs that both failed to cannulate the bile duct. Past Medical History: -Adenocarcinoma of left chest wall s/p resection and radiation/chemotherapy -Hypothyroidism -Hypercholesterolemia -S/P tonsillectomy Social History: Past history of 30 pack years tobacco; quit 6 years ago (-)ETOH. Housewife. Family History: Father, brother w/ CAD, MI Mother w/ HTN Physical Exam: Gen: Pleasant elderly femal in no acute distress Alert and oriented x3 HEENT: Pupils equal, round and reactive to light and accommodation, extraocular movements intact, skin jaundiced, mild scleral icterus CV: Regular rate and rhythm, no murmur appreciated Pulm: Clear to auscultation bilaterally, no wheeze/rales/rhonchi Abd: Soft, non-tender, non-distended, no masses appreciable, +normoactive bowel sounds Ext: No clubbing, cyanosis, or edema Pertinent Results: [2189-7-27] 09:15PM GLUCOSE-116* UREA N-6 CREAT-0.7 SODIUM-141 POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13 [2189-7-27] 09:15PM CALCIUM-9.0 PHOSPHATE-2.7 MAGNESIUM-1.7 [2189-7-27] 08:13AM ALT(SGPT)-411* AST(SGOT)-188* ALK PHOS-449* AMYLASE-65 TOT BILI-6.7* DIR BILI-5.0* INDIR BIL-1.7 LIPASE-96* ALBUMIN-3.8 [2189-7-27] 08:13AM WBC-8.0 RBC-4.34 HGB-12.5 HCT-38.4 MCV-89 MCH-28.8 MCHC-32.5 RDW-14.7 PLT COUNT-253 [2189-7-27] 08:13AM PT-11.8 PTT-24.1 INR(PT)-0.9 [2189-7-28] 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-7.0 LEUK-NEG [2189-7-27] ERCP: Fifteen spot fluoroscopic images are provided from ERCP performed by Dr. [Last Name (STitle) ]. The pancreatic duct is nondilated. Images demonstrate periductal opacification secondary to extramucosal injection with extraluminal air. The common bile duct is not opacified. A plastic pancreatic duct stent is placed. IMPRESSION: Extramucosal injection of contrast and small amount of extraluminal air. Nondilated pancreatic duct with plastic pancreatic duct stent placed. CTA ABD W&W/O C & RECONS; CT ABDOMEN W/CONTRAST [2189-7-27] 1 A 1.3-cm rounded hypoattenuating lesion in the periampullary region of the pancreatic head concerning for an early pancreatic head or periampullary tumour. Secondary dilatation of the intra- and extrahepatic biliary tree,non distended pancreatic duct with stent in situ. 2. No evidence of metastatic disease. 3. Cholelithiasis Pathology report, pancreatic specimen Histologic Type: Ductal adenocarcinoma. Histologic Grade: G3: Poorly differentiated. EXTENT OF INVASION Primary Tumor: pT3: Tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery. Regional Lymph Nodes: pN1b: Metastasis in multiple regional lymph nodes. Brief Hospital Course: Patient was admitted on [2189-7-27] with jaundice and pruritis from a pancreatic mass obstructing the common bile duct. An ERCP performed the day of admission had failed to cannulate the bile duct due to distal obstruction. A CTA of the abdomen was done to further define the mass in anticipation of surgical excision. A chest x-ray, electrocardiogram, and U/A were performed with no abnormalities noted. Labs revealed elevated liver function tests with a total bilirubin of 6.7. The patient underwent a Whipple procedure on [2189-7-28] and the pancreatic mass was successfully resected. The patient tolerated the surgery without complications intraoperatively. An epidural was placed pre-operatively for pain control. The common protocol for patients following a whipple procedure was followed. She was placed on subcutaneous heparin, venodynes, and thigh-high [Male First Name (un) ] stockings for DVT prophylaxis. She remained NPO on IV fluids with a nasogastric tube in place. Nutrition was consulted for recommendations post-whipple procedure. Her JP drain was noted to be draining serosanguinous fluid of appropriate volume. The patient was out of bed to a chair on POD1 and ambulated with assistance on POD2. The patient's urine output decreased slightly on POD3 and she required 2 normal saline boluses of 500cc. Her blood pressure and heart rated remained stable. The epidural catheter was removed on POD3 by pain service with the tip intact and the patient was placed on a PCA for pain control. The nasogastric tube was also discontinued on POD3. The patient had an episode of coffee ground emesis and continued to have low urine outputs. Overnight on POD3 the patient's hematocrit was noted to decrease from 27.9 to 22.8 then 20.5 and the JP output was noted to be more sanguinous than previously with a larger volume draining. INR was 2.5. At this time the patient also began experiencing abdominal pain and was noted have tenderness on exam. Her heart rate was in the 60s and her blood pressure was stable at this time. The patient was transferred to the SICU and transfused 3units PRBCs and 4units FFP. The JP amylase level at this time was 253. The patient continued to have a decreasing hematocrit despite transfusions and the patient was taken to the operating room for a presumed post-operative bleed after discussion with the patient's son. She was found to have a retroperitoneal hematoma commented in the operative note as "right upper quadrant bleeding presumably from the mesopancreas of uncinate process with acute-dissection deep into retroperitoneum down to pelvis". The patient tolerated the procedure well and was noted to have a hematocrit increasing to 28.8. She remained intubated in the SICU and was monitored closely. She recovered well and had no evidence of further bleeding. TPN was initiated due to the patient's prolonged NPO status. The patient was extubated on POD7/3. She was transferred to the floor on POD9/5. The patient's diet was advanced beginning on POD [10-19] and TPN was discontinued when she was on a regular diet ([2189-8-10]). Physical therapy evaluated and followed the patient on the floor and recommended continuation of therapy upon discharge. The patient was discharged to rehab on [2189-8-12] (POD 15/11) in good condition. Medications on Admission: Lipitor Synthroid Folic Acid Fosamax Discharge Medications: 1. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Please continue until ambulating frequently. 3. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Location (un) ] Discharge Diagnosis: Pancreatic mass Discharge Condition: Good Discharge Instructions: Please call if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also call if your wound becomes red, swollen, warm, or produces pus. You may resume your regular diet as tolerated. Followup Instructions: Please call Dr.[Name (NI) 9886] office for an appointment on Monday, [8-24]. ([Telephone/Fax (1) 14347]. ICD9 Codes: 2851, 2449, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7814 }	Medical Text: Admission Date: [2165-6-25] Discharge Date: [2165-7-4] Date of Birth: [2095-5-14] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1505] Chief Complaint: [First Name3 (LF) 26058] Mitral leaflet, CAD Major Surgical or Invasive Procedure: Cardiac Catheterization [2165-6-27] CABGx1 (SVG->OM), Mitral Valve Replacement (pericardial) History of Present Illness: 70 y.o. female with HTN, CAD, recent PCI in [2163] w/ stent to RCA, 2 days s/p discharge from [Hospital Unit Name 196] presents with dypsnea and found to have acute mitral regurgitation. She was in her USOH after her discharge from [Hospital1 18] 2 days ago (during which time a pMIBI demonstrated a reversible inf/lat defect without cardiac cath). She then quickly became markedly dyspneic and was unable to lie flat. She presented to the ER where SBP 155, HR 112, O2 was 80% on RA and 100% on CPAP. She was given 180 IV lasix, morphine and nitro with marked improvement in dyspnea. She was admitted to the CCU on 2 liters O2 and a bedside echo demonstrated severe 4+ MR [First Name (Titles) 151] [Last Name (Titles) ] posterior mitral leaflet. Past Medical History: 1. HTN 2. CAD s/p stenting (see below) 3. DM 4. s/p hip and [Last Name (un) ] fracture secondary to fall, recently d/c'ed from Rehab 5. former smoker Echo [9-17]: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular ejection fraction is normal (LVEF 60%); the basal segments of the inferior free wall and posterior wall are hypokinetic. 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. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but not stenotic. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is no pericardial effusion. . Cath [9-17]: 1. Selective coronary angiography showed a right dominant system with two vessel disease. The LMCA was without significant disease. The stent in the proximal LAD was widely patent without flow limiting stenosis. The distal LAD had a 50% stenosis. The LCX had a 40% stenosis in its mid segment and a 60% stenosis in its distal portion. The RCA had a patent stent proximally. The mid RCA was subtotally occluded. 2. Successful PCI of the mid-RCA with a 3.0 x 33 mm Cypher DES. Final angiography demonstrated no dissections, no residual stenosis, and TIMI-3 flow. Social History: Patient is a housewife. She lives at home with her husband, and her son and daughter's family live in the same house. Patient smoked [12-16] PPD for 33 years, and she quit 18 years ago. Family History: Mother died of an MI at 86. Father died of an accident Sister has history of premature CAD Physical Exam: BP: 104/55, HR:112, RR:18, O2:100% on CPAP Gen: HEENT MMM. lips slightly dry. No JVD. neck supple. No appreciable lymphadenopathy. Sclerae anicteric LUNGS: CTA B/L. No R/W/C CV: S1 S2. Grade III/VI Systolic murmur best heard at LSB radiating to apex and to the back. ABD: soft NT/ND. BS + EXT: 1+ peripheral pulses. mild ankle swelling. No C/C/or other pedal edema. NEURO: A/O x 3. Motor [4-18]. [Last Name (un) ]:GI to LT. CN II-XII GI. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2165-7-3] 05:25AM 28.8* [2165-7-2] 05:59AM 6.9 3.13* 9.5* 27.3* 87 30.4 34.8 13.9 290 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2165-7-3] 05:25AM 3.9 [2165-7-2] 05:59AM 112* 9 0.3* 135 3.9 98 301 11 Brief Hospital Course: After surgery was able to be transferred to the SICU in critical but stable condition on epi, milrinone and neo. She was extubated by post operative day one. He drips were weaned to off and she was transferred to the step down unit by post op day four. She had no complications post operatively and was ready for discharge to rehab. Medications on Admission: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 7. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day. 8. Glucophage 500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). Disp:120 Capsule, Sustained Release(s) Refills:2 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:45 Tablet(s) Refills:2 7. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Location (un) 246] Nursing Center - [Location (un) 246] Discharge Diagnosis: CAD, MR, EF 40% s/p PCIx3 DM hyperlipidemia HTN Discharge Condition: Good. Discharge Instructions: No driving or lifting until follow up appointment with surgeon or while taking pain medication. Call with temperature greater than 100.5, redness or drainage from incision, weight gain more than 2 pounds in one day or five in one week. [Month (only) 116] shower, wash incision with mild soap and water, pat dry. No creams, lotions, powders, no baths. Followup Instructions: Dr. [Last Name (STitle) ] 4 weeks Dr. [Last Name (STitle) 26056] 2 weeks Dr. [Last Name (STitle) 26059] 2 weeks Completed by:[2165-7-4] ICD9 Codes: 4240, 4280, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7815 }	Medical Text: Admission Date: [2188-1-14] Discharge Date: [2161-2-9] Date of Birth: [2141-8-5] Sex: F Service: ADMISSION DIAGNOSIS: Unstable angina. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Status post coronary artery bypass graft times two. HISTORY OF THE PRESENT ILLNESS: The patient is a 46-year-old woman with a history of chest pain and positive stress test who is referred for cardiac catheterization. Previously to this, she has had chest pain approximately once a month with increasing frequency to approximately one to two times per week. The pain is substernal chest pressure associated with left arm pain. It usually occurs at rest and lasts between three to 30 minutes. No associated shortness of breath. Positive for dyspnea on exertion. The patient had a positive ETT as well as a positive stress echocardiogram. She had cardiac catheterization performed on [2188-1-11] which revealed an ejection fraction of 60%, right dominant coronary artery system and 70% stenosis of the left main. The patient presents for revascularization. PAST MEDICAL HISTORY: 1. Thirty pack year smoking history. 2. Hypercholesterolemia. 3. Renal insufficiency in the past. 4. Bilateral reimplantation of the ureters at age ten. 5. Cesarean section times two. 6. Pilonidal cyst. 7. Tonsillectomy. ALLERGIES: The patient is allergic to sulfa and shrimp. No allergy to dye. ADMISSION MEDICATIONS: 1. Lipitor 20 mg q.d. 2. Atenolol 50 mg q.d. 3. Wellbutrin 300 mg q.d. 4. Zoloft 100 mg q.d. 5. Multivitamin q.d. 6. Aspirin q.d. PHYSICAL EXAMINATION ON ADMISSION: General: The patient was a middle-aged woman in no acute distress. HEENT: Normocephalic, atraumatic. PERRL, EOMI, anicteric. The throat was clear. The neck was supple and midline without masses or lymphadenopathy. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm without murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended without masses or organomegaly. Extremities: Warm, noncyanotic, nonedematous times four. Neurological: Grossly intact. LABORATORY DATA ON ADMISSION: CBC 11.8/14.2/40.7/193. INR 1.0. Chemistries 143/4.3/105/33/10/0.6. HOSPITAL COURSE: The patient had coronary artery bypass graft times two on [2188-1-15]. The patient tolerated the procedure well and was transferred to the Intensive Care Unit on a propofol drip. The patient was extubated without incident on postoperative day number one. She was also maintained on a Neo drip for labile blood pressures. The patient was incredibly anxious and called out with any procedure as small as tape removal. She was much more cooperative after Ativan was begun. On postoperative day number one, the patient was transfused 1 unit of packed red blood cells for a hematocrit of 23. Post transfusion, the hematocrit was 27. Unable to wean Neo at that time. On postoperative day number two, the patient remained A paced with an underlying rhythm in the 70s to keep systolic blood pressure greater than 90. Neo was weaned down and eventually to off. Physical Therapy began work with the patient. On postoperative day number three, the patient was transferred to the floor without incident. On the floor, she continued to do well and diuresed off quite a bit of fluid. In addition, she continued to work with Physical Therapy. The patient was cleared for discharge home on postoperative day number five. On postoperative day number five, the patient was discharged to home, tolerating a regular diet, and adequate pain control on p.o. pain medications and having had the chest tubes and wires discontinued. PHYSICAL EXAMINATION ON DISCHARGE: The patient is a middle-aged woman who is intermittently quite anxious. The vital signs were stable, afebrile. The heart revealed a regular rate and rhythm without murmurs, rubs, or gallops. The chest was clear to auscultation bilaterally. There was no sternal click and no sternal drainage. The patient does have 1+ pedal edema bilaterally. MEDICATIONS ON DISCHARGE: 1. Percocet 5/325 p.r.n. 2. Lipitor 20 mg q.d. 3. Wellbutrin 150 mg b.i.d. 4. Zoloft 100 mg q.d. 5. Plavix 75 mg q.d. 6. Aspirin 325 mg q.d. 7. Colace 100 mg b.i.d. 8. Lasix 20 mg q.d. times five days. 9. Potassium chloride 20 mEq q.d. times five days. 10. Lopressor 12.5 mg b.i.d. DISCHARGE CONDITION: Good. Cleared by PT for home. DISPOSITION: To home. DISCHARGE DIET: Cardiac. DISCHARGE INSTRUCTIONS: The patient is discharged to home with VNA for cardiopulmonary checks as well as wound care. The patient should follow-up with her cardiologist in one to two weeks time and address the need for diuresis and any adjustment for cardiac medications at the time. The patient should follow-up with Dr. [Last Name (STitle) ] in four weeks time. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern1) 5745] MEDQUIST36 D: [2188-1-20] 10:39 T: [2188-1-20] 10:47 JOB#: [Job Number 5746] ICD9 Codes: 4111, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7816 }	Medical Text: Admission Date: [2140-3-9] Discharge Date: [2140-3-11] Date of Birth: [2092-11-21] Sex: M Service: MEDICINE Allergies: bee venom (honey bee) Attending:[First Name3 (LF) 12174] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: 47 M with history of cirrhosis secondary to hepatitis C, ascites, known esophageal varices (planned to have banding done on [3-22]) who presents with GI bleed. According to the patient, two and a half weeks ago, he vomited about a half-cup of blood and was worked up for GI bleed at an outside hospital (endoscopy performed at [Location (un) ]). Last night at 10:30pm, the patient began to feel nauseated. By 11pm, he had some dry heaves that brought up a few tablespoons of blood. At whcih point he called an ambulance, which took him to [Hospital 189] Hospital. The patient also said that he had experienced some episodes of bright red blood in the toilet and on the toilet paper, but he has known hemorrhoids and thinks that the source of his BRBPR. At the outside hospital, the patient was found to be guaiac positive and started on a Protonix gtt before transfer here. He also received morphine there for mild abdominal pain. . In the ED, initial VS were: 98.6 81 110/75 16 96% ra. Pt was given pantoprazole 40mg IV once, zofran 2mg Iv once, morphine 5mg IV. Pt was typed and crossmatched. Access: 2 large bore IVs, 16 gauge, already placed. Given known varices, pt is admitted to MICU for endoscopy and close observation, plan to give protonix and octreotide drip, and Hepatology will follow. . On arrival to the MICU, the patient would have moments of somnolence from which he was readily awakened. He was generally oriented and not complaining of any pain. He was originally complaining of suprapubic discomfort, but had Foley placed and drained one liter of urine, with relief. Past Medical History: Cirrhosis Hepatitis C Esophageal varices Ascites HTN MYOCARDIAL INFARCTION HIP REPLACEMENT Social History: - Tobacco: [12-28] cigarettes per day along with snuff - Alcohol: Patient has been sober for 103 days; previously drank 25-30 beers plus schnapps. - Worked in construction. Family History: Hypertension Physical Exam: Admission: Vitals: BP: 123/74 P: 55 R: 18 O2: 100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL Neck: supple, no cervical lymphadenopathy CV: S1, S2, no murmurs auscultated Lungs: Clear to auscultation bilaterally, no wheezes Abdomen: Umbilical hernia, caput medusae, fluid wave, some tenderness at RUQ and hernia to deep palpation GU: Foley in place 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, no asterixis. Discharge: VS: 98.3, 92-104/45-66, 65-69, 20, 98-100% RA. GENERAL: mildly jaundiced, AAOx3 HEENT: Sclera mildly icteric. MMM. CARDIAC: RRR, nl S1/S2, no m/r/g LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: Distended but soft, tender to epigastrium on palpation with voluntary guarding, over an area of a fascial defect with a ventral hernia on Valsalva. No HSM or tenderness appreciated. EXTREMITIES: No edema. Warm and well perfused with varicosities, with 2+ DP pulses, no clubbing or cyanosis. Pertinent Results: Admission; [2140-3-9] 10:24PM SODIUM-121* POTASSIUM-4.0 CHLORIDE-92* [2140-3-9] 10:24PM HCT-33.4* [2140-3-9] 05:00PM URINE HOURS-RANDOM UREA N-432 CREAT-56 SODIUM-251 POTASSIUM-42 CHLORIDE-249 [2140-3-9] 05:00PM URINE OSMOLAL-749 [2140-3-9] 12:35PM GLUCOSE-101* UREA N-9 CREAT-0.6 SODIUM-122* POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-21* ANION GAP-13 [2140-3-9] 12:35PM estGFR-Using this [2140-3-9] 12:35PM ALT(SGPT)-119* AST(SGOT)-235* ALK PHOS-150* TOT BILI-1.6* [2140-3-9] 12:35PM LIPASE-57 [2140-3-9] 12:35PM ALBUMIN-2.9* CALCIUM-8.3* PHOSPHATE-3.9 MAGNESIUM-1.5* [2140-3-9] 12:35PM WBC-7.5 RBC-3.76* HGB-12.0* HCT-34.2* MCV-91 MCH-32.0 MCHC-35.3* RDW-16.8* [2140-3-9] 12:35PM NEUTS-64.0 LYMPHS-21.2 MONOS-8.4 EOS-5.8* BASOS-0.5 [2140-3-9] 12:35PM PT-18.6* INR(PT)-1.8* [2140-3-9] 12:35PM PLT COUNT-81* Discharge: [2140-3-11] 05:58AM BLOOD WBC-5.3 RBC-3.65* Hgb-11.6* Hct-33.1* MCV-91 MCH-31.8 MCHC-35.1* RDW-17.2* Plt Ct-69* [2140-3-11] 05:58AM BLOOD Glucose-108* UreaN-9 Creat-0.7 Na-125* K-4.9 Cl-95* HCO3-23 AnGap-12 [2140-3-11] 05:58AM BLOOD ALT-114* AST-245* LD(LDH)-237 AlkPhos-101 TotBili-1.6* [2140-3-11] 05:58AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.4 Mg-1.6 Pertinent: HELICOBACTER PYLORI ANTIBODY TEST (Final [2140-3-11]): NEGATIVE BY EIA. Brief Hospital Course: 47 year old male with history of HCV and EtOH cirrhosis, complicated by ascites and grade II esophageal varices s/p banding, now admitted with upper GI bleed likely secondary to portal gastropathy and antral erosions. . # Upper GI bleed - Most likely secondary to portal gastropathy with erosions and/or grade II esophageal varices, which were visualized and banded on repeat EGD. He remained hemodynamically stable and has not had any more hematemesis during this hospitalization. He was monitored for 48 hours without any further bleeding episodes. PPI and carafate QID were continued. H pylori serologic testing was negative. . # Hyponatremia - Given high urine sodium and osmolality with otherwise normal electrolytes and lack of renal failure, likely a large component of SIADH, which seemed to improve while he was NPO for EGD. Loop diuretics may help to decrease the action of ADH by washing out the osmolar gradient, so there were restarted slowly in light of borderline hypotension (SBP 90-100). Free water restriction to 1.5L per day was begun. Consider outpatient workup for SIADH. # Epigastric abdominal pain - His pain was located over site of ventral hernia and has been intermittent for several months while outside of the hospital. No symptoms concerning for strangulation, as the hernia is reducible and no changes in bowel habits. Would recommend outpatient follow-up by general surgeon . # HCV and EtOH cirrhosis: Known treatment-naive HCV with last viral load in [2140-2-25] of 8.36 million IU/ml. No liver biopsy in our records to help assess the grade of inflammation or fibrosis. Likely component of EtOH as well, given heavy alcohol abuse history. Known complications of varices and ascites, though no extensive ascites on exam. Nadolol and spironolactone were continued. Consider transplantation workup as an outpatient. . # Chronic itching: Hydroxine was continued. . # Chronic pain: Home dose oxycodone was continued. Medications on Admission: cyclobenzaprine 10 mg Tablet 1 Tablet(s) by mouth per day as needed for muscle spasm furosemide 40 mg Tablet 1 Tablet(s) by mouth once a day hydroxyzine HCl 50 mg Tablet 1 Tablet(s) by mouth per night lisinopril 10 mg Tablet 1 Tablet(s) by mouth once [Last Name (un) 5490] nadolol 20 mg Tablet 1 Tablet(s) by mouth once a day omeprazole 40 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by mouth twice a day ondansetron 4 mg Tablet, Rapid Dissolve 1 Tablet(s) by mouth every 8 hours as needed as needed for nausea nr oxycodone 5 mg Tablet 1 Tablet(s) by mouth three times per day as needed for hip and back pain spironolactone 100 mg Tablet 1 Tablet(s) by mouth once a day zinc Dosage uncertain Discharge Medications: 1. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 2. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:100 Tablet(s) Refills:2 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. hydroxyzine HCl 25 mg Tablet Sig: Four (4) Tablet PO QHS (once a day (at bedtime)). 8. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain: do not drive while taking this medication. 11. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO ONCE (Once) for 1 doses. 13. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain. 14. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Discharge Disposition: Home Discharge Diagnosis: Primary: Upper GI bleed Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname ], It was a pleasure caring for you at [Hospital1 18]. You were admitted with bleeding from your gastrointestinal tract. A study was done where a camera was placed down your esophagus and we saw evidence of erosions that were likely causing your bleeding. We also noted varices that we banded. You will need to follow-up in [1-29] weeks with the GI doctors [Name5 (PTitle) ] they [Name5 (PTitle) ] repeat the study. We have made the following changes in your medications: START sucralfate 1 gram four time a day for your stomach erosions CHANGE furosemide (Lasix) to 20mg daily ([12-28] original dose) because your blood pressure is a little low CHANGE spironolactone t0 50mg daily ([12-28] original dose) because your blood pressure is a little low STOP lisinopril for now, until your blood pressure increases. You do not need this right now. Please take the rest of your medications as prescribed. Followup Instructions: Department: LIVER CENTER When: FRIDAY [2140-5-20] at 11:40 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: ENDO SUITES When: TUESDAY [2140-4-5] at 2:00 PM Department: DIGESTIVE DISEASE CENTER When: TUESDAY [2140-4-5] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD [Telephone/Fax (1) 463] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3202] Campus: EAST Best Parking: Main Garage ICD9 Codes: 2761, 3051, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7817 }	Medical Text: Admission Date: [2178-5-5] Discharge Date: [2178-5-12] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1190] Chief Complaint: mental status change Major Surgical or Invasive Procedure: None History of Present Illness: This is an 89 year-old woman who has been living at [Hospital ] with her sister for the past month with multiple medical problems who presented on [5-5] with mental status change. Pt awoke at 7 am on the morning of admission "not feeling well" and was noted to have a change in mental status. At 8:40 am the patient was noted to have a right facial droop in the setting of hypotension. Pt was evaluated by the stroke service who determined that the reported deficits had resolved following correction of her hypotension. A CT of the head did not reveal any infarcts or acute changes. On arrival in ER, patient noted to be hypotensive to high 60's and hypoxic to 80's on room air. She was admitted to the [Hospital Unit Name 153] with septic physiology of unknown source, but given history of UTI's and few localizing symptoms, felt secondary to urosepsis. Initially started on vanc/levo/flagyl in ED. Dirty U/A. Patient given 5 liters of normal saline in [Hospital Unit Name 153], Zosyn/vancomycin maintained and patient's blood pressure improved to systolics in 120's overnight. Patient less hypoxic, satting well on 4 liters. Patient transferred to the floor on [2178-5-6]. At this time, her mental status is improved and appears to be at baseline. She has dementia at baseline. She denies localizing complaints ongoing prior to admission or at this time. Says she just felt sleepy before coming in. Denies cough, sputum production, chest pain. Denies dysuria, irritative symptoms. Denies abdominal pain, nausea, vomiting, diarrhea. No recent change in bowel habits. Denies hematochezia, melena, hemoptysis, hematemesis. Past Medical History: 1. NSAID-induced gastropathy with an upper GI bleed in [5-31]. Prior studies: [9-2] colonoscopy: diverticulus in sigmoid colon, polpy in rectum, otherwise normal. [9-2] EGD: no evidence of old or active bleeding in gastric body [5-31] EGD: hiatal hernia, barretts, NSAID induced gastropathy, duodenitis.) 2. Hypertension. 3. Chronic obstructive pulmonary disease. 45-60 PY tobacco. 2L O2 via NC at baseline. 4. Atrial fibrillation not currently anticoagulated secondary to fall risk. 5. Osteoporosis. 6. Urinary incontinence. 7. Syncope. 8. Peripheral vascular disease. 9. Congestive heart failure. EF=70-80% [2176]. 10. Dementia Social History: Lives in [Hospital3 537]. Ex-marine in World War II. Ex-smoker. Proxy: nephew [Name (NI) ] [Telephone/Fax (1) 32445] and [First Name8 (NamePattern2) 622] [Last Name (NamePattern1) ] [Telephone/Fax (1) 32446]. Pt lives on the [Location (un) 470] of the [Last Name (un) ]. Sister lives there as well. Big coffee drinker. Family History: non-contributory Physical Exam: ON admit: PE: T=96.7, BP=130/45 HR=61, O2sat=99% 15 l face mask GEN: lying in bed, nad HEENT: mm dry, poor dentition, JVP=6-8cm CV: rrr, nl s1/s2 PULMO: decreased breath sounds at right base with bibasilar rales ABD: slightly distenede, typannitic, bs+, no masses EXT: 1+ PT/DP, slight edema b/l, warm NEURO: AxOx3 On transfer to the floor PE: T=97.4, BP=128/68 HR=66, O2sat=99% 4 liters GEN: comfortable, no apparent distress, sitting in chair, elderly, very frail appearing HEENT: EOMI, sclera anicteric, MMM, poor dentition, op without lesions, JVP to 8 cm, no carotid bruits, no appreciable cervical or supraclavicular lymphadenopathy Lungs: bibasilar crackles CV: RR, S1 and S2 wnl, [3-8] hsm ABD: slight distention, +b/s, soft, nt, no masses EXT: no cyanosis, clubbing, trace edema, good dp pulses NEURO: AAOx3, although demented, cn ii-xii in tact, good strength throughout, Pertinent Results: Admit labs: [2178-5-5] 09:50AM WBC-9.6# RBC-3.46* HGB-9.7* HCT-29.0* MCV-84 MCH-27.9 MCHC-33.4 RDW-16.3* [2178-5-5] 09:50AM NEUTS-87* BANDS-7* LYMPHS-6* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2178-5-5] 09:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2178-5-5] 09:50AM GLUCOSE-126* UREA N-27* CREAT-1.6* SODIUM-127* POTASSIUM-3.9 CHLORIDE-88* TOTAL CO2-25 ANION GAP-18 [2178-5-5] 09:50AM PT-15.5* PTT-40.6* INR(PT)-1.5 Urinalysis: [2178-5-5] 10:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2178-5-5] 10:05AM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-FEW EPI-[4-4] [2178-5-5] 10:05AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.009 LFT's: [2178-5-5] 09:50AM ALT(SGPT)-13 AST(SGOT)-32 ALK PHOS-38* AMYLASE-124* TOT BILI-0.1 Cortisol: [2178-5-5] 09:50AM CORTISOL-119.1* Cardiac Enzymes: [2178-5-5] 09:50AM cTropnT-0.03* [2178-5-5] 09:50AM CK(CPK)-34 [2178-5-5] 09:50AM CK-MB-NotDone [2178-5-5] 07:34PM CK(CPK)-33 [2178-5-5] 07:34PM CK-MB-2 cTropnT-<0.01 [2178-5-5] 10:00PM CK(CPK)-48 [2178-5-5] 10:00PM CK-MB-2 [2178-5-6] 04:43AM BLOOD CK(CPK)-74 [2178-5-6] 04:43AM BLOOD CK-MB-2 cTropnT-<0.01 Labs on transfer to the floor: [2178-5-6] 04:43AM BLOOD WBC-7.3 RBC-3.32# Hgb-9.3 Hct-28.0* MCV-84 MCH-28.2 MCHC-33.4 RDW-17.4* Plt Ct-200 [2178-5-6] 04:43AM BLOOD Plt Ct-200 [2178-5-6] 04:43AM BLOOD Glucose-115* UreaN-23* Creat-0.9 Na-133 K-3.1* Cl-102 HCO3-24 AnGap-10 [2178-5-6] 04:43AM BLOOD Albumin-2.4* Calcium-6.5* Phos-3.5 Mg-1.8 [5-5] head CT: FINDINGS: Study is being compared to prior examination from [2176-2-15]. No significant changes are noted. Motion artifact is again present, limiting the evaluation. No intracranial masses, nor hemorrhages are identified. Midline structures are normal in position. Ventricles and subarachnoid spaces are within normal limits for age. Decreased attenuation is again visualized in the left posterior frontal white matter consistent with a chronic infarction. Patchy areas of low density is seen in the periventricular and deep white matter of both cerebral hemispheres, consistent with chronic microvascular ischemic changes. No acute major vascular territorial infarctions are identified. INTERPRETATION: Chronic infarct in the posterior left frontal lobe. Chronic microvascular ischemic changes. MRI is more sensitive in detecting acute infarction. [5-5] Chest x-ray: INDICATION: Right facial droop. Question infiltrate. Examination is limited due to kyphoscoliosis and flexed position of the patient's neck, partially obscuring the superior mediastinum and lung apices. There is a new patchy area of consolidation within the right lower lobe as well as an area of ill-defined opacity in the left perihilar region. The latter finding is best visualized on the second of two images in this series. Cardiac and mediastinal contours are stable with a hiatal hernia noted, although this was previously better visualized on prior studies. IMPRESSION: Patchy right lower lobe and left perihilar opacities, which may be due to aspiration or pneumonia. Followup radiographs are suggested to document resolution. [5-6] chest x-ray: INDICATION: 89-year-old woman with pneumonia. TECHNIQUE: Portable AP chest radiograph. COMPARISON: Chest x-ray dated [2178-5-5]. FINDINGS: Note is made of marked kyphosis and tortuosity of thoracic aorta and trachea. The patient head is partially overlying the upper lung fields. Cardiac and mediastinal contours are overall unchanged compared to the prior study. Note is made of CHF. Note is made of increased bilateral pleural effusion with atelectasis versus consolidation. Healed fracture of the right humerus is noted. IMPRESSION: Worsening CHF, bilateral pleural effusion and bibasilar consolidation versus atelectasis, which can represent worsening pneumonia. EKG on admit [5-5]: nl sinus ryhthm @ 88 bpm with a PAC. nl axis. nl intervals. elevated ST segments in V2-V4 (no change from [1-3]), no T wave inversions. Brief Hospital Course: This is an 89 year-old woman who presented with acute mental status change, hypotension, noted to have urinary tract infection and possible pneumonia. She had a very short intensive care unit stay. The following issues were addressed on this admission: ID: Patient admitted with septic shock, hypotension requiring brief dopamine and 5 liters of IVF. Suspected source was urine given pyuria, many bacteria but urine culture returned negative. Also with possible pneumonia by chest x-ray but poor films, possibly just atelectasis and does not report history of cough, trouble breathing, chest pain. Unclear if sick contacts at [Name (NI) ]. No other sources identified, no localizing symtoms. Blood cultures remained negative throughout admission. The patient's altered mental status quickly returned to baseline and septic physiology resolved on broad spectrum vanco/zosyn. Concern for possible aspiration but swallowing study done [5-6] identified patient as not increased aspiration risk. No bacteremia by blood cultures of [5-5]. Patient was maintained on zosyn/vancomycin until [5-8]. At that time switched to levoquin/flagyl to cover possible urinary tract infection and possible aspiration pneumonia. Repeat chest x-rays on [5-7] and [5-8] were more concerning for consolidation/possible aspiration. and thus antibiotics were continued. Plan is for 14 day course of levoquin/flagyl (total gram negative and anaerobe coverage including zosyn dosing). Needs 6 more days. Cardiovascular: ischemia: Patient with no known history of CAD, although was on aspirin on admit. Decision made to stop aspirin given history of previous GI bleeds and decreased crit on admit from baseline. Beta-blockade intially held with hypotension. Once stabilized beta-blockade was re-instituted at previous outpatient dosing. (metoprolol changed to atenolol). Pump: Patient was mildy volume overloaded after aggressive IVF's for sepsis. She has a history of hyperdynamic ventricle, ef 70-80%, likely diastolic dysfunction. She was diuresed over her hospital course a few liters. Also maintained on beta-blockade and ace inhibition at outpatient dosing without adjustments. Rhythm: history of PAF: not on anticoagulation given hx of GIB. Atenolol for rate control. Patient was in normal sinus rhythm throughout admission including by EKG on [5-11]. Acute renal failure: Patient with Creatinine baseline <1.0. Elevation on admission likely secondary to hypoperfusion of kidneys (prerenal) given BUN/Cr and hypotension, responded to fluids. After fluids and through diuresis creatinine stable at 0.7. . Heme: a)Anemia: Hct drop 29 to 22 after 5L IVF, likely secondary to hemodilution. However, does have history of GIB. Has been guiaic negative here. She received one unit of blood in ICU and another on floor. Responded well both times, maintained crit >28 given COPD. Has been in low to mid 30's since transfusions. b)Coagulopathy on admit: PTT: 40.6 INR: 1.5. Pt not on any anticoagulant, unclear etiology. Corrected with vitamin K: monitor for now. Normal platelets, do not think it is DIC. . Hyponatremia: On admission, felt to be hypovolemic hyponatremia, responded to fluids. Normalized. Baseline in very low 130's for years now. Pulmonary/History of COPD: on home oxygen 2l, "order a tank when I need it." Received albuterol/atrovent nebs here. Flovent/singulair maintained. As per previous notes, patient with baseline oxygen saturations in 80's on 2 liters at home. Multi-factorial pulmonary etiologies including habitus, COPD. Maintain oxygen, saturations generally mid to high 80's on [4-3] liters but no acute explanations for low oxygen saturation. Dementia: Continued Donepezil. . Depression: Maintained on Remeron Osteoporosis: Maintained on raloxifene, vitamin D and calcium. . Maintained on protonix for GI prophylaxis, subcu heparin for DVT prophylaxis. . Patient's CODE status was DNR/DNI throughout. Medications on Admission: atenolol 25 lisinopril 20 lasix 40 [Hospital1 ] protonix 40 flovent atrovent albuterol evista 60 accolate 20 [Hospital1 ] mirtazapine aricept 10 colace senna calcium vitamin D multi-vitamin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO QD (). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day. 7. Donepezil Hydrochloride 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 9. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:6 Tablet(s) Refills:0 13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days. Tablet(s) 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheeze. 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 17. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: pneumonia, urinary tract infection, sepsis, copd, dementia, depression Discharge Condition: stable Discharge Instructions: Contact MD if you have chest pain, shortness of breath or if you develop any pain or concerning symptoms. Follow-up as below. All medications as prescribed. Followup Instructions: Should contact Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 608] this week to make an appointment. ICD9 Codes: 0389, 5990, 486, 5070, 5849, 2761, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7818 }	Medical Text: Admission Date: [2170-5-15] Discharge Date: [2170-5-23] Date of Birth: [2102-5-16] Sex: M Service: CARDIOTHOR HISTORY OF THE PRESENT ILLNESS: This is a 68-year-old gentleman, who was admitted through the emergency room for chest pain. He was referred into the Cardiology Medical Service on [5-15]. He had been having these types of pains for years. He had a stress test in the past, which were unrevealing for any perfusion defects. The stress test performed on admission also was equivocal. The patient was symptom free on presentation. PAST MEDICAL HISTORY: 1. Chest pain. 2. Hypertension. 3. Insulin-dependent diabetes mellitus. 4. Hypercholesterolemia. 5. Hypothyroidism. 6. Gastroesophageal reflux disease. ALLERGIES: The patient has two allergies listed and they are as follows: TETRACYCLINE, HYDROCHLOROTHIAZIDE, AND DYAZIDE. On admission, the patient was hemodynamically stable, saturating 98% on room air, in sinus rhythm at 75. Heart revealed regular rate and rhythm with S1 and S2. LABORATORY DATA: Admission labs were as follows: Sodium 139, potassium 5.3, chloride 103, CO2 25, BUN 33, creatinine 1.1, blood sugar 155, CK 165 with MB of 2, troponin I less than 0.3. White count 9.1, hematocrit 40 and platelet count 279,000. HOSPITAL COURSE: The patient was admitted to the Cardiology Service. He was started on aspirin, beta blockers in preparation for cardiac catheterization. MEDICATIONS ON ADMISSION: 1. Aspirin. 2. Zestril. 3. Catapres. 4. Lipitor. 5. Prilosec. 6. Lasix, 7. Glipizide. 8. Glucophage. 9. Atenolol. 10. Synthroid. 11. NPH insulin. He was seen by Dr. [Last Name (STitle) 70] of Cardiothoracic Surgery and Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 25067]. After his cardiac catheterization, which showed a 70% lesion of the LAD, 80% of OM1, 90% lesion of the left posterolateral, 50% lesion of the RCA, as well as 80% lesion of the RCA, ejection fraction of 70%. The patient denied any history of CVA, transient ischemic attack, or claudication. The patient was symptom free at the time that he saw the physician. [Name10 (NameIs) ] stopped smoking twenty years ago. The patient also consented to the Cariporide study run by the Cardiac Surgery team. On [5-17], the patient underwent coronary artery bypass grafting times three by Dr. [Last Name (STitle) 70] with LIMA to the LAD, vein graft to PDA and vein graft to OM. The patient was transferred to the cardiothoracic ICU in stable condition on the following medications: propofol, cariporide, and Neo-Synephrine. On postoperative day #1 he had an uneventful night and he was extubated. He was hemodynamically stable in sinus rhythm in the 90s with a blood pressure of 151/70, saturating 93% on nasal cannula. Postoperatively, the white count was 12.7 with the hematocrit of 27.1, platelet count 226,000, potassium 4.5, BUN 15, creatinine 0.7. Heart was regular rate and rhythm. Chest tube output was tapering off. Lungs were clear bilaterally with decreased breath sounds bibasilarly. Abdominal examination was benign. Chest tubes were removed later in the day. Urine output was good. He had been on nitroglycerin at 5, which was weaned down and he completed his cariporide infusion. He was seen by the Nutrition Department and the Department of Physical Therapy and he was transferred out to the floor. On postoperative day #2, again, no events were noted overnight. He was started on his postoperative medicines, including the resumption of the Synthroid and Lopressor. The BUN came down to 14 and the creatinine was 1.0. Hematocrit of 29.8, white count 15.3. Temperature maximum was 100.3, saturation 94% on room air. Sternum was stable. Incisions were clean, dry, and intact. Diet was advanced. He completed his perioperative antibiotics, and he went out to the floor. Sugar was managed with sliding scale regular insulin. He had a little bit of sinus tachycardia on postoperative day #3 with a temperature maximum of 101, blood pressure 145/84. Heart was regular rate and rhythm. He was dosed with Amiodarone. Breath sounds were decreased with the right greater than the left at the base. Laboratory work remained stable. Central line and Foley were pulled and the patient remained in sinus rhythm. On postoperative day #4, he remained stable with slightly elevated blood pressure. The sternal incision was healing well. Wires remained in. He continued to have decreased breath sounds at both bases. He remained in sinus rhythm at a rate of 80. Wires were pulled. He was restarted on Zestril for better blood pressure control, and he continued to ambulate on the floor. On postoperative day #5, he had some emesis overnight. He was complaining of no nausea at the time of the examination. Incisions were clean, dry, and intact. He continued to have decreased breath sounds at the bases. Abdomen was mildly distended, but soft. Labs and LFTs were checked again. He started Clonidine for blood pressure control with a pressure of 164/78. He remained in sinus rhythm at 80. He was made NPO. On the evening of the 7th, the patient had some dizziness and confusion. He was slightly disoriented. He was pale and diaphoretic in the evening with a blood pressure of 90/50 and heart rate of 68. Blood sugar was 146. He was given some fluids as a bolus. Blood pressure came up to 102/60. Clonidine was discontinued. On postoperative day #6 he was tolerating clear fluids. He had temperature maximum of 100.1 in the morning. Pressure was 114/64 with a heart rate of 64, saturating 96% on room air. He was alert, oriented, and comfortable. Incision on the sternum was clean, dry, and intact. Abdomen was mildly distended, but soft with positive bowel sounds and positive flatus. Diet was advanced. He continued to ambulate out of bed. On [5-23], on the day of discharge, the patient was afebrile. Chest incision was healing well. Heart was regular in rate and rhythm. Abdomen was soft. Only complaint was constipation. He was discharged to home in stable condition on the following medications: DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o.b.i.d. 2. Zantac 150 mg p.o.b.i.d. 3. Enteric coated aspirin 325 mg p.o.q.d. 4. Synthroid 0.125 mg p.o.q.d. 5. Glipizide 5 mg p.o.q.AM; Glipizide 7.5 mg p.o.q.PM. 6. Tylenol 650 mg p.o.p.r.n.q.6h. 7. Oxycodone 5 mg to 10 mg p.o.p.r.n.q.4h. to 6h. 8. Metformin 1000 mg p.o.b.i.d. 9. Amiodarone 200 mg p.o.b.i.d. times one week; Amiodarone 200 mg p.o.q.d. times three weeks; then to be discontinued. 10. Lopressor 75 mg p.o.b.i.d. 11. NPH 12 units subcutaneously. 12. Insulin q.h.s. 13. Zestril 40 mg p.o.q.d. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting times three. 2. Coronary artery disease. 3. Hypertension. 4. Insulin dependent diabetes mellitus. 5. Hypercholesterolemia. 6. Hypothyroidism. 7. Gastroesophageal reflux disease. The patient was instructed to followup with his primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ] in two weeks post discharge and to see Dr. [Last Name (STitle) 70] for his postoperative check in six weeks. The patient was discharged home in stable condition on [2170-5-23]. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 76] MEDQUIST36 D: [2170-7-11] 10:20 T: [2170-7-11] 10:31 JOB#: [Job Number 93136] ICD9 Codes: 4111, 2449, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7819 }	Medical Text: Admission Date: [2132-9-7] Discharge Date: [2132-10-21] Date of Birth: [2097-8-29] Sex: F Service: MEDICINE Allergies: Percocet / Penicillins / Vicodin / Heparin Agents Attending:[First Name3 (LF) 348] Chief Complaint: diffuse weakness, episodic numbness, diffuse body pain Major Surgical or Invasive Procedure: Mechanical pleurodesis and Left Upper Lobe Wedge Resection History of Present Illness: 35 yo woman discharged from [Hospital1 2025] (admitted [Date range (1) 32318], then [Date range (1) 74351]) s/p pleurodesis/VATS for bleb removal. Pt. was admitted to [Hospital1 2025] from OSH with a L pneumothorax on [8-22], has a chest tube placed, and on [8-26] had L flexible bronch, VATS, and pleurodesis. She tolerated the procedure well, with no complications, and her pain was controlled with a Dilaudid PCA -> Morphine PCA -> PO Dilaudid. She was seen by the pain service there and discharged on 2 mg Dilaudid PO Q4 per their recs. She was readmitted on [9-1] with a recurrent pneumothorax and got a 2nd L sided chest tube. She was discharged on [9-7] on Dilaudid 2 mg PO Q8. . Pt. presented to the [Hospital1 18] ED [9-7] c/o diffuse weakness, episodic numbness, diffuse body pain. She was given 2 mg IV Dilaudid in ED, 0.5 mg Ativan, and admitted to medicine for pain control. She was started on Amitriptyline however she never received a dose. In the morning she was found to be complaining of back pain and pain at the site of her chest tube placement. She denied constipation, diarrhea or bowel incontinence, dysuria or incontinence of urine, weakness or numbness, though she did report "tingling" in her abdomen, and that she "can't feel bowel movements coming out." At 9PM that evening, she was found to be unresponsive with a poor respiratory effort. She was moving all extremities spontaneously. She was lethargic but appropriate 20 minutes before. Initially her O2 sats were 70% on RA, HR 100, SBP 160. Her O2 sats improved to 94% on a face mask. She had clear breath sounds bilaterally. She was intubated for airway protection. Her ABG was found to be 6.86/179/168/35/lactate 2.4. Of note her WBC count increased to 22.4 with 78% Neutrophils and 0% bands from 7.8 earlier today. She received Narcan x1. She was transferred to the MICU. Past Medical History: Bleb -> Pneumothorax, s/p Pleurodesis/VATS and Chest tube placement at [Hospital1 2025] [8-22]- 8/12 L shoulder subluxation Boating accident [2125] -> pelvic fracture and renal laceration, managed non-operatively Spontaneous Pneumothorax in R, [2126] Social History: Engaged to be married, lives with daughter 17, son, and [Name2 (NI) 802] that she has is raising. Employed as a surgical tech at [Hospital ], hasn't worked recently. She started smoking in [2125]; smokes ~10 cigs per day, however, last cigarrette [8-22] when admitted to [Hospital1 2025] with pneumothorax. Mother reports that she does not abuse ETOH or illicit drugs. She takes ativan [Hospital1 ] for anxiety. Family History: FH: Mother with h/o VT s/p ablation Uncle with CAD s/p CABG Denies family h/o neurologic disorders Physical Exam: T 98.1 78 136/72 18 98% on RA Gen: sleeping, mild distress moaning eomi: tiny minimally reactive pupils, eomi neck: nl movement, no tenderness lungs: cta x 2 heart: bandages on her left side covering two former chest tube wounds abd: soft flat, nt +bs ext: difficult to test strength secondary to pain, +pulses, ext warm no sensory deficit to light touch AOx3 Pertinent Results: Chest CT, [9-8]: There is no pneumothorax. There is scarring around a previous chest tube tract at the left lung apex. Linear scarring is also present in the right and left lower lobes. There is pleural thickening or small amount of pleural fluid at the right lung base. Scattered blebs are present in both lungs. The airways are patent to the level of segmental bronchi. There is no mediastinal or axillary lymphadenopathy. There is no evidence of hilar lymphadenopathy on non-contrast evaluation. The heart and great vessels appear unremarkable. There is no pericardial effusion. . The visualized portions of the liver and spleen appear unremarkable. There are no suspicious lytic or sclerotic lesions in the visualized osseous structures. . IMPRESSION: No pneumothorax. Right basilar pleural thickening versus a small pleural effusion. Admission Labs: [2132-9-7] 10:40PM GLUCOSE-110* UREA N-8 CREAT-0.7 SODIUM-141 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-18 [2132-9-7] 10:40PM CALCIUM-9.9 PHOSPHATE-3.7 MAGNESIUM-1.9 [2132-9-7] 10:40PM WBC-7.8 RBC-4.31 HGB-12.6 HCT-37.0 MCV-86 MCH-29.2 MCHC-34.0 RDW-12.4 [2132-9-7] 10:40PM NEUTS-74.9* LYMPHS-21.7 MONOS-2.7 EOS-0.4 BASOS-0.2 [2132-9-7] 10:40PM PT-13.2 PTT-28.3 INR(PT)-1.2 CT CHEST INDICATION: History of recurrent pneumothoraces, Guillain-[Location (un) ] syndrome, pulmonary embolism with increasing left-sided chest pain. Comparison is made to the prior chest CT dated [2132-9-18] and prior chest x-ray on the same day. TECHNIQUE: Multidetector CT scanning of the chest was performed following intravenous administration of 150 cc of Optiray contrast. Multiplanar reconstructions were also obtained. FINDINGS: Compared to the prior CT scan, there has been interval development of a large left-sided pneumothorax. This also appears to have progressed significantly compared to the chest x-ray performed on the same day. There are associated atelectatic changes in the left lung. There is again evidence of left upper lobe wedge resection. Multiple peripheral blebs are noted along the right upper lobe. Linear atelectatic changes are demonstrated in the right lower lobe with marked interval reexpansion of the right lower lobe. There has been development of an oval shaped roughly 3.8 x 2.1 cm low-attenuation lesion in the right lower lobe with a few foci of gas most consistent with loculated fluid. The pulmonary arteries demonstrate no evidence of pulmonary embolism. The heart, pericardium, and great vessels are within normal limits. Note is made of a tracheostomy tube. An NG tube is also noted. No pathologically enlarged axillary, mediastinal, or hilar lymph nodes are demonstrated. BONE WINDOWS: There are no suspicious lytic or sclerotic lesions. CT RECONSTRUCTIONS: The above findings were confirmed with multiplanar reconstructions. IMPRESSION: 1. Interval development of very large left-sided pneumothorax. 2. Marked interval reexpansion of the right lower lobe compared to the prior CT scan with residual small loculated fluid collection in the right lower lobe. 3. No evidence of pulmonary embolism. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7832] Approved: SAT [2132-9-27] 9:06 AM Procedure Date:[2132-9-26] Clinical: Left recurrent pneumothorax. Gross: The specimen is received fresh and labeled with the patient's name, medical record number and "right upper lobe wedge" and consists of three wedge resections of lung, the smallest measuring 2.8 x 1.2 x 0.5 cm, the second measuring 3.6 x 1.2 x 0.6 cm, and the largest measuring 8.5 x 2.5 x 1.5 cm. The pleural surface is smooth and without any gross abnormalities. Serial sectioning reveals a red-brown spongy cut surface without any lesions. The specimen is represented in A-C. TWO VIEW CHEST, [2132-10-16] AT 14:51 COMPARISON: Previous study of earlier the same date at 8:24. INDICATION: Status post removal of left-sided chest tube. Since the recent chest radiograph, a left-sided chest tube has been removed. A small left apical pneumothorax is present, best visualized on the lateral view. In retrospect, this is also present on the pre-chest tube removal radiograph and is without interval change. On the PA view, the pneumothorax was partially obscured by the overlying chest tube on the previous film, rendering it more difficult to visualize prospectively. The remainder of the chest radiograph is without change since the recent radiograph. IMPRESSION: Small left apical pneumothorax, stable in retrospect compared to pre-chest tube removal radiograph of earlier the same date. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] Approved: [Doctor First Name ] [2132-10-16] 5:53 PM Procedure Date:[2132-10-16] INDICATION: 35-year-old woman with abdominal distention. Please assess for bowel obstruction. COMPARISON: Abdominal radiograph dated [2132-10-6]. TECHNIQUE: AP supine and upright abdominal radiographs were obtained. FINDINGS: There is an NG tube which on [2132-10-6] had shape consistent with post pyloric position but now is coiled over the left abdomen presumably within the non-distended stomach. Small and large bowel are of normal caliber. Air is seen throughout loops of small bowel and within the proximal colon. There is no definite free air identified. There are two 5 cm metallic linear objects overlying the right abdomen with shape consistent with [Doctor First Name ] pins and are likely external to the patient. There is stable appearance of bilateral breast implants. Bony structures are unremarkable. IMPRESSION: No evidence of obstruction. NG tube with tip previously in post- pyloric position has now migrated back into the stomach. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7832] Approved: MON [2132-10-13] 7:27 AM Procedure Date:[2132-10-10] Brief Hospital Course: 35 yo F with h/o spontaneous PTX, GBS, HIT induced PEs, vent-associated pneumonia called out from the MICU [10-1]. Her recent history is significant for 2 admissions to [Hospital1 2025] ([Date range (1) 32318]/05) for spontaenous left pneumothoraces. On her first admission, she had a left sided chest tube placed, a VATS, and pleurodesis. She tolerated this well and was discharged on PO dilaudid for pain control. She re-presented for her second admission to [Hospital1 2025] with a recurrent pneumothorax, got a 2nd left sided chest tube, and was again discharged on PO dilaudid. After being dischraged from [Hospital1 2025] she presented the same day to [Hospital1 18] complaining of diffuse weakness and body pain as well as episodic numbness. She was initially treated with pain control with a morphine PCA per the pain service. She continued to have diffuse weakness, increasing anxiety and psychiatry was initially consulted for ? conversion disorder. On the evening of [9-9] a code was called as she was unresponsibe with a poor respiratory effort (HR 100, sBP 160, O2Sat 70% on RA --> 94% on face mask). An ABG revealed pH 6.86, pO2 168 pCOs 179). She was intubated and transferred to the MICU. 1st MICU course: A neurology consult felt her elevated LP protein (112), diffuse motor weakness, rapid time course, and rapid increase in her peripheral WBC ([8-8]) were all consistent with GBS. She was started on plasmapheresis and received four sessions (fifth session was not completed because pheresis line had to be pulled due to positive HIT antibody). She also developed ventilator associated pneumonia for which she was treated with vanco/levo/vanc for a 7 day course which was finished on [9-17]. She also developed heparin associated thrombocytopenia which improved after d/cing all heparin products. On [9-18], she had increasing respiratory distress and increasing O2 requirements and a CTA revealed pulmonary emboli found within all 3 segmental branches of the RUL pulmonary artery. Due to her positive HIT antibody, she was started on argatroban and coumadin. She was switched to a trach mask on [9-23] and tolerated this and on [9-25] was transferred to the floor. The morning of [9-26] she developed [10-27] stabbing, non-radiating, L sided chest pain. Cardiac enzymes were negative and a stat ECHO showed no WMA. A CXR was unremarkable but a CT scan showed a large L PTX and she was transferred back to the MICU. 2nd MICU course: Her INR was reversed and on [9-30] she had a mechanical pleurodesis and LUL wedge resection. No blebs were seen but there was abnormal appearing lung tissue in the apex. She was transferred out of the MICU on [10-1]. 1. Pneumothorax: unclear etiology of recurrent PTX. Possibly secondary to her stature. alpha-1-antitrypsin was negative. S/p L-sided wedge resection and pleurodesis on [9-30]. She had 2 chest tubes and one was removed [10-6], but [Initials (NamePattern4) ] [Last Name (NamePattern4) ] drain was left in place. The [Doctor Last Name ] drain was removed on [10-17] after a successful flamping trial. She will follow up with CT surgery in 1 week. 2. Pulmonary Embolism: She had a PE in all 3 branches of RUL pulmonary artery on [9-18] CT scan. Developed HIT with plasmapheresis for GBS. Restarted argatroban and coumadin [10-1] following CT surgery. She was initially on coumadin 2.5 mg PO QHS and stable with an INR between [2-21]. Her INR started to trend down, however, and her coumadin was adjusted to 3 mg PO QHS. Before discharge however, her INR started to trend up slightly past 3, so she was discharged on 2.5 mg PO QHS. Her INR will be followed up by her PCP during her appointment later this week. He has been called regarding this. 3. Guillain-[Location (un) ] Syndrome: She was s/p four cycles of plasmapheresis (didn't get fifth cycle due to developing HIT). Her tracheostomy was dwonsized on [10-10]. Trach was buttoned on [10-13] and removed on [10-14]. On discharge, her stoma was almost completely healed and well-granulated. She will continue to bandage it until completely healed (7-10 days from removal date), and will cover it with cellophane for showering. Her strength returned over the course of her admission with daily physical therapy. On discharge, she was able to walk on her own with a cane and to manage a couple flight of stairs. She has a follow-up appointment scheduled with neurology, and has the phone number of interventional pulmonary should she have any questions regarding her stoma. 4. Pain: Patient has pain secondary to her Guillain-[Location (un) ] and Pneumothorax. Her PCA was discontinued once the [Doctor Last Name 406] drain was removed, and her pain was well controlled with a fentanyl patch and oral morphine, which will be tapered as an outpatient. She will also continue neurontin 600 mg TID per neurology. She was not given oxycodone as she had a history of anaphylaxis to percocet. 5. Anxiety: She has chronic anxiety which has been heightened by recent course of events. She was placed on her home dose of standing ativan 0.5 mg PO Q6, and had several discussions with social work and psychiatry nurses in-house. 6. Ventilator-associated pneumonia - L retrocardiac opacity that has since rsesolved. Sputhm from [9-11] with Haemophilus B-lactamase negative. She completed a 7 day course of Levo/Vanc on [9-17]. She was afebrile with a normal WBC count on discharge. 7. Anemia - Her hematocrit was stable since her 2nd transfer out of the MICU and her anemia was thought to be secondary to frequent blood draws. No evidence of an RP bleed by CT scan, no evidence of hemolysis. She was transfused with 2 units on [10-8]. Her hematocrit had been stable for several days on discharge. 8. Abdominal pain - She developed intermittent abdominal pain after her second transfer out of the MICU which required placement of an NG tube with tube feeding. Her abdominal pain spontaneously improved to the point where the tube was removed and she was tolerating a regular diet, and further improved once she was told to take POs slowly and to avoid milk products. She was discharged tolerating a regular diet with no further abdominal complaints. Medications on Admission: Motrin 800 mg TID Dilaudid 2 mg PO Q8 (pt. taking it more frequently) Discharge Medications: 1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed: for constipation. Disp:30 Suppository(s) Refills:0 3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [1-20] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:1 inhaler Refills:0 4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:180 Capsule(s) Refills:0 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q 6 HRS (). Disp:56 Tablet(s) Refills:0 6. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:4 Patch 72HR(s) Refills:0 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:0 8. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for 10 days. Disp:120 Tablet(s) Refills:0 9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: 1. Spontaneous Left-sided pneumothorax 2. Heparin-induced antibody pulmonary embolism 3. Guillain-[Location (un) ] syndrome 4. Ventilator-associated pneumonia 5. Anxiety Discharge Condition: stable Discharge Instructions: 1. Please take all medications as prescribed 2. Please go to all follow-up appointments 3. If you develop difficulty breathing or persistent chest pain, or have other concerning medical issues, please seek medical attention or call 911. Followup Instructions: 1. You have a follow-up appointment with Thoracic Surgery/Dr. [Last Name (STitle) ] [2132-10-28] Tuesday at 2:00 PM on the [Location (un) ] the [Hospital Ward Name 23] Clinical Center at [Hospital1 69] ([Telephone/Fax (1) 170]). 45 minutes prior to appointment that day, go to Sharpiro Clinical Center [Location (un) ] for chest xray. 2. You will not need a follow-up appointment with interventional pulmonology regarding your tracheostomy. However, if you have questions or if your stoma does not heal in [7-27] days, you may call [Telephone/Fax (1) 3020] to schedule an appointment with Dr. [First Name (STitle) ] [Name (STitle) ] 3. You have a follow-up appointment with Dr. [Last Name (STitle) ] and Dr. [First Name (STitle) 951] (of Neurology) on [2132-11-14] Friday at 4:45 PM in the [Hospital Ward Name 23] Building, [Location (un) ], of [Hospital1 69]. [Telephone/Fax (1) 1040]. 4. You have a follow-up appointment with your primary care doctor, Dr. [First Name (STitle) 951] on [2132-10-24] Friday at 10:20 AM. 5. You have a follow-up appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], with whom you would like to establish your primary care follow-up, on [2132-10-29] at 1:30 PM on the [Location (un) ] North Suite of [Hospital Ward Name 23] at [Hospital1 69] [Telephone/Fax (1) 250]. Completed by:[2132-10-21] ICD9 Codes: 486, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7820 }	Medical Text: Admission Date: [2120-9-27] Discharge Date: [2120-9-29] Service: [Hospital Unit Name 196] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 1402] Chief Complaint: transfer from outside hospital for biventricular pacemaker placement and further medical management Major Surgical or Invasive Procedure: biventricular pacemaker placement, [2120-9-27] History of Present Illness: [Age over 90 ] y/o male with complicated cardiopulmonary PMHx notable for CAD s/p MI [4-4], CABG x 4 complicated by wound staph infection leading to sternectomy. Dialated cardiomyopathy with EF 10-20%. Also with DM, CRI, esophageal mass obstruction, s/p bx with indeterminate path; s/p stenting with relief of obstruction. Also with COPD, O2sats high 80s on RA baseline. Presented at OSH on [2120-9-18] with COPD exacerbation, ? asp PNA and dehydration with increased Cre. Stay was c/b over diuresis and pressor dependent hypotension felt to be [3-4] diuresis and ACEI therapy. Pt also c. diff positive and Rx flagyl day 7 of 10 on [9-27]. ECG revealed wide LBBB. [Name (NI) 1094] son Dr. [First Name4 (NamePattern1) ] [Known lastname 58305] arranged for transfer to [Hospital1 18] for consideration for biventricular PM to help pt from recurrent CHF hospitalizations. Lenghty discussion with son and pt with EP fellow and Dr. [Last Name (STitle) ] re: risk/benefit of [Hospital1 ]-ventricular pacer placement in elderly pt with co-morbidity. Pt son understood the risk including possibility of obtaining little clinical benefit; but still wished to proceed. Pt remianed full code. Past Medical History: CAD s/p CABG COPD Congestive heart failure Social History: former TOB Family History: noncontributory Physical Exam: GEN: Elderly M in NAD HEENT: NCAT, PERRLA, OP clear Heart: S1S2 tachycardic Lungs: CTA anteriorly Abdomen: nontender, nondistended Extremities: trace pulses throughout, no edema Brief Hospital Course: Pt transferred from outside hospital and brought directly to EP laboratory where he underwent biventricular pacemaker placement without complication. Pt tolerated procedure well and then brought to CCU for close monitoring. Pt did well in CCU without symptoms, mentating well, answering questions appropriately. Pt then transferred to [Hospital Ward Name 121] 3 but remained on CCU team. About 5 AM [2120-9-29], pt found to have SBP in 50s and CCU team called emergently. Pt found to be hypoxic with O2 sats in 70s, not mentating appropriately, and emergently intubated. Pt brought back to CCU and started on dopamine for BP support. Pt's hypotension continued despite increasing dopamine and adding levophed & dobutamine, with MAPs in the 30s. [Name (NI) 1094] son was called & came to bedside. Per family wishes, no further aggressive measures were undertaken. Pt went into ventricular fibrillation at 1:30 PM [2120-9-29] and passed away within minutes. [Name (NI) 1094] son declined post-mortem. Medications on Admission: digoxin, protonix, zocor, advair, aspirin, prednisone 5 qd, lasix 90 qd, flagyl, insulin sliding scale, colace, Zofran. Discharge Medications: none Discharge Disposition: Extended Care Facility: passed away Discharge Diagnosis: ventricular fibrillation and cardiac arrest congestive heart failure coronary artery disease Discharge Condition: passed away Discharge Instructions: passed away Followup Instructions: passed away Completed by:[2120-9-29] ICD9 Codes: 4280, 4254, 496, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7821 }	Medical Text: Unit No: [Numeric Identifier 30310] Admission Date: Discharge Date: Date of Birth: Sex: F Service: CHIEF COMPLAINT: Status post IMI with new onset atrial fibrillation. HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old woman with a history of myasthenia [Last Name (un) 2902] and TIAs who awoke at 1:00 a.m. with diffuse chest and back pain. She called her daughter who arrived and found the patient down and pulseless. The patient started breathing spontaneously one to five minutes later. The patient was then taken to [Hospital3 7900] where an EKG revealed ST elevations in the inferior leads. She received IV nitroglycerin and became hypotensive so nitroglycerin was discontinued. She was started on a heparin drip and given aspirin and Plavix which she is already taking as an outpatient. She was then transferred to the [Hospital1 69] for cardiac catheterization which revealed an LCMA, normal LAD with 30 percent stenosis, LCX normal, and RCA with 100 percent stenosis proximal with a thrombus. The RCA occlusion was stented. The procedure was complicated by bradycardia and hypotension with reperfusion and rapid atrial fibrillation of 280 during the right heart catheterization. The patient was shocked times two and went back into normal sinus rhythm. She then went into atrial fibrillation again and was shocked again. At this time, an Amiodarone drip was implemented with conversion to normal sinus rhythm. The patient was also started on dopamine for hypotension. PAST MEDICAL HISTORY: Myasthenia [Last Name (un) 2902]. TIAs. Carotid disease, status post left CEA with Dacron graft. Benign breast lump, status post excision. Whipple disease. Migraines with visual aura. Mild asthma. High cholesterol. Esophageal spasm. MEDICATIONS: 1. Plavix 75 mg p.o. q.d. 2. Aspirin 81 mg p.o. q.d. 3. Multivitamin. 4. Mestinon 50 mg p.o. q.i.d. ALLERGIES: Lidocaine which causes hives, IV contrast dye which causes hives, Demerol, codeine, Betadine, penicillin which causes GI upset, and gatifloxacin. SOCIAL HISTORY: She is a former tobacco user. She was born in [Location (un) ]. She is a widow. She lives with her daughter who is a physician at [Name (NI) ]. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Vital signs: Pulse 67, blood pressure 109/49. General appearance: Lying in bed in no acute distress, refused to be examined. Lungs: Anteriorly clear to auscultation bilaterally. No rhonchi, no wheezes. Coronary: Regular rate and rhythm. S1, S2. No murmurs, rubs, or gallops. Abdomen: Obese, soft, nontender, nondistended. Groin: Right-sided sheath in place. Extremities: Dorsalis pedis are palpable bilaterally. LABORATORY DATA: On admission, CBC revealed a crit of 32, white count 13.0, platelets 331,000. Chem-7 was all within normal limits. Coagulations were within normal limits. CK MB was 128 with an index of 16. Troponin T was above 50. Chest x-ray had revealed mild CHF. EKG revealed normal sinus rhythm at 71, [Street Address(2) 1766] elevation in II, III, and aVF, ST depressions in V2-V6, I, and aVL, normal axis. This was obtained at the outside hospital. HOSPITAL COURSE: The patient is a 74-year-old woman with a prior history of CAD, who presented with an inferior myocardial infarction now status post stenting of the RCA with periprocedural atrial fibrillation required cardioversion times three and Amiodarone drip and also with hypotension which required a dopamine drip. CARDIOVASCULAR: The patient is status post IMI with stenting of the RCA with good TIMI III flow. She, however, has evidence of RV infarction. She was continued on Plavix, aspirin, and treated with an Integrelin drip for 18 hours. Lopressor was started and increased to 25 mg p.o. b.i.d. The rest of her hospital course was uneventful and she was discharged on metoprolol 25 p.o. b.i.d., Atorvastatin 5 mg p.o. q.d., Plavix, and aspirin. PUMP: An echocardiogram was obtained which revealed an EF above 55 percent with inferior hypokinesis and 1+ MR. A repeat echocardiogram was recommended in one to two months. The patient remained in normal sinus rhythm. He electrolytes were repleted as needed. The Amiodarone drip was stopped. PULMONARY: Her oxygenation initially was 100 percent on 4 liters. On the day of discharge, her lung examination revealed no crackles. She had no shortness of breath and she was breathing well at room air with normal oxygenation. DISCHARGE PLAN: The patient was discharged home with follow- up with her primary care physician who is Dr. [First Name (STitle) ]. She was also referred to Cardiology with whom she will have to follow-up within one month with recommendation to have an echocardiogram repeated. DISCHARGE DIAGNOSIS: Inferior myocardial infarction complicated by rapid atrial fibrillation and hypotension. Congestive heart failure. DISCHARGE MEDICATIONS: 1. Metoprolol 25 mg p.o. q.d. 2. Guaifenesin p.r.n. 3. Atorvastatin 5 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. 5. Plavix 75 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. 7. Pyridostigmine 50 mg p.o. q.i.d. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 30311], [MD Number(1) 30312] Dictated By:[Name8 (MD) 30313] MEDQUIST36 D: [2182-6-21] 17:10:42 T: [2182-6-21] 18:03:42 Job#: [Job Number ] ICD9 Codes: 4280, 9971, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7822 }	Medical Text: Admission Date: [2179-4-6] Discharge Date: [2179-4-12] Date of Birth: [2152-4-24] Sex: F Service: MEDICINE Allergies: Penicillins / Tetracycline Attending:[First Name3 (LF) 2290] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: Endotracheal Intubation (tube placed at outside hospital) Mechanical Ventilation Bronchoalveolar Lavage/bronchoscopy Central venous line placement History of Present Illness: Mrs [Known lastname 77625] is a 26 yo female with history of obesity, childhood asthma, smoker, poorly controlled diabetes. She initially presented to [Hospital3 ] ED with cough, fever, chills, myalgias, N/V/D x2 days with progressive SOB in the setting of several recent sick contacts. She had also been non-compliant with her diabetes medications with glucose elevated to 537 with no gap. On arrival to the ED, vitals were remarkable for T 103, HR 140, satting 91% on 2 L, WBC elevated to 16.4. ABG showed hypercarbic respiratory failure and the pt was intubated. Right subclavian was placed and she was started on moxifloxacin, albuterol, duonebs and insulin. She was transfererred to the CHA ICU on [2179-3-29]. . At [Hospital 8] hospital, she was treated with tamiflu and started on ceftriaxone and azithromycin for PNA, which was broadened to vanc, cefepime, gent on [4-4] with persistent fevers. Treatment was based on her presenting symptoms however CT chest on [3-31] did not show any consolidations, CTA did not show any evidence of PEs, however per OSH report there was concern for tracheomalacia. Extubation was attempted on [4-1] but failed. There was also concern for sepsis and she was started on solumedrol 60 [Hospital1 ] but did not require pressors. Cxs were negative with the exception of 1 blood cx growing coag negative staph. HIV test was ordered and was pending on transfer. Aspergillis serology was sent due to elevated IGE levels. CT head was done to eval for sinus infection and was pending. She was also treated for cdiff with PO vanco given new diarrhea with abx (cdiff assay pending). She was treated with insulin and started on tube feeds. CEs were drawn and found to be mildly elevated with a normal EKG, therefore enzymes were trended and this was thought to be due to demand ischemia. ECHO showed EF 70%, mild RA enlargement, mild PHTN, mild MR, TR. She was transferred for further work-up of her respiratory distress and possible bronchial stenting. . On the floor, pt is intubated and sedated, opens eyes to voice but is otherwise not responsive. Past Medical History: Asthma Bipolar d/o NIDDM ADHD obesity Hemorrhoids Social History: Most of care at [Hospital1 2177], 5 year old son [Name (NI) 449]. Lives with mother who is also chronically ill and med non-compliant per report. Tobacco, EtoH, illicit drug denies. Family History: Mother: Diabetes Physical Exam: Admission Physical Exam: Vitals: T:101.6 BP:142/60 P:54 R: 16 O2:95 % on vent General: NAD, opens eyes to voice, intubated HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA, OG tube in place Neck: supple, JVP not elevated, no LAD Lungs: Rhonchorous throughout CV: Distant heart sounds, RRR, no MRG Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, mild edema bilaterally. NEURO: opens eyes to voice, moves all extremities freely Pertinent Results: Admission Labs: [2179-4-6] 03:28AM BLOOD WBC-11.1* RBC-3.31* Hgb-9.4* Hct-28.8* MCV-87 MCH-28.4 MCHC-32.7 RDW-13.5 Plt Ct-266 [2179-4-6] 03:28AM BLOOD Neuts-71.7* Lymphs-21.6 Monos-6.3 Eos-0 Baso-0.4 [2179-4-6] 03:28AM BLOOD PT-13.1 PTT-21.5* INR(PT)-1.1 [2179-4-6] 03:28AM BLOOD Plt Ct-266 [2179-4-6] 03:28AM BLOOD Glucose-184* UreaN-20 Creat-0.7 Na-143 K-4.5 Cl-104 HCO3-32 AnGap-12 [2179-4-6] 03:28AM BLOOD ALT-64* AST-39 LD(LDH)-260* CK(CPK)-138 AlkPhos-44 TotBili-0.4 [2179-4-6] 03:36PM BLOOD CK(CPK)-129 [2179-4-6] 03:28AM BLOOD CK-MB-1 cTropnT-<0.01 [2179-4-6] 03:36PM BLOOD CK-MB-1 cTropnT-<0.01 [2179-4-6] 03:28AM BLOOD Albumin-3.5 Calcium-9.3 Phos-6.0* Mg-2.6 [2179-4-6] 03:32AM BLOOD Type-ART pO2-86 pCO2-55* pH-7.39 calTCO2-35* Base XS-6 [2179-4-6] 03:32AM BLOOD Lactate-2.1* [2179-4-6] 03:32AM BLOOD freeCa-1.26 [4-6] CXR: Endotracheal tube tip is approximately 1 cm above the carina. Retraction 3 cm is recommended. Lung volumes are low. Pulmonary vascular congestion is likely secondary to low lung volumes. Heart size is within normal limits given low lung volumes. No focal consolidation, pleural effusion, or pneumothorax is seen on this single view. [4-8] ECHO: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a very small pericardial effusion. Microbiology [4-8] Rapid Resp Viral Screen: negative [4-8] BAL: GRAM STAIN (Final [2179-4-8]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): commensal flora LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Preliminary): negative FUNGAL CULTURE (Preliminary): negative ACID FAST SMEAR (Preliminary): negative ACID FAST CULTURE (Preliminary): negative [4-8] Blood Cx: pending [4-8] Urine Cx: yeast >100,000 [4-7] CVL tip culture: negative [4-7] Sputum culture: --gram stain: >25 PMNs and <10 epithelial cells/100X field; 2+ YEAST --respiratory culture pending --fungal culture pending [4-6] Urine legionella antigen negative [4-6] Blood cultures: pending [4-6] Stool: negative for C. diff [4-6] Urine: Yeast >100,000 ORGANISMS/ML. Brief Hospital Course: 26 yo female admitted to OSH([Hospital1 ]->[Hospital1 8]->[Hospital1 ]) for respiratory distress, intubated and treated with abx with minimal improvement in sxs, persistent fever, med flighted to [Hospital1 18] for further management. She initially was treated in the Medical Intensive Care Unit ([Date range (1) 90132]), and then she was transferred out to the floor. Her brief hospital course, organized by problem, was as follows: # Respiratory failure: History of course prior to transfer to [Hospital1 18] somewhat unclear, though per notes/reports on initial presentation patient c/o cough, sputum production and shortness of breath, which raises concern for PNA, however this was not confirmed by imaging. History also suggestive of possible influenza given reports of fevers and myalgias, though patient tested negative for flu and completed course of treatment with oseltamivir. Shecompleted treatment course of vanc/cefepime ([Date range (1) 90133]). Other viral illnesses and atypical infections including PCP and legionella were also considered, however were not confirmed by testing. HIV test was negative. Patient was slowly weaned from the vent and was extubated on [2179-4-8] without difficulty. She was also followed by infectious disease. She was scheduled for pulmonary follow-up at [Hospital1 18]. An albuterol inhaler was prescribed on discharge. #. Fevers: Patient continued to have persistently high fevers during her first few days of hospitalization. As with her respiratory failure discussed above, the etiology of fevers unclear, and differential included PNA (completed vanc/cefepime course), C. diff (though stool negative x4), viral infection (completed ostelmavir course), drug fever, NMS (CK within normal limits, no new pharmaceuticals). Patient does have possible immune compromise in setting of poorly controlled IDDM. Blood cultures, urine cultures and sputum cultures were consistently negative for bacterial growth. Patient eventually deferveshed and was afebrile for >24 hours prior to being transferred to the floor. # Leukocytosis: The patient had a significant leukocytosis upon arrival. The most likely source was felt to be respiratory, however given the very unclear history she was repeatedly re-cultured from blood, urine and sputum. Blood, urine, sputum cultures remained largely negative or were still pending at the time of transfer to the floor, however patient's leukocytosis had trended down as she clinically improved. A CBC should be repeated by her PCP at her next visit to trend he leukocytosis. # Diarrhea: The patient was intially started on PO vanco at OSH for presumed Cdiff, however upon arrival [Hospital1 18] was notified her toxin studies were negative x2. Negative X2 in house as well. Diarrhea likely antibiotic associated, with less concern for other infx etiologies given the development of her symptoms while in hospital. She had serial abdominal exams. # EKG changes: Upon presentation to the MICU, she had new TWI on EKG and a slightly prolonged QTc. Recent w/u at OSH with elevated CEs concerning for demand ischemia based on cardiology review. Pt now with new septal t-waves concerning for ischemia. Her cardiac enzymes were trended and did not bump. Her home aspirin and statin were continued and she was monitored on telemetry. She had a repeat EKG prior to transfer from the MICU with resolution of the changes. # Bipolar d/o: patient was intubated and sedated upon arrival, however from OSH records it was apparent that she was on several psychoactive medications and she carried a diagnosis of bipolar disorder. She was continued on her home medications including lithium, lorazepam, seroquel, risperidone, and trazadone. Her lithium levels were monitored. Once she was extubated and could converse, psychiatry was consulted for help with management of her psychiatric medications. They recommended using haldol for agitation and following up with her outpatient psychiatrist Dr. [Last Name (STitle) ]. Social work was also consulted as it was felt that the patient may have difficultly caring for herself and her young son, as her uncontrolled blood sugars likely played a part in this episode. She was told to call her psychiatrist the Wed/Friday of discharge for follow-up as no appointments could be scheduled for her the day of discharge. # NIDDM: The patient had a recent diagnosis of diabetes, with a HbA1c of 13.5. Per OSH records, she had apparently been non-compliant with her medications and was requiring very large doses of insulin. She was continued on an insulin drip for her first few days in the MICU and then weaned to an insulin sliding scale. [Last Name (un) ] was consulted, and she was started on lantus 40 units, with 15 units humalog w/meals plus sliding scale. She was also restarted on metformin 500mg [Hospital1 ] once she started eating (recommendation to uptitrate to 1000mg [Hospital1 ] [First Name8 (NamePattern2) ] [Last Name (un) ]). Additionally an anti-GAD was sent to assess DM1 vs DM2 which was still pending upon her transfer from the ICU. Once stable they recommend she receive an eye exam, baseline check of renal function, lipid panel, a review of her psych meds which could contribute to her hyperglycemia and a dietary review. [Last Name (un) ] saw the patient prior to discharge and recommended an increase in her Lantus to 44 U if her AM blood sugars remained elevated > 200. She was given insulin teaching and set up with [Initials (NamePattern4) ] [Last Name (NamePattern4) ] endocrinologist and teaching RN within 10 days of discharge. # Anemia: The patient had a normocytic anemia upon presentation. Her hematocrit was closely monitored and it remained stable. She had iron studies sent which showed Fe, TIBC, transferrin within normal limits. Her ferritin was elevated which may suggest anemia of chronic disease, or perhaps was functioning as an acute phase reactant. Stools were guaic negative. # Nutrition: She received tube feeds while she was intubated, and she was followed by nutrition. Once she was extubated, her diet was rapidly advanced to a diabetic, consistent carbohydrate diet. Medications on Admission: Home medications (from OHS records): Asa 81mg benztropine mesylate diphenydromine glipizide 10 [Hospital1 ] lisinopril 5 mg daily lithium 300 qhs lithium 600 [Hospital1 ] lorazepam 1 mg TID metformin 1000 mg [Hospital1 ] Necon 1/35 P day risperdone 1.5 qhs seroquel 50 mg qhs simvastatin 10 mg . Meds on transfer from OHS: insulin gtt vanco 250 mg PO vanco 1500 IV colace 200 mg solumedrol 60 mg IV BID cefepime 2 grams IV q 12 gentamycin 550 mg IV q 24 seroquel 50 mg q HS Lithum 600 [Hospital1 ] Lithium 300 mg q HS duonebs midazolam gtt fentanyl gtt ASA Pravastatin 20 mg daily Lisinopril 5 mg daily Risperadol 6 mg q HS Famotidine 20 mg IV q 12 Heparin 5000 q8 tylenol PRN Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:2 4. risperidone 1 mg/mL Solution Sig: 6 mg PO HS (at bedtime). 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:12 Tablet(s) Refills:2 6. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO EVERY MORNING AT 0800 (). 7. lithium carbonate 300 mg Capsule Sig: Three (3) Capsule PO QHS (once a day (at bedtime)). 8. Seroquel 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. Disp:30 Tablet(s) Refills:0 10. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Lantus 100 unit/mL Solution Sig: Forty (40) U Subcutaneous QAM. Disp:12 mL Refills:2 12. insulin lispro 100 unit/mL Solution Sig: One (1) injection Subcutaneous four times a day: per attached sliding scale. Disp:20 mL Refills:2 13. lancets Misc Sig: One (1) lancet Miscellaneous twice a day. Disp:1 box Refills:2 14. syringe (disposable) 50 mL Syringe Sig: One (1) syringe Miscellaneous four times a day. Disp:1 box Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: Respiratory Failure Secondary Diagnosis: Insulin Dependent Diabetes Mellitus Bipolar Disorder Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted with respiratory distress requiring admission to the ICU, intubation, and mechanical ventilation. The cause of your respiratory failure was thought to be due to a viral infection. No bacterial infection was identified. You were taken off the breathing machine and did well. The following changes were made to your medicaton. 1. Insulin: Take 40 [Location 17632] (LONG ACTING INSULIN) at night and the insulin sliding scale with meals as directed. If your blood sugars are greater than 200 tomorrow morning ([4-13]), please increase your Lantus to 44 U at breakfast. 2. Decrease metformin from 1 gram twice a day to 500 mg twice a day since you are on insulin now. 3. Started trazodone 50 mg by mouth at night for sleep 4. We held your benztropine because we did not get confirmation from your psychiatrist that you take this medication. Followup Instructions: Name: [Last Name (LF) ],[First Name3 (LF) 251] C. Location: [Hospital3 ] HEALTH CENTER Address: [State ], [Location (un) ],[Numeric Identifier 38978] Phone: [Telephone/Fax (1) 14167] Appt: [4-14] at 11am Name: [Last Name (LF) 3310],[First Name8 (NamePattern2) ] [Name8 (MD) ] MD Location: [Hospital6 ] Address: [Location (un) 11452] [Last Name (un) 19988] 9, [Location (un) ],[Numeric Identifier 18406] Phone: [Telephone/Fax (1) 63382] Apppt: IMPORTANT***Please call the office this Wed or Friday morning at 7:30am to book a same day appt. Dr [Last Name (STitle) ] did not have any sooner appts patient should call on Wed or Fri morning this week to book a same day appt. Put this above in appts Location: [Last Name (un) ] DIABETES CENTER Address: ONE [Last Name (un) ] PLACE, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2378] Appt: [4-19] at 10AM [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] NP Appt: [4-19] 11AM with the Nurse Educator Department: PULMONARY FUNCTION LAB When: WEDNESDAY [2179-4-28] at 3:30 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [2179-4-28] at 4:00 PM With: DR. [First Name8 (NamePattern2) 3688] [Last Name (NamePattern1) ] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2179-4-13**] ICD9 Codes: 2859, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7823 }	Medical Text: Admission Date: [2103-4-1] Discharge Date: [2103-4-3] Date of Birth: [2031-9-10] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6088] Chief Complaint: Flank pain Major Surgical or Invasive Procedure: None History of Present Illness: 71 y/o male presents to ED with right sided flank pain radiating around to his right lateral abdomen beginning at 7:30AM yesterday. Pain constant. Associated with feeling of urinary urgency but only "drops" urinated. Also with feeling of needing to defecate but could not. No fevers, chills, back pain, chest pain, headache, leg pain. No hematuria. Diarrhea x1 episode 3 days ago but none since. Past Medical History: MI [04]-15yrs ago, PVD Rt>Lt leg (claudication), no prior interventions PSH: none Social History: N/C Family History: N/C Physical Exam: T: 98.3 HR:61 BP: 113/67 RR: 18 Spo2: 94% RA FS: 109 Gen : NAD, Alert and oriented x 3 Neuro: CN II-XII Cardiac: RRR, no mrg Abd: + BS, soft, NT, ND Warm extremities Pulses: Fem [Doctor Last Name ] DP PT [Name (NI) 2325] palp palp palp dop Right palp palp palp dop Pertinent Results: [2103-4-2] 03:17AM BLOOD WBC-8.4 RBC-3.95* Hgb-11.7* Hct-34.3* MCV-87 MCH-29.6 MCHC-34.1 RDW-14.5 Plt Ct-203 [2103-4-1] 01:30AM BLOOD WBC-10.5 RBC-4.60 Hgb-14.0 Hct-41.5 MCV-90 MCH-30.4 MCHC-33.7 RDW-13.4 Plt Ct-230 [2103-4-1] 01:30AM BLOOD Neuts-76.6* Lymphs-17.2* Monos-5.2 Eos-0.4 Baso-0.6 [2103-4-2] 03:17AM BLOOD Plt Ct-203 [2103-4-1] 01:30AM BLOOD Plt Ct-230 [2103-4-1] 01:30AM BLOOD PT-13.9* PTT-27.5 INR(PT)-1.2* [2103-4-3] 05:05AM BLOOD Glucose-89 UreaN-16 Creat-1.0 Na-139 K-4.3 Cl-103 HCO3-25 AnGap-15 [2103-4-2] 03:17AM BLOOD Glucose-105* UreaN-15 Creat-1.5* Na-136 K-4.1 Cl-104 HCO3-26 AnGap-10 [2103-4-1] 01:30AM BLOOD Glucose-129* UreaN-13 Creat-1.1 Na-134 K-4.2 Cl-102 HCO3-21* AnGap-15 [2103-4-3] 05:05AM BLOOD Calcium-8.7 Mg-2.1 [2103-4-2] 03:17AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.9 [2103-4-1] 5:05 am MRSA SCREEN Source: Nasal swab. FINAL REPORT [2103-4-3] MRSA SCREEN (Final [2103-4-3]): No MRSA isolated. [Known lastname ],[Known firstname ] [Medical Record Number 103268] M 71 [2031-9-10] Radiology Report CT PELVIS W/O CONTRAST Study Date of [2103-4-2] 1:04 PM [Last Name (LF) ],[First Name3 (LF) 251] [Initials (NamePattern4) ] [Last Name (NamePattern4) 147] FA5 [2103-4-2] 1:04 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # [Clip Number (Radiology) 103269] Reason: ? nephrollithiasis, requested by urology [Hospital 93] MEDICAL CONDITION: 71 year old man with Chronic Type B dissection., renal stones REASON FOR THIS EXAMINATION: ? nephrollithiasis, requested by urology CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: ARHb MON [2103-4-2] 4:35 PM Persistent right nephrogram and moderate right hydrouterer extending just proximal to UVJ. No ureteral or bladder calculi. ? Filling defect in distant right ureter at level of transition. [Month (only) 116] represent recent passed stone with blood clot in ureter vs neoplasm. Comparison to outside prior would be helpful, but if not available MRU recommended. Preliminary Report !! WET READ !! Persistent right nephrogram and moderate right hydrouterer extending just proximal to UVJ. No ureteral or bladder calculi. ? Filling defect in distant right ureter at level of transition. [Month (only) 116] represent recent passed stone with blood clot in ureter vs neoplasm. Comparison to outside prior would be helpful, but if not available MRU recommended. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3904] Wet read entered: MON [2103-4-2] 4:35 PM [Known lastname ],[Known firstname ] [Medical Record Number 103268] M 71 [2031-9-10] Radiology Report RENAL U.S. Study Date of [2103-4-1] 3:08 PM [Last Name (LF) ],[First Name3 (LF) 251] [Initials (NamePattern4) ] [Last Name (NamePattern4) 147] CSRU [2103-4-1] 3:08 PM RENAL U.S. Clip # [Clip Number (Radiology) 103270] Reason: PT WITH RT FLANK, HYDRONEPHROSIS VS KIDNEY STONE [Hospital 93] MEDICAL CONDITION: 71 year old man with chronic type B dissection w/sudden flank pain REASON FOR THIS EXAMINATION: hydronephrosis vs kidney stone Provisional Findings Impression: SBNa SUN [2103-4-1] 4:47 PM PFI: Marked right-sided hydronephrosis and hydroureter with likely impacted stone in the right UVJ measured 1.3 x 0.9 x 1.1 cm. Final Report RENAL ULTRASOUND COMPARISON: None. HISTORY: Flank pain, evaluate for hydronephrosis or stone. FINDINGS: The right kidney measures 12.1 cm. There is moderate hydronephrosis and hydroureter extending to the level of the bladder. There is no evidence of renal calculi. However, there is a 1.3 x 0.9 x 1.1 cm echogenic focus at the right UVJ concerning for large right UVJ stone. The bladder contains a Foley catheter and is decompressed. The left kidney measures 11.8 cm. There is a simple cyst in the lower pole of the left kidney measuring 1.1 x 1.2 x 1.5 cm. There is no evidence of hydronephrosis on the left. There is diffuse increased echogenicity of the liver. IMPRESSION: 1. Marked right-sided hydronephrosis and hydroureter with likely impacted stone in the right UVJ measured 1.3 x 0.9 x 1.1 cm. 2. Fatty infiltration of the liver. Findings were discussed with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] at 4:30 p.m. via telephone. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 8648] [Name (STitle) 8649] DR. [First Name8 (NamePattern2) 7722] [Last Name (NamePattern1) 7723] Approved: SUN [2103-4-1] 6:09 PM Brief Hospital Course: [2103-4-1] Patient was transferred from [Hospital3 ] with flank pain and CT showing Aortic dissection. Admitted to CVICU for blood pressure control on labetalol gtt for uncontrolled hypertension. CTA obtained (see report). Stable overnight. Pain controlled with po/IV pain medication. Plan to transfer to VICU in am. Urology consulted for periureteral straining ? stone. Medical management at this time only for dissection only per vascular service. [2103-4-2] VSS. Urology seen and examined patient. Patient should follow-up with Dr. [Last Name (STitle) ] as an outpatient for elective stone procedure vs. cysto. Stable overnight, no acute events. [2103-4-3] Resumed all home medications and blood pressure medications. SBP < 140 goal on home meds. Foley removed, able to void. Pain managed with oral medication. Discharged home. Will follow-up with Dr. [Last Name (STitle) ] [Last Name (STitle) ] Dr. [Last Name (STitle) ] as an outpatient. Medications on Admission: plavix 75, metoprolol 25', isosorbide 5mg, folic acid, captopril 12mg', norvasc 5mg', lipitor 20mg', tylenol Discharge Medications: 1. Oxycodone 5 mg Capsule Sig: [12-23] Capsules PO Q4H (every 4 hours) as needed for pain. Disp:40 Capsule(s) Refills:0 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day): Take when taking pain medication . Disp:60 Refills:2 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/temp. 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [12-23] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for Constipation: as needed only. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation: as needed- over the counter. Disp:30 Tablet(s) Refills:0 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: Aortic dissection PMH: MI Bilateral lower extremity claudication Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to [Hospital1 18] for a descending aortic dissection. You were also found to have right hydronephrosis and hydroureter and periureteral stranding. The Vascular Surgeon decided that the best way to manage your vascular problem is to have good blood pressure control on oral medication. You were also seen by the Urology service and they would like to follow up with you in 2 weeks. Your kidney level was within normal limits on discharge. Pain will be controlled with Oxycodone. Take Colace, Senna and ducolax while on pain medications to prevent constiptation. Followup Instructions: Please call Dr. [Last Name (STitle) ] office [Telephone/Fax (1) 2395] to schedule a follow-up appointment in [1-24] weeks. You should follow-up with the Urologist Dr. [Last Name (STitle) ] [Last Name (STitle) ] 2 weeks. Call him for an appointment when you get home [Telephone/Fax (1) 921] Completed by:[2103-4-3] ICD9 Codes: 4019, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7824 }	Medical Text: Admission Date: [2197-10-5] Discharge Date: [2197-10-11] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: My head hurts Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 83M s/p fall from standing. +LOC otherwise questionable hx. EMS notified daughter that her father had fallen and was en route to [Hospital1 18] for further evaluation, but she was unable to provide additional information. Pt denies use of Coumadin, ASA, or Plavix over past week. Past Medical History: PMHx: DM2, HTN, BPH Social History: Social Hx: married, lives in [Location 10059] Family History: Family Hx: noncontributory Physical Exam: On arrival PHYSICAL EXAM: afeb, 72 250/94 11 96%NRB Gen: comfortable, NAD. HEENT: PERRLA, 3->2mm bilaterally, EOMI scant blood from R external auditory canal Neck: Supple. Lungs: CTAB. Cardiac: RRR. nl S1/S2. Abd: +BS, soft, NT/ND. Extrem: Warm and well-perfused. No pelvic instability. Rectal: nl sphincter tone. Neuro: Mental status: AA+Ox2 (not to time), cooperative with exam, normal affect. Naming intact. No dysarthria or paraphasic errors. CNII - XII grossly intact. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors, or clonus. Strength full power [6-17] throughout. No pronator drift. Toes downgoing bilaterally. On discharge awake alert oriented x 3 speech clear, no facial asymetry, follows all commands, Perrla, EOMI, facial sensation intact, slight left pronation, small amount of dried blood to right ear with cerumen imapaction, unable to visualize membrane, motor exam seems to be 4+ throughout without focal deficit. Pertinent Results: Cardiology Report ECHO Study Date of [2197-10-7] PATIENT/TEST INFORMATION: Indication: Left ventricular function. Syncope. Height: (in) 64 Weight (lb): 130 BSA (m2): 1.63 m2 BP (mm Hg): 168/80 HR (bpm): 80 Status: Inpatient Date/Time: [2197-10-7] at 14:57 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W040-0:39 Test Location: West SICU/CTIC/VICU Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.4 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 3.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 5.1 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.2 cm Left Ventricle - Fractional Shortening: 0.30 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: 3.8 cm (nl <= 3.6 cm) Aorta - Ascending: 3.6 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.8 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 1.2 m/sec Mitral Valve - E/A Ratio: 0.67 Mitral Valve - E Wave Deceleration Time: 160 msec INTERPRETATION: Findings: Patient unable to cooperate with Valsalva manuever; therefore unable evaluate for inducible outflow tract gradient. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Transmitral Doppler and TVI c/w Grade I (mild) LV diastolic dysfunction. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA systolic pressure. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Mild (grade I) diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Preserved global biventricular systolic function. Mild diastolic dysfunction. Mild aortic regurgitation. Mild aortic dilation. Inability to assess for inducible left ventricular outflow tract gradient given inability of patient to perform Valsalva manuever. No cardiac etiology of syncope identified. Electronically signed by [First Name8 (NamePattern2) ] [Name8 (MD) ], MD on [2197-10-7] 15:21. [Location (un) ] PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. ([Numeric Identifier 74556]) RADIOLOGY Final Report CT HEAD W/O CONTRAST [2197-10-7] 9:02 AM CT HEAD W/O CONTRAST Reason: interval change on CT. Please schedule for [10-7] at 0600 [Hospital 93] MEDICAL CONDITION: 83 M s/p fall, R frontal SAH, L parietal/frontal SDH, R temporal fx REASON FOR THIS EXAMINATION: interval change on CT. Please schedule for [10-7] at 0600 CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Trauma. COMPARISON: [2197-10-6]. FINDINGS: Contusions in the paramedian inferior frontal lobes have minimally increased in size. Subdural hematoma layering over the left frontal, parietal and temporal convexities as well as the left tentorium is relatively unchanged. Mild increase in extra-axial space overlying right frontal and parietal convexities. Bilateral subarachnoid hemorrhage is also stable. The ventricles are unchanged in size and there is mild layering interventricular hemorrhage. A non-displaced fracture of the right temporal bone is unchanged and the right mastoid air cells are moderately opacified. IMPRESSION: 1. Mild interval increase in paramedian bifrontal lower lobe contusion. 2. No new foci of hemorrhage are identified. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Doctor Last Name ] DR. [First Name (STitle) 3905] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3906] Approved: SAT [2197-10-7] 3:03 PM Cardiology Report ECG Study Date of [2197-10-5] 4:50:34 PM Sinus rhythm. Right bundle-branch block. Left anterior hemiblock. The P-R interval is within normal limits. No previous tracing available for comparison. Read by: [Last Name (LF) ],[First Name3 (LF) ] F. Intervals Axes Rate PR QRS QT/QTc P QRS T 75 178 148 446/472 68 -58 51 ([-8/4428]) RADIOLOGY Final Report CAROTID SERIES COMPLETE [2197-10-6] 1:43 PM CAROTID SERIES COMPLETE Reason: SYNCOPAL EPISODE [Hospital 93] MEDICAL CONDITION: 83 year old man with ? syncopal episode REASON FOR THIS EXAMINATION: assess arterial blood flow, ? stenosis CAROTID SERIES COMPLETE REASON: Syncope. FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal plaque was identified. On the right peak systolic velocities are 93, 120, 102 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 0.8. This is consistent with less than 40% stenosis. On the left peak systolic velocities are 106, 94, 139 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 1.1. This is consistent with less than 40% stenosis. There is antegrade flow in the right vertebral artery. The left vertebral artery is not visualized. IMPRESSION: Minimal plaque with bilateral less than 40% carotid stenosis. The left vertebral artery appears occluded. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: SUN [2197-10-8] 4:29 AM Brief Hospital Course: Pt was admitted through the emergency department. A syncope w/u was performed to include Echo and EKG as well as carotid duplex. The findings are in the pertinent results section of this summary. He was taken off telemetry monitoring and placed to floor status. He was seen by PT/OT and advanced in his diet and activity. He has serial head CT's which have been stable. He was screened for rehab placement. He had a swallow eval during his stay and their recommendations for a regular diet with thin liquids/ whole pills in puree, were followed. His family was updated throughout the hospitalization. His atenolol was increased to 50 mg po bid for better bp control. He is also on hydralazine PRN if his SBP goes over 160. The patient is neurologically intact on the day of discharge. Medications on Admission: Atenolol 50' Flomax 0.4' Detrol 2' HCTZ 12.5' finasteride 5' metformin 500' Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Outpatient Lab Work Please have your dilantin level checked within 2 weeks and have the results sent to your PCP. 11. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for SBP > 160: hold for SBP < 100 or HR < 60. Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: right temporal fracture left parietal and left frontal sub dural hematoma Discharge Condition: neurologically stable Discharge Instructions: HEAD INJURY ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered 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, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Please return to the office in 4 weeks with a cat scan of the brain to be seen by Dr. [Last Name (STitle) ] [Telephone/Fax (1) ]. You should follow up with your primary care physician [Name Initial (PRE) 176] 2 weeks of discharge - you had a 'syncope work up' while here and your PCP should review this results. Also we increased your atenolol to 50mg twice a day for better blood pressure control. Please have your PCP check your dilantin level as well. Completed by:[2197-10-11*] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7825 }	Medical Text: Admission Date: [2148-3-30] Discharge Date: [2148-4-19] Date of Birth: [2098-10-23] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 10293] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 49 yo F with h/o heavy ETOH use now with hematemesis. States her father's funeral was Thursday [3-28] and she drank her normal 3 glasses of wine that evening. The whole day she had only eaten a [Location (un) 6002] platter. At 3 a.m. on Friday [3-29] she started having intense abd cramps and started vomiting blood. At the same time she started having copious black diarrhea. States throughout the day she vomited and had diarrhea approx 20 times. States she briefly felt better around 2 p.m. and had a rum and coke but then had more vomiting. Had more rum and coke at 11 p.m. and hematemesis continued and her sister convinced her to go to the [Name (NI) ] ED. States she has had light-headedness but has not passed out. Pt states before this she has never had hematemesis or black stools. Denies knowledge of liver disease. . At [Hospital1 ] Hct was 28.2, plt 23, blood ETOH 103. Pt was given 1L NS, Zofran 4mg IV, Protonix 40mg IV, one unit pRBC's, vitamin K 10mg IM and was transfered to [Hospital1 18] where she vomited once in the ED with dark brown emesis. At [Hospital1 18] Hct was 30.6, INR was 1.6. She was given anzemet 25mg IV, octreotide 50mcg IV, and phenergan 12.5mg IV. . Past Medical History: HTN hypothyroidism torticolis "spasms" diagnosed by neurologist several years ago Social History: Lives with her husband in [Name (NI) 1110], MA. Her eldest son died last year. She has 2 other grown children. Used to work as a cook but is now retired. States she and her husband drink approx [2-25] glasses of wine each evening and have occasional hard alcohol on the weekends (x 30 years). States that when she doesn't drink she gets more shakey and doesn't feel well but has never had seizures. She smokes [2-25] - 1 ppd. Denies any cocaine, marijuana, heroin, or other substances. Family History: denies knowledge of liver disease. Physical Exam: 101.2, 118, 130/67, 18, 98% on RA GEN: appears slightly anxious, in NAD HEENT: OP clear, dry. No petechiae or evidence of bleeding. Skin: no palmar erythema or spider angiomata. CV: tachy, regular, no m/r/g Abd: s/nt/slightly distended but no obvious fluid wave. +bs. Lungs: CTAB Ext: no c/c/e. Rectal: guaiac positive black stool. Neuro: A&Ox3, no focal abnormalities. Pertinent Results: CHEST SINGLE VIEW ON [3-31] HISTORY: Oxygen requirement, question pneumonia or fluid overload. There are no old films available for comparison. There is an area of increased opacity in the left lower lobe consistent with left lower lobe pneumonia. There is a small left pleural effusion. The heart is upper limits normal in size. The bony thorax is normal. IMPRESSION: Left lower lobe pneumonia. . Brief Hospital Course: 1. GI bleed: at admission, the patient underwent banding of grade 2 varices. Her hematocrit remained stable and she was transferred to the floor. She had a repeat endoscopy during the admission with repeat banding of the varices. She was on sucralfate and PPI. She will have subsequent endoscopies and banding as an outpatient. . 2. Alcoholic liver disease: the patient had a new diagnosis of alcoholic liver disease and likely cirrhosis. She did not undergo liver biopsy during this admission. She has marked hepatomegaly and splenomegaly, ascites and esophageal varices. Her course was complicated by alcoholic hepatitis. Her discriminate function was 36, however, she was not a candidate for steroids given the recent GI bleed and infection (see below). She had prolonged abdominal distention and pain (see below) despite improvement in her LFTs. She underwent three paracenteses and was started on diuretics to control her fluid accumulation. There was no evidence of SBP. Her relatively low blood pressure limited the dose of diuretics. She will have liver center follow up as an outpatient. The patient was actively drinking prior to admission. HBsAb neg, HAV neg, anti smooth muscle antibody neg, IgG 1406. IgA 540 (elevated). Ceruloplasmin negative. . 3. Pain: the patient suffered from chronic abdominal pain which was difficult to control. Her pain was severe despite resolution of her alcoholic hepatitis. CT scan did not have evidence of liver bleed or abscess or other anatomic reason for her pain. She required high doses of narcotics for pain control, and denied (repeatedly) ever using narcotics before. It was suspected that her pain was from capsular stretch from hepatomegaly. Ultimately, pain service was involved and she was put on 30 mg Oxycontin twice daily with oxycodone for breakthrough and Neurontin. This regimen provided improved pain control. The patient has an addiction (alcohol) history and attempts to wean her narcotics were unsuccessful. At discharge, the patient was given Oxycontin 40 mg [Hospital1 ] and prn oxycodone for breakthrough and Neurontin. She was given 2 weeks of narcotics and was told she needs to see her PCP for chronic narcotic management. . 4. Community acquired pneumonia: the patient was diagnosed with pneumonia at admission. She completed 10 days of Levoquin and 7 days of Flagyl. The patient continued to spike fevers during her prolonged hospitalization. Repeat xray showed no infiltrate. . 5. UTI: group A strep urinary infection treated with four days of Augmentin with subsequent clean culture. The patient continued to spike fevers and Ceftriaxone was added to her regimen to complete at 10 day course for the UTI in this patient with liver disease. The patient was transferred to Cefpodoxime at discharge. . 6. Alcohol abuse/addiction: the patient was actively drinking prior to admission. She has a long history of alcohol use with [2-25] drinks of wine daily. She was seen by addiction services and social work during this hospitalization and was given material regarding alcoholics annonymous and other abstinence programs. There was also a strong suspicion of outpatient Vicodin abuse given overheard conversations between the patient and her husband, however, this was denied repeatedly on direct questioning. The patient displayed drug-seeking behaviors while inpatient. She was repeatedly informed that she can no longer drink alcohol and verbalized understanding. . 7. Hypertension: the patient had a history of hypertension prior to admission, but her blood pressure tended to run low during this hospitalization. It is likely that this is related to lack of alcohol while hospitalized and pain medication. The patient also was started on Nadolol for her varices, but was unable to tolerate this in addition to the doses of Lasix and Aldactone needed to control her abdominal distention. . 8. Hypothyroidism: continued outpatient levoxyl. . 9. Disposition: the patient was discharged home to complete a 10 day course of Cefpodoxime. She was given a prescription for 2 weeks of narcotics and will follow up with her PCP. [Name10 (NameIs) ] has close liver center follow up. She had been cleared by PT for going home. She requires daily magnesium repletion. She was full code. Medications on Admission: Lisinopril 5mg daily Levoxyl 5 mg daily Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 6. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 8. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: Two (2) Tablet Sustained Release 12 hr PO twice a day. Disp:60 Tablet Sustained Release 12 hr(s) Refills:0 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:90 Capsule(s) Refills:1 10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 11. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Alcoholic liver disease Variceal bleed Alcoholic hepatitis Ascites Secondary Esophageal varices Thrombocytopenia Hypothyroidism Hypertension Abdominal pain Discharge Condition: Stable. Tolerating a regular diet. Pain improved. Able to walk with walker. Discharge Instructions: You were admitted with bleeding from your GI tract and then treated for alcoholic hepatitis. Please call your doctor or come to the ED if you develop vomiting blood, blood per rectum, dark tarry stools, nausea, vomiting, uncontrollable pain, inability to take your medications, increase size of your abdomen, worsening lower extremity swelling, chest pain or shortness of breath. . There are several new medications for you to take daily: 1. Lasix (diuretic) 80 mg daily 2. Spironolactone (diuretic) 150 mg daily 3. Oxycontin 40 mg twice a day 4. Oxycodone 5 mg every 4-6 hours as needed for pain 5. Protonix (acid blocker) 40 mg twice a day 6. Folate (Vitamin) 1 mg daily 7. Thiamine (Vitamin) 100 mg daily 8. Neurontin (pain medication) 300 mg three times daily 9. Magnesium oxide (electrolyte replacement) 400 mg daily 10. Cefpodoxime 200 mg twice daily for 6 days (antibiotic, start [2148-4-20]). Followup Instructions: Repeat endoscopy: Provider: [Name10 (NameIs) ] WEST,ROOM FIVE GI ROOMS Date/Time:[2148-4-24] 8:30 Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 2424], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2148-4-24] 8:30 Liver Center follow up: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 7128], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2148-5-22] 8:30 . Primary Care Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Telephone/Fax (1) 72189] Call to schedule appointment ICD9 Codes: 486, 5990, 4019, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7826 }	Medical Text: Admission Date: [2183-6-13] Discharge Date: [2183-8-1] Date of Birth: [2183-6-13] Sex: M Service: NEONATOLOGY HISTORY: Baby [Name (NI) ] [Known lastname ] [Known lastname 42042] was born at 30 weeks gestation to a 28-year-old gravida I, para I woman. Her prenatal screens were blood type A positive, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, and group B strep negative. This pregnancy was uncomplicated except for the presence of large fibroids until the day of delivery, when the mother was transferred from [Hospital3 ] for pre-term labor and question of abruption. The infant was born by spontaneous vaginal delivery. Apgars were 8 at one minute and 9 at five minutes. The infant did require blow-by oxygen and Narcan in the delivery room. PHYSICAL EXAMINATION: Reveals a premature, vigorous, pink infant. The anterior fontanel is open and flat. There is positive cranial molding. The facies are flattened, with deviated nares that has improved over time. The palate is intact. Positive bilateral red reflex. Respirations are unlabored at the time of admission. Lungs sounds are clear and equal. Normal S1, S2 heart sound, no murmur. The infant is pink and well perfused. The abdomen is soft and nontender. The testes are in the canal bilaterally. The neurological examination is nonfocal and age-appropriate. Birth weight is 1310 grams, birth length 40.5 cm, and birth head circumference 24.5 cm. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: The infant was intubated soon after the time of admission for increasing respiratory distress. He required four doses of surfactant. He weaned to nasopharyngeal continuous positive airway pressure on day of life number seven, and then successfully weaned after several attempts to room air on day of life 21. He remained in room air until requiring nasal oxygen after a blood transfusion on day of life 41, and then again weaned to room air on day of life 46, and has remained there. He was treated with caffeine citrate for apnea of prematurity from day of life 11 until day of life 30. His last episode of apnea and bradycardia was on [2183-7-22]. On examination, his respirations are unlabored. Lung sounds are clear and equal. 2. Cardiovascular: He was treated with Indocin on day of life three for a patent ductus arteriosus that was documented by cardiac echocardiogram. After that course of medication, the murmur resolved and also the other symptoms. He required dopamine for blood pressure support from day of life three to five, concurrent with his patent ductus treatment. He has remained normotensive since that time. He has had an intermittent murmur, felt to be hemodynamically insignificant, since that time. On examination, he is pink and well perfused. 3. Fluids, electrolytes and nutrition: Enteral feeds were begun on day of life seven. He was advanced to full volume by day of life number 12. On day of life number 13, he had guaiac positive stool, bilious aspirates, and increased work of breathing, prompting 48 hours of bowel rest. Enteral feeds were restarted on day of life 15, and reached full volume by day of life 20, and then were advanced to calorie-enhanced breast milk or formula, 30 calories/ounce with added ProMod. At the time of discharge, he is eating breast milk 28 calories/ounce with 4 calories/ounce added with Neosure powder, and 4 calories/ounce added with corn oil. The infant is taking approximately 180 cc/kg/day on an ad lib feeding schedule. At discharge, his weight is 2635 grams, length 43 cm, and head circumference 27 cm. 4. Gastrointestinal: The infant was treated with phototherapy for physiologic hyperbilirubinemia from day of life number two until day of life number six. His peak bilirubin occurred on day of life number two, and was total 8.3, direct 0.4. A right inguinal hernia was evident on his physical examination on day of life number 48. It was reducible, however, not easily reducible. He was seen by [Hospital3 18242] surgeon, Dr. [Last Name (STitle) ], and repair is being scheduled. He will be followed by attending physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 732]. 5. Hematology: His last hematocrit on [8-7] was 36.8% He received two transfusions of packed red blood cells, last on [2183-7-23]. He has been receiving supplemental iron of 2 mg/kg/day. His blood type is O negative, direct Coombs negative. 6. Infectious Disease: The infant was started on ampicillin and gentamicin at the time of admission for sepsis risk factors. He completed a seven day course of those antibiotics for presumed sepsis. His blood and cerebrospinal fluid cultures did remain negative. He was again started on antibiotics, vancomycin and meropenem on day of life number 13 for a clinical presentation of possible sepsis (meropenem was the drug of choice due to another infant in the unit having pseudomonas at that time). The antibiotics were discontinued after 48 hours when the blood cultures remained negative and the infant was clinically well. He has remained off antibiotics since that time. 7. Neurology: The head ultrasounds done on [5-30] and [2183-7-17] were all within normal limits. Sacral ultrasound was performed because of a sacral dimple on [2183-8-5] - normal study with cord noted at L1. No evidence of tethered cord was noted. 8. Sensory: Audiology: Hearing screening was performed with automated auditory brain stem responses, and the infant passed in both ears on [2183-7-20]. Ophthalmology: Mature retinal vessels noted on [2183-8-4]. 9. Psychosocial: The parents are married. They have been visiting daily and have been involved in the infant's care throughout his Newborn Intensive Care Unit stay. CONDITION AT DISCHARGE: Good. DISCHARGE DISPOSITION: The infant is being discharged to home. PRIMARY PEDIATRIC CARE: Pediatrician is Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 42043] in [Hospital1 2436], [Location (un) 42044]. [Apartment Address(1) 42045], [Hospital1 2436], [Numeric Identifier 42046] [Telephone/Fax (1) 42047] FAX [Telephone/Fax (1) 42048]. CARE RECOMMENDATIONS: 1. Feedings: 26 calorie/ounce breast milk with 4 calories/ounce added with Neosure powder and 2 calories/ounce added with corn oil on an ad lib feeding schedule. 2. Medications: Fer-in-[Male First Name (un) ] 0.2 cc by mouth once daily to provide 5 mg/day of elemental iron 3. State newborn screens were sent on [6-16] and [2183-6-28], and both were within normal limits. 4. The infant received his hepatitis B vaccine on [2183-7-26]. DISCHARGE DIAGNOSIS: 1. Status post prematurity 2. Status post hyaline membrane disease 3. Presumed sepsis 4. Sepsis ruled out 5. Status post patent ductus arteriosus 6. Status post apnea of prematurity 7. Status post circumcision, [2183-7-30] 8. Status post anemia of prematurity 9. Status post physiologic hyperbilirubinemia 10. Status both bilateral inguinal hernia repair on [2183-8-6]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 37237], M.D. [MD Number(1) 37238] Dictated By:[Last Name (NamePattern1) 37333] MEDQUIST36 D: [2183-8-1] 02:44 T: [2183-8-1] 04:02 JOB#: [Job Number 42049] ICD9 Codes: 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7827 }	Medical Text: Admission Date: [2189-12-26] Discharge Date: [2190-1-6] Date of Birth: [2127-4-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2698] Chief Complaint: chest pain, shortness of breath Major Surgical or Invasive Procedure: cardiac cath s/p stent to left main, LAD IABP placement History of Present Illness: 62 yr old male with 3VD, CHF 20-25% with 3-4+ MR, bilateral carotid stenoses s/p L ICA stent now awaiting CABG/MVR who presented with chest pain and shortness of breath. Pt states that the chest pain came on while at rest, located on the right side radiating down his right arm, described as sharp, associated with shortness of breath, diaphoresis, nausea, no vomiting. Multiple episodes of chest pain over the day, lasting one minute at a time. On further questioning, pt states that he has had these episodes of chest pain x 2 weeks. He has also noted that his lower ext swelling has gotten worse over the past few days as well. +2-pillow orthopnea, no PND. Two days prior to admission, pt presented to [Hospital1 18] [Location (un) 620] complaining of lower abd pain, described as a sharp pain across his lower abdomen, associated with nausea, vomiting and dry heaves. LFTs, amylase and lipase were found to be elevated. RUQ ultrasound, abd CT were both negative for gallstones, liver pathology. Pt has no hx of gallstones, no hx of alcohol use; he has been taking tylenol (6 extra strength tabs/day). Pt states that his abd pain went away after some fluids. Past Medical History: 1. CAD (3VD) s/p MI x 2 -cath in [9-21]: 100% pRCA, 80% p-mLAD, 70% diag, 100% pLCx 2. [2-19]+ MR 3. bilateral carotid stenoses s/p L ICA stent (R ICA not ammenable to stent) 4. DM, dx in [2179] 5. CHF, EF 20-25% 6. COPD 7. shoulder surgery Social History: married with 3 children, lives with wife smoking 2 ppd for 30yrs, no down to 6 cigarettes per day no EtOH Family History: dad has HTN, CHF, grandparents have DM. Physical Exam: temp 97.3, BP 86-99/49-72, HR 87, RR 18, O2 98% RA Gen: NAD, appears comfortable HEENT: PERRL, EOMI, MMM, anicteric sclera Neck: no bruits heard, JVP 7cm at 80 degrees CV: distant heart sounds, 3/6 systolic murmur at apex, no radiation to axilla; PMI not palpable Chest: crackles at base bilaterally, no wheezes Abd: +BS, +midly distended, nontender to deep palpation, liver edge non-palpable, guaic negative in ED Ext: 3+ pitting edema to mid-thigh, 2+ DP Neuro: CN 2-12 intact Pertinent Results: CBC [2189-12-26] 09:25PM WBC-9.0 RBC-4.05* HGB-12.7* HCT-39.3* MCV-97 MCH-31.4 MCHC-32.3 RDW-16.7* [2189-12-26] 09:25PM PLT COUNT-280 [2189-12-26] 09:25PM NEUTS-80.1* LYMPHS-12.1* MONOS-5.7 EOS-1.4 BASOS-0.6 [2189-12-26] 09:25PM PT-14.3* PTT-29.6 INR(PT)-1.3 . [2189-12-26] 09:25PM D-DIMER-763* . chem [2189-12-26] 09:25PM GLUCOSE-312* UREA N-43* CREAT-1.3* SODIUM-125* POTASSIUM-5.5* CHLORIDE-88* TOTAL CO2-23 ANION GAP-20 [2189-12-26] 09:25PM ALT(SGPT)-346* AST(SGOT)-114* LD(LDH)-272* ALK PHOS-590* AMYLASE-141* TOT BILI-1.5 [2189-12-26] 09:25PM LIPASE-137* . CE [2189-12-26] 09:30PM CK(CPK)-156 cTropnT-0.03* . CTA: No pulmonary embolism. Mediastinal lymphadenopathy. . Chest X-Ray: Cardiomegaly without overt failure. . RUQ U/S: 1. No evidence of cholelithiasis or cholecystitis. 2. Simple right renal cyst. . Cardiac Cath: 1. Resting hemodynamics on IABP revealed significantly elevated right (RA mean 19 mm Hg, RVEDP 21 mm Hg) and left (PCWP mean 22 mm Hg) sided filing pressures. The C.I was significantly reduced (1.2 L/imn/m2). 2. IABP was placed: Augmented DP 140, Unloaded systolic 90, Unassisted systolic 100, mean BP 90. 3. Selective coronary angiography of only the left system revealed a 80% ostial LM, 100% proximally occluded LCX, 90% mid LAD stenosis, 80% distal LAD stenosis. The RCA was known to be T.O and was not engaged (RCA was filling viw left to right collaterals). 4. Successful stenting of the LM with two overlapping Cypher DES (3.5x13 and 3.5x8mm, postdilated to 3.75) (See PTCA comments). 5. Successful stenting of the mid LAD with a 3.5x18mm Cypher DES postdilated to 3.75 (See PTCA comments). 6. Successful stenting of the distal LAD with a 2.5x8mm Cypher DES (See PTCA comments). 7. Abdominal aortography revealed mild distal disease with no critical lesions in the iliacs and common femorals. . Chest CT: 1) Bronchiectasis and peribronchial opacity that is most prominent within the posterior right lower lobe with associated small effusions. This finding is suggestive of pneumonia. Atelectasis is a less likely consideration. A similar lesser amount of opacity is seen within the posterior left upper lobe. 2) An intraaortic balloon [Year/Month/Day 4581] is in place with its distal tip below the carina. The inflated balloon in place at the origin of the celiac axis. 3) Unchanged enlarged mediastinal lymph nodes. 4) Emphysema. 5) Cardiomegaly and pericardial effusion. . ECHO: The left ventricular cavity is severely dilated. Resting regional wall motion abnormalities include diffuse hypokinesis with anteroseptal and apical akinesis, basal to mid inferior akinesis and basal inferolateral akinesis. No apical thrombus seen (cannot definitively exclude). Right ventricular chamber size is normal. Right ventricular systolic function is borderline preserved. The aortic valve leaflets are mildly thickened. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Mitral regurgitation increases to moderate to severe (3+) with the intra-aortic balloon [Year/Month/Day 4581] off. There is a trivial/physiologic pericardial effusion. EF < 15% . Brief Hospital Course: A/P: 62 yr old male with severe 3VD, MR, CHF now s/p L ICA stent, awaiting CABG admitted for chest pain and shortness of breath . 1. CAD, chest pain: Given the pt's chest pain and shortness of breath, a CTA was done and ruled out PE. Pt was initially scheduled for elective cath with stenting of the LAD to determine whether this would improve his EF. If his EF improved, then the plan would be to pursue MVR and CABG. Given his presentation of recurrent chest pain his elective cath was moved up. On admission, EKG was noted to have old TWI in the inferior leads and a troponin of 0.03 so heparin was started given his extensive cardiac hx. Pt went to cardiac cath on hospital day #3 which revealed 80% LM, 90% LAD, 100% LCx and 100% RCA. Pt then underwent PTCA with cypher stent placed to 80% ostial LM lesion and cypher stent x 2 to LAD. Due to a severely depressed cardiac index, a balloon [Year/Month/Day 4581] was placed and the pt was started on Dobutamine. During cath, pt received 60mg of IV lasix and he diuresed 2L. In CCU, pt continued to diurese another 8L with lasix and he was weaned off the dobutamine and IABP. The cardiac surgery team evaluated the pt and determined that he was not a surgical candidate at the time due to his concurrent tobacco abuse. They recommended smoking cessation and medical management. He was continued on ASA, plavix, beta-blocker, ACE-I, imdur and statin. . 2. [Last Name (LF) ], [First Name3 (LF) ] 20-30%: Pt's CHF is multifactorial including ischemia (3VD) and severe MR. As above, pt was maintained on dobutamine and an IABP in the CCU for aggressive diuresis and diuresed approximately 10L. He was evaluted but CT surgery but was not a surgery candidate at the time. He was loaded on digoxin in the CCU and continued on BB, lasix and spironolactone. A repeat echo after his cath showed a further decreased EF of <15%. . 3. Elevated LFTs/amylase/lipase: Pt admits to a hx of lower abd pain associated with nausea and vomiting however, the location of the pain was not typical for pancreatitis and pt was able to tolerate po's. Other etiologies included medication-related, especially lipitor, though would not expect elevated pancreatic enzymes. Also possible would be a passed gallstone, RUQ U/S negative. Pt with neg hepatitis panel, EBV, toxo, CMV IgM in [9-21] when being evaluated for heart transplant and were negative again when rechecked. All enzymes trended down and there was still no clear etiology of his elevated LFTs on day of discharge. . 3. ARF: Urine lytes indicated that the pt was pre-renal secondary to poor forward flow. His creatinine improved over his hospital stay as his cardiac medications were adjusted to increase flow to the kidney. . 4. Hyponatremia: Likely [1-20] CHF and it resolved over the hospital stay. . 5. DM: Pt was on an insulin drip in the CCU and then continued on his home dose of NPH while on the floor. Medications on Admission: ASA 325 Plavix 75mg qd Lipitor 80mg qd Lasix 40mg [Hospital1 ] Aldactone 12.5mg qod Lisinopril 10mg qd NPH 20U qam, 15U qpm Lopressor 25mg [Hospital1 ] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 10. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Twenty (20) units units Subcutaneous QAM. 11. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Eighteen (18) units Subcutaneous QPM. 12. NitroTab 0.3 mg Tablet, Sublingual Sig: One (1) TAB Sublingual Q5min as needed for chest pain: use q5 min up to 3 times to relieve chest pain. Disp:30 days Refills:0 13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. Coronary Artery Disease s/p stent 2. Congestive Heart Disease, EF 20-25% 3. Diabetes 4. COPD 5. tobacco abuse Discharge Condition: good, chronic lower ext swelling, breathing well 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: 1.5L . 1. Please take all medications as prescribed (we have stopped your lopressor and started on you on carvedilol instead). 2. Go to all follow-up appointments 3. Call your PCP or go to the ED if you experience any of the following: chest pain, shortness of breath, weight gain, lower ext swelling, lightheadedness/dizziness, fevers/chills 4. It is essential that you quit smoking. Followup Instructions: Heart Failure: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4582], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 3512] Date/Time:[2190-1-21] 3:00 . Please follow-up with your PCP within the next 2-4 weeks. . Go to your follow-up appointment with Dr. [Last Name (STitle) ] next Friday. ICD9 Codes: 4111, 5849, 4280, 2761, 496, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7828 }	Medical Text: Admission Date: [2169-11-2] Discharge Date: [2169-11-7] Date of Birth: [2106-5-20] Sex: M Service: MEDICINE Allergies: Naproxen / Sulfa (Sulfonamides) / Doxycycline Attending:[First Name3 (LF) 7223] Chief Complaint: Ventricular tachycardia Major Surgical or Invasive Procedure: Ventricular tachycardia ablation procedure and dual chamber ICD(defibrillator) implantation. History of Present Illness: This is a 63 year old Pakistani male with hx type IDDM, HTN, remote 70 pack year smoking history, CAD s/p MI and 4v CABG in 99, s/p cath and stent in [2163] anatomy unknown, who presented to an OSH with palpitations. Pt reports that approximately 1 month ago, while in [State 108], he noted palpitations. He went to see a PCP at that point, who told him that his HR was "slow." He decreased his lopressor dose at that time, and his palpitations temporarily resolved. . He then reports that 1 week ago, he began to have worsening shortness of breath, orthopnea, and LE edema. His dyspnea was mostly on exertion, and he reports becoming windy after "several step." This is far from his baseline exercise tolerance, which is "several blocks of walking." He went to see his PCP at this time 1 week ago and his lasix dose was increased with improvement of his symptoms. . 1 day prior to admission, at around 2 pm, he began to have palpitations. He reports that these palpitations are similar to the palpitations that he had previously 1 month ago. He also notes that he began to have shortness of breath and also reports feeling weak, tired, lightheaded and felt as though a "curtain was going down in his field of vision." He denies LOC, chest pain, fever, chills, cough. . At the OSH, he was found to have EKG c/w ventricular tachycardia and was started on an amiodarone drip 150 mg bolus amio over 20 mins followed by 1 mg/min gtt. He was then given lidocaine bolus with 2 mg/min which reportedly resulted in breaking his VT for 2 minutes, he was then given Magnesium sulfate x 3 boluses followed by a 20mg/min gtt which resulted in sinus rhythm with runs of VT. His palpitations resolved at 8pm yesterday. . EVENTS / HISTORY OF PRESENTING ILLNESS: . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: Cardiac Risk Factors: Diabetes, Hypertension . Adenosquamous carcinoma s/p ??left upper lobe lobectomy . RLL lung nodule stable since [11-11] . PVD s/p left LE bypass graft done in [Country 9819] in [2161] . CRI baseline Cr 2.3 Social History: Social history is significant for the absence of current tobacco use. Remote tobacco use, [3-11] PPD x 35 years, last cigarette 10 years ago. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Brother died of pophyria. Father MI at age 60s, died of porphyria. Physical Exam: VS: Afebrile, BP 129/99 , HR 94 , 12 RR , O2 98% on 2L Gen: WDWN middle aged male mildly diaphoretic, no resp distress Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 8cm CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Decreased breath sounds on right lower base, bibasilar crackles. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP MEDICAL DECISION MAKING Pertinent Results: EKG demonstrated paroxysmal ventricular tachycardia, RAD . TELEMETRY demonstrated: paroxysmal ventricular tachycardia at HR 100s . 2D-ECHOCARDIOGRAM performed in [2167] demonstrated: 40-45% mild LV enlargement and area of focal akinesis in inferior wall and LV apex Brief Hospital Course: 63 yo male with CAD s/p 4v CABG in [2161] and sytolic HF, EF now 25-30% who presents with a paroxysmal ventricular tachycardia. . 1. Ventricular Tachycardia: He has a ventricular arrhythmia with underlying structural heart disease, CAD with EF 25-30%. focused VT was ablated and on EP testing, he was also found to have inducible VT. There were no events on tele between the ablation and the ICD placement. On [11-6] he had a ECHO which showed LVEF 30% and increased wedge pressure. He had an ICD placed on [11-6]. It was interrogated by EP. He remained hemodynamically stable, and without evidence of end organ ischemia. patient had lidocaine gtt and amiodarone gtt. pt continued on home beta blocker. TSH is normal. home Lasix was held, to re-evaluate with PCP 2. Acute systolic heart failure: Appeared mildly fluid overloaded admission, resolved with PRN lasix. , likely compounded by his tachycardia. On echo here, he was found to have sytolic dysfunction with EF 25-30%, which is reduced from his previous EF of 40-45% in [2167]. CHF at this time may be due to ischemia or secondary to arrythmia. Took of standing home lasix dose, because pt euvolemic after several PRN doses. Cardiac markers negative for MI, but trace positive, probably due to demand ischemia. . 3. CAD: Cont ASA, statin, BB. . 4. CKD: Acute on chronic renal failure on admission. Cr 2.8 on admission, 2.3 at baseline. CKD likely secondary to DMII and HTN. acute KD likely pre-renal secondary to poor renal perfusion in the setting of frequent VTs. Normalized to baseline by discharge. . 5. Leukocytosis: No localizing symptoms. He is without cough, dysuria, fever. urinalysis, cx-ray, blood cxs all negative. . 6. DM: Glargine 40, ISS, FSG QID. PRN glargine. Medications on Admission: Atrovent ASA 81 Flovent 2 puffs Glargine 40 daily Lispro 4 before meals lasix 60 [Hospital1 ] lopressor 50 [Hospital1 ] norvasc 5 pravachol 40 ranitidine 150 Avapro-->discontinued at OSH Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 4. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:30 Tablet(s) Refills:2 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Insulin Lispro 100 unit/mL Solution Sig: Four (4) units Subcutaneous qAC. 8. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous qAM. 9. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 1 days. Disp:4 Capsule(s) Refills:0 10. Avapro 150 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Ventricular tachycardia Sinus bradycardia Acute renal failure Congestive heart failure Hypermagnesemia . SECONDARY DIAGNOSES: Diabetes mellitus HTN Chronic renal insufficiency Discharge Condition: stable, ambulating Discharge Instructions: You were diagnosed with a ventricular tachycardia. You underwent an ablation procedure and subsequent ICD(defibrillator) and pacemaker placement without complications. . Please follow up with device clinic as indicated below. . Please take all medications as prescribed. You will have to take antibiotics for 1 more day as prescribed. . Please take note that we increased your pravastatin to 80mg because of your elevated cholesterol levels. Also note that your lasix and norvasc have been discontinued. . Please return to the hospital or see your PCP if you have any chest pain, shortness of breath, fever or pain in the insertion site of your ICD/pacemaker. Followup Instructions: DEVICE CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2169-11-14] 2:30 . We have scheduled an appointment for you with your cardiologist, Dr. [Last Name (STitle) 62081]([Telephone/Fax (1) 75003]) Tues, [11-21] at 3pm. . Please follow-up with your primary care physician in the next 7-10 days. You had an abnormal finding on your chest x-ray for which you should follow with him. Please call Dr. [Last Name (STitle) 3273] at [Telephone/Fax (1) 45347]. Completed by:[2169-11-9] ICD9 Codes: 4271, 5849, 4280, 4439, 412, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7829 }	Medical Text: Admission Date: [2175-9-1] Discharge Date: [2175-9-22] Date of Birth: [2147-8-13] Sex: F Service: SURGERY Allergies: Demerol / Unasyn / Cephalosporins / Levaquin Attending:[First Name3 (LF) 668] Chief Complaint: End stage renal disease Major Surgical or Invasive Procedure: Cadaveric kidney transplant [2175-9-1] Right retroperitoneal exploration with washout of hematoma and transplant kidney biopsy [2175-9-8] Post-op bleeding necessitating re-exploration of transplant kidney and hematoma evacuation [2175-9-11] History of Present Illness: Ms. [Known lastname 14323] is a 28-year-old female with end-stage renal disease secondary to lupus. She underwent pre transplant evaluation as a suitable candidate for kidney transplantation. A donor organ became available. Crossmatch was negative. She now presents for kidney transplantation. Past Medical History: - SLE - diagnosed in [2166]. Complicated by lupus, nephritis, anemia, serositis, and ascites. Currently in remission. - ESRD on HD (M/W/F), [1-11] lupus - h/o VSD - s/p ocrrective surgery at age 13 - Hypertension - ITP - MSSA endocarditis - [Month/Day (2) 14165] cell trait - s/p L oophorectomy - related to IUD-associated infection - restrictive lung dz noted on PFTs from [2166]. In [2173] chest CT w/ diffuse ground glass opacity w/ paratracheal adn, persistent on repeat in [2-10]. +peripheral adn ? sarcoid. echo c/w pulm htn. ACE level low. Referred to pulm. - GERD since [2172] - domestic violence Social History: Patient immigrated from [Country ] and lives at home with her mother, husband, and 11 year old son. Past episodes of physical/verbal abuse from husband. Denies etoh, smoking, or drugs. Family History: Mother with diabetes, [Country 14165] cell traint. Sister deceased at age 33 from SLE. Has 7 siblings. Maternal grandmother died of diabetes at age 56. Grandfather otherwise healthy. No h/o CA, hypercholesterolemia, stroke, lupus. Physical Exam: Physical Exam upon admission T 98.6 HR 64 BP 114/82 RR 20 SaO2 99RA Gen: Alert and oriented x3, no acute distress HEENT: PERRLA, EOMI, anicteric sclerae, mucus membranes pink, moist Neck: no JVD, no bruits, well healed scars on neck from previous HD catheters Lungs: faint rales in left lower lobe CV: Regular rate and rhythm, S1 S2, 3/6 systolic ejection [Country 9413] Abd: soft, non-distended, non-tender, no hepatosplenomegaly, small umbilical hernia, well healed midline scar Ext: no edema or cyanosis Skin: well demarcated dark round flat lesions on legs Pertinent Results: [2175-9-1] 12:30PM WBC-6.5 RBC-4.76 HGB-15.0 HCT-43.6 MCV-92 MCH-31.5 MCHC-34.4 RDW-19.9* PLT COUNT-44* [2175-9-1] 12:30PM UREA N-27* CREAT-6.3# SODIUM-141 POTASSIUM-5.1 CHLORIDE-94 TOTAL CO2-33* ANION GAP-19 [2175-9-1] 12:30PM CALCIUM-10.8* PHOSPHATE-4.7# MAGNESIUM-2.1 CHOLEST-147 [2175-9-1] 12:30PM ALT(SGPT)-23 AST(SGOT)-20 LD(LDH)-238 [2175-9-1] 12:30PM PT-12.3 PTT-28.3 INR(PT)-1.0 Please see electronic record for detailed results of radiology and laboratory studies. Brief Hospital Course: 28-year-old female with end-stage renal disease secondary to lupus admitted for a cadaveric renal transplant. The patient underwent the surgery on the day of admission. She was given the standard perioperative immunosuppressant regimen of anti-thymocyte globulin, solumedrol, and cellcept. She was also given lamivudine and HBIG for a donor kidney with positive hepatitis B core antibody. Please see operative note for details. She was noted to have bleeding from the biopsy site on the donor kidney intraoperatively and had an EBL of 1000cc and was given FFP, PRBCs, and platelets in the OR. Post-op she was given 2units PRBCs for blood loss anemia. She initially made 670cc of urine but then became gradually oliguric in the PACU. An ultrasound was obtained showing normal vascular flow and resistive indices. A tiny post-operative perinephric fluid collection was noted. She remained intubated and was kept in the PACU for close observation. She was extubated the morning of POD1. She had a pressor requirement and also became hyperkalemic while still in the PACU. She underwent urgent HD for hyperkalemia and was transferred to the surgical ICU. She remained in the SICU until POD4. She was on pressor support until POD3 and was dialyzed again for hyperkalemia. She received another 2U PRBCs for low hematocrit and was maintained on the standard protocol for immunosuppressants along with HBIG and lamivudine. She remained in ATN/DGF with minimal urine output. She had a fever spike on POD3 =101.9 and was noted to have a positive U/A at that time. Levofloxacin was started. She was transferred to the floor on POD4. Her platelets had dropped and a HIT panel later was negative. Heparin was changed to fondaparinux in the interim until the results of the HIT were found to be negative. She had a significant amount of pain and her abdomen was distended. She was started on labetolol and nifedipine for hypertension. She was passing some flatus but was slow to have a return of bowel movements. She was maintained on a regular dialysis schedule and remained oliguric with UOP 80-200cc per day. On POD6 her hematocrit decreased and her pain and distension were more prominent. She was taked back to the OR for a washout and hematoma evacuation. A biopsy of the kidney was also done which revealed acute tubular necrosis. She continued to have abdominal pain post-operatively. On POD1/8 she had a KUB that was consistent with post-op ileus. She moved her bowels following this with some relief of her pain. She required 4units of PRBC on POD [1-18] for continuing anemia. She was again taken back to the OR on POD3/10 for exploration due to a continuing low hematocrit and persistent pain. Additional PRBCs were given in the OR. A hematoma was evacuated and the retroperitoneum washed-out. She was extubated in the PACU and did well following this final surgery. She was admitted to the surgical ICU for observation post-op. She remained on dialysis. Hematology was consulted for her coagulopathy and thrombocytopenia. A bleeding time was elevated at >15minutes. She remained under observation in the SICU until POD3/6/13. Her hematocrit remained stable and she had no further bleeding. The patient did well on the floor and was able to tolerate a regular diet and was seen by physical therapy who worked with her daily. She continued on dialysis and continued to make approximately 150-200cc of urine per day. Her blood pressure medication regimen was optimized and she remained stable on an immunosuppressant regimen of Tacrolimus, Cellcept, and Prednisone. Her JP drain was removed on POD7/10/17 and her bowel function returned on a bowel regimen although she remained intermittently constipated with the need for additional bowel medication. Her kidney function gradually improved and she went without dialysis during the last few days leading up to discharge. Her pain was controlled. She was able to ambulate on her own and walk stairs. She was discharged to home with services on [2175-9-22]. She will follow-up closely with the transplant center to monitor her progress and her medications. Medications on Admission: prednisone 5', protonix 40', nifedipine SR 60', minoxidil 2.5', labetolol 800", clonidine 0.6", nephrocaps', renagel 1600''' Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:2 2. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:30 Tablet(s) Refills:2 3. Lamivudine 10 mg/mL Solution Sig: Five (5) PO DAILY (Daily). 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:15 Tablet(s) Refills:0 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Disp:140 Refills:2 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:64 Tablet(s) Refills:2 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:64 Capsule(s) Refills:2 9. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:84 Tablet(s) Refills:2 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:84 Tablet(s) Refills:2 11. Clonidine 0.2 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:42 Tablet(s) Refills:1 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:30 Tablet(s) Refills:0 13. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). Disp:30 Tablet Sustained Release(s) Refills:1 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 15. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take with 3-one mg cap for total of 8mg twice a day. Disp:64 Capsule(s) Refills:0 16. Prograf 1 mg Capsule Sig: Three (3) Capsule PO twice a day: take with a 5mg capsule for total dose of 8mg twice a day . Disp:180 Capsule(s) Refills:1 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:40 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: End stage renal disease secondary to lupus s/p cadaveric kidney transplant Secondary diagnoses: hypertension pulmonary hypertension gerd post-op ileus Discharge Condition: stable Discharge Instructions: Call [Telephone/Fax (1) 673] if fevers, chills, nausea, vomiting, inability to take medications, decreased urine output, weight gain of 3 pounds in a day, leg edema, bleeding/pus or redness of incision or inability to eat. No heavy lifting [Month (only) 116] shower No driving if taking pain medications Labs every Monday & Thursday for cbc, chem 7, calcium, phosphorus, ast,t.bili, albumin, urinalysis and trough prograf level. Results to be fax'd to [Telephone/Fax (1) 697] Followup Instructions: Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2175-9-22] 9:10 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2175-9-25] 11:00 Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2175-10-2] 3:30 ICD9 Codes: 2851, 5845, 2767, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7830 }	Medical Text: Admission Date: [2170-6-28] Discharge Date: [2170-7-4] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1055] Chief Complaint: transfer from [Hospital3 26615] Hospital w/ GIBleed Major Surgical or Invasive Procedure: CABG [2161] cholecystectomy appendectomy Total abdominal hysterectomy History of Present Illness: Pt is an 85 yo lady w/ recent admit for NSTEMI, CHF ?EF, LE cellulitis, Afib on coumadin, severe AS, who presents from [Hospital 39437] ICU w/ LGIB. She initially presented from a subacute facility on [2170-6-24] with "mahogany stools" x 1 day. She had a hct checked which was 29.9 from 34.2 on [6-21]. She was supposed to have outpatient c scope/sigmoidoscopy, but then started passing bright red clots and was admitted to the ICU. VS noted to be BP 116/60, P 60's, sat 98%. . She was evaluated with a colonoscopy that showed blood throughout the colon but "darker" on the right side. Small polyps noted, but not removed. A larger 1.5 cm polyp noted at 40 cm in sigmoid that was bleeding from its base. This was not removed [2-7] coagulopathy (INR 2.3), but endoloop placed at the base and three hemoclips placed w/ good hemostasis. Non bleeding hemorrhoids also noted. Since the procedure, patient has been "oozing" blood and has required 2 units per day, totalling 7? units since her admission, 3 units of FFP. She had a pan positive bleeding scan throughout colon (see report below). She remained hemodynamically stable throughout her admission and was transferred here for further evaluation and treatment. Aspirin, plavix, and coumadin were held. Vitamin K given as well. Patient has been monitored in the MICU. She received blood transfusions as well as FFP to reverse her coagulopathy ; aspirin, plavix and coumadin were all held. She was evaluated by GI and underwent a colonoscopy whihc demonstrated an AVM as the cause of bleeding. The bleeding site was cauterized. She was also found to have diverticulosis of the sigmoid colon that was non-bleeding. Her hematocrit remained stable. MICU course was complicated by episodes of desaturation whihc seemed to resolve spontaneously and were thought to be secondary to mucus plugs. Past Medical History: CAD w/ recent NSTEMI [6-10] CHF w/ ?EF- no data sent AS with area 0.86 cm2 per OSH record CABG [2161] Afib chronic voice hoarseness-- known benign polyps osteoporosis chronic LE edema PVD w/ non healing ulcers w/ recent tx for cellulitis cholecystectomy appendectomy TAH Social History: quit tobacco 25 yrs ago- 10 pack year history; no etoh; lives alone; DNR/DNI per records. Family History: father died of colon ca, age 70; CAD and HTN Physical Exam: T Afebrile BP 138/42 HR 69 RR 31 sat 97% Humidified air Gen: comfortable, thin, elderly lady, NAD HEENT: MM dry, nasal cannula in place, hoarse/quiet voice Neck: supple, JVP to ear? Lung: bibasilar crackles, decreased breath sounds b/l with poor inspiratory and expiratory effort. CV: [Year (4 digits) 64063] [Last Name (LF) 64063], [First Name3 (LF) ], harsh [3-11] crescendo/decrescendo sysolic murmur w/ no rads to carotids or axilla. Poor peripheral pulses (Upper and lower exremities). Abd: soft, NT, normal bowel sounds, ND, no hsm Ext: thin, dry skin, no edema, ecchymoses over LUE near IV site Neuro: alert, conversant, appropriate, alert and oriented x 1 (self). Follows all commands. cranial nerves intact. Pertinent Results: [2170-6-28] 10:18PM HCT-32.2* [2170-6-28] 05:43PM GLUCOSE-76 UREA N-27* CREAT-0.8 SODIUM-148* POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-44* ANION GAP-10 [2170-6-28] 05:43PM ALT(SGPT)-14 AST(SGOT)-31 LD(LDH)-197 CK(CPK)-69 ALK PHOS-65 TOT BILI-1.8* [2170-6-28] 05:43PM CK-MB-NotDone cTropnT-0.07* [2170-6-28] 05:43PM CALCIUM-9.2 PHOSPHATE-3.3 MAGNESIUM-1.4* [2170-6-28] 05:43PM WBC-8.5 RBC-4.12* HGB-11.7* HCT-34.1* MCV-83 MCH-28.4 MCHC-34.3 RDW-17.9* [2170-6-28] 05:43PM NEUTS-82.9* LYMPHS-10.8* MONOS-4.3 EOS-1.4 BASOS-0.5 [2170-6-28] 05:43PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MICROCYT-1+ [2170-6-28] 05:43PM PLT COUNT-86* [2170-6-28] 05:43PM PT-12.8 PTT-26.8 INR(PT)-1.1 Brief Hospital Course: 85F with history of NSTEMI, CHF, LE cellulitis, Afib on coumadin, severe AS, who presented from [Hospital3 26615] ICU w/ LGIB. . 1. GI bleed: Evidence of bleeding on colonoscopy with bleeding polyp in the colon s/p endoloop placed at the base and three hemoclips placed w/ good hemostasis but that continue to bleed. Pt was seen by GI because she continued to have blood loss per rectum. Given patient's recent MI there was concern for ischemia if bleeding recurred. Pt was typed and crossed in the event of a recurrent bleed. . 2. Aortic stenosis: fluid balance was carefully regulated given pt' pre load dependent status. Of note, Aortic Valve 0.8 cm; gradient unknown. . 3. CAD: Aspirin/plavix were held as was atenolol (pt bradycardiac). Had recent NSTEMI ([6-10]) and CABG [2161]. EKG on [2170-7-4] showed previous atrial fibrillation with PVCs, left axis deviation, IV conduction defect and lateral ST-T changes likely due to myocardial ischemia. The pt also continued to have a persistent Trop leak that had been noted at the outside (referring) hospital. During her admission, the pt did not complain of any chest pain. . 4. AF: given pt's GI bleed and relative bradycardia, coumadin and beta-blocker were held, respectively. . 5. CHF: EF unknown. We did decide to repeat echo if pt went into respiratory distress. We managed the pt's pleural effusions with Lasix prn and gave her prbc's to prevent further cardiac strain. . 6. GI: was on flagyl 250 po tid at the OSH for presumed C.Diff. She had no wbc elevation. We planned on sending stool cultures in the event of future diarrhea suggestive of C. difficile. Pt had a few episodes of LGIB and on colonoscopy was found to have an AVM in transverse colon that was cauterized. 7. code: After discussion with the family it was decidde that the patient's code status would be DNR/DNI and CMO. The patient expired on [2170-7-4] due to progressive respiratory distress likely due to mucus plugging. She had a progressive decline in mental status and was eventually at a risk for aspirating. AFter extensive discussion with the family it was decided that the staff would provide comfort only measures. Medications on Admission: MEDS ON transfer: Protonix 40 mg IV qd lasix 20 mg po bid (+lasix IV prn (in between prbc's) atenolol 12.5 mg qd ntg patch 0.1 on am, off pm asa 325 mg on hold plavix on hold digoxin 0.125 mg qd zoloft 50 mg qd coumadin on hold flagyl 250 po tid KCl 10 meq qd vitamin K 10 mg PO and 10 mg sc x 1 Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: 1. AVM 2. CAD w/ recent NSTEMI [6-10] 3. CHF 4. Aortic Stenosis 5. Afib 6. Chronic voice hoarseness-- known benign polyps 7. Osteoporosis 8. Chronic Lower Extremity edema 9. Peripheral Vascular Disease Discharge Condition: Patient expired [2170-7-4]. Discharge Instructions: Not applicable Followup Instructions: Not applicable Completed by:[2170-9-17**] ICD9 Codes: 4280, 2851, 5119
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7831 }	Medical Text: Admission Date: [2148-4-11] Discharge Date: [2148-7-7] Date of Birth: [2148-4-11] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: Baby boy [Known lastname ] [Known lastname ] is a former 930 gram product of 26-week twin gestation pregnancy born to a 35-year-old primiparous mother who was admitted on the day prior to delivery with preterm labor and shortened cervix. She previously had been on bed rest for four weeks for shortened cervix and preterm labor. She was treated with magnesium sulfate and betamethasone. Progression of cervical dilatation led to delivery on the morning of [4-11]. Prenatal screens revealed A positive, antibody negative, hepatitis B surface antigen negative, rapid plasma reagin nonreactive, group B strep status unknown. Rupture at the time of delivery. No infection risk factors. In the delivery room, the infant was delivered vaginally with a spontaneous cry and a heart rate always greater than 100. The infant was intubated with a 2.5 endotracheal tube for work of breathing. Apgar scores were 5 at one minute and 7 at five minutes. The infant was transferred to the Newborn Intensive Care Unit after visiting with parents. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed a pink and nondysmorphic infant. A few bruises noted above the legs. Fused eyes. Head somewhat edematous. Bilateral breath sounds with crackles and equal breath sounds bilaterally. The abdomen was benign. Genitalia was normal. A premature male with bilateral undescended testes. Spine was intact. Decreased spontaneous movement and tone consistent with gestational age. A nonfocal neurologic examination. Heart was regular in rate and rhythm. No murmurs. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. RESPIRATORY ISSUES: As stated above, the infant was intubated in the delivery room and received two doses of surfactant. He was transitioned to continuous positive airway pressure on day of life one. Several hours after transition to continuous positive airway pressure, the infant was noted to have a severe bradycardic episode and desaturation. The infant required reintubation and then noted to have bloody secretions from the endotracheal tube consistent with pulmonary hemorrhage. The infant was placed on high-frequency ventilator. The infant was also noted to have a patent ductus arteriosus by echocardiogram and was started on indomethacin. The infant was transitioned to the conventional ventilator on day of life five with ventilator settings of 18/5 and a rate of 20. He weaned from ventilator settings and again was transitioned to continuous positive airway pressure on day of life 12. He remained on continuous positive airway pressure until day of life 17 when he again required reintubation for increased apnea and bradycardia. The infant remained on continuous positive airway pressure until day of life 25 when he then had another trial off continuous positive airway pressure to nasal cannula oxygen, on which he remained until day of life 65. The infant was started on caffeine on day of life one. He remained on caffeine supplementation until day of life 66. At the time of discharge, the infant's respiratory status was stable. He was on room air with a baseline respiratory rate in the 30s to 60s. He has been free of apnea and bradycardia for greater than five days. 2. CARDIOVASCULAR SYSTEM: The infant initially required two normal saline boluses for a marginally low blood pressure. As stated above, the infant was noted to have a large patent ductus arteriosus with left-to-right flow confirmed by echocardiogram. He was treated with one course of indomethacin. After the pulmonary hemorrhage, the infant did require two more normal saline boluses and dopamine with a maximum dose of 10 mcg/kg per minute. This was discontinued on day of life two. The infant received another echocardiogram on [4-15] and on [4-19] and had no further signs of a patent ductus arteriosus on echocardiogram. The infant had a soft intermittent murmur, consistent with PPS, throughout his stay and a stable blood pressure of 70s/30s with means in the 40s. Baseline heart rate was 130s to 160. 3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The infant initially had an umbilical artery catheter and a umbilical venous catheter. The umbilical artery catheter was discontinued on day of life five and the umbilical venous catheter was discontinued on day of life seven. At that time, percutaneous intravenous catheter was placed. He was started on parenteral nutrition on day of life one, and trophic feeds were started on day of life 10. He advanced to full feedings by day of life 16 at 150 cc/kg of breast milk. Enteral caloric density was increased to 30 calories per ounce. As his weight increased and demonstrated adequate growth, the calories were transitioned back down to 20 calories per ounce. Nutrition laboratories on [6-11] were 139, 4.3, 104, 26. Alkaline phosphatase was 229. Calcium was 10.9. Phosphorous was 5.7. The infant did receive supplemental iron and vitamin E. Initially, in his early days, the infant needed supplemental sodium chloride which was discontinued by day of life 30. He is currently receiving ferrous sulfate 2 mg/kg per day; equal to 0.25 cc, and supplemental Poly-Vi-[Male First Name (un) ] 1 cc p.o. once per day. He is voiding and stooling. 4. GASTROINTESTINAL ISSUES: The infant did demonstrate physiologic jaundice. He had a peak bilirubin of 6.4/0.5 which responded to double phototherapy. This was resolved by day of life 20 with a rebound bilirubin of 3.2/0.2. 5. HEMATOLOGIC ISSUES: The infant is O positive and antibody negative. He did require three blood transfusions during this admission, the first on day of life one after his pulmonary hemorrhage, and the last being on [5-8]. At that time, his hematocrit was 26.3 and reticulocyte count was 5.8. He has not had a repeat hematocrit since that time. 6. INFECTIOUS DISEASE ISSUES: The infant had an initial blood culture and complete blood count because of gestational age and respiratory distress to rule out infection. The initial white blood cell count was 5.1 (with 24% polys and 1% bands), platelets were 319, and hematocrit was 38. He was treated with antibiotics for seven days because of the severity of illness. He had a lumbar puncture done on day of life five which revealed white blood cell count of 375,000 and red blood cell count was 132,500. Culture on day of life eight came back with rare gram-positive cocci. At that time, the infant had been off antibiotics for one day and was clinically stable. Therefore, a repeat lumbar puncture was done on day of life 10 which revealed a white blood cell count of 178 and a red blood cell count 13,556. Protein was 27.7 and glucose was 31. Culture on that lumbar puncture was negative. The infant was not restarted on antibiotics. He has had no further issues with infection during this admission. He did have gentamicin levels while on ampicillin and gentamicin of 1.8 and 6.8. 7. NEUROLOGIC ISSUES: The infant had his initial head ultrasound on day of life four which showed bilateral intraventricular hemorrhage with mild-to-moderate ventriculomegaly. Serial follow-up head ultrasounds initially showed an increase in ventricular size. He did not require any intervention. Over time, the ventricular size has decreased. His last head ultrasound was on [6-18] at corrected gestational age of 36 weeks. This showed mild ventriculomegaly with no change from his previous one. Per parental request, Neurology will not follow him after discharge unless there are clinical indications for them to consult. 8. SENSORY ISSUES: A hearing screen was performed with automated auditory brain stem responses; results passed on [2148-6-18]. 9. OPHTHALMOLOGIC ISSUES: The infant has had serial eye examinations done with the last one being on [6-26] which showed regressing stage I retinopathy of prematurity in the right eye in zone three 2 clock hours; in the left eye zone two 3 clock hours. The plan was to re-examine in two weeks; which will be the week of [7-8]. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 36137] will be following the infant (telephone number [Telephone/Fax (1) 36249]). 10. PSYCHOSOCIAL ISSUES: The parents have been visiting daily and are quite involved in care. Mother is an emergency physician, [Name10 (NameIs) ] father is a pediatric ophthalmologist. They look forward to transitioning home with the twins. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: Discharge status was to home with parents. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) 1743] [Last Name (NamePattern1) 37517] with [Hospital 1887] Pediatrics (telephone number [Telephone/Fax (1) 37518]; fax number [Telephone/Fax (1) 37519]). CARE RECOMMENDATIONS: 1. Continue ad lib feeding of breast milk. 2. MEDICATIONS: Ferrous sulfate 25 mg/cc 2.5 cc (which equals 2 mg/kg per day) and Poly-Vi-[Male First Name (un) ] 1 cc p.o. once per day. 3. Car seat position screening passed on [6-30]. 4. State newborn screening status; serial screens were done. Initially, he had a low T4 and elevated 170H progesterone. This resolved with maturity of gestational age. His state screen on [5-19] was within the normal range. A discharge state screen will be sent on the day of discharge. IMMUNIZATION RECEIVED: Hepatitis B vaccine on [6-21], DTaP on [6-21], HIB on [6-21], IPV on [6-22], and pneumococcal conjugate vaccine on [6-22]. IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial virus 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 gestation. (2) Born between 32 and 35 weeks gestation with plans for day care during respiratory syncytial virus season, with a smoker in the household, or with preschool siblings; and/or (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 care givers should be considered for immunization against influenza to protect the infant. DISCHARGE INSTRUCTIONS/[Month (only) ]: 1. Follow-up appointment with Dr. [Last Name (STitle) 37517], primary pediatrician, on [2148-7-9]. 2. Follow up with ophthalmology (Dr. [Last Name (STitle) 36137] the week of [7-8]; parents to make this appointment. 3. Declined [First Name (Titles) 407] [Last Name (Titles) 4939]. 4. Early intervention; [Hospital1 10478] Program, [Apartment Address(1) 48762], [Hospital1 10478], [State 350] (telephone number [Telephone/Fax (1) 44213]; fax number [Telephone/Fax (1) 48763]). 5. Infant Follow-Up Program at the [Hospital3 1810]. Ms [Last Name (Titles) 48764] [Doctor Last Name 6633] [Doctor Last Name 8182], IFUP co-coordinator, will be contacting the parents to schedule the first appointment between 6-12 months of age. DISCHARGE DIAGNOSES: 1. Former 26-week premature male. 2. Corrected gestational age 38 and 5/7 weeks. 3. Status post respiratory distress syndrome. 4. Status post pulmonary hemorrhage. 5. Status post presumed sepsis. 6. Status post patent ductus arteriosus; treated with indomethacin. 7. Status post apnea and bradycardia of prematurity. 8. Status post anemia of prematurity. 9. Status post intraventricular hemorrhage. 10. Retinopathy of prematurity. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 36532] Dictated By:[Last Name (NamePattern1) 36251] MEDQUIST36 D: [2148-7-6] 02:56 T: [2148-7-6] 04:06 JOB#: [Job Number ] ICD9 Codes: 769, 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7832 }	Medical Text: Admission Date: [2139-9-6] Discharge Date: [2139-9-25] Service: CARDIOTHORACIC Allergies: Percocet / Penicillins / Sulfa (Sulfonamides) / Ertapenem Attending:[First Name3 (LF) 1505] Chief Complaint: Weakness Major Surgical or Invasive Procedure: s/p Coronary Artery Bypass Graft x 4(LIMA->LAD, SVG->OM, Ramus, PDA) [2139-9-11] s/p pacer lead placement and generator change [2139-9-18] History of Present Illness: This is an 86 y/o male with multiple cardiac risk factors and previous MI with evidence of CAD on prior cath who felt some generalized weakness for several days. Also c/o shortness of breath for one week. At OSH his troponin I was 7.4 and CK was 207 with MB 9.2. He then underwent a cardiac cath which revealed three vessel coronary artery disease. He was then transferred to [Hospital1 18] for surgical intervention. Past Medical History: s/p PCI, s/p perm. pacemaker placement, Diabetes Mellitus, Hypertension, Dyslipidemia, Peripheral Vascular Disease s/p R fem-distal BPG, s/p R 1st toe amp, Benign Prostatic Hypertrophy, Chronic Renal Insufficiency, Anemia Social History: Lives with wife. [Name (NI) ]. ETOH. +Tob but quit 50 yrs ago. Family History: Non-contributory Physical Exam: General: WD/WN elderly male in NAD HEENT: EOMI, PERRL, NC/AT Neck: Supple, FROM, -JVD Cardiac: RRR -c/r/m/g Lungs: CTAB -w/r/r Abd: Soft, NT/ND, +BS Ext: Warm, Dry -edema Neuro: A&O x 3, MAE, non-focal Pertinent Results: CNIS/Vein Mapping [9-7]: Moderate-to-significant plaque with bilateral 60-69% carotid stenosis. Duplex evaluation was performed of the left lower extremity venous system. The left lesser saphenous vein is patent, but somewhat calcified at range in diameter from 0.17-0.24 cm. The left greater saphenous vein is also patent with calcification approximately diameters ranges from 0.18-0.24 cm. CTA Neck [9-9]: 1. Substantial calcification and luminal narrowing within the carotid artery bifurcation bilaterally. 2. Diminutive right vertebral artery likely secondary to heavy atherosclerotic disease versus congenital anomoly. 3. Small right pleural effusion with bilateral calcification at the lung apices. Echo [9-11]: PRE-BYPASS: Overall left ventricular systolic function is mildly depressed. There is an inferobasal left ventricular aneurysm. There is mild regional left ventricular systolic dysfunction with hypokinesis of inferobasal wall. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. The aortic valve leaflets (3)are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. Mild to moderate ([11-24]+) mitral regurgitation is seen. The left atrium is mildly dilated. There are simple atheroma in the descending thoracic aorta. POST-BYPASS: Preserved right ventricular systolic function. Overall LVEF 45%. Mild to moderate mitral regurgitation. Mild aortic regurgitation. [2139-9-6] 05:55PM BLOOD WBC-7.1 RBC-4.67 Hgb-12.9* Hct-38.6* MCV-83 MCH-27.5 MCHC-33.4 RDW-17.6* Plt Ct-183 [2139-9-10] 07:00AM BLOOD WBC-6.2 RBC-4.04* Hgb-11.1* Hct-32.7* MCV-81* MCH-27.4 MCHC-34.0 RDW-17.5* Plt Ct-174 [2139-9-13] 02:36AM BLOOD WBC-18.3* RBC-3.70* Hgb-10.5* Hct-30.3* MCV-82 MCH-28.3 MCHC-34.6 RDW-17.7* Plt Ct-144* [2139-9-21] 05:40AM BLOOD WBC-6.9 Hct-30.8* [2139-9-6] 05:55PM BLOOD PT-13.0 PTT-35.2* INR(PT)-1.1 [2139-9-22] 06:25AM BLOOD PT-25.1* INR(PT)-2.5* [2139-9-6] 05:55PM BLOOD Glucose-317* UreaN-29* Creat-1.5* Na-134 K-4.5 Cl-98 HCO3-23 AnGap-18 [2139-9-22] 06:25AM BLOOD Glucose-75 UreaN-46* Creat-1.9* Na-138 K-5.1 Cl-103 HCO3-27 AnGap-13 [2139-9-19] 04:30AM BLOOD Calcium-7.7* Phos-3.6 Mg-2.1 [2139-9-25] 05:40AM BLOOD Hct-30.4* [2139-9-23] 06:05AM BLOOD WBC-8.0 RBC-3.64* Hgb-10.2* Hct-30.5* MCV-84 MCH-28.1 MCHC-33.6 RDW-17.2* Plt Ct-322# [2139-9-25] 05:40AM BLOOD PT-30.0* INR(PT)-3.2* [2139-9-24] 06:20AM BLOOD PT-27.0* INR(PT)-2.8* [2139-9-23] 06:05AM BLOOD PT-25.1* INR(PT)-2.5* [2139-9-22] 06:25AM BLOOD PT-25.1* INR(PT)-2.5* [2139-9-21] 05:40AM BLOOD PT-17.7* INR(PT)-1.6* [2139-9-25] 05:40AM BLOOD K-4.4 [2139-9-24] 06:20AM BLOOD Glucose-76 UreaN-44* Creat-1.8* Na-138 K-4.5 Cl-102 HCO3-29 AnGap-12 [2139-9-23] 06:05AM BLOOD Glucose-57* Creat-2.0* K-4.8 Brief Hospital Course: As mentioned in HPI, Mr. [Known lastname ] was transferred from OSH for coronary artery bypass surgery. Upon admission Mr. [Known lastname ] [Last Name (Titles) 21110] usual pre-operative work-up along with carotid studies, vein mapping and echocardiogram. Vascular surgery was consulted d/t his peripheral vascular disease. He remained in hospital receiving medical management while undergoing diagnostic studies and awaiting Plavix washout. He was finally brought to the operating room on [9-11] where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. He tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. Patient received several blood products post-operatively for bleeding. He was weaned from sedation on post-op day two, awoke neurologically intact and was extubated. Chest tubes were removed on post-op day two and EP was consulted for pacemaker interrogation. Diuretics were initiated and he was gently diuresed towards his pre-op weight. He remained in the CSRU for several more days needing hemodynamic support with Neo-Synephrine and epinephrine. Once he was weaned from theses beta blockers were started. He also stayed in the CSRU d/t aggressive pulmonary toilet therapy and confusion/delirium. On post-op day six he was transfused with one unit of pRBCs and on post-op day seven he underwent pacemaker lead placement and generator change. There was evidence of underlying Atrial Fibrillation. Later on this day he appeared to be doing quite well and was transferred to the SDU. On post-op day eight his epicardial pacing wires were removed and he was experiencing some right upper extremity edema. He underwent u/s which revealed acute vein thrombus. Coumadin was started for both AFIB and DVT. He will be discharged with Coumadin with a goal INR of [12-25].5. He remained stable over the next several days receiving physical therapy for strength and mobility. He was discharged to rehab facility on post-op day 14 with the appropriate follow-up appointments. Medications on Admission: Lipitor, Norvasc, Doxazosin, Procrit, Aspirin, Insulin, Heparin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days: then reassess need for diuresis. 8. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous q AM. 9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:QS Tablet(s) Refills:2 12. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: sliding scale Subcutaneous four times a day. Discharge Disposition: Extended Care Facility: [Hospital1 ] Senior Healthcare - [Location (un) 1887] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: s/p PCI, s/p perm. pacemaker placement, Diabetes Mellitus, Hypertension, Dyslipidemia, Peripheral Vascular Disease s/p R fem-distal BPG, s/p R 1st toe amp, Benign Prostatic Hypertrophy, Chronic Renal Insufficiency, Anemia Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for temp>101.5, sternal drainage. Followup Instructions: Make an appointment with your primary care provider [Last Name (NamePattern4) ] [11-24] weeks. Make an appointment with Dr. [First Name (STitle) 1075] for 1-2 weeks. Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Appt. at [Hospital ] Clinic [2143-11-25]:30 am, [Hospital Ward Name 23] 7 [Telephone/Fax (1) 59] Completed by:[2139-9-25] ICD9 Codes: 5859, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7833 }	Medical Text: Admission Date: [2201-8-19] Discharge Date: [2201-8-25] Date of Birth: [2143-10-4] Sex: M Service: MEDICINE Allergies: Codeine / Streptokinase / Iodine / Bee Pollens Attending:[First Name3 (LF) 3991] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 57M with AF on coumadin, h/o dvt, CHF, CAD h/o MI, COPD on 4L home O2, 4 prior intubations for PNA, who presented with 4d of worsening SOB. He was admitted at [Hospital3 3583] approximately 5 wks ago for PNA and intubated for approximately 6 days. At baseline, he takes 160mg Lasix TID. He began to feel short of breath 4 days prior to admission at [Hospital1 18], with orthopnea, mild cough with one episode of coughing up brown non-bloody sputum, and fever to 100 on the morning of admission, with no prior known fevers. He reports weight loss of 20lb over the past few weeks and more than 80lbs over the past year secondary to poor appetite. He denied any recent sick contact/travel, missed medication doses, or dietary alterations. In the ED, initial vs were T 97.6 HR 120 BP 186/103 RR 20 sat 96% 5L. Prior to transfer to ICU vs were HR 108 afib, BP 131/101, RR 15, 95% on 5L. The patient was given vanco/ceft/azithro (without cultures), nebs, and K repletion. CXR showed cardiomegaly, bilateral pleural effusions R>L, and RML/RLL opacity concerning for PNA. Given the patient's history, he was admitted to the MICU for possible airway control and possible MRSA PNA. Past Medical History: Type II Diabetes on oral agents Systemic Lupus Erythematosus Coronary Artery Disease s/p MI in [2186] Hepatitis C COPD with emphysema and asthmatic component (FEV1 60% predicted [1-6]) Diastolic Congestive Heart Failure EF 55% in [3-/2198] Seizure disorder TIA [2187] Colon Cancer s/p resection in [2194] without chemotherapy s/p abdominal trauma with subsequent splenectomy and amputation of digits of his left hand Hyperlipidemia Hypertension h/o cocaine abuse Neuropathy and chronic pain on methadone Chronic Atrial Fibrillation on coumadin Obstructive Sleep Apnea on home CPAP Left Total Knee Replacement [2201] Social History: Pt lives with his wife, daughter, son and granddaughter. [Name (NI) ] is on disability. He used to be a diesel mechanic. He served in [Country 3992] and was badly injured in an explosion. The patient quit smoking in [2181], 4ppd x 20yrs. "Cheats" with cigars on occasion. Last cigar was smoked in [9-7]. No alcohol abuse. History of cocaine abuse, but has been clean since [2181]. Denies current recreational drug use. Family History: Adopted Physical Exam: Vitals: T: 96.8 BP: 158/96 P: 78 R: 18 O2: 96% 4L NC FS 178 General: alert, oriented, obese male with head of bed elevated to 20 degrees, in no distress HEENT: sclera anicteric, MMM, oropharynx clear Neck: thick, no LAD, no appreciable JVD Lungs: mildly diminished at the bases, no wheezes, crackles, or rhonchi CV: irregularly irregular rate, normal S1 + S2, no m/r/g Abdomen: obese, soft, non-tender, non-distended, midline vertical surgical scar, bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis, no lower extremity edema, pneumoboots in place Pertinent Results: [2201-8-19] 07:45PM BLOOD WBC-13.3* RBC-3.68* Hgb-10.4* Hct-31.5* MCV-86 MCH-28.3 MCHC-33.0 RDW-16.9* Plt Ct-396 [2201-8-19] 07:45PM BLOOD Neuts-82.0* Lymphs-12.9* Monos-3.5 Eos-1.0 Baso-0.7 [2201-8-23] 10:35AM BLOOD WBC-11.4* RBC-3.18* Hgb-9.1* Hct-27.6* MCV-87 MCH-28.7 MCHC-33.1 RDW-17.6* Plt Ct-412 [2201-8-19] 07:45PM BLOOD PT-44.3* PTT-31.3 INR(PT)-4.7* [2201-8-23] 10:35AM BLOOD PT-18.2* INR(PT)-1.6* [2201-8-19] 07:45PM BLOOD Glucose-198* UreaN-11 Creat-1.0 Na-141 K-3.4 Cl-96 HCO3-35* AnGap-13 [2201-8-20] 04:25AM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.7 Mg-2.1 [2201-8-20] 04:25AM BLOOD ALT-7 AST-11 LD(LDH)-169 CK(CPK)-38* AlkPhos-112 TotBili-0.4 [2201-8-19] 07:45PM BLOOD proBNP-6217* [2201-8-19] 07:45PM BLOOD cTropnT-<0.01 [2201-8-20] 04:25AM BLOOD CK-MB-1 cTropnT-<0.01 . [2201-8-19] 09:45PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.005 [2201-8-19] 09:45PM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [2201-8-19] 09:45PM URINE RBC-0 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0 . Blood cx x2 negative . ECG [8-19] Atrial fibrillation 94bpm. Modest low amplitude lateral lead T wave changes are non-specific. Since the previous tracing of [2201-6-8] no significant change. . CXR [8-19]: IMPRESSION: Right mid to lower lung opacity concerning for pneumonia. Cardiomegaly with bilateral effusions and pulmonary vascular congestion also present. . Echo [8-20]: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2200-2-18], significant systolic and diastolic dysfunction of the left ventricle are now both present. . CXR [8-20]: Cardiomediastinal contours are unchanged. The component of the pulmonary edema has resolved. Persistent right mid and right lower lobe opacities concerning for pneumonia are unchanged. The lateral CP angles were not included on the film. Evaluation of pleural effusion included. There is no evident pneumothorax. . Repeat TTE [2201-8-24]: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. The estimated right atrial pressure is 10-15mmHg. The left ventricular cavity is moderately dilated. There is moderate global left ventricular hypokinesis with relative preservation of apical setments. (LVEF = 30%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([1-31]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2201-8-20], the severity of mitral regurgitation and the estimated pulmonary artery systolic pressure are slightly reduced. Biventricular cavity sizes and systolic function are similar. Brief Hospital Course: Mr. [Known lastname 3989] is a 57 yo man with a PMH of AF on coumadin, h/o DVT, CHF, CAD h/o MI, COPD on home O2 of 4L, h/o of intubation 4 x during previous admissions for pneumonia, on methadone who presented with a 4d history of worsening SOB, principally secondary to CHF. . #. SOB: At baseline, the patient has COPD with 4L of 02 at home. The patient required approximately the same amount of 02 during the ICU and floor course. The shortness of breath was likely multifactorial, with CHF as the major contributor. His SOB and CXR improved with diuresis. He was put on vanc/levo on admission, which was discontinued on [8-24] after a 5d course. The consulting pulmonary team did not feel that he had pneumonia. He received nebs and bi-pap in house. . #. Diastolic and systolic CHF: The patient was taking furosemide 160 mg TID at home. The patient has had difficulty with fluid overload in the past. Pro-BNP was 6217. On admission, he had a CXR suggestive of pulmonary edema so was diuresed on a Lasix drip overnight in the MICU, with follow-up CXR showing resolution of the edema and lung exam free of rales. On the floor, he was diuresed with a goal of negative fluid balance 1-2L/d and was euvolemic by discharge, with no crackles or edema. Initially, furosemide 80IV tid was used (equivalent to his home dose), switched to torsemide 100mg daily per cardiology recommendations on [8-23]. He was also discharged on spironolactone 12.5 mg, which was started in house. . Past echos had shown diastolic failure with preserved EF, but echo on this admission showed new systolic failure with EF of 30%. Cardiology felt this might be secondary to poorly controlled hypertension and fluid overload rather than interval ischemic event so recommended up-titrating his carvedilol dose, as per below. . #. Afib/History of PE & DVT/anticoagulation: The patient suffers from paroxysmal atrial fibrillation and also has a history of PE and DVTs. He was admitted with supratherapeutic INR of 4.7, so warfarin was initially held, then restarted at half dose on [8-21] and full dose on [8-22]. . #. Hypertension: Cardiology recommendation is a DBP goal of <80. Carvedilol was titrated to 50 mg TID from 12.5 mg TID. He was at goal at time of discharge. . # Chronic pain: patient was discharged on methadone 10 mg QID, per discussions with patient's PCP about decreasing dose from 20 mg. He takes methadone for chronic knee pain. Medications on Admission: - ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler 1-2 puffs Q4-6H prn cough/wheezing - CAPTOPRIL 12.5 mg PO TID - CARBAMAZEPINE 400 mg PO TID - CARVEDILOL 50 mg Tablet PO BID - FLUTICASONE-SALMETEROL 250 mcg-50 mcg 1 puff po BID - FUROSEMIDE 160mg po TID - HYDROXYCHLOROQUINE 200 mg Tablet PO BID - IPRATROPIUM-ALBUTEROL 0.5 mg-2.5 mg/3 mL Solution NEB inhaled Q6H - ISOSORBIDE DINITRATE 40 mg PO TID - METHADONE 20mg PO Q6H prn pain - NITROGLYCERIN 0.4 mg/Dose Spray prn chest pain - OMEPRAZOLE 20 mg Capsule, Delayed Release(E.C.) PO daily - OXAZEPAM 30 mg Capsule PO QHS - OXYGEN 4L - POTASSIUM CHLORIDE 20 mEq Tab Sust.Rel. Particle/Crystal PO TID - PREGABALIN [LYRICA] 100 mg Capsule PO TID - SIMVASTATIN 80 mg Tablet PO at bedtime - SUCRALFATE 1 gram PO twice a day as needed for heartburn - TIZANIDINE 4 mg Capsule PO QHS - WARFARIN 17.5 mg Tablet once a day. - ASPIRIN - 325 mg PO once a day - ISS - CYANOCOBALAMIN 1,000 mcg Tablet SR PO daily - MULTIVITAMIN by mouth daily (no vit k in mvi) (pharmacy - [Numeric Identifier 3997]) Discharge Medications: 1. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Take a half pill. Take in the morning. Disp:15 Tablet(s) Refills:2 2. Captopril 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 3. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:112 Tablet(s) Refills:0 4. Torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 6. Isosorbide Dinitrate 40 mg Tablet Sig: One (1) Tablet PO three times a day. 7. Warfarin 17.5 mg once a day 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 10. Ipratropium Bromide 0.02 % Solution Sig: [1-31] puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. Carbamazepine 400 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO three times a day. 12. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Oxazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 16. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 17. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 18. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for heartburn. 19. Tizanidine 4 mg Capsule Sig: One (1) Capsule PO at bedtime. 20. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 22. Insulin Please follow your home regimen. Discharge Disposition: Home Discharge Diagnosis: congestive heart failure hypertension diabetes mellitus COPD Discharge Condition: Mental status: Alert, orientedx3 Ambulatory status: Ambulatory On home oxygen Discharge Instructions: You were admitted with shortness of breath, likely due to impaired functioning of your heart with fluid in your lungs. You were given diuretics to remove the excess fluid, with recommendations from the cardiology team about the best medication choices. You also received antibiotics, which were then discontinued because the pulmonologists did not think you had pneumonia. Social work saw you to discuss your questions about [Hospital3 ]. Discharge instructions: 1. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. 2. Avoid salty foods. The following medication changes were made: (1) Lasix was stopped (2) Spironolactone 12.5 mg once a day was added. This is a diuretic. (3) Torsemide 100 mg once a day was added. This is also a diuretic. (4) Captopril was increased to 50 mg three times a day. This is for your blood pressure. (5) Methadone dose was decreased to 10 mg four times a day. No other changes were made to your medications. You were also give a prescription for [Hospital 3998] rehab, which is to help your lungs. You have been given the phone number for a pulmonary rehab in [Location (un) 3320] by [Hospital3 3583], which you had requested. This phone number is [Telephone/Fax (1) 3999]50. Please call to schedule an appointment. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [2201-8-31] at 2:30 PM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: TUESDAY [2201-9-15] at 12:00 PM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3990], [First Name3 (LF) ] [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3990] DO 12-BJM ICD9 Codes: 486, 4280, 496, 412, 2768, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7834 }	Medical Text: Admission Date: [2120-4-2] Discharge Date: [2120-4-6] Date of Birth: [2054-2-6] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 66 year old female with a history of HCV cirrhosis, hepatocellular carcinoma, known varices/vascular ectasia, and multiple recent admissions for hepatic encephalopathy, who presented to the Emergency Department with chest pain and malaise times one day. The patient describes left sided chest pain which lasted one hour with nausea, vomiting and light-headedness. The patient ruled out for a myocardial infarction in the Emergency Department by enzymes. While in the Emergency Department, she was noted to have a large melanotic stool, which was heme positive. Her hematocrit was noted to be 25.0 on presentation with a baseline between 25.0 and 30.0. She had no hemodynamic instability but was admitted to the Intensive Care Unit for further monitoring. In the Intensive Care Unit, she received three units of packed red blood cells with a rise in her hematocrit appropriately but no further melena. She remained in Intensive Care Unit for one day prior to transfer to the floor. She denied hematemesis or bright red blood per rectum although her stools continued to be dark and trace heme positive. The liver team/gastroenterology were notified but elected not to do nasogastric tube or esophagogastroduodenoscopy secondary to known varices. She was started on twice a day proton pump inhibitor, Octreotide, and Estradiol per gastroenterology and also on increasing Lactulose given that she was felt to be mildly confused initially. PAST MEDICAL HISTORY: 1. HCV cirrhosis secondary to transfusion diagnosed in [2086], status post Interferon treatment. 2. Hepatocellular carcinoma, status post radiofrequency ablation. 3. History of hepatic encephalopathy. 4. Hypertension. 5. Diabetes mellitus type 2. 6. Hypothyroidism. 7. Gastric antrum vascular ectasia. 8. Grade I varices. 9. Anemia. 10. Thrombocytopenia. 11. Status post cholecystectomy. 12. Status post total abdominal hysterectomy, bilateral salpingo-oophorectomy. 13. Transthoracic echocardiogram [11-27], showing ejection fraction greater than 55%, left ventricle mildly dilated and mild pulmonary hypertension. MEDICATIONS ON ADMISSION: 1. Pantoprazole 40 mg p.o. q12hours. 2. Propranolol 20 mg p.o. twice a day. 3. Lasix 20 mg p.o. twice a day. 4. Spironolactone 50 mg p.o. once daily. 5. Estradiol 0.5 mg p.o. once daily. 6. Synthroid 88 mcg p.o. once daily. 7. Lactulose 30cc p.o. twice a day. 8. Vitamin D. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives alone but in same complex as daughter and has nearly 24 hour supervision. She is widowed but daughter is very close. No history of ETOH. She ambulates with cane. Two pack per day tobacco use, quit at age 56. LABORATORY DATA: On admission, white blood cell count was 2.2, 72% neutrophils, 20% lymphocytes, hematocrit 25.4, baseline at 25.0 to 30.0, platelet count 63,000, baseline 50,000 to 60,000. INR 1.3. Sodium 134, potassium 4.3, chloride 108, bicarbonate 22, blood urea nitrogen 15, creatinine 1.5, baseline 1.3 to 1.7, glucose 143. Cardiac enzymes negative. NH3 162, amylase 110, lipase 104. At baseline TSH 11.0. Chest x-ray showed no cardiopulmonary disease. Electrocardiogram showed normal sinus rhythm at 77 beats per minute, no ST-T wave changes. HOSPITAL COURSE: 1. Gastrointestinal bleed - The patient had active type and cross and three units of packed red blood cell transfusion on admission but did not require any further blood. Her hematocrit was monitored twice daily and then changed to once daily and remained stable around 30.0. She was started on Octreotide for two days and p.o. twice a day proton pump inhibitor and was also started on a small dose of estrogen daily to decrease the likelihood of arteriovenous malformation bleed per the liver service. 2. Cirrhosis - The patient's mentation seemed to clear with increasing Lactulose four times a day titrated to three to four bowel movements per day. She continued home regimen of Propranolol, Lasix and Spironolactone and Ceftriaxone for two days for spontaneous bacterial peritonitis prophylaxis. Per liver service, she did not need to continue on antibiotics as an outpatient. 3. Elevated bilirubin - The patient was noted during admission to have somewhat elevated bilirubin, which peaked at 6.7 from 2.4 but decreased by discharge to the 3.0 range. Liver team did not feel that this was significant and would follow this as an outpatient. 4. Hypothyroidism - The patient continued Synthroid. 5. Anemia - The patient continued iron supplements. 6. Type 2 diabetes mellitus - The patient continued NPH as per home dose and Regular insulin sliding scale. 7. Prophylaxis - The patient continued proton pump inhibitor, Calcium and Vitamin D supplements and Folate. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed likely secondary to arteriovenous malformation. 2. Hepatitis C cirrhosis. 3. Hepatocellular carcinoma. 4. History of hepatic encephalopathy. 5. Type 2 diabetes mellitus. 6. Thrombocytopenia and splenomegaly. 7. Gastric antrum and colonic vascular ectasia. 8. Colonic arteriovenous malformation. 9. Grade I esophageal varices. 10. Status post cholecystectomy and total abdominal hysterectomy and bilateral salpingo-oophorectomy. MEDICATIONS ON DISCHARGE: 1. Pantoprazole 40 mg p.o. q12hours. 2. Propranolol 20 mg p.o. twice a day. 3. Lasix 20 mg p.o. twice a day. 4. Spironolactone 50 mg p.o. once daily. 5. Estradiol 0.5 mg p.o. once daily times six weeks. 6. Synthroid 88 mcg p.o. once daily. 7. Lactulose 30cc p.o. four times a day titrated to three to four bowel movements per day. 8. Vitamin D. DISCHARGE STATUS: To home with services. FOLLOW-UP PLANS: The patient will follow-up with Liver Service in the next two to three weeks and with her primary care physician [2120-4-26]. Her primary care physician had closely followed the patient during her admission. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) 2511], M.D. Dictated By:[Last Name (NamePattern1) 1606] MEDQUIST36 D: [2120-4-6] 20:55 T: [2120-4-7] 11:03 JOB#: [Job Number 106823] ICD9 Codes: 5715, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7835 }	Medical Text: Admission Date: [2123-2-22] Discharge Date: [2123-2-28] Date of Birth: [2063-12-31] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6075] Chief Complaint: Headache. Major Surgical or Invasive Procedure: Arterial line for blood pressure monitoring. History of Present Illness: Patient is a 59 year old right handed Chinese man with past medical history of hypertension, asthma, eczema, allergic rhinitis, chronic low back pain, who presented to [Hospital1 18] ED on [2123-2-22] complaining of headache pain. Patient was in his usual state of health until evening of [2123-2-21]. At that time, he had gradual onset of headache, described as a dull vise-like tightness, in the frontal area. Associated with nausea, dizziness as in lightheadedness, bilateral tingling of hands. No focal weakness, visual changes, fevers, chills, meningismus, phonophobia, photophobia. He took aspirin and motrin without relief. He tried a Chinese herbal tea without relief. After headache had persisted for greater than 12 hours he called 911 and was transported to the [Hospital1 18] ED. On arrival to ED, vitals temp 97.7, HT 84, BP 155/74, RR 17, oxygen 98%/Room air. While in the ED, the numbness in his fingers resolved. While in the ED, he received Toradol 30 mg IV, Compazine 5 mg IV, Hydralazine 10 mg IV, and was loaded with 1 gram of Dilantin. Head CT showed a large right parietal parasagittal hemorrhage with intraventricular hemorrhage as well. He was seen by Neurosurgery, who deferred surgical intervention. Per Neurosurgery recommendations, patient underwent an MRI/MRA while in ED. This showed ntraparenchymal hemorrhage within the medial right occipital lobe extending into the right lateral ventricle without underlying enhancement. Given the presence of multiple tiny foci of abnormal signal on susceptibility imaging within the cerebral cortex, the basal ganglia, the brainstem, and cerebellum, this finding was felt to represent an acute intraparenchymal hemorrhage in the setting of chronic amyloidosis or chronic hypertensive hemorrhage. He was admitted to the Neurology service for further work up and management. Follow up head CT on [2123-2-23] showed stable appearance of hemorrhage and no evidence of increased intracranial pressure or hydrocephalus. Past Medical History: 1. Hypertension 2. Asthma 3. Eczema 4. Allergic Rhinitis 5. Chronic low back pain, described as sciatica, L4/L5 level 6. Right renal cyst 7. History of renal artery stenosis Social History: Married. Lives with wife and son. [Name (NI) 1403] at [University/College ] doing research in an animal lab. No tobacco, alcohol, drug use. Family History: Father with hypertension, deceased at 89 years old from gastric cancer. Mother died of unknown causes. No family history of stroke, aneurysm, bleeding diathesis. Physical Exam: General: Well-developed, well-nourished Chinese man, uncomfortable from headache, appears stated age, in mild distresss. HEENT: Normocephalic, atraumatic, oropharynx clear. Neck: Supple, no carotid bruits. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate, normal s1/s2, no murmurs, rubs, gallops. Extremities: No clubbing, cyanosis, edema. 2+ dorsalis pedis pulses bilaterally. Neurologic Exam: Mental status: Oriented to person, place and time. Alert. Able to say months of year backwards. Fluent speech, repetition, naming intact. Able to read and write. Memory [1-21] registration, recall [1-21] at 5 minutes. No apraxia. Left sided neglect. Cranial nerves: Patient unable to cooperate with formal visual fields but blinks to threat bilaterally. Pupils round 2 mm-> 1.5mm with light. Extraocular eye movements intact without nystagmus. Normal facial sensation and strength. Hearing intact to finger rub. Palate rises symmetrically. Tongue midline. Motor: Normal tone and bulk. No tremors or fasciculations. Pronator drift absent. Patient in fair amount of distress from headache, so did not formally test resistance. Able to hold both arms and legs against gravity for several seconds. Reflexes: There are [12-25] reflexes in upper extremities. Right patella 3+ with spread. No clonus. Plantar reflexes extensor bilaterally. Sensory: Intact to light touch. Coordination: Intact finger to nose bilaterally. Pertinent Results: [2123-2-22] 06:35AM WBC-11.9# RBC-5.02 HGB-15.5 HCT-45.3 MCV-90 MCH-31.0 MCHC-34.3 RDW-13.2 [2123-2-22] 06:35AM NEUTS-78.1 LYMPHS-18.4 MONOS-3.0 EOS-0.3 BASOS-0.2 [2123-2-22] 06:35AM PLT COUNT-222 [2123-2-22] 06:35AM PT-12.7 PTT-33.7 INR(PT)-1.0 [2123-2-22] 06:35AM GLUCOSE-147* UREA N-15 CREAT-1.1 SODIUM-139 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17 [2123-2-22] 06:35AM CALCIUM-9.4 PHOSPHATE-1.9* MAGNESIUM-2.0 URIC ACID-4.7 [2123-2-22] 06:35AM CK(CPK)-55 [2123-2-22] 06:35AM CK-MB-NotDone [2123-2-22] 08:00AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.012 [2123-2-22] 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2123-2-22] 08:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 ----- CT head without contrast: There is a nearly 24-mm area of acute hemorrhage within the right parietal lobe in a medial parasagittal locale. There is moderate extension of the hemorrhage into the right lateral ventricle, with a tiny amount of hemorrhage seen in the anterior aspect of the third ventricle near the foramen of [Last Name (un) 2044]. A small quantity of blood is also seen in the right temporal [Doctor Last Name 534]. There is a mild amount of edema surrounding the right parietal hemorrhage, most notably superior to the hemorrhage itself. Additionally, there is an 11- mm area of hypodensity within the left frontal lobe white matter and an approximately 5 mm solitary hypodense zone within the right frontal white matter. There is no hydrocephalus. There is effacement of the right cerebral hemisphere cortical sulci superiorly, likely due to the mass effect of the hemorrhage. There is no shift of normally midline structures. There is a prominent degree of mucosal thickening within both ethmoid sinus complexes, the right maxillary sinus, and in the sphenoid sinus. There is a suggestion that some of this mucosal thickening may be polypoid in configuration. Additional probable polyps are seen within the nasal cavity bilaterally. No other overt extracranial abnormalities are seen. CONCLUSION: Large right parietal parasagittal hemorrhage with intraventricular hemorrhage as well. In conjunction with the hypodense areas within both frontal lobes, the most common differential diagnostic consideration would be hemorrhage, possibly into an underlying infarction with additional areas of prior brain infarction. This diagnosis is favored if there is a history of chronic hypertension. Alternatively, hemorrhage into a preexistent tumor, with the additional hypodense foci possibly representing other sites of neoplastic disease could be considered. An underlying vascular malformation would be statistically less likely. ----- MRI head [2123-2-22]: A focus of acute hemorrhage is present within the medial right occipital lobe with extension into the right lateral ventricle. No underlying abnormal enhancement is present. Scattered tiny foci of abnormal signal on susceptibility imaging are present in the cerebral cortex, thalamus, basal ganglia, pons, and cerebellum. . A chronic area of lacunar infarction is present within the white matter of the left frontal lobe. There is no evidence of hydrocephalus or shift of midline structures. There is no evidence of signal abnormalities on diffusion weighted imaging to suggest acute infarction. IMPRESSION: 1. Intraparenchymal hemorrhage within the medial right occipital lobe extending into the right lateral ventricle without underlying enhancement. Given the presence of multiple tiny foci of abnormal signal on susceptibility imaging within the cerebral cortex, the basal ganglia, the brainstem, and cerebellum, this finding likely represents an acute intraparenchymal hemorrhage in the setting of chronic amyloidosis or chronic hypertensive hemorrhage. 