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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7900
} | Medical Text: Admission Date: [**2167-3-2**] Discharge Date: [**2167-3-15**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
VATS, talc pleuradesis
Bronchoscopy
Pleurax cath placement
History of Present Illness:
82 F s/p RULobectomy for stage IIIA [**4-7**] Lung Ca now c/b
malignant effusion s/p thoracentesis week prior to this now with
SOB and recurrent effusion
Past Medical History:
Coronary artery disease s/p cardiac catheterization '[**61**], aortic
stenosis, Abdmoninal aortic aneurysm s/p aortobifememoral graft
'[**61**]
([**Doctor Last Name **]), Hypertension, hypercholesterolemia, s/p sigmoid
colectomy for Cancer s/p chemotherapy/radiation therapy and
anastamotic recurrence, nephrectomy (benign dz), Right internal
carotid stenosis, Left knee neuropathy, Ejection fraction 76%
Social History:
55 ppy smoking hx, quit 7 years ago
previously married x2, 1st husband died of accident, 2nd died
age 42- MI.
7 children, 9 grandchildren, 4 great grandchildren
Family History:
Father - died at 92- old age
Mother -died at 92- old age
brother died 60's- MI
sister died [**2163**] of cerebreal aneurysm
Physical Exam:
per readmission note
IRIRR
decreased BS and crackles on R
soft NT/ND
no c/c/e
Pertinent Results:
[**2167-3-14**] 04:57AM BLOOD WBC-13.2* RBC-3.25* Hgb-8.8* Hct-27.6*
MCV-85 MCH-27.1 MCHC-32.0 RDW-16.8* Plt Ct-288
[**2167-3-13**] 02:00AM BLOOD WBC-11.2* RBC-3.05* Hgb-8.4* Hct-26.0*
MCV-85 MCH-27.5 MCHC-32.3 RDW-16.8* Plt Ct-288
[**2167-3-4**] 03:58PM BLOOD WBC-21.0* RBC-3.77* Hgb-10.0* Hct-32.3*
MCV-86 MCH-26.5* MCHC-30.9* RDW-15.8* Plt Ct-504*
[**2167-3-4**] 09:15AM BLOOD WBC-21.6*# RBC-3.68* Hgb-9.7* Hct-31.4*
MCV-85 MCH-26.3* MCHC-30.8* RDW-15.7* Plt Ct-514*
[**2167-3-3**] 11:14AM BLOOD WBC-13.2* RBC-3.96* Hgb-10.4* Hct-32.7*
MCV-83 MCH-26.3* MCHC-31.8 RDW-15.9* Plt Ct-608*
[**2167-3-2**] 09:25PM BLOOD WBC-11.7* RBC-4.00* Hgb-10.9* Hct-31.9*
MCV-80*# MCH-27.2 MCHC-34.1 RDW-15.9* Plt Ct-565*
[**2167-3-14**] 04:57AM BLOOD Glucose-142* UreaN-22* Creat-1.0 Na-140
K-4.1 Cl-94* HCO3-39* AnGap-11
[**2167-3-13**] 02:00AM BLOOD Glucose-111* UreaN-19 Creat-0.7 Na-144
K-3.8 Cl-103 HCO3-34* AnGap-11
[**2167-3-2**] 09:25PM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-135
K-4.3 Cl-95* HCO3-28 AnGap-16
[**2167-3-4**] 01:10PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2167-3-4**] 09:40PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2167-3-5**] 06:50AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2167-3-14**] 02:51PM BLOOD Type-ART pO2-78* pCO2-69* pH-7.40
calTCO2-44* Base XS-13
[**2167-3-14**] 05:21AM BLOOD Type-ART pO2-118* pCO2-54* pH-7.47*
calTCO2-40* Base XS-14
[**2167-3-13**] 06:32PM BLOOD Type-ART pO2-83* pCO2-51* pH-7.45
calTCO2-37* Base XS-9
[**2167-3-13**] 01:27PM BLOOD Type-ART pO2-168* pCO2-56* pH-7.42
calTCO2-38* Base XS-10
[**2167-3-12**] 06:53AM BLOOD Type-ART PEEP-5 FiO2-50 pO2-126* pCO2-44
pH-7.47* calTCO2-33* Base XS-8 Vent-SPONTANEOU Comment-PSV 12
[**2167-3-5**] 02:05PM BLOOD Type-ART Temp-36.2 pO2-266* pCO2-56*
pH-7.22* calTCO2-24 Base XS--5 Intubat-NOT INTUBA
[**3-2**] CXR - IMPRESSION: Large right-sided pleural effusion, which
may mask a pneumonia or mass.
[**3-5**] CTA - IMPRESSION:
1. Bilateral pleural effusions and sclerosis in the right
pleural space consistent with prior pleurodesis.
2. Loculated fluid collection in the anterior right pleural
space as well as multiple foci of gas which may be secondary to
recent VATS procedure.
3. Pulmonary edema.
4. No evidence of pulmonary embolism.
5. Patchy airspace disease predominantly at the right lung base,
which may represent aspiration or infection, clinical
correlation is recommended.
6. Emphysema.
Brief Hospital Course:
She was readmitted on [**3-2**], made NPO, given lopressor for her
A_fib, on [**3-3**] she had a R vats, talc pleurodesisShe was stable
immediately post op, but did have low UOP requirng boluses. CT
was left to suction post op. On [**3-5**] she desated on the floor
and was solmnent - transferred to CSRU and intubated. CTA neg
for PE. She was started on an amio gtt in the CSRU for A-fib
control and Cipro for a UTI. CT was placed to waterseal and
removed on [**3-6**]. She extubated on [**3-6**]. She had labored
breathing post extubation and remained in the CSRU and was
converted to PO Amio and lopressor. IV access was consulted for
PICC line placement. IP was consulted and they did a bronch
which showed thick secretion swere seen in the RML. on [**3-11**] in
the early morning she was reitnubated for resp failure and
required levophed. On [**3-12**] she had a CT guided pleurax cath
placed - ~60 cc drained immediately. She also had been started
on Vanc/Zosyn for ? VAP. She was diuresed with a hop of getting
her pressure support down. She was extubated on [**3-14**] to see if
she would make it - plan was she would be DNI after this. She
extubated successfully that morning. Her respiratory situtation
worsened and she decided she wanted to be comofrt measures only
and was started on a morphine gtt for comfort. She had
respiratory failure on [**3-15**] and went into asystole and was
evaluated by the TICU resident who pronounced her as diseased on
[**2167-3-15**] at 210PM.
Medications on Admission:
Toprol
Norvsc
Zocor
Plavix
Prilosec
Folic acid
ativan
Zoloft
Colace
albuterol
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Respiratory failure and death secondary to malignant effusion
secondary to lung cancer
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 486, 5990, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7901
} | Medical Text: Admission Date: [**2200-2-4**] Discharge Date: [**2200-2-14**]
Date of Birth: [**2143-12-24**] Sex: M
Service: [**Hospital1 212**]
CHIEF COMPLAINT: Left upper extremity numbness and weakness.
HISTORY OF PRESENT ILLNESS: This is a 56-year-old male with
no significant past medical history who presented to
[**Hospital3 3834**] [**Hospital3 **] with acute onset of numbness and
weakness on the left upper extremity. He initially noted
paresthesias in the left lateral shoulder while working on
his computer on the evening of admission. Within 5-10
minutes of onset, his entire left upper extremity became numb
and paralyzed. He immediately went to [**Hospital3 3834**],
where his left upper extremity was noted to be cold, pale,
and pulseless from the axilla distally. He had no sensation
from the forearm to the fingers. He was sent to [**Hospital1 346**] for insufficiency and Vascular
Surgery consult.
On arrival to the Emergency Department, he subjectively noted
improvement in his symptoms, but persistent absent radial
pulse in the left upper extremity and no pulse in the
dorsalis pedis, posterior tibialis in the right lower
extremity. His blood pressure was 183/141, and therefore he
was taken for a CTA to rule out aortic dissection. He was
found to have very large bilateral pulmonary embolism,
splenic infarct, chronic infrarenal aortic and right common
iliac dissections.
He denied any trauma to the arm or shoulder. He had a 10 day
history of dyspnea on exertion complaining of shortness of
breath with two flights of stairs. He denies any chest pain,
nausea, vomiting, or diaphoresis. There is no other weakness
or numbness elsewhere on his body. He denies any bright red
blood per rectum, melena, or bleeding gums. There is no
recent history of travel, plane flights or long car rides.
Again, he denies any fever, chills, night sweats, or weight
loss.
PAST MEDICAL HISTORY:
1. Gout.
2. Left Bell's palsy 10 years resolved after one year.
3. Hernia repair as a child.
4. Sciatica.
5. Questionable hypertension.
6. No history of coronary disease or coagulopathies.
SOCIAL HISTORY: He has smoked for the past 40 years anywhere
from half to [**4-1**] of a pack per day. He has episodically
tried to quit smoking. He socially uses alcohol. He has a
history of experiment drug use as a teenager which includes
marijuana, cocaine, and LSD, but no current experimental drug
use at this time. He denies any IV drug use. He works as a
computer engineer living at home with his three children. He
recently separated from his wife and moved into the area. He
is not sexually active.
FAMILY MEDICAL HISTORY: Mother died of brain cancer at age
[**Age over 90 **]. Father with arrhythmia and died with a complication of a
hernia repair, no bleeding disorders.
ALLERGIES: None.
OUTPATIENT MEDICATION: Indocin prn for gout, last use was a
month ago.
PHYSICAL EXAM UPON ADMISSION: Temperature is 96.6, blood
pressure 175/128, pulse 92, respiratory rate 16, and 96% on
room air. Generally, this is a pleasant male in no acute
distress who is resting comfortably in bed. HEENT: Mucous
membranes are moist and oropharynx is clear. Jugular venous
pressure is not elevated. The neck is supple and without
carotid bruits. His sclerae is anicteric. Chest was clear
to auscultation bilaterally. Cardiovascular: Regular, rate,
and rhythm. Normal S1, S2, no murmurs or gallops noted.
Abdomen is soft, nontender, and nondistended with normoactive
bowel sounds. No hepatosplenomegaly felt. Extremities:
Pale left hand with capillary refill greater than three
seconds. There is no radial pulse in the left upper
extremity. There is presence of an ulnar pulse in the left
upper extremity. There is also a presence of a dorsalis
pedis and posterior tibial pulses bilaterally.
Neurologically, the patient is alert and oriented times
three. Cranial nerves II through XII intact except for the
left lower facial weakness. The left is 4+/5 and left upper
extremity flexion and extension is 4+/5. Right upper
extremity is [**6-2**]. Decreased sensation in the left hand and
forearm which have been improving.
White count 10.8, hematocrit 45.8, platelets 154, chloride
142, potassium 3.9, 105 for chloride, bicarb of 22, BUN of
11, creatinine 0.9, glucose 110. Differential on the white
count was 82% neutrophils, 12% lymphocytes, 4% monocytes,
1.5% eosinophils. PT is 13.6, PTT is 28.9, INR 1.2.
Chest x-ray showed no infiltrate or effusion. CT scan showed
bilateral large pulmonary embolism, splenic infarct, and
chronic infrarenal, aortic, or right common iliac dissection.
ELECTROCARDIOGRAM: Normal sinus rhythm at a rate of 84.
There is a right heart strain pattern in V2 through V4 with
T-wave inversion in III. Right bundle branch is noted.
HOSPITAL COURSE:
1. Pulmonary system. Pulmonary embolism. Given that the
patient had bilateral pulmonary embolism discovered on CTA,
patient was put on Heparin for a PTT of 60-80. Doppler of
the lower extremities showed a right popliteal deep venous
thrombosis, but no deep venous thrombosis on the left.
Patient was then sent for MRI of the pelvis which showed no
evidence of clot in the femoral vein or IVC. Therefore, the
patient did not require any IVC filters at this time.
It is unusual why the patient would have pulmonary embolism
since there is no recent history of travel or long car rides.
His extensive smoking history may predispose him to neoplasm
hypercoagulable state. Subsequent studies that his protein-C
was normal at 66, protein-S at 139, anticardiolipin IgG as
well as IgM were normal at 1.2 and 4.3 respectively.
However, he was found to have high levels of homocystine at
70.5, where the high range of normal is 12.4. He was
therefore then started on vitamin B6, vitamin B12, and
folate.
His prothrombin gene mutation and factor-[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12843**] were still
pending. He was then started on Coumadin 5 mg to reach an
INR between [**3-3**]. He eventually reached 2.2 on the day of
discharge with a regimen of Coumadin 5 and 7.5 mg alternating
days.
2. Vascular system. Left subclavian artery clot status post
embolectomy. Given the patient's symptoms of neurological
and vascular compromise in his left upper extremity, Vascular
Surgery was consulted. They eventually took him for
embolectomy of a very large subclavian artery clot. After
the embolectomy, neurological and vascular functions were
returned to the patient's left upper extremity.
3. Cardiovascular. Patent foramen ovale status post
clam-shell placement. Given that the patient had all of
these clots, thrombolysis was a consideration, therefore
Cardiology consult was called to do an echocardiogram. The
echocardiogram actually revealed a patent foramen ovale with
a right-to-left shunt in light of a normal pulmonary pressure
with PR gradient of 17 mm Hg. Also noted on the
echocardiogram was preserved left ventricular ejection
fraction, mild right ventricular dilation, mildly depressed
right ventricular function, and apical-septal aneurysm.
Given the right-to-left shunting and embolization without
elevated pulmonary artery pressure along with his known deep
venous thrombosis, it was felt that a PF closure with a
clam-shell would be best. The clam-shell was placed without
complications.
However, on hospital day five, the patient did spike a fever
of 101.3. He was given 48 hours of Vancomycin along with
other antibiotics which he was taking for his pneumonia until
blood cultures were clear for 48 hours. The blood cultures
did remain negative for 48 hours, so the Vancomycin was
discontinued. Given the clam-shell placement, the patient
should be on 75 mg of Plavix for the next three months.
4. Hematology. Homocystinemia. Given that the patient had
many clots in a situation, where he did not have many risk
factors that led to the tests that were mentioned above in
the course of finding the etiology of the pulmonary embolism.
It was discovered that he had elevated homocystine levels of
70.5.
At that time, Hematology recommended starting vitamin B6,
vitamin B12, and folate. He is to remain on these cofactors
for breaking down the homocystine for life. He is to be on
Coumadin with INR of 2.3 for at least six months. At that
time, it should be reassessed whether the patient should be
on life-long Coumadin. There is no literature mentioning
whether life-long anticoagulation would be called for in the
state of homocystinemia.
5. Infectious Disease. Pneumonia. When the patient spiked a
fever on hospital day five, a chest x-ray was obtained along
with blood and urine cultures. The chest x-ray revealed a
left basilar infiltrate and left pleural effusion. Patient
was empirically started on azithromycin for five days and
ceftriaxone for 14 days. However, the course of ceftriaxone
was decreased down to seven days given that the fever may
also be due to the gout that the patient was having.
6. Rheumatology. Gout. In the middle of the hospital
course, the patient complained of right ankle and right first
metatarsal erythema, swelling, and pain. He says that these
symptoms were similar to his gout flares, so he was given
Indomethacin. The indomethacin helped resolve the symptoms
on the right foot, but then he started noticing pain,
swelling, and erythema with his left first metatarsal. He
was continued on indomethacin until a day before discharge,
where his gout flare had resolved.
DISCHARGE DIAGNOSES:
1. Pulmonary embolism.
2. Patent foramen ovale status post clam-shell placement.
3. Homocystinemia.
4. Left subclavian artery clot status post embolectomy.
5. Pneumonia.
6. Gout.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po q day.
2. Indomethacin 25-75 mg po tid prn gout.
3. Folate 2 mg po q day.
4. Pyridoxine 50 mg po q day.
5. .................... 400 mcg po q day.
6. Thiamine 100 mg po q day.
7. Plavix 75 mg po q day.
8. Aspirin 81 mg po q day.
9. Lisinopril 5 mg po q day.
10. Atenolol 100 mg po q day.
11. Warfarin 5 and 7.5 mg po alternating.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Home.
FOLLOW-UP APPOINTMENT: The patient is to followup with Dr.
[**First Name (STitle) **] [**Name (STitle) **] on [**2200-2-26**] for blood pressure and INR
check.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2200-2-21**] 03:41
T: [**2200-2-21**] 05:18
JOB#: [**Job Number 46529**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7902
} | Medical Text: Admission Date: [**2176-1-24**] Discharge Date: [**2176-1-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Lower extremity edema; tachypnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] year-old man with a history of CAD s/p CABG
and prior CVA who presents with lower extremity edema and
tachypnea.
Per patient and son (who translated in Italian), the patient was
feeling well until approximately one week prior to admission
when he began noting increasing LE edema. He has also had
insomnia, waking every 30 minutes or so. He uses one pillow at
night; this has been stable. It is unclear on history if he has
PND - he describes feeling "suffocated" at times though he
doesn't wake up acutely short of breath. More often than not,
he simply wakes up to so his wife can make food for him.
Given these symptoms, he presented to his PCP who referred him
to the ED.
In the ED, initial vitals showed BP of 205/74, HR 65, RR 24 with
96% on room air. BP remained >190 systolic and was given SL
nitro x3, aspirin and 40 IV lasix. After this, noted to be
breathing more comfortably though RR remained elevated. As the
BP did not improve, nitro gtt was started and increased 11.8
with a BP of 156/82 at the time of transfer.
On review of systems, he reports a prior stroke with left-sided
weakness. No history of deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. Also
denies recent fevers, chills or rigors. Denies any dietary
indiscretion or weight gain. Per son, he will frequently not
take his antihypertensives. Has nocturia x4-5 per night though
denies any fevers or dysuria.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:
(+) Diabetes
(-) Dyslipidemia
(+) Hypertension
.
2. CARDIAC HISTORY:
-CABG: Prior CABG ~23 years ago; unclear anatomy
-PCI: None known
-PACING/ICD: None known
.
3. OTHER PAST MEDICAL HISTORY:
- History of atrial fibrillation, [**2173**] after trauma
- History of CVA, [**2172**]
- Nephrolithiasis
- L Total Hip Replacement
Social History:
- Italian speaking; lives with wife in grandson's house
- Tobacco history: Smoked in the [**2117**] but quit.
- ETOH: None currently.
- Illicit drugs: None.
Family History:
NC
Physical Exam:
VS: T= BP=171/80 HR=68 RR=20-24 O2 sat= 97% on 2LNC
GENERAL: Lying in bed in no distress. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric, pale. PERRL, brisk, EOMI.
Conjunctiva were pink, no cyanosis of the oral mucosa dry. No
xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3,
?S4.
LUNGS: Increased AP diameter, resonant to percussion, resp were
unlabored, no accessory muscle use. CTAB, no crackles, wheezes
or rhonchi.
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. Abd aorta not
palpable. No abdominial bruits.
EXTREMITIES: No femoral bruits. 2+ LE edema, pitting 1/3 up to
tibia b/l.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ could not appreciate DP/PT [**3-18**]
edema.
Left: Carotid 2+ Femoral 2+ could not appreciate DP/PT [**3-18**]
edema.
Neuro: A&Ox3, goal directed communication, follows commands.
Pupil 4->2mm b/l, brisk. EOMs intact. VF intact to threat b/l.
no facial droop, V, VII, IX - XII intact. Motor: normal tone
and bulk, [**Month/Day (2) **] [**6-19**] throughout, LUE limited ROM proximally, biceps
4+/5, triceps [**5-20**], wrist ext [**5-20**], [**6-19**] flxn. RLE [**6-19**] throughout.
RLE [**6-19**] to foot, w/ [**5-20**] foot ext but [**6-19**] flx. Sensory: intact
to Pain and LT b/l throughout, proprioception not assessed.
DTRs: 1+ [**Name2 (NI) **] and RLE, 3+ LUE and LLE (C5,6 and L3,4 tested
only). Negative babinski b/l; No pronator drift, HTS impaired
b/l, FTN intact b/l, impaired [**Doctor First Name **] b/l with dysrhythmia and
impaired amplitude, no tremor. Gait not tested.
Pertinent Results:
[**2176-1-24**] 11:56AM GLUCOSE-124* UREA N-27* CREAT-1.5* SODIUM-145
POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-24 ANION GAP-15
[**2176-1-24**] 11:56AM CK(CPK)-42
[**2176-1-24**] 11:56AM cTropnT-0.03*
[**2176-1-24**] 11:56AM CK-MB-NotDone proBNP-[**Numeric Identifier 18214**]*
[**2176-1-24**] 11:56AM CALCIUM-9.5 PHOSPHATE-2.9 MAGNESIUM-2.0
[**2176-1-24**] 11:56AM WBC-8.1 RBC-3.83* HGB-11.9* HCT-33.1* MCV-87
MCH-31.0 MCHC-35.9* RDW-13.5
[**2176-1-24**] 11:56AM NEUTS-63.1 LYMPHS-30.7 MONOS-4.0 EOS-1.9
BASOS-0.2
[**2176-1-24**] 03:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2176-1-24**] 05:03PM TYPE-[**Last Name (un) **] PO2-103 PCO2-30* PH-7.50* TOTAL
CO2-24 BASE XS-1 INTUBATED-NOT INTUBA
[**2176-1-24**] 03:30PM URINE RBC-[**7-25**]* WBC->50 BACTERIA-OCC
YEAST-NONE EPI-0
[**2176-1-24**] 12:06PM LACTATE-1.8
proBNP: [**Numeric Identifier 18214**]
EKG ([**2173**]; old): RBBB with LAFB; old inferior MI
EKG (admission): Similar to old.
Lung Scan ([**1-24**]): 1. The above findings are consistent with low
probability of pulmonary embolus.
2. Small airways disease.
CXR ([**1-24**]): The lungs are clear. There is no evidence of
pneumonia or
congestive heart failure. The cardiac and mediastinal contours
are stable in configuration. The patient is status post median
sternotomy. There are multiple old healed rib fractures. The
visualized osseous structures are otherwise unremarkable with no
evidence of acute fractures. There is no evidence of
pneumothorax or pleural effusions.
LENIs ([**1-24**]): No evidence of bilateral lower extremity DVT.
TTE ([**1-25**]): The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy. There is mild regional
left ventricular systolic dysfunction with focal hypokinesis of
the distal inferior wall, distal septum and apex. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild focal LV systolic dysfunction. Probable
diastolic dysfunction. Mild aortic regurgitation. Mildly
dilated aortic root and ascending aorta.
Compared with the prior study (images reviewed) of [**2174-1-26**],
the basal to mid inferior hypokinesis and apical lateral
hypokinesis have improved. The other findings are similar.
Brief Hospital Course:
ASSESSMENT AND PLAN: [**Age over 90 **]M with history of CAD, CHF who presents
with LE edema and tachypnea.
# CONGESTIVE HEART FAILURE, DIASTOLIC and SYSTOLIC, ACUTE ON
CHRONIC: Prior echo with EF of 45% and LVH. Presented this
hospitalization with right heart > left heart failure. The
right heart failure seems subacute. Given his hypertension to
the high 180's to 190's in the ED, this may have been the
percipitant to his acute heart failure. He was treated with 40
mg of lasix IV twice and diuresed over 2 L. He was continued on
his [**Last Name (un) **] and metoprolol. By the morning of discharge his legs
looked much less edematous and his tachypnea had resolved. A
TTE showed an EF of 45-50% with mild focal LV systolic
dysfunction, probable diastolic dysfunction and mild aortic
regurgitation. When compared with the prior study of
[**2174-1-26**], the basal to mid inferior hypokinesis and apical
lateral hypokinesis were improved. The other findings are
similar. His home po lasix was increased to 40 mg daily and he
was discharged and asked to follow up with his PCP within the
next two weeks.
# TACHYPNEA/RESP ALK: Etiologies include dyspnea related to
elevated pulmonary pressures in the setting of CHF (without
overt hypoxia). PE (though low probability on V/Q), central
process, pain/anxiety, among others. Does have pH of 7.5 with
pCO2 of 30; this is consistent with acute resp alk. No apparent
acidosis present. His tachypnea resolved over night and given
that his the lower extremity ultrasounds were negative for DVT
and his V/Q scan was low probability he was not suspected to
have had a PE. Given the resolution with diuresis, this was
likely due to acute CHF.
# CORONARIES: The patient has a history of CAD s/p CABG > 20
years ago. He was asymptomatic during this hospitalization. He
was continued on aspirin, a beta-blocker, and tricor.
# RHYTHM: The patient remained in normal sinus rhythm during
his hospitalization.
# PYURIA: Patient with pyuria on his UA, but without dysuria,
abdominal pain, or fever. Urine culture has been no growth to
date.
# ANEMIA: Patient with a stable hct in low 30s. Never had a
colonoscopy and denies any symptoms of GIB. [**Month (only) 116**] be due to
anemia of chronic kidney disease. No clinical evidence of
bleeding during this hospitalization.
# CHRONIC KIDNEY DISEASE: The patient's baseline is 1.8 to 1.9.
Was below his baseline during this hospitalization.
Medications on Admission:
MEDICATIONS ([**Last Name (un) 3072**] Pharmacy, [**Location (un) 745**] MA [**Telephone/Fax (1) 48147**])
1. Aspirin 81mg daily
2. Losartan 100mg [**Hospital1 **]
3. Amlodipine 10mg [**Hospital1 **]
4. Metoprolol 125mg [**Hospital1 **]
5. Hydralazine 50mg [**Hospital1 **]
6. Furosemide 20mg daily
7. Tricor 145mg daily
8. Levemir 26 units QAM
9. Haldol 1mg Q8H (last filled [**7-23**])
10. Vitamin B12
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Losartan 100 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Insulin Detemir 100 unit/mL Solution Sig: Twenty Six (26)
units Subcutaneous qam.
8. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Vitamin B-12 Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
1. Congestive Heart Failure
2. Hypertension
3. Coronary Artery Disease
Discharge Condition:
afebrile, hemodynamically stable
Discharge Instructions:
You were admitted to the hospital with congestive heart failure
and hypertension. You were treated with diuretics to remove the
fluid from your legs. Your hypertension was controlled with
medications.
The following changes were made to your medications:
Take Lasix 40mg by mouth once a day (this was increased from 20
mg daily). Otherwise continue your outpatient medications as
prescribed. It is very important that you take your medication
regularly and do not miss a dose.
Limit your fluid intake to 1200ml per day. Limit your salt
intake to less than 2gram per day. Weigh yourself everyday and
call your doctor for any weight gain of > 3 lbs.
Please call your doctor or come to the hospital for any fevers >
100.4, chills, night sweats, chest pain, shortness of breath,
abdominal pain, nausea, vomiting, worsening leg swelling or any
other symptoms that concern you.
Followup Instructions:
Please see your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**] within
the next week. His phone number is [**Telephone/Fax (1) 19196**].
Completed by:[**2176-1-25**]
ICD9 Codes: 4280, 412, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7903
} | Medical Text: Admission Date: [**2181-10-17**] Discharge Date: [**2181-10-22**]
Service: MEDICINE
Allergies:
Metronidazole / Morphine / Percocet
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], MD
.
REASON FOR MICU TRANSFER: Respiratory Failure.
CHIEF COMPLAINT: Shortness of Breath.
Major Surgical or Invasive Procedure:
Mechanical Ventilation
Endotracheal intubation
History of Present Illness:
Ms. [**Known lastname 20802**] is a [**Age over 90 **] y.o. F with diastolic CHF (EF 55% on [**9-2**]
echo), recent PE on [**2-/2181**], recent GI bleeding attributed to
colon diverticuli seen on colonoscopy during recent [**Hospital1 18**]
hospitalization in [**2181-9-25**], transferred from OSH ([**Hospital1 **])
with respiratory failure attributed to flash pulmonary edema.
.
From [**10-11**] - [**2181-10-16**], the patient was admitted to [**Hospital1 18**] for
rectal bleed for 2 days. On presentation, pt [**Name (NI) 4650**], stable Hct,
and supratherapeutic INR 3.8. Rectal exam with gross blood in
rectal vault. No other episodes of rectal bleeding in hospital.
Transfused 2 pRBCs and given vitamin K for colonoscopy. [**Last Name (un) **]
showed diverticuli. Hct stable. Patient was discharged without
anticoagulation after discussing risk of GI bleed, fall risk and
benefit of coumadin. Was also diuresed while in hospital with
[**Hospital1 **] lasix (from home daily dose of lasix). Discharged to
[**Location (un) 5481**] on [**2181-10-16**].
.
The patient was admitted on [**2181-10-17**] to [**Hospital3 **] after
episode of acute shortness of breath at [**Hospital1 1501**]. Per Patient Care
Referral form, pt found pale, unable to breath with oxygen
fluctuating between 60 and 70%, was on 2 L NC and then increased
to 5 L NC. Transferred to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. She was intubated for
this. No documentation of DNR/DNI was with her at OSH. CXR
showed pulmonary edema. Given lasix IV but limited by
hypotension this AM to SBP 70s. Gave 200 cc IVF bolus ---> SBP
110. Troponins now 0.04 --> 0.29 --> 0.38 (cutoff 0.5). EKG
initially in atrial fibrillation in ED and given cardizem x 1
with conversion to NSR. EKG this AM without ischemic changes [**Name8 (MD) **]
MD. Bedside echo was ordered, but no report yet. Cardiology
consulted and believed may be due to ischemia but hesitant to
anticoagulate due to recent GI bleed. Noted to have leukocytosis
that has been trending up to 18,000 today. Pt was cultured and
placed on zosyn and vancomycin for broad coverage. Noted to
have a UTI also. Attempted CPAP trial this morning, but she
failed by report from MD.
.
Currently, pt is sedated and intubated.
.
ROS: Cannot obtain as intubated and sedated.
Past Medical History:
- CAD - stress [**2170**] showed 1-1.[**Street Address(2) 1755**] depression consistent
with
ischemia, nl echo treated medically. Repeat echo [**2175**]: LVEF>60%,
1+MR, trace AI. Exercise MIBI [**2175**]: nl study with EF 78% ; TTE
[**11-1**]: hyperdynamic, EF 80%
- LUL spiculated lung mass-likely bronchalveolar CA
- recurrent R sided pleural effusion--likely due to dCHF, lower
suspicion for TB.
- Recent PE
- HTN
- Hyperlipidemia
- Hypothyroidism
- GERD
- Breast ca, followed by Dr. [**Last Name (STitle) **] at [**Hospital1 2177**], dx [**2162**], s/p XRT
- urge incontinence
- Osteoporosis
- s/p CCY [**2175**]
- s/p TAH, BSO age 40
- Macular degeneration
Social History:
She lives in independent living at [**Location (un) 5481**]. Performs her
own ADLs. She does not smoke or drink alcohol, but did smoke
tobacco in the past (quit 38 yrs ago). She does not use any
illicit drugs.
.
Family History:
All female family members except 1 daughter with breast cancer.
Mother with CVA. Mother and sister with CHF. No h/o colon
cancer, GI bleed.
Physical Exam:
Vitals - T: 99.5 BP: 129/39 HR: 94 RR: 13 02 sat: 100% on AC
450 x 14, PEEP 5, FiO2 50%
GENERAL: sedated and intubated
HEENT: PERRL, OP - MM dry, no cervical LAD
CARDIAC: RRR, nl S1, S2, II/VI SEM at LLSB, no r/g
LUNG: anterior BS rhoncherous
ABDOMEN: NDNT, soft, NABS
EXT: no c/c/e
NEURO: able to squeeze fingers on command
Pertinent Results:
[**Hospital1 **] LABS:
[**10-17**] UA cloudy, trace blood, positive nitrite, moderate LE, WBC
[**6-2**], bacteria 2+
.
[**10-17**]
WBC 18.1 Hgb 10.1 Hct 30.7 Plt 232
Neut 89 Band 6 Lymph 2 Mono 3
Trop 0.04 --> 0.29 --> 0.38 (range 0 - 0.5)
BNP 396
.
Na 138 K 3.9 Cl 96 CO2 35 BUN 15 Cr 1.0 Gluc 139
Alb 3.1 TP 5.5 Bilirubin 0.3 Direct bili 0.1 Ca 8.1
Alk phos 60 ALT 19 CK 78 AST 30
.
7.32 / 73 / 209 / 38 (drawn at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with NRB 100%)
.
INR 1.23
.
MICROBIOLOGY: None.
.
STUDIES:
OSH EKG [**10-17**]: atrial fibrillation with controlled ventricular
response. nonspecific ST-T wave abnormalities
.
OSH PCXR [**10-17**]: R pleural effusion, pulmonary edema. Suggest CHF
or volume overload.
.
CXR (my read): slightly congested pulm vasculature, R pleural
effusion, no overt infiltrate.
.
EKG: NSR at 80 bpm, nl axis, nl intervals, no Q waves
.
TTE [**2181-8-28**]:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is mild functional
mitral stenosis (mean gradient 6 mmHg) due to mitral annular
calcification. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild calcific aortic stenosis. Mild calcific mitral stenosis.
Moderate pulmonary hypertension. Bilateral pleural effusions.
.
Compared with the prior study (images reviewed) of [**2180-10-26**],
pleural effusions are new. The other findings are similar.
CXR - PORTABLE CHEST, [**2181-10-21**]
FINDINGS: Pulmonary vascularity appears engorged, but there is
no overt
evidence of pulmonary edema. Bilateral moderate-to-large pleural
effusions
are again demonstrated with adjacent areas of basilar
atelectasis. Interval removal of endotracheal tube and
nasogastric tube.
[**2181-10-22**] 07:10AM BLOOD WBC-8.4 RBC-3.05* Hgb-8.2* Hct-25.4*
MCV-84 MCH-26.9* MCHC-32.2 RDW-15.3 Plt Ct-241
[**2181-10-17**] 06:00PM BLOOD PT-14.3* PTT-29.9 INR(PT)-1.2*
[**2181-10-22**] 07:10AM BLOOD Glucose-118* UreaN-22* Creat-0.8 Na-140
K-4.5 Cl-98 HCO3-36* AnGap-11
Brief Hospital Course:
[**Age over 90 **] y.o. F with diastolic CHF (EF 55% on [**9-2**] echo), recent PE on
[**2-/2181**], recent GI bleeding attributed to colon diverticuli seen
on colonoscopy during recent [**Hospital1 18**] hospitalization in [**Month (only) **]
[**2181**], transferred from OSH ([**Hospital1 **]) with respiratory failure
attributed to flash pulmonary edema.
# Acute Respiratory Failure/Flash Pulmonary Edema: She required
intubation for hypoxic respiratory failure in the setting of
flash pulmonary edema. She was diuresed aggressively and
extubated. She was also managed with a lasix gtt, nitro gtt and
labetolol. Her blood pressure medications were titrated and
blood pressure was well controlled on captopril and metoprolol.
Her lasix was restarted at a lower dose after the acute
decompensation but will likely need uptitration of this
medication.
# Acute Renal Failure: She had ARF likely in the setting of
diuresis. Her creatinine returned to her baseline of 0.9-1.0.
# CAD/diastolic heart failure: She had no evidence of acute
events and was continued on a beta blocker, aspirin, statin,
beta blocker and aceI. Her lasix was restarted at a lower dose
after the acute decompensation in her respiratory status but she
will likely need uptitration of this medication (was on lasix 80
mg po daily at home).
# Hyperlipidemia: resumed atorvastatin
# Hypothyroidism: held levothyroxine initially and then
restarted.
# Urinary Incontinence: continued tolterodine
# CODE: DNR/DNI --> no chest compression, no defibrillation, no
ACLS medications. Pressors are okay
# CONTACT: [**Name (NI) **] [**Name (NI) **] (son in law - HCP, [**Telephone/Fax (1) 20803**])
Medications on Admission:
.
MEDICATIONS: From Discharge Summary on [**2181-10-16**]
Verapamil 120 mg po qhs
Aspirin 81 mg po daily
Atorvastatin 10 mg po daily
Furosemide 80 mg po daily
Multivitamin 1 tablet po qhs
Isosorbide Mononitrate SR 30 mg po daily
Levothyroxine 25 mcg po daily
Lisinopril 40 mg po daily
Metoprolol Succinate SR 300 mg po daily
Omeprazole 20 mg po qhs
Tolterodine 2 mg po BID
Trazodone 75 mg po qhs prn insomnia
.
TRANSFER MEDICATIONS:
Colace 100 mg po BID prn
Humulin SSI
Lasix 80 mg IV x 1
Lovenox 30 mg SQ daily
MOM prn
Maalox prn
Nitrostat 0.4 mg SL q3 - 5 minutes prn
Protonix 40 mg IV daily
Tylenol 650 mg po/pr q6 hours prn
Vancomycin 1 mg IV daily (day 1 = [**2181-10-17**])
Zosyn 2.25 mg IV daily ([**2181-10-17**])
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] TCU
Discharge Diagnosis:
Primary:
Acute hypoxic respiratory failure
Acute pulmonary edema
Acute on chronic diastolic heart failure
Secondary:
Hypertension
Hyperlipidemia
Hypothyroidism
Discharge Condition:
Good
Discharge Instructions:
You were admitted because of high blood pressure, trouble
breathing, and fluid in your lungs. You required breathing
support with an endotracheal tube and also needed medications to
reduce your blood pressure and reduce the fluid in your lungs.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
Return to the hospital if you have trouble breathing, chest
pain, shortness of breath, fevers, chills, or any other
concerns.
Followup Instructions:
Scheduled Appointments :
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD Phone:[**Telephone/Fax (1) 10492**]
Date/Time:[**2181-10-31**] 11:15
Provider [**Name9 (PRE) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2181-12-17**] 11:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
ICD9 Codes: 5849, 5990, 4280, 2449, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7904
} | Medical Text: Admission Date: [**2187-8-31**] Discharge Date: [**2187-9-3**]
Date of Birth: [**2133-11-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Hypertensive Urgency
Major Surgical or Invasive Procedure:
Hemodyalysis
History of Present Illness:
53yo M w/ longstanding DM, IgA & diabetic nephropathy on HD,
frequent admission for fluid overload and hypertensive urgency,
who was sent to the ED from angiography today w/ BP 230/120.
The pt speaks only cantonese, therefore the interview was
conducted with his daughter interpreting & with the aid of
ED&renal notes. Mr. [**Known lastname 724**] [**Last Name (Titles) 58901**] to the angio suite for b/l
subclavian angiography to evaluate for fistula today; at start
of porcedure SBP=200-->230/120 after procedure. He was sent to
ED.
On arrival to ED, BP as stated above, increasing to 242/136, HR
179. HE was given labetolol 20mg IV x 1 (w/ 2 more subsequent
doses for total of 60mg), started on a nitro drip, and given
hydralzaine 50mg po X 2, asa 325mg. HIs ekg demonstrated TWI in
I, aVL, V4-6 & 0.5mm ST depression in I. CE's elevated with
initial CK = 333, MB 5, trop 0.39-->253, 0.36-->222, 0.4. CXR
revealed cardiomyopathy & mild CHF. He was seen by renal who
did not fell he needed HD acutely. He got a head CT to r/o
stroke, which did not demonstrate acute pathology (however, it
was limited by residual contrast from earlier study). He was
briefly started on heparin, however, on informal discussion with
cardiology, it was felt that his increased enzymes were [**3-8**] ESRD
& CHF, therefore heparin was d/c'd.
BP decreased to 160's systolic with above medications. Txf'd to
CCU on nitro gtt. Pt denies medication non-compliance. Denies
CP, SOB, weakness, sensory changes.
Past Medical History:
-Hypertension
-IgA & Diabetic nephropathy on HD since [**6-9**] (Tues, Thurs, Sat)
-Diabetes
-hypercholesterolemia
-anemia of chronic disease
-impaired vision/legally blind (? [**3-8**] diabetic retinopathy)
-Right upper extremity DVT ([**7-10**])
Social History:
Social History: Cantonese speaking only, immigrated to the US 10
yrs ago, currently lives with wife and 3 children, works in a
restaurant, no health insurance, no history of tobacco use,
alcohol, or illicit drug use
Family History:
No DM, CAD, Stroke, HTN, or Renal Disease
Physical Exam:
T 97.7 HR 87 BP 177/97 RR 16 O2 97% wt 63.4kg
gen-awake, alert, in mild distress
HEENT-anicteric sclera, no lymphadenopathy, no JVD
Chest-normal resp effort, decreased bs's at bases w/ rales ~[**4-7**]
way up
Cardio-rr, nml s1s2, no m/r/g
GI-(+)bs, soft, NT/ND, no organomegaly
Ext-1(+) LE edema
Neuro-moving all extremities, responding to q's.
Pertinent Results:
[**2187-8-31**] 08:21PM GLUCOSE-151* UREA N-24* CREAT-5.3* SODIUM-134
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-28 ANION GAP-12
[**2187-8-31**] 08:21PM CK(CPK)-222*
[**2187-8-31**] 08:21PM CK-MB-5 cTropnT-0.40*
[**2187-8-31**] 02:25PM CK(CPK)-253*
[**2187-8-31**] 02:25PM cTropnT-0.36*
[**2187-8-31**] 07:20AM CK(CPK)-333*
[**2187-8-31**] 07:20AM CK-MB-5 cTropnT-0.39*
[**2187-8-31**] 07:20AM WBC-7.5 RBC-3.95* HGB-11.3* HCT-32.2* MCV-82
MCH-28.6 MCHC-35.1* RDW-15.0
.
EKG: NSR @ TWI in I, aVL, V4-6 & 0.5mm ST depression in I
Brief Hospital Course:
53yo male w/ HTN, DM2, IgA/DM nephropathy on HD, frequent
admissions for fluid overload and hypertensive urgency, now here
for hypertensive urgency which has improved w/ aggresive BP meds
& nitro gtt w/ associated CHF.
.
#Hypertensive urgency: the pt was asymptomatic when he was found
to have systolic pressures >200--no neurologic symptoms, no
chest pain, nor shortness of breath. On exam, however, there
was evidence of volume overload--crackles bilaterally on
auscultation. The pt's signs of heart failure were likely due
to hypertensive urgency as well as volume overload given his
chronic renal failure.
The pt was admitted to the CCU, where his BP was initially
lowered with IV anti-hypertensives. Given the pt's reported
baseline SBP between 140 and 160's, a goal SBP <160 was set.
The pt was weaned off nitro gtt while his PO medications were
restarted. His Losartan dose was increased from 25 mg to 50 mg
daily. His dose of lisinopril was increased from 20 mg to 40 mg
daily and amlodipine 10 mg was added. Hydralazine was
discontinued.
Regarding pt's increased cardiac enzymes, it was thought that
this was due to enzyme leak in the setting of CHF coupled with
poor enzyme clearance in the setting of CRI. He was not thought
to have ACS.
.
#ESRD: the pt was volume overloaded upon admission despite
having HD on the day prior to presentation. Renal was consulted
and felt that the patient did not need urgent dialysis The pt
underwent HD the morning after admission. He was continued on
phosphate binders and EPO.
.
#DM2: He was covered with RISS and his NPH dose was halved since
he was not eating as much in the hospital. He was discharged on
his standard insulin dosing schedule.
.
#Hypercholesterolemia: pt received his regular dose of
atorvastatin
.
#Anemia: pt has h/o anemia of chronic disease & prior GI bleed.
Not an active issue while hospitalized. Continued EPO & iron.
.
#Diet: Of note, though pt & wife reported following low-salt
diet, the pt was seen eating high-salt food here (Chinese food
brought by his wife). The pt & his wife may need more teaching
on what foods are low in salt.
Medications on Admission:
-atorvastatin 40qd
-asa 325qd
-losartan 25qd
-lisinopril 20qd
-metoprolol SA 200qd
-hydralazine 50 qid
-metoclopramide 10tid
-pantoprazole 40qd
-epo 10,000 QHD
-CaCO3 500 TID,
-NPH/reg 15 qam/4 qpm
-simethicone 80-160 tid prn
-sevelamer 800 tid
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
8. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. Metoprolol Succinate 200 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day.
11. Insulin
NPH/reg 15 qam/4 qpm
12. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Hypertensive Urgency
Volume Overload
Chronic renal insufficiency
.
Secondary:
Diabetes
IgA nephropathy
Blindness
Right subclavian thrombus
Anemia of Chronic Disease
Hypercholesterolemia
Discharge Condition:
Stable
Discharge Instructions:
-Please continue taking your blood pressure medications as
prescribed. Please make the following changes to your
medications:
1) Increased your dose of Losartan from 25 mg to 50 mg daily.
Until you fill your new prescription you can take 2 of your old
25 mg tablets daily.
2) Increased your dose of lisinopril from 20 mg to 40 mg daily.
You can take two of your old 20mg tablets daily until you run
out, and then fill the 40 mg prescription.
3) We have added amlodipine (Norvasc) to your regimen, which you
will take once a day.
4) STOP taking your hydralazine, as we have discontinued this
medication.
-YOU SHOULD ADHERE TO A 1 LITER FLUID RESTRICTION DAILY! Do not
drink more than a liter of fluid for the whole day.
-If you have chest pain, shortness of breath, severe headache,
dizziness, weight gain >3lb, nauseau, vomiting, or diarrhea,
please contact your PCP or go to the [**Name (NI) **].
-Please maintain a low salt diet.
Followup Instructions:
-Please make an appointment with your primary care [**First Name8 (NamePattern2) **]
[**First Name11 (Name Pattern1) 3078**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 32199**] for follow-up of your blood pressure within
one week--Phone# [**Telephone/Fax (1) 8236**].
Please keep the following appointments:
-Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK at [**Hospital1 18**]
Date/Time:[**2187-9-3**] 1:00 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-9-3**] 2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 5856, 4280, 3572, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7905
} | Medical Text: Admission Date: [**2132-1-15**] Discharge Date: [**2132-1-22**]
Date of Birth: [**2070-3-3**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
- Vertigo, dysarthria, diplopia, left-sided paresthesia, muffled
hearing in left ear.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname 55542**] is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1425**] 61 year-old right-handed woman with a
history of hypertension and hyperlipidemia who presented to
[**Hospital1 **]-[**Location (un) 620**] following three days of vertigo, dysarthria, visual
changes, left limb weakness and sensory changes, and was
transferred to to the [**Hospital1 18**] [**1-15**] when found to have basilar
artery occlusion.
The patient explains she felt well until about one month ago
when she developed a sinus infection. In the week prior to
presentation she also developed [**Month/Day (4) **] typically associated
with her migraine headaches such as positive visual phenomena
and scintillating scotoma. However, she was struck by a new
constellation of [**Month/Day (4) **] three days prior to presentation.
On [**1-13**], she awakened with ringing in the left ear and the
sensation that everything in her visual field was "flipping."
After about one minute, it began to feel as if her head was
spinning. The syndrome was associated with nausea, vomiting,
and gait unsteadiness. She also noticed left face, arm, and leg
"tingling" that can sometimes accompany her migraine. The
syndrome was quite pronounced for 8 hours. She and her husband
were away on [**Location (un) **], so she delayed seeking medical advice
pending arrival home.
She called her PCP [**Last Name (NamePattern4) **] [**1-14**]. She was given a prescription for
meclizine and advised to try afrin. After the second dose of
meclizine, at about [**2-19**] pm, she developed the onset of blurred
vision, slurred speech, and weakness of the left arm and leg.
The tingling sensation in the left hemibody evolved into a
"numbness." However, she attributed the new [**Month/Day (1) **] to the
meclizine, having read that many of the [**Month/Day (1) **] could represent
adverse effects. She and her husband reasoned that the drug
would be out of her system within about 8 hours and she would
call the doctor [**First Name (Titles) **] [**Last Name (Titles) **] persisted this morning.
The [**Last Name (Titles) **] continued this morning. When the patient called
the PCP, [**Name10 (NameIs) **] was reportedly advised to present to the ED. She
went first to [**Hospital1 **]-[**Location (un) 620**]. There, a CTA demonstrated a basilar
artery thrombosis. A heparin drip was started and she was
transferred to the [**Hospital1 18**] for further evaluation and care.
NEUROLOGICAL REVIEW OF SYSTEMS
- Positive for: as above, neck discomfort, muffled hearing on
left
- Negative for: lightheadedness, headache, trouble swallowing,
difficulty producing or understanding speech, bowel
incontinence, urinary incontinence or retention.
GENERAL REVIEW OF SYSTEMS:
- Positive for: as above
- Negative for: fevers, chest discomfort, shortness of breath,
abdominal pain, dysuria, rash.
Past Medical History:
PAST MEDICAL HISTORY:
- hypertension
- hyperlipidemia
- GERD
- migraine
PAST SURGICAL HISTORY
- hysterectomy
Social History:
- Married 39 years
- Three children, 6 grand-children
- Enjoys playing with granchildren
Family History:
- Positive for stroke (mother 72 years), migraine (brother,
son),
CAD/MI (brother had MI at 49 years)
- Negative for seizure, clotting disorders, multiple pregnancy
losses
Physical Exam:
Vitals: T: 98.2 P: 60 R: 16 BP: 133/76 SaO2: 100% RA
General: Awake, cooperative, NAD. Dysarthric.
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
Mucus
membranes moist, no lesions noted in oropharynx
Neck: Supple. No evidence of nuchal rigidity. No carotid
bruits
appreciated.
Cardiac: Regular rate, normal S1 and S2.
Pulmonary: Lungs clear to auscultation bilaterally.
Abdomen: Round. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: Alert. Able to relate history without
difficulty.
* Orientation: Oriented to person, place, day, month, year,
situation
* Attention: Attentive. Able to name the [**Doctor Last Name 1841**] backwards without
difficulty.
* Memory: Pt able to repeat 3 words immediately and recall [**11-19**]
unassisted at 30-seconds on initial trial --> after 2 additional
trials [**1-17**] at 30 seconds and 5-minutes.
* Language: Language is fluent without evidence of paraphasic
errors. Repetition is intact. Comprehension appears intact; pt
able to correctly follow midline and appendicular commands.
Prosody is normal. Pt able to name high (pen) and low frequency
objects (knuckles) without difficulty. [**Location (un) **] and writing
abilities intact.
* Neglect: No evidence of neglect.
* Praxis: No evidence of apraxia.
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 3 to 2 mm and brisk. Visual fields full to
confrontation. Fundi not well-visualized.
* III, IV, VI: evidence of one and a half syndrome; most obvious
eye movement is abduction of the left eye, which is associated
with horizontal left-beating nystagmus.
* V: Facial sensation intact to light touch in the V1, V2, V3
distributions.
* VII: right facial asymmetry (family is uncertain but thinks it
is different from baseline)
* VIII: Hearing intact to finger-rub on right, "muffled" on left
* IX, X: Palate elevates symmetrically.
* [**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally.
* XII: Tongue protrudes in midline.
Motor:
* Tone: Normal.
* Drift: left pronator drift.
Strength:
* Left Upper Extremity: 4 Delt, 5 Biceps, 4 Triceps, 5 Wrist
Ext, 5 Wrist Flex, 4+ Finger Ext, 5 Finger Flex
* Right Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Left Lower Extremity: 4 Iliopsoas, 5 Quad, breakable Ham, 5
throughout Tib Ant, Gastroc, Ext Hollucis Longis
* Right Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
Reflexes:
* Left: brisk throughout Biceps, Triceps, Bracheoradialis,
Patellar, 1+ Achilles
* Right: brisk throughout Biceps, Triceps, Bracheoradialis,
Patellar, 1+ Achilles
* Babinski: strong withdrawal making interpretation difficult
Sensation:
* Light Touch: intact bilaterally in lower extremities, upper
extremities, trunk, face
* Pinprick: decreased in distal left lower extremity; intact
bilaterally upper extremities, trunk, face
* Temperature: decreased in distal left lower extremity;
otherwise intact to cold sensation in arms, face
* Vibration: decreased in distal left lower extremity;
appreciated at level of left patella, intact at left index
finger; intact at right great toe
* Proprioception: decreased in distal left lower extremity (left
great toe); intact at left ankle, intact at level of right great
toe
* Extinction: No extinction to double simultaneous stimulation
Coordination
* Finger-to-nose: decreased accuracy on left, intact on right
* Heel-to-shin: intact bilaterally
* Finger Tapping: decreased speed on left
Gait:
* Description: declined
Pertinent Results:
[**2132-1-22**] 05:35AM BLOOD WBC-5.1 RBC-3.58* Hgb-11.6* Hct-33.9*
MCV-95 MCH-32.3* MCHC-34.2 RDW-13.2 Plt Ct-280
[**2132-1-15**] 04:57PM BLOOD Neuts-65.0 Lymphs-28.5 Monos-4.6 Eos-1.2
Baso-0.8
[**2132-1-21**] 12:40PM BLOOD PT-21.0* PTT-64.4* INR(PT)-2.0*
[**2132-1-21**] 06:50AM BLOOD Glucose-91 UreaN-14 Creat-0.7 Na-136
K-4.7 Cl-101 HCO3-27 AnGap-13
[**2132-1-16**] 02:06AM BLOOD ALT-37 AST-42* LD(LDH)-200 AlkPhos-122*
[**2132-1-21**] 06:50AM BLOOD Calcium-9.3 Phos-4.7* Mg-2.0
[**2132-1-16**] 02:06AM BLOOD %HbA1c-5.8 eAG-120
[**2132-1-16**] 02:06AM BLOOD Triglyc-95 HDL-56 CHOL/HD-3.4 LDLcalc-117
[**2132-1-17**] 12:19AM BLOOD TSH-1.6
[**2132-1-15**] 04:57PM BLOOD ASA-4.6 Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-POS Tricycl-NEG
[**2132-1-16**] 02:06AM BLOOD FACTOR V LEIDEN-PND
[**2132-1-15**] 06:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.050*
[**2132-1-15**] 06:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2132-1-15**] 06:20PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
[**2132-1-15**] 06:20PM URINE bnzodzp-NEG barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
CTA Head and Neck [**2132-1-21**]
IMPRESSION:
1. Slight increase in flow within the basilar artery, although a
significant segment of the basilar artery is still occluded.
2. Likely patulous left A2 arterial segment, centered at a
branch point. Less likely, this focal dilation could be a
small, asymptomatic aneurysm.
3. Opacification of the right maxillary sinus, multiple right
ethmoidal air cells, and the frontal sinuses bilaterally could
represent an ongoing inflammatory process.
The study and the report were reviewed by the staff radiologist.
Transthoracic Echo [**2132-1-16**]
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. Mild (1+) aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. Focal calcifications on the aortic leaflets likely
reflect the aging process. A healed/chronic vegetation cannot be
excluded. Mild aortic regurgitation. Dilated thoracic aorta.
Negative bubble study.
MRI/MRA [**2132-1-16**]
MRI IMPRESSION: Acute acute/subacute ischemic changes identified
within the right side of the pons and anterior medulla
oblongata, consistent with partial occlusion of the basilar
artery. There is no evidence of acute intracranial hemorrhage.
MRA IMPRESSION: IMPRESSION: Vascular occlusion of the mid
segment of the basilar artery and also proximal segment with no
visualization of the posterior inferior cerebellar arteries, the
V3 segment of the left vertebral artery apparently is patent.
There is no evidence of flow stenotic lesions or occlusions in
the anterior circulation, no aneurysms are identified.
Brief Hospital Course:
Mrs. [**Known lastname 55542**] is a 61-year-old right-handed woman with
hypertension and dyslipidemia, presenting with vertigo,
dysarthria, diplopia, left-sided paresthesia, muffled
hearing in left ear on [**2132-1-15**].
Presented to [**Hospital1 **] [**Location (un) 620**] with the above. The above [**Location (un) **]
recapitulate those of prior migraine, likely delaying
presentation by a few days. However, migraine had been present
since fourth grade (precluding misdiagnosed basilar
insufficiency). Heparin gtt and oral anticoagulation commenced,
particularly given a new diagnosis of paroxysmal atrial
fibrillation. There is little other evidence of cerebrovascular
disease, so it seems most likely that this was cardioembolic.
Nonetheless, given LDL above goal, simvastatin dose was
increased to 20 mg daily. The length of the occlusion was
decreased a small amount between the two CTA scans from [**2132-1-15**]
to [**2132-1-21**]. TTE showed LVEF 60-65%, no ASD/PFO. N-acetylcysteine
and fluids were given for renal protection in the context of
receiving IV contrast.
Mrs. [**Known lastname 55542**] was seen by Cardiology given new atrial
fibrillation. Diltiazem and propranalol doses on admission were
not tolerated given bradycardia, so diltiazem was stopped and
propranalol dose was reduced, then propranolol was increased to
two thirds of her home dose after a short episode of atrial
fibrillation with rapid rate (home dose 240 mg daily, current
dose 160 mg daily). She will follow-up with Cardiology for
consideration of rhythm control after a period of
anticoagulation.
Anticoagulation will be followed by her primary care doctor [**First Name8 (NamePattern2) **] [**Location (un) 33570**], Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 931**].
Alkaline phosphatase was elevated at admission, but liver
enzymes were normal on discharge.
Medications on Admission:
- meclizine 25 mg po tid prn vertigo
- firoicet 2 tabs at onset of migraine
- propanolol ER 240 mg po daily
- diltiazem ER 120 mg po daily
- carafate 1 gram po QID
- nexium 40 mg po bid
- simvastatin 20 mg po daily
- tylenol PM prn insomnia
Discharge Medications:
1. propranolol 160 mg Capsule,Extended Release 24 hr Sig: One
(1) Capsule,Extended Release 24 hr PO once a day.
Disp:*30 Capsule,Extended Release 24 hr(s)* Refills:*2*
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Will likely need less than 5 mg daily on an ongoing basis.
Rehabilitation will adjust and write the appropriate script. .
6. Benadryl 25 mg Capsule Sig: Two (2) Capsule PO at bedtime as
needed for insomnia.
7. Tylenol 8 Hour 650 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO three times a day as needed for pain:
Do not exceed 2 g daily given interaction with coumadin.
8. Fioricet 50-325-40 mg Tablet Sig: Two (2) Tablet PO At onset
of migraine as needed for headache: This contains Tylenol - do
not use both medications. .
9. Outpatient Lab Work
Please check PT/INR and fax to: Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 931**], Fax:
([**Telephone/Fax (1) 55736**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary
Brainstem ischemic stroke, basilar artery occlusion
Atrial fibrillation, paroxysmal
Secondary
Dyslipidemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came to [**Hospital1 18**] from [**Hospital1 **] [**Location (un) 620**] after it was found that a
portion of your basilar artery was occluded. Heparin IV and
coumadin were started given that this was likely embolic. An
embolic cause seems more likely given that your heart was found
to be irregular at time - atrial fibrillation. Cardiology were
consulted and you will also see them as an outpatient. We have
changed your medications:
- STOP taking diltiazem (your heart rate was low on this
medication while you were here)
- DECREASE propranolol to 160 mg daily
- INCREASE simvastatin to 40 mg daily (after this event your
goal cholesterol is lower)
Followup Instructions:
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
in Internal Medicine at [**Hospital1 **] [**Location (un) 620**] ([**Telephone/Fax (1) 3070**]) on [**2-5**] at
11:20. Once you are discharged from rehab, contact Dr.
[**Last Name (STitle) 931**] to monitor your INR lab values. Dr. [**Last Name (STitle) 931**] will
organize for you to be followed by the coumadin clinic at
[**Location (un) 620**].
You have a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
Cardiology ([**Telephone/Fax (1) 62**]) on [**2-22**] at 9:20 in the [**Hospital Ward Name 23**]
Building, [**Location (un) **].
You have a follow up appointment with Dr. [**Last Name (STitle) **] in Neurology
([**Telephone/Fax (1) 2574**]) on [**4-1**] at 5:00 in the [**Hospital Ward Name 23**] Building, [**Location (un) 6749**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7906
} | Medical Text: Admission Date: [**2195-6-18**] Discharge Date: [**2195-6-28**]
Date of Birth: [**2127-6-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Latex / Shellfish Derived
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**2195-6-22**] Aortic valve replacement (23mm St. [**Male First Name (un) 923**] Mechanical),
Coronary artery bypass grafting times one (Left internal mammary
artery to Left anterior descending artery)
History of Present Illness:
Mr. [**Known lastname 1124**] is a 67 year-old male with known aortic
stenosis/bicuspid aortic valve/coronary artery disease, now with
increasing dyspnea.
Past Medical History:
1. Coronary artery disease one vessel disease status post
catheterization on [**11-23**] with an left anterior descending
coronary artery stent.
2. Atrial fibrillation status post DCCV on the [**12-5**]. This was unsuccessful and he was subsequently
started on Amiodarone.
3. Hypercholesterolemia.
4. Status post acetabular fracture.
5. Seizure disorder 15 years ago.
Percutaneous coronary intervention in [**2188**]: 90% proxLAD, 70%
midLAD, 95% D1, 60% RI, mid systolic and diastolic dysfunction.
Social History:
Social history: Lives in [**Hospital1 **] with his Wife.
[**Name (NI) 1403**] at home making signs for museums and galleries is
significant for the absence of current .
There is no history of alcohol abuse or IVDU/illicit drug use or
tobacco use.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Pulse: 56 Resp:18 O2 sat: 98 RA
B/P Right:100/61 Left:
Height: 5'4" Weight:180lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []kyphosis
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur III/VI SEM throughout
precordium
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
Pulses:
Femoral Right: 1+ Left:1+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right: 2+ Left:2+
Pertinent Results:
[**2195-6-26**] 04:24AM BLOOD WBC-9.6 RBC-3.05* Hgb-9.2* Hct-27.0*
MCV-88 MCH-30.1 MCHC-34.1 RDW-15.6* Plt Ct-192
[**2195-6-26**] 04:24AM BLOOD PT-19.9* PTT-52.3* INR(PT)-1.9*
[**2195-6-25**] 07:00PM BLOOD PT-16.9* PTT-35.8* INR(PT)-1.5*
[**2195-6-26**] 04:24AM BLOOD Glucose-104 UreaN-20 Creat-1.0 Na-142
K-3.4 Cl-104 HCO3-30 AnGap-11
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 99258**] (Complete)
Done [**2195-6-22**] at 12:25:07 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2127-6-26**]
Age (years): 67 M Hgt (in): 65
BP (mm Hg): 108/60 Wgt (lb): 170
HR (bpm): 45 BSA (m2): 1.85 m2
Indication: Intra-op TEE for AVR, CABG
ICD-9 Codes: 440.0, 424.1
Test Information
Date/Time: [**2195-6-22**] at 12:25 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW03-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: *3.9 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *68 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 45 mm Hg
Aortic Valve - LVOT diam: 2.3 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
pre-bypass exam revealed normal wall function and severely
stenotic aortic valve. No PFO was recognized.
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
is seen in the LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Simple atheroma in aortic
root. Mildly dilated ascending aorta. Mildly dilated descending
aorta.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve leaflets. Critical AS (area <0.8cm2). Moderate (2+)
AR.
MITRAL VALVE: Mild mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
post-bypass:
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. There is severe
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. There are simple atheroma in the aortic root. The
ascending aorta is mildly dilated. The descending thoracic aorta
is mildly dilated. The aortic valve is bicuspid. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Moderate
(2+) aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being AV paced
1. A mechanical prosthesis is well positioned in the aortic
position. Annulus is stable, leaflets open well. Washing jets
are seen. No perivalvular leaks are noted. Mean gradient is 4 mm
of Hg.
2. Bi ventricular function is preserved.
3. Aorta is intact post decannulation.
4. Other findings are unchanged
Brief Hospital Course:
Mr. [**Known lastname 1124**] was admitted on [**2195-6-18**] for a cardiac catheterization,
pre-operative work-up and intra-venous heparin. His surgery was
post-poned for an elevated INR and then his INR was allowed to
drift down without intervention. On [**2195-6-22**] he underwent an
aortic valve replacement (23mm St. [**Male First Name (un) 923**] Mechanical), coronary
artery bypass grafting times one (LIMA to LAD). Please see the
operative note for details. His bypass time was 133 minutes with
a crossclamp x of 104 minutes He tolerated this procedure well
and was transferred in critical but stable condition to the
surgical intensive care unit. He remained hemodynamically
stable in the immediate post-op period and on the morning of
POD1 he was extubated.
On post-operative day two he was transferred to the stepdown
floor for continued recovery and post-op care. His tubes, lines
and drains were removed according to cardiac surgery protocol.
His activity was advanced with the assistance of physical
therapy and on POD #6 he was discharged home with visiting
nurses
Medications on Admission:
coumadin 2, ASA 81, lopressor 75, lasix 40
[**Hospital1 **], lipitor 80, amiodarone 200
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*1 mdi* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*1*
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for AVR mech : Dr. [**Last Name (STitle) 99259**] to deose couamdin based on
INR for Mech AVR.
Disp:*30 Tablet(s)* Refills:*1*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO three times a
day for 7 days: 3 times daily for 7 days then twice daily on
going.
Disp:*75 Tablet(s)* Refills:*1*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days: check with your cardiologist if you should
continue this medication.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*1*
12. Outpatient Lab Work
check bun/creat, potassium and INR on [**6-29**].
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
aortic stenosis s/p Aortic Valve Replacement(mech), coronary
artery disease s/p Coronary artery bypass graft x1 , atrial
fibrillation
PMH: Congestive heart failure(diastolic), Hyperlipidemia,
seizure disorder, Rt hip fracture s/p repair, PTCA-stent(LAD),
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**]), please
call for appointment.
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 838**] (PCP) in [**1-23**] weeks ([**Telephone/Fax (1) 4775**]), please
call for appointment.
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (cardiologist) in [**1-23**] weeks, please call for
appointment.
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
INR to be drawn on [**2195-6-29**] with results sent to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2716**] at
the Cardiology [**Hospital3 **] Fax [**Telephone/Fax (1) 9672**], Phone
[**Telephone/Fax (1) 99260**]. Plan confirmed with Ms. [**Name13 (STitle) 2716**] on [**6-26**].
Completed by:[**2195-6-28**]
ICD9 Codes: 4241, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7907
} | Medical Text: Unit No: [**Numeric Identifier 76691**]
Admission Date: [**2192-2-1**]
Discharge Date: [**2192-2-24**]
Date of Birth: [**2192-2-1**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: The patient was born at 32 6/7
weeks' gestational age on [**2192-2-1**]. Birth weight was
1705g (25th %ile), length is 44.5 cm (50th %ile), head
circumference 29.5 cm, (25th %ile), born to a 21-year-old,
G1, P0, now 2, A+, antibody negative, hepatitis B surface
antigen negative, rubella immune, RPR nonreactive, GBS
unknown, HIV negative. Mom had a history of HSV with active
lesions, gonorrhea and chlamydia in the past, spontaneous
rupture of mono-di twins due to preterm labor. Preterm labor
was treated with magnesium, had a complete course of
betamethasone, spontaneous onset of labor led to cesarean
section under spinal anesthesia. Rupture of membranes was at
delivery. There was no intrapartum fever or chorioamnionitis.
Intrapartum antibiotic therapy was not administered. The
infant was vigorous at delivery. She was orally and nasally
bulb suctioned and dried and tactile stimulation was provided
for apnea. Subsequently she was pink with no distress on room
air until onset of intercostal retractions on admission to
the NICU. Apgars were 8 at one minute and 9 at five minutes.
DISCHARGE PHYSICAL EXAM: Weight 2205g (10-25th %ile), length
45.5 cm (25th %ile), head circumference 32.5 cm (25-50th%ile)
Gen: alert, NAD, In open crib
Heent: AFOSF, posterior fontanel is open, palate intact, no
lesions, red reflex present bilaterally, no ovious strabismus
Resp: NAD, CTA Bilaterally, no wheeze or rhonchi, no distress
Cards: RRR, no murmur, Good pulses, no Brachial-Femoral delay
Abd: Soft NT ND no mass,+Bs, no organomegaly
Ext: WWP, moves all four spontaneous, negative Barlow, ortalani,
and galeazzi signs on hip examination
GU: Normal female, small sacral pigmented nevus
Neuro: Alert, no focal deficits, normal DTR??????s
HOSPITAL COURSE: Respiratory: On admission to the NICU the
patient was initially put on a CPAP of 6. She had increasing work
of breathing with subcostal suprasternal retractions and
nasal flaring which required intubation. The patient was
intubated and was given 2 doses of surfactant. The patient
continued to be intubated until day of life 2 and the patient
was extubated to room air. Respiratory course was also
complicated by apnea and bradycardia which were not severe
enough to require caffeine treatment. The patient had no
apnea or bradycardia for greater than 5 days prior to discharge.
Cardiovascular: The patient had no central lines and blood
pressure was stable throughout hospital course. The patient
had some desaturations and bradycardia which did not occur 5
days prior to discharge.
Fluid, electrolyte and nutrition: The patient was put on IV
fluids initially and started per gastric enteral feeds on day of
life 2. She remained on enteral feeds on day of life 5 and was
taking this volume by mouth by day of life 20. Electrolytes
throughout the NICU course were normal.
GI: The patient had a maximum bilirubin on day of life 4 of
9.7 mg/dL and was started on phototherapy. On day of life 5
bilirubin was down to 6.4. Phototherapy was discontinued and
had a rebound bilirubin on day of life 6 of 5.4. She also had a
bili sent on DOL 16 that was 4.1 (0.3) mg/dL.
Infectious disease: Due to respiratory distress and
prematurity, the infant had a rule out sepsis evaluation. No
growth on blood cultures after 48 hours and antibiotics were
discontinued. She had viral culture sent after birth for HSV
that was negative from [**2-3**].
Heme: Her hct upon admission was 43.9%. She had a hematocrit of
32% on DOL 16. She is on iron supplementation.
Neurology: Ultrasound was not done due to gestational age at
birth of 33 weeks.
Sensory: Audiology hearing screen was performed by automated
auditory brainstem response. Results were normal bilaterally.
She needs f/u as an outpatient with repeat testing secondary to
active maternal HSV lesions at the time of birth.
Ophthalmology response: The patient did not have an
examination secondary to gestational age of 33-2/7 weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
PRIMARY CARE PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Hospital1 37224**]Health
Center, [**Telephone/Fax (1) 3581**].
PSYCHOSOCIAL: [**Hospital6 256**] Social
Work was involved with family. Social work can be contact[**Name (NI) **]
at [**Telephone/Fax (1) **]. There was reported domestic violence early in
pregnancy. A letter for Scattered Shelter has been written on
behalf of Ms. [**Known lastname **].
CARE RECOMMENDATIONS: Feedings at discharge: The patient was
discharged on Enfamil 24 feeds. The patient should continue
on the fortified feeds until 6-9 months of corrected age.
Medications: Ferrous Sulfate 6.25 mg by mouth daily (2 mg/kg/day)
The patient is currently receiving formula.
Vitamin D supplementation is unnecessary at this time. The
patient's birth weight was 1705, therefore should receive a
total of 4 mg/kg/day of iron. her formula provides 2 mg/kg/day
iron.
Car seat position screen: Passed prior to discharge.
State newborn screen: Done on day of life 2 and day of life
14. Screen was normal.
IMMUNIZATIONS RECEIVED: The patient received hepatitis B
vaccination on [**2192-2-20**]. The patient also received
Synagis prior to discharge. Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for all infants who
meet any of the following criteria: 1) born at less than 32
weeks, 2) born between 32 and 35-0/7 weeks with 2 of the
following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, 3) with chronic lung disease, or 4)
hemodynamic significant CHD.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life),
immunization against influenza is recommended for household
contacts and out-of-home caregivers. This infant did not
receive the Rotavirus vaccine. The American Academy of
Pediatrics recommend initial vaccination of preterm infants
at or following discharge from the hospital if they are
clinically stable and at least 6 but not fewer than 12 weeks
of age.
Follow-up appointment is to be scheduled with Dr. [**First Name (STitle) **] within 2
days of discharge.
DISCHARGE DIAGNOSIS: Prematurity, respiratory distress
syndrome, rule out sepsis, twin gestation.
[**Doctor First Name 11709**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 41519**], M.D. [**MD Number(2) 75306**]
Dictated By:[**Last Name (NamePattern1) 76457**]
MEDQUIST36
D: [**2192-2-22**] 13:39:36
T: [**2192-2-22**] 15:48:50
Job#: [**Job Number 76692**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7908
} | Medical Text: Admission Date: [**2169-5-23**] Discharge Date: [**2169-6-2**]
Service: Neurosurgery/cardiac medicine
HISTORY OF PRESENTING ILLNESS: Mr. [**Known lastname 30097**] is a 79 year-old
Russian male with history of renal cell carcinoma diagnosed
in [**2166**], status post left nephrectomy in 2,000, status post
IL2 therapy, with lung metastasis, hypertension, atrial
fibrillation, and diabetes who presented one year ago with an
metastatic renal cell carcinoma in [**Month (only) 547**] of this year. An
MRI on [**2169-5-1**] showed a dural based mass involving the
calvarium and superior sagittal sinus. He was admitted on
[**5-23**] for tumor embolization and left frontal parietal
craniectomy with resection of the tumor and cranioplasty on
the 13th. The patient's surgery was uneventful. On the
evening of [**5-24**], however, the patient developed right arm
Enzymes were cycled at that time and the patient ruled in for
non-Q wave myocardial infarction with troponin peaking at
greater than 50 and CK of 1,014 with an MB of 82.
Electrocardiogram showed a new left bundle branch with ST
elevation and T wave inversions in V3 and V4. The patient
was started on intravenous Lopressor and nitroglycerin. The
patient was then taken for cardiac catheterization which
revealed three vessel disease with left main disease and an
intra-aortic balloon pump was placed prophylactically. At
this time the patient came under care at the Cardiac Care
Unit team. At the time of our evaluation the patient had no
complaints.
PAST MEDICAL HISTORY: 1) Metastatic renal cell carcinoma
left, diagnosed in [**2167-11-11**] with lung metastasis at
diagnosis. Patient underwent IL2 therapy beginning in
[**Month (only) 956**] of 2,000 complicated by atrial fibrillation.
Patient underwent left nephrectomy in [**2168-5-12**]. Brain
metastasis a per History of Present Illness. 2) Non-insulin
dependent diabetes mellitus. 3) Hypertension. 4) Anemia.
5) Paroxysmal atrial fibrillation secondary to IL2 treatment.
6) Status post appendectomy.
MEDICATIONS (Outpatient): 1) Digoxin 0.25 mg q. day, 2)
Atenolol 25 mg p.o. q. day, 3) Coumadin. 4) Colace. 5)
Multivitamin. 6) Boost.
TRANSFER MEDICATIONS: 1) Insulin sliding scale. 2)
Lopressor 25 mg b.i.d. 3) Nitroglycerin drip. 4) aspirin
325 mg q. day. 5) Captopril 25 mg t.i.d.
SOCIAL HISTORY: The patient moved to the U.S. in [**2126**] from
[**Country 12930**]. He has worked as an engineer until retirement last
month. He has a tobacco history but said he quit in the
[**2117**].
PHYSICAL EXAMINATION: On transfer temperature of 99, blood
pressure of 150/90, pulse was 75, O2 saturation was 95% on
three liters. In general the patient was an elderly male who
was lying flat in bed and appeared comfortable. He was in no
acute distress. Head, eyes, ears, nose and throat
examination revealed a bandaged scalp with an incision that
went across the top of his head. Pupils are equal, round and
reactive to light. There were no oral lesions. Mucous
membranes were moist. Neck was supple without bruits. Heart
was regular rate and rhythm with a grade II/VI holosystolic
murmur at the apex radiating to the axilla. Lungs were clear
to auscultation anteriorly. Abdomen was soft and nontender.
Extremities were without edema. A balloon pump was placed in
the right femoral vein. Patient had warm feet. On brief
neurologic testing the patient showed no focal signs.
Cranial nerves appeared to be intact and patient was alert
and oriented with fluent language.
LABORATORY STUDIES: White count was 8.2 with hematocrit of
28 and platelets of 194. Chem-7 was remarkable only for BUN
of 36, creatinine of 1.7 which was the patient's baseline.
Serum glucose was 285. CKs peaked at 1,014 with an MB of 82
and MB index of 8. Troponin was greater than 50. Chest
x-ray showed mild congestive heart failure and no focal
infiltrates. Electrocardiogram on [**5-17**] showed sinus
bradycardia with left ventricular hypertrophy and left axis
deviation. There was poor R wave progression and left
anterior vesicular block. Electrocardiogram on [**5-24**]
showed bigeminy with flattened T waves anteriorly and later
in the evening with development of chest pain and new left
bundle branch block. Electrocardiogram on [**5-25**]
elevations in V3 and V4 with T wave inversion.
Echocardiogram from [**2168-4-11**] showed left atrial enlargement
with slight left ventricular hypertrophy. Ejection fraction
was measured at 45 percent. Echocardiogram postoperatively
on this admission showed left atrial enlargement as well as
right atrial enlargement. There was left ventricular
hypertrophy. Ejection fraction was estimated at 20 to 25
percent. Patient had pulmonary hypertension, moderate aortic
stenosis, 1 to 2+ mitral regurgitation and wall motion
abnormality. Cardiac catheterization on [**5-25**] showed left
main disease with an ostial 38 or 40 percent, distal 90
percent, mid LAD lesion of 80 percent, diagonal of 100
percent, mid left circumflex of 90 percent with right to left
collateral flow distally, RCA with 90 percent involving the
PDA.
HOSPITAL COURSE AFTER TO CARDIAC CARE UNIT BY SYSTEMS:
1) Cardiovascular. Given the patient's three vessel with
left main disease the patient was evaluated by CT surgery.
With the severity of his disease, decreased ejection
fraction, and other co-morbid illnesses the patient was
thought to be too high risk exceeding the possible benefit of
bypass grafting. The patient was initially maintained on
intravenous nitroglycerin and intravenous heparin was
discontinued after removal of intra-aortic balloon pump and
intravenous nitroglycerin was weaned. The patient was
maintained on daily dose of aspirin and Lopressor was
increased gradually to 100 mg t.i.d. and later switched to
150 mg b.i.d. Accupril was increased slowly to 100 mg t.i.d.
Given the patient's elevated left ventricular and diastolic
pressure of 26 the patient was diuresed and later started on
a daily dose of Lasix orally. As for the patient's atrial
fibrillation with the patient's increasing risk of falling
anticoagulation was discussed wit the neurosurgery team who
felt that it would be wise to hold off on restarting Coumadin
postoperatively and to re-evaluate this in one month after
the patient is back on his feet.
2) Hematology. The patient's hematocrit stayed persistently
between 28 and 30 while the intra-aortic balloon pump was in.
Hemolysis laboratories were sent ruling this out as the
etiology. Patient was transfused several units of blood with
inappropriate bumps after intra-aortic balloon pump was
removed hematocrit climbed to the 33 and was stable for
several days. During the time the balloon pump was in the
platelets also fell from approximately 200 to low 100s.
Heparin was discontinued and Zantac was changed to Prilosec.
Platelet count began to rise after the balloon pump was
removed.
3) Neurology. On postoperative day #6 the patient' activity
the was changed from out of bed to chair. At this point it
was noted that he was not able to bear weight on his right
lower extremity. On muscle strength testing the patient
showed an upper motor neuron distribution of weakness with
proximal muscle strength muscle groups being 4 to 4+/5 on
motor testing. A head CT obtained showed postoperative
changes with edema and effacement of the sulci over the left
parietal region. There was no hemorrhage or infarction in
any major territory noted. MRI obtained showed mild compression
of the lateral
[**Doctor Last Name 534**] on the left . After
discussion with neurosurgery these changes were considered
normal for his postoperative course and the patient's
strength was expected to improve. On subsequent days motor
strength was improved. On the date of discharge right and
left biceps were noted to 4+/5, triceps were 5-/5, right
iliopsoas was -[**4-15**], quads and hamstrings were [**4-15**], tibialis
anterior was [**4-15**] and plantar flexors were [**4-15**]. The remainder
of the neurologic examination was unremarkable. The patient
will have follow up radiation therapy in one week with
radiation of the sagittal sinus portion of the tumor that was
unresectable.
3) Diabetes mellitus. The patient was maintained on a
regular insulin sliding scale with fingerstick blood glucose
checks. The patient will likely benefit from daily doses of
scheduled NPH and regular insulin.
4) Renal. Given the patient's chronic renal insufficiency
creatinine was followed daily, especially when the
intra-aortic balloon pump was in place. Patient' creatinine
stayed stable at 1.7 to 1.9 with adequate urine output.
5) Infection disease. The patient was eventually started on
ciprofloxacin renally dosed for his creatinine clearance of a
sterile pyuria.
6) Oncology. The patient will have follow up with Dr. [**Last Name (STitle) 17466**]
in the radiation therapy clinic. As per discussion with Dr.
[**Last Name (STitle) 17466**] prognosis is good given tumor responsiveness to IL2
therapy. For prophylaxis the patient was prophylaxed with
heparin subcutaneously a well as pneumoboots and Prilosec
p.o.
DIAGNOSIS ON DISCHARGE:
1. Metastatic renal cell carcinoma.
2. Status post tumor embolization and left
frontoparietal craniotomy with resection of tumor
and cranioplasty.
3. Postoperative non-Q wave myocardial infarction.
4. Congestive heart failure with decreased left
ventricular systolic function.
5. Anemia.
6. Resolving right sided lower extremity hemiparesis
secondary to postoperative surgical edema.
7. Diabetes mellitus.
MEDICATIONS ON DISCHARGE: 1) Lopresor 150 mg p.o. b.i.d., 2)
Captopril 100 mg t.i.d., 3) Lipitor 10 mg p.o. q. day, 4)
Isordil 20 mg p.o. t.i.d., 5) Lasix 20 mg p.o. q. day. 6)
enteric coated aspirin 325 mg p.o. q. day. 7) Colace 100 mg
p.o. b.i.d. 8) Prilosec 20 mg q. day. 9) Heparin
subcutaneously 5,000 units subcutaneously t.i.d. 10)
Dulcolax 10 mg p.o./p.r. p.r.n. 11) sublingual
nitroglycerin 0.4 mg sublingual q. 5 minutes times 3 p.r.n.
12) regular insulin sliding scale 0 to 70 give D50 or juice,
71 to 160 give nothing, 161 to 200 give 2 units, 201 to 250
give 4 units, 251 to 300 give 6 units, 301 to 350 give 8
units, 351 to 400 give 10 units, greater than 401 give 12
units.
STATUS: To [**Hospital3 **].
CONDITION: Satisfactory.
FOLLOW UP: The patient will follow up with the brain tumor
clinic on [**6-12**] at 3 P.M. for radiation therapy. The
patient will follow up with his primary care physician. [**Name10 (NameIs) **]
note, the patient had a mildly elevated heart rate at
discharge to rehabilitation in the 80s given his high dose of
beta blocker. Hematocrit was found to be within normal
limits. TSH was still pending at the time of discharge.
Please follow up with these results.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Name8 (MD) 10039**]
MEDQUIST36
D: [**2169-6-2**] 11:01
T: [**2169-6-2**] 12:14
JOB#: [**Job Number 9901**]
ICD9 Codes: 9971, 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7909
} | Medical Text: Admission Date: [**2164-7-4**] Discharge Date: [**2164-7-20**]
Date of Birth: [**2164-6-29**] Sex: M
Service: NBB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **], surname after
discharge to be [**Last Name (un) 22107**], is the former 34 and [**4-10**] week
gestation infant, born to a 20 year-old, Gravida I, Para 0
woman with the following prenatal screens: A positive, DAT
negative, Hepatitis B surface antigen, rubella immune, GBS
unknown. Birth occurred at [**Hospital **] Hospital on [**2164-6-29**].
Pregnancy was notable for delivery at 34 and 3/7 weeks
gestation pregnancy. The pregnancy was complicated by
premature rupture of membranes occurring 24 hours prior to
delivery. The mother proceeded to spontaneous vaginal
delivery. She received multiple courses of Penicillin prior
to delivery for unknown group beta strep status. The infant
emerged depressed, requiring positive pressure ventilation in
the delivery room. He developed respiratory distress and was
intubated and started on mechanical ventilation. He received
a dose of Surfactant. He was also noted to have mild
hypotension, treated with normal saline. The infant was
transferred to [**Hospital3 1810**], [**Location (un) 86**], for further care.
Hospital course at [**Hospital3 1810**] was notable for rapid
improvement in respiratory status, exhibited by extubation to
room air by day of life #2. Chest x-ray was notable for
faint, diffuse opacifications, consistent with pneumonia.
Hemodynamic instability resolved. Cardiac echo was performed
on [**2164-6-30**] showing a structurally normal heart with a small
patent ductus arteriosus and mildly depressed biventricular
function. Enteral feeds were introduced and advanced without
difficulty. Multiple lumbar puncture attempts were
unsuccessful. The blood culture from [**Hospital **] Hospital was
negative. There was some concern for slightly depressed
neurologic exam on admission and a head ultrasound was
obtained on [**2164-7-3**] which showed small bilateral germinal
matrix hemorrhages. Due to concern for possible meningitis
and a prolonged antibiotic course, transfer was arranged to
[**Hospital1 69**] on day of life #5,
[**2164-7-4**].
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit at [**Hospital1 69**],
weight was 2.155 kg. Birth weight was 2.150 kg with a birth
length of 43 cm and a head circumference of 30 cm. General:
Active and vigorous infant, responsive to exam. Skin:
Jaundiced, ruddy and warm. Underlying color pink. Head,
eyes, ears, nose and throat: Fontanel soft and flat. Ears
and nares patent. Palate intact. Palpebral fissures
slightly down sloping. Neck supple, no lesions. Chest:
Clear to auscultation. No grunting, flaring or retracting.
Cardiac: Regular rate and rhythm without murmur. Normal S1
and S2. Femoral pulses +2. Abdomen soft, no organomegaly, no
masses. Active bowel sounds. Genitourinary: Normal male.
Testes descended bilaterally. Anus patent. Extremities, hips
and back normal. Neuro: Appropriate tone and activity.
Intact Moro.
HOSPITAL COURSE:
1. Respiratory: [**Known lastname **] was in room air for his entire
Neonatal Intensive Care Unit admission at the [**Hospital1 29402**]. No spontaneous episodes of
apnea were noted.
2. Cardiovascular: An intermittent murmur has been audible.
[**Known lastname **] has maintained normal heart rates and blood
pressures. Baseline heart rate is 140 to 160 beats per
minute with a recent blood pressure of 73/40 mmHg with a
mean blood pressure of 52 mmHg.
3. Fluids, electrolytes and nutrition: [**Known lastname **] has been on
full volume enteral feedings during admission. He was
initially receiving most of his feedings by gavage. He
has transitioned to all oral feeds. At the time of
discharge, he is breast feeding or taking expressed
breast milk fortified to 24 calories per ounce with 4
calories of Similac powder. Weight on the day of
discharge is 2.565 kg with a corresponding length of 45.5
cm and a head circumference of 31 cm.
4. Infectious disease: A lumbar puncture was performed on
[**2164-7-5**] showing 44,500 red blood cells and [**Pager number **] white blood
cells. Protein was 280 mg/dl and glucose was 18 mg/dl.
These findings were consistent with meningitis and
[**Known lastname **] received a 21 day course of Ampicillin and
Gentamycin. The antibiotics were discontinued on
[**2164-7-20**]. Cerebrospinal fluid culture was no growth.
5. Gastrointestinal: Peak serum bilirubin occurred on day
of life #5, total of 8.4 mg per dl. He did not require
any treatment with phototherapy. [**Known lastname **] has had a
significant diaper dermatitis that is being treated with
Criticaid ointment. There are open areas of excoriation
in the perianal area.
6. Hematologic: [**Known lastname **] did not receive any transfusions
of blood products during admission.
7. Neurology: Repeat head ultrasounds were obtained on [**7-9**]
and [**2164-7-19**]. Both showed persistence of the bilateral
germinal matrix hemorrhages with the scan on [**2164-7-19**]
showing slight extension of the hemorrhage still limited
to the germinal matrix, more significant on the left than
the right. A repeat head ultrasound has been scheduled as
an outpatient for [**8-2**] at 1:50 p.m. at [**Hospital1 62374**]. [**Known lastname **] has maintained a normal neurologic
exam during admission.
8. Sensory: Hearing screening was initially performed at
[**Hospital3 1810**] on [**2164-7-3**] with [**Known lastname **] passing in
both ears. Repeat hearing screen was passed at [**Hospital1 35990**] on [**2164-7-20**]. Due to the
concern for meningitis, a repeat hearing screen is
recommended at 3 months of age.
9. Psychosocial: As previously noted, surname after
delivery will be [**Last Name (un) 22107**]. Both parents have been very
involved in [**Known lastname 22033**] care.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, [**Location (un) 67370**]., [**Location (un) 67371**], [**Numeric Identifier 67372**]. Phone number [**Telephone/Fax (1) 65703**].
CARE AND RECOMMENDATIONS: Ad lib breast feeding or oral
feeding. Breast milk fortified to 24 calories per ounce with
4 calories by Similac powder.
MEDICATIONS:
1. Ferrous sulfate 0.3 ml p.o. once daily of 25 mg per ml
dilution.
2. Tri-vi-[**Male First Name (un) **] 1 ml p.o. once daily.
3. Car seat position screening was performed. [**Known lastname **] was
observed for 90 minutes in his car seat without any
episodes of bradycardia or oxygen desaturation.
4. State newborn screens have been sent 3x on [**4-17**] and
[**2164-7-13**]. No notification of abnormal results has been
received to date.
5. Immunizations: Hepatitis B vaccine was administered on
[**2164-7-16**].
6. 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: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
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.
1. Follow-up appointments: Appointment with Dr. [**Last Name (STitle) **],
primary pediatrician, on [**2164-7-23**] at 9:15 a.m.
Head ultrasound on [**8-2**], 1:50 p.m. at [**Hospital3 1810**],
[**Location (un) 86**].
Hearing screening at 3 months of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and [**4-10**] week gestation.
2. Status post respiratory distress and pneumonia.
3. Presumed meningitis.
4. Diaper dermatitis.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2164-7-20**] 02:15:16
T: [**2164-7-20**] 05:04:07
Job#: [**Job Number 67373**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7910
} | Medical Text: Admission Date: [**2160-12-9**] Discharge Date: [**2160-12-13**]
Date of Birth: [**2160-12-9**] Sex: M
Service: NEONATOLOG
HISTORY OF PRESENT ILLNESS: The child was the 3.755 kg
product of a full term gestation born to a 32 year old G2
P1-2 mother. Maternal screen notable for maternal blood type
O positive, antibody negative, hep B surface antigen
negative, RPR nonreactive, rubella immune, group B strep
an absent left kidney and later a constellation of findings
consistent with tuberous sclerosis complex including cardiac
rhabdomyomas and subependymal CNS tubers. The child was
delivered by C-section, emerged vigorous and looked good
initially.
HOSPITAL COURSE:
He was started on CPAP and then rapidly weaned to room air.
He subseuqently had multiple desaturation episodes of
undetermined etiology. Sepsis, cardiac and neurological
evaluations were negative. The episodes resolved spontaneously,
and he has been asymptomatic for a period of 5 days prior to
discharge. They are being attributed to respiratory immaturity,
now resolved.
2. Cardiovascular. He developed some mild hypotension. He
was given normal saline boluses times two. Cardiac rhythm
was also noted to be mildly abnormal. Hypotension
rapidly resolved and he did not require any further boluses
or blood pressure medications. Echo was performed which
showed the presence of rhabdomyomas, but no outflow
obstruction and good ventricular function. EKG was
consistent with intermittent sinus arrhythmia with premature
atrial contractions. At this time
patient's cardiac status is stable. He will require cardiac
followup. He had one episode of bradycardia with
desaturation which was self-resolving. Cardiology and
neurology were involved. The event was thought to be
clinically insignificant and idd not recur in the 5 days prior to
discharge.
3. FEN. He was initially started on IV fluids. Gradually
feeds were advanced. At the time of dictation he is
tolerating full enteral feeds of approximately 100 cc per kg
per day. His weight is 3.695 kg.
4. Neurology. He had an MRI done which showed the presence
of multiple subependymal tubers in a classic distribution for
tuberous sclerosis. He has not had any evidence of seizures.
He is on no neurologic medications. 72-hour intermittent EEG was
ordered because of the desaturation episodes, but these resolved
before the test was started. The report on this investigation is
pending at the time of discharge.
5. Infectious disease. CBC and blood culture were done. He
was given 48 hours of antibiotics. His culture remained
negative and he is no longer on antibiotics.
6. Renal. Post natal ultrasound was done which showed the
presence of both kidneys with normal parenchyma.
CONDITION ON DISCHARGE: Good.
RECOMMENDATIONS: Continue to monitor his growth and feeding.
Follow up in cardiology clinic. Follow up with neurology as
an outpatient for followup head imaging in approximately six
to eight weeks. He should be followed up by ophthalmology as
an outpatient. An appointment should be made with Dr.
[**Last Name (STitle) 44853**] at [**Telephone/Fax (1) 43283**]. He should follow up with genetics.
Genetic testing has been sent. The child should have a
followup renal ultrasound in approximately one to two months.
DISCHARGE DIAGNOSES: Tuberous sclerosis complex.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Doctor Last Name 44592**]
MEDQUIST36
D: [**2160-12-12**] 18:01
T: [**2160-12-12**] 19:38
JOB#: [**Job Number **]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7911
} | Medical Text: Admission Date: [**2120-6-20**] Discharge Date: [**2120-6-24**]
Date of Birth: [**2046-10-18**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Imdur / Lisinopril
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
unresponsiveness/s/p cardiac arrest
Major Surgical or Invasive Procedure:
intubation
therapeutic hypothermia protocol
History of Present Illness:
73M with h/o severe cardiomyopathy (EF [**9-19**]) s/p biV/ICD
([**2115**]), afib on coumadin and dig, rheumatic heart disease s/p
mitral valve repair in [**2109**] with residual 3+ MR, CRI, h/o CVA,
who was found unresponsive on park bench s/p cardiac arrest and
loss of pulse during EMS transport on way to [**Hospital1 18**] ED.
.
Complex story pieced together with family report, ED records,
OMR, and info from ICD interrogation. Per OMR note, patient had
increasing LE edema since 6 days PTA, called Dr. [**First Name (STitle) 437**] and was
told to restart lasix 20mg [**Hospital1 **]. Per family report, patient had
not been feeling well for 2 days PTA with fatigue, vague
symptoms. On AM of admission, pt had ICD firing for sensed VT at
11am with LOC prior to shock, with episode of incontinence. Pt
called Dr. [**First Name (STitle) 437**] at 2pm who thought that patient may be
hypokalemic, told to take 40meq KCL with planned f/u in [**Hospital 3782**]
clinic. Patient then went to park to meet friends with possible
marijuana use (?laced with cocaine) and was found unresponsive
on park bench for unknown amt of time and EMS called.
.
No EMS records, but per ED report, pt had loss of pulse in
transport, was given seconds of chest compressions, and on
arrival in ED at 5:20pm, was in pulseless wide complex
tachycardia concerning for polymorphic VT. CPR commenced and pt
given epi 1mg x 1, atropine 1mg x 1, and intubated (initial gas
7/16/32/189), femoral line placed. During course in ED, patient
went in and out of pulseless VT/WCT (loss of pulse for minutes
at a time) requiring intermittent shocks by ICD (x 5 shocks per
ICD interrogation between 4:46pm and 5:39pm), external
defibrillation, and medications (amiodarone, epi, vasopressin,
atropine). When regained pulse, pt hypotensive (SBP 36-67/26-29)
so pt started on Neosynephrine and Levophed. Labs significant
for INR 4.4, Hct 28.2, Cr 1.2, K 2.8. Given 30mg IV KCL, 2mg Mag
sulfate, and given Hct drop from b/l of 32-35, sent for CT head
for concern of bleed in setting of elevated INR. Wet read of CT
head with no bleed, mass effect, or shift. Also given 4amps of
Digibind after labs drawn. Patient lost pulse while down at CT
scan, required one round of epi/atropine/CPR and regained pulse
after 3 min, and was sent up to CCU directly on Neosynephrine at
4.8 and Levophed at 2.6.
.
On arrival to CCU, patient was intubated, sedated with fentanyl
and versed. Met with family for update, identification, and
confirmed full code. Overnight, Arctic sun cooling protocol
initiated, reached goal temperature at 8:30pm. Started on
dopamine, levophed and neosynephrine weaned off. ICD
interrogated showing 6 episodes of ATP/shock for sensed VT/VF.
Bedside ECHO done showing no large change from prior. ECG showed
v-pacing and resolution of global WCT in limb leads, continued
to have ACT in precordial leads with changed morphology from old
ECG. Repeat ABG was 7/22/45/70, PEEP increased to 10. Cr
increased from 1.2-> 1.9, INR decreased to 3.3, K was 5, lactate
was 5.6. Given 20mg IV lasix with no response, then 40mg IV x 1
for volume overload by exam, CXR, no UOP ->50cc urine output.
BNP [**Numeric Identifier **]. Cardiac arrest team notified, patient enrolled in IV
steroid clinical trial with family consent.
.
Unable to obtain review of systems as patient unresponsive. Per
OMR, patient with recent increase in LE edema.
Past Medical History:
1. CARDIAC RISK FACTORS:
(-)Diabetes, (-)Dyslipidemia, (-)Hypertension
2. CARDIAC HISTORY:
-severe dilated cardiomyopathy w/ valvular heart dz, LVEF
10-15%,
-rheumatic heart dz
-s/p mitral valve repair in [**2109**] with residual moderate MR
[**Name13 (STitle) **] on Coumadin, status post cardioversion in the past, but in
afib recently (Recent INR 1.5-2.8)
-mild renal insufficiency (Cr baseline is 1.2-1.6)
-hx of CVA.
-PACING/ICD: BiV ICD placed in [**2115**]
Social History:
-Tobacco history: none
-ETOH: Alcohol abuse until 25 years ago
-Illicit drugs: + marijuana currently
Family History:
NC
Physical Exam:
VS: T= 94.6 BP=82/63 - 108/67 HR=72 - 91 Sat: 95-100%,
AC(550/20/10/100%)
GENERAL: Pt intubated. Sedated.
HEENT: Sclera anicteric. Pupuls 7mm bilaterally, PERRL.
NECK: Supple with JVP of 16cm.
CARDIAC: Heart sounds soft and difficult to hear with
ventilator. Irregular with no murmur/rubs/gallops appreciated
LUNGS: Course breath sounds anterior lung fields, no
rhonchi/crackles. Unable to assess lower lobes given
positioning.
ABDOMEN: Difficult to assess given cool suit. Soft, ND.
EXTREMITIES: 1+ dependent lower extremity edema. No
clubbing/cyanosis appreciated. Distal extremities cool to touch.
SKIN: Hematoma right arm. No other rashes, bruising appreciated.
PULSES:
R: Diminished Radial, DP, PT
L: Diminished Radial, DP, PT
Neuro: Pupils 7mm equal and reactive to light. Increased tone in
bilateral upper and lower extremity. Unable to illicit patellar,
tricep, or bicep reflex. Bilateral upgoing toes.
Pertinent Results:
EKG: Multiple EKGs, 1723 - 1745 in ED. Rate ranged from 83 - 150
highly irregular polymorphic wide complex tachycardia. With
pacer spike occasionally prior to QRS complex and occasionally
within QRS complex. Multiple QRS morphology. EKG from 1744,
shows possible concordance in precordial leads. [**2043**] on arrival
to CCU, EKG compared to prior EKG prior negative deflection in
V3 now positive.
.
2D-ECHOCARDIOGRAM: [**8-11**]
1.The left atrium is moderately dilated. The left atrium is
elongated. The right atrium is moderately dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is severely dilated. There is severe global
left ventricular hypokinesis. Resting regional wall motion
abnormalities include akinesis of the mid and distal septum, mid
and distal inferior wall and apex. The remaining segments are
severely hypokinetic. The remaining left ventricular segments
are hypokinetic.
3. Right ventricular systolic function appears depressed. There
is an echogenic density in the RV consistent with a pacemaker
lead.
4.The aortic root is mildly dilated. The ascending aorta is
mildly dilated. The aortic arch is mildly dilated.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 6.The mitral
valve leaflets are mildly thickened. Moderate to severe (3+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure.
7.There is mild pulmonary artery systolic hypertension.
8.There is no pericardial effusion.
.
ETT: [**2120-4-11**]
Negative dipyridamole stress test
.
CARDIAC CATH: [**6-8**]
1. Selective coronary angiography showed a right dominant
system
without evidence for angiographically significant stenoses.
2. Limited resting hemodynamics revealed moderate pulmonary
hypertension (PA mean 39 mmHg). The right and left sided filling
pressures were elevated (RA mean 18 mmHg, RVEDP 20 mmHg, PCW
mean 24
mmHg). Cardiac output and index were reduced (CO 3.5 l/min, CI
1.7
l/min/m2).
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Elevated left and right sided filling pressures
3. Moderate pulmonary hypertension.
.
LABS ON ADMISSION:
Initial labs in ED:
3.1\_8.4_/100
/ 28.2\
ABG: 7.16/32/189/12 ( initial ABG after intubation)
.
K: 3.1 BUN: 22 Cr: 1.2
.
PT/PTT/INR: 41.3/51.5/4.4
Fibrinogen: 146
Lip: 34
MOST RECENT LABS:
[**2120-6-23**] 03:54AM BLOOD WBC-11.0 RBC-3.49* Hgb-9.5* Hct-30.9*
MCV-89 MCH-27.2 MCHC-30.8* RDW-17.6* Plt Ct-133*
[**2120-6-23**] 03:54AM BLOOD Plt Ct-133*
[**2120-6-23**] 03:54AM BLOOD PT-31.0* PTT-40.9* INR(PT)-3.1*
[**2120-6-23**] 03:54AM BLOOD FDP-80-160*
[**2120-6-22**] 08:00PM BLOOD FDP-10-40*
[**2120-6-23**] 03:54AM BLOOD Glucose-162* UreaN-65* Creat-4.6* Na-138
K-4.3 Cl-103 HCO3-17* AnGap-22*
[**2120-6-23**] 04:18AM BLOOD Lactate-3.1*
Brief Hospital Course:
73M with h/o severe cardiomyopathy (EF [**9-19**]) s/p biV/ICD
([**2115**]), afib on coumadin and dig, rheumatic heart disease s/p
mitral valve repair in [**2109**] with residual 3+ MR, CRI, h/o CVA
who was found unreponsive and s/p cardiac arrest from unknown
etiology with multiple rounds of ICD firing and ACLS/CPR
admitted on cooling protocol and pressor support. Patient found
to be in polymorphic ventricular tachycardia in setting of
hypokalemia and worsened severe end stage cardiomyopathy
(Patient with known severe cardiomyopathy from valvular dz/NYHA
IV sCHF with EF 10-15%). By ICD interrogation, patient had 6
episodes of ineffective ATP leading to shock with one episode at
11am, and one at 4:46pm which may have correlated with patient's
episodes of unresponsiveness. Initial lytes showed hypokalemia,
acidemia. Utox for cocaine negative and dig level normal. No
evidence of ACS as etiology. Patient was s/p multiple episodes
of loss of pulse with wide complex tachycardia, so started on
cooling protocol on admission. Patient cooled on Arctic Sun
protocol with goal cooling achieved at 8:30pm of night of
admission. Continuous EEG in place, and per cardiac arrest team,
per EEG and neuro exam post sedation, patient had very little
chance of meaningful neurologic recovery. Patient required
pressors for BP support, which was switched to milrinone and
neosynephrine with no ability to achieve urine output with
lasix. Patient's renal function continued to deteriorate from Cr
1.2 to 4.6, he went into DIC.
Given patient's poor prognosis, critical condition, and low
chance of meaningful neurologic recovery, family meeting was
held on [**6-23**] and patient was made comfort measures only and kept
comfortable with versed for myoclonic movements, morphine gtt,
scopolamine patch, and ativan prn. His pressors were
discontinued, and the patient was extubated at 5:45pm on [**6-23**].
The patient passed away at 2:20 am on [**2120-6-24**] comfortable,
with family at the bedside.
COMM: Daughter [**First Name8 (NamePattern2) 12556**] [**Known lastname **] ([**Telephone/Fax (1) 104570**], Sister [**Name (NI) 2048**]
[**Name (NI) 6515**] ([**Telephone/Fax (1) 104571**].
Medications on Admission:
- carvedilol 3.125 mg tablets three tablets in the morning, two
tablets at bedtime
- digoxin 0.125 mg Monday through Friday
- nasal spray as needed
- Lasix 20 mg twice a day (unclear if patient taking)
- potassium 20 mg daily (unclear if patient taking)
- Coumadin
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
ICD9 Codes: 5849, 2762, 2768, 5859, 4271, 4254, 4168, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7912
} | Medical Text: Admission Date: [**2116-5-2**] Discharge Date: [**2116-5-8**]
Date of Birth: [**2067-9-11**] Sex: M
Service: VASC [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 15537**] is a 48 year old
male who is status post aortobifemoral bypass grafting as
well as right sided femoral to popliteal artery bypass
grafting, right sided iliac stenting and aortohepatic bypass
grafting with erosion of his graft into his duodenum
requiring repair approximately four months ago, as well as a
history of a left sided axillary femoral artery with fem-[**Doctor Last Name **]
bypass grafting in [**2116-1-17**], and redo of his left
femoral popliteal bypass in [**Month (only) 958**] of this year with a left
sided toe amputation, who presented complaining of two days
of drainage of his left groin incision and tenderness.
HOSPITAL COURSE: This was diagnosed as a wound infection
and he was placed on broad-spectrum antibiotics and had wound
management performed at this time. He was admitted to the
Floor and was doing well up until hospital day number three
where he was noted to have a large amount of bloody emesis,
approximately two liters, with hypotension. He was
subsequently transported into the Intensive Care Unit, had
large bore intravenous access obtained, and had an
esophagogastroduodenoscopy performed showing a large duodenal
blood clot.
He continued to require large amounts of blood and went down
to Angiography the next morning. In the Angio Suite, it was
found that his axillary to femoral bypass graft was
thrombosed, requiring TPA administration. He also had
evidence of active bleeding requiring multiple coil
embolization of multiple aortic branches. He returned to the
Intensive Care Unit following this procedure in very
critically ill condition.
He was maintained on high inotropic support and aggressive
fluid and blood products administration. However, he went
into liver failure that morning and given the poor prognosis,
a discussion was carried out with the family and they felt
that continuing further support was against his wishes and
made the patient comfort measures only.
Following this, all inotropic support was removed, and the
patient expired at 09:51 a.m. on [**2116-5-8**]. No post-mortem
examination was to be performed by the family's request.
DISCHARGE DIAGNOSES:
1. Massive upper gastrointestinal bleed of unknown origin.
2. Thrombosed axillary femoral bypass graft.
3. Sepsis.
4. Multi-organ failure.
5. Status post multiple vascular bypass procedures.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Name8 (MD) 15538**]
MEDQUIST36
D: [**2116-5-8**] 11:25
T: [**2116-5-11**] 11:28
JOB#: [**Job Number 15539**]
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7913
} | Medical Text: Admission Date: [**2187-3-13**] Discharge Date: [**2187-3-22**]
Date of Birth: [**2127-10-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Emesis, Low blood glucose
Major Surgical or Invasive Procedure:
[**3-16**]: Coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending coronary artery;
reverse saphenous vein single graft from the aorta to the first
obtuse marginal coronary; as well as reverse saphenous vein
single graft from the aorta to the posterior descending coronary
artery.
Endoscopic left greater saphenous vein harvesting.
[**3-14**]: Cardiac Catheterization
History of Present Illness:
59 year old male with Type I Diabetes
Mellitus who has felt ill for past week (poor oral intake,
dizziness and emesis). He was found yesterday morning with
fasting blood glucose of 19. Taken to ED where Troponin was
found
to be elevated (2.21) and he was brought for a cardiac cath on
[**3-14**]. Cath revealed severe three vessel coronary artery disease
and he was referred for surgical revascularization.
Past Medical History:
Diabetes Mellitus
Hypertension
Gastroesophageal reflux disease
Melanoma s/p removal left leg
Social History:
Race: Caucasian
Last Dental Exam: many yrs ago
Lives: alone
Occupation: does not work
Tobacco: [**4-5**] cigs/day
ETOH: social
Enrolled in any clinical/research study?
Family History:
non-contributory
Physical Exam:
Height: 5'[**87**]" Weight: 68kg
General: well-developed thin male lying supine in bed in bo
acute
distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X] Poor dentitian
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X] Anterior
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
[X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: bandage from cath
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: -
Pertinent Results:
[**2187-3-21**] 07:35AM BLOOD WBC-7.7 RBC-3.48* Hgb-10.5* Hct-31.2*
MCV-90 MCH-30.2 MCHC-33.7 RDW-14.5 Plt Ct-330
[**2187-3-20**] 05:35AM BLOOD WBC-6.7 RBC-3.49* Hgb-10.7* Hct-31.8*
MCV-91 MCH-30.8 MCHC-33.8 RDW-14.8 Plt Ct-259#
[**2187-3-21**] 07:35AM BLOOD Glucose-49* UreaN-19 Creat-1.3* Na-140
K-4.4 Cl-101 HCO3-33* AnGap-10
Prebypass
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with hypokinesia of the
apex, apical portions of the inferior, anterior and septal
walls. The mid portion of the inferior and anterospetal walls
are also hypokinetic. Overall left ventricular systolic function
is moderately depressed (LVEF= 35 %). No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size and
free wall motion are normal. There are complex (>4mm) atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) 914**] was notified in person of the results on [**2187-3-16**] at
830am.
Post bypass
Patient is in sinus rhythm and receiving an infusion of
phenylephrine. LVEF is now 40%. RV function is normal. Mild
mitral regurgitation persists. Aorta is intact post
decannulation.
Brief Hospital Course:
59 year old male with Type I Diabetes Mellitus who has felt ill
for past week (poor oral intake, dizziness and emesis). He was
found yesterday morning with fasting blood glucose of 19. Taken
to ED where Troponin was found to be elevated (2.21) and he was
brought for a cardiac cath on [**3-14**]. Cath revealed severe three
vessel coronary artery disease and he was referred for surgical
revascularization.
He was taken to The Operating Room on [**2187-3-13**] and underwent a
CABG x3 (LIMA-LAD, SVG to OM,PDA)-see operative note for
details. Post operatively he remained intubated and was admitted
to the ICU for invasive hemodynamic monitoring. He awoke
neurologically intact and was extubated. His chest tubes and
temporary pacing wires were removed per protocol. His statin
therapy was resumed and he was started on betablockers and
diuresed toward his pre-op weight. He remained in the ICU due to
hyperglycemia requiring an insulin drip. [**Last Name (un) **] was consulted.
Insulin drip was stopped and euglycemia was achieved with lantus
and sliding scale humalog. Once glucoses were stablized, he was
transferred to the step down unit. He was evaluated by physical
therapy for strength and conditioning and was cleared for
discharge to home on POD#6.
Medications on Admission:
Lovastatin 20mg qd, Naprosyn 500mg [**Hospital1 **],
Lantus 16 units qhs and SSI, Prilosec 20mg [**Hospital1 **], Neurontin 300mg
[**Hospital1 **], Iron 325mg qd or MVI, Aspirin 81mg qd, Nitro prn
Plavix - last dose: 600mg [**3-14**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. lantus
lantus insulin 30 units SQ qam.
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day for 7 days.
Disp:*7 Capsule, Sustained Release(s)* Refills:*0*
13. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
s/p CABGx3 (LIMA>LAD, SVG>OM, SVG>PDA)
Past Medical History: Diabetes Mellitus TYPE 1, Hypertension,
gastroesophageal reflux disease, Melanoma s/p removal left leg,
? Splenectomy [**2185**]
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Sternal wound healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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:
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] [**2187-4-3**] @1:00PM
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7449**], MD Phone:[**Telephone/Fax (1) 1971**] [**2187-5-4**] @
8:30AM
Please call for appointments:
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 608**] in [**3-7**] weeks
Cardiologist: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 81063**] in [**3-7**] weeks
Completed by:[**2187-3-22**]
ICD9 Codes: 5849, 4019, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7914
} | Medical Text: Admission Date: [**2146-9-12**] Discharge Date: [**2146-9-15**]
Date of Birth: [**2073-4-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7223**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
implantable pacemaker placement
History of Present Illness:
Mrs. [**Known lastname 12967**] is a 73 yo woman from [**Country 3587**] with history of
HTN who presented to a hospital in [**Country 3587**] about two weeks
prior to admission with a heart block which she was told would
require pacemaker implantation. She left the hospital without
getting a pacemaker and travelled to the United States. Per
chart, she reported that she had CP, palpitations and dyspnea 2
weeks ago when she was seen in [**Country 3587**]. She however reports
that she has never had CP, palpitations or dyspnea and that when
she was diagnosed with the "[**Last Name **] problem" that she did not have
any symptoms. She also reports having recent fevers and chills.
No cough, rashes, arthralgia.
.
She reports that today, she came to the ED because she felt that
her blood pressure was high. She says that when her blood
pressure is elevated, she has "tongue heaviness" which she
currently endorses. Otherwise she denies headache, weakness. She
does report slurred speech which has been progressive for 1
month.
.
She presented to [**Hospital1 18**] and was found to have complete heart
block on her initial EKG. Initial VSs were 96.8 HR 40 178/64 RR
16 97% RA
.
On review of symptoms, 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.
Past Medical History:
Hypertension
Social History:
Flew over from [**First Name9 (NamePattern2) 74912**] [**Country **] last week, staying with family.
Family History:
non-contributory
Physical Exam:
VS: T Afebrile, BP 182/61 , HR 90, RR 22, O2 97% on RA
Gen: WDWN elderly woman in NAD, resp or otherwise. Pleasant,
appropriate.
HEENT: NCAT. Sclera anicteric. EOMI.
Neck: JVP of 8 cm.
CV: Bradycardic but regular, normal S1, S2. No S4, no S3.
Chest: No crackles, wheeze, rhonchi anteriorly
Abd: Obese, soft, NTND, No HSM or tenderness
Ext: No c/c/e
Pulses:
Right: Carotid 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; 2+ DP
Pertinent Results:
[**2146-9-12**] ADMISSION LABS:
CBC:
WBC-16.8* RBC-4.66 Hgb-14.3 Hct-41.0 MCV-88 MCH-30.6 MCHC-34.8
RDW-13.8 Plt Ct-297 Neuts-58.0 Lymphs-29.4 Monos-5.2 Eos-7.1*
Baso-0.2
.
COAGS:
PT-12.1 PTT-28.0 INR(PT)-1.0
.
CHEM:
Glucose-133* UreaN-18 Creat-1.1 Na-140 K-4.0 Cl-101 HCO3-27
AnGap-16 Calcium-9.9 Phos-4.2 Mg-2.4
.
LFTs:
ALT-28 AST-20 CK(CPK)-68 AlkPhos-98 Amylase-92 TotBili-0.5
Lipase-57 Albumin-4.1
.
cTropnT-<0.01
.
TSH-2.2
.
COMPLETE HEART BLOCK AND EOSINOPHILIA WORKUP:
RPR: negative
[**2146-9-13**] 9:17 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2146-9-14**]**
OVA + PARASITES (Final [**2146-9-14**]):
NO OVA AND PARASITES SEEN.
.
Blood Cultures: negative
Urine Culture: negative
Toxo: IgG positive, IgM negative
Lyme: negative
Strongyloides: POSITIVE (result returned after discharge)
Chagas: negative
.
[**2146-9-15**] DISCHARGE LABS:
CBC:
WBC-13.6* RBC-4.35 Hgb-13.3 Hct-38.4 MCV-88 MCH-30.5 MCHC-34.5
RDW-13.9 Plt Ct-213 Neuts-66.9 Lymphs-19.1 Monos-4.1 Eos-9.8*
Baso-0.1
.
CHEM:
Glucose-98 UreaN-13 Creat-0.9 Na-139 K-4.2 Cl-102 HCO3-27
AnGap-14
Calcium-9.3 Phos-4.2 Mg-2.2
.
STUDIES:
CT head: no intracranial process
.
Admission EKG:
Sinus rhythm, rate 95-100. There is high degree or complete A-V
block with
junctional pacemaker at rate 40. No previous tracing available
for comparison.
TRACING #1
.
ECHO:
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%) There is no left ventricular outflow
obstruction at rest or with Valsalva. There is no ventricular
septal defect. The right ventricular cavity is dilated. Right
ventricular systolic function is borderline 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. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
POST-PACEMAKER EKG:
Normal sinus rhythm, rate 78, with ventricular synchronous
pacing. Compared with tracing of [**2146-9-13**] the rhythm has changed
from sinus at rate 70 with probable high degree A-V block to
sinus at rate 78 with ventricular synchronous pacing. The
ventricular rate has increased from 35 to 78.
Brief Hospital Course:
75F with HTN presents with complete heart block. Hospital course
by problem.
.
# CHB - patient was monitored on telemetry and was taken to the
EP lab where a dual chamber pacmaker was placed. An echo showed
a normal EF of 70%. Surveillence telemetry and CXR indicated a
malpositioned atrial lead, and she was taken back to the EP lab
for revision. Subsequent pacing was appropriate and leads were
confirmed on CXR. She was discharged with follow up in the
device clinic, and with 3 additional doses of post-procedure
prophylactic Kefzol. Infectious etiologies for CHB including
syphilis and chagas disease were negative. Of note, the
patient's strongyloides antibody titer did return postitive (see
"Eosinophilia" below), but strongyloides infection is not known
to cause CHB.
.
# HTN - patient reported being on HCTZ in the past. Was
restarted on HCTZ with only marginal BP control. Amlodipine 5mg
was also begun prior to discharge.
.
# Eosiniophilia - ranged from 6.4 to 9% on differential. No
known allergies or asthma. An infectious workup was pursued,
including stool O+P, which was negative, and blood and urine
cultures, which were also negative. A lyme antibody was
negative. However, after discharge, her strongyloides antibody
returned positive. Interestingly, the stronglyoides [**Doctor First Name **] may be
positive even when repeated examinations of stool samples have
been unrevealing, as was the case in this patient. Also of note,
rhe anti-strongyloides antibody assayed in the [**Doctor First Name **] serology
can persist for years after treatment. It is currently unknown
whether or not the patient has ever been treated for
strongyloides. However, given her high degree of peripheral
eospinophilia, it is not unreasonable to assume that she may
currently be infected. PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11616**] was notified via email,
patient has appointment with him on [**10-18**] (in 12 days time).
Medications on Admission:
HCTZ 25mg daily
occasional metaclopramide
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Keflex 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
doses.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary: complete heart block
secondary: hypertension
Discharge Condition:
good, stable
Discharge Instructions:
You were admitted tot he hospital with an abnormal heart rhythm
called complete heart block. You received an implantable
pacemaker to treat this condition. After discharge, you will
need to take 3 more doses of antibiotics to protect against
infection. You will also need to follow up with the electrical
device clinic to make sure the pacemaker is working properly.
.
You were also found to have high blood pressure. You are now
taking 2 blood pressure medicines, called hydrochlorothiazide
and amlodipine.
.
Please take all medications as prescribed. Please attend all
follow up appointments. If you experience any chest pain,
shortness of breath, lightheadedness, or other symptoms, please
call your doctor or return to the ER.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2146-9-21**]
9:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 7976**]
Date/Time:[**2146-10-18**] 4:15
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7915
} | Medical Text: Admission Date: [**2168-11-28**] Discharge Date: [**2168-12-2**]
Date of Birth: [**2092-3-27**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 76 year-old female
with coronary artery disease status post coronary artery
bypass graft in [**2153**] and multiple percutaneous interventions
who was brought to the Emergency Department after a witnessed
cardiac arrest. The patient was in the mall and had a
witness cardiac arrest. There was bystander CPR at two
minutes and after eight minutes an AED arrived and the
patient was shocked. CPR continued for five to six minutes
and then EMS arrived. Initial rhythm was complete heart
block and the patient was treated with epinephrine. This led
to ventricular tachycardia and the patient was shocked
leading to a rhythm of ventricular fibrillation, which
converted to sinus rhythm after two further shocks.
Electrocardiogram showed inferior ST elevations and lateral
ST depressions. The patient was intubated and brought to the
Emergency Department. In the Emergency Department she was
treated with heparin and Integrilin, but this was
discontinued due to coffee ground emesis. A chest x-ray
showed a right pneumothorax and a chest tube was placed. The
patient became hypotensive and Dobutamine and Levophed were
started for blood pressure support. The patient was
transferred to the Coronary Care Unit and the pressors were
weaned off with fluid boluses.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Coronary artery disease status post coronary artery
bypass graft in [**2153**], multiple PCIs and a redo coronary
artery bypass graft in [**2163**].
4. Bladder prolapse.
PHYSICAL EXAMINATION ON ADMISSION: Pulse 100 to 120. Blood
pressure 60 to 80/40 to 60. Oxygen saturation 86 to 90% on
the ventilator. Her heart was regular with no murmurs.
There were rhonchorous breath sounds bilaterally. The
abdomen was benign and there was no edema.
HOSPITAL COURSE: The patient was admitted to the Coronary
Care Unit status post cardiac arrest and resuscitation. The
main concern of the family from the time of admission was the
patient's wishes regarding end of life care and previous
discussions suggesting that she wished not to be intubated or
resuscitated. After extensive discussions with the family it
was determined to give the patient 48 hours to determine,
which direction her neurologic status would go. The
neurology consult team followed throughout the
hospitalization and while she initially showed some positive
signs by [**12-1**] it appeared that the patient was not
going to make a rapid recovery back to her baseline
functional status as she would have wished. Additionally the
patient's respiratory status was compromised both by right
pneumothorax secondary to rib fracture sustained during CPR
as well as probable aspiration pneumonia. On [**12-2**]
another meeting with the patient's two sons and daughter was
held. They believed firmly that it would be their mother's
wishes to withdraw care as she never wished to have her life
sustained with heroic measures. Therefore in the afternoon
of [**12-2**] the patient's mechanical ventilation was
discontinued and she quickly had a respiratory arrest. The
patient was pronounced dead at 2:40 p.m. The family declines
postmortem examination.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 15468**]
MEDQUIST36
D: [**2168-12-2**] 03:09
T: [**2168-12-7**] 07:08
JOB#: [**Job Number 95435**]
ICD9 Codes: 5070, 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7916
} | Medical Text: Admission Date: [**2185-2-21**] Discharge Date: [**2185-2-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Admitted from clinic for cardiac tamponade.
Major Surgical or Invasive Procedure:
Pericardial drainage.
History of Present Illness:
[**Age over 90 **] yo male w no significant past medical history, who was seen
in clinic this a.m. and scheduled for ECHO. Was in his usual
state of health until a few weeks prior to admission when he had
an episode of shaking chills at his home in [**State 108**] and was
taken to the hospital. At the [**Hospital 108**] Hospital, he was admitted
for two nights and apparently told that he had a "big heart" on
(x-ray) and lower extremity edema and was discharged on 40mg PO
lasix.
Of note, pt. reports that he had two previous episodes of
shaking chills a few months ago while he was in [**Location (un) 86**] which
resolved overnight without medical intervention. Also reports a
non-productive cough over the same timeline. He denies any chest
pain, no shortness of breath, no orthopnea, no PND, no decrease
in exercise tolerance, no history of malignancy and no sick
contacts.
[**Name (NI) **] returned to [**Location 86**] and daughter had him see Dr. [**First Name (STitle) 437**] in
clinic on the morning of admission. Was tachycardic in clinic
with distant heart sounds and elevated JVP. Had ECHO which
demonstrated 3 cm pericardial effusion, evidence of R
ventricular collapse and tamponade physiology. Was taken to the
cath lab for pericardial drainage with removal of 2L of brownish
fluid and insertion of pericardial drain. Pt was then
transferred to the CCU for further management.
Past Medical History:
hx of GI bleeds
Right colon adenoma s/p R hemicolectomy in [**2180**]
Anemia
DM II - on oral hypoglycemics
umbilical hernia
s/p appendectomy
s/p TURP
h/o nephrolithiasis
Social History:
No tobacco, Occasional alcohol. Widowed, lives alone in [**State 108**]
part of the year.
Family History:
Non-contributory
Physical Exam:
Vitals: T - 98.4, HR - 99, BP - 120/66, SpO2 - 99% on 2L NC.
.
PE: General: Pleasant gentleman, looks younger than stated age.
In bed lying flat, looks comfortable, in NAD
HEENT: PERRLA, sclera anicteric, MMM
NECK: No carotid bruits.
CHEST: CTAB, decreased breath sounds at bases, no w/r/r
CARDIAC: RRR, nl. S1 S2, 2/6 SEM @ L upper sternal border. JVP
not elevated. Pericardial drain present.
ABDOMEN: Soft, NT, ND, + BS, R lateral vertical scar in abdomen
w healed osotomy scar.
EXT: No edema, warm, well-perfused
NEURO: Alert & Oriented X 3
Pertinent Results:
Admission labs:
141 102 38 AGap=16
------------<
4.3 27 2.1
estGFR: 30/36 (click for details)
RheuFac: 4
.
11.7
6.8>---<269
34.1
.
PT: 14.8 PTT: 27.3 INR: 1.3
.
Pericardial fluid:
TotProt: 4.2 Glucose: 97 LD(LDH): 1110 Amylase: 21 Albumin:
3.0 WBC: 3700 Hct,Fl: 5.0 Polys: 2 Lymphs: 95 Monos: 2
Atyps: 1 Plasma: 0
.
[**Doctor First Name **]: Negative
.
EKG: Sinus tach @ 100bpm, low voltages, no ST changes.
.
Imaging:
[**2185-2-21**] ECHO:Large circumferential pericardial effusion with
echocardiographic findings c/w tamponade physiology. At least
mild aortic stenosis. Mild symmetric left ventricular
hypertrophy with preserved global biventricular systolic
function. EF - 55%
.
Cardiac Cath ([**2185-2-21**])
1. Pericardial tamponade.
2. Successful removal of 2050cc dark, bloody fluid.
3. No significant residual pericardial fluid at the conclusion
of the
procedure.
.
Hemodynamics:
Pre-Cath: Baseline resting hemodynamics revealed tamponade
physiology with a mean RA of 20mmHg, RVED of 22mmHg, mean PCWP
of 23mmHg, PAD of 27mmHg, and a pericardial pressure of 23mmHg.
The pulsus paradoxus was
approximately 31mmHg. Initial femoral artery systolic pressure
was
118mmHg. The cardiac index was depressed at 2.0l/min/m2.
.
Post-Cath: Post procedure hemodynamics revealed a mean RA of
9mmHg, PCWP of 11mmHg, and pericardial pressure of -5mmHg. The
femoral systolic pressure increased to 144mmHg and the cardiac
index increased to 3.8l/min/m2.
.
CXR [**2185-2-23**]: Pericardial drainage catheter has been removed.
There has been no change in the cardiomediastinal contour. Small
bilateral pleural effusions are still present. No pneumothorax.
Left basal atelectasis is stable. Lungs, otherwise clear.
Brief Hospital Course:
A/P: 93-yo gentleman with no significant PMH, admitted with
large chronic pericardial effusion and tamponade, of unknown
etiology, stable s/p cardiac cath with drainage of 2L of dark,
bloody fluid.
.
1. Pericardial Effusion/Tamponade: s/p drainage of large chronic
pericardial effusion with pericardial drain. Etiology is unclear
at this time but could most likely be secondary to malignancy
(no clear source at this time), occult infection given his h/o
shaking chills although no fevers/white count, uremia/ renal
failure or connective tissue disease or idiopathic. The
pericardial drain put out minimal fluid after initial placement
and was uneventfully removed. Pulsus remained low after initial
drainage. Cultures were pending with NGTD at time of discharge.
ECHO post catheter removal showed trivial pericardial effusion.
The evening of catheter placement he was febrile to 101.4. He
was cultured (blood and urine) and started on ceftriaxone and
vanco out of concern for catheter related infection. Since all
cultures were negative these were stopped after 72 hours.
.
2. Pump: Has an EF of 55% by ECHO. Decreased cardiac index
probably due to tamponade with good recovery post-drainage. Did
not require diuresis after pericardial drainage.
.
3. Acute on Chronic Renal Insufficiency: Likely pre-renal
secondary to poor cardiac output due to tamponade physiology.
Baseline creatnine is ~1.3, improved on this hospital stay to
1.4-1.6.
.
4 Normocytic Anemia: Has prior history of anemia and GI bleeds,
hematocrit is 34.1,which is around his baseline with no obvious
source of bleeding. iron studies consistent with mixed anemia of
chronic disease and iron deficiency.
.
5 Diabetes: Has a history of NIDDM, possibly on glyburide in the
past, blood glucose monitored here and <150, no sliding scale
was needed so discharged off medication.
.
6 Code: FULL
Medications on Admission:
asa 81 mg qd
lasix 40 mg qd
Folate/B12
glyburide ?
.
Allergies: NKDA
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial effusion.
Discharge Condition:
Good.
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow-up appointments. Please notify your primary care doctor,
Dr. [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 42160**] ([**Telephone/Fax (1) 42161**], or your cardiologist,
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], or return to the Emergency Department if you
experience fevers, chills, shortness of breath, chest pain or
pressure, light-headedness, feeling faint, nausea, vomitting,
diarrhea, or any symptoms that concern you.
Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 42160**] within 1-2 weeks of discharge. Please call
[**Telephone/Fax (1) 42162**] for this appointment.
.
Please follow-up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] of cardiology within 1
week of discharge. Please call [**Telephone/Fax (1) 4451**] to schedule this
appointment.
ICD9 Codes: 5849, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7917
} | Medical Text: Admission Date: [**2145-2-20**] Discharge Date: [**2145-2-23**]
Date of Birth: [**2070-2-11**] Sex: F
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 34521**] is a 75-year-old
female without any prior cardiac history who presented with
10/10 chest pain. The patient first noted exertional chest
pain over the last week. The patient was seen at her primary
care physician's office for evaluation of upcoming rectocele
surgery and was noted to have electrocardiographic changes
from prior EKGs two years ago. The patient underwent an
exercise stress test on Friday which was reported as positive
with ischemic changes shortly after initiation of the study.
The patient reported that she received sublingual
Nitroglycerin and had plans for cardiac catheterization early
next week. The patient states that at 5:30 p.m., she
suddenly developed 10/10 chest pain while at rest. She took
sublingual Nitroglycerin without relief and went to the
Emergency Room. She was started on aspirin, Heparin,
nitrates, and 2B3A inhibitor without relief of pain.
Electrocardiogram showed anterior T wave inversion, poor R
wave progression, and she was transferred to [**Hospital6 1760**] for cardiac catheterization.
At cardiac catheterization, she was found to have 100%
occlusion of the proximal left anterior descending artery.
The patient received percutaneous transluminal coronary
angioplasty with stent to the proximal left anterior
descending artery and percutaneous transluminal coronary
angioplasty to the D-1 where the thrombus extended.
Apparently the patient was noted to have a small amount of
coffee ground emesis while down in the catheterization
laboratory. She was continued on 2B3A inhibitor and
transferred to the Coronary Care Unit.
PAST MEDICAL HISTORY: The past medical history revealed
hypertension and anxiety/depression.
MEDICATIONS: Verapamil SR 100 mg q. day, Spironolactone,
Hydrochlorothiazide, aspirin, Selenium, Zoloft.
ALLERGIES: Ceclor.
FAMILY HISTORY: There is no coronary artery disease in the
family.
SOCIAL HISTORY: There is a remote tobacco history. The
patient has occasional alcohol use.
PHYSICAL EXAMINATION: Vital signs revealed blood pressure
130/80, pulse 76, respirations 20, pulse oximetry 98% on 2
liters nasal cannula. In general, the patient was resting in
bed in no apparent distress. HEENT examination revealed
clear oropharynx, anicteric sclerae, moist mucous membranes.
The neck revealed no jugular venous distention. The carotids
were 2+, no bruits. Cardiac examination revealed regular
rate and rhythm, normal S1 and S2, no murmurs, gallops, or
rub. The abdomen was soft, nontender, and nondistended with
positive bowel sounds. The extremities revealed no pedal
edema. There were 2+ dorsalis pedis and posterior tibialis
pulses bilaterally. The extremities were warm.
LABORATORY DATA: Laboratory studies from the outside
hospital revealed white blood cell count 5.9, hematocrit 39,
platelets 267,000, sodium 137, potassium 3.5, chloride 95,
bicarbonate 27, BUN 15, creatinine 1, glucose 125, INR 1,
troponin 0.09. Electrocardiogram per report from the outside
hospital revealed up-sloping ST segments with T wave
inversions in V2 through V3. There was poor R wave
progression. The electrocardiogram after catheterization
revealed resolution of up-sloping ST segments. T wave
inversions were present in V1 through V4 with possible
biphasic T wave in V4. Chest x-ray from the outside hospital
revealed no effusion, no infiltrate, and no evidence of
congestive heart failure or cardiomegaly.
Catheterization revealed moderate anterior lateral
hypokinesis with an ejection fraction of 50%. There was a
100% proximal LAD with thrombus filling. LAD filling was via
collaterals right to left. There was 40% right coronary
artery stenosis. The left anterior descending artery was 0%
status post stent placement. The D-1 revealed 30% after
percutaneous transluminal coronary angioplasty.
SUMMARY OF HOSPITAL COURSE
Coronary artery disease: The patient tolerated
catheterization well. She remained on Integrelin for 18
hours and was started on Plavix. The patient's
antihypertensive medications were changed from Verapamil and
Hydrochlorothiazide to Lopressor and Captopril which were
titrated up as tolerated. The patient was started on a daily
aspirin and continued on Plavix. The patient had no further
episodes of chest pain. She was seen by physical therapy and
found to have good exercise tolerance. The patient had a
mild elevation of her troponin to 4.3 post catheterization.
Her CKs peaked at 180.
Arrhythmia: The patient had a 7-8 beat episode of
ventricular tachycardia within 24 hours of the
revascularization. The patient was noted to have an ejection
fraction of 50% on ventriculography. The patient remained on
telemetry for another 24-36 hours with no further episodes of
prolonged ventricular tachycardia.
Gastrointestinal: The patient was noted to have a small
amount of coffee ground emesis in the catheterization
laboratory and had nausea on admission to the Coronary Care
Unit. The patient had nasogastric lavage with a small amount
of coffee ground emesis that cleared after 100 cc of normal
saline lavage. The patient's hematocrit was 39 at the
outside hospital and was 34 post catheterization. The
patient remained on Prilosec 40 mg b.i.d. and her hematocrit
remained stable. The patient was discharged on Prilosec 40
mg q. day and was told to follow up with her primary care
physician.
DISCHARGE MEDICATIONS: Lisinopril 5 mg p.o. q. day, Atenolol
25 mg p.o. q. day, Lipitor 10 mg p.o. q. day, Plavix 75 mg
p.o. q. day, aspirin 325 mg p.o. q. day, Zoloft 50 mg p.o. q.
day, Prilosec 40 mg p.o. q. day.
DISCHARGE STATUS: To home.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSIS: Non-Q wave myocardial infarction.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 16516**]
MEDQUIST36
D: [**2145-2-23**] 20:23
T: [**2145-2-24**] 19:50
JOB#: [**Job Number 34522**]
cc:[**Numeric Identifier 34523**]
ICD9 Codes: 4271, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7918
} | Medical Text: Admission Date: [**2113-2-15**] Discharge Date: [**2113-2-19**]
Date of Birth: [**2044-5-8**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
altered mental status, hypotension
Major Surgical or Invasive Procedure:
R IJ central line
History of Present Illness:
68 y/o M with SLE who p/w 1d hx of dysuria, polyuria, chills,
mental status changes. Driving with wife and drove onto grass [**Street Address(1) 29525**]. States urine was "bright red" with increasing
urgency, called PCP and was told to go to hospital. En route,
had episodes of n/v, worsening mental status. Denies pain.
In ED, initially given ASA, lopressor, then MUST protocol
started. Got 4.5L IVFs, started on levophed/vasopressin.
Lactate=4.4; Given dose of levo/flagyl. T 101.3 HR 115 BP 129/63
RR 18 96% on RA. Dirty urine.
In MICU, weaned off pressors. Switched to GENT for empiric
coverage of GNR bacteremia. Started on Fluconazole emperically
for yeast in the blood. Hydrated with IVF and remained
hemodynamically stable.
Transferred to Medicine on [**2112-2-17**].
Past Medical History:
SLE- on plaquenil
Social History:
doesn't smoke, [**4-14**] glasses wine/night
Married, no children, retired writer
Family History:
non-contributory
Physical Exam:
On admission [**2113-2-15**]
vitals: T 101.3, BP 129/63, HR 115, RR 18, 96% RA
Gen: ashen appearing, cachectic, but NAD
HEENT: PERRLA/EOMI; MMM; OP Clear
PUlM: CTA b/l. no r/r/w
CV: Normal S1/S2. tachycardic. no m/r/g
ABD: BS present, soft, NT/ND
EXT: no edema, warm
Neuro: A&O x 3. downgoing toes b/l. 5/5 strength
skin: no rash/lesions
Neck: R neck hematoma, RIJ in place
*
On transfer from MICU [**2113-2-17**]
vitals: 97.9, BP 122/70, HR 47, RR 20 , 95% on RA
Gen- well appearing, sitting up in bed, communicating
appropriately
HEENT- PERRLA/EOMI. no scleral injection. OP w/ mild posterior
pharyngeal erythema.
Neck- supple. R IJ central line in place
PULM- CTA b/l. no r/r/w
CV- RRR. no m/r/g. normal s1/s2
ABD- soft, NT/ND. NABS
EXT- 2+ pedal edema b/l. No joint swelling or redness.
NEURO- A&O x 3. CN II-XII intact.
SKin- no diaphoresis, no rash
Pertinent Results:
Admission labs:
*
WBC-2.0* RBC-4.29* Hgb-13.5* Hct-39.7* MCV-93 MCH-31.4 MCHC-33.9
RDW-13.6 Plt Ct-151
Neuts-78* Bands-7* Lymphs-13* Monos-2
Gran Ct-1680*
Glucose-125* UreaN-20 Creat-0.9 Na-138 K-3.3 Cl-105 HCO3-23
AnGap-13
BLOOD ALT-15 AST-18 AlkPhos-42 Amylase-32 TotBili-0.3
Albumin-2.7* Calcium-6.8* Phos-0.8* Mg-1.3*
BLOOD Cortsol-36.6*
BLOOD Genta-0.8*
BLOOD Type-[**Last Name (un) **] pO2-35* pCO2-37 pH-7.40 calHCO3-24
BLOOD Lactate-4.4*
*
Micro:
Blood Cx [**2-14**]: Enterobacter (4/4 bottles) pansensitive, Yeast
Urine Cx [**2-15**]: Negative
Blood Cx [**2-17**]: no growth to date
Blood Cx [**2-18**]: no growth to date
*
Radiologic Studies:
CXR [**2113-2-15**]: negative for failure/infiltrate
CT abdomen [**2113-2-18**]: gallstones w/ gallbladder wall edema,
moderate bilateral pleural effusions, normal colon with no
evidence of diverticulosis/diverticulitis
*
Transthoracic ECHO [**2113-2-15**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
Mild to moderate ([**2-12**]+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Brief Hospital Course:
Brief [**Hospital **] Hospital Course is outlined below:
1) Enterobacter bacteremia: The patient was initially admitted
to the ICU on the MUST protocol based on a lactate of 4.4. He
was mildly hypotensive and febrile to 101.4. He was aggressively
hydrated with IVF and empirically initiated on amp/gent. He was
briefly placed on levophed/vasopressin pressors but was able to
be weaned off by his second hospital day. Blood cultures from
admission grew enterobacter in [**5-15**] bottles, pan sensitive. In
addition cultures were positive for yeast, unspeciated upon
discharge. Fluconazole was added to his regimen and ampicillin
was discontinued. The source of his infection was unclear,
although urine source was suspected given dirty urine on
admission. Admission urinalysis showed >50 RBCs, >50 WBC's and
moderate leukocytes, although urine cultures were negative. The
patient was transferred to the medicine service on [**2-17**], hospital
day #3. ID was consulted and recommended a switch to levaquin
based on culture sensitivities. Flagyl was also added for
empiric GI coverage pending further evaluation. CT abdomen was
performed and demonstrated no evidence of abscess or bowel
pathology. There was mention of gallstones and gallbladder wall
thickening suspicious for cholecystitis. However the patient
remained afebrile with no abdominal pains and normal liver
function tests. Given his clinical stability with maintenance of
his blood pressure off IVF, tolerance of PO intake, and absence
of fever, he was discharged to home on [**2-19**]. He was discharged
home on PO levaquin and PO fluconazole for a 14 day course based
on ID recommendations. Flagyl was discontinued. He will
follow-up with his PCP [**Last Name (NamePattern4) **] [**2-12**] weeks.
2) Rheumatoid arthritis- previoiusly on plaquenil, so relatively
immunosuppressed. Granulocyte count on admission= 1680, so he
was not neutropenic. He was re-started on plaquenil after he was
clinically stable.
3) Anemia: secondary to SLE likely. Goal HCT>27. Hct remained
>30 through his hospital course. Initital decrease in hematocrit
was likely secondary to IVF hydration.
4) Edema: Noted peripheral edema following IVF hydration. He was
also noted to have bilateral pleural effusions by CT scan, also
likely secondary to aggressive fluid resuscitation. He was not
started on lasix since he was able to autodiurese well, with >2
liters off over the last 24 hours prior to discharge.
5) Mental status change: Initially delirious on admission,
likely secondary to his underlying infection. Once infection
cleared his mental status improved back to baseline. No further
evaluation was performed.
Medications on Admission:
home meds: plaquenil 200mg/400mg alternating days
Discharge Medications:
1. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet
PO EVERY OTHER DAY (Every Other Day).
2. Hydroxychloroquine Sulfate 200 mg Tablet Sig: Two (2) Tablet
PO EVERY OTHER DAY (Every Other Day): alternate days with 200mg
dose.
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Enterobacter bacteremia (pan-sensitive)
Secondary Diagnosis:
1. SLE
2. Rheumatoid arthritis
Discharge Condition:
good. hemodynamically stable. afebrile.
Discharge Instructions:
Report fever, chills, lightheadedness, stomach pains or bleeding
to your PCP.
Please complete your antibiotic regimen as prescribed below.
Stay well-hydrated. Drink at least [**4-14**] 8oz glasses of water each
day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1007**] in [**2-12**] weeks at phone #
[**Telephone/Fax (1) 10492**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7919
} | Medical Text: Admission Date: [**2154-2-1**] Discharge Date: [**2154-2-7**]
Date of Birth: [**2079-6-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
AMS, intubated
Major Surgical or Invasive Procedure:
Extubation
History of Present Illness:
Patient is a 66 yo F with a history of CVA, HTN, HLD who was
transferred from an OSH with altered mental status. Per report,
the patient had a fall 2 days ago after slipping on ice after
the snowstorm and falling on her right side. She was diagnosed
with R sided rib fractures during an urgent care visit at the
[**Hospital 6598**] [**Hospital **] Clinic the next day. She was prescribed vicodin
and asked to come back for CT scan. Family states the patient
took [**1-20**] a tablet of vicodin last night, but did not become
altered until this morning. When they came to see her at home,
they found she was more altered; she was lying on the couch,
more lethargic, not taking good POs or any of her medications,
and complaining of a headache. She was brought into the OSH
([**Hospital1 **]/[**Hospital1 6136**]) for further evaluation. There, the patient
was given Narcan without good effect. She was reportedly
intubated for a GCS of 6 and for airway protection in the
setting of vomiting. Labs at the OSH significant for Hct of
42.9, Plts 221, INR of 1.0, Na 139 K 3.9, Cre: 1.3, negative
EtOH, tylenol, and ASA levels . Pt was guaiac negative, and
gastric occult negative. Head CT at OSH was also negative for
acute new infarct. Received Zosyn 3.25 mg IV x1. She was placed
on propofol for sedation, but subsequently noted post-intubation
to become hypotensive, required 1 L IVFs and was started on
peripheral dopamine and transferred to [**Hospital1 18**] for further
evaluaton.
.
In the ED, admission VS were 88 141/78 (dopa) 20 100% (PS [**10-28**]
PEEP of 5). Pt received a fentanyl boluses with midazolam gtt.
Her dopamine was quickly weaned with 2 L of IVFs. Labs sig for
Cre of 1.3, WBC of 15.8, Hct of 32.9, and urine toxicology
screen positive for benzos and methadone. Vancomycin 1 gram IV
x1 given. Patient noted to be interacting appropriately on
minimal sedation. Trauma series was performed (CT Head, CT
C-spine, CT Torso) which showed a LLL consolidation and rib
fractures but no obvious bleed or C-spine fractures. Head CT
negative for acute intracranial process but does show old
MCA-PCA watershed infarct. C-collar was placed. Trauma Surgery
was consulted and will be following for tertiary survey in AM
and clearance of C-spine in AM.
.
On the floor, patient was alert and interactive. Able to
indicate pain from her rib fractures.
REVIEW OF SYSTEMS:
(+)ve:
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
chest pain, palpitations, rhinorrhea, nasal congestion, cough,
sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, nausea, vomiting, diarrhea, constipation,
hematochezia, melena, dysuria, urinary frequency, urinary
urgency, focal numbness, focal weakness, myalgias, arthralgias
Past Medical History:
PAST MEDICAL HISTORY:
h/o CVA in [**2151**]
Hypertension
Hyperlipidemia
.
Past Surgical History:
s/p hysterectomy
s/p carotid endarterectomy
Social History:
Lives alone. Ambulates independently without a walker but has
had some difficulty walking recently after her stroke. +tobacco
(1 ppd); occasional EtOH use; no illegal drugs or IVDU (per
sister)
Family History:
unknown
Physical Exam:
Exam: 97.6, HR 73, BP 126/55, 94% (88-94%) on 4Lnc
GEN: elderly F looking younger than stated age
HEENT: PERRLA. pinpoint pupils, ~ 1 mm in diameter, MMM.
NECK: neck supple
PULM: bibasilar rales
CARD: RRR S1/S2 present. no m/g/r.
ABD: soft NT +BS
EXT: wwp no edema
NEURO: AAOX3 but in and out of responsiveness, could not say
months of year backwards
Pertinent Results:
[**2154-2-1**] 08:41PM TYPE-ART PO2-86 PCO2-49* PH-7.32* TOTAL
CO2-26 BASE XS--1
[**2154-2-1**] 08:41PM LACTATE-0.8
[**2154-2-1**] 08:19PM TYPE-[**Last Name (un) **] TEMP-36.7 PEEP-5 PO2-35* PCO2-57*
PH-7.28* TOTAL CO2-28 BASE XS--1 INTUBATED-INTUBATED
[**2154-2-1**] 07:49PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->1.050*
[**2154-2-1**] 07:49PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2154-2-1**] 07:49PM URINE RBC-3* WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
[**2154-2-1**] 07:48PM GLUCOSE-122* UREA N-26* CREAT-1.2* SODIUM-138
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12
[**2154-2-1**] 07:48PM CK(CPK)-291*
[**2154-2-1**] 07:48PM CK-MB-5 cTropnT-0.04*
[**2154-2-1**] 07:48PM CALCIUM-7.7* PHOSPHATE-4.1 MAGNESIUM-1.9
IRON-14*
[**2154-2-1**] 07:48PM calTIBC-278 VIT B12-516 FOLATE-GREATER TH
FERRITIN-170* TRF-214
[**2154-2-1**] 07:48PM WBC-ERROR DISR RBC-ERROR DISR HGB-ERROR DISR
HCT-ERROR DISR MCV-ERROR DISR MCH-ERROR DISR MCHC-ERROR DISR
RDW-ERROR DISR
[**2154-2-1**] 02:30PM UREA N-30* CREAT-1.3*
[**2154-2-1**] 02:30PM estGFR-Using this
[**2154-2-1**] 02:30PM LIPASE-22
[**2154-2-1**] 02:30PM URINE HOURS-RANDOM
[**2154-2-1**] 02:30PM URINE HOURS-RANDOM
[**2154-2-1**] 02:30PM URINE GR HOLD-HOLD
[**2154-2-1**] 02:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2154-2-1**] 02:30PM WBC-15.8* RBC-3.73* HGB-11.6* HCT-32.9*
MCV-88 MCH-31.2 MCHC-35.5* RDW-14.1
[**2154-2-1**] 02:30PM PLT COUNT-195
[**2154-2-1**] 02:30PM PT-12.9 PTT-23.1 INR(PT)-1.1
[**2154-2-1**] 02:30PM FIBRINOGE-512*
[**2154-2-1**] 02:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2154-2-1**] 02:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2154-2-1**] 02:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**12-8**]
[**2154-2-1**] 02:30PM URINE GRANULAR-0-2 HYALINE-[**6-28**]*
[**2154-2-1**] 02:30PM URINE AMORPH-FEW
Brief Hospital Course:
#. Altered mental status: Patient was initially found to have
altered mental status after slip and fall on ice. She sustained
R sided rib fractures which were treated with vicodin. She was
found by family to be altered and brought to OSH where she was
intubated for GCS 6. She had also had a URI prior to OSH
presentation. Initial AMS was likely multifactorial due to
infection (pneumonia, likely acquired in setting of splinting
from rib pain [**2-20**] fractures), medication induced from narcotics
(received vicodin for pain control) but urine toxicology screen
also positive for methadone, and ABG showed an acute respiratory
acidosis concerning for respiratory depression. Toxicology
screen negative at OSH for EtOH, APAP, and ASA. No evidence of
new ICH or stroke on head CT. No evidence of UTI on urine
analysis. Cardiac etiology was ruled out with cardiac enzymes
negative x 2. Patient was extubated with good mental status but
subsequently became increasingly altered, thought to be
associated with morphine use for pain control. This delirium
resolved upon avoiding opioid medications such as morphine and
oxycodone.
.
# Respiratory Failure: Pt initially hypoxic with pna and
splinting from pain, intubated [**2-20**] altered mental status. The pt
was extubated after transfer from [**Hospital1 18**], with decreasing O2
requirement. She was found to have a pneumonia and was started
on Levaquin for presumed CAP. However, patient continued spiking
despite abx. Given sputum cx stained 2+ GPC in pairs and chains,
2+ [**Name (NI) **], pt was broadened to Vanc/Zosyn (pt is allergic to
penicillins but has tolerated zosyn in the past). Abx were
continued for an eight day course (last day [**2-9**]). She was also
encouraged to use incentive spirometer and pain was controlled
as below.
.
# [**Last Name (un) **], prerenal, hypovolemic: pt??????s cr increased from nadir 1.0
to 1.5. Cr improved with ivf hydration. Cr was 1.2 by next day.
.
# normocytic anemia: Hct down to 32.9 from 42 at OSH. HCT slowly
trending down. No evidence of intra-abdominal bleed on CT scans.
Iron studies [**Location (un) 381**] levels, showing element of iron
deficiency, likely mixed with anemia of chronic disease. no
colonoscopy in system. B12 and folate nl.
.
#. Rib fractures: s/p fall with R sided rib fractures from
T3-T7. Pain control with standing tylenol, lidocaine patch x3
for rib fractures, oxycodone prn pain. Patient initially treated
with morphine however it was felt to contribute to here AMS.
Patient's pain controlled with around the clock Tylenol and
lidocaine patches.
.
# Mediastinal Lymphadenopathy: CT scan showed areas of
mediastinal lymphadenopathy thought to be less consistent with
reactive process. Could be sarcoid vs. malignancy. Should be
followed up with an outpatient biopsy to assess for malignancy.
Patient scheduled for Interventional Pulmonology clinic on [**2-18**]
at noon. MD made aware at facility.
.
# Adrenal nodule: Incompletely visualized. Should be followed up
outpt with a dedicated adrenal MR [**First Name (Titles) **] [**Last Name (Titles) **].
.
#. Clearing C-spine: clinically cleared per trauma
.
#. Hypertension: home antihypertensives
.
#. Hyperlipidemia: continue statin
.
# Anxiety: held ativan for protection of respiratory status
Medications on Admission:
(per [**Hospital3 **] Records and confirmed with pt's pharmacy
(Stop and Shop in [**Location (un) 6598**] #([**Telephone/Fax (1) 88247**])
Folic Acid
Aspirin 81 mg PO daily
Amlodipine 5 mg PO daiy
Metoprolol Tartrate 50 mg PO BID
Vicodin 5-500 mg 1 tablet prn:pain
HCTZ 12.5 mg PO daily
Ativan 0.5 mg PO QHS
Trazadone 150 mg [**1-20**] tablet PO QHS
Mevacor 20 mg PO daily
.
OLD MEDS:
Buspirone (old, filled last back in [**2152**])
Combivent Inhaler (filled last back in [**2152-3-19**])
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*1*
11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): Please complete on
[**2154-2-9**].
12. piperacillin-tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours): Please complete on
[**2154-2-9**].
13. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
14. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
metabolic encephalopathy
community-acquired pneumonia
Rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 88248**],
You were transferred to our hospital to care for a pneumonia
that was the result of a probable aspiration event during a
state of altered mental status. We believe the pain medications
in the opioid class (including morphine, vicodin, codeine)
worsen your mental status and make you delirious. Please AVOID
TAKING THESE MEDICATIONS. We treated your probable pneumonia
with antibiotics, that should be completed on [**2154-2-9**]. We
placed a special i.v. into your arm that can be used for these
medications.
Also of note, a CAT scan at the beginning of your visit here
showed a left lower lobe infiltrate consistent with pneumonia.
However, it also showed a couple abnormalities that will require
followup. This includes:
1) Mediastinal lymphadenopathy - size is less compatible with
reactive nodes, and may be compatible with metastatic nodes or
sarcoidosis.
2) Left adrenal nodule, incompletely characterized - a dedicated
adrenal CT
Please follow up with our pulmonologists and your primary doctor
to set up these examinations to further evaluate these findings.
We controlled your pain from your rib fractures with Tylenol and
lidocaine patches, since other medications worsened your mental
state. Please continue to take these as needed for your pain.
Followup Instructions:
Please follow up with your primary care physician as soon as you
can after discharge
Please also follow up with our pulmonary clinic to follow up on
the abnormal CAT scan findings. You have an appointment with the
interventional pulmonology clinic here at [**Hospital1 18**] [**Hospital Ward Name **] at
12 PM on [**2154-2-18**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5070, 2762, 5849, 4019, 2724, 3051, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7920
} | Medical Text: Admission Date: [**2193-7-1**] Discharge Date: [**2193-7-5**]
Date of Birth: [**2146-2-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
Ascending aorta replacement (valve-sparing [**Doctor Last Name **]
procedure)[**2193-7-1**]
History of Present Illness:
47 yo male with known dilated aorta. Referred to Dr. [**Last Name (STitle) 1290**]
for surgical repair. Cath done [**5-21**] showed no CAD, right
dominant system, aortic aneurysm. Echo [**4-20**] showed aortic root
4.9cm, ascending 5.2 cm, 1+ MR, trivial TR, no AI, EF 55%. Prior
CT done [**6-/2187**] showed no dissection, and aortic root size 4.7cm x
5.0cm indicating further aneurysmal dilation.
Past Medical History:
? pericarditis [**2186**]
s/p childhood tonsillectomy
Social History:
lives with partner
self employed in real estate/antique sales
occasional ETOH
quit smoking 20 years ago
Family History:
mother with ? MR
Physical Exam:
Hr 74 RR 18 right 114/74, left 110/70
6'6" 220#
NAD
skin/HEENT unremarkable
neck supple with full ROM and no carotid bruits
CTAB
RRR no murmur
abd soft/NT/ND +BS
warm, well-perfused, no edema or varicosities
neuro grossly intact
2+ bilat. fem/DP/PT/radials
Pertinent Results:
Echo [**7-1**]: Prebypass: A patent foramen ovale is present. There
is a bidirectional shunt across the interatrial septum at rest.
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal. The aortic root is moderately dilated. The
sinuses of Valsalva are dilated. The ascending aorta is
moderately dilated. There are three aortic valve leaflets. There
is no aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen. Post Bypass: Biventricular
systolic function is unchanged. Mild aortic insufficiency
present. Trace to mild mitral regurgitation present. Graft
material seen in the ascending aorta.
CXR [**7-3**]: The patient is status post median sternotomy and CABG.
A tiny left apical pneumothorax is present. Chest tubes,
mediastinal drains, and Swan-Ganz catheter have been removed.
Heart is normal in size. Mediastinal and hilar contours are
unchanged. Left lower lobe atelectasis is improving. Tiny right
pleural effusion is present. Pulmonary vascularity is within
normal limits.
[**2193-7-1**] 05:10PM BLOOD WBC-7.7# RBC-2.06*# Hgb-6.7*# Hct-18.1*#
MCV-88 MCH-32.3* MCHC-36.9* RDW-13.3 Plt Ct-167
[**2193-7-3**] 07:45AM BLOOD WBC-13.0* RBC-3.11* Hgb-9.7* Hct-27.9*
MCV-90 MCH-31.2 MCHC-34.7 RDW-13.1 Plt Ct-181
[**2193-7-5**] 07:05AM BLOOD Hct-24.6*
[**2193-7-1**] 05:10PM BLOOD PT-16.9* PTT-59.1* INR(PT)-1.6*
[**2193-7-2**] 03:08AM BLOOD PT-12.5 PTT-28.8 INR(PT)-1.1
[**2193-7-1**] 06:58PM BLOOD UreaN-16 Creat-0.9 Cl-106 HCO3-27
[**2193-7-3**] 07:45AM BLOOD Glucose-123* UreaN-17 Creat-0.9 Na-135
K-3.9 Cl-97 HCO3-33* AnGap-9
[**2193-7-5**] 07:05AM BLOOD K-4.3
Brief Hospital Course:
Mr. [**Known lastname 19568**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On [**7-1**] he was brought
directly to the operating room where he underwent a ascending
aorta replacement. Please see operative report for surgical
details. Following surgery he was transferred to the CSRU for
invasive monitoring in stable condition on a titrated propofol
drip. Later on op day he was weaned from sedation, awoke
neurologically intact and extubated. That evening he was off all
drips and then transferred to the floor on post-op day one. Beta
blockers and diuretics were initiated and he was gently diuresed
towards pre-op wt. Foley and chest tubes were removed on post-op
day two. Pacing wires removed on post-op day three and beta
blockade titrated for HR/BP management. Physical therapy
followed him throughout post-op course for strength and
mobility. He continued to improve quite rapidly without any
post-op complications. He was discharged to home with VNA
services and the appropriate follow-up appointments on post-op
day four.
Medications on Admission:
wellbutrin 200 mg [**Hospital1 **]
prilosec 20 mg daily
metoprolol 25 mg [**Hospital1 **]
ambien prn
alprazolam prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. 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*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Ascending Aortic Aneurysm s/p valve-sparing ascending aorta
replacement ([**Doctor Last Name **] procedure)
PMH: ? h/o pericarditis [**2186**], s/p tonsillectomy
Discharge Condition:
stable
Discharge Instructions:
no lotions, creams or powders on any incision
no driving for one month
call for fever greater than 100, rednes or drainage
no lfting greater than 10 pounds for 10 weeks
may shower over incisions and pat dry
Followup Instructions:
follow up with Dr.[**Doctor Last Name 19569**] in [**12-17**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**1-18**] weeks
follow up with Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2193-7-24**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7921
} | Medical Text: Admission Date: [**2146-12-25**] Discharge Date: [**2147-4-4**]
Date of Birth: [**2146-12-25**] Sex:
Service:
HISTORY OF PRESENT ILLNESS: This patient's post discharge
name will be [**Name (NI) 76463**] [**Name (NI) 76464**].
Baby [**Name (NI) **] [**Known lastname 76463**] [**Known lastname **] delivered at 28 and 4/7 weeks
gestation and was admitted to the newborn intensive care unit
for management of respiratory distress and prematurity. Birth
weight 1060 (25th percentile). Length 37 cm (25 to 50th
percentile). Head circumference 24 cm (10th percentile).
Mother is a 39 year-old, gravida 3, para 0, now 1 mother with
estimated date of delivery of [**2147-3-15**]. Prenatal screens
included blood type A positive, antibody negative, RPR
nonreactive, Rubella immune, hepatitis B surface antigen
negative and group beta strep status unknown. The mother
presented to [**Hospital1 69**] from
Bermuda for continued management of preterm labor on
[**2146-11-24**] at 24 and 1/7 weeks gestation. The mother received
a complete course of betamethasone on [**2146-11-25**]. Preterm
labor was managed by Terbutaline and vaginal progesterone
suppositories. The mother was stable on antepartum floor
until day of delivery when her membranes spontaneously
ruptured and she had a fever to 100.4. Labor was allowed to
progress. The delivery was by spontaneous vaginal delivery.
Membranes had been ruptured 7 hours prior to delivery. The
infant initially emerged with good activity and spontaneous
respiratory effort. He received routine dry and suctioning
and stimulation but his respiratory effort became poor with
poor color, requiring positive pressure ventilation and then
intubation with slow but steady improvement. His heart rate
was always greater than 100. His Apgar scores were 4 at 1
minute, 6 at 5 minutes and 8 at 10 minutes.
PHYSICAL EXAM AT DISCHARGE: Weight 3695 grams (75 to 90th
percentile). Length 52 cm (75 to 90th percentile). Head
circumference 36 cm (75 to 90th percentile). In general, a
well-appearing, alert infant. Head sutures approximated.
Eyes clear red reflex bilaterally. Nose patent. No cleft.
Vigorous cry. Chest: Breath sounds bilaterally equal, clear.
Mild subcostal retracting. Heart: Normal S1 and S2, no
murmur, normal pulses and perfusion. Abdomen: Soft, no
hepatosplenomegaly, no masses. Active bowel sounds. Skin:
Pale, pink, nevus flammeus on eyelids and forehead. A 3.5 x
3.5 cm raised papillary hemangioma on back. Genitalia:
Normal male. External genitalia: Uncircumcised, testes
descended bilaterally. Skeletal: Spine straight and intact,
no dimple. Hips stable. No clicks or clunks. Moves all
extremities equally. Neuro: Tone appropriate for gestational
age. Able to elicit suck, grasp.
HOSPITAL COURSE BY SYSTEMS: Placed on conventional
ventilation on admission. Received 2 doses of Surfactant, due
to 100% oxygen requirement, was changed to high frequency
oscillatory ventilation with a mean airway pressure of 13,
Delta P of 28 with a good response. His oxygen requirement
slowly came down and he weaned back to conventional
ventilation on day of life 4. He was extubated to continuous
positive airway pressure (CPAP) on day of life 6. He
successfully transitioned off CPAP on day of life 46 to nasal
cannula oxygen. He remains on nasal cannula oxygen 25 cc
flow. He started Lasix on day of life 57 for chronic lung
disease. He continues on Lasix around 2 mg/kg once every
Monday, Wednesday and Friday. His respiratory rates range in
the 30's to 60's with mild subcostal retracting. He will be
discharged home on nasal cannula with home oxygen and a
saturation monitor which the mother has received teaching
for.
Respiratory: [**Known lastname 76463**] started caffeine on day of life 4 and it
was discontinued on day of life 60. His last apnea and
bradycardia episode, which was associated with a feed, was on
day of life 86 ([**2147-3-21**]).
Cardiovascular: He received normal saline on admission for
hypotension. He has remained hemodynamically stable since.
Received Indocin on day of life 4 for patent ductus
arteriosus that was diagnosed by echocardiogram. A follow-up
echocardiogram on day of life 8 showed no patent ductus
arteriosus and a left peripheral pulmonic stenosis, mild.
Intermittently, a murmur is heard which is probably related
to the PPS. His heart rate ranges in the 120's to 170's. A
recent blood pressure was 63 over 44 with a mean of 48.
Fluids, electrolytes and nutrition: He was n.p.o. on
admission, receiving total parenteral nutrition. Enteral
feeds were started on day of life 6 and he was gradually
advanced to full volume feeds by day of life 14 without
problems. The caloric density was increased gradually to a
total of 30 calories per ounce with added BeneProtein. We
started weaning the calories on day of life 52. At
discharge, he is receiving breast milk mixed with Enfamil
powder to equal 24 calories per ounce or does breast feed
also. His electrolytes have been followed on Lasix. He did
receive potassium chloride supplements that were discontinued
on [**2147-3-27**]. With electrolytes followed after the potassium
chloride was discontinued, his electrolytes have been stable.
His most recent set was on [**2147-4-3**] and showed a sodium of
138, potassium of 5.8, chloride 102, C02 of 30.
Gastrointestinal: Received 12 days of phototherapy for
indirect hyperbilirubinemia. His peak bili was on day of
life 2, total of 5.8, direct of 0.3.
Hematology: His blood type is A negative. The direct Coombs
was negative. He received a total of 2 packed red blood cell
transfusions with the last one on day of life 22. His most
recent hematocrit was on [**2147-3-20**], 31.4% with a reticulocyte
count of 2.1%.
Infectious disease: He received 21 days of ampicillin and
gentamycin for suspicion for sepsis and meningitis. We were
unable to rule out meningitis with a lumbar puncture
secondary to the intraventricular hemorrhages. His blood
culture was negative.
He received 48 hour rule out of Vancomycin and gentamycin,
due to increased apnea and bradycardia episodes on day of
life 33. The CBC was benign and the blood culture was
negative.
Neurology: He was followed closely with frequent ultrasounds
due to the initial ultrasound showing bilateral
intraventricular hemorrhage with mild ventriculomegaly. The
most recent head ultrasound was on [**2147-2-17**] on day of life 54
and it showed resolved intraventricular hemorrhages and a
left caudal thalamic cyst. His ventricular size was the upper
size of normal.
Skin: [**Known lastname 76463**] has a large 3.5 x 3.5 cm strawberry hemangioma
on his back. It was initially small and has increased in size
as he has grown.
Sensory: Audiology hearing was performed with automated
auditory brain stem responses. He passed both ears.
Ophthalmology: Eyes were examined most recently on [**2147-3-6**]
revealing mature retinal vessels. A follow-up examination is
recommended at 9 months of age.
CONDITION ON DISCHARGE: 100 day old, now 42 and 6/7 weeks
post menstrual age infant with chronic lung disease, stable
in nasal cannula oxygen.
DISCHARGE DISPOSITION: Baby will be discharged with mother
to her apartment in [**Name (NI) 86**] for one day, with the plan to fly
to [**State 108**] the following day on [**2147-4-5**] and stay in [**State 108**]
for about 2 weeks and then return to Bermuda. Portable
oxygen has been arranged for discharge and the airline
flights and for [**State 108**].
PEDIATRICIAN: Pediatrician in [**State 108**] will be Dr. [**Last Name (STitle) 76465**]
[**Name (STitle) **], telephone number [**Telephone/Fax (1) 76466**].
The pediatrician in Bermuda will be Dr. [**Last Name (STitle) **] at [**Doctor Last Name **] Care
Pediatrics, telephone number 1-[**Telephone/Fax (1) 76467**]. Fax #1-[**Telephone/Fax (1) 76468**].
CARE AND RECOMMENDATIONS: Feeds: Ad lib feeds with breast
milk mixed with Enfamil powder to equal 24 calories per
ounce. Mother may breast feed as desired but will give
several bottles per day for the calories.
Medications:
Lasix 7 mg once every Monday, Wednesday and Friday.
Goldline baby vitamins 1 ml daily.
Ferrous sulfate 0.6 ml daily.
Iron and vitamin D supplementation: Iron supplementation is
recommended for preterm and low birth weight infants until 12
months corrected age. All infants fed predominantly breast
milk should receive Vitamin D supplementation at 200 i.u.
(may be provided as a multi-vitamin preparation) daily until
12 months corrected age.
Car seat position screening test done and passed.
State newborn screens were followed and are within range.
Immunizations received:
Received hepatitis B immunization on [**2147-1-26**].
Received 2 month immunizations on [**2147-2-28**] which consisted
of PediaRx, Hib and Pneumococcal 7-Falent conjugate vaccine.
Received Synagis on [**2147-4-2**].
Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease or (4) hemodynamically significant
congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
FOLLOWUP: Recommended:
Follow-up appointment with Dr. [**First Name (STitle) **] in [**State 108**] is scheduled
for [**2147-4-7**].
Dr. [**First Name (STitle) **] to arrange VNA visits in [**State 108**].
Pulmonology follow-up with Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**]. This will be done
by phone as he is in [**Location (un) 86**].
Early intervention to be arranged by pediatrician in Bermuda.
A follow-up eye appointment with Pediatric ophthalmology
recommended at 9 months of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 28 and 4/7 weeks.
2. Respiratory distress syndrome.
3. Patent ductus arteriosus resolved.
4. Presumed sepsis meningitis resolved.
5. Indirect hyperbilirubinemia.
6. Strawberry hemangioma.
7. Retinopathy of prematurity resolved.
8. Hypertension at birth, resolved.
9. Bilateral intraventricular hemorrhages, resolved.
10.Anemia.
11.Apnea of prematurity resolved.
12.Chronic lung disease.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2147-4-4**] 01:29:56
T: [**2147-4-4**] 05:25:13
Job#: [**Job Number 76469**]
ICD9 Codes: 769, 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7922
} | Medical Text: Admission Date: [**2112-10-5**] Discharge Date: [**2112-10-8**]
Date of Birth: [**2056-9-18**] Sex: M
Service:
ADMISSION DIAGNOSIS: Morbid obesity.
DISCHARGE DIAGNOSIS: Morbid obesity, status post open
gastric bypass with roux-en-y reconstruction.
HISTORY OF PRESENT ILLNESS: The patient is a 56 year old man
with morbid obesity and multiple comorbidities from his
obesity. These comorbidities include sleep apnea,
osteoarthritis, lymphedema, congestive heart failure, and
ventral hernia. The patient weighs 500 pounds and a BMI of
60. He has been on multiple weight loss regimens in the past
without any significant long term success. The patient
presents for elective gastric bypass surgery.
PHYSICAL EXAMINATION: In general, the patient is in no acute
distress, morbidly obese. Vital signs are stable, afebrile.
Chest is clear. Cardiovascular is regular rate and rhythm
without murmurs, rubs or gallops. The abdomen is obese,
soft, nontender, nondistended. Extremities - venous stasis
disease without active ulcers, 1+ pitting edema bilaterally
in the lower extremities. Neurologically, the patient is
alert and oriented times three. No gross deficits.
PAST MEDICAL HISTORY:
1. Atrial fibrillation, status post pacemaker.
2. Congestive heart failure.
3. Sleep apnea.
4. Osteoarthritis.
5. Lymphedema in pannus and right groin.
6. Ventral hernia repair [**2102**].
MEDICATIONS ON ADMISSION:
1. Lasix 80 mg once daily.
2. Zoloft 50 mg once daily.
3. Toprol 50 mg once daily.
4. Coumadin 10 mg once daily.
5. Lovenox 45 mg once daily.
6. Cozaar 50 mg once daily.
7. Tylenol p.r.n.
HOSPITAL COURSE: The patient was admitted for elective open
gastric bypass surgery. The surgery proceeded without
complication. The patient was left intubated and sent to the
Intensive Care Unit for closer monitoring and ventilatory
support. This is due to his cardiac status. The patient did
have a known ejection fraction of 30 to 35% documented on
echocardiogram.
Postoperatively the patient did well and was extubated on
postoperative day number one without complication. The
patient was also advanced to Stage I diet. On postoperative
day two, the patient was transferred to the floor and
advanced to Stage II diet. The patient did complain of a
little bit of chest pressure. An electrocardiogram was
obtained which was unchanged from his preoperative
electrocardiogram. The patient described his chest pressure
as feeling as if he had eaten too much. Decision was made
not to cycle cardiac enzymes. The patient did well
otherwise.
On postoperative day three, the patient was advanced to a
Stage III diet. The patient was subsequently discharged to
home tolerating a Stage III diet.
CONDITION ON DISCHARGE: Good.
DISPOSITION: To home.
DIET: Stage III diet per gastric bypass protocol.
MEDICATIONS ON DISCHARGE:
1. Roxicet Elixir one to two teaspoons q4hours p.r.n.
2. Actigall 300 mg p.o. twice a day.
3. Zantac Liquid 150 mg p.o. twice a day.
4. Vitamin B12 1000 mcg once daily.
5. Lasix 80 mg once daily.
6. Zoloft 50 mg once daily.
7. Toprol 50 mg once daily.
8. Coumadin 10 mg once daily.
9. Lovenox 45 mg once daily.
10. Cozaar 50 mg once daily.
11. Tylenol p.r.n.
FOLLOW-UP: The patient is to follow-up with the Surgical
[**Hospital **] Clinic in two weeks time. He is to maintained a
Stage III diet until that time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2112-10-8**] 09:28
T: [**2112-10-9**] 09:12
JOB#: [**Job Number 37816**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7923
} | Medical Text: Admission Date: [**2135-12-19**] Discharge Date: [**2135-12-31**]
Date of Birth: [**2078-1-25**] Sex: F
HISTORY OF PRESENT ILLNESS: This is a 51-year-old woman with
a history of a recent stroke, asthma, insulin-dependent
diabetes, and renal disease who was at Stone Hinge
Convalescent Center and noted to have changes in her behavior
On the day of admission at 2:25 p.m. she had an episode of
unresponsiveness and then she developed status epilepticus at
[**Hospital 882**] Hospital. She received 6 mg of Ativan and Versed as well
loaded on Dilantin intravenously. At that time she was intubated
and then transferred to the Neurology Intensive Care Unit.
Congestive heart failure, stroke, lupus, asthma,
insulin-dependent diabetes, renal disease.
MEDICATIONS ON ADMISSION: Synthroid 0.1, Catapres
transdermal patch 2 every week, Novolin NPH 24 units,
Serevent 2 puffs b.i.d., Zantac 150 mg p.o. b.i.d., [**Doctor First Name 233**] Ciel,
hydralazine, furosemide, Flovent, calcium, Milk of Magnesia.
PHYSICAL EXAMINATION ON PRESENTATION: Blood pressure 217/97,
heart rate 119, 100% on room air. Rectal temperature of 100.
Cardiovascular revealed tachycardia with a 2/6 systolic
murmur. Chest revealed bilateral crackles, low breath sounds
(left compared to right). The abdomen was soft, nontender,
and nondistended. Extremities revealed no clubbing, cyanosis
or edema. Neurologically, intubated and sedated, positive
tongue abrasion. Held her right hand in fist with eyes
contracted. Right leg flexed spontaneously. Did not follow
commands. Pupils revealed left 4 mm to 5 mm, right 3.5 mm,
reactive to light bilaterally. No blink to visual threat.
Extraocular movements appeared conjugate. Left side had
decreased abduction with dolls. Positive occasional right
nystagmus with dolls. No obvious facial asymmetry which was
difficult to tell with a tube in place. Positive gag.
Positive cough. Motor revealed spontaneously moved the right
side more than the left. Spontaneous movement in the right
upper and lower extremities. Positive withdrawal to pain on
the left lower extremity. Positive extension to pain in the
left upper extremity. Her reflexes were symmetric
bilaterally with upgoing toes bilaterally, 4+ on the right
ankle, 1+ on the left ankle.
PERTINENT LABORATORY DATA ON PRESENTATION: The patient had
basic laboratories with a white blood cell count of 15.8, a
hematocrit of 32.2. Normal electrolytes except for her blood
glucose which was 336. PT, PTT, and INR were normal. Her
urinalysis showed 0 to 2 white blood cells, and rare
bacteria.
RADIOLOGY/IMAGING: Head CT done at the time showed only
chronic microvascular changes. No infarct. No axillar
hemorrhage.
Chest x-ray showed left lower lobe opacity, a question of
atelectasis.
HOSPITAL COURSE: The patient was admitted to the
Neurolgy Intensive Care Unit and followed. Blood
pressure was controlled. She was moving all extremities to
pain, left greater than right. Slight increased tone on the
right side.
She was started on a maintenance dose of Dilantin. Acute coronary
artery syndrome was r/o with serial EKGs, creatine kinases and
troponin. Magnetic resonance imaging showed extensive
encephalomalacia change in atrophy from multiple old infarct. No
acute infarct. MRA at the same time was read as motion artifact,
severely aluminated the Circle of [**Location (un) 431**], visualized internal
carotid arteries were likely vertebrobasilar system patent;
however, the patient after extubation had new left arm weakness
which was not at her baseline. When the stroke team reviewed her
MRA they felt that she could possibly have basilar artery
stenosis; and, therefore, she was started on a heparin drip.
Prior to that a workup for the seizure included a lumbar
puncture which was unrevealing with 1 white blood cell, no
red blood cells, and a differential of 65% lymphocytes,
30% monocytes, and 5% polys. Glucose was 126. No protein
was sent.
She was continued on Synthroid. Her serum glucose was
controlled. She did require an insulin drip at one point
until she started eating again. In addition, she had an
electroencephalogram on [**12-20**] which showed very low
voltage background with beta in most areas, not epileptiform.
She was transferred out from the NICU to the Neurologyfloor on
[**2135-12-22**] and remained stable on a heparin drip. Her PTT
was kept between 60 and 80. Her blood pressure was watched
carefully.
At the time she was transferred she was alert and oriented times
hospital. She felt well, and she was consistently following
commands. She moved her right arm and had some difficulty
moving her left arm. Her Dilantin levels were followed and
on [**12-22**] it was 9.3. She was bolused with Dilantin with
subsequent repeat being 10.9, and her chronic dose was
increased. During her stay, her hematocrit fell to 28. Because
of her diabetes and risk factors for coronary artery disease, she
was transfused 2 units with a repeat hematocrit of 34 on
[**2135-12-25**]. We continued to follow her hematocrit, and
again it dipped down to 28, and she needed to receive another
transfusion. Her Dilantin was continued, and her mental
status improved.
She was started on Levaquin for a possible aspiration
pneumonia and then found to have urinary tract infection, and
thus the Levaquin was continued. Her urine grew out
Staphylococcus aureus and group B strep. She was started on
vancomycin and continued on the levofloxacin. The
sensitivities studies showed methicillin-resistant
Staphylococcus aureus, and a peripherally inserted central
catheter line was placed for a prolonged course of
vancomycin. Vancomycin peak and trough was checked on
[**2135-12-29**] which showed a peak of 22 and a trough of
10.9, which seemed adequate and continued on the vancomycin
dose 500 mg q.24h.
The patient's neurologic examination improved with her able
to have antigravity movement with her left hand. Her heparin
was discontinued after the second hematocrit drop, and
Gastrointestinal was consulted. They had originally planned
to take her for upper and lower endoscopy; however, her
daughter did not want any intervention unless the patient had
life threatening problems, and after the discontinuation of
the heparin, her hematocrit remained stable. The patient was
then started on Plavix for stroke prophylaxis since she had
an aspirin allergy. Her stools were consistent
guaiac-positive through the hematocrit drops, and thus we
thought that the source was gastrointestinal.
MEDICATIONS ON DISCHARGE:
1. Dilantin 100 mg p.o. t.i.d.
2. Nitroglycerin patch 0.4 mg q.d.
3. Catapres 0.2 mg transdermal patch every week.
4. Serevent meter-dosed inhaler 2 puffs b.i.d.
5. Flovent meter-dosed inhaler 2 puffs b.i.d.
6. Vancomycin 500 mg intravenously q.24h.
7. Protonix 40 mg p.o. q.d.
8. Plavix 75 mg p.o. q.d.
9. Zantac 150 mg p.o. q.d.
10. Regular insulin sliding-scale.
11. NPH 12 units q.a.m. and 4 units q.p.m.
12. Labetalol 100 mg p.o. b.i.d. (hold for a blood pressure
of less than 160 and heart rate less than 40).
13. Synthroid 100 mcg p.o. q.d.
14. Colace 100 mg p.o. b.i.d.
DISCHARGE DIAGNOSES:
1. Seizure and question stroke.
2. Diabetes.
3. Gastrointestinal bleed.
DISCHARGE FOLLOWUP: Follow up with stroke team.
[**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**]
Dictated By:[**Last Name (NamePattern1) 8853**]
MEDQUIST36
D: [**2135-12-29**] 16:41
T: [**2135-12-29**] 18:06
JOB#: [**Job Number 37481**]
ICD9 Codes: 5990, 4280, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7924
} | Medical Text: Admission Date: [**2185-9-3**] Discharge Date: [**2185-9-5**]
Date of Birth: [**2153-12-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
Vomiting blood
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD)
History of Present Illness:
This is a 31 y.o male w/ past medical history of GERD and
alcohol abuse who reports being in his normal state of health
until last night when he developed nausea and went to the
bathroom where he vomited [**11-26**] tablespoons of red blood mixed w/
emesis. He had previously had symptoms similar to this so he
wasn't particularly concerned and then went back to bed. He went
on to have two further episodes of bloody emesis during which he
filled up the sink and then the toilet with what appeared to be
pure blood by his report. This led him to seek care at [**Hospital 1562**]
Hospital. There, he was hemodynamically stable by report but
nevertheless received two units of blood and was started on
octreotide and PPI drips and was trensferred here. Over the
course of these symptoms he reports that he developed mild to
moderate epigastric pain. No chest pain or shortness of breath.
He reports he did develop some dizziness as he was riding to
[**Hospital1 1562**] but has had none since. No syncope.
.
In the ED, initial VS were T 97.2, P 83, BP 139/80, RR 16, O2
Sat 97 % on RA. He was placed on PPI drip and an NG lavage was
done that yielded red blood which then failed to clear. His PPI
and octreotide drips were continued and he was admited to the
ICU.
.
Currently, he reports mild abdominal discomfort and nausea but
no other symptoms at this time.