2. Foci of abnormal signal within the periventricular white matter that have an appearance suggestive of chronic microvascular angiopathy, as well as a chronic lacunar infarction within the centrum semiovale on the left. ----- CT/CTA head [2123-2-22]: The high density material in the right parieto-occipital region and in the right lateral ventricle is unchanged from previous examination consistent with stable hematoma with ventricular extension. There is no definite new findings. Ventricular dimension is stable. IMPRESSION: Stable appearance of right parieto-occipital hemorrhage with intraventricular extension. CT ANGIOGRAM: There is no evidence of aneurysm or flow abnormality. No deficient branches noted in the right parieto-occipital or posterior cervical regions. IMPRESSION: Negative CT angiogram. ----- CT head without contrast [2123-2-25]: This examination is unchanged when compared to [2123-2-23] with a stable intraparenchymal hemorrhage within the medial right occipital lobe extending into the right lateral ventricle with associated surrounding edema/mass effect. The ventricles and sulci are unchanged in size. No new areas of hemorrhage are seen. Foci of hypoattenuation within the centrum semiovale bilaterally are stable. Bone windows showed continued opacification of both sphenoid sinuses and the ethmoid air cells. IMPRESSION: Unchanged examination when compared to [2123-2-23]. Brief Hospital Course: Patient is a 59 year old Chinese man with past medical history of hypertension who presented to the [Hospital1 18] ED on [2123-2-22] for evaluation of 12 hours of bifrontal dull headache pain associated with nausea, bilateral hand tingling. Neurologic exam reveals left neglect, albeit full exam is limited by patient's distress from headache pain. Imaging has revealed a large right parietal parasagittal hemorrhage with intraventricular hemorrhage as well. MRI susceptability images revealed areas of microbleeding in the thalami bilaterally. Differential diagnosis for etiology of bleeding includee amyloid angiopathy, cavernous angioma, hemorrhagic stroke or hypertension. Patient was admitted to the Neurology ICU. Blood pressure was monitored with goal <160 systolic. Repeat CT scans showed stable size of hemorrhage and ventricular system. On CT Angiogram, there was no evidence of aneurysm or flow abnormality. No deficient branches noted in the right parieto-occipital or posterior cervical regions. MRI/MRA demonstrated intraparenchymal hemorrhage within the medial right occipital lobe extending into the right lateral ventricle without underlying enhancement. Given the presence of multiple tiny foci of abnormal signal on susceptibility imaging within the cerebral cortex, the basal ganglia, the brainstem, and cerebellum, this finding was felt to likely represent an acute intraparenchymal hemorrhage in the setting of chronic amyloidosis. On neurologic exam, he initially had a left visual neglect. Over the course of his hospital stay, this neglect improved. Blood pressure was well controlled on his home Diltiazem regimen. Headache pain was initially controlled with narcotics, but patient was later transitioned to Tylenol for pain control. An aggressive bowel regimen was ordered to prevent straining and subsequent increased intracranial pressure. Supportive care was given for nausea and vomiting, including intravenous fluids and antiemetics. Patient was evaluated by physical therapy, who felt he could benefit from a home safety evaluation. On day of discharge, his headache pain was well controlled with Tylenol alone. He was tolerating a regular diet with no nausea or vomiting. Neurologically, he had no discernable focal deficits. Given the microhemorrhage seen on MRI, suggestive of extensive amyloid angiopathy, patient needs to avoid aspirin and non-steroidal medications as these increase his risk of subsequent bleeding. Tylenol should be utilized for pain control. Medications on Admission: 1. Aspirin 2. Diltiazem 3. Ibuprofen 4. Flonase Discharge Medications: 1. Fexofenadine HCl 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 3. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:30 Tablet(s) Refills:0 4. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: 1. Right parietal intraparenchymal hemorrhage with intraventricular extension 2. Hypertension Discharge Condition: Stable. Hemodynamically stable. No neurologic deficits except for question of left visual neglect, flattening of left nasolabial fold. Discharge Instructions: Please return to the hospital if you develop severe headache, nausea/vomiting, chest pain, shortness of breath or any other severe symptoms. Please call your doctor with any questions about your symptoms. Due to an increased risk of bleeding in your pain, you should avoid use of aspirin or any non-steroidal pain medication like Ibuprofen or Naprosyn. Use Tylenol for pain control. Followup Instructions: The following appointment has already been scheduled: Provider: [First Name8 (NamePattern2) ] [Known lastname ], [Name Initial (NameIs) ].D. Where: [Hospital6 29] [Hospital ] Phone:[Telephone/Fax (1) 250] Date/Time:[2123-3-29] 11:40 Follow-up with Drs. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and [Name5 (PTitle) ] [Doctor Last Name ] in [Hospital 4038] Clinic. Call [Telephone/Fax (1) 657] to schedule an appointment. ICD9 Codes: 431, 2765, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7836 }	Medical Text: Admission Date: [2173-10-17] Discharge Date: [2173-10-19] Date of Birth: [2105-12-1] Sex: F Service: MEDICINE Allergies: Penicillins / erythromycin / Cephalosporins / Latex Attending:[First Name3 (LF) 10488] Chief Complaint: Dyspnea, fatigue Major Surgical or Invasive Procedure: EGD Colonoscopy 2unit RBC transfusion History of Present Illness: Mrs [Known lastname 805] is a pleasant 67 yo woman with hx of chronic anemia, OSA, HTN, HLD, rheumatic heart disease with mitral stenosis and regurg, who presents with 2 days of "heaviness" in arms and legs. Pt states that she came in today because she was feeling so tired that she couldn't do her usual stretching exercises prior to work. She denies any chest pain, palps, myalgias, malaise, bloody BMs, states they are always dark. She has not had any fevers, chills, N/V/D. She does endorse a cough which is chronic and she attributes to seasonal allergies and GERD. Pt had an EGD this year and [Last Name (un) ] last year which were unremarkable, as well as a normal capsule study [6-21]. She does have a history of anemia (iron deficiency) thought to be secondary to chronic GI bleed, though never found a source. She has been followed by GI and heme for this and had been recently upped to two pills a day. In the [Name (NI) ], pt was initially hypertensive to the 150s, HR to 109, BP decreased to the 110s and HR to the 80s on transfer. Guiac was positive. She was seen by GI who recommended EGD/[Last Name (un) ] tomorrow. EKG was performed and showed sinus tach with no acute changes. 2 units were ordered but not hung on transfer, she was given 1 L of fluid and 2 PIVs were placed. CXR was unremarkable. On the floor, patient continues to c/o ongoing fatigue. She says that she looked up her sxs earlier today and then had a panic attack because she was concerned that she was dying. This was the first time that this has ever happened. During this event, she felt SOB and felt a pounding in her ears, however this resolved when she felt less anxious. Review of systems: (+) Per HPI, also + cough [1-13] seasonal allergies, GERD (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies 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: Hypertension Hyperlipidemia Arthritis- L knee, feet, R thumb, s/p L thumb operation Mitral valve stenosis. Had rheumatic heart disease as a child. GERD Seasonal allergies Social History: No tobacco, EtOH, illicits. She is married with one grown daughter. Currently works as a life insurance [Doctor Last Name 360]. Lives in [Location ]. Family History: Diabetes on maternal side of family, father died of black lung, mother died of bladder CA Physical Exam: ADMISSION EXAM: Vitals: T:99.1 BP:136/65 P:82 R: 18 O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, 2/6 SEM heard throughout the precordium, not radiating to the carotids, blunted S1/S2 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: aaox3, CNs [1-23] intact, 5/5 strength throughout DISCHARGE EXAM: VS - Temp 99.2F, BP 118/64, HR 80, R 18, O2-sat 99% RA GENERAL - well-appearing female, comfortable in bed, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, nl S1, soft S2, [2-14] harsh diastolic murmur best heard in left parasternal area ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DP, PTs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [4-15] throughout, sensation grossly intact throughout Pertinent Results: Admission labs: [2173-10-17] 09:00AM WBC-6.3 RBC-2.18# HGB-6.3# HCT-20.0# MCV-92 MCH-29.1 MCHC-31.6 RDW-17.4 [2173-10-17] 09:00AM NEUTS-54.0 LYMPHS-41.0 MONOS-4.0 EOS-0.8 BASOS-0.3 [2173-10-17] 09:00AM PLT COUNT-264 [2173-10-17] 09:00AM GLUCOSE-130* UREA N-23* CREAT-1.3* SODIUM-137 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13 [2173-10-17] 09:00AM CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-2.1 [2173-10-17] 12:05PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 [2173-10-17] 09:00AM BLOOD cTropnT-<0.01 [2173-10-17] 03:00PM BLOOD CK-MB-1 cTropnT-<0.01 [2173-10-18] 01:46AM BLOOD CK-MB-1 cTropnT-<0.01 [2173-10-19] 06:40AM BLOOD Hapto-185 [2173-10-17] 12:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG Hematocrit trend: [2173-10-17] 09:00AM BLOOD WBC-6.3 RBC-2.18# Hgb-6.3# Hct-20.0# MCV-92 MCH-29.1 MCHC-31.6 RDW-17.4 Plt Ct-264 [2173-10-18] 01:46AM BLOOD WBC-6.4 RBC-2.87# Hgb-8.4# Hct-25.9* MCV-91 MCH-29.3 MCHC-32.4 RDW-17.1* Plt Ct-275 [2173-10-18] 01:37PM BLOOD Hct-27.7* [2173-10-19] 06:40AM BLOOD WBC-7.4 RBC-2.70* Hgb-8.0* Hct-25.0* MCV-93 MCH-29.8 MCHC-32.2 RDW-17.1* Plt Ct-250 EGD [2173-10-18]: Normal mucosa in the whole esophagus Normal mucosa in the whole duodenum Erythema and petechiae in the fundus and stomach body compatible with vascular ectasias (biopsy) Otherwise normal EGD to third part of the duodenum Colonoscopy [2173-10-18]: External hemorrhoids Normal mucosa in the whole colon Otherwise normal colonoscopy to cecum Brief Hospital Course: 67 yo F with PMHx chronic anemia, admitted for symptomatic anemia with 10 pt crit drop from baseline, concerning for ongoing bleed. # GIB: Patient presented with symptomatic anemia with hct 10 below baseline. EGD [10-18] showed stomach vascular ectasia, likely source of ongoing slow GI blood loss. No active bleeding. No intervention at this time. [Last Name (un) ] [10-18] normal. Hct increased appropriately to 2u pRBC transfusion, patient symptoms improving. Continued home dose iron supplement. Started twice a day 40mg of omeprazole. GI recommended repeat EGD in 8 weeks, if vascular ectasia still present, consider APC therapy. Follow up biopsy results. # Heaviness: Diffuse, likely due to weakness in the setting of blood loss, however given some chest heaviness, was ruled out with 3 sets of cardiac enzymes and a repeat EKG. # OSA: continued CPAP # HLD: continued ezetimibe, niacin # HTN: held valsartan in setting of GIB # Rhinitis/allergies: continued flonase, olopatadine eye gtts, loratidine. # GERD: [Hospital1 ] omeprazole (see above) # Transitional issues: Consider repeat EGD in 8 weeks, if vascular ectasia still present, consider APC therapy. Follow up biopsy results. Medications on Admission: EXTROVEN - - 1 tablet daily evening EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth daily FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - 50 mcg Spray, Suspension - 1 spray at bedtime FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - one Tablet(s) by mouth daily NIACIN [NIASPAN EXTENDED-RELEASE] - (Prescribed by Other Provider) - 1,000 mg Tablet Extended Release - 1.5 Tablet(s) by mouth at bedtime OLOPATADINE [PATANOL] - (Prescribed by Other Provider) - 0.1 % Drops - 2 drops OS twice a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice daily POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 10 mEq Capsule, Extended Release - three Capsule(s) by mouth daily VALSARTAN [DIOVAN] - (Prescribed by Other Provider: [Name10 (NameIs) ] [Last Name (STitle) 118] - 160 mg Tablet - [12-13] Tablet(s) by mouth twice a day . Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth at bedtime for arthritis pain ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily CALCIUM CARBONATE-VIT D3-MIN [CALTRATE 600+D PLUS MINERALS] - (Prescribed by Other Provider) - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth twice a day CARBOXYMETHYLCELLULOSE SODIUM [REFRESH TEARS] - (Prescribed by Other Provider) - 0.5 % Drops - 1 drop in each eye as needed for dryness FERROUS GLUCONATE - 236 mg (27 mg iron) Tablet - one Tablet(s) by mouth each day with one tablet of vitamin C, 2 hours before or after other food or medications GLUCOSAMINE SULFATE - (OTC) - 1,000 mg Capsule - 1 Capsule(s) by mouth daily GUAIFENESIN [MUCINEX] - (Prescribed by Other Provider) - 600 mg Tablet Extended Release - one Tablet(s) by mouth at bedtime LORATADINE [CLARITIN] - (Prescribed by Other Provider; OTC) - Dosage uncertain MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Niaspan Extended-Release 1,000 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO qHS. 5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:0 6. potassium chloride 10 mEq Capsule, Extended Release Sig: Three (3) Capsule, Extended Release PO once a day. 7. valsartan 80 mg Tablet Sig: One (1) Tablet PO twice a day. 8. acetaminophen Oral 9. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Capsule Sig: One (1) Capsule PO once a day. 10. guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO QAM PRN () as needed for chest congestion. 11. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. ferrous gluconate 236 mg (27 mg iron) Tablet Sig: Two (2) Tablet PO once a day. 13. loratadine Oral 14. Patanol 0.1 % Drops Sig: Two (2) Ophthalmic twice a day: OS. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Vascular ectasia- stomach UGIB Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname 805], It was a pleasure taking care of you during your hospitalization. You were admitted because you felt weak. We found that your anemia was worse, and gave you 2 units of blood transfusions. You had EGD (a scope to look at your stomach) and colonoscopy. The colonoscopy was normal. The EGD showed a small vessel abnormality in your stomach, which likely caused your bleeding. You will need to follow up with the gastroenterologist and may need repeat EGD in [3-17] weeks. We made the following changes to your medications: INCREASED omeprazole to 40mg twice daily Followup Instructions: Department: [Hospital ] MEDICAL GROUP When: THURSDAY [2173-10-21] at 8:45 AM With: DR. [First Name8 (NamePattern2) 507] [Name (STitle) ] [Telephone/Fax (1) 133] Specialty: Internal Medicine Building: [Street Address(2) 3375] ([Location (un) ], MA) [Location (un) 858] Campus: OFF CAMPUS Best Parking: On Street Parking Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2173-10-27] at 2:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3014], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: RADIOLOGY When: MONDAY [2173-11-29] at 9:30 AM With: RADIOLOGY [Telephone/Fax (1) 1125] Building: [Street Address(2) 1126] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Department: GASTROENTEROLOGY When: TUESDAY [2173-12-14] at 12:45 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6970], MD [Telephone/Fax (1) 463] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2173-10-20] ICD9 Codes: 5849, 2851, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7837 }	Medical Text: Admission Date: [2165-6-22] Discharge Date: [2165-6-30] Date of Birth: [2119-8-21] Sex: F Service: Cardiology Medicine HISTORY OF PRESENT ILLNESS: This is a 45-year-old woman with a history of complete AV node block as a complication of mitral valve replacement, controlled by pacemaker, who developed CHF with dyspnea on exertion and fatigue in [2165-4-6]. Echocardiogram at that time demonstrated global hypokinesis of the left ventricle with an ejection fraction of 30%-40%. She was begun on beta-blocker for the CHF, but was unable to tolerate the drug secondary to bradycardia and increased dyspnea. She presented for placement of a dual- chamber pacemaker, as synchronized AV pacing will improve her tolerance of beta-blocker and CHF. PAST MEDICAL HISTORY: 1. Mitral valve prolapse. 2. Rheumatoid heart disease complicated by endocarditis. 3. Mitral valve replacement in [2155]. 4. VDI pacemaker placement in [2155]. 5. Asthma. PHYSICAL EXAMINATION: Vital signs: Temperature 98.3, blood pressure 105/58, heart rate 38, respiratory rate 18, oxygen saturation 98% on room air. General: Awake, alert, in no acute distress. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Tongue with serpiginous fissures. No JVD. Heart: Irregular S1 and S2. No S3-S4 murmurs or rubs. Lungs: Slight crackles of the bases bilaterally. Clears with deep breath and cough. Abdomen: Soft and nontender. Positive bowel sounds. Extremities: Warm. She had 2+ radial and dorsalis pedis pulses bilaterally. No edema. LABORATORY DATA: Echocardiogram on [2165-6-25]: Global right ventricular hypokinesis with elevated pressure gradient across mitral valve, elevated pulmonary artery systolic pressures. Transesophageal echocardiography on [2165-6-25]: Global right ventricular hypokinesis with large thrombus on mitral valve. HOSPITAL COURSE: 1. AV conduction block: The patient has a history of complete AV conduction block as a complication of mitral valve replacement in [2155]. This was controlled on admission with VVI pacemaker; however, given the patient's development of CHF over the two months prior to admission and her inability to tolerate beta-blocker, she was admitted for placement of a biventricular pacemaker for synchronized AV pacing. In preparation for her procedure, the patient's Coumadin was discontinued,and IV heparin was started to maintain anticoagulation therapy. She was maintained on IV heparin, weight-based protocol until her pacer revision was performed on [2165-6-24]. The pacer revision was successful with no complications. The patient was asymptomatic during this time. Following her pacemaker revision, the patient's Coumadin was restarted with a goal INR of greater than 3. IV heparin was continued until INR was greater than 3, at which time the heparin was discontinued, and the patient was continued on her current Coumadin dose. At the time of discharge, INR was greater than 3, and the patient was recommended to follow-up with her primary care physician for continued Coumadin monitoring. 1. CHF: The patient had developed CHF in the two months prior to admission with echocardiogram from [2165-4-6] showing global left ventricular hypokinesis with an ejection fraction of 30%-40%. On admission, she was without symptoms of dyspnea or orthopnea. Treatment was continued with her outpatient doses of Lasix and Lisinopril with good affect. 1. Mitral valve thrombus: During pacemaker interrogation on the morning of [2165-6-25], the patient became acutely dyspneic and was noted to be tachycardiac. Echocardiogram was performed showing elevated pressure gradients across her mitral valve and global right ventricular hypokinesis. Emergent TEE was performed demonstrating a large thrombus on the mitral valve. Cardiothoracic surgery was consulted, and felt that the patient was at high operative risk and would be better served by anticoagulation and thrombolysis. The patient was admitted to the CCU for treatment and observation and was treated thrombolytic therapy using alteplase. Following thrombolysis, repeat echocardiogram demonstrated disappearance of the mitral valve thrombus. The patient's symptoms resolved, and she was hemodynamically stable and was thus called out from the CCU to the medicine floor. Treatment was continued with IV heparin until Coumadin was therapeutic with an INR greater than 3 as above. At discharge, the patient has no dyspnea or signs of pulmonary edema. She is asymptomatic and is recommended to follow-up with her primary care physician and with her cardiologist in [12-7] weeks for further evaluation. At the time of discharge, it is evident that she will require repeat mitral valve replacement in the near future. DISCHARGE STATUS: Stable to go home with close follow-up. PRIMARY DISCHARGE DIAGNOSIS: 1. AV node block. 2. Mitral valve thrombus. 3. Congestive heart failure. DISCHARGE MEDICATIONS: 1. Sertraline 50 mg 2 tab p.o. daily. 2. Warfarin 2 mg 3 tab p.o. q.h.s. FOLLOW UP: 1. Follow-up with Dr. [Last Name (STitle) ] in [12-7] weeks. 2. Follow-up with Dr. [Last Name (STitle) 911] in [12-7] weeks. 3. Follow-up in cardiology device clinic in one month. [First Name11 (Name Pattern1) 919] [Last Name (NamePattern1) ], [MD Number(1) 10119] Dictated By:[Last Name (NamePattern1) 4547] MEDQUIST36 D: [2166-5-6] 12:50:52 T: [2166-5-6] 13:40:55 Job#: [Job Number 10120] ICD9 Codes: 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7838 }	Medical Text: Admission Date: [2195-1-24] Discharge Date: [2195-2-2] Date of Birth: [2127-4-5] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 896] Chief Complaint: Tachycardia/Rigors Major Surgical or Invasive Procedure: Endotrachial intubation Placement of midline IV IR drainage History of Present Illness: 67 year old male with past history of metastatic rectal cancer s/p pelvic exenteration, colostomy and urostomy, multiple enterocutaneous fistulas, clear cell renal cancer, atrial flutter, CKD, COPD who recently has been residing at [Location (un) 8220] [Hospital1 1501]. Recent UTI's, on ceftriaxone. Noted to be tachycardic with BP 88/60 and rigoring last night at [Hospital1 26276] transferred to [Hospital1 18] ED for evaluation. In the ED, patient was noted to be hypotensive to 105/42 with lactate of 6.5, acute on chronic renal failure and leukocytosis. He was resuscitated with 4L NS/LR with improvement in blood pressures, no pressors needed. Chest x-ray was concerning for pneumonia. CT A/P with contrast showed pelvic fluid collcetion with air and contrast from CT 2 days ago concerning for bowel leak - surgery consulted and do not feel suregery indicated given history of cancer and previous documentation of pelvic fluid collection. He was started on Vanc/Levo/Flagyl. Repeat lactate 1.1. On arrival to floor, vitals are BP 134/93 HR 136 RR 20 O2sat 97%RA. Patient is very nervous and anxious, otherwise no complaints. States that he has no pain, breathing comfortably, but is tired of being moved around from place to place. Notes from [Hospital1 1501] detail left eye drifting , full body tremors and tan drainage from penis this week. Urine culture pending. Also notations of having poor appetite and some nausea/vomiting 1 week prior. Patient states that he feels like he is standing up despite lying in bed. ROS: The patient denies any fevers, abdominal pain, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, lightheadedness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: - History of rectal cancer s/p pelvic exenteration, cystectomy, formation of ileal conduit and colostomy; in remission - Enterocutaneous fistula s/p enterectomy, enteroenterostomy in [3-/2188] with urostomy and colostomy placement. - Recent IR placed pigtail catheter for deep pelvic collections, removed [2194-12-1] and patient declining any more pigtail placements - Clear cell RCC s/p partial right nephrectomy [2-/2193] - Chronic renal failure (baseline Cr 1.4-1.6) - COPD - Atrial flutter s/p DCCV - Hypertension - Asthma - Depression - H/o C. diff colitis - Bicuspid AV with AS and AI Social History: Lives at [Location (un) 169] [Hospital1 1501] with no family support. Retired truck driver. Divorced with no children. 20 pack year smoking (now <10 cig/day). Denies illicit drugs, alcohol. Family History: Brother with renal cancer died in his 60s, brother with lung cancer died in his 60s. Family history of heart disease. Physical Exam: On Admission: Vitals: T: BP: 134/93 HR: 136 RR: 20 O2Sat: 97%RA GEN: Elderly, anxious, tremulous HEENT: Dry mucous membranes, sclera anicteric, no epistaxis or rhinorrhea, no dentition, OP appears clear, tongue dry. PERRL. NECK: No JVD, Left IJ in place, no bruits, no cervical lymphadenopathy, trachea midline COR: tachycardic, irregular, trace systolic murmur at aortic position. radial pulses +2 PULM: Lungs CTAB anteriorly, no wheeze or rhonchi appreciated ABD: Soft, NT, ND, +BS, urostomy with health pink tissue and clear yellow urine, ostomy bag with light brown liquid stool and healthy pink tissue at ostmy. EXT: No C/C/E, no palpable cords, distal pulses 2+. Pain to palpation over left forarm and elbow - movement limited by pain; no appreciable swelling, + echymosies. NEURO: alert, oriented to person, place, not time. Eye movements appear to be dancing with smooth pursuit and active motion intact except for lateral movement of left eye, which stops at midline. otherwise CN II-XII appear intact, no facial droop. Moves all 4 extremities. Plantar reflex downgoing. SKIN: No jaundice, cyanosis, or gross dermatitis. + ecchymoses. no petechiae. GU: uncircumcised male genitalia with no rash or appreciable discharge. Discharge: Alert and interactive Abdomen soft and non-tender; ostomy and urostomy draining well Pertinent Results: Discharge Labs: [2195-1-31] WBC-4.6 RBC-3.80* Hgb-10.4* Hct-32.2* MCV-85 MCH-27.3 MCHC-32.2 RDW-18.0* Plt Ct-182 Glucose-96 UreaN-12 Creat-1.3* Na-139 K-4.0 Cl-105 HCO3-27 AnGap-11 ABSCESS culture ([2195-1-25]) FINAL REPORT [2195-1-29] GRAM STAIN (Final [2195-1-25]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): BUDDING YEAST. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). CT ABD & PELVIS W/O CONTRAST ([2195-1-24]) 1. Approximately 8 x 6 cm pelvic fluid collection with gas and fecalized contrast, concerning for adjacent bowel leak. 2. Findings consistent with acute tubular necrosis/renal dysfunction with retained IV contrast from exam two days prior. 3. Dense filling defects in a prominent CBD with mild intrahepatic biliary dilatation, unchanged. The differential includes sludge or stones, but metastatic implantation cannot be excluded. 4. New left lung base atelectasis and consolidation which may reflect superimposed pneumonia. Brief Hospital Course: 1. Sepsis / Pelvic fluid collection. Secondary to chronic bowel leak. Admission lactate of 6.5 normalised following fluid resuscitation. Treated with broad spectrum antibiotics (IV vancomycin and meropenem) given a history of ESBL E. Coli in pelvic abscess and oral metronidazole; 2 week course is planned with final day [2195-2-6]. It was unclear regarding the patient's wishes as on discussion with his surgeon, Dr. [Last Name (STitle) ], he had previously mentioned that he did not want further surgery. As his rectal cancer was in remission and that IR drainage may provide bridge to surgery, this was pursued. He had a drain placed into his pelvic collection on [1-25]. There were no complications and drained feculent material which was cultured and grew mixed flora. On [1-28] post extubation, his pelvic drainage decreased. CT abdomen showed that the left posterior drainage pigtail catheter was withdrawn such that the tip was in the posterior gluteus/subcutaneous tissues. After discussion with IR, his catheter was cut and removed. It was difficult to insert and they felt that given the complexity of the case that surgical treatment should first be sought. Latterly, surgery felt no further surgical intervention was necessary at this time although this may be revisited in the future. 2. Encephalopathy. On [1-24], patient became progressively confused and was severely agitated requiring restraints, speech became unintelligible and he had severe whole body tremors with evidence of mild tetany. He also had abnormal eye movements which where darting from randomly without evidence of nystagmus or restriction in eye movement. On reviewing his severe metabolic derangements, he was found to have severe hypomagnesemia (0.3) and hypocalcemia (4.8) which were the likely cause of confusion (metabolic encephalopathy), tremors and eye signs. These were repleted with IV magnesium and calcium aggressively and normalised. For periodic agitation, haloperidol was used. 3. Aflutter/AF: On presentation he was noted to be tachycardic in Aflutter with variable block but given concomitant agitation and severe metabolic derangement he was initially treated with IV metoprolol and was fluid resuscitated. Due to borderline BPs and after intubation on [1-24] he was supported with IV pressors. Given persistent tachycardia to 140s, his norepinephrine was changed to phenylephrine and was treated with IV diltiazem and latterly a diltiazem infusion. Post-extubation on [1-28], his heart rate was still problem[Name (NI) 115] and he was converted from a diltiazem IV infusion to oral diltiazem and metoprolol. 4. Metabolic acidosis: The patient presented with a combined elevated anion gap metabolic acidosis and a non AG metabolic acidosis and of note, he had his metabolic acidosis on previous admissions. His hyperchloremic acidosis was considered likely from ostomy and NaCl resuscitation. Acidosis was felt likely multifactorial in the setting of renal failure, increasing urostomy output and sepsis secondary to his chronic pelvic collection. He was treated with oral bicarbonate and his acid-base status corrected. 5. Acute on Chronic Renal Failure: Baseline of chronic renal failure with a creatinine 1.4-1.6. On admission this was elevated to 4.2 in ED. FeNa: 1.7% was suggestive of ATN and he was aggressively fluid resuscitated. Creatinine improved and was 1.3 in discharge. 6. Respiratory failure: On presentation, there was the possibility of LLL pneumonia on portable CXR [1-24] based on radiology read with possible atelectasis vs consolidation in retrocardiac region. 7. Left arm pain: Left upper extremity was negative for fracture, dislocation or osteolytic lesions on XR and UENI negative for DVT. This was monitored and managed symptomatically with acetaminophen prn for pain and his pain improved. 8. Goals of care. Per review patient is in remission from dual malignancies (colon cancer + clear cell carcinoma). On discussing with his nursing home, he was indeed listed as his own emergency contact and had no next of [Doctor First Name ] or friends per patient. Per surgery, IR guided drainage of pelvic collection may provide a bridge to operative management and this occurred but when his drain fell out and was latterly removed, it was felt that no further intervention was needed at this time. There were however concerns regarding Mr [Name13 (STitle) 21862] capacity and his wishes were unclear. [Name2 (NI) ] was maintained as full code and will need a court-appointed guardian to serve as HCP as his choice of his RN could not be his HCP due to policy. SW talked to legal, they are looking for anything short of guardianship which will likely be the only option. Patient has been discussed at a previous admission but it is unclear why this was not pursued. Medications on Admission: Ceftriaxone 1g IM qday (Start [1-21]) Tylenol 650 mg PO prn Albuterol nebs prn Aspirin 81 mg PO qday Calcium 500/Vitamin D 125 units 1 tablet PO TID Calcium Carbonate 500 mg tablet PO BID Diltiazem XR 360 mg PO qday Ipratropium nebs prn q6h Metoprolol XL 200 mg PO daily Multivitamin 1 daily Omeprazole 20 mg [Hospital1 ] Potassium Chloride 10 mEq daily Simvastatin 20 mg daily Vicodin 1 tab q6h prn pain Zofran 4mg SL q6h prn nausea Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 2. 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. 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO three times a day. 5. diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath. 7. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. haloperidol 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 13. Meropenem 500 mg IV Q6H Day 1 = [1-24] 14. Vancomycin 1000 mg IV Q 24H Day 1 = [1-24] Discharge Disposition: Extended Care Facility: [Hospital ] LivingCenter - [Hospital1 8218] - [Location (un) ] Discharge Diagnosis: 1. Abdominal/Pelvic abscess with sepsis 2. Atrial flutter 3. Encephalopathy 4. Dysphagia 5. Acute renal failure 6. Rectal cancer 7. Renal cell cancer 8. Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear. Mr. [Known lastname ], You were admitted to [Hospital1 18] with an infection in your pelvis. This was treated with drainage and will require additional IV antibiotics. You will also need follow-up with providers (see below). Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2195-2-4] at 3:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2195-2-4] at 3:30 PM With: [First Name4 (NamePattern1) 2053] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2195-6-29] at 11:00 AM With: [Doctor First Name 900] [Name8 (MD) 901], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 0389, 5845, 5849, 2762, 2930, 5990, 2851, 5859, 311, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7839 }	Medical Text: Admission Date: [2161-11-16] Discharge Date: [2161-11-28] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 759] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: trans-esophageal echo and dccv [2161-11-25] - no complications History of Present Illness: 86 yo woman with multiple medical conditions here with 3-4 days of weakness and acute onset of short of breath. Otherwise, no chest pain, palpitation, lightheadedness or dizziness. No orthopnea or PND. No nausea, vomiting, diarrhea or abdominal pain. No [Month/Day/Year 5162], chills, cough or other URI symptoms. No dysuria or frequency. No change in appetite or bowel habit. ED: Afib with rapid ventricular rate up to 130s, EKG with lateral ST depressions, CXR with multifocal infiitrates and blood tests revealed hyperglycemia and elevated Cr. Past Medical History: PMHx: 1. Heart block, junctional rhythm - pacemaker placed 2. CHF - EF 30% 3. PVD - followed by Dr. [First Name (STitle) ] 4. Significant bilateral carotid disease 99% 5. Hx of PE in [2144] 6. DM 7. MR [First Name (Titles) ] [Last Name (Titles) ] 8. Iron deficiency anemia 9. Osteoporosis 10. Eczema 11. Basal cell CA Social History: widowed, no children, lives alone, smoked 2 packs per day, quit in 89, no drinking or drug use. Family History: non-contributory Physical Exam: PE: 99.5, 110, 100/61, 24, 100%6L (88%RA) Gen: cachectic elderly woman, NAD HEENT: anicteric, OP clear, dry MMM CV: IRIR, tachy Lungs: diffuse coarse breath sounds Abd: soft, NT Ext: no edema Skin: diffuse rashes, dry skin Neuro: nonfocal Pertinent Results: Labs on Admission: CK: 242 MB: 8 Trop-T: 0.09 Vit-B12:347 Folate:18.4 Other Blood Chemistry: Iron: 19 calTIBC: 211 Ferritn: 334 TRF: 162 135 102 61 ------------< 468 4.8 24 1.3 Mg: 2.1 MCV=96 WBC=7.9 HgB=9.5 Plt=140 Hct=27.7 PT: 14.0 PTT: 28.8 INR: 1.2 Other Urine Chemistry: UreaN:575 Creat:66 Na:17 UA: negative CT Chest: 1) Confluent areas of consolidation right upper lobe and patchy nodular areas of consolidation in the right lower lobe most consistent with multifocal pneumonia. 2) Likely element of superimposed pulmonary edema. 3) Left greater than right small pleural effusions. Brief Hospital Course: 86F PMH of CAD, CHF--EF 30% with severe MR, Dermatomyositis, DM, presented on [11-16] c/o generalized weakness for 1 week, with acute onset of SOB on the evening of [11-15], both at rest and with exertion. Pt also noted to have had loose stools for the past week, but no other symptoms. 1. PNA: On admission CXR, pt was noted to have a multifocal pneumonia and was started on azithromycin and ceftriaxone. She was also noted on admission to have ARF and hyperglycemia. She was placed on O2NC and given steroids and albuterol/ipratropium nebs. She remained afebrile, and appeared to have a stable leukocytosis. Influenza was considered, but no washing was obtained at the lab; the patient was placed on droplet precautions. On the floor, the patient continued to develop SOB, and required ICU transfer. Respiratory decompensation at that time thought secondary to super-imposed pulmonary edeam. In the ICU, she continued on ceftriaxone/azithromycin for community-acquired PNA. CT chest showed interstitial lung disease with persistent RUL PNA. She clinically improved and was transferred to the floor where antibiotic treatment was continued (D1=[11-17]). She is currently scheduled to complete her antibiotics on [12-1] and has picc line in place for this. As mentioned above, sputum was not obtained. It is unclear as to the etiology of this multi-focal PNA. Given h/o dermatomyositis, there were concerns of underlying lung dz. However, no formal PFTs were ever documented prior to this PNA. Her oxygen requirements have decreased through-out her stay but she was advised to f/u Pulmonary for an outpt managemnt. She has been asked to call radiology to for repeat CXR in 4 weeks time to re-assess interval progression. Her oxygen requirement has improved, but she still remains on 2-4L NC. This should be weaned as tolerated to keep sats 93%-95%. 2. Afib: On admission, pt found to be in rapid Afib, which apparently had occurred 1 time before. She was started on a heparin drip for anticoagulation, lopressor PO for rate control, and was scheduled for an Echo which was not performed prior to transfer. While on the floor, HR were 90s - 110s, with BP 115/58. It is thought that her transfer to the ICU was the result of CHF in the setting of rapid afib. In the ICU, she was eventually rate controlled w/ beta blockade and dig. Following transfer back to the floor, she underwent TEE (no thrombus) followed by DCCV on [2161-11-26]. She will continue on digoxin and beta blockade and her goal inr will be 2.0-3.0. At the time of dishcarge, she remains in sinus rhythm. She should have f/u w/ dr. [Last Name (STitle) ] as outlined in discharge instructiions and also w/ device clinic for interoggation of pacer. 3. ARF: On admission, BUN/Cr was 63/1.7, up from baseline Cr of 1.1-1.3. The FENa was 0.3% indicating likely prerenal. She was given gentle hydration and her ACEI (lisinopril) was initially held (restarted after renal failure resolved). While on the floor, her Cr decreased to baseline. As mentioned above, she was felt to be in failure necessitating transfer to the icu. She has tolerated aggressive diuresis w/o bumps in creatinine. 4. CHF: On admission, the patient had no evidence of CHF. ACEI and norvasc were held due to decreased BP (90/60). As noted from her PMH, she has a history of EF 30% with severe MR [First Name (Titles) ] [Last Name (Titles) 1192] AR. Trop were mildly elevated and stable at 0.1-0.09, with negative MBs, and felt to be [12-23] ARF. She was continued on ASA, lipitor, but plavix was held. She was started on heparin drip, and ACEI and imdur were gradually added back. Repeat Echo showed severe MR, [Month/Day (2) 1192] AR, and worsened EF compared with an Echo from [12-25]. As mentioned above and below, pt had episode of acute resp decompensation necessitating transfer to MICU early in hospital course. At this point, CXR c/w worsening pulmonary edema. At the time, she was also in rapid afib. In the ICU, she did not require invasive resp support and was aggressively diuresed w/ iv lasix 40 iv bid. She was negative 6 liters total upon transfer from the ICU. Gentle diuresis was continued on the floor. Rate control will be crucial for her and she will continue on Toprol 150 qd and remains on Lisinopril 40 qd. The morning following her dccv, she had a brief acute hypoxic resp decompensation. She was quickly stabilized. It was felt that this may have been secondary to transient worsening CHF in the setting of recent cardioversion. Pt stabilized w/ continued diuresis and she will be discharged on oral lasix 80 mg qd. 5. Mental status: The patient had one episode of sun-downing during her ICU stay, it resolved in the morning. 6. DM: Initially placed on Insulin GTT, then changed to Insulin SS with NPH. Her NPH was increased during her admission for hyperglycemia. Current regimen is NPH 25 units qam and NPH 6 units qpm. 7. CAD: continued ASA, toprol, lipitor, ACEI. The initial troponin leak was thought to be in the setting of CHF flare with some renal failure. Pt has refused catheterization in the past. 8. Carotid artery disease: continued ASA 9. Anemia: Pt was initially transfused 1 U PRBC which ?precipitated CHF flare. Hematocrit was kept >28 during hospitalization. *10. Code: Should be addressed w/ PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ]. Still remains vague. At this point, pt does not wish for heroic measures to prolong her life. However, she was not against intubation. Based upon discussions w/ PCP and pt, pt is DNR but ok for intubation. Obviously, prolonged course on vent would need to be discussed further. Medications on Admission: Insulin 70/30 31 UQAM, [3-26] U QPM Amlodipine 5 mg Miacalon NS QD Doxepin 25 mg qhs ASA 81 Flonase 2 sprays QD Lasix 80 mg Imdur 60 mg Lipitor 20 mg Lisinopril 40 mg Plavix 75 mg Toprol XL 100 mg ALL: NKDA Discharge Medications: 1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) spray Nasal DAILY (Daily). 2. Doxepin HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: Two (2) Spray Nasal QD (). 4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed. 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) [Hospital1 ] PO BID (2 times a day). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 15. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 17. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1) infusion Intravenous Q24H (every 24 hours) for 3 days: thru [2161-12-1]. 18. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours). 19. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 20. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID (3 times a day). 21. Outpatient Lab Work please check INR on [2161-11-30] - goal inr is 2.0-3.0 22. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: see below units Subcutaneous twice a day: NPH 25 units SC qam and 6 units of NPH SC qpm. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Presumed multi-focal PNA improving CHF exacerbation, resolving New onset atrial fibrillation s/p successfull DCCV Acute renal failure resolved Anemia Discharge Condition: stable Discharge Instructions: please return to ed or [Name8 (MD) 138] md [First Name (Titles) ] [Last Name (Titles) 5162], chills, shortness of breath, coughing, chest pain, decreased mentation. please do not drink more than 2 liters of fluid per day. please [Name8 (MD) 138] md if weight gain is greater than 3 lbs please take medications as directed. Followup Instructions: please call pulmonary clinic at [Telephone/Fax (1) 612] for appt in 1 months time after cxr repeated. please call radiology at [Telephone/Fax (1) 327] to schedule repeat CXR (pa and lateral) in 3 weeks time. Provider: [Name10 (NameIs) 676] CLINIC Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 59] Date/Time:[2161-12-28] 1:00 Provider: [First Name11 (Name Pattern1) 610] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 285] Date/Time:[2161-12-28] 1:30 Provider: [First Name11 (Name Pattern1) 674] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], M.D. Where: [Hospital6 29] [Hospital ] Phone:[Telephone/Fax (1) 250] Date/Time:[2162-1-5] 10:20 Completed by:[2161-11-28**] ICD9 Codes: 486, 4280, 5849, 2765, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7840 }	Medical Text: Admission Date: [2182-9-10] Discharge Date: [2182-9-21] Date of Birth: [2110-8-18] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 87302] Chief Complaint: febrile neutropenia Major Surgical or Invasive Procedure: Mediastinoscopy [2182-9-13] Bone marrow biopsy [2182-9-13] PICC placement times 2 PICC line removal time 2 Port placement [2182-9-20] History of Present Illness: 72-year-old male with likely lymphoma admitted to ICU with febrile neutropenia. He had been to his doctor's office today for lower extremity edema and a decubitus ulcer on his coccyx. He was found to be hypotensive and was transferred to the Emergency Department. He was given a 500cc bolus of crystalloid by EMS. In the ER vitals were initially 100.6, 112, 112/62, 22, 99% 2 L. In the ER the patient was given Vancomycin and Cefepime. A CT was done which showed no PE, extensive mediastinal LAD, and 4 mm left upper lobe pulmonary nodule. Labs were notable for WBC of 0.9 with 72% PMNs, HCT of 23.8 and PLT of 58. Calcium 7.7, troponin <0.01, lactate 2.3. On arrival to the MICU, patient's VS 98.8, 100, 109/62, 27, 98% RA. On review of systems the patient endorses a non-productive cough,60 lb weight loss over past year, night sweats, rhinorrhea with blood, constipation (ongoing) without blood. Past Medical History: Rotator cuff repair 12 years ago Lymphadenopathy since [Month (only) 958] sciatica B12 deficiency Social History: Lives with partner [Name (NI) ]. Worked for self as a collectibles dealer. Drinks 1 glass wine/month, no smoking, no IVDU. Family History: Denies any family history of cancer Physical Exam: Admission: Vitals: 98.8, 100, 109/62, 27, 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, splenomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+ edema Skin: stage I decubitus ulcer on coccyx Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, resting tremor. Discharge: Vitals: T 97.7 BP 100-140/58-73 HR 71 RR 18 O2 Sat 98% on RA BM times 1 UOP 4.[0-0-] General: Patient sitting at edge of bed in NAD HEENT: Pupils equal and round. MMM. Neck: Base of the neck with bandage at the site of mediastinoscopy C/D/I Cardiac: RRR. No M/R/G. Chest: Right chest with accessed port with bandage superiorly that is c/d/i. No erythema. no TTP. Lungs: Equal breath sounds bilaterally though deminished at the bases bilaterally. Nml work of breathing. No crackles or wheezes. Abd: Soft. NT/ND. BS+. Ext: 1+ pitting edema of the LE bilaterally extending midway of the shins bilaterally. Non-pitting swelling of RUE compared to left that is improved at the level of the wrist. Pertinent Results: Admission [2182-9-10] 02:10PM WBC-0.9* RBC-2.58* HGB-7.9* HCT-23.8* MCV-92 MCH-30.7 MCHC-33.2 RDW-19.8* [2182-9-10] 02:10PM NEUTS-72* BANDS-2 LYMPHS-19 MONOS-2 EOS-1 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 PROMYELO-2* [2182-9-10] 02:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TARGET-OCCASIONAL [2182-9-10] 02:10PM PLT SMR-VERY LOW PLT COUNT-58* [2182-9-10] 02:02PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2182-9-10] 02:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2182-9-10] 02:02PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE EPI-<1 [2182-9-10] 02:02PM URINE MUCOUS-MOD [2182-9-10] 12:37PM LACTATE-2.3* [2182-9-10] 12:30PM GLUCOSE-121* UREA N-23* CREAT-1.0 SODIUM-130* POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-21* ANION GAP-13 [2182-9-10] 12:30PM estGFR-Using this [2182-9-10] 12:30PM ALT(SGPT)-13 AST(SGOT)-59* LD(LDH)-468* ALK PHOS-91 TOT BILI-0.7 [2182-9-10] 12:30PM cTropnT-<0.01 [2182-9-10] 12:30PM proBNP-415* [2182-9-10] 12:30PM ALBUMIN-2.8* CALCIUM-7.7* PHOSPHATE-3.4 MAGNESIUM-1.8 URIC ACID-6.1 Imaging: CHEST (PA & LAT) Study Date of [2182-9-10] IMPRESSION: No definite acute cardiopulmonary process. Blunting of the left posterior costophrenic angle, potentially due to atelectasis or Bochdalek hernia, noting at underlying consolidation cannot be completely excluded. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [2182-9-10] 1. No evidence of pulmonary embolism or acute aortic syndrome. 2. Extensive mediastinal lymphadenopathy and splenomegaly concerning for lymphoma. 3. 4-mm left upper lobe pulmonary nodule. This does not need to be followed in a low-risk patient. In a high-risk patient, one-year followup may be obtained. Lower Extremity Doppler [2182-9-11] No evidence of deep venous thrombosis within the bilateral lower extremities. Echo [2182-9-12] The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality due to body habitus. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not well seen. No significant valvular abnormality. Normal estimated pulmonary artery systolic pressure. Mediastinal lymph node biopsy [2182-9-13] Lymph node, mediastinal (A-B): Classical Hodgkin lymphoma, see note. Note: The nodal tissue is effaced with a dense infiltrate comprised predominantly of small lymphocytes with condensed nuclear chromatin. Frequent large atypical cells containing one to two nuclei with vesicular chromatin, large eosinophilic nucleolus, and moderate amount of cytoplasm consistent with Hodgkin cells and [Doctor Last Name ]-Sternberg cells, are present. Scattered apoptotic "mummified" cells are noted. By immunohistochemistry, the large neoplastic cells are positive for CD30, subset dimly positive for CD15, dim positive for PAX-5, and co-express CD20, consistent with Hodgkin cells and its variants. The background reactive lymphoid infiltrate consists predominantly of small T-cells which are CD3 positive and TdT negative, along with scattered CD20 and PAX-5 positive B-cells. CD23 highlights residual disrupted follicular dendritic framework but does not stain the large neoplastic cells. BCL-2 highlights the majority of the background small reactive lymphocytes. Reticulin stain highlights fibrous tissue, separating the lymphoid tissue into vague nodules. Pericellular fibrosis is not seen. Overall, the features are consistent with classical Hodgkin lymphoma. Immunophenotyping [2182-9-13] INTERPRETATION Immunophenotypic findings show a B cell population. However, preliminary tissue biopsy reveals features suggestive of Hodgkin lymphoma (see separate report). Correlation with clinical and morphological findings is recommended. Bone marrow biopsy [2182-9-14] SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: Fibrotic bone marrow with involvement by Hodgkin lymphoma, see note. Note: By immunohistochemistry, the large atypical cells stain positively with CD30, CD15 (dim), and CD20, and are negative for CD43. The staining pattern supports the above diagnosis. RUE Doppler [2182-9-15] IMPRESSION: Partially occlusive thrombus along the right PICC throughout the entirety of the right basilic vein, extending into the right axillary and likely right subclavian veins. CXR [2182-9-16] The left PICC line lies in the mid SVC. The right PICC line has been removed. No other changes are seen. Discharge labs: [2182-9-21] 04:48AM BLOOD WBC-1.2* RBC-2.61* Hgb-8.0* Hct-23.6* MCV-91 MCH-30.7 MCHC-33.9 RDW-19.3* Plt Ct-38* [2182-9-21] 04:48AM BLOOD Neuts-65.8 Lymphs-29.3 Monos-0.9* Eos-3.8 Baso-0.1 [2182-9-21] 04:48AM BLOOD Glucose-101* UreaN-11 Creat-0.6 Na-139 K-3.8 Cl-106 HCO3-29 AnGap-8 [2182-9-21] 04:48AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.9 Brief Hospital Course: 72-year-old male with likely lymphoma admitted to ICU with febrile neutropenia # Hypotension: Patient was hypotensive in ED and at PCP office with SBP in 80's. Blood pressure improved with 500 cc IVF given by EMS. He did not require pressors. Differential diagnosis includes sepsis vs hypovolemia. Patient appeared volume depleted on exam and endorsed decreased PO intake. Baseline BP 115-125. Patient was fluid resuscitated and blood pressure improved. # Febrile Neutropenia: Patient presented with fever in setting of neutropenia (ANC 648). Etiology unclear, but possibly due decubitus ulcer on coccyx. Patient endorsed no respiratory symptoms and chest x-[Month/Day/Year ] showed no acute processes. He also had no urinary symptoms and normal U/A. Patient was treated with vancomycin and cefepime. Blood cultures were negative. Fever curve improved and antibiotics were discontinued [9-14] after a 5 day course. # Lymphadenopathy- Patient has lymphadenopathy concerning for underlying lymphoma. He had an inguinal biopsy the week prior to which showed benign lymph node with fatty replacement. CT showing extensive mediastinal lymphadenopathy and splenomegaly. The patient was seen by Atrius hematology/oncology. Thoracic surgery was consulted for mediastinal biopsy, which was performed [2182-9-13]. Biopsy consistent with Hodgkin lymphoma, as was bone marrow biopsy done [9-14]. Patient started cycle 1 of ABVD on [2182-9-16]. # DVT: Right PICC placed [2182-9-13]. Patient subsequently developed right upper extremity swelling. An ultrasound showed a partially occlusive thrombus along the right PICC throughout the entirety of the right basilic vein, extending into the right axillary and likely right subclavian veins. Right PICC was removed and patient was started on Lovenox. Due to concern for future issues with PICC, port placement was done [2182-9-20] and left PICC was also removed. Previously in hospitalization, there was concern about lower extremity DVT due asymmetric edema, but LENIs were negative. # Pancytopenia: WBC 0.9, HCT 23.8 and PLT 58 on presentation secondary to underlying hematological malignancy. Patient received a total of 5 units of PRBCs over the course of his hospitalization ([9-10], [9-11] in anticipation of planned biopsy, [9-16], [9-19] in anticipation of port placement, [9-21]). He also received 3 bags of platelets (1 prior to biopsy [9-12], 2 with port placement). #. Tremor: Per patient, has been present for the past 1 year. Seems to have some Parkinsonian features, workup not done during this hospitalization. Medications on Admission: Cyanocobalamin, Vitamin B-12, (VITAMIN B-12) 1,000 mcg/mL Injection Solution Inject 1000mcg IM Codeine-Guaifenesin (CHERATUSSIN AC) 10-100 mg/5 mL Oral Liquid TAKE 10ML BY MOUTH EVERY SIX HOURS AS NEEDED FOR COUGH Discharge Medications: 1. Enoxaparin Sodium 150 mg SC DAILY RX enoxaparin 150 mg/mL 1 injection via synringe daily Disp #30 Syringe Refills:0 2. Docusate Sodium (Liquid) 100 mg PO BID 3. Ex-Lax Maximum Strength NF* (sennosides) 25 mg Oral [Hospital1 ]:PRN constipation * Patient Taking Own Meds * 4. Ondansetron 8 mg PO Q8H:PRN nausea RX ondansetron 4 mg [1-28] tablet(s) by mouth every 8 hours Disp #100 Tablet Refills:0 5. Allopurinol 200 mg PO DAILY RX allopurinol 100 mg 2 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Acetaminophen [Telephone/Fax (1) 1999] mg PO Q6H:PRN pain, fever page house officer for fever not >4 g/day 7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q8H:PRN pain do NOT take this medication with alcohol. do NOT operate a car or heavy machinary. RX oxycodone 5 mg 0.5-1 tablet(s) by mouth every 8 hours Disp #40 Tablet Refills:0 Discharge Disposition: Home With Service Facility: All Care VNA Discharge Diagnosis: Hodgkin lymphoma Right upper extremity deep venous thrombosis Tremor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you during your hospitalization at [Hospital1 69]. You were hospitalized with fever and found to have a low number of infection fighting cells. The cause of your fever was never found. You underwent a lymph node biopsy by the thoracic surgeons, and the biopsy results showed a new diagnosis of Hodgkin's Lymphoma. You were started on chemotherapy for treatment of Hodgkin's Lymphoma, which you will continue as an outpatient. You developed a blood clot in your right upper extremity secondary to a PICC line. The PICC line was discontinued, and you were started on a medication called Lovenox to thin your blood. You will need to have 1 injection administered daily for the next 3 months. Go pick up your prescription from the pharmacy at [Location (un) 1456] [University/College ] [University/College 38299] on the day of your discharge so that the visiting nurse [First Name (Titles) ] [Last Name (Titles) 5050] your daily injection starting [2182-9-22]. Take all other medications as prescribed. A list of your medications is provided for you in your discharge paperwork. We wish you the best going forward. Followup Instructions: Oncology follow-up: [Last Name (LF) 766], [2182-9-23] at 2 PM with Dr. [First Name4 (NamePattern1) 12967] [Last Name (NamePattern1) ] at the [University/College ] [First Name9 (NamePattern2) 38299] [Location (un) ] Office. It is very important that you keep this appointment. Thoracic surgery follow-up: You will need to call the Thoracic surgery office of Dr. [Last Name (STitle) 1007] to set up appointment in 1 week from discharge. The telephone number to his office is ([Telephone/Fax (1) 111924]. Primary care follow-up: You will need to establish primary care at the [University/College ] [University/College 38299] Office in [Location (un) 1456], MA to continue to be followed by a regular doctor in light of your new diagnosis. Completed by:[2182-9-24*] ICD9 Codes: 4589, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7841 }	Medical Text: Admission Date: [2116-12-1] Discharge Date: [2116-12-6] Date of Birth: [2041-11-25] Sex: F Service: MEDICINE Allergies: Codeine / Fosamax / Nsaids / Lisinopril / Astelin / Hydrochlorothiazide / ipratropium Attending:[First Name3 (LF) 2009] Chief Complaint: abdominal pain, constipation Major Surgical or Invasive Procedure: None History of Present Illness: HMED ADMISSION NOTE ADMIT DATE: [2116-12-1] ADMIT TIME: 0400 . 74 yo female with severe end-stage COPD on home oxygen, dCHF, on treatment for MAC with recent admission for COPD exacerbation presents to the ED with abdominal pain and constipation. . Patient reports [10-3] lower quadrant abdominal pain x 1 day. Also with severe nausea and one episode of vomiting (non-bloody). Last BM was [2116-11-16]. Patient has been taking miralax, senna and colace daily. Started lactulose yesterday and glycerin suppository without any effect. Poor po intake with increasing fatigue. Daughter called patient's palliative care doctor (for end-stage COPD) who recommended coming to the ED for further evaluation. . Patient was recently hospitalized [2116-11-17] - [2116-11-20] with dyspnea from end-stage COPD. Palliative care involved, per note patient realized she is end-stage however does not wish to be dnr/dni at this time. Although daughter elaborates that patient would not want aggressive measures however feels that if she is dnr/dni she doesn't receive adequate medical treatment in the hospital. . Upon arrival on the floor patient reports she feels slight better but continues to have significant abdominal pain. NGT is on intermittent wall suction and is preventing episodes of vomiting. Denies any cp, lightheadedness or dizziness. SOB unchanged from baseline. No recent fever or chills. . Patient had a fall on Friday ([2116-11-27]), tripped over a fan and has a bruise on left ankle and left arm. . ED: 97.6 96P 150/70 20 94%3L NC; 2L NS, morphine 4mg iv x 2, zofran 2mg, dilaudid 1mg iv x 2; CXR stable, KUB dilation of bowels, NGT placed, CT a/p with contrast no SBO with extensive fecal loading . ROS: as per HPI, 10 pt ROS otherwise negative Past Medical History: COPD on home O2 3LNC, chronic steroids (PFT [10-4] - FEV1 1.08 (59%), FEV/FVC 48 (70%) MAC infection initiated on ethambutol, azithromax, levaquin on [2116-10-23] acquired hypogammaglobulinemia on IVIG / decreased T-cell subset = idiopathic immune dysfx Hypertension Diastolic CHF EF 65% with moderal mitral regurgitation Pulm Nodules (benign per work up at [Hospital3 14659]) GERD Hyperlipidemia Hypothyrodism Osteoporosis with compression fractures (T7/T9/T11) Osteoarthritis Chronic Back pain s/p Appendectomy s/p partial thyroidectomy for benign thyroid nodule Social History: Lives with her husband; 2 daughters help [Name2 (NI) ]. Retired banker. Past tobacco with 90 pack year history, no etoh or illicits. Family History: mother with stroke and htn sister renal cell carcinoma sister bladder cancer x 2 Physical Exam: VS: 96.4 108/63 110P 22 93%3LNC Appearance: tired appearing, NGT in place Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mm very dry, cracked lips, no JVD, neck supple Cv: +s1, s2 -m/r/g, L>R 1+ edema, 2+ dp/pt bilaterally Pulm: diminished throughout, poor air movement, diffuse wheeze Abd: soft, very distended, tympanic, diffuse mild ttp, hypoactive bs Msk: L ankle with hematoma and swelling, left upper arm with ecchymoses Neuro: cn 2-12 grossly intact, no focal deficits Skin: no rashes Psych: appropriate, pleasant Heme: no cervical [Doctor First Name ] Pertinent Results: [2116-11-30] 10:35PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-8* PH-6.0 LEUK-TR [2116-11-30] 10:35PM URINE RBC-2 WBC-4 BACTERIA-FEW YEAST-NONE EPI-0 [2116-11-30] 07:00PM GLUCOSE-134* UREA N-18 CREAT-1.4* SODIUM-127* POTASSIUM-3.5 CHLORIDE-88* TOTAL CO2-24 ANION GAP-19 [2116-11-30] 07:00PM ALT(SGPT)-23 AST(SGOT)-26 ALK PHOS-66 TOT BILI-0.9 [2116-11-30] 07:00PM LIPASE-21 [2116-11-30] 07:00PM CALCIUM-9.8 PHOSPHATE-4.4 MAGNESIUM-2.6 [2116-11-30] 07:00PM WBC-24.2# RBC-4.47 HGB-14.0 HCT-39.9 MCV-89 MCH-31.3 MCHC-35.0 RDW-13.5 [2116-11-30] 07:00PM NEUTS-93 BANDS-1 LYMPHS-1* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2116-11-30] 07:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL [2116-11-30] 07:00PM PLT SMR-NORMAL PLT COUNT-248 . [2116-11-30] CT a/p without contrast: Extensive fecal loading without evidence of obstruction. Small quantity of free fluid in the left paracolic gutter is a non-specific finding. Small 7-mm left renal hyperdensity should be further characterized with repeat renal ultrasound or MR on a non-emergent basis. . [2116-11-30] CXR: No significant interval change. Stable bibasilar opacities most likely relate to atelectasis. Pulmonary emphysema. . [2116-11-30] Humerus xray: No evidence of acute fracture. . [2116-11-30] L. ankle xray: Soft tissue swelling about the lateral malleolus without acute fracture seen. No dislocation. . [12-2] Renal ultrasound 1. Numerous cysts within bilateral kidneys. The hyperdense lesion on CT corresponds to a simple-appearing cyst on ultrasound 2. No hydronephrosis. . Last Chest xray: [2116-10-3] The interpretation of this study is limited due to rotation of the patient, the lateral aspect of the left hemithorax was not included on this radiograph. Left lower lobe atelectasis has probably increased. Right lower lobe atelectasis is unchanged. Cardiomediastinal contours cannot be evaluated. Brief Hospital Course: 74 yo female with severe end-stage COPD on home oxygen, dCHF, on treatment for MAC with recent admission for COPD exacerbation admitted with abdominal pain and severe constipation. She was initially treated for severe constipation, and seen by GI and palliative care. Despite aggressive bowel regimen, she continued to have severe obstipation. Gastrograffin enema was performed on the day of ICU transfer. This also did not relieve constipation. On the day of transfer to the ICU, she developed respiratory distress after a renal ultrasound. . ICU course: Pt developed acute respiratory distress shortly after renal ultrasound while in the waiting room. Unclear cause, though some iniciting factor that precitpated a COPD exacerbation. She was transferred to the [Hospital Unit Name 153] for evaluation. She was started on BiPAP and expressly stated she did not want to be intubated. She was empircally started on broad spectrum antibiotics for PNA and IV heparin for possible (though unlikely PE). After family meeting to discuss goals of care, it was decided with inclusion of the patient in decision making to focus on the comfort of the patient. IV heparin and antibiotics were discontinued. She continued with oxygen, steroids, inhalers/nebulizers. She was transferred to the floor. Palliative care following. . She returned to the medical floor on [12-4] to my service. She was comfort measures. She was enrolled in inpatient hospice. She expired peacefully, with her daughter [Name (NI) ] at her bedside, at 9:39 on [2116-12-6]. Autopsy was declined. Medications on Admission: Advair 500/50 [Hospital1 ] spiriva 18 mcg daily combivent 2 puffs q6h prn alubterol neb q6h prn guaifenesin 1200mg [Hospital1 ] prednisone morphine ER 15mg [Hospital1 ] morphine 2.5 cc q4h prn amphoterecin B 50 mg in 1L sterile water, 10 cc swish/spit TID synthroid 75mcg daily pravastatin 80mg daily amlodipine 5mg daily hctz 12.5mg daily esomeprazole 40mg [Hospital1 ] tums 500mg [Hospital1 ] teriparatide 20mcg sc qhs colace 100mg [Hospital1 ] senna 2 caps [Hospital1 ] miralax 17gm daily zofran prn azithromycin 500mg daily ethambutol 800mg daily bactrim ss 1 tab daily Discharge Disposition: Expired Discharge Diagnosis: Endstage COPD COPD exacerbation Obstipation Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired ICD9 Codes: 5845, 486, 2761, 2762, 5990, 4280, 2724, 2449, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7842 }	Medical Text: Admission Date: [2138-6-26] Discharge Date: [2138-7-7] Date of Birth: [2076-11-29] Sex: M Service: CSU CHIEF COMPLAINT: Exertional chest pain. HISTORY OF PRESENT ILLNESS: Mr. [Known firstname 55223] [Known lastname 56494] is a 61- year-old male who presented to [Hospital 1474] Hospital with exertional chest pain. He had a positive exercise tolerance test and a cardiac catheterization which revealed 3-vessel coronary artery disease and an ejection fraction of 50 percent. He was transferred from [Hospital 1474] Hospital to [Hospital1 1444] for coronary artery bypass grafting. PAST MEDICAL HISTORY: Significant for type 2 diabetes mellitus, hypercholesterolemia, hypertension, hypertrophic obstructive cardiomyopathy, benign prostatic hypertrophy, and claudication. MEDICATIONS ON ADMISSION: 1. Lipitor 20 mg by mouth once per day. 2. Humulin NPH insulin 20 units in the morning and 10 units in the evening. 3. Lisinopril 10 mg by mouth once per day. 4. Verapamil 100 mg by mouth once per day. 5. Atenolol 50 mg by mouth once per day. 6. Nitroglycerin as needed. 7. Advil as needed. 8. Aspirin 81 mg by mouth once per day. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: Remote tobacco use. He smoked one to two packs per day times 35 years. He quit approximately eight years ago. He quit alcohol use 13 years ago. He lives with his son. FAMILY HISTORY: Positive for coronary artery disease. PHYSICAL EXAMINATION ON ADMISSION: In general, an elderly gentleman in no acute distress. Head, eyes, ears, nose, and throat examination revealed the sclerae were anicteric and non-injected. The pupils were equally round and reactive to light. The extraocular movements were intact. The oropharynx was benign. No adenopathy. The neck was supple. There was no thyromegaly. The carotids were 2 plus and without bruits. The lungs were clear to auscultation. Cardiovascular examination revealed a regular rate and rhythm. Normal first and second heart sounds. There were no murmurs, rubs, or gallops. The abdomen was soft and nontender. There were no masses. There were positive bowel sounds. There was no hepatosplenomegaly. The extremities were warm and well perfused. There was no clubbing, cyanosis, or edema. Pulses revealed radial pulses were 2 plus bilaterally, femoral pulses were 2 plus bilaterally, dorsalis pedis pulses were trace, and posterior tibial pulses were 1 plus. Neurologic examination was nonfocal. PERTINENT RADIOLOGY-IMAGING: Catheterization revealed left main with no significant disease, the left anterior descending with a long irregular lesion 80 percent mid stenosis. The left circumflex with an 85 percent eccentric proximal stenosis. Right coronary artery with an 80 percent to 85 percent irregular ulcerated stenosis in the proximal right coronary artery. Ejection fraction of 50 percent. Trace mitral regurgitation. SUMMARY OF HOSPITAL COURSE: Following admission, the patient was sent to had carotid ultrasounds which showed no significant stenosis in the right or the left carotids. Additionally, the patient was sent for vein mapping which showed bilateral tibial disease. An echocardiogram also done on hospital day one, showed left ventricular hypertrophy with multiple wall motion abnormalities and an ejection fraction of 40 percent. The echocardiogram was done because the patient had severe bradycardia on monitor to the 30s alternating with episodes of short runs of nonsustained ventricular tachycardia. A urinalysis done on admission was found to have bacteria with a few white blood cells. Therefore, the patient was started on levofloxacin 500 mg once per day. Ultimately, the patient was brought to the operating room on [7-1]. Please she the Operative Report for further details. In summary, the patient had coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending a saphenous vein graft to the obtuse marginal and a saphenous vein graft to the posterior descending artery. His bypass time was 93 minutes with a cross-clamp time of 65 minutes. The patient tolerated the procedure well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was A-paced at 80 beats per minute with a mean arterial pressure of 64 and a CVP of 8. His propofol was at 20 mcg/kilogram per minute, and he also had a phenylephrine drip to maintain a mean arterial pressure of 60. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated. On postoperative day one, the patient remained hemodynamically stable on no cardiovascular drips. His chest tubes remained in place for somewhat elevated drainage. His beta blockade was resumed. He was started on Lasix for diuresis, and he was transferred to [Hospital Ward Name 121] Two for continued postoperative care and cardiac rehabilitation. On the floor - with the assistance of the nursing staff and Physical Therapy - the patient's activity level was gradually increased. He remained hemodynamically stable over the next several days. His chest tube were removed on postoperative day three. On postoperative day six, it was decided that the patient was stable and ready to be discharged to home. At the time of this dictation, the patient's physical examination was as follows. Temperature was 96, his heart rate was 77 (sinus rhythm), his blood pressure was 150/75, his respiratory rate was 18, and his oxygen saturation was 98 percent on room air. Weight preoperatively was 74.5 kilograms. At discharge, weight was 71.6 kilograms. Neurologically, the patient was alert and oriented times three. He moved all extremities. He followed commands. Respiratory examination revealed the lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. First heart sounds and second heart sounds. The sternum was stable. The incision with Steri-Strips open to air - clean and dry. The abdomen was soft, nontender, and nondistended. There were normal active bowel sounds. The extremities were warm and well perfused with no edema. The left lower extremity saphenous vein graft site with Steri-Strips open to air - clean and dry. Laboratory data revealed a white blood cell count of 6.7, his hematocrit was 30.4, and his platelets were 207. Sodium was 140, potassium was 4.8, chloride was 106, bicarbonate was 28, blood urea nitrogen was 23, creatinine was 1.1, and his blood glucose was 95. MEDICATIONS ON DISCHARGE: 1. Lisinopril 20 mg by mouth once per day. 2. Atenolol 50 mg by mouth once per day. 3. Ferrous sulfate 325 mg by mouth once per day. 4. Vitamin C 500 mg by mouth twice per day. 5. Atorvastatin 20 mg by mouth once per day. 6. Aspirin 325 mg by mouth once per day. 7. Insulin NPH 15 units in the morning and 8 units in the evening. 8. Regular insulin sliding scale. 9. Percocet 5/325-mg tablets one to two tablets by mouth q.4h. as needed. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: Coronary artery disease; status post coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending , a saphenous vein graft to the obtuse marginal, and a saphenous vein graft to the posterior descending artery. Hypertension. Hypercholesterolemia. Type 2 diabetes mellitus. Hypertrophic obstructive cardiomyopathy. DISCHARGE STATUS: The patient was to be discharged to home with visiting nurse followup. DISCHARGE FOLLOWUP: The patient was instructed to follow up with Dr. [Last Name (STitle) ] [Last Name (STitle) ] three weeks as well as with Dr. [First Name (STitle) ] [Last Name (Prefixes) 411] in four weeks. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2138-7-8] 11:52:37 T: [2138-7-8] 15:36:55 Job#: [Job Number 56495] ICD9 Codes: 4271, 4111, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7843 }	Medical Text: Admission Date: [2109-6-7] Discharge Date: [2109-6-21] Date of Birth: [2027-11-19] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3200] Chief Complaint: Peritonitis, PV gas Major Surgical or Invasive Procedure: [2109-6-19]: Picc line placment [2109-6-12] EXPLORATORY LAPAROTOMY; ABDOMINAL WOUND WASHOUT; ABDOMINAL CLOSURE [2109-6-9] Abdominal washout, possible closure [2109-6-7] ex lap, appendectomy History of Present Illness: 81 yoM with 5 days of worsening abdominal pain which he thought was the flu. He was seen at an OSH where he was treated for flu and sent home. He represented this morning with worsening pain and was found, on workup, to have acute renal failure with a creatinine of 2.6. His WBC was only 6. He was taken for CT scan which revealed severe pneumatosis and portal venous air throughout the liver, SMA and splenic vein. On arrival to our hospital, he was tachycardic (120's) and hypotensive (80's systolic). He vomited bloody fluid in the ED bay and an NGT was placed. A foley released 30 cc of urine. His abdomen was diffusely distended. His family arrived with him. Both he and his famiyl were told that there was a high chance of death with or without an operation, but that without an aoperation he was likely to die very soon, and his best chance of living was an operation. All persons agreed to an operative exploration. He was taken urgently to the operating room. Past Medical History: HTN, GERD, HCHOL, ? melanomatous skin cancer Social History: Lives with wife Family History: n/c Physical Exam: Physical examination upon admission: [2109-6-7] EXAM: T: 100.3 HR 90-120 SBP 80-90 RR: 10 Sat 98% 2l AAOx3, in pain tachycardic, No MRG CTA B/L no RRW Soft, distended, tender mildly thoughout, no peritoneal signs no CCE Physical examination upon discharge: [2109-6-21]: Vital signs: t=96.8, 140/70, hr=55, sat=96%, resp 18 General: HOH, alert and orietned x 3, speech clear CV: Ns1, s2, -s3, -s4 ABDOMEN: soft, remainder of staples intact, small amount creamy tan drainage from lower aspect of wound, non-tender EXT: warm, + dp bil., + 1 ankle edema bil., no calf tenderness bil PICC right antecubital: DSD Pertinent Results: [2109-6-20] 05:33AM BLOOD WBC-11.0 RBC-3.26* Hgb-10.7* Hct-30.5* MCV-93 MCH-32.7* MCHC-35.0 RDW-13.9 Plt Ct-365 [2109-6-19] 05:11AM BLOOD WBC-15.5* RBC-3.29* Hgb-10.8* Hct-30.5* MCV-93 MCH-32.8* MCHC-35.4* RDW-13.9 Plt Ct-314 [2109-6-18] 02:29AM BLOOD WBC-22.2* RBC-3.43* Hgb-11.2* Hct-31.8* MCV-93 MCH-32.7* MCHC-35.2* RDW-13.6 Plt Ct-300 [2109-6-17] 09:29AM BLOOD WBC-25.3* RBC-4.12* Hgb-13.1* Hct-38.8* MCV-94 MCH-31.8 MCHC-33.7 RDW-13.7 Plt Ct-368 [2109-6-7] 08:50PM BLOOD WBC-7.5 RBC-3.96* Hgb-12.6* Hct-35.6* MCV-90 MCH-31.9 MCHC-35.4* RDW-12.8 Plt Ct-276 [2109-6-7] 08:50PM BLOOD Neuts-41* Bands-28* Lymphs-7* Monos-24* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2109-6-20] 05:33AM BLOOD Plt Ct-365 [2109-6-19] 05:11AM BLOOD Plt Ct-314 [2109-6-18] 02:29AM BLOOD PT-16.1* PTT-36.4* INR(PT)-1.4* [2109-6-11] 01:57AM BLOOD Fibrino-640# [2109-6-8] 12:10AM BLOOD Fibrino-346 [2109-6-20] 05:33AM BLOOD Glucose-103 UreaN-28* Creat-1.7* Na-131* K-4.0 Cl-104 HCO3-22 AnGap-9 [2109-6-19] 05:11AM BLOOD Glucose-116* UreaN-32* Creat-1.8* Na-134 K-3.7 Cl-104 HCO3-23 AnGap-11 [2109-6-18] 04:50PM BLOOD Glucose-126* UreaN-32* Creat-1.9* Na-134 K-3.7 Cl-104 HCO3-24 AnGap-10 [2109-6-17] 09:29AM BLOOD Glucose-158* UreaN-39* Creat-2.1* Na-135 K-4.2 Cl-103 HCO3-24 AnGap-12 [2109-6-8] 11:37AM BLOOD Glucose-111* UreaN-61* Creat-2.9* Na-137 K-3.8 Cl-107 HCO3-22 AnGap-12 [2109-6-8] 03:58AM BLOOD Glucose-119* UreaN-64* Creat-3.0* Na-138 K-3.9 Cl-108 HCO3-19* AnGap-15 [2109-6-8] 12:10AM BLOOD Glucose-111* UreaN-62* Creat-2.8* Na-141 K-3.6 Cl-113* HCO3-18* AnGap-14 [2109-6-7] 08:50PM BLOOD Glucose-127* UreaN-68* Creat-3.6* Na-139 K-3.9 Cl-102 HCO3-21* AnGap-20 [2109-6-15] 01:32AM BLOOD ALT-38 AST-31 AlkPhos-53 TotBili-0.8 [2109-6-13] 02:23AM BLOOD ALT-37 AST-37 AlkPhos-44 Amylase-191* TotBili-0.7 [2109-6-11] 01:57AM BLOOD ALT-47* AST-63* LD(LDH)-216 AlkPhos-39* TotBili-0.6 [2109-6-13] 02:23AM BLOOD Lipase-131* [2109-6-7] 08:50PM BLOOD Lipase-18 [2109-6-9] 11:20PM BLOOD CK-MB-18* MB Indx-1.6 cTropnT-0.45* [2109-6-9] 12:07PM BLOOD CK-MB-22* cTropnT-0.46* [2109-6-9] 05:57AM BLOOD CK-MB-26* MB Indx-1.7 cTropnT-0.39* [2109-6-8] 10:24PM BLOOD CK-MB-14* MB Indx-2.8 cTropnT-0.26* [2109-6-20] 05:33AM BLOOD Calcium-7.1* Phos-2.9 Mg-1.8 [2109-6-19] 05:11AM BLOOD Calcium-7.3* Phos-3.4 Mg-2.0 [2109-6-18] 04:50PM BLOOD Calcium-7.4* Phos-3.4 Mg-2.4 [2109-6-13] 02:23AM BLOOD calTIBC-91* Ferritn-645* TRF-70* [2109-6-13] 02:23AM BLOOD Triglyc-299* [2109-6-9] 10:03AM BLOOD Cortsol-54.5* [2109-6-9] 09:05AM BLOOD Cortsol-45.8* [2109-6-19] 05:11AM BLOOD Vanco-10.9 [2109-6-18] 06:19AM BLOOD Type-ART pO2-66* pCO2-30* pH-7.50* calTCO2-24 Base XS-0 [2109-6-13] 08:23AM BLOOD Type-ART pO2-111* pCO2-36 pH-7.40 calTCO2-23 Base XS--1 [2109-6-18] 06:19AM BLOOD Lactate-1.0 [2109-6-7] 09:35PM BLOOD Lactate-6.5* [2109-6-18] 06:19AM BLOOD freeCa-1.10* [2109-6-12] 02:26AM BLOOD freeCa-1.15 [2109-6-7]: EKG: Sinus tachycardia with non-specific ST-T wave abnormalities. No previous tracing available for comparison. [2109-6-8]: Echo: Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Preserved [Hospital1 ]-ventricular systolic function. Mild tricuspid regurgitation. [2109-6-8]: EKG: Atrial fibrillation with rapid ventricular response. Diffuse non-specific ST-T wave abnormalities. Compared to the previous tracing of [2109-6-7] atrial fibrillation is present and ST-T wave abnormalities are more prominent. There is now poor R wave progression in leads V1-V3 consistent with possible interim anteroseptal myocardial infarction, although this may be related to lead positioning. [2109-6-10]: echo: Conclusions The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a moderate resting left ventricular outflow tract obstruction. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is systolic anterior motion of the mitral valve leaflets. Mild to moderate ([2-3]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. [2109-6-12]: chest x-ray: Cardiomediastinal contours are unchanged. Large bilateral pleural effusions, right greater than left, associated with atelectasis are stable. There are no new lung abnormalities. Lines and tubes remain in place in standardposition. [2109-6-12]: x-ray abdomen: Additional findings; there is a single loop of dilated bowel in the right abdomen. Degenerative changes are also seen along the spine. [2109-6-15]: EKG: Likely atrial flutter with variable conduction. Possible prior septal myocardial infarction of indeterminate age. Compared to the previous tracing of [2109-6-9] atrial flutter is seen. There are non-specific ST-T wave changes on the current tracing, although these are difficult to differentiate from the P waves of the atrial flutter. [2109-6-16]: cat scan of abdomen and pelvis: IMPRESSION: 1. There has been significant interval improvement in the appearance of the small bowel; however, mild small bowel dilatation of the mid ileum is present and thickening of the distal ileum. 2. No intra-abdominal collection. Free fluid is present around the liver and pelvis. 3. Bilateral pleural effusions with associated atelectasis. 4. Gallbladder has high density material within it, possible sludge. [2109-6-16]: chest x-ray: 1. Resolving changes at right base with persistent opacity, question loculated pleural fluid. 2. Persistent left lower lobe collapse and/or consolidation, possibly slightly improved. 3. No CHF. 4. Bilateral effusions seen posteriorly. [2109-6-19]: chest x-ray: The right PICC line tip is at the level of low SVC. Left subclavian line tip is at the same level as well. There is slight interval progression of bilateral pleural effusions with no change in bibasilar atelectasis. Mild interstitial pulmonary edema is slightly more pronounced on the current study as compared to prior radiograph. No pneumothorax is seen. Brief Hospital Course: Patient was taken to the OR emergently for a exploratory laparotomy. He was found to have a perforated appendix causing a closed loop obstruction. An appendectomy was performed and he was taken to the SICU postoperatively intubated with an open abdomen for continued resuscitation. On POD 1, the patient did have transient hypotension and was bolused with albumin. He also had an episode of atrial fibrillation associated with hypotension. He was started on amiodaorne gtt and pressors. Serial troponins were elevated. Aspirin was started and he was transfused 1 uprbc given the elevated troponins and hct of 27. On POD 2, cardiology was consulted re: elevated troponins--they believed it was secondary to demand ischemia and recommended a TTE. On POD 3, he was taken back to the OR for a washout. No ischemic bowel was seen. On POD [5-3] he was started on a lasix drip briefly to facilitate diuresis and abdominal closure. On POD [6-3], he was taken back to the OR for a definitive abdominal closure. On POD 6/3/1 he was extubated and weaned off pressors. He was started on a clear liquid diet. ON POD 7/4/2 he was afebrile but had a persistently elevated leukocytosis. He had a speech and swallow eval and they rec'd thin liquids, ground solids. On [6-16], he had a CT scan given the persistent leukocytosis which was negative for intrabdominal fluid collection. On [6-17] a central line was placed as he is very difficult access and PICC service would not put a PICC line in given the leukocytosis. Pan cultures were sent. On [6-18], the patient remained stable so he was sent to the floor in good condition. Transferred to the surgical floor on [2109-6-18]. He was started on ciprofloxacin for empiric coverage of c. diff. He continued on vancomycin and zosyn for his bowel coverage. He had a PICC line placed on [6-18] for access to intravenous antibiotics, and his central line was discontinued. He resumed his pre-hospital medication except for his hydrocholorthiazide which was held related to his creatinine and hemodynamic status. He was evaluated by physical therapy and recommendations have been made for additional rehabilitation because of his deconditioning. His vital signs are stable and he is afebrile. His creatinine is 1.7 and his WBC is 11.0. He is tolerating a regular diet. He has been out of bed. He will complete his course of piperacillin and flagyl. He is preparing for discharge to an extended care facility. He will follow-up with the acute care service in 2 weeks. Medications on Admission: Lisinopril, simvastatin, HCTZ, zantac Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 2. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): please apply to left foot. 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days: continue up to [6-28]. Disp:27 Tablet(s) Refills:0 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. HydrALAzine 10 mg IV Q6H:PRN SBP> 160 9. 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. 10. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day: HOLD, related to increased creatinine, and blood pressure..please reassess prior to resuming. 11. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 gm Intravenous every six (6) hours for 1 days: complete course [6-22]. 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stool. Discharge Disposition: Extended Care Facility: [Doctor First Name 391] Bay Skilled Nursing & Rehabilitation Center - [Hospital1 392] Discharge Diagnosis: perforated appendix pneumotosis portal venous gas abdominal distention Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted to the hospital with abdominal pain. Upon admission, you were also found to be in renal failure. You had imaging studies of your abdomen done which showed you had a perforated appendix and which caused the intestinal obstruction. You were taken to the operating room where you had your appendix removed. Your abdomen was left open and then you returned to the operating room to have your abdomen closed. You have been on antibiotics. You are recovering from your surgery and you are now preparing for discharge to an extended care facility with the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [6-11] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please follow-up with the acute care service in 2 weeks. You can schedule your appointment by calling # [Telephone/Fax (1) 600] Completed by:[2109-6-21*] ICD9 Codes: 0389, 5849, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7844 }	Medical Text: Admission Date: [2138-12-31] Discharge Date: [2139-1-6] Date of Birth: [2080-2-8] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7055] Chief Complaint: Ventricular Tachycardia Major Surgical or Invasive Procedure: Ventricular Tachycardia Ablation Intracardiac Defibrillator History of Present Illness: Ms [Known lastname 22437] is a 58 year old woman with history of coronary artery disease s/p myocardial infarction, hyperlipidemia and lyme disease, presenting from [Hospital3 10377] with persistant VT. Per report, patient was in her usual state of health until the morning of admission, when she began feeling chest pain that was associated with diaphoresis and light headedness and later with nausea and dry heaves. EMS was called and on arrival found her alert and oriented but with once placed in the monitor was found to be in V-Tach and was defibrillated a total of 3 times (unknown shock, intially VT, VT and lastly VF). On arrival to [Hospital3 ], 127/75, HR 67, RR 13, 96% 3L NC. Patient was started on lidocaine with bolus of 100mg and maintenance at 4mg/hr. Patient developed nausea and vomiting, was decreased with 4,000 heparin bolus and drip at 1,000. Patient at 1900 reported fluttering in her chest, again was noted to be in VT and was given 150mg bolus and was defibrillated with restoration of sinus rhythm. At [2149] she experienced another, self terminating episode of VT. 2138, a narrow complex tachycardia was noted and she was again bolused with 150mg of amiodarone and 6mg of adenosine with restoration of sinus rhythm. Patient was then med flighted to [Hospital1 18] for further management. While en route, patient developed a WCT x 3 which responded to defibrillation with 200J, 200J and 50J. On arrival, pt was alert and interactive. While being moved and situated, she again went into a WCT at a rate of ~150bpm and was cardioverted with 50J shock x 1 after sedation was administered. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. No recent viral illness, no diarrhea, no burning with urination and no medication changes, no alcohol and no illicit drugs. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes, (+)Dyslipidemia, (-)Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: [2127], totally occluded proximal LCx and RCA with bridging collaterals. 3. OTHER PAST MEDICAL HISTORY: Lyme disease in [2137] Social History: smokes one ppd Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T 98.8 HR 55 BP 113/61 RR 20 O2 95% General Appearance: Well nourished Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI Holosystolic murmur at base, III/VI crescendo/decrescendo at RUSB Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Crackles : bases) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: 1+, Left lower extremity edema: 1+ Skin: Warm, No(t) Rash: , No(t) Jaundice Neurologic: Attentive, Responds to: Not assessed, Movement: Not assessed, Sedated, Tone: Not assessed Pertinent Results: ADMISSION LABS [2138-12-31]: [2138-12-31] 10:59PM WBC-11.9# Hgb-12.3 Hct-36.5 Plt Ct-215 [2138-12-31] 10:59PM Neuts-67.6 Lymphs-26.0 Monos-4.5 Eos-1.5 Baso-0.4 [2138-12-31] 10:59PM PT-12.4 PTT-56.6 INR(PT)-1.0 [2138-12-31] 10:59PM Glucose-101 UreaN-17 Creat-0.6 Na-140 K-4.3 Cl-107 HCO3-25 AnGap-12 [2138-12-31] 10:59PM CK(CPK)-626* [2138-12-31] 10:59PM CK-MB-13* MB Indx-2.1 cTropnT-0.27* [2138-12-31] 10:59PM Calcium-9.2 Phos-3.8 Mg-2.1 CE TREND: [2138-12-31] 10:59PM CK(CPK)-626* [2139-1-1] 04:06AM CK(CPK)-630* [2139-1-1] 08:44PM CK(CPK)-524* [2139-1-2] 02:37AM CK(CPK)-420* [2139-1-3] 06:50AM CK(CPK)-198* [2138-12-31] 10:59PM CK-MB-13* MB Indx-2.1 cTropnT-0.27* [2139-1-1] 04:06AM CK-MB-11* MB Indx-1.7 cTropnT-0.23* [2139-1-1] 08:44PM CK-MB-13* MB Indx-2.5 cTropnT-0.71* [2139-1-2] 02:37AM CK-MB-13* MB Indx-3.1 cTropnT-0.88* [2139-1-3] 06:50AM CK-MB-3 cTropnT-0.59* LFTs [2139-1-2] 02:37AM ALT-69* AST-64AlkPhos-68 TotBili-0.7 [2139-1-4] 05:12AM ALT-46 AST-28 AlkPhos-81 TotBili-0.5 TFTs [2139-1-2] 02:37AM TSH-4.6* [2139-1-2] 02:37AM T4-6.9 MICROBIOLOGY: BCx - NGTD UCx - negative IMAGING: Cardiac Cath: COMMENTS: 1. Selective coronary angiography of this right-dominant system revealed two-vessel coronary artery disease. The LMCA and LAD had no significant stenoses. The LCX was occluded proximally and filled distally from LAD collaterals. The RCA was occluded in the mid-vessel and filled from LAD collaterals. 2. Limited resting hemodynamics demonstrated normal central aortic pressures. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. [2139-1-1] CXR: Cardiac size is top normal. Interstitial minimal alveolar opacities in the perihilar regions are on the bases of the lungs slightly asymmetric greater on the left side are consistent with mild to moderate pulmonary edema. Left pleural effusion is small. [2139-1-3] CXR: The pacemaker defibrillator leads terminate in right atrium and right ventricle. Cardiomediastinal silhouette is stable. The patient is in pulmonary edema, moderate, grossly unchanged since the prior study. There is no pleural effusion. There is no pneumothorax. Degenerative changes are seen in the thoracic spine on the lateral projection DISCHARGE LABS [2139-1-6]: [2139-1-6] 05:45AM WBC-10.3 Hgb-12.4 Hct-37.1 Plt Ct-193 [2139-1-6] 05:45AM Glucose-95 UreaN-21* Creat-0.8 Na-140 K-5.0 Cl-105 HCO3-28 AnGap-12 Brief Hospital Course: 58 year old woman with remote history of 2 vessel CAD, total occlusion of LCx and RCA, presenting with VT / Electrical storm. . # VT STORM: Pt was stabilized on th floor with continued amiodarone load overnight, at 1mg/min and reduced to .5mg/min the following day. Given her inability to remain in sinus tachycardia, she was also continued on IV Liocaine with 100mg bolus + was2mg/hr drip. She was started on metoprolol which was up titrated to her BP and HR. She was also started on a heparin drip overnight for stunned myocardium which was discontinued the following day. Her cardiac enzymes were noted to be slightly elevated, with CK disproportionately higher than her CKMB or Troponins, making irregular electrical activity from prior scar formation more likely than a new ischemic event. ECG showed ectopic atrial rhythm but otherwise no abnormalities. No ECG was obtained while pt was in VT. Cardiac catheterization was performed the following day which showed stable blockage of the LCx but no new blockages. Electrophysiology was consulted. Amiodarone was continued and lidocaine was stopped. Pt went for ablation but lesion was not able to be identified and/or ablated. ICD was placed without complication. She continued to have brief episodes of sustained VT, HR < 170 which self resolved. Pt described a flutter in her chest but no other symptoms. She did not receive any shocks from the ICD. To reduce the frequency of ventricular tachycardia and to prevent firing of the ICD, pt continued amiodarone load at dosing of 400mg tid, reduced to 400mg [Hospital1 ] X 1 week on which patient was discharged. After one week she was instructed to reduce her amiodarone dose to 400mg daily. . # CORONARIES: Given pt has history of cardiac disease, pt was continued on aspirin. Statin was increased to maximum dosage. Beta blocker was started and uptitrated. . # SYSTOLIC HEART FAILURE, CHRONIC: Pt did not require any treatment for her chronic heart failure. Medications on Admission: Atorvastatin 60mg daily Metoprolol 50mg [Hospital1 ] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. Disp:14 Tablet(s) Refills:0 4. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 3 weeks: start on [2139-1-13]. . Disp:21 Tablet(s) Refills:0 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:2 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 8. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 9. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 10. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO twice a day. 11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO three times a day for 4 days. Disp:12 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Ventricular Tachycardia Chronic systolic Dysfunction: EF 45% Coronary Artery Disease Dyslipidemia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had ventricular tachycardia, a serious heart arrhythmia that caused you to collapse at home. We cannot find a specific cause for the ventricular tachycardia, but think it is caused by scarring from an old heart attack. You received an internal defibrillator to shock your heart out of this rhythm. This feels like being kicked the the chest and you should let Dr. [Last Name (STitle) 7047] know if the ICD fires. . Medication changes: 1. Start amiodarone: take 400 mg twice daily for one week, then decrease to 400 mg daily for 3 weeks. Dr. [Last Name (STitle) 7047] will let you know how much to take after that. 2. Increase Atorvastatin to 80 mg daily to prevent more blockages in your coronary arteries. 3. Increase your metoprolol to 150 mg daily (changed to extended release) 4. Start Lisinopril at 5mg daily 5. Start Cephalexin to prevent the small infection in your left arm at the IV site from getting worse. . You have an IV site infection, this should be treated with warm packs. four times a day. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Primary Care: [Last Name (LF) ],[First Name3 (LF) ] D. Phone: [Telephone/Fax (1) 6699] Date/time: please keep any scheduled appts. . Cardiology: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7047] Phone: [Telephone/Fax (1) 8725] Date/time: Office will call you at home with an appt on [1-15] to get the ICD checked. . Completed by:[2139-1-6] ICD9 Codes: 4271, 5180, 4275, 412, 3051, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7845 }	Medical Text: Admission Date: [2135-7-15] Discharge Date: [2135-7-25] Date of Birth: [2096-2-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1070] Chief Complaint: SOB Major Surgical or Invasive Procedure: [2135-7-17] IVC Filter Placed History of Present Illness: 39 y/o M with PMHx of HTN, iritis, who presented to his PCP's office with a 2 days of worsening SOB, and dizziness on standing after going to the gym. Patient said on tuesday he noticed left calf "knot" after swimming, with no other symptoms. On weds/thurs. he noticed he was sob, dizzy and diaphoretic with normal exertion (walked [1-3] block). Finally, on friday, his left calf "knot" was not resolved with vigorous massage, and his symptoms of SOB, dizziness and diaphoresis were not improved so he saw his PCP. [Name10 (NameIs) ] arrived to his PCP's office who found him to be hypotensive and tachycardic, and he was sent into the ED. Interestingly, patient notes ~ 5 weeks ago he had some sob while boxing, and 3 weeks ago he also had sob after a long flight. . Brief hospital course: In the ED, VS: T98.1, HR116, BP96/80, RR16 o2sat: 97% RA. His CT scan showed bilateral PEs and he was given ASA 325 x1, & started on hep gtt. The patient was admitted to the ICU, and for his saddle emboli he was continued on heparin gtt, and had an IVC filter placed. He will start coumadin. His ARF was treated with fluids, which led to improvement. In the setting of PE/hypotension, his blood pressure meds were held and he was aggressively hydrated Past Medical History: 1)HTN 2)Iritis Social History: The patient grew up in a farm in [Location (un) 3844], currently works for EScription Services for the past 3 years. There is a lot of traveling around the country for up to a week at a time. He works pretty hard but likes his job. He has no history of alcohol, drug abuse, or smoking. He currently lives in the [Location (un) 4398]. He lives alone. He has an occasional male partner with whom he is sexually active. He does use condoms. He has no history of sexually transmitted diseases. Family History: Mother has hypercholesterolemia and history of alcohol abuse; diagnosed with breast cancer one year ago. His father has nonmelanoma skin cancer. No other fam hx of blood clots or malignancy. Physical Exam: On Admission to ICU... Vitals: T 99 BP 106/63 HR 95 RR 22 O2: 98% on 2L Gen: Well appearing male in NAD; able to talk in complete sentences HEENT: Anicteric sclera. O/P clear. MMM. Neck: No elev JVP. No cervical or supraclavicular LAD. Cardio: Regular, nml s1,s2. No murmurs Resp: CTAB. No c/w/r. Abd: Soft. NTND. No TTP. No inguinal LAD Ext: 2+ pulses bilat, no edema. No erythema. (-) [Last Name (un) 5813] sign Neuro: AAOx3 GU: No testicular masses palpated. RECTAL: Guiaic (-) in ED per notes. . on floor: Vitals: 98.4, 104/70, 96, 16, 95% RA Gen: Well appearing male in NAD HEENT: Anicteric sclera. O/P clear. MMM. Neck: No JVD noted, no [Doctor First Name ], no bruit noted Cardio: Regular, nml s1,s2. No murmurs Resp: CTAB. No c/w/r. Abd: Soft. NTND. + BS Ext: 2+ pulses bilat, no edema. No erythema. no calf tenderness. IVC filter in right thigh Neuro: AAOx3 RECTAL: Guiaic (-) in ED per notes. Pertinent Results: [2135-7-15] Chest CT: Massive bilateral pulmonary emboli involving the bilateral distal, lobar and multiple proximal segmental pulmonary arteries. Focal gound glass opacity in the left upper lobe may represent focal infarction, although follow up films are recommended to ensure resolution. [2135-7-15] CXR: The heart size and mediastinal contours are normal. There is no pleural effusion or pneumothorax. The lungs are clear. [2135-7-16] ECHO - Right ventricular cavity enlargement with free wall hypokinesis and preserved apical function c/w acute RV pressure overload/pulmonary embolism. [2135-7-16] LE Doppler - Occlusive intraluminal thrombus is seen within the right distal superficial femoral vein extending inferiorly into the right popliteal and calf veins. . EKG on admission: Sinus tachycardia. Inferior Q of waves doubtful significance. Since previous tracing, rate faster. . admission labs: [2135-7-15] 11:10AM D-DIMER-4016* [2135-7-15] 11:10AM WBC-12.2* RBC-5.80 HGB-16.1 HCT-46.8 MCV-81* MCH-27.7 MCHC-34.4 RDW-13.3 [2135-7-15] 11:10AM CK-MB-6 cTropnT-0.11 [2135-7-15] 11:10AM CK(CPK)-684* [2135-7-15] 11:10AM UREA N-21* CREAT-1.4* SODIUM-137 POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-27 ANION GAP-19 [2135-7-15] 11:10AM GLUCOSE-68* [2135-7-15] 08:30PM D-DIMER-4256* [2135-7-15] 08:30PM NEUTS-66.6 LYMPHS-22.4 MONOS-5.5 EOS-3.4 BASOS-2.1* [2135-7-15] 08:30PM WBC-10.7 RBC-5.63 HGB-16.0 HCT-45.0 MCV-80* MCH-28.3 MCHC-35.4* RDW-13.4 [2135-7-15] 08:30PM CK-MB-5 [2135-7-15] 08:30PM cTropnT-0.03* [2135-7-15] 08:30PM GLUCOSE-95 UREA N-24* CREAT-1.5* SODIUM-135 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-18 Brief Hospital Course: This is 39 y/o M with h/o HTN who presents with intermittant SOB, and hypotension found to have massive bilateral saddle emboli . 