.
Review of systems: No fevers, chills, weight loss, night sweats.
Reports
.
Past Medical History:
Past Medical History:
-MVA in [**2173**] with multiple fractures, now takes chronic
narcotics for chronic pain
-History of GSW to right leg
-GERD
Social History:
EtOH abuse in the past, currently 1ppd, has wife and 2 children
Family History:
Mother reportedly died of "untreated ulcer"
Physical Exam:
Afebrile 142/75 p80 96%RA
Large M sitting in unit bed without shirt on, wife in chair next
to bed, watching Pats game on TV. Nice, alert, oriented, no
distress.
CTAB no w/c/r/r
S1 S2 are clear, light 1-2/6 systolic murmur noted, with heart
sounds and murmur decreasing in intensity moving towards the
apex. Radial pulses are 2+ bilaterally.
Abd with prominent midline scar from ex lap, per pt. No TTP in
any quadrant. BS+.
RUE has 2 PIV's well placed. No c/c/e.
RLE with scar tissue on anterior aspect of shin, LLE with
prominent scar tissue and deformity near ankle. DP's are 2+.
There is no LE edema.
Pertinent Results:
WBC 11.4 --> 4.5 on discharge
Hct 38.1 --> 32.0
Plts 289
Chems BUN/Cr 21/0.8 on admission but otherwise all normal
through admission
LFT's normal
Lipase 37
H. pylori serology positive
[**2185-9-3**] EKG
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
EGD [**2185-9-3**]
Findings: Esophagus:
Mucosa: Several areas of ulceration with erythema and evidence
of prior bleeding were noted in the gastroesophageal junction
and cardia. There was no active bleeding or visible vessel, and
due to patient intolerance after repeated procedure attempts, no
intervention was performed.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Impression: Erythema and ulceration in the gastroesophageal
junction and cardia
Otherwise normal EGD to second part of the duodenum
Recommendations: Routine post procedure orders
Serial HCTs.
IV PPI gtt.
NPO with sips.
If stable overnight can advance to clears tomorrow.
Will need 6-8 weeks of [**Hospital1 **] PPI therapy and repeat endoscopy to
assess for healing.
Brief Hospital Course:
31yo healthy M with sujective h/o severe GERD admit for
hematemesis, found to have multiple GE junction ulcerations not
actively intervened upon, to be treated with medical therapy.
1. GI bleed--Admitted to MICU hemodynamically stable and was
stable through admission. Had received 2U PRBC's at OSH but did
not require any blood products at [**Hospital1 18**]. Had EGD without any
active bleeding or varices and only old blood and multiple
ulcers with clot. Had difficult tolerating procedure so no
electrocautery employed or clipping done, GI recommended [**5-2**] wks
of PPI therapy and reassessment with repeat EGD in future.
Serial Hct's post procedure was stable and rest of hospital
course uncomplicated. Pt was hemodynamically stable through
admission and on discharge.
2. History of alcohol abuse--Pt with h/o considerable alcohol
consumption in the past, but less so currently by history. Had
h/o mild withdrawal symptoms (tremulous and anxious) but no
seizures or complicated withdrawal. Kept on CIWA scale, no
complications this admission.
3. PUD, H. pylori positive--Given prescription for triple
therapy with Clarithromycin, Amoxicillin, and Omeprazole. N.b.
Discharge worksheet showing Rx for 2wks Omeprazole, with GI recs
for 6-8wks PPI Tx --> Called both pt's PCP and pt to make them
aware and give 6-8wks of Tx. Stressed importance of ABx
compliance. Will need repeat EGD in future after medical therapy
complete.
Medications on Admission:
Oxycodone/APAP PRN
Discharge Medications:
1. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day for 2 weeks.
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO twice a
day for 2 weeks.
Disp:*56 Capsule(s)* Refills:*0*
3. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Upper GI tract bleed
2. Ulcers at gastoesophageal junction, H. Pylori positive
Discharge Condition:
By the time of discharge, the pt's hematocrit was stable, vital
signs were stable, the pt was taking good PO food and liquids,
and was medically clear for discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] after you vomited a large amount of
blood. You were given 2 units of blood at an outside hospital
and transferred to [**Hospital1 18**], where you were admitted to the
intensive care unit. You had a procedure to visualize your
esophagus and stomach and were found to have bleeding ulcers at
the junction of your stomach and esophagus. It was not actively
bleeding and no interventions were taken because you were not
tolerating the procedure well. You will need to treat these
ulcers with medical therapy for several weeks.
You will need to be treated for a bacterial infection of your
stomach that contributes to ulcers. You will need to take this
medicine regimen for two weeks:
1. Omeprazole 20mg twice daily
2. Amoxicillin 1g twice daily
3. Clarithromycin 500mg twice daily
Please note that if you do not complete the course of
antibiotics for two weeks, you risk recurrence of the ulcers.
Please seek immediate medical attention if you experience
further vomiting of blood, blood in your stool, dizziness or
lightheadedness, signs of bleeding from anywhere in your body,
abdominal pain that does not spontaneously resolve, or any other
concerns.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 84672**], at [**Street Address(2) 84673**], [**Location (un) **],MA, sometime THIS WEEK
to have your hematocrit checked. The clinic has already been
called, at [**Telephone/Fax (1) 14916**], and they will contact you sometime this
week to set up this appointment. This is VERY important and it
is important that you keep this appointment.
You will also need a repeat EGD (a procedure to visualize your
esophagus and stomach) in [**5-2**] weeks to assess your ulcers. You
can arrange this by calling the Department of Gastroenterology
at [**Hospital1 18**] at([**Telephone/Fax (1) 2233**] and telling them that you were seen
while an inpatient and need to set up a follow up appointment.
Or, you can ask your primary care doctor to arrange this for
you.
Completed by:[**2185-9-11**]
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7925
} | Medical Text: Admission Date: [**2126-5-8**] Discharge Date: [**2126-7-1**]
Date of Birth: [**2060-8-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Weakness, rash
Major Surgical or Invasive Procedure:
catheter exchange [**5-10**] and [**2126-5-17**]
ultrasound-guided percutaneous cholecystostomy
History of Present Illness:
Mr. [**Known lastname 13275**] is a 65 yo M who presented on day +27 status post
non-myeloblative matched unrelated donor stem cell transplant
for myelofibrosis with weakness and a rash. He reports that he
had been feeling well at the time of discharge on [**2126-4-29**] but
had become progressively weaker in the interval. Three days
prior to presentation the patient first noted a decrease in his
energy, and over the previous two days he was so weak he could
not even stand for a few minutes. This was associated with some
dizziness with standing, which was without sensation of movement
or vertiginous features. He also reported that his rash had
worsened despite an increase in prednisone with mild pruritus.
Cough had also developed on the day of presentation, which was
productive of clear phlegm. He denied dysuria, fevers, chills,
diarrhea, nausea or abdominal pain. At presentation he did
endorse a mild [**1-12**] headache that was dull and not associated
with photophobia, nausea or neck stiffness. He denied
palpitations or dyspnea. His chronic low back pain is at
baseline, dull, [**3-12**], and not associated with leg weakness,
saddle anesthesia or bowel/bladder incontinence. He did report
constipation x 4 days. He had noted some decrease in appetite
but was unsure regarding weight loss.
On the day of presentation the patient was seen in clinic and
found to be orthostatic from 141/93 to 119/80 with symptoms. He
received 2 L NS, and had labs drawn including cultures. He was
admitted to the BMT sertvice to further work up his weakness and
rash. His dizziness improved after IVF.
ROS: Positive per HPI and otherwise essentially negative. The pt
denied recent fevers, night sweats, chills, changes in hearing
or vision, including amaurosis fugax, neck stiffness,
lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia,
odynophagia, heartburn, nausea, vomiting, diarrhea, steatorrhea,
melena, hematochezia, cough, hemoptysis, wheezing, shortness of
breath, chest pain, palpitations, dyspnea on exertion,
increasing lower extremity swelling, orthpnea, paroxysmal
nocturnal dyspnea, leg pain while walking, joint pain.
Past Medical History:
ONCOLOGIC HISTORY
====================
Diagnosed with primary myelofibrosis (w/ JAK2 mutation) in
[**8-/2125**] with progressively declining platelet count.
-Matched unrelated donor non-myeloablative
allogeneic stem cell transplant with Fludarabine/Busulphan/ATG
conditioning - day 0 was [**2126-4-11**] complicated by grade 2 acute
cutaneous GVHD for which he was started on steroids and hadn his
cyclosporine dose increased
OTHER PAST MEDICAL HISTORY
=============================
- Epistaxis
- TIAs (3 episodes in past 5 years)
- Coronary Artery Disease (asymptomatic, diagnosied by positive
stress test 8 yrs ago; stress test with imaging in [**2123**] showed a
small area of mild distal inferior apical ischemia. He had a
radionucleotide stress test recently, however, that stratified
him to low risk.)
- Hypertension
- Chronic Low Back Pain, found by MRI to have spinal stenosis
and disc disease
- History of leg edema of unclear etiology
- heterozygote for the C282Y gene mutation (hemochromotosis
gene; His baseline ferritin in [**1-11**] was 970)
Social History:
He is married with four children and 10 grandchildren. He works
as a cement finisher and also ploughs snow in the winter. He has
an 80 pkyr smoking history, having quit 11 years prior to
admission. He drinks 2-3 alcoholic beverages per week.
Family History:
No history of cancer, marrow disorders.
Physical Exam:
Vitals: T:96.7 BP: 138/81 P: 81 R: 20 SaO2: 99 RA
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: Blanching erythema noted on face, chest and abdomen. No
open sores or lesions. Some flaking noted on face.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. Finger to nose normal on RIGHT but some
difficult with passing finger on LEFT. Patient unable to spell
WORLD backwards. Patient forgets [**2-5**] words at 2 minutes but
rememebers [**2-5**] with prompting. No deficits to light touch
throughout. No nystagmus, dysarthria, intention or action
tremor. 2+ biceps, triceps, brachioradialis, 2+ ankle jerks
bilaterally. Plantar response was flexor bilaterally.
Pertinent Results:
LABORATORY RESULTS
==================
On Admission:
WBC-4.1 RBC-3.46* Hgb-9.6* Hct-26.4* MCV-76* RDW-19.1* Plt
Ct-20*
--Neuts-42* Bands-3 Lymphs-22 Monos-22* Eos-5* Baso-1 Atyps-2*
Metas-1* Myelos-1* Promyel-1* NRBC-11*
Glucose-151* UreaN-28* Creat-0.8 Na-128* K-4.1 Cl-95* HCO3-24
AnGap-13
ALT-44* AST-30 LD(LDH)-597* AlkPhos-186* TotBili-1.1
On Discharge:
WBC 20.9
RBC 3.62
Hgb 11.1
Hc2 33.0
Na 119
K 5.0
Cl 91
HC03 16
Creat 1.8
BUN 59
ALT 3458
AST 7528
AP 636
Tot Bili 5.4
Ca 7.4
Mg 2.2
Phos 6.9
ABG: 7.05/50/80
MICROBIOLOGY
==============
Blood Cultures on [**5-10**], [**5-17**], [**5-23**]: No Growth
Urine Cultures: All negative
CMV Viral Load [**5-13**], [**5-20**], [**5-25**], [**6-3**]: Not detected
Stool Toxin Assay for C Diff [**5-12**], [**5-13**], [**5-14**], [**5-23**], [**5-30**], [**5-31**]:
Negative
Parainfluenza postive respiratory culture
PCR of Adenovirus with [**Numeric Identifier 81563**] copies
Sputum [**6-20**] GNR
Mini BAL [**6-21**] GNR
PATHOLOGY
=========
Skin Biopsy [**2126-5-10**]:
DIAGNOSIS:
1. Skin, right lateral eyebrow (A,B):
Squamous cell carcinoma, well to moderately differentiated
and invasive; extends to the peripheral and to the deep specimen
margins.
2. Skin, left medial canthus (C,D):
Basal cell carcinoma, superficial and nodular types with
superficial excoriation and squamous differentiation; extends to
the peripheral and to the deep specimen margins.
Skin Biopsy [**2126-5-13**]:
DIAGNOSIS:
Skin, left abdomen, punch biopsy (A):
Vacuolar interface dermatitis with satellite cell necrosis
and scattered eosinophils (see note).
Note: The findings raise a histologic differential diagnosis
that includes acute graft versus host disease and a drug
eruption. Clinical correlation is required.
GI Biopsies [**2126-5-15**]:
DIAGNOSIS:
Colonic mucosal biopsies:
A. Descending:
1. Features consistent with involvement by acute graft vs.
host disease; see note.
2. No viral inclusions identified on immunostain for CMV.
B. Sigmoid:
1. Features consistent with involvement by acute graft vs.
host disease; see note.
2. No viral inclusions identified on immunostain for CMV.
C. Rectum:
1. Features consistent with involvement by acute graft vs.
host disease; see note.
2. No viral inclusions identified on immunostain for CMV.
Note: The biopsies demonstrate focally prominent crypt
apoptoses, rare crypt abscess, and focal cryptitis with only a
mild associated mixed inflammatory infiltrate, consistent with
involvement by acute GVHD. Foci of crypt drop-out are
identified. While CMV immunostains are negative for viral
inclusions, a concomitant infectious process cannot be entirely
excluded.
Radiology
==========
Chest Radiograph [**2126-5-8**]:
IMPRESSION: PA and lateral chest.
Lungs are fully expanded and clear. Cardiac silhouette
exaggerated by a mild pectus deformity is top normal size. There
is no pulmonary edema, pleural effusion, or evidence of central
adenopathy.
Dual-channel central venous catheter has backed out to the
junction of the
brachiocephalic veins. This may have no clinical significance
but is
sometimes seen when thrombus develops at the tip of the
catheter.
Unilateral Upper Extremity U/S [**2126-5-8**]:
Within this limitation, the right internal jugular vein,
axillary vein,
brachial veins x 2 and basilic veins were all patent. Limited
views of the
right subclavian vein were obtained due to patient's bandage.
The vein
appears to be patent but the useful assessment for clot cannot
be made. Chest radiograph from [**2126-5-8**] showed the tip to lie
over the region of the brachiocephalic confluence or proximal
SVC. The report at that time is noted. It would be not be
possible on ultrasound to interrogate the tip of the catheter,
as this is essentially a retrosternal location. A
contrast-enhanced study is recommended to further evaluate for
clot.
RIGHT Venogram
1. Venogram demonstrating no clot in the inferior portion of the
right
brachiocephalic vein and in the SVC.
2. Existing catheter exchanged with a longer triple-lumen
tunneled Hickman
catheter with tip in the SVC.
CT Torso W/Contrast [**2126-5-11**]:
1. Wall thickening and inflammatory fat stranding of the
terminal ileum,
ascending colon and transverse colon. Differential diagnosis
includes
inflammatory, infectious and ischemic etiology. SMA/SMV are
patent. No
evidence of free fluid, free air or pneumatosis. Colonoscopy
after
treatment/resolution is recommended.
2. Splenomegaly.
3. Bilateral renal hypodensities.
4. 1.5-cm pericardial effusion.
MRI Head W and W/O Contrast [**2126-5-11**]:
FINDINGS: There are scattered areas of white matter
hyperintensity on the
FLAIR images in both the deep and subcortical white matter.
These suggest
chronic small vessel ischemia. The remainder of the brain
appears normal with no evidence of hemorrhage, edema, masses,
mass effect, or infarction. The ventricles and sulci are within
the range of normal for a patient of this age. There are no
diffusion abnormalities. There is no abnormal enhancement after
contrast administration.
CONCLUSION: Findings suggesting chronic small vessel ischemia.
No evidence
of hemorrhage, infarction, or infection.
Chest Radiograph [**2126-5-13**]:
IMPRESSION: No change or evidence of acute pneumonia.
Chest Radiograph [**2126-5-17**]:
INDICATION: Line change.
Right internal jugular vascular catheter terminates in the mid
superior vena cava, with no evidence of pneumothorax. New
widespread interstitial opacities are likely due to acute
interstitial edema.
CT Head W/O Contrast [**2126-5-17**]:
IMPRESSION: No acute intracranial process.
Liver/GB Ultrasound [**2126-5-18**]:
IMPRESSION: No evidence of biliary obstruction.
Transthoracic Echocardiogram [**2126-6-3**]:
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is 0-5
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2126-3-26**],
the pericardial effusion is slightly larger (still small).
CXR [**2126-6-14**]: The Hickman catheter tip is at the level of mid
SVC. The cardiomediastinal silhouette is stable. There is
interval development of left lower lobe opacity that is
concerning for infectious process. Evaluation with PA and
lateral radiographs is recommended for precise characterization
of this worrisome for infectious process abnormalities.
Cardiomegaly is unchanged, moderate compared to the prior
study
RUQ US [**2126-6-19**]: 1. New extra-hepatic biliary ductal dictation.
No evidence of choledocholithiasis in the visualized portions,
however the head of the pancreas and distal common bile duct are
not well visualized. MRCP is recommended. 2. Normal
gallbladder.
MRCP [**2126-6-16**]: 1. Limited exam. The extrahepatic common duct is
dilated, new from [**2126-5-3**]. It is seen to the level of the
ampulla, with no definite stone. Some internal signal in the
distal CBD could represent sludge. However, artifacts
significantly limit the images obtained.
2. Hemosiderosis.
3. Abnormal appearance of small bowel loops in the right lower
quadrant and distention of the splenic flexure of the colon.
These findings may be related to graft versus host disease.
CTA [**2126-6-17**]: 1. No central pulmonary embolus. Severe
respiratory motion limits evaluation of the segmental and
subsegmental pulmonary arteries, especially in the lower lobes.
2. Multifocal pulmonary opacities, predominently ground glass,
with areas of consolidation in the bases. While these findings
are consistent with given history of pneumonia, drug toxicity or
cryptogenic organizing pneumonia could have a similar appearance
CXR [**2126-6-18**]: FINDINGS: In comparison with the study of [**6-14**],
there is increasing opacification at the left base in the
retrocardiac area, as well as some increasing opacification at
the right base. This is consistent with the clinical diagnosis
of a developing pneumonia
[**6-23**] RENAL U.S. PORT; DUPLEX DOP ABD/PEL LIMITED
IMPRESSION: No evidence of hydronephrosis. Markedly limited
Doppler
examination, probable gross venous patency although if renal
vein thrombus
were of significant clinical concern then CT or MR would better
evaluate.
Echo [**2126-6-24**]: There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. The
number of aortic valve leaflets cannot be determined. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. The tricuspid valve leaflets are mildly thickened. The
pulmonary artery systolic pressure could not be determined.
There is a small pericardial effusion. The effusion appears
circumferential. The effusion is echo dense, consistent with
blood, inflammation or other cellular elements. There is brief
right atrial diastolic collapse. There is significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, consistent with impaired ventricular filling.
Compared with the prior study (images reviewed) of [**2126-6-3**], the
pericardial effusion is slightly larger, especially posterior to
the heart. There is now evidence of impaired ventricular
filling. The left ventricle is smaller and the right ventricle
(although not well seen) is probably milldy dilated and
hypokinetic. However, the patient is now ventilated with a high
PEEP which may explain these findings.
Gallbladder US
IMPRESSION:
1. Increasing intrahepatic and extrahepatic biliary ductal
dilatation. No
cholelithiasis or stone seen within the proximal or mid CBD, but
visualization of distal CBD is limited.
2. Distended gallbladder with interval appearance of sludge and
questionable
gallbladder wall edema. The findings are nonspecific given
hypoproteinemia and biliary distention but acute cholecystitis
cannot be
excluded; HIDA scan could be performed for further evaluation of
biliary
tract function.
[**6-29**] Echo
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated with moderate global free wall
hypokinesis. There is a small circumferential pericardial
effusion. There is very brief right atrial invagination, but no
echocardiographic signs of tamponade.
IMPRESSION: Limited study. Small pericardial effusion without
signs of tamponade. Right ventricular dilation and systolic
dysfunction.
[**6-30**] CXR
FINDINGS: Comparison is made to the prior studies from [**2126-6-29**].
Right-sided central venous catheter, nasogastric tube, left IJ
central venous
catheter, and nasogastric tube are unchanged in position. There
are again
seen diffuse airspace opacities throughout both lung fields
which are
unchanged.
Brief Hospital Course:
65 year old male who presented on D+27 of matched unrelated
donor non-myeloblative allogeneic stem cell transplant with
worsening GVHD and weakness found to have worsening acute GVHD.
.
# Acute Graft Versus Host Disease: The patient presented with
worsening rash but no diarrhea and normal bilirubin and
transaminases. As his rash had not improved on prednisone and
he was having primarily weakness and some mental status changes
at presentation concern for severe, acute GVHD was low and
concern for infection was much higher. Therefore prednisone was
stopped on [**2126-5-12**]. Unfortunately, within the first five days
of presentation the patient developed severe diarrhea with >1500
ml of stool per day. This led to strong suspicion of acute GVHD
being the primary cause of his presentation and symptoms and the
patient was put on 1 mg/kg methyprednisolone on [**2126-5-13**] and made
NPO. GI biopsies were performed on [**2126-5-15**] with flexible
sigmoidoscopy, which were consistent with GVHD and negative for
CMV while skin biopsies of his rash from [**5-13**] were
non-dignostic.
On [**2126-5-19**] there was an attempt made to wean this steroids back
in the context of potential improvement but his diarrhea once
again worsened and bilirubin started to climb so that by [**2126-5-22**]
he was back on 1mg/kg methylprednisolone per day. On [**2126-5-23**]
the patient was advanced to 2mg/kg IV methylprednisolone per day
divided into two doses and on [**2126-5-24**] he was started on
mycophenolate motefil for what was now considered steroid
refractory acute GVHD. Methylprednisolone dosing was was dropped
back to 1mg/kg on [**5-26**] as there was minimal improvement and
considerable concern about the risk of this high of a steroid
dose. Bilirubin peaked at 7.3 on [**5-25**] but then began to fall
along with the patient having decreased volume of diarrhea and
improving rash. The patient was allowed rice once again on
[**2126-6-2**] as his stool output had dropped below 500 cc per day and
bilirubin was back to less than 4. However, his stool output
continued then increased the first week of [**Month (only) **].
PO diet was stopped and he was continued on TPN for nutrition.
His symptoms continued to worsen, along with increasing of his
LFTs. RUQ US was done which showed sludge in the common bile
duct. ERCP was held off secondary to respiratory issues. Stools
stopped once intubated (started on sedation and narcotics). On
[**6-26**], in the ICU, IR placed percutaneous cholecystostomy with
pigtail.
.
# Weakness/Cough: At presentation the outpatient oncologist was
quite concerned these symptoms could indicate occult infection
given the patient was less than 1 month post transplant. Culture
data remained unrevealing and UA and chest radiograph were
benign and and respiratory viral screen was unremarkable. When
CT torso revealed colitis the patient was empirically started on
ciprofloxacin/metronidazole on [**2126-5-12**] though C diff assay was
negative. On [**2126-5-17**] the patient was briefly febrile and had
rigors so cipro/metronidazole was discontinued and vancomycin/
pipercillin-tazobactam were started for empiric coverage of a
possible enteric infection. His hickman was also changed over a
wire as the cuff was noted to be protruding from the skin though
culture of the tip remained negative. All cultures remained
negative and vancomycin stopped on [**5-21**], pipercillin-tazobactam
stopped [**5-22**]. These were briefly restarted after another fever
on [**5-23**] but weaned off by [**5-26**] as once again cultures remained
negative and no source of fevers were found.
The patient remained afebrile thereafter, until [**2126-6-15**] when he
spiked a temp and was started on cefepime and vancomycin for
suspected pulmonary source. The patient's respiratory symptoms
quickly progressed. A CT of the chest was performed on [**2126-6-17**]
which showed bilateral infiltrates. Pulmonary was consulted for
possible bronchoscopy, however the patient became more hypoxic
on [**2126-6-18**] and required transfer to the [**Hospital Unit Name 153**] for monitoring. Was
intubated due to hypoxia and SOB. Found to have parainfluenza on
viral culture. Started on Tamiflu. Also found to have highly
positive PCR in blood for adenovirus, and was started on
cidofovir on [**6-21**] with pretreatement of renal protection with
probenicid. Also had sputum and mini-BAL from [**6-20**] and [**6-21**]
showing GNRs identified as STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA sensitive to SMX TMP. ID followed pt and also had
changed micafungin to voirconazole on transfer to [**Hospital Unit Name 153**],
continued cefepime and discontinued Vancomycin. BMT decreased
steriods, cellcept and cyclosporine due to infection.
.
# Respiratory Distress: On the evening of [**2126-5-17**] while having
his hickman changed the patient developed acute shortness of
breath during the procedure associated with an anxiety attack.
The patient is quite claustrophobic and reacted poorly to being
placed for the procedure but also developed brief hypoxia that
resolved with supplementary O2. Chest radiograph from the time
of the procedure showed interstitial edema and it seems likely
the patient had flash pulmonary edema in the context of volume
overload and being placed flat. He was gently diuresed over the
ensuing two days and did well thereafter. The patient had
another episode of respiratory distress on [**2126-6-17**] after being
diagnosed with bilateral multifocal pneumonia. He became
acutely hypoxic and was transferred to the medical ICU ([**Hospital Ward Name 332**])
as above on [**2126-6-18**]. Due to TPN and required medications patient
was 21 L positive in the [**Hospital Unit Name 153**] and difficult to diuresis.
Eventually required Lasix drip with pressor support. While he
was able to be weaned from pressors during his ICU stay, on [**6-29**]
his requirements increased and phenylepherine and vasopressin
were added. On [**6-30**], his respiratory status declined and he had
worsening acidosis and hypoxia. Pt gradually became
bradycardic. Family was called to come to bedside. Family
arrived to be with the patient in his last moments. Pt was
noted to be asystolic on telemetry. Mechanical ventilation was
discontinued. On exam, pt had no pupillary reflexes, breath
sounds, or heart tones. Pt was pronouced dead at 4:28 AM.
.
# Hypotension: During ICU stay patient developed hypotension.
All outpatient HTN medications were stopped. Patient was started
on Levophed for support, which was transitioned over to
Phenylephrine due to tachycardia. Later in his stay vasopression
was added. Etiology of hypotension most likely sepsis from
infections as described above. Patient was weaned off pressors
but then became hypotensive and pressors were restarted.
.
# Acute Renal Failure: Patient developed renal failure following
cidovir dose which is a known nephrotoxin. Renal ultrasound was
preformed which demonstrated no obstruction. CVVHD started on
[**6-25**]. Renal failure did not improve significantly throughout his
ICU stay,
.
# Confusion: On presentation the patient's wife was concerned
about mild deficites in memory and concern about his mental
status. These were never particularly obvious to the treating
team. Imaging of the head (CT and MRI) were benign and these
deficits resolved over his first 3-4 days in the hospital so no
further work up was pursued. Most likely this represented
delirium in the setting of acute illness.
.
# Cardiac status: The patient intermittently complained of
dyspnea, particularly when standing up though he had no problems
with laying flat. ECG remained stable, CXR remained benign, and
he was never hypoxic except as described above. Echocardiogram
was also completely stable. His BB was weaned down over concern
his dyspnea could have been due to difficulty augmenting his
cardiac output in the context of standing with beta blockade but
this wasn't particularly helpful. Ultimately, there was
suspciion his shortness of breath was primarily due to
deconditioning/anxiety once other pernicious etiologies were
excluded. In the ICU, pt had afib with RVR, tx with amiodarone.
.
# Myelofibrosis s/p BMT: The patient's counts remained
relatively stable throughout his hospitalization with low
platelets and relatively stable anemia but no leukopenia or
neutropenia. There continued to be abnormal forms in his
peripheral smear presumed due to his myelophthisic process
(despite this GVHD and resolution of his previous splenomegaly
both suggest significant graft versus tumor effect). He was
supported with transfusions and cyclosporine was continued with
addition of mycophenolate and prednisone as described.
.
# Hematochezia: After his flexible sigmoidoscopy with biopsies
the patient had hematochezia for the following two days. He
remained hemodynamically stable and anemia did not worsen during
his hematochezia. This stopped without further intervention.
During [**Hospital Unit Name 153**] course GI continued to follow, however patient was
felt unstable for flex sigmoidoscopy.
.
# Hypertension: The patient initially required increased
nifedipine dosing in the context of his increased steroid dosing
and secondary worsening of hypertension. Eventually, beta
blocker was decreased due to concern of worsening his dyspnea.
During [**Hospital Unit Name 153**] stay patient became hypotensive and all outpatient
HTN medications were held.
.
# Pain: The patient has chronic low back pain secondary to
degenerative joint disease. This was well controlled with PO
oxycodone in the hospital.
.
# Prophylaxis: On presentation the patient was on voriconazole
for fungal prophylaxis as there was concern fluconazole had
worsened his rash. This was changed to micafungin out of
concern the vori was contributing to his mental status changes.
Later in [**Hospital Unit Name 153**] changed back to vori due to unclear cause of PNA.
Acyclovir was briefly stopped out of concern it contributed to
rash but he remained on this throughout most of his
hospitalization for viral prophylaxis. He never demonstrated
signs or symptoms of herpes reactivation. He remained on
ursodiol for VOD prophylaxis.
.
# Hypernatremia: had Na up to 155 in [**Name (NI) 153**], unclear cause. Given
D5W and sodium improved.
.
# FEN: The patient was NPO from [**Date range (1) 81564**] and supplemented with
TPN. Lytes were repleted per standing scales.
Medications on Admission:
ACYCLOVIR 400 mg po TID
CYCLOSPORINE MODIFIED 200 mg po BID
FOLIC ACID 1 mg po
LORAZEPAM - 0.5 - 1 mg po QHS
METOPROLOL SUCCINATE 200 mg po daily
NIFEDIPINE CR 60 mg po daily
OXYCODONE 5 -10 mg po Q4H prn
OXYCONTIN 10 mg po BID
PENTAMIDINE [NEBUPENT] - (given in clinic on [**5-1**]) - 300 mg
Recon Soln - 1 inh po monthly given in clinic [**5-1**]
PREDNISONE 40 mg po BID
RANITIDINE HCL - 150 mg po BID
SULFACETAMIDE SODIUM - 10 % Drops - 2 gtts ou four times a day
for 7 days for eye infection ([**2126-5-7**] - [**2126-5-14**])
URSODIOL 300 mg po BID
VORICONAZOLE 200 mg po BID
ZOLPIDEM - 10 mg Tablet po QHS
Medications - OTC
DOCUSATE SODIUM 100 mg prn
MVI
SENNA
WHITE PETROLATUM-MINERAL OIL [DERMACERIN] - (discharge med) -
Cream - apply to face as needed for for dry, flaky, or itchy
skin
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Graft vs host disease, cardiorespiratory failure
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 5849, 2760, 0389, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7926
} | Medical Text: Admission Date: [**2199-9-20**] Discharge Date: [**2199-9-22**]
Date of Birth: [**2117-3-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
The patient is an 82-year-old male with history of CAD, s/p MI
in [**2187**], CHF w/ EF 10-15% who had a recent admission to
[**Hospital 16843**] hospital for CHF exacerbation. He was discharged 1
week prior to this admission on [**2199-9-22**]. The patient has been
complaining of shortness of breath since his last
hospitalization. He reports new exertional dyspnea after walking
just "10 feet" and he has [**1-13**] pillow orthopnea and needs to
sleep upright on occasion. No new lower extremity swelling and
he reports weight loss of 15lbs over the last 2-3 months. Has
has a "constant cough" with white/green phlegm but no blood. No
sick contacts. [**Name (NI) **] recent travel. By report from family patient's
lasix dose was recently decreased by his home visiting
nurses/CNAs due to low blood pressures. Previously had been
taking 60mg [**Hospital1 **] and now was taking 40-60mg daily (unclear,
patient limited historian and daughter uncertain).
Patient was admitted to [**Hospital3 7571**]Hospital a week ago where
he was treated for a CHF exacerbation. 2D Echo done at [**Hospital **]demonstrated an EF of 10% w/ severe global LV
hypokinesis, pulmonary HTN, and severe aortic stenosis. BNP was
elevated to 5,000, Troponin I of 0.05. Mr. [**Name14 (STitle) 75012**] was diuresed
1.5L but fluid removal was limited by hypotension. The [**Hospital 228**]
hospital course was further complicated by acute on chronic
renal failure with Cr 1.7, and by recurrent NSVT. He was started
on amiodarone infusion at OSH. Impression from cardiology was
for re-stenosis of stents placed in [**2199-2-9**] and he was
transferred to [**Hospital1 18**] for cardiac catheterization and EP consult
for discussion of possible upgrade of ICD to BivPM.
.
In the cath lab, RHC demonstrated CI 1.78, PCWP 28, RA pressure
of 5, PAP of 34. LHC demonstrated LM w/ obstruction, LCX with
proximal TO, RCA and LAD with minimal disease. Were unable to
cross the LCx w/ wire. Felt to be a CTO. Post-procedure patient
was hypotensive to upper 70's low 80's. Baseline BP 80-90's.
Also with brief episode of chest pain post procedure (no EKG
changes). Transferred to CCU for further management.
.
On arrival in CCU, patient was chest pain free and otherwise had
complaints of mild dyspnea. No complaints of dizziness, back
pain, groin pain, or leg pain.
.
Past Medical History:
CAD with MI in [**2187**], underwent angiogram at [**Hospital1 498**] (no stent
placed)
ICD placement in [**2193**] at [**Hospital6 15083**]
Prostate Cancer, no intervention, "slow growing" per patient
HTN
Nephrolithiasis
Gout
h/o pancreatic duct obstruction
Borderline Diabetes, diet controlled
Acute on Chronic Kidney Disease
Social History:
Social history is significant for the absence of current tobacco
use. Past tobacco use over 50years ago. There is no history of
alcohol abuse or drug abuse per patient. Patient is a retired
firefighter and is currently still very active working with
lumber. He ambulates 2 flights of stairs easily.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father lived to be [**Age over 90 **] years old.
Physical Exam:
T 98.3 F, HR 103, NBP 82/62, ABP 95/61, RR 15-20, O2 sat 98 % 2L
NC.
Gen: Well appearing elderly man resting supine in bed, NAD, very
pleasant affect
HEENT: NCAT, pupils constricted, reactive b/l symmetric,
Neck: supple, fully recumbent and unable to appreciate JVD.
Lungs: rales at bases bilaterally L>R
Heart: RRR, systolic murmur at apex, S3 noted, weak carotid
upstrokes bilaterally
Abd: soft, nontender and nondistended, no abdominal bruits,
Ext: cold LE bilaterally, dopplerable DP/PT pulses, no LE edema,
1+ left femoral pulse, 1+ radial pulses b/l
Neuro: AOx3, CN II-XII grossly intact, full strength upper and
lower extremities and no focal moror or sensory deficits on
exam.
Skin: Warm but pale comlexion
Pertinent Results:
[**2199-9-20**] 08:04PM TYPE-ART PO2-132* PCO2-32* PH-7.51* TOTAL
CO2-26 BASE XS-3 INTUBATED-NOT INTUBA
[**2199-9-20**] 08:04PM LACTATE-2.3*
[**2199-9-20**] 07:32PM GLUCOSE-158* UREA N-40* CREAT-1.4* SODIUM-140
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-26 ANION GAP-18
[**2199-9-20**] 07:32PM estGFR-Using this
[**2199-9-20**] 07:32PM ALT(SGPT)-30 AST(SGOT)-24 LD(LDH)-251*
CK(CPK)-91 ALK PHOS-113 TOT BILI-0.9
[**2199-9-20**] 07:32PM CK-MB-NotDone cTropnT-0.04* proBNP-[**Numeric Identifier **]*
[**2199-9-20**] 07:32PM CALCIUM-9.4 PHOSPHATE-4.8*# MAGNESIUM-2.2
[**2199-9-20**] 07:32PM WBC-8.1 RBC-4.30* HGB-13.5* HCT-39.7* MCV-92
MCH-31.4 MCHC-34.1 RDW-16.8*
[**2199-9-20**] 07:32PM PLT COUNT-251#
[**2199-9-20**] 07:32PM PT-22.3* PTT-62.4* INR(PT)-2.1*
[**2199-9-20**] 04:36PM TYPE-ART RATES-/34 O2 FLOW-2 PO2-124*
PCO2-46* PH-7.44 TOTAL CO2-32* BASE XS-6 INTUBATED-NOT INTUBA
COMMENTS-NASAL [**Last Name (un) 154**]
[**2199-9-20**] Admission EKGs: Several for review, baseline rhythm is
Sinus with LBBB, occasional PVC's, 1st degree AV conduction
delay, no ST T changes. One EKG with no discernable p-waves and
atrial fibrillation .
.
TELEMETRY: Several runs of polymorphic NSVT on arrival to floor
on [**2199-9-20**] and on [**2199-9-21**].
.
[**2199-9-21**] 2D-ECHOCARDIOGRAM: The left atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. No masses or thrombi are
seen in the left ventricle. Overall left ventricular systolic
function is severely depressed (LVEF= 15-20 %) with global
hypokinesis. The inferior and infero-lateral walls are thinned
and akinetic. There is no ventricular septal defect. Right
ventricular chamber size is normal. There is mild global right
ventricular free wall hypokinesis. The aortic valve leaflets are
moderately thickened. Significant aortic stenosis is present
(not quantified). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**12-12**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
.
CARDIAC CATH [**2199-9-21**]: RHC demonstrated CI 1.78, PCWP 28, RA
pressure of 5, PAP of 34. LHC demonstrated LM w/ obstruction,
LCX with proximal TO, RCA and LAD with minimal disease. Were
unable to cross the LCX w/ wire. Felt to be a CTO.
[**2199-9-21**] 04:06AM BLOOD WBC-9.2 RBC-4.36* Hgb-13.6* Hct-40.6
MCV-93 MCH-31.3 MCHC-33.6 RDW-16.0* Plt Ct-256
[**2199-9-21**] 04:06AM BLOOD Glucose-194* UreaN-45* Creat-1.9* Na-141
K-4.8 Cl-99 HCO3-29 AnGap-18
[**2199-9-21**] 04:06AM BLOOD CK-MB-162* MB Indx-22.3* cTropnT-1.47*
Brief Hospital Course:
In summary, the patient is an 82yo male with longstanding
history of CHF with poor EF of [**9-25**]%, severe aortic stenosis
and CAD who was transferred from OSH for evaluation of
progression of CHF and question of in-stent re-stenosis. He
underwent cardiac catheterization which showed CTO of LCX and no
other acute lesions. He had complication post-procedure for
hypotension and he was transferred to the CCU.
.
CORONARY ARTERY DISEASE /NSTEMI: The patient had a prior CABG,
an MI in [**2187**] and a PCI 6 months ago at OSH. He also has
advanced COPD and he has had several CHF episodes in the recent
past. The patient had CTO of LCX but otherwise no obstructive
disease was noted on his cardiac catheterization. He initially
had no elevation in his CK level and a mild increase in his
troponin which was attributed to his worsening renal function.
Unfortunately, however, his CK trended up from 469 to 726
post-catheterization and MB-I went up to 22.3 from 19.8 and
troponins increased from .75 to 1.47 on [**2199-9-21**]. He had some
T-wave changes suggesting ischemia and a possible NSTEMI on EKG.
Follow-up EKG later in the evening after admission showed left
axis deviation, evidence of old inferior wall myocardial
infarction with q-waves and old anteroseptal myocardial
infarction. He also had marked intraventricular conduction delay
and continuing ST-T wave changes which were non-specific and
difficult to interpret amongst his LBBB. For NSTEMI management,
hHe was continued on his ASA 325 mg daily, Plavix 75 mg,
Atorvastatin 80mg daily and a heparin drip was started. He
continued to have intermittent mild to moderate chest pains
during his hospital stay which were relieved with low doses of
IV Morphine. Beta blockers were held given the concern for
cardiogenic shock and his extremely low EF.
.
CHF: The patient had decompensated heart failure with elevated
PCWP and low CI. He had an EF of [**9-25**]% on most recent ECHO and
his blood pressures began to worsen throughout his CCU stay. He
entered the CCU with systolic BPs in the 80-90 range which
worsened to SBP in the 70s and diastolic pressures in the
mid-40s. An arterial line was placed for better monitoring of
his hemodynamics and his non-invasive BP was noted to be
approximately 10mmHg less then arterial measurement.
He was given some gentle diuresis as tolerated by SBP and his
Spironolactone was held due to his low BPs. Unfortunately, the
patient continued to required increasing amounts of supplemental
oxygen to maintain oxygen saturations above 90%. ECHO done (TTE)
on [**2199-9-21**] showed a dilated LA and LV and severely depressed LV
function (LVEF= 15 %) with global hypokinesis. The inferior and
infero-lateral walls were notably thinned and akinetic and there
was global right ventricular free wall hypokinesis as well.
.
HYPOTENSION: The patient's SBPs of 80-90s declined to the low
70s and his MAP by arterial line measure dropped into the
mid-40s to low 50s range so the patient was started on a
Dopamine drip.
.
AORTIC STENOSIS: On physical exam the patient had a prominent
mid-systolic ejection murmur best heard at the right second
intercostal space, with radiation into the right neck. TTE also
noted severe aortic stenosis. The patient's valvular disease
further contributed to Mr. [**Last Name (Titles) 75103**] poor cardiac output and
worsening heart failure.
.
RHYTHM: The patient was in normal sinus rhythm initially but
began to have multiple episodes of short NSVT, PACs and
progressive tachycardia into the 160s. He had started on
Amiodarone at an OSH just prior to admission but this was held
in the setting of his severe hypotension. He was monitored via
continuous telemetry.
.
RENAL FAILURE : The patient's renal dysfunction and climbing
creatinine were felt to be secondary to his poor forward flow
and faltering cardiac index in the setting of his advanced heart
failure and overnight NSTEMI.
.
PULMONARY EDEMA/ RESPIRATORY DISTRESS: Mr. [**Name14 (STitle) 75012**] was hypoxic
from accumulating pulmonary edema from his worsening CHF. He
remained difficult to wean off of oxygen and diuresis was
limited because of extreme renal failure and inability to dose
large amounts of lasix in the setting of his extreme hypotension
with SBPs in the 70s. Moreover, the patient had underlying risk
factors for interstitial lung disease and COPD history per
records which also negatively impacted his pulmonary reserve.
.
PRE-DIABETES: The patient was placed on sliding scale insulin
for glycemic control in the setting of ACS. He had a poor
appetite during his stay and was unable to take in oral food
over the last day of his CCU stay prior to his death as he was
in fulminant CHF with respiratory distress.
.
ADDITIONAL CARE / PROPHYLAXIS: -In terms of wound care, the
patient was given a Duoderm for additional care of his buttock
ulcer during his hospital course. A bowel regimen was given with
Colace and Senna tablets and Heparin drip per ACS protocol
covered the DVT prophylaxis concerns.
.
As the patient's clinical status rapidly declined Mr. [**Name14 (STitle) 75012**]
and his family were counseled and a family meeting was held to
discuss the patient's goals of care and end of life wishes. The
patient expressed his desire to be DNR/DNI status and he
expressed his desire to be made as comfortable as possible in
the closing hours of his rapidly failing heart. The EP team was
called to deactivate the patient's pacemaker and he was given IV
Morphine for comfort and IV Lasix drip for additional relief of
his gross fluid overloaded state and pulmonary edema. He became
hypotensive and bradycardic and went into respiratory arrest.
Unfortunately, the patient passed away after respiratory arrest
and was pronounced on [**2199-9-22**].
Medications on Admission:
- lasix 40mg daily (?60mg [**Hospital1 **])
- Potassium 10 meq [**Hospital1 **]
- Metoprolol 12.5 daily
- Allopurinol 300mg daily
- ASA 325mg daily
- Plavix 75mg daily
- Fish Oil 1000mg daily
- Vitamin D 1000 units daily
- Spironolactone [**12-12**] pill daily
- MVI daily
Discharge Medications:
patient deceased, pronounced on [**2199-9-22**]
Discharge Disposition:
Expired
Discharge Diagnosis:
patient deceased, pronounced on [**2199-9-22**]
Discharge Condition:
patient deceased, pronounced on [**2199-9-22**]
Discharge Instructions:
patient deceased, pronounced on [**2199-9-22**]
Followup Instructions:
patient deceased, pronounced on [**2199-9-22**]
Completed by:[**2199-9-26**]
ICD9 Codes: 4280, 5849, 5859, 2749, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7927
} | Medical Text: Admission Date: [**2174-5-11**] Discharge Date: [**2174-6-7**]
Date of Birth: Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENTING ILLNESS: Mr. [**Known lastname 174**] is a 43-year-old
Caucasian gentleman who is status post liver re-
transplantation for hepatitis C cirrhosis. This was
complicated amongst other things by pancreatic pseudocyst
development requiring surgical drainage. He was admitted
with tachycardia and altered mental status with fever.
PAST MEDICAL HISTORY: Remarkable for end-stage liver disease
secondary to hepatitis C and alcohol-related cirrhosis. He
had a failure of his first transplant with subsequent re-
transplant. Liver failure was due to hepatic artery
stenosis.
MEDICATIONS ON ADMISSION:
1. Bactrim.
2. Epogen.
3. Ribavirin.
4. Protonix.
5. Ursodiol.
6. Interferon.
7. Olanzapine.
8. Insulin.
9. Imodium.
10. Lasix.
11. Reglan.
12. Atenolol.
13. Miconazole.
14. Tacrolimus.
15. Cortisone.
He has recently been treated for hepatitis C recurrence. He
also has a history of profound depression.
PHYSICAL EXAMINATION: On exam, he was awake but somewhat
disoriented. He had a temperature to 103 degrees, heart rate
of 130, and blood pressure of 110/65. He had crackles on his
chest, on the left side. Heart sounds were normal. His
abdomen was soft and nondistended. His extremities were
normal.
LABORATORY DATA: His LFTs showed a bilirubin of 18, and he
had a white cell count of 12.2.
HOSPITAL COURSE: He was admitted to the intensive care unit,
and an extensive workup was done, including CAT scan,
ultrasound, and he was started on broad-spectrum antibiotics
consisting of linezolid and Zosyn. He was kept n.p.o. on
TPN, and supportive care was provided. Subsequent liver
biopsy was consistent with fibrosing cholestatic hepatitis.
Over the next 2 weeks, he had a progressively deteriorating
course of worsening cholestasis and then proceeded to develop
multiple organ failure requiring intubation and pressor
support. In light of the poor prognosis of the underlying
condition and after extensive discussion with the family, it
was decided to withdraw support, subsequent to which the
patient rapidly expired.
DISCHARGE DIAGNOSES: Fibrosing cholestatic hepatitis, liver
failure subsequent to liver transplant, and multiple organ
failure.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]
Dictated By:[**Name8 (MD) 32797**]
MEDQUIST36
D: [**2174-9-27**] 14:23:28
T: [**2174-9-28**] 07:07:20
Job#: [**Job Number 45122**]
ICD9 Codes: 2765, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7928
} | Medical Text: Admission Date: [**2138-12-3**] Discharge Date: [**2112-2-8**]
Date of Birth: [**2070-1-22**] Sex: M
Service:
NOTE: This is a Discharge Summary Addendum to the previous
Addendum from [**2139-1-12**].
HOSPITAL COURSE CONTINUED: The patient had a question of a
right middle lobe infiltrate on chest x-ray noted on [**2139-1-11**]. The patient was started on ceftazidime for presumed
Medical Intensive Care Unit associated pneumonia.
On [**1-12**], the patient underwent a bronchoscopy to
further elucidate the question of a right middle lobe
infiltrate. It was noted that there was no purulent
discharge or tracheoesophageal fistula on bronchoscopy. The
patient has remained clinically without pneumonia since his
bronchoscopy.
On [**2139-1-13**], it was decided that the patient most
likely did not have pneumonia and ceftazidime was stopped.
The patient had also been on vancomycin for presumed tracheal
cuff cellulitis. The area around the cuff was erythematous;
however, it was not warm nor was it indurated. It most
likely was a result of inflammatory and/or irritative changes
to the skin. The patient did not have clinical cellulitis
around the tracheal pallor. The patient's vancomycin was
stopped.
The patient has been weaned off CPAP to a tracheal mask for
durations of up to 16 hours on [**1-12**] and on [**1-13**].
The patient has been tolerating these weanings appropriately.
The patient was started on Mucomyst for secretion to help
decrease the thickness of his secretions. The patient was
tolerating his current respiratory support well.
The patient was ready for discharge to rehabilitation when
rehabilitation is available.
[**Last Name (NamePattern4) **], M.D. [**MD Number(1) 98036**]
Dictated By:[**Last Name (NamePattern1) 98037**]
MEDQUIST36
D: [**2139-1-13**] 14:14
T: [**2139-1-13**] 14:28
JOB#: [**Job Number **]
ICD9 Codes: 4280, 5119, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7929
} | Medical Text: Admission Date: [**2123-10-6**] Discharge Date: [**2123-10-10**]
Date of Birth: [**2123-10-6**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy, [**Known lastname 449**] [**Last Name (NamePattern1) **] [**Known lastname **] or
"[**Doctor First Name **]" as his parents call him, was [**Doctor First Name **] at 34 and 1/7 weeks
and admitted to the newborn intensive care unit for issues
related to prematurity. He was [**Doctor First Name **] to a 34 year old gravida
2, P1-2-3 mom with [**Name2 (NI) **] type O positive, antibody negative,
hepatitis B surface antigen negative, rubella immune, RPR
nonreactive, group B strep unknown. This was IUI pregnancy
with twin gestation. Pregnancy was uncomplicated until mother
presented in preterm labor. This baby was [**Name2 (NI) **] by vaginal
delivery and had Apgars of 8 and 9 at 1 and 5 minutes. He was
given blow-by oxygen and transported to the newborn intensive
care unit for further management.
PHYSICAL EXAMINATION: Birth weight of 1.965 kg, just under
the 50th percentile; length 44.5 cm, 50th percentile; head
circumference 30.5 cm, 50th percentile. On examination he was
pink and well perfused, active and vigorous. His skin was
clear with no rashes or birth marks. HEENT: Anterior fontanel
was open and flat. Eyes were clear. Nares intact. Palate
intact. Mucous membranes moist and pink. Neck supple. No
masses. Clavicles intact. Chest symmetric. Clear and equal
breath sounds. Comfortable respiratory pattern.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs. Pulses
+2 and equal. ABDOMEN: No hepatosplenomegaly. Active bowel
sounds. Cord clamped. GENITALIA: Normal external male
genitalia with testicles descending. Patent anus. Spine
smooth. Hips stable. Symmetric reflexes.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Doctor First Name **] has
remained in room air breathing between 30 and 40 with oxygen
saturations greater than 96%. He has had no periodic
breathing or evidence of apnea of prematurity to date.
CARDIOVASCULAR: Apical pulse 130 to 150s. [**Doctor First Name **] pressure
53/30 with a mean of 46. He has remained hemodynamically
stable.
FLUIDS, ELECTROLYTES AND NUTRITION: Access was via
peripheral IV. Total fluids were initiated at 80 per kg and
advanced to currently at 120 per kg. He initially had IV
fluids running and was euglycemic with an initial D-stick of
81. He transitioned from IV fluids to enteral feeds by day of
life 2. Currently he is taking breast milk or PE-20 at 120
per kg with some breast feeding, minimal PO feeding and the
rest by gavage. He has tolerated this well with no issues. He
is voiding and stooling meconium. His electrolytes were
followed and were noted to be in the normal range. TF
increased to 140 cc/k/d this am.
GASTROINTESTINAL: Bilirubin was checked at 24 hours and was
5.2/0.3. Phototherapy was started on day of life 3 for
bilirubin of 9.3/0.2. Currently the baby remains under
phototherapy. Bili on the morning of transfer is 7.4/0.3.
HEMATOLOGY: Initial CBC upon admission revealed white [**Doctor First Name **]
cell count of 19.5, with 53 polys, and 6 bands, hematocrit of
48.5% and platelet count 296,000. [**Doctor First Name **] culture was also
obtained and remains sterile. The baby received 48 hours of
ampicillin and gentamycin and has remained clinically well
off antibiotics.
NEUROLOGIC: Appropriate for gestational age.
SENSORY: Hearing screen has not yet been performed on Zed.
OPHTHALMOLOGY: An eye examination is not indicated at this
gestational age.
PSYCHOSOCIAL: Parents have been present, involved in care
and mother is being discharged on [**2123-10-10**], and
desires the baby to be transferred to [**Hospital3 3765**] at
that time for continued care and feeding maturity. They have
another small child at home and have good supports.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Level II nursery at [**Hospital3 3765**].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 53161**] [**Name (STitle) 10351**].
CARE RECOMMENDATIONS:
1. Feedings at the time of discharge are breast feeding as
tolerated, PO feedings with feeding cues at 140 ml/kg of
breast milk or PE-20.
2. Medications - none at this time.
CAR SEAT POSITION SCREEN: Car seat position screening has
not been performed, but is recommended prior to ultimate
discharge home.
HEARING SCREENs have not yet been performed, but are
recommeneded prior to ultimte discharge home.
THE STATE NEWBORN SCREEN: The last State Newborn Screen was
sent on [**2123-10-9**], and results are pending.
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following three criteria.
1. [**Month (only) **] at less than 32 weeks.
2. [**Month (only) **] between 32 and 35 weeks with two of the
following:
2. daycare during the RSV season.
3. a smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings.
4. infants with chronic lung disease.
1. 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.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and 1/7 weeks, twin No. 1.
2. Sepsis ruled out with antibiotics.
3. Physiologic jaundice.
[**Known lastname 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 62536**]
MEDQUIST36
D: [**2123-10-9**] 23:44:14
T: [**2123-10-10**] 00:40:47
Job#: [**Job Number 62695**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7930
} | Medical Text: Admission Date: [**2153-12-19**] Discharge Date: [**2153-12-28**]
Date of Birth: [**2084-5-16**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Reason for consult: R frontal hemorrhage
Major Surgical or Invasive Procedure:
stereotactic R frontal mass biopsy
History of Present Illness:
HPI: 69 yo RH male with MS, DM, HTN, HL, s/p CABG ("quintuple")
in [**2147**], defribillator placement who presents with 2 days of
worsening dysarthria and L sided weakness (baseline - flaccid
paralysis of LE bilaterally). Pt awoke with symptoms and with
worsening function, he presented to OSH - [**Location (un) **]/[**Location (un) 1459**].
There, CT demonstrated 2x3 cm hemorrhage lesion concerning for
underlying mass. pt was then transferred to [**Hospital1 18**].
Past Medical History:
PAST MEDICAL HISTORY:
DM, HTN, HL, CAD
MS: dx 10 yrs ago by Dr. [**Last Name (STitle) 76767**] in [**Location (un) **]. has not followed
up 2/2 insurance reasons. baseline wheel chair bound
hx of trigeminal neuralgia on left
Social History:
SOCIAL HISTORY:
lives with wife in [**Name (NI) **]. >10 PPD tob hx (stopped in [**2114**]). no
EtOH, no IVDA. used to be attendent for handicapped individual
before MS diagnosis
Family History:
FAMILY HISTORY:
no HTN, no CA
Physical Exam:
EXAM
VS: T 97 HR 88 BP 153/92 RR 16 Sat 95 % on 2L NC
PE: General NAD
HEENT AT/NC, MMM no lesions
Neck Supple, no bruits
Chest CTA B
CVS RRR, no m/r/g
ABD soft, NTND, + BS
EXT no C/C/E, no rashes or petechiae
NEUROLOGICAL
MS: waxes/wanes with intermittent confusion most likely from
decadron,
cooperative, following commands.
General: alert,interactive
Orientation: waxes/wanes, mostly oriented to person, place,
date, situation
Speech/[**Doctor Last Name **]: fluent w/o paraphasic errors but with slow
responses; simple
and complex command-following w/o L/R
confusion. Repetition, naming intact. perseverative "i don't
want to talk to psychiatry"
Calculations: 7 quarters = $1.75
CN:
II,III: difficulty keeping eyes open, VFFTC, pupils 4-2 mm
bilaterally to light, optics discs sharp and flat
III,IV,V: EOMI, eyelids half mast. Normal saccades/pursuits
V: sensation decreased on left
VII: Facial strength decreased on left, decreased nasolabial
fold
VIII: hears finger rub bilaterally
IX,X: voice slightly thickened, palate elevates symmetrically
[**Doctor First Name 81**]: SCM/trapezeii [**5-5**] bilaterally
XII: tongue protrudes midline without atrophy or fasciculation
Motor: Normal bulk and tone in UE. decreased tone in LE.
occasional faciculations of LE bilaterally
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
R 5 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
2 4- 4- 4 4 5-
Reflex:
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 4+/clonus Extensor
R 2 2 2 2 4+ clonus Extensor
Sensation: No extinction of DSS.
Coordination: Finger-nose-finger without dysmetria on R
Gait: not testing
Pertinent Results:
Color
Yellow Appear
Clear SpecGr
1.020 pH
6.5 Urobil
1 Bili
Neg
Leuk
Sm Bld
Lg Nitr
Neg Prot
Tr Glu
Neg Ket
Tr
RBC
[**11-20**] WBC
21-50 Bact
Many Yeast
None Epi
0
CTA w/wo contrast [**2153-12-19**]
IMPRESSION:
1. Unchanged 3-cm right frontal intraparenchymal hematoma with
surrounding vasogenic edema, without evidence of feeding artery
or draining veins suggestive of AVM or AVS.
2. No significant abnormality in intracranial anterior and
posterior circulation.
3. Atherosclerotic disease of the bilateral carotid arteries and
right vertebral artery.
4. Small left vertebral artery with no flow in V3 and V4
segment, suggestive of prior dissection or occlusion . Further
evaluation by MRA or CTA of the neck is recommended on
outpatient basis.
5. Extensive sinus disease with prior endoscopic surgery and
sinus-nasal polyposis.
IMAGING:
CT brain: 1. 2.9-cm right frontal intracranial hemorrhage,
likely related to underlying mass lesion with small component of
subarachnoid hemorrhage. There is moderate surrounding edema
and
minimal mass effect.
2. Evidence of prior infarction in the left occipital lobe.
3. Moderate cranial atrophy.
4. Evidence of prior left occipital craniotomy.
5. Extensive sinonasal polyposis.
CTA with contrast: Hemorrhagic mass in right high frontal lobe
is
unchanged in appearance - no tangle of vessels to suggest an
AVM.
Major vessels of COW patent.
[**12-26**]
IMPRESSION: No pathologic ehnacement with stable right frontal
parenchymal hemorrhage and decreased right subarachnoid
hemorrhage since [**2153-12-20**].
[**2153-12-28**] 06:20AM BLOOD WBC-7.6 RBC-4.19* Hgb-13.6* Hct-39.8*
MCV-95 MCH-32.5* MCHC-34.2 RDW-13.6 Plt Ct-297
[**2153-12-28**] 06:20AM BLOOD WBC-7.6 RBC-4.19* Hgb-13.6* Hct-39.8*
MCV-95 MCH-32.5* MCHC-34.2 RDW-13.6 Plt Ct-297
[**2153-12-28**] 06:20AM BLOOD PT-13.8* PTT-26.1 INR(PT)-1.2*
[**2153-12-28**] 06:20AM BLOOD Plt Ct-297
[**2153-12-28**] 06:20AM BLOOD Glucose-116* UreaN-22* Creat-1.1 Na-142
K-3.6 Cl-108 HCO3-23 AnGap-15
[**2153-12-28**] 06:20AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
[**2153-12-28**] 06:20AM BLOOD Carbamz-4.3
[**2153-12-28**] 06:20AM BLOOD Phenyto-9.0*
Brief Hospital Course:
69 yo male with MS, HTN, DM, HL who presents with R frontal
hemorrhage, with concern for underlying mass. He was admitted to
the ICU for 72 hours followed with serial head CTs and CTA that
did not show any source for the bleed.
On [**2153-12-21**] patient underwent a R frontal mass biopsy, pathology
prelimary showed reactive tissue no tumor however at this
writing the pathology is not completely confirmed.
Post-operatively he had slight confusion, which improved over a
couple of days. On [**2153-12-28**] he is alert and oriented x 3,
reports leg pain with prolonged sitting in one position. Pain is
controlled when repositioned and also with oral pain meds
Mr. [**Known lastname **] diet was advanced and pt tolerated diet well, he
is voiding without any difficulties.
His exam remains stable - his right upper extremity motor is
full, [**5-5**]; he does not have any movement in left upper
extremity, and no movement in bilateral lower extremities. His
dysarthia is slowly improving. His staples were removed on
discharge the site was clean and dry no redness.
Mr. [**Known lastname 4223**] will follow up with Dr. [**Last Name (STitle) **] in two weeks. Pt and
significant other agrees with plan.
Medications on Admission:
MEDICATIONS:
metformin 1000 [**Hospital1 **]
simvastatin 20 QD
amiodarone 200 QD
metoprolol 50 [**Hospital1 **]
neurontin 300 QID
tegretol 200 QID
avandia 8 mg QD
lisinopril 10 QD
lasix 20 QD
flovent 110 mcg [**Hospital1 **]
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QID (4
times a day).
5. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Please use stool softeners as long as
you use pain meds.
Disp:*60 Tablet(s)* Refills:*0*
11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
13. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2)
Capsule PO BID (2 times a day).
14. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO every
eight (8) hours for 1 days: three tablests every eight hours on
[**2153-12-28**]; use two tablest every eight hours [**Date range (3) 76768**];
use 1 tablet every eight hours [**2153-12-31**] - [**2154-1-1**], then stop.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
R frontal hemorrhage
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a 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,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? 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
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 2 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITH CONTRAST
Completed by:[**2153-12-28**]
ICD9 Codes: 431, 5990, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7931
} | Medical Text: Admission Date: [**2103-10-26**] Discharge Date: [**2103-10-31**]
Date of Birth: [**2054-2-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Fatigue, palpitations
Major Surgical or Invasive Procedure:
[**2103-10-26**] Aortic Valve Replacement(25mm St. [**Male First Name (un) 923**] mechanical
valve), with Maze Procedure and Ligation of Left Atrial
Appendage
History of Present Illness:
This is a 49 year old gentleman with longstanding history of
heart murmur who has been followed with serial echocardiograms
for aortic insufficiency. Recent echocardiograms revealed that
his aortic insufficiency has now become severe. He also has
atrial fibrillation which he has had since [**2102-5-18**]. His
symptoms include palpitations and fatigue.
Past Medical History:
Aortic insufficiency
Atrial fibrillation
Non-ischemic cardiomyopathy
Hypertension
Hyperlipidemia
s/p Right wrist surgery following MVA 30 yrs. ago
Social History:
Last Dental Exam: 2 years ago
Lives with: alone
Occupation: manufacturing- industrial floors and plastics
Cigarettes: Smoked no [X] yes [] Hx:
Other Tobacco use:
ETOH: < 1 drink/week [] [**12-25**] drinks/week [] >8 drinks/week [X]
30 pack of beer per week
Illicit drug use: Denies
Family History:
Denies premature coronary artery disease. Father died at 69 with
renal failure and hypertension. Mother died at 69 with
Rheumatoid Arthritis
Physical Exam:
General: NAD, anxious, slightly slow to respond
Skin: Dry [X] intact [X] numerous tattoos
HEENT: PERRLA [] EOMI [X] left round and reactive, right is
sluggish
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [] Irregular [X] Murmur [] grade - not appreciated
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None
Neuro: Grossly intact [X]
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: none
Pertinent Results:
[**2103-10-26**] Intraop TEE
PRE-CPB: 1. The left atrium is moderately dilated. The left
atrial appendage emptying velocity is depressed (<0.2m/s). No
thrombus is seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is mildly dilated. Overall left
ventricular systolic function is moderately depressed (LVEF= 30
%).
4. Right ventricular chamber size and free wall motion are
normal.
5. The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is a possible
vegetation on the RCC. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. Moderate to severe (3+) aortic regurgitation is seen.
7. Mild (1+) mitral regurgitation is seen.
POST-CPB: On infusion of epi, phenylephrine. AV pacing for sinus
bradycardia. Well-seated mechanical valve in the aortic position
with trivial paravalvular leak, most likely representing suture
gaps and most of which resolving post protamine dose. Preserved
biventricular systolic function on inotropic support. LVEF is
now 40%. MR remains 1+. Aortic contour is normal post
decannulation.
[**2103-10-31**] 05:38 Hematocrit 27.3* 40 - 52 %
[**2103-10-31**] 05:38 PT/INR: 27.7*1 2.7*
[**2103-10-30**] 06:56AM BLOOD WBC-8.3 RBC-3.02* Hgb-9.5* Hct-28.2*
MCV-93 MCH-31.7 MCHC-33.9 RDW-15.1 Plt Ct-164#
[**2103-10-29**] 05:15AM BLOOD WBC-8.9 RBC-2.93*# Hgb-9.3*# Hct-27.0*
MCV-92 MCH-31.8 MCHC-34.6 RDW-15.2 Plt Ct-91*
[**2103-10-28**] 06:10AM BLOOD WBC-7.6 RBC-2.31* Hgb-7.3* Hct-21.9*
MCV-95 MCH-31.5 MCHC-33.2 RDW-14.5 Plt Ct-61*
[**2103-10-30**] 08:40AM BLOOD PT-19.7* PTT-63.5* INR(PT)-1.9*
[**2103-10-30**] 06:56AM BLOOD PT-19.8* PTT-61.9* INR(PT)-1.9*
[**2103-10-29**] 05:15AM BLOOD PT-16.7* INR(PT)-1.6*
[**2103-10-28**] 06:10AM BLOOD PT-18.0* INR(PT)-1.7*
[**2103-10-27**] 01:10AM BLOOD PT-14.6* PTT-31.1 INR(PT)-1.4*
[**2103-10-26**] 01:11PM BLOOD PT-14.5* PTT-32.8 INR(PT)-1.4*
[**2103-10-26**] 12:03PM BLOOD PT-18.6* PTT-32.2 INR(PT)-1.8*
Brief Hospital Course:
Mr. [**Known lastname 10010**] was admitted and underwent a mechanical aortic valve
replacement along with Maze procedure and ligation of left
atrial appendage. For surgical details, please see operative
note. Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. He maintained stable
hemodynamics and transferred to the SDU on postoperative day
one. He was transfused with packed red blood cells to maintain
hematocrit near 30%. Chest tubes and pacing wires were removed
per protocol without complication. Warfarin anticoagulation was
started for mechanical aortic valve replacement and atrial
fibrillation. Warfrin was dosed daily and titrated for goal INR
between 2.5 to 3.5. He went into a rapid atrial fibrillation to
the 160's on POD3. His Lopressor was increased, boluses with
Amiodarone and placed on a drip. Lisinopril was added for
hypertension management. His rhythm at the time of discharge was
his basline afib. He did have some minimal sternal drainage but
WBC was normal and he was afebrile so no antibiotics were
started. Prior to discharge, arrangements were made with [**Hospital1 **] [**Hospital 197**] Clinic to monitor his PT/INR as an outpatient.
Again, his goal INR is between 2.5 to 3.5. (Fax [**Telephone/Fax (1) 91209**]On
POD #5 his INR was therapuetic, he was ambulating without
difficulty, tolerating a full oral diet and his incision was
drainging very scant amounts of old bloody drainage. He was
discharged home with VNA services and all follow up arrangements
were arranged.
Medications on Admission:
ATENOLOL 100 mg once a day
DIGOXIN 125 mcg once a day
DILTIAZEM HCL 120 mg once a day
FUROSEMIDE 40 mg once a day
LISINOPRIL 20 mg once a day
SIMVASTATIN 20 mg once a day bedtime
ASPIRIN 325 mg once a day
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
take 400mg for 7 days then change to 200mg daily until advised
to stop.
Disp:*60 Tablet(s)* Refills:*2*
9. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 7 days.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
12. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
13. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: dose
based on INR goal 2.5-3.5.
Disp:*60 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication Mechanical AVR
Goal INR 2.5-3.5
First draw [**2103-11-1**]
Results to [**Hospital3 **] [**Hospital 197**] Clinic Fax [**Telephone/Fax (1) 91209**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Insufficiency
Atrial Fibrillation
Non-ischemic Cardiomyopathy
Hypertension
Dyslipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema and scant bloody drainage
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] on [**2102-12-4**] at 1:00 PM in the [**Hospital **] medical
office building , [**Doctor First Name **] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2102-12-3**] at 2:00 PM
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3373**] in [**2-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Mechanical AVR
Goal INR 2.5-3.5
First draw [**2103-11-1**]
Results to [**Hospital3 **] [**Hospital 197**] Clinic Fax [**Telephone/Fax (1) 91209**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2103-11-2**]
ICD9 Codes: 4241, 4254, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7932
} | Medical Text: Admission Date: [**2169-9-25**] Discharge Date: [**2169-9-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88 year old female with questioned history of renal artery
stenosis and hypertension, presents with shortness of breath.
The patient went to the bathroom this morning and felt short of
breath. It seemed to improve with rest, but then occurred again
soon after, and she called 911. She denies any chest pain or
pressure, dizziness, or changes in vision during that time. In
the ED her blood pressure was found to be 206/107, HR of 120,
with O2Sa of 88% on RA. She was placed on Bipap with good
results. Lasix 80mg IV was given, morphine 2mg x2 and a nitro
drip was started. There were questioned ST depressions in V4-V6;
cardiology was consulted and believed they were rate related
changes. Troponin was 0.05 and CK-MB of 3.
.
Patient was brought to the CCU with a BP of 135/57 and O2Sa of
97% on 4L NC. In the CCU, patient stated much improved shortness
of breath and denied chest pain. She had no vision changes or
lightheadedness. She denies any recent changes in her
medications, has been taking them as prescribed except for her
clonidine patch which she has not had since Thursday [**2169-9-21**] but
has supplemented with clonidine PO. Denies recent change in her
diet. She denies nausea, vomiting, change in appetite, fevers,
chills, or dysuria.
.
Patient was admitted in [**Month (only) **] at [**Hospital1 2025**] for similar symptoms.
Patient had very elevated BP while at a physicians office,
became dyspnic and was admitted to the ICU with flash pulmonary
edema. She was intubated for 2 days during that stay. Patient
also has history of renal artery stenosis diagnosed
approximately one year ago, although ultrasound done in [**Month (only) **] did
not show any evidence of stenosis.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope. Patient does have baseline level of edema on her
lower extremities R>L, and there has been no change recently.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY: No history of MI
3. OTHER PAST MEDICAL HISTORY:
Hypertension (up to SBP211 on clinic visit on
CRI (baseline 1.5-1.7)
?Renal Artery Stenosis (L 60-90%)
Hypothyroidism, s/p thyroidectomy
Hip dislocation as child with subsquent growth defect in
effected leg
Thrombocytosis
Admission in [**2169-8-1**] at [**Hospital1 2025**] for hypertensive urgency with
pulmonary edema and respiratory distress requiring intubation
Social History:
Occupation: Retired
Drugs: na
Tobacco: distant history
Alcohol: na
Other: Lives in [**Location **], manages all ADLs, retired secretary,
widowed.
Family History:
No known family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
GENERAL: WDWN ** in NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. No evidence of flame
hemorrhage. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm. Right external jugular vein line
CARDIAC: PMI located in 5th intercostal space, lateral
clavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. Diffuse
wheezes with rales at the bases. Decreased breath sounds
particularly at the bases bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ pedal on the left, 2+ on the right. Left leg
shorter than the right. No femoral bruits.
SKIN: Some mild erythematous change on the right shin, no change
per patient
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Neuro: CNII-XII intact, stregnth equal bilaterally, no gross
sensory deficits
Pertinent Results:
[**2169-9-25**] 09:30AM BLOOD WBC-13.9* RBC-3.15* Hgb-8.7* Hct-28.1*
MCV-89 MCH-27.8 MCHC-31.1 RDW-17.8* Plt Ct-417
[**2169-9-26**] 02:14AM BLOOD WBC-6.7# RBC-2.94* Hgb-8.3* Hct-25.3*
MCV-86 MCH-28.1 MCHC-32.7 RDW-17.8* Plt Ct-323
[**2169-9-27**] 06:15AM BLOOD WBC-5.4 RBC-2.82* Hgb-8.1* Hct-24.3*
MCV-86 MCH-28.8 MCHC-33.4 RDW-17.3* Plt Ct-301
[**2169-9-28**] 06:45AM BLOOD WBC-3.8* RBC-2.53* Hgb-7.1* Hct-21.9*
MCV-86 MCH-28.1 MCHC-32.5 RDW-17.4* Plt Ct-364
.
[**2169-9-25**] 09:30AM BLOOD Neuts-84.9* Lymphs-7.3* Monos-6.8 Eos-0.4
Baso-0.6
[**2169-9-26**] 12:50PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
.
[**2169-9-25**] 09:30AM BLOOD PT-11.9 PTT-22.2 INR(PT)-1.0
[**2169-9-26**] 12:20PM BLOOD Fibrino-613*
[**2169-9-26**] 12:50PM BLOOD Ret Aut-2.4
.
[**2169-9-25**] 09:30AM BLOOD Glucose-267* UreaN-58* Creat-1.8* Na-135
K-6.6* Cl-96 HCO3-27 AnGap-19
[**2169-9-25**] 04:38PM BLOOD Glucose-109* UreaN-60* Creat-2.1* Na-139
K-5.3* Cl-98 HCO3-30 AnGap-16
[**2169-9-26**] 02:14AM BLOOD Glucose-101* UreaN-61* Creat-2.0* Na-139
K-4.4 Cl-97 HCO3-29 AnGap-17
[**2169-9-27**] 06:15AM BLOOD Glucose-95 UreaN-65* Creat-1.7* Na-138
K-4.1 Cl-98 HCO3-33* AnGap-11
[**2169-9-28**] 06:45AM BLOOD Glucose-96 UreaN-72* Creat-1.9* Na-139
K-4.3 Cl-100 HCO3-33* AnGap-10
.
[**2169-9-25**] 04:38PM BLOOD CK(CPK)-99
[**2169-9-26**] 02:14AM BLOOD CK(CPK)-95
[**2169-9-25**] 09:30AM BLOOD CK-MB-3 proBNP-[**Numeric Identifier 19353**]*
[**2169-9-25**] 09:30AM BLOOD cTropnT-0.05*
[**2169-9-25**] 04:38PM BLOOD CK-MB-5 cTropnT-0.10*
[**2169-9-26**] 02:14AM BLOOD CK-MB-4 cTropnT-0.06*
.
[**2169-9-25**] 09:30AM BLOOD Calcium-8.0* Phos-6.0* Mg-2.7*
[**2169-9-25**] 04:38PM BLOOD Calcium-8.4 Phos-5.1* Mg-2.7*
[**2169-9-26**] 02:14AM BLOOD Calcium-8.3* Phos-5.3* Mg-2.6
[**2169-9-26**] 12:20PM BLOOD Iron-13*
[**2169-9-27**] 06:15AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.6
[**2169-9-28**] 06:45AM BLOOD Calcium-7.6* Phos-4.6* Mg-2.5
.
[**2169-9-26**] 12:20PM BLOOD calTIBC-230* Hapto-154 Ferritn-135
TRF-177*
[**2169-9-25**] 09:30AM BLOOD %HbA1c-6.3* eAG-134*
.
[**2169-9-25**] 09:30AM BLOOD TSH-0.77
[**2169-9-25**] 09:56AM BLOOD Glucose-254* K-4.8
.
[**2169-9-25**] 1:35 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2169-9-28**]**
MRSA SCREEN (Final [**2169-9-28**]): No MRSA isolated.
.
[**2169-9-25**] 08:15AM URINE RBC-[**4-14**]* WBC-0-2 Bacteri-0 Yeast-NONE
Epi-0-2 TransE-0-2
[**2169-9-25**] 08:15AM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2169-9-25**] 08:15AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
.
ECG [**9-25**] 0739
Sinus tachycardia. Left atrial abnormality. Left ventricular
hypertrophy.
Non-specific QRS widening and diffuse non-diagnostic
repolarization
abnormalities. No previous tracing available for comparison.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
131 118 112 296/420 74 0 116
.
ECG [**9-25**] 1300
Sinus rhythm. Compared to the previous tracing deep T wave
inversion in the
anterior precordial leads is now present. Heart rate is now
reduced.
TRACING #3
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
73 148 108 426/448 48 -3 5
.
Chest Xray [**9-26**] 0745
AP UPRIGHT RADIOGRAPH OF THE CHEST: There has been marked
interval
improvement in the parenchymal aeration suggesting improving
pulmonary edema.
There is mild residual, right greater than left. Retrocardiac
consolidation
is either atelectasis or pneumonia. There are small bilateral
pleural
effusions.
Marked kyphoscoliosis of the thoracolumbar spine and related DJD
is noted.
There is a moderate-sized cardiac enlargement with dense
atherosclerotic
aortic calcifications. Surgical clips are seen in the neck.
IMPRESSION:
1. Improving parenchymal aeration with mild residual pulmonary
edema and
small bilateral pleural effusions.
2. LLL atelectasis and/or pneumonia.
Brief Hospital Course:
#Hypertensive Urgency: Patient had similar episode in [**Month (only) **] or
[**Month (only) 205**] with hypertensive urgency and flash pulmonary edema, but
little support for RAS. Likely similar etiology to current
shortness of breath and pulmonary edema. BP responded quickly to
nitro drip. Will maintain blood pressure at 140s, as patient's
baseline is in 170s and if decreased too quickly may get
decreased perfusion. Patient shows no obvious end organ damage
of the hypertension. No change in mental status, no vision
changes or neurologic deficits, creatinine close to baseline.
Patient has history of hypertension with evidence of LVH. Likely
etiology of exacerbation of essential hypertension appears to be
transition from clonidine patch to po. Unknown if PO dose was
adequate or if pt was taking medication properly. Possible
rebound hypertension in setting of inappropriate clonidine
dosing. No recent change in diet.
Pt has a questionable history of renal artery stenosis per OSH
records, however ultrasound in [**Month (only) **] was negative and per
nephrologist, he does not believe she has RAS. Given conflicting
record, would prefer not to start an ACEi. TSH was normal. BPs
well controlled morning after admission with home medication
regimen, no longer requiring nitro gtt. She was started on
Amlodipine, metoprolol succinate, and continued on the clonidine
patch. Hydralazine was discontinued for lack of ease of
administration.
.
#Pulmonary Edema: Acute elevation of BP decreasing forward flow,
likely caused flash pulmonary edema; similar to previous episode
in [**Month (only) **]. Denies chest pain, cardiac enzymes negative (troponin
minimally elevated in setting of CRI), perfusion scan on [**2169-8-7**]
was normal. Does have some EKG changes possibly suggestive of
ischemia, although more likely related to LV strain. Symptoms of
SOB have improved and patient appears less volume overloaded
than on admission after over 2L negative. O2Sa stable on 3L NC.
CXR questioned possible pneumonia in right lobe on [**2169-9-25**], but
afebrile and no history of cough, leukocytosis has resolved. CXR
this morning does not show opacity in RUL and improved vascular
congestion. Clinical picture appears to coincide with pulmonary
edema secondary CHF and proBNP elevated to [**Numeric Identifier 19353**]; however, will
monitor for signs of infection. No further diuresis will be done
today as patient had good response yesterday, is a petite women,
and will begin to mobilize fluid into her vasculature.
.
# CRI - Baseline creatinine of 1.5-1.7. Mildly elevated to 1.8
upon admission and up to 2.1 today. Will continue to monitor and
should improve with improved forward flow. Also has proteinuria
on UA. Could be secondary to hypertensive nephropathy, HbA1c at
6.3%. Pt will follow with her outpatient nephrologist who was
contact[**Name (NI) **] during her admission.
.
# Anemia - Patient has baseline Hct in high 20s, however did
decrease to 23.8 this AM. No obvious source of bleeding, guiac
negative, no abdominal complaints, no hematuria. Patient had
similar decrease in Hct during previous admission for similar
episode. [**Month (only) 116**] be secondary to dilution as increase mobilization
of fluid into vasculature. Microangiopathic hemolytic anemia can
be seen with hypertensive urgency, however less likely. Anemia
will be followed as outpatient by heme.
.
#Hypothyroidism: If over treated with medication, could cause
hypertensive urgency. Will continue current synthroid dose. TSH
normal.
.
# Thrombocytosis - has been treated with anagrelide. Will
continue anagrelide
.
#Diabetes Mellitus: questioned history of DM with previous HbA1c
at 7, it is 6.5% here. Monitor as an outpatient.
Medications on Admission:
Metoprolol 75mg PO BID
Vit D 800 daily
Hydralazine 10mg PO QID
Anagrelide 1mg PO BID
Clonidine Patch 0.3mg/24hrs transdermal qweek
Lasix 20mg daily
Synthroid 88mcg daily
Metronidazole cream. 0.75% [**Hospital1 **] to affected area
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
Disp:*4 Patch Weekly(s)* Refills:*2*
2. Outpatient Lab Work
Please check chem 7 and CBC on [**2169-10-2**] and call results to [**First Name8 (NamePattern2) 717**]
[**Last Name (NamePattern1) **] or Dr. [**Last Name (STitle) 19354**] at [**Telephone/Fax (1) 19355**]
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Hold for loose stools.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a
day.
12. Metronidazole 0.75 % Cream Sig: One (1) application Topical
as directed.
13. Anagrelide 1 mg Capsule Sig: One (1) Capsule PO twice a day:
Please check with the previously prescipbing physician for [**Name Initial (PRE) **]
refill.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Hypertensive urgency
Flash Pulmonary Edema
Chronic Renal Insufficiency
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had another episode of hypertensive urgency that led to
fluid backing up into your lungs. We think this is because you
had trouble with your medicines at home. We have now simplified
your medicine regimin after talking with Dr. [**Last Name (STitle) 19356**].
Medication changes:
1. Stop taking Hydralazine
2. start taking Amlodipine (Norvasc) to treat your high blood
pressure
3. Continue taking your clonidine patch, you have a new
prescription for this.
4. Increase the Metoprolol to 200 mg once a day (NOT twice a
day)
5. Start taking Iron (ferrous sulfate) to treat your anemia with
colace to prevent constipation
6. The visiting nurses can check labs on [**10-3**] so that [**First Name8 (NamePattern2) 717**]
[**Last Name (NamePattern1) **] NP has the information when she sees you on [**10-4**].
7. Start aspirin daily (take chewable baby aspirin)
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 19354**] if weight goes
up more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Name: NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital3 **] [**Hospital3 **]
Address: [**Age over 90 19357**], [**Location (un) **],[**Numeric Identifier 19358**]
Phone: [**Telephone/Fax (1) 19355**]
Appointment: Wednesday [**2169-10-4**] 11:20am
We are working on a follow up appointment in Nephrology with Dr.
[**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 19356**] within 16-30 days. The office will contact you at
home with an appointment. If you have not heard or have any
questions please call [**Telephone/Fax (1) 10574**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7933
} | Medical Text: Admission Date: [**2177-4-2**] Discharge Date: [**2177-4-7**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 81-year-old woman
with a history of AFib that has been difficult to rate
control, who is scheduled for elective pacemaker placement
and AVJ ablation on day of admission. After completion of
pacemaker placement, patient's blood pressure dropped to
50/palpable. Volume resuscitation was begun and
echocardiogram showed a large effusion with tamponade.
Emergent pericardiocentesis was 300 cc of frank blood and
improved blood pressure.
Blood pressure decreased again and another 400 cc blood was
pulled off. Pacing wire was repositioned successfully in the
right ventricle and pacer was set at DDD at 90.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypothyroidism.
3. Hypercholesterolemia.
4. Atrial fibrillation.
5. Atrial flutter.
6. Status post right atrial isthmus ablation in summer of
[**2175**]. Was on amiodarone, but discontinued secondary to
nausea and headache. Status post several admissions with
AFib with RVR with rates in the 160s. Referred for pacer and
AVJ ablation. Stress echocardiogram in [**2175-4-17**] showed
an ejection fraction of 65%, mild AS and AI, mild MR [**First Name (Titles) **] [**Last Name (Titles) **].
ALLERGIES: Amiodarone causes headache and nausea.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 b.i.d.
2. Univasc 15 mg q.d.
3. Lescol 80 mg p.o. q.d.
4. Cartia 120 mg p.o. b.i.d.
5. Coumadin.
6. Levoxyl 75 mg p.o. q.d.
7. Vitamin E.
8. Vitamin C.
9. Calcium.
10. Magnesium citrate.
11. Calcium citrate.
FAMILY HISTORY: Negative for diabetes and otherwise
noncontributory.
SOCIAL HISTORY: Denies drugs, tobacco, and alcohol. Lives
in [**Location **] with friend.
PHYSICAL EXAM ON ADMISSION: Temperature 97.3, blood pressure
120/59, heart rate 90, respiratory rate 16, and sats 100% on
room air. Height is 5'5.5", weight 128 pounds. HEENT was
moist mucous membranes. Clear oropharynx. Neck was supple.
Jugular venous pressure is 6 cm. Cardiovascularly: S1, S2
with a 2/6 systolic ejection murmur at the right upper
sternal border, and pericardial drain that was clean, dry,
and intact. Lungs were clear to auscultation bilaterally.
Abdomen was soft, nontender, and nondistended, positive bowel
sounds. Extremities: No cyanosis, clubbing, or edema.
Neurologic examination: Awake, alert, and oriented times
three. Cranial nerves II through XII are grossly intact.
Intact strength and motor function, normal sensation. Skin:
No rashes or lesions.
LABORATORIES ON ADMISSION: White count 16.1, hematocrit
30.4, platelets 222. Potassium 4.2, creatinine 0.7, INR 1.3,
PTT 25.1.
Echocardiogram at 11:18 on day of admission showed
moderate-to-large sized pericardial effusion with RV
diastolic collapse. This is impaired filling and tamponade
physiology. At 11:21 a.m. status post pericardiocentesis,
just trivial physiologic pericardial effusion.
HOSPITAL COURSE: This was an 81-year-old woman with a
history of atrial fibrillation, atrial flutter, status post
right atrial isthmus ablation in the summer of [**2175**] admitted
for pacer placement. Procedure complicated by RV perforation
requiring pericardiocentesis with removal of 700 cc of blood.
1. Hemorrhagic pericardial effusion with tamponade: Patient's
drain output
continued to decline and patient's drain was eventually
removed with good results. Patient remained hemodynamically
stable. She got 2 units of packed red blood cells in the
Cath Lab, but was otherwise stable. Patient had follow-up
echocardiogram with no recurrence of the effusion even after
Coumadin was removed. Plans were to stay off Coumadin for at
least one month secondary to this bleed.
Otherwise, patient was started on Ancef 1 gram q.8 initially
and then titrated off.
2. Atrial fibrillation: Patient continued to have episodes
of tachycardia. Patient was continued on her outpatient
regimen eventually and titrated up as tolerated. Patient's
diltiazem dose was titrated up to 180 b.i.d. at time of
discharge. Her atenolol at her home b.i.d. dose regimen was
titrated up to 50 mg b.i.d. Patient was started on aspirin
to which she is to continue especially while she is off
Coumadin. Otherwise, patient was doing well and was planned
for EP study as an outpatient. Patient will follow up with
[**Hospital **] Clinic, on [**4-9**] for Device Clinic and then will
return on [**4-29**] for AVJ ablation.
3. Pneumothorax: Patient had a small pneumothorax after her pacer
placement. Leads were in place and pneumothorax had resolved by
the time of dischar ge on follow-up chest x-ray.
3. Hypothyroidism: The patient was continued on her home
dose of Levoxyl. Patient's TSH was elevated, but her free T4
was in the normal range, and this was likely secondary to
subacute hypothyroid picture. No changes were made during
this acute setting.
DISCHARGE DIAGNOSES:
1. Right ventricle perforation.
2. Atrial fibrillation.
3. Atrial flutter.
4. Hypertension.
5. Hypothyroidism.
6. Pericardial effusion and tamponade.
7. Pneumothorax.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. once a day.
2. Atenolol 50 mg p.o. b.i.d.
3. Diltiazem extended release 180 mg p.o. b.i.d.
4. Ascorbic acid 500 mg p.o. b.i.d.
5. Vitamin E 400 units p.o. q.d.
6. Levothyroxine 75 mcg p.o. q.d.
DISCHARGE CONDITION: Good. Patient is ambulating without
difficulty. Chest pain free at present, no oxygen
requirement.
DISCHARGE STATUS: Discharged to home with followup.
FOLLOW-UP INSTRUCTIONS: The patient is to see her PCP [**Last Name (NamePattern4) **] [**1-17**]
weeks. Patient is to followup in Device Clinic on [**4-9**]
at 9:30 and then for return on [**2177-4-29**] for an AVJ
ablation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2177-4-7**] 13:50
T: [**2177-4-8**] 08:58
JOB#: [**Job Number 26913**]
ICD9 Codes: 9971, 4019, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7934
} | Medical Text: Admission Date: [**2120-12-11**] Discharge Date: [**2120-12-17**]
Date of Birth: [**2045-6-11**] Sex: F
Service: CARDIOTHOR
HISTORY OF THE PRESENT ILLNESS: This is a 75-year-old
Portuguese-speaking female with known history of aortic
stenosis seen by the primary care practitioner [**First Name (Titles) **] [**Last Name (Titles) 37566**].
TTE was consistent with critical aortic stenosis. The
patient denies angina, TIAs, syncope, or claudication. There
is no history of orthopnea, paroxysmal nocturnal dyspnea, or
lower extremity edema. Cardiac catheterization revealed
critical aortic stenosis with atrial valve area of .4-cm
squared and mild three-vessel coronary artery disease.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Hiatal hernia.
ALLERGIES: The patient is allergic to FLU SHOTS.
PHYSICAL EXAMINATION: Examination revealed the patient to be
afebrile, vital signs were stable. LUNGS: Lungs were clear.
HEART: Regular rate and rhythm, 3/6 systolic murmur.
ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: No
edema; palpable pulses.
SUMMARY OF HOSPITAL COURSE: The patient was brought to the
operating room on [**2120-12-12**]. The procedure performed
was an AVR and CABG times three. A 19-mm pericardial CE
valve was placed. The saphenous vein graft went to LAD, PDA,
and OM. CVP was 189 minutes, XCL 150 minutes. The
pericardium was left open. A Swan-Ganz catheter was placed.
Two atrial and ventricular wires along with two mediastinal
and one pleural tube were also placed. The patient had an
episode of ventricular fibrillation coming off pump and,
therefore, an amioardone drip was started. In the ICU the
patient was rapidly extubated and the Levo drip was weaned.
On postoperative day #1 the patient was observed in the ICU
and stable. On postoperative day #2, she was transferred to
the floor. On postoperative day #3, due to a low hematocrit,
two units of packed red blood cells were given. She also had
a run of atrial fibrillation on postoperative day #3 for
which she was started on oral Amiodarone. Due to a low
output from the pleural and mediastinal tubes, they were
removed. On postoperative day #4, the patient was tolerating
p.o. diet well. The Foley catheter was removed. On
postoperative day #5, the patient was stable for discharge to
rehabilitation. Wires were also removed.
LABS ON DISCHARGE: Laboratory data revealed the following:
White count 176, hematocrit 28.7, platelet count 172,000,
sodium 139, potassium 4.6, chloride 105, bicarbonate 27, BUN
20, creatinine .8, glucose 103, calcium 1.11, magnesium 2.0,
and phosphorus 3.1.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg b.i.d. times seven days.
2. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mg b.i.d. times seven days.
3. Enteric coated Aspirin 325 mg q.d.
4. Captopril 50 mg t.i.d.
5. Lipitor 10 mg q.d.
6. Lopressor 25 mg b.i.d.
7. Amiodarone 400 mg t.i.d. times two days; 400 mg b.i.d.
times seven days; 400 mg q.d. times 14 days.
8. Percocet one to two tablets, q. 4 to 6h.p.r.n.
9. Colace 100 mg b.i.d.
DISCHARGE STATUS: The patient is discharged to a
rehabilitation facility.
FOLLOW-UP CARE: The patient will follow up with the primary
care provider or cardiologist in three weeks. The patient
will followup with Dr. [**Last Name (STitle) 1537**] in four weeks.
DIAGNOSIS: Status post coronary artery bypass graft times
three/AVR.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2120-12-17**] 10:13
T: [**2120-12-17**] 10:16
JOB#: [**Job Number 37567**]
ICD9 Codes: 4241, 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7935
} | Medical Text: Admission Date: [**2163-2-14**] Discharge Date: [**2163-2-16**]
Date of Birth: [**2111-11-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides) / Tape / Ativan / Aloe / Dilantin
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Headache and Visual Disturbance
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 51 year old female with metastatic melanoma to
brain well known to our service who presented [**Hospital3 3583**]
with headache and visual disturbance but otherwise GCS 15. She
had a Head CT which was consistent with large right parietal
intraparencymal hemorhage and 7 mm midline shift. She was
intubated for transfer and transferred here for further care.
Past Medical History:
- Malignant melanoma w/ metastases to brain s/p ICH evacuation
and IP shunt placement for hydrocephalus
- Graves' disease s/p Tapazole treatment 13yrs ago
- cervical dysplasia s/p LEEP
- s/p resection of melanoma from left lower back
- s/p resection of intradermal melanocytic nevus from left
lateral chest wall
Social History:
Previous smoker 28 pack years, recently quit. Social alcohol.
Denies illicit drug use. No pets, currently living with her
mother and working as a buyer for [**Name (NI) 9400**] NY. Never married.
Family History:
Father with carotid stenosis and history of CVA
x2, age 78. Mother age 68 and healthy. Brother, age 50,
healthy. No known early CAD or cancer history.
Physical Exam:
On Admission:
O: T: 97.7 BP: 107/63 HR:119 R: 19 O2Sats100% on ventilator
assist control
BASIC COAGULATION ( PT, PTT, PLT, INR)
[**2163-2-14**] 12.2 26 387 1
Gen: intubated and sedated
HEENT: Pupils: 3.5-3 EOMs:pt unable to perform
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status/Orientation: GCS 10T/eyes-3,motor-6 verbal-1T
Recall: pt intubated
Language:pt intubated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3.5 to 3
mm bilaterally. Visual fields unable to test
III, IV, VI: Extraocular movements unable to test
V, VII: Facial strength grossly intact and symmetric.
VIII: unable to test pt intubated
IX, X: unable to test pt intubated
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius unable to test pt sedated
with intubation medications from outside hospital.
XII: Tongue -unable to test pt intubated.pt sticks toungue out
minimally to command
Motor: Normal bulk and tone bilaterally. Strength pt minimally
moving fingers and toes to command. Pronator drift unable to
test
Sensation: unable to test -pt sedated.
Toes downgoing bilaterally
Coordination:unable to test
On Discharge:
AOx3, left side neglect. R pupil [**4-12**], L pupil [**6-13**] both briskly
reacting. MAE with left sided weakness -[**6-15**]. Speech is clear and
fluent. Comprehension is intact. Right vision has been blurry.
Pertinent Results:
CT Head [**2163-2-14**]:
IMPRESSION:
1. Compared to the examination from two hours prior, there is
stable large
right intraparenchymal hemorrhage with intraventricular
extension. There is stable 5-mm leftward shift of midline.
2. Compared to the [**Month (only) 1096**] examination, a left occipital
intraparenchymal
hemorrhage has increased in size.
3. Stable right frontal encephalomalacia and right frontal
subdural hematoma.
4. Stable position of the ventriculostomy catheter. Stable
post-surgical
changes along the right calvarium.
ECHO: [**2163-2-14**]
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild mitral
regurgitation with normal valve morphology
MR [**Name13 (STitle) **] [**2163-2-14**]
IMPRESSION:
1.Right frontoparietal, occipital, and left occipital lesions
consistent
with metastases with associated hemorrhage and surrounding
vasogenic edema.
2. Stable right craniotomy changes and left frontal
ventriculostomy catheter placement.
CT Brain [**2163-2-14**]
IMPRESSION:
1. Minimal decrase in size of large right parieto-occipital
intraparenchymal bleed.
2. Slight increase in size of the hyperdense left occipital
lesion.
Brief Hospital Course:
Ms. [**Known lastname 1806**] was admitted to the [**Hospital1 18**] ICU in an intubated state.
After sedating medications wore off she was able to readily
follow commands. She was extubated soon thereafter. Neurologic
examinationa after extubation revealed a left hemiplegia that
was attributable to the ICH. Subsequent serial imaging revealed
no interval change in ICH. Her neurologic status remained stable
in the remaining hospital course. PT and OT were consulted and
she was able to go home with services.
Medications on Admission:
Keppra 1000 mg [**Hospital1 **]
Metoprolol 25 mg po QD-[**Hospital1 **]
Discharge Medications:
1. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*1*
10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Intraventricular hemorrhage
Intracerebral Hemorrhage
Atrial Fibrillation
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.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????Continue Keppra as prescribed.
* Please stay on the Dexamethasone until Dr. [**First Name (STitle) **] sees you in
follow-up
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 9403**] 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.
* Please call and schedule an appointment with your primary care
physcian regarding an episode of Afib while inpatient. You have
been given Amiodarone for this.
* Dr. [**First Name (STitle) **] has call [**Hospital3 3583**]- please call and setup an
appointment for Radiation treatment with them.
Completed by:[**2163-2-16**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7936
} | Medical Text: Admission Date: [**2193-6-21**] Discharge Date: [**2193-7-8**]
Date of Birth: [**2131-11-17**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Pentothal / Codeine / Wellbutrin / Zosyn
/ Meropenem
Attending:[**Doctor First Name 5188**]
Chief Complaint:
raw skin around ostomy
Major Surgical or Invasive Procedure:
Takedown/reversal of ileostomy with ileorectal anastomosis.
History of Present Illness:
This is a 61 yo woman with h/o colostomy/ileostomy, COPD, morbid
obesity who presents with increased output from wound adjacent
to ostomy. Of note she went home from rehab at the end of [**Month (only) 116**]
(about 2 weeks ago) and things seem to be worse since. She notes
the VNA nurse told her about a week ago she had an open area
adjacent to her ostomy that was draining. She has had such
discomfort from the skin around her ostomy that she has been
unable to keep an ostomy bag on it for the last week or so. She
was seen by someone (? PCP) [**6-12**] who started her on keflex to try
to help the abdominal wall irritation improve (with no sign
change-finished [**6-19**]) and also started her on macrobid for a UTI
(but Ms. [**Known lastname **] took it [**Hospital1 **] instead of QID so is still taking
it even though it was to finish [**6-19**] and took 1/2 dose). She
states she couldnt take it at home anymore so came in. Denies
change in stool consistency, fevers or chills. She feels diffuse
abdominal pain. No nausea or emesis but has been eating less
intentionally so she could reduce her stool output for the last
3 days.
.
Past Medical History:
Hypertension
Diabetes
Obesity
COPD on home O2 2-3L at all times
Obstructive Sleep Apnea on home CPAP: don't know settings
Obesity hypoventilation syndrome
diastolic CHF (by c.cath [**1-/2192**])
Osteoarthritis
s/p total colectomy for c.diff colitis with end ileostomy [**2-18**]
Social History:
Quit smoking [**1-18**] after 40-50 pack years. No etoh, or illicit
drugs. Recently moved home with her husband after long rehab
stay.
Family History:
There is family history of premature coronary artery disease-
her father died in his 40s of an MI.
Physical Exam:
VS: T 98.4 HR 84 BP 126/74 RR 18 Sat 99% 3L NC
GEN: chronically ill appearing woman in NAD
HEENT: EOMI, PERRL, conjunctiva clear, sclera anicteric, mmm, OP
clear
Neck: No JVD, no LAD, no thyromegaly, no carotid bruits
Cardiovascular: RRR, nl S1/S2, no m/r/g
Respiratory: CTA bilaterally, comfortable, no wheezing, no
rhonchi, no rales
Gastrointestinal: soft, non tender, no rebound, obese, no
hepatosplenomegaly, normal bowel sounds, G tube in place, left
side with large (15cm x 10cm) pink ulceration and erythema
Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint
swelling, trace edema in the bilateral extremities
Neurological: Alert and oriented x3, fluent speech, sensation
WNL, CNII-XII intact
.
At Discharge:
Gen: a and o x3, NAD
V.S 99.1, 84, 134/66, 18, 100% RA.
CV: RRR no m/r/g
RESP: LSCTA, sl decreased at bases.
ABD: soft, sl tender at incision site, obese, nd.
Incision: abd ota with staples, small open area with w-d
dressing, old G-Tube site with dressing. No s/s of infection at
either site.
Ext: Bilat lE edema
Pertinent Results:
[**2193-6-20**] 06:20PM BLOOD WBC-9.7 RBC-3.87* Hgb-10.4*# Hct-32.2*#
MCV-83 MCH-26.9* MCHC-32.4 RDW-18.4* Plt Ct-413
[**2193-6-20**] 08:28PM BLOOD PT-13.2 PTT-21.5* INR(PT)-1.1
[**2193-6-20**] 06:20PM BLOOD Glucose-113* UreaN-29* Creat-1.7* Na-138
K-4.9 Cl-101 HCO3-26 AnGap-16
[**2193-6-20**] 06:20PM BLOOD %HbA1c-5.7
[**2193-6-20**] 06:20PM BLOOD TSH-2.5
[**2193-6-20**] 06:30PM BLOOD Lactate-1.0
.
CT Abd
CT ABDOMEN WITH IV CONTRAST: Focal consolidation at the left
lung base is
unchanged, and likely represents atelectasis. There is no
pleural effusion. The heart is normal in size without
pericardial effusion.
In the abdomen, the liver, gallbladder, pancreas, spleen,
adrenal glands,
stomach, and duodenum are unremarkable. The kidneys enhance and
excrete
contrast symmetrically. There is no free air or free fluid in
the abdomen.
The abdominal aorta demonstrates mild atherosclerotic
calcification. Scattered mesenteric and retroperitoneal lymph
nodes do not meet CT criteria for pathologic enlargement.
A percutaneous G-tube terminates in the stomach.
CT PELVIS WITH IV CONTRAST: The patient is post colectomy.
Multiple loops of small bowel contain oral contrast, and are not
distended. Contrast extends through the small bowel to the
ileostomy site in the anterior abdominal wall, and passes freely
through the ileostomy. Only a single channel of contrast passes
through the abdominal wall. No contrast-filled enterocutaneous
fistula is identified. A small focus of air within the deep
subcutaneous/muscular layers adjacent to the ileostomy site is
noted, decreased since the prior study. There is no associated
fluid collection to suggest abscess. Stranding is noted in the
subcutaneous tissues.
The urinary bladder, distal ureters, uterus, and adnexa are
unremarkable.
There is no free fluid in the pelvis. There is no pelvic or
inguinal
lymphadenopathy by size criteria.
OSSEOUS STRUCTURES: S-shaped curvature of the spine is
unchanged. There is
no fracture or worrisome bony lesion. Soft tissues are
unremarkable.
IMPRESSION:
1. No evidence of enterocutaneous fistula at this time.
2. Interval decrease in size of subcutaneous air adjacent to the
ostomy. No associated fluid collection to suggest abscess.
.
[**6-26**] CT abd: dilated SB to ostomy, contrast in stomach
[**6-27**] BE: normal Hartmann pouch, no stricture/obstruction/oeak
[**2193-7-3**] 10:00PM BLOOD WBC-8.8 RBC-3.08* Hgb-8.2* Hct-26.8*
MCV-87 MCH-26.7* MCHC-30.7* RDW-17.0* Plt Ct-291
[**2193-7-3**] 10:00PM BLOOD Plt Ct-291
[**2193-6-30**] 04:42AM BLOOD PT-14.2* PTT-24.9 INR(PT)-1.2*
[**2193-7-3**] 10:00PM BLOOD Glucose-138* UreaN-25* Creat-1.9* Na-138
K-3.7 Cl-103 HCO3-29 AnGap-10
[**2193-7-1**] 05:59AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.2
[**2193-6-25**] 07:25AM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.4 Mg-2.3
Iron-28*
[**2193-6-25**] 07:25AM BLOOD calTIBC-239* TRF-184*
[**2193-6-20**] 06:20PM BLOOD %HbA1c-5.7
Brief Hospital Course:
In short, Ms [**Known lastname **] is a 61 y/o F with hx of colostomy, COPD,
HTN, DM and obesity who presented from home with inability to
care for her ostomy and worsening skin breakdown around the
site.
.
# Ostomy wound and skin breakdown - patient was evaluated in the
ED with a CT scan showing flow through the ostomy without any
entero-cutaneous fistulas. Wound care nurse at home told patient
there was a fistula. Surgery evaluated her in the ED and does
not think there is a fistula as the wound adjacent to the ostomy
was probed and could not be passed. The ostomy nurse examined
the patient and recommended some various wound cleaning
suggestions, as well as placing a bag over the ostomy. She
continued to have pain around her wound throughout her admission
and was treated with dilaudid PO which controlled the pain to an
acceptable level. The wound did not appear infected.
.
# Nausea and vomitting - the two days prior to discharge, the
patient developed some nausea and vomitting. It is unclear the
etiology. She felt better with zofran. She thinks it was
something in the food that she ate. She had the same level of
abdominal pain that she had upon admission, and was tolerating
POs and having appropriate output through her colostomy.
Surgery was following along and did serial exams that were not
concerning for an acute abdomen. She can continue to be treated
wtih antiemetics as needed as long as she has appropriate stool
output and vomit remains non bilious and non bloody.
.
# UTI - had positive UA but culture grew yeast and was likely a
contaminant. Had one day of cipro and then it was stopped when
culture data returned.
.
# DM - patient takes metformin at home, sugars have been well
controlled, was d/c'ed on lantus previously. We held the
metformin because of her CKD and put her on insulin sliding
scale. Her HbA1c was 5.7. She can stay on insulin for now but
eventually go back on metformin (if her kidney function is ok)
as she would be unlikely to be able to administer insulin to
herself.
.
# Neuropathy - patient with severe peripheral bilateral
neuropathy today. At home takes celebrex and dilaudid for pain
medicines. Held celebrex for CKD and added gabapentin for
neuropathy. Per patient, gabapentin helped pain improve.
.
# CKD - seems to be at baseline, but creatinine has been
variable past few months. Received some IVFs the night prior to
CT scan, and creatinine was not rechecked because she refused
labs every time.
.
# COPD - stable, did fine on room air
.
# OSA - stable, do not know CPAP settings
.
# Depression - was tearful and obviously depressed throughout
hospitalization, she was on venlafaxine per old disharge
summaries, but she does think she's taking it anymore. She kept
saying that she hoped she died, but always denied suicidal
ideation. Psych was consulted because depression was hindering
her ability to get well from a medical standpoint. She was
started on celexa.
MICU Course ([**Date range (1) **])
Transferred to ICU after failure to extubate. Thought to be [**2-11**]
hypoventilation in the setting of narcotics for post-op pain and
baseline disease (COPD, obesity hypoventilation). Tolerated PS
trial in ICU and was successfully extubated. Started on a
dilaudid PCA. Bolused w fluid for hypotension. Transferred to
floor.
.
The patient was transferred to the floor and was continued as
NPO, with foley, G-tube to gravity and IV meds/IVF. An NGT was
placed secondary to N/V and decreased ostomy output.
On [**2193-6-28**] the patient was taken to the OR for Takedown/reversal
of ileostomy with ileorectal anastomosis. She returned to the
floor and was made NPO with IVF/Foley/G-Tube to gravity and IV
Meds. With the return of bowel function and flatus her diet was
advanced from sips to regular. Here G-tube was than removed,
however it was noted that there was output from the g-tube site
and a CT scan was done. See report.
Staples were removed from her incision and packed with w-d
dressing [**Hospital1 **].
Physical thearpy worked with patient daily and pt got oob to
chair. The patient refused skin care, explained to patient the
risks of this and she still refused.
The patient will return to rehab for physical therapy and wound
care. She will follow up with Dr. [**Last Name (STitle) 5182**] in 1 week.
Medications on Admission:
Meds: patient largely unable to verify
DuoNeb 0.5-2.5 mg/3 mL [**1-11**] q4h prn shortness of breath
zantac 150mg daily (confirmed)
Dilaudid 2 mg PO q3h prn as needed for pain - takes at least
daily
nystatin powder
santyl ointment to ostomy
macrobid as above
metformin [**Hospital1 **] (does not know dose)
celebrex 200mg daily
.
Maybe:
Calcium Acetate 667 PO TID W/MEALS
Quetiapine 50 mg PO at bedtime
.
No longer taking we think:
Arinesp 16mcg sc qWednesday
Venlafaxine 75 mg PO DAILY
Insulin 7 units Lantus SC qhs plus sliding scale
Lorazepam 0.5 mg PO bid prn as needed for anxiety
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] center [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
1. Skin Breakdown around ostomy
2. Diabetes
3. Depression
4. COPD
5. Nausea and Vomitting
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medications.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow up appointment.
-Steri-strips will be applied and will fall off on their own.
Please remove any remaining strips 7-10 days after application.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Dressing:
ABD: please continue with wet-dry dressing changes [**Hospital1 **].
.
G-Tube was removed during your hospital stay.
Followup Instructions:
1. Please call Dr.[**Name (NI) 6045**] office, [**Telephone/Fax (1) 5189**], to make a
follow up appoinmtent in 1 week.
2. Please follow up with your PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15131**] at [**Telephone/Fax (1) 18203**]
within one to two weeks after you are discharged from rehab.
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
ICD9 Codes: 5990, 2762, 496, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7937
} | Medical Text: Admission Date: [**2194-10-14**] Discharge Date: [**2194-10-21**]
Date of Birth: [**2123-6-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
bleeding per rectum
Major Surgical or Invasive Procedure:
endoscopy with epinephrine injection
History of Present Illness:
Mr. [**Known lastname 84279**] is a 71 year-old Russian with a history of
coronary artery disease s/p CABG and PCI [**7-/2194**] with DES, as
well as a remote history of gastric ulcers s/p resection of [**1-8**]
of his stomach, who presents with weakness, chest pain, and
bright red blood per rectum. He states that all of these
symptoms have evolved over the past 4 days. The chest pain comes
and goes and is described as pressure similar to his usual
angina. This time it has not been related to exertion but was
responsive to nitroglycerin until an episode last night that was
not. With regard to the BRBPR, he states that this has been
ongoing with most stools for the past 3-4 days and consists of
red blood mixed with brown stool. He denies black stool
(although his daughter states that he has been telling her he is
having black stool). He also denies abdominal pain, nausea,
vomitting, or diarrhea. He denies any history of similar
symptoms. Of note, he did have stomach ulcers in [**Country 532**] in [**2186**]
and is s/p removal of "[**2-6**] of his stomach." He has never had a
colonoscopy.
.
In the ED, initial VS T 98.6, HR 116, BP 110/90, RR 18, O2 100%
RA. Exam was notable for palor and melena in the rectal vault.
EKG was concerning for acute ischemia, and code STEMI was
called. The patient was taken directly to the cath lab without
any heparin given concern for GIB. Catheterization revealed no
change in prior diffuse coronary disease with open stents. A
nitroglycerin drip was started (reportedly for hypertension to
the 170s, although apparently patient was also having ongoing
chest pain).
.
On arrival to the ICU, Mr. [**Known lastname 84279**] complains of ongoing
substernal chest pressure. He denies shortness of breath or
palpitations. He denies abdominal pain, nausea, or vomitting. He
has not had any bowel movement since arrival to the hospital.
Past Medical History:
-hypertension
-dyslipidemia
-CABG: 3 vessels in [**Country 532**]; [**2186**] per patient
-PCI [**11/2193**] with diffuse native disease and grafts open. PTCA
and stenting of proximal LCx with BMS. [**7-/2194**] stenting of Lcx
with DES.
-stomach ulcer s/p resection of [**1-8**] of stomach
-appendectomy
Social History:
He previously smoked 1 PPD but quit in 12/[**2192**]. He has recently
decreased his alcohol intake from TID vodka but unclear exactly
how much he drinks. He lives with his wife.
Family History:
not obtained
Physical Exam:
VS: Afebrile BP 125/65, HR 107, RR 13, O2 100% on RA
GENERAL: appears comfortable, pale, lying flat on back after
cath
HEENT: pale mucosa, oropharynx clear
NECK: supple, JVP not elevated
CARDIAC: regular, no murmur appreciated, no chest wall
tenderness
LUNGS: clear anteriorly
ABDOMEN: Soft, NTND, +BS. No HSM or tenderness.
EXTREMITIES: R groin site clean, dry, nontender. No peripheral
edema. Peripheral pulses not palpable but dopplerable. Evidence
of multiple vein graft harvesting sites.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2194-10-14**] 04:30PM WBC-8.5 RBC-2.65*# HGB-7.0*# HCT-22.1*#
MCV-83 MCH-26.6* MCHC-31.9 RDW-16.5*
[**2194-10-14**] 04:30PM NEUTS-68.5 LYMPHS-25.6 MONOS-4.0 EOS-0.6
BASOS-1.3
[**2194-10-14**] 04:30PM GLUCOSE-124* UREA N-36* CREAT-0.8 SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
Brief Hospital Course:
A 71 year-old man with a history of CAD s/p recent DES on ASA
and Plavix presented with GI bleed.
.
# GI bleed:
In the MICU:
Initially unclear if upper or lower, as patient had variably
endorsed both black stool and brown stool admixed with BRB. Hct
had fallen 38-->30 over 6 months [**11-13**] to [**4-14**]. Had fell an
additional 10 points over the ensuing 6 months, and he did not
follow up with the colonoscopy as an outpatient as instructed on
previous admission. He was given a total of 9 units of pRBC,
and Hct slowly increased although not to the extent expected.
PPI drip was started. Endsoscopy was performed which showed a
bleeding ulcer at the site of his prior anastomosis which was
injected with epinephrine and cauterized. Despite achieving
hemostasis, the patient continued to have melena and a falling
hematocrit requiring transfusion. A second EGD was performed
and the ulcer was cauterized once more for oozing, but it was
the general sense that this oozing was not the source of the
continued bleeding. It was recommended that the patient
follow-up as an outpatient for repeat EGD in [**5-13**] weeks and that
he may need to have a colonoscopy if his hematocrit remains
unstable. He required a totoal of 12 units of blood thoughout
his stay. His aspirin and Plavix were held during his time in
the MICU but aspirin was restarted prior to transfer to the
floor.
On the floor:
PPI was switched to IV BID, two large bore IVs and a type and
cross were maintained. He had a transfusion goal of >30 but did
not require further blood products. His aspirin was restarted on
arrival to the floor. After some debate, his plavix was
restarted one day later because, based on cardiology and GI
consult input, the risk posed for coronary stent occlusion was
deemed superior to GI bleeding. He was rescheduled for an EGD in
6 weeks for a biopsy at the ulcer site. He did not have any more
episodes of melena or hematochezia prior to discharge.
.
.
# CAD:
In the MICU:
Nothing acutely occluding arteries on cath, but the patient had
ongoing severe chest pain with ST depressions precordially
despite a nitroglycerin drip. Thus, he was aggressively
transfused to Hct >30. With this, the nitroglycerin drip was
titrated off, and his home dose of long-acting nitrate was
restarted. Beta blocker was initially held but restarted for
tachycardia likely related to withdrawal of the med and ACEI
were held while there was concern of imminent hemodynamic
instability Aspirin and Plavix were initially held and aspirin
was restarted prior to transfer.
On the floor, Plavix was restarted given the high risk of
coronary stent occlusion knowing that this would pose a greater
risk for repeat GI bleed. His metoprolol and ACE-inhibitor and
statin were also restarted.
.
# Elevated INR: thought to be [**1-7**] nutritional issues. He was
given vitamin K in the MICU.
.
# HTN: chronic issue, patient was normotensive-hypertensive in
the MICU in the setting of bleed. His BP increased once bleeding
stopped and amlodipine and lisinopril were restarted.
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. isosorbide mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) Injection DAILY (Daily) for 2 days.
Disp:*2 ml* Refills:*0*
9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Upper GI bleed
Secondary: CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 84279**],
you were admitted to the [**Hospital3 **] Medical center for a bleed
in your stomach. You were sent to the ICU and seen by the
gastroenterologist you performed 2 esophagealgastroduodenal
(EGD) endoscopies to diagnose and stop the bleeding. Your
ongoing bleeding required 12 Unites of blood before stabilizing.
During your bleeding, your aspirin and plavix were held, but
these were restarted once your bleeding stopped. You were stable
on the floor and did not have repeat episodes of bleeding. Your
hematocrit (a measure of red blood cells) was stable without
transfusions for several days and you were deemed stable for
discharge home.
During your stay some of your medications were changed, you
should START the following:
-Pantoprazole 40mg Twice every day (for decreasing stomach acid)
-Senna and docusate (for constipation)
You should INCREASE:
- Metoprolol to 25 mg twice every day
Please obtain a hematocrit blood test with Dr. [**Last Name (STitle) 3357**] on your
next appointment. You will need a repeat endoscopy at some
point to reevaluate your ulcer and get a biopsy. You will have
to discuss with your cardiologist if it is safe to be off plavix
for this biopsy.
You should continue all your other medications as prescribed by
your physicians. It is important that your take your aspirin and
plavix every day.
Please call your PCP [**Name Initial (PRE) **]/or return to the Emergency if you have
bloody/dark black stools or if your feel lightheaded or dizzy or
have chest pain.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**]
Phone: [**Telephone/Fax (1) 4606**]
When: Tuesday, [**10-28**], 9:30AM
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2194-12-9**] at 2:30 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7938
} | Medical Text: Admission Date: [**2129-10-17**] Discharge Date: [**2129-11-2**]
Date of Birth: [**2082-3-8**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Motorcycle collision
Major Surgical or Invasive Procedure:
Open reduction internal fixation ABC to pelvic fracture with
plating of the symphysis.
History of Present Illness:
[**Known firstname **] [**Known lastname 1968**] is a 47-year-old gentleman who was involved in a
motorcycle accident on [**2129-10-17**] resulting in anterior posterior
compression type 2 pelvic fracture with symphyseal diastasis.
Past Medical History:
HTN, NIDDM
Social History:
NA
Family History:
NA
Physical Exam:
GCS: 15
HEENT: normocephalic, atraumatic; PERRLA, TM's clear
NECK: nontender, in cervical collar
CV: RRR, no M/R/G
RESP: CTA b/l
ABD: obese, NT
PELVIS: TTP, ecchymosis to b/l thighs,
NEURO: nl rectal tone, sensation and motor grossly intact
strength 5/5 b/l UE, 4+/5 b/l LE secondary to pain
Pertinent Results:
[**2129-10-17**] 08:00PM NEUTS-75* BANDS-8* LYMPHS-10* MONOS-5 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2129-10-17**] 08:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2129-10-17**] 08:00PM PT-13.3 PTT-24.3 INR(PT)-1.2
[**2129-10-17**] 08:00PM PLT SMR-NORMAL PLT COUNT-395
[**2129-10-17**] 08:00PM FIBRINOGE-380
[**2129-10-17**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.035
[**2129-10-17**] 08:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2129-10-17**] 08:00PM URINE RBC-[**2-5**]* WBC-[**5-13**]* BACTERIA-FEW
YEAST-NONE EPI-[**2-5**]
Brief Hospital Course:
Upon admission, on [**2129-10-17**] the symphysis was widely malplaced
at least 4 cm and the patient was significantly symptomatic and
required a pelvic bandage to relieve comfort. He remained
hemodynamically stable on the day of admission. He now
([**2129-10-19**]) presents for open reduction internal fixation ABC to
pelvic fracture with plating of the symphysis. The patient
tolerated the procedure well and was taken to the recovery room
without incident. Dr. [**Last Name (STitle) 1005**] was present through the entire
procedure. The patient was brought to CC6 and placed on lovenox
for DVT prophylaxis. He was evaluated by physical therapy and
occupational therapy and did well. His diabetes was kept in
good control. On [**2129-10-24**] the patient's potassium was low at
3.0, so it was replaced with 40 mEq IV potassium. It was found
to be low again on [**2129-10-25**] and another 40 mEq of potassium was
given. His potassium stabilized with po. Hospital course was
otherwise without incident. He is being discharged today to his
home in stable condition. he was cleared by pt and was okay to
be dc'd home with pt and ot
Medications on Admission:
Glucophage
HTN medication
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*0*
2. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 4 weeks.
Disp:*30 syringes* Refills:*0*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
Indigestion.
4. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Anterior posterior compression type 2 pelvic fracture with
symphyseal diastasis
Discharge Condition:
Stable
Discharge Instructions:
Keep your incision clean and dry. You may shower, but do not
tub bathe or immerse in water. Watch for signs of infection as
written in the nursing discharge sheet. If you notice any
fever, increased pain, swelling, or redness report to the
emergency room. If you have any questions you may call the
orthopaedic clinic. Do not bear weight on your legs for [**5-11**]
wks. Take your medications as prescribed. Please follow up with
Dr [**Last Name (STitle) 1005**] in 2 weeks.
Physical Therapy:
Strict NWB bilateral lower extremities
Treatments Frequency:
Staple removal at orthopaedic clinic with Dr. [**Last Name (STitle) 1005**]
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1005**] at the [**Hospital1 18**] orthopaedic
clinic in 2 weeks. You may call [**Telephone/Fax (1) **] to make an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2129-11-2**]
ICD9 Codes: 2851, 4019, 2768, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7939
} | Medical Text: Admission Date: [**2120-4-27**] Discharge Date: [**2120-4-30**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 49761**] is an 87 y/o female with a history of CHF, afib, pulm
htn [**3-7**] COPD who was transferred from BIDN for respiratory
distress likely from a pneumonia. She was noted to be short of
breath at her nursing facility the day PTA and was found to have
an O2 sat of 80% on RA and was put on 2L of 02 which brought her
up to 88%. The following day she destated again with an O2 sat
of 70% on 2L with worening tachypnea and tachycardia. She was
sent to BIDN where she was noted to have a fever of 103 and a
CXR with RLL infiltrate worse than previous concerning for
pneumonia. Her blood gas was 7.44/58/62/She was given
Ceftriaxone, Levaquin and dexamethasone and transferred to [**Hospital1 18**]
for ICU admission.
.
In the ED, initial VS were: 97.9 104 104/62 20 92% 8L venti
mask. She was noted to be mentating well with crackles noted
bilaterally and decreaed breath sounds on the right side. Vital
Signs Upon Transfer were: Temp: 97.4 ??????F (36.3 ??????C) (Oral), Pulse:
94, RR: 29, BP: 108/44, O2Sat: 94%, O2Flow: 8L (Mask).
.
On arrival to the MICU, she appeared comfortble and in NAD. She
was speaking in full sentences and not using any accessory
muscle use. She was a venti mask sating 95%.
.
While in MICU [**Location (un) **], the patient did well. She was started on
vancomycin, cefepime and azithromycin to treat for HCAP.
Solumedrol was discontinued as this was not thought to be
secondary to a COPD exarbaction. Given where she lives, the
decision was made to treat for CAP instead of HCAP so vancomycin
and cefepime were discontinued on [**4-28**]. The patient was weaned
down to 2L NC with saturations maintained in the mid-90s with no
shortness of breath. BPs were initially low so home Bumex was
held but they improved today so the medication was resumed. She
is being transferred to the medicine floor for further
management
.
On arrival to the floor, vital signs were T: 97.7, BP- 108/55,
HR- 60, RR- 20, SaO2- 96% on 2L. The patient denies fevers,
chills, chest pain or shortness of breath and reports feeling
better.
Past Medical History:
1. COPD/emphysema, not on home oxygen.
2. Possible diastolic dysfunction/congestive heart failure.
3. Pulmonary hypertension.
4. Hypertension.
5. Hyperlipidemia.
6. Diverticulosis.
7. Question diabetes mellitus/hyperglycemia/impaired fasting
glucose.
8. Status post cholecystectomy.
9. History of vitamin B12 deficiency.
10. History of Pemphigoid and lichen planus.
Social History:
Lives alone currently in Recuperative Services Unit at NewBridge
on the [**Doctor Last Name **]. Reports that her kids are not very close by, but
are in
contact. [**Name (NI) **] son is the healthcare proxy. [**Name (NI) **] husband passed
away a
few years ago. She smoked 1 pack a day for more than 60 years
and still smokes 1 to 2 cigarettes a day. She says, "I drink
little if anything." Denies drug history. Uses walker for ADLs.
Family History:
NC
Physical Exam:
On arrival to the floor
Vitals: T: 97.7, BP- 108/55, HR- 60, RR- 20, SaO2- 96% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, NC in
place
Neck: supple, JVP 12cm, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar crackles, decreased breath sounds in right
base, good respiratory effort.
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 1+ edema bilaterally. no clubbing,
cyanosis
Pertinent Results:
Labs on admission:
[**2120-4-27**] 06:53AM BLOOD WBC-8.1 RBC-4.07* Hgb-10.3* Hct-35.5*
MCV-87 MCH-25.4* MCHC-29.1* RDW-16.5* Plt Ct-266
[**2120-4-27**] 06:53AM BLOOD Neuts-89.7* Lymphs-7.8* Monos-2.2 Eos-0
Baso-0.2
[**2120-4-27**] 06:53AM BLOOD PT-11.4 PTT-26.3 INR(PT)-1.1
[**2120-4-27**] 06:53AM BLOOD Glucose-201* UreaN-29* Creat-0.9 Na-142
K-4.8 Cl-100 HCO3-35* AnGap-12
[**2120-4-27**] 06:53AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.2
[**2120-4-27**] 06:53AM BLOOD Digoxin-0.9
[**2120-4-28**] 06:00AM BLOOD Digoxin-1.3
[**2120-4-27**] 06:28PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.028
[**2120-4-27**] 06:28PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2120-4-27**] 06:28PM URINE RBC-7* WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1
Labs on discharge:
[**2120-4-30**] 05:40AM BLOOD WBC-5.4 RBC-4.27 Hgb-11.0* Hct-36.4
MCV-85 MCH-25.8* MCHC-30.3* RDW-16.5* Plt Ct-253
[**2120-4-30**] 05:40AM BLOOD Glucose-97 UreaN-23* Creat-0.9 Na-137
K-4.7 Cl-99 HCO3-31 AnGap-12
[**2120-4-30**] 05:40AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.4
[**2120-4-28**] 06:00AM BLOOD Digoxin-1.3
Microbiology:
[**2120-4-27**] 6:28 pm URINE Source: CVS.
**FINAL REPORT [**2120-4-28**]**
Legionella Urinary Antigen (Final [**2120-4-28**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
Blood cultures ([**2120-4-27**]): pending at discharge
Urine culture- no growth
Urine legionella- negative
Sputum culture- contaminant
Imaging CXR PA/Lateral [**4-27**]:
AP and lateral upright chest radiographs were reviewed with no
prior studies available for comparison.
Heart size is enlarged. Bilateral prominence of pulmonary
arteries is most
likely consistent with pulmonary hypertension, although some
degree of
lymphadenopathy cannot be excluded. Coronary and aortic valve
calcifications are noted.
Patient is in interstitial pulmonary edema associated with
bilateral pleural effusions. There is no pneumothorax.
Re-evaluation of the patient is recommended to assess the hila
for the presence of lymphadenopathy versus enlarged pulmonary
arteries.
Chest x-ray ([**2120-4-28**])
FINDINGS: In comparison with the study of [**4-27**], there is little
interval
change. Continued enlargement of the cardiac silhouette with
evidence of
increased pulmonary venous pressure, bilateral pleural effusions
with
compressive atelectasis, and probable engorgement of central
arteries
consistent with pulmonary artery hypertension or
lymphadenopathy.
Chest x-ray ([**2120-4-29**])
FINDINGS: In comparison with the study of [**4-28**], there is
continued
enlargement of the cardiac silhouette with pulmonary vascular
congestion and bilateral pleural effusions with compressive
atelectasis. Asymmetric
opacification at the right base could well reflect developing
consolidation. Hilar prominence is again seen.
Brief Hospital Course:
Ms. [**Known lastname 49761**] is an 87 y/o female with a history of CHF, afib, pulm
htn [**3-7**] COPD who was transferred from BIDN for respiratory
distress, likely [**3-7**] pneumonia.
# Respiratory Distress: She was noted to have a RLL infiltrate
in the setting of fevers making pneumonia the likely diagnosis.
She also has a history of congestive heart failure whioch may be
contributing to her shortness of breath. She was treated
initially with azithromycin, Vanc and Cefepime. She improved
dramatically in terms of her shortness of breath and was able to
be weaned to 2L NC on day 3 of admission. She was subsequently
transferred to the general medicine floor, at which time Vanc
and cefepime were discontinued. On the medicine floor, she was
switched from azithromycin to levofloxacin and did very well.
Home bumetanide was also resumed on day of transfer to the
medicine floor. She was weaned down to 2L NC with no fevers,
shortness of breath, cough or any signs of hemodynamic
instability. She walked without worsening of symptoms. Of
note, the patient recently qualified for home oxygen at 2L NC so
we will recommend that she be discharged on oxygen. Plan is to
complete a total of 5 days of antibiotics (day 1- [**4-27**]). She
will go out on levofloxacin 750mg q48hrs for one more dose on
[**2120-5-1**].
# Atrial Fibrillation: She has a history of going in to afib
with RVR. She apparently was well controlled on her current
regimen as an outpatient. We continued metoprolol, digoxin
0.125 mcg and aspirin 325 mg without any episodes of RVR. She
had been on extended release metoprolol prior to admission in
[**3-/2120**] but was on short acting on discharge on [**2120-4-9**], which we
recommended she continue on this discharge well. She will
continue metoprolol tartrate 75mg [**Hospital1 **].
# Diastolic Congestive Heart Failure: Patient has a history of
CHF and is on Bumex for diuresis as an outpatient. Last TTE was
done on [**3-/2120**] which showed a preserved EF. Her bumex 1 mg
daily was restarted on transfer to the floor and she never
demonstrated any signs of gross volume overload. Home bumex was
continued on discharge.
# Hyperlipidemia- Previous notes say the patient had been on
atorvastatin in the past but rehab paperwork state the patient
has been taking pravastatin 40mg of late, which is what she was
discharged on from this hospitalization.
Medications on Admission:
[**First Name8 (NamePattern2) **] [**Location (un) 620**] D/C summary
1. Bumex 1 mg p.o. daily.
2. Metoprolol 75 mg p.o. 3 times daily.
3. Digoxin 0.125 mg p.o. daily.
4. Aspirin 325 mg p.o. daily.
5. Atorvastatin 10 mg p.o. at bedtime.
6. Caltrate plus D 600 mg 400 international units p.o. twice
daily.
7. Avoid beta agonists (that causes tachycardia).
8. Prilosec 20 mg p.o. at bedtime.
9. Tylenol 1 gram p.o. twice daily p.r.n. pain.
10. Prednisone 2.5 mg p.o. daily for her arthritis.
Per rehab paperwork:
1. bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day.
2. metoprolol tartrate 75mg twice daily
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. acetaminophen 650 mg Tablet Sig: 1 Tablets PO q4hr as needed
for pain.
7. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. bisacodyl 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation.
9. magnesium hydroxide 30mg daily as needed consiptation
10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
11. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
12. calcium carbonate 1300 mg daily
13. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation every eight (8) hours as needed for shortness of
breath or wheezing.
Discharge Medications:
1. bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day.
2. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO twice a
day.
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO twice a day
as needed for pain.
7. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 1 doses: last dose- [**2120-5-1**].
9. bisacodyl 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation.
10. magnesium hydroxide Oral
11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
12. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
13. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO once a day.
14. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation every 6 hours as needed for shortness of breath or
wheezing.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary- Pneumonia
Secondary- Diastolic CHF
Atrial fibrillation
COPD
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with difficulty breathing.
You presented to [**Hospital1 **]-[**Location (un) 620**] and were transferred to [**Hospital1 18**] for
further management. On arrival here, you were admitted to the
ICU and they determined that you had a pneumonia. You were
treated with IV antibiotics and steroids and you responded very
well. The IV medications were discontinued and you were kept on
an oral antibiotic for a pneumonia. While on the medicine
service, you did very well and did not have any shortness of
breath or fevers. You were kept on 2L of supplemental oxygen;
you should continue this on discharge.
The following changes were made to your medications:
1. START levofloxacin 750mg by mouth ONCE daily (only one dose
left. last day- [**2120-5-1**])
2. STOP your metoprolol ER (metoprolol succinate) once daily
3. START metoprolol tartrate 75mg by mouth TWICE daily
Mo other changes were made to your home medications. Please
resume your other medications as you were taking them prior to
the admission.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Location: [**Hospital **] MEDICAL ASSOCIATES-[**Location (un) **]
Address: ONE [**Location (un) 542**] ST, [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 8506**]
Appointment: WEDNESDAY [**5-8**] AT 2:45PM
Completed by:[**2120-4-30**]
ICD9 Codes: 486, 4168, 4019, 2724, 3051, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7940
} | Medical Text: Admission Date: [**2103-4-24**] Discharge Date: [**2103-5-1**]
Date of Birth: [**2059-9-15**] Sex: M
Service: SURGERY
Allergies:
Dicloxacillin
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Liver mass
Major Surgical or Invasive Procedure:
hepatic segment 4b and 5 resection [**2103-4-24**]
History of Present Illness:
43-year-old man with end-stageliver disease due to hepatitis C
who is also coinfected with HIV. He has evidence of mild portal
hypertension including
thrombocytopenia and splenomegaly. He has never had ascites.
Found to have a 1.5 x 1.5 cm hyperenhancing mass in segment IV b
concerning for HCC.
A recent endoscopy demonstrates no esophageal varices,
although he does have a report of an upper GI bleed several
years ago. Risks and benefits of the procedure as well as
alternative procedures including liver transplantation and a
percutaneous ablative therapies were discussed with the
patient and his girlfriend. Appropriate consents were
signed.
Past Medical History:
kidney stones s/p lithptripsy, DM II (on insulin), HTN,
neuropathy, anxiety, [**Doctor Last Name 933**] disease, hypercholesterolemia, HIV,
HCV
Social History:
Single. Supportive partner. Not currently working. Denies
tobacco, etoh or recent substance use. Smoked 1ppd x10 yrs
Family History:
unremarkable for liver disease
Pertinent Results:
[**2103-4-24**] 01:20PM BLOOD WBC-16.5*# RBC-3.84* Hgb-12.7* Hct-36.5*
MCV-95 MCH-33.0* MCHC-34.8 RDW-15.6* Plt Ct-142*#
[**2103-5-1**] 04:43AM BLOOD WBC-5.2 RBC-3.14* Hgb-10.2* Hct-30.3*
MCV-96 MCH-32.3* MCHC-33.5 RDW-16.0* Plt Ct-90*
[**2103-4-27**] 03:00AM BLOOD PT-16.2* PTT-26.1 INR(PT)-1.4*
[**2103-5-1**] 04:43AM BLOOD Glucose-143* UreaN-15 Creat-1.0 Na-137
K-4.2 Cl-105 HCO3-28 AnGap-8
[**2103-4-24**] 01:20PM BLOOD ALT-77* AST-190* AlkPhos-121 TotBili-2.5*
[**2103-5-1**] 04:43AM BLOOD ALT-90* AST-164* AlkPhos-167* TotBili-0.7
[**2103-5-1**] 04:43AM BLOOD Calcium-7.1* Phos-2.5* Mg-1.7
Brief Hospital Course:
On [**2103-4-24**], he underwent exploratory laparotomy, intraoperative
ultrasound, cholecystectomy, and segment 4b/5 resection. Surgeon
was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed in the bare area
behind the right lobe as well as in the resection bed. Please
refer to operative note for details. Postop, BP was low
requiring a neo drip, and iv albumin was given. BP responded to
these treatments. Neo drip was stopped and BP stabilized.
He complained of a lot of abdominal pain and was medicated with
IV Dilaudid and methadone then a Ketamine drip. A Dilaudid PCA
was also started. He was transferred to the CSICU for
management. The pain service was consulted for difficult pain
control management.
Pain control improved. Ketamine was weaned off. Neurontin was
increased. Mental status was notable for sleepiness.
Blood sugars were elevated and an insulin drip was used with
improvement. Diet was advanced. Hepatology was consulted.
Recommendations included starting Lactulose and Rifaximin.
[**Last Name (un) **] was consulted and assisted with insulin management.
Insulin drip was switched to Lantus and Humalog sliding scale.
Of note, Levoxyl was started. Recommendations included checking
TSH, T4 and T3.
Hepatology was consulted and recommended increasing Rifaximin
dose titration of Lactulose per BMs. Home dose of Methadone was
resumed. Diet was advanced. Abdomen was distended. He did have
multiple stools likely from Lactulose. JP drain outputs
(ascites)increased to ~ 1100-1000 ml/day. Abdomen became more
distended concerning for ascites. Diet was changed to 2gm sodium
and Lasix 20mg qd was started on [**5-1**] for 3 days.
PT evaluated him and declared him safe for discharge to home. He
was discharged and scheduled to f/u with Drs [**Last Name (STitle) **] and [**Name5 (PTitle) 497**]
on [**5-4**].
Medications on Admission:
albuterol, Xanax, Reyataz, Truvada, Nizoral, levothyroxine,
lisinopril, methadone, omeprazole, oxycodone, Isentress, Norvir,
Androderm, and NPH insulin
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath.
2. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
5. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): decrease to 15ml 3x/day when Rifaximin available.
you should have2-3 stools/day. if greater than 4 stools,
decrease to 15ml 3x/day.
Disp:*1000 ml* Refills:*2*
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. levothyroxine 150 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: f/u with Dr. [**Last Name (STitle) **] [**5-4**] for further dosing.
Disp:*10 Tablet(s)* Refills:*0*
12. NPH insulin human recomb 100 unit/mL Suspension Sig:
Seventeen (17) units Subcutaneous once a day.
13. NPH insulin human recomb 100 unit/mL Suspension Sig: Five
(5) units Subcutaneous at bedtime.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. testosterone 5 mg/24 hr Patch 24 hr Sig: One (1)
Transdermal once a day.
16. methadone 10 mg Tablet Sig: Four (4) Tablet PO three times a
day: for pain.
Disp:*84 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] VNA
Discharge Diagnosis:
HCC
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if you have:
fever (101 or greater), chills, nausea, vomiting, jaundice,
increased abdominal pain, increased abdominal distension,
incision redness or bleeding.
You will take Lasix 20mg daily for the next 3 days.
Weigh yourself EVERY DAY. Write weight down on paper. Bring
record of weights to next appointment with Dr. [**Last Name (STitle) **]
[**Name (STitle) **] Dr.[**Name (NI) 8584**] office [**Telephone/Fax (1) 673**] if your weight increases
by 2 pounds in a day.
check your blood sugar prior to meals and write down results.
follow up with your PCP
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2103-5-4**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2103-5-4**] 10:40
Completed by:[**2103-5-3**]
ICD9 Codes: 5715, 2875, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7941
} | Medical Text: Admission Date: [**2195-10-18**] Discharge Date: [**2195-10-24**]
Service: MEDICINE
Allergies:
Penicillins / Valsartan / Ace Inhibitors
Attending:[**First Name3 (LF) 6578**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Endogastric duodenoscopy
colonoscopy
History of Present Illness:
Ms. [**Known lastname 57871**] is an 84 year old woman with a past medical history
significant for left femur fracture, repaired [**Date range (1) 57872**] and on
coumadin until [**10-8**], found with bright red blood per rectum at
[**Hospital3 **]. There was also a report of a ? vaginal
bleeding. The patient denies presyncope or hematemesis. She
refuses to participate in the rest of the interview because she
is very nervous.
Of note, in a conversation with her daughter, it appears that
Ms. [**Known lastname 57871**] had a hysterectomy about 1 year ago.
Past Medical History:
left femur fracture, repaired [**Date range (1) 57872**] and on coumadin until
[**10-8**]
HTN
CAD
DM-2
Parkinson's
Hypothyroid
Hyperlipidemia
Pancreatitis
h/o syncope
h/o hysterectomy
Social History:
TOB-denies
IVDA-denies
ETOH-denies
Family History:
noncontributory
Physical Exam:
Vitals: T 98.7 BP 119/70 HR 87 RR 18 O2 sat 100% on RA
Gen: anxious appearing awake lying in bed
HEENT: dry MM, EOMI, pupils reactive
CV: RRR
Pulm: CTAB no crackles
Abd: soft NT ND + BS no guarding no rebound obese
Ext: WWP DP 2+ bilaterally
skin: ecchymosis throughout
Pertinent Results:
[**2195-10-18**] 01:30PM HCT-28.0*
[**2195-10-18**] 07:48AM GLUCOSE-258* UREA N-37* CREAT-0.7 SODIUM-139
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
[**2195-10-18**] 07:48AM ALT(SGPT)-7 AST(SGOT)-18 ALK PHOS-66
AMYLASE-77 TOT BILI-0.4
[**2195-10-18**] 07:48AM LIPASE-40
[**2195-10-18**] 07:48AM NEUTS-79.5* BANDS-0 LYMPHS-15.4* MONOS-3.9
EOS-0.8 BASOS-0.4
[**2195-10-18**] 07:48AM PLT SMR-NORMAL PLT COUNT-395#
[**2195-10-18**] 07:48AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2195-10-18**] 07:48AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.023
Brief Hospital Course:
# GIB - Patient was noted to have maroon stool, observed in the
ED. The patient underwent EGD which revealed a Duodenal ulcer
in bulb, Erythema in the antrum compatible with gastritis,
Erythema and erosions in the second part of the duodenum
compatible with duodenitis, Small hiatal hernia. A colonoscopy
was prematurely terminated due to inadequate preparation. She
was started on [**Hospital1 **] Protonix. She then experienced an episode of
hypotension and tachycardia with passage of bloody stool. Her
hematocrit was noted to drop from 33 to 23 and she was
transferred to the MICU for further observation and transfusion
of PRBCs. A repeat EGD revealed ulcers in the distal bulb and
first part of the duodenum, one with a stigmata of bleeding
(thermal therapy), and an ulcer in the distal stomach body on
the greater curvature. This area was successfully cauterized.
Her HCT remained stable over the next 72 hours and she tolerated
a PO diet upon discharge.
The daughter and rehab center reported vaginal bleeding. A
speculum exam was performed revealing no stigmata of bleeding in
her vagina. Gynecology was curbsided and recommended no further
intervention since she has had a prior TAH/BSO.
# Parkinsons- Stable and continues on current medications.
# Urinary tract infection- Urinalysis revealed a urinary tract
infection, >100k GNR and was started on a 7d course of
levofloxacin.
Medications on Admission:
Aspirin
atenolol 12.5 QD
iron
levoxyl 150 QD
senna
zocor 80 mg
mirapex 0.125 QD
sinemet 25/100 QID
lasix 60 QD
glipizide XL 10
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
2. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Pramipexole Dihydrochloride 0.125 mg Tablet Sig: One (1)
Tablet PO QD ().
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Trazodone HCl 50 mg Tablet Sig: 0.25 Tablet PO HS (at
bedtime) as needed.
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours)
for 2 weeks: after 2 weeks, you may go to once per day. Ask your
doctor.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
11. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed.
12. Glipizide 10 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO once a day.
13. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO four times a day.
15. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
16. Morphine Sulfate 2 mg/mL Syringe Sig: One (1) Injection Q4H
(every 4 hours) as needed for 5 days: hold for sedation.
17. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
peptic ulcer disease
Parkinson's disease
urinary tract infection, complicated
Hypertension
Diabetes Mellitus
Hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
Please continue your home medications. Call your doctor if you
feel short of breath, dizzy, or if you have dark stool. You
should also call if you vomit blood or feel weak.
Do not take aspirin until after your appointment with Dr. [**First Name (STitle) 572**]
who will decide when you can start taking it.
Followup Instructions:
Please call your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 57873**] for an
appointment in the next 2 weeks. Your PCP should look up the
results of your h. pylori serologies.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Where: LM [**Hospital Unit Name 22399**] Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2195-12-3**] 2:15
ICD9 Codes: 5990, 4241, 2760, 2768, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7942
} | Medical Text: Admission Date: [**2118-7-6**] Discharge Date: [**2118-7-12**]
Service: SURGERY
Allergies:
Penicillins / Ranitidine / Erythromycin Base / Ciprofloxacin /
Enalapril / Bactrim
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
abdominal pain, distention, leukocytosis
Major Surgical or Invasive Procedure:
[**2118-7-6**] Exploratory lap with lysis of adhesions
History of Present Illness:
[**Age over 90 **]-year-old female with a history of prior small bowel resection
and repair of a
femoral hernia who presented with 24 hours of nausea, vomiting
and abdominal pain with distention. The patient was evaluated by
her outside hospital physician who sent her to the emergency
department. In the emergency department, she was found to be
significantly distended with diffuse
abdominal tenderness and cramping. Her white count was 22,000
with a lactate of 2.7. An abdominal CT scan was consistent with
bowel obstruction with proximal small bowel dilatation, distal
decompression. Based on these findings, the decision was made to
take her to the operating room for laparotomy.
Past Medical History:
R hip fx s/p repair
HTN
hypercholesterolemia
atrial fibrillation
GERD
duodenal ulcer
legally blind
severe OA
fluid retention
urinary incontinence
Social History:
Currently lives with her daughter- very involved in care.
Denies tobacco/ETOH.
Family History:
Non-contributory
Pertinent Results:
[**2118-7-6**] 04:30PM GLUCOSE-152* UREA N-24* CREAT-0.6 SODIUM-136
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-24 ANION GAP-13
[**2118-7-6**] 04:30PM CK-MB-6 cTropnT-<0.01
[**2118-7-6**] 04:30PM CALCIUM-7.6* PHOSPHATE-2.7 MAGNESIUM-1.9
[**2118-7-6**] 04:30PM WBC-5.1# RBC-3.22* HGB-9.8* HCT-30.4* MCV-94
MCH-30.3 MCHC-32.1 RDW-14.1
[**2118-7-6**] 04:30PM PLT COUNT-390
[**2118-7-6**] 04:30PM PT-12.2 PTT-31.1 INR(PT)-1.0
CHEST (PORTABLE AP)
Reason: s/p ex lap/ SOB low saturation
[**Hospital 93**] MEDICAL CONDITION:
s/p ex lap
REASON FOR THIS EXAMINATION:
s/p ex lap/ SOB low saturation
REASON FOR EXAMINATION: Decreased saturations.
Portable AP chest radiograph compared to [**2118-7-7**].
The NG tube was removed in the meantime interval.
There is worsening of bilateral perihilar opacities suggesting
worsening of pulmonary edema.
In addition, there is a significant increase in bilateral
pleural effusion. The heart size is mildly enlarged but
unchanged and there is also no change in the appearance of the
mediastinum.
IMPRESSION: Worsening pulmonary edema accompanied by increased
pleural effusions. These findings were communicated to Dr. [**Last Name (STitle) **]
during the time of dictation.
Cardiology Report ECG Study Date of [**2118-7-8**] 2:29:54 AM
Sinus tachycardia. Left ventricular hypertrophy with ST-T wave
changes.
Compared to the previous tracing of [**2118-7-6**] no diagnostic interim
change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
111 154 84 296/[**Telephone/Fax (2) 98653**] 174
Brief Hospital Course:
She was admitted to the Surgery Service and taken to the
operating room for an exploratory laparotomy and lysis of
adhesions. There were no intraoperative complications.
Postoperatively she did have episodes of decreased oxygen
saturations requiring supplemental oxygen. Her chest xray did
show some evidence of pulmonary edema and she was given IV
Lasix. Her oxygen was eventually weaned off and she is
saturating well.
A Speech and Swallow evaluation was also done because of concern
for aspiration; there was evidence of aspiration with thin
liquids. It is being recommended that she have thickened liquids
and that her medications be crushed and given in applesauce or
yogurt.
A Rheumatology consult was placed during her hospital stay
because of an elevated sed rate. In reviewing her paper work
from her previous rehab stay it appears that this was not a [**Last Name **]
problem associated with this hospitalization and that a
Rheumatology consult was initiated. She does have a history of
osteoarthritis but no history of PMR. It is recommended that she
follow up with the Rheumatologist at rehab for further workup of
this problem.
Physical therapy was consulted and has recommended that she go
to a rehab facility after hospital discharge.
Medications on Admission:
Norvasc 5'
Betaxolol eye gtts
Colace
Dulcolax
Lidoderm patch
Lopressor 25''
Protonix 40'
Dig .125'
Rosuvastatin 5'
Tylenol prn
Ultram 50 prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name **]: One (1) ML
Injection TID (3 times a day).
3. Insulin Regular Human 100 unit/mL Solution [**Last Name **]: One (1) dose
Injection four times a day as needed for per sliding scale: See
attached sliding scale.
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name **]:
[**2-1**] Adhesive Patch, Medicateds Topical QDAY ().
5. Betaxolol 0.25 % Drops, Suspension [**Month/Day (2) **]: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): apply to left eye .
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
8. Rosuvastatin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day): hold for HR <60; SBP <110.
10. Tramadol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6)
hours as needed for pain.
11. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day:
hold for HR <60.
12. Norvasc 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: hold
for SBP <110.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Stable
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**2-1**] weeks, call [**Telephone/Fax (1) 6439**] for an
appointment.
Completed by:[**2118-8-8**]
ICD9 Codes: 4280, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7943
} | Medical Text: Admission Date: [**2189-6-11**] Discharge Date:
Date of Birth: [**2115-4-20**] Sex: M
Service: CCU
NOTE: This is an addendum to Dr. [**Last Name (STitle) **] dictation which
describes the presentation, as well as the hospital course
through [**6-26**].
On [**6-26**], the patient was stable with an improved
congestive heart failure after his milrinone therapy with a
creatinine of 2.4 and a sodium of 129 and the he was
currently awaiting placement in rehabilitation. Over the
next three days, his creatinine began to rise and he had
fluid retention, increased peripheral edema and increased
crackles on exam. On [**6-29**], it was decided he was not
suitable for rehabilitation placement at that point and was
decompensating and was thus restarted on milrinone with
almost immediate symptomatic improvement. On [**6-30**], his
creatinine was 3.0 and sodium 123. His weight was 168.8
pounds, so he was started on milrinone at 0.28 mcg per kg per
minute.
Over the next several days, his creatinine began to decrease
and sodium began to increase. The patient had good
symptomatic improvement. On [**7-3**], the rate of milrinone
was increased to 37.5 mcg per kg per minute as he was being
evaluated for potential of home intravenous milrinone
therapy. Also, on [**7-3**], the patient spiked to a fever to
101.9?????? Fahrenheit with 15 white blood cells in his
urinalysis. He was thus started on a seven day course of
oral ciprofloxacin. The patient defervesced the following
day. On [**7-3**], his creatinine was down to 1.8 and his
sodium was up to 131 and his weight was continuing to
decrease, such that on [**7-5**] his weight was 157.3 down 10
pounds in less than a week. Also, on [**7-5**], he had
another gout flare in his right ankle and was started on
colchicine 0.6 mg q day, as well as a short prednisone taper.
During this time, the patient was followed by the heart
failure team to be evaluated for the possibility of
intravenous home milrinone versus intravenous milrinone at
rehabilitation facility. There was no rehabilitation
facilities that could take the patient with intravenous
milrinone and thus the milrinone was stopped on [**7-8**], at
which time his creatinine was 1.6, his sodium was 136 and his
weight was 154 pounds. Also, during the milrinone therapy,
his carvedilol dose was able to be increased to 4.685 mg [**Hospital1 **],
so he has continued to do well off milrinone and is currently
stable with PICC line placed for potential home milrinone
therapy should he require it. His insurance company
ultimately approved intravenous home milrinone should he need
it and he is currently stable and being discharged to
rehabilitation facility. In rehabilitation, he will need his
digoxin level and INR checked 2x per week.
DISCHARGE MEDICATIONS:
1. Carvedilol 4.685 mg po bid
2. Lisinopril 5 mg po qd
3. Digoxin 0.125 mg po q od
4. Mexiletine 150 mg po bid
5. Amiodarone 200 mg po bid
6. Coumadin 3 mg po q hs
7. Synthroid 0.125 mg po qd
8. Flomax 0.4 mg po qd
9. Lasix 120 mg po qd
10. Neurontin 100 mg po bid
Discharge summary should be held until the rehabilitation
facility is known, at which time it can be printed from the
computer.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**]
Dictated By:[**Last Name (NamePattern1) 104596**]
MEDQUIST36
D: [**2189-7-10**] 09:17
T: [**2189-7-10**] 10:22
JOB#: [**Job Number 33507**]
ICD9 Codes: 4280, 4254, 5849, 2761, 4019, 2449, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7944
} | Medical Text: Admission Date: [**2119-2-2**] Discharge Date: [**2119-2-7**]
Date of Birth: [**2047-3-19**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Iodipamide Meglumine
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Hypotension and hypoxia
Major Surgical or Invasive Procedure:
Central Line Placement [**2118-2-4**] and removal on [**2119-2-7**]
History of Present Illness:
71 F with HTN, dyslipidemia, recent pacer placement for sinus
arrest complicated by recurrent hemorrhagic pericardial
effusions, admitted to [**Hospital1 18**] for episode of hypoxia in the
setting of worsened chest pain and DOE; on [**2-3**] she is
transferred to the ICU for hypotension, new O2 requirement and
confusion.
.
She was reportedly doing well at rehab s/p hemorrhagic
pericardial effusion after PPM placement, until the day prior to
presentation, when she developed worsening chest pain and SOB.
She reported that the pain felt like it was "going around her
heart", was sharp, worse with deep inspiration, and radiated to
the left jaw. She also had SOB, with worsening DOE while walking
at rehab. She otherwise denied n/v, diaphoresis. No lower
extremity pain or swelling. She was found to have an O2 sat of
69% on RA. She was placed on a NRB with improvement in O2 sat to
89%. Sent to ED for evaluation.
.
ED Course: O2 sats >97% on 3L by NC, and SBP remained > 100. She
had a bedside focused echo which showed a "small effusion and no
wall motion abnormalities." Pulsus measurements in the ED
remained < 10 mm Hg. A subsequent formal TTE showed a small to
moderate circumferential pericardial effusion that was echo
dense, consistent with "blood, inflammation or other cellular
elements", without echocardiographic signs of tamponade. Overall
EF 70%. She also received a V/Q scan for an elevated D-dimer
(h/o contrast allergy) which showed multiple large and small
matched defects through out all lobes of the lungs, consistent
with COPD. It also showed an unmatched defect (greater on
perfusion) in the posterior left lower lobe, thought related to
shifting effusion upon position change from ventilation to
perfusion. The study was read as intermediate probability.
.
Hospital Course: patient was admitted to medical service. Today
([**2-3**]) patient had trigger episode with hypotension responsive to
IVF (75/48), new O2 requirement (96% on 2L), mental status
changes - found to be cool and diaphoretic; this prompted her
transfer to the ICU team. ABG at the time was 7.33/43/145.
.
Recent [**Last Name (un) 1724**] Course: Initially presented to [**Hospital3 **] with
syncope and found to have sinus pause with junctional escape of
35. She received PPM on [**1-10**] @ [**Last Name (un) 1724**]. On [**2119-1-13**] (2 days after
discharge for pacer implantation) came back to [**Last Name (un) 1724**] with chest
pain and palpitations and was found to be in atrial fibrillation
with a rapid ventricular response of 190. She was electrically
cardioverted, but remained hypotensive. She was found to have a
pericardial effusion with tamponade. A pericardiocentesis
drained 200 cc of hemorrhagic fluid. However, she had recurrent
effusion later that same day, and ultimately underwent
mediastinotomy, where she was found to have a small bleeding
vessel "at the site of her prior pericardiocentesis." Her atrial
lead could also be seen in the atrium, though it was noted not
to be protruding through, and was oversewn. Also of note, she
was evaluated here for SIADH - found to have normal urine Osm
(656) and low serum Osm (278), urine Na of 81; this resolved
spontanteously. She was discharged to [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] at [**Location (un) 78090**] on [**2119-1-23**].
Past Medical History:
Hypertension
Hyperlipidemia
Parkinson's
Seizure disorder
s/p PPM placement for sinus arrest with syncope ([**Hospital3 **]
[**2119-1-10**])
c/b hemorrhagic effusion and tamponade physiology from "leaking
vessel"
Cerebellar anerysm s/p coiling
Blind in left eye [**1-28**] aneurysm
Social History:
Lives with daughter's family. Current tobacco, ~1ppd x 50yr. No
EtOH or illicits.
Family History:
NC
Physical Exam:
Vitals - T 96.4, BP 107/67, HR 91, RR 18, O2 sat 97% 2L NC, wt
56.1 kg, pulsus 10 mm Hg
General - elderly female, NAD
HEENT - L eye medially deviated. R eye EOMI. OP clr, MM dry, no
JVD
CV - RRR, no rubs
Chest - decr BS at L base
Abdomen - soft
Back - non-tender
Extremities - no edema
.
Pertinent Results:
[**2-1**] VQ Scan: INTERPRETATION:
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 6 views
demonstrate multiplelarge and small defects through out all
lobes of the lungs, consistent with COPD.
Perfusion images in the same 6 views show matched defects with
the ventilation scan with a somewhat greater sized perfusion
defect seen in the posterior leftlower lobe, likely related to
shifting effusion upon position change fromventilation to
perfusion.
Chest x-ray shows a small left pleural effusion.
The above findings are consistent with an indeterminant
probability scan.
IMPRESSION: Indeterminant probability scan. Severe COPD.
[**2-5**] CXR:Comparison is made with prior study performed a day
earlier.
There has been progressive interval increase in
small-to-moderate right pleural effusion, moderate left pleural
effusion is unchanged as is left lower lobe retrocardiac
atelectasis. Left transvenous pacemaker leads terminate in the
standard position in the right atrium and right ventricle. Right
subclavian catheter tip remains in the proximal right atrium.
The aorta is elongated. Cardiac size is top normal. There is
engorgement of the pulmonary vasculature with no overt CHF.
Patient is post median sternotomy.
[**2119-2-1**] EKG: Sinus rhythm. T wave inversion in leads VI-V2 and T
wave flattening in leads aVL and V3 which is non-specific.
Ischemia should be considered. Clinical correlation is
suggested. No previous tracing available for comparison.
[**2119-2-3**] ECHO: The left ventricular cavity is small. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is not well seen. There is a moderate sized
pericardial effusion subtending the apex, right ventricular free
wall, and lateral wall. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements. There are
no echocardiographic signs of tamponade. No right atrial or
right ventricular diastolic collapse is seen.
Compared with the findings of the prior study (images reviewed)
of [**2118-2-2**], the findings are similar.
[**2119-2-1**] 05:15PM BLOOD WBC-12.3* RBC-4.87 Hgb-14.1 Hct-42.8
MCV-88 MCH-29.0 MCHC-33.0 RDW-14.6 Plt Ct-176
[**2119-2-5**] 02:01AM BLOOD WBC-8.6 RBC-3.58* Hgb-10.4* Hct-31.5*
MCV-88 MCH-29.0 MCHC-33.0 RDW-14.9 Plt Ct-157
[**2119-2-1**] 05:15PM BLOOD Neuts-82.1* Lymphs-13.5* Monos-4.0
Eos-0.3 Baso-0.1
[**2119-2-3**] 08:57PM BLOOD Neuts-92.4* Lymphs-4.2* Monos-3.3 Eos-0.2
Baso-0
[**2119-2-5**] 02:01AM BLOOD PT-13.0 PTT-34.8 INR(PT)-1.1
[**2119-2-1**] 05:15PM BLOOD D-Dimer-[**2076**]*
[**2119-2-5**] 02:01AM BLOOD Glucose-81 UreaN-17 Creat-0.5 Na-134
K-4.0 Cl-104 HCO3-25 AnGap-9
[**2119-2-3**] 12:45PM BLOOD ALT-8 AST-46* LD(LDH)-202 CK(CPK)-8*
AlkPhos-173* TotBili-0.4
[**2119-2-1**] 05:15PM BLOOD cTropnT-<0.01
[**2119-2-2**] 04:00AM BLOOD cTropnT-<0.01
[**2119-2-2**] 11:05AM BLOOD cTropnT-<0.01
[**2119-2-2**] 05:05PM BLOOD cTropnT-<0.01
[**2119-2-3**] 06:10AM BLOOD CK-MB-2 cTropnT-<0.01
[**2119-2-3**] 12:45PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2119-2-3**] 12:45PM BLOOD Albumin-2.4* Calcium-7.6* Phos-2.7 Mg-1.6
[**2119-2-5**] 02:01AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.5*
[**2119-2-2**] 11:05AM BLOOD Osmolal-272*
[**2119-2-3**] 06:10AM BLOOD TSH-3.9
[**2119-2-3**] 06:10AM BLOOD Free T4-1.3
[**2119-2-3**] 11:00PM BLOOD Cortsol-37.3*
[**2119-2-3**] 10:41AM BLOOD Lactate-1.6
[**2119-2-3**] 10:41AM BLOOD Type-ART pO2-145* pCO2-43 pH-7.33*
calTCO2-24 Base XS--3
Brief Hospital Course:
A/P: 71 F with HTN, dyslipidemia, recent pacer placement for
sinus arrest complicated by recurrent hemorrhagic pericardial
effusions, admitted to [**Hospital1 18**] for episode of hypoxia in the
setting of worsened chest pain and [**Hospital **] transferred to the ICU
for hypotension (75/48), new O2 requirement (96% on 2L) and
mental status changes. Was found to have Klebsiella UTI, was
started on broad spectrum ABX and then tailored to cipro.
Clinically improved, vitals stable >24hrs. Pt transferred back
to medicine floor on [**2-5**], where she remained until day of
discharge.
.
#) Klebsiella UTI/septicemia -- Pt presented with a high white
cell count and hypotension. She was started on broad spectrum
antibiotics. The urine culture grew Klebsiella, and with
subsequent sensitivities was changed to oral course of
ciprofloxacin. The WBC count improved and the hypotnesion
resolved on antibiotics. End date for ciprofloxacine is [**2119-2-17**]
for 14 day course.
.
#) Atrial fibrillation- Atrial fibrillation with RVR in the
setting of sepsis. She was hemodynamically stable without signs
of tamponade (pulses paradoxes <10). She initially required 15
iv metoprolol and 10 mg iv dilt to control her rate, and was
placed on dilt gtt temporarily for rate control. She continued
on her previous dose of amiodarone. She was not anticoagulated
given her recent history of hemorrhagic effusion. She converted
to Sinus Rhythm (SR) on dilt gtt and remained in SR for the
remainder of her hospitalization. She was transitioned to PO
diltiazem 30mg QID and dilt gtt was weaned. Following
conversion to sinus rhythms, the pt remained asymptomatic
throughout the remainder of her admission. We discharged the pt
on PO diltiazem and her outpt dose of amiodarone.
.
#) anemia, acute blood loss: In the setting of volume repletion
for hypotension/sepsis, and right subclavian line placement.
Guaiac has been negative. At rehab, the pt should have repeat
Hct drawn for the next 2 days to ensure that Hct does not
continue to decrease. At discharge, iron studies and vitamin
B12/folate were pending. Please call for results.
.
#) Hypoxia - initially pt required 2-3L supplemental O2 by nasal
cannula to maintain O2 sats. Given her long tobacco history, and
CXR findings, she likely has COPD and may now be at baseline. Pt
initially reported some symptoms of pleuritic CP, thus raising
the question of PE --> VQ scan was performed and demonstrated
multiple matched defects, cw COPD but intermediate probability
for PE. However, LENIs were negative. Anticoagulation was not
considered given recent h/o hemorrhagic pericardial effusion.
CXR did demonstrate [**Last Name (LF) 78091**], [**First Name3 (LF) **] pt was started on incentive
spirometry. Her hypoxia significantly improved throughout her
hospitalization, and she no longer had an O2 requirement by day
of discharge.
.
#) Pericardial effusion - no evidence of tamponade physiology on
exam: Pulsus wnl, hemodynamically stable. TTE was performed on 2
occasions during this hospitalization, both with no
echocardiographic signs of tamponade. She did not demonstrate
any symptoms or signs of tamponade during her admission.
.
#) Hyponatremia - SIADH. Admitted with Na of 129 but clinically
dehydrated, and with Bu:Cr > 20. Pt was administered NS to
alleviate hypotension. Serum Na improved to 130-134, with no
clinical signs of dehydration. [**Last Name (un) **] stim test and TSH were
normal. Pt did not demonstrate any sx/signs of hyponatremia this
hospitalization. At rehab, her SIADH can likely be managed with
free H2O restriction initially 2L and then less if needed and
close monitoring.
.
#) HTN - pt was hypotensive at admission, most likely due to
urosepsis/SIR. Thus, hypertension meds were held this admission.
Diltiazem was initiated for atrial fibrillation and worked well
for her hypotension throughout the remainder of her stay.
Lisinopril can be reinitiated at the discretion of her rehab
physcian.
.
#) Parkinsons: we continued outpt regimen of Sinemet. Pt
remained stable this admission.
.
#) Seizure Disorder: we continued outpt regimen of Depakote; pt
remained stable.
.
#) Code Status: was changed to full this admission (pt changed
from DNR/I to full code after discussions with family).
Medications on Admission:
Combivent
Amiodarone 200 qd
Lipitor 20 qd
Sinemet 25/100 2 tabs tid
Depakote 250 tid
folate 1 qd
lisinopril 10 qd
senna
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
three times a day.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed.
9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location 1820**] Ctr.
Discharge Diagnosis:
Primary:
1) Urosepsis
2) Hypoxia due to atelectasis- resolved
3) Pericardial effusion- hemorrhagic- stable
4) Atrial fibrillation
.
Secondary:
HTN
Hyperlipidemia
Parkinson's
Seizure disorder
Discharge Condition:
Stable, improving.
Discharge Instructions:
Please return to the emergency room or call your rehab doctor if
you develop dizziness, heart racing, fevers, chills, confusion,
abdominal pain, nausea, vomiting, or any other worrisome
symptoms.
.
The following changes were made to your medications:
ADDED:
1) Ciprofloxacin- for treatment of your urinary tract infection
2) Diltiazem- for treatment of your atrial fibrillation.
3) Ipratropium-Albuterol Inhaler- prescribed to improve your
breathing/oxygenation
We stopped your lisinopril as we added diltiazem which is also a
blood pressure pill.
Followup Instructions:
Follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-28**] weeks.
ICD9 Codes: 5990, 5119, 2851, 5180, 496, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7945
} | Medical Text: Admission Date: [**2140-6-25**] Discharge Date: [**2140-7-1**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Septic shock
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
Ms. [**Known lastname 20598**] is an 84yo female with PMH significant for c.diff
sepsis, CAD, and atrial fibrillation who is being admitted to
the MICU for septic shock. Patient was recently discharged to
rehab on [**6-17**] after being hospitalized for septic shock thought
to be [**1-2**] c. diff infection. She underwent an elective left
total hip replacement at [**Hospital1 2025**] on [**4-27**]. She subsequently developed
diarrhea and was admitted to an OSH in [**Month (only) **] and was found to be
positive for c.diff toxin. She underwent an CT abd/pelvis during
this time which showed diffuse colonic wall thickening with
generalized mesenteric inflammation/edema. She was then
transferred to [**Hospital1 18**] for further work-up and during this time
required pressors to maintain her blood pressure.
During her recent admission, she was admitted to the [**Hospital Unit Name 153**]. She
completed a course of PO Vancomycin for c.diff. Her hospital
course was also complicated by acute on chronic diastolic CHF
and she was placed on a Lasix gtt and was diuresed aggressively.
She also went into afib with RVR and was loaded with Amiodarone
and was anti-coagulated on Coumadin. She was already on Coumadin
given her history of DVT. She was discharged to [**Hospital 20605**] on [**6-17**].
This evening, the patient was found to be lethargic and febrile
to 102.5. Blood and urine cultures were drawn and her urine was
noted to be concentrated, foul, and dark. She received Tylenol
2gm and was started on IVFs. In route to [**Hospital1 18**], she was
hypotensive and received IVFs.
In the ED, initial vitals were T 100.8 Tmax 101.5 BP 71/56 AR 96
RR 16 O2 sat 91% RA, 96% on 4L. She received Vancomycin, Cipro
400mg IV, and Flagyl 500mg IV. A RIJ central line was placed and
she received a total of 4L NS.
Past Medical History:
1)CAD s/p stenting of LCx and RCA per OMR cath report [**12-4**]
2)PAF
3)C. diff colitis
4)LE DVT
5)HTN
6)Hyperlipidemia
7)Urinary incontinence
8)Osteoporosis
9)s/p ORIF and LTH
10)s/p hepatobiliary surgery
[**42**])s/p hysterectomy
12)s/p cholecystectomy
[**44**])s/p RTK x 1, LTK x 2
Social History:
Lives in [**Location 7658**], MA with husband; 3 children live outside of
MA; no ETOH, tobacco.
Family History:
Non-contributory
Physical Exam:
vitals T 97.6 BP 87/45 AR 120 RR 15 O2 sat 100% on NRB
Gen: Awake and alert, mentating well
HEENT: MMM
Heart: Irregularly irregular, 2/6 systolic murmur
Lungs: CTAB, crackles at posterior bases
Abdomen: Soft, NT/ND, +BS
Extremities: [**12-2**]+ DP/PT pulses bilaterally; PICC line in place
Pertinent Results:
[**2140-6-25**] 09:05PM BLOOD WBC-22.4*# RBC-3.08* Hgb-9.2* Hct-27.4*
MCV-89 MCH-29.9 MCHC-33.6 RDW-16.1* Plt Ct-278
[**2140-6-30**] 05:48AM BLOOD WBC-8.9 RBC-3.80* Hgb-11.2* Hct-34.8*
MCV-92 MCH-29.4 MCHC-32.1 RDW-15.7* Plt Ct-248
[**2140-6-25**] 09:05PM BLOOD Glucose-78 UreaN-33* Creat-1.0 Na-137
K-3.9 Cl-106 HCO3-19* AnGap-16
[**2140-6-30**] 05:48AM BLOOD Glucose-80 UreaN-19 Creat-0.8 Na-140
K-3.9 Cl-115* HCO3-20* AnGap-9
[**2140-6-26**] 05:41PM BLOOD Albumin-2.9* Calcium-7.1* Phos-2.4*
Mg-1.7
[**2140-6-30**] 05:48AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.8
[**2140-6-28**] 07:23AM BLOOD Vanco-17.8
[**2140-6-25**] 09:05PM BLOOD cTropnT-0.02*
[**2140-6-26**] 02:49AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2140-6-25**] 09:05PM BLOOD CK(CPK)-19*
[**2140-6-26**] 02:49AM BLOOD CK(CPK)-21*
.
C. diff [**2140-6-25**]:
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2140-6-26**]):
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
CXR [**2140-6-27**]:
The right internal jugular line tip terminates in mid-distal
SVC. The right PICC line demonstrated on the prior study cannot
be seen on the current exam, most likely removed in the meantime
interval. Significant dextroscoliosis is again noted with
subsequent left mediastinal shift. There is no change in the
appearance of the cardiac silhouette. Interval increase of the
bilateral right more than left pleural effusions is present with
overall no appreciable change in the degree of vascular
engorgement. No overt pulmonary edema is demonstrated. There is
no pneumothorax.
.
Left wrist film due to wrist pain [**2140-6-14**]:
IMPRESSION:
1. No acute fracture.
2. Widening of the scapholunate interval is compatible
scapholunate
ligamentous injury.
3. Severe degenerative changes of the STT and first CMC joints.
Apparent
collapse of the trapezoid and trapezium as described.
.
[**2140-6-4**] previous admission L UE U/S:
IMPRESSION: No evidence of DVT of the left upper extremity.
Brief Hospital Course:
Ms. [**Known lastname 20598**] is an 84yo female with PMH as listed above who
presents with septic shock.
1)Septic shock: Patient presented with hypotension, tachycardia,
leukocytosis which was consistent with diagnosis of septic
shock. She started having increasing amounts of diarrhea at the
rehab facility and her urine was noted to be dark, concentrated,
and foul smelling at rehab. She was recently admitted to [**Hospital1 18**]
MICU for sepsis [**1-2**] c.diff. On admission, sepsis protocol was
initiated. She was pan-cultured and started on broad spectrum
antibiotics-Cipro, Vancomycin IV, PO Vancomycin, and Flagyl. The
c.diff toxin came back positive. Her antibiotic regimen was
weaned down to Flagyl IV and PO vancomycin. She should continue
Flagyl for 2 week course and she should continue the Vancomycin
PO which should be tapered over the next few months.
Vancomycin taper as follows:
125mg PO four times daily for 6 days (last dose q6hrs is on
[**2140-7-6**])
125mg PO twice daily for 7 days
125mg once daily for 7 days
125mg every other day for 7 days
125mg every 3 days for 14 days
2)Diastolic CHF: Patient has history of diastolic CHF and
required aggressive diuresis with a lasix gtt during her last
admission. Cardiac enzymes were negative. She initially appeared
volume overloaded on exam but is likely intravascularly dry
based on her CVP since she presented with sepsis. Her Lasix was
held given her hypotension and then restarted. She was restsrted
on her home lasix regimen of lasix 20mg PO BID.
3)Atrial fibrillation: Patient first diagnosed with afib w/RVR
during last admission. She is also anticoagulated with Coumadin.
On admission, she was restarted on Amiodarone. The beta-blocker
was held in light of her hypotension but then restarted after a
few days. Anti-coagulation was also held given the
supratherapeutic INR and coumadin 1.5mg PO daily was restarted
today when her INR was 2.1 (see details below).
4)Anemia: Baseline hematocrit per OMR is low to mid 30's. She
was transfused 2 units pRBCs in light of her hypotension. She
was also maintained on iron supplements. Her HCT has since been
stable.
5)Coagulopathy: Patient presented with elevated INR on
admission. Remains elevated on transfer to medical floor. Likely
[**1-2**] antibiotics she had received. She was restarted on coumadin
1.5mg PO daily today and should have daily INRs while at rehab
given her c. diff history, amlodipine, and antibiotic regimen.
6)Non anion gap acidosis: Likely [**1-2**] diarrheal losses and she
appears to be compensating based on the pH. Her bicarbonate
level was followed daily.
7)Hypertension: Her outpatient anti-hypertensive regimen was
initially held given hypotension and sepsis. The beta-blocker
was restarted after her hypotension resolved. On several
occasions in the last few days we have administered her
beta-blocker despite SBP in the high 90s in order to control her
heart rate as she has A fib and diastolic heart failure.
Medications on Admission:
Aspirin 325mg PO daily
Clotrimazole 1% cream [**Hospital1 **]
Acetaminophen 325-650mg PO Q6H PRN
Ferrous Sulfate 325mg PO daily
Warfarin PO daily
Metoprolol Tartrate 50mg PO TID
Atrovent neb
Lasix 20mg PO BID
Lansoprazole 30mg PO BID
Amiodarone 200mg PO daily
Discharge Medications:
1.Ferrous Sulfate 325 mg PO DAILY
2.Ipratropium Bromide 0.02 % Solution 1 Inhalation Q6H PRN
3.Amiodarone 200 mg Tablet PO DAILY
4.Sodium Chloride 0.9 % Syringe 10 ML Injection daily and PRN as
needed for line flush.
5.Acetaminophen 325 mg Tablet 1-2 Tablets PO Q8H PRN
6.Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup 5 ML PO Q6H
as needed for [**Hospital1 **].
7.Metoprolol Tartrate 50 mg PO TID
8.Trazodone 25 mg Tablet PO HS
9.Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10.Furosemide 20 mg Tablet PO BID
11.Warfarin 1 mg Tablet, 1.5 Tablets PO DAILY
12.Vancomycin 125 mg Capsule PO Q6H for 7 days
125mg PO twice daily for 6 days (last dose q6hrs is on [**2140-7-6**])
125mg once daily for 7 days
125mg every other day for 7 days
125mg every 3 days for 14 days
13.Lansoprazole 30 mg Capsule PO BID
14.Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback, One
Intravenous Q8H for 9 days: Last dose to be given on [**2140-7-9**]
Total duration was 14 days.
15. Aspirin 325 mg Tablet PO daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary diagnosis:
1. c. diff sepsis
2. Acute on chronic diastolic heart failure
.
Secondary diagnosis:
1. A fib
2. Coagulopathy
3. Anemia
4. Hypertension
Discharge Condition:
Good. Diarrhea is improving.
Discharge Instructions:
You were admitted with c. diff sepsis. You were treated with IV
fluids and with flagyl IV and PO vancomycin. Your infection has
greatly improved and you need to finish a two week course of IV
flagyl (last day [**2140-7-9**]) and you will take PO vancomycin for the
next 6 weeks with the following taper:
125mg PO four times daily for 6 days (last dose q6hrs is on
[**2140-7-6**])
125mg PO twice daily for 7 days
125mg once daily for 7 days
125mg every other day for 7 days
125mg every 3 days for 14 days
.
Your Coumadin was held during your hospitalization because your
INR was supertherapeutic. You are being discharged on Coumadin
1.5mg PO daily and you should have your INR followed daily at
rehab as you are on a number of medications that can make your
INR.
.
Please note we changed the doses of the following medications:
Coumadin.
.
We have started you on the following new medications:
1. Flagy IV
2. Vancomycin PO
3. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup 5 ML PO Q6H
as needed for [**Date Range **].
4.Trazodone 25 mg Tablet PO HS
5.Benzonatate 100 mg Capsule One Capsule PO TID for [**Date Range **].
.
You have been discharged on all your other home medications at
their usual doses.
.
Please keep pt on telemetry for A fib
.
Please return to the hospital if you develop worsening diarrhea,
abdominal pain, fevers, bleeding, shortness of breath, or chest
pain.
Followup Instructions:
Please schedule a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 572**]
for 2 weeks from now. Phone number [**Telephone/Fax (1) 1983**].
.
Infectious disease follow up appointment on [**2140-8-15**] at 10:00am
with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 4020**] at [**Hospital1 18**] [**Hospital Ward Name 517**] [**Last Name (NamePattern1) 20606**]. Phone number ([**Telephone/Fax (1) 4170**]
Completed by:[**2140-7-1**]
ICD9 Codes: 5990, 2762, 4280, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7946
} | Medical Text: Admission Date: [**2191-1-12**] Discharge Date: [**2191-1-17**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
male with persistent cough found to have left upper lobe mass
on chest x-ray. Chest CT on [**2190-11-9**] confirmed the presence
of a 6 cm cavitary left upper lobe mass and right hilar
lymphadenopathy. The patient has lost about 30 pounds in the
past six weeks. Fatigued on standing. Persistent cough.
Right shoulder pain for the past six weeks with certain
movements. No headaches.
PAST MEDICAL HISTORY: Status post XRT eight years ago for
prostate cancer. Mild hypertension. Pedal edema. AAA 2.4
cm in [**5-9**].
PAST SURGICAL HISTORY: None.
ALLERGIES: None.
MEDICATIONS: Aspirin 81 mg twice weekly.
PHYSICAL EXAMINATION: The patient was a well appearing
normal in no acute distress. HEENT pupils equally round and
reactive to light. No scleral icterus. Lungs clear to
auscultation bilaterally. Heart regular rate and rhythm, no
murmurs. Abdomen negative. Extremities no cyanosis,
clubbing or edema. Neuro no focal deficits.
LABORATORY DATA: CAT scan on [**2190-11-9**] showed a 6 cm large
cavitary left upper lobe mass and 2 cm right hilar mass. PET
scan reported no peripheral mets, but question mediastinal
involvement.
HOSPITAL COURSE: The patient was admitted on [**2191-1-12**] and was
taken directly to the operating room where left upper lobe
resection and ribs two, three and four resections were
performed. The patient did all right postoperatively and was
transferred to the surgical ICU postoperatively, intubated.
On transfer the patient didn't have any problems
postoperatively. This was particularly important because the
patient was an extremely difficult intubation. The patient
had an epidural in place for pain. He received Kefzol
perioperatively. He did have some postoperative oliguria
requiring periodic fluid boluses. Chest tubes were in place
and to suction.
On postoperative day one the patient was successfully
extubated. He had his diet advanced successfully and was
heplocked. He was transferred to the floor. He stayed on
the floor for another three days secondary to high chest tube
output. On [**2191-1-17**] the chest tubes were removed
successfully. His epidural was removed and the patient was
changed to p.o. pain medication. He is doing well and will
be discharged in the morning to a rehab facility.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern4) 12487**]
MEDQUIST36
D: [**2191-1-17**] 16:05
T: [**2191-1-17**] 17:09
JOB#: [**Job Number 53753**]
ICD9 Codes: 4019, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7947
} | Medical Text: Admission Date: [**2111-6-16**] Discharge Date: [**2111-6-26**]
Date of Birth: [**2065-6-19**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
septic shock
Major Surgical or Invasive Procedure:
[**2111-6-17**]: ERCP
History of Present Illness:
45 yo F with recent admission for gallstone pancreatitis s/p
ERCP w/ pseudocyst now transferred from [**Hospital3 3583**] with
hypotension, leukopenia and gram negative rod bacteremia.