1) Pulmonary embolism - The patient was admitted with extensive bilateral pulmonary emboli. As this is a very serious condition and the patient was unstable in the ED (but responding to fluids) the patient was admitted to the ICU and started on heparin. In the ICU, he was hemodynamically stable, so no lytic therapy was started. After transfer, the patient remained stable, and his course on the floor was without events. He remained on heparin and coumadin and we waited until he became therapeutic, by closely monitoring his PT, PTT and INR and adjusting his coumadin dose. As an outpatient he will remain on coumadin and should have a hypercoaguability workup, TTE, and a repeat chest CT. . 2) Deep vein thrombus: The patient was noted to have an intraluminal thrombus within the right distal superficial femoral vein extending inferiorly into the right popliteal and calf veins. As above, the patient was treated with heparin and coumadin, but due to this large clot that had potential to break off, he was placed with an IVC filter. The patient responded well to the IVC filter and anticoagulation, and should have this IVC filter in for life for protection. . 3) Right Ventricular strain: On admission, the patient was noted to have elevated troponins, and this was attributed to the right ventricular strain from the pulmonary embolism. The case was discussed with cardiology, and since he was hemodynamically stable and responding to anticoagulation they felt lytic therapy was unnecessary. The right ventricle is resilient and should recover, in time. The patient had no problems during his course, and will have a repeat ECHO in 3 months to revalute. . 4) Anemia: The patient was noted to have a mild anemia. He was hemodynamically stable, and we felt this could be followed up further as an outpatient. . 5) Hypertension - The patient was hypotensive on admission, and in the setting of a pulmonary embolism, his blood pressure medications were held. He remained normotensive during his course, and therefore we continued to hold his medications as they can be restarted as an outpatient. . 6) Acute renal failure: On admission the patient presented with a creatinine of 1.4, increased from his baseline of 1.0. This improved with hydration, although increased again during the course to 1.3. The Fena was calculated to be ~ 1% and therefore assumed to be pre-renal. Hydration was provided and the patient improved, leading to the diagnosis of pre-renal failure. Medications on Admission: Lisinopril 20mg QD Claritin Discharge Medications: 1. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day: You can retake your home claritin. 2. Outpatient Lab Work Please check PT, PTT, INR 3. Warfarin 2 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime): take 8 mg daily. Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. Pulmonary embolism 2. Deep vein thrombosis 3. Anemia 4. Mulculoskeletal pain Discharge Condition: stable, tolerating medications, afebrile Discharge Instructions: 1. Please attend all appointments 2. Please take all medications as prescribed, we are holding your lisinopril because your blood pressure was low. This should be readdressed with Dr. [Last Name (STitle) ]. 3. Please return for worsening shortness of breath, chest pain, vomiting, high fever and inability 4. Please have your labs drawn in 2 days (bring lab slip prescription), at Dr.[Name (NI) 6001] office. Followup Instructions: 1. Would have a repeat chest CT in 3 months 2. You need a repeat ECHO in 3 months 3. You need a work-up for hypercoagulability, which Dr. [Last Name (STitle) ] will help you coordinate. 4. You have an appointment with Dr. [Last Name (STitle) ] (# [Telephone/Fax (1) 250]) on Friday [7-29] at 9:50 am. ICD9 Codes: 5849, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7846 }	Medical Text: Admission Date: [2184-10-8] Discharge Date: [2184-10-13] Date of Birth: [2126-8-27] Sex: M Service: NEUROSURGERY Allergies: IV Dye, Iodine Containing Contrast Media / myeclog cream Attending:[First Name3 (LF) 78] Chief Complaint: Headache Major Surgical or Invasive Procedure: [2184-10-8]: Bifrontal craniotomy for tumor resection History of Present Illness: 58M with hx of HTN, HL, GERD presenting with 3-4 weeks of [Hospital 91670] from OSH after CT head showed new R frontal mass. He says he first began having headaches about 3-4 weeks ago. They were initially occurring [1-11] x per week but within the last week have been occurring daily. He does not usually get headaches so this was unusual for him. He describes the headaches as a throbbing pain over his whole head. Recently they have been present when he awakes in the morning and last all day,fluctuating somewhat in severity. He takes advil occasionally which helps somewhat. He also reports some nausea and decreased appetite when the pain is severe; has not vomited. His wife also notes some cognitive changes over the last 6-9 months including increased forgetfulness, "vagueness," just not quite acting like himself. He saw his PCP today due to the increased frequency of his headaches and was sent to [Hospital 8641] Hospital for a CT scan. The scan showed a large R frontal mass and he was transferred to [Hospital1 18] for further evaluation. Past Medical History: HTN HL GERD PVD PSH: L knee surgery Umbilical hernia repair Social History: Lives at home with wife and step daughter. [Name (NI) 1403] as a machinist for GE. Never smoked, drinks occasional alcohol. Denies illicits. Family History: Mother with [Name (NI) 11964] / renal cell carcinoma Father with stroke in 60's Sister with brain tumor - unknown what type, family says it is "deep" and inoperable so she is being monitored, asymptomatic and has been stable. Physical Exam: Upon admission The pt was awake alert and oriented with a non focal neurological exam. His headaches were controlled with oral medication. Upon discharge ********** Pertinent Results: [2184-10-8] PATHOLOGY [2184-10-8] MRI BRAIN Final Report CLINICAL HISTORY: 58-year-old man with headache. Diagnosed to have right frontal lesion on MRI. Pre-surgical mapping. COMPARISON: MRI without and with contrast dated [2184-10-1]. TECHNIQUE: Axial T1 and axial MP-RAGE images were obtained after administration of contrast with sagittal and coronal reconstructions. FINDINGS: Again is noted an enhancing mass in the right basifrontal region measuring 2.6 x 2.4 x 2.2 cm in craniocaudad, AP and transverse dimensions. It is associated significant perilesional edema. It causes mass effect on the surrounding brain parenchyma and the frontal [Doctor Last Name 534] of right lateral ventricle. A prominent vessel is noted arising from right supraclinoid internal carotid artery and reaching upto the lesion suggestive of hypervascularity of the lesion. The lesion is more likely intra-axial rather than extra-axial. There is no evidence of new enhancing lesion. The ventricles are stable in size. Brainstem and cerebellum appear normal. The visualized paranasal sinuses and mastoid air cells are clear. Orbits are unremarkable. IMPRESSION: Enhancing right basifrontal mass with surrounding perilesional edema and mass effect which is unchanged since the prior study. The lesion is more likely intra-axial rather than extra-axial. This likely represents metastasis. [2184-10-8] CT BRAIN Final Report INDICATION: Right frontal tumor, status post craniotomy for resection. Please evaluate for postoperative changes. TECHNIQUE: Sequential axial images were acquired through the head without administration of intravenous contrast material. COMPARISON: MR head from [2184-10-8], at 09:45 a.m. FINDINGS: The patient is status post frontal craniotomy with resection of a right frontal lobe lesion. There is a small quantity of hemorrhage within the resection bed. Mild pneumocephalus is seen overlying both frontal lobes. There is vasogenic edema within the right frontal lobe with associated 9 mm leftward shift of the normally midline structures (2:14), not significantly changed compared to the prior MR. There is no large volume intracranial hemorrhage. There is no evidence of acute large vascular territorial infarction. The ventricles are normal in size. Aerosolized secretions and fluid is seen within the frontal sinuses and middle and anterior ethmoidal air cells. The remainder of the visualized portions of the paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: 1. Expected postoperative changes in the right frontal lobe, status post resection of a right frontal lobe mass. 2. Persistent vasogenic edema within the right frontal lobe along with unchanged leftward shift of normally midline structures. 3. No large volume intracranial hemorrhage. 4. Minimal new pneumocephalus overlying both frontal lobes. [2184-10-9] MRI BRAIN Final Report EXAM: MRI brain. CLINICAL INFORMATION: Status post resection of brain tumor. TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and diffusion axial images were obtained before gadolinium. T1 axial and MP-RAGE sagittal images acquired following gadolinium. Comparison was made with the MRI of [2184-10-8]. FINDINGS: Since the previous study, the patient has undergone resection of right inferior frontal lobe mass. Blood products and air are seen in the region. No definite residual enhancement identified. Linear, somewhat tortuous area of enhancement indicating a vascular structure posterior to the surgical cavity is again identified, unchanged from prior study. There is dural enhancement in the region which could be postoperative in nature. The edema in the right frontal lobe is unchanged. No midline shift or hydrocephalus seen. There is no new area of restricted diffusion to suggest acute infarct. IMPRESSION: Status post resection of right inferior frontal lobe mass with blood products in the region. The enhancement at the margin of the surgical cavity is mostly meningeal and could be postoperative in nature. No definite residual parenchymal enhancement is seen. No evidence of acute infarct, mass effect, or hydrocephalus. The edema is unchanged LENIS [2184-10-11] - 1. Superficial thrombosis of the lesser saphenous vein of the right calf, with additional deep venous thrombosis of what is likely the gastrocnemius vein on the right. 2. No evidence of DVT in left lower extremity. Brief Hospital Course: Pt electively admitted and underwent a bifrontal craniotomy with cranialization of the frontal sinus. Plastic surgery was involved with the procedure. The pt awoke from anesthesia without complication and was extubated immediately. He was started on a 7 day course of Ancef for sinus coverage. He remained in the ICU overnight and then was transferred to step down. His post operative imaging was stable. He was seen and evaluated by PT OT. There were no events. Medicine and radiation oncology teams were [Month/Day/Year 653] regarding completed treatment. On [2184-10-11], pt had a LENIs which demonstrated a right calf DVT. Given that he had a craniotomy, it was demed that patient require a IVC filter. IR was consulted for IR IVC filter placement. Because of a clot in the IVC, a filter was not placed. He is to continue his SQH while in hospital. On [10-13], patient is ambulatory and voiding appropriately. Pathology results are still pending and PT has cleared patient safe to go home with PT. His IV antibiotics was changed to PO cephalexin and he will have a slow taper of his decadron. He was discharge home on [10-13*]. He can also restart his aspirin 81mg today. Medications on Admission: brimonidine-timolol [Combigan]0.2-0.5 % Drops One (1) Ophthalmic three times a day. brinzolamide 1 % Drops, Suspension One (1) Ophthalmic three times a day. dexamethasone 2 mg Tablet Two (2) Tablet by mouth every six (6) hours. 240 Tablet(s) 2 fiorocet 1-2 tabs every six (6) hours as needed for pain. 30 0 hydrochlorothiazide12.5 mg Capsule Two (2) Capsule by mouth DAILY (Daily). latanoprost0.005 % Drops one (1) Drop Ophthalmic HS (at bedtime). levetiracetam750 mg Tablet One (1) Tablet by mouth twice a day. 60 Tablet(s) 2 lisinopril20 mg Tablet Two (2) Tablet by mouth DAILY (Daily). omeprazole20 mg Capsule, Delayed Release(E.C.) Two (2) Capsule, Delayed Release(E.C.) by mouth DAILY (Daily). pravastatin20 mg Tablet Two (2) Tablet by mouth DAILY (Daily). Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:90 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 3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Combigan 0.2-0.5 % Drops Sig: One (1) Ophthalmic tid (). 5. brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic tid (). 6. latanoprost 0.005 % Drops Sig: One (1) Ophthalmic qhs (). 7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 9. dexamethasone 2 mg Tablet Sig: refer to other instructions Tablet PO refer to other instructions: Please take 3mg (1 [1-11] tab) TID for 2 days, then take 2mg (1 tab) TID for 5 days, then 2mg (1 tab) [Hospital1 ] until seen in follow up. Disp:100 Tablet(s) Refills:2 10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. cephalexin 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 2 days. Disp:8 Tablet(s) Refills:0 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 34004] Discharge Diagnosis: Right frontal brain tumor Deep vein thrombosis right gastroc vein Elevated BUN High blood pressure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you during your stay at the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ]. You presented for removal of a right frontal brain tumor which was discovered at your last hospital admission. The operation was successful and was a combined procedure with both plastic surgery and neurosurgery involved and the biopsy result from this is awaited. You were also found to have a deep vein thrombosis in your right calf revealed on ultrasound tests of your legs. We discussed treatment options with oncology and given taht interventional radiology felt that placing a filter was unsafe due to vein involvement of your renal cancer. You were therefore started on aspirin. You were also started on anti-seizure medication given the risk of seizures following your brain tumor removal. You did well post-operatively and were deemed safe for discharge on [2184-10-13]. You have a brain [Hospital 91671] clinic appointment on [2184-10-25] with MRI. You also have neuro-oncology follow-up as below. 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 with a mild shampoo, or just wanter run over your incision. ?????? 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, Advil, and Ibuprofen etc for one week post operativly. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. 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 [7-18] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 6 weeks. ??????You will need an MRI of the brain with and without gadolinium contrast. YOU HAVE AN APPOINTMENT IN THE BRAIN [Hospital ] CLINIC ON [10-25] with an MRI at 7:55 am [Hospital Ward Name 23] 4 and Brain [Hospital 341] Clinic at 9:30 / IF YOU ARE UNABLE TO MAKE THIS APPOINTMENT PLS CALL [Telephone/Fax (1) ] Department: NEUROLOGY When: MONDAY [2184-10-25] at 11:30 AM With: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD [Telephone/Fax (1) 1844] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage If Pathology does show that kidney is your primary lesion, please contact Dr. [Last Name (STitle) 9449], Dr. [Last Name (STitle) ], and Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 82797] to schedule an appointment to be seen. Completed by:[2184-10-13] ICD9 Codes: 4019, 4439, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7847 }	Medical Text: Admission Date: [2170-8-8] Discharge Date: [2170-8-15] Date of Birth: [2113-9-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2181] Chief Complaint: symptomatic bradycardia, syncopal episode Major Surgical or Invasive Procedure: Craniotomy [2170-8-10], Temporary pacing wire placed in R IJ [2170-8-10] and removed [2170-8-13] History of Present Illness: This is a 56yoM w/recent h/o fall [8-1] evaluated here and found to have subdural hematoma (treated conservatively) who presented with syncopal episode. He reports that he was home yesterday afternoon napping when the phone rang, and he woke up to answer it. As he stood up and walked to the other room, he grabbed the door, "spun around" and fell. He reports no LOC with this fall. Reports hitting his head on the ground. Denies SOB, chest pain or palpitations prior to the fall but felt very lightheaded post fall. Denies any loss of continence. Denies seizure like activity but fall was unwitnessed. Denies visual changes. +Mild headache. He sat on the ground post fall and then called his girlfriend who brought him to the ER. . Of note, pt does report use of klonopin (unclear #) since discharge from [Hospital1 18] for "anxiety". Also reports ongoing headaches that occured during hospitalization and persisted on discharge. . In the ED, vitals were T HR 44 BP 114/78 RR14; EKG showed sinus bradycardia, No ST/T changes, no evidence of heart block. serum tox +benzos. CT head with possible increase in midline shift; improved SDH. Neurosurgery evaluated and felt SDH stable. He received Morphine 2mg and Acetaminophen 1000mg. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies cough, sputum production, dysuria, nausea/vomiting, diarrhea or constipation. Denies any sick contacts. Past Medical History: Oxycodone/percocet abuse s/p Left knee surgery s/p Right hip replacement 2 lumbar spine surgeries (?fusion, last one 3 years ago) Ear surgery for otitis media externa 20 years ago Social History: Social history is significant for the 1ppd current tobacco use. + h/o Oxycodone and percocet abuse (previously on suboxone; reports none in past few years. Lives with girlfriend, has 3 children; 1 past away and 2 daughters alive; one in [State 2690] and one in MA. Former fisherman. Drinks 4 drinks/week; used to drink heavily when fishing but not in past 10 years. Family History: Non-contributory Physical Exam: VS: T 98, BP 125/56 , HR 57 , RR 20 , 96 O2 % on RA Gen: White Middle aged male, NAD, slightly disheveled. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL (5mm->3mm b/l), EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, JVP flat, + carotid bruit b/l. CV: PMI located in 5th intercostal space,2/6 SEM heart at RUSB Chest: Clear to ausculatation bilaterally. No crackles, wheeze, rhonchi. Abd: soft, NTND, No HSM or tenderness. Ext: No LE edema/clubbing Skin: Large ecchymosis on forearms bilaterally Pulses: 2+DP/PT pulses bilaterally NEURO: A&O x3, knows president is "[Last Name (un) 2450]" CN 2-12 grossly intact Sensation intact throughout 5/5 strength in both UE/LE equally, bilaterally Possibly mild asterixis Pertinent Results: EKG demonstrated bradycardia, no evidence of heart block or ST/T changes. . CT Head on admission(wet read): Interval evolution of the recent left subdural hematoma without significant increase in size. Minimal increase in the rightward subfalcine herniation, now measuring 8 mm compared to prior 6 mm. The temporal parenchymal contusion has also evolved appearing less dense today. No other interval changes. . CT C-spine on admission(wet read):no acute fractures or dislocations. Post surgical changes from C4 to C6 laminectomy. . CXR on admission(my read): bases not visualized, o/w no evidence of pleural effusion/edema, no consolidations noted . LABORATORY DATA: CK: 67 MB: Notdone TNI:<.01 WBC 13.2 (77N, 15L) Hct 38.1 Plts 270 . 136 / 99 / 13 / --------------- 4.1 / 26 / 0.7 . CK: 67 Trop <.01 . ALT 42, AST 27 Alk phos 79, T. Bili 0.4 U/A negative Dilantin 14.9 Serum Tox- Positive for benzos Urine Tox- positive for benzos [2170-8-7] 10:40PM TSH-1.0 [2170-8-8] 06:34AM GLUCOSE-120* UREA N-12 CREAT-0.7 SODIUM-137 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13 [2170-8-8] 06:34AM ALBUMIN-4.2 [2170-8-8] 06:34AM WBC-9.8 RBC-4.08* HGB-12.2* HCT-34.1* MCV-84 MCH-29.9 MCHC-35.8* RDW-13.1 [2170-8-8] 04:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2170-8-7] 10:40PM CK-MB-NotDone cTropnT-<0.01 Brief Hospital Course: A/P: 56 yo male with no signficant PMH who recently sustained SDH s/p fall who now presents with syncopal episode and fall and found to have sinus bradycardia. . # Syncope: New onset sinus bradycardia. Likely related to increased vagal tone from recent SDH + sinus bradycardia related to Dilantin. No structural heart disease (had TTE w/ EF of >55%, no LV dysfunction or aortic stenosis, no septal defects or vegetations), no ischemia (EKG w/o any evidence of this, all cardiac enzymes were negative), ingestions of medications, (pts serum Benzo positive). He was also found to be orthostatic. Less likely seizure given no incontinence/post-ictal period/therapeutic dilantin levels. The patient was given 1 L NS bolus, q2-4 hour neuro checks, and monitored on telemetry. His Dilantin was changed to Keppra 500 [Hospital1 ]. Patient has no carotid bruits on exam. TIA and seizure were considered less likely on the differential, so Carotid doppler U/S and EEG were deferred and can be done on an outpatient basis. Due to continued bradycardia w/ symptomaticity (hypotension), and a rpt Head CT on 7.25 showing increased midline shift, he was taken to the OR on 7.25 for SDH evacuation and given a pacer. Pts bradycardia subsequently improved and temporary pacer was removed [2170-8-13]. Pt was transferred to the floor on [2170-8-13] and telemetry documented a HR between mid 40's to high 80s. He had no more symptomatic bradycardic events before discharge. . # Rhythm: Sinus bradycardia w/o evidence of AVB; likely due to increased vagal tone in setting of SDH. Other etiology may include recently started Dilantin which can also contribute and cause bradycardia. Dilantin level was therapeutic at time of admission and albumin was WNL, but this medication can still cause sinus bradycardia even when not at toxic levels. Hypothyroidism was unlikely given his TSH was normal. Pacer pads were kept in place, and atropine and dopamine were kept at bedside, but were never required. His opiod medications were also held. Because the patient lives in [State 350], Lyme serologies were sent and were found to be negative. The patient was evaluated by the EP service, and the initial recommendation was to not place a pacer, and to have Holter monitering 2 weeks after discharge. The patient was sent to the floor, and proceeded to have bradycardia to the 20s while he slept, responsive to atropine. He was then transferred back to the MICU. Following this, he was found to be bradycardic and symptomatic (hypotensive) requiring a dopamine gtt to increase heart rate. At this point EP decided it was appropriate to to place a temporary pacing wire. He was then re-transferred back to the MICU for monitoring, and after SDH evacuation, his HR improved and his temporary pacing wire was removed. He was transferred back to the floor and monitored on telemetry, where his HR remained in the mid 40s to high 80s. # MS changes: Unclear if this patient truly has any MS changes; per notes, there was a question of a personality change; however exam unrevealing. LFTs were within normal limits. Family believes patient's MS is at baseline. . # SDH/HA: His SDH from [2170-8-1] fall was stable in size from previous admission, with a minimal midline shift only slightly increased from admission per Head CT. Pts phenytoin level 14.9 on admisison. Neurosurgery evaluated pt in ED and felt SDH stable and its undergoing chronification process that can cause minimal increased in mass effect but currently w/o symptoms except for headache. Dilantin was changed to Keppra (see above), and patient was given Tylenol and Codeine (low dose and as needed to prevent increased bradycardia) for chronic headache likely related to SDH. He also received an evacuation of the SDH (see above "Seizure/Sinus Bradycardia") on [8-10] . # Leukocytosis: Predominant lymphocytosis (WBC 13) more c/w viral etiology/stress response. He was afebrile during his hospital course. WBC trended down to 9.8 on discharge. No source of infection at this time. His CXR showed no evidence of PNA, and urine analysis was negative. No antibiotics were given. His WBC increased to 14 on [8-13] and trended down to 10.2 on the day of discharge. He remained afebrile on the floor. . #[Name (NI) ] Pt was mildly hypertensive in the ED, and received Hydralazine. he was subsequently hypotensive and orthostatic. His BP improved w/ 1 Liter NS Bolus x1. Dopamine and atropine were kept at his beside, but his BPs remained stable w/ MAPS > 60 while in the ICU and did not require pressors. On the floor, his blood pressure was stable and he did not require further anti-hypertensive medication. . #[Name (NI) ] Pt required occasional percocet to control HA on the medicine floor. HA did not change in character, and was classified as dull, L sided, constant, nonphotophobic and without N/V and neurological symptoms. . # FEN: Regular diet. Electrolytes checked daily. . # Prophylaxis: pneumoboots (no ASA or heparin SC given recent SDH). No PPI or bowel reg necessary. . #Access- 2 PIVs . # Code: Full (confirmed with pt) . # Communication: Daughter [First Name8 (NamePattern2) 547] [Name2 (NI) ] [Telephone/Fax (1) 79646] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 79646] Jacks [Telephone/Fax (1) 79647] . # Dispo: Home with at home safety evaluation Medications on Admission: Dilantin 100mg TID x10 days (started [8-3]) Klonopin 1mg prn Ativan 2mg prn . Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:30 Tablet(s) Refills:0 2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Sinus Bradycardia Subdural Hematoma Discharge Condition: good, normal vital signs Discharge Instructions: You were admitted to the [Hospital1 18] with the diagnosis of bradycardia (low heart rate.) This is likely related to the initiation of the anti-seizure drug Dilantin, which can sometimes cause low heart rates, and your nervous sytem reaction to the recent subdural hematoma (head bleed). You had a pacer placed on [8-10] to stabilize your Heart Rate and this was removed on [2170-8-13] . Your head bleed is stable on imaging, but was causing some increased brain swelling and continued low heart rate, so you underwent an drainage of the bleed. and has not increased in size. The Dilantin was changed over to another medication called Keppra which does not have the same heart slowing effects. You were discharged in good health. Please return to the nearest ED or contact your primary care physician if you experience another fall where you injure your head or another part of your body, dizziness, loss of consciousness/blackouts, palpitations, chest pain, or any other symptoms not listed here that are concerning to you. . . Please DO NOT drive a car, operate any heavy machinery or any other automated vehicles in the next 6 months or until you are cleared by your primary care physician or cardiologist that you can operate these vehicles safely. Followup Instructions: Please make an appointment to follow up with your primary care physician. [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ] [Telephone/Fax (1) 8572]. . You should have your PCP contact the [Hospital1 18] microbiology laboratory at ([Telephone/Fax (1) 20850] to follow up on the results of the tests for Lyme disease that were still pending at the time of your discharge. . Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2170-9-4] 9:45 . Please follow up with the neurosurgeons who treated you for your subdural hematoma. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6214], MD Phone:[Telephone/Fax (1) 3736] Date/Time:[2170-9-4] 11:45. . Please follow up with cardiology, as they would like to do a Holter monitering assessment for you in about 2 weeks after you are discharged. The cardiology fellow who was following you was Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5858]. Completed by:[2170-8-16] ICD9 Codes: 4019, 4589, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7848 }	Medical Text: Admission Date: [2128-6-8] Discharge Date: [2128-6-24] Date of Birth: [2073-7-29] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 297] Chief Complaint: shortness of breath; transfer from OSH Major Surgical or Invasive Procedure: 1) Tracheostomy 2) PEG tube placement History of Present Illness: This is a 54 year old woman with past medical history significant for multisystem atrophy, previously thought to have Parkinson's Disease, but found to have rapidly progressing symptoms and autonomic phenomena, followed by Dr. [Last Name (STitle) ] for her movement disorder, who has had several major hospitalizations in the past including hospitalization earlier this year in [State 108] for urosepsis, intubated, and transferred up to [Hospital1 18] for continuity of care and had failure to wean from the vent, eventually transferred to [Hospital ] Rehab facility and weaned successfully, who presents as a transfer from [Hospital ] Hospital where she had presented with two days of shortness of breath. The patient is nonverbal, but her husband provides the history of two days of upper respiratory symptoms including coughing, wheezing, sounding congested but with no sputum production. She was advised by her primary care physician's coverage to try mucinex for secretions, but this did not help, and she developed a low grade temperature to 99 or 100 at home. She became more short of breath as noticed by her husband, and was seen by [Name (NI) 269] on [6-7] and advised to go to the ER. She was taken by rescue to [Hospital ] Hospital ER, where she received one dose each of Vanco, Azithro, Levaquin, and two doses of Zosyn before being transferred to [Hospital1 18] the following day for continuity of care; she was accepted to a neurology stepdown bed. She was at [Hospital ] Rehab after her last [Hospital1 18] discharge until [3-2]. At baseline, she is wheelchair-bound over the past year and one half, and nonverbal except for an occasional word (ie, saying "okay.") Past Medical History: Hx C/S (G2P2) 1) MSA, originally diagnosed with PD in [2120] - followd by Dr [Last Name (STitle) ] for movement disorder 2) Hx C/S (G2P2) 3) ? pituitary adenoma 4) Osteoporosis 5) Admit [1-2] urosepsis c/b respiratory failure with prolonged wean requiring tracheostomy Social History: The patient lives at home with her husband, who is her primary caretaker. She has two children. She has a distant smoking history but does not drink alcohol. Family History: Father with myocardial infarction. Mother with [Name2 (NI) 499] cancer at age 80. Physical Exam: Physical Exam: Vitals: T: P: R: BP: SaO2: General: Awake, alert, and cooperative with exam in no acute distress. HEENT: Normocephalic, no scleral icterus noted, clear oropharynx with moist mucus membranes Neck: supple, with no JVD or carotid bruits appreciated Pulmonary: Lungs clear to auscultation bilaterally without wheezes, rhonchi or rales Cardiac: regular rate and rhythm, with no murmurs Abdomen: soft, nontender, with normoactive bowel sounds, no masses or organomegaly noted. Extremities: Warm with no edema and good pulses throughout Skin: no rashes or lesions noted. Neurologic: Mental status: Nonverbal, able to close and open eyes on command and can open/close eyes to denote "yes" or "no" (with number of blinks). Moans once during exam. Awake and attentive. Cranial Nerves: Olfaction not tested. Pupils equal, round and reactive to light bilaterally, 4->3 mm bilaterally; visual fields intact by blink to threat from lateral and medial directions (both eyes). No ptosis is noted, extra-ocular muscles were intact with saccadic movements; 3-4 beats nystagmus bilaterally far gaze. Sensation was intact to light touch over face. No facial asymmetry was noted, and hearing was intact to voice bilaterally. Unable to assess SCMs and traps. Unable to assess uvula, tongue if midline. Motor: bilateral hand tremor and left leg tremor visible when limbs lifted by observer. Unable to assess for drift. Bilateral deltoid atrophy. Left hand dystonia, in flexor position (wrist, elbow), adducted; right leg flexed at knee and foot dorsiflexed at rest, with upgoing toe. Unable to lift hands against gravity but is able to hold them up for 1 second before dropping. Legs held up for split second before dropping, unable to lift on her own against gravity. No obvious fasiculations. Sensory: Patient winces and blinks eyes once (meaning "yes") to pain in all four extremities Coordination: Normal finger to nose and heel to shin, with no dysmetria. No dysdiadochokinesia noted on rapid alternating hand movements or finger tapping. Reflexes: 2+ biceps, triceps, brachioradialis, 3+ left patellar 2+ right patellar and 2+ ankle jerks bilaterally. The patient had bilaterally upgoing toes on plantar response. Gait: Unable to assess Pertinent Results: [2128-6-24] 04:07AM BLOOD WBC-6.7 RBC-3.13* Hgb-9.0* Hct-27.5* MCV-88 MCH-28.8 MCHC-32.8 RDW-13.6 Plt Ct-311 [2128-6-23] 04:06AM BLOOD WBC-8.4 RBC-3.68* Hgb-10.6* Hct-32.8* MCV-89 MCH-28.8 MCHC-32.3 RDW-13.8 Plt Ct-396 [2128-6-22] 04:00AM BLOOD WBC-8.1 RBC-3.44* Hgb-10.2* Hct-30.6* MCV-89 MCH-29.5 MCHC-33.2 RDW-13.5 Plt Ct-332 [2128-6-21] 04:15AM BLOOD WBC-9.9 RBC-3.53* Hgb-10.4* Hct-31.8* MCV-90 MCH-29.3 MCHC-32.6 RDW-13.8 Plt Ct-336 [2128-6-20] 04:12AM BLOOD WBC-9.0 RBC-3.43* Hgb-10.0* Hct-30.7* MCV-90 MCH-29.2 MCHC-32.6 RDW-13.6 Plt Ct-297 [2128-6-19] 04:55AM BLOOD WBC-8.5 RBC-3.49* Hgb-10.2* Hct-31.0* MCV-89 MCH-29.3 MCHC-33.0 RDW-13.5 Plt Ct-263 [2128-6-8] 11:29PM BLOOD WBC-9.1 RBC-3.79* Hgb-10.9* Hct-36.1 MCV-95 MCH-28.9 MCHC-30.3* RDW-13.1 Plt Ct-189 [2128-6-9] 03:57AM BLOOD Neuts-78.2* Lymphs-15.7* Monos-4.5 Eos-1.3 Baso-0.2 [2128-6-24] 04:07AM BLOOD Plt Ct-311 [2128-6-13] 02:58AM BLOOD Plt Ct-171 [2128-6-8] 11:29PM BLOOD Plt Ct-189 [2128-6-8] 11:29PM BLOOD PT-12.3 PTT-26.8 INR(PT)-1.0 [2128-6-24] 04:07AM BLOOD Glucose-98 UreaN-12 Creat-0.4 Na-136 K-4.1 Cl-102 HCO3-29 AnGap-9 [2128-6-23] 04:06AM BLOOD Glucose-109* UreaN-11 Creat-0.4 Na-141 K-4.4 Cl-101 HCO3-31 AnGap-13 [2128-6-21] 04:15AM BLOOD Glucose-103 UreaN-14 Creat-0.5 Na-138 K-4.9 Cl-98 HCO3-35* AnGap-10 [2128-6-8] 11:29PM BLOOD Glucose-112* UreaN-7 Creat-0.5 Na-138 K-5.2* Cl-100 HCO3-33* AnGap-10 [2128-6-15] 02:26PM BLOOD ALT-14 AST-20 LD(LDH)-233 AlkPhos-78 Amylase-70 TotBili-0.2 [2128-6-15] 02:26PM BLOOD ALT-14 AST-20 LD(LDH)-233 AlkPhos-78 Amylase-70 TotBili-0.2 [2128-6-18] 04:10AM BLOOD Lipase-84* [2128-6-15] 02:26PM BLOOD Lipase-75* [2128-6-24] 04:07AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.8 [2128-6-15] 05:38PM BLOOD Vanco-10.6* . EMG IMPRESSION: . Limited, abnormal study. There is electrophysiologic evidence for a generalized dysfunction of motor fibers but this limited study cannot adequately discriminate between a process involving motor nerves or muscles. . CT IMPRESSION: 1. Probable inflammatory/allergic abnormalities in paranasal and mastoid sinuses, as noted above. 2. Soft tissue density in the nasopharynx and oropharynx, probably representing secretions. Clinical correlation is recommended. NOTE: There is prominent cerebellar and brainstem atrophy. The prominent electromyographic finding is one of generalized poor activation, consistent with the patient's known central nervous system disorder. The limited neuromuscular transmission studies were normal. CXR ([6-23]): Bilateral moderate pleural effusions that are stable. Brief Hospital Course: CC:[CC Contact Info 100324] HPI: 54 yoF w/ for multisystem atrophy transferred from OSH with pneumonia and hypoxia, admitted to Neuro step dow unit. The patient is nonverbal, but her husband provides the history of two days of upper respiratory symptoms including non-productive cough and wheezing, followed by low grade fever (99-100). On [6-7] she developed worsening shortness of breath and was advised by [Month/Year (2) 269] to go to ED, where T 102.1 EMS took her to [Hospital 100325] hospital, where she received Vanco, Azithro, Levaquin, and two doses of Zosyn before being transferred to [Hospital1 18] [6-8]. At baseline, she is wheelchair-bound for the past year and one half, and nonverbal except for an occasional word (ie, saying "okay."). On the neurolofy floor, T 97, bp 100/57, HR 111, resp 31, 95% 10 L FM. She became progressively hypoxic to 88% on 10 L FM. ABG 7.14/111/76. She was intubated for hypercarbic respiratory failure and transferred to the MICU. The patient was transferred to the neurology floor and was initially noted to be in no acute distress, on 10L O2 FM but with O2 sats in the high 90s. Her respiratory rate was in the 18 range. She was not noted to be particularly sleepy or agitated. One hour later, her sats were dropping and she was tachypneic. She was placed on 100% nonrebreather and ABG was performed with the following results: PH 7.14; PCO2 111, PO2 40 O2 Sats 76%; Temp noted to be 99.5. Code status readdressed with husband who confirmed Full Code. MICU notified. Patient continued to deteriorate and a code was called. Anesthesia intubated her and she was transferred to the MICU. PROBLEM LIST: 1. MRSA PNA 2. ESBL KLEB PNEUMONIAE UTI 3. RECURRENT FEVERS 4. MASTOIDITIS 5. FUNGURIA MICRO: CDIF (-) X 1, SPUT [6-14], [6-19] (mrsa), [6-21] (GPC 2+), BLD 7/16/17/18 (-), URINE >100K YEAST) RAD ([6-22]): CXR slight decrease in left pleural effusion, right stable. no new inflitrate SUMMARY: 15 DAY hospital course, 54 yoF w/ multisystem atrophy presents with hypercarbic respiratory failure likely secondary to multifocal pneumonia superimposed on chronic respiratory acidosis in the setting of hypoventilation. Stabilized early in course put proved difficult to wean from mechanical ventilation secondary to periodic apnea and indicated by poor NIF scores. . 1) Hypercarbic respiratory failure: likely [12-31] multifocal pneumonia (CAP vs aspiration) superimposed on chronic respiratory acidosis in the setting of hypoventilation. Given neuromuscular weakness, patient proved difficult to wean and underwent a tracheostomy and PEG tube placement on HD 14. - ceftriaxone/azithromycin/clindamycin initially administered for CAP/aspiration pna. Changed to vancomycin with MRSA positive sputum. - Urinary legionella Ag negative; blood, urine clx negative - alb/atr MDI standing and PRN throughout hospitalization - Vancomycin-> completed 10 day course for MRSA pneumonia . 2) Fevers: Persistent fevers despite meropenem and vancomycin. Resolved on [2128-6-21]. [Month (only) 116] be component of Shy [Last Name (un) ] Syndrome, however, patient worked up and treated for multiple other potential etiologies. Sinus CT [6-15] with fluid in mastoids bilaterally, potential for mastoiditis; Treated per ENT recommendations with meropenam x 7 days. - concern for loculated pleural effusions; unable to find tappable pocket - bilateral LENI negative - [6-9] ucx grew resistant klebsiella pneumoniae; although subsequent ucx have been negative. Completed 7 day course of meropenam. . 3) Multisystem atrophy: Initially methylphenidate, Midodrine, carbidopa/levodopa, fludrocort for now. Restarted carbidopa/levodopa and methylphenidate per neuro. Added back fludrocrot given postural hypotension. EMG c/w shy-[Last Name (un) ], no other abnormalities seen. Neurology followed closely throughout hospitalization. . 4) Chronic constipation: large amount of stool in bowel. Chronic constipation in setting of Shy [Last Name (un) 16294]. C. diff neg. Aggressive bowel regimen resulted in acceptable stool output. [Month (only) 116] need to consider home bowel regiment. Medications on Admission: Sinemet, Ritalin, florinef, methylphenidate, zoloft, proamatine, macrobid, ambien, atrovent and albuterol nebs, nasonex (recently d/c'ed). Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q2H PRN (). 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [11-30] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for constipation. 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO every other day. 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 10. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): Please give doses at 7am, 10am, 1pm, and 4pm daily. . 11. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please give doses at 7am and 10pm daily. . 12. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO 5X/D (5 times a day): Please give doses at 7am, 10am, 1pm, 4pm, and 7pm daily. . 13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 14. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please give at 7am daily. . 15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 16. Famotidine in Normal Saline 20 mg/50 mL Piggyback Sig: Twenty (20) mg Intravenous Q12H (every 12 hours). 17. Lorazepam 1-2 mg IV Q4H:PRN 18. Morphine Sulfate 1-3 mg IV Q4H:PRN Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: HYPERCARBIC RESPIRATORY FAILURE PNEUMONIA Discharge Condition: STABLE/GOOD Discharge Instructions: FOLLOW UP WITH PRIMARY CARE PHYSICIAN AND NEUROLOGIST CARE PER [Hospital1 ] GUIDELINES- TRACHEOSTOMY CARE, PHYSICAL/OCCUPATIONAL THERAPY PEG CARE- PER PROTOCOL Followup Instructions: Please call your PCP (Dr. [First Name (STitle) 1313] [Telephone/Fax (1) 7318]) for a follow up appointment after discharge from rehab. ICD9 Codes: 5990, 2762, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7849 }	Medical Text: Admission Date: [2165-6-25] Discharge Date: [2165-7-2] Date of Birth: [2165-6-25] Sex: F Service: NB HISTORY: Baby Girl [Known lastname ] [Known lastname ], triplet #1, delivered at 32 5/7 weeks gestation and was admitted to the Newborn Intensive Care Unit for management of prematurity. Birth weight was 1865 grams. The mother is a 31 year-old gravida V, para I, now IV woman with estimated date of delivery [2164-8-15]. Prenatal screens included blood type A positive, antibody screen negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, cystic screening negative, and group B strep unknown. [Hospital 37544] medical history notable for depression treated with Zoloft. OB history notable for infertility treated with Clomid. This pregnancy was complicated by triplet gestation, cervical shortening, and pregnancy-induced hypertension. Delivery was by cesarean section under spinal anesthesia for pregnancy-induced hypertension. There was no labor or fever. Membranes were ruptured at delivery for clear fluid. The mother did not receive any antibiotics prior to delivery. The infant emerged vigorous at delivery, was given free flow oxygen. Apgars scores were 8 at one minute and 8 at five minutes. PHYSICAL EXAMINATION: On admission birth weight 1865 grams (50th to 75th percentile), head circumference 32.5 cm (90th percentile), length 42 cm (25th to 50th percentile). A well appearing infant in no distress, nondysmorphic, palate intact, head, neck mouth normal, normocephalic, mild nasal flaring, red reflex normal, no retractions, good breath sounds bilaterally, no crackles, well perfused with regular rate and rhythm, femoral pulses normal, normal S1, S2, no murmur. Abdomen soft, nondistended, no organomegaly, no masses. Bowel sounds active, anus patent, three vessel umbilical cord, normal female genitalia, active, alert with AGA tone and symmetric, moves all extremities equally. Gag and suck intact. Grasp symmetric. Skin without lesions. Normal spines. Stable hips. HOSPITAL COURSE: RESPIRATORY: Was placed on continuous positive airway pressure with room air from mild respiratory distress. She weaned off C-PAP at 12 hours of life. Has been in room air since with comfortable work of breathing. Respiratory rates in the 40s to 60s. No apnea. CARDIOVASCULAR: Has been hemodynamically stable throughout this hospitalization. No heart murmur. Heart rate ranges in 130s to 160s. Recent blood pressure is 70/37 with a mean of 53. FLUIDS, ELECTROLYTES AND NUTRITION: Initially NPO receiving IV fluid of D10W. Antral feeds were started on day of life 1 and she advanced to full volume feedings of breast milk or Special Care formula on day of life 6 without problems. Presently she is receiving breast milk 20 or Special Care 20 at 150 ml per kilo per day with tolerance. She is farting and stooling appropriately. Most recent electrolytes on day of life 1 were sodium 131, potassium 5.8, chloride 98 and CO2 20. On discharge weight is 1820 grams unchanged from previous day. Feedings are 150 cc/k/d of breast milk or special Care 24. GASTROINTESTINAL: Physiologic jaundice with peak bilirubin total 7.2, direct .3 on day of life 4 ([2165-6-29]). Bilirubin on day of life 5 ([2165-6-30]) was down to total of 6.9, direct .3. She did not receive phototherapy. HEMATOLOGY: Hematocrit on admission 46%. Did not receive blood transfusions. INFECTIOUS DISEASE: Received Ampicillin and Gentamicin for 48 hours for rule out sepsis. CBC on admission showed a white count of 9.3 with 20 polys, 0 bands, platelets were 350,000. Blood culture was negative. NEUROLOGY: Head ultrasound not indicated. SENSORY: Has not had hearing screen yet. Will need prior to discharge home. CONDITION AT DISCHARGE: Stable 7 day-old former 32 [6-8] week and now 33 5/7 weeks post menstrual age. DISCHARGE DISPOSITION: Transfer to [Hospital ] Hospital. Name of primary pediatrician is Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at 1 Parkway in [Location (un) ], [Numeric Identifier 62015]. Telephone number is [Telephone/Fax (1) 62016]. CARE AND RECOMMENDATIONS: 1. FEEDS: Breast milk or Special Care formula 24 calories per ounce at 150 ml per kilo per day. 2. MEDICATIONS: On no medications at present. 3. STATE NEWBORN SCREEN: Was sent on [2165-6-28] and is pending. 4. Has not received any immunizations. DISCHARGE DIAGNOSES: 1. AGA 32 5/7 weeks preterm female. 2. Triple #1. 3. Transitional respiratory distress, resolved. 4. Physiologic jaundice. 5. Perinatal sepsis ruled out. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2165-7-1] 16:23:34 T: [2165-7-1] 17:33:43 Job#: [Job Number 62017] ICD9 Codes: 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7850 }	Medical Text: Admission Date: [2188-8-28] Discharge Date: [2188-8-30] Date of Birth: [2136-2-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1515] Chief Complaint: transfer from OSH for arrhythmia Major Surgical or Invasive Procedure: cardiac cath History of Present Illness: 52 year old male with CABG [11/2186] who presented to [Hospital 487] Hospital with description of "blacking out". Patient presented to [Hospital1 487] at 6 pm and described "blacking out" with chest pain. His presenting vitals were Bp 111/76, HR 111, RR 22, T 98.8. Per report patient's rhythm was rapid Atrial Fibrillation with frequent runs of ventricular tachycardia. EKG demonstrates A Fib with RVR and non-sustained v tach. HR as high as 150-200. Patient was given ASA, Heparin and plavix 300mg. Per nursing record patient was given Amiodarone 150 mg, Lidocaine 75 mg, Magnesium 2g. Cardioversion was attempted with 50 J. Patient was then started on Diltiazem and Lidocaine drip. Transferred to [Hospital1 18] ED for further care. Prior to transfer patient was in sinus. On presentation to [Hospital1 18] ED BP 82/57, BP improved with cessation of diltiazim. Patient was admitted to CCU for closer monitoring. . Patient describes one day history of pre-syncope as "blacking out". Denies syncope. On presentation to [Hospital1 487] he describes chest discomfort - unable to describe further - which resolved prior to transfer. He describes palpatations and nausea. Denies shortness of breath. Yesterday he experienced chest pain with inspiration, which has since improved. Otherwise patient describes his usual state of health. Denies chest pain or SOB with exertion since CABG in [Month (only) 404]. . He denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Past Medical History: 1. CARDIAC RISK FACTORS: Denies diabetes, + dyslipidemia, denies hypertension 2. CARDIAC HISTORY: -CABG: s/p Coronary artery bypass graft surgery (left internal mammary artery>left anterior descending, saphenous vein graft>obtuse marginal 1, saphenous vein graft > obtuse marginal 2 > obtuse marginal 3, saphenous vein graft > posterior descending artery) [2187-12-13] Social History: Former boxer, former truck driver Tobacco 1 1/2 packs per every two days for > 20 years Family History: Mother with CAD. No family history of DM, sudden death Physical Exam: On discharge: T 98.2, HR 60-71, 87-122/54-78, R18-20, 95-96% on RA, Is and Os not recorded. GEN: lying comfortably in bed, NAD HEENT: MMM CV: RRR, no MRG PULM: CTA B ABD: soft, NT, ND, +BS EXT: WWP, no CCE Pertinent Results: [2188-8-30] 07:30AM BLOOD WBC-10.1 RBC-5.24 Hgb-15.4 Hct-45.6 MCV-87 MCH-29.5 MCHC-33.9 RDW-13.2 Plt Ct-289 [2188-8-29] 04:17AM BLOOD Ret Aut-1.5 [2188-8-30] 07:30AM BLOOD Glucose-145* UreaN-17 Creat-1.0 Na-140 K-4.4 Cl-105 HCO3-23 AnGap-16 [2188-8-29] 04:17AM BLOOD CK-MB-11* MB Indx-6.0 [2188-8-30] 07:30AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.0 [2188-8-29] 04:17AM BLOOD calTIBC-308 Ferritn-153 TRF-237 [2188-8-28] 05:32AM BLOOD TSH-1.2 . Cardiac cath [8-28]: . Native LAD fed well by patent LIMA; LCX w/ small OM1 and small OM2. OM2 upper pole w/ lesion that was treated fairly effectively by 2.0mm PTCA. Lower pole was occluded. Attempt to wire the lower pole failed. Distal LCX that fed into an OM3 had a stenosis as well. This was treated by PTCA and 2.5x18mm Promus stent. RCA fed well by SVG. . [8-28] ECHO: . The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with severe global 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 appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [2187-12-8], there is now inferior-posterior hypokinesis and severe global right ventricular hypokinesis. Brief Hospital Course: 52 year old M history of CABG who presented to OSH for pre-syncope. Patient found to be in A Fib with RVR, non-sustained VT and sustained VT, s/p cath with stent placement. He was discharged on [Doctor Last Name ] of hearts monitor out of concern for potential return of a ventricular arrhythmia. . # RHYTHM: EKG from the OSH showed A Fib with RVR with rate up to 150-200 and non-sustained VT which explains his pre-syncopal episodes on admission to the OSH. OSH reported sustained VT but no record of this episode. While he c/o CP one day prior to admission, seemed to be pleuritic and there were no EKG changes concerning for MI or pericarditis. He was in sinus rhythm on admission and discharge to this hospital. Although we planned to discharge him on Sotalol 80 mg [Hospital1 ], dose was decreased on discharge because of low pressures and pulse. He was discharged on [Doctor Last Name ] of hearts for arrhythmia monitoring and was also told to send daily recordings to check for QT prolongation given initiation of sotalol. Pt will f/u with EP at [Hospital1 ] as well as his out-pt cardiologist, Dr [Last Name (STitle) 29070]. . # CORONARIES: Troponin elevation most likely related to rate and cardioversion at OSH(50 J). However, pt was cathed out of concern for ACS stents placed to OM2 and distal LCX that fed into an OM3. He on Plavix given his recent stent placement. ACE held due to low BPs. . # PUMP: [8-28] ECHO showed EF 40-50%, inferior-posterior hypokinesis and severe global right ventricular hypokinesis not seen on prior ECHO in [11-30]. Pt was treated with BBlocker, aspirin, and statin for systolic HF. ACE held due to low BPs, however would recommend starting as an outpatient if tolerated. . # Hyponatremia: Normalized during the admission. Most likely related to D5W in lidocaine drip. . Pt was FULL CODE. Medications on Admission: - ASA 81 mg - Unknown herbal medication for high cholesterol Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): DO NOT STOP TAKING UNLESS DIRECTED BY YOUR CARDIOLOGIST. . Disp:30 Tablet(s) Refills:2 4. Sotalol 80 mg Tablet Sig: one-half Tablet PO twice a day: Take one half tablet twice a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Atrial Fibrillation Ventricle Tachycardia Coronary artery disease Discharge Condition: Good, ambulating, no chest pain. Discharge Instructions: You were admitted for an abnormal heart rythym. To investigate the underlying cause you had a cardiac catherization which demonstrated blockage in one of your grafts and consequently a stent was placed. It is very important for your heart to take your new medications. . Medications: NEW Aspirin, Sotalol, Atorvastatin, Plavix DO NOT STOP PLAVIX UNLESS TOLD BY YOUR CARDIOLOGIST TAKE ALL YOUR MEDICATIONS THEY ARE VERY IMPORTANT FOR YOUR HEART . You are being discharged on a heart monitor to monitor your rythym. It is very important you follow the instructions given to you. You must transmit data each day to monitor your rythym on Sotalol. . Follow-up: -Call your cardiologist Dr [Last Name (STitle) 29070] ([Telephone/Fax (1) 37284]) to schedule an appointment in [11-23] weeks -Call your primary care doctor for follow-up in 2 weeks. -Also, please make an appointment with with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in Dr [Last Name (STitle) 34490] clinic in 2 weeks. You can make this appointment by calling the clinic at [Telephone/Fax (1) 62]. . Return to the hospital if you experience dizziness, chest pain, shortness of breath, blacking out or any other concerning symptoms. Followup Instructions: Follow-up: Call your cardiologist Dr. [Last Name (STitle) 29070] ([Telephone/Fax (1) 37284]) to schedule an appointment in [11-23] weeks Call your primary care doctor for follow-up in 2 weeks. Also, please make an appointment with with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in Dr [Last Name (STitle) 34490] clinic in 2 weeks. You can make this appointment by calling the clinic at [Telephone/Fax (1) 62]. ICD9 Codes: 2761, 4271, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7851 }	Medical Text: Admission Date: [2108-6-26] Discharge Date: [2108-7-2] Date of Birth: [2049-2-6] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 301] Chief Complaint: Morbid obesity Major Surgical or Invasive Procedure: [2108-6-26]: Laparascopic sleeve gastrectomy History of Present Illness: [Known firstname ] has class III extreme morbid obesity with weight of 364.3 pounds as of [2108-5-29] (her initial screen weight on [2108-5-22] was 368 pounds), height of 65 inches and BMI 60.6. Her previous weight loss efforts have included HMR for one year in [2104] losing 20 pounds, off-label prescription weight loss medication combination of fenfluramine/phentermine ("Fen/Phen") in [2092] for one year losing 70 pounds and [Street Address(1) 41635] visits on/off over the past 5 years with very little weight loss. She has exercise for two years at Curves for Women losing 50 pounds and one year of [Location (un) 86] Sports Club in [2106] to [2107] losing 20 pounds. In all of her efforts whatever weight she loss she was unable to maintain from no more than one year. She denied taking over-the-counter ephedra-containing appetite suppressant/herbal supplements. Her weight at age 21 was 150 pounds with her lowest adult weight 125 pounds and her highest weight being 377 pounds earlier this year (2/[2108]). She weighed 192 pounds at age 33, 200 pounds at age 38, 286 pounds at age 46 and 325 pounds at the age of 50. She stated she developed a significant [Last Name 4977] problem at the age of 35 and has been struggling with weight since birth of her second child and quit smoking in [2081]. Factors contributing to her excess weight include large portions, genetics, too many carbohydrates and emotional eating. For exercise she does water aerobics 60 minutes 5 days per week since [Month (only) 359] and lap swimming 90 minutes 5 days per week. She denied history of eating disorders and does have depression but has not been followed by a therapist nor has she been hospitalized for mental health issues and she is on psychotropic medication (sertraline). Past Medical History: Past Medical History: Notable for fatty liver, rotator cuff tendinitis, right shoulder, obstructive sleep apnea, type 2 diabetes with A1c of 6%, dyslipidemia, gastroesophageal reflux, osteoarthritis of the knees, aortic valve regurgitation, past depression. Past Surgical History: C-section x 2, carpal tunnel, right hand Social History: She smoked one to two packs a day for 25 years quit [2091], no recreational drugs, has occasional alcohol, drinks caffeinated beverages. She is a retired teacher, is divorced and has two adult children Family History: Her family history is noted for father deceased age 58 with heart disease, hyperlipidemia and obesity; mother living with hyperlipidemia; sister deceased at 36 years of age secondary to bulimia; maternal and paternal grandparents with heart disorders. Physical Exam: VS: T 98, HR 86, BP 149/65, RR 18, O2 97%RA Constitutional: NAD Neuro: Alert and oriented x 3 Cardiac: RRR, NL S1,S2 Lungs: CTA B Abd: Soft, appropriate peri-incisional tenderness, no rebound tenderness/guarding Wounds: Abd lap sites with steri-strips CDI, no periwound erythema, + periwound ecchymosis Ext: No edema Pertinent Results: LABS: [2108-6-27] 07:40AM BLOOD Hct-36.2 [2108-6-26] 04:21PM BLOOD Hct-38.4 [2108-6-28] 09:38AM BLOOD Type-ART pO2-70* pCO2-47* pH-7.40 calTCO2-30 Base XS-2 [2108-6-30] 06:40AM BLOOD WBC-5.6 RBC-4.21 Hgb-11.3* Hct-36.6 MCV-87 MCH-26.7* MCHC-30.7* RDW-15.2 Plt Ct-184 Neuts-81.0* Lymphs-12.6* Monos-3.6 Eos-2.7 Baso-0.1 IMAGING: [2108-6-27]: UGI SGL CONTRAST W/ KUB: IMPRESSION: No evidence of obstruction or leak. Brief Hospital Course: The patient presented to pre-op on [2108-6-26]. Pt was evaluated by anaesthesia and taken to the operating room where she underwent a laparascopic sleeve gastrectomy. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, then transferred to the [Hospital1 ] for observation. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with a PCA and then transitioned to oral Roxicet once tolerating a stage 2 diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was triggered on POD2 for desaturations with an increased oxygen requirement. The patient was subsequently transferred to the TSICU on POD2 where she was weaned to 3L nasal cannula; vancomycin was initiated as empiric therapy. She was subsequently transferred back to the general surgical [Hospital1 ] on POD3 and weaned completely from O2 on POD5. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. The pt was maintained on CPAP overnight for known sleep apnea. GI/GU/FEN: The patient was initially kept NPO. On POD1, an upper GI study, which was negative for a leak, therefore, the diet was advanced sequentially to a Bariatric Stage 2 diet, which was well tolerated. However, on POD2, during period of acute oxygen desaturation, the pt was made NPO. A methylene blue dye test was performed without change in character of drain output which remained serosanguinous throughout the admission. The patient's diet was resumed and she was able to tolerate a stage 3 diet without incident. Patient's intake and output were closely monitored. ID: The patient's fever curves were closely watched for signs of infection, of which there were none; empiric treatment with vancomycin was administered from POD2 through POD5 as described above. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and [Last Name (un) ] dyne boots were used during this stay; she was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a stage 3 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: Metformin 500 mg [Hospital1 ] Omeprazole 20 mg daily Sertraline 50 mg daily Simvastatin 20 mg daily Vitamin D3 5000 units daily Multivitamin with minerals 1 tablet daily Discharge Medications: 1. ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day for 6 months. Disp:360 Capsule(s) Refills:0 2. ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day for 1 months. Disp:600 ml Refills:0 3. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: [6-21] mL PO every four (4) hours as needed for pain. Disp:250 ml Refills:0 4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day. Disp:250 ml Refills:0 5. multivitamin with minerals Tablet Sig: One (1) Tablet PO once a day: Chewable/crushable; no gummy. 6. metformin 500 mg Tablet Sig: 0.5 Tablet PO twice a day. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: Open capsule; sprinkle contents onto applesauce, swallow whole. 8. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Morbid obesity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Diet: Stay on Stage III diet until your follow up appointment. Do not self advance diet, do not drink out of a straw or chew gum. Medication Instructions: Resume your home medications except: 1. Please decrease your metformin to 250 mg twice daily. Please continue to monitor blood sugars and report elevated or low readings to your prescribing provider. CRUSH ALL PILLS. You will be starting some new medications: 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. You should begin taking a chewable complete multivitamin with minerals. No gummy vitamins. 3. You will be taking Zantac liquid 150 mg twice daily for one month. This medicine prevents gastric reflux. 4. You will be taking Actigall 300 mg twice daily for 6 months. This medicine prevents you from having problems with your gallbladder. 5. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 6. You must not use NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. Activity: No heavy lifting of items [11-26] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Department: BARIATRIC SURGERY When: WEDNESDAY [2108-7-11] at 11:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 304], MD [Telephone/Fax (1) 305] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: BARIATRIC SURGERY When: WEDNESDAY [2108-7-11] at 11:30 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RD [Telephone/Fax (1) 305] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2108-7-2] ICD9 Codes: 4241, 2724, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7852 }	Medical Text: Admission Date: [2176-1-16] Discharge Date: [2176-1-23] Date of Birth: [2112-3-7] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2176-1-17] Cardiac catheterization [2176-1-19] Coronary artery bypass graft x 3 (Left internal mammary arrtery to left arterial descending, Saphenous vein graft to obtuse marginal, Saphenous vein graft to posterior descending artery) History of Present Illness: 63 year old male who presented to [Hospital3 3765] with 6/10 chest tightness that was dull, heavy and was radiating to the bilateral upper extremities that occurred acutely while he was on the treadmil at the gymnasium about 10-15 minutes into exertion. The pain subsided following termination of his exertional activity and he went home and the pain returned while he was at rest. He was transferred to [Hospital1 18] for further evaluation. He was found to have coronary artery disease upon cardiac catheterization and is now being referred to cardiac surgey for revascularization. Past Medical History: Hypertension Hyperlipidemia Social History: Patient lives at home with his wife in [Location (un) 1514], MA. He has three children and currently works in Finance. He denies any smoking history. He drinks [2-5] glasses of wine during the week and [3-9] beers on the weekends. He exercises 2-3 times a week with aerobic exercise on the treadmill and some light free-weight lifting. He denies recreational substance use. Family History: His father died of sudden cardiac death at age 47 and his mother suffered a stroke/TIA in her 60s. No family history of early arrhythmia or cardiomyopathies. Physical Exam: Pulse:52 Resp:20 O2 sat:100/RA B/P Left: 119/65 Height:6'1" Weight:212 lbs General:NAD, alert, cooperative 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 [] No Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + x Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: +2 Left:+2 DP Right:+2 Left:+2 PT [Name (NI) 167]: +2 Left:+2 Radial Right:+2 Left:+2 Carotid Bruit Right:none Left:none Pertinent Results: [2176-1-17] CARDIAC CATH - Selective coronary angiography of this right-dominant system demonstrated 3 vessel coronary artery disease. The LMCA had no angiographically apparent flow limiting disease. The LAD had a 90% proximal and 80% mid-vessel stenosis. The LCx had a 90% ostial OM lesion and a 100% mid-LCx lesion after the OM. The RCA had a 50% mid-vessel stenosis and an 80% ostial PDA lesion. Limited resting hemodynamics revealed normal systemic arterial pressures. Left-filling pressures were mildly elevated with an LVEDP of 22 mmHg. There was no gradient across the aortic valve on pullback from the left ventricle to the ascending aorta. Three vessel coronary artery disease. Normal systemic arterial pressures. No aortic stenosis. . [2176-1-19] ECHO - PRE-CPB:1. The left atrium is normal in size. No mass/thrombus is seen in the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. 7. There is a trivial/physiologic pericardial effusion. Drs. [Last Name (STitle) ] and [Name5 (PTitle) ] were notified in person of the results. POST-CPB: On infusion of phenylephrine briefly. AV pacing for slow atrial bigeminy. Preserved biventriculat systolic function. LVEF = 60%. MR is trace. Aortic contour is normal post decannu8lation. [2176-1-16] 11:12PM BLOOD WBC-13.0* RBC-4.53* Hgb-14.5 Hct-42.4 MCV-94 MCH-31.9 MCHC-34.1 RDW-12.8 Plt Ct-221 [2176-1-21] 06:50AM BLOOD WBC-11.2* RBC-3.38* Hgb-10.7* Hct-32.2* MCV-95 MCH-31.6 MCHC-33.1 RDW-12.9 Plt Ct-141* [2176-1-16] 11:12PM BLOOD PT-11.2 PTT-40.9* INR(PT)-1.0 [2176-1-19] 01:08PM BLOOD PT-13.4* PTT-28.3 INR(PT)-1.2* [2176-1-16] 11:12PM BLOOD Glucose-134* UreaN-19 Creat-0.9 Na-137 K-4.2 Cl-104 HCO3-26 AnGap-11 [2176-1-21] 06:50AM BLOOD Glucose-101* UreaN-14 Creat-1.0 Na-139 K-4.4 Cl-104 HCO3-29 AnGap-10 [2176-1-22] 04:13AM BLOOD UreaN-14 Creat-0.8 Na-138 K-4.1 Cl-105 [2176-1-21] 06:50AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.0 [2176-1-21] 06:50AM BLOOD WBC-11.2* RBC-3.38* Hgb-10.7* Hct-32.2* MCV-95 MCH-31.6 MCHC-33.1 RDW-12.9 Plt Ct-141* [2176-1-22] 04:13AM BLOOD UreaN-14 Creat-0.8 Na-138 K-4.1 Cl-105 Brief Hospital Course: Mr. [Known lastname 56289] came to [Hospital1 18] complaining of chest pain with exercise. He underwent cardiac catheterization which showed significant 3-vessel disease, with a an LMCA that had no angiographically apparent flow limiting disease, an LAD had a 90% proximal and 80% mid-vessel stenosis, LCx had a 90% ostial OM lesion and a 100% mid-LCx lesion after the OM; and the RCA had a 50% mid-vessel stenosis and an 80% ostial PDA lesion. Given the extent of disease, no intervention was employed and he was evaluated by Cardiac Surgery, who felt non-emergent, but urgent CABG was warranted. He underwent usual pre-operative work-up and underwent coronary artery bypass grafting on [2176-1-19] with Dr. [Last Name (STitle) ]. Please refer to operative report for further surgical details. He tolerated the procedure well and was transferred to the CVICU intubated and sedated. He was weaned off nitroglycerin and propofol drips, awoke neurologically intact and extubated. All lines and drains were discontinued per protocol. Beta-blocker/statin/aspirin and diuresis were initiated. On post-op day one he was transferred to the step down unit for further monitoring. Physical therapy was consulted for evaluation of strength and mobility. Chest tubes and epicardial pacing wires were removed per protocol. The remainder of his hospital course was essentially uneventful. He continued to progress and was cleared for discharge to home on POD#4. All follow up appointments were advised. Medications on Admission: Simvastatin 20 mg PO daily Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 8. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 5 days. Disp:10 Tablet Extended Release(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 3 Hyperlipidemia Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg:Left - healing well, no erythema or drainage. Edema ................ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] Wednesday [2-21] at 1:15pm Cardiologist: Dr. [Last Name (STitle) ] Wednesday [2-7] at 10:00am Wound check: [Hospital Ward Name ] Bldg, [Hospital Unit Name ] [1-30] at 10:00am Please call to schedule appointments with your: Primary Care Dr.[Last Name (STitle) 59917] in [5-9] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2176-1-23] ICD9 Codes: 2724, 2859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7853 }	Medical Text: Admission Date: [2161-3-17] Discharge Date: [2161-3-21] Date of Birth: [2077-4-13] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 689] Chief Complaint: Fatigue, anemia Major Surgical or Invasive Procedure: Upper endoscopy with biopsies History of Present Illness: 83yo male with dementia, prostate ca (per son this has been stable, untreated for several months), UTIs who was noted at his NSG home to have malaise, poor PO intake and low grade fevers (no note of fever in paperwork) for past 2d. They thought he might have a UTI but were unable to get urine, so he was given a dose of cipro. The staff at his nursing home had difficulties managing him so he was sent to the ED for further work-up. When EMS arrived, he was noted to be pale in color. He also became unresponsive for approximately 30 seconds when he was lifted onto the stretcher. In the ED, initial vs were: 96.7 89 111/63 18 98. On exam the patient was pale and lethargic. Labs notable for HCT 22, INR of 1.1. He had dark maroon colored stool. Tried to NG lavage and didn't tolerate this. Difficult match for [Last Name (LF) ], [First Name3 (LF) ] he did not receive any [First Name3 (LF) ]. Patient was given Vanco and Levoquin for reports of fever at the nsg home. He has gotten 1.2L of NS. CXR unremarkable. BPs 90-100 systolic (hypertensive baseline) and tachy 90s-110s. Upon transfer, vitals: 97 91/62 RR 20 100% on RA. On the floor, the patient is pale appearing but baseline mental status according to his son (pleasant, no short term memory, likes to sing and hum). Review of systems: (+) Per HPI (-) Denies pain currently otherwise unable to assess. Past Medical History: Dementia UTIs Prostate CA Social History: Lives at [Location 35689] ALF. Has a son, [Name (NI) ], who serves as his health care proxy. - Tobacco: Denies - Alcohol: Denies - Illicits:Denies Family History: No history of colon cancer Physical Exam: Vitals: T: 96.4 BP: 116/68 P:93 R: 18 O2:96% on RA General: Alert, oriented, no acute distress, singing to himself HEENT: Sclera anicteric, MMM, oropharynx clear, pale 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: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS ON ADMISSION: [2161-3-17] 08:14PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.018 [2161-3-17] 08:14PM URINE [Year/Month/Day 3143]-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2161-3-17] 08:12PM HCT-24.4* [2161-3-17] 08:12PM PT-12.8 PTT-19.6* INR(PT)-1.1 [2161-3-17] 03:30PM PT-13.3 PTT-21.1* INR(PT)-1.1 [2161-3-17] 02:21PM COMMENTS-GREEN TOP [2161-3-17] 02:21PM GLUCOSE-161* NA+-143 K+-4.2 CL--108 TCO2-21 [2161-3-17] 02:21PM HGB-7.4* calcHCT-22 [2161-3-17] 02:00PM GLUCOSE-165* UREA N-65* CREAT-1.0 SODIUM-143 POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-21* ANION GAP-18 [2161-3-17] 02:00PM estGFR-Using this [2161-3-17] 02:00PM CK(CPK)-47 [2161-3-17] 02:00PM cTropnT-<0.01 [2161-3-17] 02:00PM CK-MB-NotDone [2161-3-17] 02:00PM WBC-8.6 RBC-2.56* HGB-7.3* HCT-22.0* MCV-86 MCH-28.6 MCHC-33.2 RDW-12.9 [2161-3-17] 02:00PM NEUTS-78.5* LYMPHS-17.3* MONOS-3.7 EOS-0.4 BASOS-0.1 [2161-3-17] 02:00PM PLT COUNT-256 LABS ON DISCHARGE: [2161-3-20] 08:35AM [Year/Month/Day 3143] WBC-6.8 RBC-3.16* Hgb-9.7* Hct-28.2* MCV-89 MCH-30.7 MCHC-34.4 RDW-14.9 Plt Ct-171 [2161-3-20] 08:35AM [Year/Month/Day 3143] Plt Ct-171 [2161-3-20] 08:35AM [Year/Month/Day 3143] Glucose-102* UreaN-18 Creat-0.6 Na-145 K-3.5 Cl-112* HCO3-28 AnGap-9 Studies: Urinalysis: negative in detail Images: CXR Portable [2161-3-17]: There are low lung volumes. The cardiomediastinal contours are within normal limits. There is no focal consolidation, pleural effusion or pneumothorax. There is bibasilar atelectasis, right greater than left. Degenerative changes of the thoracic spine are noted. Upper Endoscopy [2161-3-17]: Normal esophagus. Stomach: Mucosa: Thickened, edematous folds were noted in the body of the stomach suggestive of an infiltrating process. The mucosa was also friable. Cold forceps biopsies were performed for histology at the stomach. Duodenum: Normal duodenum. Impression: Abnormal mucosa in the stomach (biopsy) Otherwise normal EGD to second part of the duodenum Pathology: HELICOBACTER PYLORI ANTIBODY TEST (Final [2161-3-18]): POSITIVE BY EIA. (Reference Range-Negative). MRSA SCREEN (Final [2161-3-20]): No MRSA isolated. URINE CULTURE (Final [2161-3-18]): NO GROWTH. Brief Hospital Course: Patient is a 83 year-old man with a history of hypertension and dementia who presented with an upper gasterointestinal bleed. For his upper GI bleeding, the patient received IV fluids and was transfused with [Year/Month/Day ]. He received intravenous pantoprazole therapy. Patient underwent an EGD that showed edematous mucosa and thickened folds concerning for malignancy with no evidence of active. H. pylori testing was positive and he was started on lansoprazole amoxicillin, and clarithromycin. He had biopsies taken during endoscopy. The results will be communicated by Dr. [First Name (STitle) ] [Name (STitle) ] and appropriate followup will be arranged depending on results by gastroenterology. For his hypertension, home hydrocholrothiazide and lisinopril medications was held during this admission given concerns over his GI bleed. These were still held at the time of discharge and can be restarted as an outpatient. The patient did not have any active issues regarding his Alzheimer's dementia. He was continued on his namenda and aricept during this admission. The patient did not have any active issues regarding his prostate cancer. He was continued on casodex. CODE : DNR but OK to intubate Medications on Admission: (per NSG home notes): Acetaminophen 650 [Hospital1 ] (standing) for wrist pain Casodex 50mg po qAM HCTZ 12.5mg PO daily Lipitor 10mg PO daily Lisinopril 10mg PO daily Namenda 5mg PO daily Aricept 5mg PO qHS Loperamide 2mg for loose stool Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day) as needed for H.pylori. Disp:60 Tablet,Rapid Dissolve, DR(s) Refills:2 2. Amoxicillin 500 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO twice a day for 12 days. Disp:48 Tablet(s) Refills:0 3. Clarithromycin 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO twice a day for 12 days. Disp:24 Tablet(s) Refills:0 4. Memantine 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO daily (). 5. Donepezil 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO HS (at bedtime). 6. Atorvastatin 10 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 7. Bicalutamide 50 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO twice a day. 9. Loperamide 2 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO twice a day as needed for diarrhea. Discharge Disposition: Extended Care Facility: [Last Name (un) 35689] house Discharge Diagnosis: Primary: Gastrointestinal bleeding H. pylori infection Secondary: Hypertension Alzheimer's disease Discharge Condition: Mental Status: Confused - always Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted for fatigue. You were found to have low [Last Name (un) ] counts and received four [Last Name (un) ] transfusions. You were noted to have abnormalities in your stomach and biopsies were taken. The results of these biopsies were pending at the time of discharge. Please take all your medications as prescribed. The following changes were made to your medication regimen. 1. Please take lansoprazole 30 mg by mouth two times a day ongoing 2. Please take amoxicillin 1000 mg two times a day for 12 more days 3. Please take clarithromycin 500 mg by mouth twice a day for 12 more days 4. Your lisinopril and hydrochlorothiazide were being held at the time of discharge and your [Last Name (un) ] pressures were stable. These can be restarted as an outpatient by your primary care physician. Please keep all your follow up appointments as scheduled. Followup Instructions: Please follow up with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) ] within 2-3 days of discharge. Your hematocrit should be rechecked at this time. Dr. [Last Name (STitle) ] will contact you with the results of your stomach biopsies. After the results of the biopsies return a decision will be made as to appropriate referral. If you have not heard from Dr. [Last Name (STitle) ] by Tuesday [2161-3-24] please call her office at ([Telephone/Fax (1) 667] ICD9 Codes: 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7854 }	Medical Text: Admission Date: [2138-8-29] Discharge Date: [2138-9-10] Date of Birth: [2062-12-27] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 50891] is a 76 year-old male who was recently diagnosed with a submental meningioma who was undergoing cardiac clearance prior to meningioma excision and resection. It should be noted that patient has baseline schizophrenia and is very difficult to get to comply with any kind of medical testing or treatment. His son obtained legal guardianship and was authorizing all his medical care. The patient was admitted on [2138-8-29] to the cardiology service to undergo his preoperative clearance. PAST MEDICAL HISTORY: Is significant for meningioma, paranoid schizophrenia, chronic renal insufficiency, hypertension, angina, hypercholesterolemia, herpes Zoster, urinary frequency, history of nephrolithiasis, history of subtotal gastrectomy, bleeding ulcers, hemorrhoids, peripheral neuropathy, spinal stenosis and homocystinuria. His medications at home include Topomax 25 mg p.o. b.i.d., Zocor, Atenolol, aspirin, vitamin B6, vitamin C, B12, vitamin E, Lasix p.r.n., Proscar, ibuprofen, sublingual nitroglycerin p.r.n. and folic acid. He has no known drug allergies. He is divorced and a retired marine engineer. PHYSICAL EXAMINATION: He is afebrile with heart rate of 114 and blood pressure of 127/66. He was in no apparent distress. Heart was regular rate and rhythm. Lungs were clear to auscultation. Abdomen was soft, nontender, nondistended, no masses. Extremities were no clubbing or cyanosis but did have bilateral edema. Neurologically cranial nerves 2 to 12 were intact but he did have baseline paranoia and aggression. PERTINENT LABORATORY DATA: Hematocrit was 40.7, white count ws 9.1, potassium of 4.2, BUN/creatinine 25/1.2. His liver function tests were all within normal limits. Due to the patient's paranoid schizophrenia psychiatry was also consulted and has been following along during his hospital course. Patient subsequently underwent a cardiac stress test on [2138-9-1] which did not reveal any electrocardiogram changes and patient did not reportedly experience any angina. However, he continued to proceed with his preoperative clearance and then undergoing cardiac catheterization the following day which revealed 80 percent PDA stenosis, 50 percent native RCA stenosis, 100 percent proximal LAD stenosis and 100% mid circumflex disease and 70 percent OM1 disease. Then patient was referred to cardiac surgery to undergo coronary revascularization. Patient subsequently underwent coronary bypass grafting times three on [2138-9-5]. He received a LIMA graft to the LAD, saphenous vein graft to the OM1 and saphenous vein graft to the PDA with a jump graft to the RPL. Three vessels were used for targets. Patient tolerated the procedure well and was transferred to the Intensive Care Unit in stable condition. Patient was soon thereafter extubated and was noted to be doing be doing well. The following day patient experienced what seemed to be a seizure although the actual seizure activity was unclear. [Name2 (NI) ] did receive a stat head CT which did show any change from the previous films. The subfrontal hemangioma was still present but there was no new hemorrhage, midline shift or any evidence of cerebrovascular accident or any acute changes. Neurology was consulted also and patient was continued on Dilantin for seizure prophylaxis. On postoperative three patient continued to remain stable after his event on postoperative day one and was transferred to the floor. On the floor critical therapy was consulted. Again patient was noted to be walking well with assistance. However, due to his baseline mental status and paranoid schizophrenia patient required special attention and care when ambulating out of his room. His postoperative course on the floor has been most notable for him refusing to take medications. With much effort and discussion and explanation he has been agreeing to take his medications. However, certain effort is required. On postoperative day four his Dilantin level was noted to be 7.7, his hematocrit was 27.4. The patient today is postoperative day five, Dilantin remains 7.7 and he remains stable. He is afebrile with stable vital signs. He has recently begun taking his cardiac medications, again with explanation needed. He has not experienced any seizure activity since the one that occurred on postoperative day number one. Thus he is currently awaiting a rehabilitation placement. The plan is the patient will go to rehabilitation for a few weeks until Dr. [Last Name (STitle) 1338], neurosurgeon, deems it appropriate to proceed with excision of his meningioma. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: Coronary artery disease, status post coronary artery bypass graft times four. SECONDARY DIAGNOSIS: Paranoid schizophrenia. Hypertension. Hypercholesterolemia. Nephrolithiasis. DISCHARGE MEDICATIONS: Include Lopressor 50 mg p.o. b.i.d., Hydralazine 10 mg p.o. q.i.d., Zantac 150 mg p.o. b.i.d., Dilantin elixir 250 mg p.o. t.i.d., aspirin 81 mg p.o. q.d., Zocor 5 mg p.o. q.d., vitamin C 500 mg p.o. q.d., Proscar 5 mg p.o. q.d., Percocet 525 one to two p.o. q. 4 to 6 hours p.r.n., Colace 100 mg p.o. b.i.d., B6 100 mg, B12 injections. DISCHARGE INSTRUCTIONS: Patient will be discharged to rehabilitation. He is to follow up with Dr. [Last Name (STitle) 1537] in approximately two weeks. Patient to continue to take Dilantin at rehabilitation facility and continue to exert effort in order to make patient comply with medications and patient should be followed also by Dr. [Last Name (STitle) 1338], neurosurgeon here at [Hospital1 69]. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Name8 (MD) 3181] MEDQUIST36 D: [2138-9-10] 11:22 T: [2138-9-10] 12:44 JOB#: [Job Number ] ICD9 Codes: 4111, 5990, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7855 }	Medical Text: Admission Date: [2151-6-13] Discharge Date: [2151-7-1] Date of Birth: [2095-3-27] Sex: F Service: MEDICINE Allergies: Morphine Attending:[First Name3 (LF) 2297] Chief Complaint: SOB Transfer for Management of Tamponade Major Surgical or Invasive Procedure: Pericadriocentesis with Drain Placement ([6-13]) Pericardial window procedure with drain ([6-15]) Right femoral central venous line ([6-26]) History of Present Illness: 56yo F with hx of metastatic ovarian CA s/p pericardial effusion drained on [5-19] is transferred for recurrence of pericardial effusion with tamponade physiology. The pt initially presented to [Hospital1 ] with shortness of breath. Was found to have a pulsus of 15, HR 120, SBP120. ECHO at OSH demonstrated tamponade physiology with RV collapse. Referred to [Hospital1 18] for emergent pericardiocentesis. In the ED T 98.8, HR 114, BP 131/79, RR 29, 100% on 3 LNC and facemask. At 5:00 pm, underwent multiple sub-xyphoid punctures - 240 cc of bloody fluid drained. Initial pericardial pressures were 13 mm and were nearly 0 after removing the fluid. Pulsus was then 11 and HR 117. ECHO was done following the procedure. Pt was scheduled to see CT surgery for a window as an outpt but develop symptoms prior to appointment. . Patient denied fevers, chills, N/V, or chest pain. No abd pain, back pain. Does have leg edema. When she had a pericardial effusion several weeks ago, developed shortness of breath as weel, was relieved with drainage of the effusion. Had 400 + ccs of bloody fluid drained. Shortness of breath has been slowly worsening since her last tap. . Past Medical History: 1. Ovarian CA metastatic to lungs originally diagnosed in '[37] at which time the pt underwent TAH with recurrence in '[45]: ---s/p hysterectomy in '[37] ---s/p chemo with multiple regimens in past. ---hx of recurrent right pleural effusion s/p thoracentesis and talc sclerosis therapy, plurex catheter placement on 6L chronic home O2. ---hx of recurrent pericardial effusion with tamponade s/p pericardiocentesis on [2151-5-19], [2151-6-13]. 2. HTN 3. Hypothyroidism 4. Skin graft to left lower extremity due to opening of wound of unclear reasons 5. s/p LLE fracture in '[42] Social History: Used to smoke 1 PPD but quit in [2125]. No ETOH. Lives with her mother in [Name (NI) 13040], MA with [Name (NI) 269] who comes twice a day. Family History: Father: on blood thinners for ?CVA, on home oxygen Mother: HTN Physical Exam: Upon Admission: VS: 112, 127/84, 30, 90% on 6L NC. GEN: Middle aged AA female sitting up in bed with pursed lip breathing. Pt appears older than her stated age and appears to be in some discomfort. Conversing in short sentences. HEENT: PERRLA, EOMI, anicteric, no exophthalamus NECK: JVD appreciated to angle of mandible at 60 to 70 degrees. CHEST: CTA bilaterally anteriorly. The pt refused to sit up saying it hurts too much. Drain in place with mild tenderness to palpation. ABD: dressing over umbilicus, distended, soft, NT, ND, BS+ EXT: wwp, 3+ edema bilaterally, LLE with erythema and warmth. wound appears clean with good margins and granulation. No drainage from wound itself (although pt reports clear drainage). NEURO: A+O x3. . Upon Admission to MICU [6-26]: VS - T98.3, BP 117/88, HR 118, O2 95% 6L General - sedated, barely arousable female in NAD, breathing heavily; awakes to loud voice and follows commands only after repeated stimulation HEENT - pupils small and minimally reactive, patient not opening mouth Neck - enlarged area of left parotid with surrounding erythema CV - 2-3/6 holosystolic murmur loudest at apex. Chest - mild wheezes, no crackles anterially (patient will not sit up for exam) Abdomen - distended, multiple firms masses bilaterally, +BS, +wound from recent pericardial drain around epigastric area, dressing c/d/i; + ascities Ext - 1+ pitting edema bilaterally, wound bandaged on LLE. Pertinent Results: STUDIES: EKG: sinus tachycardia at 112 bpm, LAD, TWF in I, inversion in aVL, ? low voltage II, poor R wave progression . CK 23 Trop I < 0.04 . [2151-6-4] ECHO: LV hyperdynamic systolic function, EF 75-80%, left strium - normal, right strium - normal, aortic root - noral, pericardium - moderate sized pericardial effusion with organized material on the visceral pericardium, consistent with thrombus or tumor, aortic valve - thickened, mitral valve - thickened, tricuspid/pulmonic valves - normal, trace TR . [2151-6-25] CT Neck - 1. Severe parotitis without a focal sialolith. Etiology may be infectious, related to chemotherapy, or idiopathic in nature. No stone is identified. Several lymph nodes are seen in the region of the enlarged left parotid gland, some of which may be reactive in nature. 2. Extensive lymphadenopathy seen throughout the neck and superior mediastinum as well as the right axilla. Likely, these findings are all metastatic in nature. Many of these lymph nodes are calcified and may relate to psammomatous calcification given history of ovarian cancer. 3. Soft tissue nodules in the right anterior chest and upper right back are also likely metastatic in nature. 4. Diffuse lung metastases and probable metastatic lesions within the lower cervical and upper thoracic spine. Brief Hospital Course: Patient is a 56 year old female with metastatic ovarian cancer with history of recurrent pericardial effusions causing tamponade originally admitted [2151-6-13] for SOB [1-28] tamponade, treated with pericardiocentisis then pericardial window on [2151-6-15]. Pt then developed severe right side parotiditis with sepsis and was transferred to the MICU on [2151-6-26]. . Shortly after her admission to the MICU, the patient became diaphoretic and developed acute respiratory address (RR 30's, O2 sats 80s), and was intubated due to increased work of breathing. She subsequently became hypotensive (MAP 50s), with cool, mottled appearing lower extremities. A right femoral TLC was placed and patient was begun on vasopressors (levophed/vasopressin) and IVF boluses. The etiology of her acute decompensation was felt likely to be sepsis caused by transient bacteremia seeded from the partoiditis. Pt was status post a course of nafcillin, and was begun on empiric treatment with levoquin and unasyn per ENT recommendation. . # SEPSIS: The most likely etiology was felt to be transient bacteremia from parotiditis. However, evaluation for other sources of infection included CXR, cultures of blood, urine, sputum, stool for c. diff, and parotid gland. RUQ and abdominal ultrasound were unremarkable for hydronephrosis, cholecystitis and ascites (small amount, insufficient to tap). Evaluation for cardiogenic sources of shock included enzymes (unremarkable), EKG, and repeat ECHO. In addition, the femoral TLC (felt to be dirty) was replaced with a subclavian TLC, and a right arterial line was placed. - continue treatment with unasyn/levoquin (started [6-26]) empirically. - pt received single dose of vancomycin to cover for MRSA. - continue levophed/vasopressin to maintain MAP > 60. - cardiac enzymes unremarkable. - hold home metoprolol. . # RESPIRATORY FAILURE: Felt likely [1-28] sepsis induced acidemia in the setting of poor pulmonary reserve (multiple metastatic pulmonary nodules). Pt seen by ENT and felt that parotiditis was not likely to cause airway compromise. Pt on 6L home O2 for chronic lung disease felt likely [1-28] metastatic lung disease and treatment. . # PAROTITIS: No stone seen on CT scan. Pt being followed by ENT. Most common organisms are staph aureus, oropharyngeal flora, or GNR. Parotid gram stain shows GPR. Plan is to continue treatment with antiobiotics (unasyn, levo, vancomycin) started on [6-26], warm compresses, massage as tolerated, sialigogues (once no longer sedated), and agressive hydration. - concern regarding further swelling of neck resulting in respiratory obstruction felt unlikely by ENT. pt also at risk for osteomyelitis of adjacent facial bone. . # ARF: Baseline creatine ~1.2 up to 1.9 upon admission, felt most likely prerenal (sepsis, prior lasix, poor PO intake). However, given history of course of nafcillin for LLE cellulitis, urine examined for eos (AIN). Other casues include post-renal obstruction (ureter mets from ovarian ca), however abdominal usn was negative for hydronephrosis. . # UGI BLEEDING: Dark, maroon colored aspirate noted from NGT overnight [6-26] during episode of acute respiratory failure and hypotension. . # CARDIAC TAMPONADE: Pt is s/p repeat pericardiocentesis [6-13] (240cc) for recurrent malignant pericardial effusions casusing tamponade, and pericardial window procedure [6-15] (with removal of an infected port-a-cath device) with placement of a chest tube for ongoing drainage of ascites fluid [1-28] a presumed connection bewteen abdominal and pericardial spaces. The chest tube was removed on 6/XX/06. - EKG [6-14] showed q-waves in III and avF suggestive of prior MI. - given pts recent episode of hypotension, serial cardiac enzymes were performed to r/o a cardiogenic etiology, and were unremarkable. - ECHO ([6-18]) LVEF >55%. RV [Male First Name (un) 4746] normal. 1+ MR. Trivial pericardial effusion. - episode of X overnight [6-26], pt started on metoprolol. . # HYPOTHYROID: - continue levothyroxine 62.5mg IV while not taking home dose (125mcg PO QD). . # LLE WOUND: The 5x2cm wound appears to be clean with good granulation, and currently without edema/warmth. Pt is s/p a course of nafcillin starting [6-13] for concern over cellulitis, and the wound is being followed by wound care rn. . # METASTATIC OVARIAN CA: Pt is being followed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] (covered by Dr. [Last Name (STitle) ], and per the most recent note has elected to pursue further treatment which is being planned to follow the resolution of her inpatient issues. Medications on Admission: ALLERGIES: Morhpine --> nausea . MEDICATIONS: Levothyroxine 125mcg once daily Lasix 80mg once daily Aldactone 50mg TID Coumadin 1mg QHS for port in place for chemo. no hx of DVT or PE Benzonatate Megace two teaspons [Hospital1 ] Reglan 15mg before meals TID Pennkinetic suspension Etoposide 2 pills/day . Discharge Medications: Levothyroxine 125mcg once daily Lasix 80mg once daily Aldactone 50mg TID Coumadin 1mg QHS for port in place for chemo. no hx of DVT or PE Benzonatate Megace two teaspons [Hospital1 ] Reglan 15mg before meals TID Discharge Disposition: Home Discharge Diagnosis: 1)Cardiac Tamponade 2) Metastatic ovarian cancer 3) Hypertension 4) Hypothyroidism Discharge Condition: . Discharge Instructions: Please take medications as indicated. Treatment of ovarian cancer per oncologist (Dr. [Last Name (STitle) ]. Followup Instructions: . Completed by:[2151-8-9] ICD9 Codes: 0389, 5990, 5849, 4280, 4271, 2449, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7856 }	Medical Text: Admission Date: [2112-5-5] Discharge Date: [2112-5-16] Date of Birth: [2056-6-11] Sex: F Service: OME HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old woman with metastatic breast cancer on Xeloda and Herceptin who presents with nausea and diarrhea. The patient has also been complaining of lightheadedness. In addition, the patient also reports having very little p.o. intake over the past two to three days and, in fact, vomited the day of admission and several days prior to admission. As part treatment for this the patient started taking Imodium and noted a decreased frequency of diarrhea from four bowel movements a day to two bowel movements a day, but they were still liquidly in consistency. She has also had increased dry heaves and crampy abdominal pain and is not even able to tolerate juice. REVIEW OF SYSTEMS: Negative for chest pain, upper respiratory infection symptoms, dyspnea, dysuria, cough. She has had extreme fatigue over the past several months. PAST MEDICAL HISTORY: 1. Metastatic breast cancer first diagnosed in [2101] status post auto bone marrow transplant in [2104], metastatic to bone, liver, and lungs, status post multiple cycles of chemotherapy. Currently on Herceptin, Xeloda, and monthly Zometa. 2. Anemia of chronic disease. 3. Status post TRAM flap. MEDICATIONS ON ADMISSION: Zantac q. day. ALLERGIES: 1. Intravenous contrast. 2. Sulfa. PHYSICAL EXAMINATION: On exam patient's temperature is 98.1, pulse 102, BP 135/61, respiratory rate 20, satting 100 percent on room air. In general, she is in no acute distress but uncomfortable. Neck veins are flat. Neck is supple. Lungs: Clear to auscultation bilaterally. Her heart is tachycardiac and regular. There is normal S1 and S2 and no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities have no cyanosis, clubbing, or edema. LABORATORY DATA: White count of 1.9, hematocrit 0.6, platelets 95. Her sodium was 132, potassium 4.5, chloride 99, bicarbonate 12, BUN 21, creatinine 1.0, glucose 94. ABG was drawn. It was 7.34/22/14. Lactate was 1.9. SUMMARY OF HOSPITAL COURSE: 1. Diarrhea: The time course fits well with Xeloda toxicity. However, the differential diagnosis was still broad and stool studies were sent and were essentially negative. The patient on night of admission spiked a temperature of 104.3. Given concern for a possible infectious diarrhea she was started on Levofloxacin. In addition, the patient was given bicarbonate repletion and intravenous fluids to improve her metabolic acidosis. The following day the patient was given broad antibiotic coverage as her neutrophil count was continuing to fall from the chemotherapy. She was on ampicillin, Levofloxacin, and Flagyl for gut protection. As will be detailed below, the patient suffered a ventricular tachycardia arrest and was briefly in the Intensive Care Unit. Following that transfer the patient was called out to the floor. Patient was given a peripherally inserted central catheter line and started on TPN for parenteral nutrition. Her diet was fully advanced from sips to clears, which she generally tolerated, although she had a few episodes of emesis towards the end of her stay. The patient was started on Imodium for control of her bowel movements and over the course of her admission both the frequency and amount of stool declined significantly. At the time of this dictation she was having just one to two bowel movements per day. 1. Ventricular tachycardia arrest: On the second day of admission the patient was talking to the nurse and then abruptly lost consciousness. The patient had been on telemetry due to abnormalities in the EKG and it was seen on tele as being monomorphic or polymorphic ventricular tachycardia leading to a VT arrest. A Code was called. Right before the patient was shocked she reverted back to sinus rhythm. At this point she was intubated and brought to the Intensive Care Unit for closer observation over the next three days. The patient was extubated within 12 hours and her electrolytes continued to improve. A Cardiology consult was obtained and they noted that her QT interval was significantly prolonged possibly due to Levofloxacin, and so she was initially changed to Cipro and then her antibiotic coverage was changed altogether. She was on telemetry for the duration of her admission, and there were no further telemetry events. In addition, she was started on low-dose beta blocker as VT prophylaxis. She will have this followed up as an outpatient with Dr. [Last Name (STitle) 284]. Moreover, while in the ICU she had an echocardiogram that was essentially negative for any structural disease. 1. Fluids, electrolytes, and nutrition: As mentioned previously, the patient has had decreased p.o. intake over the past several weeks. She was initially started on sips of clears and then graduated to thin liquids and then to full liquids, which she tolerated exceptionally. She would occasionally have an episode of nausea, but these were generally self-limited and she was started on total parenteral nutrition or additional nutrition while her gut continues to recover. Hopefully, she will not need to be maintained on TPN for that much longer. 1. Breast cancer: The patient had a torso CT to help stage her malignancy. The CT torso showed interval increase in the size of a left hepatic lobe metastasis and diffuse osseous metastatic disease. In addition, the patient was noted to have this questionable tracheal compression on a chest film, so she had a CT trachea which showed widely patent airways, more extensive osseous metastatic disease, and pleural thickening in the right hemithorax likely also looked metastatic disease. Further treatment of her breast cancer will be discussed with her primary oncologist, Drain. Come. 1. Heme: During her Intensive Care Unit stay her INR was as high as 2.1 likely possible secondary to poor nutrition. It rapidly corrected with subcutaneous vitamin K. 1. Code: Patient is a Full Code at time of the of this dictation. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Metastatic breast cancer. 2. Xeloda toxicity. 3. Ventricular tachycardia arrest. 4. Anemia of chronic disease. DISCHARGE MEDICATIONS: 1. Toprol XL 25 mg p.o. q.d. 2. Ambien 5 mg q. h.s. p.r.n. 3. Protonix 40 mg p.o. q.d. 4. Phenergan 25 mg p.o./IV q.6 hours p.r.n. nausea [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], [MD Number(1) 101050] Dictated By:[Last Name (NamePattern1) 6997] MEDQUIST36 D: [2112-5-16] 11:51:33 T: [2112-5-16] 12:44:50 Job#: [Job Number 101051] ICD9 Codes: 2765, 4271, 4275