Past Medical History:
PMH: h/o gallstone pancreatitis, thoracic outlet syndrome s/p
rib resection, with chronic pain
PSH: CCY [**2100**], umbilical hernia [**2095**], epigastric incisional
hernia [**2103**]
Family History:
N/A
Physical Exam:
On discharge:
AFVSS
Gen: NAD
RRR
CTAB
Abd: soft, mild distended, mild TTP in epigastrium, +BS
Ext: WWP
Pertinent Results:
[**2111-6-16**] 08:12PM BLOOD WBC-7.7 RBC-2.82* Hgb-9.5* Hct-28.8*
MCV-102* MCH-33.7* MCHC-33.0 RDW-13.8 Plt Ct-110*#
[**2111-6-18**] 01:40AM BLOOD WBC-8.4 RBC-2.97* Hgb-9.9* Hct-29.4*
MCV-99* MCH-33.2* MCHC-33.5 RDW-15.1 Plt Ct-97*
[**2111-6-21**] 02:32AM BLOOD WBC-7.5 RBC-2.98* Hgb-9.7* Hct-28.7*
MCV-96 MCH-32.5* MCHC-33.8 RDW-15.1 Plt Ct-146*
[**2111-6-24**] 04:23AM BLOOD WBC-13.6* RBC-3.25* Hgb-10.3* Hct-32.5*
MCV-100* MCH-31.6 MCHC-31.6 RDW-15.8* Plt Ct-475*#
[**2111-6-25**] 04:48AM BLOOD WBC-11.4* RBC-3.22* Hgb-10.4* Hct-32.4*
MCV-101* MCH-32.3* MCHC-32.1 RDW-15.5 Plt Ct-538*
[**2111-6-16**] 08:12PM BLOOD Fibrino-185 D-Dimer-5454*
[**2111-6-17**] 03:30PM BLOOD Fibrino-322#
[**2111-6-21**] 02:32AM BLOOD Fibrino-322
[**2111-6-16**] 08:12PM BLOOD Gran Ct-7200
[**2111-6-16**] 08:12PM BLOOD Glucose-142* UreaN-14 Creat-0.9 Na-141
K-4.1 Cl-117* HCO3-16* AnGap-12
[**2111-6-17**] 03:30PM BLOOD Glucose-100 UreaN-12 Creat-0.6 Na-137
K-3.9 Cl-113* HCO3-16* AnGap-12
[**2111-6-20**] 02:06AM BLOOD Glucose-110* UreaN-3* Creat-0.4 Na-140
K-3.5 Cl-107 HCO3-27 AnGap-10
[**2111-6-24**] 04:23AM BLOOD Glucose-107* UreaN-16 Creat-0.5 Na-138
K-4.7 Cl-104 HCO3-27 AnGap-12
[**2111-6-25**] 04:48AM BLOOD Glucose-104 UreaN-15 Creat-0.5 Na-138
K-4.4 Cl-105 HCO3-25 AnGap-12
[**2111-6-16**] 08:12PM BLOOD ALT-126* AST-251* LD(LDH)-302*
AlkPhos-199* Amylase-31 TotBili-1.2
[**2111-6-17**] 02:29AM BLOOD ALT-137* AST-210* CK(CPK)-91 AlkPhos-224*
Amylase-39 TotBili-2.5*
[**2111-6-17**] 03:30PM BLOOD ALT-120* AST-110* AlkPhos-231* Amylase-33
TotBili-3.5*
[**2111-6-18**] 01:40AM BLOOD ALT-96* AST-79* AlkPhos-223* Amylase-28
TotBili-2.9*
[**2111-6-19**] 01:48AM BLOOD ALT-65* AST-38 AlkPhos-251* TotBili-2.3*
[**2111-6-20**] 02:06AM BLOOD ALT-53* AST-30 AlkPhos-310* TotBili-2.2*
[**2111-6-21**] 02:32AM BLOOD ALT-42* AST-25 AlkPhos-336* Amylase-29
TotBili-1.3
[**2111-6-22**] 05:20AM BLOOD ALT-33 AST-18 AlkPhos-333* TotBili-0.8
[**2111-6-25**] 04:48AM BLOOD ALT-22 AST-22 LD(LDH)-240 AlkPhos-277*
Amylase-42 TotBili-0.6
[**2111-6-16**] 08:12PM BLOOD Lipase-28
[**2111-6-17**] 02:29AM BLOOD Lipase-21
[**2111-6-17**] 03:30PM BLOOD Lipase-11
[**2111-6-18**] 01:40AM BLOOD Lipase-9
[**2111-6-21**] 02:32AM BLOOD Lipase-24
[**2111-6-25**] 04:48AM BLOOD Lipase-40 GGT-215*
[**2111-6-25**] 04:48AM BLOOD Albumin-3.6 Calcium-9.2 Phos-4.9* Mg-2.0
[**2111-6-16**] 08:12PM BLOOD Albumin-2.7* Calcium-5.7* Phos-2.5*#
Mg-1.2* UricAcd-3.9
[**2111-6-21**] 02:32AM BLOOD Albumin-2.5* Calcium-8.1* Phos-2.9 Mg-2.0
[**2111-6-23**] 04:09AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.2
.
CT abd/pelvis: [**2111-6-22**]
IMPRESSION:
1. Marked improvement of the pancreatitis and pseudocysts, with
a residual
pseudocyst near the body of the pancreas measuring 3.5 cm.
2. Small bilateral pleural effusions, the left is larger and the
right is new from prior study.
3. Multiple low-attenuating foci within a large uterus, likely
represents degenerating fibroids.
4. Stable hepatic cysts.
Brief Hospital Course:
45 yo F with recent admission for gallstone pancreatitis s/p
ERCP w/ pseudocyst now transferred from [**Hospital3 3583**] with
hypotension, hypoxia, acidemia, leukopenia and gram negative rod
bacteremia. Admitted intubated and sedated on pressors, first to
MICU and then transferred to SICU. Broad spectrum abx were
given. Review of her CT scan from [**Hospital3 3583**] showed
resolving pancreatitis, no abscess. However, her LFTs were
elevated, notably her Tbili=2.5. A RUQ u/s showed: No
intrahepatic or extrahepatic biliary dilatation.
Nonvisualization of the pancreas and peripancreatic region. Two
small liver cysts. The GI team was consulted and felt that ERCP
with stent placement was indicated. This was performed on
[**2111-6-17**]. This showed sphincterotomy was widely patent, mormal
bliliary tree, and a bilary stent was placed.
Cultures from [**Hospital3 3583**] grew out Enterobacter sensitive to
cefepime. Thus her abx were switched to cefepime.
She was weaned off her pressors and then weaned off of the vent
on HD5. She was then transferred to the floor.
A follow-up CT on [**6-22**] showed Marked improvement of the
pancreatitis and pseudocysts, with a residual pseudocyst near
the body of the pancreas measuring 3.5 cm.
Of note, she was on TPN during her hospitalization, but was
weaned off and tolerating a regular low fat diet by the day of
discharge.
All cultures from this hospitalization were negative (bld,
urine, cath tip).
She had had 11 days of abx, and was discharged on po cipro for 3
more days for a total course of 14 days.
On the day of discharge she was in stable condition, Afebrile,
VSS, tolerating a regular low fat diet, had had a bowel movement
the day prior and continued to pass flatus, was making adequate
urine with no foley and pain was well=controlled on po pain
medications.
Medications on Admission:
diazapam 5', amytriptyline 50', oxycodone 15''', vicodin 500'''
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed: Do not drive or drink alcohol while taking
this. take a stool softener while taking this.
Disp:*40 Tablet(s)* Refills:*0*
2. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed.
3. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take this while taking taking your narcotic pain
medications.
Disp:*60 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days: Please take all of your antibiotics.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis
gallstone Pancreatitis
Discharge Condition:
stable
Discharge Instructions:
Please contact us or seek medical attention immediately for any
increased abdominal pain, abdominal distention, nausea,
vomiting, chest pain, shortness of breath, or any other
concerning signs or symptoms.
Please continue to eat a low fat diet until instructed
otherwise.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) 2819**]. Please call his office for an
appointment: ([**Telephone/Fax (1) 6347**]
Please also follow-up with Dr. [**Last Name (STitle) **], please call [**Telephone/Fax (1) 65629**]
for your appointment. It is currently scheduled for [**2111-7-16**] at
11am. Please call to verify.
ICD9 Codes: 0389, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7948
} | Medical Text: Admission Date: [**2123-11-19**] Discharge Date: [**2123-11-23**]
Date of Birth: [**2043-2-23**] Sex: M
Service: MEDICINE
Allergies:
Cipro
Attending:[**Known firstname 134**]
Chief Complaint:
Fever, malaise, fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80yoM with a history of DM, PVD, s/p mechanical AVR (19 years
ago) for AI is transferred from [**Hospital6 3105**] after
initially presenting with a fever and s/p a fall. The patient
was apparently in his USOH until two days prior to admission
when per his wife had chills. He then got up to go to bed and
fell, unwitnessed, no LOC. He got up and went to the kitchen
and his wife noticed he had an abrasion on his head, she said he
never lost consciousness and it seemed that he had tripped on
the stairs. He was walking normally and had normal speech. He
then went to sleep. The next a.m. he awoke and continued to
have chills, he then went to the bathroom. While on the toilet
he asked his wife for his jacket as he felt very cold. When she
arrived with his jacket he had shaking chills and was conscious
and conversive. Then he all of a sudden started staring
straight ahead and was no longer conversing and seemed to have
lost consciousness. His wife called 911 and she returned to
find him still on the toilet but leaning on the wall. He had no
abnormal movements while unconscious and no abnormal eye
movements. Per wife his speech now seems the same as his speech
when he is not wearing his dentures.
.
No measured temps at home, he has been more somnolent and having
body aches over the past 2 weeks. No cough or rhinorrhea. No
urinary symptoms. No chest pain or shortness of breath per his
wife. [**Name (NI) **] [**Name2 (NI) **] contacts but does have 8 grandchildren. No recent
dental work.
.
At [**Hospital3 **] his initial BP was 200/110, he was noted to
have a superficial abrasion on his R scalp and a negative Head
CT. He was given IV labetalol and his BP then was 180/90. He
was noted to be febrile to 102 F and blood cultures were drawn,
an LP was performed which was negative, and he was given 2g IV
ceftriaxone. In addition he was noted to have "seizure like"
activities in the ER and was given IV ativan.
On review of systems, he denies any headache, blurred vision, he
states he has had difficulty speaking for the last 2 days.
Denies any weakness or numbness. No shortness of breath or
orthopnea, no Chest pain or discomfort. No abdominal pain. No
diarrhea or constipation, last BM today and was normal. No
blood in stool or melena.
Past Medical History:
1. Coronary artery disease s/p CABG (1 Vessel in [**2104**] with AVR)
2. Hypertension
3. Dyslipidemia
4. Diabetes mellitus on PO meds only
5. Peripheral [**Year (4 digits) 1106**] disease
6. Cerebrovascular accident in [**2114**] manifest by slurred speech
and L hand paresthesia.
7. Transient ischemic attack with therapeutic INR so INR range
increased to 3-4 range
8. bladder cancer in [**2113**], s/p resection
9. CRI
PAST SURGICAL HISTORY:
1. [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] aortic valve replacement [**2104**].
2. One vessel coronary artery bypass graft.
3. Status post bladder resection for bladder carcinoma in '[**13**]
4. Status post femoral popliteal bypass in [**2115-1-19**]
5. [**2119-12-7**]-Left lower extremity angiography, angioplasty of
anterior tibial artery, angioplasty and stenting of
superficial femoral artery.
Social History:
-Tobacco history: denies
-ETOH: denies
-Illicit drugs:
lives with wife, independent in ADLs, functional at baseline
Family History:
Mother with DM
Father with DM and renal failure
Physical Exam:
VS: T 98.7 BP 154/84 HR 71 RR 18 O2 sat 95% on RA
GENERAL: NAD, AOX2, date is [**12-19**] but knows it is
Halloween and year [**2121**].
HEENT: JVP 8. OP clear, MM dry, sclera anicteric, PERRL, EOMI,
conjunctiva are pink without lesions, no carotid bruits
CARDIAC: RRR, [**2-24**] diastolic murmur at LUSB, no thrill, no
radiation
PULM: Dullness at R base, otherwise CTAB
ABD: SOFT, NT, ND, no masses or organomegaly, BS+
EXT: doppler DP and PT bilaterally, warm, no c/c/e
NEURO: as above AOx2, able to follow commands and answer
questions appropriately. PERRL, EOMI, CN2-12 intact. Slightly
dysarthric speech but no assymetry of mouth and upper jaw is
adentate. [**5-24**] stregnth in UE bicep, tricep, deltoid, grip,
wrist flex / extend. [**5-24**] stregnth in LE quad, hams, abduct,
adduct, dorsiflex, plantar flex. Normal sensation to light
touch throughout. Diminished reflexes in UE brachioradialis and
biceps but bilat symmetric and 1+ bilat patellar reflexes bilat
symmetric. Toes downgoing.
Pertinent Results:
[**2123-11-23**] 07:25AM BLOOD WBC-7.7 RBC-3.71* Hgb-11.6* Hct-34.7*
MCV-94 MCH-31.3 MCHC-33.5 RDW-13.9 Plt Ct-197
[**2123-11-19**] 12:09PM BLOOD Neuts-79.0* Lymphs-15.0* Monos-5.4
Eos-0.4 Baso-0.4
[**2123-11-22**] 06:55AM BLOOD PT-33.8* PTT-35.0 INR(PT)-3.5*
[**2123-11-19**] 12:09PM BLOOD Fibrino-579*#
[**2123-11-19**] 12:09PM BLOOD ESR-44*
[**2123-11-23**] 07:25AM BLOOD Glucose-114* UreaN-47* Creat-2.2* Na-141
K-4.3 Cl-110* HCO3-25 AnGap-10
[**2123-11-19**] 12:09PM BLOOD ALT-16 AST-35 LD(LDH)-298* CK(CPK)-1263*
AlkPhos-142* TotBili-0.5
[**2123-11-19**] 12:09PM BLOOD CK-MB-7 cTropnT-0.07*
[**2123-11-22**] 06:55AM BLOOD Mg-1.9
[**2123-11-19**] 12:09PM BLOOD CRP-4.3
[**11-21**] MR [**Name13 (STitle) **]:
1. No acute infarction.
2. Patent major intracranial arteries, without flow limiting
stenosis,
occlusion or aneurysm more than 3 mm, within the resolution of
MR angiogram. Some stenosis of the left distal vertebral,
cavernous segments, and the middle cerebral artery on the right
are noted, as described above.
[**11-20**] CXR:
In comparison with the study of [**11-19**], there are continued low
lung
volumes in this patient with intact sternal sutures. The
nasogastric tube has been removed.
Some increasing opacification is seen at the left base in the
retrocardiac
region. Although this could merely represent atelectasis, in
view of the
patient's fever of the possibility of supervening pneumonia
cannot be
excluded.
ECHO [**11-19**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). There are complex (>4mm) atheroma
in the descending thoracic aorta. A bileaflet aortic valve
prosthesis is present and appears well-seated. The aortic valve
prosthesis leaflets appear to move normally. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. No vegetation or
abscess seen.
LABS/STUDIES
OSH labs [**11-18**]: Na 143, K 4.1, Cl 113, Bicarb 25, BUN 37, Cr
2.2, Glucose 122, Ca 8.5
Dilantin 7.1
WBC 9.3 (normal diff), HCT 35, plt 160
INR 3.2
.
u/a negative
alk phos 128, alb 3.4
ck 334, ast 26, alt 18, t prot 6.8, t bili 1.0
ck mb 7, MBI 2.1
.
CSF: `WBC 3, RBC 44, no bacteria
CSF protein 85 (high), Glucose 61
.
CT HEAD W/O CONTRAST [**2123-11-18**]: no acute bleed. Microvascular
changes c/w chronic infarcts, moderate ventriculomegaly.
.
EKG: NSR rate of 80. Normal axis and QRDS / QT intervals. PR
prolonged at 240ms. no ST / T wave changes, normal RWP, isolate
Q wave in III. No changes from prior in [**2121**].
Brief Hospital Course:
FEVER: Patient presenting with vague febrile illness and
fatigue. Pulmonary infection seemed most likely, given some
evidence of progression of pulmonary infiltrates on CXR.
Presentation would also be consistent with viral infection,
although flu test negative. Originally transferred for TEE but
this was negative for valvular pathology. Blood cultures
negative. Story not very concerning for seizure. Since
admission was afebrile with no leukocytosis. LP was negative.
ESR and CRP elevated suggesting some subacute organic illness.
UA suggested dehydration but no UTI. He was started on empiric
Vancomycin for endocarditis on [**11-19**]. which was stopped. He was
treated with a three day course of azithromycin of CAP. He
improved with IV fluids.
.
ALTERED MENTAL STATUS: He was on dilantin at OSH for question
of possible seizure. However, the story was more consistent
with rigors. He had a normal head CT at the OSH and a non-focal
neuro exam. He has a history of CVA and TIAs while on coumadin
but none since his INR goal has been increased to [**3-23**], making
TIA / CVA very unlikely especially given a non-focal neuro exam.
An MRI/MRA showed mild stenosis in distal vessels.
He also had several episodes of night-time delerium, at times
requiring haldol and ativan for sedation.
He was seen by geriatrics who felt he was at significantly
elevated risk for the development of delirium given advanced
age, multiple medical comorbidities, acute hospitalization w/
multiple transfers, and question of underlying cognitive
impairment. While pt does not meet CAM criteria by evaluation
this evening, there is clear evidence of delirium by history and
given typical fluctuating course. His delerium improved after
leaving ICU and he will follow up with geriatrics.
.
CORONARY ARTERY DISEASE: CAD s/p single vessel CABG in
conjunction w/ AVR in [**2104**], per wife no chest pain and CABG was
reportedly LIMA to LAD. He had no ischemic changes on EKG and
was continued on crestor.
.
HISTORY OF ATRIAL FIBRILLATION: He was in sinus rhythm but has
had AF at OSH, in addition has had CVA in past and TIA while on
coumadin, so INR range is [**3-23**] for him. He was continued on
coumadin and metoprolol.
.
ACUTE RENAL FAILURE: On admission, he had a creatinine slightly
above baseline. He had a FeNa of 0.7 % suggesting good kidney
function with avid sodium retention. He also appeared dry on
exam in the setting of possible infection. He was rehydrated
with IV NS@150cc.
.
DIABETES: His oral hypoglycemic (actos) was held. He was
started on NPH 14u sc bid with humalog sliding scale and
switched to 14 U SC QAM and 12 U SC QPM. He was discharged on
his home regimen including actos and insulin.
.
FEN: Heart healthy, diabetic diet. IVF as above
ACCESS: PIV's
PROPHYLAXIS: INR supratherapeutic, PPI, pneumoboots
CODE: FULL
Medications on Admission:
Insulin 75/25 60 units daily (? in OMR is 25 units [**Hospital1 **])
Coumadin 2mg M,F, 4mg daily on other days
Neurontin 300mg po bid
Crestor 20mg daily
Prilosec 20mg daily
Lopressor 50mg daily
Actos 15mg daily
Allopurinol 100mg daily
Avodart 0.5mg daily
Flomax 0.4mg daily
Discharge Medications:
1. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,FR)
as needed for ON MONDAY AND FRIDAY.
2. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO 5X/WEEK
([**Doctor First Name **],TU,WE,TH,SA).
3. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Metoprolol Succinate 100 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*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
9. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day.
10. home equipment
Commode for use at the bedside please.
11. Insulin
Please continue your home insulin regimen
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Delerium
Community acquired pneumonia
Viral syndrome with fevers
Syncope
Acute Renal Failure
Diabetes
Discharge Condition:
BUN 47
creat 2.2
Hct 34.7
K 4.3
Discharge Instructions:
You had a likely viral illness with a fever. All of your culture
results were negative and you did not have any signs of
infection in your heart. You became acutely confused and
received some medicine to calm you down. A follow-up
appointment with Dr. [**First Name (STitle) 1022**] in the gerontololgy department here at
[**Hospital1 18**] was made on [**12-13**]. A MRI was done that preliminarily does
not show any sign of an acute problem. There is a question of a
pneumonia on your chest Xray, you have 1 more day of antibiotics
(azithromycin) to take when you go home.
.
New medicines:
1. Your Metoprolol was replaced by a long acting type,
Metoprolol Succinate
2. We have held your Furosemide.
3. Continue to take the insulin dose you were on at home.
.
Please stop smoking. Information was given to you on admission
regarding smoking cessation. A nicotine patch of 14 mg per day
was used during your hospital stay and should be used after
discharge instead of smoking.
Followup Instructions:
[**Month/Year (2) **] Surgery:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2123-12-20**] 10:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2123-12-20**] 11:00
Cardiology:
Provider: [**Known firstname 122**] [**Last Name (NamePattern1) **], MF Phone: [**Telephone/Fax (1) 18438**] Date/Time:
[**2124-1-7**] 03:00pm
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2124-1-7**]
2:00
Primary Care:
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] MD Phone: [**Telephone/Fax (1) 3110**] Date/Time:
Gerontology:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 1022**], MD Phone: [**Telephone/Fax (1) 719**] Date/Time: [**12-13**] at 1:30. [**Last Name (NamePattern1) 439**], [**Location (un) 18439**] in the
garage right next door.
Please make a Neurology appointment with Dr.[**Name (NI) 5255**] office.
Their number is [**Telephone/Fax (1) 1694**].
Completed by:[**2123-11-26**]
ICD9 Codes: 486, 5849, 2930, 5859, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7949
} | Medical Text: Admission Date: [**2167-12-4**] Discharge Date: [**2167-12-10**]
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is an 84 year-old
male with a history of Parkinson's disease who was admitted
to MICU on [**2167-12-4**] with presumed left upper lobe aspiration
pneumonia. On his initial presentation in the Emergency Room
the patient was tachypneic with shortness of breath and a
temperature of 103. He was treated with Ceftriaxone 2 grams
intravenous and Levaquin 500 mg intravenous and Flagyl 500 mg
intravenous. While in the MICU the patient was on a
nonrebreather mask and was weaned overnight to nasal cannula.
By the following morning he was stable for transfer to the
floor. The patient has a 24 hour care giver who lives with
him at home. According to care giver and his family they
reported a one week history of increasing coughing with
eating and increased dysphagia especially with solids. There
is also some concern by the visiting nurse that the patient
was not receiving his regular doses of Sinemet over the past
several weeks. Either the patient nor care giver recalls
specific aspiration events. The patient currently denies
shortness of breath, lightheadedness, chest pain, nausea,
vomiting, diarrhea.
PAST MEDICAL HISTORY: Parkinson's disease since [**2161**],
depression, T-12-L2 compression fractures, status post
transurethral resection of the prostate in [**12/2165**] for benign
prostatic hypertrophy now with chronic retention and chronic
Foley catheter. Left heel ulcer. Remote history of peptic
ulcer disease. History of otosclerotic hearing loss.
ALLERGIES: No known drug allergies.
HOME MEDICATIONS: BuSpar 5 mg po b.i.d., Duragesic patch 25
micrograms per hour, change every 72 hours. Mirapex 1.5 mg
po t.i.d., Sinemet 25/100 every day at 7:00 a.m., 10:00 a.m.,
1:00 p.m., 4:00 p.m. and 7:00 p.m. In addition to Sinemet
5200 q.a.m. and q.h.s. Amantadine 100 mg po b.i.d.
HOSPITAL MEDICATIONS: Paxil 30 mg po q.d., Lorazepam 1 mg po
q.h.s., Mirapex 1.5 mg po t.i.d., Sinemet 50/200 q.a.m. and
q.p.m., in addition to Sinemet 2500 every day at 7:00 a.m.,
10:00 a.m., 1:00 p.m., 4:00 p.m. and 7:00 p.m., Amantadine
100 mg po b.i.d., BuSpar 5 mg po b.i.d., Duragesic patch 50
micrograms per hour change every 72 hours, Tylenol prn, 5000
units subQ heparin b.i.d., Zantac 50 mg intravenous t.i.d.,
Levaquin 500 mg intravenous q day, Flagyl 500 mg intravenous
q 8 hours.
FAMILY HISTORY: Parkinson's disease.
SOCIAL HISTORY: The patient lives alone with care giver, her
significant other and her son lives in an apartment below.
He has a fifty pack year tobacco history. He quit twenty
years ago. His health care proxy is daughter Syva [**Name (NI) 13470**] who
lives in [**Name (NI) 531**] City. Contact information home phone
number [**Telephone/Fax (1) 22176**]. Work number [**Telephone/Fax (1) 22177**]. Pager number
1-[**Telephone/Fax (1) 22178**].
PHYSICAL EXAMINATION: Temperature 98.2. Pulse 69. Blood
pressure 118/48. Respiratory rate 24. O2 sat 97% on 8
liters nasal cannula. General, the patient is sitting in
chair in no acute distress with slowed speech, ______
spotting movements. HEENT pupils are equal, round and
reactive to light. Oropharynx moist. Lungs positive for
rales at bilateral bases left greater then right.
Cardiovascular regular rate and rhythm. No murmurs. Abdomen
soft, nontender, nondistended. Positive bowel sounds.
Extremities no edema. 2+ peripheral pulses. Left heel with
2 cm dry ulcer with black base, minimal surrounding erythema.
No drainage. Nontender to palpation. Neurological
examination rigid body with cogwheeling of bilateral upper
extremities, occasional resting tremor in upper extremities,
no strength deficits.
LABORATORY: Urine culture positive for Citrobacter. Blood
culture negative, sputum culture negative. White blood cell
count 6.2, hematocrit 24.9, platelets 258, sodium 131,
potassium 4.0, chloride 99, bicarb 26, BUN 25, creatinine .9,
glucose 117.
HOSPITAL COURSE: 1. Neurology/Parkinson's disease: The
patient was maintained on Parkinson's medication on a regular
schedule. This included his Sinemet 25/100 five times a day
in addition to his Sinemet 50/200 twice a day. It is very
important for the patient to receive these on a regular
schedule. He was also continued on his Amantadine and
Mirapex. The patient periodically received Botox injections
in his jaw secondary to bruxism and limited jaw movement.
The patient was seen by neurology consul.t, however, they
deferred Botox injections at this time. He follows up
regularly with his outpatient neurologist Dr. [**Last Name (STitle) 10442**]. He is
due for Botox injections in [**Month (only) 958**].
2. Infectious disease/aspiration pneumonia: The patient was
started on intravenous Levaquin and Flagyl. He is to
complete a fourteen day course of these antibiotics. The
patient's O2 sat is stable on 4 liters and can be weaned as
tolerated.
3. Gastrointestinal: Aspiration risk, the patient had a
video swallow study, which revealed inability to swallow. As
a result of this study and a discussion with the patient and
his family a PEG tube was placed in order to decrease
aspiration risk and also in order to maintain nutrition and
to allow the patient to receive his medication. A PEG tube
was placed on [**2167-12-9**] without complications. Tube feeds were
started on [**2167-12-10**]. Per nutrition consult he was started on
Promote with fiber at 10 cc per hour. This was increased by
10 cc an hour every four to six hours to his goal rate of 55
cc an hour. If the patient requires additional hydration he
can receive 150 cc free water boluses twice a day through his
PEG tube. All of the patient's previously po medications are
now being administered through his PEG tube.
4. Left heel ulcer: The patient's heel ulcer was evaluated
by podiatry. They do not feel that his ulcer is ischemic nor
infectious in nature. No need for surgical debridement at
this time. The patient to maintain Multi-Podus boot and
strict nonweight bearing to his left heel. The patient may
benefit from enzymatic debridement of necrotic tissue either
application of Accuzyme ointment or wet to dry dressing
changes b.i.d.
5. Anemia: According to the patient's iron studies the
patient has anemia of chronic disease. No evidence of GI
bleeding while in the hospital.
6. Code status: The patient is DNR/DNI.
CONDITION ON DISCHARGE: Satisfactory.
DISCHARGE STATUS: Discharge patient to rehab.
DISCHARGE MEDICATIONS: 1. Mirapex 1.5 mg t.i.d. via PEG
tube. 2. Carbidopa/levodopa 50/200 q.a.m. and q.h.s. via
PEG tube. In addition to Carbidopa/levodopa 25/100 q 7:00
a.m., 10:00 a.m., 1:00 p.m., 4:00 p.m., 7:00 p.m. every day
via PEG tube. 3. Amantadine 50 mg per 5 ml suspension, 100
mg via PEG tube b.i.d. 4. Paxil 30 mg via PEG tube q day.
5. BuSpar 5 mg via PEG tube b.i.d. 6. Heparin 5000 units
subQ b.i.d. 7. Duragesic patch 50 micrograms per hour
transdermal change every 72 hours. 8. Zantac 150 mg q day
via PEG tube. 9. Levaquin 500 mg intravenous q day until
[**2167-12-14**]. 10. Flagyl 500 mg intravenous q 8 hours until
[**2167-12-14**].
DISCHARGE DIAGNOSES:
1. End stage Parkinson's disease.
2. Aspiration pneumonia status post failed swallow study now
with PEG tube.
Discharge summary for [**Hospital **] Rehab Hospital.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 7112**]
MEDQUIST36
D: [**2167-12-9**] 23:55
T: [**2167-12-10**] 08:40
JOB#: [**Job Number 22179**]
ICD9 Codes: 5070, 5990, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7950
} | Medical Text: Admission Date: [**2110-11-28**] Discharge Date: [**2110-11-30**]
Date of Birth: [**2110-11-28**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 2745 gm male infant born at
37 weeks gestation by repeat cesarean section by placenta
previa to a 35 year old gravida 4, para 1 now 2 mother.
Pregnancy was complicated by intermittent episodes of vaginal
bleeding. Also mother with a history of anti cardiolipin
antibodies, rupture of membranes at delivery, no maternal
fever.
Prenatal screens - O negative, antibody negative, Rubella
immune, RPR nonreactive, hepatitis B surface antigen
negative, Group B Streptococcus unknown.
The infant emerged with spontaneous respirations. Apgars
were 8 at one minute and 9 at five minutes. Infant was noted
to be grunting at approximately 2 hours of age and was
transferred to the Neonatal Intensive Care Unit for
respiratory distress.
PHYSICAL EXAMINATION: Physical examination on admission
reveled birthweight 2745 gm, length 44.5 cm, head
circumference 32 cm. Anterior fontanelle open and flat.
Palate intact. Bilateral breath sounds clear and equal.
Grunting, flaring and retraction noted. No murmur, normal S1
and S2, pink, well perfused. Abdomen soft, nontender, no
hepatosplenomegaly, no masses, three vessel cord, positive
bowel sounds. Anus patent. Normal male genitalia. Spine
intact. Clavicles intact. Hips stable. Normal tone for
gestational age.
HOSPITAL COURSE: (By systems) Respiratory - Infant noted to
have grunting, flaring and retraction at approximately 2
hours of age. Infant was placed on nasal CPAP, 6 cm of water
requiring 21% FIO2. Infant transitioned to room air by day
of life #1. Respiratory rates have been in the 30s to 60s.
Infant has remained in room air with oxygen saturation 99 to
100%. Infant has not had any apnea or bradycardia this
hospitalization. Cardiovascular, infant has remained
hemodynamically stable this hospitalization, no murmur.
Heart rate 120s to 140s with mean blood pressures 49 to 53.
Fluids, electrolytes and nutrition - The infant was in
initially nothing by mouth, receiving 60 cc/kg/day of D10/W.
Enteral feedings were started on day of life #1 and he
advanced to full volume feedings by day of life #1. Infant
tolerated the feedings without difficulty. Dextrose sticks
have been 61 to 83. The infant is currently taking Enfamil
20 cal/oz p.o. ad lib. The most recent weight on day of life
#2 was 2595 gm.
Gastrointestinal - The most recent bilirubin on day of life
#2 showed a total of 7.8 with a direct of 0.3. The infant
has not received phototherapy.
Hematology - Blood type 0 negative, Coomb's negative. The
infant has not received any blood transfusions this
hospitalization. Hematocrit on admission was 46%.
Infectious disease - Infant received 48 hours of Ampicillin
and Gentamicin for rule out sepsis. All blood cultures
remained negative to date. Complete blood count on admission
showed a white blood cell count of 13.6, hematocrit 46%,
platelets 243,000, 73 neutrophils, 4 bands.
Neurology - Normal neurological examination.
Sensory - Hearing screening is recommended prior to discharge
home.
Psychosocial - Parents involved with infant.
CONDITION ON DISCHARGE: Stable in room air.
DISCHARGE DISPOSITION: To level 1 newborn nursery.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Location (un) 36298**],
Phone [**Telephone/Fax (1) 53258**].
CARE/RECOMMENDATIONS:
Feedings at discharge - Enfamil 20 cal/oz p.o. ad lib
Medications - None
Carseat position screening - Not recommended
State newborn screen - Due on day of life #3.
Immunizations - Infant has not received any immunizations
this hospitalization. Hepatitis B vaccine is recommended
prior to discharge.
Follow up - Appointment with primary pediatrician after
discharge home.
DISCHARGE DIAGNOSIS:
1. Status post respiratory distress, most likely transient
tachypnea of the newborn
2. Status post rule out sepsis with antibiotics, ruled out
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**]
Dictated By:[**Last Name (NamePattern1) 47014**]
MEDQUIST36
D: [**2110-11-30**] 19:52
T: [**2110-11-30**] 20:06
JOB#: [**Job Number 53259**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7951
} | Medical Text: Admission Date: [**2109-2-23**] Discharge Date: [**2109-3-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
chest/abd pain
Major Surgical or Invasive Procedure:
[**2109-2-22**]: central venous line, internal jugular
[**2109-2-26**]: PICC line, left arm, removed [**2109-3-9**]
History of Present Illness:
Mr. [**Known lastname 805**] is a [**Age over 90 **]-year-old man with a history of atrial
fibrillation not anticoagulated, hypertension, type 2 diabetes,
anemia, and history DVT in [**2100**]. History is per patient and OMR.
He was in his usual state of health until the morning of
admission when he awoke with periumbilical abdominal pain. The
pain is constant and non-radiating. It was accompanied by
anorexia, no nausea or vomitting. There was no diarrhea or blood
in his stools. Patient reports no eating and no gas or bowel
movement since yesterday, although by report he was brought to
the ED after being found unresponsive after a bowel movement by
the Sherrrill House staff. At the time his BP was stable at
119/66 but O2 Sat 84% on RA-->95% on 2L. He was given an extra
dose of lasix 40 mg PO and levofloxacin 500 mg PO x 1 as well as
nebs. Received 2 units insulin for FS 393.
.
In the ED, he was hypotensive with initial vitals BP 84/52, HR
85, RR 20, O2 Sat 84% on RA and 95% on 2L. He was responsive,
A&O x 1. On ROS he complained of abdominal pain. He underwent CT
scan which was negative for intra-abdominal pathology but showed
right lung consolidation and effusion. CXR also notable for RLL
consolidation. He received levofloxacin 750 mg IV and
ceftriaxone 1 gIV as well as 3 L of IV fluid. BP rose to 100/50,
HR 87, O2 Sat 98% on 5L NC. A central venous line was placed.
.
On ROS, he denies any recent cough, shortness of breath, chest
pain. He denies fevers, chills, night sweats or weight loss. No
change in bowel movements, blood in bowel movements, or
abdominal pain prior to today.
Past Medical History:
Diabetes Type II
Hypertension
Partial gastric resection with bilroth II anastomosis for
bleeding peptic ulcer ([**2056**])
Multiple prior episodes of SBO
Atrial tachycardia: recent hypotensive event from atrial
tachycardia causing TIA like symptoms, no evidence of CVA on
MRI.
Peripheral Neuropathy
Remote EtOH
Circumcision ([**2106**])
L ankle fracture
L DVT s/p filter [**2100**], GIB on coumadin
Pernicious anemia
GERD
Osteoarthritis
Right leg bakers cyst
Social History:
Widowed. No children. Active in church, sings in choir. Lives
with friend from church [**Name (NI) **] although recently at [**First Name4 (NamePattern1) 2299**]
[**Last Name (NamePattern1) **].
Pt has remote former EtOH and tobacco history, recently
discharged to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] but had been living with adopted son
prior to recent admission.
*** DNR/DNI per HC [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (h) [**Telephone/Fax (1) 79368**] and (c)
[**Telephone/Fax (1) 79369**]
Physical function: Independent at baseline with dressing,
toileting, and walking wtih rolling walker. [**Doctor Last Name **] assists with
meal preparation, housekeeping, laundry, errands. No home
services.
Family History:
Unknown
Physical Exam:
Vital Signs: BP 104/52, HR 90, T 96.4, RR 16, weight 91.6 kg,
CVP 6-8
Gen: elderly man lying in bed with flat affect, no apparent
distress
HEENT: moist mucous membranes, pupils bilaterally round and
reactive, oropharynx clear without erythema or exudates
Neck: supple, JVP ~8 cm
Heart: RRR, no audible murmur, faint heart sounds
Lungs: few crackles at b/l bases, scant wheezes
Abdomen: diffusely tender, maximal in epigastrium and right
upper quadrant with inconsistent voluntary guarding, no rebound,
hypoactive bowel sounds
Extremities: 2+ pitting edema bilaterally, L>R, TEDS in place,
extremities warm, pulses doppler-able
Rectal: good tone, light brown stool in vault, guaiac negative
Pertinent Results:
LABS ON ADMISSION 1/9/9:
.
HEMATOLOGY:
[**2109-2-22**] 05:10PM BLOOD WBC-7.6# RBC-3.37* Hgb-10.9* Hct-31.9*
MCV-95 MCH-32.2* MCHC-34.1 RDW-15.2 Plt Ct-202#
[**2109-2-23**] 02:25AM BLOOD Hct-25.7*
[**2109-2-23**] 08:43AM BLOOD Hct-25.6*
[**2109-2-23**] 02:07PM BLOOD Hct-25.3*
[**2109-2-24**] 05:16AM BLOOD Hct-24.3*
[**2109-2-22**] 05:10PM BLOOD Neuts-41* Bands-41* Lymphs-2* Monos-3
Eos-0 Baso-1 Atyps-0 Metas-8* Myelos-4*
[**2109-2-22**] 05:10PM BLOOD PT-15.3* PTT-33.2 INR(PT)-1.4*
.
CHEMISTRY:
[**2109-2-22**] 05:10PM BLOOD Glucose-277* UreaN-43* Creat-2.2* Na-137
K-4.4 Cl-96 HCO3-26 AnGap-19
[**2109-2-22**] 05:10PM BLOOD ALT-16 AST-12 AlkPhos-78 TotBili-0.8
[**2109-2-22**] 05:10PM BLOOD Albumin-3.6 Calcium-8.5 Phos-4.6* Mg-1.6
.
CARDIAC ENZYMES:
[**2109-2-22**] 05:10PM BLOOD CK(CPK)-670* cTropnT-0.07*
[**2109-2-22**] 11:20PM BLOOD CK(CPK)-532* CK-MB-2 cTropnT-0.05*
[**2109-2-23**] 02:25AM BLOOD CK-MB-3 cTropnT-0.06*
.
OTHER:
[**2109-2-22**] 05:10PM BLOOD Cortsol-61.1*
[**2109-2-22**] 05:10PM BLOOD CRP-193.2*
[**2109-2-22**] 05:47PM BLOOD Lactate-4.9*
[**2109-2-23**] 02:43AM BLOOD Lactate-2.1*
.
c.diff neg x 4
[**3-8**] KUB: Interval improvement with no significant dilatation of
the loops of large bowel.
[**3-5**] KUB: Remaining colonic distention, likely of the
rectosigmoid region, with interval improvement in the degree of
colonic distension
[**3-4**] KUB: Worsening pseudoobstruction
[**2-28**] CT abd: Dilated loops of descending and transverse colon
but with no lead point identified. Wall thickening rectosigmoid
and lower left colon c/w colitis
[**2-26**] U/S: No LE DVT bilat
1/9 CXR: New ill-defined opacity within the right lower lobe
concerning for pneumonia.
.
Labs prior to discharge:
[**2109-3-8**] CBC:
WBC-3.5* RBC-2.44* Hgb-7.9* Hct-22.7* Plt Ct-372 --> transfused
1un pRBC --> [**2109-3-9**] Hct-24.2*
[**2109-3-8**] Lytes:
Glucose-124* UreaN-9 Creat-1.0 Na-139 K-4.1 Cl-105 HCO3-31
AnGap-7*
Brief Hospital Course:
A [**Age over 90 **] year-old man with a history of DM and HTN presented after
an episode of syncope. In the ED he was hypotensive and
complained of abdominal pain. He underwent an abd CT scan. The
CT scan was negative for abd pathology (did mention slight
distention of redundant sigmoid colon) but did show RLL and RML
and pneumonia. He stayed in CCU for 2 days for concern of
sepsis and was transferred to the floor on [**2-24**].
# [**Hospital 7502**] health care associated
Upon transfer to the floor, he was treated w/ levoflox [**Date range (1) 79372**];
ceftriaxone on [**11-26**]; vanco on [**11-27**]. A PICC was placed
on [**2-26**] for IV abx and it was removed the day of discharge. He
remained afebrile and his respiratory status improved
clinically.
.
# Colonic pseudo-obstruction
Pt initially presented with abdominal pain. Pt's abdomen was
distended and repeat KUBs showed colonic distentions. A CT scan
was concerning for colitis but it was not clinically correlated
and pt was c. difficile negative x 4. Multiple bowel regimens
were tried and bowel movements resulted, however, he continued
to have worsening distention. Rectal tubes were attempted x 2
and may have been slightly helpful. On [**3-6**], GI performed a
colonic decompression in which they were able to advance scope
to beyond splenic flexure, saw large amount of stool. The next
day, the pt was given 1L golytely with resulting multiple soft
stools. He did not have a BM after the golytely but his stomach
remained soft and repeat KUB showed improvement.
.
# Decreasing WBC
Has been worked up for leukopenia and thrombocytopenia in the
past ([**11-21**]). No intervention was made at that time and his
cell lines increased on their own. [**Month (only) 116**] be [**3-18**] meds but no new
meds. [**Month (only) 116**] be a myelodysplastic picture. By discharge, his WBC
was increasing again.
.
# Anemia
Progressively decreasing HCT w/ low reticulocyte count.
Transfused 1un pRBC with modest increase in HCT.
.
# Stage II coccyx ulcer
Aggressively cared for by nursing.
.
# Syncope
Most likely caused by hypotension secondary to sepsis and
increased vagal tone after bowel movement.
.
# Acute renal failure
Admission creatinine was 2.2 (baseline 1.2). Most likely
secondary to poor perfusion in the setting of sepsis and
hypotension. With fluids, his Cr decreased appropriately. All
meds were renally dosed.
.
# Diabetes
Pt had been on metformin at home but given his ARF at admission
and his multiple radiology studies, this medicine was
discontinued. He was started on insulin sliding scale and his
blood glucoses were usually inthe mid 100s. The sliding scale
was continued on discharge.
Medications on Admission:
metformin 500 mg qd
trazodone 25 mg qhs
docusate 200 mg qhs
acetaminopohen 500 mg q6h prn
bisacodyl 10 mg suppository qd prn
clotrimazole cream 1% [**Hospital1 **]
levothyroxine 75 mcg qd
simvastatin 20 mg qd
furosemide 40 mg qd
omeprazole 20 mg qam
MVI
RISS
fleet enema PRN
milk of magnesia PRN
senna PRN
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas/abd pain.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
10. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection QACHS: See attached insulin instructions.
11. Golytely 236-22.74-6.74 gram Recon Soln Sig: One (1) L PO No
more than 2x weekly as needed for constipation: Please use under
the direction of a physician. [**Name10 (NameIs) **] only be used when pt has
not had a bowel movement for >4 days (and is eating a regular
diet).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
health care- associated pneumonia
Colonic pseudo-obstruction
Syncope
Secondary:
pernicious anemia, possible myelodysplastic syndrome
Stage II coccyx ulcer
Diabetes mellitus type II, uncontrolled with complications
Discharge Condition:
Fair
Discharge Instructions:
You were admitted after you passed out. You had a chest xray
that revealed you had pneumonia. You were treated with
antibiotics. You also had abdominal pain. This was most likely
related to colonic pseudo-obstruction. This was treated with
laxatives and colonoscopy.
Attached, is a list of your medications. While in the hospital,
your blood pressure medicines were stopped. They were not
restarted upon your discharge because your blood pressure was
stable. Please follow up with your primary care doctor
regarding the need to re-start these medications. Also, you
need to make sure that you are on a bowel regimen. It is very
important that you have regular bowel movements. If you have
not had a bowel movement by [**2109-3-11**], please call your physician.
[**Name10 (NameIs) **] may need to take another medicine to help you go or you may
need more intensive treatment.
Please adhere to your follow-up appointments. They are important
for managing your long-term health.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
You need to follow up with your primary care doctor, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 79370**], at the [**Hospital 86**] [**Hospital6 **]. Please call
[**Telephone/Fax (1) 41354**] 5415 to schedule this apointment sometime in the
next 1 to 2 weeks. Please call her sooner if you do not have a
bowel movement within the next few days.
[**Telephone/Fax (1) **] UNIT
Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2109-3-20**] 10:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2109-3-11**]
ICD9 Codes: 486, 0389, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7952
} | Medical Text: Admission Date: [**2187-12-1**] Discharge Date: [**2188-1-2**]
Date of Birth: [**2118-3-31**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / Cephalosporins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Fall from standing
Major Surgical or Invasive Procedure:
[**2187-12-28**]: Flexible bronchoscopy
[**2187-12-1**]: Open abdominal aortic aneurysm repair
[**2187-12-17**]: Percutaneous tracheostomy placement
History of Present Illness:
69 year old woman with multiple medical problems now presenting
on transfer from an OSH with a C-2 cervical fracture. She
suffered a fall from standing. She did not lose consciousness.
Immediately after the fall, she felt a pain
in the back of her neck. Her daughter discovered her and called
EMS. She was taken to an OSH where a CT scan of the neck
revealed a C2 fracture. She was placed in a hard collar and
transferred to [**Hospital1 18**] ED for further management. Neurosurgery
evaluation at [**Hospital1 18**] recommended conservative management.
Initial
trauma workup revealed widened mediastinum on chest x ray.
Follow-up CT of the torso was consistent with leaking infrarenal
AAA. In further questioning of the family, we found she also was
complaining of abdominal pain increasing in intensity radiating
to the back.
Past Medical History:
-diabetes
-COPD
-anxiety
-high blood pressure
-s/p knee replacement
-s/p abdominal hernias and surgery
-h/o pneumonia
-h/o recent leg cellulitis
Social History:
-lives by self
-walks with walker
-no tobacco or alcohol use
Physical Exam:
Admission exam
97.5 66 153/98 28 96%ra
General: no acute distress
Neck: in hard collar, trachea midline
Lungs: decreased breath sounds at the bases
CV: regular rate and rhythm; no murmur/rub
Abdomen: mildly tender to palpation diffusely, multiple
reducible incisional hernias no rebound. Multiple healed
abdominal scars
Ext: warm, no edema. DP 2+ Left/ 1+Right. Faint femoral pulses.
Hemosiderin deposits bilaterally in lower extremities.
Sensation decreased b/l LE distally in stocking distribution.
Pertinent Results:
Day of discharge~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
[**2188-1-2**] 01:48AM BLOOD WBC-15.1* RBC-2.48* Hgb-7.9* Hct-23.8*
MCV-96 MCH-31.8 MCHC-33.0 RDW-19.0* Plt Ct-379
[**2188-1-2**] 01:48AM BLOOD Plt Ct-379
[**2188-1-2**] 01:48AM BLOOD PT-13.6* PTT-31.7 INR(PT)-1.2*
[**2188-1-2**] 01:48AM BLOOD Glucose-116* UreaN-24* Creat-0.8 Na-137
K-3.8 Cl-103 HCO3-29 AnGap-9
[**2187-12-2**] 10:01PM BLOOD CK-MB-3 cTropnT-0.01
[**2188-1-2**] 01:48AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.4
[**2188-1-2**] 03:59AM BLOOD Type-ART pO2-107* pCO2-53* pH-7.37
calTCO2-32* Base XS-3
ADMISSION LABS~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
[**2187-12-1**] 01:35PM BLOOD WBC-14.5* RBC-4.00* Hgb-12.4 Hct-36.9
MCV-92 MCH-31.1 MCHC-33.7 RDW-14.4 Plt Ct-260
[**2187-12-1**] 01:35PM BLOOD PT-13.0 PTT-29.8 INR(PT)-1.1
[**2187-12-1**] 01:35PM BLOOD Glucose-173* UreaN-8 Creat-0.4 Na-141
K-3.9 Cl-104 HCO3-27 AnGap-14
[**2187-12-2**] 02:23AM BLOOD ALT-18 AST-38 LD(LDH)-388* AlkPhos-48
Amylase-27 TotBili-0.7
[**2187-12-1**] 01:35PM BLOOD CK-MB-16* MB Indx-3.8 cTropnT-<0.01
[**2187-12-1**] 01:35PM BLOOD Calcium-9.2 Phos-3.5 Mg-1.9
[**2187-12-1**] 11:15PM BLOOD Type-ART pO2-210* pCO2-39 pH-7.37
calTCO2-23 Base XS--2
RADIOLOGY STUDIES~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CTA ABD W&W/O C & RECONS [**2187-12-1**] 8:23 PM
IMPRESSION:
1. 5.8 x 6.3 cm infrarenal abdominal aortic aneurysm measuring
approximately 10 cm in length. Blood in the retroperitoneal
cavity is consistent with leak. There is at least one focus of
extraluminal contrast which is likely contained in the wall. All
branches of the abdominal aorta remain patent. The inferior
mesenteric artery originates from the inferior aspect of the
aneurysm.
2. Normal intrathoracic aorta. Mediastinal widening on previous
chest x-ray was likely related to an overabundance of
mediastinal fat and bilateral dependent atelectasis.
3. Left lower quadrant abdominal hernia as described above.
Small amount of fluid at the hernia apex.
4. Gallstones.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT C-SPINE W/O CONTRAST [**2187-12-1**] 1:04 PM
IMPRESSION: Mildly displaced acute C2 fracture extending through
both lateral masses and into the posteroinferior portion of the
odontoid.
NOTE ADDED AT ATTENDING REVIEW: The fracture extends into the
left transverse foramen, raising the possibility of vertebral
artery injury. If this is a clinical concern, then an MR
examination with axial T1 images and an MRA are recommended.
This is more reliable than CTA for this purpose.
Osteophyte formation at C [**1-27**] and [**3-30**] narrow the spinal canal.
CT lacks soft tissue contrast resolution to exclude ligamentous
injury or disk or hematoma compromising the canal.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT HEAD W/O CONTRAST [**2187-12-1**] 1:04 PM
IMPRESSION: No fractures, no acute intracranial hemorrhage
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CHEST (PORTABLE AP) [**2187-12-1**] 7:40 PM
IMPRESSION:
Marked widening of the mediastinum concerning for mediastinal
hematoma and possible aortic injury in the setting of trauma.
CTA of the chest is recommended for further characterization.
Small right pleural effusion and adjacent lung opacity.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT PELVIS W&W/O C [**2187-12-4**] 3:23 PM
IMPRESSION:
1. In this patient that is post open repair of a ruptured
abdominal aortic aneurysm, there is absent perfusion of the
right kidney.
2. No evidence of pneumatosis, as clinically questioned. Mild
left colonic wall thickening and mildly dilated loops of small
bowel, which are nonspecific findings, however, can be seen in
the setting of bowel ischemia. Recommend close interval followup
and clinical correlation.
3. Gallstones.
4. Small bilateral pleural effusions and adjacent atelectases
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2187-12-13**] 8:12 AM
IMPRESSION:
1. Cholelithiasis without cholecystitis.
2. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease including severe hepatic
fibrosis/cirrhosis cannot be excluded on this examination.
3. No biliary duct dilatation
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT CHEST W/O CONTRAST [**2187-12-26**] 10:42 AM
IMPRESSION:
1. Tracheomalacia. Assessment of likely tracheal stricture
around tracheostomy tube would require extubation. Bronchi
normal.
2. New, nonhemorrhagic pericardial effusion; no evidence of
tamponade.
3. Small, nonhemorrhagic, left pleural effusion.
4. Bibasilar atelectasis.
5. Atherosclerotic aortic arch ulcer; aortic contour unchanged
since [**2187-12-2**].
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT HEAD W/O CONTRAST [**2187-12-26**] 10:42 AM
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Evidence of chronic microvascular infarction.
3. New, partial opacification and possible fluid level within
the left mastoid air cells. This could represent mastoiditis in
the appropriate clinical setting.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Cardiology Report ECHO Study Date of [**2187-12-27**]
IMPRESSION: Moderate-sized pericardial effusion without
echocardiographic
signs of tamponade. Symmetric LVH with preserved global systolic
function.
Mild aortic regurgitation. Mildly dilated thoracic aorta.
Compared with the focused TEE study of [**2187-12-2**] (images reviewed),
the LV
systolic function has improved, and there is now a pericardial
effusion, as
described above.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CHEST (PORTABLE AP) [**2188-1-1**] 8:19 AM
IMPRESSION:
1. Increased left-sided basilar/retrocardiac opacity. Given the
lack of deviation of the left main stem bronchus it is felt to
likely represent an underlying consolidation with superimposed
pleural effusion.
Brief Hospital Course:
Patient was admitted after initial evaluation in trauma ED for
emergent ruptured abdominal aortic aneurysm repair by Dr.
[**Last Name (STitle) **] of vascular surgery. Please see operative note for
details of procedure. The patient tolerated this procedure well
and was taken to the surgical intensive care unit still
intubated and in critical, but stable condition. Her course in
the intensive care unit was remarkable for development of
ischemic colitis following the operation that resolved with
conservative management. A flexible sigmoidoscopy was performed
that confirmed this diagnosis intially and general surgery
followed the patient as she resolved from this condition. She
remained ventilator dependent and the decision to perform a
tracheostomy was made. She underwent a bedside percutaneous
tracheostomy on [**2187-12-17**]. Since that time she was weaned on the
ventilator to the current status of alternating trach mask and
CPAP+PS as tolerated.
Tube feedings were intitiated via NGT (PEG deferred secondary to
abdominal operations). She tolearated this at goal.
Infectious issues were a ventilator associated pneumonia with
respiratory cultures revealing proteus from [**12-7**]. She completed
a course of zosyn and flagyl on [**12-17**] (on abx from day of
surgery). Later in her hospitalization urine cultures revealed
yeast, proteus and klebsiella for which she was treated as well.
A mild leukocytosis developed the week of planned discharge with
no evident source on work-up. The WBC was decreasing at the
time of discharge.
Retention sutures placed in the OR were removed on [**2187-12-31**] when
her nutritional status had improved. Her wounds were healing
well without complications.
Cardiology evaluated the patient on [**2187-12-28**] for a small
pericardial effusion seen on echocardiography. The patient was
asymptomatic from this and it was deemed that no further work-up
was necessary unless hypotension developed. The patient
remained stable throughout. A repeat echocardiography was
recommended as follow-up (1week).
The patient was out of bed frequently and had been seen by
physical therapy prior to discharge.
Medications on Admission:
glucophage, glyburide, advair, xanax, zestril, amitriptyline,
lasix, vicodin, lipitor, lopressor
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4-6H (every 4 to 6 hours).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
18. Insulin Sliding Scale
Fingerstick QACHSInsulin SC Fixed Dose Orders
Q12H
70 / 30 30 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL [**11-27**] amp D50 [**11-27**] amp D50 [**11-27**] amp D50 [**11-27**] amp D50
61-120 mg/dl 0 Units 0 Units 0 Units 0 Units
121-140 mg/dL 4 Units 4 Units 4 Units 4 Units
141-160 mg/dL 7 Units 7 Units 7 Units 7 Units
161-180 mg/dL 10 Units 10 Units 10 Units 10 Units
181-200 mg/dL 13 Units 13 Units 13 Units 13 Units
201-220 mg/dL 16 Units 16 Units 16 Units 16 Units
221-240 mg/dL 19 Units 19 Units 19 Units 19 Units
241-260 mg/dL 22 Units 22 Units 22 Units 22 Units
261-280 mg/dL 25 Units 25 Units 25 Units 25 Units
281-300 mg/dL 28 Units 28 Units 28 Units 28 Units
301-320 mg/dL 31 Units 31 Units 31 Units 31 Units
321-340 mg/dL 34 Units 34 Units 34 Units 34 Units
341-360 mg/dL 37 Units 37 Units 37 Units 37 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Abdominal aortic aneurysm
Ischemic colitis
Diabetes Melitus
COPD
Ventilatory Reqirement s/p tracheostomy
Discharge Condition:
Stable
Discharge Instructions:
Please call with any concerns or questions.
Ventilator weaning for trach per protocols.
C-collar to remain in place at all times with follow-up for open
MRI needed when stable for transport and study.
Please follow intermittent CBC to monitor mild leukocytosis and
stable anemia.
Followup Instructions:
Follow-up needed:
Open MRI on [**Hospital Ward Name 516**] of C-spine in 1-2weeks or when stable
off vent consistently
Appointments with
Dr. [**Last Name (STitle) **]. Please call for appointment in [**12-29**] weeks. ([**Telephone/Fax (1) 16580**]
Neurosurgery appointment needed following MRI. Please call for
appointment with Dr. [**Last Name (STitle) 739**]. ([**Telephone/Fax (1) 88**]
General surgery for trach. Please call for appointment when off
ventilator support. Dr. [**Last Name (STitle) **]. ([**Telephone/Fax (1) 1483**]
Please obtain echocardiography to assess pericardial effusion on
[**2188-1-4**] (approximately). Follow-up with cardiology. Call for
appointment ([**Telephone/Fax (1) 7437**]
ICD9 Codes: 496, 5990, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7953
} | Medical Text: Admission Date: [**2102-3-13**] Discharge Date: [**2102-3-13**]
Date of Birth: [**2029-12-18**] Sex: F
Service: MEDICINE
Allergies:
Crestor
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 yo female with afib, CHF (EF 30-35%), and metastatic colon
cancer undergoing palliative chemotherapy transferred from BIDN
for hypoxia in the context of bilateral multifocal pneumonia
seen on CXR. Patient c/o productive cough, SOB, subjective fever
(T to 100.1 at NH) for the past several days, given augmentin
500mg TID (D1=[**2102-3-11**]) at nursing home and brought to BIDN were
she was found to be hypoxic to the 70s on RA, 80% on 5L NC. VS
at BIDN: 93/50, 91, 25, 93% on nonrebreather. Labs at BIDN
included: WBC 11.0 (83.6% N), K 3.0, lactate 1.7, AST 82, AP
204, alb 2.6. CXR reportedly showed bilateral multifocal PNA.
Patient was given 2L NS, potassium supplementation (20meq),
duonebs, as well as vancomycin 1gm IV and zosyn 3.375gm IV at
10:15pm and transferred to [**Hospital1 18**] for an ICU bed given hypoxia.
Denies chest pain, nausea/vomiting, abdominal pain. She is
DNR/DNI, confirmed with patient, but is okay with pressors.
.
In the ED inital vitals were T 97, HR 97, BP 112/61, RR 24, O2
sat 83% on 15L nonrebreather. Patient is reportedly confused,
not understanding she has a foley in. Patient received 700 cc
IVFs in ED. UA showed small leuks, 25 WBCs. Per nursing home,
patient has a history of ESBL in urine. Vital signs on transfer
were HR 108, BP 107/52, RR 28, sat 95% on 15L nonrebreather,
however drops to 70s on RA.
.
On arrival to the ICU, VS T 98.6, HR 99, BP 107/61. RR 29, Sat
95% on 4L 100% nonrebreather, but desatted to the 70s with
attempting to get out of bed to go to the bathroom. At rest,
feels comfortable, without complaints except for cough
exacerbated with speaking.
Past Medical History:
- colorectal cancer (dx 08) s/p low anterior resection and
transverse
colostomy [**12-21**] and is status post 14 cycles of Capox which she
started in [**2099-2-12**] and completed in [**2100-8-12**]. She was
then started on irinotecan in [**2100-9-12**] with the last dose
being on [**12-24**] when she was hospitalized with abdominal pain and
nausea. CT scan of the abdomen at that time showed progressive
disease and new pulmonary metastases. She was subsequently sent
to rehab since then and has not been on any further
chemotherapy.
- atrial fibrillation
- CHF, EF 30-35%
- coronary artery disease s/p CABG in [**2087**] at the [**Hospital1 24300**] Hospital; the patient has been followed by Dr. [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) **]; echocardiogram on [**2098-11-12**] showed inferior apical
left ventricular aneurysm and ejection fraction of 30%-35%
- htn
- hyperlipidemia
- hypothyroidism
- UTI with ESBL
- schizoaffective disorder
- depression
- anxiety
- arthritis, knees
- alcoholism
- cataracts
Social History:
Lives at [**Location 931**] House Nursing Center at baseline is alert,
oriented and follows instructions. Ambulates with assistance.
Ms. [**Known lastname **] is single and has no children; she previously worked
as a housekeeper and companion. She has a 75-pack-year history
of cigarette smoking.
Family History:
Father died at age 58 from myocardial infarction and her mother
died from complications of diabetes at age 78; a brother had
lung cancer and a sister had breast cancer at age 74; a maternal
uncle died of cancer; there is no family history of colon
cancer.
Physical Exam:
ADMISSION EXAM
Vitals: T 98.6, HR 99, BP 107/61. RR 29, Sat 95% on 4L 100%
nonrebreather
General: Alert, oriented, working to breathe
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: nonrebreather on, using abdominal muscles to breathe,
rales throughout lungs bilaterally with minimal end-expiratory
wheezes, no rhonchi
CV: Tachycardic rate and reg 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 in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, calves nontender and symmetric.
Pertinent Results:
[**2102-3-13**] 04:38AM BLOOD Glucose-115* UreaN-11 Creat-0.5 Na-142
K-3.5 Cl-108 HCO3-23 AnGap-15
[**2102-3-13**] 04:38AM BLOOD ALT-26 AST-79* LD(LDH)-509* AlkPhos-168*
TotBili-0.9
[**2102-3-13**] 04:38AM BLOOD Albumin-3.3* Calcium-8.3* Phos-3.7 Mg-1.8
CXR [**2102-3-13**]
There are extensive bilateral upper zone opacities
with air bronchograms suggestive of pneumonia, previously
diagnosed at an
outside hospital. Outside hospital imaging was not available for
direct
comparison. Left hemidiaphragm is not visualized and suggests
left lower
field atelectasis and/or pleural effusion.
Brief Hospital Course:
72 yo female with afib, CHF (EF 30-35%), and metastatic colon
cancer undergoing palliative chemotherapy transferred from BIDN
for hypoxia in the context of bilateral multifocal pneumonia
seen on CXR.
She was initially started on vancomycin, levaquin and cefepime
for HCAP. Overnight she became progressively dyspneic and
hypoxic. In the morning, she was started on BiPAP to assist with
breathing. Around 11am, she was found to have right sided
hemiplegia and dysphasia, with a constricted right pupil,
suggesting that she had had a large hemispheric CVA. This
information was explained to her health care proxy, [**Name (NI) **] [**Name (NI) **].
The decision was made to pursue Comfort Measures Only and all
treatment was stopped. She was taken off the BiPAP and given a
morphine drip and ativan for comfort. She expired at 13:31. The
medical examiner was notified as she died within 24 hours of
admission. An autopsy was waved and also declined by next of
[**Doctor First Name **], her sister [**Name (NI) 43726**] [**Name (NI) 74569**].
Medications on Admission:
zyprexa 20 mg daily
colace 100mg [**Hospital1 **]
Senna 1 tab Qday
Magnesium oxide 400mg [**Hospital1 **]
Synthroid 75mcg daily
Melatonin 3mg Qhs
sertraline 100 mg daily
MV 1 tab daily
Trazodone 50mg Qhs
Ativan 0.5mg q4h prn anxiety
Morphine 2mg SL q4h prn pain
lidoderm patch 5%, 12hrs on, 12hrs off
Motrin 600mg Q6hrs prn pain
Acidophilus 2 tabs TID for 21 days (started [**3-9**])
Augmentin 500mg TID (started [**3-11**])
Started [**3-13**]: Saline nasal spray, duonebs, robitussin
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Colon cancer
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
ICD9 Codes: 486, 4019, 2724, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7954
} | Medical Text: Admission Date: [**2102-11-9**] Discharge Date: [**2103-3-7**]
Date of Birth: [**2102-11-9**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**Known lastname 5621**] [**Known lastname 37227**] was [**Known lastname **] with
a birhtweight of 730 gm and gestational age of 28 and 2/7th
week gestation baby boy to a 29-year-old gravida 3 para 2 to 3
mother. The patient's mother was transferred from [**Hospital6 11241**] prior to admission due to the fact that the [**Hospital1 2177**]
Neonatal Intensive Care Unit was full.
The pregnancy was notable for decreased fetal growth noted two
weeks prior to delivery and the mother was admitted to [**Hospital6 11241**] on [**11-7**] with a biophysical of [**2-26**].
The mother had two healthy full term infants prior to this.
Placenta was normal on gross examination. There was
no history of maternal hypertension. [**Name (NI) **] mother
was treated with one dose of betamethasone prior to
delivery.
Prenatal screens: Maternal blood type of O-, antibody
negative, Hepatitis B surface antigen was negative. Group
B strep was unknown. RPR was nonreactive.
In the delivery room, the patient emerged with decreased
tone, respirations and heart rate. The patient did respond
to bag and mask ventilation and was intubated in the delivery
room for poor effort. Apgars were 4 at 1 minute and 6 at 5
minutes. The patient was transferred to the Neonatal
Intensive Care Unit for further management.
ADMISSION PHYSICAL EXAM: On admission, the patient weighed
730 gm that was approximately the 50th percentile. He was
pink, active and non dysmorphic. The skin was without any
lesions. There was bilateral red reflex noted. Nares were
patent. The palate was intact. The head circumference was
23 cm that was also the 50th percentile. Lungs were coarse
and crackly with bilateral breath sounds. Cardiac exam was
noted to be regular rate and rhythm without murmur. The
abdomen was soft, nontender without hepatosplenomegaly.
Genitalia was normal for this gestational age. (Both testes
were undescended). The hips were stable and the back and
skeletal structures were normal. The neurological exam was
nonfocal and appropriate for age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: The patient was initially intubated in the
delivery room and over the course of the first day received 3
doses of surfactant. He was initially placed on the
conventional ventilator however was quickly transferred to the
high frequency ventilator because of the severity of his lung
disease. He was minimally responsive to the surfactant
therapy and his progressive respiratory distress necessitated
high frequency ventilation for the first 35 days of life.
During this time, the patient also developed bilateral pleural
effusions. The infant had a chest tube for drainage
bilaterally from the [**10-23**] until the [**10-28**].
(There were bilateral chest tubes placed during that period).
The patient was also briefly on caffeine for apnea of
prematurity, although this is no longer an issue. His
respiratory distress progressed to severe chronic lung
disease which has been managed with fluid restriction at 130
cc per kg per day as well as diuretic therapy. He was
intermittently on Combivent from the period of [**12-4**]
to [**1-16**] which resulted in marginal improvement. At
2 months of age, attempts were made to wean him from the
ventilator using inhaled betamethasone therapy. While this
did result in some improvement in oxygen requirement, the
infant still required moderate to high ventilatory settings
due to the inability to ventilate. During this time diuretic
therapy was also maximized. Initially, Diuril and Lasix was
given and maximized, but because of hypokalemia the Lasix was
discontinued.
Pulmonary consultation at that time recommended initiation of
systemic dexamethasone therapy due to severe unremitting
bronchopulmonary dysplasia. This was initiated [**1-15**], and the infant received a prolonged taper of
dexamethasone. Efforts to improve his pulmonary status using
high doses or corticosteroids proved to have marginal effect.
Tracheostomy was recommended to the family for better chronic
management of his pulmonary disease and to allow transfer to a
rehabilitation hospital for further care.
Baby [**Known lastname 5621**] underwent a tracheostomy on [**1-29**] without
any incidents. Bronchoscopy was done at that time that
showed bilateral vocal cord granulation tissue. This
surgical procedure was performed at [**Hospital3 1810**] where
the postoperative recovery period was also done. The baby
was transferred back to the [**Hospital3 **] Medical Center on
[**2-3**] for further care. His ventilatory settings at the
time was 24/6 x25 with an FIO2 in the mid 40s to 50%. He had
a 3.5 Shiley tracheostomy tube in place. This has
subsequently been changed to a 4.0 Shiley.
Baby [**Known lastname 37236**] blood gases were acceptable and consistently
had a PCO2 in the 70s (compensated). He received intermittent
doses of Lasix during the last two weeks of [**Month (only) 958**]. His
respiratory status did improve slowly and he was able to be
converted to neonatal pressure support on [**2103-2-14**] (on
day of life 97). At that time, the settings were as follows:
Neonatal pressure support of 18, PEEP of 6, FIO2 in the 50s
to 70%. After discussion with the pulmonary consultation, it
was decided to augment his respiratory care with a scheduled
course of Flovent. Over the next week, we were able to wean
Baby [**Known lastname 26524**] pressure support down to 16 while keeping
the oxygen requirements from 50% to 70%. However, by [**2-23**], his pulmonary status worsened again a chest x-ray showed
bilateral coarse markings consistent with severe
bronchopulmonary dysplasia and low lung volumes. He was
switched back to SIMV support to a setting of 26/6 x28.
Sepsis evaluation was performed at this this and cbc was
unremarkable. Of note, a bagged urine specimen had grown
[**Known lastname 37228**]. However, a catheter urine specimen that was sent
later was negative. Trach secretions were also sent for
culture as well as Mycoplasma. The Mycoplasma is pending as
of today. Combivent use was also added as part of his
respiratory therapy. Currently, Baby [**Known lastname 37227**] is on a vent
setting of 30/6 with a rate of 26 with an oxygen requirement
of 55% to 65%. After discussion with pulmonary consult as
well as the team, we concluded that Baby [**Known lastname 5621**] would
probably not benefit from a second course of systemic
steroids. Currently, his chronic lung disease is at a stage
that will require prolonged ventilatory support for now. He
is stable and comfortable on his current ventilatory settings
via his tracheostomy (of note, his tracheostomy was upsized to
a 4.0 Shiley on [**2-22**] without any improvement). His
current respiratory related medications include Flovent,
Combivent, Diuril, and Aldactone.
2. CARDIOLOGY: Baby [**Known lastname 5621**] had his first echocardiogram
on [**11-10**] at birth. This showed a large patent ductus
arteriosus with dilated left and right atrium, good left
ventricular and right ventricular function and a patent
foramen ovale. The patient received a course of indomethacin
to close the ductus. The patient does not currently have a
murmur. During the first week of life, the patient did
receive dopamine for low blood pressures. He has had no
other problems with cardiac function.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Due to abdominal
concerns and concerns for sepsis, the infant was not fed for
the first 20 days of life and was dependent solely on
parenteral nutrition. Feedings were slowly advanced between
day of life 25 and day of life 35 until he obtained full
feeds. The patient has been tolerating full feeds and is
currently PE-32 with ProMod 130 cc per kg per day pg. His
transfer weight is 3355gm.
His electrolytes reflect chronic respiratory acidosis and
diuretic therapy. He is currently on Diuril and Aldactone.
He is also receiving supplemental sodium and potassium.
His most recent electrolytes were Na 139 K 6.0 Cl 102 CO2 26
BUN 15 Cre 0.2
Nutrition labs: Alk phos - 266 Ca 10.6 PO4 6.6 Albumin 4.1
Baby [**Known lastname 5621**] had also had some difficulties with
hypoglycemia and has been followed by the Endocrine Consult
service form [**Hospital3 1810**]. The is felt to be most
likely secondary to prematurity and will hopefully resolve
over time. Occasionally, his blood glucose still dips into the
mid 50s. His metabolic evaluation has included urine organic
acid and serum immuno acids which have been unremarkable. He
did not show any evidence of metabolic acidosis.
His newborn screens were also unremarkable, including a normal
TSH. He did have a corticotropin stimulation test which was
within normal limits. An insulin level was drawn at one
point when he had hypoglycemia which was 6 which is within
normal limits..
Currently, his hypoglycemic episode has improved and he has
not had any hypoglycemic episodes while his feeds are given
over 1.5 hours. We recommend that his glucose levels be
continued to be monitored with the hopes that these
hypoglycemic episodes are transient. If these hypoglycemic
episodes persists, endocrinology may have to be reconsulted.
Currently, their recommendation is observation. They do note
that the patient will need endocrine follow up with an
endocrinologist when transferred to [**Hospital1 13820**]. So
far, they feel that the previous recurrent hypoglycemic
episode may have been related to the pharmacological steroid
use.
4. GASTROINTESTINAL: The patient had initial problems with
sepsis as well as total parenteral nutrition dependency for
the first 20 to 25 days of life. It was also noted that he
had elevated transaminases with an elevated alkaline
phosphatase and direct bilirubin. He has been on
phenobarbital due to elevated conjugated bilirubin.
Recently, his conjugated bilirubin has been trending
downward. Bilirubin on [**3-6**] was 0.4 total and 0.2 direct.
Hepatitis serology has been negative. He has been tested for
the alpha-1 antitrypsin mutation. His genotype is MM which is
usually normal. A HIDA scan that was performed showed a
decrease in clearance of bile.
He is on Zantac and Reglan due to concerns for
potential reflux. This was started on [**1-12**] and has
been continuing. He has not had a pH probe or upper
gastrointestinal study. His trach secretions have been
tested and is not consistent with microaspirations.
5. NUTRITION: He has been growing satisfactorily. He is on
potassium phosphate, potassium chloride and sodium chloride
supplementation. He is on iron, vitamin E.
6. INFECTIOUS DISEASE: The patient had a sepsis evaluation
after birth. Early abdominal films showed a distended
abdomen with some concerns of possible medical necrotizing
enterocolitis. There was no clear mention of pneumatosis in
his early abdominal films. He received 14 days of
ampicillin, clindamycin and gentamicin. On [**11-23**], due
to further emerging sepsis concerns, his ampicillin was
switched to Vancomycin for an additional seven days. He
ended up receiving a total course of 21 days of triple
antibiotics. At one and a half months of life, cefotaxime
and gentamicin were initiated due to concern for possible
[**Known lastname 37228**] tracheitis. A lumbar puncture was obtained at
that time which was benign. He was treated with antibiotics
for 14 days. He is currently not on any antibiotics and has
not been on any since a brief rule out sepsis that was done
on [**2-23**] when he had worsening pulmonary status.
CBC was negative, however, the blood culture did grow out
gram positive cocci. Another blood culture was done prior to
the start of antibiotics (Vancomycin and gentamicin) during
this period and that culture remained negative. Because
[**Known lastname 26524**] pulmonary status improved after we switched him
to SIMV and the repeat culture prior to antibiotics remained
negative and the gram positive cocci that initially grew
appeared to be a contaminant, the antibiotics were
discontinued after three days of therapy (48 hours after the
repeat culture had been negative).
Currently from an infectious disease standpoint, [**Known lastname 5621**]
has not had any evidence of an active infection. His
previous hospital history has noted that his trachea may be
colonized with [**Known lastname 37228**] pneumonia that is resistant to
gentamicin.
7. NEUROLOGY: The infant has had several cranial
ultrasounds. His initial ultrasound on day of life 3 showed
left grade 3 intraventricular hemorrhage. Progressive
ultrasounds have shown resolution of this hemorrhage with
relatively normal appearance of the lateral ventricles and the
presence of small choroid plexus cyst. His last ultrasound
was on [**2103-2-20**] which noted improvement as well.
Neonatal neurology clinic follow up is needed. The patient
also passed a recent hearing screen. His neurological exam
includes an alert active boy moving all extremities equally.
He is a bit hypertonic on all four extremities.
8. OPHTHALMOLOGY: The infant has been evaluated for
risk of retinopathy of prematurity and developed only mild
Stage I disease. This regressed completely and most recent
examination on the [**3-9**] shows maturity of the retinal
vessels bilaterally with no ROP.
9. AUDIOLOGY: Hearing screening was performed on [**2103-3-4**]
with automated auditory brainstem responses and passed in both
ears.
10. IMMUNIZATIONS: The baby has received his two month
immunization as his second hepatitis B immunization. He has
also received Synagis x2, the last one given on [**2103-3-5**].
10. PSYCHOSOCIAL: The social worker has been involved with
the family. They are French Creole speaking. They have been
involved in and are participating in his care. They do have
another child at home. We have had multiple family meetings
including a recent discharge summary meeting. The parents
are pleasant and understand [**Known lastname 26524**] medical conditions.
[**Known lastname 5621**] will need to be followed by pulmonology consultant,
endocrine consultant and neurology consultant.
DISCHARGE CONDITION: Stable
DISCHARGE DISPOSITION: To [**Hospital 13820**] Hospital
CARE RECOMMENDATIONS AT DISCHARGE:
1. NUTRITION: The infant is receiving 130 cc per kg per day
of PE-32 fortified with ProMod.
2. MEDICATIONS: Ranitidine 5.5 mg po/pg q8h, Reglan 0.27 mg
po/pg q8h, potassium phosphate 1 milliequivalent po pg q 12
hours, sodium chloride supplement 2 milliequivalents po/pg
qd, Flovent 44 mg 2 puffs [**Hospital1 **], vitamin E 5 international
units po/pg qd, Combivent metered dose inhaler 2 puffs via
trach q8h, Fer-In-[**Male First Name (un) **] 0.25 cc po/pg qd, aldactone 5.5 mg
po/pg qd, Diuril 55 mg po/pg q 12 hours, potassium chloride
supplements 2 milliequivalents po/pg q 12 hours.
DISCHARGE DIAGNOSES:
1. History of surfactant deficiency, severe respiratory
distress syndrome that progressed to severe chronic lung
disease.
2. History of bilateral pleural effusions, resolved.
3. History of medical necrotizing enterocolitis, resolved.
4. History of [**Known lastname 37228**] tracheitis/pneumonia, treated for
14 days.
5. Patent ductus arteriosus, status post medical closure
with indomethacin.
6. Presumed sepsis, resolved.
7. Persistent direct hyperbilirubinemia secondary to
prolonged TPN use, resolving.
8. Presumed gastroesophageal reflux disease being treated
with metaclopramide and ranitidine.
9. Resolved left grade 3 intraventricular hemorrhage.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern1) 37239**]
MEDQUIST36
D: [**2103-3-6**] 13:03
T: [**2103-3-6**] 13:38
JOB#: [**Job Number 37240**]
ICD9 Codes: 2762, V053, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7955
} | Medical Text: Admission Date: [**2183-7-27**] Discharge Date: [**2183-8-1**]
Date of Birth: [**2108-6-10**] Sex: M
Service: MEDICINE
Allergies:
Lasix / Paxil / Allopurinol / Lipitor
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Intubation, Central Venous Access
History of Present Illness:
HPI: 75yo M with complex history, including CCU admission
[**Date range (1) 61041**] for NSTEMI c/b shock w/ IABP, intubation,
trach/[**Date range (1) 282**], and s/p medicine admission [**Date range (1) 61042**] with repeat
NSTEMI, trach replacement, removed 1 wk ago, now w/acute on
chronic dyspnea x 2d. He was in his USOH, living at home on 2L
NC O2 until 1 week ago when his prednisone was d/c'd, after
trach removal. He gradually became dyspneic and on [**2183-7-25**] noted
inability to lie flat and marked PND. He was brought to the ED
today where he was in moderate respiratory distress and was
transiently on BiPAP. He was then weaned to 2L NC with O2 100%
after Bumex and Solumedrol. ABG: 7.26/73/79, concerning for
hypercarbic respiratory failure.
Past Medical History:
1.NSTEMI [**4-29**] - cardiac cath [**4-29**] w/ 3VD: distal LM 50%, Lcx
60%, OM2 90%, OM1 80%, no intervention, dropped BP at end of
cath w/ PEA arrest---> resuscitated w/ epi/pressors
2. EF 35% 1-2+MR [**5-29**] echo (had flash pulm edema on last admit)
3. COPD on home Oxygen (2L for years) Dr. [**Last Name (STitle) **] is pulm
fev1 590 cc by report- no pft's here
4. h/o pneumothorax
5. depression
6. IABP on last admit- was evaluated by CT surgery for CABG but
was thought not to be a surgical candidate given MMP
7. ARF on last admit - Cr 1.7, now 0.98
8. GIB-- AVM on last admit at hepatic flexure- s/p embolization
by IR (after 4 bleeding scans, c scope, push enteroscopy,etc)
REQUIRED 15 units of prbc's on last admit
Social History:
Married with two children. Tobacco: 2 ppd x 25 years, quit 35
years ago. No EtOH.
Family History:
Non-contributory
Physical Exam:
Vit - 106/65 100 24 69% 2L
Gen - elderly male, fatigued, depressed mood
HEENT - NC/AT, PERRLA, EOMI
Neck - JVP 10 cm, no carotid bruits, tracheostomy site C/D/I
CV - tachycardic, regular rhythm, normal S1, S2, II/VI systolic
murmur
Pulm - increased accessory muscle use, diffuse rales
Abd - benign
Ext - 1+ peripheral edema bilaterally, 1+ DP and PT pulses
bilaterally, weak LE bilaterally
Skin - multiple excoriated regions on LE bilaterally
Pertinent Results:
ADMISSION LABS:
6.2 > 10.3/32.1 < 495 MCV=88
.
N:81.0 L:7.5 M:6.4 E:4.7 Bas:0.5 Hypochr: 3+ Poiklo: 1+
.
136 / 95 / 12
--------------< 154
4.7 / 36 / 0.8
.
Ca: 8.7 Mg: 1.9 P: 3.1
.
CK: 33 Trop-*T*: 0.06 (trended down to 0.03 on [**7-28**])
proBNP: [**Numeric Identifier **]
.
PT: 12.1 PTT: 28.8 INR: 1.0
.
ABG: 7.26/73/79/34
.
[**7-29**] - Cortisol: 36.1
.
EKG [**2183-7-27**]:
Sinus rhythm. Left atrial abnormality. Left axis deviation with
left anterior fascicular block. Right bundle-branch block.
Probable old inferior wall myocardial infarction. Lateral ST-T
wve changes which are non-specific. Compared to the previous
tracing of [**2183-7-16**] no significant diagnostic change
.
CXR [**2183-7-27**]:
1. Interval increase of hazy opacities in the right upper lung
zone and right lower lung zone. These findings could represent
asymmetric CHF, but an infectious process cannot be excluded.
2. Cardiomegaly.
3. Interval removal of the tracheostomy tube. There is an area
of narrowing of the trachea, where the lumen is as narrow as 1
cm. This could reflect post intubation stenosis or edema.
4. Fibrotic changes of the lung and emphysema.
.
ECHO [**2183-7-29**]:
The left atrium is mildly elongated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated with regional dysfunction including
hypokinesis of the distal half of the anterior septum and
anterior walls, apex, and distal inferior and lateral walls. The
remaining segments contract well. The right ventricular cavity
is mildly dilated with mild global free wall hypokinesis. The
aortic valve leaflets are moderately thickened. There is
moderate aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild to
moderate ([**1-26**]+) mitral regurgitation is seen. There is
mild-moderate pulmonary artery systolic hypertension. There is
a trivial/physiologic pericardial effusion.
Compared with the prior study (tape reviewed) of [**2183-6-9**], the
left
ventricular cavity is now dilated, moderate aortic valve
stenosis is now
identified. The right ventricle was mildly dilated with free
wall hypokinesis on review of the prior study.
.
Brief Hospital Course:
# Respiratory distress- Likely COPD and CHF exacerbation
worsened by rapid decrease in steroids. Patient's hypercapnia
was attributed to chronic CO2 retention. He was able to be
weaned off the ventilator back to NC oxygen, which he uses at
home, by the time of discharge. He responded well to nebulizer
treatments and was restarted on steroids with a plan for a long
slow taper over the next few months. At discharge patient was
on nasal canula and satting above 90. Continue fluticasone
inhaler, albuterol and atrovent nebs as outpatient. And
continue PO steroids at 30 mg per day with slow taper down to 5
mg. Patient will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] on
[**2183-8-18**] for reassessment of his pulmonary function.
# CAD: Patient has known 3VD, last cath ([**4-29**]), no intervention
at that time given concurrent illness. CABG unlikely given
severe COPD. Continued ASA, BB, ACEi, and weaned Nitro gtt. At
discharge BB was changed to Toprol XL 25 mg and Lisinopril
increased to 10 mg. Pressures and HR stable. Patient will
follow up with Dr. [**Last Name (STitle) **] on [**2183-8-14**].
# Pump: EF 35% on echo ([**5-29**]) with 1-2+MR. Repeat ECHO from
this admission showed EF 35-40%. Continue Ethacrynic Acid 25
mg daily as outpt.
# h/o GIB with gastritis and multiple polyps. Continued on PPI
during hospitalization.
# Anemia - Patient received 1 unit of PRBCs during this
hospitalization.
# FEN: Electrolytes were repleted to maintain K>4, Mg>2.
Patient was advanced to a low sodium heart healthy diet.
# Prophylaxis - Patient was continued on PPI for gastric ulcer
prophylaxis and heparin for DVT prophylaxis.
# Code status: Patient clarified that he would like to be DNI
only, not DNR
# Dispo: Discharged to home with VNA and cardiac rehab.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY
2. Diclofenac Sodium 0.1 % Drops Sig: One (1) Ophthalmic once
a day ().
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY
5. Pravastatin Sodium 20 mg Tablet Sig: Four (4) Tablet PO HS
6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Two (2)
Tablet Sustained Release 24HR PO once a day.
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO BID
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS
10. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS
11. Hydrocortisone 1 % Cream Sig: One (1) Appl Topical TID
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY
14. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H
15. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
q4-6h:PRN.
16. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID as needed.
18. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-26**] Sprays Nasal
TID as needed.
19. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Pravastatin Sodium 80 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ethacrynic Acid 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Take 30 mg (3 tablets) every day for next 10 days, then
decrease to 20 mg (2 tablets) every day for the next 10 days.
Follow up with pulmonary for further taper regimen.
Disp:*60 Tablet(s)* Refills:*2*
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
10. Diclofenac Sodium 0.1 % Drops Sig: One (1) Ophthalmic qd
().
Disp:*1 bottle* Refills:*2*
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*1 Capsule, Sust. Release 24HR(s)* Refills:*2*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*2 MDI units* Refills:*1*
14. Atrovent 18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*2 MDI units* Refills:*1*
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CHF and COPD exacerbation
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] on [**2183-8-18**] at
2:15PM
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 10548**] Date/Time:[**2183-8-14**] 3:30
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2183-8-18**]
2:15
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2183-9-19**]
ICD9 Codes: 4280, 2762, 4240, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7956
} | Medical Text: Admission Date: [**2111-6-16**] Discharge Date: [**2111-6-28**]
Date of Birth: [**2057-4-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Antifreeze ingestion
Major Surgical or Invasive Procedure:
Hemodialysis
Endotracheal intubation
RIJ central line placement
History of Present Illness:
Mr. [**Known lastname 78991**] is a 54 year old male who presents with antifreeze
ingestion. Per report, the patient ingested 1.5-2L of antifreeze
at 6 pm on [**2111-6-16**]. He vomited four times and EMS was called. He
told the woman he was living with, [**First Name4 (NamePattern1) 2152**] [**Last Name (NamePattern1) **], that he would like
to jump in front of a car, but didn't want to upset the driver.
He initially complained of some burning in his throat and some
slurred speech per report. He was transferred to
[**Hospital3 **]. There he was given 2L 5%EtOH,
Vitamin B1 100 mg POx1, Vitamin B6 100 mg POx1. He had diarrhea
x 1 at the OSH which reportedly looked like antifreeze. He was
then sent to BIMDC for consideration of HD.
At [**Hospital1 18**], VS Temp 99.8, HR 50-60, BP 147/91, R 20. the patient
was intermittently apneic. To sternal rub, he would wake up and
call out "I want to die, let me die," and would not answer
history questions. He was intubated in the [**Hospital1 18**] ED and was
given a dose of 15 mg/kg fomepizole at toxicology
recommendations. His pH was 7.19 and renal was consulted for
consideration of HD. He was given 3 liters normal saline
Past Medical History:
Depression
h/o ETOH abuse
Social History:
Divorced; 1 son- doesn't keep in touch with family. Lives with
[**First Name4 (NamePattern1) 2152**] [**Last Name (NamePattern1) **] (listed as next of [**Doctor First Name **])- she is his landlord. history
of ETOH abuse, sober for 12 yrs. Extent of ETOH unknown. No
tobacco. no drugs. History of marijuana & cocaine use ~ 20 years
ago. Currently works as a delivery driver for the [**Location (un) 86**] Globe.
Family History:
NC
Physical Exam:
VS: 97.5 121/62 71 22 100 AC 550/14/5/50%
Gen: intubated, sedated, does not follow commands
HEENT: conjunctival erythema bilaterally. pupils equal round and
reactive to light. approx 2 mm
Car: RRR no murmur
Resp: coarse BS bilaterally
Abd: soft, mildly distended, tympanic to percussion, hypoactive
BS, no guarding
Ext: no LE edema, 2+ DP/PT bilaterally
Pertinent Results:
[**2111-6-16**] 11:00PM BLOOD WBC-14.2* RBC-4.26* Hgb-13.5* Hct-41.4
MCV-97 MCH-31.7 MCHC-32.6 RDW-13.7 Plt Ct-269
[**2111-6-16**] 11:00PM BLOOD Neuts-92.6* Bands-0 Lymphs-5.3*
Monos-1.7* Eos-0.2 Baso-0.1
[**2111-6-17**] 02:45AM BLOOD PT-13.6* PTT-22.5 INR(PT)-1.2*
[**2111-6-16**] 11:00PM BLOOD Plt Ct-269
[**2111-6-18**] 03:42AM BLOOD Ret Aut-2.1
[**2111-6-16**] 11:00PM BLOOD Glucose-549* UreaN-8 Creat-1.1 Na-135
K-4.3 Cl-101 HCO3-11* AnGap-27*
[**2111-6-16**] 11:00PM BLOOD ALT-14 AST-14 LD(LDH)-177 AlkPhos-62
TotBili-0.6
[**2111-6-16**] 11:00PM BLOOD Albumin-4.5 Calcium-8.5 Phos-2.3* Mg-2.1
[**2111-6-19**] 03:15AM BLOOD calTIBC-190* VitB12-147* Folate-GREATER
TH Ferritn-799* TRF-146*
[**2111-6-16**] 11:00PM BLOOD Osmolal-461*
[**2111-6-19**] 03:15AM BLOOD Osmolal-296
Relevant Imaging:
1) CT [**2111-6-19**]
IMPRESSION:
1. Very small amount of stranding and fluid in the right
retroperitoneum,
most consistent with a small retroperitoneal hemorrhage, likely
related to
right femoral central venous catheter placement. Amount of blood
does not
appear large enough to explain clinical hematocrit drop from 40
to 24.
2. Dense bilateral lung base consolidations, concerning for
aspiration or
infection.
2) CXR [**2111-6-22**]
Brief Hospital Course:
Mr. [**Known lastname 78991**] is a 54 year old male with depression s/p ethylene
glycol ingestion for suicide attempt, acidotic with hospital
course c/b fevers, hypotension, anemia, and difficult weaning
from ventilator secondary to AMS.
1)Ethylene glycol ingestion: Patient was admitted to the MICU
after an ethylene glycol ingestion. He had been started on an
ethanol gtt at the OSH. Upon transfer to [**Hospital1 18**], renal was
consulted and he was started on fomepizole and access was
established for hemodialysis. He underwent two hemodialysis
sessions and the ethylene glycol level was montiored until it
was no longer detectable. The HD line was then removed.
2)Fevers: During his hospital stay, the patient spiked high
fevers. The cause was thought to be a pneumonia given his sputum
which grew staph aureus and the cxray which suggested a possible
LLL infiltrate. He was started on Vancomycin Zosyn but he
continued to spike through antibiotics. The decision was made to
stop the antibiotics given lack of clear source of infection. He
continued to have fevers but lower than they had been. Cultures
remained negative.
3)Respiratory Failure: Patient was intubated initially for
airway protection given changes in his mental status. There was
also some thought that there was a component of PNA vs. volume
overload. He was treated briefly for hospital aquired pneumonia
(which were then stopped) and he was also diuresed with Lasix.
He was successfully extubated and his mental status slowly
improved.
4) Anemia: Patient had a significant drop in his hematocrit from
admission. He was guaiac negative. He also underwent a CT
abdomen/pelvis which was negative for an RP bleed. He did
received 2 units of pRBCs during his stay in the MICU.
5)Depression: Patient presented with ethylene glycol ingestion
as part of suicide attempt. Pscyhiatry and social work were
consulted once patient was extubated.
Medications on Admission:
None
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Primary Diagnoses:
1. Ethylene Glycol ingestion (Suicide attempt)
2. Acute Renal Failure
3. Bradycardia
4. Depression
Secondary Diagnoses
1. Recovering Alcoholism
Discharge Condition:
Medically Stable
Discharge Instructions:
You have been admitted to the hospital after an ingestion of
Ethylene glycol. While you were here you were in the Intensive
Care Unit.
Please take all medications as directed.
Please return to the Emergency Room for Chest Pain, Shortness of
Breath or any other medical concern.
Followup Instructions:
In-patient psychiatric Care
ICD9 Codes: 5849, 2762, 5185, 311, 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7957
} | Medical Text: Admission Date: [**2206-1-25**] Discharge Date: [**2206-1-29**]
Date of Birth: [**2152-1-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
dyspnea, respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 7086**] is a 54M h/o smoking, severe end-stage COPD on home
O2 of 2-5LNC, presenting with increasing dyspnea, sputum
production and transferred to MICU for need for NIPPV.
.
Roughtly one week prior to admission reports gradual onset nasal
congestion, Patient called [**Company 191**] triage on [**1-24**] with c/o that
congestion had progressed to his chest, and noted associated
thick secretions.
.
Wake this with morning with acute worsening of SOB. Progressive
symptoms prompted patient to call EMS. Sat 86% on RA per EMS, RR
30s-40s. On arrival to the ED, patient noted to be tri-poding.
Exam consistent with poor air entry and wheeze therefore
Treatment for COPD flare initiated with solumedrol 125mg,
azithro/CTX and patient placed on NIPPV; off CPAP desaturated
87% on 3L. CXR demonstrated hyperlucency of upper and mid zones
c/w severe emphysema, patchy opacities at bilateral bases,
left>right c/w crowding at emphysematic bases though cant rule
out super-imposed infiltrate. VS prior to transfer 100%02 on
CPAP 5/5 100%, RR: 18, additional VS: 139/79 HR 98.
Past Medical History:
- COPD, on 4 L home oxgyen and 10 mg prednisone every other day,
followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/[**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **], no prior intubations
- Diabetes Mellitus, type 2
- Obstructive sleep apnea, followed by [**First Name8 (NamePattern2) 450**] [**Last Name (NamePattern1) 437**], in
process of starting therapy but not currently on non-invasive
- Likely CAD (coronary calcifications on CT)
- Depression/Anxiety
- Diverticulosis
- Scrotal hydrocele
- Dupuytren contractures
Social History:
- Tobacco: Smokes one pack per day ([**11-26**] PPD) since age 13
- Alcohol: Occasional
- Illicits: Denies
Family History:
(per chart)
Multiple family members with DM
Brother with [**Name2 (NI) 499**] cancer
No family history of lung disease
Physical Exam:
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 rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: significantly redused air entry with distant breath
sounds, scattered wheezes. R less air entry than L.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Admission Labs:
[**2206-1-25**] 07:00AM BLOOD WBC-9.4 RBC-4.69 Hgb-13.7* Hct-40.1
MCV-85 MCH-29.2 MCHC-34.2 RDW-12.6 Plt Ct-254
[**2206-1-25**] 07:00AM BLOOD PT-11.4 PTT-27.9 INR(PT)-1.1
[**2206-1-25**] 07:00AM BLOOD Glucose-155* UreaN-10 Creat-0.8 Na-142
K-3.8 Cl-97 HCO3-35* AnGap-14
[**2206-1-25**] 12:23PM BLOOD Type-ART Temp-37.2 pO2-154* pCO2-89*
pH-7.28* calTCO2-44* Base XS-11 Intubat-NOT INTUBA
[**2206-1-25**] 04:33PM BLOOD Type-ART FiO2-40 pO2-74* pCO2-78*
pH-7.34* calTCO2-44* Base XS-11 Intubat-NOT INTUBA
[**2206-1-25**] 10:15PM BLOOD Type-ART pO2-64* pCO2-68* pH-7.38
calTCO2-42* Base XS-11 Intubat-NOT INTUBA
[**2206-1-26**] 06:08AM BLOOD Type-ART pO2-84* pCO2-76* pH-7.36
calTCO2-45* Base XS-12 Intubat-NOT INTUBA
[**2206-1-25**] 10:15PM BLOOD O2 Sat-92
Discharge Labs:
[**2206-1-28**] 05:15AM BLOOD WBC-8.3# RBC-4.40* Hgb-12.7* Hct-37.8*
MCV-86 MCH-28.8 MCHC-33.6 RDW-12.6 Plt Ct-199
[**2206-1-28**] 05:15AM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-142
K-3.7 Cl-99 HCO3-39* AnGap-8
ECGs:
Cardiovascular Report ECG Study Date of [**2206-1-25**] 8:07:40 PM
Sinus rhythm. Poor R wave progression, probable normal variant.
Non-specific lateral ST-T wave changes. Compared to the previous
tracing of [**2206-1-25**] the sinus rate is slower. The findings are
otherwise similar.
Cardiovascular Report ECG Study Date of [**2206-1-25**] 7:09:08 AM
Baseline artfact. Probable sinus tachycardia. Poor R wave
progression.
Non-specific ST-T wave abnormalities, although artifact makes
interpretation difficult. Compared to the previous tracing of
[**2204-5-10**] sinus tachycardia and artifact are new.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
120 0 98 [**Telephone/Fax (2) 57074**]2
IMAGING:
- Portable TTE (Complete) Done [**2206-1-27**] at 1:56:18 PM FINAL
-
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global and regional biventricular
systolic function. No valvular pathology or pathologic flow
identified. Dilated ascending aorta.
CLINICAL IMPLICATIONS:
The patient has a mildly dilated ascending aorta. Based on [**2203**]
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in 1 year; if
previously known and stable, a follow-up echocardiogram is
suggested in [**12-27**] years.
Brief Hospital Course:
Mr. [**Known lastname 7086**] is a 54 year old man with history of current tobacco
use, severe end-stage COPD on home O2 of 2-4L NC, admitted to
the MICU for COPD exacerbation, requiring NIPPV on presentation.
# COPD Exacerbation
Patient was admitted for COPD exacerbation, initially to MICU
for non-invasive ventilation, then transitioned back to nasal
canula over one day. Patient reports that last exacerbation was
about six months ago, for which he was not hospitalized, but he
created his own prednisone taper based on symptoms, which lasted
a couple of months. Patient was initially started on
ceftriaxone and azithromycin for treatment of potential LLL
pneumonia. Ceftriaxone was discontinued in MICU because
pneumonia was felt to be unlikely. He required albuterol
nebulizers every 2 hours in the MICU, transitioned to every 6
hours on the floor. He was also started on prednisone 60mg
daily on admission, transitioned to 40mg daily after 4 days.
Prednisone taper as follows: prednisone 40mg x 4 more days,
then decrease to prednisone 30mg x 6 days, then prednisone 20mg
x 6 days, then prednisone 10mg x 6 days, then back to home dose
of prednisone 10mg every other day. Patient may uptitrate for
symptoms if needed, but he should call primary care physician
[**Last Name (NamePattern4) **]. [**First Name (STitle) 216**] if doing so. He would like to join outpatient
pulmonary rehab at [**Hospital1 18**] once he meets requirements for smoking
cessation. Followup appointment with Dr. [**Last Name (STitle) **] was set up.
He was also started on alendronate in setting of chronic
prednisone use.
# Tobacco Use
Patient was counseled extensively on smoking cessation. He will
use nicotine patches at home, starting with 21mg/day patches,
which he states he already has. He was seen by social work for
extra support.
# DM2
Patient was well controlled on home metformin, but had a few
elevated blood sugars while on high dose steroids. He was
maintained on insulin sliding scale during hospitalization, but
transitioned back to metformin 500mg daily on discharge. Blood
sugars should be monitored while on prednisone taper.
# Hypertension
Patient with elevated blood pressures at primary care office on
multiple occasions, not on any medications yet. Had moderately
elevated blood pressures during hospitalization, ranging
120s-160s systolic. Will defer starting low dose [**Doctor Last Name 360**] to
primary care physician.
# Depression
Patient became anxious after discussion about severity of his
COPD. Spoke with social work for extra support. Continued on
home venlafaxine.
Transitional Issues:
- smoking cessation
- dilated aortic root seen on TTE (which was done in MICU to
look for dCHF as potential etiology of shortness of breath) -->
needs followup echocardiogram in 1 year or in [**12-27**] years if
clinically stable
- monitor blood pressures
- consider starting bactrim for PCP [**Name Initial (PRE) 1102**]
Medications on Admission:
FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 2 sprays each
nostril once daily *** not currently taking
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 inhaled twice a day
LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day as
needed for allergic symptoms *** not currently taking
METFORMIN [GLUCOPHAGE] - 500 mg Tablet - 1 Tablet(s) by mouth
once a day
PREDNISONE - 10 mg Tablet - 1 Tablet(s) by mouth 1-3x/day as
directed, but took 50mg today, and had been taking 60 earlier
this week
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - one capsule inhaled once a day Empty
capsule into inhalation device
VENLAFAXINE - (Prescribed by Other Provider) - 225 mg Tablet
Extended Rel 24 hr - 1 (One) Tablet(s) by mouth
Discharge Medications:
1. prednisone 10 mg Tablet Sig: AS DIRECTED Tablet PO once a
day: - Prednisone 40mg x 4 days
- Prednisone 30mg x 6 days
- Prednisone 20mg x 6 days
- Prednisone 10mg x 6 days,
- then back to your previous dosing of prednisone 10mg every
other day
.
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) cap Inhalation once a day.
3. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO DAILY (Daily).
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. temazepam 30 mg Capsule Sig: One (1) Capsule PO at bedtime as
needed for insomnia.
7. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergic symptoms.
8. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
9. alendronate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
10. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 5 weeks.
Disp:*30 Patch 24 hr(s)* Refills:*0*
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) capsule Inhalation every six (6) hours
as needed for shortness of breath.
12. ipratropium bromide 0.02 % Solution Sig: One (1) capsule
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
COPD Exacerbation
Diabetes Mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 7086**],
You were admitted to [**Hospital1 **] for a COPD
exacerbation. You were started on high dose prednisone and
given a 5 day course of azithromycin treatment. You will need
to continue prednisone for a few weeks, as listed below. As we
discussed, if you feel that the taper is too rapid, you can
increase your dose as needed, but please call Dr. [**First Name (STitle) 216**] if you
need to do this. Please also discuss smoking cessation with Dr.
[**First Name (STitle) 216**].
The following changes have been made to your medications:
* Prednisone taper as follows:
- Prednisone 40mg x 4 days
- Prednisone 30mg x 6 days
- Prednisone 20mg x 6 days
- Prednisone 10mg x 6 days, then back to your previous dosing
of prednisone 10mg every other day
* Please also start Alendronate 10mg daily and discuss this with
your primary care physician. [**Name10 (NameIs) **] must be seated upright when
taking this medication and drink a full glass of water with it.
* Please continue taking calcium and vitamin D
* Please start using the Nicotine Patch as follows:
- nicotine patch 21 mg/day (highest dose) for 5 more weeks
- nicotine patch 14 mg/day for 2 weeks
- nicotine patch 7 mg/day for 2 weeks
(Your current prescription is only for 30 days of the 21mg/day
nicotine patch.)
While you were here you were seen by social work. She provided
you with information on smoking cessation and relaxation
techniques. It was alos recommended that you engage in out
atient therapy to help you cope with your chronic illness and
anxiety. You can contact one of the following to make an
appointment:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Street Address(2) 57075**]
[**Hospital1 8**] MA
[**Telephone/Fax (1) 57076**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 1046**]
[**Street Address(2) 57077**]
[**Hospital1 **] MA
[**Telephone/Fax (1) 57078**]
[**First Name8 (NamePattern2) **] [**Last Name (un) 41140**], [**Last Name (un) 1046**]
[**Location (un) 57079**] MA
[**Telephone/Fax (1) 57080**]
If you need more referrals or any further assistance, please
contact the social worker you saw while you were here: [**Name (NI) 636**]
[**Last Name (NamePattern1) 12471**] [**Telephone/Fax (1) 57081**]
Followup Instructions:
Please be sure to keep your followup appointments as listed
below:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2206-2-5**] at 10:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2206-2-13**] at 2:40 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: THURSDAY [**2206-2-13**] at 3:00 PM
With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 3051, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7958
} | Medical Text: Admission Date: [**2109-3-31**] Discharge Date: [**2109-4-5**]
Date of Birth: [**2026-11-6**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
cath
History of Present Illness:
84F h/o MI in [**2086**] and CVA [**2099**], on Coumadin FOR AFIB, denies
CABG or stents, c/o 1 hr of chest tightness, nausea,
diaphoresis, onset while at rest watching TV. Followed by Mark
[**Doctor Last Name **] at [**Location (un) **]. In ED had inferior STEMI with 2>3 STE in
inferior leads. She got ASA and a Heparin bolus. INR was >3 so
no gtt started. She was not given plavix prior to procedure.
She was taken to the cath lab where she was found to have
90-100% mid RCA occlusion. The wire was delpoyed across the
lesion but due to her INR of >3 and fragile appearing [**Last Name (un) 12599**]
she was not felt to be a canditate for stenting. She underwent
baloon angioplasty.
.
Following proceure, As radial T band was being remove she
vagaled and had SBP drop to 50's with HR in the 150's. Was given
1-2 mg of atropine, started on dopamine. Systolics rose to the
80's. She was then given 10mg IV diltiazem followed by 15mg IV
metoprolol with control of her HR to the 130's and SBP to 100's.
She arrives ont he floor on 10 of dopa.
.
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: CAD
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Knwon MI in [**2088**]
- CVA
- Afib on coumadin
-
Social History:
- Tobacco history: Quit smokign 21 years ago
- ETOH: occasional glass of wine
- Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: 120 97/70 RR18 02 SAT 100%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVP elevation
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
.
Exam at discharge:
Vitals T 98.4 BP 125-156/76-86 HR 85-100RR 18 O2 94RA
I/O:
Tele: AF, rate 90's-low 100's no VEA
Weight: 58.3(58.6)
.
General Appearance: NAD, sitting in chair
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: irregularly irregular (S1: Normal), JVP 12cm
H2O, no murmurs, rubs or gallops
Respiratory / Chest: CTAB
Abdominal: Soft, Non-tender
Extremities: right LE with 1+, LLE nl.
Neurologic: Oriented to self, [**Hospital1 18**], Month, year, good attention
Pertinent Results:
ADMISSION LABS:
[**2109-3-31**] 06:15PM BLOOD WBC-6.6 RBC-3.59* Hgb-12.1 Hct-36.5
MCV-102* MCH-33.8* MCHC-33.3 RDW-12.6 Plt Ct-219
[**2109-3-31**] 07:00PM BLOOD PT-40.4* PTT->150 INR(PT)-4.0*
[**2109-3-31**] 07:00PM BLOOD Glucose-113* UreaN-17 Creat-1.0 Na-144
K-3.0* Cl-105 HCO3-26 AnGap-16
[**2109-3-31**] 06:15PM BLOOD cTropnT-<0.01
[**2109-4-1**] 12:54AM BLOOD CK-MB-88* MB Indx-12.0* cTropnT-3.54*
[**2109-4-1**] 05:11AM BLOOD CK-MB-87* MB Indx-11.0* cTropnT-3.65*
[**2109-4-1**] 12:54AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.5*
[**2109-3-31**] 07:00PM BLOOD %HbA1c-5.9 eAG-123
[**2109-3-31**] 07:00PM BLOOD Triglyc-81 HDL-52 CHOL/HD-2.3 LDLcalc-52
[**2109-3-31**] 06:22PM BLOOD Glucose-109* Lactate-2.3* Na-141 K-3.3
Cl-102 calHCO3-28
PERTINENT INTERVAL LABS:
[**2109-3-31**] 07:00PM BLOOD WBC-7.0 RBC-3.35* Hgb-11.0* Hct-33.1*
MCV-99* MCH-32.9* MCHC-33.3 RDW-12.7 Plt Ct-194
[**2109-4-1**] 12:54AM BLOOD Hct-32.2* Plt Ct-199
[**2109-4-1**] 05:11AM BLOOD WBC-7.5 RBC-3.35* Hgb-10.9* Hct-33.4*
MCV-100* MCH-32.5* MCHC-32.6 RDW-12.8 Plt Ct-203
[**2109-4-2**] 01:31AM BLOOD WBC-8.5 RBC-3.13* Hgb-10.4* Hct-31.0*
MCV-99* MCH-33.3* MCHC-33.6 RDW-12.9 Plt Ct-182
[**2109-4-3**] 06:29AM BLOOD WBC-6.4 RBC-3.12* Hgb-10.2* Hct-31.6*
MCV-101* MCH-32.7* MCHC-32.3 RDW-13.4 Plt Ct-179
[**2109-3-31**] 07:00PM BLOOD PT-40.4* PTT->150 INR(PT)-4.0*
[**2109-4-1**] 05:11AM BLOOD PT-29.3* PTT-41.3* INR(PT)-2.8*
[**2109-4-2**] 12:31PM BLOOD PT-38.9* INR(PT)-3.8*
[**2109-4-3**] 06:29AM BLOOD PT-29.0* PTT-38.1* INR(PT)-2.8*
[**2109-3-31**] 07:00PM BLOOD Glucose-113* UreaN-17 Creat-1.0 Na-144
K-3.0* Cl-105 HCO3-26 AnGap-16
[**2109-4-1**] 05:11AM BLOOD Glucose-131* UreaN-18 Creat-1.1 Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
[**2109-4-2**] 01:31AM BLOOD Glucose-118* UreaN-22* Creat-1.2* Na-141
K-3.6 Cl-104 HCO3-22 AnGap-19
[**2109-4-3**] 06:29AM BLOOD Glucose-78 UreaN-21* Creat-1.0 Na-142
K-3.5 Cl-107 HCO3-25 AnGap-14
[**2109-4-1**] 12:54AM BLOOD CK(CPK)-734*
[**2109-4-1**] 05:11AM BLOOD CK(CPK)-788*
[**2109-4-1**] 01:22PM BLOOD CK(CPK)-633*
[**2109-4-2**] 01:31AM BLOOD CK(CPK)-603*
[**2109-4-3**] 06:29AM BLOOD ALT-41* AST-67* AlkPhos-41 TotBili-0.7
[**2109-3-31**] 06:15PM BLOOD Lipase-59
[**2109-3-31**] 06:15PM BLOOD cTropnT-<0.01
[**2109-4-1**] 12:54AM BLOOD CK-MB-88* MB Indx-12.0* cTropnT-3.54*
[**2109-4-1**] 05:11AM BLOOD CK-MB-87* MB Indx-11.0* cTropnT-3.65*
[**2109-4-1**] 01:22PM BLOOD CK-MB-48* MB Indx-7.6* cTropnT-2.35*
[**2109-4-2**] 01:31AM BLOOD CK-MB-25* MB Indx-4.1 cTropnT-1.88*
[**2109-4-1**] 12:54AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.5*
[**2109-4-2**] 01:31AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.8
[**2109-4-3**] 06:29AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.1
[**2109-3-31**] 07:00PM BLOOD %HbA1c-5.9 eAG-123
[**2109-3-31**] 07:00PM BLOOD Triglyc-81 HDL-52 CHOL/HD-2.3 LDLcalc-52
STUDIES:
ECG ([**3-31**]):
Sinus rhythm. Right bundle-branch block. Inferior ST segment
elevation
consistent with an acute inferior myocardial infarction and
probable lateral extension with slight ST segment elevation in
leads V5-V6. There is reciprocal ST segment depression in leads
I, aVL and V1-V2. No previous tracing available for comparison.
Cardiac Cath ([**3-31**]):
COMMENTS:
1) Selective coronary angiography of this right-dominant system
demonstrated one-vessel coronary artery disease. The LMCA, LAD,
and LCx
had minimal disease but were free of angiographically-apparent
flow-limiting stenoses. The mid-RCA was subtotally occluded.
2) After the mid-RCA angioplasty, she began complaining of
nausea and
dizziness and was noted to have a noninvasive sBP in the high
50s. The
transducer was connected to the right radial arterial sheath
sidearm,
with blunted pressure recordings. Noninvasive readings were
consistently below sBP 70. She was given 2 mg atropine for
presumed
vagal reaction, and started on IV fluids and dopamine, up to 20
mcg/kg/min. A right common femoral arterial sheath was placed
in
preparation for possible IABP placement. However, her sBPs were
then
noted to be in the 80s-90s. At that time, her heart rates were
in the
140s-150s (transiently as high as 200) and appeared to be atrial
fibrillation; she was then given 15mg IV metoprolol with
resulting heart
rates in the 120s and stable sBPs in the 100s. The RCFA sheath
was
manually pulled and a TR band was applied to the RRA site. She
was
transported to the CCU in stable condition.
ADDENDUM: PCI COMMENTS:
Initial angiography revealed a subtotally occluded RCA. We
planned to
treat this using PTCA. A 6 Fr JR5 guiding catheter provided
reasonable
support throughout the procedure. Chronic Warfarin therapy with
known
INR of 3.2 48 hours prior. A Prowater wire was successfully
advanced
across the target lesion and positioned in the distal vessel. An
Apex
2.0 x 8 mm balloon was used to pre-dilate the occlusion,
restoring flow
to the vessel. Attempts were made to deliver a Mini-Vision 2.0 x
12 mm
and then a 2.0 x 8 mm stent, however we were unable to advance
these
across the lesion. Final angiography showed TIMI 3 flow within
the
vessel and no apparent dissection. It was elected to stop with
conventional balloon angioplasty given her elevated INR. Post
angioplasty hemodynamic course as documented above. Hemostasis
achieved
at right radial arterial access site using TR band.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease status post primary
balloon
angioplasty of the mid-RCA stenosis.
2. Vagal reaction and hypotension requiring pressors and fluids.
.
ECG ([**2109-3-31**]): rate 84, Baseline artifact makes P wave morphology
difficult. This could be sinus rhythm with premature atrial
contractions and ventricular premature beats versus atrial
fibrillation with ventricular premature beats. Right
bundle-branch block. Inferior and lateral ST segment elevation
consistent with an acute inferior myocardial infarction.
Compared to tracing #1 baseline artifact is more pronounced.
.
ECG [**2109-3-31**]: rate 133. Probable atrial fibrillation with a rapid
ventricular response and baseline artifact. Right bundle-branch
block. Left anterior fascicular block. Q waves in leads III and
aVF consistent with an inferior myocardial infarction which is
probably acute. Compared to tracing #2 the inferior and lateral
ST segment elevation is less pronouced. Q waves are more
apparent in leads III and aVF. TRACING #3
.
ECG [**2109-3-31**]: rate 126. Possible atrial flutter with variable
block. Right bundle-branch block with left anterior fascicular
block. Slight ST segment elevation in leads III and aVF with Q
waves suggesting evolution of an inferior myocardial infarction.
Premature ventricular contraction is also present. Lateral ST-T
wave changes consistent with ongoing ischemia. Compared to
tracing #3 atrial flutter may be present. The ventricular
premature beat is new.
.
ECG [**2109-3-31**]: rate 123. Probable atrial fibrillation with a rapid
ventricular response. Right bundle-branch block with left
anterior fascicular block. Inferior myocardial infarction which
is evolving. ST-T wave changes suggest ongoing ischemia.
Compared to tracing #5 the ventricular rate is slower.
.
ECG [**2109-4-1**]: rate 86. Atrial flutter at an atrial rate of about
300 with variable block. Right bundle-branch block with left
anterior fascicular block. Inferior myocardial infarction with
inferior T wave inversions suggesting an evolving inferior
myocardial infarction. Non-specific T wave flattening in leads
V4-V6. Compared to tracing #6 the ventricular rate is slower.
The ST segment depression in leads V1-V2 is less pronounced.
.
ECHO [**2109-4-1**]: The left atrium is elongated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 5-10 mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild to moderate regional left ventricular
systolic dysfunction with severe hypokinesis of the basal half
of the inferior septum, inferior and inferolateral walls. The
remaining segments contract normally (LVEF = 35 %). The right
ventricular cavity is mildly dilated with normal free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**11-26**]+) mitral regurgitation is seen.
Severe [4+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
moderate regional systolic dysfunction c/w CAD. Severe tricuspid
regurgitation. Pulmonary artery hypertension. Mild-moderate
mitral regurgitation.
Labs on Discharge:
[**2109-4-5**] 06:55AM BLOOD WBC-6.3 RBC-3.12* Hgb-10.2* Hct-31.4*
MCV-101* MCH-32.6* MCHC-32.4 RDW-13.6 Plt Ct-198
[**2109-4-5**] 06:55AM BLOOD PT-26.2* INR(PT)-2.5*
[**2109-4-5**] 06:55AM BLOOD UreaN-19 Creat-0.9 Na-144 K-3.8 Cl-108
HCO3-30 AnGap-10
[**2109-4-4**] 06:56AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.9
Brief Hospital Course:
Brief Clinical Summary:
Ms. [**Known lastname **] is an 82 year old woman with history of CAD, Afib on
coumadin and CVA who presented with inferior STEMI secondary to
RCA occlusion now s/p percutaneous balloon angioplasty with
immediate post procedural course complicated by hypotension and
tachycardia initially requiring pressors, hospitalization
complicated by delirium.
Issues:
# Inferior STEMI:
Because patient presented with supratherapeutic INR, decision
was made not to commit patient to plavix with PCI, so she
underwent POBA of the RCA. She was chest pain free with
resolution of ST changes after intervention. She was initially
hypotensive and bradycardic on presentation, requiring dopamine
for support which was soon weaned off. She also received a dose
of atropine on the night of presentation, after which she became
more delirious. She was continued on aspirin, beta blocker.
Atorvastatin dose was increased to 80mg daily. Lisinopril 2.5mg
was started prior to discharge. TTE showed EF of 35%, symmetric
LVH with moderate regional systolic dysfunction, severe TR,
moderate mitral regurgitation, and RV failure. Hemoglobin A1c
was 5.9% consistent with prediabetes. Lipid panel showed HDL
54, LDL 47 and trigl 108. The patient has been arranged with
cardiac follow-up.
# Acute Systolic Dysfunction: EF 35% on ECHO. No signs of CHF
during her hospital stay. Her discharge weight is 128 pounds.
She will require daiy weights with the consideration of starting
a diuretic if her weight increases or she shows signs of CHF. An
ECHO should be scheduled in [**3-1**] weeks to assess LV function.
# Delirium:
ICU course was complicated by significant delirium which quickly
resolved on the floor. She was given several doses of
olanzapine and quetiapine in the ICU in efforts to restore her
sleep-wake cycle.
# Afib with RVR:
She remained in atrial fibrillation throughout hospitalization.
CHADS score is 4. Presented with supratherapeutic INR, so
warfarin was initially held, then restarted prior to discharge.
She was continued on metoprolol.
# Hypertension
Home antihypertensives were initially held in the setting of
hypotension. When hemodynamically stable, she was restarted on
metoprolol in setting of atrial fibrillation, and she was
started on low dose lisinopril. Her metoprolol was increased to
150 of succinate once per day. Home HCTZ was discontinued.
# Code Status was FULL CODE during this hospitalization
# Husband: [**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 18277**].
Transitional Issues:
1. cardiology f/u
2. uptitrate lisinopril as tolerated
3. uptitrate metoprolol as tolerated
Medications on Admission:
Warfarin 3.75-7mg
Calcium 600 D
HCTZ 25 mg QD
Lipitor 10mg QD
Immodium PRN
Maalox 2 tsp QHS
Metoprolol 50mg QD
MVI
Probiotics
Tylenol 500mg [**Hospital1 **] PRN
-
Discharge Medications:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
[**Hospital1 **]:*45 Tablet Extended Release 24 hr(s)* Refills:*0*
2. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day:
please adjust dose as instructed by your doctor.
[**Last Name (Titles) **]:*90 Tablet(s)* Refills:*2*
3. Calcium 500 + D Oral
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
5. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Last Name (Titles) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
7. immodium Sig: One (1) once a day as needed for diarrhea.
8. Maalox RS Oral
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. probiotics Sig: One (1) once a day.
11. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Delirium
Hypertension
Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital because you had a heart
attack. We started you on new medications to help protect your
heart. You had some delirium (confusion) in the hospital, which
is now improved.
The following changes were made to your medications:
- STOP Hydrochlorothiazide
- DECREASE Warfarin to 3mg daily and adjust your dose as
instructed by your doctor
- INCREASE Lipitor to 80mg daily to lower your cholesterol
- START Aspirin 325mg daily to prevent blood clots
- INCREASE Metoprolol Succinate to 150mg daily to slow your
heart rate
- START lisinopril 2.5mg daily
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
Name: MARK [**Name Initial (MD) **] [**Name8 (MD) **],MD
Location: [**Hospital3 **] CARDIOLOGISTS
When: Tuesday [**4-9**] at 1pm
Address: [**2109**], [**Location (un) **],[**Numeric Identifier 8934**]
Phone: [**Telephone/Fax (1) 18278**]
Completed by:[**2109-4-5**]
ICD9 Codes: 4254, 4271, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7959
} | Medical Text: Unit No: [**Numeric Identifier 72703**]
Admission Date: [**2114-4-9**]
Discharge Date: [**2114-4-9**]
Date of Birth: [**2114-4-9**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Patient is the 485 gram
product of a 28-week gestation born to a 25-year-old prima
1st mother with an [**Name (NI) 37516**] of [**2114-7-4**]. Mother was admitted
on [**2114-3-29**], for evaluation of disconcordant growth of
these di-di twins. Infant uterine growth restriction and low
amniotic fluid was noted in sibling of this child. The
estimated fetal weight of twin A on [**3-30**], of this twin
was 541 grams and the sibling was 863 grams on [**2114-3-30**]. Biophysical profiles at that time were reassuring. A
course of betamethasone was done during that admission on
[**2114-3-30**].
The pregnancy was otherwise complicated by migraines,
irritable bowel syndrome, and maternal anxiety. She received
[**Year (4 digits) 34491**] p.r.n. for her migraines.
Prenatal screens showed a maternal blood type of A-positive
with a negative antibody screen, hepatitis B surface antigen
was negative, RPR nonreactive, rubella immune. Maternal group
B strep colonization status was unknown.
The mother was readmitted on [**4-5**], at 27 weeks and 1 day
for fetal monitoring. There was absent diastolic flow noted
on a Doppler of this twin. Fetal
testing remained otherwise reassuring through this evening
when abnormalities of fetal heart monitoring for twin B were
noted. Given the history of poor growth and absent diastolic
flows, decision was made to proceed to C-section.
MATERNAL HISTORY: Notable for, according to labor and
delivery records, for a history of migraines, irritable bowel
syndrome, and anxiety. The mother was treated with [**Name (NI) 34491**]
on a p.r.n. basis.
At delivery, the patient emerged vigorous with Apgars of 6
and 7. She was treated with blow-by O2, then CPAP. The
development of moderate respiratory distress prompted
intubation in the delivery room with a 2.0 oral ETT> (Larger tube
not attempted).
PHYSICAL EXAM ON ADMISSION: Shows pink, active,
nondysmorphic infant intubated with good perfusion and
saturations. Left great toe is held in flexion and sl abducted.
Bones appear normal to palpation Skin is without lesions. HEENT
exam was
unremarkable. Cardiac exam shows a normal S1 and S2 without
murmurs. Abdomen is benign. Lungs show bilateral crackles
with moderate retractions. Genitalia shows a normal premature
female. Anus was patent. The spine is intact. Hip exam was
normal. The patient, who is in breech presentation, shows a
left hyperextended hip at rest. Again, hip exam otherwise
appears normal. Neuro exam was nonfocal and age appropriate.
HOSPITAL COURSE BY SYSTEMS:
1. The patient was intubated in the delivery room as noted
above. Initial dose of Survanta was administered in the
NICU. The patient has weaned to settings of 14/5 IMV 20 60->
30% O2.
Mean blood pressure on admission was in the 30s.
2. Fluid, electrolytes, and nutrition: Patient was
maintained NPO, IV fluids of D10W at 120 cc per kilogram
administered. Initial blood sugar was 40 prior to start of
IVF
3. Infectious disease: CBC and blood culture were sent at
the time of admission. These results remain pending.
Ampicillin and gentamicin were begun for a presumed 48-
hour rule out.
4. Routine healthcare maintenance: Newborn screening sample
was to be sent prior to transfer to [**Hospital3 1810**].
Hearing screening has not been accomplished, but is
suggested prior to ultimate discharge home. PMD not yet
identified.
DISCHARGE DIAGNOSES:
1. Twenty-eight-week preemie.
2. Respiratory failure requiring intubation.
3. Hyaline membrane disease.
4. Rule out sepsis.
5. ? positional deformity of left great toe.
6. Intra-uterine growth restriction.
DISCHARGE DISPOSITION: Patient is to be transferred to
[**Hospital3 1810**] neonatal intensive care unit care of Dr.
[**Last Name (STitle) **]. Parents had signed consent for transfer and had visited
with infants prior to their transfer.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 56160**]
MEDQUIST36
D: [**2114-4-10**] 00:03:51
T: [**2114-4-10**] 05:41:23
Job#: [**Job Number 72704**]
ICD9 Codes: 769, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7960
} | Medical Text: Admission Date: [**2124-8-5**] Discharge Date: [**2124-8-13**]
Date of Birth: [**2066-5-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2124-8-7**]
Coronary artery bypass graft x 5 (Left internal mammary artery >
left anterior descending, Saphenous vein graft > diagonal >
obtuse marginal, saphenous vein graft > right coronary artery >
posterior descending artery) [**2124-8-9**]
History of Present Illness:
58M presented to [**Hospital1 **] [**Location (un) 620**] with a three day history of chest
pain, now severe and radiating to his upper back. The patient
was hypertensive to 198/124, equal in both arms. CXR was
negative. He was given labetalol, NGT, and ASA. Troponin was
elevated to 0.268, CK-MB 51, MBI 13. CXR was negative.
Transferred to [**Hospital1 18**] for CTA to rule out dissection.
.
Patient drove up to MA a few days ago and noticed tightness in
his shoulders and back. Played golf the next day and continued
to have upper back and upper chest pain b/l. Denies SOB,
dizziness. Had some nausea at first, but resolved. Continued
to play golf. At night used a cold pack to releive the pain and
was able to sleep. The next day he continued to have the pain
without relief so he went to the [**Hospital1 **] at [**Location (un) 620**].
.
In the ED, the troponin was elevated to 0.4, MB 88. A CTA was
negative for acute dissection. Patient was seen by cardiology
and they recommended heparin, integrillin gtt's for possible
cath.
Past Medical History:
1. slipped disc durgery in [**2087**]
2. rhinoplasty in [**2097**]
Social History:
Patient works in the golf buisness, recently had been caddying
and walks 6 to 10 miles per day. Lives in [**Doctor First Name 5256**], now
in [**Location (un) 7349**] for the summer; in MA on a visit to play golf.
-Tobacco history: Patient has smoked [**1-26**] ppd for 20 years
-ETOH: has about 4 drinks per night. Denies having hangovers
or withdrawal symptoms.
-Illicit drugs: hx of cocaine use in the 80's, nothing recently
Family History:
His paternal grandfather had an MI at the age of 39, otherwise
non-contributory.
Physical Exam:
VS: T= 97.6 BP= 130/82 HR= 55-64 RR= 18 O2 sat= 96 % on RA
GENERAL: middle-aged male lying in bed in NAD. Alert and
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, MMM
NECK: Supple with JVP of 7 cm.
CARDIAC: Regular and bradycardic, normal S1, S2. No m/r/g.
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: no rashes
Pertinent Results:
[**8-5**] Chest CT: 1. No aortic dissection 2. Findings concerning
for right lower lobe pneumonia with slightly enlarged medistinal
nodes. 3 month followup is recommended to ensure resolution.
.
EKG: Sinus bradycardia, T wave inversions in III, aVF, V5, and
V6 and biphasic T waves in II and V4.
.
[**8-7**] Cardiac cath: 1. Selective coronary angiography of this
right dominant system revealed three vessel disease. The LMCA
had no significant disease. The LAD had an 80% stenosis
involving the bifurcation at the D1. The D1 additionally had at
the mid segment an 80% stenosis. The OM1 was a small vessel
with 95% stenosis. The OM2 had a 100% total occlusion with a
large proximal thrombus. The OM2 had retrograde filling by
collaterals. The RCA had an 80% stenosis at the proximal
segment, an 90% stenosis at the mid/distal segment. The R-PDL
had an 80% stenosis. 2. Limited resting hemodynamic assessment
demonstrated normal systemic arterial pressure with a central
aortic pressure of 138/78 mm Hg. The LVEDP was mildly elevated
at 22 mm Hg, which was suggestive of diastolic dysfunction.
Carefull pullback across the aortic valve showed no evidence of
aortic stenosis. 3. Left ventriculogram demonstrated normal
systolic function and normal wall motion. There was no mitral
regurgitation.
[**8-9**] Echo: PRE-BYPASS: The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with mild focal abnormalities
in the lateral wall, apex and inerior wall.. Overall left
ventricular systolic function is mildly depressed (LVEF= 45 to
50 %). Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild (1+)mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on Mr. [**Known lastname 2093**], D at
10 AM on [**2124-8-9**].
Post_Bypass: Ascening aortic contour is intact. Mild MR and
there is no change from the preop. Normal RV systolic function.
Overall LVEF 50%.
[**2124-8-5**] 02:55AM BLOOD WBC-10.2 RBC-4.49* Hgb-13.7* Hct-39.7*
MCV-88 MCH-30.5 MCHC-34.5 RDW-13.6 Plt Ct-196
[**2124-8-11**] 06:40AM BLOOD WBC-9.6 RBC-3.20* Hgb-10.0* Hct-28.7*
MCV-90 MCH-31.2 MCHC-34.8 RDW-13.1 Plt Ct-184
[**2124-8-5**] 02:55AM BLOOD PT-13.2 PTT-28.6 INR(PT)-1.1
[**2124-8-10**] 01:11AM BLOOD PT-13.6* PTT-29.9 INR(PT)-1.2*
[**2124-8-5**] 02:55AM BLOOD Glucose-136* UreaN-20 Creat-0.9 Na-139
K-3.6 Cl-104 HCO3-28 AnGap-11
[**2124-8-11**] 06:40AM BLOOD Glucose-110* UreaN-22* Creat-1.2 Na-137
K-4.5 Cl-101 HCO3-28 AnGap-13
[**2124-8-11**] 06:40AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.0
Brief Hospital Course:
58 yo male smoker with no PMH found to have a NSTEMI with
positive cardiac enzymes.
On [**8-7**] he underwent a cardiac cath which revealed sever three
vessel coronary artery disease. He was appropriately worked-up
for bypass surgery and on [**8-7**] he was brought to the operating
room where he underwent a coronary artery bypass graft x 5.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later on op day he was weaned from
sedation, awoke neurologically intact and extubated. On post-op
day two beta-blockers and diuretics were started and he was
transferred to the telemetry floor for further care. Also on
this day, chest tubes were removed without incident. The
remainder of his postoperative course was uneventful and he
progressed well. He was discharged to home on POD#4 on [**8-13**].
Medications on Admission:
None
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
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. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Multivitamin 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:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 5
Myocardial Infarction
PMH: s/p Back surgery, s/p Rhinoplasty
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Chest CT scan in 3 months as follow up for enlarged mediastinal
lymph nodes.
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - ([**Telephone/Fax (1) 2037**] - you have an appointment on
[**9-21**] at 1pm
Dr [**Last Name (STitle) **] in 4 weeks - please call to schedule appointment
It is recommended that you remain locally until follow up
appointment with Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) **]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7961
} | Medical Text: Admission Date: [**2107-9-21**] Discharge Date: [**2107-9-27**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
left chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient speaks minimal English. Most of history obtained from
chart. He arrived via ems from day care program with report s/p
fall - report pt slid off of chair and hit back of head - no
LOC.
Complains of pain L chest and L knee
Past Medical History:
COPD
CAD (severe LAD disease, ?no stent per UMG but on plavix)
Chronic diastolic heart failure
DM (followed by [**Last Name (un) **])
HTN
Arthritis
s/p compression fx L1
Spinal stenosis L4-5
presumed Gout, on colchicin
Stage II chronic renal failure
Social History:
Lives at [**Location 78275**] living ([**Telephone/Fax (1) 78276**]). Uses cane at baseline.
No EtOH, smoking, drugs per patient
Family History:
No sudden death or early CAD
Physical Exam:
Time Pain Temp HR BP RR Pox
+ 10:12 5 98.5 64 162/68 22 96
Looks well, in pain.
Alert and oriented.
No scalp injury.
Pupils equal and reactive;
Neck: No tenderness
Lungs: Clear bilateral;Decreased air entry bilateral bases
Tenderness L chest
Heart: Regular rate and rhythm
Abdomen: soft nondistended. Some tenderness RLQ
Rectal: Sphincter tone present. No occult blood
Spine: Tenderness in lower thoracic spine and lumbar spine
Pertinent Results:
[**2107-9-21**] 11:45AM WBC-5.4 RBC-4.50* HGB-13.1* HCT-39.6* MCV-88
MCH-29.1 MCHC-33.0 RDW-14.7
[**2107-9-21**] 11:45AM NEUTS-72.8* LYMPHS-19.6 MONOS-4.8 EOS-2.2
BASOS-0.6
[**2107-9-21**] 11:45AM PLT COUNT-129*
[**2107-9-21**] 11:45AM GLUCOSE-328* UREA N-34* CREAT-2.0* SODIUM-135
POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
[**2107-9-21**] CT Chest/Abd/pelvis : 1. L1 vertebral body compression
fracture with an 8-mm retropulsion of indeterminate age,
although no surround hematoma or soft tissue swelling.
Retropulsion causes severe spinal canal narrowing at this level,
which increases risk of spinal cord injury. If clinical concern,
MRI is more sensitive in evaluation of spinal cord injury.
2. Multiple bilateral rib fractures as above, with underlying
left chest
wall/mediastinal contusion/hematoma. Multiple old-healing
fractures, as
detailed above.
3. Cholelithiasis.
[**2107-9-21**] C Spine CT :
1. No acute fracture or subluxation.
2. Multilevel degenerative changes including osteophytes with
mild spinal
canal narrowing at C3-C4, increasing risk of spinal cord injury.
If clinical concern for spinal cord or ligamentous injury, MRI
is more sensitive.
[**2107-9-21**] Head CT :
Fracture of nasal spine of the maxilla, age indeterminate.
Lucency in the anterior left maxilla, of indeterminate age.
Findings may be periapical and dental related, although while
felt less likely, traumatic injury is not excluded
[**2107-9-21**] Right hip and knee :
No evidence of acute fracture involving the right hip, right
femur, or right knee.
[**2107-9-22**] Carotid studies : On the right,likely carotid occlsuion
with recanalization. On the left, there has been progression in
the plaque, now with 70-79% carotid stenosis. Clinical
correlation MRA or CTA evaluation is warranted.
[**2107-9-22**] Cardiac echo : The left atrium is dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the basal inferior and
inferolateral segments. Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is an anterior space which most
likely represents a fat pad.
Compared with the report of the prior study (images unavailable
for review) of [**2106-5-5**], a focal wall motion abnormality can be
seen on the current study. This may have been present on the
prior but image quality precluded certainty. Mild symmetric LVH
is seen on the current study.
[**2107-9-24**] CXR : Left lower lobe opacity has minimally increased;
this could be due to atelectasis, pneumonia cannot be totally
excluded but less likely. There are low lung volumes.
Cardiomegaly is unchanged. Atelectasis in the right base is
stable. There are no enlarging pleural effusions or
pneumothorax.
[**2107-9-24**] KUB :
The ascending colon has a large amount of stool. The
transverse colon is
slightly distended measuring 8.5 cm in maximal diameter. There
are no air-
fluid levels. The visualized sigmoid colon is of normal caliber.
Haziness of the abdomen could be due to patient body habitus
and/or ascites. There are degenerative changes in the lumbar
spine.
[**2107-9-26**] Video swallow :
There is penetration and aspiration with thin consistency. There
is also penetration with nectar consistency, but no evidence of
aspiration. For further details, please refer to full speech
and swallow division note in OMR.
FINDINGS: Penetration with thin and nectar consistencies.
Aspiration with thin consistency.
Brief Hospital Course:
Mr. [**Known lastname 78277**] was evaluated in the ER by the Trauma Service and
Ct scans of the C Spine, Chest, Abdomen and Pelvis were notable
for multiple rib fractures and an old L1 compression fracture.
He was admitted to the Trauma floor for pain control, pulmonary
toilet and a syncopal work up. It was difficult to fully
explain the mechanism of his fall despite the help of the
Italian interpreter and on exam he seemed to have no vision in
the left eye. Eventually his daughter explained that his visual
problems were old secondary to a detached retina.
He had carotid studies which showed a string sign on the right
and 70-79% occlusion of the left internal carotid artery. The
vascular surgery service was consulted and recommended an MRA of
the neck however this was not obtained as the family felt that
surgery was not an option due to his age and comorbidities.
His pain was partially controlled with a PCA but language
barrier limited more instruction therefore he was changed to
Tylenol around the clock and prn oxycodone.
Unfortunately despite resuming his pre admission inhalers and
pulmonary toilet he desaturated to the mid 80's on 2 liters and
was tachypneic prompting transfer to the ICU. A chest Xray
revealed a left lower lobe density and he was placed on IV
Vancomycin and Zosyn. After a 48 hour stay in the ICU for
pulmonary toilet he was transferred back to the Trauma floor and
was evaluated by the Physical Therapy service. Due to his age
and deconditioned state as well as his pulmonary compromise he
was transferred to rehab to further help increase his mobility
and contine pulmonary toilet.
He remained afebrile with a normal WBC and was changed to oral
Cipro in [**2107-9-27**] which will continue thru [**2107-10-1**]. His
cultures were negative but the antibiotic was for Xray findings.
His main complaint of left sided rib pain was controlled with
Tylenol and prn Oxycodone.
Medications on Admission:
Vitamin D 1,000 unit Cap; Plavix 75 mg Tab
Advair Diskus 100 mcg-50 mcg/Dose for Inhalation
Aspir-81 81 mg Tab; Omeprazole 10 mg Cap, Isosorbide Mononitrate
10 mg Tab Glipizide SR 2.5 mg 24 hr Tab
Sertraline 25 mg Tab; Atrovent HFA 17 mcg/Actuation Aerosol
Inhaler; *flaxseed oil 1000mg Once Daily
Lasix 20', Colace 100 "
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 2.5 mg Inhalation Q6H (every 6 hours).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
250/50 mcg/Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP < 100 HR < 60.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on / 12 hours off.
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
16. Oxycodone 5 mg/5 mL Solution Sig: 5-10 mls PO Q6H (every 6
hours) as needed for pain.
17. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP < 100.
18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): Thru [**2107-10-1**].
19. Insulin Regular Human 100 unit/mL Solution Sig: 2-8 units
Injection four times a day as needed for elevated blood sugars
per sliding scale: Check blood sugars Pre meal and HS.
20. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO BID (2 times a day).
21. Brimonidine 0.2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): Both eyes.
22. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): Both eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
S/P fall with :
Left anterior [**5-15**] rib fracture
Right anterior 7th rib fractuer
Left lateral 6th rib fracture
Old L1 compression fracture with stenosis
Bilateral carotid stenoses
COPD
CAD
DM2
Discharge Condition:
stable
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 600**] for a follow up appointment in 2
weeks
Call Dr. [**Last Name (STitle) 4321**] at [**Telephone/Fax (1) 608**] for a follow up appointment in
[**12-10**] weeks
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2107-9-27**]
ICD9 Codes: 486, 4280, 496, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7962
} | Medical Text: Admission Date: [**2165-3-1**] Discharge Date:[**2165-3-7**]
Date of Birth: [**2101-5-12**] Sex: M
Service:
ADDENDUM: Two days prior to discharge the patient developed
an oral lesion consistent with erythema multiforme likely
related to a penicillin reaction. As a result, the patient's
penicillin was discontinued. He was switched to intravenous
vancomycin one gram intravenous q. 12 hours. He tolerated
this without any problems. His oral lesions did not
progress, ruling out the possibility of [**Doctor Last Name **]-[**Location (un) **]
syndrome development. The patient remained comfortable
throughout the rest of his hospital stay. He had no further
problems.
DISCHARGE INSTRUCTIONS:
1. Continue vancomycin for a total of two weeks with an end
date of [**2165-3-19**].
2. Continue all outpatient medications.
3. Use viscous lidocaine and Vaseline to oral lesions as
needed.
4. Follow up with primary care physician on [**3-10**] to assess
progress and make sure arrangements are made to have PICC
line discontinued.
5. Follow up with neurology on [**2165-4-9**] at 1 PM with Dr.
[**Last Name (STitle) 1004**] in the [**Hospital Ward Name 23**] Building.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 1595**]
MEDQUIST36
D: [**2165-3-7**] 12:57
T: [**2165-3-7**] 13:07
JOB#: [**Job Number 36674**]
ICD9 Codes: 5180, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7963
} | Medical Text: Admission Date: [**2197-1-7**] Discharge Date: [**2197-1-11**]
Date of Birth: [**2144-5-19**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 52 year old
gentleman with a past medical history significant only for
heavy smoking, who was transferred from outside hospital for
management of an acute myocardial infarction and nonsustained
ventricular tachycardia. The patient has a seventy plus pack
year history of tobacco use, who presented to the outside
hospital with new left-sided chest pain that occurred at
rest. He described the chest pain as radiating to his left
shoulder and neck and eight to nine out of ten in intensity.
The pain started at 8:00 p.m. the night prior to admission
and continued until the patient presented to [**Hospital1 1474**]
Emergency Department. The patient had inferolateral ST
depressions on his initial electrocardiogram. After three
sublingual Nitroglycerin, the patient became pain free. In
the [**Hospital1 1474**] Emergency Department, he was started on
Nitroglycerin drip, Lovenox, Lopressor, Aspirin and Aggrestat
drip. The patient was then transferred to the [**Hospital1 1474**] CCU.
There, the patient had initial CK of 271 with a MB of 4.4 and
troponin less than 0.3. However, CK #2 came back at 1360
with a MB of 172 and troponin greater than 50. The patient
was also noted to have frequent runs of nonsustained
ventricular tachycardia and was transferred to [**Hospital1 346**] for further management. Of note, at
baseline, the patient is an active gentleman. He walks
several rounds of golf a week and he can climb five flights
of steps without difficulty experiencing no shortness of
breath or chest pain. He had one episode of chest pain in
[**2170**], which he attributed to musculoskeletal strain.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: Status post appendectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: No medications as an outpatient.
FAMILY HISTORY: Grandfather with myocardial infarction at
age 80.
SOCIAL HISTORY: He works as a carpenter. He is divorced.
He lives alone. He continues to smoke. He smokes two packs
a day and he has for thirty-five years. He denies any
alcohol or drug use.
PHYSICAL EXAMINATION: The patient's weight is 75 kilograms,
his temperature on presentation was 97.4, his blood pressure
was 103/62, heart rate 52 and regular, respiratory rate 15
and oxygen saturation 99% on two liters nasal cannula.
Generally, he is well developed, well nourished male sitting
up in bed in no acute distress. Head, eyes, ears, nose and
throat examination - The pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
are intact. The oropharynx is clear and moist. He is
anicteric. The neck is supple, jugular venous pressure was
seven to eight centimeters, 2+ carotid upstroke bilaterally,
and there were no bruits. Cardiovascular is regular rate and
rhythm, normal S1 and S2, no murmurs, rubs or gallops. Lungs
are clear to auscultation bilaterally. Abdomen is soft,
nontender, nondistended, with normal bowel sounds.
Extremities - no cyanosis or edema but there was clubbing
which was marked in all four extremities.
LABORATORY DATA: On arrival, the patient had the following
laboratory values: White blood cell count 9.0, hemoglobin
14.6, hematocrit 42.4, platelet count 241,000. He had a
prothrombin time of 12.4, partial thromboplastin time 60.8 on
Heparin and INR 1.0. His chemistry seven was sodium 139,
potassium 4.1, chloride 104, bicarbonate 26, blood urea
nitrogen 20, creatinine 0.9, glucose 111, calcium 8.7,
magnesium 2.1, phosphate 3.2.
The patient had a normal chest x-ray.
The patient was taken to the Cardiac Catheterization
Laboratory on [**2196-1-10**], where he had the following findings:
Sinus bradycardia at 49 beats per minute. Left
ventriculogram showed pressures in the left ventricle of 92/4
with a mean of 20. The patient was found to have
anterolateral hypokinesis with a left ventricular ejection
fraction of 45%. His coronary angiography was as follows:
He had a right dominant system. His left main coronary
artery had an ostial lesion 30% stenosis. He had a twin left
anterior descending system with a large bifurcating diagonal
vessel with eccentric proximal 50% stenosis in the left
anterior descending. The left anterior descending itself is
small and diffusely diseased vessel. The D1 was a large
vessel with multiple branches supplying the lateral wall.
The left circumflex and right coronary artery were
nonobstructed. The patient had a stent placed in the D1 and
then rescue of the jailed left anterior descending without
complications.
His electrocardiograms showed sinus bradycardia with normal
axis, normal intervals. He had Q wave in aVL and flipped T
waves in leads I and aVL. He also had some concave minor ST
elevation in leads II, III, aVF, and V3. He had Q waves in
V1, V2, V3, V4, and he had T wave flattening in V1, V2, V3
and T wave inversion in V4, V5 and V6 upon discharge.
HOSPITAL COURSE: As previously mentioned, the patient was
admitted for acute myocardial infarction and cardiac
catheterization.
1. Cardiovascular - The patient was started on beta blocker
and Captopril, however, his blood pressure remained
borderline low with systolic pressure around 90 and his heart
rate remained roughly around 45 to 50. Therefore, during his
hospital stay, the Metoprolol was generally held. The ace
inhibitor was administered intermittently. Two days prior to
discharge, the patient was switched from Metoprolol to
Acebutolol for intrinsic symptomatic activity and although
the patient's blood pressure remained borderline low in the
80s to low 90s systolic and his heart rate in the 40s, he
seemed to tolerate these pressures well and there is a
question of whether these are baseline parameters as he was
able to walk around without difficulty with no orthostasis,
no chest pain or shortness of breath. He was also treated
with Atorvastatin 20 mg p.o. once daily, Aspirin and he
continued Heparin and Aggrestat drips following his cardiac
catheterization. As previously mentioned, the cardiac
catheterization demonstrated a significant lesion in a twin
left anterior descending system and he had a large diagonal
stented and a jailed left anterior descending rescued with
restoration of good flow.
From a rhythm standpoint, the patient had roughly three to
four runs of nonsustained ventricular tachycardia of up to
eight beats the first two days of admission but thereafter he
experienced no ectopy but remained in sinus bradycardia.
2. Pulmonary - Although the patient has extensive smoking
history, his chest x-ray was normal.
3. Hematologic - The patient had a hematocrit drop of
roughly five points the day following catheterization which
is expected and which was stabilized the day of discharge.
CONDITION ON DISCHARGE: The patient was in good condition at
discharge.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Status post anterolateral myocardial infarction, non ST
elevation, with a peak CK of 1163 at our hospital with a peak
MB of 124 and troponin greater than 50.
2. Tobacco abuse.
3. Hyperlipidemia, the patient has LDL of 144, total
cholesterol 200, HDL 43.
4. Sinus bradycardia.
5. Borderline baseline hypotension.
MEDICATIONS ON DISCHARGE: The plan was to discharge the
patient on the following medications:
1. Acebutolol 200 mg p.o. once daily.
2. Plavix 75 mg p.o. once daily times nine months.
3. Captopril 6.25 mg p.o. three times a day.
4. Atorvastatin 20 mg p.o. once daily.
5. Aspirin 325 mg p.o. once daily.
FOLLOW-UP PLANS: The patient is to follow-up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 7047**] in [**Hospital1 1474**]. He will be given the telephone number
and indicates that he will do so.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 47155**]
MEDQUIST36
D: [**2197-1-11**] 08:26
T: [**2197-1-11**] 18:42
JOB#: [**Job Number **]
ICD9 Codes: 4271, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7964
} | Medical Text: Admission Date: [**2198-11-22**] Discharge Date: [**2198-11-27**]
Date of Birth: [**2124-8-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Compazine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypoxia / hypotension.
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
74 F with EtOH cirrhosis who presents from rehab with hypoxia
and hypotension. Pt recently dc'd from [**Hospital1 18**] on [**11-15**] after
hospitalization for ARF (creatinine incrased to 4.8), VRE UTI,
and cellulitis. During that admission she was diagnosed with
pulmonary hypertension. The work up was unrevealing for
etiology. She was started on diltiazem on discharge empirically
per pulmonary consult for her pulmonary hypertension. Pt denies
any SOB, DOE, cough, F/C, dysuria, frequency. Pt feels well. She
does report some ? increased diarrhea with lactulose for which
the dose of her lactulose was halved recently. In [**Name (NI) **], pt
bradycardic to 30s. Noted to be hypotensive to 50s. Pt
resuscitated without effect with 3L NS. Throughout time in ED,
she was mentating and making urine. Pt also given Levoquin for
+UA.
Past Medical History:
1. Alcoholic cirrhosis with portal HTN, esophageal varices
(grade 1) and hepatic encephalopathy
2. a-fib. not anticoagulated
3. s/p meningitis with epidural abscess
4. BCC s/p MOHS excision
5. pseudogout
6. VRE UTI
7. Lower extremity edema
8. CRI, baseline cr 1.5-1.9 until recent admit [**10-24**]
9. Anemia of Chronic Inflammation
10. Chronic Thrombocytopenia
11. Pulmonary HTN / RV dysfunction
Social History:
Pt lived with her daughter in [**Name (NI) **]. She has not had alcohol
in [**3-23**] years. She continues to smoke [**1-21**] ppd.
Family History:
CAD, Hyperlipidemia
Physical Exam:
VS T 95. HR 47 BP 80/30s RR 22 O2 92% 2L
Gen: elderly F arousable. oriented x 3.
HEENT: PERRL. mild scleral and sublingual icterus. MM dry.
tongue midline. facial mm symmetic.
Neck: flat neck veins
CV: bradycardic. 2/6 sem with loss of S2 at apex
Lungs: + crackles focally in LLL. + decreased BS at bases
Abd: active BS. soft. NT. no masses. liver span 10 cm. no caput
Extr: 2+ pitting edema to knees b/l. DP 2+. feet warm. no palmar
erythema. no asterixis. + slight tremor.
Neuro: MAE.
Pertinent Results:
CXR: + increased interstitial markings. loss of L costaphrenic
angle. unchanged from [**2198-11-13**].
.
CXR ([**2198-11-26**]): An endotracheal tube has been withdrawn in the
interval and now terminates approximately 2 cm above the carina
with the neck in a flexed position. A left subclavian vascular
catheter remains in satisfactory position. Cardiac silhouette is
mildly enlarged. Previously reported minimal pulmonary edema has
resolved in the interval. Bilateral pleural effusions are again
demonstrated with improvement on the right and no significant
change on the left. Gastric distension appears decreased in the
interval with mild-to-moderate distention remaining.
.
EKG: nl axis. nl intervals. sinus brady. ST segment depression
in I, AVL unchanged from old EKG.
.
Renal U/S: The right kidney measures 9.8 cm, and the left kidney
measures 9.2 cm. There is no hydronephrosis. Nonobstructing
stones are present in both kidneys. There is an 11-mm stone in
the lower pole of the right kidney, which was previously seen on
[**2198-11-3**]. There is a 4-mm stone in the upper pole of the
left kidney. The bladder is decompressed by a Foley catheter. No
hydronephrosis. Bilateral nonobstructing renal stones.
.
echo ([**11-13**]): 1. The left atrium is mildly dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. 2. Left ventricular
wall thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal. 3.
The right ventricular cavity is dilated. Right ventricular
systolic function appears depressed. 4. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen.
5. Moderate [2+] tricuspid regurgitation is seen. 6. Compared
with the findings of the prior study of [**2198-11-5**], there has been
no significant change.
.
echo ([**2198-11-26**]): The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Left ventricular systolic function is hyperdynamic (EF>75%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is moderately dilated. Right ventricular
systolic function is normal. The aortic root is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. The main pulmonary
artery is dilated. There is a trivial pericardial effusion.
There are no echocardiographic signs of tamponade.
Brief Hospital Course:
Mrs [**Known lastname **] initially presented with hypotension and bradycardia
in the setting of chronic liver failure and acute on chronic
renal failure. The presenting symptoms of hypotension and
bradycardia were due to nodal toxicity caused by recently
started dilitazem plus chronic nadolol, worsened by renal
failure. While she initially responded to treatment for beta
blocker toxicity, her hypotension was persistent, and
attributable to chronic vasodilatation with liver failure, and
severe right heart failure and low left ventricle filling in
context of severe pulmonary hypertension. Her chronic renal
failure worsened, and the consulting renal team agreed with the
assessment that her renal failure was due to a combination of
hepato-renal syndrome and pre-renal azotemia in the context of
her low flow state. No hemodialysis was pursed for the
worsening acidemia because of her hemodynamic instability.
Compounding her renal and liver failure, she developed
progressive respiratory distress and hypoxemia, for which she
was intubated and placed on assist control mechanical
ventilation. Patient was confirmed to be DNR in conversation
with her daughter, and after being apprised of the poor
prognosis given multi-organ system failure, her daughter elected
for terminal extubation. The patient was placed on a morphine
drip, extubated, and, after several hours with family and
friends, she died peacefully with her family and friends
present.
Medications on Admission:
Diltiazem 120 mg QD
Nadolol 20 mg po BID
Lactulose 15 cc TID
Phytonadione 5 mg po QD
Protonix 40 mg Q am
Ursodiol 600 mg Q AM and 300 mg Q pm
Linezolid (not on rehab record though pt just dc'd [**2198-11-15**])x 7
d. last day [**2198-11-21**]
Discharge Disposition:
Expired
Discharge Diagnosis:
Cirrhosis with portal hypertension and hepatic encephalopathy
renal failure
severe pulmonary hypertension
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2198-11-28**]
ICD9 Codes: 5849, 4280, 2762, 5856, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7965
} | Medical Text: Admission Date: [**2156-3-16**] Discharge Date: [**2156-3-20**]
Date of Birth: [**2100-10-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
decreased energy
Major Surgical or Invasive Procedure:
[**2156-3-16**] AVR ( [**Street Address(2) 11688**]. [**Male First Name (un) 923**] Regent mechanical)
History of Present Illness:
55 year old man with a known childhood murmur who was echoed
during a recent admission
for pneumonia and found to have severe aortic stenosis. Referred
for AVR after cath showed clean coronaries.
Past Medical History:
bicuspid aortic valve, aortic stenosis,
aortic insufficiency, valvular induced cardiomyopathy, moderate
pulmonary hypertension (52/23), recent pneumonia
Social History:
Last Dental Exam: 2 years ago
Lives with: fiance
Occupation: teamster trucker
Tobacco: none
ETOH: rarely
Family History:
non-contributory
Physical Exam:
Pulse: 82 O2 sat: 96%
B/P Left: 96/57
Height: 73" Weight: 90.9kg
General: Well-developed male in no acute distress
Skin: Dry [x] intact [xx]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur II/VI SEM radiating to
carotids and across precordium
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:- Left:-
Pertinent Results:
Conclusions
PRE-CPB:1. The left atrium is moderately dilated. No spontaneous
echo contrast is seen in the left atrial appendage. No thrombus
is seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity is moderately dilated. Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction.
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the descending thoracic aorta.
6. The aortic valve is bicuspid. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic
regurgitation is seen. The severity of aortic regurgitation may
be underestimated. The aortic regurgitation jet is eccentric,
directed toward the anterior mitral leaflet.
7. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is bilateral retraction of the
mitral valve.
8. There is a small to moderate sized pericardial effusion.
9. A moderate left pleural effusion is seen.
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] were notified in person of the
results.
POST-CPB: On infusions of epi, neo. AV pacing , then a pacing.
Well-seated mechanical valve in the aortic position. Coronary
flow seen in LMCA and RCA. Trace AI consistent with washing
jets. Preserved ventricular function on inotropic support. LVEF
is now 40%. Trace MR. Aortic contour is normal post
decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2156-3-16**] 14:13
Brief Hospital Course:
Mr. [**Known lastname 30814**] was admitted on [**2156-3-16**] and underwent AVR( mech AVR
#23 St. [**Male First Name (un) 923**]) with Dr. [**Last Name (STitle) **]. See operative note for details.
Post operatively he remained intubated and was transferred to
the CVICU in stable condition on epinephrine, phenylephrine,
propofol, and lidocaine drips. He awoke neurologically intact,
was weaned from the ventilator and extubated. Vasoactive
medications were weaned after hemodynamic stability was
achieved. Betablockers, diuretics and statin therapies were
initiated and titrated. Chest tubes and temporary pacing wires
were removed per protocol. Coumadin therpay was intiated for
mechanical AVR. He was evaluated and treated by physical therapy
for strength and conditioning. Mr. [**Known lastname 30814**] was cleared for
discharge to home on POD#4 with an INR of 2.0 by Dr. [**Last Name (STitle) **].
Medications on Admission:
lasix 20mg daily
zocor 40mg daily
KCL 20mEq daily
coreg 3.125mg daily
Amox 500mg (cont. after dental d/t symptoms from pna)
ASA
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 for pain.
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
10. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: goal INR 2.5-3.0 for mechcanical aortic valve.
take 2.5 mg on sunday then as directed by Dr. [**Last Name (STitle) 83774**].
Disp:*60 Tablet(s)* Refills:*2*
11. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing indication mechanical aortic valve -
goal INR 2.5-3.0 with results to [**Hospital1 **] heart center coumadin
clinic fax # [**Telephone/Fax (1) 31080**] attn coumadin clinic and Dr [**Last Name (STitle) 6254**] -
first draw monday [**2156-3-22**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Aortic stenosis, aortic insufficiency s/p Aortic valve
replacement (Mech -#23mm St. [**Male First Name (un) 923**])
valvular-induced cardiomyopathy
pulmonary hypertension
recent Pneumonia
chronic systolic/diastolic heart failure
Discharge Condition:
alert and oriented
ambulating with steady gait
Sternal pain managed with dilaudid
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:
Surgeon Dr. [**Last Name (STitle) **] at [**Hospital1 **] [**4-8**] @ 9:00 AM [**Telephone/Fax (1) 6256**]
Please call to schedule appointments
Primary Care Dr. [**First Name (STitle) **] in [**1-31**] weeks
Cardiologist Dr. [**Last Name (STitle) 6254**] in [**1-31**] weeks
Labs: PT/INR for coumadin dosing indication mechanical aortic
valve - goal INR 2.5-3.0 with results to [**Hospital1 **] heart center
coumadin clinic fax # [**Telephone/Fax (1) 31080**] attn coumadin clinic and Dr
[**Last Name (STitle) 6254**] - first draw monday [**2156-3-22**]
Completed by:[**2156-3-20**]
ICD9 Codes: 4241, 4254, 4168, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7966
} | Medical Text: Admission Date: [**2148-2-26**] Discharge Date: [**2148-3-7**]
Date of Birth: [**2077-7-1**] Sex: M
Service: MEDICINE
Allergies:
Quinolones / Morphine
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
CC: Unresponsive, hypotensive
Major Surgical or Invasive Procedure:
Intubation/Extubation
Central Line placement
Arterial Line placement
PICC line placment.
History of Present Illness:
HPI: 70yo male w/hx of Multiple Sclerosis and chronic indwelling
foley who was brought to ED via EMS after having a witnessed
syncopal event on [**2-26**]. While eating dinner, he lost
conciousness and his head fell back and his arms went up. He was
noted by his wife and son to be gurgling. His family denies any
prodromal complaints aside from fatigue a few days prior. The
EMS team found him to be unresponsive with some emesis in his
mouth. Pt brought to ED, intubated for airway protection.
Received Vanco/Cefepime/Clinda initially and an additional
2Liters of NS. MICU course notable for hypotension unresponsive
to IVF requiring intermittient Levophed gtt.
Additionally a CT head postive for L post/temp intraparenchymal
bleed which was then re-read as an AVM. CT Angiogram of the
Chest was performed and revealed a R subsegmental non-occlusive
thrombi with a chronic appearance. While in the MICU the pt
failed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test, developed aspiration pneumonia, had
labile blood pressures requiring Nitroprusside gtt, and [**11-21**]
positive bld cx for Staph Epi. Pt ruled out for MI, Echo was
nml, and EKG with old AV delay and type I 2nd degree AV block
(Wenkebach)with a normal rate.
Past Medical History:
1. Multiple Sclerosis
2. Hypertension
3. Neurogenic Bladder (chronic indwelling catheter)
4. Hyperlipidemia
5. GERD
7. s/p L foot 1st, 3rd and 4th metatarsal fractures
8. s/p L knee arthroscopy, resection of plica [**2-/2139**]
9. Bradycardia with first deg AV block
10. BPH
Social History:
occasional EtOH use; no tobacco or an IV recreational drug use;
worked as a judge, currently lives at home with good social
support
Family History:
Non contributory
Physical Exam:
T99.6, Tc 98.6, 140-170/55-72, 72-80, 12, 95% 3LNC
GEN: NAD, A & O x 3
HEENT: PERRL, EOMI, OP: clear
CV:Reg rate, S2, S2
PULM:Bilat course BS, crackles at bases
ABD:Distended, soft +BS
EXT:+1 Bilat lower ext edema
Neuro: grossly intact, strength 4/5, able to get to edge of bed
but difficulty ambulating.
Pertinent Results:
[**2148-2-26**] 11:00PM TYPE-ART TEMP-37.8 RATES-/14 TIDAL VOL-650
PEEP-5 O2-40 PO2-185* PCO2-40 PH-7.41 TOTAL CO2-26 BASE XS-1
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2148-2-26**] 03:49PM WBC-9.9 RBC-3.24* HGB-10.1* HCT-29.2* MCV-90
MCH-31.0 MCHC-34.4 RDW-13.8
[**2148-2-26**] 03:49PM GLUCOSE-202* UREA N-33* CREAT-1.0 SODIUM-147*
POTASSIUM-3.5 CHLORIDE-113* TOTAL CO2-23 ANION GAP-15
[**2148-2-26**] 03:53PM LACTATE-3.4*
[**2148-2-26**] 05:03AM CORTISOL-23.3*
[**2148-2-26**] 05:30AM CORTISOL-24.7*
[**2148-2-26**] 03:13AM ALT(SGPT)-20 AST(SGOT)-21 LD(LDH)-197
CK(CPK)-67 ALK PHOS-67 AMYLASE-368* TOT BILI-0.3
[**2148-2-26**] 03:13AM LIPASE-32
[**2148-2-26**] 03:13AM CK-MB-NotDone cTropnT-0.01
[**2148-2-26**] 03:13AM CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-2.1
[**2148-2-26**] 03:13AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2148-2-25**] 10:15PM FIBRINOGE-525*
[**2148-2-25**] 10:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2148-2-26**] 03:49PM PLT COUNT-130*
Brief Hospital Course:
70yo male with hx of Multiple Sclerosis and chronic indwelling
foley catheter a/w syncope, aspiration pneumonia, and possible
intraparenchymal CNS bleed.
1. Hypotension/Syncope: Hypotension resolved while in MICU. [**Month (only) 116**]
have been related to septic physiology on presentation. CTA with
non-occlusive segmental thrombi in R pulm art. which was thought
to be chronic and not related to primary event. Echo w/ nml EF
and wall motion, and valves, CT head with AVM stable on repeat
imaging and confirmed by MRI/MRA, EEG w/o epileptiform activity.
Pt has h/o vaso-vagal symptoms and was eating at the time of the
event which is the most likely cause. 1st degree AV block with
Wenckebach intermittently would not be a cause of syncope since
his heart rate was always normal. Neurosurgery consultation
recommended anticoagulation with Hep gtt while in house given
the PE and pt is immobile, but no long term anticoagulation is
recommended (pt is a fall risk, risk of CNS bleed, and PE is an
incidental finding)Bilateral LENIS were negative. We
specifically discussed with the patient about all the risks and
benefits of being anticoagulated and also not being
anticoagulated. He understood everything and agreed with the
plan. His outpt neurologist at [**Hospital1 2025**] was also contact[**Name (NI) **] and is
aware of his hospitalization.
2. ARF: Likely due to hypotension/ATN vs UTI. Normalized with
fluids.
3. ID: Bilateral aspiration PNA, + MRSA, and possible
bacteremia. Intubated for two days. Blood cultures only [**11-21**] grew
Coag neg staph, thought to be a contaminant. MRSA grew in
sputum. Total body macular rash developed while pt was on Zosyn
and Ceftriaxone.
-initially covered w/Vanco/Zosyn Dced upon transfer to floor.
Was on Clinda for two days but spiked through it to 103. Started
Flagyl/Aztreonam/Vanc [**3-1**] given allergy to quinolone and ? rash
to cephalosporins.
-DC A-line and DC Central Line [**2-28**], sent tip for culture.
-Surveillance cultures were all negative. Repeat CXR with slight
improvement.
-Pt has chronic indwelling foley but U/A has been negative.
4. Neuro: Multiple Sclerosis, and h/o CNS AVM. Pt seen by
neurology and neurosurgery early in hospital course. Pt was
deconditioned, weak, and fatigued for most of his stay with
limited mobility. Will need aggressive PT and cont treatment for
MS. [**Name13 (STitle) **] been on Cytoxan in the past and is followed by [**Hospital1 2025**]
Neurologist.
5. Code: Full
6. Dispo: to rehab
7. Communication: Wife = (o)[**Telephone/Fax (1) 96660**] or (h)[**Telephone/Fax (1) 96661**]
PCP([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**])[**Telephone/Fax (1) 96662**]. (call between 6A and 6P)-
Neurologists: Dr. [**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 45435**] [**Hospital1 2025**] [**Telephone/Fax (1) 88304**] and Dr. [**Last Name (STitle) **] at
[**Hospital1 112**].
Medications on Admission:
ASA 81 qd
Colace
Senna
Nexium 40 qd
Enalapril 10 qd
Lipitor 10 qd
HCTZ 25 qd
Baclofen 20 [**Hospital1 **]
Ativan prn
Neurontin
Detrol
Cytoxan
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: Two (2) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Regular Sliding scale.
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Baclofen 10 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
10. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO QPM (once a
day (in the evening)).
12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
13. Baclofen 10 mg Tablet Sig: Three (3) Tablet PO Q NOON ().
14. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
18. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed.
19. Vancomycin HCl 10 g Recon Soln Sig: One (1) gm Intravenous
Q24H (every 24 hours) for 9 days.
20. Aztreonam in Dextrose(IsoOsm) 1 g/50 mL Piggyback Sig: One
(1) gm Intravenous three times a day for 9 days.
21. Heparin Sodium 5,000 unit/0.5 mL Syringe Sig: One (1)
Injection three times a day: For DVT prophylaxis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 100**] Rehab-MACU
Discharge Diagnosis:
1. Aspiration Pneumonia
2. MRSA Pneumonia
3. Syncope
4. Stable CNS AVM
5. Subacute Pulmonary Embolus
6. Multiple Sclerosis
7. 1st degree AV block, without bradycardia
Discharge Condition:
Stable to Rehab
Discharge Instructions:
Please see your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge.
Followup Instructions:
1. Please see your PCP [**Name Initial (PRE) 176**] 1-2 weeks
2. Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2148-3-13**] 3:00
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11642**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2148-3-14**] 2:20
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5070, 5849, 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7967
} | Medical Text: Admission Date: [**2138-2-1**] Discharge Date: [**2138-2-19**]
Date of Birth: [**2066-10-28**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Demerol
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
transferred for OSH with hemothorax
Major Surgical or Invasive Procedure:
chest tube placement right chest wall
intubation
hemodialysis
placement and removal of left groin hemodialysis catheter
History of Present Illness:
71 M admitted to thoracic surgery with right hemothorax likely
related to supratherapeutic [**Hospital 31291**] transfered to MICU because of
respiratory failure, hypotension, and other comorbidities.
.
The patient was transferred [**2138-2-1**] from [**Hospital 1562**] hospital with
spontaneous hemothorax on right with no prior history of trauma.
He had intially complained shortness of breath and dyspnea on
exertion for the past 2-4 weeks. He also reports intermittent
diarrhea w/ small amount of blood, with INR of >4 the week prior
to admission, which was been held 4 days prior to admission(was
1.0 on initial presentation). Denies chest pain or fever or
chills. He had a right sided pleural effusion at [**Hospital1 1562**] by
CXR, and had right thoracentesis and was diagnosed with
hemothorax and transferred to [**Hospital1 18**].
.
At [**Hospital1 18**] he was intially scheduled to go to OR and have VATS vs
thoracotomy, but deveoped resp failure and hypoxia and was
intubated on [**2-3**]/05while on the floor ([**Hospital Ward Name **] 10) with suspected
mucous plug. A chest tube was placed instead. He was requiring
Levophed temporarily while intubated but this was weaned off,
and he was extubated [**2138-2-5**]. The chest tube is scheduled to be
pulled on [**2138-2-6**].
.
Of note, his hospital course include ongoing HD for ESRD
followed by the nephrology service. The patient had thrombosed
RUE and LUE AV fistulas which will require fistulogram. He has
been getting HD via groin line. He had a TTE to evaluate for CHF
showing NL EF. He had required 3U of PRBC's for bloody drainage
of hemothorax, but there is no report of bloody stools or
hematuria. On [**2138-2-6**] he was noted to spike a temp to 101.0.
This temp spike resolved transiently per-HD on [**2-6**]. He was
transferred from SICU to MICU for further medical managmeent
Past Medical History:
1. type II diabetes mellitus x 25yrs
2. end stage renal disease secondary to DM, s/p RUE
brachiocephalic v fistula ([**8-/2133**], revised [**12-17**]), s/p failed
renal transplant ([**12-17**]) -> failed, hemodialysis since [**2135**]
3. CAD s/p MI ([**3-16**]), s/p 4v-CABG ([**3-16**])->revised; h/o positive
stress and stent of OM2 [**5-/2136**]
4. CHF (but w/ NL EF by TTE [**2138-2-4**])
5. Sternal dehiscence-> osteomyelitis (coag neg Staph), s/p
sternal debridement ([**5-19**])
6. Hypertension
7. Elevated Cholesterol
8. H/O broken L ankle -> rehab -> RLE DVT ([**4-19**]), s/p IVC filter
9. s/p R cataract extraction
10. Chronic myelogenous leukemia since '[**36**] on Gleevec
11. Osteoporosis
12. DVT [**4-/2136**], was on Coumdin
Social History:
Lives with his wife [**Name (NI) 622**].
previous Etoh abuse history (quit in '[**31**]) quit tobacco 30 years
ago, no current Etoh or tobacco use.
Family History:
Mom and sister w/ [**Name2 (NI) 499**] Ca, Brother w/ prostate Ca, no family
h/o cardiac disease
Physical Exam:
Tc=99.1 Tm=101.0, BP=(121/51)90s-150s/40's-50s, HR=100-120(102),
RR=20, O2=99% on 4L NC; I/O's=357/0(+357)
PE: GEN: Patient appears comfortable, lethergic, but in NAD
HEENT: nonicteric, mucosa slightly dry
CHEST: course exp BS's ant/lat; no wheezes noted
CV: RRR, no appreciable abnormal heart sound
ABD: good BS's, obese, soft, NT, ND
EXT: 2+ pitting LE edema bileraterally
NEURO: Oriented to person; patient is generally weak and not
cooperative w/ exam; no frank asterixis noted
Pertinent Results:
[**2138-2-6**] 03:15AM BLOOD WBC-13.7* RBC-2.88* Hgb-8.3* Hct-25.4*
MCV-88 MCH-29.0 MCHC-32.9 RDW-14.9 Plt Ct-182
[**2138-2-5**] 03:33AM BLOOD WBC-17.9* RBC-3.15* Hgb-9.4* Hct-27.1*
MCV-86 MCH-29.9 MCHC-34.8 RDW-14.8 Plt Ct-238
[**2138-2-4**] 02:46PM BLOOD WBC-22.8*# RBC-3.35* Hgb-9.9* Hct-28.9*
MCV-86 MCH-29.6 MCHC-34.3 RDW-14.4 Plt Ct-239
[**2138-2-6**] 04:00AM BLOOD PT-12.9 PTT-29.8 INR(PT)-1.1
[**2138-2-6**] 03:15AM BLOOD Plt Ct-182
[**2138-2-5**] 03:33AM BLOOD Plt Ct-238
[**2138-2-5**] 03:33AM BLOOD PT-12.8 PTT-31.5 INR(PT)-1.0
[**2138-2-6**] 03:15AM BLOOD Glucose-137* UreaN-75* Creat-8.2*#
Na-148* K-5.8* Cl-113* HCO3-23 AnGap-18
[**2138-2-5**] 03:33AM BLOOD Glucose-84 UreaN-59* Creat-7.1* Na-146*
K-4.7 Cl-110* HCO3-24 AnGap-17
[**2138-2-6**] 03:15AM BLOOD Calcium-8.5 Phos-4.9* Mg-2.2
[**2138-2-5**] 03:33AM BLOOD Calcium-8.1* Phos-4.4 Mg-2.4
[**2138-2-6**] 06:24AM BLOOD Type-ART pO2-126* pCO2-35 pH-7.31*
calHCO3-18* Base XS--7
[**2138-2-6**] 06:24AM BLOOD Lactate-0.8
[**2138-2-6**] 06:24AM BLOOD freeCa-1.02*
[**2138-2-3**] 10:42PM BLOOD CK(CPK)-65
[**2138-2-3**] 04:49PM BLOOD CK(CPK)-66
[**2138-2-3**] 09:28AM BLOOD CK(CPK)-84
[**2138-2-3**] 10:42PM BLOOD CK-MB-NotDone cTropnT-0.62*
[**2138-2-3**] 04:49PM BLOOD CK-MB-5 cTropnT-0.52*
[**2138-2-3**] 09:28AM BLOOD CK-MB-NotDone cTropnT-0.43*
CXR: [**2-6**]: The
right-sided pleural densities are similar to what has been
noticed on the
preceding study and also the chest tube position is unchanged.
No
pneumothorax has developed after instrument removal.
[**2-3**] - CTA neg for PE, loculated R hydropneumothorax; also w/
large L sided-effusion w/ assoc atelectesis
.
[**2-4**] - TTE w/ EF>55%(suboptimal, mod LAE, mild [**Last Name (un) **], 1+ AR)
.
EKG's
[**2-1**] - NSR at 88 bpm, 1 mm STD's and TWI's V4-V6, TWI's I & AVL
[**2-3**] - NSR at 84 bpm, resolved TWI's and STD's V4-V6; still w/
TWI's I & AVL (ols changes compared to [**5-/2136**])
[**2138-2-7**]: IMPRESSION:
1) AV fistulogram demonstrated complete thrombosis of the
brachiocephalic
vein fistula. Multiple stenoses are present throughout the
outflow cephalic vein. A significant stenosis was identified
within the right brachiocephalic vein.
2) Successful lysis of the thrombosed fistula using a total of
10 mg of t-PA.
3) Venoplasty of the outflow cephalic vein stenoses using an
8-mm balloon and of the severe right brachiocephalic stenosis
using a 12-mm balloon, all with good angiographic success and
restoration of forward flow.
[**2138-2-10**] Chest, Abd, Pelvis CT:
1) No evidence of abscess, and no definite evidence of
pneumonia. The lung examination is somewhat limited by
respiratory motion. There is airspace opacity along the tract of
the prior chest tube which may represent contusion vs.
consolidation.
2) There are bilateral pleural effusions, loculated, which have
increased in the interim since the prior exam. The left
effusion is large and the right effusion is moderate, and there
is associated atelectasis.
[**2138-2-11**] Head CT:
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or mass effect.
2. Scattered areas of hypodensity within both thalami and the
basal ganglia having an appearance consistent with chronic
lacunar infarction.
[**2138-2-14**] RUQ U/S:
IMPRESSION: Tumefactive sludge within the gallbladder. No
ultrasonographic evidence of cholecystitis. Limited
visualization of the pancreas due to overlying bowel gas.
[**2138-2-15**] CXR:
Left-sided PICC line is in distal SVC. There are small
bilateral pleural
effusions and associated bibasilar atelectases, essentially
unchanged since the prior film of [**2138-2-11**]. No new lung
lesions.
Brief Hospital Course:
71 year old man type II diabetes mellitus, coronary artery
disease s/p CABG, congestive heart failure (nml EF), CML, end
stage renal disease s/p failed renal transplant on hemodialysis,
transferred from outside hospital with hemothorax to Transplant
surgery SICU team. Hospitalization complicated by mutiple
issues:
1. Hemothorax: The patient was initially transferred for VATS
and thoracotomy by the thoracic surgery team. He developed
respiratory failure requiring intubation on [**2138-2-3**], and
transfer to the MICU. A chest tube was placed. Studies were
not done on the initial specimen showing a spun Hct >50%. The
cause of the hemothorax was unknown. He was ruled out for PE by
negative CTA. There was no history of trauma or previous
history of COPD or bled formation. Pleural effusions
reaccumulated after removal of the chest tube. A thoracentesis
was done which showed an exudative effusion on the right, the
side of the hemothorax, and a transudative effusion on the left.
Gram stain and culture were negative; however, the patient was
on antibiotics (levofloxacin) at the time of the tap for
treatment of post-intubation tracheobronchitis. Cytolgy showed
no malignant cells. The patient was extubated [**2138-2-5**], and
supplemental O2 requirements weaned. By the time of discharge
he had stable small bilateral pleural effusions by CXR and was
saturating well on room air, not short of breath. The effusions
were attributed to CHF and chronic renal failure; the right
appearing exudative as a complication of the high blood count.
2. Hypoxia: Postextubation the patient required supplemental
O2. He was treated with a 7 days course of levofloxacin 250mg
Q48hrs for treatment of tracheobronchitis. The initial
decompensation requiring intubation was thought to be due to
mucus plugging. CHF status remained stable. He was continued
on aspirin, metoprolol, and a statin for secondary prophylaxis.
3. Fevers: postextubation on [**2138-2-6**] he was noted to spike a
fever to 101.0. CXR, chest CT, abdominal CT, blood cultures,
urinalysis, and urine cultures were nondiagnostic. There was no
sign of pneumonia or abscess. He was treated for a day with
Zosyn and Vancomycin for concern of hospital acquired or
aspiration pneumonia. Sputum grew gram negative rods E. coli
and Enterobacter. As no findings were seen on CXR or chest CT,
this was attributed to tracheobronchitis and treated with a 7day
course of levofloxacin.
4. Delirium: the patient developed a delirium complicated by
agitation requiring a 1:1 sitter, Zyprex and Haldol, soft
restraints. The delirium resolved with treatment of his
multiple medical issues. He was continued on Zyprexa qHS.
5. Nutrition: During his delirium he had an NG tube placed,
and he was sustained on tubefeeds. A swallow study was done
once the patient was more alert and initially showed risk of
aspiration. He was started on a nectar-thickened diet. Two
days prior to discharge a repeat swallow study was done. The
patient passed. He was discharged on a diabetic, renal, heart
healthy, low sodium diet of thin liquids and regular solids.
6. Hypotension: in the ICU the patient became hypotensive and
required a small dose of levophed. He was also treated with
stress dose steroids. This resolved prior to discharge from the
ICU.
7. Pancreatitis: On [**2138-2-12**], after initiating a po diet, the
patient developed nausea and epigastric pain. LFTs showed
mildly elevated transaminases, normal alk phos and total
bilirubin, and moderately elevated lipase and amylase. RUQ
ultrasound showed sludging in the gallbladder. It was felt he
developed a pancreatitis secondary to gallbladder sludging while
on tubefeeds. He was made NPO, treated with gentle ivf's.
Nausea and abdominal pain resolved. Diet was advanced slowly,
to clears, then to full diet. He was tolerating a full diet as
described above prior to discharge.
8. History of DVT: the patient had a DVT diagnosed in [**4-18**].
He completed his course of anticoagulation and has an IVC filter
in place. He was treated with DVT prophylaxis with heparin SC.
No further anticoagulation was indicated. His dialysis line was
noted to have thromboses. This was corrected by interventional
radiology procedure. A temporarily groin line was placed for
dialysis. This was pulled and the A-v fistula was used 4 times
for dialysis prior to discharge.
9. Cardiac: He has known CAD s/p CABG and stent and CHF.
Echo was done and showed mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], 1+MR, otherwise
normal. He was treated with aspirin, metoprolol and statin. He
ruled out for acute MI, and no further acute cardiac issues
developed.
10. End stage renal disease: He was continued on M,W,F
hemodialysis.
11. Type II diabetes mellitus: he was monitored with QID
fingersticks and treated with a regular insulin sliding scale.