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7857 }	Medical Text: Admission Date: [2142-3-26] Discharge Date: [2142-4-10] Date of Birth: [2083-10-25] Sex: M Service: CHIEF COMPLAINT: Fevers. HISTORY OF PRESENT ILLNESS: This is a 58-year-old white male with a complicated past medical history including diabetes type 1 with retinopathy, nephropathy, and neuropathy, end-stage renal disease status post living related kidney transplant in [2130] now with evidence of chronic rejection now on hemodialysis status post peritoneal dialysis catheter placed in [2141-12-9]. Patient has had multiple hospitalizations in [2142-1-8] for choledocholithiasis and cholecystitis status post ERCP and cholecystectomy. Patient presented on [2142-3-26] with complaints of fevers. Patient underwent abdominal CT scan to look for source of fevers, however, subsequent days patient developed worsening respiratory distress on [3-28]. Patient was found to be hypoxic respiratory failure and transferred to the MICU for acute respiratory distress. Patient was urgently dialyzed in the MICU and respiratory status improved. Upon return to the floor, patient felt well and was breathing comfortably. Denied any headache, abdominal pain, shortness of breath, was tolerating p.o. Patient was continued on his regular hemodialysis schedule. PAST MEDICAL HISTORY: As above. ALLERGIES: Compazine and dicloxacillin. MEDICATIONS ON ARRIVAL: 1. Prednisone 5. 2. Subq Heparin. 3. Aspirin. 4. Atenolol. 5. Pravastatin. 6. Gabapentin. 7. Imdur. 8. Calcium carbonate. 9. Proton-pump inhibitor. 10. Calcitriol. 11. Insulin-sliding scale. 12. Nifedipine. 13. Nephrocaps. 14. Synthroid. 15. Midodrine. VITAL SIGNS ON ADMISSION: 97.2, 129/51, heart rate 17, and breathing 97% on 3 liters. PHYSICAL EXAM: Exam was unremarkable. Lungs with mild crackles. LABORATORIES: Notable for a white blood cell count of 7.5, hematocrit of 29.5, platelets of 127. Chemistries with BUN and creatinine of 26 and 4.2. Glucose of 118. HOSPITAL COURSE BY SYSTEM: 1. End-stage renal disease: Patient was continued on his usual schedule of hemodialysis. Patient's peritoneal dialysis catheter was thought to be possible source of infection, and it was therefore removed on the 20th of ........ Patient was continued Nephrocaps, calcitriol, PhosLo, and calcium carbonate, as well as low dosed prednisone. Patient will be setup for outpatient dialysis upon discharge. 2. Fevers of unknown origin: Patient had multiple workups in the past for high fevers and multiple ID consults in the past, however, no workup has been fruitful. Early in this hospital course the patient spiked a fever to 104.7. A gallium scan was obtained per prior ID recommendations, however, the gallium scan was negative. ID was reconsulted and recommended following blood cultures and urine cultures for fevers greater than 101.5. After peritoneal dialysis catheter, there was evidence of erythema and mild induration on patient's abdomen. Patient was treated with a course of Vancomycin and treated the MRSA growing from his wound. There is also evidence proteus growing in the wound, however, further additional antibiotic therapy was not indicated. Patient's ESR and C-reactive protein were also checked. ESR was 55 indicating no significant acute inflammatory process and C-reactive protein level was 7.8, which the lowest level the patient has had in the past 2-3 years. At the time of discharge, patient had been afebrile for approximately five days. Abdominal wound is healing well, and no evidence of pain or infection in his right foot. 3. Diabetes: Patient was continued on his home dose of glargine as well as insulin-sliding scale and diabetic diet. Blood sugars were elevated during this admission as high as 400 to 600, but were controlled appropriately with insulin. 4. Cardiovascular status stable during this admission. All home medications were continued. 5. Code status: Full code. CONDITION ON DISCHARGE: Stable, afebrile. DISCHARGE STATUS: Discharged to home with services. MEDICATIONS ON DISCHARGE: 1. Synthroid 25 mcg p.o. q.d. 2. Aspirin 325 mg p.o. q.d. 3. Isosorbide mononitrate 90 mg p.o. q.d. 4. Atenolol 100 mg two tablets p.o. q.d. 5. Nifedipine 60 mg p.o. q.d. 6. Calcium acetate 667 mg tablet two tablets t.i.d. with meals. 7. Pravastatin 40 mg p.o. q.d. 8. Gabapentin 300 mg p.o. b.i.d. 9. Multivitamin one tablet p.o. q.d. 10. Prednisone 5 mg p.o. q.d. 11. Calcium carbonate 500 mg p.o. b.i.d. 12. Calcitriol 0.25 mcg p.o. q.d. 13. Protonix 40 mg p.o. q.d. 14. Midodrine 5 mg p.o. t.i.d. 15. Glargine 14 units q.h.s. 16. Nephrocaps one tablet p.o. q.d. FOLLOW-UP INSTRUCTIONS: Patient is to followup with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 805] within 7-10 days. Patient is also to keep his outpatient hemodialysis schedule. [Name6 (MD) 1344] [Name8 (MD) 1345], M.D. [MD Number(1) 1346] Dictated By:[Last Name (NamePattern1) 20637] MEDQUIST36 D: [2142-4-10] 08:23 T: [2142-4-10] 08:27 JOB#: [Job Number 20638] ICD9 Codes: 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7858 }	Medical Text: Admission Date: [2174-7-8] Discharge Date: [2174-7-12] Date of Birth: [2108-9-11] Sex: M Service: [Hospital Unit Name 196] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2698] Chief Complaint: substernal chest pressure, shortness of breath Major Surgical or Invasive Procedure: ICD placement on [2174-7-11] History of Present Illness: Patient is a 65 year old male with a history of an inferior myocardial infarction in [2154], hyperlipidemia, 50 year smoking history and family history of heart disease who presented to the ER at an outside hospital via EMS after he had a syncopal episode that lasted for 30 seconds on [2174-7-8] associated with substernal chest pressure, shortness of breath, lightheadedness, no diaphoresis, no nausea or vomiting. The pain did not radiate. EMS found the patient to be in ventricular tachycardia and administered 100 joules which converted the patient into torsades de pointes. He was shocked again at 200 and he converted to sinus rhythm. He was placed on a lidocaine drip at which he maintained sinus rhythm and was then transferred to the [Hospital1 69] for possible cardiac catheterization and electrophysiologic evaluation. Past Medical History: Hyperlipidemia CAD s/p inferior MI in [2154] Social History: Patient is a smoker of 1 pack per day for 50 years. He drinks occasional alcohol. He works with Airborne Express and lifts heavy objects at work. He lives with his family. Family History: The patient's father died at the age of 44 with an MI. His mother passed away with cancer and an "enlarged heart". He has a brother who suffered an MI in his 40's and underwent CABG. Physical Exam: T 97.2 P = 84 BP = 139/74 RR=25 96% O2 on RA General - In no apparent distress, alert and oriented x 3 HEENT - Pupils equally responvie to light and accomodation, no JVD, =2 carotid pulses with no bruits bilaterally Heart - faint S1, S2, no murmurs, rubs or gallops Lungs - Bilateral wheezes at both bases Abdomen - soft, nontender, nodistended, with active bowel sounds Extremities - no cyanosis, clubbing or edema, +2 dorsalis pedis, posterior tibial and femoral pulses bilaterally Pertinent Results: [2174-7-8] 06:22PM POTASSIUM-3.8 [2174-7-8] 06:22PM CK(CPK)-1318* [2174-7-8] 06:22PM CK-MB-4 [2174-7-8] 06:22PM PLT COUNT-166 [2174-7-8] 05:00AM GLUCOSE-155* UREA N-18 CREAT-1.0 SODIUM-143 POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-24 ANION GAP-13 [2174-7-8] 05:00AM CK(CPK)-616* [2174-7-8] 05:00AM CK-MB-4 [2174-7-8] 05:00AM CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-2.2 CHOLEST-112 [2174-7-8] 05:00AM TRIGLYCER-111 HDL CHOL-31 CHOL/HDL-3.6 LDL(CALC)-59 [2174-7-8] 05:00AM WBC-10.5 RBC-4.71 HGB-14.8 HCT-43.2 MCV-92 MCH-31.5 MCHC-34.3 RDW-13.2 [2174-7-8] 05:00AM PLT COUNT-175 [2174-7-8] 05:00AM PT-13.2 PTT-28.7 INR(PT)-1.2 [2174-7-7] 11:00PM GLUCOSE-164* UREA N-17 CREAT-1.0 SODIUM-142 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17 [2174-7-7] 11:00PM CK(CPK)-411* [2174-7-7] 11:00PM CK-MB-4 cTropnT-<0.01 [2174-7-7] 11:00PM MAGNESIUM-2.8* [2174-7-7] 11:00PM WBC-12.3* RBC-5.31 HGB-16.6 HCT-48.8 MCV-92 MCH-31.3 MCHC-34.0 RDW-13.1 [2174-7-7] 11:00PM NEUTS-78.3* LYMPHS-15.0* MONOS-4.4 EOS-1.7 BASOS-0.7 [2174-7-7] 11:00PM PLT COUNT-196 [2174-7-7] 11:00PM PT-12.8 PTT-27.4 INR(PT)-1.1 Brief Hospital Course: The patient was transferred to the ICU under the service of the CCU. 1. Cardiac - The patient was maintained on a lidocaine drip at 2 mg/kg/min which was discontinued on [2174-7-9]. He maintained sinus rhythm. His CPK maximized at 411, CK_MB at 4, and his troponins were negative. He underwent a cardiac catheterization on [2174-7-8] during which his right coronary artery was stented with a TAXUS stent. He was found on ventriculogram to have an EF of 35% with mild hypokinesis posterobasally, a left circumflex lesion of 30% proximal to the second obtuse marginal, a 90% lesion in the proximal and mid RCA. His posterolateral was seen to be receiving collaterals from the left. He was maintained on an aspirin, beta blocker, ACE inhibitor, a statin and Plavix. On [2174-7-11], an ICD was placed without complications. Afterwards, he maintained sinus rhythm with occasional runs of NSVT. If the patient decides to enroll in the SMASH VT trial, he will return in 1 month for ablation. 2. Pulmonary - The patient has a strong history of smoking and presents with wheezing on exam. As a result, Wellbutrin was started on [2174-7-9] to aid smoking cessation. The patient was discharged on [2174-7-12] in normal sinus rhythm and good condition status post ICD placement on [2174-7-11]. Medications on Admission: ASA, Lipitor Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 2. Atorvastatin Calcium 80 mg Tablet Sig: half tablet Tablet PO at bedtime. 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Metoprolol Tartrate 50 mg Tablet Sig: half tablet Tablet PO twice a day. 5. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Lisinopril 20 mg Tablet Sig: half tablet Tablet PO once a day. 7. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 6 doses. Discharge Disposition: Home Discharge Diagnosis: Ventricular tachycardia secondary to old infarct Coronary Artery Disease with a TAXUS stent in the right coronary artery Hypertension Discharge Condition: Good Discharge Instructions: Please return to the ER or call your primary physician if you experience any chest pain, shortness of breath, lightheadedness, dizziness, or if you pass out. Followup Instructions: If you decide to enroll in the SMASH VT protocol, you will need to follow up with your electrophysiologist in 1 month for VT ablation. Provider: [Name10 (NameIs) 676] CLINIC Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 59] Date/Time:[2174-7-15] 2:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ],MD Where: [Hospital Ward Name ] BUILDING ([Hospital Ward Name ] COMPLEX) Phone:[Telephone/Fax (1) 1983] Date/Time:[2174-9-23] 12:30 Provider: [Name10 (NameIs) ] WEST,ROOM FIVE GI ROOMS Where: GI ROOMS Date/Time:[2174-9-23] 12:30 ICD9 Codes: 4271, 4019, 2720, 3051, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7859 }	Medical Text: Admission Date: [2144-4-7] Discharge Date: [2144-4-22] Service: HISTORY OF PRESENT ILLNESS: The patient is a [Age over 90 ]-year-old woman with a history of coronary artery disease, hypertension, hypercholesterolemia, who presented to an outside hospital Emergency Department on [2144-4-1], with the complaint of increasing abdominal pain since [3-27], p.o. intake secondary to decreased appetite. She denied bright red blood per rectum but had black tarry stools which she thought was secondary to her iron supplement tabs. Her pain was mainly in her right lower quadrant without radiation. Abdominal CT scan on [4-1] showed a 3-4 cm mass in her ascending colon. The patient was guaiac positive in an apple-core lesion in the descending colon with pin-hole size lumen, as well as diverticulosis and descending colon polyps. Biopsy of the lesion revealed invasive adenocarcinoma in the ascending colon. The patient was tolerating clears on admission. Surgery was consulted at the outside hospital for right hemicolectomy, which the patient consented to; however, the patient has a significant cardiac history and needed cardiac work-up prior to surgery and was transferred to [Hospital6 1760] for further cardiology work-up. The patient has a history of aortic stenosis, coronary artery disease, bifascicular heart block. Echocardiogram in [2143-12-29] showed an ejection fraction of 75-80%, concentric left ventricular hypertrophy, and mitral regurgitation. The patient has had dyspnea on exertion and chest heaviness for the past few years. Persantine study showed large anterior wall reversible defect on [2144-4-6]. The patient had another echocardiogram on [2144-4-6], which showed mild aortic stenosis and an aortic valve area of 1.1 cm. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Coronary artery disease. 4. History of skin cancer.r 5. History of breast cancer status post bilateral mastectomy. 6. Glaucoma. 7. Aortic stenosis. 8. Spinal stenosis status post back surgery. 9. Status post appendectomy. 10. Status post right oophorectomy. MEDICATIONS ON ADMISSION: Ambien, Lopressor 50 b.i.d., Zantac q.d., Hydrochlorothiazide 25 mg q.d., Lipitor 40 mg q.d., Iron Sulfate q.d., Isosorbide. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient is a widow and lives alone and performs all activities of daily living independently. She denied alcohol and tobacco use. PHYSICAL EXAMINATION: Vital signs: On admission temperature was 98??????, pulse 78, blood pressure 150/70, respirations 22, oxygen saturation 92% on room air. General: She was a pleasant woman, looking than her stated age in no acute distress. HEENT: Pupils equal, round and reactive to light. Oropharynx clear. Moist mucous membranes. Extraocular movements intact. Neck: Supple. No lymphadenopathy. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular, rate and rhythm. Normal S1 and S2. There was a 2/6 systolic ejection murmur best heard at the right upper sternal border. Abdomen: Flat and soft. There was mild right lower quadrant tenderness. No rebound or guarding. Extremities: No clubbing, cyanosis, or edema. Neurological: She was alert and oriented times three. Cranial nerves II-XII intact. LABORATORY DATA: On admission white count was 7.1, hematocrit 32.9, platelet count 291; chemistries with a sodium of 138, potassium 4.0, chloride 103, bicarb 26, BUN 6, creatinine 1.1, glucose 98, calcium 8.7. Electrocardiogram normal sinus rhythm, 80 beats per minute, right bundle branch block, first degree AV block, Q-waves in II, III, and AVF, T-wave inversion in V1 and V2 with no ST elevations or depressions. Echocardiogram on [4-6] at the outside hospital was with mild aortic stenosis with valve area of 1.17 mm, normal left ventricular function. Carotid ultrasound done at the outside hospital showed no significant stenosis. HOSPITAL COURSE: The patient was admitted to the Medical Service for preoperative work-up considering her cardiac history. Cardiology consult was obtained, and a repeat echocardiogram was performed which showed left ventricle with mild symmetric left ventricular hypertrophy, ejection fraction greater than 55%, aorta with trace regurgitation, aortic valve and mitral valve with 1+ mitral regurgitation, mild to moderate aortic stenosis, and a ventricular inflow pattern suggestive of impaired relaxation and mild pulmonary artery systolic hypertension. A stress test was also obtained that was performed with a ................... injection where the patient had no anginal symptoms or ischemic electrocardiogram changes. Nuclear scan showed no myocardial perfusion defects to suggest ischemia and an ejection fraction of 89%. Cardiology suggested were to use perioperative beta-blocker, and the patient was started on Lopressor, as well as postoperative cardiac enzymes and electrocardiogram. At that time on [4-10], a PICC line was placed for TPN and preoperative, as well as postoperative nutrition. The patient was taken to the Operating Room on [2144-4-14], where an ileectomy was performed under general anesthesia. Total intravenous fluids in the procedure were 2500 cc. Urine output was 260 cc. Estimated blood loss was minimal. The patient was taken to the PACU and extubated in stable condition. Postoperatively the patient was transfused 1 U packed red blood cells secondary to a hematocrit of 27.3. Postoperatively she was continued on TPN and given LR fluid boluses to maintain urine output. The patient was also received an electrocardiogram postoperatively that was unchanged from preoperative electrocardiogram. Intraoperatively the patient had a right CVL placed, and chest x-ray was performed postoperatively which showed no pneumothorax. Cardiac enzymes were sent after the exiting the operating room, and CK was 59, and troponin was less than 0.3. The patient's pulse was around 100, and her blood pressure was running around 150/70; therefore, Lopressor was increased to 5 mg q.4 hours. The patient also had Hydralazine p.r.n. for blood pressures above 180. The patient had more cardiac enzymes drawn with a troponin on the third set that increased to 1.2. The patient had no electrocardiogram changes or complaints of any chest pain, and ischemic cardiac event was unlikely. On postoperative day #3, the patient was started on clears and tolerated this well. TPN was continued at this time. Morphine PCA provided good pain control and was continued at this time. Lopressor was increased to 7.5 mg q.4 hours, as her pulse remained around 100, and blood pressure was 150/70. On postoperative day #4, the patient continued to do well. Physical Therapy was consulted, and she was continued on clears at that time. On postoperative day #6, TPN was decreased to half goal TPN. She was transferred over to all p.o. medications, including p.o. Lopressor. She was placed on a regular diet, taking minimal p.o. intake secondary to no appetite but had no complaints of nausea or vomiting. Her Foley catheter was discontinued. On postoperative day #7, the patient was noted to be confused, thinking that she was in jail and thought that her brother was upset at her. This was the first time during this admission that the patient had been confused. On exam her vitals signs were normal, and she was afebrile. She had no focal neurological deficits. She knew the date and time. Labs were drawn at that time. CBC was with a slightly elevated white count of 13. Hematocrit was 30. Magnesium was 1.7, potassium 4.0, and the rest of the chemistries were normal. Repeat electrocardiogram at that time was unchanged. The episode of this delirium was of unclear etiology but was improved without any specific therapy. On postoperative day #8 she was alert and oriented times three. She knew that she was in the hospital, and she was able to take adequate p.o. intake. She is being discharged to rehabilitation. DISCHARGE MEDICATIONS: Aspirin 81 mg p.o. q.d., Atorvastatin 40 mg p.o. q.d., Lopressor 50 mg p.o. b.i.d., Isosorbide Dinitrate 20 mg p.o. t.i.d., Hydrochlorothiazide 25 mg p.o. q.d., Tylenol 325-650 mg p.o. q.4-6 hours, Colace 100 mg p.o. b.i.d. FOLLOW-UP: The patient is to follow-up with Dr. [Last Name (STitle) 1888] in [1-30] weeks; she is to call his office for an appointment. The staples have been removed from her right lower quadrant incision. Discharge Diagnoses 1. Cecal Colon cancer 2. Aortic Valve Stenosis 3. Hypertension 4. Hx Breast Cancer 5. Glaucoma [Last Name (NamePattern4) 1889], M.D. [MD Number(1) 1890] Dictated By:[Last Name (NamePattern1) 49174] MEDQUIST36 D: [2144-4-22] 10:01 T: [2144-4-22] 09:59 JOB#: [Job Number 49175] ICD9 Codes: 5180, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7860 }	Medical Text: Admission Date: [2130-7-10] Discharge Date: [2130-7-14] Date of Birth: [2047-4-25] Sex: F Service: SURGERY Allergies: Penicillins / Morphine / Codeine Attending:[First Name3 (LF) 148] Chief Complaint: Jaundice and abdominal pain. Major Surgical or Invasive Procedure: [2130-7-10] - ERCP with stent removal and new stent placement. History of Present Illness: 83 year-old female presents as transfer from [Location (un) 620] with jaundice and abdominal pain. The patient has a known peri-ampullary cancer. She had an ERCP in [4-/2130] that revealed a bulky/friable major papilla and a 15 mm shouldered stricture at the ampullary level. She was stented at that time. EUS 2 days later revealed pancreas parenchyma with changes of chronic pancreatitis. Changes of acute on chronic pancreatitis noted in the head of the pancreas, and dilated pancreatic and bile duct to the ampulla. Distal CBD brushings were positive for malignancy. The patient is scheduled to have Whipple next week by Dr. [Last Name (STitle) ]. Patient was seen for preadmission testing last week and was doing well. . However, she now presents 3 days of severe RUQ abdominal pain and jaundice. Her urine has been dark, and she has been having small brown bowel movements. She also reports vomiting on and off for 4 days. She went to the ED at [Hospital1 18] [Location (un) 620] today where she was found to be jaundiced and slightly hypotensive with SBP in 80s. Her BP responded well to IVF. She was diagnosed with cholangitis and transferred to [Hospital1 18] main campus for ERCP. At the time of transfer, she was mentating well and not complaining of any chest pain. She only felt slight abdominal pain. SBP ranged from mid 80s to 110. Past Medical History: PMHx: AF (not on coumadin), CAD, HTN, Hypothyroidism, Type II DM, Hypercholesterolemia, Anemia, h/o Myasthenia [Last Name (un) ], GERD, Dysphagia, h/o Bronchitis, chronic pancreatitis, periampullary cancer. . PSHx: TAH, Sinus surgery, ORIF UE fx w/ bone grafting Social History: Retired from work in accounting office and as florist. No tobacco, alcohol, drugs. Patient will be discharged to a skilled nursing facility, where her husband resides. Family History: Non-contributory Physical Exam: On Admission: VS: 98.0 116 104/62 18 96%2L Gen: NAD. A&Ox3. HEENT: Scleral icterus. Moist mucus membranes Neck: No JVD. No LAD. No TM. CV: RRR. Pulm: CTAB. Abd: Soft. NT. ND. +BS. DRE: Normal tone. No masses. No gross or occult blood. Ext: Warm and well perfused. No peripheral edema. Neuro: Motor and sensation grossly intact. Pertinent Results: [2130-7-10] 10:48PM GLUCOSE-132* UREA N-35* CREAT-1.1 SODIUM-137 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-22 ANION GAP-12 [2130-7-10] 10:48PM CALCIUM-7.3* PHOSPHATE-3.3 MAGNESIUM-2.0 [2130-7-10] 10:48PM WBC-10.7 RBC-2.65* HGB-8.7* HCT-25.7* MCV-97 MCH-32.9* MCHC-33.9 RDW-18.7* [2130-7-10] 10:48PM NEUTS-94* BANDS-2 LYMPHS-3* MONOS-0 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [2130-7-10] 10:48PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-1+ OVALOCYT-1+ TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL [2130-7-10] 10:48PM PLT SMR-NORMAL PLT COUNT-232 [2130-7-10] 10:48PM PT-15.1* PTT-25.9 INR(PT)-1.3* [2130-7-10] 05:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-1 PH-6.5 LEUK-NEG [2130-7-10] 05:50PM URINE RBC-0-2 WBC-[1-26] BACTERIA-FEW YEAST-NONE EPI-[1-26] [2130-7-10] 04:45PM GLUCOSE-143* UREA N-39* CREAT-1.3* SODIUM-135 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-25 ANION GAP-11 [2130-7-10] 04:45PM ALT(SGPT)-96* AST(SGOT)-155* CK(CPK)-72 ALK PHOS-828* TOT BILI-8.4* [2130-7-10] 04:45PM LIPASE-64* [2130-7-10] 04:45PM cTropnT-0.29* [2130-7-10] 04:45PM CK-MB-NotDone [2130-7-10] 04:45PM ALBUMIN-2.4* . Cardiology Report ECG Study Date of [2130-7-10]: Sinus tachycardia with atrial premature beats. Non-specific diffuse low amplitude T waves. Compared to the previous tracing of [2130-7-6] sinus tachycardia is new and the Q-T interval is no longer prolonged. Intervals Axes: Rate PR QRS QT/QTc P QRS T 108 116 90 362/446 38 -2 12 . [2130-7-10] ERCP: Distal migration of the pre-existing biliary stent in the major papilla. Pus and sludge released from the bile duct following removal of stent. Biliary stricture consistent with the patients known ampullary cancer. 10F 7cm Cotton [Doctor Last Name ] biliary stent placed for drainage. Otherwise normal EGD to third part of the duodenum. . Cardiology Report ECG Study Date of [2130-7-11]: Sinus rhythm. T wave inversions in leads V1-V6. Cannot exclude myocardial ischemia. Prolonged Q-T interval. Low QRS voltage in the precordial leads. Compared to tracing #1 of [2130-7-10] sinus tachycardia and atrial premature beats are absent. The T wave inversion is new. Intervals Axes: Rate PR QRS QT/QTc P QRS T 69 0 84 458/473 0 -9 -142 . [2130-7-11] CXR: Mild pulmonary edema with low lung volumes and bibasilar atelectasis. Brief Hospital Course: The patient with a history of peri-ampullary cancer was admitted from [Hospital1 ] [Location (un) 620] ED to the SICU on [2130-7-10] in stable condition for treatment of cholangitis. She was made NPO, started on IV fluids and IV Cipro and Flagyl, a foley was placed, and she was transfused 1 unit PRBC for a HCT 24.5 prior to ERCP. She then underwent ERCP, which revealed distal migration of the pre-existing biliary stent in the major papilla. Pus and sludge released from the bile duct following removal of stent. Biliary stricture consistent with the patients known ampullary cancer was seen. A new stent was placed. The patient was then transferred to the [Hospital Unit Name 153]. . [Hospital Unit Name 153] Course [Date range (3) 29786]: The patient was transferred to the [Hospital Unit Name 153] post ERCP for monitoring of respiratory status and continued intubation given her history of myasthenia [Last Name (un) 2902]. She was hypotensive, and CVL and A-line were placed. She received LR boluses and was started on levophed drip with improvement in her CVP to 16-18 and MAPs>70. UOP was approximately 20-25cc/hr. Troponin's elevated 0.19-0.29 range; no EKG changes or ST elevation. Recent persantine stress test normal. Believed to be due to demand ischemia secondary to hypotensive episode and/or sepsis. No acute cardiac events. The patient was extubated without events and transferred to the SICU for continued management. . SICU Course [Date range (3) 29787]: Returned to SICU NPO except medications, on IV fluids and IV antibiotics in good condition and hemodynamically stable. Electrolytes repleted, started on sips and home medications, ambulated. Cleared for transfer to the floor. . Floor Course [Date range (3) 29788]: Tranferred to the floor; was hemodynamically stable. Diet abvanced to clears, then regular by [2130-7-13] with good tolerability. Experienced no significant pain. IV fluids discontinued. Foley catheter was discontinued; the patient was able to void on her own without problem. Restarted on remaining home medications with the exception of Metoprolol, which was prescribed as 100mg [Hospital1 ] as blood pressure and heart rate well controlled, instead of home dose of Toprol XL 250mg daily. Physical Therapy evaluated and worked with the patient prior to discharge. At the time of discharge on [2130-7-14], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with assistance, voiding without assistance, and not experiencing any significant pain. The patient was discharged to the same skilled nursing facility, where her husband has been admitted. She will return for planned Whipple surgery [2130-8-2]. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Aspirin EC 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Mestinon 60 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO as needed for Anxiety. 11. Imuran 50mg PO BID. 12. Metoprolol SR 250mg (200mg + 50mg) PO daily. 13. HCTZ 25mg PO QAM. Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold Aspirin starting [2130-7-19] (two weeks prior to surgery). 5. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Mestinon 60 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO Qday-[Hospital1 ] as needed for Anxiety. 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 9 days. Disp:27 Tablet(s) Refills:0 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days. Disp:18 Tablet(s) Refills:0 13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day: [Month (only) 116] increase to 200mg [Hospital1 ] if indicated by BP & HR. 15. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [2-27] hours as needed for fever or pain. Discharge Disposition: Extended Care Facility: [Location (un) 29789] Country Manor - [Location (un) 29789] Discharge Diagnosis: 1. Periampullary cancer 2. Cholangitis 3. [First Name9 (NamePattern2) ] [Last Name (un) ] 4. Anemia Discharge Condition: Stable Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-2] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: You have been scheduled for Whipple surgery on [2130-8-2]. Please take nothing by mouth after midnight on [8-2]. Stop your Aspirin on [2130-7-19]. Please do NOT take your Metformin and hydrochlorothiazide the morning of surgery. You will be contact[Name (NI) ] with other pre-operative instructions prior to this date. Please call Dr.[Name (NI) 2829] Office at ([Telephone/Fax (1) 2828] with any questions. Please call ([Telephone/Fax (1) 7761] to arrange a follow-up appointment with Dr. [Last Name (STitle) ] (PCP) in [11-25] weeks. Completed by:[2130-7-14*] ICD9 Codes: 0389, 5849, 4019, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7861 }	Medical Text: Admission Date: [2185-7-5] Discharge Date: [2185-7-12] Date of Birth: [2136-2-21] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5018] Chief Complaint: left sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 49 yo R-handed man with no known previous medical history, who developed acute onset L-sided weakness. Code stroke was called. . The patient was at home, watching TV from his bed. Around 6pm he tried to stand up and then fell towards the left. He did not hurt himself and denies LOC. He had no warning signs and no associating symptoms. He noticed that he could not move his L arm and leg. He could not stand up and it took him a while to get to the phone. . A code stroke was called at 8.48, the patient arrived at 8.58. The NIHSS was 13 (see below). The patient had no headache, dizziness, nausea, vomiting, double or blurry vision. No numbness or tingling. He was not able to move his L-leg and L-arm and sounded dysarthric. Upon arrival, his glc was 410. His BP was 230-241/118-133. He was given boluses of 20mg labetolol iv and then started on a drip to goal BP <185/<110. Insulin was administered to control his glucose. . A CT head was obtained that showed no bleed, mass effect, or developing infarct. A CTA head and neck showed no occlusion of the intracranial vessels. . Given the neurological deficits and his young age, the option of tPA was discussed with the patient, even though he was getting out of the time window. The patient understood that there was an increased risk for hemorrhage given he was out of the time window. The patient agreed to proceed with tPA in case his BP and glucose could be controled in a timely fashion. Around 10.30, his glucose was 380 and his BP was well controled to 171/89. At that point, tPA was given (9mg iv push; 81mg as iv infusion over one hour). . Past Medical History: -none; has not seen an physician in years Social History: Works as landscaper Smoking: no; EthOH: no; drug abuse: no Married: no; no children. Family History: father stroke at age 76; DM mother Physical Exam: VITALS: T afbebrile HR110 BP230-241/118-133 RR12 sO299 GEN: poor dentition; on stretcher; NAD HEENT: mmm; poor dentition NECK: no LAD; no carotid bruits; goiter on the R LUNGS: Clear to auscultation bilaterally HEART: Regular rate and rhythm, normal S1 and S2, no murmurs, gallops and rubs ABDOMEN: normal bowel sounds, soft, nontender, nondistended EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema . NIHSS: 13 1a. Level of consciousness: 0 fully arousable to obey, answer, or respond 1b. LOC questions: 0 (age and month) 1c. LOC commands: 0 (squeezes right hand and closes eyes to command) 2. Best gaze: 0 3. Visual: 0 4. Facial Palsy: 3 5. Motor Arm: 0/4, no effort against gravity 6. Motor Leg: 0/4, no effort against gravity 7. Limb ataxia: 0 8. Sensory: 1 9. Best Language: 0 10. Dysarthria: 1 11. Extinction: 0 . MENTAL STATUS: Awake and alert, cooperative with exam, normal affect. Oriented to place, month, day, and date, person. Attention: MOYbw. Memory: Registration: [2-4] items; Recall [2-4] at 5 min. Language: fluent; repetition: intact; Naming intact; Comprehension intact; clear dysarthria, no paraphasic errors. Writing: intact. [Location (un) ]: intact; Prosody: normal. Fund of knowledge normal; No Apraxia. No Neglect. . CRANIAL NERVES: II: Visual fields are full to confrontation, pupils equally round and reactive to light both directly and consensually, 5-->3 mm on R, 4.5-->3 on L. Disc margins unable to assess. III, IV, VI: Extraocular movements intact without nystagmus. Fixation and saccades are normal. No ptosis. V: Facial sensation intact to light touch and pinprick. VII: PRominent L-facial droop, involving upper and lower face. VIII: Hearing intact to finger rub bilaterally. IX: Palate elevates in midline. XII: Tongue protrudes in midline, no fasciculations. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. . MOTOR SYSTEM: Normal bulk. Tone increased in R-leg. L-arm and leg flaccid. No adventitious movements, no tremor, no asterixis. Full strength on the R. No movement in the L-arm (would extend following noxious); No movement in the L-leg; later able to move a bit from the hip ([1-9]). No pronator drift on R. No rebound. . SENSORY SYSTEM: Sensation intact to light touch, pin prick, temperature (cold) on the R. Decreased on the L, but present. . REFLEXES: B T Br Pa Pl Right 2 2 2 1 0 Left 2 2 2 1 0 Toes: downgoing on R; up on the L. . COORDINATION: Normal [Last Name (LF) 11140], [First Name3 (LF) ], HTS. No dysmetria or pastpointing. . GAIT: unable Pertinent Results: Admission Labs: [2185-7-5] 09:05PM PT-10.9 PTT-21.0* INR(PT)-0.9 [2185-7-5] 09:05PM WBC-12.2* RBC-5.41 HGB-15.7 HCT-41.6 MCV-77* MCH-29.0 MCHC-37.8* RDW-14.2 PLT COUNT-183 [2185-7-5] 09:05PM ALBUMIN-4.5 URIC ACID-5.1 [2185-7-5] 09:05PM CK-MB-5 cTropnT-0.02* CK(CPK)-253* [2185-7-5] 09:05PM LIPASE-56 GGT-44 [2185-7-5] 09:05PM ALT(SGPT)-14 AST(SGOT)-20 LD(LDH)-310* ALK PHOS-98 AMYLASE-38 TOT BILI-0.7 [2185-7-5] 09:05PM GLUCOSE-441* UREA N-15 CREAT-1.5* SODIUM-139 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17 [2185-7-5] 09:50PM %HbA1c-9.2* [2185-7-5] 10:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 [2185-7-5] 10:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG [2185-7-5] 10:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.029 [2185-7-5] 10:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG . Head CT [7-5]: There is a 2 mm chronic lacunar infarct within the right lentiform nucleus. There is no evidence for intracranial hemorrhage, mass effect, shift of normally midline structures or hydrocephalus. There is partial demonstration of what is likely a small left maxillary antral mucus-retention cyst. . CT ANGIOGRAPHY OF THE NECK AND HEAD [7-5]: FINDINGS: There is no definite contour abnormality involving the cervical carotid system on either side. No hemodynamically significant stenosis or ulceration is seen in this locale. There is demonstration of a nearly 4 x 6 cm right thyroid lobe mass with speckled calcifications. The left vertebral artery appears hypoplastic throughout its course. . Intracranially, no definite sign of a hemodynamically significant stenosis or vascular occlusion is detected, again allowing for the limited analysis available at the time of this emergency study. . Also noted on the sagittal reconstructions is moderate degenerative change of the atlanto-dental interval superiorly. . MRI Head [7-5]: A number of the conventional images are degraded by patient motion. Nevertheless, the study clearly shows a comet-shaped area of restricted diffusion, with the "head" of the comet within the posterior body of the right caudate nucleus, extending anteroinferiorly across the posterior limb of the right internal capsule with the "tail" this lesion in the right lentiform nucleus. Although the FLAIR images are of poor quality due to patient motion, there is slightly increased signal in this locale, consistent with a developing subacute phase of this lesion. The right lentiform nucleus chronic lacunar infarct, previously noted on the CT scan is also imaged on this study. There is no hydrocephalus, shift of normally midline structures or other perceptible signal intensity abnormality within the brain parenchyma. No overt extracranial abnormalities are seen other than demonstration of what is likely a small left maxillary antral mucous retention cyst. . CONCLUSION: Acute/subacute area of brain infarction within the right caudate nucleus/posterior limb of internal capsule/lentiform nucleus, with other findings as noted above. . MR [First Name (Titles) ] [Last Name (Titles) 48987]S: Unfortunately, this study is of very limited quality due to extensive patient motion. At best, the major vascular tributaries of the circle of [Location (un) 431] are imaged, but no further analysis regarding the contour of the branched vessels can be rendered. The previously noted hypoplastic left vertebral artery does not produce perceptible flow signal on the projected images. . Repeat CT Head [7-6]: Right caudate nucleus/posterior limb of internal capsule/lentiform nucleus hypodensity, indicative of evolving infarct corresponding to the comet-shaped region of restricted diffusion on the concurrent MR. There is no significant mass effect and no hemorrhage. . CXR [7-7]: Heart is top normal size. Lungs are grossly clear and there is no pleural effusion. Mediastinal widening could be due to fat deposition, but adenopathy cannot be excluded and it should be noted that this examination does not represent a reliable way to exclude small lung nodules . Thyroid US [7-8]: The right lobe of thyroid is enlarged and is of mixed echogenicity with some cystic areas and some calcification. Most of the right lobe of the thyroid appears to be replaced by this large nodule. This nodule measures 3.5 x 3.8 x 3.3 cm. The isthmus is unremarkable. . The left lobe of thyroid measures 3.7 x 1.6 x 1.9 cm. No evidence of any nodules in relation to the left lobe of thyroid. . Note is made of some prominent lymph nodes in the right side of the neck adjacent to the internal jugular vein. One of these measures 1.5 x 1.8 cm. The cortex is thickened at 0.42 cm. Some further smaller nodes are identified more superiorly in the right side of the neck. . CONCLUSION: Large nodule in relation to the right lobe of the thyroid with calcification. This is a focal dominant nodule. No other nodules identified. Biopsy of this nodule is advised. Note also made of prominent lymph nodes in the right side of the neck. . Brief Hospital Course: Pt. was admitted to the Neuro ICU for close monitoring after tPA infusion. He had no improvement in his deficits, but had no evidence of bleeding or adverse effects from the tPA. Repeat Head CT 24 hrs after tPA administration showed no evidence of intracerebral hemorrhage. Pt. was therefore transferred to the floor for further monitoring. There his exam was stable and on discharge pt. had 0/5 strength in his L arm and leg with increased tone. He worked with PT and OT, who recommended acute rehab after discharge. He was evaluated by Speech and Swallow who recommended a regular diet with no restrictions. . In terms of stroke work-up, pt was monitored on telemetry throughout his hospital stay with no evidence of A fib or other arrythmia. FLP was checked and showed total cholesterol 144, triglycerides 201, HDL 30, LDL 74. Pt. was started on a low dose Statin, and should have a repeat lipid panel checked by his PCP in follow up to evaluate its efficacy. Given his young age a hypercoaguability was sent. This showed ESR 8, Lupus anti-coagulant pending, Factor 8 127 (WNL), Protein C and Protein S pending, Anti-cardiolipin Ab negative, AT III pending, homocysteine 13.4 (mildly elevated, normal 4.5-12.4), [Doctor First Name ] negative, Factor V leiden pending, prothrombin mutation analysis pending. Pending results should be followed up by [Doctor First Name ]. [Last Name (STitle) ] and [Name5 (PTitle) ] in follow up. Daily Aspirin was started and should be continued long-term. . [Last Name (un) ] was consulted about pt's elevated blood glucose. HA1C was checked and was 9.2. Pt was initially managed on an Insulin drip, and was then transitioned to a RISS and 20 [Location 17632]. Once he was transferred to the floor he was started on Metformin 500 mg [Hospital1 ], continued on Lantus, and his sliding scale was decreased and changed to a Humalog scale [First Name8 (NamePattern2) ] [Last Name (un) 9718] recs. Glucose was well controlled for several days prior to discharge, and pt. was asked to follow up with [Last Name (un) ] after discharge for further management on his newly diagnosed Type II DM. He should have his fingersticks recorded at Rehab, and be given a log to take to his follow up with [Last Name (LF) ], [First Name3 (LF) ] that his glucose control can be evaluated by them. . Pt's Thyroid mass was evaluted by ultrasound (see results above) A thyroid panel was checked and showed TSH 12, T4 6.4, T3 104, free T4 0.9. Pt. was started on low dose Synthroid [First Name8 (NamePattern2) ] [Last Name (un) ] recs. Repeat TFTs should be checked by [Last Name (un) ] in follow up. Pt's throid mass was biopsied by Radiology on [7-11]. Cytology was pending at time of discharge and should be followed up by [Last Name (un) ]. . Pt. was started on Metoprolol and Captopril for HTN, and both were titrate up on the floor. This titration should continue in rehab, with goal SBP 120-140, and continued on an outpatient basis. . Pt. was seen by Social work on the floor for concerns re: his home situation (home noted to be in disarray by EMS on entering) Pt. was appropriate in his interactions with nursing and medical staff throughout hospitalization and cooperative with all care provided. He was evaluated by Psychiatry per social work recommendation. Psychiatry felt that he was competent to make his own medical decisions and to participate in rehab, and had need for acute psychiatric evaluation. They did recommend referral to outpatient treatment for hoarding after discharge, to be set up by PCP. Medications on Admission: None Discharge Medications: 1. Humalog Sliding Scale Please administer Humalog before meals per the attached sliding scale 2. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever, pain. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Captopril 12.5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Right subcortical infarction (ischemic stroke) Type II Diabetes Mellitus Hypertension Thyroid mass- biopsy results pending Hypothyroidism Discharge Condition: Stable, with residual L hemiparesis (strength 0/5 in L arm and leg) Discharge Instructions: Please take all medications as prescribed. . Please attend all follow up appointment. Please do not forget to bring a log of your fingersticks to your follow up appointment with Dr. [Last Name (STitle) 14591] at [Last Name (un) ]. . Please call your doctor or go to the ER if you have any worsening of the numbness or weakness in your arm or leg, any changes in your vision, any fevers, chills, cough, shortness of breath, chest pain, or develop any other new symptoms that concern you. Followup Instructions: 1) Please attend the following primary care appointment: Provider: [Name10 (NameIs) 14876] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2185-9-6] 1:30 pm ([Hospital3 ] [Hospital Ward Name 23] building [Location (un) ] atrium suite). You should call them before the appointment so they have your contact information. . 2)Please attend the neurology appointment: Provider: [Name Initial (NameIs) 1220]. [Name5 (PTitle) ] & [Doctor Last Name ] Phone:[Telephone/Fax (1) 2574] Date/Time:[2185-9-7] 1:00 pm ([Hospital ] [Hospital Ward Name 23] building [Location (un) ] neurology). . [Last Name (un) ]: Dr. [Last Name (STitle) 14591], [Last Name (un) ] Diabetes Center, [7-27] at 3:00. Please bring a log of your fingersticks to this appointment. Please call [Telephone/Fax (1) 27773] with any questions. [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2185-7-12] ICD9 Codes: 2449, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7862 }	Medical Text: Admission Date: [2183-3-6] Discharge Date: [2183-3-6] Date of Birth: [2106-1-11] Sex: M Service: NEUROLOGY REASON FOR ADMISSION: Left sided weakness. HISTORY OF PRESENT ILLNESS: This is a 77 year old man with a past medical history of hemophilia A requiring Factor A transfusions, HIV, and Hepatitis A and C, who was at his bedside this morning, on the morning of admission, at 05:00 a.m., able to urinate, but at 06:00 or 06:15, he was unable to move the left arm. He also noted some numbness in the left leg. He was brought to the [Hospital1 190]. He was evaluated in the Emergency Room and found to have an intraparenchymal hematoma measuring about 1.6 to 1.7 cm in the right thalamic region. He was initially alert, conversant and talking but his blood pressures elevated and Ativan was given to calm him down which was only 0.5 mg. In a few hours, his clinical condition deteriorated to which point he was unresponsive and comatose. In the process, he was being given Factor VIII to combat the bleeding of the intraparenchymal hematoma. PAST MEDICAL HISTORY: 1. Hemophilia. 2. Hepatitis A and C. 3. Migraines. 4. Human Immunodeficiency Virus. 5. Possible paroxysmal atrial tachycardia. 6. Right knee osteotomy in [2154]. 7. Hypertension. 8. Anemia. 9. Left inguinal hernia repair. 10. Left hemorrhoidectomy. 11. Cataract surgery in the past. 12. History of shingles. MEDICATIONS ON ADMISSION: 1. Protonix 40 mg p.o. q. day. 2. Tolterodine. 3. Percocet. 4. Megestrol. 5. Epoetin 5000 units q. week. 6. Colace 100 mg p.o. twice a day. 7. Lactulose 30 mg p.o. four times a day. 8. Nystatin suspension. 9. Factor VIII, 3000 units biweekly on Monday and Thursday. 10. Sevelamer 800 mg p.o. three times a day. 11. Verapamil 180 mg p.o. q. day. 12. Metoprolol 50 mg p.o. twice a day. 13. Calcium carbonate 500 mg p.o. three times a day. 14. Saline nasal spray. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lived in [Location 745] and had four children. He lived with his wife. [Name (NI) ] was retired. He did smoke a pipe. PHYSICAL EXAMINATION: Upon presentation, temperature 98.6 F.; blood pressure 216/80; heart rate 66; respiratory rate 18; O2 saturation 97% on two liters. In general he was appearing well. HEENT examination reveals dry mucous membranes. Cardiovascular examination revealed a regular rate. The respiratory examination revealed lungs that were clear to auscultation bilaterally. The abdomen was soft and nontender. The extremities showed some generalized atrophy. Neurologically: On mental status examination he was alert and oriented. He speech was fluent and he was following commands initially. Cranial nerves: The extraocular movements were intact with a right pupil that was slightly irregular and not reactive at 4 mm and a left pupil at 5 mm and minimally reactive. There was some questionable left facial flattening but the excursion was good bilaterally. The tongue was midline. The light touch on the face was the same symmetrically. The visual fields were full. On motor examination, he had difficulty lifting his left arm and appeared to have initially some left sided weakness in the proximal but more distally in the upper extremities. In the lower extremities he was only able to hold up his iliopsoas for about five to ten seconds. The tibialis anterior gastroc were four to five bilaterally. Sensation was intact to proprioception in the left arm. There was diminished light touch in the left leg greater than the left arm. The gait examination was deferred. The reflexes were zero in the lower extremities and three plus in the biceps and brachioradialis. The toe was upgoing on the left. LABORATORY: On admission, his white blood cell count was 11.4 and his hematocrit was 35.3. His coagulation studies showed a PTT of 50.3 and an INR of 1.1 with a PT of 12.9. His chemistries were remarkable for a BUN of 23 and a creatinine of 2.3. His CK was 67. HOSPITAL COURSE: As mentioned, the patient had a clinical deterioration while in the Emergency Room and he was rescanned through the CT scanner without contrast. At 10:50 a.m., this scan showed markedly increased size of the hemorrhage which occupied the entire right basal ganglionic region and the right frontal and temporal lobes. There was intraventricular hemorrhage and there was shift of midline structures and acute hydrocephalus. Neurosurgery consultation was called and they did not feel that evacuation would be beneficial but that ventricular drain might potentially be beneficial for the hydrocephalus itself. Because there was no adequate way to stop the bleeding and the incredible amount of pressure intracranially, the prognosis was thought to be very poor and this was explained to the family. Thereafter, no further interventions were requested by the family and he was admitted to the Neurologic Intensive Care Unit for comfort care. He was intubated, it should be mentioned, at the time of the clinical deterioration and the endotracheal tube was discontinued. Late in the afternoon of the [12-6] he was started on a morphine drip and with the family present, he became asystolic at 07:55 p.m. after an episode of bradycardia. [Name6 (MD) 4267] [Last Name (NamePattern4) 4268], M.D. [MD Number(1) 4269] Dictated By:[Name8 (MD) 4064] MEDQUIST36 D: [2183-3-28] 16:19 T: [2183-3-28] 17:20 JOB#: [Job Number 94798] ICD9 Codes: 431
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7863 }	Medical Text: Unit No: [Numeric Identifier 69399] Admission Date: [2131-6-22] Discharge Date: [2131-7-10] Date of Birth: [2131-6-22] Sex: M Service: NB HISTORY: Baby [Name (NI) ] [Known lastname 69400] was the 2.17-kilogram product of a 32-6/7-weeks gestation. Infant was born to a 29-year-old G5, P1 mother. Prenatal screens: O-positive, antibody negative, RPR nonreactive, hepatitis negative, GBS unknown, rubella unknown. Benign prenatal course until yesterday. Mother transferred from [Name (NI) 1474] Hospital with complaint of fever, right lower quadrant abdominal pain, and high ketones in her urine. She was evaluated for possible sepsis, amniocentesis without chorioamnionitis, coagulations consistent with DIC of unclear etiology possibly due to abruption versus dehiscence of uterine scar. Received 1 dose of betamethasone, 1 dose of terbutaline night before delivery. Ultrasound on the day prior to delivery with normal fetal anatomy thought to be dehydrated and received volume. Transferred to the [Hospital3 ] for further medical care. Urine toxicology: Negative. PREVIOUS OB HISTORY: Prior cesarean section in [2116] for 36 weeker. Perinatal course significant for unknown GBS status. Maternal temperature max of 100.4, rupture of membranes at delivery. Infant delivered by cesarean section. Emerged active with large amount of oral secretions, moderate respiratory distress with periods of apnea. Received positive pressure ventilation x10 breaths and CPAP during transport to newborn intensive care unit. Apgars were assigned at 7 at 1 minute and 7 at 5 minutes respectively. PHYSICAL EXAM ON ADMISSION: Weight 2.170 kilograms. Active. Anterior fontanel: Open and flat. Normal S1, S2, no murmur. Breath sounds: Coarse. Moderate-to-severe intercostal/subcostal retractions. Abdomen: Distended, yet soft, decreased bowel sounds. Extremities: Well perfused. Tone appropriate for gestational age. Bilateral hydroceles present. Of note, maternal hepatitis status was sent on day of delivery and was negative. HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: [Known lastname ] was admitted to newborn intensive care unit and was intubated for management of respiratory distress syndrome. He received a total of 1 dose of surfactant and was extubated within the 1st 24 hours of life. He was on nasal cannula O2 briefly and transitioned to room air, and has been stable in room air for the past 2 weeks. [Known lastname ] was receiving caffeine citrate for management of apnea and bradycardia of prematurity. Caffeine citrate was discontinued on [2131-6-30]. He continues to have occasional apnea and bradycardic episodes with the most recent being documented on [2131-7-9]. Cardiovascular: Infant has been stable without any cardiovascular concerns. Infant has an intermittent audible murmur. Blood pressures have been within normal limits, systolics of 77, diastolics of 47 with a mean blood pressure of 57, heart rates within 140s-170s. Fluid and electrolytes: Birth weight was 2.17 kilograms. Discharge weight is 2455 grams. [Known lastname ] was initially started on 80 cc per kilogram per day of D10W. He also received a bolus of dextrose for a hypoglycemic episode of 23. He has been euglycemic for the remainder of his hospital course. Enteral feedings were started on day of life #2. He achieved full enteral feedings by day of life #7 and his max caloric intake was 150 cc per kilogram per day of breast milk 24 calorie. He continues to receive breast milk 24 calorie, working on p.o. feeding skills. At current, he is mostly PG feeding. GI/GU: Peak bilirubin was on day of life #4 of 9.9/0.4. Infant received phototherapy and the most recent level was on [6-28] of 6.7/0.3. This issue has resolved. Infant has had history of trace heme positive stools. Rectal fissure was noted on exam. Hematology: Hematocrit on admission was 38.8. Infant has not required any blood transfusions during this hospital course. Infectious disease: CBC and blood culture were obtained on admission. CBC had a white count of 9.7, platelets 408, 22 neutrophils, 0 bands, 73 lymphocytes. Infant received a total of 48 hours of ampicillin and gentamicin which were discontinued with a negative blood culture. He has had no further concerns for sepsis. Neuro: Infant has been appropriate for gestational age. Sensory: Hearing screen has not been performed, but should be done prior to discharge. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: Level II. NAME OF PRIMARY PEDIATRICIAN: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 45820]. Telephone number is ([Telephone/Fax (1) 16005]. CARE AND RECOMMENDATIONS: Continue 150 cc per kilogram per day of breast milk 24 calorie. Encouraging p.o. intake [Location (un) 1131] calories as appropriate. Medications: Continue Fer-In-[Male First Name (un) ] supplementation. Car seat position screening has yet to be done. State newborn screen had been sent per protocol, most recent being on [2131-6-24]. IMMUNIZATIONS RECEIVED: Infant received hepatitis B vaccine on [2131-6-22]. DISCHARGE DIAGNOSES: Premature infant born at 32-6/7 weeks, respiratory distress syndrome, rule out sepsis with antibiotics, hyperbilirubinemia, apnea and bradycardia of prematurity, anemia of prematurity. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2131-7-10] 02:54:57 T: [2131-7-10] 04:28:07 Job#: [Job Number 69401] ICD9 Codes: 769, 7742, V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7864 }	Medical Text: Admission Date: [2136-9-12] Discharge Date: [2136-9-16] Date of Birth: [2063-1-29] Sex: F Service: NEUROSURGERY Allergies: Cortisone + Cooling Relief / Latex Attending:[First Name3 (LF) 3227] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: 73yo woman on [First Name3 (LF) ] and [First Name3 (LF) ] for CAD was walking in a parking lot today and had a mechanical fall. no LOC. Taken to [Hospital ] Hospital where Head CT revealed left SDH. [Location (un) 7622] to [Hospital1 18]. no vision changes, no N/V. Neurosurgery consultation for evaluation and treatment. Past Medical History: GERD, HTN, HL, hysterectomy, CABG x5, PCI x2 stents Social History: Widowed, lives alone. Has 4 grown children and a close friend. no tobacco, rare etoh. ambulates without assistance. daughter [Name (NI) ] [Telephone/Fax (1) 87052] is who she would like called if she can't make her own decisions. Family History: NC Physical Exam: PHYSICAL EXAM: BP: 132/64 HR:66 R 16 O2Sats 98%RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL 3mm EOMs intact Neck: hard collar Abd: Soft Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation limited by large temporal hematoma. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [4-25] throughout. No pronator drift Sensation: Intact to light touch, propioception Toes downgoing bilaterally Exam upon discharge: a nad o x3, motor full, no pronator drift. ecchymosis left eye Pertinent Results: [2136-9-12] 03:45PM PT-11.9 PTT-23.1 INR(PT)-1.0 [2136-9-12] 03:45PM PLT COUNT-235 [2136-9-12] 03:45PM NEUTS-68.1 LYMPHS-23.6 MONOS-4.3 EOS-2.5 BASOS-1.5 [2136-9-12] 03:45PM WBC-7.6 RBC-4.48 HGB-14.0 HCT-41.6 MCV-93 MCH-31.4 MCHC-33.8 RDW-13.7 [2136-9-12] 03:45PM GLUCOSE-126* UREA N-23* CREAT-1.1 SODIUM-142 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16 CTH [9-12] CT Head: 4mm left frontal-parietal acute SDH. no mass effect or midline shift Repeat CT head [9-12] 1. Stable small 4-mm transverse diameter area of left subdural hemorrhage. No new foci of hemorrhage. 2. Stable extensive left scalp hematoma and hematoma surrounding the left orbit. CT cervical spine [9-12] No fracture or subluxation repeat Head CT [2136-9-13]: stable CT head [9-13] Stable exam, no change from previous CT scan. Brief Hospital Course: [9-12] Pt admitted to neurosurgery service and the ICU on [9-12] for strict blood pressure control less than 140 systolic and q1 neurochecks. Given her use of [Month/Year (2) ] and [Month/Year (2) 4532] she did receive 1 unit of platelets. She did well overnight with no complaints or change in her neurological exam. She did have a repeat head CT 4 hours after admission that showed no change in her subdural hematoma. [9-13] Pt seen on A.M rounds and doing well. She did have some complaints of seeing things that were not there but she says this has been happening for some time and has seen multiple doctors as [Name5 (PTitle) ] outpatient for workup. She says these episodes are self limited and there has been no change in their frequency since her fall. She will see cognitive neurologist Mark [Doctor Last Name 8012] as an outpatient for neurologic evaluation. She had a repeat CT head on this day that again showed no change in amount of subdural blood and she was transfered to the floor in stable condition. [9-14] Upon arrival to the floor she was seen by the physical therapy team and worked with them until cleared for discharge to home with home services. Medications on Admission: [Last Name (LF) 4532], [First Name3 (LF) ], metoprolol, levothyroxine, ranitidine, lovastatin, Vit D Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 7 days. Disp:21 Capsule(s) Refills:0 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for T>38.5, pain. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while on pain med. Disp:60 Capsule(s) Refills:0 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for h/a. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital6 486] Discharge Diagnosis: Left frontal subdural hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc.until seen in follow up. ?????? You were on [Hospital6 ] (clopidogrel) and Aspirin prior to your injury, you may not safely resume taking these medications until follow up with Dr. [First Name (STitle) ] and repeat head ct in clinic in one month. Followup Instructions: ?????? Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Please follow up with Dr. [Last Name (STitle) 8012] of cognitive neurology on [9-21] at 8:30 A.M. Please call [Telephone/Fax (1) 50382] if questions or you are unable to keep this appointment. Completed by:[2136-9-16] ICD9 Codes: 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7865 }	Medical Text: Admission Date: [2138-1-2] Discharge Date: [2138-1-15] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2932] Chief Complaint: hypotension following right hip arthroplasty Major Surgical or Invasive Procedure: right hip arthroplasty History of Present Illness: 85 year old man admitted to the medical ICU from the post-operative care unit for persistent hypotension post-op. He was initially admitted [2138-1-2] with avascular necrosis/osteoarthritis of the right femoral head s/p ORIF intertrochanteric femur fracture. He underwent conversion of prior right hip fracture to total hip replacement. Post opeartively, he was agitated and hypotensive (sbp 90s). In PACU he received 1.5mg haldol over several hours, and a total of 10mg IV of morphine for agitation and pain control. Past Medical History: 1. Early dementia. 2. Back pain/Vertebral compression fractures/kyphosis. MRI L-dpine [5-1] - Diffuse disc bulge at L3-L4 asymmetric to the right causing mild canal stenosis and mild right neural foraminal narrowing. Vertebroplasty cement adjacent to L5 nerve root resulting in mild narrowing of the right neural foramen. 3. [Doctor First Name ] on clarithromycin followed by Dr. [Last Name (STitle) ] 4. Abdominal aortic aneurysm. 5. Coronary artery disease. 6. Chronic obstructive pulmonary disease/emphysema home oxygen (4L at night, 2L during day). FEV1/FVC 59% pred ([3-3]). 7. Bronchiectasis. 8. Retinal vein occlusion. 9. R hip fracture/surgery [2130]/[2136] s/p hardware removal in '[37]. 10. Seizures 11. Osteoporosis - bone density [2135] 12. Anemia - chronic Social History: Patient lives at home with his wife, who also uses home O2. Patient ambulates with cane/walker at home. Despite dementia, he was independent in his ADL's until his recent fracture/surgery Family History: Non-contributory Physical Exam: Physical Exam on admission: PE: T:98.1 BP:91/42 HR:94 O2:100%RA Gen: Alert, not oriented HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL , ruS1, S2. No murmursbs or [Last Name (un) 549] LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL, post-op NEURO: A, not oriented. CN 2-12 grossly intact. Preserved sensation throughout. Gait assessment deferred Pertinent Results: Laboratory studies on admission [2138-1-2] WBC-11.1 HGB-9.1 HCT-26.6 MCV-104 RDW-17.3 PLT COUNT-233 GLUCOSE-207* UREA N-13 CREAT-0.5 SODIUM-137 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-28 7.5* Phos-2.1* Mg-2.1 Recent Laboratory studies [2138-1-15] WBC-7.5 Hgb-11.7 Hct-34.4 MCV-95 RDW-18.8 Plt Ct-371 Glucose-143 UreaN-11 Creat-0.5 Na-145 K-3.6 Cl-108 HCO3-34 AnGap-7 [1-3] EKG: Baseline artifact. Probable sinus rhythm with a single. Vertical axis. Right bundle-branch block. Since the previous tracing of [2137-12-30] decreased QRS voltage in leads VI-V2 may be related to lead position Radiology [1-2] right hip plain films: The distal femoral component of the THA is excluded from intraoperative frontal film. There has been placement of a right total hip arthroplasty with a cemented acetabular and femoral component. On this single AP view, components are aligned. [1-3] CXR: No pneumonia or CHF. Subtle increased interstitial markings at the bases are unchanged [1-7] CT Abdomen: Moderate-sized hematoma with residual air pockets from recent surgery adjacent to right hip prosthesis. No extension with into the retroperitoneum or more inferiorly into the thigh. Bilateral small pleural effusions, mild subcutaneous edema diffusely and some collection of fluid within the perirectal fat. Findings consistent with mild anasarca. Stable bilateral adrenal adenomas [1-8] CT Chest: The heart size is normal. Extensive aortic and coronary calcifications are identified. There is no axillary, mediastinal or hilar lymphadenopathy. Evaluation of the lung parenchyma is somewhat limited by respiratory motion. Again seen are numerous small pulmonary nodules which are stable back to [2134]. Scattered tree-in-[Male First Name (un) 239] opacities are also unchanged. There are moderate bilateral pleural effusions. Visualized portions of the upper abdomen are stable with fullness of the adrenal glands again noted. There are no suspicious lytic or sclerotic osseous lesions. Degenerative changes of the thoracic spine are noted. Right proximal humeral enchondroma or bone infarct is again noted. [1-13] KUB/upright: There is no evidence of free intra-abdominal air. Normal bowel gas [Doctor Last Name 5926] seen. Mild bibasilar atelectasis is identified. There is unchanged appearance of a right prosthetic hip. High-density material overlying the L5 vertebral body unchanged and likely represents a prior history of vertebroplasty. [1-13] CXR: No evidence of pneumonia. Stable small bilateral pleural effusions. Pathology [1-2] right hip: The articular surface of the bone appears focally eburnated with small osteophyte formation of which representative sections are submitted in A-B. Decalcified. Transthoracic echochardiogram [2138-1-7]: EF 50%. Mid inferior (and probable inferolateral) hypokinesis. Trace aortic regurgitation is seen, [1-28]+ MR. Brief Hospital Course: 85 year old male initially admitted to the medical ICU with hypotenstion following a right total hip replacement. He was stabilized and transferred to the general medical floor [2138-1-6]. His hospital course was notable for NSTEMI, right hip/left groin hematomas, atrial fibrillation, and diarrhea (likely C. diff). 1) Hypotension: The patient's post-op hypotension was most likely secondary to NSTEMI (see below) and peri-op blood loss. His blood pressure stabilized and, at time of discharge, his sbp was 120s. 2) Coronary artery disease with NSTEMI: The patient's troponin peaked at 0.27 on [2138-1-5]. An echocardiogram was obtained, which showed an EF 50% (down from pre-op PMIBI 66%) with mid inferior and probable inferolateral hypokinesis. The cardiology service was consulted, who recommended medical management. He was started on high dose statin, continued on beta-blocker (sotolol), and aspirin. He will follow-up with his cardiologist as an outpatient. 3) Supraventricular tachycardia: The patients telemetry monitoring showed a predominantly sinus rhythm with PVCs and occasional runs of atrial fibrillation/flutter along with rare 4-5 beats of NSVT. His sotalol dose was increased to 80 mg daily with improved rate control. 4) Mental status change: The cause of the patient's poor mental status, which was clearing by time of discharge, was likely multifactorial - delirium due to multiple acute illnesses (diarrhea, recent surgery/anesthesia, pain) superimposed on his underlying dementia. The patient was restarted on Namenda and Donepezil. Vitamin B12, RPR, and TSH were within normal limites. The patient was very sensitive to narcotics, and, on the evening of [2138-1-9] required multiple doses of Narcan for depressed mental status. At time of discharge, his pain was controlled on standing tylenol with tramadol as needed. 5) Right hip and left groin hematomas: These developed while the patient had a supratherapeutic INR. He required 2 tranfusions of PRBC (last [1-10]), and his INR was reversed with vitamin K and FFP. His hematocrit remained stable (34.4 on discharge), and he was restarted on coumadin. His hematocrit will need to be closely monitored as an outpatient, particularly while he is anticoagulated. 6) Anemia: This was likely due to peri-operative bleeding as well as to the hematomas mentioned above. The patient was transfused 6 units of blood in the immediate post-op period, followed by 2 units of blood (the last [1-10]) when he developed the above hematomas. Further work-up included iron studies (not consistent with deficiency, vitamin B12/folate (not deficient), haptoglobin (not consistent with hemolysis), SPEP/UPEP (negative), and fibrinogen (not consistent with DIC). His hematocrit on discharge was stable at 34.4. He will need to have his hematocrit monitored closely (especially while he is anticoagulated). 7) Right total hip replacement: The patient was followed by the orthopedics service throughout his hospital stay. He will be maintained on coumadin (goal INR 2-2.5) for a total of 6 weeks from surgery (4 additional weeks following discharge). He was briefly on Keflex given serosanguinous drainage from the right hip incision site, which was discontinued once the incision was dry. He will follow-up 1 week following discharge for staple removal. 8) Diarrhea: The patient developed copious diarrhea while in-house. He was started on empiric metronidazole for suspected C. diff with good effect, although C. diff A toxin was negative X 5. C. diff toxin B is pending at discharge. Given clinical improvement, he will continue metronidazole for a 14 day course for presumed C. difficile colitis. 9) COPD: The patient was continued on albuterol/atrovent and flovent. He remained stable on his home O2 (2 liters). 10) Chronic [Doctor First Name ]: The patient was continued on azithromycin. 11) Urinary retention: The patient failed multiple voiding trials while in-house (most recent Foley placed [2138-1-15]). He was started on Flomax and should have a repeat voiding trial at rehab. Medications on Admission: Acetaminophen Oxycodone 20 mg Tablet Sustained Release 12HR Sig Oxycodone 5 mg Tablet Sig Calcium Carbonate 500 mg Tablet Cholecalciferol (Vitamin D3) 400 unit Tablet Phenobarbital 30 mg Tablet Sotalol 80 mg 0.5 tablet daily Aspirin 81 mg Tablet Donepezil 5 mg Tablet Gabapentin 300 mg Capsule Docusate Sodium 100 mg Capsule Fluticasone 110 mcg/Actuation Aerosol Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Memantine 5 mg [Hospital1 ] Senna Enoxaparin 30 mg/0.3 mL Pantoprazole 40 mg Tablet Lidocaine 5 %(700 mg/patch) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day. 4. Phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Sotalol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a day (in the evening)): at 9 p.m. 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 13. Memantine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for dementia. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Azithromycin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). 17. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 18. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days: through [2138-1-20]. Tablet(s) 20. Tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pain: hold for oversedation. 21. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) for 4 weeks: to complete 6 weeks of anticoagulation from surgery. 22. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed: to groin. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary: total hip replacement for avascular necrosis Secondary: hypotension, coronary artery disease, NSTEMI, congestive heart failure, atrial fibrillation, right thigh/left groin hematoma, anemia, myocbacterium avium complex, diarrhea Discharge Condition: Stable Discharge Instructions: 1) Please take all medications as prescribed. - you have been started on atorvastatin - you will complete a 14 day course of metronidazole for C. diff colitis; it is important that you not drink alochol while taking this medication. - Flomax was added to your regimen for benign prostatic hypertrophy - you have been started on anticoagulation to prevent clots following surgery; you will continue this for 4 weeks following discharge. 2) Please follow-up as indicated below. 2) Please come to the emergency room if you develop chest pain, shortness of breath, increased pain, or other symptoms that concern you. Followup Instructions: 1) Orthopedics Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10486], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2138-1-24] 3:00 - plan for staple removal at that time 2) Primary Care: Please follow-up with your PCP [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 3393]) within 1-2 weeks following discharge. 3) Pulmonary: Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ]/DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2138-4-10] 12:00 Provider: [Name10 (NameIs) 1571] BREATHING TESTS Phone:[Telephone/Fax (1) 612] Date/Time:[2138-4-10] 11:40 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 2937] Completed by:[2138-1-15] ICD9 Codes: 496, 2851, 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7866 }	Medical Text: Admission Date: [2200-6-16] Discharge Date: [2200-7-1] Date of Birth: [2160-7-22] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1781] Chief Complaint: multi trauma Major Surgical or Invasive Procedure: 1. Lower extremity angiography via the right common femoral arterial approach. 2 The left superficial femoral artery to posterior tibialis bypass with reversed right greater saphenous vein, 4 compartment fasciotomy of left lower extremity. 3. PROCEDURES: a. Closed reduction knee dislocation. b. Closed reduction proximal tibial plateau fracture. c. Application of multiplanar external fixator. d. ORIF left tibial plateau and External fixator History of Present Illness: 39 yo Male +ETOH fell down stairs with left tibial plateau fracture, posterior knee dislocation with cold left foot Past Medical History: PAST PSYCHIATRIC HISTORY: Denies PAST MEDICAL HISTORY: Denies Social History: SUBSTANCE ABUSE HISTORY: - Uses [12-27] bags per day of heroin - Consumes 12-18 beers daily - Occasional Benzos (1-2 times per week) - Multiple detox admits in past - History of withdrawal from heroin and EtOH (denies history of seizures) - Longest period of sobriety 8 months - Smokes 1ppd tobacco Family History: non contributary Pertinent Results: [2200-6-29] BLOOD WBC-7.2 RBC-2.79* Hgb-8.5* Hct-24.5* MCV-88 MCH-30.6 MCHC-34.8 RDW-14.7 Plt Ct-570* [2200-6-29] BLOOD Plt Ct-570* [2200-6-29] BLOOD Glucose-92 UreaN-11 Creat-0.6 Na-140 K-4.2 Cl-103 HCO3-29 AnGap-12 [2200-6-29] BLOOD Calcium-8.6 Phos-4.4 Mg-2.2 Brief Hospital Course: Pt admitted on [6-16] PROCEDURES: Left lower extremity angiography via the right common femoral arterial approach. PROCEDURES: 1. Closed reduction knee dislocation. 2. Closed reduction proximal tibial plateau fracture. 3. Application of multiplanar external fixator PROCEDURE: The left superficial femoral artery to posterior tibialis bypass with reversed right greater saphenous vein, 4 compartment fasciotomy of left lower extremity. Pt tolerated all the procedures well Psyche consulted for Agitation and question of opiate withdrawal, there recommendations were. RECOMMENDATIONS: Monitor for alcohol and benzodiazepine withdrawal with CIWA Ativan 2mg IV q2hrs PRN CIWA > 10 Bentyl, Robaxin and NSAIDs PRN GI discomfort, cramping and pain associated with opiate withdrawal For acute agitation, offer Haldol 5mg IV QID:PRN in lieu of Ativan (as this will cloud withdrawal vs. intoxication picture) Monitor EKG while using neuroleptics (can cause QTc prolongation) MVI/Thiamine/Folate IV Pt had post operative normal course / VAC dressing on fasciotomy site changed every third day [6-23] Pt transferred to orthopedics for closure of fasciotomy site / and closed reduction of fracture. [Date range (1) 12535] On Ortho service. patient stable. VSS. On Methadone 10mg [Hospital1 ] without symptoms od withdrawal. Receiving physical therapy ([Hospital1 19489] on Left), pin care and wound VAC to medial fasciotomy left thigh. Left bypass graft palpable. [2200-6-26]: Ortho performed ORIF left tibial plateau and External fixator [Date range (1) 24392] Continues on Ortho service. Stable from Vascular standpoint. Medial Fasciotomy VAC changed every 3 days. Graft is palpable. VSS. Tmax 100.9. Pain controlled with Dilaudid. Patient working with physical therapy and is extremely motivated for rehab. Patient transferred back to Vascular Service [2200-6-30]: Patient stable. Left graft pulse palpable and PT. Plan for transfer to rehab. Continue pin care and DSD to Ortho surgical sites. Medial fasciotomy site: Wound VAC. Methadone decreased to 5mg [Hospital1 ]. [2200-7-1]: To rehab. Will continue Metadone taper.Will continue 5mg [Hospital1 ] [7-1] and stop on [7-2]. Continue PT, [Name (NI) 19489] [Name (NI) ]. Medial wound VAC to get reapplied on arrival to rehab. Medications on Admission: none Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 7. Methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): pt on tapered dose...will continue 5mg [Hospital1 ] [7-1] and stop on [7-2] . 8. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: Posterior knee dislocation of the left side with decreased ABI. Schatzker 5 tibial plateau fx. Compartment syndrome Ischemic left foot. Left popliteal dissection. POSTOPERATIVE DIAGNOSIS: Left knee dislocation. Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ??????You should get up out of bed every day and gradually increase your activity each day ??????Increase your activities as you can tolerate- do not do too much right away! Continue [Hospital1 19489] status [Hospital1 ] 2. It is normal to have swelling of the leg you were operated on: ??????Elevate your leg above the level of your heart (use [12-27] pillows or a recliner) every 2-3 hours throughout the day and at night ??????Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ??????You will probably lose your taste for food and lose some weight ??????Eat small frequent meals ??????It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ??????To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ??????You should gradually increase your activity ??????Increase your activities as you can tolerate- do not do too much right away! ??????Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ??????Redness that extends away from your incision ??????A sudden increase in pain that is not controlled with pain medication ??????A sudden change in the ability to move or use your leg or the ability to feel your leg ??????Temperature greater than 100.5F for 24 hours ??????Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Physical Therapy: Activity: Out of bed to chair Left lower extremity: Non weight bearing Followup Instructions: Call dr [Last Name (STitle) ] office and schedule an appointment for 2 weeks after DC. She can be reached at [Telephone/Fax (1) 2395] Call Ortho: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1005] ([Telephone/Fax (1) 2007] or Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. ([Telephone/Fax (1) 2007] in 2 weeks Completed by:[2200-7-1] ICD9 Codes: 4439, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7867 }	Medical Text: Admission Date: [2138-8-2] Discharge Date: [2138-8-3] Date of Birth: [2055-3-1] Sex: M Service: MEDICINE Allergies: Phenylephrine Attending:[First Name3 (LF) 1711] Chief Complaint: Altered mental status, hypotension, respiratory distress Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 49411] is a 83 yo Russian-speaking male with a history of three vessel CAD, sCHF, AF, AS, DM, CKD and a history of aspiration events, recently discharged from the [Hospital1 18] CCU service who re-presents from his rehab facility to the ED today. Around 10AM on the day of admission, the patient was noted to acutely desaturate and his rehab and become lethargic. Initial ABG demonstrated 7.34/50/54. His supplemental oxygen was increased and he was eventually placed on NIPPV. His PO2 increased to 93 with this but he remained somnolent. He was also noted to become hypotensive with SBPs in the 60s, shortly prior to his transfer to the ED. He was given 250cc NS bolus x 2 for this and for poor urine output. He was also noted to have tremulous extremities. . In the ED, the patient was found to be hypoxic, with sats in the 70s on 100% FiO2, as well as hypotensive to the 60s systolic. A chest x-ray was concerning for CHF. The patient was intubated for progressive respiratory distress. A femoral line was placed and he was started on dopamine and Levophed for blood pressure support after receiving 3L NS. His serum K was noted to be elevated and he was treated with Ca, insulin, glucose and bicarb. He was also emperically treated with ciprofloxacin and Flagyl. . The patient's most recent admission was for evaluation of hypotension in the setting of receiving SL NTG despite his known AS. His hospital course was complicated by hematuria, a UTI, and a new diagnosis of frequent aspiration. Just prior to that [Hospital1 18] admission, he had been hospitalized at [Hospital3 ] medical center for an NSTEMI complicated by cardiogenic shock. During that hospitilization, PCI for the patient's known CAD was attempted but could not be performed. While on the [Hospital1 18] CCU service, the patient's [Hospital3 ] cath films were obtained and reviewed by both interventional cardiology and cardiac surgery; he was not felt to be a candidate for revascularization. . On arrival to the CCU, the patient is somnolent and unresponsive to painful stimuli. ROS is unable to be obtained. . Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: 3. OTHER PAST MEDICAL HISTORY: . MR AS, severe CHF, systolic and diastolic dysfunction, Recurrent MI with cardiogenic shock [2133-8-7]. Multiple PCI procedures PAD with IC Right foot plantar ulcer CRI. Bronchiectasis/emphysema/recurrent bronchitis Diabetic neuropathy, possible early diabetic nephropathy Chronic recurrent left ear infection Social History: Lives at home with wife. -Tobacco history: Denies. -ETOH: Rare social EtOH. -Illicit drugs: Family History: Noncontributory. SOCIAL HISTORY . No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GENERAL: Critically ill adult male, intubated, sedated. Diffuse, intermittent muscle twitching. [Month/Day/Year 4459]: NCAT. Sclera anicteric. PERRL but sluggish to respond. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. NECK: Supple; neck veins difficult to assess. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No R/R/G. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Mechanical breath sounds. Decreased breath sounds at bases bilaterally. Few rhonchi; no frank wheezing. ABDOMEN: Distended, tympanitic abdomen with decreased bowel sounds. No HSM. No abdominial bruits. EXTREMITIES: No C/C/E. No femoral bruits. SKIN: Mild stasis dermatitis changes. No other ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ Left: Carotid 2+ Femoral 2+ DP 2+ Pertinent Results: [2138-8-2] 11:43PM GLUCOSE-199* UREA N-58* CREAT-3.6* SODIUM-130* POTASSIUM-6.1* CHLORIDE-98 TOTAL CO2-21* ANION GAP-17 [2138-8-2] 11:43PM ALT(SGPT)-122* AST(SGOT)-108* LD(LDH)-394* CK(CPK)-51 ALK PHOS-218* TOT BILI-0.6 [2138-8-2] 11:43PM WBC-15.7# RBC-3.63 HGB-10.7* HCT-34.4* MCV-95 MCH-29.5 MCHC-31.1 RDW-15.3 [2138-8-2] 04:50PM WBC-8.8 RBC-3.08* HGB-9.3* HCT-28.9* MCV-94 MCH-30.1 MCHC-32.1 RDW-15.4 [2138-8-2] 10:26PM LACTATE-2.1* K+-6.2* [2138-8-2] 04:50PM cTropnT-0.11* [2138-8-2] 04:50PM CK-MB-NotDone proBNP-[Numeric Identifier 49412]* EKG: Sinus bradycardia at 59. NA; first degree AV delay. LBBB. Compared to prior tracing from [2138-7-27], QRS duration is wider and QRS axis has shifted to the right. . 2D-ECHOCARDIOGRAM: ([2138-7-18]) The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. LV systolic function appears depressed (ejection fraction 30 percent) secondary to akinesis of the posterior wall and anterior septum, and hypokinesis of the rest of the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . CXR ([2138-8-2]): 1. Moderate congestive heart failure with small bilateral pleural effusions. 2. Bibasilar opacities may reflect atelectasis, but infection is not excluded. . CT C/A/P ([2138-8-2]) (PFI): Pulmonary edema, bilateral plueral effusions. Fluid in trachea and bronchi concerning for aspiration. Gallbladder severely enlarged with stone in neck may relate to cholecystitis. US should be considered for further evaluation. . CT Head ([2138-8-2]) (PFI): No acute intracranial pathology; chronic small vessel ischemic changes; fluid in the nasopharynx likely due to intubation. . PFTs ([4-14]): Mild obstructive ventilatory defect. The reduced FVC may be due to gas trapping but a coexisting restrictive defect cannot be excluded. Suggest lung volume measurements if clinically [Month/Year (2) 9304]. Compared to the prior study of [2137-12-27] the FVC has increased by 0.35 L (+16%). . Brief Hospital Course: 83 yoM with multiple medical problems including extensive CAD, AS, sCHF, AF, DM and CKD presents from rehab with lethargy, hypoxic respiratory failure and hypotension. Pt was brought to the CCU intubated and on pressors. Some ECG changes were noted on admission, likely due to pt's significant acidemia. Pt was significantly fluid overloaded by CXR. Exact precipitant was unclear but pt was given cautious diuresis. Pt was simultaneously hypotensive, on dopamine and levophed. Hypoxic respiratory failure/respiratory acidosis/question aspiration persisted and vent settings had to be maximized. Pt's muscle fasciculations continued in CCU, likely related to his uremia or hyperkalemia. Despite aggressive medical management, pt's condition continued to deteriorate rapidly in the CCU. A family meeting was called where goals of care were discussed and patient made DNR/DNI. Pt was found unresponsive, without electrical activity on cardiac monitor and with no pupillary reflex. Pt expired at 4:19 am on [2138-8-3] w/ pt's wife present at the bedside. Medical Examiner declined the case and autopsy declined by the family. Medications on Admission: 1. Fluticasone-Salmeterol 250-50 [Hospital1 ] 2. Allopurinol 150 mg daily 3. Spironolactone 12.5 mg daily 4. Gabapentin 600 mg [Hospital1 ] 5. Lisinopril 5 mg daily 6. Simvastatin 80 mg daily 7. Aspirin 81 mg daily 8. Pantoprazole 40 mg daily 9. Ferrous Sulfate 325 daily 10. Amiodarone 200 mg daily 11. Metoprolol Tartrate 25 mg [Hospital1 ] 12. Furosemide 40 mg daily 13. Lantus 50 units qHS 14. Insulin Lispro sliding scale 15. Simethicone 80 mg four times daily PRN 16. Polyethylene Glycol [Hospital1 ] PRN constipation 17. Senna 8.6 mg 1-2 tabs [Hospital1 ] PRN 18. Bactrim DS [Hospital1 ] through [2138-8-3] for UTI . ALLERGIES: Phenylephrine Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: congestive heart failure acute renal failure respiratory failure acidosis Discharge Condition: expired Discharge Instructions: patient expired Followup Instructions: expired ICD9 Codes: 4254, 5070, 5849, 2761, 5990, 4280, 4241, 5859, 3572, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7868 }	Medical Text: Admission Date: [2125-9-17] Discharge Date: [2125-9-22] Date of Birth: [2067-8-25] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1406] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: Aortic Valve Replacement (25mm Trifecta) [2125-9-17] History of Present Illness: 57 year old with history of hypertension and hyperlipidemia was found to have bigeminal PVCs on routine office visit with PCP. [Name10 (NameIs) ] was referred to cardiology. An echo was obtained which revealed moderate to severe aortic insufficiency with normal ejection fraction. A cardiac catheterization was performed as part of the pre-op work-up which revealed no significant coronary artery disease. He was evaluated by Dr. [Last Name (STitle) ] for an aortic valve replacement and returns today for preadmission testing. He denies chest pain, shortness of breath, dizziness or light-headedness. Past Medical History: - Aortic Insufficiency - hypertension - small abdominal aortic aneurysm - H/O elevated LFTS - diverticulosis Past Surgical History - left knee surgery- arthroscopy - appendectomy for perforated gangrenous appendix c/b abdominal abscesses post operatively treated with 6 weeks of IV antibiotics - tonsillectomy Social History: Lives with: wife Contact: wife Phone # [Telephone/Fax (1) 110523] [Name2 (NI) ]pation: retired from real estate. Loves to golf. Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx: 1 cigar daily Other Tobacco use: ETOH: denies < 1 drink/week [] [3-6] drinks/week [X] >8 drinks/week [] Illicit drug use Family History: No cardiac history Mother died at 77, had Lupus Father living with PPM at 87yo Physical Exam: Pulse: 60 Resp: 16 O2 sat: 96%RA B/P Right: 170/83 Left: 180/87 Height: 6'4" Weight: 210lb General: NAD, WGWN, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR, Nl S1-S2, I/VI diastolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] No Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [Name (NI) 167]: 2+ Left:2+ Radial Right: 2+ Left: cath site Carotid Bruit Right: Left: no bruits Discharge Exam: VS: T 98.2 HR: 50's SB BP: 130'[3-/2093] Sats: 98% RA WT: 100 kg General: 58 year-old male in no apparent distress HEENT: normocephalic mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1, S2 no murmur Resp: clear breath sounds throughout GI: benign Extr: warm no edema Incision: sternal clean dry intact no erythema Neuro: awake,alert, oriented walking in halls Pertinent Results: [2125-9-22] WBC-6.3 RBC-4.01* Hgb-12.8* Hct-39.4* MCV-98 MCH-31.9 MCHC-32.5 RDW-12.9 Plt Ct-138* [2125-9-19] WBC-10.5 RBC-4.33* Hgb-14.1 Hct-42.5 MCV-98 MCH-32.7* MCHC-33.3 RDW-12.9 Plt Ct-84* [2125-9-18] WBC-12.0* RBC-4.31* Hgb-13.7* Hct-41.3 MCV-96 MCH-31.8 MCHC-33.2 RDW-12.8 Plt Ct-105* [2125-9-22] UreaN-22* Creat-1.1 Na-138 K-4.8 Cl-101 [2125-9-19] Glucose-93 UreaN-19 Creat-1.0 Na-137 K-4.6 Cl-102 HCO3-30 [2125-9-18] Glucose-116* UreaN-17 Creat-0.9 Na-140 K-4.1 Cl-109* HCO3-24 [2125-9-17] Na-140 K-4.2 Cl-110* [2125-9-22] PT-11.9 INR(PT)-1.1 TTE [2125-9-17] Prebypass: The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Moderate to severe (3+) aortic regurgitation is seen. With jet area 50% of Left Ventricular outflow tract, no aortic diastolic flow reversal. The mitral valve appears structurally normal with trivial mitral regurgitation and presence of [First Name4 (NamePattern1) 11270] [Last Name (NamePattern1) 11271] murmur. Dr. [Last Name (STitle) ] was notified in person of the results on [2125-9-17] at 1230. Postbyass: The patient is A-Paced, on no inotropes. There is a tissue valve in the aortic position which is well-positioned with no leak and no AI. Residual mean gradient = 11 mmHg. Preserved biventricular systolic fxn. Aorta intact. PA & Lat CXR: [2125-9-21]; FINDINGS: PA and lateral chest radiographs were obtained. A small left pleural effusion is new. The aeration of the lungs has improved since three days ago. There is no consolidation or pneumothorax. Median sternotomy wires are intact. Aortic valve ring sits in appropriate position. IMPRESSION: New small left pleural effusion. Brief Hospital Course: The patient was brought to the Operating Room on [2125-9-17] where the patient underwent AVR with Dr. [Last Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Of note, pacing wires were left in until POD4 due to a low platelet count. On POD 4, platelet count had increased to 105,000 and Hit was negative. He did develop rapid atrial fibrillation which was rate controlled with Amiodarone and titration of beta blocker. Anti-coagulation was started with Coumadin. Dr. [First Name (STitle) 6164] will manage this as an outpatient. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Atorvastatin 10 mg PO DAILY 2. Metoprolol Tartrate 100 mg PO BID 3. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO DAILY 3. Acetaminophen 650 mg PO Q4H:PRN pain, fever 4. Docusate Sodium 100 mg PO BID 5. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth once a day Disp #4 Tablet Refills:0 6. Senna 1 TAB PO BID RX sennosides [senna] 8.6 mg 1 tablet by mouth once a day Disp #30 Tablet Refills:0 7. Warfarin 5 mg PO AS DIRECTED RX warfarin [Jantoven] 5 mg 1 tablet(s) by mouth as directed Disp #30 Tablet Refills:0 8. Warfarin 1 mg PO AS DIRECTED RX warfarin 1 mg 1 tablet(s) by mouth as directed Disp #100 Tablet Refills:0 9. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain RX hydromorphone 2 mg [1-29] tablet(s) by mouth every six (6) hours Disp #60 Tablet Refills:0 10. Amiodarone 400 mg PO BID 400 twice daily x 7 days 200 twice daily x 7 days then 200 daily RX amiodarone 200 mg 2 tablet(s) by mouth twice daily then as directed Disp #60 Tablet Refills:1 11. Metoprolol Succinate XL 25 mg PO Q12H RX metoprolol succinate 25 mg 1 tablet(s) by mouth every twelve (12) hours Disp #60 Tablet Refills:5 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: - Aortic Insufficiency - hypertension - small abdominal aortic aneurysm - H/O elevated LFTS - diverticulosis Past Surgical History - left knee surgery- arthroscopy - appendectomy for perforated gangrenous appendix c/b abdominal abscesses post operatively treated with 6 weeks of IV antibiotics - tonsillectomy 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: Shower daily including washing incisions gently with mild soap, no baths or swimming for 4 weeks Daily weights: keep a log. NO lotions, cream, powder, or ointments to incisions No driving for approximately one month or while taking narcotics. No lifting more than 10 pounds for 10 weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [Telephone/Fax (1) 170], [2125-9-27] 10:45 in the [Hospital 110524] Medical Building [Last Name (NamePattern1) ] Surgeon Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170], [2125-10-18] 1:15 in the [Hospital ] Medical Building [Last Name (NamePattern1) ] Cardiologist Dr. [Last Name (STitle) 911] [Telephone/Fax (1) 62] Date/Time:[2125-10-3] 2:00 Please call to schedule the following: Primary Care Dr. [First Name (STitle) ],[First Name3 (LF) 1730] O. [Telephone/Fax (1) 4475] in [5-3] 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 Dr. [First Name (STitle) 6164] will follow INR/Coumadin dosing First INR draw [2125-9-23] Results to Dr. [First Name (STitle) 6164] Phone: [Telephone/Fax (1) 4475] Fax: [Telephone/Fax (1) 29683] Completed by:[2125-9-22] ICD9 Codes: 4241, 4019, 2875, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7869 }	Medical Text: Admission Date: [2179-3-12] Discharge Date: [2179-3-19] Date of Birth: [2120-6-26] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [2179-3-15] Urgent coronary artery bypass graft x4: Left internal mammary artery to left anterior descending artery and saphenous vein grafts to posterior descending, obtuse marginal and the ramus arteries. History of Present Illness: 58 year old male who developed shortness of breath and wheezing after carrying a copy machine up a flight of stairs approximately 3 weeks ago. He p/t his PCP who ran [Name Initial (PRE) ] series of tests. Stress test was abnormal, and cath revealed multi-vessel CAD. He is referred for cardiac surgery evaluation. Past Medical History: coronary artery disease diabetes mellitus, type II hypertension Social History: Lives with: alone Occupation: owns insurance business Tobacco: never ETOH: quit 30 yrs. ago Activity: walks dog 2.5miles daily Family History: mom died at 82, s/p 3x CABG (1st at 45yo) dad died at 82- cancer Physical Exam: Pulse: 65 Resp: 20 O2 sat: 98%RA B/P Right: 108/70 Left: Height: Weight: 95.3kg General: Skin: Dry [x] intact [x] no rash HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] no edema or varicosities Neuro: Grossly intact x Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [Name (NI) 167]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right: Left: no bruits appreciated Pertinent Results: [2179-3-16] 02:44AM BLOOD WBC-11.4* RBC-3.56* Hgb-10.3* Hct-28.6* MCV-80* MCH-28.9 MCHC-35.9* RDW-14.1 Plt Ct-172 [2179-3-15] 08:25PM BLOOD Hgb-9.7* Hct-27.2* MCHC-35.7* [2179-3-15] 01:55PM BLOOD WBC-14.0* RBC-3.80* Hgb-11.1* Hct-30.4* MCV-80* MCH-29.1 MCHC-36.4* RDW-14.0 Plt Ct-178 [2179-3-16] 02:44AM BLOOD Glucose-104* UreaN-19 Creat-0.8 Na-136 K-4.4 Cl-107 HCO3-24 AnGap-9 Prebypass No atrial septal defect is seen by 2D or color Doppler. There is severe regional left ventricular systolic dysfunction with akinesia of the apex, akinesia of the apical portions of the inferior, anterior and septal walls. The mid portions of the septal, inferior, inferoseptal and anterior walls are also hypokinetic. . Overall left ventricular systolic function is severely depressed (LVEF= 20 %). with borderline normal RV free wall function. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results on [2179-3-15] at 1000am. Post bypass Patient is in sinus rhythm and receiving an infusion of phenylephrine, milrinone and epinephrine. LVEF=25%. Mild moderate mitral regurgitation persists. Aorta is intact post decannulation. [2179-3-19] 06:35AM BLOOD WBC-8.1 RBC-3.20* Hgb-9.4* Hct-26.2* MCV-82 MCH-29.3 MCHC-35.7* RDW-14.1 Plt Ct-219 [2179-3-19] 06:35AM BLOOD Plt Ct-219 [2179-3-19] 06:35AM BLOOD Glucose-139* UreaN-24* Na-134 K-4.0 Cl-98 HCO3-29 AnGap-11 [2179-3-12] 03:15PM BLOOD ALT-19 AST-16 LD(LDH)-160 AlkPhos-60 TotBili-0.4 [2179-3-19] 06:35AM BLOOD Mg-2.4 Brief Hospital Course: Admitted to the hospital for pre-operative evaluation and work up. Heparin was initiated for ostial LAD disease. Echo revealed chronic systolic heart failure with an ejection fraction of 15-20%. He was brought to the operating room on [2179-3-15] where the he underwent coronary artery bypass graft. See operative report for further details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis given his inpatient stay of longer than 24 hours preoperatively. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamics were maintained with milrinone, which was eventually weaned. He continued to progress and was transferred to the floor. Physical therapy worked with him on strength and mobility. He was ready for discharge home with services on postoperative day four. Medications on Admission: metformin 1000'' HCTZ 25' neurontin 300' simvastatin 80' asa 81' lopressor 25'' Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:60 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 5. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 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. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:0 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks: please follow up with cardiologust prior to completion . Disp:14 Tablet(s) Refills:0 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 2 weeks. Disp:14 Capsule, Sustained Release(s) Refills:0 11. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: coronary artery disease, s/p coronary artery bypass Acute on chronic systolic heart failure diabetes mellitus, type II hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2179-4-26] 1:00 Please call to schedule appointments Primary Care Dr. [Last Name (STitle) 45327],[First Name3 (LF) ] N. [Telephone/Fax (1) 8058] in [1-2] weeks Cardiologist Dr. [Last Name (STitle) 8051] [Telephone/Fax (1) 8058] in [1-2] weeks [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2179-3-19] ICD9 Codes: 4271, 4019, 4280, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7870 }	Medical Text: Admission Date: [2141-5-6] Discharge Date: [2141-5-23] Date of Birth: [2064-10-30] Sex: M Service: MEDICINE Allergies: Keflex Attending:[First Name3 (LF) 398] Chief Complaint: s/p cardiopulmonary arrest Major Surgical or Invasive Procedure: Mechanical Ventilation (previously trached) Central venous Catheter R SC placed [5-6] -> d/c'd and changed to PICC line left femoral A-Line placed [5-6] Chest tube removal History of Present Illness: This is a 76 y/o male with with history of large right MCA and MCA/PCA watershed infarct in [2-15], likely cardioembolic due to his history of atrial fibrillation; cardiomyopathy with EF 15%; s/p MRSA pneumonia, now with E.coli pleural effusion; C.diff infection; and s/p recent trach and PEG on [4-28] for inability to wean vent from recurrent aspirations; found unresponsive at the [Hospital1 ] Facility this morning. Patient is interactive but non-verbal ([1-13] trach) at baseline, but it is not clear from records when he was last seen normal. . This morning at rehab, at approximately 7:20 am he was found to be unresponsive and pulseless, but had a blood pressure of at least 100/60. He was given CPR for 8 minutes, although the records document a pulse at one minute, and he received epinephrine, after which he had Vtach at 192, for which pt was loaded with amiodarone and started on amiodarone gtt. Per patient's sister, he has been having increased secretions from trach +/- bloody secretions, requiring increased suctioning. This is not documented in NH records. . He was then transferred to the [Hospital1 18] ED, with stable BP in 120's/70's and HR in 70's. Initial VS in ED were Tc 98.4, BP 124/70, HR 80's, RR 18, SaO2 100%/vent. He was continued on amiodarone and given levofloxacin for abx coverage. He had blood and urine cx sent, CXR, CT head (negative), and CT torso done. Upon initial exam, he was noted to flex his limbs to noxious stimuli, but his eyes were deviated up and to the left, and he had a "resting tremor" of the left arm, which was described as intermittent twitches of the arm that were not sustained or rhythmic. He was then transferred to the MICU for further management. Just before he was transported his nurse in the ED noticed more pronounced left arm twitching. The ED resident evaluated him and then called Neurology for a consult re:?seizure, while the patient was being taken to the ICU. . Upon arrival to the MICU, pt's VS were stable, however he was noticed to have left arm twitching and blood at the corner of his mouth. Upon opening his mouth, the tongue was found to be bitten and macerated, with tongue fasiculations. An oral airway was placed. Patient was given 4 mg IV ativan total and loaded with 1 gm dilantin. Past Medical History: - Hypertension - hypercholesterolemia - disc bulge L4-5 w/o herniation - hx of osteomyelitis T12-11 [2136] - screening carotid study '[37]: bilateral mild to moderate carotid stenosis - s/p laminectomy thoracic spine - Cardiomyopathy with LVEF 10-15% - Ischemic MCA CVA [2-15] - Paroxsymal Afib - History of GI bleed - Aspiration PNA (patient failed speech and swallow in past) - CRI with baseline Cr 1.8-2.2 - s/p trach/PEG [4-29] Social History: From [Hospital ] rehab. No history of tobacco, history of heavy alcohol use (2 pint/day) but has been less recently. Retired biochemist. Family History: NC Physical Exam: VS: Tc 95.6, BP 129/79 ->80's/40/s with dilantin, HR 83-100, RR 19, SaO2 100%/AC 450 x 14, FiO2 50%, PEEP 5. General: Unresponsive male with rightward eye gaze, biting down on tongue HEENT: Pupils pinpoint and non-reactive. No doll's eye reflex. +tongue biting and fasiculations. Oral airway in place. Trached. Neck: supple, unable to assess JVD Chest: Diffue coarse rhonchi, right chest tubes in place CV: RRR s1 s2 distant, no murmurs appreciated Abdomen: obese, soft, active bowel sounds, PEG c/d/i Ext: +2 edema in LE and UE b/l; heel ulcer Neuro: Unresponsive except to noxius stimuli, pupils pinpoint and NR, trace corneal reflex. +tongue fasiculations. +hyperactive DTR's, +clonus, +upgoing toes. Pertinent Results: [2141-5-6] 11:45AM BLOOD WBC-15.6* RBC-2.92* Hgb-8.1* Hct-24.8* MCV-85 MCH-27.5 MCHC-32.5 RDW-20.4* Plt Ct-336 [2141-5-6] 11:45AM BLOOD Neuts-84* Bands-0 Lymphs-3* Monos-11 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-1* [2141-5-6] 11:45AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Target-1+ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ [2141-5-6] 11:45AM BLOOD Glucose-128* UreaN-70* Creat-1.6* Na-147* K-3.6 Cl-106 HCO3-32 AnGap-13 [2141-5-8] 04:24AM BLOOD Glucose-140* UreaN-84* Creat-2.3* Na-144 K-4.1 Cl-106 HCO3-26 AnGap-16 [2141-5-10] 03:21AM BLOOD Glucose-124* UreaN-92* Creat-2.7* Na-145 K-3.5 Cl-108 HCO3-26 AnGap-15 _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ [2141-5-6] 07:56PM BLOOD Phenyto-13.8 [2141-5-9] 04:04AM BLOOD Phenyto-12.5 Phenyfr-2.7* %Phenyf-22* [2141-5-10] 03:21AM BLOOD Phenyto-12.1 Phenyfr-2.6* %Phenyf-21* _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ CT TorsoW/CONTRAST [2141-5-6] CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST CT CHEST WITH IV CONTRAST: The patient has a tracheostomy tube with tip that terminates at the thoracic inlet. There are multiple mediastinal and axillary lymph nodes, none of which are pathologically enlarged. The aorta is moderately calcified along with coronary artery calcifications. There is a right-sided pleural effusion that is small in size and decreased compared to prior study. Two chest tubes are seen within the effusion. There is a small amount of associated pneumothorax. There is also atelectasis of the right lower lobe; the possbility of superimposed airspace disease cannot be excluded. Both air and fluid are decreased compared to prior study. There is a tiny left pleural effusion. Within the lung parenchyma, there is ground glass opacity diffusely thoughout the left lung, nonspecific, although the possibility of infection cannot be excluded. Subcutaneous emphysema is seen along the chest tube tracts. CT ABDOMEN WITH IV CONTRAST: Within the liver, there is a focal hypodense hepatic cyst within the left lobe measuring 19 mm. Within the caudate lobe of the liver, there is an additional 8 x 14 mm hypodensity also likely representing hepatic cyst. The gallbladder contains a small amount of fluid. There is a small amount of perihepatic fluid. There is thickening of the aderenal glands bilaterally without evidence of focal lesion. The pancreas, spleen, and kidneys are unremarkable. The small and large bowel are within normal limits. There is no evidence of obstruction. There is a small- to- moderate amount of fluid within the pelvis. Calcifications extend along the course of the aorta into the iliac and common femoral arteries. CT PELVIS WITH IV CONTRAST: The urinary bladder, prostate, and rectum are unremarkable. There is a rectal tube in place. There is a moderate amount of soft tissue edema throughout the entire torso, most notable within the pelvis and proximal thighs. There is a lipoma in the distal psoas muscle, incidentally noted. BONE WINDOWS: There are no suspicious lytic or sclerotic bony lesions. There is fusion of T10/T11 with an angular kyphosis, unchanged and either postinfectious, postraumatic, or congenital in etiology. Multilevel degenerative change of the thoracolumbar spine are seen. _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ CT HEAD W/O CONTRAST [2141-5-6] 12:58 PM FINDINGS: Again demonstrated is a large low-density area within the right MCA distribution consistent with a subacute/chronic infarction which is not significantly changed compared to prior study from [2141-3-21]. There are also linear hyperdense foci near the vertex of the posterior temporal region likely representing cortical mineralization secondary to the infarct. There is no evidence of acute intracranial hemorrhage. The ventricles are similar in size. There is no shift of the midline. IMPRESSION: Stable head CT with no evidence of new intracranial hemorrhage. Stable right MCA territorial chronic/subacute infarction. _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ Neurophysiology Report EEG Study Date of [2141-5-7] FINDINGS: PUSHBUTTONS: Five events were identified for periods of rhythmic eye-blinking. Apart from eye-blink artifact, no other changes in the EEG were seen. The eye-blinking lasts for many seconds at a time, and in short periods between the eye-blinking, the EEG does not show signs of epileptiform activity. When the eye-blinking stops, no epileptiform changes are seen. AUTOMATED INTERICTAL EPILEPTIFORM ACTIVITY: Background activity consists of very low amplitude [2-13] Hz mixed delta and theta frequency slowing. Throughout, EKG artifact is seen as a rhythmic change in the EEG. AUTOMATED SPIKE DETECTION: This algorithm captured 141 events, all for eye-blink artifact. AUTOMATED SEIZURE DETECTION: This algorithm captured no events. SLEEP: No normal sleep or wake transitions were seen. CARDIAC MONITOR: Revealed a generally regular rhythm with average rate of 120 bpm. IMPRESSION: This is an abnormal 24 hour bedside telemetry due to the presence of extremely suppressed background activity. The episodes of eye-blinking do not appear to be ictal, but clinical correlation is suggested. Automated algorithms have failed to identify any epileptiform activity. . 146 105 73 179 AGap=15 3.5 30 1.8 CK: 62 MB: Notdone Trop-T: 0.20 Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi Ca: 9.0 Mg: 2.8 P: 3.5 ALT: AP: Tbili: Alb: 2.9 AST: LDH: Dbili: TProt: [Doctor First Name ]: Lip: Phenytoin: 13.8 Source: Line-art 85 14.4 8.5 406 26.5 Source: [Name (NI) 37626] PT: 18.1 PTT: 34.2 INR: 1.7 Source: Catheter Color Yellow Appear Clear SpecGr 1.023 pH 5.0 Urobil Neg Bili Neg Leuk Neg Bld Sm Nitr Neg Prot 30 Glu Neg Ket Neg RBC 0 WBC 0 Bact None Yeast None Epi <1 [2141-5-6] 6:08p pH 7.42 pCO2 48 pO2 98 HCO3 32 BaseXS 5 Type:Art; Temp:35.8 [2141-5-6] 11:55a Na:147 K:3.6 Cl:106 TCO2:32 Glu:124 Lactate:1.1 [2141-5-6] 11:45a 147 106 70 128 AGap=13 3.6 32 1.6 estGFR: 42/51 (click for details) CK: 46 MB: Notdone Trop-T: 0.18 Comments: cTropnT: Notified Whitehead,E Ew 5.26 At 1.30p cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi Ca: 9.0 Mg: 3.0 P: 3.4 ALT: 17 AP: 63 Tbili: 0.5 Alb: 2.6 AST: 19 LDH: Dbili: TProt: [Doctor First Name ]: 70 Lip: 18 85 15.6 8.1 336 24.8 N:84 Band:0 L:3 M:11 E:1 Bas:0 Myelos: 1 Nrbc: 1 Comments: Hct: Notified [Initials (NamePattern4) ] [Last Name (NamePattern4) 37627] 12:19pm [2141-5-6] Plt-Ct: Verified By Smear Plt-Ct: Occ Large Plt Present Hypochr: 3+ Anisocy: 2+ Poiklo: 1+ Microcy: 2+ Polychr: OCCASIONAL Target: 1+ Plt-Est: Normal PT: 17.9 PTT: 40.0 INR: 1.7 [2141-5-6] 11:20a Color Yellow Appear Clear SpecGr 1.016 pH 5.0 Urobil Neg Bili Neg Leuk Tr Bld Neg Nitr Neg Prot 30 Glu Neg Ket Neg RBC [5-21] WBC [2-13] Bact Few Yeast None Epi 0-2 Brief Hospital Course: 76 y/o male with PMH significant for MCA stroke, s/p recent trach/PEG, s/p chest tubes for recent empyema, now presenting from rehab s/p cardiac arrest and in status epilepticus. . # s/p cardiac arrest - PEA primary rhythm, thought to be secondary to hypoxia from mucous plugging or blood clots in trachea. He had no signs of sepsis and blood cultures were all negative. Troponin was elevated in the setting of renal failure but had no ECG changes. The patient was initially was dobutamine and dopamine for pressor support and then later to levophed which was discontinued after 2nd hospital day. He was continued on hydrocortisone and fludrocortisone for 7 days for presumed adrenal insufficiency which was started prior to arrival to the MICU. He was initially amiodarone but was stopped after 24 hours. The patient had no further cardiac arrhthymia during his MICU stay. . # Seizure/anoxic brain injury/stroke - Most likely [1-13] anoxic brain injury in setting of cardiac arrest and hypoperfusion to brain as well as later repeat MRI brain on [5-10] showed a new right posterior temporal/superior parietal/occipital regions, posterior to the chronic infarct, which was the culprit for seizure/twitching. He was loaded with 1gm of dilantin initially and was continued on 100mg iv q8h which achieved a good therapeutic dilantin level. His twitching improved with dilantin but still continued to have intermittent eye twitching. After 5 days of not showing any evidence of meaninful and/or purposeful responsiveness over the course of the MICU stay, neuro consultant felt that his prognosis for recovery was poor. Pt was continued on ASA. Pt was switched to po dilantin on [5-16] and repeat dilantin level after 2 days of po dilantin was 12.4. Continue current dilantin dosing. - Free dilantin level goal of [1-13].3 to correlate with a total of 13-15. . # Respiratory failure - in setting of recurrent aspiration [1-13] CVA, now trached and pegged. Continued ventilation and aggressive chest PT and pulmonary toilet. Chest tube to suction, and IP injected tPA x 4 days break up to loculation and further facilitate drainage. - Pt was continue on Aztreonam 1 gm q8 for E.coli PNA c/b empyema during last admission, course until [2141-5-28]. Sputum was also growing MRSA and started vancomycin on [2141-5-6], last day at least [2141-5-28]. Vancomycin was held on [2141-5-22] with plans for dosing by level given renal insufficiency. Hold dose for level >15. - Chest tube # 2 was removed on [2141-5-19] after confirming no air leak and no further drainage. Repeat CXR after #2 removed showed no changes in hemopneumothorax. However, Chest tube #1 continued to have air leak and drainage. The right sided chest tube was placed to water seal on [2141-5-22] with a chest xray that showed a stable pneumothorax and no significant change or worsening with re-expansion of the right lung. Please continue to keep chest tube in place until there is no longer an air leak present. The Chest tube may be removed at that time. Please continue IV Vanco and IV Aztreonam for 2 additional weeks (end date [2141-6-6]) to complete a total of a 6 wk course of Abx for his empyema. Please monitor daily Vanco levels and give an Vancomycin 1g prn for vanco trough <15. His Vanco trough on day of discharge ([5-23]) was 22.4. . # h/o CHF - EF 15%, was on afterload agents including BB, Isordil, digoxin, hydralazine. Initially, all were held given pressor-dependent hypotension.The patient was restarted on BB and was aggressively diuresed with IV lasix and lasix gtt. The lasix gtt was discontinued on [2141-5-22] and the patient was transitioned to lasix 100 mg IV TID and diuril 500 mg IV BID with goal -500 to 1 liter each day. In the future, this high dose of lasix may not be beneficial and consideration should be made for bumex + diuril. . # Anemia- The patient required intermittent blood transfusion for drifting down hct which was partially attributed to phlebotomy. However, he had bleeding from trach site for which he underwent bronch on [5-15] and showed suction trauma with granulation tissues at the carina without any active bleeding. He was given vitamin K. IP repeated bronch on [5-16] which only showed slight trach displacement with was repositioned and only saw granuation tissues. He did have guaiac positive stool on [4-19] but lavage from PEG was negative for any coffee ground materials or blood. The patient may have swallowed blood resulting in melena. However, H2 blocker was switched to iv PPI. - His hematocrit remained low at 24 but stable with no active issues. . # h/o C diff colitis - Flagyl was discontinued on arrival to the ICU given its ability to lower the seizure threshold. He had no more recurrence of diarrhea and negative C. Diff cultures from [2141-5-10]. . # A fib - The patient was in normal sinus rhythm on transfer. Anticoagulation was held given the low hematocrit and concern for GI bleed in addition to acute stroke, ? hemorrhagic. The patient is on ASA 325 mg. . # CRI - Cr now stable at 1.5-1.6. Continue to monitor with diuresis. # F/E/N - with G tube on tube feeds, monitor lytes . # PPx - heparin SC, famotidine . # Access - R SC placed [5-6] -> d/c'd and changed to PICC line, left femoral A-Line [5-6] d/c'd . # Code - FULL . # Communication - sister [Name (NI) 382], [Name (NI) ]) [First Name4 (NamePattern1) ] [Name (NI) ] [Telephone/Fax (1) 37628] . Medications on Admission: 1. Digoxin 125 mcg qod 2. Lansoprazole 30 mg qd 3. Ascorbic Acid 90 mg/mL drops [Hospital1 ] 4. Therapeutic Multivitamin Liquid qd 5. Heparin SC tid 6. Ferrous Sulfate 300 mg/5 mL liquid qd 7. Isosorbide Dinitrate 10 mg tid 8. Senna 8.8 mg/5 mL [Hospital1 ] 9. Docusate Sodium 50 mg [Hospital1 ] 10. Hydralazine 50 mg q8 hrs 11. Albuterol nebs prn 12. Ipratropium nebs prn 13. Metoprolol 100 mg tid 14. Aspirin 325 mg qd 15. Aztreonam [2133] mg IV Q8H 16. Flagyl 500 mg tid Discharge Medications: 1. Senna 8.8 mg/5 mL Syrup [Year (4 digits) ]: One (1) Tablet PO BID (2 times a day) as needed. Tablet(s) 2. Mineral Oil-Hydrophil Petrolat Ointment [Year (4 digits) ]: One (1) Appl Topical TID (3 times a day) as needed. 3. Artificial Tear with Lanolin 0.1-0.1 % Ointment [Year (4 digits) ]: One (1) Appl Ophthalmic PRN (as needed). 4. Aspirin 325 mg Tablet [Year (4 digits) ]: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 50 mg/5 mL Liquid [Year (4 digits) ]: One (1) PO BID (2 times a day). 6. Phenytoin 100 mg/4 mL Suspension [Year (4 digits) ]: One (1) PO Q8H (every 8 hours). 7. Metoprolol Tartrate 25 mg Tablet [Year (4 digits) ]: One (1) Tablet PO TID (3 times a day). 8. Ipratropium Bromide 17 mcg/Actuation Aerosol [Year (4 digits) ]: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed. 9. Albuterol 90 mcg/Actuation Aerosol [Year (4 digits) ]: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed. 10. Insulin Lispro (Human) 100 unit/mL Solution [Year (4 digits) ]: One (1) Subcutaneous ASDIR (AS DIRECTED). 11. Nystatin 100,000 unit/mL Suspension [Year (4 digits) ]: Five (5) ML PO QID (4 times a day). 12. Bisacodyl 10 mg Suppository [Year (4 digits) ]: One (1) Suppository Rectal DAILY (Daily). 13. Famotidine 20 mg Tablet [Year (4 digits) ]: One (1) Tablet PO Q24H (every 24 hours). 14. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 15. Lorazepam 2-4 mg IV Q1-2H:PRN seizure 16. Heparin Flush Midline (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 17. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 18. Chlorothiazide 500 mg IV BID 19. Furosemide 100 mg IV TID 20. Heparin (Porcine) 5,000 unit/mL Solution [Year (4 digits) ]: One (1) Injection TID (3 times a day). 21. Zinc Sulfate 220 mg Tablet [Year (4 digits) ]: One (1) Tablet PO DAILY (Daily) for 14 days. 22. Ascorbic Acid 500 mg Tablet [Year (4 digits) ]: One (1) Tablet PO DAILY (Daily). 23. Chlorothiazide 500 mg IV BID Please give 30 mins prior to Lasix. 24. Aztreonam in Dextrose(IsoOsm) 1 g/50 mL Piggyback [Year (4 digits) ]: One (1) gram Intravenous every eight (8) hours for 2 weeks: End date [6-6]. 25. Vancocin 1,000 mg Recon Soln [Month/Year (2) ]: One (1) gram Intravenous once a day for 2 weeks: End date [6-6]. Dose by levels as patient has renal failure. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Anoxic brain injury Cerebrovascular accident Congestive heart failure, EF 15% Empyema s/p chest tube Air leak in chest tube from likely bronchopleural fistula Discharge Condition: Poor prognosis for neurologic recovery, non-purposeful movement of eyes. Does not follow commands. Discharge Instructions: Please check dilantin level in 5 days and dose accordingly. Please monitor electrolytes and creatinine with IV diuresis. Please have chest tube removed once there is no air leak present. Please continue IV Vancomycin/IV Aztreonam for 2 more additional weeks to treat his empyema. His Vancomycin has been dosed by daily levels as his renal failure has required q48 hour dosing. Followup Instructions: Please follow up with your neurologist, Dr. [Last Name (STitle) 851], in 4 weeks. Please follow up with your pulmonogist in 4 weeks. ICD9 Codes: 4254, 4280, 5859, 5845, 4271
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7871 }	Medical Text: Admission Date: [2164-1-11] Discharge Date: [2164-1-25] Date of Birth: [2111-6-2] Sex: M Service: SURGERY Allergies: Codeine Attending:[First Name3 (LF) 2534] Chief Complaint: s/p ~20 ft fall Major Surgical or Invasive Procedure: [2164-1-19] PROCEDURES: 1. Percutaneous endoscopic gastrostomy tube. 2. Open tracheostomy. 3. Placement of inferior vena cava filter. History of Present Illness: 52 y/o male s/p fall off ~20 foot high scaffolding. Landed on back on concrete. Positive LOC; he was taken to an area hsopital and transferred to [Hospital1 18] for further care. . Past Medical History: CAD, DM Family History: Noncontributory Physical Exam: Upon admission: BP: 159 / 104 HR: 101-105 R 23 O2Sats: 100% NRB Gen: Uncomfortable and complaining of severe back pain on back board on CT table. HEENT: Pupils: 3-2.5 EOMs intact Neck: Trauma collar on Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake, but lethargic Orientation: Oriented to self, date and president, confused about location states he is in [State ] State. Language: Speech fluent with good comprehension. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,3 to 2.5 mm 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 [3-21] throughout. No pronator drift Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: [2164-1-11] 03:27PM K+-4.3 [2164-1-11] 03:27PM HGB-17.7 calcHCT-53 [2164-1-11] 03:10PM UREA N-15 CREAT-1.1 [2164-1-11] 03:10PM LIPASE-25 [2164-1-11] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2164-1-11] 03:10PM WBC-25.4* RBC-5.47 HGB-15.6 HCT-45.3 MCV-83 MCH-28.4 MCHC-34.4 RDW-13.7 [2164-1-11] 03:10PM PLT COUNT-278 [2164-1-11] 03:10PM PT-11.7 PTT-23.4 INR(PT)-1.0 [2164-1-11] 03:10PM FIBRINOGE-271 IMAGING: [2164-1-11] CT head: 1. Minimal interval change in acute left midbrain hemorrhage, now measuring 10 mm compared to 11 mm previously. 2. Right temporal subarachnoid, intraparenchymal and possible small subdural hematoma unchanged appearance. 3. Hyperdense focus in the left frontal vertex may represent a vessel; however, small focus of hemorrhage is not excluded. . [2164-1-11] CXR: Multiple left rib fractures. Subcutaneous emphysema in right chest wall. . [2164-1-11] CT head: 1.1 cm focus of left brainstem acute hemorrhage. Right temporal subarachnoid, intraparenchymal and possible small subdural hematoma. . [2164-1-11] CT torso: Suboptimal reformatted images of the thoracolumbar spine. If high clinical concern for spine fracture, consider repeat study of the thoracolumbar spine. 2. Left 2nd-7th rib fractures. Comminuted left clavicle fracture. 3. Right 1st rib costochondral diastasis, with associated subcutaneous emphysema. Small right pneumothorax. 4. No evidence of acute visceral injury in the abdomen or pelvis. . [2164-1-11] CT c-spine: WETREAD - No fx or malalignment. Micro/Imaging: [2164-1-18] LENIS neg b/l [2164-1-15] BAL - R GS-3+PMNs,2+GPRs [2164-1-15] BAL - L GS-3+PMNs,1+GPRs [2164-1-14] sputum cx GS->25PMNs,1+GPCS (pairs/clusters);Cx-Commensal Respiratory Flora [2164-1-14] sputum cx cx GS->25PMNs,1+GPCS (pairs/clusters);Cx-Commensal Respiratory Flora [2164-1-14] sputum cx GS->25 PMNs,2+GPCs,2+GNRs,2+GPRs;Cx-Commensal Respiratory Flora [2164-1-14] BCx no growth [2164-1-14] BCx no growth [2164-1-14] UCx no growth Brief Hospital Course: He was admitted to the Trauma service. Neurosurgery was consulted; he was admitted to the Trauma ICU where frequent neurologic checks and serial head CT scans were followed. He was loaded with Dilantin and remained on it for 10 days for seizure prophylaxis; there were no seizures reported during his hospital stay. His current mental status is awake, alert with intermittent confusion likely related to delirium. He was given intermittent doses of Ativan and Haldol for this. It is being recommended that antipsychotic be used to treat his delirium vs. benzodiazepines as this can worsen delirium. He had chest tubes placed initially for his pneumothorax and those have since been removed. Last chest xray on [1-21] revealed some atelectasis; he is prescribed nebulizers prn. He was also seen by ENT for left hemotympanum; he was prescribed ear drops and should follow up with ENT as an outpatient. The Pain Service was consulted for epidural analgesia due to his rib fractures but recommended intravenous narcotics given that at the time his cervical spine had not been cleared. He is currently on an oral regimen and his pain appears to be adequately controlled. His left clavicle fracture was evaluated by Orthopedics and was managed non operatively. he should not bear full weight on his left arm. he will follow up as an outpatient. He was evaluated by Physical therapy and is being recommended for rehab after his acute hospital stay. Medications on Admission: [Last Name (un) 1724]: none All: Codeine Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection four times a day as needed for per sliding scale. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID (2 times a day). 5. Acetaminophen 500 mg/15 mL Liquid Sig: Fifteen (15) ML's PO Q4H (every 4 hours) as needed for fever or pain. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO twice a day as needed for constipation. 7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for Pain. 8. CIPRODEX 0.3-0.1 % Drops, Suspension Sig: Four (4) drops Otic twice a day for 8 days. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation four times a day as needed for shortness of breath or wheezing. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation four times a day as needed for shortness of breath or wheezing. 12. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for agitation. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 701] Discharge Diagnosis: s/p 20 foot Fall Scalp laceration Right subarachnoid hemorrhage Intraparenchymal hemorrhage Left [12-25] rib fractures Small right pneumothorax Comminuted left clavicle fracture Respiratory failure Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Alert and interactive Activity Status: Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were hospitalized following a ~20 ft fall where you sustained a bleeding injury to your brain, rib fractures and a fractures collar bone. Your injuries did not require surgery. You did require 2 procedures where a tracheosotmy for breathing was placed and a feeding tube was placed in your abdomen so that you could receive nutrition. As you recover from your injuries it is expected that the tracheostomy and feeding tube will be able to be removed. Followup Instructions: Follow up in 1 month with Dr. [Last Name (STitle) ], Neurosurgery for a repeat head CT scan. Call [Telephone/Fax (1) 1669] for an appointment. Follow up in 1 month with Dr. [Last Name (STitle) ], Trauma surgery for evalaution of your rib fractures, tracheosotmy and PEG removal. Call [Telephone/Fax (1) 2359] for an appointment. Follow up in [Hospital ] clinic for an audiogram in 1 month, call [Telephone/Fax (1) 41] for an appointment. Follow up in 1 month in [Hospital ] clinic with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP for your clavicle fracture, call [Telephone/Fax (1) 1228] for an appointment. Completed by:[2164-2-9] ICD9 Codes: 5180, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7872 }	Medical Text: Admission Date: [2104-11-21] Discharge Date: [2104-11-26] Date of Birth: [2035-3-21] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[First Name3 (LF) 1515] Chief Complaint: NSTEMI transferred for cardiac catherization Major Surgical or Invasive Procedure: Cardiac Catherization [2104-11-24] with drug eluting stents to the right coronary artery x1 and to the obtuse marginal artery x2. History of Present Illness: Pt is a 68 year old M with PMHx HTN, HLD, CAD s/p MI with 4 vessel CABG x4 at [Hospital 4415]. He presented to [Hospital6 3105] with chest pain. He initially presented to [Hospital6 5016] with SOB and chest tightness in 9/[2104]. TTE at the time revealed mild TR, mildly elevated [Last Name (un) 6879] 38 mmHg, LVEF 55% and stress test with nuclear imaging showed abnormal myocardia perfusion with a fixed posterior lateral defect, without evidence of ischemia or reversibility. He was discharged but then later presented to Cardiologists office on [2104-10-6] with intermittent chest pain, which did not appear to be anginal in nature. Patient reports that he has been having chest pain at night when he lays down in bed and that the pain is relieved with Maalox. Given perfusion study only few weeks prior his symptoms were thought to be GERD and he was started on PPI. Patient returned to cardiologist for follow up appointment when he was found to be hypertensive with CP c/w angina. CP occuring with exertion, relieved at rest and radiating to left arm. . Per discussion with patient, he denies ever having CP with exertion and he is able to ambulate and do light work without symptoms. He is adament that he only has chest pain when going to bed at night laying down. The pain requires him to sit up and maalox relieves symptoms. He describes the pain as pressure like and also involving his back. He has never had N/V, diaphoresis with these episodes. The pain is not radiating and is does not change with position or with respirations. . Patient presented to LGH ED after referral from Cardiologist for CP/SOB. EKG done in ED showed RBB, LAFB, Q waves in inteferior lead c/w old MI. First topinin came back elevated at 6.29. At that time he was given chewable aspirin, plavix, and started on heparin drip. TSH was normal. Met panel was normal except for AST of 50. CXR without acute process, Trop peaked at 7.17. . Cardiac Catherization (L wrist) was performed on [2104-11-21] which showed LIMA to LAD patent, SVG to RCA with tight stenosis at the ostium/graft and bifurcation (thought to be culprit lesion). Patient had some chest pain at end of procedure, given 2 mg morphine, 2 sprays of ntg with improvement in his symptoms. He was transiently placed on a nitro drip for CP but this was stopped prior to transfer. . Plan was transfer directly to [Hospital1 18] cath lab for intervention today, however the patient was fed beef stew at around 1pm, so he was transferred to [Hospital Ward Name 121] 3 directly. On transfer, patient off nitro drip and vitals 104/58. Telemetry showed sinus rhythm with 1st degree/bundle hr 50s, 97%RA . Cardiac review of systems is notable for current absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. He does described dyspnea with heavy exertion but denies SOB with light slow walking (COPD has been an issue in terms of functional limitations Past Medical History: - CAD: MI s/p 4 vessel CABG at [Hospital1 336] in [2089] - HLD - HTN - COPD - Glucose Intolerance - Former Smoker Social History: -Semi-Retired Fence Builder -Tobacco history: Former 40 pack-yr smoker, Quit in [Month (only) ] -ETOH: None -Illicit drugs: None Family History: - CAD - Mother lived until [Age over 90 ]yo - Father had MI, lived until 85yo Physical Exam: ADMISSION PHSYICAL EXAM: Afebrile 109/54 56 22 94%RA W: 180lbs H 5'3" GENERAL: Well appearing 69yo M who appears stated age. Comfortable, appropriate and in good humor HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with low JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. NO lower extremity edema, LLE has chronic skin change over medial aspect over tibia, pink-red with some scabbed scratched. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE PHYSICAL EXAM: VS: 98.6 81 104-116/60-68 18 98%RA GENERAL: NAD, comfortable, appropriate HEENT: PERRL, EOMI, OP clear NECK: Supple, no JVD CARDIAC: RRR, nlS1S2, no mrg LUNGS: Resp unlabored, CTA b/l, no crackles, wheezes or rhonchi. ABDOMEN: Soft, obese, nontender naBS EXTREMITIES: Warm and well perfused, no cyanosis/edema; R groin c/d/i, L groin c/d/i, R radial c/d/i, no hematoma or ecchymosis at any site PULSES: feet warm Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: . [2104-11-21] 05:45PM BLOOD WBC-12.2* RBC-4.16* Hgb-14.0 Hct-40.3 MCV-97 MCH-33.6* MCHC-34.8 RDW-12.4 Plt Ct-243 [2104-11-22] 07:26AM BLOOD WBC-8.6 RBC-3.97* Hgb-13.2* Hct-38.3* MCV-96 MCH-33.3* MCHC-34.5 RDW-12.6 Plt Ct-183 [2104-11-21] 05:45PM BLOOD PT-12.1 PTT-24.3 INR(PT)-1.0 [2104-11-21] 05:45PM BLOOD Glucose-129* UreaN-18 Creat-0.9 Na-139 K-4.8 Cl-100 HCO3-31 AnGap-13 [2104-11-21] 05:45PM BLOOD Calcium-9.1 Phos-2.7 Mg-2.4 [2104-11-21] 05:45PM BLOOD CK-MB-6 cTropnT-0.89* . PERTINENT LABS: . [2104-11-21] 05:45PM BLOOD CK-MB-6 cTropnT-0.89* [2104-11-25] 01:16AM BLOOD CK-MB-7 cTropnT-0.58* [2104-11-25] 06:16AM BLOOD CK-MB-17* MB Indx-6.7* cTropnT-0.77* [2104-11-26] 07:25AM BLOOD CK-MB-10 MB Indx-3.3 cTropnT-1.10* [2104-11-24] 08:00AM BLOOD %HbA1c-5.8 eAG-120 . DISCHARGE LABS: . [2104-11-26] 07:25AM BLOOD WBC-9.1 RBC-3.79* Hgb-12.7* Hct-36.2* MCV-96 MCH-33.6* MCHC-35.1* RDW-12.6 Plt Ct-194 [2104-11-26] 07:25AM BLOOD Glucose-110* UreaN-24* Creat-0.9 Na-138 K-4.1 Cl-100 HCO3-28 AnGap-14 [2104-11-26] 07:25AM BLOOD CK-MB-10 MB Indx-3.3 cTropnT-1.10* [2104-11-26] 07:25AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.9 . MICRO/PATH: . MRSA SCREEN (Final [2104-11-27]): No MRSA isolated. . IMAGING/STUDIES: . TTE [2104-11-24]: 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 to moderate regional left ventricular systolic dysfunction with hypokinesis of the inferior and inferolateral walls and near akinesis of the mid lateral wall. The remaining segments contract normally (LVEF = 40-45 %). Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) 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 multivessel CAD. Mild mitral regurgitation with normal valve morphology. . C.CATH [11-24]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe ostial SVG-RCA stenosis. 3. Severe distal SVG-OM stenosis at touchdown. 4. Successful PTCA and stenting of ostial SVG-RCA with endeavor stent 5. Successful PTCA and stenting of distal SVG-OM with two overlapping endeavor [Name Prefix (Prefixes) ] [Last Name (Prefixes) 10157]. No-reflow improved by end of case. 6. Please see full report in OMR for full details of angiography and PCI. 7. Successful RRA TR band. 8. Successful RFA angioseal. . C.CATH [11-24]: FINAL DIAGNOSIS: 1. No acute angiographically aparant occlusion to explain the patient's ST elevations. 2. Patent SVG to RCA 3. Patent SVG to OM with slow flow, a side branch occlusion and a 40% proximal hazy lesion. Brief Hospital Course: 69M with hx of HTN, HLD, CAD, COPD, an MI s/p 4 vessel CABG in [2089] who presents to LGH with [Hospital 39700] transferred to [Hospital1 18] now s/p high-risk PCI with [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 3 complicated by subsequent chest pain and vagal episode without significant findings on repeat cath. . ACTIVE DIAGNOSES: . # NSTEMI: Patient admitted to LGH with CP, SOB and elevation in troponins consistent with NSTEMI. Cardiac catherization at LGH showed LIMA to LAD patent, but with severe disease of grafts: 95% SVG to OM, 99% RCA and total occlusin of SVG to Diag with a bifurcation lesion suspected as the culprit lesion causing his NSTEMI. He was loaded with plavix 300mg at OSH and was given ASA 325 as well as heparin drip and transferred to [Hospital1 18] for further evaluation and treatment in the CCU. He had a TTE which showed LVEF of 40-45% and regional systolic dysfunction c/w multivessel CAD. He was taken to the cath lab where he was found to have severe three vessel disease with severe ostial SVG-RCA stenosis and severe distal SVG-OM stenosis. He had [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 1 to ostial SVG-RCA and overlapping [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 to SVG-OM lesion. Several hours following the procedure he had a vagal event and increased chest pain concerning for in-stent thrombosis and was taken to the cath lab without acute angiographically apparent occlusion to explain the patient's symptoms. Following this his symptoms resolved. He was discharged on atorvastatin, metoprolol, plavix, full dose aspirin, and imdur and had follow-up appointments arranged. . CHRONIC DIAGNOSES: . # Hypertension: Chronic and stable with BPs in 140s as an outpatient. He was switched from atenolol to metoprolol, started on imdur, and continued on his home diovan. . # COPD: Chronic, stable without recent acute exacerbations or intubations or need for home oxygen. He was continued on his home advair, and albuterol/ipratropium inhalers as needed. . # Glucose Intolerance: Chronic and Stable with A1c of 5.8 this admission. He will benefit from lifestyle counseling as an outpatient. . # Hyperlipidemia: Chronic, Stable, LDL <100 but not at goal <70 given extent of CAD. His home atorvastatin was increased to 80mg daily. . TRANSITIONAL ISSUES: -He was arranged with outpatient follow-up at discharge -He will need to be on aspirin and plavix until his cardiologist tells him to discontinue either medication -He would benefit from lifestyle counseling in the outpatient setting Medications on Admission: HOME MEDICATIONS: confirmed with pt -Aspirin 81 mg Daily -Diovan 160 mg Daily -Simvastatin 40 mg QHS -HCTZ 25 mg Daily -Lasix 20 mg Daily -Atenolol 25 mg [Hospital1 ] -Advair Diskus 250/50 i inh Daily -Albuterol sulfate 2 puff Q4H PRN -Atrovent 2 puff QID pnr -Econazole cream applied to feet daily Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:30 Tablet Extended Release 24 hr(s) Refills:0 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:2 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 10. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. econazole Topical Discharge Disposition: Home Discharge Diagnosis: Active: - Non ST elevation myocardial infarction Chronic: - Coronary artery disease - Hyperlipidemia - Hypertension - Chronic obstructive pulmonary disease - Glucose Intolerance - Former Smoker Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [Known lastname 90789], It was a pleasure treating you during this hospitalization. You were transferred to [Hospital1 69] for cardiac catherization after you were found to have severe coronary artery disease at [Hospital6 3105]. Your history and lab work suggested that you had a small heart attack and you were treated with IV blood thinners. You received a cardiac catherization that showed a tight blockage in two of your arteries that were opened and three drug eluting stents were placed. Your repeat echocardiogram showed an area that was still weak but your overall heart function is OK. You are being discharged in stable condition and with the following changes made to your home medications. - START Imdur 30mg by mouth daily to prevent further chest pain - START Clopidogrel 75mg Daily and Aspirin 325 mg daily to keep the stent open. Do not stop taking clopidogrel or aspirin for any reason or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless Dr. [Last Name (STitle) ] says it is OK to do so. - START Atorvastatin 80mg daily to prevent further blockages instead of simvastatin - START Metoprolol 100mg Daily instead of Atenolol to lower your heart rate - STOP Furosemide, simvastatin, and atenolol Followup Instructions: Name: STUPNYTSKYI,OLEKSANDR Specialty: PRIMARY CARE Address: [Street Address(2) ] [Apartment Address(1) 3882], [Hospital1 ],[Numeric Identifier 66038] Phone: [Telephone/Fax (1) 83705] We were unable to contact your PCP to schedule [Name Initial (PRE) ] follow up appointment. It is recommended you see your PCP [Name Initial (PRE) 176] 1 week of your discharge from the hospital. Please contact your PCP at the number above. Name: [Last Name (LF) 5423],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD Location: [Location (un) ] CARDIOLOGY Address: [Last Name (un) 39144], STE#404 [Hospital1 ], [Numeric Identifier 39146] Phone: [Telephone/Fax (1) 5424] Appointment: WEDNESDAY [12-31] AT 2:45PM Completed by:[2104-11-29] ICD9 Codes: 412, 496, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7873 }	Medical Text: Admission Date: [2133-3-26] Discharge Date: [2133-4-3] Date of Birth: [2088-3-23] Sex: F Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 1] Chief Complaint: Right foot swelling and pain, cellulitis Major Surgical or Invasive Procedure: debridement of Right dorsal foot in OR History of Present Illness: Mrs. [Known lastname 185] is a 45yo morbidly obese female who presented to OSH last Thursday with 3 days of spreading cellulitis from dorsum of foot up front calf. She reports increased edema, pain, and formation of bullae. She underwent an MRI at OSh which revealed liquification of Right dorsum of foot. She was transferred to [Hospital1 18] Surgical ICU for furhter management and possible debridement of area in OR. Past Medical History: morbid obesity, OSA, asthma, GERD, anxiety/panic disorder, sleep apnea, C/S x 2, post-partum depression Social History: Married. Lives with husband. Supportive mother & father. Family History: Type 2 diabetes Physical Exam: Vitals: 99.1, 78, 119/75, 20, RA-100% Blood sugars-97-133 Gen: NAD, A/O x3 CV: RRR, no m/r/g Resp: CTAB ABD: +BS, soft, NT/ND, obese Extrem: no edema RLE-erythema improving, clear yellow serous output, dressing intact, kerlix wrap Pertinent Results: [2133-3-26] 07:30PM BLOOD WBC-14.0* RBC-3.79* Hgb-10.0* Hct-30.9* MCV-82 MCH-26.5* MCHC-32.5 RDW-14.3 Plt Ct-237 [2133-3-26] 07:30PM BLOOD Neuts-90.1* Bands-0 Lymphs-8.1* Monos-1.5* Eos-0.2 Baso-0 [2133-3-26] 07:30PM BLOOD PT-13.5* PTT-30.4 INR(PT)-1.2* [2133-3-26] 07:30PM BLOOD Glucose-115* UreaN-15 Creat-0.8 Na-140 K-3.6 Cl-106 HCO3-24 AnGap-14 [2133-3-26] 07:30PM BLOOD CK(CPK)-152* [2133-3-27] 12:20AM BLOOD Calcium-7.2* Phos-3.0 Mg-2.0 [2133-3-28] 10:20AM BLOOD Vanco-41.0* [2133-3-28] 07:43PM BLOOD Vanco-8.1* . RADIOLOGY Final Report ANKLE (AP, MORTISE & LAT) RIGHT [2133-3-26] 7:38 PM [Hospital 93] MEDICAL CONDITION: 45 year old woman with severe infection of R foot/lower leg IMPRESSION: Diffuse leg edema without evidence of osteomyelitis or subcutaneous gas. . RADIOLOGY Final Report CHEST PORT. LINE PLACEMENT [2133-3-27] 4:43 AM HISTORY: 45-year-old woman with cellulitis with new placed central venous line. IMPRESSION: 1. New right central line in a satisfactory location ends in proximal SVC. 2. Small persistent left lower lobe atelectasis and small- to- moderate left pleural effusion. 3. Improved lung volume. . RADIOLOGY Preliminary Report PICC LINE PLACMENT SCH [2133-3-30] 10:37 AM Reason: please place picc for abx use [Hospital 93] MEDICAL CONDITION: 45 year old woman with nec cellulitis RLE IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 4 French single-lumen PICC line placement via the left brachial venous approach. Final internal length is 44 cm, with the tip positioned in SVC. The line is ready to use. Brief Hospital Course: Mrs.[Known lastname 185] was transferred from OSH. She was admitted to SICU in preparation for debridement of RLE cellulits in OR. Her operative course was uncomplicated. She remained intubated and transferred back to SICU overnight in case for need of further debridement. . Right foot wound remained stable POD1. No further deterioration of dermis. No further debridement required. Plastics team consulted, and agreed with assessment. Plan for placement of vacuum dressing once wound bed stable. Patient extubated, all IV vasopressors discontinued, vital signs remained stable. Afebrile. Blood cultures pending. . Transferred to 11 [Hospital Ward Name 1827] for further management. Wound RN consulted. Adjustments made to wound care. Physical therapy consulted-touch down on right foot only. Non-weight bearing. Patient ambulated well with walker. Occupational Therapy consulted. Right calf and foot continue to drain copius amounts of serous fluid. Vac dressing not appropriate at this time. . Nutrition consulted for education re: hight protein, [Doctor First Name ], low-[Doctor Last Name ] diet. Patient started on regular food. Blood sugars checked QID & HS, treated with Regular insulin sliding scale as indicated. Patient reports poor appetite. Encourage proper food choices to minimize hyperglycemia, and promote healing. . SL PICC line inserted due to poor peripheral access. Continued with IV antibiotics. Skin culture grew BETA STREPTOCOCCUS GROUP A. Antibiotic regimen switched to oral Levaquin. Remained afebrile with normal WBC. Plan to continue oral Levaquin for [2-22] weeks at rehab. PICC line removed prior to discharge. Screened for rehab placement by [Hospital1 ] for complex wound care. Plan for vacuum dressing to be applied once surrounding epidermis around wound stops weeping, and able to adhere dressing to this area. Plastic surgeon will assume managment of antibiotics, and wound care after discharge. Plan for split-thickness skin graft to site in about 3 weeks. . Patient seen by social work during admission due to depressed appearance, and to provide support due to medical condition. Has been on antidepressants in past for post-partum depression, and has seen therapist. Stopped taking medication on her own, and has not been seeing therapist. Unable to remember names of therapist or medications. PCP [Name (NI) 653] to verify depression history and medications trialed. No medications of diagnosis of depression on file. Continue assessment & management of depressed symptoms during admission in rehab due to possible [Hospital 4820] hospital course. Consider involvement of Psych if and when appropritate. . Dermatitis: Generalized across back and back of calves. Possible related to hospital linen, or IV Morphine. Patient reports tolerating Levaquin in past without rash. Continue to assess skin. Continue PO Benadryl, Pepcid, Sarna Lotion for symptom relief. Consider involvment of Dermatology as indicated. Medications on Admission: Zyrtec Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 7. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Morphine 4 mg/mL Syringe Sig: One (1) Injection three times a day as needed for pain: Please give 10 minutes prior to dressing changes only . 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 weeks: Continue until follow-up with Plastic surgeon. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection QAC & HS: Refer to sliding scale. 11. Regular Insulin Sliding Scale 61-100 mg/dL 0 Units 101-120 mg/dL 2 Units 121-140 mg/dL 4 Units 141-160 mg/dL 6 Units 161-180 mg/dL 8 Units 181-200 mg/dL 10 Units 201-220 mg/dL 12 Units 221-240 mg/dL 14 Units 241-260 mg/dL 16 Units 261-280 mg/dL 18 Units 281-300 mg/dL 20 Units 301-320 mg/dL 22 Units > 320 mg/dL Notify M.D. Check blood sugars before each meal and at bedtime. 12. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety for 2 weeks. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 1121] - [Location (un) 1456] Discharge Diagnosis: Primary: Righ lower extremity nectrotizing cellulitis Depression . Secondary: morbid obesity, OSA, asthma, GERD, C/S x 2, postpartum depression Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication 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. Followup Instructions: 1.Please make a follow-up appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]([Telephone/Fax (1) 77766], in [1-21] weeks. 2.Make a follow-up appointment with your primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) 63252] [Telephone/Fax (1) ] in 1 week or as needed. Completed by:[2133-4-3] ICD9 Codes: 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7874 }	Medical Text: Admission Date: [2138-10-6] Discharge Date: [2138-10-11] Date of Birth: [2079-3-12] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: chest pressure Major Surgical or Invasive Procedure: [2138-10-6] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to LPDA) History of Present Illness: 59 yo male with known CAD and stent placement in [2136]. Had a + ETT in [8-29] and suubsequent cath revealed 3V CAD. Referred for CABG. Past Medical History: Coronary Artery Disease s/p CX stent [12-27], Hypercholesterolemia Social History: lives with wife, works as an educator, quit smoking at age 20,several drinks per week Family History: NC Physical Exam: 5' 11" 160# HR 76 RR 14 (at PAT : right 175/80 left 150/80) NAD skin unremarkable EOMI, PERRL, NCAT neck supple, full ROM, no JVD or carotid bruits appreciated CTAB no W/ R/R RRR no murmur soft, NT. ND, + BS warm, well-perfused, no edema or varicosities noted nonfocal neuro exam, alert and oriented x3, MAE 2+ bil. fem/DP/PT/radials Pertinent Results: [2138-10-6] Echo: PREBYPASS: 1. The left atrium is normal in size. No atrial septal defect or PFO is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. 5 .The mitral valve leaflets are structurally normal, with slight ballooning of A2 segment although coaptation point remains below the level of the annulus. Mild (1+) mitral regurgitation is seen. 6. Left ventricular function is good with EF 50-55%. During exam it was noted that the basal lateral, inferolateral and inferior walls became hypokinetic, but this resolved on it's own. 7. There is no pericardial effusion. 8. Dr. [Last Name (STitle) ] was notified in person of all results. POSTBYPASS: 1. Patient is on nitroglycerin infusion. 2. Left ventricular function is unchanged. No wall motion abnormalities are noted. 3. Aortic contours smooth after decannulation 4. All other parts of the exam are unchanged. 5. Dr. [Last Name (STitle) ] was notified of the findings. [2138-10-6] 03:51PM BLOOD WBC-10.4# RBC-3.06# Hgb-9.5# Hct-26.4# MCV-86 MCH-31.0 MCHC-35.9 RDW-12.1 Plt Ct-139* [2138-10-10] 05:44AM BLOOD WBC-8.6 RBC-3.04* Hgb-9.5* Hct-26.4* MCV-87 MCH-31.3 MCHC-36.1* RDW-13.7 Plt Ct-197 [2138-10-6] 03:51PM BLOOD PT-16.6* PTT-46.6* INR(PT)-1.5* [2138-10-7] 04:23AM BLOOD PT-14.7* PTT-33.6 INR(PT)-1.3* [2138-10-6] 05:17PM BLOOD UreaN-14 Creat-0.7 Cl-114* HCO3-26 [2138-10-9] 05:20AM BLOOD Glucose-122* UreaN-20 Creat-0.8 Na-139 K-3.7 Cl-103 HCO3-30 AnGap-10 Brief Hospital Course: Mr. [Known lastname 79388] was a same day admit after undergoing all preoperative workup as an outpatient. and underwent surgery with Dr. [Last Name (STitle) ]. On day of admission he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later that day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. Later on post-op day one/two his hematocrit was found to have decreased, he received a transfusion with good response. Also underwent chest x-ray which showed small effusions and apical pneumothorax. On post-op day two he appeared to be well despite his lowered hematocrit and two of his chest tubes were removed and was later transferred to the telemetry floor for further care. Again on post-op day three he received blood transfusion and also had his epicardial pacing wires and the remainder of his chest tubes removed. He also required re-insertion of urinary catheter due to urinary retention. He continued to remain stable while working with physical therapy for strength and mobility. His hematocrit also appeared to be stable but slightly lower than normal. He was discharged home on [10-11], POD 5 with VNA services and the appropriate follow-up appointments. Medications on Admission: ASA 325 mg daily toprol XL 25 mg daily vytorin 10/10 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:1 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:1 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:1 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:30 Tablet(s) Refills:0 10. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:60 Tablet(s) Refills:0 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: .Caregroup home care Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: s/p CX stent [12-27], Hypercholesterolemia Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision no lifting greater than 10 pounds for 10 weeks shower daily and pat incisions dry call for fever greater than 100.5, redness or drainage no driving for one month AND until off all narcotics Followup Instructions: [Hospital 409] clinic in 2 weeks Dr. [Last Name (STitle) ] in [1-22] weeks Dr. [Last Name (STitle) 12526] in [2-23] weeks Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Completed by:[2138-10-11] ICD9 Codes: 5119, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7875 }	Medical Text: Admission Date: [2122-9-3] Discharge Date: [2122-9-15] Date of Birth: [2055-7-16] Sex: F Service: CSU CHIEF COMPLAINT: Ms. [Known lastname 57763] is a 67-year-old woman who is initially seen at [Hospital3 35813] Center in [Doctor Last Name 792]for pressure-like chest discomfort radiating to her left arm and associated with shortness of breath relieved with some IV and sublingual nitroglycerin. HISTORY OF PRESENT ILLNESS: The patient had a cardiac catheterization done following a positive stress test on [2122-8-24]. The cardiac catheterization showed an ejection fraction of 70 percent with an ostial LAD at 90 percent, mid LAD 70 percent, diagonal 70 percent lesion, mid circumflex lesion of 80 percent and RCA with a 50 percent stenosis. The patient ruled out for an myocardial infarction following her cardiac catheterization when she represented to the emergency room on [2122-9-3]. She was ruled in for an myocardial infarction and was transferred to [Hospital1 190] for evaluation for coronary artery bypass grafting. The patient was admitted to the cardiology service on admission to the [Hospital1 69]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Zocor q.d. 2. Aspirin 325 q.d. 3. Metoprolol 25 b.i.d. 4. Plavix 75 q.d. 5. Lovenox 50 q. 12. PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia, coronary artery disease and carotid endarterectomy done in [2122-5-16]. SOCIAL HISTORY: The patient lives with her husband in [Name (NI) 26532]. She is very active. Alcohol--one drink per day. Tobacco--quit 40 years ago. FAMILY HISTORY: Three brothers and one sister with coronary artery disease. All had myocardial infarctions and coronary artery bypass grafts in their 50's; hypertension and hypercholesterolemia also. REVIEW OF SYMPTOMS: Positive pneumonia in [2092] as well as one year ago ([2121]); angina and shortness of breath; palpitations; arthritis of the toes and back and degenerative joint disease of the lower back. PHYSICAL EXAMINATION: Height is 5 feet and 4 inches. Weight is 116 pounds. Vital signs are 98.1, 120/60, heart rate 64, Respiratory rate 18. O2 sat is 96 percent on room air. General: Sitting in chair in no acute distress. Neurological: Alert and oriented times 3, grossly intact. Neck: Supple. No lymphadenopathy. No carotid bruits. Well- healed right CEA incision. Respiratory: Clear to auscultation bilaterally. Cardiovascular: S1 and S2. No murmurs, rubs or gallops. Extremities: Warm and well perfused with no edema and no varicosities. Pulses are 2 plus throughout. LABORATORY DATA: White blood cell count is 5.9, hematocrit is 37.2, platelets are 220, PT 13.8, PTT 67.9 and INR 1.2, sodium 142, potassium 4.1, chloride 106, CO2 29, BUN 16, creatinine 0.6, glucose 98, ALT 29, AST 28, alk phos is 69, total bili is 0.7, mag 2.1, UA was negative. Chest x-ray shows mild emphysema. The patient was seen by cardiothoracic service and accepted for coronary artery bypass grafting. The surgery was scheduled for [2122-9-7]. Until that point, the patient was followed by the medical and cardiology service. On [2122-9-7], the patient was brought to the Operating Room where she underwent coronary artery bypass grafting times 3. Please see the OR report for full details. In summary, the patient had a LIMA to the LAD, saphenous vein graft to OM and saphenous given graft to diagonal. Bypass time was 55 minutes with a cross clamp time of 44 minutes. She tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was A paced at 80 beats per minute with a mean arterial pressure of 67, central venous pressure of 7. She had Neo-Synephrine at 0.3 mcg per kg per minute and Propofol at 20 mcg per kg per minute. The patient did well in the immediate postoperative period. Her anesthesia was reversed. She was weaned from the ventilator. However, when she was weaned to CPAP, the patient had periods of apnea. The decision was made to keep the patient intubated over night on the day fo her surgery to allow her to more fully awaken prior to extubation. On the morning of postoperative day 1, the patient continued to be somewhat sleepy with shorter periods of apnea and the decision was made at that time to extubate which ws done successfully on the morning of postoperative day 1. Throughout the day, the patient remained hemodynamically stable. However, we kept the patient in the Intensive Care Unit to monitor her respiratory status. Additionally, the patient continued to need Neo-Synephrine infusion to maintain an adequate blood pressure. On postoperative day 2, the patient remained hemodynamically stable. Her Neo-Synephrine drip was weaned to off. Her chest tubes were removed and the patient was started on diuretic therapy. The patient remained hemodynamically stable on postoperative day 3 and she was transferred from the cardiothoracic Intensive Care Unit to the floor for continuing postoperative care and cardiac rehabilitation. With the assistance of physical therapy and the nursing staff, the patient's activity level was increased over the next several days. However, on postoperative day 5, it was noted that the patient had a cellulitic appearing saphenous vein graft harvest site and she was begun on IV antibiotics following which the patient developed a rash on her back which was felt to be a contact dermatitis. Despite that the patient's antibiotics were changed to IV vancomycin as well as oral levofloxacin. Over the next several days, the patient's rash resolved. The cellulitis of her leg markedly improved. During this entire period, the patient remained hemodynamically stable and on postoperative day 7, it was decided that the patient remain afebrile and had a normal white blood cell count. On the following morning, she would be discharged to home. At the time of this dictation, the patient's physical examination was as follows: vital signs: temperature 98.2, heart rate 81 in sinus rhythm, blood pressure is 109/56, Respiratory rate is 20. O2 saturation is 97percent on room air. Weight preoperatively is 51.8, at discharge is 51.2. LABORATORY DATA: White blood cell count is 8.2, hematocrit is 35.7, platelets 379, sodium 142, potassium 4.7, chloride 104, CO2 30, BUN 10, creatinine 0.6, chloride 172. PHYSICAL EXAMINATION: Neurological: Alert and oriented times 3, moves all extremities, follows commands. Respiratory: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm, S1 and S2 with a 2/6 systolic ejection murmur. Sternum is stable. Incision with steri- strips, open to air, clean and dry. Abdomen: Soft and nontender and nondistended with normal active bowel sounds. Extremities: Warm and well perfused with no edema. Right endoscopic saphenous vein graft harvest site with minimal erythema. No pain or drainage. 2 plus dorsalis pedis and posterior tibial pulses. The patient's condition at discharge is stable. She is to be discharged home with visiting nurses. DISCHARGE DIAGNOSIS: Coronary artery disease, status post coronary artery bypass grafting time three with a LIMA to the LAD, saphenous vein graft OM and saphenous vein graft to diagonal. Postoperative course was complicated by cellulitis of the right endoscopic harvest site. Hypertension. Hypercholesterolemia. Status post right CEA. DISCHARGE MEDICATIONS: 1. Aspirin 325 q.d. 2. Simvastatin 10 mg q.d. 3. Metoprolol 25 mg b.i.d. 4. Levofloxacin 500 mg q.d. times 10 days. 5. Percocet 5/325 one to two tabs q. 4 hours p.r.n. as needed. The patient is to have follow up with Dr. _____ in Winsockett, [Doctor Last Name 792]in two weeks. Follow up with Dr. [First Name (STitle) 4944] _____ in [Location (un) ], [Doctor Last Name 792]in 3 to 4 weeks and follow up with Dr. [First Name (STitle) ] [Name (STitle) ] in one month. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2122-9-15] 15:14:19 T: [2122-9-16] 06:11:23 Job#: [Job Number 57764] ICD9 Codes: 4111, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7876 }	Medical Text: Admission Date: [2128-6-22] Discharge Date: [2128-6-25] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8684] Chief Complaint: Dizziness Major Surgical or Invasive Procedure: none History of Present Illness: The patient is an 81 yo Mandarin-speaking female, who was recently discharged from [Hospital1 18] on [6-20] after a 4 day admission for evaluation of hematemesis. On her last admission, the patient had a HCT of 28 on admission. She received 2 U PRBCs in the ED. She underwent EGD on [6-16]. EGD disclosed "a few superficial non-bleeding 3 mm ulcers in the pylorus and incisura of the stomach. Red blood was seen in the fundus and stomach body. The blood was unable to be suctioned or lavaged due to clotting. A single cratered 9 mm ulcer was found in the incisura of the stomach. A visible vessel suggested recent bleeding. Five Epi injections were applied for hemostatis with success. Electrocautery was applied for hemostasis." The patient was started on an IV PPI [Hospital1 ]. Her ulcers are secondary to NSAID use. In addition, she was using a Chinese herbal medicine which may cause increased gastric acid secretion. Following her brief MICU stay, the patient was transferred to the floor. She received an additional unit of PRBCs. Her HCT remained stable, and she was discharged on [6-20] with a HCT=33.6. Last evening, the patient felt dizzy, and she was taken to [Hospital1 8685]. There she was found to have a SBP ~80. She was found to have a HCT=24. She was transferred back to [Hospital1 18] for further management. Per her daughter, the patient denies any episodes of hematemesis or melena since her discharge. In the ED, the patient was hemodynamically stable (BP 100/58, HR 71). She was administered 1 L NS and 2 U PRBCs. The patient declined NG lavage. Past Medical History: Remote (10 years ago) history of maroon stools Glaucoma Social History: She is originally from [Country 651]. She lives with husband. Notes former tobacco use. Family History: The patient has a sister with diabetes. Physical Exam: General: Pale appearing elderly Chinese female in NAD. VS: Tm 99.4 Tc 98.6 BP 110/50-70 P 70-80 O2 97% RA HEENT: NC/AT. Sclerae anicteric. MMM. OP clear. Neck: Supple. No cervical LAD. Lungs: CTAB. CVS: RRR. S1, S2. No m/r/g. Abd: Soft, NT, ND, +BS. Extr: No c/c/e. Warm. Skin: No rashes or lesions. Pertinent Results: FINAL REPORT [2128-6-18] HELICOBACTER PYLORI ANTIBODY TEST (Final [2128-6-18]): POSITIVE BY EIA. Reference Range: Negative. [2128-6-24] 08:44PM BLOOD Hct-33.7* [2128-6-24] 09:20AM BLOOD Hct-30.9* [2128-6-24] 05:30AM BLOOD Hct-31.8* [2128-6-23] 08:20PM BLOOD Hct-30.7* [2128-6-23] 03:46AM BLOOD WBC-7.6 RBC-3.59* Hgb-11.2* Hct-32.6* MCV-91 MCH-31.2 MCHC-34.4 RDW-14.4 Plt Ct-206 [2128-6-21] 11:15PM BLOOD PT-11.9 PTT-22.6 INR(PT)-0.9 [2128-6-23] 03:46AM BLOOD Glucose-84 UreaN-20 Creat-0.6 Na-144 K-3.4 Cl-112* HCO3-23 AnGap-12 [2128-6-22] 05:49AM BLOOD Glucose-99 UreaN-27* Creat-0.6 Na-141 K-3.9 Cl-110* HCO3-23 AnGap-12 [2128-6-23] 03:46AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.0 [2128-6-23] 03:46AM BLOOD TSH-0.18* [2128-6-23] 03:46AM BLOOD T4-11.0 T3-95 Free T4-2.1* Brief Hospital Course: Pt was readmitted for Hct 24. She was transfused 2 u and given IVF. EGD was performed to show small ulcer on lesser curvature and was subsequently cuterized with epi. Her hematocrit has been stable at 31-32 since transfusion. She was transferred to floor on [6-23]. Her stool color has returned to [Location 213]. During the hospitalization, her TSH was found to be 0.18 and the rest of thyroid indicies are pending at the time of discharge. SHe has been recovering steadily and to be followed up at the Dr. [Name (NI) 8686] clinic on monday [6-30] for Hct check and further thyroid evaluation Medications on Admission: Brimonidine Tartrate 0.15% Ophth 1 drop OU [Hospital1 ] Dorzolamide 2%/Timolol 0.5% Ophth 1 drop OU [Hospital1 ] Latanoprost 0.005% Ophth soln 1 drop OU hs Pantopraxole 40 mg PO q12h Discharge Medications: Por 1. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours) for 12 days. Disp:48 Capsule(s) Refills:0 5. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. Disp:24 Tablet(s) Refills:0 6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO q12 Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital6 1952], [Location (un) 86] Discharge Diagnosis: GI ulcer/bleed Low TSH Discharge Condition: stable and recovering Discharge Instructions: You should call 911 or return to emergency room if you experience dizziness, chest pain, shortness of breath, black/bloody stool Followup Instructions: You will follow up with Dr.[Name (NI) 8687] nurse practioner on Monday at 10:10am to have hematocrit check and follow up of thyroid studies. ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7877 }	Medical Text: Admission Date: [2171-4-14] Discharge Date: [2171-5-9] Date of Birth: [2119-7-10] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Dilantin / Prozac Attending:[First Name3 (LF) 6743] Chief Complaint: - abdominal pain Major Surgical or Invasive Procedure: - exploratory laparotomy - extensive lysis of adhesions - small bowel resection with re-anastomosis - radical resection of pelvic tumor - rigid proctoscopy History of Present Illness: This is a 51-year-old woman with a history of pseudomyxoma peritonei, with initial debulking in [2159] and recurrence and second debulking in [2161]. She presented from her rehab facility to the ED on [4-14] with abdominal pain. A CT scan of the abdomen and pelvis revealed a likely small bowel obstruction with multiple transition points, as well as multiple cystic structures concerning for recurrence of her mucinous cystic ovarian cancer. Past Medical History: - pseudomyxoma peritonei - epilepsy - history of right [Doctor Last Name 555] paralysis - depression and post-traumatic stress disorder - hypothyroidism - gastroesophageal reflux disease . - left temporal lobectomy, [2152] - total abdominal hysterectomy, bilateral salpingo-oophorectomy, debulking, [2159] - debulking of recurrent pseudomyxoma peritonei, [2161] Social History: - denies tobacco, alcohol, and recreational drug use - lives in rehabilitation facility given functional impairment due to seizures Family History: - denies family history of malignancy Physical Exam: On admission: Vitals - T:97.6 HR:61 BP:161/81 -> 117-146/64-88 RR:18 O2sat:100% room air General: asleep, easily arousable, uncomfortable appearing, winces when moving Lungs: CTAB CV: RRR Abdomen: healed vertical midline incision, distended, tympanic in upper abdomen, dull to percussion in lower abdomen, non-tender with percussion, tender to palpation diffusely, worst in upper abdomen, + voluntary guarding Pelvic: normal external genitalia, significant tenderness on palpation of cervix and posterior vaginal wall limiting exam, unable to palpate any masses but exam very limited . On discharge: Vitals - T:98.5 BP:110/60 HR:104 RR:16 O2sat:96% room air General: NAD, resting comfortably CV: RRR Lungs: CTAB Abdomen: soft, bowel sounds present, healing vertical mid-line incision C/D/I with steri-strips in place Extremities: no calf edema or TTP Pertinent Results: [2171-4-13] WBC-6.0 Hgb-12.1 Hct-35.7 Plt Ct-309 [2171-4-13] Neuts-84.3 Lymphs-12.5 Monos-1.9 Eos-1.1 Baso-0.3 [2171-4-16] WBC-2.5 Hgb-12.7 Hct-36.6 Plt Ct-224 [2171-4-16] Neuts-32 Bands-19 Lymphs-33 Monos-13 Eos-1 Baso-0 Metas-2 Myelos-0 [2171-4-17] WBC-4.3 Hgb-13.1 Hct-38.2 Plt Ct-227 [2171-4-17] Neuts-69 Bands-10 Lymphs-14 Monos-6 Eos-0 Baso-0 Metas-1 Myelos-0 [2171-4-20] BC-10.2 Hgb-10.5 Hct-31.8 Plt Ct-229 [2171-4-20] Neuts-77 Bands-0 Lymphs-11 Monos-6 Eos-5 Baso-0 Metas-1 Myelos-0 [2171-4-23] WBC-11.8 Hgb-11.5 Hct-34.8 Plt Ct-455 [2171-4-30] WBC-9.9 Hgb-10.8 Hct-32.0 Plt Ct-557 [2171-5-9] WBC-6.6 Hgb-10.6 Hct-31.5 Plt Ct-293 [2171-4-13] Glucose-117 UreaN-16 Creat-0.9 Na-139 K-4.4 Cl-97 HCO3-34 [2171-4-16] Glucose-120 UreaN-9 Creat-0.6 Na-139 K-3.3 Cl-104 HCO3-26 [2171-4-20] Glucose-115 UreaN-10 Creat-0.4 Na-139 K-4.1 Cl-103 HCO3-30 [2171-4-23] Glucose-134 UreaN-17 Creat-0.6 Na-143 K-3.8 Cl-107 HCO3-30 [2171-5-1] BLOOD Glucose-94 UreaN-16 Creat-0.6 Na-141 K-4.0 Cl-107 HCO3-28 [2171-5-9] Glucose-95 UreaN-18 Creat-0.8 Na-136 K-4.3 Cl-103 HCO3-26 [2171-4-15] Calcium-9.4 Phos-3.8 Mg-1.8 [2171-4-19] Calcium-8.5 Phos-1.9 Mg-1.9 [2171-4-25] Calcium-8.6 Phos-4.5 Mg-2.0 [2171-4-30] Calcium-9.1 Phos-4.1 Mg-1.8 [2171-5-9] Calcium-9.3 Phos-4.0 Mg-1.8 [2171-4-13] ALT-12 AST-23 AlkPhos-86 TotBili-0.2 [2171-4-17] ALT-7 AST-17 AlkPhos-37 TotBili-1.1 [2171-4-16] Triglyc-38 [2171-4-26] Triglyc-61 [2171-4-23] TSH-8.0 [2171-4-30] TSH-3.0 [2171-4-23] T3-60 Free T4-1.0 [2171-4-30] T3-117 Free T4-1.3 [2171-4-13] CT Abdomen/Pelvis: IMPRESSION: 1. Small-bowel obstruction with small bowel measuring up to 3.5 cm in diameter. Multiple transition points representing multiple strictures in the mid lower abdomen are noted, please note that closed loop obstruction cannot be excluded. 2. Multiple cystic structures within the pelvis. Given history of prior mucinous cystic tumor of the ovary, this is most consistent with recurrence. No definite solid component identified. [2171-4-23] CT Head: IMPRESSION: No acute intracranial process. [2171-5-8] CTA Chest: IMPRESSION: 1. No acute pulmonary embolism or acute thoracic aortic pathology detected. 2. Cluster of tiny 2-mm pulmonary nodules in both lung bases, a few of which are calcified, likely represent prior granulomatous disease. 3. No evidence of metastatic disease in the chest. Brief Hospital Course: ) Small Bowel Obstruction She was taken to the operating room for surgical exploration. Intra-operative findings were significant for recurrent pseudomyxoma peritonei, extensive adhesions of the bowel to the anterior abdominal wall and to other portions of bowel, and small bowel obstruction. She underwent a small bowel resection with re-anastamosis and resection of pelvic tumor. Please see the operative report in OMR for full details. A nasogastric tube (NGT) was placed intra-operatively and left in place, and she was maintained on bowel rest. Total parenteral nutrition (TPN) was initiated. On post-operative day #5, NGT output had decreased, and after clamping the tube with minimal residual output, it was removed. However, the following day she developed nausea and vomiting, and the tube was replaced. Her NGT output gradually decreased and her bowel function slowly returned; the NGT was clamped on post-operative days #14-15, with a low residual output, and was removed on post-operative day #16. Her diet was slowly advanced as bowel function returned. TPN was weaned off and then discontinued as her diet was advanced. She was discharged on a regular diet with nutritional shake supplementation. ) Hypotension/Shock Intra-operatively she developed hypotension and was placed on pressors; she was admitted to the ICU post-operatively. On admission to the ICU she had a white blood cell count of 2,000 and tachycardia, meeting criteria for SIRS. She was aggressively hydrated with IVF boluses and continuous drips. She was also given 2 units of FFP to reverse coagulopathy and transfused with PRBC due to intra-operative blood loss and a hematocrit that drifted down in the post-operative period. She was initially on a norepinephrine drip, but this was weaned off with good effect. Vancomycin and Zosyn for broad coverage of enteric pathogens were started. She stayed in the ICU for 4 days post-operatively; she was hemodynamically stable when transferred to the surgical floor. ) ID In the immediate post-operative period she had a low white blood cell count with a bandemia to 19. Vancomycin and Zosyn were initiated for broad-spectrum coverage of enteric pathogens, due to her extensive bowel surgery. For the first 3 days post-operatively she continued to intermittently become febrile, with gradual resolution of her fevers. The antibiotics were discontinued once she had been afebrile for 48 hours. On post-operative day #7 she had a low-grade fever to 100.8, which spontaneously resolved, and remained afebrile after this. All cultures (urine, blood) negative, and chest imaging was negative for pneumonia. Her fevers were attributed to intra-abdominal exposure to intestinal contents/bacteria, as well as inflammation after extensive surgery. During the last 3-4 days of her hospitalization she developed diarrhea, but no fevers or other associated symptoms. Stool was sent for C. difficile, which was negative, and her symptoms were overall stable on discharge with 3-4 loose stools per day. She was started on clotrimazole lozenges and oral Nystatin for thrush on post-operative day #19 and received one dose of IV fluconazole and two doses of oral fluconazole, with subsequent improvement of her thrush. ) Cardiovascular She was initially tachycardic up to the 120's after surgery, which was attributed to her fevers and general state of inflammation post-operatively. Her heart rate gradually normalized to the 80-90's. On post-operative day #20, she was again noted to be intermittently tachycardic, low 100's to 110's. On post-operative day #22, as this persisted, an ECG and CTA chest were performed. The ECG was unremarkable and unchanged from prior, and CTA was negative for pulmonary embolism. Her oxygen saturation was good, and her heart rate was stable at 90-low 100's on discharge. ) Pulmonary She was electively intubated for surgery and remained intubated in the setting of hypotension and possible sepsis/shock post-operatively. She was successfully extubated on post-operative day #3. On the surgical floor she had one episode of desaturation to 87% on room air, but this was in the setting of a likely post-ictal state and immediately normalized with supplemental oxygen. The oxygen was weaned off and she afterwards maintained excellent oxygen saturation on room air. On CTA chest performed to rule out pulmonary embolism, 2mm tiny pulmonary nodules consistent with prior granulomatous disease were noted incidentally. ) Epilepsy Ms. [Known lastname 1661] has a longstanding history of seizures and has undergone a temporal lobectomy in the past. As an outpatient, her regimen consisted of 3 agents - Keppra, Lamictal, and Ativan. Due to her small bowel obstruction, she was made NPO. Neurology was consulted for input regarding her medications, and recommended continuing IV Keppra and increasing IV Ativan to cover her usual Lamictal (unavailable in an IV form). Post-operatively, Ativan was initially held due to sedation/intubation. Her Keppra was continued throughout her hospital course. When she was extubated and more alert, Ativan was re-started at a low dose. She continued to have intermittent seizure activity, but these were consistent with episodes in the past in which she became symptomatic but had no epileptiform activity on EEG, suggesting that there may be a component of stress/anxiety. Her Ativan was slowly titrated up, with subsequent good control of her seizure activity. Lamictal was re-started on post-operative day #18 and gradually titrated up per Neurology's recommendations. ) Depression/Post-traumatic Stress Disorder Due to being NPO for a prolonged period of time, she was unable to receive her usual anti-depressant medication. Psychiatry was consulted and continued to follow and provide support during her hospital course, as did Social Work. Her anti-depressant was re-started when she was able to tolerate oral intake. ) Hypothyroidism Her levothyroxine was continued, after conversion to IV dosing ([12-1] po dose = IV dose). Thyroid function tests were checked at the suggestion of Neurology, who felt that thyroid function could be affecting her seizure activity. TSH was initially elevated, with normal free T4. Endocrinology was informally consulted and thought this to be consistent with sick euthyroid syndrome after surgery/illness. Labs were re-checked 1 week later and her TSH had normalized, with normal free T4 and T3, so her usual dose of levothyroxine was maintained and transitioned back to oral dosing when she was able to tolerate oral intake. ) Fall On post-operative day #7 she attempted to move out of her bed and fell onto her hands and knees; the fall was unwitnessed but she maintained consciousness and denied any head trauma. Her vital signs were normal, and a CT of the head was negative for acute injury. Medications on Admission: - Colace - lamotrigine 1500mg/2000mg - Keppra 1500mg/2000mg - levothyroxine 88mcg daily - Ativan 1mg daily, prn for increased seizure activity - nefazodone 100mg/200mg - Metamucil - multi-vitamin - Senna Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain,fever. 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Nefazodone 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 7. Nefazodone 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 8. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane DAILY (Daily). 9. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 10. Levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO QPM (once a day (in the evening)). 11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain. 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 14. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 15. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous once a day: until ambulating more frequently. Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) ] Discharge Diagnosis: - recurrent pseudomyxoma peritonei - small bowel obstruction . - epilepsy - depression - hypothyroidism 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 take your medications as prescribed. No heavy lifting or strenuous activity for 4 weeks. . Please call your doctor for the following: - fever greater than 100.4 - severe pain that does not improve with medication - persistent nausea or vomiting - difficulty breathing or chest pain - increasing redness around your incision - bleeding or thick discharge from your incision - if your incision re-opens . Instructions for titrating lamotrigine and lorazepam: - currently lamotrigine 100 mg [Hospital1 ], started [5-8] - in 4 days (from [5-8]) increase the dose to 200 mg [Hospital1 ] - in 4 days, increase the dose to 300 mg [Hospital1 ] - for lorazepam, reduce dose by [12-3] each week, now 0.5mg every 4 hours Followup Instructions: - follow up with Dr. [Last Name (STitle) 2028] in early [Month (only) 205] - please call to make an appointment, [Telephone/Fax (1) 5777] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 6753*] ICD9 Codes: 2851, 2449, 0389
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7878 }	Medical Text: Admission Date: [2157-11-8] Discharge Date: [2157-12-12] Service: NSU MEDICATIONS ON ADMISSION: Aspirin. PAST MEDICAL HISTORY: Past medical history is remarkable for osteoarthritis, laminectomy, polymyalgia rheumatica, inclusion body myopathy and upper GI bleed. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 59937] is an 87 year old gentleman with a history of fall. He had a fall prior to admission with neck pain and presented to an outside hospital. He had a CAT scan and MRI done of the neck which did show question of osteomyelitis and abscess at the C5-C6 level. He was transferred to [Hospital1 188]. PHYSICAL EXAMINATION: Heart rate was 98. Blood pressure was 132/70. Respiratory rate was 16. He was in a hard collar. Extraocular movements were intact. Lungs were clear to auscultation bilaterally. Heart showed regular rate and rhythm, no murmurs, rubs or gallops. Abdomen showed positive bowel sounds, soft, nontender, nondistended, no CVA tenderness. Neurologic exam - he opened his eyes to voice. He followed commands in all four extremities and was alert and oriented. HOSPITAL COURSE: He was admitted to the Trauma Intensive Care Unit for close neurological monitoring. He was started on IV antibiotics. Cultures were obtained. He was also seen by ORL for his posterior pharyngeal fluid collection which was evacuated. He was left intubated after this procedure. He did receive a PICC line for long term antibiotic and was also started on TPN. Dr. [Last Name (STitle) 1327] from Surgery did discuss with the family the patient undergoing a C5-6 anterior cervical diskectomy and fusion with allograft and screw and plate fixation. On [2157-11-15], he was brought to the Operating Room where he did have an anterior cervical diskectomy and fusion from C4 to C6 performed by Dr. [Last Name (STitle) 739]. Postoperatively, he was sedated. Vital signs were stable. Blood pressure was 142-170/53-70. His hematocrit was 31.6. He was able to move all four extremities to command. Dressing was clean, dry and intact. He remained intubated and was followed with C-spine films. He was able to have his activity increased postoperatively, but he was kept intubated. His TPN was resumed. He then had both tracheostomy and PEG tubes placed for long term management. On [2157-11-19], he had lower extremity Dopplers which did not show a DVT. On x-rays done on [11-22], a new mild retrolisthesis of C4 on C5 was seen. However, due to his degree of osteoporosis, Dr. [Last Name (STitle) 739] felt a posterior fusion was warranted and discussed this with the family who agreed and he was brought to the Operating Room on [2157-11-28] for a posterior cervical laminectomy and fusion. Prior to that day he had a tracheostomy and post-op Cspine Xrays showed that the superior plate screws had partially moved .He was placed on imipenem for Enterobacter found in sputum culture and this was continued for 14 days. Postoperatively, he was uneventful radiographically and posterior instrumentation was in good position. He was neurologically stable and his activity was once again increased and Physical Therapy and Occupational Therapy assisted. On [11-30], the patient was found to have upper GI bleeding and was scoped emergently and was found to have a shallow crater at the gastroesophageal junction with slight ooze. It was recommended that he be followed with serial hematocrits and transfused as needed and to have Protonix twice per day. He did require frequent suctioning while he was in the Intensive Care Unit but this did slowly subside and he was able to be transferred to the Neurological Stepdown Unit on [12-6]. Both Physical Therapy and Occupational Therapy worked with him closely and felt he would benefit from a rehab placement. He was seen by Dr. [Last Name (STitle) 59938] for question of leg movements at night and they did recommend an EEG with video monitoring for future evaluation. This could be performed as an outpatient or at the rehab facility. DISCHARGE MEDICATIONS: His medications at the time of discharge are bisacodyl 10 mg pr at bedtime prn, heparin 5000 units subcutaneously tid, miconazole 2 percent cream, one application [Hospital1 ], lisinopril 5 mg daily, sliding scale insulin, acetaminophen 650 mg prn, oxycodone/acetaminophen elixir 5-10 mg q4h prn, pramipexole dihydrochloride 0.125 mg daily at 7 p.m., nystatin oral suspension 5 mg po qid prn, calcium carbonate 500 mg po qid, metoprolol 50 mg po bid, pantoprazole 40 mg po bid. DISCHARGE DIAGNOSES: His diagnoses include osteomyelitis, diskitis, osteoarthritis, inclusion body myopathy, upper GI bleeding. FOLLOW UP: He should follow up with Dr. [Last Name (STitle) 739] in his office in four weeks and should have x-rays at the time of the appointment. He should also have an EEG performed while at rehab and follow up with [Last Name (STitle) 59938]. [Name6 (MD) ] [Name8 (MD) 739], MD [MD Number(2) 2930] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2157-12-12] 11:09:05 T: [2157-12-12] 11:42:24 Job#: [Job Number 59939] ICD9 Codes: 5185
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7879 }	Medical Text: Admission Date: [2172-5-15] Discharge Date: [2172-5-20] Service: MEDICINE Allergies: Vancomycin / Oxycodone Attending:[First Name3 (LF) 23347] Chief Complaint: LLQ abdominal pain Major Surgical or Invasive Procedure: status post IR-guided embolization of the inferior epigastric artery History of Present Illness: 87 yo man with h/o pAFib on Coumadin, COPD (on 3L NC at home), and CAD s/p CABG who presented to the ED from his nursing home with LLQ abdominal pain and a supratherapeutic INR of 4.4. In the ED, the patient had a CT scan of his abdomen, which demonstrated a rectus sheath hematoma with evidence of active extravasation into the retroperitoneum. His Hct on arrival to the ED was 29.9, which was decreased from his baseline, so he was transfused 1 unit blood and 2 units of FFP. He also received Vitamin K and his repeat INR was 1.7. Upon discussion with IR, the patient was admitted to the SICU for observation overnight. . While in the ICU, the patient had an emergent IR-guided embolization of the inferior epigastric artery on [2172-5-15]. He was observed throughout the day, and he received a total of 7 [Location 31200] and 2 [Location 16678] to date during this hospital stay. His Hct has remained stable throughout the day after his IR-guided embolization. As his surgical issues are now stable, request was placed for transfer to medicine. Past Medical History: PMH: Tracheobronchomalacia s/p stent [9-5] and multiple bronchs GOLD stage III COPD p-Afib Prostate Ca CLL HTN Hyperlipidemia GERD Depression CAD s/p CABG and then stent within last 10 years CKD (baseline creatinine 1.5-2.1) Aortic Stenosis Vit B12 defic Arthritis Ventral hernia Hx of enterococcal urosepsis CCY . PSH: Silicon wire stent placement in [8-/2171], s/p CABG and then stent within last 10 years, CCY Social History: Widower x 3 times, Used to be in airline sales. smoked a pipe for 10 years (quit 40y ago), no current tobacco use. Family History: No family history of pulmonary disease Physical Exam: VS - afebrile, 98/60, 94-104, 20, 98% 3L NC Gen'l - sitting in chair, NAD HEENT - OP clear, MM somewhat dry Lungs - occasional crackles at right base, o/w clear CV - RRR no m/r/g Abd - soft, tender over left abdomen over location of hematoma, markedly distended, +BS GU - no foley Ext - SCDs present, no c/c/e Skin - ecchymoses over abdomen over site of heparin SQ injections Pertinent Results: LABS ON ADMISSION: [2172-5-15] 11:10AM BLOOD WBC-21.7# RBC-3.24 Hgb-10.1* Hct-29.9* MCV-92 MCH-31.2 MCHC-33.7 RDW-16.1* Plt Ct-213 [2172-5-15] 11:10AM BLOOD Neuts-65.9 Lymphs-31.5 Monos-1.7* Eos-0.6 Baso-0.4 [2172-5-15] 11:10AM BLOOD PT-31.7* PTT-27.9 INR(PT)-3.2* [2172-5-15] 11:10AM BLOOD Glucose-170* UreaN-42* Creat-1.3* Na-135 K-4.7 Cl-104 HCO3-25 AnGap-11 [2172-5-15] 11:10AM BLOOD ALT-18 AST-17 AlkPhos-50 TotBili-0.4 [2172-5-18] 01:25AM BLOOD CK(CPK)-535* [2172-5-15] 11:10AM BLOOD Lipase-38 [2172-5-18] 01:25AM BLOOD CK-MB-5 cTropnT-0.05* [2172-5-15] 11:10AM BLOOD Albumin-3.4* Calcium-7.8* Phos-3.1 Mg-2.1 [2172-5-15] 11:21AM BLOOD Lactate-1.5 . LABS ON DISCHARGE: [2172-5-18] 03:59PM BLOOD WBC-14.2* RBC-3.21* Hgb-9.4* Hct-27.8* MCV-87 MCH-29.2 MCHC-33.7 RDW-17.1* Plt Ct-157 [2172-5-18] 03:59PM BLOOD Neuts-77.8* Lymphs-20.6 Monos-1.3* Eos-0.2 Baso-0.1 [2172-5-18] 03:59PM BLOOD Plt Ct-157 [2172-5-18] 06:50AM BLOOD Glucose-121* UreaN-30* Creat-1.3* Na-134 K-3.9 Cl-98 HCO3-27 AnGap-13 [2172-5-18] 03:59PM BLOOD CK(CPK)-427* [2172-5-18] 03:59PM BLOOD CK-MB-6 cTropnT-0.06* [2172-5-18] 06:50AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0 . CXR Portable [5-17] FINDINGS: Cardiomediastinal contours are stable in appearance. Bibasilar patchy and linear areas of atelectasis are present. No areas of airspace consolidation are identified to suggest a source of infection within the lungs, but standard PA and lateral chest radiographs may be helpful for more complete [Month/Year (2) 2742] when the patient's condition permits. . CT ABD/PELVIS IMPRESSION: 1. Large left anterior abdominal wall hematoma with two distinct areas of active extravasation. Hematoma extends into retroperitoneal space as well as into the subcutaneous tissues. 2. Ventral abdominal hernia containing nonobstructed loops of bowel. Brief Hospital Course: 87 y/o male on coumadin for paroxsymal afib presents with rectus sheath hematoma with RP extension s/p reversal of anticoagulation and s/p angio embolizalization of left inferior epigastric artery. . # rectus sheath hematoma: emergent IR-guided embolization of the inferior epigastric artery on [2172-5-15]. He received a total of 7 [Location ] and 2 [Location 16678] prior to transfer to the medical service. On the medical floor, patient received 2 more units of pRBC and his hematocrit was stable for 24 hours prior to discharge. Aspirin and coumadin were initially held in setting of active bleeding, but resumed once Hct was stable. Aspirin was resumed but Coumadin should be resumed day after discharge on [5-21]. . # pAFib on Coumadin: p/w elevated INR and rectus sheath hematoma with evidence of active extravasation into the retroperitoneum. Aspirin and coumadin were initially held in setting of active bleeding, but resumed once Hct was stable. Patient was continued on home amiodarone dose and home lopressor was resumed and changed to 25mg TID. . # Leukocytosis: no active signs/symptoms of infection. Felt to be related to stress response as opposed to infection, given CXR without infiltrate, U/A without signs of infection, and lack of fever. . # COPD: on 3L NC at home. Stable. Continued prn nebulizers and oxygen via NC. . # CAD s/p CABG and Unstable Angina: patient developed SSCP x 2 with dynamic EKG changes while on the medicine floor. Cardiology was consulted, and etiology was felt to be demand ischemia in setting of low Hct as opposed to plaque rupture. Per discussion with cardiology and surgery, no plavix/heparin was initiated. Patient was transfused to keep Hct > 30. Telemetry was without events or arrhythmias. Patient was restarted on aspirin, BB, statin. ECHO showed Moderate aortic stenosis. Mild basal left ventricular hypertrophy with preserved left ventricular systolic function. Elevated PCWP. . # HTN: initially held antihypertensives in setting of bleeding, but resumed on discharge. . # HLD: continued statin . # GERD: continued PPI . # CKD: baseline creatinine 1.5-2.1, currently at baseline. . # Pain: continued tylenol and ultram, morphine only for severe breakthrough pain. Continued IS . # Elevated BG: continued QID fingersticks and ISS while in house. Did not require significant doses, and does not need to continue BG checks on discharge. . Code: DNR, But may intubate and cardiovert for afib Medications on Admission: HOME MEDICATIONS (From Rehab med sheet): Alburol nebs prn Tylenol prn Amiodarone 200 mg daily Aspirin 81 mg daily Lipitor 80 mg daily Benzonatate 200mg TID Citalopram 20mg daily Advair 500/50 [Hospital1 ] Atrovent neb prn Imdur 60 mg daily Lopressor 50 mg [Hospital1 ] Pred 10 mg daily Ativan .25 mg TID Coumadin ?dose (not on rehab med sheet from today) . [Last Name (un) 1724]: Alburol neb tylenol prn amio 100 aspirin 81 lipitor 80 benzonatate 200mg TID Citalopram 20mg advair 500/50 atrovent neb imdur 60 lopressor 50 prednisone 10 ativan 0.25TID coumadin ?dose (not on rehab med sheet from today)previously 2 mg Advair 250 mcg-50 mcg/Dose [Hospital1 ] Xopenenx 50 mg [Hospital1 ] Omeprazole 40 mg qday Spiriva 18 mcg Capsule daily mucinex 1200 mg tab [Hospital1 ] Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for shortness of breath. 10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 18. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 19. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 20. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 21. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO bid (). 22. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: to be titrated by coumadin clinic Please start on [5-21]. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: PRIMARY: 1. rectus sheath hematoma 2. supratherapeutic INR 3. status post IR-guided embolization of the inferior epigastric artery . SECONDARY: 1. Tracheobronchomalacia 2. GOLD stage III COPD 3. paroxysmal atrial fibrillation 4. prostate Ca 5. hypertension 6. hyperlipidemia 7. GERD 8. Depression 9. CAD s/p CABG [71]. CKD 11. Aortic Stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for elevated INR and rectus sheath hematoma. You underwent a surgical procedure (IR-guided embolization of the inferior epigastric artery) to control the bleeding. Your blood counts and hematocrit were stable for 24 hours prior to discharge. . During your admission, you also had two episodes of chest pain. You met with the cardiology doctors for further [Name5 (PTitle) 2742]. Your chest pain was felt to be related to low hematocrit and not from a tight blockage in your coronary artery. . NEW MEDICATIONS/MEDICATION CHANGES: - DECREASE Imdur to 30 mg daily - CHANGE metoprolol (lopressor) to 25 mg three times a day - DECREASE prednisone to 5 mg daily. This can be tapered per your primary care doctor. - START ultram 25 mg every four hours as needed for pain . Please seek medical attention for dizziness, lightheadedness, worsening abdominal swelling or pain, blood in the stools, chest pain, shortness of breath, fevers, or any other concerning symptoms. Please weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Followup Instructions: Please call [Telephone/Fax (1) 719] to schedule a follow-up appointment with your primary care doctor, Dr. [Last Name (STitle) 713], in [11-30] weeks time. . Department: GERONTOLOGY When: THURSDAY [2172-5-21] at 9:00 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 719] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: PODIATRY When: TUESDAY [2172-6-16] at 10:10 AM With: [First Name11 (Name Pattern1) 3210] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], DPM [Telephone/Fax (1) 543] Building: Ba [Hospital Unit Name 723] ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: GERONTOLOGY When: TUESDAY [2172-6-16] at 11:30 AM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 719] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage [Name6 (MD) ] [Last Name (NamePattern4) 23348] MD, [MD Number(3) 23349] ICD9 Codes: 2851, 496, 5859, 4241, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7880 }	Medical Text: Admission Date: [2183-8-6] Discharge Date: [2183-8-16] Service: SURGERY Allergies: Versed / Lactose Attending:[First Name3 (LF) 695] Chief Complaint: painless jaundice Major Surgical or Invasive Procedure: ERCP with bile duct stent and sphincterotomy on [8-6] History of Present Illness: [Age over 90 ]M h/o AAA repair in [2154], h/o CVA [2175], h/o iliac stenting who developed painless jaundice 4d prior to admission. He is admitted for observation following ERCP with biliary stenting and sphincterotomy today. There was a stricture in his CBD with evidence of gallstones and possible extrinsic compression found on the ERCP. His LFTs are significant for a dirict bilibunemia to above 5 with elevated ALT and AST above 500s. He was hospitalized one year ago with cholecystitis at [Hospital3 ], but was found to not be a surgical candidate and he was treated with medical management and low fat diet. He has intermittent episodes of RUQ pain but has not been for that recently. He is not a drinker and he does not know if has been diagnosed with hepatitis before if he has had blood transfusions. ROS: denies SOB, DOE, orthopnea, CP, but he is minimally active given L leg weakness. denies previous coronary stenting, prior MI, or recent TTE Past Medical History: AAA s/p repair in [2154] iliac stenting and embolization treatment (aneurysm?) L leg weakness following AAA repair CVA without residual symtpoms, presented with L arm weakenss [2175] bladder cancer [2161] h/o diverticulitis h/o falls Social History: lives alone, daughter lives in house next door wife is in [Name (NI) 1501] for dementia retired vet former smoker no ETOH Family History: father with diabetes Physical Exam: Physical Exam on Admission: 120/84, HR 60, afebrile extremely pleasant elderly male with poor hearing, aox3, no distress heent: scleral icterus present neck supple CV: RRR NMRG, JVP not distended PULM: CTAB no wheezes abd: soft, trace RLQ tenderness, but no rebound, not distended extremities: L foot with joint deformity skin: jaundice, multiple sebhorric keratosis on back, no skin breakdown or ulceration in LE neuro: CN grossly intact, speech fluent, L leg strength diminished psych: calm Pertinent Results: [2183-8-6] 01:15PM BLOOD WBC-4.7 RBC-3.64* Hgb-10.1* Hct-31.2* MCV-86 MCH-27.8 MCHC-32.4 RDW-14.2 Plt Ct-192 [2183-8-6] 01:15PM BLOOD PT-14.9* PTT-26.2 INR(PT)-1.3* [2183-8-6] 01:15PM BLOOD UreaN-31* Creat-1.6* Na-142 K-4.6 Cl-105 HCO3-27 AnGap-15 [2183-8-6] 01:15PM BLOOD ALT-389* AST-454* AlkPhos-1059* Amylase-37 TotBili-6.7* DirBili-5.0* IndBili-1.7 [2183-8-6] 01:15PM BLOOD Lipase-19 ERCP report: Procedures: A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Cytology samples were obtained for histology using a brush. A 13cm by 10FR Cotton [Doctor Last Name ] biliary stent was placed successfully. Impression: Successful cannulation of bile duct (cannulation) Successful sphincterotomy was performed Irregular 2 cm common hepatic stricture Cytology samples were obtained for histology using a brush. A 13cm by 10FR Cotton [Doctor Last Name ] biliary stent was placed successfully. Otherwise normal ercp to third part of the duodenum EKG sinus brady, first degree AV block, L axis deviation, poor R wave progression, Brief Hospital Course: Primary reason for hospitalization: [Age over 90 ]M yo M with history of AAA repair in [2154], CVA [2175], iliac stenting who developed painless jaundice 4d prior to admission, and after ERCP with sphincterotomy developed a GI bleed with 10 point Hct drop, thus was transferred to the ICU. Active Diagnoses: #GI bleed: Upon admission to the ICU the patient had a 10 point Hct drop after 2 maroon BMs on the floor. Also with 1 episode of black emesis. Thus, upper GI bleed is most likely, and given recent ERCP with sphincterotomy, source of bleeding is most likely secondary to instrumentation. On arrival to ICU, another bloody BM. Vital signs are stable, no hypotension/tachycardia and patient asymptomatic. He was given a total of 4 units pRBCs, and q6h hematocrits were checked. Asprin and plavix were held in the setting of spincerotomy and bleed. He received a PICC line for venous access. Hct stabilized over the course of the day and patient did not require any further transfusions. Patient received another ERCP in which no active bleeding was seen. #Jaundice: On ERCP, there was an irregular 2 cm common hepatic stricture. Also, a single irregular stricture that was 2 cm long was seen at the common hepatic duct. There was no post-obstructive dilation. Two large stones were seen just outside common hepatic duct. On CT scan, moderately dilated bile ducts, hypodensities in R hepatic [Last Name (LF) 3630], [First Name3 (LF) ] ill defined soft tissue mass which may be neoplastic implant. The gallbladder itself is decompressed and the wall is indistinct. This raised concern for infiltrating gallbladder carcinoma into the adjacent hepatic parenchyma. Patient afebrile and [Last Name (LF) 3584], [First Name3 (LF) ] no concern for cholangitis. [Month (only) 116] also be sclerosing cholangitis, but less likely. Mirizzi syndrome on differential. Hepatitis is not likely as no known history, but possible. Hepatitis serologies were obtained and returned negative. Patient was empirically covered on Unasyn. Patient was taken for ERCP and was found to have purulent drainage and 2cm hepatic stricture, raising the possibility of Mirizzi's syndrome. Previously placed stent had migrated and was remove and two other stents placed. Surgery was consulted and took the patient to the OR for open cholecystectomy on [2183-8-11]. At the time of surgical exploration, he had a gallbladder that was filled with 3 large stones and severalsmaller stones. There were marked adhesions around the gallbladder. Frozen sections of the gallbladder obtained intra-op were sent to patholohy and demonstrated no evidence of malignancy. During the procedure after removing the stones in the upper portion of the gallbladder, a small glimpse of stent in the common duct at the base of the inside of what had been the gallbladder was noted, and was thought to most likely be the base of the cystic duct communicating with the common duct. There was no bile emanating from this site,and was a very small pinpoint opening. A JP drain was placed. The patient recovered well post-operatively and was tolerating a clear liquid diet by POD#1 and was later advanced to a regular diet on POD#2 without issue. However on POD#1 it was noted that output from the JP drain had become bilious and the volumes persisted in the range of 500-700 daily over the following days. Due to concern that this might be secondary to obstruction or further migration of his biliary stents, the patient was sent for a repeat ERCP on POD#4 ([2183-8-15]) which demonstrated a biliary leak as well as two small superficial non-bleeding ulcerations in the wall of the bile ducts secondary to migration of the previous biliary stents. The stents were replaced and re-positioned in the R. and L. main hepatic ducts. The patient did well post-procedure, with improvement in his serum bilirubin levels. #PVD: Patient with history of AAA repair: ASA and plavix were held prior to sphincterotomy and continued to be held in the setting of GI bleed following first ERCP. Aspirin and plavix were re-started following the open cholecystectomy and third ERCP. #CKD: Patient with stage 3 chronic kidney disease, with previous Cr measured at 1.6 in [2179] prior to admission. Medications were renally dosed. Upon discharge, Cr was stabilized to 1.4-1.5 As the patient was working well with physical therapy, tolerating PO, pain was well managed, and continued to recover well post-op, he was determined to be stable for discharge to [Hospital ] nursing home on POD#5 with JP drain until follow-up appointment with Dr. [Last Name (STitle) ]. PICC line was removed prior to discharge, without complication. Medications on Admission: simvastatin 40mg qhs atenolol 25mg qd aspirin 81mg qd (held 4d ago) plavix 75mg qd (held 4d ago) fluticasone nasal spray remeron 7.5mg qhs tylenol PRN Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) 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. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily): 2 sprays in each nostril once daily as needed. 4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Maximum 6 tablets daily. 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital ] Nursing Home - [Location (un) ] Discharge Diagnosis: Mirizzi's syndrome (status-post ERCP complicated by bleeding from the sphincterotomy site and now status-post open cholecystectomy) CAD/atherosclerosis AAA s/p repair History of CVA ([2175]) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: [Year (4 digits) ] and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Wound (Right abdominal incision along the costal border): Incision is closed with subcutaneous sutures. Please leave the overlying steri-strips in place as they will fall off on their own with regular wear. Patient may shower as per usual routine. Avoid baths/soaking. Avoid application of topical creams/lotions to the incision. Can cover with dry gauze dressing as needed. Drain (JP drain in the right mid-abdomen): This drain will remain in place and will be re-evaluated upon follow-up. Please empty the drain every four hours or sooner as needed if full. It is very important that the amount of all drain output be recorded on the sheets provided. Strip the drain hourly and after each emptying. Pain: Low dose oxycodone and tylenol (2 grams daily maximum) Activity: Ambulate as tolerated. Avoid heavy lifting (>10lbs) Followup Instructions: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD, [Telephone/Fax (1) 673]. Follow up appointment will be arranged and you will receive a call regarding follow-up from [First Name4 (NamePattern1) 698] [Last Name (NamePattern1) 699] RN, Hepatobiliary Coordinator [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2183-8-16] ICD9 Codes: 2851, 4439