A standing regimen of insulin was not initiated as the patient's
diet fluctuated with tubefeeds, then NPO, then slowly advancing
diet. He was continued on prednisone 5mg daily for his failed
renal transplant.
12. Chronic myelogenous leukemia: Diagnosed in [**2136**], the
patient was previously on Gleevec. This was held in the setting
of his acute pulmonary issues. His counts remained stable
throughout the hospitalization. Hematoloyg/Oncology was
consulted. They recommended holding the patient's Gleevec until
he follows up with outpatient Oncology given his persistant
state of fluid overload (he still had small pleural effusions),
modestly elevated LFTs and recent course of pancreatitis. He
will be following up with Dr. [**Last Name (STitle) 410**] in Heme/Onc for further
care. He should bring all records regarding his history of CML
and iron overload to that appointment.
13. Elevated CK: On [**2138-2-10**] the patient was noted to have an
elevated CK to 1300. There was no CK-MB or Trop elevation to
suggest a cardiac etiology. It was felt this was likely
muscular and resulted from IM haldol injection. Subsequent IM
injections were held, and the CK trended down to normal.
14. Dispo: the patient was discharged to rehab. He was
evaluated by physical therapy and occupational therapy prior to
discharge. He will follow up with his primary care physician Dr
[**Last Name (STitle) 15170**]. He should also plan to follow-up with his
endocrinologist regarding diabetes care, nephrologist regarding
his end stage renal disease, and Dr. [**Last Name (STitle) 410**] regarding his
chronic myelogenous leukemia. He is a full code. Communication
is with the patient and his wife [**Telephone/Fax (1) 32904**].
Medications on Admission:
Meds at Home: Vicodin prn, Neurontin 100 QD, Nephrocaps,
Metoprolol 25 [**Hospital1 **], Gleevec 400 [**Hospital1 **], Prednisone 5 QD, Tums prn,
Coumadin 7.5/10 alternating, Paxil 10 QD, RISS (+/- NPH?)
.
Meds on Transfer: Ipratropium Bromide Neb Q6H, Lorazepam 0.5-1
mg IV Q4H:PRN, Albuterol 0.083% Neb Soln 1 NEB IH Q4-6H:PRN,
Calcium Acetate 667 mg PO TID W/MEALS, Famotidine 20 mg IV Q24H,
Paroxetine HCl 20 mg PO DAILY, Fentanyl Citrate 25-100 mcg IV
Q4H:PRN, Phenylephrine HCl 0.5-5 mcg/kg/min IV DRIP TITRATE,
Prednisone 5 mg PO DAILY, Insulin SC
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed for shortness of breath or
wheezing.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
7. Epoetin Alfa 20,000 unit/2 mL Solution Sig: Five (5) thousand
units Injection ASDIR (AS DIRECTED): To be dosed at dialysis.
8. Aspirin 325 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. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
units Injection ASDIR (AS DIRECTED): regular insulin per sliding
scale: see attached scale.
11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for to groin.
14. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO HS (at bedtime).
15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Primary:
pleural effusions
conjestive heart failure
end stage renal disease on hemodialysis
type II diabetes mellitus
coronary artery disease
pressure ulcers
pancreatitis
chronic myelogenous leukemia
respiratory failure
Secondary:
h/o osteomyelitis/ sternal dehiscence
osteoporosis
h/o DVT [**4-18**], [**4-19**]
s/p cataract surgery
hypercholesterolemia
hypertension
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as prescribed.
Please participate in all rehabilitation activities.
If you develop fever >101.3, chest pain, shortness of breath,
abdominal pain, or persistant nausea, please call your primary
care physician [**Name Initial (PRE) **]/or return to the emergency department.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] in Hematology/Oncology.
[**Telephone/Fax (1) 3760**]. Please bring all records from your oncologist
regarding
your CML, history of chronic transfusions, and iron overload.
Please also plan to follow up with your primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 15170**]. You can call [**Telephone/Fax (1) 19657**] to make an appointment.
You should be seen within the next 1-2 weeks to review your
hospital course.
You will continue on Mon, Wed, Fri hemodialysis
The following appointments have been made for you:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Where: [**Hospital6 29**]
HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2138-3-12**] 1:00
Provider: [**Name10 (NameIs) 2502**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 4054**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2138-3-12**] 1:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 4280, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7968
} | Medical Text: Admission Date: [**2128-9-20**] Discharge Date: [**2128-9-26**]
Date of Birth: [**2051-10-4**] Sex: M
Service: CSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Unstable Angina
Major Surgical or Invasive Procedure:
CABG scheduled for [**2128-9-21**]
History of Present Illness:
77 year-old male with history of hypertension and type II
diabetes who presents with 2 week history of exertional angina.
During the past two years, he had increasing fatigue with
exertion. He developed shortness of breath on exertion over the
past 2 months. Two weeks ago, he developed chest tightness on
walking 3 blocks that improved with rest. He had a exercise
stress test on [**9-15**] changes in the precordial
leads and a reversible anterior wall defect. On [**9-20**], he had
chest pain when walking to see his PCP. [**Name10 (NameIs) **] was sent for cardiac
catherization at that time and had chest pain at rest in the
catherization lab. This study showed left main disease and
diffuse 3 vessel disease. A balloon pump was placed and he was
scheduled for CABG. On review of systems, he has had nausea and
diaphoresis over the past 3 weeks. He denies orthopnea or PND.
Past Medical History:
Hypertension that is well controlled with ACEI
Type II diabetes that is well controlled (A1c = 6.2)
GERD for which he takes PPI
Hiatal hernia
BPH for which he takes finesteride
s/p appendectomy
s/p cholecystectomy
s/p bilateral knee arthroscopy
h/o difficult intubation with appendectomy without any problems
with later surgeries
Social History:
He lives at home with his wife. There are 6 steps in his house.
He does not smoke, he drinks socially 1-2x per year, he does
not use recreational drugs.
Family History:
He has a significant family history of CAD. His father had a
CABG in his late 70s. Two brothers also had a CABG at the ages
of 60 and 80, resepctively.
Physical Exam:
General: Alert and oriented, in no acute distress.
HEENT: EOMI, moist mucus membranes
Cardiac: RRR, S1, S2, no murmurs, rubs, or gallops. No JVD, no
carotid bruits, no peripheral edema.
Pulm: CTA in anterior fields, no wheezes or rhonchi.
Abdomen: Bowel sounds present, nondistended, nontender, soft.
Extremities: 2+ dorsalis pedis and tibialis anterior pulses, no
cyanosis.
Pertinent Results:
[**2128-9-20**] 05:23PM WBC-7.6 RBC-3.81* HGB-12.2* HCT-33.2* MCV-87
MCH-32.0 MCHC-36.7* RDW-13.8
[**2128-9-20**] 05:23PM NEUTS-71.3* LYMPHS-20.7 MONOS-4.3 EOS-3.0
BASOS-0.8
[**2128-9-20**] 05:23PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ BURR-1+
BITE-OCCASIONAL
[**2128-9-20**] 05:23PM PLT COUNT-230
[**2128-9-20**] 05:23PM PT-14.5* INR(PT)-1.3
[**2128-9-20**] 05:00PM TYPE-ART O2 FLOW-2 PO2-112* PCO2-44 PH-7.35
TOTAL CO2-25 BASE XS--1 INTUBATED-NOT INTUBA
[**2128-9-20**] 05:00PM GLUCOSE-125*
[**2128-9-20**] 05:00PM HGB-11.0* calcHCT-33 O2 SAT-98
[**2128-9-20**] 12:00PM INR(PT)-1.0
Brief Hospital Course:
77 year-old male with HTN and DM type II who presented with
unstable angina. Cardiac catherization showed left main disease
and diffues 3VD. A balloon pump was placed and he was scheduled
for CABG.
1. CAD: He was continued on ASA 325 qd. He was started on
captopril 12.5 tid (in lieu of lisinopril 5 qd), atorvistatin 40
mg qd, metoprolol 12.5 mg [**Hospital1 **], heparin drip with goal PTT 60-80
for a ballon pump, and a nitroglycerin drip 0.5-5 mg/kg/min.
Due to his chest pain at rest, will check 3 sets of cardiac
enzymes to rule out acute MI. His ejection fraction is 55% and
he appears euvolemic, therefore, his pump function seems
adequate. He is scheduled for a CABG [**9-21**].
2. Diabetes: Will not continue outpatient glipizide or
glucophage. He was started on an insulin sliding scale.
3. GERD: Will continue PPI pantoprazole.
4. BPH: Will continue outpatient finesteride 5 mg qd.
5. FEN: He can have cardiac healthy and diabetic diet. He will
be NPO after midnight for CABG. Will monitor electrolytes.
6. PPX: Bowel regimen: Senna, docusate, bisacodyl; DVT: heparin;
GI ulcer: pantoprazole.
7. Access: He has peripheral IVs. He will need central line and
A-line for CABG.
8. Dispo: He is sheduled for CABG. If he has chest pain
overnight, he will likely need an emergent CABG. Will check UA,
CXR, and EKG for pre-op evaluation. He has been type and
crossed for 4 units.
Medications on Admission:
Lisinopril 5 mg po qd
ASA 325 mg po qd
Glucophage 1000 mg qd
Glipizide 5 mg po 2 tab qd
Finesteride 5 mg po qd
Rabeprazole 200 mg po qd
Discharge Medications:
1. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO QD (once a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: resume pre op
medication.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*7 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD sp CABG X 3 [**2128-9-21**]
GERD
BPH
Hiatal hernia
Discharge Condition:
stable
Discharge Instructions:
Please call physician if experiencing redness/drainage from the
wound, chest pain/shortnes of breath, persistent
nausea/vomiting.
Do not lift > 10 lbs for 6 weeks. Do not swim or bath for 6
weeks. [**Month (only) 116**] shower. Follow cardiac healthy diet. Follow up
with PCP regarding new medications (Lasix X 1 week, lopressor,
plavix, lipitor). You will need laboratory tests while on
taking lipitor.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 4 weeks; call the office for
an appointment. Call the office for an appointment. Follow up
with PCP regarding medications in [**12-26**] weeks (lipitor, lopressor,
plavix).
Completed by:[**2128-9-27**]
ICD9 Codes: 4111, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7969
} | Medical Text: Admission Date: [**2186-7-1**] Discharge Date: [**2186-7-2**]
Date of Birth: [**2130-11-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2186-7-1**] CVL placement
History of Present Illness:
Mr. [**Known lastname 52653**] is a 55 yo M with end-stage sarcoid on 3LNC at
baseline, transferred from Radius with shortness of breath,
tachypnea, hypoxia and fevers. According to reports from Radius
has has been hypoxic for several days with O2 sats 91-92% on
100% NRB with desaturation to 86% with minimal exertion, patient
refusing to come to hospital.
.
In the ED T99.2 BP 145/84 RR 20-30 HR 92-140 96% on 100%NRB. He
was noted to be significantly hypoxic and tachypnic and was
intubated due to concern for increasing work of breathing. He
was given 2.5LNS, levofloxacin 750mg IV, cefepime 2g IV x1,
decadron 10mg IV x1 and versed 2mg IV x1.
Past Medical History:
1. Hepatitis C, diagnosed as part of the lung transplant workup
at the [**Hospital1 756**]. He is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in GI. He
is hepatitis B core surface antibody positive and surface
antigen
negative. In addition, he has hepatitis C antibody plus type 2b
with a viral load in [**8-/2185**], of 5.5 million. He had grade 2
fibrosis on [**2184-4-28**]. He is not thought to be a candidate
currently for interferon treatment given his sarcoidosis. He has
transaminitis.
2. Sarcoidosis. He is followed by Dr. [**Last Name (STitle) 2168**]. The patient has
been obtaining PFTs from Dr. [**Last Name (STitle) **], and he is currently on
azathioprine and prednisone with prophylaxis Bactrim.
3. Sleep apnea.
4. Erectile dysfunction.
5. Emotional lability and anxiety.
6. Status post mandible fracture [**8-20**].
7. Status post multiple rib and clavicle fractures over the past
year secondary to fall.
8. Spinal stenosis: diagnosed on MRI and is followed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 363**], [**First Name3 (LF) **] orthopedic physician at the [**Hospital1 18**]. The diagnosis was
established as part of a workup for progressive lower leg
weakness, which led to multiple falls and currently an inability
to ambulate.
9. Shingles in [**12/2184**] on the right side of the face with
residual neuropathic pain.
Social History:
Has been living in a rehab facility since recent admission in
[**2186-4-13**]. Previously lived in an apartment in [**Location (un) 1459**] with his
27 yo daughter who is s/p traumatic brain injury in a motor
vehicle accident. Has another daughter from whom he is
estranged. Recently divorced from his wife of 33 years who he
says did "not want to take care of him." Patient is a former
food salesman, selling restaurant supplies to pizzerias. Has
been unemployed for about a year, no longer on unemployment.
Recently obtained some disability benefits. Reports a 10 pack
year smoking history, but quit 20 years ago. Reports no history
of ethanol use or IV drug use. Pt had previous admission in
which he was on high doses of methadone and benzodiazepenes that
were verified by PCP to be prescribed by an outpatient physician
to treat his pain from spinal stenosis; pt believed to withdraw
from both on previous admissions.
Family History:
Noncontributory of pulmonary disease.
Physical Exam:
Physical Exam (per Dr. [**First Name8 (NamePattern2) 4311**] [**Last Name (NamePattern1) 4312**])
Vitals: T97.6 BP 93/68 HR 100-115 RR 24 99% on CMV 100% TV 500
RR 20 PEEP 10
Gen - sedated, intubated, non responding to verbal or physical
stimulation
HEENT: NC AT, intubated, NG tube in place, pupils 2mm equal and
reactive to light
CV- distant heart sounds unable to appreciate murmur
Lungs - coarse vented breath sounds, crackles bilaterally,
expiratory wheezing
Abd - multiple scattered bruises diffusely over abdomen, soft,
ND, no apparent guarding, BS +
Ext: somewhat cachectic lower extremities, 2+ pitting edema,
right foot warm to palpation, left foot cool, DP's by doppler
Pertinent Results:
On admission [**2186-7-1**]:
Na 142 K4.7 Cl 102 HCO 33 BUN 29 creat 0.5 Gluc 93
CK 29 MB - Trop <0.01
AST 100 ALT 102 AP 317
WBC 13.2 HCT 32.1 PLT 307 29% bands
UA: leuk neg, mod blood, nitr neg, [**2-15**] granular casts, [**11-2**]
hyaline casts
.
[**2186-7-1**] EKG:sinus tachycardia at 125bpm, normal axis, normal
intervals, poor baseline, no apparent ST segment or T wave
changes. Compared with [**2186-4-7**] sinus tachycardia is new
otherwise no clear change.
.
Micro:
[**3-1**] Blood Cx: pending
.
Imaging:
[**2186-7-1**] CXR: (prelim dictation) extensive pulm fibrosis and
emphysema unchanged, no effusion, no PTX, ETT terminates 4.5cm
above carina, RIJ at cavo-atrial junction, OG tube in esophagus.
Otherwise no acute cardiopulmonary changes.
.
[**2186-4-8**] CTA chest:
1. Small PE of segmental/subsegmental right upper lobe branch.
This was communicated by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 24949**] with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3766**] by telephone in the AM on [**2186-4-10**].
2. New minimally displaced fracture of the lateral right ninth
rib. Multiple additional bilateral healing rib fractures.
3. Healing left distal clavicle fracture.
3. Resolution of right upper lobe pneumonia.
4. Chronic severe pulmonary fibrosis in the setting of
sarcoidosis.
.
[**2185-11-8**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is dilated. Right
ventricular systolic function appears depressed. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is moderate
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2185-10-6**],
right ventricular systolic function now appears depressed.
Brief Hospital Course:
SIRS/Sepsis: Patient met SIRS criteria based on tachycardia and
bandemia of 29%. Most likely cause is PNA given underlying
severe sarcoidosis, other consideration is infected midline
which has been in place for unclear duration of time. Vancomycin
IV was started to cover for possible line infection. Meropenem
was started to provide coverage for resistant pseudomonas seen
on recent sputum culture. Patient's urinalysis was
unremarkable. Urine cultures were obtained. PICC line was
discontinued on arrival to ICU. Patient had central line placed
in ED. IVF fluids were administered to maintain CVP 8-10. With
progressive hypoxia patient became hypotensive requiring
norepinephrine and phenylephrine to maintain MAP > 65 on his
second day of admission. Additional fluid boluses had no effect
on hypotension and tachycardia. Pressors were discontinued only
after the family made the decision to make him CMO.
Hypoxic respiratory failure: In the setting of fever and recent
pseudomonas-positive sputum culture, pneumonia superimposed on
underlying sarcoidosis is most likely etiology. No clear
infiltrate on CXR although difficult to interpret in the setting
of already severe pulmonary fibrosis. Sputum and blood culture
were obtained. Due to his increased susceptibility patient was
treated empirically with vancomycin and meropenem for possible
PNA, with levoquin added for double PSA coverage and atypical
coverage. He was also covered empirically for PJP, although he
had been on bactrim prophylaxis, and ETT PCP DFA was ordered.
Patient also received frequent nebulizer therapies. Patient was
intubated on arrival to ED and became progressively more hypoxic
during his admission. Pt ultimately required maximum ventilator
settings to keep his SpO2 above 80%. Multiple blood gases
obtained illustrated his further deterioration. Patient was
given trial of pressure controlled ventilation, volume
controlled ventilation and APRV at varying levels of PEEP, but
all failed to improve oxygen saturations. Pt was then placed in
prone position so as to improve O2 sats, with no effect.
Patient's daughter was present and the status of patient was
discussed. She informed other family members who then met at
the hospital for a family meeting. Family meeting was conducted
with physicians and nurses present. They were in acceptance of
pts deteriorating state and at that point did not want any
resuscitative measures. Patient was started on comfort measures
and remained ventilated.
.
End stage sarcodiosis: Patient has severe sarcoidosis at
baseline; is currently on high dose steroids. Pt was continued
on high dose steroids, and PCP prophylaxis with bactrim until
the decision was made to take comfort measures only. Pt was
kept on mechanical ventilation.
.
Chronic pain/spinal stenosis: home medications (ms contin and
percocet) were held. Pt was sedated with fentanyl/midazolam.
.
Communication: daughter [**Name (NI) **] [**Last Name (NamePattern1) 52655**] is HCP
H:[**Telephone/Fax (1) 52656**] c: [**Telephone/Fax (1) 52657**]
.
Code status - On presentation to the [**Name (NI) **] pt was full code. After
discussion of the patient's status with his daughter/HCP the
decision was made to declare him DNR. Once other family members
were notified of his health status and given the opportunity to
come to the hospital the decision was made to offer Comfort
Measures Only and withdrawal all supportive care.
Medications on Admission:
-Albuterol Sulfate 2.5 mg/3 mL neb q4 hours and q7 hours prn
-Atrovent Nebs Q4Hours and Q 7 hours prn
-Solu-medrol 60mg IV Q6hrs
-Novalog sliding scale QACHS
-mucomyst 10% 3ML INH QID
-Clonazepam 1 mg PO TID prn
-NPH insulin [**Hospital1 **] (unclear dosing had been on 12QAM and 6QPM
during last admit)
-Nexium 40mg daily
-dulcolax 10mg pr qday prn
-colace 100mg po bid
-milk of magnesia 30ML daily
-MS Contin 45mg [**Hospital1 **]
-percocet 1-2 tabs TID prn
-zocor 20mg daily
-heparin SQ 5000mg TID
-Azathioprine 150 mg PO DAILY
-cymbalta 90mg po daily
-ASA 325mg daily
-Sennakot 1 [**Hospital1 **]
-Bactrim DS 1 tab QMWF
-trazodone 25mg qhs prn
-vitamin b1 100mg daily
-risperdal 1mg [**Hospital1 **]
-haldol 1mg po BID prn
-lactulose 30mg po tid prn
-saline nasal spray 2 sprays each nostril QID
-Mirtazapine 15 mg PO HS
-roxanol 10mg po q3hrs prn
-fleet enema pr daily prn
-MTV daily
-primaxin IV 250mg Q6 hours
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Sarcoidosis, pneumonia, hypoxic respiratory failure
Discharge Condition:
expired
Discharge Instructions:
Patient has expired
Followup Instructions:
none
ICD9 Codes: 0389, 486, 4589, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7970
} | Medical Text: Admission Date: [**2200-12-28**] Discharge Date: [**2200-12-31**]
Date of Birth: [**2129-6-25**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 5850**] is a 71-year-old
male with an extensive cardiac history. His last cardiac
catheterization was [**7-25**] during which he had a stent to his
D1 and presented with unstable angina. Patient describes
stable angina as substernal chest pain with walking "one city
block". He states his chest pain was relieved with rest.
Today the patient describes sudden onset of substernal chest
pain at rest while having a bowel movement around 2 pm.
Per patient report and wife, had an ETT at Dr.[**Name (NI) 5765**] office
on Friday that was within normal limits. Today, his chest
pain was [**8-2**] consistent with previous angina associated with
nausea, dry heaves, positive shortness of breath, and perfuse
diaphoresis. The patient called EMS, his wife was not home.
His blood pressure at the time was 168/92 with a pulse of 90.
Patient had missed his am medications. The patient was given
aspirin, sublingual nitroglycerin, albuterol, and his chest
pain decreased to [**3-2**]. At the outside hospital Emergency
Department, the patient was started on Plavix, Integrilin,
and Heparin, intravenous nitroglycerin, morphine sulfate, and
Lopressor.
His electrocardiogram showed anterior ST elevations, and he
was taken to the catheterization laboratory. At the
catheterization laboratory, he was shown to have a complex
bifurcation stenosis at the left anterior descending
artery/D1. Balloon angioplasty was performed to the D1 and
left anterior descending artery with residual 30% stenosis in
each. Patient was chest pain free status post procedure. He
was then transferred to [**Hospital1 69**]
for further management.
At [**Hospital1 69**], the patient was
asymptomatic with no chest pain, no shortness of breath, and
his vital signs were stable.
PAST MEDICAL HISTORY:
1. CABG in [**2181**], LIMA to the left circumflex, saphenous vein
graft to the PDA. Cardiac catheterization [**2200-4-23**]
performed for dyspnea on exertion, patent LIMA to the left
circumflex, patent saphenous vein graft to the PDA, 80%
stenosis of the proximal left anterior descending artery.
The patient had balloon angioplasty, but no stenting of this
lesion as the stent could not be passed. Cardiac
catheterization on [**2200-8-10**] performed for continued
dyspnea on exertion. The patient had PCI of the left main
into the diagonal with atherectomy and stenting of a long
segment of disease from the distal left main to a major high
first diagonal branch and proximal left anterior descending
artery. The previously treated mid left anterior descending
artery on [**4-24**] was widely patent. The patient had PTCA of
ostial left anterior descending artery, pulmonary capillary
wedge pressure was 7.
2. Diabetes x20 years, diet controlled. No hemoglobin A1C on
CCC records.
3. Left kidney atrophy since childhood, question infectious
versus congenital anomaly.
4. Hypertension.
5. Chronic renal insufficiency.
6. Chronic vascular diabetic nephropathy with a baseline
creatinine of 1.2-1.5.
7. High cholesterol.
8. Carotid stenosis.
9. Barrett's esophagus with esophageal strictures.
10. Gout.
11. Mild aortic insufficiency.
12. High homocysteine levels.
13. Osteoarthritis.
MEDICATIONS ON ADMISSION:
1. Lipitor 10 q am, 40 q pm.
2. Atenolol 125 q day.
3. Aspirin 325 q day held for recent EGD x2 weeks.
4. Plavix 75 q day.
5. Allopurinol 100 q day.
6. Imdur 60 q day.
7. Folic acid 3 [**Hospital1 **].
8. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq q day.
9. Lasix 20 q day.
10. Norvasc 10 q day.
11. Prevacid 30 q day.
12. Lotensin 10 q day.
13. Vitamin E.
14. Vitamin B1, B6, and B12.
15. Vioxx.
SOCIAL HISTORY: The patient is a retired construction
worker. He drinks two gin and tonics or vodka tonics each
night. No history of DT's or withdrawal seizures per patient
and per wife. [**Name (NI) **] tobacco history. Lives with wife. She is
a nurse.
REVIEW OF SYSTEMS: Two-pillow orthopnea, negative PND,
negative change in baseline lower extremity edema, no fevers,
chills, upper respiratory symptoms, no diarrhea, no abdominal
pain.
PHYSICAL EXAMINATION ON ADMISSION: Blood pressure
150-170/60-80, heart rate 80-90, normal systolic, respiratory
rate 19-22, sat 99% on 2 liters nasal cannula. Weight is
94.5 kg. In general, alert and oriented times three, anxious
in appearance, chest pain free. HEENT: Pupils constricted,
equal bilaterally, status post bilateral cataract surgery.
Extraocular muscles are intact. Heart regular, rate, and
rhythm, S1, S2, [**1-29**] soft systolic murmur at the left upper
sternal border. Lungs are clear anteriorly. Anterior chest
wall with rib tenderness to palpation. Abdomen is benign.
Extremities: 2+ pitting edema bilaterally, per patient is
baseline. Distal pulses not palpable, DP and PT pulses
dopplerable bilaterally. Groin hematoma: Right groin status
post catheterization, indurated, nontender, 4 x 4 cm
hematoma. Neurologic is alert and oriented times three.
DATA ON ADMISSION: Hematocrit 39.4, white count 11.3,
platelet count 201. Chemistries: 138, 4, 103, 23, 16, and
1.3. Of note, creatinine was 1.6 at outside hospital.
Glucose 145. PT 12.9, PTT 44.2, INR 1.1. Calcium 8.2,
magnesium 1.0, phosphorus 2.7, albumin 4.3. Cardiac enzymes:
CK 189 at outside hospital. At [**Hospital1 188**], 2,149, MB of 3.1 at outside hospital to 169 at [**Hospital1 1444**]. Troponin went from 0.03 at
the outside hospital to greater than 50 at [**Hospital1 346**]. Of note, the outside hospital
laboratories were at 4 pm and the [**Hospital1 190**] laboratories were at 8 pm.
ELECTROCARDIOGRAMS: When performed by the EMT, the
electrocardiogram showed sinus rhythm with a right bundle
branch, left axis deviation, [**Street Address(2) 1766**] elevations in the
anterior leads and 2-[**Street Address(2) 2051**] elevation in the inferior and
lateral leads at the outside hospital, normal sinus rate at
72 with a right bundle branch block, ST elevations V1 and V2
with [**Street Address(2) 1766**] elevations in II, III, and aVF, V4 through V6
and aVL with [**Street Address(2) 1766**] depressions. At [**Hospital1 190**], sinus with a normal axis and normal
intervals, no bundle branch block, 1-[**Street Address(2) 1766**] depressions in
the lateral leads, [**Street Address(2) 4793**] depressions in the inferior leads
and borderline left ventricular hypertrophy.
ASSESSMENT AND PLAN: This is a 71-year-old male with
recurrent myocardial infarction secondary to stenosis, plaque
of the left anterior descending artery territory. The
patient is status post angioplasty to the left anterior
descending artery and D1. Electrocardiogram changes
resolving. The patient is chest pain free. The patient is
transferred to the [**Hospital1 69**] CCU
for closer monitoring, groin hematoma status post
catheterization, history of bleeding.
1. From a cardiac standpoint, the patient was continued on
Integrilin for 18 hours, aspirin, and Plavix. Heparin was
held secondary to the groin hematoma. The patient was given
initially metoprolol 5 mg IV x3 for a heart rate normal sinus
in the 90s. He was then given 75 mg po Lopressor. He was
started on Captopril 12.5 tid and a nitroglycerin drip to
keep his blood pressure between 110-120 systolic and to
decrease preload and therefore cardiac stress. His CKs were
continued to be cycled. Daily electrocardiograms were
checked, and he was continued on his statin.
From a pump standpoint, the patient had an echocardiogram on
the 6th that showed decreased ejection fraction of 35-40%.
Of note, the patient's last ejection fraction was 50% on
[**2200-4-24**] with this echocardiogram showing severe hypokinesis
of the left ventricle, anterior wall, and septum. From the
rhythm standpoint, patient was continued on Telemetry with
normal sinus rhythm. He was placed on Lopressor [**Hospital1 **].
On Telemetry, he was noted to have NSVT, highest 4. EP was
consulted as this patient has a known low ejection fraction
and myocardial scarring along with NSVT. The EP consult,
they performed a signal average electrocardiogram which was
positive by [**1-26**] criteria with a QRS of greater than 114 and a
LAF of greater than 38. It was decided that the patient
should follow up after discharge on the 29th at 1:10 pm to
have more formal EP studies.
2. Renal: History of chronic renal insufficiency with
baseline creatinine of 1.2-1.6. The patient was given
postcatheterization hydration at 75 cc of normal saline per
hour. He was also treated with Mucomyst 600 po x2 and his
magnesium was repleted for a magnesium of 1.0, he received 4
grams of magnesium sulfate x1. His magnesium corrected to
1.5 on [**2200-12-30**].
3. Neurologic: The patient was noted to be agitated on
evenings and required Ativan prn and a few doses of 1 mg of
Haldol for agitation. He however, had no episodes of DT's or
withdrawal seizures. He was placed on a CWA scale, but never
had a CWA level of greater than 10.
The patient was discharged to home on [**2200-12-31**]. He had no
further episodes of chest pain or shortness of breath. He
had worked with Physical Therapy and ambulated well without
decrease in sats and was able to walk stairs without
significant elevation in blood pressure or heart rate.
DISCHARGE MEDICATIONS:
1. Imdur 60 q day.
2. Metoprolol 100 qid.
3. Captopril 12.5 tid.
4. Folic acid 3 mg [**Hospital1 **].
5. Plavix 75 q day.
6. Atorvastatin 50 q day.
7. Allopurinol 100 q day.
8. Aspirin 325 q day.
9. Protonix 40 q day.
10. Multivitamin.
11. Thiamine.
12. Vitamin E.
[**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern1) 1731**], M.D. [**MD Number(1) 1732**]
Dictated By:[**Last Name (NamePattern1) 5851**]
MEDQUIST36
D: [**2201-1-25**] 19:12
T: [**2201-1-27**] 07:41
JOB#: [**Job Number 5852**]
ICD9 Codes: 4271, 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7971
} | Medical Text: Admission Date: [**2188-7-1**] Discharge Date: [**2188-8-2**]
Date of Birth: [**2121-12-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Small Bowel Obstruction
Incarcerated Umbilical Hernia
Major Surgical or Invasive Procedure:
Exploratory Laparotomy
Adhesiolysis
Repair of Umbilical Hernia
Re-exploration of recent laparotomy
History of Present Illness:
66 yoF with multiple medical problems [**Name (NI) 78191**] CHF, HCV
Cirrhosis, CKD comes with altered mental status from a nursing
home. On exam noted to have two large hernias, one in the R
inguina and the other umbilical. KUB in ED showed multiple
small
bowel loops the largest of which are 4 cm.
Past Medical History:
1. HCV cirrhosis currently undergoing transplant work-up, had
SBP in [**5-6**]
2. Diabetes mellitus type 2: Per old records, pt had diagnosis
of diet controlled type 2 diabetes.
3. Umbilical hernia
4. [**Date Range **] in [**5-6**]: EKG c/w anteroseptal MI with new ST elevations
in V2-3. Elevated troponins but not cath candidate. Echo
confirmed anteroseptal WMA and pt was medicallly managed.
5. diastolic CHF
6. CKD
Social History:
From [**Location (un) 5354**], lived alone there and now moved in with her
brother here in [**Name (NI) 86**]. Presented to the ED directly from the
airport upon arrival in [**Location (un) 86**] several weeks ago for possible
liver txplnt. Former smoker, 20 pack-years, quit 10 years ago.
Former moderate EtOH consumption. Denies current EtOH use.
Denies illicit drug use/IVDU.
Family History:
Father died of MI at age 62, brother had MI at age 60, brother
also has DM.
Physical Exam:
N: grossly non verbal, responds in all four extremites to deep
pain stimulation. Icteric, PERLA.
CV: RRR, tachy at times, no MRG
R: CTA B/L short quick inspiratory effort, non compliant with
deep breath
ABD: soft, protuberant with ascites, large umbilical hernia
with
early erythematous skin changes, tender to palpation,
non-reducible. Large R inguinal hernia, soft, minimal erythema,
fluid filled, partially reducible with immediate return, mildly
tender to palpation. No obvious scars from previous surgery.
EXT: minimal edema, pulses palpable throughout.
Pertinent Results:
[**2188-7-1**] 10:05AM AMMONIA-198*
LACTATE-5.3*
[**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-NEG
WBC-6.6 RBC-2.67*# HGB-9.0* HCT-26.9* MCV-101*# MCH-33.8*
MCHC-33.6 RDW-18.6*
10:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
cTropnT-0.16*
LIPASE-29
ALT(SGPT)-47* AST(SGOT)-62* CK(CPK)-88 ALK PHOS-159* TOT
BILI-5.2*
[**2188-7-1**] 08:12PM
TYPE-ART PO2-191* PCO2-37 PH-7.38 TOTAL CO2-23 BASE XS--2
LACTATE-3.7* freeCa-1.09*
GLUCOSE-104 UREA N-26* CREAT-1.4* SODIUM-144 POTASSIUM-4.3
CHLORIDE-113* TOTAL CO2-21* ANION GAP-14
CALCIUM-8.7 PHOSPHATE-3.9 MAGNESIUM-1.4*
WBC-6.1 RBC-2.04* HGB-6.8* HCT-20.5* MCV-101* MCH-33.4*
MCHC-33.2 RDW-18.3*
PLT COUNT-72* PT-21.2* PTT-45.3* INR(PT)-2.0*
ECG Study Date of [**2188-7-1**] 10:16:44 AM
Sinus tachycardia. Baseline artifact. Poor R wave progression.
Compared to
the previous tracing of [**2188-5-18**] sinus tachycardia and artifact
are new.
CHEST (PORTABLE AP) Study Date of [**2188-7-1**] 10:13 AM
IMPRESSION: No evidence of pneumonia.
CT HEAD W/O CONTRAST Study Date of [**2188-7-1**] 10:15 AM
IMPRESSION: No acute intracranial process.
PORTABLE ABDOMEN Study Date of [**2188-7-1**] 10:27 AM
IMPRESSION: Findings suggestive of small bowel obstruction. CT
may be performed to further evaluate.
ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2188-7-28**] 2:32 PM
IMPRESSION:
1. Heterogeneous liver with no focal masses seen.
2. No biliary dilatation.
3. Splenomegaly.
4. Right pleural effusion and a small amount of perihepatic
ascites.
Brief Hospital Course:
This is a 66 yo F with HCV cirrhosis and minimal reserve
initially admitted with hepatic encephalopathy, and small bowel
obstruction.
# Small Bowel Obstruction: On [**2188-7-1**] the patient went to the OR
for repair of umbilical hernia and reduction of small bowel
obstruction. On [**2188-7-7**], she had Re-exploration of above
laparotomy for Bacterial peritonitis, extremely high peritoneal
ascites white count of 19,000. In that her liver failure
continued to progress, and she was vasopressor-dependent and had
poor urine output, there was concern for an intra-abdominal
pathology source fueling this peritonitis. Upon repeat
laparotomy, there was no evidence of any compromise or bowel
death or obstruction; bowel was inflamed and edematous, as would
be expected from peritonitis, but there was no evidence of any
compromise nor incarcerated hernia. She was treated with a
course of zosyn/vanco, was weaned off pressors and was
transferred out of the SICU onto the liver medical service.
# Altered Mental Status: She was confused and at times
inappropriate and agitated. Pt attempted to remove Foley and
PICC on several occasions. This was thought not entirely due to
hepatic encphalopathy as she was stooling well on standing
lactulose and rifaximin with decrease in asterixis. She had
soft restraints and a 1:1 sitter. Her mental status was
improving. She was evaluated by Psych on [**2188-7-14**]. They
recommended Haldol as needed initially, and then standing doses
of Haldol after PRN was not sufficient. Psych also recommended
using lactulose for her hepatic encephalopathy. On [**7-28**] the
patient appeared somnolent and her standing Haldol dose was
[**Month/Year (2) 8910**] with an improvement in her mental status. She
remained intermittantly confused, but was minimally agitated for
the remainder of her hospital course.
# Liver Failure/ HCV Cirrohsis: Pt was followed by the
Transplant team but determined not to be a transplant candidate.
She received lactulose enemas daily. She was having high ascitic
output, at times as much as 8 liters/day. With the high JP
output, her urine output was low (Hypovolemia). JP output was
replaced with saline. She was also ordered for Albumin to help
with the ascites.
She was unable to tolerate NGT feedings and she had a high
residual. Tubefeedings were stopped and she was started on TPN
while on the surgical service. She was seen by Speech and
Swallow and cleared for nectar thick liquids and ground
consistency solids, however, due to her poor PO she was
continued on TPN. Her bilirubin continued to climb and this was
thought due to TPN.
# Hyperbilirubinemia: Total bilirubin was 5.2 on admission, and
with minor fluctuations, rose to 18.0 on [**7-24**]. Bilirubin
continued to rise daily to 28 on [**7-29**]. No further labs were
obtained after that time.
# Renal Failure: Upon callout from the surgical ICU, her
creatinine began to rise. She had large volume output of
ascites from lap site that continued so it was intially
postulated that she was likely intravascularly dry due to
inadequate intake and high volume output from abdomen and stool.
Her renal function, did not, however improve with fluid and
albumin challenge and thus renal was consulted for probable HRS.
Given the trajectory of her renal failure and development of
oliguria/anuria, hemodialysis was considered. In discussion
with her health care proxy, however, it was decided that rather
than to initiate HD, team would focus on comfort care.
# Anemia/GIB: She had post-op Anemia and received PRBCs as
needed for [**Month/Day (4) **] loss anemia. Her HCT on POD 1 was 20 and rose
to 26. Her HCT remained stable and low in the 23-24 range.
Thrombocytopenia was also noted. INR remained elevated. On [**7-26**]
the patient was found to have guiac positive emesis and a drop
in her hematocrit from 25-->19. She was transferred to the ICU
and transfused 3 U pRBCs. Endoscopy showed evidence of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **] tear with stimata of recent bleeding. She was sabilized
and returned to the hepatorenal service on [**7-27**]. Her hematocrit
was stable for 24 hours until she had a large heme positive
stool and her hct dropped again from 25-->20. She again was
transfused 2u with an approptiate response with stable
hematocrit thereafter.
# DNR/DNI/CMO: On [**2188-7-30**], the issue of resusitation orders were
discussed with the patient's brother [**Name (NI) **] [**Name (NI) 78192**]. During
this discussion, it was determined that in light of her
ineligability for transplant, DNR/DNI orders should be made.
The issue of her imminent renal failure was also approached and
this lead to the decision by her brother that dialysis should
not be initiated. On [**2188-7-31**], the patient was made CMO and all
unnecessary medical therapy was stopped. Pt remained on
lactulose to maintain mental status. The patient died
peacefully on the morning of [**8-2**].
Medications on Admission:
-Acetaminophen 500 mg 1 tab PO Q6 hrs PRN pain
-Albuterol Sulfate 2.5 mg/3 mL [**Male First Name (un) **] for neb. inhalation Q4 hrs
PRN
-Aspirin 325 mg tab PO daily
-Ciprofloxacin 250 mg tab PO q24 hrs
-Folic Acid 1 mg tab PO daily
-Furosemide 40 mg 1 tab PO daily
-Hexavitamin 1 Cap by mouth DAILY
-Lactulose 10 gram/15 mL syrup 30 ML PO TID (titrate to 3 BM
daily)
-Metoprolol 25 mg 0.5 tab PO BID
-Pantoprazole Delayed Release (E.C.) 40 mg 1 tab PO daily
-Spironolactone 100 mg 1 Tab PO daily
-Insulin Regular Human 100 unit/mL solution 0-10 Solution(s)
sliding scale.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
3. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
5. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO QID
(4 times a day).
6. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
7. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
Discharge Disposition:
Expired
Discharge Diagnosis:
Incarcerated Right Inguinal Hernia
Umbilical Hernia
Small bowel Obstruction
Hepatic Encephalopathy
Cirrhosis
Renal Failure
Cardiopulmonary arrest
Discharge Condition:
Deceased
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2188-8-20**]
ICD9 Codes: 5856, 2851, 5849, 5715, 4280, 4589, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7972
} | Medical Text: Admission Date: [**2200-7-31**] Discharge Date: [**2200-8-4**]
Date of Birth: [**2141-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2200-7-31**] - Coronary artery bypass graft x4, left internal mammary
artery to left anterior descending artery and saphenous vein
grafts to diagonal, obtuse marginal, and posterior descending
arteries. Mitral valve repair with size 28 CG Feature Complete
Ring.
History of Present Illness:
This is a 59-year-old patient who presented with recent
myocardial infarction, was investigated, and was found to have
severe 3-vessel disease with a diminished ejection fraction of
40%. Intraoperative echocardiogram also showed at least moderate
mitral regurgitation. The plan was to proceed with coronary
bypass grafting and mitral valve repair.
Past Medical History:
Coronary artery disease s/p CABG
Myocardial infarction
prior stent/angioplasty
Right bundle branch block
Stroke [**2192**] ( post-cath)-residual memory impairment/right sided
weakness
Hypertension
obesity
asthma
Obstructive sleep apnea-Bipap
depression
dyslipidemia
Seizures
Noncompliance
Social History:
Lives with: self in [**Hospital3 **]
Occupation: disabled/past clothes buyer(TJX)
Tobacco:no
ETOH:no
Recreation drugs: no
Family History:
History:father with MI at 70
Physical Exam:
Pulse: 98 Resp: 16 O2 sat: 97%-RA
B/P Right: 122/76 Left:
Height: 5'6" Weight: 240lbs
General:Obese man/NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] No M/R/G
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: no
Varicosities: None [x]
Neuro: Grossly intact, strength 5/5 on right [**4-11**] on left-upper
and lower extremities. Gait normal
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit no Right: Left:
Pertinent Results:
ECHO [**2200-7-31**]
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is moderately depressed
(LVEF=30-40 %). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. Trace aortic regurgitation is seen. A mitral valve
annuloplasty ring is present. Trivial mitral regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Moderately depressed left ventricular systolic
function. No pericardial effusion.
[**2200-8-4**] 05:20AM BLOOD WBC-16.6* RBC-3.25* Hgb-9.3* Hct-28.2*
MCV-87 MCH-28.6 MCHC-33.0 RDW-14.2 Plt Ct-385
[**2200-8-3**] 07:15AM BLOOD WBC-18.0* RBC-3.04* Hgb-9.0* Hct-27.3*
MCV-90 MCH-29.7 MCHC-33.1 RDW-14.3 Plt Ct-265
[**2200-7-31**] 02:20PM BLOOD PT-14.5* PTT-33.1 INR(PT)-1.3*
[**2200-8-4**] 05:20AM BLOOD Glucose-100 UreaN-28* Creat-0.8 Na-133
K-3.9 Cl-97 HCO3-28 AnGap-12
[**2200-8-3**] 07:15AM BLOOD UreaN-26* Creat-0.8 Na-135 K-4.5 Cl-97
Brief Hospital Course:
Mr. [**Known lastname 26258**] was admitted to the [**Hospital1 18**] on [**2200-7-31**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to four vessels and a mitral valve repair. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. Over the next 24 hours, he
had awoke neurologically intact and was extubated. On
postoperative day one he was transferred to the step down unit
for further recovery. Aspirin, a statin and beta blocker were
resumed. He was gently diuresed towards his preoperative weight.
The physical therapy service was consulted for assistance with
his postoperative strength and mobility. Postoperative course
was uneventful and the patient was discharged on POD 4. He was
discharged to [**Hospital 3548**] [**Hospital 3549**] Rehab, as he lives alone. He did
develop some sternal drainage, and was discharged on keflex.
Medications on Admission:
Celexa 20'
Ambien 10'
Proventil 3.7'
Trileptal 300'
ASA 325'
Toprol XL 100'
Niaspan 2gm'
Lisinopril 20'
MVI
Prozac 20'
Crestor 20'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 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).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Niacin 500 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO BID (2 times a day).
14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
16. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Myocardial infarction
prior stent/angioplasty
Right bundle branch block
Stroke [**2192**] ( post-cath)-residual memory impairment/right sided
weakness
Hypertension
obesity
asthma
Obstructive sleep apnea-Bipap
depression
dyslipidemia
Seizures
Noncompliance
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Left - healing well, no erythema or drainage.
Edema -trace in LEs
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) No driving for approximately one month until follow up with
surgeon
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] (for Dr. [**First Name (STitle) **] in 3 weeks at [**Hospital1 **] for wound
check and post-op follow-up : [**Telephone/Fax (1) 6256**] Thursday, [**9-4**], 9am
Dr. [**First Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 77271**] in 3 weeks [**Telephone/Fax (1) 6256**]
Dr. [**Last Name (STitle) 1295**] [**Telephone/Fax (1) 6256**] in 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2200-8-4**]
ICD9 Codes: 4240, 2851, 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7973
} | Medical Text: Admission Date: [**2118-8-17**] Discharge Date: [**2118-9-1**]
Date of Birth: [**2118-8-17**] Sex: M
Service: NB
INTERIM SUMMARY OF [**8-15**].
HISTORY: Baby [**Name (NI) **] [**Known lastname **], Twin number 1, was born on
[**2118-8-17**] to a 30-year-old gravida 2, para 0, now 2 mother,
with insulin dependent diabetes mellitus, who had surgery for
an ovarian torsion 1 month prior to delivery. She received
betamethasone at that time. She was readmitted to the
hospital with preterm labor on the day of delivery, as well
as the question of placental abruption, so she was taken for
cesarean section. Baby [**Name (NI) **] [**Known lastname **] was born at 31-1/7 weeks
gestation. His Apgar scores were 7 and 8.
PRENATAL LABS: Mom had [**Name2 (NI) **] type B positive, antibody
screen negative, hepatitis B surface antigen negative,
rubella immune, RPR nonreactive, GBS status unknown.
PHYSICAL EXAMINATION ON ADMISSION: Notable for a pink,
active, nondysmorphic infant who was well-perfused and with
decreased aeration on CPAP. He had moderate increased work
of breathing. His head and neck exam were normal. His
cardiac exam was normal without murmurs. His testes were
palpable high in the inguinal canal. His hips were normal.
His anus was patent. His birth weight was 2,260 gm.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: He was intubated shortly after birth for
respiratory distress syndrome secondary to surfactant
deficiency and received 2 doses of surfactant over the
first day of his life. He was weaned on the ventilator
and extubated to CPAP which he was on briefly on day of
life 2. Over days of life 3 and 4, he was transitioned
off CPAP to nasal cannula and eventually to room air by
day of life [**3-7**]. Initially, he had no significant apnea
nor bradycardia, but has had a few mild spells beginning
on day of life 9. He has not received any caffeine. At
the time of this interim summary, his last spell was on
the [**8-30**]. He remains on room air.
1. CARDIOVASCULAR: He has had a normal cardiovascular exam
with normal perfusion and [**Month (only) **] pressures throughout his
stay. A soft murmur was heard on day of life 2, but this
resolved and has not been appreciated on subsequent
examinations.
1. FLUIDS, ELECTROLYTES AND NUTRITION: He was initially on
IV fluids with normal electrolytes, and glucoses 66 and
115 on the first day of life. He had a high potassium of
7 on day of life 2 which was a heel stick and was repeated
with a serum level of 4.3. Feeds were initiated on day of
life 3 and were slowly advanced to full enteral volume by
day of life 6. He is currently on Similac Special Care 26
with ProMod. He has received maternal breast milk, but at
the time of this interim summary, his mother had received
IV contrast for imaging of a clot next to her abdominal
incision from delivery and had to be discarding her pumped
breast milk. He is receiving all gavage feeds and has had
no issues with feeding intolerance. He has had normal
urine output.
1. GI: He has been receiving his gavage feeds over an hour
and a half secondary to emesis. He had one 12 cc aspirate
on the [**8-30**] that was partially digested and was
subtracted from his total volume. He has had no other
gastrointestinal issues throughout his stay. He had a
bilirubin of 11.6 on the [**8-21**], and single
phototherapy was initiated. He was on phototherapy for 3
days, and his phototherapy was discontinued on day of life
7 with a rebound bilirubin of 6.1.
1. HEMATOLOGY: His initial hematocrit was 50 percent with 29
neutrophils and 0 bands.
1. INFECTIOUS DISEASE: He received 48 hours of ampicillin
and gentamicin secondary to his respiratory distress and
prematurity. His antibiotics were discontinued at 48
hours of life when [**Month (only) **] culture was negative. He has had
no other infectious disease issues.
1. NEUROLOGY: He had a head ultrasound on day of life 7 that
was normal.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 53433**], MD, phone number [**Telephone/Fax (1) 57438**].
INTERIM DISCHARGE DIAGNOSES: Prematurity at 31-1/7 weeks.
Twin gestation.
Rule out sepsis.
Hyperbilirubinemia.
Respiratory distress syndrome.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2118-9-1**] 09:32:21
T: [**2118-9-1**] 10:02:56
Job#: [**Job Number **]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7974
} | Medical Text: Admission Date: [**2109-9-24**] Discharge Date: [**2109-9-28**]
Date of Birth: [**2054-12-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
s/p coronary artery bypass grafting x 5 (Left internal mammary
artery grafted to 1st Diagnal/saphenous vein grafted to distal
left anterior descending/posterior descending artery/posterior
left ventricle/ 2 obtuse marginal)on [**2109-9-24**]
History of Present Illness:
Mr. [**Known lastname 5239**] is a 54 year old man who initially presented to the
[**Hospital3 **] ED with chest pain for the past 2 weeks. He
describes it as a band-like burning pressure which does not
radiate. He has it several times per day and it is
non-exertional. On the day of presentation he awoke feeling
unwell. He later was smoking a cigarette and became acutely
diaphoretic, lightheaded and "disoriented" according to the
patient. He decided to come to the ED. He cannot recall if he
was experiencing chest pain during this episode. In the OSH ED,
ECG was sinus bradycardia at [**Street Address(2) 17364**] or T wave changes.
His
Troponin was 1.62 without CK done. He was placed on heparin and
integrilin gtts, and was given aspirin 325mg x 1, plavix 600mg x
1, atorvastatin 80mg x 1. Metoprolol was held due to
bradycardia. He has been having intermittent episodes of the
chest pressure all day, lasting for minutes and self-resolving.
He has some shortness of breath at rest but does not note any
orthopnea. He does not exercise and walks very little. He does
not have
shortness of breath or chest pain on exertion but does notice
calf pain when walking several hundred yards. He underwent
cardiac cath this AM which revealed triple vessel coronary
artery disease and cardiac surgery was consulted.
Past Medical History:
Diabetes mellitus type I
Social History:
Tobacco history: smokes 1ppd x 40 years
ETOH: drinks [**12-15**] glasses of wine twice a week and "too much"
[**Doctor Last Name 17365**] irish cream on a daily basis
Illicit drugs: marijuana occasionally
Works as a property manager. Lives with mother and sister. [**Name (NI) **] a
girlfriend. Previously divorced, has 3 children
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Reports that his mother recently underwent pacemaker insertion
due to syncope.
Physical Exam:
Admission Physical Exam
Pulse: 69 Resp: 18 O2 sat: 100% RA
B/P Right: 110/56 Left:
Height: 66" Weight: 70.9 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]upper dentures, lower teeth poor
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: cath site Left: 2+
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2109-9-24**]
PRE-CPB: 1. The left atrium is normal in size. No spontaneous
echo contrast is seen in the left atrial appendage. No thrombus
is seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 50 %).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen.
7. Mild (1+) mitral regurgitation is seen. Mild posterior MAC is
seen.
POST-CPB: On infusion of phenylephrine, a-pacing. Preserved
biventricular systolic function. Mitral regurgitation remains
1+. Aortic contour normal post decannulation.
[**2109-9-26**] 04:30AM BLOOD WBC-10.9 RBC-2.97* Hgb-9.2* Hct-26.2*
MCV-88 MCH-31.1 MCHC-35.2* RDW-13.2 Plt Ct-173
[**2109-9-26**] 04:30AM BLOOD Glucose-181* UreaN-16 Creat-1.0 Na-133
K-4.5 Cl-101 HCO3-30 AnGap-7*
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2109-9-24**] where the patient underwent coronary
artery bypass grafting x 5 with the left internal mammary artery
to the second diagonal artery and reverse saphenous vein grafts
to the posterior descending artery, posterior left ventricular
branch artery, second obtuse marginal artery, and left anterior
descending artery. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically stable
on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD ___ the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
home with visitng nurse services in good condition with
appropriate follow up instructions.
Medications on Admission:
Lantus 24 units SC BID
Humalog Sliding Scale
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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
11. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
13. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units
Subcutaneous twice a day.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Coronary artery disease
s/p coronary artery bypass grafting x 5 (Left internal mammary
artery grafted to 1st Diagnal/saphenous vein grafted to distal
left anterior descending/posterior descending artery/posterior
left ventricle/ 2 obtuse marginal)on [**2109-9-24**]
-IDDM
-NSTEMI [**2109-9-16**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema-trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**10-16**] at 1pm
Cardiologist: You will need a referral from Dr. [**Last Name (STitle) 17369**] for a
cardiologist
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 17369**] in [**3-18**] weeks [**Telephone/Fax (1) 17368**]
**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:[**2109-9-28**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7975
} | Medical Text: Admission Date: [**2188-5-10**] Discharge Date: [**2188-5-17**]
Date of Birth: [**2129-6-19**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Ibuprofen / Aspirin
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Pericardial effusion/tamponade
Major Surgical or Invasive Procedure:
Insertion of Pericardial drain
Cardiac Catheterization showing lesion in left circumflex artery
History of Present Illness:
The patient is a 58 year old male with a history of "benign"
colonic neoplasm, h/o positive PPD, bronchitis, HTN and
hyperlipidemia who was transferred from [**Hospital 1263**] hospital s/p
tamponade with large pericardial effusion s/p pericardial drain.
Prior to admission, the patient had visited the ER with flu-like
symptoms and placed on Zpack and advair. He also initially
reported noticing a swollen right ankle that was later described
by [**Name8 (MD) **] MD [**First Name (Titles) 3**] [**Last Name (Titles) **] +1 pedal edema. He denies any arthralgias
or rashes. He denies any contact with TB, recent travel or sick
contacts. [**Name (NI) **] admits to having night sweats, chills and a cough
with rusty sputum for the past few weeks with increased
shortness of breath and orthopnea, no chest pain. He denies any
recent weight loss and denies ever having a colonic neoplasm,
benign or malignant, with a recent colonoscopy at [**Hospital 1263**]
hospital 1 month ago. He does admit to having smoked 1 ppd for
5-7 years but quit 20 years ago. He also admits to having been
exposed to asbestos as a former shipyard worker for 10 years 20
years ago.
His first troponin was 0.02 and then 2.8 at [**Doctor Last Name 1263**]. Echo was
positive for tamponade with a negative CT for dissection. On
[**2187-5-9**], underwent pericardiocentesis with 1800 cc fluid
obtained with negative cytology with cell block pending. Opening
wedge was 28 and final wedge 12.
Pericardial fluid:
protein 7.7
LDH 339
WBC 7
Hct 21%
Amylase 63
AFB pending, fungal pending, culture pending, GS pending
EKG [**2188-5-8**]:
Electrical alternans, normal axis. low voltage.
Past Medical History:
Bronchitis
HTN
s/p MVA
Hyperlipidemia
h/o pleural effusion
h/o "benign" colonic neoplasm? -documented by MDs at [**Doctor Last Name 1263**]
where colonoscopy was performed but denied by patient
hemorrhoids
diverticulosis
h/o positive PPD - born in the US, likely exposed as child in
[**State 3908**]
Social History:
The patient works for [**Company 2318**]. He is married. He is a former smoker
having smoked 1 ppd for 5-7 years in the past. He admits to
occasional EtOH. He also admits reluctantly to a history of
cocaine use but will not elaborate. He admits to having tested
for HIV in the past. He was formerly exposed to asbestos as a
former shipyard worker from [**2153**]-[**2163**].
Family History:
Mother - deceased from bone cancer, ?CHF
Father - Alcoholic, deceased at young age from alcoholism
Physical Exam:
P=112 BP=130/94 RR=28 95%
Gen- Mildly anxious, appears upset, AOX3
HEENT - PERLA, EOMI, positive nontender submandibular [**Doctor First Name **] with
palpable, nontender thyroid, no supraclavicular,
anterior/posterior cervical [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3495**] - Regular rate and rhythm, no murmurs/rubs or gallops
Lungs - Clear to auscultation bilaterally
Abdomen - Pericardial drain in place with clean, intact site
with no pus, Soft, no hepatosplenomegaly, active bowel sounds,
nontender/nondistended
Ext - No C/C/E
Pertinent Results:
Echo [**2188-5-11**]:
Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%)
Conclusions:
1. LV function is moderately depressed with an estimated
ejection fraction of
35-40%. There is akinesis of the mid to distal septum. Due to
poor apical
windows, other focal wall motion abnormalities cannot be
excluded.
2. There are no hemodynamically signficant valve abnormalites.
3. There is a small pericardial effusion with some pericardial
thickening.
There is no RV or RA collapse. There is no echo evidence of
cardiac tamponade.
4. The RV appears at least mildly dilated with at least mildly
depressed
systolic function.
CHEST (PORTABLE AP) [**2188-5-10**] 7:02 PM
IMPRESSION: [**Month/Day/Year **] small pleural effusion. Enlarged cardiac
silhouette consistent with the patient's history of pericardial
effusion.
Brief Hospital Course:
The patient is a 58 year old African-American male with a
history of positive PPD, ?colonic neoplasm who presented to
[**Hospital 1263**] hospital with large pericardial effusion s/p
pericardiocentesis on [**2188-5-8**] with pericardial drain transferred
to [**Hospital1 18**] for medical management.
1. Pericardial effusion: He had a pericardial drain in place on
transfer. This was pulled out 1 day after admission when output
had decreased to a minimal amount of serosanguinous fluid. All
cultures of fluid from [**Doctor Last Name **] hospital were negative (AFB,
fungal, aerobic), and cell block/cytology was also negative. He
had multiple repeat echos while in-house to assess for
reaccumulation or change. There was no reaccumulation, and
effusion was trivial at time of discharge. Given that he had a
positive PPD (placed while in-house), sputum was sent x 3 for
AFB smear and was negative. Although the cause of his effusion
was still unclear at time of discharge, it was likely a viral
myocarditis/pericarditis (given malignancy and TB virtually
excluded). Given his positive PPD, the decision was made to
treat with Isoniazid (and vitamin B6) prophylactically). He
will have his LFt's checked monthly through his PCP while on
this therapy. He was also instructed no to drink alcohol while
on this medication.
2. CAD: He was noted to have a depressed EF (to 30-35%) on TTE.
He underwent a ETT-MIBI that showed EF=35% with global HK, no
fixed/reversible defects. The decision was made to take him for
cardiac catheterization (?3vd or other balanced lesions
contributing to global HK). Catheterization showed 70% lesion
of left circumflex. No stent was inserted, for patient had a
?[**Doctor Last Name **] allergy. He was desensitized for [**Doctor Last Name **] prior to discharge
and will return for stenting of left circumflex. He was started
on a beta blocker, ACEI, [**Last Name (LF) 4532**], [**First Name3 (LF) **], lipitor prior to
discharge. Of note, TTE on the day prior to discharge showed an
improved EF of 40%. He never had any anginal symptoms while
in-house.
3. Hypertension: He was on HCTZ on admission. This was stopped,
and he was maintained on ACEI/BB and discharged on these
medications. His bp remained under good control throughout
hospitalization.
4. Tachycardic: He was tachycardic to 100-110's. This
persisted even after removal of the pericardial drain. He was
started on a beta blocker with some improvement in the
tachycardia
6. Dispo: He was discharged after [**First Name3 (LF) **] desensitization and will
return for cardiac catheterization 2-3 days after discharge. He
was instructed about the importance of taking his [**First Name3 (LF) **] and [**First Name3 (LF) 4532**]
daily to avoid in stent thrombosis (and to avoid resensitization
to [**First Name3 (LF) **]).
Medications on Admission:
Meds on Admission:
MVI
HCTZ
ALL:
[**First Name3 (LF) **]-hives/rash
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*
4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
Please check AST, ALT, alkaline phosphatase, total bilirubin
once a month and fax results to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 51132**], fax ([**Telephone/Fax (1) 101287**]
7. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO once a day for
9 months.
Disp:*30 Tablet(s)* Refills:*8*
8. Vitamin B-6 50 mg Tablet Sig: One (1) Tablet PO once a day
for 9 months.
Disp:*30 Tablet(s)* Refills:*8*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Pericardial tamponade/effusion
2. Congestive Heart Failure, EF=30%
Secondary Diagnoses:
1. Hypretension
Discharge Condition:
Good
Discharge Instructions:
1. Please take all your medications as described in this
discharge paperwork. We made the following changes to your
medication regimen.
- We added Toprol XL 100 mg daily, to help with your
heartrate and blood pressure
- We added Lisinopril, a medication to help with your blood
pressure. Please take 10 mg daily
- We stopped your hydrochlorothiazide.
- We added Isoniazid, a medication to be taken for your
possible exposure to tuberculosis. You should take this
medication for 9 months. Do not drink alcohol while on this
medication, for this could cause serious liver damage. In
addition, you should have your liver function tested monthly
while on this medication. You should also take Vitamin B6 daily
while on this medication
- Please take Lipitor, a medication to help lower your
cholesterol, 20 mg daily
- Please take Aspirin 325 mg daily. Also take [**Telephone/Fax (1) **] 75 mg
daily. It is extremely important that you take these
medications every day. If you miss a dose, you risk clotting
off the stents in your heart which could cause death. In
addition, missing aspirin doses may result in becoming allergic
to this medication again.
2. Please follow up with your PCP and cardiology as described
below.
3. Please call your PCP if you are experiencing chest pain,
shortness of breath, fever, chills, lightheadedness, dizziness,
or with any other concerns.
Followup Instructions:
1. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 51132**] ([**Telephone/Fax (1) 89769**])
within 1-2 weeks of discharge. He should check your liver
function tests at this time while you are on Isoniazid and
Lipitor. You will need to get your liver function tested
monthly (results faxed to ([**Telephone/Fax (1) 101288**].
2. Please plan on coming in for your cardiac catheterization on
Monday, [**2188-5-19**], to [**Hospital Ward Name **] 4. Do not eat breakfast on this
morning. Cardiology (Dr. [**Last Name (STitle) 5021**] will call you to schedule
this and confirm date and time.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
ICD9 Codes: 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7976
} | Medical Text: Admission Date: [**2181-11-30**] Discharge Date: [**2181-12-3**]
Service: SURGERY
Allergies:
Gentamicin
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain, jaundice, change in mental status, fevers
Major Surgical or Invasive Procedure:
ERCP [**2181-12-1**]
History of Present Illness:
81 year-old female who is s/p open cholecystectomy on [**2181-11-18**]
who presents from an extended care facility with fevers to 103,
change in mental status, abdomnal pain and jaundice.
On arrival she was unresponsive. A central line was placed in
the ED and volume recussitation was started.
Past Medical History:
PMHx: DM, HTN, Hyperthyroid, Depression, Loss of hearing, s/p
TAH/BSO, s/p L hip
Social History:
At extended care facility. Daughters are healthcare proxy. The
[**Name2 (NI) 64485**] is DNR/DNI.
Family History:
Non-contributory.
Physical Exam:
Temp 100.8 HR 76 BP 101/27
The patient is quite jaundiced. She is minimally reponsiver
withdrawing only to pain.
Lungs are clear, heart is tachy but regular without obvious
murmur.
Abdomen is soft and nondistended with right upper quadrant
tenderness. Incisions are clean and dry.
A foley is inplace and the urine is quite turbid.
Ext. warm, perfused, palpable DP bilaterally.
Pertinent Results:
[**2181-11-30**] 08:21PM LACTATE-2.7*
[**2181-11-30**] 08:10PM GLUCOSE-92 UREA N-78* CREAT-2.6*# SODIUM-148*
POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-24 ANION GAP-16
[**2181-11-30**] 08:10PM CK(CPK)-30
[**2181-11-30**] 08:10PM ALT(SGPT)-487* AST(SGOT)-531* ALK PHOS-1481*
AMYLASE-39 TOT BILI-8.7* DIR BILI-7.8* INDIR BIL-0.9
[**2181-11-30**] 08:10PM LIPASE-41
[**2181-11-30**] 08:10PM CK-MB-NotDone cTropnT-0.01
[**2181-11-30**] 08:10PM ALBUMIN-2.5* CALCIUM-10.7* PHOSPHATE-4.4
MAGNESIUM-1.7
[**2181-11-30**] 08:10PM WBC-16.8* RBC-3.85* HGB-10.2* HCT-31.8*
MCV-83 MCH-26.6* MCHC-32.2 RDW-23.0*
[**2181-11-30**] 08:10PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0-2
[**2181-11-30**] 08:10PM URINE BLOOD-LG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2181-11-30**] 08:10PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
Brief Hospital Course:
The patient was admitted on [**12-1**]. An ERCP was perfored in the
ICU on admission. This procedure required intubation. Consent
for both the intubation and ERCP was obtained from the patient's
daughter (healthcare proxy). ERCP revealed bile without pus in
the biliary tree. There were no filling defects suggestive of
obstruction.
A subsequent CT scan revealed no source of abdomnal pathology
and a diagnosis of urosepsis was made. Over the ensuing 48
hours blood pressure required norepinephrine for support. On
[**12-3**] a meeting was held with the family and and the decision
was made to remove the ETT and stop all pressors.
She expired after withdrawl of support.
Medications on Admission:
lopressor, ASA, heparin, protinix, elavil, atrovent, albuterol,
RISS
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
death
Discharge Condition:
dead
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 0389, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7977
} | Medical Text: Admission Date: [**2194-1-23**] Discharge Date: [**2194-2-5**]
Date of Birth: [**2138-6-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back pain, leg weakness
Major Surgical or Invasive Procedure:
Thoracic instrumented fusion T1-12
History of Present Illness:
HPI: Pt is a 55 yo male w/ PMHx sig for metastatic renal cancer
to the thoracic spine, rheumatoid arthritis who presents as a
transfer from an OSH for leg weakness. The patient was found to
have a renal tumor in [**2190**] s/p resection. In [**6-21**] the patient
was found to have an extradural mass at T5 that was felt to be
metastases. The patient is also known to have a kyphotic
collapse at T10. The patient was seen in Dr.[**Name (NI) 2845**] office
several days ago where it was felt that the patient would need
surgical instrumentation of the thoracic spine for
stabilization.
This was scheduled for the future. In the last couple of days,
the patient has had increased difficulty walking and numbness in
his legs. He was seen at an OSH and then transferred to [**Hospital1 18**]
for further evaluation.
Pt denies headache, vertigo, tinnitus, hearing loss, dysarthria,
dysphagia, visual changes, shortness of breath, chest pain,
abdominal pain, joint pain, bleeding, nausea, vomiting, fevers,
chills, night sweats, bowel/bladder incontinence, rash
: deferred
Past Medical History:
Past Medical History: rheumatoid arthritis x 20 years, renal ca
s/p nephrectomy, metastatic spine disease
Social History:
Social History: Lives with a friend and his wife. 2 ppd x
30-40
years. Recovering alcoholic. Past history of drug abuse, clean
for last two years.
Family History:
Family History: father deceased at 63 yo of heart disease.
Physical Exam:
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: radial deviation of MCP joints of both hands.
Neurological Exam:
Mental status: A & O x3, relays coherent history. Fluent speech
with no paraphasic or phonemic errors. Adequate comprehension.
Follows simple and multi-step commands. Repetition intact (no
ifs, ands or buts). Able to name low and high frequency
objects.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light. VFF.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**5-19**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift.
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB
C5 C7 C6 C8 L2 L3 L4-S1 L4 L5 L5
RT: 5 5 5 5 5 5 5 3 5 3- 4 5 4 4
LEFT: 5 5 5 5 5 5 5 4+ 5 4+ 5 5 4+ 5
Sensation: Decreased pinprick from ~ T10 to R thigh but intact
to
pinprick on left. Impaired proprioception large movements at
the
ankle, decreased vibration in toes.
Reflexes: Bic T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes upgoing bilaterally.
Coordination: FNF intact.
Gait: deferred
Pertinent Results:
[**2194-1-24**] 07:00AM BLOOD WBC-8.0 RBC-4.64 Hgb-11.2* Hct-34.0*
MCV-73* MCH-24.2* MCHC-33.1 RDW-13.8 Plt Ct-296
[**2194-2-3**] 05:35AM BLOOD Hct-26.1*
[**2194-2-1**] 08:49AM BLOOD PT-13.5* PTT-45.8* INR(PT)-1.2*
[**2194-2-1**] 02:04AM BLOOD Glucose-146* UreaN-27* Creat-0.7 Na-131*
K-4.5 Cl-101 HCO3-26 AnGap-9
[**2194-2-1**] 02:04AM BLOOD Calcium-7.7* Phos-2.1* Mg-1.9
CT [**2194-1-22**]: IMPRESSION: Enhancing lytic mass involving the left
posterior elements of T5 with left lateral epidural extension
and near complete extension into the left T4/5 foramen.
Severe destructive changes of the T9 vertebral body and the T10
vertebral body with focal kyphosis measuring approximately 50
degrees. Approximately 2-cm anterior spondylolisthesis of T8 on
T10. This is causing severe canal stenosis and likely
compression of the cord.
High-density material seen within and around the destroyed T9
vertebral body and right posterior elements with some
well-circumscribed bony defects of the T9 body on the left.
These findings likely represent prior corpectomy with graft
material or polymethylmethacrylate placement. The lytic lesions
causing the bony destructive changes at these levels likely
represent metastases given the prior right nephrectomy.
Differential diagnostic possibility would also include myeloma.
Mild anterior wedge deformity of the T11 vertebral body.
Brief Hospital Course:
Pt was admitted to the hospital for increasing leg weakness and
pain. He had pain management and was readied for the OR. On
[**2194-1-28**] he went to Or where under general anesthesia he
underwent thoracic instrumented fusion T1-12. H etolerated this
procedure well, was kept intubated and transferred to ICU post
op for close monitoring. He was extubated on POD#1. He required
PCA pain management. He had 2 JP drains placed intraop and
output was followed closely along with hematocrit. The first
drain was removed [**2194-1-31**] and second [**2194-2-1**] without any
difficulties. He was then transferred to the floor. Diet and
activity were advanced. he pain was well controlled. His leg
strength improved. He was evaluated by PT. On discharge he was
noted to have some serosangous drainage from his wound no
redness, fluid collection or edema. His staples should stay in
an additional 7 days.
Medications on Admission:
Medications: Celexa 20 mg PO DAILY, Methadone 50 mg/50 mg/20 mg,
Cyclobenzaprine, Dilaudid 4 mg PO DAILY.
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Methadone 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
7. Methadone 10 mg Tablet Sig: Five (5) Tablet PO Q 6 AM AND Q 6
PM ().
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
14. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) for 2 days.
15. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours) for 2 days.
16. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily)
for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Renal cell carcinoma metastatic to thoracic spine
Discharge Condition:
Neurologically improved
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ change dressing daily / take daily showers
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed
at your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
Have your staples removed at rehab on [**2194-2-12**].
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT
Completed by:[**2194-2-5**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7978
} | Medical Text: Admission Date: [**2190-4-20**] Discharge Date: [**2190-5-6**]
Date of Birth: [**2154-7-21**] Sex: M
Service: Transplant
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 35-year-old
male with a history of diabetes times 30 years who had an
unrelated living kidney transplant two years prior and now
presents for a pancreas transplant.
One year prior he had received a pancreas transplant which,
secondary to arterial thrombosis, had to be removed on the
day of the operation.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Insulin-dependent diabetes mellitus.
2. Hypertension.
3. End-stage renal disease.
4. History of hepatitis A.
5. Seizure disorder.
PAST SURGICAL HISTORY:
1. Status post renal transplant two years ago.
2. Status post pancreas transplant one year ago.
3. Status post removal of pancreas transplant.
4. Status post open kidney biopsy.
MEDICATIONS ON ADMISSION: (Medications on admission
included)
1. Neoral 150 mg p.o. twice per day.
2. CellCept 1 g p.o. twice per day.
3. Prednisone 10 mg p.o. once per day.
4. Dilantin 200 mg p.o. twice per day.
5. Diltiazem 240 mg p.o. once per day
6. Phenobarbital 30 mg p.o. three times per day.
7. Pepcid 20 mg p.o. once per day.
8. Lasix 40 mg to 80 mg p.o. once per day.
9. Atenolol 50 mg p.o. once per day.
10. Celexa 10 mg p.o. once per day.
ALLERGIES: Allergy to CODEINE (which causes nausea and
vomiting).
SOCIAL HISTORY: The patient has smoked one and a half pack
of cigarettes per day. The patient does not use ethanol, and
denies any illicit drug use.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, the
patient was afebrile. Vital signs were unchanged and stable.
He was comfortable. Pupils were equal, round, and reactive
to light. The oropharynx was clear with no lesions. The
neck was supple. No lymphadenopathy or bruits. The chest
was clear to auscultation bilaterally. The heart was
regular. The abdomen was soft and nontender with well-healed
surgical scars; one midline and one in the right lower
quadrant. His extremities had no edema. Dorsalis pedis and
posterior tibialis pulses were palpable.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission included a hematocrit of 39.7 and platelets of 327.
INR was 0.9. Blood urea nitrogen was 28 and creatinine was
1.3. All other laboratories were within normal limits.
Glucose was 158 on admission. Urinalysis was negative.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no
infiltrate or congestive heart failure.
Electrocardiogram revealed a normal sinus rhythm with no
ischemia.
HOSPITAL COURSE: On the day of admission, the patient was
taken to the operating room where he underwent a pancreas
transplant. He received all of the appropriate
immunosuppression and antibiotic prophylaxis prior to going
to the operating room. He also received intravenous
immunoglobulin 30 mg intravenously in the operating room. He
tolerated the procedure well. There was 600 cc estimated
blood loss and 10,000 cc of crystalloid provided.
Postoperatively, he remained stable. He was transferred to
the Postanesthesia Care Unit extubated. His early glucose
control was excellent with blood sugars ranging from 99 to
110. He was then transferred to the floor for the remainder
of his recovery.
The patient's early postoperative course early on was
uncomplicated. He received a steroid taper as per protocol.
He began his immunosuppression and was receiving intravenous
immunoglobulin per protocol. He was also maintained on
intravenous heparin early postoperatively, and his glucose
was under good control.
On postoperative day three, the patient's hematocrit was 26
and he was transfused one units of packed red blood cells.
By postoperative day seven, the patient's diet had been
advanced. He was ambulating. He did complain of some mild
left abdominal pain but reported flatus and had a bowel
movement. Also, he continued to have good glycemic control.
On postoperative day eight, he continued to have this
abdominal pain. A computerized axial tomography was ordered
to rule out an abscess. There was some free fluid in the
pelvis, and evaluation by the Interventional Radiology
Service felt they could not access this percutaneously. The
patient was stated on Unasyn empirically as well. The pain
continued to worsen. The patient underwent an ultrasound
study of the graft which showed good arteriovenous flow. The
patient then became hyperglycemic over the next 24 hours with
a high of 403.
The decision was made to take the patient to the operating
room for a exploratory laparotomy and washout. In the
operating room there was no evidence of any abscess. The
graft appeared viable with no evidence of necrosis. The
patient was washed out with copious amounts of antibiotic
irrigation and was transferred to the Postanesthesia Care
Unit in stable condition.
Following this procedure, the patient remained stable. He
continued to complain of some pain which was now more in the
epigastric region. A computed tomography angiogram was
performed of the chest to rule out a pulmonary embolus, and
this was negative. The patient's diet was then slowly
advanced. He continued to have occasional glucose levels
that were elevated, but this was covered with subcutaneous
insulin. He continued to improve. His abdominal improved.
His diet was advanced. He was ambulating and was stable for
discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2190-5-6**] 11:40
T: [**2190-5-6**] 17:42
JOB#: [**Job Number 35894**]
ICD9 Codes: 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7979
} | Medical Text: Admission Date: [**2120-7-24**] Discharge Date: [**2120-8-2**]
Date of Birth: [**2058-8-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
recurrant adenoCA of the lung
Major Surgical or Invasive Procedure:
thoracotomy for right lower lobectomy
History of Present Illness:
Mr. [**Known lastname 7011**] is a very pleasant 61-year-old gentleman with a prior
history of stage IIIB carcinoma of the left upper lobe diagnosed
by Dr. [**Last Name (STitle) 20042**] in the
remote past and treated with chemoradiotherapy. He was recently
also diagnosed with CLL and then was found to have a second lung
primary in [**2117**], treated with video-assisted local resection.
This was found to be an adenocarcinoma. A followup shows
increasing infiltrative appearance of the right lower lobe,
prompting a bronchoscopy done earlier this month, which
unfortunately confirms recurrent adenocarcinoma. The patient
notes somewhat worsening dyspnea on exertion.
Past Medical History:
coronary artery
disease, status post CABG in [**2115-11-15**]; inguinal hernia
repair; some degree of obstructive lung disease; non-small cell
cancer as above; and emphysema.
Social History:
previous smoker
Family History:
noncontributory
Physical Exam:
His weight is 156.6 pounds, pulse 52 and regular, blood pressure
103/69, and his room air saturation is 94%.
HEENT: He has no scleral icterus.
LYMPHATICS: There is no palpable cervical or supraclavicular
adenopathy.
CHEST: Breath sounds are diminished at the right base, and air
entry is otherwise equivalent here. He has a well-healed
sternotomy as well as VATS incisions on the right chest.
HEART: Regular rhythm and rate without a murmur or gallop.
EXTREMITIES: He has no peripheral cyanosis, clubbing, or edema.
Pertinent Results:
[**2120-8-1**] 10:30AM BLOOD WBC-27.2* RBC-3.76* Hgb-11.6* Hct-34.7*
MCV-92 MCH-30.9 MCHC-33.5 RDW-15.1 Plt Ct-353
[**2120-7-30**] 07:55AM BLOOD Glucose-117* UreaN-20 Creat-0.8 Na-138
K-4.2 Cl-101 HCO3-27 AnGap-14
Brief Hospital Course:
Patient was taken to the OR on [**2120-7-24**] for bronchoscopy,
mediastinoscopy, and thoracotomy for RLL lobectomy. Frozen
section of mediastinal LN were negative for lung CA but CLL
involvement could not be ruled out. In the PACU, Neo was
required to maintain blood pressure and the patient was admitted
to the SICU post-op. Urine output was good, but blood pressure
did not improve despite several fluid boluses. Epidural d/c'd in
PACU as it was not working. Pain controlled with Dilaudid PCA.
POD 2 Levofloxacin added for ?PNA on CXR. Neo still necessary to
maintain BP on POD 2. Cortisol stim test was negative.
Transfused 1U PRBC on POD 3 for a HCT which was steadily
trending down, and again 1U PRBC on POD4. Mitodine started POD5
and Neo gtt could be stopped. Patient was transfered to floor
on POD 5. Episode of rapid AFib late POD 4, controlled with
metoprolol. CT #2 also d/c'd on POD5. CT #1 d/c'd POD6,
post-pull CXR showed substantial PTX. New CT placed POD 6 with
poor placement (along diaphragm). CT replaced on POD 7. Late
POD 7, patient again in rapid AFib, did not convert with
lopressor, Amiodorone started. CT water sealed POD 8 able to d/c
O2. CT d/c'd on POD 9, post-pull CXR showed very small R apical
PTX and R pleural effusion. Pt discharged home on POD 9 with a
total of 14 days Levoquin and PO amiodorone.
Medications on Admission:
Altace 10mg po daily
Lipitor 10mg po daily
Atenolol 25 mg po daily
ASA 81 mg po daily.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*120 Tablet(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day): Take 2 tablets 3 times a day until [**8-5**]. Then take 2
tablets 2 times a day until [**8-12**]. Then take 2 tables once a day
until seen in clinic.
Disp:*60 Tablet(s)* Refills:*1*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Bronchioalveolar carcinoma, s/p Right lower lobectomy
Discharge Condition:
good
Discharge Instructions:
Amiodorone 400mg TID until [**8-5**], 400mg [**Hospital1 **] [**Date range (1) 20043**], 400mg qday
until seen in clinic.
Call Dr.[**Doctor Last Name 4738**] office for: fever, shortness of breath, chest
pain, drainage from incision site. You may remove the dressing
Sunday morning then you may shower. No tub baths or swimming for
3-4 weeks.
You may keep the chest tube sites covered with small dressings
as needed.
Do not remove small strips on incision site, let them fall off.
No lifting more than 5 pound for 2 weeks, them as per lung
surgery booklet.
Restart regular medicine as previous except hold Atenolol &
Altace until seen by Dr. [**Last Name (STitle) **].
Take new medication as directed for pain. No driving if taking
narcotic medication. Can transition to tylenol when able
Followup Instructions:
Call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 170**] for a follow up
appointment in [**9-27**] days. You will need to arrive 45 minutes
prior to your appointment and report to [**Location (un) **] [**Hospital Ward Name 23**]
Clinical center radiology for a chest XRAY.
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7980
} | Medical Text: Admission Date: [**2197-6-5**] Discharge Date: [**2197-6-14**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Positive ETT
Major Surgical or Invasive Procedure:
[**2197-6-7**] Three Vessel Coronary Artery Bypass Grafting(LIMA to LAD
with vein grafts to Ramus and PLV) and Aortic Valve Replacement
utilizing a 23 millimeter CE pericardial tissue valve.
History of Present Illness:
Mr. [**Known lastname 1683**] is a pleasant 82 year old gentleman with known
coronary artery disease, prior MI and PCI in the past. An ETT in
[**2197-5-22**] depressions but negative for
chest pain. Nuclear imaging showed a dilated LV with an ejection
fraction of 24%. There was a large inferior and inferolateral
fixed defect with a large reversible apical defect. Based upon
the above results, he was referred for repeat cardiac
catheterization. On admission, he denied chest pain, SOB,
fatigue, syncope, palpitations and pedal edema. He reported one
episode of dizziness which lasted only several seconds
approximately one week prior to this admission.
Past Medical History:
Ischemic Cardiomyopathy, EF 24%
CAD and AS
History of MI and RCA stent [**2188**]
Hyperlipidemia
HTN
BPH
Prior Hernia repairs
Social History:
Married with 3 children. He denies tobacco and excessive ETOH.
Family History:
Denies premature CAD.
Physical Exam:
Vitals: BP 127/76, HR 75, RR 14, SAT 97%on room air
General: well developed elderly male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, 3/6 systolic murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: alert and oriented, nonfocal
Pertinent Results:
[**2197-6-5**] 11:20AM BLOOD WBC-8.4 RBC-4.24* Hgb-13.0* Hct-38.1*
MCV-90 MCH-30.6 MCHC-34.0 RDW-12.7 Plt Ct-234
[**2197-6-5**] 11:20AM BLOOD PT-15.5* PTT-65.0* INR(PT)-1.4*
[**2197-6-5**] 11:20AM BLOOD Glucose-174* UreaN-12 Creat-0.9 Na-134
K-3.9 Cl-102 HCO3-22 AnGap-14
[**2197-6-5**] 11:20AM BLOOD ALT-14 AST-24 CK(CPK)-71 AlkPhos-61
Amylase-81 TotBili-0.8
[**2197-6-5**] 11:20AM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE
[**2197-6-13**] 07:10AM BLOOD Hct-36.9*
[**2197-6-11**] 04:55AM BLOOD WBC-13.4* RBC-3.90*# Hgb-11.9* Hct-34.0*
MCV-87 MCH-30.6 MCHC-35.1* RDW-14.4 Plt Ct-108*#
[**2197-6-13**] 07:10AM BLOOD UreaN-23* Creat-1.3* K-3.9
[**2197-6-11**] 04:55AM BLOOD Glucose-104 UreaN-21* Creat-1.0 Na-133
K-3.7 Cl-95* HCO3-26 AnGap-16
[**2197-6-10**] 08:53AM BLOOD HEPARIN DEPENDENT ANTIBODIES- negative
Brief Hospital Course:
Mr. [**Known lastname 1683**] was admitted and underwent cardiac catheterization
which was significant for severe three vessel coronary artery,
including left main disease, and severe ischemic cardiomyopathy.
Coronary angiography demonstrated a right dominant system with
an 80% left main lesion; 60% mid LAD stenosis; diffuse diagonal
disease; 85% lesion in the first OM; and 95% PLV stenosis. The
RCA stents were widely patent. Left ventriculography showed an
LVEF of 25% and no mitral regurgitation. Angiography was also
notable for a self limited retrograde dissection of the commom
iliac artery which required no intervention. Based on the above
results, cardiac surgery was consulted for surgical
revascularization and further evaluation was performed. An
echocardiogram showed moderate to severe aortic stenosis with [**First Name8 (NamePattern2) **]
[**Location (un) 109**] of 0.7cm2 with peak and mean gradients of 35 and 19 mmHg
respectively. The LVEF was estimated between 35-40%. A carotid
ultrasound demonstrated minimal disease of both internal carotid
arteries. The rest of his preoperative hospital course was
unremarkable except for occasional runs of asymptomatic NSVT. He
remained pain free on medical therapy. On [**6-7**], Dr. [**Last Name (STitle) **]
performed three vessel coronary artery bypass grafting and a
pericardial aortic valve replacement. Following the operation,
he was brought to the CSRU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated.
Initially hypoxic, required steady diuresis. He maintained
stable hemodynamics and was gradually weaned from inotropic
support. He was intermittently transfused with PRBC to keep
hematocrit near 30%. Amiodarone was initially utilized to
prevent atrial arrhythmias. His CSRU course was otherwise
uneventful and he transferred to the SDU on postoperative day
three. His platelet count dropped as low as 70K. HIT assays were
checked and negative for heparin PF4 antibodies. Throughout his
hospital stay, he remained thrombocytopenic but his platelet
count did improve prior to discharge. He experienced some
urinary retention for which he was started on Flomax. Prior to
discharge, his foley was *****. His postoperative course was
otherwise uneventful. He continued to maintain stable
hemodynamics and remained in a normal sinus rhythm. Given no
occurence of atrial arrhythmias, Amiodarone was eventually
discontinued. Given his depressed LV function, he was maintained
on Coreg, Captopril and diuretics. He tolerated medical therapy.
Due to continued clinical improvements, he was cleared for
discharge on postoperative day 7. He had a 400cc residual and
had a foley catheter placed prior to d/c. He will follow up
with Dr. [**Last Name (STitle) 770**] of urology in 1 week for foley removal.
Medications on Admission:
Zocor 40qd, Captopril 25 qd, Terazosin 5 qd, Aspirin 325 qd,
MVI, Vit E, Vit C
Discharge Medications:
1. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*60 Cap(s)* Refills:*2*
5. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 MDI* Refills:*2*
12. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 14
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD and AS - s/p CABG and AVR
History of MI and RCA stent [**2188**]
Hyperlipidemia
HTN
BPH
Right Iliac Dissection
Prior Hernia repairs
NSVT
Urinary Retention
Thrombocytopenia
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) **], cardiac surgeon in [**4-26**] weeks
Dr. [**Last Name (STitle) 6700**], PCP [**Last Name (NamePattern4) **] [**2-24**] weeks
Dr. [**Last Name (STitle) **], cardiologist in [**2-24**] weeks
[**Hospital Ward Name 121**] 2 in 2 weeks for wound check
Completed by:[**2197-6-14**]
ICD9 Codes: 4241, 2875, 2724, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7981
} | Medical Text: Admission Date: [**2101-2-25**] Discharge Date: [**2101-3-4**]
Date of Birth: [**2045-11-1**] Sex: F
Service: MEDICINE
Allergies:
Latex Exam Gloves
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Hyperglycemia, back pain
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Ms. [**Known lastname **] is a 55 yo F w/PMHx sx for autoimmune hepatitis on
chronic prednisone, IDDM, CAD, seizure d/o, hypertension,
asthma, hx RCC, and ET who presents with hyperglycemia.
.
Patient recently admitted to [**Hospital1 18**] from [**Date range (1) 65044**] with URI and
asthma exacerbation and received nebulizers and steroids. Her
fingersticks during that admission were in the 200-300s. She had
multiple episodes of chest pain while hospitalized, with
negative workup for ischemia, with episodes relieved by
oxycodone. She improved her peak flows to 300 and was
subsequently discharged. At home, patient fell on her back [**2-11**]
dizziness thought to be from diarrhea and vomiting, with assoc
subjective fevers and chills. SHe was then seen at [**Hospital1 65045**] in [**Location (un) 260**] MA where she was admitted from
[**Date range (1) 65046**], and given the diagnosis of an L1 compression fracture.
She was taken off her prednisone during this admission per her
report, and was sent home without pain medications. Today, she
presented to [**Company 191**] complaining of [**10-19**] lower back pain. Patient
was also sent home on 65u lantus qhs, decreased from her
baseline of 100u qhs. Patient's BS at home have ranged from
300s-500s. She also notes urinary incontinence, which is her
baseline from her early 40s, but denies stool incontinence. She
also notes numbness, tingling and weakness of her legs. She
states that her back pain is relieved only by muscle relaxants
and narcotics. Pt also notes polyuria, polydipsia, and extreme
thirst. She also notes dizziness on standing. She denies
dysuria. She does admit to diffuse abdominal pain, occasional
difficulty breathing. She denies chest pain. Pt's baseline BS
per her report are in the 200s.
.
In the ED patient was found to have blood sugars in the 400s.
Patient was also found to have an anion gap of 15, with trace
ketones in the urine. Patient's EKG showed old ST depressions in
V1-V3 with TWI< unchanged from prior. Her UA was negative for
infection. Her CXR was unremarkable as well. She was admitted
for management of her blood sugars.
.
ROS: Positive for polyuria, polydipsia, abd pain, fevers,
chills, thirst, shortness of breath, abdominal pain, urinary
frequency. Negative for headache and dysuria, or fecal
incontinence.
Past Medical History:
1. Autoimmune hepatitis diagnosed in [**2098**], cirrhosis diagnosed
in [**4-/2099**]: h/o encephalopathy, ascites, jaundice
2. DM
3. Asthma
4. Coronary artery disease s/p MI [**2097**]
5. Epilepsy [**2-11**] to being hit by a car at age 5. Was on
phenobarb and dilantin for most of life, but self d/c'd these
meds approx. 7 years ago and has been seizure free since then.