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7881 }	Medical Text: Admission Date: [2122-8-21] Discharge Date: [2122-8-27] Date of Birth: [2053-7-27] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2901] Chief Complaint: Transfer from OSH for management of STEMI. Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [Known lastname 1140] is a 69 year old man with a past medical history of diabetes, hypertension, hyperlipidemia, peripheral [Known lastname 1106] disease s/p lower extremity percutaneous revascularization, CVA secondary to left carotid stenosis s/p endovascular stenting, presenting from [Hospital 882] hospital after developing chest pain this morning. He initially presented to [Hospital1 882] with a complaint of nausea, decreased oral intake and dark tarry stools x5 days. His hematocrit at presentation was 23.7 and he was given 2U PRBC. He underwent colonoscopy and endoscopy that showed multiple polyps and ulcerations; 3 esophageal ulcers, 5 gastric ulcers, 2 sessile polyps in ascending colon, 2 in the transverse colon and two in the splenic flexure and three just distal to the anus, with multiple biopsies obtained. . This morning, he acutely developed substernal chest pain, rated [7-5], worsened with inspiration and non radiating, not associated with nausea or diaphoresis. He also desaturated to 88%, developed pallor and malaise. Temp 98, HR 132, BP 147/93, 92% on 2L NC. No complaints of arm, neck or jaw pain. He was given sublingual nitroglycerin, aspirin, atorvastatin 80mg. Labs revealed CK of 25, TropI 0.36, ABG 7.41/31/113. Second set of cardiac enzymes revealed CPK 36 Tn 1.32. Cardiology was consulted and Dr [Last Name (STitle) ] recommended transfer to tertiary center given ongoing GI bleeding and likely ACS. . On arrival, he reported his pain had resolved and he was only experiencing some numbness of his left superior foot. Denied any active chest pain, nausea, shortness of breath, dizziness or any other symptoms. . On review of systems, he reports a prior history of stroke (residual mild left sided deficits), denies prior deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis. Cough for the last 3 days. As per HPI patient with black tarry stools. He denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for dyspnea on exertion with less than one block of walking, denies paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Hypertension, Hyperlipidemia 2. CARDIAC HISTORY: NONE 3. OTHER PAST MEDICAL HISTORY: CVA: In [5-/2122], RMCA territory s/p right carotid stent History of percutaneous revascularization of bilateral lower extremies in [6-/2122] -- Balloon angioplasty and Stent placement of right external iliac artery. -- Balloon angioplasty and Stent of left common iliac and left external iliac artery COPD ETOH abuse: (prior) complicated by cardiomyopathy and pancreatitis, no hx of withdrawal seizures, last drink >1 year ago HTN COPD Social History: History of ETOH abuse. Smokes 1.5ppd--90pky smoking hx, denies illicit drug use. Retired security guard. He is divorced and has 8 estranged children. He currently lives with an 82yo roommate in an apartment complex named [Name (NI) 9700] Estate. Uses walker. Family History: No family history of early MI, otherwise non-contributory. Physical Exam: PHYSICAL EXAM AT ADMISSION: VS: Heart rate 91, oxygen saturation of 100%, blood pressure 106/56. GENERAL: Well appearing thin elderly male, Oriented x3 (although with wrong age). Mood, affect slightly innappropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of at sternal angle. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, distant heart sounds with 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. (+) rhonchi at the bases, no crackles, wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. Soft left femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+, warm foot Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+, warm foot .. PHYSICAL EXAM AT DISCHARGE: Pertinent Results: LABS AT ADMISSION: . [2122-8-21] 11:34PM TYPE-CENTRAL VE PH-7.38 COMMENTS-GREEN TOP [2122-8-21] 11:34PM GLUCOSE-100 K+-3.5 [2122-8-21] 11:34PM freeCa-1.18 [2122-8-21] 11:24PM PTT-32.8 [2122-8-21] 07:53PM CK(CPK)-41 [2122-8-21] 07:53PM CK-MB-NotDone cTropnT-0.09 [2122-8-21] 07:53PM HCT-31.1* [2122-8-21] 02:31PM GLUCOSE-88 UREA N-6 CREAT-0.7 SODIUM-140 POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-22 ANION GAP-11 [2122-8-21] 02:31PM estGFR-Using this [2122-8-21] 02:31PM CK(CPK)-43 [2122-8-21] 02:31PM CK-MB-NotDone cTropnT-0.16* [2122-8-21] 02:31PM CALCIUM-8.5 PHOSPHATE-2.7 MAGNESIUM-1.1* [2122-8-21] 02:31PM WBC-8.1 RBC-3.06* HGB-9.4* HCT-27.2* MCV-89 MCH-30.9 MCHC-34.7 RDW-14.9 [2122-8-21] 02:31PM PLT COUNT-316 [2122-8-21] 02:31PM PT-14.6* PTT-28.0 INR(PT)-1.3* .. STUDIES: . EKG ([2122-8-21] 4:57am, 8/10 chest pain) Normal sinus rhythm at 130, with anteroseptal 1-2mm ST elevations involving V1 to V4, with reciprocal inferior ST depressions in leads II, III and aVF. . EKG ([2122-8-21] 5:06 am, 2/10 chest pain) Normal sinus rhythm at rate of 116, with 1mm ST elevationss involving V1 ot V4, with reciprocal inferior ST depressions in leads II, III and aVF. . EKG ([2122-8-21] 14:18, 0/10 chest pain) Normal sinus rhythm at rate of 90, resolved ST elevations, low voltage and T wave flattening on precordial leads. No Q waves, normal axis. .. CXR ([2122-8-21]): FINDINGS: Small bilateral pleural effusions are new. There is increased opacity at the lung bases bilaterally which may represent lower lobe distribution of pulmonary edema in this patient with upper lobe emphysema. However, imaging alone cannot exclude bilateral infectious process. The lungs are otherwise clear. Cardiomediastinal and hilar contours are normal. There is a new left internal jugular central venous line ending in the upper SVC. There is no pneumothorax. Visualized soft tissue structures and bony thorax are normal. IMPRESSION: 1. Probable dependent distribution of edema in setting of upper lobe emphysema and less likely infection or aspiration. 2. New left IJ central line in good position with no pneumothorax. . Stress Test [2122-8-25] The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 mintues. The patient had no back, neck, arm, or chest pain during infusion or in recovery. The baseline STT wave abnormalities did not change during infusion or during recovery. The rhythm was sinus with frequent isolated apc's. There was appropriate hemodynamic response. The dipyridamole was reversed with 125mg of aminophylline. No anginal type symptoms and no signficant ST segment changes from baseline. Nuclear report to be sent separately. INTERPRETATION: Left ventricular cavity size is normal. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. There is a soft tissue attenuation in the distal anterior wall, but no definite perfusion defect. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 54%. Compared with the study of [2120-9-4], there is no significant change. IMPRESSION: Soft tissue attenuation in the distal anterior wall, but no definite perfusion defects are seen. Normal cavity size and function. Brief Hospital Course: In summary, this is a 69 year old man with a history of hypertension, hyperlipidemia, diabetes, severe [Year (4 digits) 1106] disease and acute GI bleed, presenting with acute onset of chest pain and ST changes, now resolved. Stress test showed no perfusion defect. No PCI pursued. Hospital course c/b c.diff colitis which is responding to flagyl by time of discharge. .. # CORONARY ARTERY DISEASE / ISCHEMIA: ECG at admission was concerning for left anterior descending disease, likely symptomatic in the setting of ongoing blood loss and anemia. Differential diagnosis included PE, aortic dissection, esophageal rupture, but these seemed less likely given the ST elevations. STEMI was believed to be unlikely given the complete resolution of ST changes without reperfusion therapy. Troponins were mildly elevated with flat CKs. There may have been a mild troponin leak in the setting of demand on day of admission. There was no coronary intervention, although it is very likely that he has coronary artery disease given his history of peripheral [Year (4 digits) 1106] disease and his multiple coronary risk factors. . Nuclear stress test (report attached) showed no perfusion defect c/w prospect of diffuse 3 vessel dz. We continued Aspirin at a lower dose and d/c'ed [Year (4 digits) 4532] (carotid and iliac stents placed 3+ months ago). Metoprolol dose was increased. We increased his statin to 80 mg qd, a dose which he should contiinue indefinitely if his LFTs permit. .. # CARDIOMYOPATHY: There was question of prior cardiomyopathy, although he had a normal echo one month ago. Echo at OSH showed depressed EF, but nuclear stress reveled EF=54%. His volume status was monitored closely; there was no indication for diuresis. .. # RHYTHM: He was in normal sinus rhythm throughout admission. .. # C.diff colitis: Pt started on Flagyl 500mg po tid on [8-25] for 2 week course to treat c.diff. Diarrhea began to subside before time of discharge. WBC trending down. Abdominal tenderness decreased. . #Hypomagnesemia: likely secondary to wasting during previous (now resolved) alcohol abuse. Mg was 1.8 at time of discharge despite standing oral supplementation and repeated IV supplementation. Pt given 4g IV on day of discharge. . # PUD WITH ACUTE GI BLEED: This was recently worked up at [Hospital 882] hospital. The findings are provided above in HPI. We discussed with radiology a recent CT angiogram of his abdominal and pelic vasculature; although he has superior mesenteric artery narrowing, there is no stenosis of his celiac plexus or [Female First Name (un) 899] that would cause significant mesenteric ischemia to account for his GI ulcers. The biopsy reports from his recent endoscopies are being followed at [Hospital1 882] and he should have close follow-up there. Biopsies were negative for ischemia and malignancy--further work-up is necessary. .. # DIABETES: He had a hemoglobin A1C of 5.8 in [Month (only) 205], indicating excellent glycemic control. We held his metformin and kept him on an insulin sliding scale while in house. .. # HYPERTENSION: He was not hypertensive during this admission. His metoprolol was uptitrated mainly for the benefits to be had in the setting of probable coronary artery disease. .. # HYPERLIPIDEMIA: We continued his home statin (higher dose). .. # COPD: We continued his home inhalers, but discontinued his theophylline given risk for toxicity. Spiriva was added. 02 sat maintained in the 93-100% range. .. # PERIPHERAL [Month (only) ] DISEASE: As above, we continued his home aspirin (lower dose 162mg) and discontinued [Month (only) 4532]. His foot ulcer was followed by wound care and the pt was seen and examined by [Month (only) 1106] surgery who determined that there was no active surgical issue. .. During the hospitalization, pneumoboots (and later, SQH) were used for DVT prophylaxis. He was given a cardiac, heart healthy diet and continued on PPI d/t his history of GI bleed. His code status remained full. . Dispo: Physical therapy reccommended that the patient complete Short term rehab b/c of his difficulty with ambulation. Pt refused and was deemed competent to make his own decisions regarding this issue. At the time of discharge, he was medically stable for discharge from the hospital, but went against our advice in choosing to go home over physical rehab. ====================================== Issues requiring immediate follow-up: -Hypomagnesemia: to be checked by his VNA -LFTs in six weeks b/c of increased statin dose: to be checked by his VNA/PCP [Name10 (NameIs) 57003] care for his foot -further work-up of his multiple GI ulcers: etiology currently unknown Medications on Admission: DARIFENACIN 7.5mg daily DIGOXIN 125 mcg daily FENOFIBRATE 145mg daily LISINOPRIL 10 mg daily METFORMIN 500mg daily THEOPHYLLINE 300mg [Hospital1 ] Albuterol nebs prn Aspirin 325 mg daily Montelukast 10 mg daily Escitalopram 10 mg daily Omeprazole 20 mg daily Clopidogrel 75 mg daily Simvastatin 80 mg daily Niacin 500 mg daily Oxycodone 5 mg q4h prn Fluticasone-Salmeterol 250-50 mcg/Dose Disk [Hospital1 ] Tiotropium Bromide 18 mcg Capsule daily Ipratropium Bromide nebs q6h Ferrous Sulfate 325 mg daily Brimonidine 0.15 % 1gtt daily each eye Dorzolamide 2 % Drops one gtt TID Latanoprost 0.005 % Drops one drop each eye qhs Folic Acid 1 mg daily Discharge Disposition: Home With Service Facility: Family Care Extended Discharge Diagnosis: Acute coronary syndrome/Coronary Artery Disease C. difficile colitis Acute Blood Loss Anemia secondary to Peptic Ulcer Disease Peripheral [Hospital1 ] Disease Left Great Toe Lesion: followed by [Hospital1 1106] surgeon Diabetes Mellitus Chronic Obstructive Pulmonary disease Hypertriglyceridemia Discharge Condition: stable, Hct 28.2 WBC 8.9 BUN 8 creat 0.7 Mg 1.8 Discharge Instructions: You had some heart strain that may be due to some narrowing in your coronary arteries. We did a stress test that showed no acute blockages and a mostly normal heart function. We started you on a beta blocker called metoprolol that decreases your heart rate and helps to prevent heart attacks, we also started you on Atorvastatin for your cholesterol. You need to have your liver function checked in 6 weeks. You also had a gastrointestinal bleed from stomach ulcers that made you anemic. You had an infection in your bowel and antibiotics were started. New medicines: 1. Metoprolol: to help you heart rate and prevent a heart attack. 2. Spiriva: to help you breathe 3. Nitroglycerin: to take if you have pain in your chest 4. Flagyl: an antibiotic to treat the infection in your bowel. 5. We increased your magnesium We stopped the following medicines: [Hospital1 ], Lisinopril, Theophylline, and digoxin. Please call your doctor if you have any chest pain, increasing diarrhea, nausea, inablility to eat or drink, dizziness, trouble breathing, dark or bloody stools. . Please stop smoking. Information was given to you on admission regarding smoking cessation. Followup Instructions: Provider: [Name10 (NameIs) ] [Apartment Address(1) 871] ([Doctor First Name ]) [Doctor First Name ] LMOB (NHB) Phone:[Telephone/Fax (1) 1237] Date/Time:[2122-11-12] 3:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2122-11-12] 4:15 Primary Care: [Last Name (LF) 11139], [Name8 (MD) 449], MD Phone: [Telephone/Fax (1) 11144]. Date/time: Thursday [9-10] at 1:30pm. . Cardiology: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Address: [Hospital 882] Hospital [Apartment Address(1) 57004], [Location (un) 86]. Phone:[Telephone/Fax (1) 57005] Date/Time: Friday [9-11] at 9am. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909] Completed by:[2122-8-31] ICD9 Codes: 2851, 4111, 4589, 496, 4019, 2724, 4254
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7882 }	Medical Text: Admission Date: [2129-8-9] Discharge Date: [2129-8-12] Date of Birth: [2062-6-28] Sex: F Service: MEDICINE Allergies: Aspirin / Compazine Attending:[First Name3 (LF) 7651] Chief Complaint: chest pain Major Surgical or Invasive Procedure: PICC placement [2129-8-11] History of Present Illness: 67F with h/o of CVA (L hemiparesis), NIDM, CRI, HTN, HLD, CAD s/p CABG with LIMA-LAD, SVG-OM1, SVG-OM2 with Dr. [First Name (STitle) ] on [2129-7-27] and was discharged to [Hospital ] rehab on [2129-8-4]. She was improving at rehab but developed left substernal chest pain around 9 pm last night of sudden onset and was sent to [Hospital1 18] ED. . Last night at 9pm, the patient was watching TV when she noticed sudden onset of left shoulder pain that eventually radiated to her sternum and became substernal chest pain. The pain was at first stabbing in sensation but later became a dull pressure that reminded her of her previous MI. Her pain worsened with a cough as well as inspiration. It did not seem to worsen with exertion, although she is primarily bedbound since the surgery. She also reports the pain worsens with lying flat and improves while leaning forward. She denies any associated SOB, diaphoresis, nausea, vomitting, dizziness, numbness/tingling of her extremities. She reports 6-pillow orthopnea and feels uncomfortable while lying flat currently. She denies recent PND, palpitations, lightheadedness, edema. . In the ED, initial vs were: T 98.5 P 58 BP 115/68 R20 O2 sat100% on 2L. Patient was found to have an elevated WBC to 13.8, with increased b/l pleural effusions and a possible new infiltrate on CXR. Her troponin is 0.5 x2 and she has slight t wave inversions in V3-V6 which are new from previous EKG. BNP was noted to be [Numeric Identifier 106637]. Cr. is stable at 2.1. She was given vanco/levoflox for treatment of presumed HAP. Chest pain responded to nitro gtt, given plavix as patient is allergic to aspirin. Currently, chest pain free. On review of her micro, noted to have had recent pan-sensitive pseudomonas UTI. Consulted Cards and CT surgery. . On the floor, she was found to be in [4-30] chest pain and [8-30] when she takes a deep breath. She was on a nitro gtt. She was actively orthopneic. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. 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. Past Medical History: Past Medical History: Coronary Artery Disease s/p Cerebrovascular accident with L hemiparesis noninsulin dependent Diabetes mellitus Chronic renal insufficiency with microalbuminuria Hyperlipidemia Hypertension Asthma Morbid obesity Past Surgical History: s/p Bilateral carpal tunnel release s/p CABG [2129-7-27]: LIMA-LAD, SVG-OM1, SVG-OM2 Social History: Lives alone, currently at [Hospital ] rehab s/p CABG on [2129-7-27] Occupation: nurse No history of smoking, no EtoH, no ilicit drug use, including no cocaine. Family History: Mother had DM. No known CAD. No history of early MI or blood clot. Physical Exam: Vitals: 97.7 59 141/55 16 100%2LNC General: Alert, oriented, obese, looks uncomfortable but in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated but difficult to discern given habitus, no LAD Lungs: Reduced breath sounds at the right lower and mid fields, positive egophony on the right, no wheezes, rhales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley catheter in place Ext: 1+ edema L>R however recent SVG harvest was on the left. +LLE calf tenderness but no pain. warm, well perfused, 2+ pulses, no clubbing, cyanosis. Pertinent Results: Labs on Admission: [2129-8-9] 12:08AM BLOOD WBC-13.8* RBC-2.97* Hgb-9.2* Hct-27.0* MCV-91 MCH-31.1 MCHC-34.2 RDW-15.2 Plt Ct-265 [2129-8-9] 12:08AM BLOOD Neuts-80.4* Lymphs-12.8* Monos-2.3 Eos-4.3* Baso-0.2 [2129-8-9] 12:08AM BLOOD Glucose-245* UreaN-54* Creat-2.3* Na-137 K-4.5 Cl-102 HCO3-27 AnGap-13 [2129-8-9] 12:08AM BLOOD CK(CPK)-87 [2129-8-9] 12:08AM BLOOD CK-MB-2 proBNP-[Numeric Identifier 106637]* [2129-8-9] 12:08AM BLOOD cTropnT-0.05* [2129-8-9] 12:08AM BLOOD Calcium-9.1 Phos-2.4# Mg-2.1 Other Labs: [2129-8-11] 04:30PM BLOOD PT-13.1 PTT-34.4 INR(PT)-1.1 [2129-8-11] 04:30PM BLOOD ALT-43 AST-52* AlkPhos-120* TotBili-0.5 [2129-8-11] 04:30PM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.9 Mg-2.0 Cardiac Enzymes: [2129-8-9] 12:08AM BLOOD CK-MB-2 proBNP-[Numeric Identifier 106637]* [2129-8-9] 12:08AM BLOOD cTropnT-0.05* [2129-8-9] 07:50AM BLOOD cTropnT-0.05* [2129-8-9] 03:42PM BLOOD CK-MB-2 cTropnT-0.05* [2129-8-11] 04:30PM BLOOD cTropnT-0.05* Discharge Labs: [2129-8-12] 11:00AM BLOOD WBC-5.9 RBC-5.09# Hgb-15.7# Hct-46.5# MCV-91 MCH-30.8 MCHC-33.8 RDW-15.3 Plt Ct-106# [2129-8-12] 11:00AM BLOOD Glucose-284 UreaN-66* Creat-2.7* Na-137 K-5.0 Cl-99 HCO3-30 AnGap-13 [2129-8-12] 11:00AM BLOOD Mg-1.9 ECG [2129-8-8]: Sinus bradycardia. Consider inferior myocardial infarction of indeterminate age. RSR' pattern in lead V1 with early R wave progression. Other ST-T wave abnormalities. Since the previous tracing of [2129-7-27] the axis is less right inferior. The QRS complex is narrower. T wave abnormalities are probably more prominent. Clinical correlation is suggested. CXR [2129-8-9]: PA AND LATERAL VIEWS OF THE CHEST: Lung volumes are low. There are bilateral small pleural effusions which are slightly increased in size since the previous study. There is bibasilar atelectasis which as slightly improved at the left base since the prior study. Mild cardiomegaly is unchanged. Mild central pulmonary vascular prominence is again seen, unchanged. There is no pneumothorax. Midline sternotomy wires remain intact. IMPRESSION: Bilateral pleural effusions have slightly increased in size since the previous study. TTE [2129-8-9]: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2129-7-22], the findings are similar. Bilateral Lower Ext Veins US [2129-8-10]: No evidence of DVT in the lower extremities. Unilateral Upper Ext Veins US (Left): No evidence of DVT of the left upper extremity. Brief Hospital Course: The patient is a 67yo female with h/o of CVA (L hemiparesis), DM, CRI, HTN, HLD, CAD s/p CABG [2129-7-27], admitted from [Hospital ] rehab after the acute onset of sharp, substernal chest pain on the night of [2129-8-8]. #) Chest pain: Patient c/o sharp substernal chest pain, non-radiating, and worse with inspiration. ECG revealed diffuse T wave inversions, which were concerning for possible cardiac ischemia. However, pain seemed more consistent with pleuritic chest pain than with angina, and patient ruled out for an MI after cardiac enzymes were negative x3. Other differential diagnoses for chest pain included PE, pericarditis, pneumonia, and infection of her sternotomy incision. She had bilateral lower extremity venous ultrasounds, which did not reveal any evidence of DVT, as well as a left upper extremity venous ultrasound, which also did not reveal any DVT. The patient was started on vancomycin and cefepime for possible HAP, as she had an elevated WBC on admission and possible focal consolidation on CXR. An sternotomy incision infection seemed unlikely, as her incision was without any erythema, pus, or fluctuance. CT surgery was following, and felt her pain may be incisional but did not feel the incision site was infected. Pericarditis remained on the differential, given the timing of her recent CABG and diffuse, non-specific ECG changes. An echo on [2129-8-9] did not reveal any evidence of pericardial effusion. The patient's pain had generally resolved within the first day of her admission, after being placed on a nitro gtt and receiving morphine. Given her renal disease, she was not started on ibuprofen or colchicine for presumed pericarditis, but rather will be discharged on Tylenol and oxycodone as needed for her chest pain. Her tramadol was stopped. . #)PNA: The patient was started on vancomycin and cefepime for possible HAP, as she had an elevated WBC on admission and possible focal consolidation on CXR. She remained afebrile throughout her hospital course. A PICC line was placed on [2129-8-11], and she will continue on an 8-day course of antibiotics for presumed HAP. [2129-8-16] will be the last day of her antibiotic therapy. A vanc trough on [2129-8-12] was 22.5, and the patient's vanc dose was decreased to 500mg daily. She should have a repeat vanc trough on [2129-8-14] prior to her dose of vancomycin. #) Diastolic heart failure: Patient felt to be in mild acute on chronic congestive heart failure, possibly secondary to HAP, as well as her Lasix being held. She was gently diuresed with Lasix, with cautious monitoring of her electrolytes, fluid balance, and renal fucntion. She was continued on Ramipril, but her dose was decreased in setting of her rising Cr. Dose will be further decreased to 5mg PO daily on discharge. She was ordered for metoprolol 12.5mg PO BID, but this was held for most of her admission as her HR was in the 40s-50s. She was continued on a low sodium diet. The patient was not felt to be significantly volume overloaded, and aggressive diuresis was not pursued given her elevated Cr. Her oxygen sats remained 100% on 2L nasal cannula, and remained in the 90s off oxygen. . #) Coronary artery disease: The patient's chest pain was not thought to be secondary to ACS after her cardiac enzymes remained negative, and her ECG did not significantly change over the course of her admission. She was continued on Plavix, and not given ASA given her h/o ASA hypersensitivity. She was weaned off the nitro drip within the first 24 hours of admission, and remained generally chest pain free. She was continued on a statin and metoprolol, but metoprolol was frequently held in setting of bradycardia. . #) Rising Cr - The patient's Cr was 2.3 on admission, down from 2.9 on [2129-8-4] (the day of discharge following her CABG). Her Cr rose to 2.8 on [2129-8-10], in the setting of diuresis for mild pulmonary edema. Additional Lasix was then held, with Cr trending back down to 2.6-2.7. It is unclear what the patient's baseline Cr will be, as she had an episode of ATN secondary to hypotension during her recent hospitalization, and as she also has underlying chronic renal insufficiency secondary to diabetic nephropathy. Her BUN/Cr and renal function should be closely monitored. . #) Hypertension - Her BPs were stable, and generally normotensive during her hospital course. Her hydralazine was stopped, and she was continued on Ramipril, Metoprolol, Amlodipine, Clonidine, and several doses of Lasix. As above, her metoprolol was held secondary to bradycardia. . #) Asthma - The patient had several brief episodes of SOB, which she felt may be secondary to her asthma. She was ordered for ipratropium and albuterol nebs as needed for dyspnea. . #) Sleep apnea - The patient reported having a previous diagnosis of OSA, for which she has been on BiPap in the past. A respiratory consult was ordered, and the patient may benefit from a sleep study and CPAP in the outpatient setting. . #) H/o CVA: She was continued on Crestor, plavix. . #) DM Type 2: She was on Lantus 16 units QHS, as well as an insulin s/s. She will not be discharged on pioglitazone, and her regular insulin will be changed to aspart. . #) Prophylaxis: She was on SC heparin for DVT prophylaxis. She was on colace, senna, miralax prn constipation, and lactulose prn constipation. Medications on Admission: Ranitidine HCl 150 mg PO daily Docusate Sodium 100 mg PO BID Clopidogrel 75 mg PO daily Amlodipine 10 mg PO daily Lidocaine 5 %(700 mg/patch) Adhesive Patch one DAILY (Daily) as needed for back pain. Tramadol 50 mg q 4 hours PRN pain Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) u SC Injection TID (3 times a day). Metoprolol Tartrate 12.5 mg PO BID Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gram/dose powder PO DAILY (Daily). Clonidine 0.2 mg PO TID Rosuvastatin 40 mg PO daily Ciprofloxacin 500 mg PO daily (last dose [2129-8-5]) Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Saline nasal spray Lactulose 30cc PO q 12 hours PRN constipation Trazadone 25 mg Po qhs Insulin regular sliding scale QID Glargine 16 units qhs Zolpidem 5 mg po qhs Lorazepam 1mg Po q 4 hours PRN anxiety Hydralazine 25 mg Po q6 hours nitroglycerin 0.4 mg SL q 5 minutes x3 for chest pain Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day: Hold SBP < 10. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Hold for diarrrhea. 4. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours) for 5 days. 5. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 24H (Every 24 Hours) for 5 days. 6. Lantus 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous at bedtime. 7. Insulin Aspart 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous four times a day. 8. Ramipril 5 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)): Hold SBP < 100. Capsule(s) 9. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold HR < 55. SBP < 100. 13. 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. 14. 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. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day). 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day: on for 12 hours during the day. 19. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Please give ATC for chest pain. 21. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for chest pain: Please give for breakthrough pain. 22. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 23. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) cc PO twice a day as needed for constipation. 24. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. 25. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual every 5 minutes x 3 doses as needed for chest pain. 26. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal every 6-8 hours as needed for dry nose. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Chest pain Coronary Artery disease s/p cornary artery bypass grafting diabetes Mellitus Type 2 Hypertension Hyperlipidemia history of Cerebrovascular accident Asthma Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had chest pain and was admitted for evaluation. We did not find any evidence for a heart attack. We think that the chest pain could be due to pericardial irritation from the surgery or possibly from a pneumonia. You were started on IV antibiotics and a PICC line was placed for the antibiotics and to draw blood. You will have a total of 8 days of the antibiotics. You heart rate has been low and we have been holding your metoprolol. You had an exacerbation of your congestive heart failure and some Lasix was given. Your kidney function worsened and is now improving. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. . Medication changes: 1. Stop taking Hydralazine, Tramadol, Zolpidem, Pioglitizone and gabapentin 2. Start taking Ramapril 5 mg in the am 3. Start Vancomycin and Cefepime to treat a pneumonia. You will have an eight day course. 4. Start oxycodone and tylenol to treat the chest pain 5. Start senna to treat constipation . Weigh yourself every day and call Dr. [First Name (STitle) ] if your weight increases more than 3 poounds in 1 day or 6 pounds in 3 days. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [2129-8-22] at 2:40 PM With: [First Name11 (Name Pattern1) 2053] [Last Name (NamePattern4) 2761], MD [Telephone/Fax (1) 62] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: WEDNESDAY [2129-8-24] at 2:10 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) 815], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SURGERY When: MONDAY [2129-9-5] at 2:15 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 170] Building: LM [Hospital Unit Name ] [Location (un) 551] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE ICD9 Codes: 486, 5849, 4280, 5859, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7883 }	Medical Text: Admission Date: [2189-8-5] Discharge Date: [2189-8-9] Date of Birth: [2120-4-29] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2597] Chief Complaint: Recent shortness of breath. Major Surgical or Invasive Procedure: [2189-8-5]: 1. Left carotid subclavian bypass with PTFE graft. 2. Stent graft repair of descending thoracic aortic aneurysm. 3. Thoracic and abdominal aortography. History of Present Illness: Mr. [Known lastname 17920] is a 69 year old gentleman with a history of atrial fibrillation, who had presented to outpatient clinic complaining of recent shortness of breath. He underwent a CT scan for concerns of pulmonary fibrosis, and was found to have what appeared to be a chronic Type-B descending thoracic aortic aneurysn 2-3cm distal to the left subclavian origin. He presented on [2189-8-5] for planned repair of his thoracic aneurysm. Past Medical History: PMH: HTN, gout, afib, Type B thoracic aortic dissection, remote smoking hx, 4.9cm AAA PSH: Left carotid subclavian bypass with PTFE graft, Stent graft repair of descending thoracic aortic aneurysm, Thoracic and abdominal aortography. Social History: Nonsmoker. Occasional social alcohol. Family History: CAD, DM Physical Exam: PE on admission: Gen: AAOx4, NAD CVS: RRR, no M/R/G Pulm: CTAB Abd: Obese, soft, NT/ND Ext: Warm, well perfused. Pulses: Palp throughout Neuro: CN II-XII grossly intact PE on discharge: Gen: AAOx4, NAD. Pleasant and conversant. CVS: RRR, no M/R/G (no afib presently) Pulm: Clear bilaterally Abd: Soft, obese, nontender, nondistended Ext: Warm, well perfused. Groin puncture sites clean, dry, and intact. Soft, without evidence of hematoma. No drainage, no surrounding erythema. Pulses: palpable throughout Neuro: CN II-XII grossly intact Brief Hospital Course: Mr. [Known lastname 17920] was admitted on [8-5] for planned repair of his Type B thoracic aortic aneurysm. After appropriate preparation and consent, he underwent Left carotid subclavian bypass with PTFE graft, stent graft repair of descending thoracic aortic aneurysm, and thoracic and abdominal aortography without complication. He tolerated the procedure well, and after initial recovery in the PACU, he was transferred to the vascular ICU for post-operative monitoring. On [8-6], he remained hemodynamically stable, and was successfully diuresed x 1L. His neurologic signs were monitored and remained intact. He was kept NPO and on bedrest, and his blood pressure was titrated to systolic between 100 and 140 mmHg. On [8-7], his lumbar drain was removed, his labs monitored and electrolytes repleted, and his diet was slowly advanced to regular. His pain was well controlled and he was out of bed to a chair. He was transferred to the vascular surgery floor for further recovery. On [8-8], his home medications were resumed, he was able to ambulate independently, and he was switched to oral pain medications. On [8-9], his foley catheter was removed and he was able to void without difficulty. He was ambulating independently, tolerating a regular diet, and was using only tylenol for pain control. His pulse and neurologic exams remained intact. His home coumadin was resumed with a lovenox bridge (for afib). He was deemed stable for discharge to home with follow up in 1 week with Dr. [Last Name (STitle) ] for staple removal. He will resume his home coumadin with a 5 day lovenox bridge, and will follow up with his primary care provider, [Last Name (NamePattern4) ]. [First Name (STitle) 1313] for INR checks and coumadin dosing adjustments. He will be started on aspirin 81 mg daily. Mr. [Known lastname 17920] understood these instructions and agreed with the plan. Medications on Admission: allopurinol 300'; amiodarone 200'; calcitriol 0.25'; pantoprazole 40'; valsartan-hydrochlorothiazide 320 mg-25 ''; verapamil 180 ''; warfarin ? dose; zolpidem 10'prn; vitamin D3; vitamin B-12; Fish Oil, crestor 40' Discharge Medications: 1. Diovan HCT 320-25 mg Tablet Sig: One (1) Tablet PO twice a day. 2. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for sleep. 3. verapamil 180 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). 4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAYS ([Doctor First Name ],MO,TU,WE,TH,SA): Please follow up with Dr. [First Name (STitle) 1313] for INR checks and dosing adjustments. 8. warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAYS (FR): Please follow up with Dr. [First Name (STitle) 1313] for INR checks and dosing adjustments. 9. enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous [Hospital1 ] (2 times a day) for 5 days: Until INR is therepeutic.. Disp:10 150 mg/mL syringes Refills:0 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:0 14. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Type B aortic dissection Aortic aneurysm Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: Please resume your home medications unless specifically instructed otherwise. Please take your new medications as prescribed. Avoid heavy lifting or strenuous activity until cleared by your surgeon. You may resume your usual diet. You may shower, but avoid submerging in the bathtub or swimming pool until cleared by your surgeon. Please keep your follow up appointments! Do not drive while taking pain medications. Please resume your home coumadin dosing beginning TODAY, [2189-8-9]. Take lovenox as directed twice daily for 5 days until your INR is therapeutic. Follow up with Dr. [First Name (STitle) 1313] for adjustments of your coumadin dose. Followup Instructions: Please follow up with Dr. [Last Name (STitle) ] in 1 week for wound check and staple removal. Please follow up with Dr. [First Name (STitle) 1313] for INR checks and coumadin dose adjustments. ICD9 Codes: 5119, 2859, 4019, 2749, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7884 }	Medical Text: Admission Date: [2161-2-15] Discharge Date: [2161-2-27] Date of Birth: [2094-12-30] Sex: F Service: MEDICINE Allergies: Halothane / Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2195] Chief Complaint: Acute renal failure Major Surgical or Invasive Procedure: Expired History of Present Illness: Ms. [Known lastname ] is a 66 y/o female with a history of calciphylaxis, crohn's disease, hypertension, DM2 and recent pulmonary embolism who presented from [Hospital3 105] with renal failure and a anion gap acidosis. According to [Hospital3 ] notes, approximately 1 week ago her renal function began to get worse. Her creatinine about 1 month ago was 1.1 and then in early Ferbruary it was noted to be 1.9. Renal was consulted at the time in which they felt that her declining renal function could be secondary to an occult hypotensive episode with ischemic ATN or interstitial nephritis. They stopped her clonidine and began to aggressively fluid resucitate her. Her creatinine continued to deteriorate and she began developing a metablic acidosis. She had an arterial gas which showed a pH of 7.11 with a pCO2 of 39. She was given sodium bicarb and placed on a BiPAP to help with her breathing. Her mental status was also noted to be altered in that she was drowsy. She was given Narcan and prior to transfer her pH was 7.25 with a pCO2 of 33. . In the ED, initial vs were: T 97.9 P 74 BP 99/79 R 19 O2 sat 98 4L. Patient was given Vancomycin and Zosyn. . On the floor, she was very sleepy and would only open her eyes for brief periods of time. She denied any pain or discomfort. Past Medical History: -Recurrent UTI: Recently diagnosed and treated for culture positive Pseudomonas, VRE, and ESBL E.Coli infections. Secondary to indwelling foley catheter. Foley in place to prevent urinary contamination of necrotic skin wounds. Foley last changed on [2161-1-27] -Calciphylaxis: Patient was admitted from rehab to [Hospital1 18] on [2160-11-20] for poor wound healing/skin necrosis. An extensive workup included skin biopsy and bone scan which supported a diagnosis of Calciphylaxis. Patient currently treated with sodium thiosulfate and sevelamer. -Necrotic Skin Wounds: Secondary to calciphylaxis. Patient has been receiving weekly debridement at Rehab. Wounds have been improving. -Malnutrition: Patient has poor nutritional status and was previously receiving TPN via PICC line. PICC line was removed on [1-17]. She currently has an NG tube for supplemental feeds. -Colon rupture secondary to diverticulitis and s/p LAR with end ileostomy in [8-/2160] -Crohn's Disease -Anemia: baseline Hct in mid-20s -Hypertension -Hyperlipidemia -Type 2 Diabetes, non-insulin dependent -Morbid obesity -Chronic knee pain -Cardiac murmur: ECHO on [2160-10-16] demonstrated "trivial MR" and "mild 1+ TR" with "hyperdynamic LV function" -Adrenal Adenoma -Osteoarthritis Social History: Patient previously lived at home with husband and two children, although she has not been home since 9/[2160]. Currently at [Hospital ] Rehab. She is employed as a administrative assistant at a high school. She denies tobacco, EtOH, and drug use. Family History: No history of IBD or other autoimmune diseases. Physical Exam: PEx on admission: T: 98.0 BP: 90/47 P: 74 R: 18 O2: 98 RA General: Lying in bed, comfortable in NAD HEENT: EOMI, dry MM NECK: Supple, no [Doctor First Name ] RESP: Anterior lung exam, CTA-B, -w/r/r appreciated CV: RRR, nl S1, nl S2, 3/6 systolic murmur ABD: Obese, normoactive bowel sounds, non-distended, ileostomy in place with healthy pink tissue and liquid ostomy output, no leakage from ostomy bag, no suprapubic tenderness on palpation EXT: 1+ Edema of BLE, 1+ distal pedal pulses, SKIN: Extensive skin necrosis on the lateral margins of both thighs NEURO: CNII-XII grossly intact PSYCH: Flat affect Pertinent Results: Please note that patient was made CMO in the ICU, and no further labs were checked after that point; patient expired on [2161-2-27] . RELEVANT AND REPRESENTATIVE LABS: CBC and coags: [2161-2-15] 02:30PM BLOOD WBC-22.8* Hgb-10.4* Hct-31.3* MCV-87 Plt Ct-282 [2161-2-15] 02:30PM BLOOD Neuts-81* Bands-1 Lymphs-9* Monos-3 Eos-1 Baso-1 Atyps-0 Metas-4* Myelos-0 [2161-2-16] 03:21AM BLOOD WBC-20.8* Hgb-8.7* Hct-26.7* MCV-88 Plt Ct-221 [2161-2-22] 05:54AM BLOOD WBC-12.5* Hgb-9.0* Hct-29.1* MCV-94 Plt Ct-310 [2161-2-15] 02:30PM BLOOD PT-15.2* PTT-28.0 INR(PT)-1.3* [2161-2-20] 05:10AM BLOOD PT-15.8* PTT-33.8 INR(PT)-1.4* [2161-2-15] 02:30PM BLOOD Fibrino-608* . Chem: [2161-2-15] 04:00PM BLOOD Glucose-110* UreaN-38* Creat-3.5* Na-145 K-3.8 Cl-106 HCO3-12* [2161-2-17] 06:12PM BLOOD Glucose-114* UreaN-35* Creat-3.9* Na-144 K-8.6* Cl-114* HCO3-17* [2161-2-20] 05:10AM BLOOD Glucose-118* UreaN-33* Creat-4.1* Na-152* K-3.2* Cl-117* HCO3-19* [2161-2-22] 05:54AM BLOOD Glucose-111* UreaN-36* Creat-4.3* Na-148* K-3.3 Cl-112* HCO3-22 [2161-2-15] 04:00PM BLOOD Calcium-9.9 Phos-6.1# Mg-1.5 [2161-2-16] 07:25AM BLOOD freeCa-1.34* [2161-2-18] 03:45AM BLOOD freeCa-1.40* [2161-2-21] 03:14AM BLOOD freeCa-1.29 [2161-2-22] 05:54AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.9 . Liver: [2161-2-16] 10:27AM BLOOD ALT-12 AST-17 LD(LDH)-127 AlkPhos-108* TotBili-0.2 [2161-2-17] 03:01AM BLOOD ALT-13 AST-19 AlkPhos-110* TotBili-0.2 . Misc: [2161-2-16] 03:21AM BLOOD CK(CPK)-302* [2161-2-21] 03:00AM BLOOD CK(CPK)-10* [2161-2-15] 02:30PM BLOOD Lipase-35 [2161-2-16] 03:21AM BLOOD CK-MB-7 [2161-2-16] 01:43AM BLOOD Lactate-0.8 [2161-2-15] 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . ABGs: [2161-2-16] 01:43AM BLOOD Type-ART pO2-127* pCO2-41 pH-7.13* calTCO2-14* Base [2161-2-18] 11:32AM BLOOD Type-ART Rates-/16 FiO2-40 pO2-114* pCO2-39 pH-7.27* calTCO2-19* [2161-2-21] 03:14AM BLOOD Type-MIX Temp-37 Rates-/16 Tidal V-400 PEEP-5 FiO2-40 pO2-62* pCO2-49* pH-7.23* calTCO2-22 . Micro: [2161-2-15] 2:30 pm BLOOD CULTURE FINAL REPORT [2161-2-18] Blood Culture, Routine (Final [2161-2-18]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing confirmed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [2161-2-16] 12:28 am URINE CULTURE (Final [2161-2-20]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _____________________________________________________ ESCHERICHIA COLI \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ 8 S =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S LINEZOLID------------- 2 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S 256 R TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ =>32 R Brief Hospital Course: Ms. [Known lastname ] is a 66 y/o female with a history of calciphylaxis, Crohns disease, hypertension, DM2 and a recent pulmonary embolism who was transferred from [Hospital3 105] with renal failure and an anion gap acidosis. She was admitted to the [Hospital1 18] MICU. In the MICU, she had metabolic acidosis felt (in part) secondary to thiosulfate, as well as blood cultures positive for GNRs. Initially, she had been started on Vancomycin and Zosyn, but she was transitioned to Meropenam in the context of the blood cultures. Ms. [Known lastname ] was given fluids as needed to maintain her blood pressures, but unfortunately, her urine output could not compensate for the volume of fluids that she required, and she needed to be intubated for fluid overload. She had a poor diuresis throughout her MICU stay, but was able to be extubate on [2-21]. This extubation was in the context of a goals of care discussion with the family, at which time it was decided that the team would try to extubate, but if extubation failed, then the patient should not be re-intubated. After extubation, initial oxygen saturation was in the low 90s, and increased with Lasix PRN. However, on [2-22], Ms. [Known lastname ] became quite tachypneic (40s), looked uncomfortable with frequent arrhythmias, and another family meeting was held. Per the family wishes, patient goals of care transitioned to comfort measures only. She was transferred to the floor on [2-23] on a morphine drip, and was satting in mid-80s. The morphine drip was continued, and our patient comfortably passed away with her husband at her bedside on [2161-2-27] at 18:55. The patient's family elected for an autopsy. Medications on Admission: 1. potassium chloride 20 mEq Packet Sig: Two (2) packet PO twice a day. 2. metoclopramide 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for fever or pain. 4. insulin lispro 100 unit/mL Solution Sig: per sliding scale units Subcutaneous QACHS. 5. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 6. Eucerin Topical 7. morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 8. morphine 15 mg Tablet Sig: One (1) Tablet PO q3hr as needed for pain. 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. sodium thiosulfate 25 % Solution Sig: Twenty Five (25) grams Intravenous 3X/WEEK (MO,WE,FR). 11. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) patch Transdermal once a week: change every wendesday. 12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 13. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 14. citalopram 20 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 15. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 16. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 17. fondaparinux 5 mg/0.4 mL Syringe Sig: One (1) injection Subcutaneous DAILY (Daily) as needed for PE tx. 18. camphor-menthol Topical 19. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous PRN as needed for line flush: heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. . 20. hydromorphone 2 mg/mL (1 mL) Syringe Sig: 2-4 mg Intravenous every four (4) hours as needed for pain: With dressing changes. Discharge Medications: Not applicable; patient expired on [2161-2-27] Discharge Disposition: Expired Discharge Diagnosis: Acute Renal Failure Altered Mental Status Calciphylaxis Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired ICD9 Codes: 5845, 2762, 5990, 2760, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7885 }	Medical Text: Admission Date: [2198-4-29] Discharge Date: [2198-5-3] Date of Birth: [2143-9-10] Sex: F Service: MEDICINE Allergies: Vancomycin Hcl / Rocephin Attending:[First Name3 (LF) 2297] Chief Complaint: flank pain, fever Major Surgical or Invasive Procedure: A-line placement changing of R mid-line over guidewire History of Present Illness: This is a morbidly obese 54 female w/DM1 complicated by retinopathy, neuropathy and nephropathy s/p cadaveric kidney transplant in [2193] on immunosuppression who p/w fever and flank pain to OSH ([Hospital3 ]), now being transferred here with sepsis on pressor. . Pt initially presente on [4-27] to OSH with fevers up to 102.6, b/l flank pain and difficulty urinating. Stable BP, RR of 26 on admission. Her skin revealed a reddened area over her right breast as well as an oozing opening over her morbidly obese abdomen. Lactate was 4.8 on admission to the ICU for IVF resuscitation. CT abdomen/pelvis showed inflammation over the lower anterior abdominal wall. . Pt was initially started empirically on ceftazidime and levofloxacin (allergic to Vanco and CTX), then switched to penicillin and kept on levofloxacin after culture data came back; urine culture was positive for proteus (nearly pan-sensitive per verbal signout from OSH) and Bcx came back positive for beta-hemolytic strep B (sensitive to penicillin). She was later found to be in septic shock requiring Neosynephrine drip. She was also started on stress dose steroids (hydrocortisone), but switched to prednisone on transfer. Her BP was 90/41 on tapering doses of Neo on transfer. She wa initially somewhat obtunded but responded appropriately to questions after initial resuscitation. . Her respiratory status remained stable with 93% on 2-3L NC. BNP was 143. CXR was unremarkable. Latest ABG on day of transfer was 7.30/37/62. Lactate came down to 1.5. WBC was 23.3 with 48% bands on transfer. Hct was 27.3. There were no signs of bleeding but pt has h/o GIB. Patient received 1U pRBC on day of transfer with Hct coming up to 30.6. R triple PICC is in place after unsuccessful TLC attempt. Last BUN/Cr of 50/1.5. I/Os: 3610 in and 500 out + additional 700 out on day of transfer. BGs in 200s on ISS and standing insulin. . On arrival to ICU, pt is still on Neo, mentating well, without pain, fever or SOB. . ROS: Denies any CP, abdominal pain, F/C/N, SOB. Past Medical History: 1. Type 1 Diabetes mellitus c/b nephropathy, s/p cadaveric renal transplant [2193] 2. Diabetic neuropathy. 3. Diabetic retinopathy, legally blind. 4. Hypertension. 5. Cervical cancer status post radiation. 6. Depression. 7. Status post appendectomy. 8. Status post cholecystectomy. 9. Constipation. 10. Right upper extremity AV fistula. 11. Right axillary vein thrombosis [2193] w/ SVC sydrome 12. wound seroma and infection which progressed to septic shock and respiratory arrest requiring intubation [12-19]. 13. s/p nephrostomy tube placement and capping [2-19] 14. morbid obesity walks with walker 15. obstructive sleep apnea, uses BiPAP at night 16. colitis proctitis with lower GI bleeding Social History: Lives with her husband, has 2 kids both married and out of the house. Formerly worked with Alzheimer's patients now on disability. Uses a walker to get around, unable to use the stairs in her house. Denies alcohol, illicits, IVDU. Quit smoking 5 years ago had smoked 1ppdx15 yrs prior. Family History: +for DM, neg for cancer, neg for heart disease or clot disorder Physical Exam: Vitals: T: 97.2 BP: 70/27 -> 123/76 HR: 97 RR: 19 O2Sat: 98% on 2L NC GEN: Morbidly obese female in NAD, responding to all questions HEENT: EOMI, cornea b/l scarred, no epistaxis or rhinorrhea, very dry MM, OP Clear NECK: JVD unable to assess to due obese neck COR: RRR, no M/G/R, normal S1 S2 PULM: Lungs CTAB anteriorly, no W/R/R ABD: Soft, NT, ND, sparse BS EXT: No C/C/trace LE edema, palpable pulses NEURO: alert, oriented to person, place, and time. Responds appropriately to all questions. Strength 5/5 in upper and lower extremities. SKIN: Erythema below both breasts and in both groins. No jaundice or cyanosis. RUE fistula and R PICC in place. Pertinent Results: OSH labs: WBC 25 (18% bands). Hct 29.3. Plt 168. Na 136, K 4.6, Cl 108, CO2 21, BUN 53, Cr 1.6. Glc 229. . Micro data from OSH: Bcx [4-29]: NGTD Wound cx (abdomen) [4-28]: preliminary growth with proteus, enterococcus, GNR, beta hemolytic strep B UCx [4-27]: Proteus mirabilis, pan-sensitive except for Ampicillin, Cephalothin, Gent, Nitrofurantoin, Tetracycline and Tobramycin. Bcx [4-27] (4/4 bottles): Beta hemolytic Strep B in anearobic and aerobic bottles. . Imaging: CXR at OSH: no acute process . CT abdomen/pelvis at OSH on [4-27]: Severely limited study. Small shrunken kidneys b/l. Transplanted kidney on right without gross hydro. . Echocardiogram on [2197-12-12]: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2194-1-14], there is no definite change. Renal u/s on admission: Very limited study due to patient's body habitus and clinical condition. The transplanted kidney is not clearly visualized.. TTE: IMPRESSION: Extremely difficult windows, cannot assess ventricular function or valvular abnormalities. A TEE is indicated if clinically suggested TEE: unable to perform as patient's soft tissue around neck will not support the level of sedation necessary for study without intubation for airway maintenance. Brief Hospital Course: 54 female w/DM1 complicated by retinopathy, neuropathy and nephropathy s/p cadaveric kidney transplant in [2193] on immunosuppression who p/w fever and flank pain to OSH ([Hospital 28941]), was transferred here with sepsis on pressor which could be weaned off the same night. . # Mental status: The patient was quite drowsy on various occasions likely due to a combination of her severe infections, hypercarbia when she refused her nocturnal bipap, and renal function. The day prior to discharge she returned to her baseline mental status, and remained responsive to questions and oriented x 3, although somewhat drowsy. # septic shock: The patient was started on neosynephrine for blood pressure support at the outside hospital, however on arrival to our MICU, seh received several liters of fluid and arterial line was placed which showed stable blood pressures. She was found to have three infectious sources for her sepsis: 1. Beta hemolytic group A streptococcus bacteremia: The patient was followed by the infectious disease team. No clear source was found, however she may have some abdominal cellulitis in her pannus which may be the source for this. She was started on Penicillin G IV and dose was adjusted as her renal function improved. We attempted TTE and TEE to rule out endocarditis, however TTE was not able to visualize her valves due to habitus and TEE could not be performed due to inability to protect her airway if sedated given her habitus. She will therefore be kept on Penicillin G 4 million units IV q 4 hours for a total of 4 weeks of therapy. Day 1 is [2198-4-29]. After this course is completed her R midline should be removed. 2. Proteus UTI: Teh patient had a urine infection with proteus which was sensitive to ciprofloxacin and she was started on ciprofloxacin therapy 400mg IV BID for a total of 14 days. Day one was [4-29]. 3. Coagulase negative staphalococcus bacteremia: The patient had [2-19] blood cultures which returend positive for CNS. Due to vancomycin allergy she was started on linezolid 600mg IV q24 hours and should remain on this for 2 weeks. Day 1 was [5-1]. The likely source for this was believed to be her R PICC line. On the day of discharge, this line was pulled and replaced over a wire with a new R midline. This is not ideal given the infectious site, however after repeated failed attempts at central venous access, and inability to place PICC line in her left arm given this is [Month/Year (2) ] only site for accurate blood pressure measurements, the best scenario was to remove the suspected infected PICC from the R arm and change over a wire for a new midline. This line should be used to give IV antibiotics. Her linezolid is used for a 2 week course to cover the line itself as a likely infectious source. After two weeks of linezolid is complete, the patient will still have 2 weeks left of her PCN G, and thus will have the line in place. Thus, surveillance blood cultures should be drawn three times per week after linezolid is stopped until the R midline is pulled. In total, the patient is on penicillin G 4 million units IV q4hours for total of 4 weeks (day 1 [4-29]), ciprofloxacin 400mg IV bid for total of 2 weeks with day 1 [4-29], and linezolid 600mg IV q24hours for 2 weeks with day 1 being [5-1]. After linezolid is finished blood cultures should be drawn three times per week for surveillance while line is in place. midline should be pulled after the final day of PCN G. # respiratory distress: The patient has known sleep apnea nad uses oxygen intermittently at night. She remained on 2 L NC throughout her stay. She also uses bipap at night at setting of 14/6 and should continue to do so. # Acute renal failure: this was likely prerenal in etiology and in the setting of sepsis. She received kayexelate three times for potassium elevation to the mid-5s. Her creatinine level returned to her usual baseline level of 1.1 on the day of discharge. She was followed by the renal transplant team while here. She continued on her dose of cellcept and prednisone. Her tacrolimus dose was decreased to 3 mg po bid due to elevated tacro level of [8-25], and levels were checked daily for goal FK506 level of about 5. Please continue to follow FK 506 levels at trough three times per week for goal level of 5. The patient's renal transplant attending Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] is available for questions. # hematuria: this has been a problem for [Name2 (NI) ] patient in [Name2 (NI) ] past and she has been seen by urology for this. On the day of discharge she began having blood in her foley catheter. This was chagned to a three way catheter and continues bladder irrigation was begun. After several hours, she began to have much more clear urine from her foley. Please continue CBI only until she is clear, and at that time foley may be removed or changed to a smaller (single lumen) catheter. The patient should follow up with her prior [Name2 (NI) ] for evaluation. # diastolic CHF: The patient has history of diastolic CHF with EF of 50%. As she was relatively hypotensive during her stay, and required fluids on arrival, we held her ACE inhibitor and her lasix. Fluid status and blood pressure should be monitored as an outpatient with an eye to restarting these meds at her prior doses. She continues on ASA 81mg po qday for primary prevention of heart disease. # anemia: the patient has a baseline hematocrit of 30. On arrival she received one unit of PRBCs for Hct of 27. Thereafter her hct was stable and was followed daily. # diabetes mellitus: The patient was initially put on half of her home dose of lantus (home dose is 52 units qhs), however due to high finger sticks this was rapidly titrated up. On the day of discahrge she was to receive 50 units of glargine at hs. This may be uptitrated as warranted by finger sticks in rehab. She should also continue with regular insulin slide scale per protocol. # Neuro/Psych: we continued her outpatient doses of gabapentin and citalopram. These should continue as an outpatient as well. # nausea: the patinet was treated with prn zofran and Reglan for her intermittent nauea. In general, Reglan seemed to work better for her. # chronic pain: the patient was treated with prn PO percocet for her chronic back pain. # abdominal wall cellulitis: wound care was continued to her panus as there was erythema there possibly representing [Name2 (NI) ] source of her group A strep. She was continued on penicillin as above. # general care: note that the patient's blood pressure can be gotten with an extra large cuff on her Left arm only. Although this is eomwhat difficult to read, we did get accurate reads which coincided with her arterial line. Note taht her forearms, and both legs did not produce accurate BP reads (she appeared hypotensive when she was not). # Access: Access was a difficult issue for this patient. Despite her R AV fistula, R triple lumen PICC was placed at OSH on [4-27] after unsuccessful CVL placement at OSH. After many attempts at a Left subclavian line which were unsuccessful, we decided to have her R PICC replaced over a guidewire to a R midlin, which is in place at present. This line was placed on the day of discharge and should be ckept in place only until her 4 week antibiotic course is finished. After that, please d/c her midline access as it is a possible infectious source. A-line placed on [4-29] on arrival to ICU to monitor blood pressures was pulled several days later. . # PPx: she was given protonix and subcutaneous heparin throughout her stay in the ICU. . # Code: Full code . # Communication: patient; husband [Name (NI) ] [Name (NI) 28942] [Telephone/Fax (1) 28943] Medications on Admission: Home Medications per patient: #. Prednisone 5mg daily #. Ativan 1mg q8H PRN #. Pantoprazole 40mg daily #. Mycophenolate Mofetil 500mg [Hospital1 ] #. Lisinopril 2.5mg daily #. Citalopram 20mg daily #. Acetaminophen 500mg q6H PRN pain or fever #. Insulin Glargine 52 Units qHS #. Gabapentin 300mg TID #. Insulin Regular sliding scale #. Furosemide 40mg daily #. Oxycodone 5 mg q4H PRN #. Tacrolimus 4mg q12H #. ASA 81 daily . Medications on transfer: - Neosynephrine drip at 0.8 - Nexium 40 IV daily - Cellcept [Pager number ] [Hospital1 ] - Tacrolimus 4 [Hospital1 ] - Neurontin 300 [Hospital1 ] - Prednisone 10 PO daily [Hydrocortisone 50 IV q8h (started Fri, stopped Sat)] - RISS - Levemir Insulin 18U qHS - Levaquin 750 q48h (d1 = [4-27]) - Penicillin 4 [Last Name (un) ] IV q6h (d1= [4-28]) - Atrovent 0.5 q5h - Miconazole [Hospital1 ] to groin PRN Meds: - Reglan - Zofran - Tylneol - Percocet Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection Q8H (every 8 hours). 2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed: apply to abdomen, pannus folds. 9. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed. 10. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four Hundred (400) mg Intravenous Q12H (every 12 hours) for 10 days: total fo 14 days, day 1 was [4-29]. 11. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 13. Metoclopramide 10 mg Tablet Sig: Ten (10) mg PO QID (4 times a day) as needed. 14. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: 4 million units Injection Q4H (every 4 hours) for 4 weeks: total of 4 weeks, day 1 was [4-29]. 15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 17. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred (600) mg Intravenous Q12H (every 12 hours) for 2 weeks: total of 14 days, day 1 was [5-1]. 18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ML of NS followed by 2ML of heparin solution daily and prn to each lumen of midline. 19. Outpatient Lab Work please check surveillance blood cultures three times per week after linezolid is discontinued but while patient still has line in place. (weeks [3-20]) 20. insulin 50 units of glargine qhs. check FS qid and treat with standard regular ISS. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 1121] - [Location (un) 1456] Discharge Diagnosis: group A streptococcus bacteremia with sepsis pseudomonas UTI coag negative staph bacteremia acute renal failure confusion respiratory distress nausea Discharge Condition: blood pressure stable, afebrile, renal function back to normal with Cr 1.1. Oriented and alert. Discharge Instructions: Please be sure to give all meds as directed. Pt is to continue penicillin G 4 million units q4 hours IV for total of 4 weeks (day 1: was [4-29]). Please pull R midline as soon as this is completed. Ciprofloxacin 400mg [Hospital1 ] IV q12 hours for total of 2 weeks (day 1: [4-29]). Linezolid 600mg IV q24hrs for total of 2 weeks. (day 1: [5-1]). After linezolid finishes, patient will have midline in for two more weeks to complete PCN. Please check surveillance blood cultures three times per week for those two weeks. Please run all antibiotics through her midline. Pull midline as soon as penicillin G course is finished. Please check BP only in her left upper arm, as this is [Month/Year (2) ] only accurate measurement for her. Please continued wound care to abdominal cellulitis. Please continue continuous bladder irrigation until clears, then may change foley catheter to single lumen, or pull foley catheter. Please check FK 506 (tacrolimus) levels three times per week for goal level at trough of 5. Please call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] if needed for assistance. Please follow up with your renal transplant physician, [Name10 (NameIs) ] and primary care physician within the next 2 weeks. If you have fever, hypotension, or other concerning symptoms please call your primary care physician or come to the emergency room. Followup Instructions: Please follow up with your renal transplant physician, [Name10 (NameIs) ] and primary care physician within the next 2 weeks. Completed by:[2198-5-3**] ICD9 Codes: 5990, 5849, 2930, 2859, 3572
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7886 }	Medical Text: Admission Date: [2195-2-4] Discharge Date: [2195-2-11] Date of Birth: [2134-9-19] Sex: M Service: CARDIOTHORACIC Allergies: Atenolol / seasonal Attending:[First Name3 (LF) 5790] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: [2195-2-4] Right thoracotomy and thoracic tracheoplasty with mesh, left mainstem bronchus bronchoplasty with mesh, right mainstem bronchus and bronchus intermedius bronchoplasty with mesh. Bronchoscopy with bronchoalveolar lavage. History of Present Illness: Mr. [Known lastname 12552] is a 59 year old male status-post Laparoscopic fundoplication for GERD by Dr. [Last Name (STitle) ] on [2194-1-31]. He has history of TBM with severe malacia of the distal trachea (mild more proximally), right mainstem bronchus, right bronchus intermedius and left mainstem bronchus. In the past he has experienced improvement after placement of Y stents - the most recent of which was placed [2194-12-26] but unfortunately he experienced acute rejection soon afterwards and it was subsequently removed. Following this incident the patient experienced some worsening of his respiratory symptoms and was evaluated by Dr. [Last Name (STitle) ] when seen in clinic with the Interventional Pulmonology team [2195-1-6]. He presents now for surgical repair. Past Medical History: Asthma- Xolair injections tried [7-30] were not effective Seasonal allergies Hypertension Hyperlipidemia Tracheobronchomalacia diagnosed in [2192-10-21] when he was seen by Dr. [Last Name (STitle) ]. GERD Hypercholesterolemia HTN S/p hernia repair gout . Social History: Single, works as a laborer. Smoked for three-5 years as a young adult. Drinks ETOH [2-22] drinks per night [2-22] nights per week. Currently laid off as he is a seasonal worker. He lives alone. He has two children from a previous marriage. His daughter is very involved in his care. She drove him to the hospital during this admission. NOK: Brother [Name (NI) ] [Name (NI) 12552] - [Telephone/Fax (1) 12553]/CP: [2195] Family History: Both parents had osteoarthritis. Has a niece with RA. No family h/o pulmonary diseases. Physical Exam: BP: 139/85. Heart Rate: 79. Weight: 238.9. Height: 67.25. BMI: 37.1. Temperature: 97.8. Resp. Rate: 18. Pain Score: 0. O2 Saturation%: 99. Exam: General: No acute distress; alert and fully oriented Cardiac: Regular rate and rhythm; normal S1 and S2 Chest: Prior incisions from Nissen are well-healed Pulmonary: Inspiratory wheezes through-out the right lung field; left lung field clear to auscultation Abdomen: Soft, obese, non-tender, non-distended; no palpable masses Pertinent Results: [2195-2-4] 12:40PM HGB-13.3* calcHCT-40 [2195-2-4] 12:40PM GLUCOSE-189* LACTATE-1.0 NA+-136 K+-4.8 CL--102 TCO2-26 [2195-2-4] 06:00PM WBC-15.2* RBC-3.67* HGB-12.2* HCT-34.8* MCV-95 MCH-33.1* MCHC-35.0 RDW-13.0 [2195-2-4] 06:00PM PLT COUNT-239 [2195-2-4] 06:00PM GLUCOSE-164* UREA N-16 CREAT-1.0 SODIUM-140 POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14 [2195-2-10] PA & lat CXR : As compared to the previous radiograph, there is no relevant change. The reduced volume of the right hemithorax with areas of lateral pleural thickening. The areas of pleural thickening are constant, size and morphology. Unchanged perihilar areas of fibrosis. Unchanged size and aspect of the cardiac silhouette, no pathologic changes in the left lung. Brief Hospital Course: Mr. [Name13 (STitle) 9035] was admitted to the hospital and taken to the Operating Room where he underwent a right thoracotomy with tracheoplasty and bronchoplasty. He had an epidural catheter placed for pain control. Following surgery he was taken to the SICU for further management. He maintained stable hemodynamics but had minimal pain relief from the epidural catheter. It was more effective when the solutions were split. He underwent vigorous chest PT and used his incentive spirometer effectively. Following transfer to the Surgical floor his chest tube was removed as he had no air leak and minimal drainage. He started a liquid diet and tolerated it well. His epidural was removed and his pain was controlled with oral Dilaudid. His thoracotomy incision was healing well. Once he was ambulating more frequently he had increased oral secretions and although he felt his dyspnea was less than pre op, he was still symptomatic. The pulmonary service was consulted to assist in maximizing his medications to improve his symptoms. They felt that his secretions were due to decreasing airway edema as opposed to an asthma flare. His oxygen was eventually weaned off and his room air saturations were 96%. He used his home CPAP at night and was reminded to follow up with Dr. [First Name (STitle) 437] in the sleep lab. Mucolytics were also added. He was walking independently and tolerating a regular diet. After an uneventful recovery he was discharged to home on [2195-2-11] and will follow up in the Thoracic Clinic in a few weeks. Medications on Admission: albuterol, budesonide, fluticasone nasal spray, advair 500/50, gemfibrozil 600', lisinopril 5', omalizumab 375mg q2wks, omeprazole 20' Discharge Medications: 1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 6 hrs on, 6 hrs off. Disp:14 Adhesive Patch, Medicated(s) Refills:2 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. diclofenac sodium 25 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 10. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:150 Tablet(s) Refills:0 11. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 5 days. Disp:100 ML(s) Refills:0 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 13. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Mucinex 600 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 15. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Tracheobronchomalacia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough -Incision develops drainage Pain -No driving while taking narcotics -Take stool softners with narcotics Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -No lotions or creams to incision site -Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily Followup Instructions: Department: WEST [Hospital 2002] CLINIC When: TUESDAY [2195-3-3] at 9:00 AM With: [Name6 (MD) 1532] [Last Name (NamePattern4) 8786], MD [Telephone/Fax (1) 3020] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: EAST Best Parking: [Street Address(1) 592] Garage Please report 30 minutes prior to your appointment to the Radiology Department on the [Location (un) 470] of the [Location 12555] Center for a chest xray. Call Dr. [First Name8 (NamePattern2) 12556] [Last Name (NamePattern1) 437] in Sleep Clinic for a follow up appointment. Call Dr. [Last Name (STitle) 2603] in Allergy to resume omalizumab injection therapy for his asthma. Completed by:[2195-2-11] ICD9 Codes: 4019, 2724, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7887 }	Medical Text: Admission Date: [2199-6-18] Discharge Date: [2199-6-20] Date of Birth: [2199-6-18] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: [First Name9 (NamePattern2) 67081] [Last Name (un) 67082] [Last Name (un) 4357] Erilus, also known as [Known lastname 140], baby boy is the former 2.28 kg product of a 34 and 5/7 weeks gestation pregnancy born to a 28-year- old G2, now P2 woman. Prenatal screens - blood type A positive, antibody screen negative, hepatitis B surface antigen positive, rubella immune, RPR nonreactive, group beta strep status positive. The pregnancy was notable for recurrent urinary tract infections treated with Flagyl. The mother also was in a motor vehicle accident 11 days prior to delivery and was admitted to the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] and treated with magnesium sulfate at that time. Spontaneous premature rupture of membranes occurred at 2100 hours prior to delivery. The mother was treated with interpartum antibiotics for greater than 4 hours prior to delivery. There was no maternal fever or other sepsis risk factors. The infant was born by spontaneous vaginal delivery. Apgars were 9 at 1 minute and 9 at 5 minutes. He was admitted to the neonatal intensive care unit for treatment of prematurity. PHYSICAL EXAMINATION: Upon admission to the neonatal intensive care unit weight was 2.28 kg, 60th percentile; length 47.5 cm, 60th percentile; head circumference 29 cm, 10th percentile. GENERAL: Well appearing, vigorous, active, male infant in no acute distress. HEENT: Anterior fontanel open and flat. Palate intact. Mild occipital molding. CHEST: Breath sounds clear and equal, comfortable in room air. Vigorous cry. CARDIOVASCULAR: Regular rate and rhythm. No murmurs. Femoral pulses +2. ABDOMEN: Soft, nontender, nondistended. Bowel sounds present. EXTREMITIES: Warm, pink, well perfused. GENITOURINARY: Normal male external genitalia. Anus patent. NEUROLOGICAL: Appropriate tone and reflexes. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: RESPIRATORY: [Last Name (Titles) 67081] showed lung and respiratory control maturity. He was in room air with oxygen saturations greater than 95%. He did not have any episodes of desaturation or apnea and bradycardia. CARDIOVASCULAR: This baby maintained normal heart rates and blood pressures. No murmurs were noted. FLUIDS, ELECTROLYTES AND NUTRITION: Enteral feeds were started at the time birth. He has been taking Enfamil 20 or breast feeding, taking in a minimum of 120 ml per kg plus breast feeding. Mother prefers him to be on [Name (NI) 56280] formula. Weight on the day of discharge is 2.19 kg. INFECTIOUS DISEASE: Due to the positive group beta strep status and being less than 35 weeks gestation, this infant was evaluated for sepsis. White blood cell count was [Numeric Identifier 3301] with a differential of 41% polymorphonuclear cells, 2% band neutrophils, 50% lymphocytes. A blood culture was obtained and there was no growth at 48 hours. HEMATOLOGICAL: Hematocrit at birth at 46.2%. GASTROINTESTINAL: Serum bilirubin obtained at 48 hours of life was total 7.9 mg per dL over 0.3 mg per dL direct. The infant will return to the [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] for a bilirubin check on [2199-6-21]. NEUROLOGICAL: This baby has maintained a normal neurological examination during admission. No concerns at the time of discharge. SENSORY: Audiology hearing screening was performed with automated auditory brain stem responses and this baby passed in both ears. PSYCHOSOCIAL: The baby's surname after discharge will be [Last Name (un) 4357] Erilus. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. NAME OF PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 16968] through [Hospital3 18242], Pediatric Health Associates. Phone No. [Telephone/Fax (1) 38541]. CARE RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feedings: ad lib breast feeding or feeding [Telephone/Fax (1) 56280] 24 calorie per ounce. 2. Medications: None. 3. Car seat position screening was performed. This baby was observed for 90 minutes in his car seat without any episodes of oxygen desaturation or bradycardia. 1. State newborn screens were sent on [2199-6-20] with results pending. 2. Immunizations received - hepatitis B vaccine and hepatitis B immunoglobulin were administered on [2199-6-17]. 3. Immunizations recommended. Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria. A) Born at less than 32 weeks. B) Born between 32 and 35 weeks with two of the following: 1. daycare during the RSV season. 2. a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings. 3. with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. Follow up appointments with infant include: 1. [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] NICU on [2199-6-21] for bilirubin check. 2. [Hospital6 ] visit for Saturday, [2199-6-22]. 3. Appointment with Dr. [Last Name (STitle) 16968] or primary pediatrician on [Last Name (LF) 766], [2199-6-24]. DISCHARGE DIAGNOSES: 1. Prematurity at 34 and 5/7 weeks gestation. 2. Suspicion for sepsis. [First Name11 (Name Pattern1) 3692] [Initials (NamePattern4) ] [Last Name (NamePattern4) 27992], MD [MD Number(2) 65951] Dictated By:[Last Name (Titles) ] MEDQUIST36 D: [2199-6-20] 21:08:11 T: [2199-6-20] 23:28:29 Job#: [Job Number 67083] ICD9 Codes: V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7888 }	Medical Text: Admission Date: [2189-1-25] Discharge Date: [2189-1-28] Date of Birth: [2146-2-18] Sex: M Service: MEDICINE Allergies: Penicillins / Motrin Attending:[First Name3 (LF) 338] Chief Complaint: Seizures Major Surgical or Invasive Procedure: Intubation History of Present Illness: 42-yo-man w/ HCV cirrhosis was tranferred from an OSH today, intubated for airway protection, after seizure. Per his NH staff, he was feeling well until yesterday when he developed nausea, vomiting, and diarrhea w/ multiple loose stools throughout the day. In this setting, he was unable to take his meds, including his antiepileptic medication. This AM, he was found by his nurse to be tonic w/ legs extended, staring blankly into space and unresponsive, and "foaming at the mouth." There was no uncontrolled movement, tongue biting, or bowel or bladder incontinence. The staff called EMS, who gave the pt IV ativan 4mg on arrival at the scene, and the tonic episode resolved, leaving the pt somnolent. He was then transported by ambulance to an OSH ED, where he was intubated for airway protection using vecuronium and succinylcholine, treated w/ dilantin and levoflox, and then transferred to [Hospital1 18] ED. . Of note, he has had no recent antibiotics, hematemesis, melena, or hematochezia. His roommate has also been ill with vomiting and diarrhea starting 2 days ago. . In our ED, the pt had normal vital signs but was somnolent, not responding to voice commands, but withdrawing from painful stimuli in all extremities. Neurology consultants believed that he had no ongoing seizure activity, and that his persistent somnolence was likely from sedative medications and lack of his lactulose over the past 2 days. He is now admitted to the MICU for further care. Past Medical History: - Seizure disorder: controlled w/ Keppra - Hepatitis C - cirrhosis: likely from alcohol abuse and HCV; h/o esoph varices - alcohol abuse: h/o withdrawal seizures, last drink > 1 year ago. - DM type 2 - Dementia NOS - chronic thrombocytopenia - macrocytic anemia - alcoholic marrow suppression: episodic neutropenia - peripheral neuropathy Social History: Social History (from OMR): former sanitation worker, fired from his job due to alcoholism. Lives at a nursing home for the past year. Drank 9 drinks/day for 25-30 years, last drink > 1 year ago. Used IV drugs in the past, but none currently Family History: Pt states that his father and mother both dies of cancer. Physical Exam: T 98.6, HR 83, BP 109/64, O2 sat 100% on AC 500 x 12 / 40 / 8 Gen: lying flat in bed, intubated, sedated, not responding to voice HEENT: anicteric, PERRL, OP clear w/ dry MM and ETT in place, no JVD Chest: + gynecomastia CV: reg s1/s2, + 2/6 systolic murmur at apex, no s3/s4/r Pulm: CTA b/l, no crackles or wheezes Abd: obese, +BS, soft, NT, ND, dull to percussion, no caput medusae Ext: warm, 2+ DP b/l, 1+ pitting edema to mid-leg b/l Neuro: sedated, withdraws from pain in all extrem, not responsive to voice Skin: scattered petechiae; spider hemangiomas over chest and legs . Pertinent Results: [2189-1-25] 6:55p pH 7.37 pCO2 35 pO2 502 HCO3 21 BaseXS -3 Type:Art; Intubated; FiO2%:100; AADO2:193; Req:40; Rate:/12; TV:500; Mode:Assist/Control; Temp:36.7 [2189-1-25] 2:13p ADD ON FROM HEME #634E Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative [2189-1-25] 2:07p Other Blood Chemistry: Ammonia: 188 [2189-1-25] 11:46a Lactate:2.6 [2189-1-25] 11:30a NOT A TRAUMA AS [Name6 (MD) ] PAGE RN [Pager number ] 105 28 AGap=16 -------------< 143 3.6 19 0.8 estGFR: >75 (click for details) Ca: 7.6 Mg: 2.1 P: 3.3 ALT: 47 AP: 115 Tbili: 3.9 Alb: 3.0 AST: 56 LDH: Dbili: 1.8 TProt: [Doctor First Name ]: 64 Lip: 15 Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative Phenytoin: 7.0 [2189-1-28] 03:56AM BLOOD WBC-5.3 RBC-3.58* Hgb-12.1* Hct-35.2* MCV-98 MCH-33.8* MCHC-34.4 RDW-15.7* Plt Ct-59* [2189-1-27] 03:14AM BLOOD Neuts-70 Bands-0 Lymphs-9* Monos-14* Eos-7* Baso-0 Atyps-0 Metas-0 Myelos-0 [2189-1-27] 03:14AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+ Tear Dr[Last Name (STitle) 833] [2189-1-28] 03:56AM BLOOD Plt Ct-59* [2189-1-28] 03:56AM BLOOD PT-15.8* PTT-38.1* INR(PT)-1.4* [2189-1-28] 03:56AM BLOOD Glucose-131* UreaN-27* Creat-0.9 Na-138 K-3.4 Cl-108 HCO3-22 AnGap-11 [2189-1-27] 03:14AM BLOOD ALT-47* AST-49* LD(LDH)-184 AlkPhos-104 Amylase-186* TotBili-3.2* [2189-1-28] 03:56AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.6 [2189-1-27] 04:56PM BLOOD Ammonia-56* [2189-1-25] 11:30AM BLOOD Phenyto-7.0* Cultres: Resp: [2189-1-27] 11:18 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [2189-1-27]): [9-24] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Pending): [2189-1-25] 8:30 pm URINE Site: CATHETER FINAL REPORT [2189-1-27] URINE CULTURE (Final [2189-1-27]): NO GROWTH. [2189-1-25] 8:30 pm BLOOD CULTURE #1. AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): Brief Hospital Course: A/P: 42-yo-man w/ alcoholic and HCV cirrhosis, seizure disorder, chronic thrombocytopenia, now transferred from OSH w/ somnolence after seizure. . # Altered mental status: Likely due to hepatic encephalopathy, with some contribution from sedative medications and post-ictal confusion. UTOX and STOX negative on admission. Patient was following comands well and was therefore extubated. His mental status improved to baseline off sedation after extubation. # Seizure disorder: unclear etiology in this pt, but normally controlled w/ Keppra. His seizure this AM was likely in part from lack of medications in the past 2 days. No further seizure activity since his presentation. EEG showed encephalopathy. Neuro followed and recommended continuing Keppra and no dilantin. # Nausea/diarrhea: given development of symptoms soon after his roommate was ill, possile viral enteritis. There are no signs of bacterial infxn to implicate C diff colitis or SBP. Hepatic US to rule out portal vein thrombosis, if significant ascites then consider dx paracentesis to rule out SBP. His lactulose and rifaximin were continued. # Thrombocytopenia: baseline plt count 40-70, likely from splenomegaly in setting of cirrhosis. No signs of bleeding at present. # Cirrhosis: from alcohol abuse and chronic HCV. Synthetic fxn is impaired w/ albumin 3.0 and INR 1.8. He has known esoph varices. No ascites at present and no clinical signs of sbp except for nausea. No significant ascites on RUQ ultrasound for paracentesis. Lactulose was continued and nadolol/diuretics were restarted. # DM type 2: controlled w/ metformin as outpt. - hold oral meds while inpt - check FS qid - glargine 15 units qhs for basal coverage - cover w/ HISS # Alcoholism: he has had no alcohol in > 1 year since living at the NH; serum alcohol negative on admission. No concern for withdrawal. - cont folate, thiamine, ferrous sulfate # Anxiety: controlled w/ celexa, doxepin, seroquel, and ativan as outpt. Medications on Admission: - Keppra 1500 mg [Hospital1 ] - metformin 500 mg [Hospital1 ] - lasix 20 mg daily - aldactone 300 mg daily - nadolol 20 mg daily - rifaximin 400 mg tid - lactulose 40 ml qid - omeprazole 20 mg daily - procrit 40,000 units sc weekly - seroquel 50 mg [Hospital1 ] - doxepin 100 mg qhs - celexa 40 mg daily - ativan 1 mg po tid - folate 1 mg daily - thiamine 100 mg daily - ferrous sulfate 325 mg daily Discharge Medications: 1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Spironolactone 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime: Check sugars 4x daily, and may adjust dose up or down by 4 untis daily prn. also do regular insulin sliding scale - see printout. 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed: max 2g daily. 8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): titrate to [3-6] BM daily. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Epoetin Alfa 10,000 unit/mL Solution Sig: [Numeric Identifier ] ([Numeric Identifier ]) Injection once a week. 14. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day. 16. Doxepin 100 mg Capsule Sig: One (1) Capsule PO at bedtime: hold for confusion. Discharge Disposition: Extended Care Facility: OAKWOOD Discharge Diagnosis: primary: seizure hepatic encephalopathy secondary: hepatitis C cirrhosis type 2 diabetes demenita thrombocytopenia macrocytic anemia Discharge Condition: patient was able to eat, cooperative, and satting 100% RA without further seizure activity Discharge Instructions: You were admitted for potential seizures and confusion. Please continue your previous medications, except you have been changed to glargine 15u before bedtime from metformin. Followup Instructions: Please follow up with your PCP and neurologist while at rehab. If you do not have these appointments scheduled, please schedule one with each within 2-3 weeks. Please follow up with hepatology as needed. ICD9 Codes: 5849, 2875, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7889 }	Medical Text: Admission Date: [2164-5-11] Discharge Date: [2164-5-14] Date of Birth: [2083-9-17] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 1928] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: This is an 80 year old female with a history of [Location (un) ] [Location (un) ] syndrome, HTN, anxiety who was recently discharged from [Hospital1 18] for a urinary tract infection and some altered mental status who was having increasing dyspnea at her nursing home. A chest XR was done which was reported as concerning for pneumonia. She was started on levofloxacin at 6pm on [5-10]. She then looked worse (more tachypnic and dyspneic) and was sent to [Hospital1 18] ED for evaluation. . Of note she was recently hospitalized at [Hospital1 ] for a UTI and altered mental status. She was discharged on [4-1] on a 7 day course of levofloxacin. Her mental status changes were atrributable to a UTI. She was discharged to rehab although it appears that she was admitted from home initially. . In the ED, initial vs were: 110s, 98.5, 140/80 22-24 and 85% RAsat. Patient was given Zosyn, flagyl, olanzapine, lorazepam, and tylenol. Labs were significant for a positive UA (21-50 WBC and many bacteria) and a d-dimer of 2951. A lactate was 2.8. 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. Denied arthralgias or myalgias. . 100.6, 90s, 97/52, 18-20, 96-98% NRB. Past Medical History: [Location (un) ]-[Location (un) ] Syndrome (has been electively wheelchair bound for several years after traumatic fall with elbow fracture) Osteoporosis Constipation s/p Hysterectomy for fibroids HTN Depression Anxiety Social History: She does not smoke or drink alcohol. She worked for an educational testing service. She recently moved from [State 760] to [Location (un) ], MA to be closer to her daughter. She lives alone with aides present for estimated 10 hours per day. She has been electively wheelchair bound since a fall a few years ago when she severely injured her elbow. At baseline she can stand and offer help to transition herself to her wheelchair. Family History: Father died of an MI. Mother died of pancreatic cancer. Brother died. Had asthma, heart disease, and had similar neurological problems to the patient. She has a younger sister with breast cancer that she had 20 years ago. She has only one daughter. Physical Exam: Vitals: 97.9, 81, 22, 100% on non-rebreather General: Lethargic, arousable to tactile stimuli, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: diminished at bases with crackles on the left. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mildly distended and tender on right lower quadrant to deep palpation, hypoactive bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley with dark brown fluid with large amounts of sediment and strong foul odor Ext: warm, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: ================== ADMISSION LABS ================== . [2164-5-10] 07:30PM BLOOD WBC-9.2 RBC-4.53 Hgb-12.6 Hct-40.6 MCV-90 MCH-27.9 MCHC-31.1 RDW-14.6 Plt Ct-753* [2164-5-10] 07:30PM BLOOD Neuts-75.2* Lymphs-21.5 Monos-2.2 Eos-0.5 Baso-0.5 [2164-5-10] 07:30PM BLOOD PT-12.0 PTT-22.1 INR(PT)-1.0 [2164-5-10] 07:30PM BLOOD Plt Ct-753* [2164-5-10] 07:30PM BLOOD Glucose-211* UreaN-44* Creat-0.6 Na-145 K-4.4 Cl-106 HCO3-25 AnGap-18 [2164-5-10] 07:30PM BLOOD Calcium-9.5 Phos-4.4 Mg-2.1 [2164-5-10] 08:55PM BLOOD D-Dimer-2951* [2164-5-10] 07:38PM BLOOD Glucose-206* Lactate-2.8* K-4.0 [2164-5-10] 08:01PM URINE RBC-21-50* WBC-21-50* Bacteri-MANY Yeast-NONE Epi-0-2 RenalEp-[2-10] [2164-5-10] 08:01PM URINE Blood-LG Nitrite-NEG Protein-150 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-TR [2164-5-10] 08:01PM URINE Color-[Location (un) ] Appear-Cloudy Sp [Last Name (un) ]-1.014 Microbiology data: [2164-5-10] Urine culture - VRE [2164-5-11] Urine culture - VRE [2164-5-10] Blood culture ngtd pending [2164-5-11] Blood culture ngtd pending [2164-5-11] Urine legionella negative [2164-5-11] Blood culture ngtd pending AP PORTABLE CHEST [2164-5-10] AT [2090] HOURS. FINDINGS: The patient is significantly rotated limiting evaluation. There is diffuse hazy opacity, predominantly bilateral perihilar distribution. The left lower lobe is difficult to fully assess, but there is some suggestion of focal infiltrates. The aorta is tortuous with calcified plaque. The cardiac silhouette size is difficult to assess but is grossly within normal limits for size. No effusion or pneumothorax is noted. Please note the left apex is obscured by the patient's chin. The bones are severely osteopenic with multilevel degenerative change throughout the thoracic spine noted. Deformity of upper right ribs suggest remote healed trauma. IMPRESSION: Markedly limited study to near non-diagnostic given severity of rotation. There is suggestion of bilateral perihilar opacities possibly also involving the left lower lobe. Multifocal pneumonia cannot be excluded on the basis of this examination. If clinically feasible, consider repeat radiography in the radiology suite with PA and lateral views preferred. CT Chest/Abdomen/Pelvis [2164-5-11] FINDINGS: CT CHEST: The airways are patent up to subsegmental level. There are bilateral multiple focal area of opacities, predominantly in the lower lobes, concerning for multifocal pneumonia. Additionally, there is a tree-in-[Male First Name (un) 239] pattern in the lower lobes again in keeping with likely pneumonia, or aspiration. There is bilateral small pleural effusion. There is no pericardial effusion. There are prominent lymph nodes seen in the mediastinum, nonspecific, could be reactive. There is no lymphadenopathy in the axilla. CTA CHEST: There is no evidence of PE with suboptimal segmental and subsegmental loer lobe evaluation due to breathing. There is no evidence of aortic dissection. Heart size is normal. CT ABDOMEN: The liver enhances homogeneously. There is focal hypodensity near the falciform ligament, likely fatty sparing. The main portal vein is patent. The gallbladder is not clearly identified due to multiple overlying loops of bowel in the area and lack of oral contrast. There is normal gallbladder. There is a large calcification in the spleen, could be due to prior granulomatous disease. Calcification is seen at the vessel of the spleen, could be a calcified aneurysm or calcified lymph node, (3B:12). There is no evidence of bowel obstruction. Study is limited due to lack of oral contrast. There is no free air. Moderate amount of stool in the colon. Loops of small bowel filled with fluid, could be in keeping with enteritis, difficult to evaluate for fat stranding due to patient body habitus. There is no large ascites. No lymphadenopathy according to CT size criteria. The vessels appear with normal caliber, and patent. CT PELVIS: Urinary bladder has Foley and air within. Due to placement of a Foley and due to lack of oral contrast, this study is suboptimal to evaluate for a fistula between the bladder and the colon. There is no free fluid in the pelvis. No lymphadenopathy in the pelvic or inguinal area. OSSEOUS STRUCTURES: Moderate degenerative changes throughout the spine. There is a compression fracture at the vertebral body of L1, of indeterminate age. IMPRESSION: 1. No PE, with suboptimal evaluation of the segmental and subsegmental level in the lower lobes. Patient was breathing in the scanner. 2. Multifocal opacities in the lungs and predominantly at the lung bases with a tree-in-[Male First Name (un) 239] pattern, concerning for pneumonia, or aspiration, in appropriate clinical setting with likely chronic underlying changes. 3. Small bowel filled with fluid, could be seen in setting of enteritis, although evaluation for fat stranding is suboptimal due to patient body habitus. 4. No bowel obstruction. 5. No definite fistula seen; however, scan is suboptimal due to lack of oral contrast. 6. L1 vertebral body fracture of indeterminate age. Discharge labs: CBC 13.3 > 10.5/32.6 < 563 Chem panel: 138 \| 3.3 \| 5 < 121 3.3 \| 31 \| 0.4 Ca 8.3 Phos 2.6 Mg 1.5 Brief Hospital Course: 80 year old female with a history of [Location (un) ] [Location (un) ] syndrome, HTN, anxiety who was recently discharged from [Hospital1 18] for a urinary tract infection and some altered mental status who was having increasing dyspnea at her nursing home and was found to have gross pyuria, in fair condition. She was evaluated by the palliative care service and was transitioned to hospice care prior to discharge. After discussing her current status with her daughter, her antibiotics were discontinued and she was discharged to the [Doctor First Name 1785] house. This was discussed with her daughter, who agreed with the plan. Her primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) ] was also contact[Name (NI) ] who agreed with this as well. # HOSPITAL / HEALTHCARE ASSOCIATED PNEUMONIA: Given recent hospitalization and nursing home stay, at risk for nonsocomial infections (MRSA, Pseudomonas, etc). Given these concerns, we started broad spectrum antibiotics and obtained blood and sputum cultures. Patient was treated with an 8 day course of Vancomycin with double coverage of gram negative with Zosyn and Levofloxacin. Patients respiratory status improved significantly, however noted to be at significant risk of aspiration events. Please see goals of care below for more details. As the patient's urine became positive for VRE, we changed to a course of linezolid and zosyn only. Once the decision was made to transition to hospice care, her antibiotics were discontinued. (See above) # URINARY TRACT INFECTION with VRE: Patient with recently treated UTI, unclear if recurrent infection or partially treated prior infection with resistant organism. During evaluation in ED, there was concern for fecal material in the urine, however there was no evidence in a non contrast CT of fistulization. Given concern for HAP as above, patient treated with broad systemic antibiotics. Urine cultures revealed Vancomycin Resistent Enterococcus (VRE). She was started on linezolid on [2164-5-13], but this was discontinued based on her goals of care above. Of note, she had a Foley in place on discharge and given that she still has fecal material in her urine, we felt that removing it would lead to worsening skin breakdown. # GOALS OF CARE: Spoke at length with HCP, who had recognized a rapid, sudden decline in patient's functional and mental status in the past few months. Taking into account the patient's wishes on medical treatment, palliative care team was consulted and goals of care were made to emphasize on comfort. Although patient is at very high risk of aspiration events, especially given her neuromuscular weakness and altered mental status, she will eat for comfort. Her current pneumonia and urinary track infection were treated, but once the final decision was made to transition to hospice/comfort care these antibiotics were discontinued. To continue her IV antibiotics, she would require PICC placement and her daughter did not feel that Mrs. [Known lastname ] would be able to tolerate this. Given this and her daughter's wishes, her antibiotics were discontinued on discharge. # METABOLIC ENCEPHELOPATHY: Although patient with declininc mental status, current presentation with clear acute worsening, likely secondary to active infection. Patient experienced delirium during ICU stay, and was managed with Olanzapine. After discussion with palliative care, ativan was also restarted as this has been helpful in the past for relieving the patient's anxiety. # Anxiety: Initially, ouptiatient Ativan prn given delirium, and started low dose Zyprexa while in the ICU. Ativan was restarted on discharge PRN for anxiety given that she has responded to this in the past. # Constipation: Stool softners held initially due to aspiration concerns, but restarted on discharge # Benign Hypertension: Outpatient BP meds held during acute illness and were not restarted on discharge. If her BP remains elevated to SBP > 160, would restart candesartan 16mg daily. Code: DNR/DNI, transitioned to HOSPICE Communication: Patient and daughter [Name (NI) ] H [Telephone/Fax (1) 84331] / C [Telephone/Fax (1) 84332] Medications on Admission: Candesartan 16 mg Tablet Sig: One (1) Tablet PO once a day. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO every six (6) hours as needed for anxiety. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [12-10] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for constipation. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 12660] [Last Name (NamePattern1) ] Discharge Diagnosis: [Location (un) ] [Location (un) ] syndrome Presumed enteral fistula to the bladder - VRE UTI Osteoporosis Hypertension Anxiety Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with shortness of breath and stool in your urine. You were diagnosed with pneumonia and a urinary tract infection and were started on antibiotics and transferred to the floor. The palliative care team was also consulted and you were transitioned to hospice care. The hospice team met you and spoke with your daughter and you will be returning to the the [Doctor First Name 1785] house with hospice. Medication changes: 1. Candesartan was stopped 2. Effexor was discontinued 3. Ativan was restarted as needed for anxiety 4. Aspirin was discontinued Followup Instructions: Please follow up with the hospice team as needed. You can follow up with the doctors at the [Name5 (PTitle) 1785] house (and also Dr. [Last Name (STitle) ] as needed. ICD9 Codes: 5990, 2760, 4589, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7890 }	Medical Text: Admission Date: [2117-5-25] Discharge Date: [2117-6-5] Date of Birth: [2075-10-15] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1854] Chief Complaint: consulted for new brain mass Major Surgical or Invasive Procedure: [5-26]: Left Crani for Mass History of Present Illness: Patient is a 41 yo RH man with PMH of DM, HTN and hypothyroid who began having headaches 6-12 months ago and word finding difficulty about 6 months ago. Both symptoms fluctuated. The headaches were not daily and have not been noted for the last 2 days. The word finding difficulty has fluctuated at times, but has definitely worsened the last 4 weeks. Also slightly confused at times and changes in performance at work. No personality changes, but sleeping much more than usual. No inappropriate behaviors. Past Medical History: DM, HTN, hypercholest, hypothyroid, HTN Social History: works as a networks administrator. Married. Lives in [Location (un) 3844]. Quit tob more than a year ago. Occ ETOH. NO drugs. Family History: non-contributory Physical Exam: Exam upon admission: T: 98.8 BP: 127/105 HR: 70 R 15 O2Sats 97RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [5-9] 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. Recall: [3-9] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact to high frequency words, but misses hammock. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 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 [5-11] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: [2117-6-4] 05:56AM BLOOD WBC-17.7* RBC-3.86* Hgb-11.9* Hct-33.8* MCV-88 MCH-30.8 MCHC-35.1* RDW-13.1 Plt Ct-249 [2117-6-4] 05:56AM BLOOD Plt Ct-249 [2117-6-4] 05:56AM BLOOD Glucose-142* UreaN-28* Creat-0.7 Na-135 K-4.2 Cl-102 HCO3-28 AnGap-9 [2117-6-4] 05:56AM BLOOD Amylase-94 [2117-6-4] 05:56AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.1 [2117-6-1] 04:41PM BLOOD Type-ART pO2-155* pCO2-26* pH-7.51* calTCO2-21 Base XS-0 Intubat-INTUBATED Brief Hospital Course: 41-year-old man, with history of diabetes, hypertension, who was found to have large left frontal brain mass. He was having headaches for 6 months and periods of aphasia. He was admitted to the ICU for close neurological monitoring and started on high dose steroids. On [6-1] he underwent a left sided craniotomy without complications his post op exam was intact he did not have any deficits including speech. His post operative MRI showed a partial resection. He was transferred to the floor and his steroid were weaned. He was tolerating a regular diet and ambulating without difficulty he was given a rx for outpatient OT to help with short term memory issues. He will follow up in the brain tumor clinic. Medications on Admission: Levoxyl 175, lisinopril 10 daily, metformin dose unknown, anti cholesterol med which he cannot recall. Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for seizure proph. Disp:120 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 3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: No driving while on this medication. Disp:50 Tablet(s) Refills:0 6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Dexamethasone 2 mg Tablet Sig: 1.5 tabs PO tid X 3 days, 1 tab tid for 3 days then 1 tab [Hospital1 ] until follow up Tablets PO As above. Disp:60 Tablet(s) Refills:2 9. Outpatient Occupational Therapy Cognitive and memory training s/p brain tumor removal Discharge Disposition: Home Discharge Diagnosis: Left Frontal Mass Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions/Information ??????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 Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ??????If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ??????Clearance to drive and return to work will be addressed at your post-operative office visit. ??????Make sure to continue to use your incentive spirometer while at home. 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: increasing redness, increased swelling, increased tenderness, or drainage. ??????Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [7-16] days (from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. ??????You have an appointment in the Brain [Hospital 341] Clinic with [Name6 (MD) 640] [Name8 (MD) 15756], MD Phone:[Telephone/Fax (1) 1844]. The appt is on [2117-6-28] at 4:00pm. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], on the [Location (un) 858] of the [Hospital Ward Name 23] Building. Completed by:[2117-6-5] ICD9 Codes: 4019, 2449, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7891 }	Medical Text: Admission Date: [2128-5-1] Discharge Date: [2128-5-4] Date of Birth: [2128-5-1] Sex: F HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname ] was admitted to the NICU at day two of life for evaluation of a murmur. She was born at 38 and 4/7 weeks gestation to a 36 year old gravida II, para 0 to I mother with an unremarkable past Prenatal laboratories were notable for blood type AB positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune and GBS unknown. Perinatal history was unremarkable. Delivery did occur via cesarean section for nonreassuring fetal heart rate. The weight was 3285 grams. The baby was admitted to the [Name (NI) ] Nursery and initially was well and asymptomatic. A murmur was heard on the first day of life that became louder by day two of life. At that point, the infant was transferred to the Neonatal Intensive Care Unit for evaluation. PHYSICAL EXAMINATION: Initial examination in the Neonatal Intensive Care Unit was remarkable for oxygen saturation of 85 to 92% in room air. Blood pressure, heart rate and respiratory rate were within normal limits. The infant was well appearing and nondysmorphic. Fontanelles were open, soft and flat. Palate was intact. No blunting, flaring or retracting was noted. The chest was clear. The cardiac examination was regular rate and rhythm with a loud III/VI murmur at the left sternal border radiating across the chest. S1 and S2 were normal. The abdomen was soft without hypercholesterolemia. Bowel sounds were active. Extremities were warm and well perfused. Suck, grasp, Moro, reflexes were intact. Mild jaundice was noted. The infant was active and alert and appropriately responsive. HOSPITAL COURSE: 1. Cardiac - An initial evaluation included an electrocardiogram that suggested prominent right sided forces but was otherwise within normal limits. The chest x-ray revealed normal cardiac silhouette and clear lungs. Arterial blood gases revealed pH of 7.42, pCO2 of 32, and pO2 of 82. Cardiology was consulted and echocardiogram was performed that revealed tetralogy of Fallot with pulmonary stenosis. Echocardiogram report noted severe valvular pulmonary stenosis with mild subvalvular pulmonary stenosis, a large conoventricular or ventricular septal defect with bidirectional flow, qualitatively good biventricular function, and low normal branch pulmonary arteries. No specific treatments for the cardiac disease were required. 2. Respiratory - The patient remained stable in room air with oxygen saturation of 85 to 95%. No increased work of breathing was noted. 3. FEN - The infant was initially maintained on intravenous fluids pending results of the evaluation; after the results described above, the infant was brought to breast feed which proceeded without difficulty. Urine and stool output were normal. Weight the day of discharge was 3045 grams, up 50 grams from previous day. 4. Gastrointestinal - Hyperbilirubinemia was noted. Bilirubin level on [2128-5-3], was 11.2 over 0.3. Bilirubin on [2128-5-4], the day of discharge was 15.3 over 0.3. DISPOSITION: The infant is being transferred to the Well Baby Nursery. Mother remains in hospital and is anticipated to be discharged in one day. At that point, the infant will be discharged with the mother to home. Follow-up with pediatrician and cardiology will be arranged for within one week of discharge. OTHER: The infant is breast feeding ad lib. MEDICATIONS: None. IMMUNIZATIONS: Hepatitis B vaccine will be given. [Date Range ] Screen will be sent Hearing screen will be performed. FOLLOW-UP: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], pediatrician, along with pediatric cardiologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Hospital3 18242]. DISCHARGE DIAGNOSES: 1. Tetralogy of Fallot. 2. Term [Hospital3 19402]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[Name8 (MD) 38043] MEDQUIST36 D: [2128-5-4] 17:50 T: [2128-5-4] 18:30 JOB#: [Job Number 42052] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7892 }	Medical Text: Admission Date: [2144-3-20] Discharge Date: [2144-3-29] Date of Birth: [2101-11-13] Sex: F Service: SURGERY Allergies: Codeine / Doxycycline / Aspartame / NSAIDS Attending:[First Name3 (LF) 3200] Chief Complaint: incisional hernia Major Surgical or Invasive Procedure: laparoscopic incisional hernia repair with mesh, [2144-3-20] History of Present Illness: This was 42-year-old female with multiple medical co-morbidities. She was having some difficulty with a known ventral hernia that she had had for quite some time, many, many months, but it recently has become bothering her more. She claims that it was making it difficult to do activities and having difficulty walking around secondary to the weight, which she attributes to being able to do that much because of discomfort from the hernia. Past Medical History: # HIV/AIDS - Dx [2130] - last CD4 423, nadir 43 - genotype [10-21] NRTI / NtRTI mutations: 333E NNRTI mutations: None PI mutations: 63P - prior OIs: PCP [Last Name (NamePattern4) ] [2132] - prior ARVs: Trizivir in [2135] # HCV - Genotype 2B - Liver Bx [5-22] Grade1-2 inflammation, stage 3 fibrosis Awaiting enrollment into psychiatric care and stabilization of depression and substance abuse issues prior to initiation of care. # h/o HBV - cAb positive, sAb positive # h/o diverticulitis c/b colovaginal fistula [2136] # DM2 on insulin, c/b diabetic neuropathy # Peripheral neuropathy - thought to be [2-19] HIV, prior AZT, exacerbated by DM # GERD recent EGD showing esophogitis and OMR stating ? old PUD # Bipolar/Anxiety # s/p TAH/BSO # HTN # Genital HSV # Substance abuse # Chronic pain: on narcotics contract # ASD on TTE [12/2140] w/ minimal shunting on CMR # OSA - dx on recent sleep study, refuses BiPAP, uses home O2 at night # Hypothyroidism Social History: The patient lives alone in [Location (un) 14663]. She is on disability, but she has a PCA that comes in to help her. She smokes about a half a pack a day of cigarettes. She occasionally visits her mother who lives in a retirement home but otherwise has no social support. Has no partner, no children. Has been married once. Her last fiance in [2127] died two days prior to their wedding, which was source of severe depression leading to hospitalization. She has a history of bipolar and anxiety that she reports is severe. She is not suicidal or homicidal at this time. She used to have a psychiatrist but does not currently have one. History of drug abuse most recently in [Month (only) 404] with cocaine positive in her urine in addition to very poor social support. Family History: She is adopted but a history of cervical and breast cancer in family members. Physical Exam: Vitals:=99.8,HR=61,BP=154/86,RR==18,sat= 96/4l Gen:A+Ox3 HEENT;PERRL CVS:N s1s2 Chest;CTABL Abd;soft, mildly tender,mildly distended,no rebound/guarding Ext:NO C/C/E Wound:C/D/I Pertinent Results: [2144-3-26] 08:45AM BLOOD WBC-8.5 RBC-4.08* Hgb-12.5 Hct-36.4 MCV-89 MCH-30.6 MCHC-34.2 RDW-14.5 Plt Ct-240 [2144-3-24] 07:10AM BLOOD WBC-6.7 RBC-3.78* Hgb-11.1* Hct-35.7* MCV-94 MCH-29.4 MCHC-31.2 RDW-14.2 Plt Ct-190 [2144-3-22] 06:30AM BLOOD WBC-6.7 RBC-3.82* Hgb-11.3* Hct-34.7* MCV-91 MCH-29.7 MCHC-32.7 RDW-14.0 Plt Ct-181 [2144-3-26] 08:45AM BLOOD Neuts-76.3* Lymphs-10.8* Monos-4.0 Eos-8.4* Baso-0.6 [2144-3-26] 08:45AM BLOOD Glucose-161* UreaN-9 Creat-0.8 Na-137 K-4.4 Cl-96 HCO3-33* AnGap-12 [2144-3-23] 05:00AM BLOOD Glucose-104* UreaN-9 Creat-0.8 Na-142 K-4.8 Cl-101 HCO3-37* AnGap-9 [2144-3-22] 06:30AM BLOOD Glucose-195* UreaN-12 Creat-0.8 Na-139 K-4.4 Cl-101 HCO3-35* AnGap-7* [2144-3-25] 06:30AM BLOOD ALT-19 AST-23 LD(LDH)-471* AlkPhos-86 TotBili-1.2 [2144-3-25] 06:30AM BLOOD VitB12-420 Folate-12.3 [2144-3-25] 06:30AM BLOOD TSH-34* [2144-3-26] 07:15AM BLOOD T4-5.8 T3-92 Brief Hospital Course: Ms. [Known lastname 2808] was taken to the operating room on [2144-3-20] for repair of her incisional hernia. The operation proceeded without complication. Please refer to Dr. [Last Name (STitle) 51984] operative note for additional details. Her post-op course was dominated with pain control issues, requiring initial stay in the PACU extending through the night of POD 0 into POD 1 after which she was transferred to the surgical ICU for pain management issues. She was transferred to the floor on POD 3 where she remained for the duration of her hospitalization. Pertinents of her hospitalization, by systems: Neurologically: Pain control continued to be an issue through the initial portion of her hospital stay. She was followed closely by the acute pain service - an epidural was placed and she was started on her regimen of fentanyl patch/methadone/neurontin. Her epidural was removed on POD 3 without incident and she was transitioned to a dilaudid PCA then eventually oral dilaudid medication at a rate of [2-25] mg PO every 6 hours. Psych: Ms. [Known lastname 2808] was seen by the psychiatry service to assess for acute delirium on POD 4 after alleged refusal to take medication and reported uncooperative behavior with her care. She was deemed not to be delirious with no need for further testing. She was largely cooperative with her care, without incident, throughout the rest of her hospitalization. Cardiovascular: no issues Respiratory: The patient continued to require 3-4 liters oxygen via nasal cannula throughout her hospital stay. When oxygen was removed, her oxygen saturation would lie in the low-mid 90s but desaturate further upon activity. Based on previous office visits and per patient history, this was assessed to be baseline for the patient who has arrangements for home oxygen therapy. On POD 5, the patient was triggered for an O2 sat in the 70s after activity on RA. CXR was unremarkable. Her oxygen was re-continued and she remained without incident for the remainder of her hospitalization. GI: Ms. [Known lastname 2808] had return of bowel function relatively early in her hospitalization and was advanced sequentially in diet to a regular diet on POD 3. She tolerated all advances well without issue. GU: Foley cathether was removed at midnight after the epidural was removed on POD 3. On POD 5, the patient complained of symptoms of a UTI. UA was positive for UTI and she was started on a 7 day course of ciprofloxacin. Endo: Ms. [Known lastname 51974] fingersticks were found to be elevated on her existing sliding scale. Followed by [Last Name (un) ], they were consulted on POD 4 for management of her [Last Name (un) 6801] and adjusted the scale accordingly (can be found in the discharge medications). Additionally, her TSH level was checked and found to be 34. She reported that she had inadvertently stopped taking the synthroid approximately a month prior to her admission. She was restarted on synthroid during this hospitalization. ID: Ms. [Known lastname 51974] antiretrovirals were restarted on POD 2. Please see GU section re: UTI/ciprofloxacin. On POD 8, Ms. [Known lastname 2808] was afebrile, tolerating oral intake and was cleared by physical therapy for home with physical therapy services. She was discharged home with instructions to followup with Dr. [Last Name (STitle) ], Dr. [First Name (STitle) ], Dr. [Last Name (STitle) 51969] and the [First Name4 (NamePattern1) 1193] [Last Name (NamePattern1) 1194] Center. Medications on Admission: abacavir-lamivudine 600-300', atazanavir 400', clonazepam 1'', premarin, fluoxetine 80, gabapentin 900''', hydrocortizone 2.5% cream rectally'', hydromorphone 2'', glargine 50units qam, lactulose 12g/15ml - 15-30ml'', levothyroxine 150', metformin 1000'', methadone 20'', nystatin powder, promethazine 25 prh, ranitidine 150'prn, asa 81', insulin ss Discharge Medications: 1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for skin changes. 4. methadone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for nausea. 9. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 10. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 11. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q6H (every 6 hours) as needed for pain for 5 days. Disp:60 Tablet(s) Refills:0 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: [2144-3-26] - [2144-4-1]. Disp:9 Tablet(s) Refills:0 14. insulin lispro 100 unit/mL Solution Sig: One (1) see sliding scale Subcutaneous see sliding scale: Insulin Sliding Scale as follows: Glargine 34 units with breakfast. Sliding Scale (Humalog): Breakfast Humalog Scale: 71-100: 4 101-150: 10 151-200: 13 201-250: 15 251-300: 17 301-350: 19 351-400: 22 Lunch Humalog Scale: 71-100: 4 101-150: 8 151-200:10 201-250:12 251-300:14 301-350:16 351-400:18 Dinner Humalog Scale: 71-100: 0 101-150: 4 151-200: 6 201-250: 8 251-300:10 301-350:12 351-400:14 Bedtime Humalog Scale: 71-100: 0 101-150: 0 151-200: 0 201-250: 3 251-300: 5 301-350: 6 351-400: 8 [Name8 (MD) ] MD for >400. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Incisional hernia HIV Hepatitis B Hepatitis C Diverticulitis History intravenous drug abuse Bipolar disorder Anxiety disorder Gastroesophageal reflux disease Peptic ulcer disease Morbid obesity Neuropathy Thrush Hypertension Diabetes mellitus on insulin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a surgical operation called a laparoscopic incisional hernia repair with mesh to repair your hernia. The operation went well. You are proceeding well in your recovery. You developed a urinary tract infection and are being treated with an antibiotic called ciprofloxacin. Please take this medication as described on your medication list. Your oxygen levels were low while in the hospital. It is important that you continue your existing home oxygen therapy while at home and until reviewed by your primary care physician. In the coming days, please be sure to be well rested but also be sure to ambulate several times a day and be up and out of bed as much as possible. It is recommended you take at least a short walk every hour. No heavy lifting of items [10-31] pounds for 6 weeks. You may resume moderate exercise at your discretion but no abdominal exercises. Wound Care: You may showerl; no tub baths or swimming. If there is clear drainage from your incisions, cover with a clean, dry gauze. Your steri-strips will fall off on their own. Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. Your insulin sliding scale most recently adjusted by [Last Name (un) ] is here for your convenience: Insulin Sliding Scale as follows: Glargine 34 units with breakfast. Sliding Scale (Humalog): Breakfast Humalog Scale: 71-100: 4 101-150: 10 151-200: 13 201-250: 15 251-300: 17 301-350: 19 351-400: 22 Lunch Humalog Scale: 71-100: 4 101-150: 8 151-200:10 201-250:12 251-300:14 301-350:16 351-400:18 Dinner Humalog Scale: 71-100: 0 101-150: 4 151-200: 6 201-250: 8 251-300:10 301-350:12 351-400:14 Bedtime Humalog Scale: 71-100: 0 101-150: 0 151-200: 0 201-250: 3 251-300: 5 301-350: 6 351-400: 8 Followup Instructions: You are scheduled to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on Wednesday, [2144-4-1] at 9:00 AM. You are scheduled to see Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in his clinic on Wednesday, [2144-4-1], at 1:00 PM. Phone:[Telephone/Fax (1) 3201] Also, please follow up with Dr. [Last Name (STitle) 51969], your PCP, [Name Initial (NameIs) 176] 1 week from your discharge. Other appointments in the [Hospital1 18] system: Provider: [Name10 (NameIs) 2341] [Last Name (NamePattern4) 2342], M.D. Phone:[Telephone/Fax (1) 2343] Date/Time:[2144-7-29] 1:30 Completed by:[2144-3-29] ICD9 Codes: 5990, 3572, 2449, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7893 }	Medical Text: Admission Date: [2123-9-8] Discharge Date: [2123-10-11] Date of Birth: [2105-11-18] Sex: M ervice: Trauma Surgery CHIEF COMPLAINT: Motor vehicle crash HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 44505] is a 17-year-old unrestrained driver of a car who hit a tree at approximately 70 miles per hour. He was ejected from a vehicle and was emergently transferred to [Hospital ] Hospital. He was found to have [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] Coma Scale of 3. At [Hospital ] Hospital, intravenous access was achieved and the patient was intubated. He received 4 liters of fluid and 2 units of blood prior to this transfer to [Hospital1 ] for further emergent care. He was accepted at [Hospital1 ] as a trauma plus. In the trauma bay at [Hospital1 ], Mr. [Known lastname 44505] received bilateral chest tubes, diagnostic peritoneal lavage which was negative, emergent stapling of a bleeding forehead laceration and tightening of pelvis. He received 4 liters of crystalloid and 4 units of blood. Portable films were obtained in the trauma room and from the trauma room the patient was transferred to the Intensive Care Unit for further stabilization. PAST MEDICAL HISTORY: Seizure disorder with no seizures for the last three years. PAST SURGICAL HISTORY: None MEDICATIONS: Tegretol ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION RECORDED IN TRAUMA BAY: VITAL SIGNS: Heart rate from 90 to 130, blood pressure from 108 to 113 or palpable, temperature of 35?????? Celsius. GENERAL: The patient is intubated, unresponsive with a large bleeding laceration over his forehead. HEAD, EARS, EYES, NOSE AND THROAT: He has multiple abrasions over the face. His trachea is midline. BACK: There are no deformities of the back or spine. CHEST: Crepitus over the right chest with decreased breath sounds bilaterally. ABDOMEN: Distended. Pelvis is stable. EXTREMITIES: The left thigh shows deformity and the left ankle shows deformity. There is a laceration over the left knee. Both pulses on the feet are palpable. EXAM ON DISCHARGE: Temperature 99.6??????, pulse 110, pressure 137/80, respirations 22, O2 saturation 99%. [Known firstname 3403] [Known lastname 44505] is a young man who spontaneously opened his eyes and occasionally is able to track a family member entering the room. He does close his eyes to threat. He makes some lip movements, however has no other movements of his body spontaneously or on command. He has a small puncture wound on his head which is the old drain site. He has a tracheostomy tube which is clean with a midline trachea. He has a C-collar in place. His heart is regular. He has mild rhonchi on both sides. He has palpable radial pulses. His abdomen is soft, nontender, nondistended. He has a PEG tube at its insertion site, clean, dry and intact. He has a condom catheter and his extremities are all warm. He has palpable DP pulses on both legs. He has a peripheral intravenous for intravenous access. LABORATORIES ON DISCHARGE: White count of 15, hematocrit of 30, platelet count 490. PT of 14, PTT of 26, INR of 1.4. Electrolytes: Sodium 138, potassium 4.4, chloride 101, bicarbonate 24, BUN 20, creatinine 0.4, glucose 122. His Tegretol level is 6.4 on discharge. CONCISE SUMMARY OF INJURIES: Mr. [Known lastname 44505] was initially evaluated and was found to have the following injuries: 1. Right temporal and frontal contusion. 2. Small subdural overlying the occipital lobe. 3. Left first and second rib fractures, right first and second rib fractures. 4. Bilateral scapular fractures. 5. Large bilateral pulmonary contusions. 6. Left clavicular fracture. 7. C6 to T1 posterior process fracture. 8. T1 transverse process fracture. 9. Right MCA stroke diagnosed on [9-14]. 10. Bilateral pneumothoraces, status post test tubes. 11. Multiple skull fractures and pneumocephalus. 12. Right zygomatic arch fracture, right maxillary sinus and lateral [Doctor First Name 362] of the pterygoid bone fracture. 13. Mild diaphysis of the pelvis. 14. Pneumopericardium. CONCISE SUMMARY OF HOSPITAL COURSE: Mr. [Known lastname 44505] was brought to [Hospital1 ] emergently after he was an unrestrained driver in an accident with his car hitting a tree at 70 miles per hour. On arrival, he was intubated and had [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] Coma Scale of 3T. He received aggressive resuscitation and management over his hospital course which, for the sake of understanding, is described below by systems. Neurologic: By history, prior to the accident, Mr. [Known lastname 44505] is a 17-year-old young man with no neurological deficits. His GCS on arrival was 3 and his evaluation showed that he had temporal and frontal contusions, subarachnoid hemorrhage, subdural hemorrhage and pneumocephalus. He was aggressively treated on arrival and received Mannitol, Dilantin, PCO2 control, elevation of head and ICP drain placement by neurosurgery and monitoring of cerebral venous flow through a jugular catheter pointing toward the cephalad region. Despite this aggressive management, Mr. [Known lastname 44505] [Last Name (Titles) 44506] continued to rise which can be attributed to his initial injury. This was confirmed by repeat CT scans. Given this, he received a pentobarbital coma which was continued for one week. During this coma, his ICP drain continued to drain and [Last Name (Titles) 44506] consistently came down to a level of 16 or below. After this, the pentobarbital was withdrawn and he was allowed to clear as much as he would. Over the last two weeks of admission after the pentobarbital was withdrawn, Mr. [Known lastname 44507] neurological status has slightly improved. He has awakened from his coma to the level where he opens his eyes and occasionally is tracking by his eyes. He does not follow commands and does not have any purposeful movement of his extremities. His pain medications and sedation have been weaned to off and he is on Tegretol as he was prior to his accident. An MRI scan at discharge shows improvement from his initial scans on arrival. The recommended plan from a neurosurgical perspective is to continue to monitor his mental status for improvement. He is to continue on Tegretol with levels being monitored. His last level at discharge is 6.4 which is therapeutic. Of note, during his hospital course, Mr. [Known lastname 44505] also received a four vessel angiogram of his head to rule out a vascular injury. He had normal carotid and vertebral arteries during the study. Finally, as a rule out study, an EMG was obtained which was negative for any neuropathy. His ICP drainage catheter was removed 1.5 weeks prior to discharge and since then he has been stable. Cardiovascular: On hospital day 1 to 2 of his arrival, Mr. [Known lastname 44505] was found to be slightly hypotensive, requiring pressor support to maintain his blood pressure. His evaluation included a chest CT and chest x-ray, both confirming pneumopericardium. Suspecting that this pneumopericardium may be causing a tamponade, an emergent cardiac catheterization was obtained. This cardiac catheterization was consistent with tamponade and pericardial drain was placed. This pericardial drain was weaned and taken off and follow up echocardiogram show an ejection fraction of 55% with a normal ventricular function with mild left ventricular hypertrophy. Once he recovered from the pneumopericardium, Mr. [Known lastname 44505] remained stable from a cardiovascular perspective. On discharge, he is not on any cardiac medications. Of note, during his hospital course, he received intermittent hydralazine to treat occasional hypertension. This hypertension was attributed to episodes of possible agitation during his awakening and at discharge his blood pressure was stable and normal without any medications. Respiratory: Mr. [Known lastname 44505] arrived in the trauma bay with bilateral pulmonary contusions which were severe. He received emergent chest tubes on both sides and was managed per ARDS protocol, criteria of which he met. Due to prolonged intubation of three weeks, he received tracheostomy tube placement in early [Month (only) ]. He has slowly recovered from his ARDS and at discharge has been weaned off the ventilator and is tolerating trach mask for greater than 48 hours. The plan is to do routine trach care and routine trach weaning. He did receive a course of vancomycin and Zosyn for gram positive cocci and gram negative rods in the sputum. At discharge, he is off antibiotics and has been able to wean off the ventilator. Of note, on imaging, he also has a left clavicle fracture and bilateral scapular fractures, all of which are deemed nonoperative by the orthopedic service. Gastrointestinal: Mr. [Known lastname 44505] was not found to have injury to his GI tract. This was initially confirmed by diagnostic tracheal lavage during trauma resuscitation which was negative and has further been confirmed by ability to tolerate tube feeds at goal. For the first three weeks of his hospital course, he received parenteral nutrition. This, after his pentobarbital coma was removed, had been switched to tube feeds. At discharge, he has been tolerating Impact with fiber at goal of 95 cc per hour for multiple days. He received a PEG tube placement along with his tracheostomy tube placement and is being fed by this PEG tube. He has bowel movements and a soft abdomen and the PEG tube site is clean, dry and intact. At discharge, he is not on any GI prophylaxis. Infectious disease: Mr. [Known lastname 44505] hospital course has been significant for blood cultures which showed coagulase negative Staphylococcus which were determined to be from a line infection. He also had Enterobacter, Escherichia coli and gram negative rods from his sputum. These organisms were treated with courses of oxacillin, Zosyn and vancomycin in that order. On discharge, he is finishing a course of vancomycin for coagulase negative Staphylococcus from a central line. The central line has been removed. His white count at discharge is 15 and is being followed closely. Renal: Mr. [Known lastname 44505] has had normal renal function through his hospital course. Initially, he received Mannitol for his ICP management. His electrolytes were closely monitored. At discharge, he is urinating spontaneously through a condom catheter. His creatinine was stable and normal. There are no signs of injuries to the kidneys on CT scans. Heme: During hospitalization, it was revealed to the trauma team that Mr. [Known lastname 44505] has factor VII deficiency. This manifests in slightly INR of approximately 2. Initially, during unstable period, this INR was managed by fresh frozen plasma transfusions to maintain INR below 2.0. Factor VII levels were also followed. Over time, however, as Mr. [Known lastname 44505] went through multiple pros, it became evident that he is able to clot his blood adequately. We decided to not [Male First Name (un) ] his INR and tolerate INR of less than or equal to 2. At discharge, he has not received any fresh frozen plasma transfusions for more than a week and continues to maintain INR below 2 without any signs of bleeding. Due to the factor VII deficiency and due to his head injury, we have opted to hold heparin subcutaneous. This will be discussed with neurosurgery to elucidate whether to restart heparin subcutaneous for Mr. [Known lastname 44505]. Genitourinary: On arrival to the trauma bay, Mr. [Known lastname 44505] was found to have gross hematuria. This hematuria cleared over time without any intervention. He did receive a cystogram which was negative for any bladder injury. Endocrine: Mr. [Known lastname 44505] has no history of diabetes and has maintained normal blood sugars on tube feeds without insulin. Nutrition: As described above, Mr. [Known lastname 44505] was given parenteral nutrition for the first three weeks of his admission and is now tolerating tube feeds at goal of 95 an hour which is confirmed by a nutrition consult. He receives Impact with fiber by his tube feeds along with free water flushes. He is expected to continue this course of nutrition until his mental status improves to a point where he can qualify for a swallow study. Prophylaxis: Mr. [Known lastname 44505] was given proton pump inhibitor for prophylaxis until his tube feeds were started, at which time this prophylaxis was stopped. He was also kept on [Last Name (un) ] boots without heparin subcutaneous secondary to his brain injury and secondary to his factor VII deficiency and slightly elevated INR. To prevent pulmonary embolus on early [Month (only) ], Mr. [Known lastname 44505] had an IVC filter placed. This is a permanent IVC filter placed by radiology. The question of whether to restart heparin subcutaneous needs to be discussed with neurosurgery. Activity status: Mr. [Known lastname 44505] has been cleared by neurosurgery and orthopedic surgery to be allowed to get from his bed to chair. He is to remain in C-collar until neurosurgery evaluation. The C-collar is to stay at least for six weeks from his injury. Dermatology: During his hospitalization, Mr. [Known lastname 44505] was found to have a diffuse rash over his extremity which was biopsied as per dermatology consult. This biopsy showed benign folliculitis. This rash has improved since then and at discharge he has no skin rash. Of note, he does have a decubitus ulcer over his sacrum and over back of his head. Both of his ulcers have been debrided and are clean and require protective dressing care. The ulcers are stage 1 to 2 in their progression. He needs meticulous care for these ulcers to heal. DISCHARGE MEDICATIONS: 1. Tegretol 400 mg per G-tube tid 2. Tylenol prn DISCHARGE DIAGNOSES: 1. Motor vehicle trauma 2. Closed head injury 3. Tracheostomy placement 4. PEG tube placement DISCHARGE DISPOSITION: Rehabilitation FOLLOW UP: Trauma clinic at [Hospital1 ] within two weeks of discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 6066] Dictated By:[Name8 (MD) 180] MEDQUIST36 D: [2123-10-9] 21:43 T: [2123-10-11] 13:48 JOB#: [Job Number 44508] ICD9 Codes: 486
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7894 }	Medical Text: Admission Date: [2201-1-2] Discharge Date: [2201-1-6] Date of Birth: [2139-12-17] Sex: F Service: MEDICINE Allergies: Seroquel Attending:[First Name3 (LF) 358] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 61F with PMH of schizophrenia, longstanding asthma/COPD, and tracheobronchomalacia s/p Y stenting on [2200-12-13], who now presents after being found at home after falling on the floor. She states she has been fee;ling generally weaker and weaker since her recent stenting. She endorses subjective fevers and chills and malaise. On the morning of admission, she slumped onto the floor from her bed "softly" and called lifeline herself. EMS found her with a sat in the mid-80's on room air. Her home O2 was twisted and non-functional. By report, there were pills scattered on the floor. She admits to taking 1 extra thorazine pill last night in an effort to sleep, but denies current SI. although she admits that a long time ago she did engage in self-injurious behavior. . In ED, VS were 100.4 88 107/41 17 86%RA, with labile O2 sats on [4-5] liters; Lungs were rhonchorous, with poor resp effort. ABG showed 7.33/56/99, lactate 0.8. On BiPAP ([10-5]), sats improved. She was transiently hypotensive to the 80's, which spontaneously improved to 100's; didn't get IVF b/c of spontaneous resolution. U/A was clean, but urine culture and blood cultures were sent. Labs revealed an elevated WBC count of 17.5. CXR was suspicious for aspiration or early PNA. She received vanco/zosyn/solumderol and was admitted to the ICU. . On admission to the ICU, she stated she feelt better than earlier today. She was easily transferred from a NRB to 5L NC without respiratory distress or subjective SOB. Past Medical History: Schizophrenia Anxiety/depression H/o sexual abuse Asthma COPD S/p ASD repair [2151] S/p L hip replacement [2191] S/p multiple R leg fractures [2191] Social History: Lives in group home in [Location (un) ] ("[Doctor First Name ] House"). Lives with a roommate. Mother lives nearby in family home; they are very close and see each other 1-2x/week. She has a h/o tobacco 3ppd x 10years, quit 10 years ago. Denies EtOH or other drug use. Has a h/o sexual abuse while in a hospital in the [2161]'s, and has been seeing the same psychiatrist ([First Name8 (NamePattern2) 9485] [Last Name (NamePattern1) ] [Telephone/Fax (1) 100807]) for 30 years. Family History: GM died of lung ca, mother survivor of lung ca Physical Exam: VS: 97.6 89 129/54 13-20 90-94% on 4L NC GEN: appears ashen/blue, which is normal for her as a side effect of thorzine, obese, anxious but pleasant HEENT: NC/AT, dry MM, bluish coloration in face, EOMI, PERRL Neck: thick neck, unable to assess JVD, no LAD, no bruits, supple CV: difficult to auscultate given pulm exam, but RRR, no MRG appreciated Pulm: diffuse inspiratory and expiratory rhonchi anteriorly and posteriorly, with expiratory wheezes throughout Abd: +BS, obese, protuberant, tympanic throughout, soft, nt/nd, no HSM Ext: 1+ edema B/L, no c/c, 2+DP B/L Neuro: AAOX3, CN 2-12 grossly intact B/L, nonfocal Psych: no suicidal or homicidal ideations Pertinent Results: WBC 17 Hct 31 CEs negative ABG: 7.33 / 56 / 99 / 31 lactate 0.8 . MICRO: Sputum, UCx and BCx: NG . RADIOLOGY/STUDIES: [2201-1-2] CXR FINDINGS: Tracheal Y-stent is again noted in grossly stable position. Study is significantly limited by moderate rightward patient rotation. Bibasilar ill-defined opacities are poorly evaluated with differential including atelectasis, aspiration or early pneumonia. No supine evidence of pneumothorax is detected. . [2201-1-5] CXR: Bibasilar atelectasis with interval right-sided improvement since examination from [2201-1-3]. Brief Hospital Course: 61F with PMH of COPD, TBM s/p recent Y-stenting, now presenting with acute onset hypoxia, low grade temp, with CXR concerning for early PNA. . ICU COURSE: She was rapidly weaned off bipap in ICU and has been stable on [3-4] L O2. She is on home O2, 3-4 L. She had a bronchoscopy and stent was found to be in place. She was contd on vanc/zosyn for HCP and also on steroids for possible COPD exacerbation. She was transferred to the floor. . HYPOXIA: Her hypoxia was most likely secondary to inflammatory response to y-stenting that was exacerbated by her missing her medications during the holidays. She improved quickly with broad spectrum antibiotics, but did not likely have a hospital-acquired pneumonia. She was also treated with steroids for COPD initially. These were discontinued as she did not have significant evidence of COPD. She had a bronchoscopy in the ICU that showed the stent to be in good position. Repeat chest x-ray on [1-5] showed interval resolution of consolidations. She has been at her baseline O2 requirement since [1-4]. - She will complete a course for community-acquired pneumonia, as she has been stable on this regimen with cefpodoxime and azithromycin. No quinolone [2-2] QT. - She should continue her home nebs, singulair, and chest PT - possible repeat bronchoscopy in [3-4] weeks; will follow up with pulmonary . SCHITZOPHRENIA: She was continued on thorazine, gabapentin, clonazepam, buspirone . DISPO: Home oxygen and VNA were arranged for patient at moms house, where she will have someone around for assistance. Medications on Admission: Up to date in OMR. Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 3. Buspirone 10 mg Tablet Sig: Three (3) Tablet PO twice a day. 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). 5. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: Two (2) Tablet PO once a day. 6. Chlorpromazine 100 mg Tablet Sig: Twelve (12) Tablet PO HS (at bedtime). 7. Chlorpromazine 100 mg Tablet Sig: Four (4) Tablet PO once a day. 8. Clonazepam 1 mg Tablet Sig: Three (3) Tablet PO twice a day as needed for anxiety or insomnia. 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 12. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Darvocet A[Telephone/Fax (3) ] mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 16. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) neb Miscellaneous twice a day. 17. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO HS (at bedtime). 18. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for shoulder pain. 19. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 20. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 3 days. Disp:7 Tablet(s) Refills:0 21. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:3 Tablet(s) Refills:0 22. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary: Tracheobronchomalacia, COPD, Pneumonia Secondary: Schizophrenia, Anxiety, Depression, Asthma Discharge Condition: Hemodynamically stable, afebrile and with appropriate oxygen saturation on baseline supplemental oxygen. Discharge Instructions: You were admitted after being found down in your home, with a low oxygen saturation (hypoxia). This was thought to be due to not taking some of your lung medications for several days. There was also concern that you may have an early pneumonia. Thus, you are being discharged with antibiotics and your regular home oxygen. Take all medications as prescribed. Your two new medications are Cefpodoxime and Azithromycin. You should complete the course of these mediations. Please keep all outpatient appointments. Seek medical advice if you notice increased difficulty breathing, chest pain, abdominal pain, fever > 101 degrees, chills or any other symptom which is concerning to you. Followup Instructions: Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2201-1-22] 2:40 Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] / DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2201-1-22] 3:00 Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2201-1-22] 3:00 Completed by:[2201-1-6] ICD9 Codes: 486, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7895 }	Medical Text: Admission Date: [2198-2-13] Discharge Date: [2198-2-26] Date of Birth: [2145-6-15] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3223] Chief Complaint: Large ventral hernia, threatened incarceration. Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Extensive lysis of adhesions. 3. Panniculectomy. 4. Component separation advancement myocutaneous flap. 5. Ventral herniorrhaphy. History of Present Illness: This was a 52 year old woman whom had twice previously undergone procedures for ventral hernias. In [2191], she a mesh repair for a moderate sized ventral hernia present in the epigastrium at the midline. In [2194], the patient re-presented with a small intestinal obstruction, with failure of the original mesh repair. On this admission, the patient presented to the emergency room approximately 36 hours prior to the above operation with symptoms of a small bowel obstruction consisting of pain, nausea and vomiting. A CT scan demonstrated a small bowel obstruction which appeared to be within the distal ileum. She had a massive ventral hernia. Past Medical History: Schizophrenia Prior ventral hernia repair x2 CRI (interstitial nephritis 2nd to Li tox) HTN GERD Obesity Gallstones Social History: Lives in group home, denies substances. Has a son? Family History: N/A Physical Exam: 98.1 83 156/87 18 95%RA NAD, AOx3 PERRLA, CNII-XII intact B CTA-B RRR ABD: obese, morbidly. ?distension, tympanic, hypoactive BS. Mild pain to palpation globally. Reducible ventral hernia midline epigastric area, BS audible. Guaiac neg EXT: symmetric motion, no edeam. Pertinent Results: [2198-2-12] 11:00PM BLOOD WBC-10.2 RBC-4.29 Hgb-12.3 Hct-36.4 MCV-85 MCH-28.6 MCHC-33.6 RDW-13.3 Plt Ct-311 [2198-2-15] 03:35PM BLOOD WBC-10.7 RBC-3.08* Hgb-9.0* Hct-26.8* MCV-87 MCH-29.2 MCHC-33.5 RDW-13.5 Plt Ct-261 [2198-2-22] 03:30AM BLOOD WBC-11.2* RBC-2.90* Hgb-8.3* Hct-25.7* MCV-89 MCH-28.8 MCHC-32.5 RDW-13.7 Plt Ct-299 [2198-2-12] 11:00PM BLOOD Neuts-80.3* Lymphs-15.9* Monos-3.1 Eos-0.3 Baso-0.4 [2198-2-12] 11:00PM BLOOD Plt Ct-311 [2198-2-13] 09:00PM BLOOD PT-13.7* PTT-34.2 INR(PT)-1.2 [2198-2-22] 03:30AM BLOOD Plt Ct-299 [2198-2-12] 11:00PM BLOOD Glucose-140* UreaN-14 Creat-0.9 Na-141 K-4.2 Cl-101 HCO3-30* AnGap-14 [2198-2-15] 03:35PM BLOOD Glucose-121* UreaN-17 Creat-2.0* Na-142 K-4.1 Cl-106 HCO3-29 AnGap-11 [2198-2-18] 02:42AM BLOOD Glucose-92 UreaN-25* Creat-1.5* Na-150* K-3.9 Cl-110* HCO3-33* AnGap-11 [2198-2-19] 04:33AM BLOOD Glucose-112* UreaN-26* Creat-1.4* Na-150* K-3.8 Cl-108 HCO3-34* AnGap-12 [2198-2-20] 07:49AM BLOOD Glucose-106* UreaN-26* Creat-1.3* Na-146* K-3.5 Cl-106 HCO3-33* AnGap-11 [2198-2-22] 03:30AM BLOOD Glucose-115* UreaN-20 Creat-1.1 Na-145 K-3.3 Cl-106 HCO3-31* AnGap-11 [2198-2-12] 11:00PM BLOOD ALT-23 AST-35 AlkPhos-93 Amylase-75 TotBili-0.3 [2198-2-12] 11:00PM BLOOD Albumin-4.5 Calcium-10.8* Phos-3.5 Mg-2.0 [2198-2-15] 03:35PM BLOOD Calcium-8.1* Phos-5.9* Mg-2.3 [2198-2-21] 04:48AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.2 [2198-2-16] 02:20AM BLOOD Valproa-30* [2198-2-21] 04:48AM BLOOD Valproa-59 CT ABD/Pelvis: 1) Small bowel obstruction with transition point identified in a large right ventral hernia. The bowel is maximally dilated to a diameter of 4.2 cm. No free air or pneumatosis is identified. 2) Cholelithiasis without evidence of cholecystitis. Renal US ([2-16]): 1) No evidence of hydronephrosis or calculi. 2) Cholelithiasis, without evidence of cholecystitis. CXR: 1) Unchanged appearance of right subclavian central venous catheter, which terminates within the SVC. No associated pneumothorax. 2) Small bilateral pleural effusions and associated atelectatic changes. Brief Hospital Course: NEURO: on home psyche med regimen, AOx3 CV: borderline tachycardic but stable pressures RESP: no issues FEN/GI: on home diet. Abdominal wound and graft require attention in rehab RENAL: CRI known and at baseline Pt was admitted from the ED on [2-13] with a partial SBO secondary to a recalcitrant ventral hernia, without signs of strangulation. She was made NPO with an NG tube in preparation for surgery. She was taken to the OR on HD#2 for the above procedure. The operation was without complication or finding necessitation a change in pre-operative diagnosis. However, she experienced a difficult extubation post-operatively and remained intubed in the PACU until the AM of POD#1 (HD#3). During this period of time, she was noted to be oliguric despite repeated fluid boli, likely secondary to her know CRI. After extubation, she was transferred to the TSICU for closer observation and monitoring of her fluid status. A renal consult was also obtained at this time for help in managing her acute-on-chronic CRI. A central line was placed, and her renal output improved with resolution of her 4L fluid deficit; she was transferred to the floor on POD#4. She was kept NPO until POD#5, at which time she was advanced to clears. Since her extubation, she had exhibited a somewhat obtunded mental status, however, this too improved gradually to her preop baseline by POD#8. Also, since the OR, pt had been borderline tachycardic with HRs to 95-105 without a clear etiology. By POD#8, her pain was completely controlled on an oral regimen. On POD#9, she tolerated a full PO diet, and IVF was d/c'ed. She was considered stable for D/C at this time, but was kept over the weekend due to placement issues before finally being d/c'ed on [2-26]. Through this [Hospital ] hospital course and participation of the Primary care UMG service was appreciated. Medications on Admission: Depakote 1250 mg qd Risperadol 3 mg qd Seroquel 100 mg [Hospital1 ] Colace HCTZ 25 mg qd Zestril 30 mg qd Flonase Vit E Discharge Medications: 1. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 2. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation Q4-6H (every 4 to 6 hours) as needed. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours: as needed. 5. Divalproex Sodium 250 mg Tablet Sustained Release 24HR Sig: Five (5) Tablet Sustained Release 24HR PO once a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Risperidone 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Discharge Disposition: Extended Care Facility: [Location (un) ] Manor Discharge Diagnosis: 1) Recalcitrant ventral hernia 2) Partial small bowel obstruction 3) CRI 4) Schizophrenia 5) HTN Discharge Condition: Good, improving Discharge Instructions: Discharge to [Location (un) ] Manor with instructions to take medications as perscribed and to follow up with Dr. [Last Name (STitle) 519] as stipulated below. You should remain in rehab for 1-2 weeks before discharge back to your pre-operative setting. Do not engage in heavy lifting or strenous activity until after your follow-up visit. You may shower (but do not bath or immerse yourself in water) with careful drying of your incision site. If you experience fever, unremitting abdominal pain, bloody/dark stools or any other symptoms concerning to you, please seek medical attention at a convenient ER. Followup Instructions: Please call Dr.[Name (NI) 1745] office to schedule a follow up appointment; you should see him in about 2 weeks following discharge: ([Telephone/Fax (1) 5323] These other appointments are also scheduled for you: Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ]/DR. [Last Name (STitle) ] Where: [Hospital6 29] NEUROLOGY Phone:[Telephone/Fax (1) 6856] Date/Time:[2198-3-6] 10:00 Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] OB/GYN PPS CC8 (SB) Where: OB/GYN PPS CC8 (SB) Date/Time:[2198-5-1] 11:30 Provider: [Name10 (NameIs) ] [Doctor Last Name ], OD Where: [Hospital6 29] Phone:[Telephone/Fax (1) 253] Date/Time:[2198-8-28] 10:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] ICD9 Codes: 5849, 2762, 486, 2760, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7896 }	Medical Text: Admission Date: [2171-3-18] Discharge Date: [2171-3-26] Date of Birth: [2105-5-31] Sex: M Service: MEDICINE Allergies: Pravastatin / Shellfish Derived Attending:[First Name3 (LF) 7281] Chief Complaint: presented for left total knee replacement Major Surgical or Invasive Procedure: [2171-3-18]: s/p Left total knee replacement History of Present Illness: 65M with history of ESRD s/p renal transplant [2165] c/b graft failure, on immunosuppression, HIV/AIDS on HAART, HBV, DM, HTN, currently POD #2 s/p L TKR, whose course has been complicated by [Last Name (un) ], hyperkalemia, anemia, thrombocytopenia, fevers, and altered mental status. Mr. [Known lastname ] was admitted to the Ortho service after undergoing L TKR on [2171-3-18]. He tolerated the procedure well, with about 300cc EBL. However, over the last several days he has become increasing more somnolent. This morning, was difficult to arouse, not following commands, and unable to answer questions. He has been febrile (Tmax 101.9 on [3-19], 101.4 today), though has not had a clear infectious source. His UA was unremarkable, blood cultures sent [3-19] are negative to date, and CXR earlier today was not suggestive of infection. Of note, he received Ancef peri-operatively, but otherwise has not been on antibiotics. He was initially on a dilaudid PCA, and has since been transitioned to oral oxycodone. Hct has trended down from 35.8 on [2171-3-5] to 25.8 on POD#1 to 21.7 today (POD #2). He was ordered for 2 units pRBCs but has not yet been transfused given his fevers. . Of note, his Cr has been trending up from 2.9 on admission to 4.2 this afternoon. Renal transplant team is following. Over the past 2 days he has also had worsening hyperkalemia, and K was 7.1 this morning. For his hyperkalemia, he was given kayexalate 30 once, calcium gluconate 2gm IV, albuterol neb, 10 units insulin, 40 mg IV lasix, 25 gm IV dextrose 50%, sodium bicarb 50 mEq IV. K has since trended down to 5.5, which is close to his recent baseline. Platelet count has also been decreasing, and is down to 85 today. Heme/onc also consulted, and feel this is likely thrombocytopenia secondary to sepsis. Was some concern for TTP, though labs not suggestive of this. Given worsening mental status, increased nursing requirements, and above medical issues, he is being transferred now the ICU for further evaluation and management. VS prior to transfer were 101.4, 152/62, 78, 20, 96% RA. On arrival to the ICU, patient arousable, can state name, and can follow some commands. He cannot state where he is, what the date is, or answer most questions. . Review of systems: Unable to obtain secondary to patient's mental status. On later questioning, elicited history of bilateral ankle pain, R > L. Past Medical History: * ESRD: s/p renal transplant [12/2165], c/b chronic graft failure; just recently started tacrolimus; on prednisone 5 mg daily * HIV: CD4 of 38 and viral load of 65 in [2169-12-16]. * HTN * DM: poorly controlled; recent A1c 10.8 * MGUS: UPEP and SPEP in [12/2166] showed no evidence of monoclonal protein. * Osteoarthritis * Medication noncompliance * Diastolic HF, EF 55% Social History: Lives alone. No tobacco or illicit drug use per notes. Per records, does have history of prior heavy alcohol use, but his daughter reports rare/minimal EtOH use at present. States he may have had a drink in [Month (only) 404] (Superbowl Sunday), but no other EtOH intake she is aware of. works as a chef. Has HIV but daughter who is also his healthcare proxy is unaware. Family History: Per daughter, no family history of heart or renal disease. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 100.6 BP: 135/50 P: 85 R: 18 O2: 93% on 2L General: intermittently lethargic and difficult to arouse, at other times awake, oriented to person only, able to follow some commands, not able to answer questions HEENT: pupils contricted and minimally reactive, EOMI, sclera anicteric, slightly dry MM, oropharynx clear Neck: supple, JVP not elevated Lungs: CTAB in anterior and lateral lung fields, no wheezes, rales, rhonchi CV: RRR, normal S1 + S2, mumur heard throughout precordium likely radiating from fistula Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, renal graft present in RLQ GU: no foley Ext: warm, well perfused, 2+ pulses, no lower extremity pitting edema, left knee dressing C/D/I, LUE with AV fistula with palpable thrill, right ankle with small effusion but no warmth/erythema, RUE with mild edema Neuro: EOMI, face symmetric, shrug strength 5/5, moving all four extremities, unable to cooperate with full exam, intermittent jerking/twitching movements, + asterixis . DISCHARGE PHYSICAL EXAM: VS 98.1 (98.7) 142/31 (132-155/31-39) 66 (65-72) 18 98RA (98-100RA) I/O: 1360/1550 BMx2 FSBS: 174-374 Weight: 89.6 kg GENERAL: very pleasant, comfortably lying in bed, appropriate HEENT: EOMI, PERRL, clear oropharynx NECK: Supple with low JVP, no cervical LAD CARDIAC: RRR, normal S1/S2, continuous murmur from fistula heard at sternal border LUNGS: Resp were unlabored, no accessory muscle use, moving air well and symmetrically on anterior auscultation. +Minimal rales at the bases bilaterally. ABDOMEN: Soft, non-tender to palpation. No HSM or tenderness. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. DP/PT dopplerable bilaterally. Right knee with some swelling, surgical site intact, slight erythema, no exudate. Left arm with old AV graft (not used since [2165]). NEURO: Awake, alert and oriented x3, CNs II-XII intact, moving extremities Pertinent Results: ADMISSION LABS: [2171-3-19] 06:24AM BLOOD WBC-7.8# RBC-2.84# Hgb-8.1# Hct-25.8# MCV-91 MCH-28.3 MCHC-31.3 RDW-14.5 Plt Ct-98 [2171-3-20] 06:50AM BLOOD Neuts-87* Bands-0 Lymphs-6* Monos-6 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [2171-3-20] 01:40PM BLOOD PT-12.6* PTT-33.1 INR(PT)-1.2* [2171-3-18] 04:30PM BLOOD Glucose-201* UreaN-64* Creat-2.9* Na-143 K-5.6* Cl-113* HCO3-23 AnGap-13 [2171-3-20] 06:50AM BLOOD LD(LDH)-172 CK(CPK)-215 TotBili-0.2 [2171-3-20] 01:40PM BLOOD ALT-3 AST-15 AlkPhos-33* . RELEVANT LABS: [2171-3-20] 05:39PM BLOOD Type-ART pO2-69* pCO2-33* pH-7.40 calTCO2-21 Base XS--2 [2171-3-20] 01:40PM BLOOD Creat-4.2* Na-137 K-6.1* Cl-107 [2171-3-20] 01:40PM BLOOD WBC-7.5 RBC-2.35* Hgb-6.4* Hct-21.7* MCV-92 MCH-27.4 MCHC-29.6* RDW-14.8 Plt Ct-85* [2171-3-21] 04:29AM BLOOD WBC-8.0 RBC-2.41* Hgb-6.7* Hct-21.6* MCV-89 MCH-27.7 MCHC-31.0 RDW-14.9 Plt Ct-102* [2171-3-23] 06:48AM BLOOD VitB12-432 [2171-3-23] 06:48AM BLOOD Ammonia-17 . PERTINENT LABS: [2171-3-24] 06:50AM BLOOD tacroFK-7.2 . DISCHARGE LABS: [2171-3-26] 06:00AM BLOOD WBC-6.8 RBC-2.91* Hgb-7.9* Hct-25.9* MCV-89 MCH-27.1 MCHC-30.4* RDW-18.0* Plt Ct-245 [2171-3-26] 06:00AM BLOOD PT-15.2* PTT-35.1 INR(PT)-1.4* [2171-3-26] 06:00AM BLOOD Glucose-284* UreaN-75* Creat-3.0* Na-138 K-4.8 Cl-109* HCO3-19* AnGap-15 [2171-3-26] 06:00AM BLOOD Calcium-8.2* Phos-3.2 Mg-2.5 [2171-3-26] Tacrolimus level: pending . MICROBIOLOGY: [2171-3-19] Urine culture: no growth [2171-3-19] Blood cultures x2: no growth [2171-3-20] MRSA Screen: negative [2171-3-20] Blood culture: no growth to date . PATHOLOGY: [2171-3-20]: left femoral tissue diagnosis: Consistent with osteoarthritis. . IMAGING: [2171-3-18] L knee x-ray: FINDINGS: In comparison with study of [2170-9-12], there has been placement of a left TKA that appears to be well seated without evidence of hardware-related complication. Standard post-surgical changes are seen. . CXR [2171-3-20]: In comparison with study of [2-15], there are slightly lower lung volumes. There is enlargement of the cardiac silhouette with engorgement of indistinct pulmonary vessels consistent with some elevated pulmonary venous pressure. The left hemidiaphragm is not as well seen, suggesting volume loss in the left lower lobe and possible left effusion. . [2171-3-21] unilateral RU extremity u/s FINDINGS: Grayscale and color Doppler son[Name (NI) 1417] of the bilateral subclavian veins and the right internal jugular, axillary, brachial and basilic veins were performed. There was normal compressibility, flow, and augmentation. The right cephalic vein was not visualized. IMPRESSION: No right upper extremity DVT. . [2171-3-22] CXR FINDINGS: Portable AP chest radiograph demonstrates a new right PICC terminating in the mid-to-low SVC. There are persistent left basilar opacities that probably represent atelectasis. There is no pneumothorax or pleural effusion. The heart size is within normal limits. IMPRESSION: Right PICC terminates in the mid-to-low SVC Brief Hospital Course: Mr. [Known lastname ] is a 65M with history of ESRD s/p renal transplant [2165] c/b graft failure, on immunosuppression, HIV/AIDS on HAART, HBV, DM, HTN, currently s/p L TKR, whose course has been complicated by [Last Name (un) ], hyperkalemia, anemia, thrombocytopenia, fevers, and altered mental status requiring ICU transfer. . HOSPITAL COURSE: . #TOTAL KNEE REPLACEMENT: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Patient will require 3 weeks of anticoagulation with warfarin after this hospitalization for post-op DVT prophylaxis. Subcutaneous heparin should be continued at rehab. . Postop course was remarkable for the following: 1. Nephrology Transplant consult for co-management 2. Hyperkalemia 3. Heme consult for thrombocytopenia 4. Medicine consult for co-management 5. Post-op anemia due to bloos loss - Hct 21.6 . Given the above, when pt developed altered mental status [2171-3-20] he was transferred to the Medical ICU, and once stablized, transferred to the medicine floor. . POST-OPERATIVE COURSE: On [2171-3-20], patient was transferred to the ICU for increased lethargy/AMS and further evaluation and management of his hyperkalemia, [Last Name (un) ], anemia, thrombocytopenia, and fevers. . . ACTIVE ISSUES: # Encephalopathy: Was felt to be secondary to delirium in setting of toxic-metabolic encephalopathy (post-op pain, narcotic pain medication administration, fevers, possible infection, electrolyte abnormalities, and renal impairment). His sedating medications and narcotics were initially held, though restarted at lower dosing as his mental status improved. His fever was evaluated and treated as below. While in the ICU, he became less lethargic, and while occasionally oriented to person/place/time he was intermittently confused and paranoid. Considered EtOH withdrawal, but patient's daughter did not believe he is actively drinking. . # Fevers: No clear source of infection. Patient was initially started on vanc/zosyn for possible PNA given fevers and new oxygen requirement, but these were stopped after CXR negative. UA unremarkable, and blood cultures remained negative. LFTs not suggestive of hepatitis or biliary process. Considered menigitis, especially given immunosuppression, though patient's exam and overall clinical presentation not suggestive of this infection. Also considered post-op fevers, thrombus. . # Right ankle/heel pain: Differential included gout, pressure sore, peripheral neuropathy. Evaluated by Ortho. Uric acid level was elevated at 9, however pain resolved the following day and was no longer concerning. . # RUE edema: RU extremity u/s was performed which showed no evidence of DVT. Most likely dependent edema. . # Hypoxia: Likely secondary to atalectasis, and quickly resolved. CXR negative for PNA. Also considered aspiration, and kept patient NPO until mental status improved. . # Anemia: Hct dropped to 21.6 on POD#2. Per Ortho team, this degree of anemia can be expected post-operatively. Patient had 300cc EBL in OR, and also had vac on knee that drained about 265cc per chart. Labs not suggestive of hemolysis, and direct Coombs was negative. Transfused 4 units pRBCs, intitially without appropriate HCT bump but with the 4th unit he demonstrated appropriate response. No obvious source of bleeding. Hematocrit rose to the mid-20s, and remained stable there for the rest of his hospital course. Discharge Hct was 25.9. . # [Last Name (un) ]: Patient with ESRD s/p renal transplant [2165] c/b graft failure, on immunosuppression. Recent baseline has been 2.7-3.2. Cr was 2.9 on admission [2171-3-18], rose to 4.2 on [2171-3-20]. Acute rise in creatinine was most likely secondary to allograft nephropathy in the setting of decreased renal perfusion (decreased PO intake post-op, increased insensible losses w/fevers). Over the course of admission, creatinine trended down to 3.0 at the time of discharge (within his previous baseline). His home medications were restarted. . # Hyperkalemia: Improved after administration of kayexalate, insulin, dextrose, calcium gluconate, albuterol, and bicarb earlier. Likely secondary to worsening renal function. Elevation secondary to cell lysis less likely as labs not suggestive of hemolysis. . # Thrombocytopenia: Was initially concern for TTP given concurrent anemia and AMS, though labs not c/w this diagnosis. [Month (only) 116] be secondary to decreased production in setting of fevers/sepsis and recent surgery. Heme consulted and felt also possible that tacro toxicity contributing. Would also need to consider medication effect, as patient has been on HAART and immunosuppressive agents with worsening renal function, as well as thrombocytopenia related to his underlying HIV. HIT seems less likely given timing. No known history of liver disease, and no palpable splenomegaly on exam. Platelets improved to 200 at the time of discharge. . . CHRONIC ISSUES: # HIV on HAART: Most recent CD4 count on [2171-3-5] was 327, with HIV VL undetected. Per outpt ID provider [Last Name (NamePattern4) ]. [Last Name (STitle) 724], initially held antiretrovirals for now as these may be contributing to AMS. Renal transplant team felt that HAART could be restarted and this was done on [2171-3-21]. Tacrolimus levels were followed throughout adjustment of HAART regimen. Of note, pt's daughter, who is his healthcare proxy, is unaware of his HIV status. . # Tremor: Per notes, tremor has been present for weeks. Etiology unclear, not consistent with asterixis. . # ESRD s/p transplant c/b graft failure, on immunosuppresssion. He continued weekly tacrolimus 0.5 mg and prednisone 5 mg daily. Continued bactrim ppx. . . # Osteopenia: Patient restarted his home calcitriol and Vitamin D . # HTN: BP currently well controlled. He was restarted on his home metoprolol, clonidine, Lasix and terazosin. . # DM: Most recent A1c 8.7 [2171-2-7]. [Last Name (un) ] following, appreciate input. Continued lantus plus insulin sliding scale. He was discharged on 28 units of Lantus in the morning (which was his dose prior to admission). . . TRANSITIONAL ISSUES: # Please call back to follow up tacrolimus level on [2171-3-26] (pending at the time of discharge. Level should be checked weekly, 30 minutes prior to administration of medication. IF TACROLIMUS LEVEL IS NOT WITHIN RANGE 5.0-7.0, please call Dr. [Last Name (STitle) ] [Telephone/Fax (1) 673] for further instructions. # Please continue anticoagulation with warfarin for 3 weeks, with goal INR 2-2.5. Patient should be established with [Hospital 191] [Hospital ] Clinic after discharge from rehab. # Please check INR daily until INR is therapeutic (2-2.5) and stable. Then weekly checks are adequate. # Patient's daughter/HCP does not know about his positive HIV status. She should not be informed of this. # Code: full (confirmed) # HCP: Daughter [Name (NI) 1743] [Name (NI) ] [Telephone/Fax (1) 17673] Medications on Admission: ASA 81mg qd, bactrim ss qod, terazosin 3mg qhs, novolog SS and lantus 28u qam, lasix 40mg [Hospital1 ], metoprolol 25mg [Hospital1 ], omeprazole 40mg [Hospital1 ], viread 300mg twice weekly, lamivudine 100mg qd, Ritonavir 100mg [Hospital1 ], prezista 600mg [Hospital1 ], Etravirine 200mg [Hospital1 ], tacrolimus 0.5mg qweek, prednisone 5mg qd, clonidine 0.1mg tid, gabapentin 300mg qhs (not taking) Discharge Medications: 1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. darunavir 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take with ritonavir. 4. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. insulin aspart 100 unit/mL Solution Sig: One (1) unit Subcutaneous three times a day: per sliding scale, with meals. 7. insulin glargine 100 unit/mL Solution Sig: Twenty Eight (28) units Subcutaneous once a day: in the morning. 8. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual q5 minutes as needed for chest pain. 11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 12. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. ritonavir 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take with darunavir . 14. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 15. tacrolimus (bulk) 100 % Powder Sig: 0.5 mg Miscellaneous once a week: on Tuesdays. 16. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1) Tablet PO TWICE A WEEK ON SATURDAY AND WEDNESDAY (). 17. terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 18. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain. 19. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 20. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): while at rehab. 22. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM for 3 weeks: Goal INR 2-2.5, for post-op DVT prophylaxis. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary diagnosis: Left knee osteoarthritis . Secondary diagnoses: Acute on chronic kidney disease Hyperkalemia Post-op anemia due to blood loss Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure to participate in your care here at [Hospital1 1535]! You were admitted for an elective left total knee replacement. Your post-operative course was complicated by decrease in your kidney function, low blood counts, and high potassium. We adjusted your medications to treat these problems, and you improved. Please note, the following changes have been made to your medications: - START warfarin 5 mg by mouth daily at 4 pm. This dose will be adjusted based on your labs (INR) at rehab. Then, your dosing should be followed closely by the [Hospital1 18] [Hospital 191] [Hospital ] Clinic. You should continue warfarin for 3 weeks (until [4-13]), with a goal INR of [1-17].5. - CONTINUE heparin injections three times per day while at rehab. Continue all of your other medications as you had prior to this hospitalization. The following are your post-operative 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. You may not drive a car until cleared to do so by your surgeon. 3. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) 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 at your follow-up visit in three (3) weeks after your surgery. 4. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 5. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 6. ANTICOAGULATION: Please continue your heparin while at rehab, then warfarin for three (3) weeks to help prevent deep vein thrombosis (blood clots). You may continue your Aspirin 81mg daily. [Male First Name (un) ] STOCKINGS x 6 WEEKS. 7. 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 (4) 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 at your follow-up visit in three (3) weeks. 8. VNA (once at home): Home PT/OT, dressing changes as instructed, and wound checks. 9. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. CPM/ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. 10. Weigh yourself every morning, call your doctor if weight goes up more than three pounds. Please see below for your follow-up appointments. Wishing you all the best! Followup Instructions: Department: ORTHOPEDICS When: TUESDAY [2171-4-9] at 1:40 PM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ], PA [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: TRANSPLANT CENTER When: WEDNESDAY [2171-4-10] at 8:20 AM With: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: TRANSPLANT When: TUESDAY [2171-4-16] at 9:00 AM With: TRANSPLANT ID [Telephone/Fax (1) 673] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: [Hospital3 249] When: MONDAY [2171-5-20] at 11:00 AM With: [First Name8 (NamePattern2) 1238] [Last Name (NamePattern1) 1239] [Name8 (MD) ], NP [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 7284] ICD9 Codes: 5180, 5849, 2851, 2724, 5859, 2875, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7897 }	Medical Text: Admission Date: [2132-3-7] Discharge Date: [2132-3-19] Date of Birth: [2066-10-24] Sex: F Service: MEDICINE Allergies: Gluten Attending:[First Name3 (LF) 1974] Chief Complaint: Pneumonia, Sepsis Major Surgical or Invasive Procedure: Intubation Right radial arterial line Left subclavian central venous line PICC line History of Present Illness: 65yo F with no significant PMH presents with pneumonia and severe sepsis. Pt complains of dry cough, nasal congestion, and weakness, gradually worsening over past 1-2 weeks. Also with shortness of breath at rest. Went to OSH ([Hospital1 1559]), where initial vitals were BP 110/62, P 102, RR 20, O2 sat 90-98% on FM. Cxr showed bilateral pneumonia. ABG 7.21/47/57, Lactate 1.1. She received Duonebs, Decadron 10mg IV, and 3L NS. Pressure dropped to 70/30--> minimal response w/ 2.5L NS. A femoral artery CV line placed and levophed started. She was transferred to [Hospital1 18] with BP 89/50 on transfer. . At [Hospital1 18] [Name (NI) ], pt was afebrile (T 97.7) and continued to have SBPs 80-90's despite Levophed. Cefepime 2g IV x 1 was given and potassium repleted. She was transferred to the [Hospital Unit Name 153] for further monitoring. . Pt denies fevers, chills, chest pain, abdominal pain. Does report unintentional weight loss of about 18 pounds over the past 12-15 months. Per EMS report, pt had a fall last week, w/ back pain since fall. Past Medical History: Fibromyalgia. Pt rarely sees a physician. Social History: Lives with husband in [Name (NI) 1559]. Denies current or prior smoking. No EtOH or other drug use. Family History: Non-contributory. Physical Exam: T95.4, P 79, BP 108/51, RR 23, O2sat 99% on NRB (Levophed @ 0.5) Lines: femoral CV line Gen: cachectic woman, appears older than age. HEENT: Dry MM, dental caries, brown discoloration of tongue Neck: supple, good carotid upstrokes Lungs: rhonchi heard diffusely, L>R, with egophony at L base. Also w/ bronchial breath sounds in left lung fields. Chest: RRR, no m/r/g, no JVD Abd: soft, nt, nd, NABS Extrem: 2+ pulses, WWP, no edema Neuro: oriented to person, place, and time. Very tired and not wanting to answer questions. Pertinent Results: Admission labs: [2132-3-7] 12:15AM WBC-15.6* RBC-3.66* HGB-10.7* HCT-32.2* MCV-88 MCH-29.1 MCHC-33.1 RDW-15.9* [2132-3-7] 12:15AM NEUTS-75* BANDS-2 LYMPHS-19 MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2132-3-7] 12:15AM GLUCOSE-125* UREA N-36* CREAT-0.9 SODIUM-143 POTASSIUM-2.8* CHLORIDE-115* TOTAL CO2-17* ANION GAP-14 [2132-3-7] 12:15AM CALCIUM-6.9* PHOSPHATE-4.3 MAGNESIUM-1.6 [2132-3-7] 12:24AM LACTATE-0.7 [2132-3-7] 05:07AM PLT COUNT-625* [2132-3-7] 05:07AM ALT(SGPT)-49* AST(SGOT)-34 CK(CPK)-81 ALK PHOS-140* TOT BILI-0.2 [2132-3-7] 05:07AM ALBUMIN-1.6* [2132-3-7] 05:55AM PT-21.9* PTT-50.8* INR(PT)-2.1* [2132-3-7] 06:19AM TYPE-ART TEMP-36.1 O2-70 PO2-82* PCO2-52* PH-7.12* TOTAL CO2-18* . [3-7] Admission cxr: There is extensive bibasilar consolidation with air bronchograms. Right suprahilar opacity is also evident. There is blunting of both costophrenic angles suggestive of small effusions. No pneumothorax is evident. . [3-7] Echo: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is normal (LVEF 60%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. . [3-13] Upper extremity Doppler U/S (ordered for LUE edema on side of subclavian line): No evidence of DVT. . [2132-3-14] 2:12 pm CATHETER TIP-IV Source: arterial line. WOUND CULTURE (Final [2132-3-16]): No significant growth. . [2132-3-11] 4:49 pm BLOOD CULTURE Source: Line-central. AEROBIC BOTTLE (Final [2132-3-17]): NO GROWTH. ANAEROBIC BOTTLE (Final [2132-3-17]): NO GROWTH. . [2132-3-11] 4:34 pm BLOOD CULTURE Source: Line-Aline. AEROBIC BOTTLE (Final [2132-3-17]): NO GROWTH. ANAEROBIC BOTTLE (Final [2132-3-17]): NO GROWTH. . [2132-3-10] 9:42 am URINE Source: Catheter. URINE CULTURE (Final [2132-3-11]): NO GROWTH. . [2132-3-13] 7:48 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. ACID FAST SMEAR (Final [2132-3-14]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): . [2132-3-11] 12:09 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [2132-3-11]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [2132-3-13]): MODERATE GROWTH OROPHARYNGEAL FLORA. ACID FAST SMEAR (Final [2132-3-12]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): . [2132-3-11] 12:09 pm STOOL CONSISTENCY: WATERY Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2132-3-11]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. . [2132-3-7] 2:19 pm URINE Source: Catheter. Legionella Urinary Antigen (Final [2132-3-10]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. . [2132-3-10] 09:42AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.005 [2132-3-10] 09:42AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [2132-3-10] 09:42AM URINE RBC-3* WBC-0 Bacteri-NONE Yeast-NONE Epi-0 . [2132-3-17] 05:39AM BLOOD WBC-12.9* RBC-3.03* Hgb-9.2* Hct-28.4* MCV-94 MCH-30.3 MCHC-32.3 RDW-15.3 Plt Ct-529* [2132-3-17] 05:39AM BLOOD Plt Ct-529* [2132-3-17] 05:39AM BLOOD Glucose-119* UreaN-13 Creat-0.4 Na-143 K-3.5 Cl-108 HCO3-30 AnGap-9 [2132-3-17] 05:39AM BLOOD ALT-54* AST-26 LD(LDH)-294* AlkPhos-123* TotBili-0.2 [2132-3-17] 05:39AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.5* . [2132-3-13] 03:46AM BLOOD Lipase-113* [2132-3-11] 04:27AM BLOOD Lipase-115* [2132-3-13] 03:46AM BLOOD CK-MB-8 cTropnT-0.04* [2132-3-12] 07:19PM BLOOD CK-MB-8 cTropnT-0.05* [2132-3-12] 12:49PM BLOOD CK-MB-10 MB Indx-1.2 cTropnT-0.06* [2132-3-7] 02:18PM BLOOD CK-MB-9 cTropnT-0.03* [2132-3-7] 05:07AM BLOOD CK-MB-15* MB Indx-18.5* [2132-3-18] 04:33AM BLOOD Hapto-244* [2132-3-15] 08:58AM BLOOD Triglyc-155* [2132-3-11] 04:27AM BLOOD TSH-1.3 [2132-3-12] 03:57PM BLOOD PTH-400* [2132-3-7] 02:19PM BLOOD Cortsol-10.4 [2132-3-7] 02:19PM BLOOD Cortsol-7.6 [2132-3-7] 02:18PM BLOOD Cortsol-5.9 [2132-3-12] 03:57PM BLOOD IgG-1014 IgA-204 IgM-48 [2132-3-14] 03:18PM BLOOD freeCa-1.04* . [2132-3-18] 08:20PM BLOOD Hct-24.8* [2132-3-18] 04:33AM BLOOD WBC-9.8 RBC-2.78* Hgb-8.1* Hct-24.9* MCV-90 MCH-29.3 MCHC-32.7 RDW-15.9* Plt Ct-492* [2132-3-18] 04:33AM BLOOD Neuts-70.4* Lymphs-21.1 Monos-6.8 Eos-1.3 Baso-0.4 [2132-3-18] 04:33AM BLOOD Hypochr-2+ Macrocy-1+ [2132-3-18] 04:33AM BLOOD Plt Ct-492* [2132-3-18] 04:33AM BLOOD Plt Ct-492* [2132-3-18] 04:33AM BLOOD Glucose-97 UreaN-16 Creat-0.4 Na-144 K-4.2 Cl-112* HCO3-27 AnGap-9 [2132-3-18] 04:33AM BLOOD ALT-50* AST-27 LD(LDH)-271* AlkPhos-116 TotBili-0.2 [2132-3-18] 04:33AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.7 [2132-3-18] 04:33AM BLOOD Hapto-244* . Brief Hospital Course: Admitted to the [Hospital Unit Name 153] [2132-3-7]. . 1) Hypotension: Pt was hypotensive on admission, with SBPs 80's-90's despite high doses of levophed. Pt received multiple fluid boluses and vasopressin was added with good effect. Pt had an inadequate response to a cortisol stimulation test (baseline 5.9 --> 7.6 @ 0.5hr--> 10.4 @ 1hr), and so a 7 day course of hydrocortisone 100mg IV q8h/fludrocortisone 0.05mg po daily was administered. By HD#4, pt no longer required any pressors and remained hemodynamically stable for the rest of her course. The etiology of the hypotension was likely septic shock from pneumonia. . 2) Bilateral Pneumonia: Pt was admitted with a cxr consistent with multifocal pneumonia. She was intubated on HD#1 secondary to severe acidosis (pH 7.12, pCO2 52, pO2 82). Sputum gram stain showed gram positive cocci in pairs. Sputum cultures were negative. Pt was initially treated with ceftriaxone/azithro for CAP. Given lack of clinical improvement (as measured by fever curve, WBC count, vent requirements, and persistent gram pos cocci on sputum gram stain) after a few days of tx, vancomycin was added to the regimen to cover for MSSA/MRSA. She subsequently improved and was extubated on HD#7. Post extubation, the abx coverage was narrowed to Vancomycin and Levaquin only to complete an 10 day course (completed on [3-19]). Given history of weight loss, diarrhea, cough, and positive PPD, pt was also placed in negative isolation room and ruled out x 3 sputum samples for acid fast bacilli. . 3) Fever: Pt was persistently febrile for the first 5 days of her course despite multiple days of abx therapy. Coverage of pna was expanded to vancomycin which coincided with resolution of fevers. A TTE was checked early on which showed no valvular vegetations; TEE was not pursued given low suspicion for endocarditis. A central line infection was questioned but given the requirement for frequent electrolyte repletions and IV abx, the subclavian line was not pulled until [3-15] after a PICC line was placed on [3-14]. Multiple sets of blood cultures obtained throughout course were negative. . 4) Diarrhea: Pt had persistent diarrhea from admission. Per family, pt had been having intermittent diarrhea and abdominal pain for weeks-months prior to admission, but had never seen a doctor about it. C.diff was negative x 3. Given her cachectic appearance a malnutrition syndrome was suspected. ttG-IgA was > 120units, highly suggestive of celiac disease. GI was consulted and plan is to undergo colonoscopy and small bowel biopsy as an outpatient. She was put on gluten-free diet and had resolution of diarrhea. . 5) Nutrition: OG tube feeds were initiated while pt was intubated. High probability of celiac disease prompted change of tube feeds to gluten-free elemental. However, diarrhea did not abate and her persistent electrolyte requirements and low albumin suggested she was not absorbing much through her GI tract. TPN was started on [3-13] to improve nutritional status. Modest po intake was allowed during this time. After several days of TPN, her PO intake improved and was excellent. She had good appetite and TPN was discontinued. . 6) Hypokalemia: Pt was hypokalemic on admission and required multiple daily repletions of K throughout her course. Initially this was attributed to diarrheal losses, but urine studies revealed massive renal potassium wasting. Ddx includes fludrocortisone, Mg deficiency, alkalemia. Fludrocortisone was d/c'd after 7 days and Mg/K repleted aggressively. Subsequently stable. . 7) Hypernatremia: Na was stably elevated throughout course (143-148) despite >2L free H20/day in tube feeds. Urine osmolality was inappropriately low (186), c/w diabetes insipidus. On no meds known to cause DI, although severe hypokalemia can cause DI. Sodium stabilized in high normal range. . 8) Hypocalcemia: Pt was persistently hypocalcemic, with appropriately elevated PTH. Most likely etiology vitamin D deficiency [12-28] malabsorption. Vitamin D level pending. Vit D was supplemented throughout course and CaGluconate administered prn. She should complete a 7d course of Vit D [Numeric Identifier 1871] Units daily and then be on vit d 800units and have PTH rechecked. . 9) Metabolic alkalosis: Pt initially had an acidosis [12-28] diarrheal losses and respiratory acidosis. After intubation, bicarbonate therapy and multiple LR boluses, pt developed a metabolic alkalosis. Bicarb trended down toward end of stay. . 10) Elevated CK: CK in 800's likely represents rhabdomyolysis, as CK-MB fraction is <2.5%. Most likely causes are electrolyte abnormalities and propofol. Propofol was d/c'd once extubated and electrolytes repleted prn. CK trended down. . 11) Transaminitis: mild hepatocellular pattern likely due to celiac disease and/or propofol. Improved though ALT remained just above normal range. . 12) Anemia: anemia of chronic disease picture via iron studies. Pt did not require any blood products. However, Hct was variable ranging from mid 20s to low 30s without evidence of blood loss or hemolysis. Likely some componenet of marrow suppression from sepsis. On discharge Hct stable for 2d at about 25. Hct should be monitored as outpt and if remains low, may need further hematologic workup. . 13) Coagulopathy: pt admitted with PTT 58.1 and INR 2.0. INR was reversed to normal s/p 3 doses of 5mg vitamin K. Elevation of PTT/INR likely secondary to malnutrition. PTT also trended down to normal range. . 14) LBBB on EKG: pt's EKG on presentation showed LBBB. Unclear whether new or old as no baseline available. No evidence of WMA on echo. Cardiac enzymes cycled were negative for ischemia. . 15) Acute Renal Failure: On admission, cr was 0.9. Possible ATN from sepsis. With recovery from sepsis, Cr settled around 0.4. Pt had significant post-ATN diuresis at times requiring IVF boluses to maintain BP. On d/c SBP in 100-110 range. . Communication: Husband [Name (NI) ] [Name (NI) 29571], [Telephone/Fax (1) 71808]. Daughter [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 174]. Code: FULL . Medications on Admission: Multivitamins Discharge Medications: 1. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO DAILY (Daily) for 3 days. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital ] Health Care Center - [Hospital1 1559] Discharge Diagnosis: PRIMARY: Septic shock Community acquired pneumonia, bacterial Acute renal failure Celiac disease Anemia of chronic disease Discharge Condition: Good--afebrile, vital signs stable, tolerating food and liquids. Discharge Instructions: 1. Take medications as prescribed. 2. Follow up as below. 3. Please seek medical attention for fevers, shortness of breath, chest pain, abdominal pain, diarrhea, lightheadedness, or any other symptoms that concern you. Followup Instructions: Please call your new PCP: [Name10 (NameIs) 71809] [Name11 (NameIs) ] [Telephone/Fax (1) 71810]. Make a follow up appointment after you leave rehab. You will also need referral to a GI specialist for evaluation of celiac disease. ICD9 Codes: 0389, 5849, 2762, 2760, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7898 }	Medical Text: Admission Date: [2164-10-5] Discharge Date: [2164-10-15] Date of Birth: [2164-10-5] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: Baby boy [Known lastname ] twin number one was born at 34 5/7 weeks gestation to a 32 year-old gravida one para 0 now 2 woman. Her prenatal screens are blood type O positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis surface antigen negative and group B pregnancy was uncomplicated until premature rupture of membranes of this twin one day prior to delivery. The onset of preterm labor ensued. The mother received a complete course of antibiotics prior to delivery. The infant was delivered by spontaneous vaginal delivery. Apgars were 8 at one minute and 8 at five minutes. The birth weight was 1900 grams, birth length was 43.5 cm and the birth head ADMISSION PHYSICAL EXAMINATION: Revealed a comfortable active preterm infant. Anterior fontanel is soft and flat. Some periorbital puffiness. Palette intact. Lungs clear and equal. Heart was regular rate and rhythm. No murmur. Femoral brachial pulses +2 and equal. Abdomen soft. No hepatosplenomegaly. Normal phallus. Testes high on the left, but palpable. The right is descended. Patent anus. No sacral anomalies. Stable hips. Well perfused. Generalized decreased tone. HOSPITAL COURSE: Respiratory status: The infant has remained in room air throughout the Neonatal Intensive Care Unit stay. He has had no apnea or bradycardia. His respirations are comfortable. Lungs are clear and equal. Cardiovascular status: The infant required one fluid bolus at the time of admission to maintain blood pressure and has remained normotensive since that time. On examination he has a normal S1 and S2 heart sounds. No murmur. He is pink and well perfuse. Fluids, electrolytes and nutrition: His weight at the time of discharge is 2070 grams. Enteral feeds are begun on day of life number one and advanced without difficulty to full volume feeding on day of life number two. At the time of transfer he is eating premature Enfamil 26 or breast milk 26 calories per ounce made with MCT oil and human milk fortifier. Total fluids are 150 cc per kilogram per day. He was requiring most of his feedings by gavage. Gastrointestinal status: He was treated with phototherapy for hyperbilirubinemia of prematurity on day of life number two until day of life number six. His peak bilirubin occurred on day of life number two and was total 11.2, direct 0.3. His rebound bili on day of life number seven was total 9.5, direct 0.3. Hematological status: His hematocrit on admission was 49.7. The infant has received no blood product transfusions during this Neonatal Intensive Care Unit stay. Infectious disease status: The infant was started on Ampicillin and Gentamicin at the time of admission for sepsis risk factors. The antibiotics were discontinued after 48 hours when the infant was clinically well and the blood cultures were negative. Sensory status: Hearing screening was performed with automated auditory brain stem responses and the infant passed in both ears. Psycho/social: The parents have been involved in the infant's care throughout his Neonatal Intensive Care Unit stay. DISCHARGE CONDITION: The infant is being discharged in good condition to [Hospital3 ] Special Care Nursery for continuing care. Primary pediatric care will be provided by Dr. [Last Name (STitle) ] of [Hospital ] Pediatrics in [Location (un) ] [State 350]. CARE AND RECOMMENDATIONS: Feedings at discharge are 26 calories per ounce primi Enfamil or breast milk made with 4 calories per ounce of human milk fortifier and 2 calories per ounce of MCT oil. Total fluids 150 cc per kilogram per day. Medications, Fer-In-[Male First Name (un) ] 0.2 cc po q day. The infant has not yet had a car seat test. A state newborn screen was sent on [2164-10-8]. The infant has not yet received any immunizations. Immunizations recommended, Synagis RSV prophylaxis to be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria, born at less then 32 weeks, 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 or with chronic lung disease. Influenza immunizations 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 the other care givers should be considered for immunizations against influenza to protect the infant. DISCHARGE DIAGNOSES: 1. Prematurity 34 and 5/7 weeks. 2. Twin number one. 3. Sepsis ruled out. 4. Status post hyperbilirubinemia. [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36095] Dictated By:[Last Name (NamePattern1) 37333] MEDQUIST36 D: [2164-10-15] 06:11 T: [2164-10-15] 07:11 JOB#: [Job Number 40935] ICD9 Codes: V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 7899 }	Medical Text: Admission Date: [2176-7-19] Discharge Date: [2176-7-26] Date of Birth: [2155-5-5] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4691] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: [2176-7-19]: Exploratory laparotomy, gastrotomy and enterectomy and removal of foreign bodies. History of Present Illness: Pt is 21 y/o M who was found to be unresponsive by EMS [7-19]. Per family, both pt and sister were drug mules and recently arrived from [Location 13366]. It is believed that pt had ingested packaged cocaine and heroin. Pt was found unresponsive and given narcan. His respiratory rate improved, however pt then started posturing. Pt was given ativan and subsequently intubated. Pt was also hypotensive at OSH and started on Levophed. Pt currently is off levophed. Past Medical History: PMH: Unknown PSH: Unknown [Last Name (un) 1724]: Unknown ALL: Unknown Social History: Lives with others. Family from [Male First Name (un) 1056]. +Cocaine ingestion at time of presentation. Family History: Unknown Physical Exam: P 121 BP 115/76 R 16 SaO2 100% Gen: intubated, sedated Heent: no scleral icterus Lungs: clear Heart: regular rate and rhythm Abd: soft, nontender, nondistended Extrem: no edema Pertinent Results: LABORATORIES: [2176-7-19] 05:55PM BLOOD WBC-19.9* RBC-4.47* Hgb-14.7 Hct-41.7 MCV-93 MCH-32.9* MCHC-35.2* RDW-13.0 Plt Ct-165 [2176-7-19] 05:55PM BLOOD PT-14.3* PTT-27.2 INR(PT)-1.2* [2176-7-19] 09:00PM BLOOD Glucose-110* UreaN-16 Creat-0.9 Na-139 K-5.2* Cl-108 HCO3-22 AnGap-14 [2176-7-19] 09:00PM BLOOD CK(CPK)-2167* [2176-7-19] 09:00PM BLOOD CK-MB-37* MB Indx-1.7 cTropnT-0.13* [2176-7-19] 09:00PM BLOOD Calcium-7.4* Phos-2.6* Mg-1.8 [2176-7-19] 10:18PM URINE cocaine-POS MICROBIOLOGY: [2176-7-19] SputumCx GS: 2+GPCs prs/clstrs; 2+GNRs; Cx: oral flora IMAGING: CT Head ([7-20]): 1. No acute intracranial abnormality. 2. Fluid within the sinuses, likely relates to endotracheal intubation. PATHOLOGY: None Brief Hospital Course: The patient was admitted to the acute care surgery service on [2176-7-19] as a transfer from an OSH. He was taken to ther OR for an exploratory laparotomy, gastrotomy and removal of ingested foreign bodies. The patient tolerated the procedure well. Neuro: Prior to admission, patient was intubated in the field for non-responsiveness and anoxic brain injury was suspected at this time. On transfer, the patient was intubated and sedated. Pt was taken from the OR directly to SICU where he remained sedated/intubated. He remained sedated until extubated [7-21]. Precedex was begun for agitation. Mental status Post-operatively, the patient received Dilaudid IV/PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: Pulmonary toilet including incentive spirometry and early ambulation were encouraged. The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was gradually advanced to regular and tolerated well. He developed excessive diarrhea on [2176-7-24] along with leukocytosis and a stool specimen was positive for C difficile at which point he was started on a 14 day course of Flagyl. His mental status gradually improved and a cognitive evaluation bty the Occupational Therapist was essentially normal. He was treated with antipsychotics during the acute period but all of this was stopped as he progressed back to baseline. At the time of discharge he was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain free. Medications on Admission: none Discharge Medications: 1. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for cdiff: thru [2176-8-7]. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Foreign body intestinal obstruction 2. Narcotic overdose 3. C Difficile colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the acute care surgery service for intestinal obstruction and toxic ingestion. 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 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. Incision Care: Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Call the Acute Care Clinic now at [Telephone/Fax (1) 600] for a follow up appointment in 1 week for staple removal. Clinic is located in the [Hospital 2577] Medical Office Building, [Hospital1 18], [Hospital Ward Name 517], [Location (un) 9158]. Completed by:[2176-7-26*] ICD9 Codes: 5070, 3051

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