6. HTN
7. Renal cell cancer
8. Psoriasis
9. s/p cholecystectomy in [**2099**]
10. s/p hysterectomy and b/l oophorectomy
11. Right ankle surgery.
12. Depression
13. Anxiety
14. Recurrent UTIs
15. Thrombocytosis
Social History:
Lives in [**Location 260**], Mass. alone. Recently moved back to area
from [**State 33977**] 9/[**2099**]. 3 children live locally. Denies EtOH or
other illicit drug use. Has extensive tobacco hx, approx.
60-70pack year, but quit several years ago. Not currently
working as she is on disability [**2-11**] to her health. Her son works
as her HHA (she pays him)
Family History:
Mother deceased, SLE.
.
Father deceased, gastric ca.
Physical Exam:
Vitals: T 98.3 BP 138/70 HR 69 RR 20 96RA
GEn: well-appearing, NAD
HEENT: OP clear
Neck: supple
Lung: CTA bilaterally
Cor: RRR, nml S1S2
Abd: obese, diffusely tender, no rebound or guarding
Ext: no edema, decreased sensation
Pertinent Results:
[**2101-2-25**] 06:50PM WBC-10.5 RBC-4.42 HGB-14.5 HCT-42.5 MCV-96
MCH-32.8* MCHC-34.1 RDW-15.4
[**2101-2-25**] 06:50PM NEUTS-83.6* BANDS-0 LYMPHS-11.0* MONOS-3.2
EOS-0.1 BASOS-2.1*
[**2101-2-25**] 06:50PM PLT SMR-VERY HIGH PLT COUNT-808*
[**2101-2-25**] 06:50PM GLUCOSE-446* UREA N-37* CREAT-0.9 SODIUM-135
POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-19*
[**2101-2-25**] 06:50PM ALT(SGPT)-32 AST(SGOT)-30 LD(LDH)-354*
CK(CPK)-20* ALK PHOS-52 TOT BILI-0.6
[**2101-2-25**] 06:50PM CK-MB-NotDone cTropnT-<0.01
[**Month/Day/Year 4338**] L-spine: L1 compression fracture with mild retropulsion of
bone fragments posteriorly resulting in moderate spinal canal
narrowing. There is also an epidural hematoma, which travels
inferiorly from this level and terminates posterior to L2. There
is no further spinal canal narrowing due to this epidural
hematoma.
CT C-spine:
1. No cervical spine fracture or malalignment.
2. Very mild degenerative changes as noted above.
3. Atherosclerotic calcification at the right carotid artery
bifurcation.
T/L- spine xray: Anterior wedge compression fracture of the L1
vertebral body, grossly unchanged in appearance compared to the
CT scan of two days prior
Brief Hospital Course:
1) Hyperglycemia:
Patient with blood sugars in the 400-500s initially, with anion
gap metabolic acidosis. Patient with type 2 DM, so unlikely to
be DKA, but does have evidence of ketones in urine, likely [**2-11**]
starvation. Blood sugars not as elevated as would be expected in
HHNS, and no signs of renal failure or severe dehydration.
Likely etiology of hyperglycemia is insulin deficiency from
change in insulin regimen at OSH. BS on arrival normalized to
200s. No clear infection. She was initially placed on insulin
gtt and then transitioned to lantus and humalog with SS. On
this regimen, her blood sugars were improved in 100-200s though
not perfectly controlled.
.
2) Altered mental status:
Likely due to hyperglycemia. REsolved.
.
3) Low back pain:
Patient diagnosed with L1 fracture at OSH, no records here.
Likely [**2-11**] compression fracture from chronic steroid use. Due
to question of weakness on exam, [**Month/Day (2) 4338**] L-spine obtained which
showed L1 fracture with retropulsion of fragments into spinal
canal and hematoma. Neurosurgery was consulted and recommended
conservative management given many comorbities. She was placed
in a TLSO brace which she needs to have on any time her head is
greater than 30 degreess or upright.
.
4) Autoimmune hepatitis:
LFTs stable. Continued on prednisone and imuran.
.
5) Asthma. Continue Montelukast, combivent.
.
6) Hx seizures.:
Continued on keppra.
.
7) HTN.
-continued propanolol, aldactone.
.
8) CAD:
Stable, continued on outpt regimen.
Medications on Admission:
Keppra 750 mg [**Hospital1 **]
Singulair 10 mg qd
Imuran 100 mg qAM
Lexapro 20 mg qd
Omeprazole 40 mg qd
Montelukast 10 mg qd
Novolog 20/30/30
Lantus 100 qhs
Propranolol 40 mg [**Hospital1 **]
Aldactone 25 mg [**Hospital1 **]
Oxycodone prn
Prednisone 20 mg qd
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal
QID (4 times a day) as needed.
13. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for pain.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
20. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-11**]
Puffs Inhalation Q6H (every 6 hours).
21. Lantus 100 unit/mL Solution Sig: One Hundred Four (104)
units Subcutaneous at bedtime.
22. Humalog 100 unit/mL Solution Sig: Twenty Two (22) units
Subcutaneous before breakfast.
23. Humalog 100 unit/mL Solution Sig: Thirty Two (32) units
Subcutaneous before lunch, dinner.
24. Humalog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous QACHS.
25. Cepacol 5.4 mg Lozenge Sig: One (1) loz Mucous membrane four
times a day as needed for cough for 1 weeks.
26. Robitussin-DM 10-100 mg/5 mL Syrup Sig: One (1) teaspoon PO
four times a day as needed for cough for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
L1 Vertebral fracture
Hyperglycemia
Diabetes, type 2 uncontrolled
Autoimmune hepatitis.
Discharge Condition:
Good.
Discharge Instructions:
Take medications as prescribed.
You need the TLSO brace on anytime the head of bed is greater
than 30 degrees or you are out of bed.
Please call Dr. [**Last Name (STitle) **] with any fevers, worsening back pain, new
weakness or numbness.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] (neurosurgery) at ([**Telephone/Fax (1) 88**] to
see when you have an appointment set up. His office is already
instructed to set up an appointment in [**4-15**] weeks and you will
need an xray of the spine at that time, but you should call to
find out the date.
Please follow up with Dr. [**Last Name (STitle) **] once you leave rehab.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2101-3-10**] 11:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 3294**]
Date/Time:[**2101-3-14**] 10:00
ICD9 Codes: 5715, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7982
} | Medical Text: Admission Date: [**2176-11-26**] Discharge Date: [**2176-12-3**]
Date of Birth: [**2126-1-28**] Sex: M
Service: SURGERY
Allergies:
Lactose
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
S/P MVC
abdominal pain
Major Surgical or Invasive Procedure:
[**2176-11-26**]
1. Diagnostic laparoscopy.
2. Exploratory laparotomy.
3. Control of liver hemorrhage.
4. Ileocecectomy with primary ileocolic anastomosis.
History of Present Illness:
Mr. [**Known lastname **] is a 50 year old male who was the restrained
passenger in
an MVC today. He has a history of Down's syndrome and was
agitated and grabbed the driver of a [**Doctor Last Name **] resulting in a
motor vehicle collision. He was brought to [**Location (un) 620**] where he
was noted to be hypotensive and complaining of abdominal
pain. FAST was negative. Non-contrast CT scans of the head,
C-spine, and torso revealed only a small amount of fluid in
the right paracolic gutter. He was transferred to [**Hospital 61**] for further evaluation. Currently he reports some
abdominal pain. I spoke with the manager of his group home
who reports that he has been feeling well lately and has had
no other complaints. Of note, he was given IV antibiotics at
[**Location (un) 620**] to cover for a possible infectious source as a cause
of his agitation and hypotension. He also received 3 L of IV
fluid there. Blood pressure was in the 60s to 70s for EMS.
Past Medical History:
Down's syndrome
hypercholesterolemia
hypothyroidism
pernicious anemia
intermittent explosive disorder
senile dementia
heart murmur requiring antibiotic ppx prior to dental procedures
Social History:
He lives in a group home ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]). No etoh or tobacco.
Family History:
Unknown.
Physical Exam:
Temp:97.3 HR:52 BP:79/40 Resp:20 O(2)Sat:100
Constitutional: Awake and alert
HEENT: Has some facial bruising, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft. Left flank ecchymoses. Diffuse mild
tenderness to palpation without rebound or
Pelvic: Normal tone no gross blood. Pelvis is stable
Extr/Back: No TLS tenderness to palpation
Neuro: Awake and alert. Moves all extremities. No focal
deficit. Sensation intact. Follows commands
Pertinent Results:
[**2176-11-26**] 01:10PM WBC-7.0# RBC-3.06* HGB-10.8*# HCT-32.4*
MCV-106* MCH-35.2* MCHC-33.2 RDW-13.4
[**2176-11-26**] 01:10PM NEUTS-88.5* LYMPHS-8.4* MONOS-2.4 EOS-0.2
BASOS-0.4
[**2176-11-26**] 01:10PM PLT COUNT-231
[**2176-11-26**] 01:10PM PT-13.7* PTT-22.7 INR(PT)-1.2*
[**2176-11-26**] 01:10PM ALT(SGPT)-49* AST(SGOT)-63* CK(CPK)-186 ALK
PHOS-116 TOT BILI-0.3
[**2176-11-26**] 01:10PM LIPASE-29
[**2176-11-26**] 01:10PM GLUCOSE-95 UREA N-17 CREAT-0.9 SODIUM-142
POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-22 ANION GAP-13
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2176-12-3**] 06:35 3.4* 3.54* 10.9* 32.2* 91 30.7 33.7 20.2*
151
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2176-11-26**] 13:10 88.5* 8.4* 2.4 0.2 0.4
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2176-12-3**] 06:35 151
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2176-11-27**] 00:49 184
Source: Line-aline
LAB USE ONLY
[**2176-12-3**] 06:35
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2176-12-3**] 06:35 113*1 12 0.7 137 3.0* 102 30 8
[**2176-11-26**] CT Abd : 1. Focal ileocolic stranding and focal cecal
wall thickening suggestive of mesenteric hematoma and focal
bowel wall contusion, respectively. Trace amount of
hemoperitoneum.
2. Acute fractures of the right posterior ribs 10 and 11.
3. Bilateral dependent consolidations and ground-glass
opacities, likely
atelectasis, although superimposed aspiration not excluded.
4. No other traumatic injury to the torso.
[**2176-11-26**] TTE :
Suboptimal image quality. Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
No pericardial effusion. Mild-moderate tricuspid regurgitation
[**2176-11-27**] MRI C spine :
1. There is no evidence of ligamentous disruption identified or
prevertebral soft tissue abnormality seen. No evidence of
intraspinal hematoma, cord compression, or abnormal signal
within the spinal cord.
2. Degenerative changes at the atlanto-odontoid joint and the
remaining
cervical spine as described above.
Brief Hospital Course:
Mr. [**Known lastname **] was evaluated by the Trauma team in the Emergency
Room and taken to the Operating Room emergently for a diagnostic
laparotomy followed by exploratory laparotomy ( see formal Op
note for details). He tolerated the procedure relatively well
and returned to the Trauma ICU in stable condition with a stable
hematocrit following transfusion of 3 units of packed red blood
cells.
Post op in the ICU he had persistent problems with hypotension
despite adequate resuscitation and eventually was treated with
steroids for adrenal insufficiency which immediately normalized
his blood pressure and his pressors were weaned off. He was
weaned and extubated from the respirator on post op day 2 and
was able to deep breath and cough without difficulty thereafter.
Following transfer to the Surgical floor he continued to make
steady progress. His surgical wound was healing well without
evidence of erythema or drainage and he was gradually tolerating
a regular diet after his bowel function resumed. He did require
2 more blood transfusions as his hematocrit drifted down on
[**2176-12-1**] without evidence of active bleeding. Prior to discharge
his hematocrit was 32. His steroids were tapered off ending on
[**2176-12-3**] and his blood pressure ranged between 100-110/70.
[**Known firstname **] was also evaluated by the Physical Therapy service and they
recommended a short term rehab prior to his return home in order
to improve his gait and activity tolerance. After a relatively
uncomplicated stay he was discharged to rehab on [**2176-12-3**].
Medications on Admission:
Gemfibrozil 600 mg [**Hospital1 **]
Hydrocortisone 2.5% ointment topically as directed
Lactaid 4500 units daily
Levothyroxine 88 mcg daily
MVI 1 tab daily
Neurontin 400 mg TID
Peridex 0.12% as directed [**Hospital1 **]
Robitussin DN 2 tsp QID prn
TUMS 500 mg [**Hospital1 **]
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
1. Avulsion of small bowel mesentery.
2. Injury to cecum.
3. Liver laceration.
4. Acute blood loss anemia
5. Adrenal insufficiency
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent at baseline
Discharge Instructions:
* You were admitted to the hopsital with internal injuries to
your abdomen following your car accident which required an
operation.
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 in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-10**] lbs until you follow-up with your
surgeon.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**3-6**] weeks.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2176-12-13**] 1:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2176-12-3**]
ICD9 Codes: 2851, 2762, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7983
} | Medical Text: Admission Date: [**2113-3-23**] Discharge Date: [**2113-3-27**]
Date of Birth: [**2043-2-2**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 57490**]
Chief Complaint:
cyanosis, apnea
Major Surgical or Invasive Procedure:
EEG [**2113-3-24**]
CT head [**2113-3-23**]
MRI/MRA head and neck [**2113-3-24**]
History of Present Illness:
This is a 70 year old woman with a history of frontotemporal
dementia who was well until today at about 12 noon when her
granddaughter heard her choking and coughing. She ran into the
bedroom where the patient had been sleeping. She apparently was
leaning over to her right side, frothing at the mouth with her
jaw clenched. She looked blue in the face. Her eyes were open
and
she was staring straight ahead evidently. Her granddaughter
tried
the [**Name (NI) **] maneuver because she thought she was choking. Her
body appeared limp throughout. It is not clear if she had tongue
biting. She is always incontinent of urine and stool and was in
a
diaper this morning. It doesn't appear that she had tonic-
clonic
movements. Unfortunately I do not have her EMS notes so I do not
know what her oxygenation level was. Apparently intubation was
tried in the field but failed because her jaw was unable to be
opened. She was brought to the ED where she was successfully
intubated. She was placed on propofol drip. She has never had
seizures before.
Past Medical History:
hypertension, hypercholesterolemia, multiple lacunar strokes
including pontine, frontotemporal dementia, hyperthyroidism
Social History:
has 7 children, one was just deceased. She is
cared for by her children and grandchildren.
Family History:
father had a question of [**Name (NI) 2481**]
Physical Exam:
General appearance: well appearing intubated
Heart: regular rate and rhythm without murmurs, rubs or gallops
Lungs: clear to auscultation bilaterally.
Abdomen: soft, NT
Extremities: no clubbing, cyanosis or edema
Skull & Spine: Neck is supple
Mental Status:
She follows midline and simple appendicular commands (squeeze
hand, close eyes). There is no verbal output.
Cranial Nerves:
EOMs appear intact to horizontal movements spontaneously. Pupils
are slightly reactive 3 to 2.5mm bilaterally. fundi difficult to
visualize well due to lack of cooperation. No obvious facial
droop. Grimace is symmetric. Cough and gag is intact.
Motor System:
She moves all extremities spontaneously. There is a rhythmic
flexion of the hip which seems voluntary. Her family states that
this is baseline.
Reflexes: Brisk in the upper extremities, normal at patellae and
reduced at achilles. The plantars are mute bilaterally.
Sensory: withdraws to noxious stimuli
Pertinent Results:
[**2113-3-23**] 02:57PM ALT(SGPT)-114* AST(SGOT)-170* LD(LDH)-820*
CK(CPK)-124 ALK PHOS-101 AMYLASE-80 TOT BILI-0.4
[**2113-3-23**] 02:57PM LIPASE-33
[**2113-3-23**] 02:57PM cTropnT-<0.01
[**2113-3-23**] 02:57PM ALBUMIN-3.4 CALCIUM-8.4 PHOSPHATE-6.3*#
MAGNESIUM-2.0
[**2113-3-23**] 02:57PM WBC-13.5*# RBC-4.92 HGB-13.3 HCT-42.1 MCV-86
MCH-26.9* MCHC-31.5 RDW-13.0
[**2113-3-23**] 02:57PM NEUTS-48.5* LYMPHS-45.9* MONOS-3.5 EOS-1.6
BASOS-0.5
[**2113-3-23**] 02:57PM HYPOCHROM-2+
[**2113-3-23**] 02:57PM PLT COUNT-435#
[**2113-3-23**] 02:57PM PT-14.3* PTT-23.9 INR(PT)-1.3
EEG:
FINDINGS:
ABNORMALITY #1: Occasional low amplitude, sharp waves are seen
across
the right central parietal and parietal occipital regions.
Occasional
delta with mixed theta frequency slowing was also seen both
synchronously and independently over the posterior quandrants.
ABNORMALITY #2: The background rhythm is disorganized and slowed
in the
[**5-6**] Hz theta frequency range with intermittent generalized delta
frequency slowing.
BACKGROUND: As above. At times the background rhythm does reach
an 8 Hz
alpha frequency rhythm but this is not sustained.
HYPERVENTILATION: Was not performed due to the patient's
clinical
condition.
INTERMITTENT PHOTIC STIMULATION: Was not performed because this
was a
portable study.
SLEEP: There are transitions in the record to suggest increased
arousal, otherwise, normal transitions of the sleep architecture
were
not seen.
CARDIAC MONITOR: Normal sinus rhythm with a rate of 72 bpm.
IMPRESSION: This is an abnormal portable EEG due to presence of
occasional sharp waves seen over the right anterior quandrant
with
intermittent slowing seen both synchronously and independently
over the
posterior quandrant. The presence of sharp waves in the right
anterior
quandrant suggest cortial dysfunction in this region and may
predispose to an increased risk for seizures. The bilateral
posterior
quandrant, intermittent slowing suggests subcortical dysfunction
in
these regions. The background rhythm was also noted to be slowed
and
disorganized with occasional generalized slowing suggesting
deep,
midline subcortial dysfunction. These findings could reflect and
early
encephalopathy or excessive drowsiness. No clear seizure
activity was
identified during this recording.
OBJECT: 70 YEAR OLD WOMAN WITH A HISTORY OF DEMENTIA FOUND
UNRESPONSIVE. EVALUATE FOR SEIZURES.
CT head:
FINDINGS: Comparison with the prior head CT scan of [**2111-8-12**]
re-
demonstrates moderate cerebral atrophy, most evident in both
frontal lobes.
There is a moderate degree of low density within the
periventricular white
matter adjacent to both frontal horns, once again compatible
with chronic
small vessel ischemic changes. There is no new intracranial
hemorrhage, mass
effect, or shift of normally midline structures. There is a
small amount of
fluid seen within the left frontal air cell, right maxillary
sinus, and
sphenoid sinus, with more prominent quantity of fluid within the
left
maxillary sinus. These abnormalities could relate to the
patient's intubated
status.
CONCLUSION: No acute intracranial pathology.
MRI/MRA head and neck:
Comparison was made with the previous MRI of [**2111-3-4**]. Again,
bilateral frontal
and temporal atrophy is identified, which has progressed since
the previous
MRI study. Hyperintense T2 signal predominantly in the frontal
region is also
again seen. There is no midline shift, mass effect, or
hydrocephalus. On
diffusion images, no evidence of acute infarct is seen. There
are chronic
lacunae visualized in the pons. No blood products seen on the
susceptibility
images. Fluid levels are visualized in both maxillary, sphenoid,
and ethmoid
sinuses.
IMPRESSION: No evidence of acute infarct. Bifrontal and temporal
atrophy,
which has increased since the previous MRI study of [**2111-3-4**].
Subcortical white
matter changes predominantly in the frontal region as before.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior
and posterior circulation. The right posterior cerebral artery
is fetal in
origin, a normal variation.
IMPRESSION: Normal MRA of the head.
Brief Hospital Course:
Pt intubated in ED for airway protection and concerns for
seizure versus stroke. CT and MRI ruled out any acute infract
but was noteable for known fronto-temporal atrophy consistent
with her dementia. She had an EEG which did not show any
evidence of electrographic seizures. Laboratory workup revealed
no evidence of metabolic or toxic cause for her event. She was
quickly extubated and transferred to the floor where she
remained stable and quickly to baseline functioning per her
family. There was some ongoing concern for her ability to take
PO's which has been followed closely by her PMD, Dr. [**First Name (STitle) **]. As
well, there was also a question of airway obstruction during
sleep (OSA) and the family agreed a sleep study would be
informative at a later date (to be scheduled by Dr.[**Name (NI) 14065**]
office). Pt was discharged in stable condition with plans to
follow-up with Dr. [**First Name (STitle) **] in [**1-1**] weeks and with a home nurse
visit the day after discharge. No adjustments to her
medications were made.
The final thought on the etiology of Ms [**Known lastname 103015**] event was that
she had an acute episode of choking/airway obstruction.
Medications on Admission:
1. Plavix 75mg daily
2. Risperdal 3.75mg daily
3. Metformin XR 500mg daily
4. Methimazole 5mg daily
5. Fluvoxamine 50mg in the morning and 100mg daily
6. Toprol XL
7. Lorazepam 0.5mg three times daily
8. Benadryl three times daily for hives
9. multivitamins
10. calclium
11. vitamin E
12. vitamin B12
13. Magnesium
14. pureed diet and thickened liquids
Discharge Medications:
-Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO daily ().
-Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
-Metformin HCl 500 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO DAILY (Daily).
-Fluvoxamine Maleate 50 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
-Fluvoxamine Maleate 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
-Risperidone Oral
-Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
-Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q NOON ().
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
choking episode
Discharge Condition:
stable
Discharge Instructions:
Take all medications as prescribed.
Follow-up with all appointments as recommended (please call Dr. [**Name (NI) 58830**] office ofr a follow-up appointment within 1-2 weeks).
Followup Instructions:
Please call Dr.[**Name (NI) 14065**] office for a follow-up appointment in
[**1-1**] weeks.
Completed by:[**2113-3-26**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7984
} | Medical Text: Admission Date: [**2180-5-16**] Discharge Date: [**2180-5-22**]
Service: CCU
CHIEF COMPLAINT: Transferred for anterior myocardial
infarction.
HISTORY OF PRESENT ILLNESS: Mrs. [**Known firstname 47987**] is an 82-year-old
woman who presented to [**Hospital3 1280**] Hospital on the morning of
admission with chest pain. She said the chest pain began
approximately 12 hours earlier, was substernal, and somewhere
the anginal chest pain that she has been experiencing the
past few days to weeks. The pain was different in that it
occurred. Pain was different the evening the prior to
admission, it was nonexertional and did not subside.
Electrocardiograms at [**Hospital3 1280**] demonstrated ST elevations
in V2 through V6, and T-wave inversions. She also has Q
waves in II, III, and F, which likely represent old ischemia.
The patient received IV nitrogen, Heparin, Plavix, and
Integrilin, and was transferred to [**Hospital1 190**] for catheterization. Catheterization
demonstrated discrete left anterior descending artery total
occlusion. She had a Cypher stent placed with subsequent
TIMI-III flow. Her hemodynamics were consistent with
cardiogenic shock with pulmonary capillary wedge of 34,
cardiac output of 3.32 and cardiac index of 2.02. Subsequent
flow in her artery was evaluated at TIMI-II. Intra-aortic
balloon pump was placed. The patient was transferred to the
CCU.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Congestive heart failure.
3. Coronary artery disease.
4. Hypothyroidism.
5. Status post left hip fracture and open reduction internal
fixation. Right hip with congenital deformity.
6. Osteoarthritis.
7. Hiatal hernia, large retrocardiac.
8. Gastroesophageal reflux disease.
9. Depression.
OUTPATIENT MEDICATIONS:
1. Lasix 40 po q day.
2. Atenolol 25 po bid.
3. Lisinopril 10 mg po q day.
4. Synthroid 0.088 mg po q day.
5. Detrol LA 40 mg po q day.
6. Celexa 20 mg po q day.
7. Mellaril 25 mg po q hs.
8. Protonix 40 mg po q day.
9. Trazodone 25 mg po prn.
FAMILY HISTORY: No coronary artery disease.
SOCIAL HISTORY: Lives in Catholic Convent since the age of
23. No tobacco.
PHYSICAL EXAMINATION: Temperature is 98.0, pulse 91-101,
blood pressure 91/59, augmented diastolic 123, assisted
systolic 106, respiratory rate 18, and O2 saturation 97%.
P.A. pressure 31/21 with a mean of 25. General: Pleasant,
awake, elderly woman in no acute distress. HEENT: Pupils
are equal, round, and reactive to light. Extraocular
movements are intact. Moist mucous membranes. Neck supple,
obese. Cardiovascular: Regular, rate, and rhythm, no
murmur. Pulmonary: Crackles on the left dependent side to
50%, and at the right base. Abdomen is soft, nontender,
nondistended. Extremities warm, no edema, 1+ DPP
bilaterally. Neurologic is alert, oriented, and appropriate.
LABORATORIES: White count 12.5, hematocrit 37.2, platelets
303. Sodium 136, potassium 3.3, chloride 101, bicarb 24, BUN
13, creatinine 0.5, glucose 118, calcium 8.5, magnesium 1.8,
phosphorus 4.0, albumin 3.3. CK peak of 3.925, decreased to
207 on [**5-20**].
HOSPITAL COURSE: Sister [**Name (NI) 47987**] was admitted to the Cardiac
Care Unit for further management poststent given her
cardiogenic shock.
Hemodynamics: The patient was maintained on the intra-aortic
balloon pump for 48 hours. Fluid was initially maintained as
even. She subsequently underwent diuresis with her goal dry
weight approximately 78 kg. Echocardiogram demonstrated an
ejection fraction of 25-30%, moderately dilated left atrium,
mildly dilated right atrium, severe regional left ventricular
systolic dysfunction with akinetic with anterior to mid
anterior septal, anterior apex, septal apex, lateral apex,
which is dyskinetic.
Physiologic mitral regurgitation 1+ tricuspid regurgitation,
mild pulmonary artery systolic hypertension. On
echocardiogram on [**2180-5-17**], there was a small to moderate
sized pericardial effusion without signs of tamponade.
Patient was initially maintained on anticoagulation for
intra-aortic balloon pump with plans to transition her to
long-term anticoagulation given her areas of akinesis and low
ejection fraction. However, given findings of pericardial
effusion, which was suggestive of possible hemorrhagic
effusion. Anticoagulation was stopped. Patient underwent
repeat echocardiogram on [**5-19**], which demonstrated an
ejection fraction of 30-35%, and a small pericardial effusion
without signs of tamponade. Decision was made that to
indefinitely hold further anticoagulation with Coumadin.
Ischemia: Patient was maintained on aspirin and Plavix x9
months for stent placement. She was started on a beta
blocker, titrated to 75 mg po bid as well as an ACE
inhibitor, lisinopril 5 mg po q day.
Rhythm: Patient experienced transient right bundle branch
block with left anterior fascicular block the first day
postprocedure. She underwent placement of transvenous pacing
wires on [**2180-5-16**]. She experienced no further block on
[**2180-5-17**], and wires were removed on [**2180-5-18**]. Patient had
some nonsustained ventricular tachycardia on the first 48
hours post myocardial infarction. She underwent evaluation
by Electrophysiology staff, who recommended further
evaluation with signal averaging studies. These are to be
performed on [**2180-5-22**]. Results should be reviewed at her
next cardiologist. The patient is also referred to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 41364**] for further followup of her
Electrophysiology issues.
2. Endocrine: The patient was continued on her outpatient
Synthroid dose. The TFTs are within normal limits.
3. Heme: The patient underwent oozing from her groin line
sites requiring blood transfusions. Her hematocrit remained
stable, 33-34 in the days prior to discharge.
4. Neurological: Patient developed agitation and altered
mental status on her second and third days of admission. Per
patient's companions at the convent, this is her baseline and
responded very well to treatment with Haldol. The patient
with known baseline mental disorder and was maintained on her
trazodone and Celexa in-house.
5. Diet: The patient will need to follow a low salt
heart-healthy diet, less than 2 grams of sodium per day.
Follow up arranged with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] [**6-8**] at 11:45 am.
DISPOSITION: Extended care facility.
RECOMMENDATIONS: The patient will need Physical Therapy,
monitoring of electrolytes every 2-3 days, and possible
adjustment of her Lasix dose. She will need LFTs in six
weeks, she was started on a statin drug, and follow up on her
Electrophysiology studies done on the day of discharge.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg po q day.
2. Plavix 75 mg po q day.
3. Lisinopril 5 mg po q day.
4. Metoprolol 75 mg po bid.
5. Celexa 20 mg po q day.
6. Levothyroxine 88 mcg po q day.
7. Trazodone 25 mg po q day.
8. Colace 100 mg po q day.
9. Senna two tablets po bid prn.
10. Dulcolax 10 mg po q hs prn.
11. Haldol 2 mg IV q4h prn.
12. Lasix 40 mg po bid x3 days with subsequent decrease to 40
mg po q day.
13. Potassium chloride.
14. Protonix 40 mg po q day.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Acute anterior myocardial infarction.
2. Perimyocardial infarction arrhythmia.
3. Hypothyroidism.
4. Depression.
5. Hypertension.
6. Gastroesophageal reflux.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2180-5-22**] 12:00
T: [**2180-5-22**] 12:04
JOB#: [**Job Number 47988**]
ICD9 Codes: 4271, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7985
} | Medical Text: Admission Date: [**2118-1-15**] Discharge Date: [**2118-1-18**]
Date of Birth: [**2055-1-4**] Sex: M
Service: C-MEDICINE
CHIEF COMPLAINT: Transferred from [**Hospital3 3765**] with
unstable angina.
HISTORY OF PRESENT ILLNESS: The patient developed seven out
of ten chest pain this morning with radiation to his left arm
while showering. The patient took Aspirin and three
sublingual Nitroglycerin without relief. The patient then
went to [**Hospital3 3765**] without resolution of his chest pain
with the Nitroglycerin. The patient also reports feeling
nauseous, diaphoretic and short of breath. The patient
reports that over the last month, he has had intermittent
shortness of breath that he was recently seen by his primary
care physician for and the primary care physician felt that
he had evidence of congestive heart failure. He was started
on Lasix. The patient was also seen by his cardiologist,
[**First Name8 (NamePattern2) **] [**Last Name (Titles) **], within the last week who also felt that he was
developing congestive heart failure. At [**Hospital3 3765**],
the patient was started on Heparin, intravenous
Nitroglycerin, given 2 milligrams of Morphine, 5 milligrams
of intravenous Lopressor and finally started on Integrelin.
The patient's pain was two out of ten at transfer but upon
arrival to [**Hospital1 69**] with a slight
increase in intravenous Nitroglycerin the patient was made
pain free. The patient subsequently vomited a moderate
amount of bilious liquid. The patient was admitted to the
PCU on Integrelin, Heparin, Nitroglycerin.
PAST MEDICAL HISTORY:
1. Coronary artery disease. Cardiac catheterization in [**2104**],
showed two vessel disease with 60% left circumflex and
90% right coronary artery. Cardiac catheterization on
[**11/2112**], showed an ejection fraction of 24% with 1+ mitral
regurgitation, 80% mid right coronary artery, 40% right
posterior descending artery, 30% mid circumflex and a 30%
distal circumflex. The patient had percutaneous
transluminal coronary angioplasty with stent times two to
the mid right coronary artery. The patient was also
noted to have moderate systolic and diastolic dysfunction
with global hypokinesis.
2. Carotid endarterectomy in [**2113**].
3. Status post complete heart block with pacemaker
placement.
4. History of hypertension.
5. History of high cholesterol.
6. Left bundle branch block on electrocardiogram.
MEDICATIONS:
1. Lipitor 20 milligrams q.d.
2. Isosorbide 20 milligrams t.i.d.
3. Aspirin 325 milligrams q.d.
4. Zestril.
MEDICATIONS ON TRANSFER:
1. Intravenous Nitroglycerin.
2. Intravenous Heparin.
3. Aspirin.
4. Lopressor.
5. Integrelin.
6. Morphine.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Previously smoked one pack per day and has
since quit in the last eight to ten years. The patient was a
heavy drinker but also quit eight to ten years ago and
previously would drink greater than a case of beer a week.
The patient is employed as a kitchen designer.
FAMILY HISTORY: No significant family history of coronary
artery disease or diabetes mellitus.
PHYSICAL EXAMINATION: Temperature is 97.3, pulse 60, blood
pressure 112/61, respiratory rate 18, pulse oximetry 93% on
four liters nasal cannula. In general, resting in bed,
alert, oriented in no apparent distress. Head, eyes, ears,
nose and throat - The oropharynx is clear. Anicteric sclera.
Moist mucous membranes. Neck is supple with no jugular
venous distention. Cardiovascular regular rate and rhythm,
normal S1 and S2, no murmurs, gallops or rubs. The lungs are
clear to auscultation bilaterally. The abdomen is soft,
nontender, nondistended, normoactive bowel sounds.
Extremities warm, 1+ pedal edema bilaterally, no femoral
bruits, 2+ dorsalis pedis and posterior tibial pulses
bilaterally. Neurologic - alert and oriented times three.
LABORATORY DATA: On admission, white count 9.8, hematocrit
40.6, platelets 218,000, 89% neutrophils. Prothrombin time
16.6, partial thromboplastin time 150, INR 1.8. Sodium 139,
potassium 4.3, chloride 102, bicarbonate 26, blood urea
nitrogen 23, creatinine 1.1, glucose 161. CK was 96. Chest
x-ray revealed cardiomegaly with no evidence of congestive
heart failure. Electrocardiogram revealed a paced rhythm
with left bundle branch block.
HOSPITAL COURSE:
1. Coronary artery disease - The patient remained pain free
on Integrelin, Heparin and Nitroglycerin. The patient ruled
in for myocardial infarction with positive troponin of 30
with peaked CK of 198 with positive MB fraction and index.
The patient was taken to cardiac catheterization on [**2118-1-17**],
and cardiac catheterization showed moderately elevated right
and left sided filling pressures with right atrium 9 mmHg,
wedge pressure of 25 mmHg and left ventricular end diastolic
pressure of 26 mmHg. There was also moderate pulmonary
hypertension with a pulmonary artery pressure of 49/26.
Cardiac index was low at 1.9. The patient had a 50% distal
stenosis of the left main and a 40% stenosis of an acute
marginal with patent stents in the right coronary artery.
The patient tolerated the cardiac catheterization well and
did not have any episodes of chest pain following the
catheterization.
The patient was placed on Aspirin and Lopressor and continued
on his Lipitor. The patient's lipid profile was very good
with a LDL of less than 100.
2. Congestive heart failure - The patient had evidence of
congestive heart failure on admission with an oxygen
requirement. The patient was given two doses of Lasix with
good diuresis and improved shortness of breath. The
patient's cardiac catheterization showed moderate right and
left ventricular diastolic dysfunction. The patient was
started on Zestril 5 milligrams and Lasix 20 milligrams on
discharge and will follow-up with [**First Name8 (NamePattern2) **] [**Last Name (Titles) **].
DISCHARGE MEDICATIONS:
1. Lisinopril 5 milligrams q.d.
2. Lopressor 25 milligrams b.i.d.
3. Lasix 20 milligrams p.o. q.d.
4. Potassium 8 meq p.o. q.d.
5. Sublingual Nitroglycerin.
6. Aspirin 325 milligrams p.o. q.d.
FOLLOW-UP: [**First Name8 (NamePattern2) **] [**Last Name (Titles) **].
DISCHARGE STATUS: To home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES: Acute myocardial infarction.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**]
Dictated By:[**Last Name (NamePattern1) 16516**]
MEDQUIST36
D: [**2118-1-18**] 21:06
T: [**2118-1-19**] 20:30
JOB#: [**Job Number 111264**]
ICD9 Codes: 4280, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7986
} | Medical Text: Admission Date: [**2201-7-26**] Discharge Date: [**2201-7-29**]
Date of Birth: [**2140-12-29**] Sex: M
Service: MEDICINE
Allergies:
Verapamil / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
dizzyness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 60 yo man with hx of IDDM with diabetic neuropathy, chronic
renal failure, bilateral foot ulcers, heart failure with
implanted defibrillator, atrial flutter on coumadin, and
peripheral vascular disease s/p right leg bypass, who presented
to ED today with a one week history of dizziness and mild
headache. Pt states he noted the onset of room spinning when he
stood up but it would resolve when he sat back down; it was
associated with tinnitus but no nausea/vomiting or hearing loss.
He notes that this am he may have fallen towards the left. He
also noted a mild persistent frontal headache, no neck
stiffness, fever, chills. On the morning of admission, pt woke
up and stood to walk to the bathroom and could barely make it
due to severe vertigo, again, no nausea. He came to the ED and
it was found that his INR was 16 and he had a small SAH on head
CT. Of note, pt states that he tripped over the vacuum cord 3
weeks ago and hit his left hip and elbow, cannot remember if he
hit his head, no LOC. Neurology and neurosurgery evaluated the
pt in the ED and given his multiple medical problems, he was
admitted to the MICU for close monitoring. He received 4units of
FFP, and 10mg po vitamin K.
.
ROS: no fever/chills, no n/v/d, no abd pain, no BRBPR, no
dysuria, no chest pain, no sob
Past Medical History:
Past Medical History:
1. Diabetes type 2
2. diabetic neuropathy with bilateral foot ulcers on heels
3. CRF, baseline cr 3.4
4. CHF, EF ?30% with implanted defibrillator
5. atrial flutter
5. pulmonary fibrosis
6. peripheral vascular disease s/p right leg bypass graft
7. depression
8. gout
Social History:
Patient lives alone, does own ADL's, no drugs, has VNA.
Family History:
NC
Physical Exam:
Per Note of Dr. [**Last Name (STitle) 28360**]
T: 98.8, BP: 179/79, R: 61, RR: 12, O2 100% on 2L
GEN: NAD
SKin: multiple ecchymoses with palpable small hematomas
HEENT: PERRL, EOMI, MMM
CV: RRR, [**3-1**] diastolic murmur heard best at RUSB
Chest: clear
ABD: +BS, soft, NTND
Ext: no edema, foot drop on right, decreased sensation in
bilateral feet; left foot with slow oozing ulcer on heel.
Neuro: CN 2-12 intact; old ptosis on left; strength 5/5 upper
ext bilaterally; no dorsiflexion on right [**2-25**] nerve injury; [**5-28**]
strenght in hip flexion; nl reflexes b/l.
Pertinent Results:
[**2201-7-26**] 12:10PM PT-49.3* PTT-76.5* INR(PT)-16.1
[**2201-7-26**] 12:10PM WBC-14.5*# HCT-31.4*
[**2201-7-26**] 12:10PM PLT COUNT-269
[**2201-7-26**] 08:48PM PT-17.3* PTT-40.0* INR(PT)-2.0
[**2201-7-26**] 12:10PM GLUCOSE-134* UREA N-79* CREAT-3.2* SODIUM-137
POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-17* ANION GAP-21*
FOOT AP,LAT & OBL LEFT [**2201-7-26**] 4:33 PM
IMPRESSION:
Loss of the visualization of the cortical bone of the base of
the 5th metatarsal and of the lateral aspect of the cuboid. This
is concerning for osteomyelitis. Correlate with site of ulcer.
Bone scan could be performed.
The study and the report were reviewed by the staff radiologist.
CT HEAD W/O CONTRAST [**2201-7-26**] 3:31 PM
IMPRESSION:
Small amount of subarachnoid hemorrhage seen superiorly in a
right frontal sulcus.
The study and the report were reviewed by the staff radiologist.
CT HEAD W/O CONTRAST [**2201-7-27**] 10:40 AM
COMPARISON: [**2201-7-26**].
IMPRESSION: Stable appearance of small subarachnoid hemorrhage
in a right frontal lobe sulcus
CHEST (PA & LAT) [**2201-7-26**] 3:22 PM
Reason: eval for infiltrate
IMPRESSION: No definite evidence of acute pneumonia.
Postoperative changes in the right hemithorax with stable
fibrothorax. An addendum will be dictated when more recent films
become available.
ADDENDUM: There is no significant change since the prior CXR of
[**2200-9-4**].
The study and the report were reviewed by the staff radiologist.
ECG: AV paced at 60; no st-t changes
Brief Hospital Course:
60y/o M with h/o a flutter on coumadin, CHF s/p ICD, DM type 2,
who presents with one week of dizziness, headache and found to
have a small post frontal bleed in setting of supratherapeutic
inr 16.
1. Post frontal bleed:
Spontaneous bleed in setting of supratherapeutic INR of 16,
patient denied any recent trauma prior to arrivel though did
attest to having fallen ~3 weeks ago. Per neuro findings were
c/w new/recent bleed, they said that if bleed would have
happened 3 weeks ago the composition of the blood would have
changed and not lit up as it did on CT scans. Inr was reveresed
with 4U FFP and 10mg vitamin K. Inr dropped to 2's within 8
hours of admission. Per neuro no focal neurological defects on
exam. His repeat CT was unchanged and did not show progression
of bleed. His headaches and dizziness resolved. CTA was not
performed due to his CRI with creatinines at mid 3's and MRI/MRA
not done due to his ICD. Neurosurgery s/o and recommended f/u as
outpatient in their clinic in 2 weeks with CT s contrast prior
to visit. Neuro also signed off without furhter recommendations.
2. Coagulopathy: unclear as to why patient presented with
elevated INR of 16, no change in diet, no change in medications,
could have been antibiotics but patient had been off them some
time. Possibly poor nutrition as both PT and PTT corrected with
vit K doses x 2. After reversal patients coags remained stable
and within normal. He was not restarted on his coumadin and we
recommended that he be started as an outpatient by pcp.
3. Leukocytosis: unclear etiology, no focal signs of infection,
chest x ray was clear, ua was normal, no si/sx's of infection,
his left heel ulcer appeared normal with no evidence of puss,
erythema, tenderness. Pt was afebrile thoughout stay and abx
were not started. Prior to discharge patients white count began
to decrease. No further w/u was done.
4. Acute on CRF: [**2-25**] prerenal/hypovolemia. Improved with
hydration. Stable.
5. Foot ulcers:
X ray was taken of left foot ulcer and showed cortical erosion
of the 5th metatarsal but did not correlate with location of
ulcer. Podiatry was consulted and said that changes that were
seen on the X ray are [**2-25**] his severe deformities and not due to
osteomyelitis. They recommended wet to dry dressings and daily
dressing changes.
6. DM2: glucoses remained stable, continued on his outpatient
medication regimen.
7. HTN: stable, continued on his outpatient med regimen
8. Cardiac: CHF: euvolemic, salt and fluid restricted, continued
on heart failure meds.
CAD: continued on bb and asa
Rhythm: a fib, stopped coumadin and reversed inr. Did not
restart coumadin due to CNS bleed, will have pcp restart as
outpatient. Restarted amiodarone.
9. Gout: stable, c/w allopurinol.
10. Depression: c/w fluoxetine
11. Hypercholesterolemia: c/w lovastatin and welchol.
12. Full Code
Medications on Admission:
allopurinol 100mg'
amiodarone 200mg'
aspirin 325mg'
centrum
darvocet prn
fluoxetine 20mg'
HCTZ 25mg'
Lisinopril 2.5mg'
lotrisone 0.05% [**Hospital1 **]
lovastatin 10mg'
procrit 20,000 2x per week
toprol xl 150mg'
vitamin c 500mg'
warfarin 5mg' except 7.5mg on Tuesdays
Welchol 625mg [**Hospital1 **]
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Medication
Humulin 22u qam, 12-14u qpm
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Lovastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. WelChol 625 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
Posterior frontal cerebral bleed
Left heel ulcer
Acute renal failure
Coagulopathy: supratherapeutic INR of 16
Secondary diagnosis:
Atrial flutter
Heart failure
Diabetes Mellitus type 2
Hypertension
Gout
Depression
OSA
Discharge Condition:
stable
Discharge Instructions:
Please take all your medications as prescribed and follow up
with all your recommended appointments.
Please call your doctor if you develop: fevers, chills, chest
pain, shortness of breath, confusion, dizziness, vertigo or
other concerning symptoms.
Your primary care physician will determine when you restart the
coumadin. You also need to set up an appointment with the
neurosurgeon that was following you in the hospital. Your
primary care phsysician should set up a CT of your head prior to
seeing the neurosurgeon.
Followup Instructions:
Please call to schedule an appointment with your primary care
phsyciain Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1144**]. Please schedule your
appointment within one week.
Please call to make an appointment with Dr. [**Last Name (STitle) **]
(Neurosurgery) at [**Telephone/Fax (1) 2992**], please make the appointment
within 2-4 weeks from your day of discharge. You will need to
have a CT scan of your head done prior to seeing him. Your
primary care physician will help facilitate that.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Where: BA [**Hospital Unit Name **] ([**Hospital Ward Name **]
COMPLEX) PODIATRY Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2201-7-31**] 10:50
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Where: BA [**Hospital Unit Name **] ([**Hospital Ward Name **]
COMPLEX) PODIATRY Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2201-8-4**] 1:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 28361**] PRACTICES Where: [**Name12 (NameIs) 9119**]-PRIVATE
PRACTICES Phone:[**Pager number 28362**] Date/Time:[**2201-7-31**] 12:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 431, 5849, 4280, 2765, 3572, 311, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7987
} | Medical Text: Admission Date: [**2185-7-1**] Discharge Date: [**2185-7-6**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 84 year old
male with no significant past medical history, who was
witnessed by his wife at 02:30 p.m. on the day of admission,
becoming unresponsive. She called The EMS was called and
arrived within five minutes. The patient had ventricular
fibrillation on the monitor and was cardioverted at 200
joules. He became asystolic and had CPR for one minute. The
patient received 1 mg of epinephrine and Atropine and the
patient converted to atrial fibrillation. The patient was
intubated without difficulty.
According to his wife, the patient denied chest pain,
shortness of breath. The patient only had some indigestion
fifty minutes before his arrest. The patient originally
presented to [**Hospital3 4527**] Hospital where he was given 300
mg of intravenous Amiodarone and started on an Amiodarone
drip, 5 mg of intravenous Lopressor, aspirin and was started
on a heparin drip. The patient was transferred to [**Hospital1 1444**] for cardiac catheterization.
PAST MEDICAL HISTORY: None.
HOME MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married and was visiting
daughter. [**Name (NI) **] lives with his wife outside of Montreal,
[**Name (NI) 6607**]. He has a 50 year tobacco history. He drinks at
least three drinks a day.
PHYSICAL EXAMINATION: Pulse 75; blood pressure 156/89;
saturation of 99% on assist control 700 by 14, PEEP of 5,
FIO2 of 0.5. In general, the patient is intubated and
sedated. HEENT: Dried blood surrounding his mouth.
Cardiovascular: Distant heart sounds; no murmurs. Lungs
were clear anteriorly. Abdomen soft, nontender, nondistended
with normal bowel sounds. Guaiac negative. Extremities with
no edema. Neurologically, the patient withdraws from pain,
moving all four extremities.
LABORATORY: From the outside hospital, white blood cell
count 6.4, hematocrit 43.4, MCV of 101.5. Platelets 159.
Initial CK 75, magnesium 1.9, phosphate 3.5.
EKG showed ST depressions in the precordial leads consistent
with a posterior myocardial infarction.
HOSPITAL COURSE:
1. Coronary artery disease: The patient with posterior
myocardial infarction with troponin greater than 50, CK
peaking in the high 400s. The patient was started on
heparin, aspirin and Lipitor. Cardiac catheterization was
not performed secondary to patient's agitation and inability
to cooperate. The patient would have required sedation and
intubation and undergo cardiac catheterization which the
family wanted to avoid.
The patient's heparin was briefly stopped for episodes of
hemoptysis after extubation. The patient was restarted on
Lovenox.
2. For his myocardium, a 2D echocardiogram is being
performed today; results of echocardiogram pending. The
patient was started on a beta blocker, 12.5 mg of Lopressor
twice a day.
3. Electrophysiology: The patient status post ventricular
fibrillation arrest, status post cardioversion and atrial
fibrillation. The patient on oral Amiodarone to maintain
sinus rhythm. The patient was started on a beta blocker.
The patient on Lovenox for anti-coagulation.
4. The patient was intubated in the setting of ventricular
fibrillation arrest for airway protection. The patient was
extubated two days later after his mental status improved.
5. Renal: The patient initially had marginal urine output
between 20 and 30 cc an hour despite stable blood pressure.
The patient's urine output has since improved. His
creatinine has remained stable.
6. Endocrine: The patient initially had high blood sugars
in the 300s, presumably secondary to stress reaction as
patient has no history of diabetes mellitus. The patient was
started on a Regular insulin sliding scale.
7. Neurologic: The patient is only oriented times one. The
patient initially received Fentanyl and Ativan while
intubated. The patient currently off benzodiazepines and has
been receiving Haldol p.r.n. for agitation. The patient's
inability to cooperate is limiting his ability to undergo
cardiac catheterization.
The patient is currently Full Code. Since he is about to
undergo cardiac catheterization however, this should be
readjusted with the family after cardiac catheterization. It
seems that the family wants to avoid intubation and heroic
measures.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: Transfer patient to a hospital in [**Country 6607**].
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Amiodarone 400 mg p.o. q. day.
3. Lopressor 12.5 mg p.o. twice a day.
4. Lipitor 10 mg p.o. q. day.
5. Protonix 40 mg p.o. q. day.
6. Lovenox 60 mg subcutaneously twice a day.
7. Regular insulin sliding scale.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 7112**]
MEDQUIST36
D: [**2185-7-6**] 11:33
T: [**2185-7-6**] 11:39
JOB#: [**Job Number 42098**]
ICD9 Codes: 4275, 5070, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7988
} | Medical Text: Admission Date: [**2168-7-26**] Discharge Date: [**2168-7-31**]
Date of Birth: [**2110-2-26**] Sex: M
Service: CSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
58M WITH CHEST PAIN SOB AT REST s/p emergent CABGx4 (LIMA->LAD,
SVG->OM1, ->OM2, ->DIAG), EF
PMH: HTN, s/p vasectomy
[**Last Name (un) 1724**]: none
Major Surgical or Invasive Procedure:
CORONARY ARTERY BYPASS X4 LIMA->LAD, SVG->OM1, ->OM2, ->DIAG),
History of Present Illness:
PATINET PRESENTED BY CARDIOLOGY TEAM WITH TRIPPLE VESSEL DISEASE
AND ONGOING CHEST PAIN INSPITE OF MEDICAL THERAPY
Past Medical History:
HYPERTENSION; VASECTOMY
Family History:
UNREMARKABLE
Physical Exam:
LUNGS CTA
HEART RRR NM G
STERNUM SATBLE
WOUND NO SX OF INFECTION
EXT POS PULSES EDEMA ON LEFT LEG SP SAFENECTOMY
CNS ORIENTED X3
Pertinent Results:
[**2168-7-26**] 03:31PM TYPE-ART PO2-332* PCO2-48* PH-7.37 TOTAL
CO2-29 BASE XS-2
[**2168-7-26**] 03:31PM GLUCOSE-132* K+-5.2
[**2168-7-26**] 02:52PM TYPE-ART PO2-263* PCO2-52* PH-7.34* TOTAL
CO2-29 BASE XS-1
[**2168-7-26**] 01:28PM TYPE-ART PO2-343* PCO2-47* PH-7.37 TOTAL
CO2-28 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED
[**2168-7-26**] 01:28PM GLUCOSE-106* NA+-137 K+-4.3
[**2168-7-26**] 12:34PM GLUCOSE-89 UREA N-13 CREAT-0.7 SODIUM-149*
POTASSIUM-3.2* CHLORIDE-113* TOTAL CO2-22 ANION GAP-17
[**2168-7-26**] 12:34PM PT-12.8 PTT-40.2* INR(PT)-1.1
PATIENT EXTUBATED ON [**2168-7-26**] NO POST OP COMPLICATIONS, CHEST
TUBES AND WIRES D BEFORE TRANSFER TO THE FLOOR.
Brief Hospital Course:
SP CABG x4 [**2168-7-26**] EXTUBATED 6 HOURS POST OP NO COMPLICATIONS,
CHEST TUBES DC POS OP DAY #2 WIRES DC POST OPD #3. AFEBRILE
HEMODINAMICLY STABLE. PT [**Name (NI) 58005**] TO THE FLOOR.
TOLERATING CARDIAC DIET PHYSICAL EXAM UNREMARKABLE PT [**Name (NI) 58006**].
STBALE.
Medications on Admission:
ASA
MVI
SINVASTATIN 40MG PO QDMETOPROLOL 25 MG PO BID
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for [**Name (NI) **] MORE THAN 38.
Disp:*30 Tablet(s)* Refills:*0*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
Disp:*30 Cap(s)* Refills:*2*
7. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO QD (once a day).
Disp:*30 Capsule(s)* Refills:*2*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
SP CABGx4
Discharge Condition:
GOOD SELF FEEDING SELF AMBUTATING
Discharge Instructions:
WALK 4 TIMES PER DAY, ELEVATE LOWER EXTREMITIES WHEN ON BED.
[**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) **] CHEST PAIN OR WOUND ISSUES.
Followup Instructions:
FOLLOW UP WITH DR [**Last Name (STitle) **] IN 4 WKS.([**Telephone/Fax (2) 1504**]Provider:
[**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 170**] Follow-up appointment should be
in 1 month
[**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 170**] Follow-up appointment should be
in 1 month
[**Last Name (LF) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 3183**] Follow-up appointment in 2
weeks
Completed by:[**2168-7-31**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7989
} | Medical Text: Admission Date: [**2136-7-31**] Discharge Date: [**2136-8-3**]
Service: MEDICINE
Allergies:
Amiodarone / Atorvastatin / Vancomycin Hcl
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Sepsis
Atrial Fibrillation
CHF
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
85 yo m w/ h/o metastatic prostate ca to bone, cad, chf (LVEF
21%), avr, severe mitral stenosis, PAH, PAF who p/w [**2-2**] wk h/o
n/v post meals. Patient/wife report approx 2 wk h/o vomiting
following meals. Reports delay of approx 10 minutes following
meals. Vomiting whole food. Denies abd pain/jaundice/[**Male First Name (un) 1658**]
colored stools/dk urine. Denies hematemesis. +constipation->
no bm x 1wk. Wife reports that tonite at dinner pt had multiple
episodes of vomiting (usually just one) and was accompanied by
shaking chill. Has h/o subj fevers at home. +cough over the
last several weeks, productive of yellow sputum. +cough at
night. no coughing spells. No sob/DOE/cp/palpitations. Stable
minimal exercise tolerance across room. States not limited by
resp status. .
.
According to wife, pt has had steady decline in functional
status over the last 3 months, worsened over the last month.
.
Pt rec'd first dose of Samarium 153 on [**7-5**]- carries known rx of
thrombocytopenia.
.
In ED, 102.4/138/ 117/71/ 18 88% ra, elev lactate to 9.9,
started on MUST, rec'd vanc/levo/flagyl
Past Medical History:
1) Metastatic adenocarcinoma of the prostate: [**Doctor Last Name **] score 7
(4+3) diagnosed [**6-1**]. He did not receive primary therapy to his
prostate gland due to his underlying medical conditions. He was
treated with Casodex alone from [**10-1**] until [**3-2**] with minimal
response. In [**5-2**], Lupron was initiated with a minimal
response. Several months ago, he was treated with Casodex again,
which was [**Date Range 8910**] for rising PSA and elevated LFTs.
2) CONGESTIVE HEART FAILURE, LVEF 21%
3) ANEMIA
4) CORONARY ARTERY DISEASE
5) ECZEMA
6) HYPERCHOLESTEROLEMIA
7) ATRIAL FIBRILLATION
8) SCIATICA
9) CHRONIC HEPATITIS C - Acquired through blood transfusion
associated with AVR in [**2114**].
10) RHEUMATIC HEART DISEASE
11) HYPERTENSION
12) ASTHMA, COPD
13) S/P AORTIC VALVE REPLACEMENT [**2114**]
14) PPM, ICD implant
15) VF arrest [**2133**]
16) SEVERE MITRAL STENOSIS
17) 2+ MR
Social History:
He denies a history of smoking, rare alcohol use, no IVDU. He
acquired Hepatitis C from a blood transfusion. He lives at home
with his wife and is able to perform his ADLs, although his wife
does say he is forgetful with his medications.
Family History:
NC
Physical Exam:
bp 97/59, p 68, r 24, 94% 4L NC, cvp 13 w/ prominent a waves,
SvO2 62%
Ill appearing cachectic male in NAD.
PERRL
OP clr
+JVD
Regular S1, prominent S2. No m/r/g
b/l basilar crackles
+bs. soft. nt. nd. no hepatosplenomegaly. no [**Doctor Last Name **]
1+ LE edema
Pertinent Results:
133 94 33 /135 AGap=25
5.2 19 1.1 \
.
Ca: 9.6 Mg: 2.0 P: 4.4
ALT: 26 AP: 180 Tbili: 1.8 Alb:
AST: 172 LDH: 2860 Dbili: Pnd TProt:
[**Doctor First Name **]: 74 Lip: 105
UricA:14.5
.
proBNP: [**Numeric Identifier 8915**]
Hapto: Pnd
.
98
9.4\ 9.5 / 82
/ 28.8\
N:58.6 L:36.1 M:3.5 E:0.9 Bas:1.0
.
PT: 20.9 PTT: 40.6 INR: 2.9
.
cxr: mild pulm vasc redistribution
.
Brief Hospital Course:
84 yo m w/ chf, avr, ms, w/ h/o vomiting, fever, cough, febrile
on admission, tachycardic, w/ elev lactate, and no obvious
source of infxn.
.
1) sepsis- On arrival to the ICU pt afebrile c no WBC but
tachyc, tachypneic c increased lactate. CT of chest showed L pul
infiltrate. CT abdomen showed GB wall thickening but no evid of
GI source. Pt empirically coverd c ceftriaxone, vancomycin and
flagyl. Pt developed rash in UE after one vancomycin
administration, so abx given more slowly subsequently. No
additional reaction noted. Bedside swallow showed pt at risk
for aspiration and so this likely contributed to his development
of pna.
2. Fluids- elev cvp but pt likely always runs high given known
severe MS. Concerned that patient was relatively hypovolemic
given h/o vomiting, elev lactate; therefore, initially given IVF
boluses despite elevated CVP.
.
2) chf- Pt significantly overweight but as stated previously
concern for hypovolemia. Therefore was bolused with fluid. Fluid
status balanced between diuresis for possible volume overload in
the lungs and need for increased perfusion to the tissues. On
[**2136-8-3**] pt hypotensive c decreased RR and fixed and dilated L
pupil. Pt's liver and cardiac enzymes as well as his lactate
elevated, indicating inadequate perfusion of his end organs. Pt
given ASA for cardiac damage [**Hospital1 **] sltrsfu on snyivoshulsyion.
Therefore pt was intubated by anesthesia. Follow intubation
family elected to make pt DNR and then later that day decided on
comfort measures only. Pt was extubated and on [**2136-8-3**] pt
expired. Family denied autopsy.
.
.
3) thrombocytopenia- Heme onc consulted and attributed pt's
thrombocytopenia to pt's recent dose of samarium.
.
4) elev amylase/lipase- likely [**2-1**] ongoing vomiting, no clinical
evidence of pancreatitis.
.
) ppx- pneumoboots, gi
.
Medications on Admission:
asa 81 mg qday
lisinopril 40 mg qday
lopresser 75mg [**Hospital1 **]
lasix 40mg qday
coumadin
sumarin every other wk.
Discharge Medications:
Pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Pneumonia
CHF
Discharge Condition:
Pt expired
Discharge Instructions:
Pt expired
Followup Instructions:
Pt expired
ICD9 Codes: 0389, 486, 431, 412, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7990
} | Medical Text: Admission Date: [**2170-2-8**] Discharge Date: [**2170-2-16**]
Date of Birth: [**2111-10-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Tetracycline / Sulfa (Sulfonamide Antibiotics) /
Morphine / Codeine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Cervical malacia, with shortness of breath.
Major Surgical or Invasive Procedure:
[**2170-2-8**]: Cervical tracheal resection and reconstruction
and bronchoscopy with bronchoalveolar lavage.
History of Present Illness:
The patient is a 58-year-old woman who has had a tracheostomy.
She also developed severe diffuse tracheobronchomalacia which
was treated with the right thoracotomy and posterior splinting
of her thoracic airways. After this procedure, she was noted to
have persistent and worsening cervical
tracheomalacia and some minor narrowing at the site of the
previous stoma. She was admitted following tracheal resection
and reconstruction.
Past Medical History:
# tracheobronchial malacia s/p tracheoplasty [**2169-6-13**]
# tracheostomy
# Cervical malacia
# obesity
# GERD
# avascular necrosis of the L hip s/p L hip replacement in [**2161**]
# alcohol abuse
# RUE DVT in [**2167-10-14**]
# Tracheostomy and PEG placement [**2169-3-13**]
# COPD
# granulomas in L lung
# s/p TAH
# s/p appendectomy
Social History:
Ms. [**Known lastname 42611**] had been a regional manager at insurance company.
She lives with her boyfriend of 14 years. Patient has history of
significant alcoholism. Former smoker
Family History:
Noncontributory
Physical Exam:
VS: T: 98.7 HR: 81-82 SR BP: 102-118/64 Sats: 95% 2L nasal
cannula. Room air 86-88%
BS: 126-170
Gen: pleasant in NAD
Neck: cervical incision with slight erythema, slight swelling
without drainage.
Lungs: decreased breath sounds bilateral with faint bibasilar
crackles. no wheezes
CV: RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND, PEG site clean no erythema or discharge
Ext: warm without edema
Neuro: awake, alert oriented
Pertinent Results:
CXR:
[**2170-2-15**]: Calcified left basal granuloma. Status post old left
ribs fracture. Bilateral areas of atelectasis that are basically
unchanged. No newly appeared focal parenchymal opacities. No
larger pleural effusions. No evidence of pulmonary edema.
[**2170-2-12**]: Right hemidiaphragm is chronically elevated
substantially. Persistent obscuration of the left diaphragmatic
contour indicates combination of small pleural effusion and
worsening left lower lobe atelectasis, now probably collapsed.
Upper lungs are grossly clear. Heart size normal.
[**2170-2-10**]: Lung volumes remain very low, and there is greater
consolidation at both lung bases, particularly the right since
[**2-9**], most likely atelectasis. Small left pleural
effusion has increased. Heart is top normal size, unchanged. I
see no endotracheal tube. There is no pneumothorax.
[**2170-2-14**] WBC-5.9 RBC-3.17* Hgb-8.4* Hct-25.9 Plt Ct-209
[**2170-2-13**] WBC-6.8 RBC-3.29* Hgb-8.5* Hct-26.8 Plt Ct-181
[**2170-2-8**] WBC-9.2 RBC-3.71* Hgb-9.2* Hct-28.9 Plt Ct-231
[**2170-2-7**] WBC-8.2 RBC-4.43 Hgb-11.4* Hct-35.1 Plt Ct-214
[**2170-2-14**] Glucose-117* UreaN-14 Creat-0.7 Na-145 K-4.4 Cl-101
HCO3-38
[**2170-2-11**] Glucose-123* UreaN-14 Creat-0.8 Na-146* K-4.1 Cl-107
HCO3-35
[**2170-2-8**] Glucose-137* UreaN-14 Creat-0.8 Na-148* K-3.5 Cl-111*
HCO3-27
[**2170-2-14**] Calcium-8.8 Phos-3.7 Mg-2.3
Micros: [**2170-2-8**] MRSA SCREEN Source: Nasal swab. No MRSA
isolated.
Brief Hospital Course:
Ms. [**Known firstname **] [**Known lastname 42611**] was taken to the operating room by Dr.
[**Last Name (STitle) **] on [**2170-2-8**] for a cervical tracheal resection and
reconstruction and bronchoscopy with bronchoalveolar lavage for
cervical malacia and guard suture placement. She transferred to
the ICU intubated monitored overnight.
Neuro/Pain: Initial pain management was achieved with IV
Dilaudid and propofol while intubated. This was later
transitioned to Roxicet via PEG with good control. The patient
remained neurologically per her baseline: intact but with some
memory loss. She is compulsive with taking off oxygen and
getting out of bed. She was kept under fall precautions. Her
home Seroquel of 150 mg po daily was divided to 50 mg per NGT
TID, with good effect.
Pulmonary: She was extubated on POD1. Heliox and BiPAP for
hypercarbia during POD's [**1-15**]. With Aggressive pulmonary toilet,
mucolytics nebs and incentive spirometry her oxygenation
improved. Supplemental oxygen was titrated to 2 L nasal cannula
with saturation of 97%. Titrate oxygen to maintain oxygen
saturations > 92%. Room air oxygen saturation 86-88%.
Serial Chest X-ray's (see above report)
Bronchoscopy, flexible [**2170-2-14**] showed intact cervical
anastomosis, with abnormal bronchial mucosa in the cervical
anastomosis, and abnormal bronchial mucosa in the proximal and
mid trachea. Her guard suture was removed.
CV: The patient was tachycardic initially which improved with
home diltiazem, switched to 60 mg po qid for PEG tube. She
remained hemodynamically stable throughout in sinus rhythm 80's,
blood pressure 100-120's.
GI/Nutrition: Tube feeds were resume via PEG POD1. Strict NPO
for known aspiration. She was evaluated by the registered
dietician with tube feed recommendations of replete with fiber
at 70 ml/hour.
Renal/GU: Foley removed [**2170-2-12**]. She voided well thereafter.
Electrolytes were monitored and treated as needed. Hypernatremia
peak NA 148 discharge 145, normalized with free water and
Aldactone.
Heme: No blood transfusions. Stable anemia.
ID: She remained afebrile, with stable WBC counts. CBC trends
were watched throughout her stay.
Endocrine: Fingerstick blood sugars < 200.
Drains: JP removed [**2170-2-12**].
Prophylaxis: SQ heparin and SCD's were instituted to prevent
VTE.
Disposition: Physical therapy deemed the patient appropriate for
rehabilitation. She continued to make steady progress and was
discharged to [**Hospital1 41724**] in [**Location (un) 701**] on [**2170-2-16**]. She will
follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] as an outpatient.
Medications on Admission:
1. diltiazem HCl 120 mg Capsule, Sustained Release [**Last Name (STitle) **]: One (1)
Capsule, Sustained Release PO BID (2 times a day).
2. Nexium 40 mg Capsule, Delayed Release(E.C.) [**Last Name (STitle) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. quetiapine 150 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: One (1)
Tablet Sustained Release 24 hr PO once a day.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
5. multivitamin Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day.
6. home oxygen
40% humidified oxygen continuous via trach collar.
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2
times a day) as needed for constipation.
2. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ml
Injection TID (3 times a day): SQ for VTE prophylaxis.
3. oxycodone-acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
4. acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: Three (3) ML
Miscellaneous every twelve (12) hours as needed for thick
secretions: mix with albuterol to prevent bronchospasm.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze.
6. diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day): give crushed via PEG.
7. Seroquel 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a
day: crushed via peg.
8. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day: crush, give via peg.
9. lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO BID (2
times a day): hold for loose stools.
10. guaifenesin 600 mg Tablet Sustained Release [**Last Name (STitle) **]: One (1)
Tablet Sustained Release PO twice a day.
11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Last Name (STitle) **]:
One (1) Inhalation once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Cervical malacia s/p tracheal resection and reconstruction
[**2170-2-8**]
TBM s/p right tracheoplasty [**2169-7-7**]
GERD
Esophageal dysmotility with aspiration
Tracheostomy and PEG placement [**2169-3-13**]
COPD
Granulomas in L lung
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office at [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Cervical incision develops drainage or increased redness.
Pulmonary: aggressive pulmonary toilet with mucolytic nebs
Oxygen titrate to maintain oxygen saturations > 93%
Humidified oxygen to help keep secreations loose
Diet: Strict NPO secondary to aspiration
Followup Instructions:
Appointments Location: [**Hospital Ward Name 517**] [**Hospital Ward Name 121**] Building [**Hospital1 **] I
West [**Hospital 7755**] Clinic
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2170-3-6**] 11:00 [**Hospital Ward Name 121**] Building [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 479**]
[**Hospital 7755**] Clinic
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2170-3-6**]
11:30
Provider: [**Name10 (NameIs) 5073**] INTAKE,ONE [**Name10 (NameIs) 5073**] ROOMS/BAYS Date/Time:[**2170-3-6**] 1:00
Hold Tube feedings midnight the night before her appointment for
Flexible Bronchoscopy
Completed by:[**2170-2-20**]
ICD9 Codes: 2760, 2930, 496, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7991
} | Medical Text: Admission Date: [**2166-6-5**] Discharge Date: [**2166-6-7**]
Date of Birth: [**2087-6-7**] Sex: F
Service: MEDICINE
Allergies:
Rapamune / Ativan
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 78 year old female with history of polycystic
kidney disease s/p DDRT, HTN, diastolic CHF, who presents with
malaise, fever, and hypoxia. Pt reports overall malaise, not
feeling well for the past week or so. She has had nausea and
decreased PO intake. Yesterday developed SOB with band-like
tightness across her upper abdomen. Also had L-sided chest
discomfort 2 days ago. These symptoms are similar to previous
CHF exacerbation, per pt. Has had dry cough for past few days.
Denies diarrhea, but has loose stools on lactulose. Noted temp
to 100 at home earlier today and called EMS.
.
In the ED, initial vs were: T 99.6, P BP 209/107, R O2 sat 87%
on 4L NC. She was put on [**First Name3 (LF) 597**] and then BiPap. For her BP, nitro
paste was placed and then she was transitioned to a nitro gtt
with good BP response. Temp spiked to 102 rectally and so she
was started on vanco/zosyn. CXR consistent with volume overload.
BNP> 70,000. EKG with STE in V2-3 and STD in V5-6, trop 0.1
(baseline 0.06). Cards did not feel urgent heparin was
necessary. Pt also received zofran for nausea, hydrocortison
100mg IV x 1 (given chronic steroids). Admitted to the MICU for
further monitoring.
.
On arrival to the MICU, she reports feeling much improved. Still
complains of band-like discomfort across her abdomen. Denies
SOB.
.
Review of sytems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied chest pain or tightness, palpitations. Denied vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
Past Medical History:
1. Polycystic kidney disease, s/p deceased-donor renal
transplant (DDRT) in [**2155**], s/p bilateral native nephrectomy
[**2148**], [**2152**]
2. Polycystic liver disease, s/p liver resection - left
hepatic trisegmentectomy and right lobe cyst reduction ([**2157**])
3. Recurrent partial SBO
4. S/p cholecystectomy
5. S/p appendectomy
6. Parathyroid adenoma s/p excision ([**2158**])
7. Hypertension
8. Breast cancer s/p left radical mastectomy ([**2151**])
9. History of right elbow and humeral fracture
10. History of incarcerated hernias although per history
"reduced" nonsurgically in the past
11. Spinal stenosis
12. Irreducible rectal prolapse s/p abdominal rectopexy
([**2165-3-27**])
13. Depression
14. Chronic Grade II diastolic CHF
Social History:
Lives with her husband, who is 92. Has weekly VNA and also home
health aide who assists with bathing, cooking, and cleaning. Has
2 adult children nearby. Never smoker. Occasional alcohol. Uses
a cane and sometimes a walker.
Family History:
11 family members with polycystic kidney disease.
Physical Exam:
Vitals: Afebrile, BP: 140s-150s/70s P: 60s, R: 19, O2: 95% on
RA, 90% ambulating
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, bipap mask in
place
Neck: supple, JVP not elevated, no LAD
Lungs: mild crackles at R base, no wheeze
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: multiple healed surgical scars across abdomen, BS
present, distended, diffuse mild tenderness to palpation, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, trace bilateral LE edema,
no clubbing, cyanosis. Significant R UE Fistula with thrill
Pertinent Results:
Discharge Labs:
[**2166-6-7**] 05:25AM BLOOD WBC-5.0 RBC-2.95* Hgb-9.1* Hct-28.8*
MCV-97 MCH-30.6 MCHC-31.5 RDW-17.5* Plt Ct-146*
[**2166-6-7**] 05:25AM BLOOD Plt Ct-146*
[**2166-6-7**] 05:25AM BLOOD Glucose-79 UreaN-75* Creat-3.1* Na-143
K-4.5 Cl-106 HCO3-21* AnGap-21*
[**2166-6-6**] 10:55AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2166-6-6**] 02:54AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2166-6-5**] 06:30PM BLOOD cTropnT-0.10*
[**2166-6-5**] 06:30PM BLOOD CK-MB-NotDone proBNP->[**Numeric Identifier **]
[**2166-6-7**] 05:25AM BLOOD Calcium-8.4 Phos-5.6* Mg-2.6
[**2166-6-5**] 06:36PM BLOOD Lactate-1.1
Microbiology:
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2166-6-6**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2166-6-6**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
URINE CULTURE (Final [**2166-6-6**]): NO GROWTH.
Blood Cx [**6-5**] Pending, Call [**Telephone/Fax (1) 2756**] to obtain results.
Imaging:
CXR: [**2166-6-5**] IMPRESSION: Findings are most compatible with volume
overload and CHF. Repeat radiography after appropriate diuresis
is recommended to assess for underlying infection. Please note
the patient has had prior right upper lobe pneumonias, which
appear relatively similar to the added density noted on the
current study.
Echo [**2166-6-6**]: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF 50%). 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 ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve 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 moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2165-6-19**], the left ventricular ejection fraction is
reduced. There is increased evidence for delayed
relaxation/diastolic dysfunction od the left ventricle.
Significant pulmonary hypertension persists.
Abd X-ray [**2166-6-8**]: Again seen is marked degenerative change in
thoracolumbar spine, with severe scoliotic curvature.
Degenerative changes
are seen in the hips. The gas pattern remains non-specific, with
scattered
air in the small and large bowel, with air seen extending into
the rectum.
There is no evidence for obstruction on today's study. There is
no bowel wall thickening, pneumatosis, or supine evidence of
free air. Numerous surgical clips are again seen throughout the
mid abdomen.
IMPRESSION: Non-specific bowel gas pattern, with no dilated
loops of small
bowel and air seen extending to the rectum. There is no evidence
for
obstruction.
Brief Hospital Course:
This is a 78 year-old female with Polycystic Kidney disease
status post renal transplant admitted to the MICU for Pulmonary
edema.
1) Pulmonary Edema: The patient was admitted to the MICU with
flash pulmonary edema from hypertension/CHF. She was admitted
and weaned from a nitro drip and her BPs returned to [**Location 213**]
140s. Initial concern for Pneumonia prompted tratment with
Vanc/Zosyn/Levaquin that was discontinued after normal CXR and
improving respiratory function. TTE showed decreased ejection
fraction. She was aggressively diuresed with Lasix IV and her
symptoms resolved. After transfer to the medical floor, the
patient's oxygen requirement resolved and she was discharged
with home physical thearapy. No changes to Heart Failure or
renal regimen.
2) Polycystic Renal Disease, s/p Transplant: The patient was
admitted with Creatinine elevated between 2.9-3.1. She was
continued on her anti-rejection therapy, and discharged on her
home lasix dose.
3) Elevated Troponin: The patient did have elevated troponin
without specific EK changes. She was briefly started on
Aspirin, but stopped given her GI bleed history after not
convincingly ruling in for myocardial infarction.
4) Anemia of Chronic disease with possible iron deficiency
component: Patient continued on Epogen and started on Iron
supplementation with Colace
5) Abdominal Distention: The paitent reported this was
increased from baseline, but imaging and bowel function remained
intact, and her exam was not suggestive of an acute process.
She will follow with her primary care physician.
6) Depression: Continued sertraline.
Medications on Admission:
CellCept 500mg PO BID
Prednisone 6mg PO daily
Diltiazem 240mg PO daily
Irbesartan 150mg PO daily
Furosemide 20mg PO BID
Epo 15,000 units q week
Calcitriol 0.25 mcg PO daily
Vitamin D3 400mg PO daily
Sertraline 25mg PO daily
Clonazepam 0.5mg PO QHS prn
Gabapentin 100mg PO TID
Tramadol 50 mg PO daily
Lidocaine 5% patch daily to back
Zolpidem 5mg PO qHS
Senna 8.6mg PO daily prn
Lactulose 30 ml PO TID prn
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Prednisone 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
3. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
4. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO once a day.
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Epoetin Alfa 10,000 unit/mL Solution Sig: 1.5 mL Injection
once a week.
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety/insomnia.
11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for pain.
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
16. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnoses:
1. Pulmonary Edema
2. Renal Transplant
Secondary Diagnoses
Polycystic kidney disease
Polycystic liver disease
Spinal stenosis
Depression
Chronic Grade II diastolic CHF
Discharge Condition:
Stable on room air, afebrile, ambulatory.
Discharge Instructions:
You have been admitted to the Intensive Care Unit hospital
because of shortness of [**Name (NI) 1440**] due to "Pulmonary Edema," a
condition in which your lungs collect fluid because of high
blood pressure. We have given you lasix to take off excess
fluid and correct his problem.
We have added two medications for low blood counts (anemia):
Ferrous Sulfate 325mg by mouth daily (Iron)
Colace 100mg by mouth twice daily (Stool softener)
Please call your doctor or 911 if you feel short of [**Name (NI) 1440**], have
chest pain or any other concerning symptom.
Happy Birthday!
Followup Instructions:
Please Call [**Telephone/Fax (1) 60**] to make an appointment with Dr.
[**Last Name (STitle) **] within 1 week of discharge.
ICD9 Codes: 4280, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7992
} | Medical Text: Admission Date: [**2132-9-4**] Discharge Date: [**2132-9-9**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
1. SOB x 1 week
2. intermittent black stool for 6 months
Major Surgical or Invasive Procedure:
Upper Endoscopy
Colonoscopy
History of Present Illness:
This is an 80 yo F who presents to the ED with SOB and LE edema
x1 week. On arrival to the ED, she was unable to speak in full
sentences and was wheezing. On further questioning, she claims
that she had not been taking her usual dose of lasix for one
week. Her presciption had ran out.
She also notes a 6 month history of intermittent black stool.
She has discussed this with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Her most recent
occult blood in [**2132-8-20**] was negative and according to Dr. [**Last Name (STitle) **],
the stool was brown, not black as she describes it. Patient also
claims that she has occasional BRBPR on straining with BMs, with
a history of hemorrhoids. She is on a daily ASA, and denies
other NSAID use. She has no history of alcohol consumption.
Denies abd pain/nausea/vomitting/hemetemesis.
On ROS, she denies chest pain/fever/ chills/changes in bowel
habit/headache/hemeturia/changes in diet.
Past Medical History:
1. DM II
2. HTN
3. pulmonary hypertension
4. increased cholesterol
5. chroninc low back pain and sciatica
Social History:
Denies ETOH, IVDA, or tob use.
Physical Exam:
BP 150/58 P70
Gen: comfortable, pale elderly Russian speaking female lying in
bed in NAD.
HEENT: PERRL. Anicteric. MMM. Pale conjunctiva
Neck: Supple. No masses or LAD. JVD 8-10 cm.
Lungs: diffuse crackles.
Cardiac: RRR. S1/S2. II/VI systolic M heard best at apex.
Abd: Soft, obese, NT, ND, +NABS. No rebound or guarding.
Extrem: 3+ pitting edema b/l, palpable DP pulses
Neuro: CN II-VII intact, [**4-30**] musc strength UE/LE
Pertinent Results:
[**2132-9-4**] 08:14PM HGB-5.7* calcHCT-17
[**2132-9-4**] 04:22PM URINE HOURS-RANDOM
[**2132-9-4**] 04:22PM URINE GR HOLD-HOLD
[**2132-9-4**] 04:22PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2132-9-4**] 04:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2132-9-4**] 04:22PM URINE RBC-<1 WBC-<1 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2132-9-4**] 04:18PM PT-13.3 PTT-29.5 INR(PT)-1.1
[**2132-9-4**] 03:21PM GLUCOSE-169* UREA N-86* CREAT-1.1 SODIUM-142
POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-20
[**2132-9-4**] 03:21PM CK(CPK)-38
[**2132-9-4**] 03:21PM CK-MB-NotDone cTropnT-<0.01
[**2132-9-4**] 03:21PM VIT B12-182*
[**2132-9-4**] 03:21PM WBC-10.2# RBC-1.92*# HGB-5.4*# HCT-17.0*#
MCV-88 MCH-27.9 MCHC-31.6 RDW-17.2*
[**2132-9-4**] 03:21PM NEUTS-77.8* LYMPHS-18.0 MONOS-3.0 EOS-0.7
BASOS-0.5
[**2132-9-4**] 03:21PM HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-1+
[**2132-9-4**] 03:21PM PLT COUNT-362#
Brief Hospital Course:
80 yo F w/ DM2, HTN, PA HTN p/w SOB and LE edema x1 week, now
with severe anemia
(hct of 17 noted by her PCP) thought to be secondary to UGIB,
hemodynamically stable s/p 6 Units of bld w/ increase of hct to
30. serial hcts q 6 hrs remained stable at 30.
Pt had EGD in ED ([**2132-9-5**]) which revealed granularity,
friability and erythema in the stomach body, fundus and antrum
compatible with acute gastritis (biopsy obtained). Erythema in
the duodenal bulb compatible with duodenitis. Ulcer in the
distal bulb. Otherwise normal EGD to second part of the
duodenum.
Echo:([**2132-8-23**])
1. The left atrium is mildly dilated.
2. 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%).
3. The aortic valve leaflets are mildly thickened. Mild (1+)
aortic regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
5. Compared with the findings of the prior study (tape reviewed)
of [**2128-8-18**], there has been no significant change.
1. GIB with increased BUN, likely UGIB, however LGIB initially
considered as well.
Pt had 2 large bore IV's placed. NG lavage was positive as well
as stool guiacs. EGD as above. No active bleed noted however
ulcer and gastritis likely source of anemia. Ulcer thought to be
secondary to NSAID use vs H. pylori. Will treat for H.Pylori if
indicated. Pt will follow up with GI. ASA was held secondary to
bleed. Losartan was initially held, then restarted at half
normal dose. NSAIDs were avoided. Initially given IV PPI [**Hospital1 **]
which was then changed to po. Colonoscopy performed was reported
to be normal.
2. Cardiac. EKG changes (NSR at 84, Nl axis and intervals, TWI
III, TWI V1-V4). Pt was ruled out for MI with three sets of neg
cardiac enzymes. She denied CP. ECG changes likely secondary to
demand ischemia from severe anemia. She was initially monitored
on tele with no events. An echo done on [**2132-8-23**], as above
(LVEF>55%). SOB most likely due to discontinuation of lasix for
one week in setting of diastolic CHF. Treated with 40 of lasix
IV (held off on diuresis intially secondary to concern for GI
bld).
3. Resp. CXR done on [**2132-9-5**] without overt evidence of CHF or
pneumonia. Findings suggestive of pulmonary artery hypertension.
She required O2 supplementation during her stay and was noted
to have RA sats in the 80's with ambulation likely secondary to
PA HTN. She was sent home on supplemental O2. A Repeat cxr was
suggestive of pulm congestion. Lasix given as above.
4. DM2. Initially bld sugars controlled with RISS, oral
hyperglycemics were restarted prior to discharge.
5. Anemia secondary to gastritis and PUD, as well as Fe/Vit B12
def. She was transfused a total of 6 Units of PRBC's and her hct
was monitored q 6 hrs. She was started on Vit B12
supplementation. She was continued on Niferex.
Medications on Admission:
1. Niferex 150 [**Hospital1 **]
2. metformin 850 TID
3. Losartan 50
4. Rosiglitazone 8 QD
5. Lipitor 20
6. ASA 81
7. lasix 40 [**Hospital1 **]
8. Paxil 20
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Metformin HCl 850 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Rosiglitazone Maleate 8 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
5. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
6. Pantoprazole Sodium 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*
7. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO QD (once
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO once a
day.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Supplemental Oxygen
Please use supplemental Oxygen with exerction.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Upper GI Bleed secondary to Gastritits
Secondary Diagnoses:
DM
HTN
Vitmain B12 deficiency
Discharge Condition:
Good.
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience further bleeding, shortness of
breath, or any other problems arise. Please use supplemental
oxygen with exerction.
DO NOT TAKE ASPIRIN.
Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1953**], [**Name12 (NameIs) 280**] Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-9-17**]
10:40
2. Provider: [**Name10 (NameIs) **] Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2132-9-30**] 2:20
3. Provider: [**Name Initial (NameIs) **] PAIN MANAGEMENT CENTER Where: PAIN
MANAGEMENT CENTER Date/Time:[**2132-9-17**] 3:00
4. Provider: [**First Name11 (Name Pattern1) 1955**] [**Last Name (NamePattern4) 1956**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2132-10-31**] 1:00
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7993
} | Medical Text: Admission Date: [**2119-9-29**] Discharge Date: [**2119-10-6**]
Date of Birth: [**2060-9-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
subclavian central venous catheter placement
endotracheal intubation and extubation
peripherally inserted central venous catheter
History of Present Illness:
59 yo M with advanced MS, hx of MRSA/VRE, neurogenic bladder,
g-tube/colostomy, psych disorders, hypothyroidism presents from
NH with hypoxia. Patient noted to be shortness of breath,
tachypnea, tachycardia, diaphoretic starting [**2119-9-27**]. Patient
dx with LLL PNA at [**Hospital 100**] rehab on [**9-27**] started on Augmentin
and Nebs. NH VS Tmax 100.2 HR 120-130s, BP 110/60's, RR 40 O2
sat 80's on 4 L NC. ABG was 7.56/26/83. Patient transfered to
[**Hospital1 18**] for ongoing management.
.
In the ED VS: 98.0 125 100/60 20's-40 99% NRB. CXR showing
possible aspiration, CTA protocol r/out PE c/w multilobar PNA.
Started Vanco, levo, Flagyl for aspiration PNA. Total 3 L fluid
bolus for BP 80->90s via right subclavian line placed in ED.
.
Upon arrival to the ICU, VSS, BP 110's, still very tachypneic RR
~40 however does not appear in distress, O2 sat 99% NRB, desats
to upper 70's when pulls off mask.
Past Medical History:
- Multiple sclerosis.
- Neurogenic bladder.
- Swallowing disorder.
- Schizoaffective disorder/Depression.
- Hypothyroidism.
- s/p colectomy with mucous fistula in [**2106**] secondary to C.diff
colitis, course complicated by abscess, has G-tube
- h/o aspiration pneumonia
- h/o MRSA/VRE in urine [**2107**]
- GERD
- anxiety
Social History:
The patient is a [**Hospital 100**] Rehab resident. No
ETOH, no tobacco, no IV drug use. has legal guardian
Physical Exam:
Upon arrival to the ICU:
VS: 97.3 BP 112/73 HR 121 97% NRB-->78% RA
Gen: middle aged male, contracted on left side, non verbal, NAD,
not using accessory muscles of respiration.
Neck: supple, JVD above clavicle at 45 degrees
Heent: slightly pale, MMM, PERRL, anicteric, sunken eyes
Skin: pale, no rashes, moist, few LE excoriations
Chest: rhonchi diffusely, good air entry, no rales
CVS: nl S1 S2, tachy, regular, no m/r/g appreciated
Abd: soft, colostomy draining soft brown stool, NT/ND, BS+
Ext: atrophy, no edema, +excoriations, warm, 2+ dp pulses b/l,
right arm/hand contracted
Neuro: PERRL, 2mm pupils, does not follow commands, moans, able
to use left hand
.
Pertinent Results:
Admission Labs:
[**2119-9-29**] 12:40AM WBC-10.7 RBC-3.11*# HGB-9.0*# HCT-27.1*#
MCV-87 MCH-28.9 MCHC-33.2 RDW-16.7*
[**2119-9-29**] 12:40AM PLT COUNT-156
[**2119-9-29**] 12:40AM NEUTS-84.4* LYMPHS-8.4* MONOS-5.1 EOS-1.7
BASOS-0.3
[**2119-9-29**] 12:40AM GLUCOSE-109* UREA N-31* CREAT-1.2 SODIUM-135
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15
[**2119-9-29**] 12:55AM LACTATE-2.1*
[**2119-9-29**] 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2119-9-29**] CXR: There is a consolidation at the left lower lobe
with air bronchograms. There is diffuse opacification of both
lung fields. There is mild re-distribution of pulmonary
vasculature, but no septal lines and no frank evidence for
pulmonary edema. The heart and great vessels of the mediastinum
are stable. Severe thoracolumbar scoliosis is again noted.
IMPRESSION: Left lower lobe pneumonia with more diffuse
pneumonia or mild pulmonary edema.
.
[**2119-9-29**] CTA chest:
Brief Hospital Course:
A/P: 59 yo patient with advanced MS presents with multilobar
PNA.
.
1.) Multilobar Pneumonia/Respiratory Failure: The patient had a
fever, cough, and chest xray finding s consistent with
pneumonia. He developed progressive respiratory distress and
was electively intubated and placed on mechanical ventilation.
He underwent a bronchoscopy which on lavage releaved staph
aureas (methicillin resistant) and a moderate amount of
hemorrhage. He was treated initially with broad spectrum
antibiotics which were later tailored once antibiotic
sensitivities were available. He will complete a 14 day course
of vancomycin (7 days of which after discharge). Of note, he
did develop a self-limited mild eosinophilia while on zosyn. He
did not develop a rash or clinically worsen. This should not be
thought of as an absolute contra-indication for future zosyn
therapy should this antibiotic be clinically indicated. He was
gradually weaned from the venilator as he was diuresed with
furosemide and acetazolamide. He was successfully extubated and
upon discharge he had stable oxygenation with supplemental
oxygen by face mask. A PICC line was placed for antibiotics.
His vancomycin on the day of discharge was held for a high
trough level. His goal vancomycin trough should be [**10-6**]. He
will be discharged on 1 gram of vancomycin every day which can
be adjusted per vancomycin trough. He received nebulized
bronchodilators.
.
2.) Hypotension: The patient did develop hypotension to sbp ~90
during his admission. This was thought likely to be from
sepsis. He was fluid resusitated and received brief period of
vasopressors. He had an appropriate response on [**Last Name (un) 104**]-stim
testing and did not require steroid replacement. Upon discharge
he was normotensive with maintenance of adequate urine output
and stable creatinine.
.
3.) Anemia. Hct 27 (baseline low 40's). Guiac positive ostomy
output per ED. The hematocrit drop was thought secondary to the
pulmonary hemorrhage with subsequent blood being swallowed into
the stomach. His hematocrit stabilized. He did not require
blood transfusions.
.
4.) Hypothyroid: no acute issues during this hospitalization and
he continued on his home dose of synthroid.
.
5.) GERD. PPI, elevate head of bed.
.
6.) Psych. H/o schizoaffective disorder, anxiety. The patient
is non-verbal and minimally responsive at baseline and it was
difficult to assess mood or thought disorders. A psychiatry
consult was obtained to make recommendations on use of the
patient's despiramine during this acute illness. A despramine
level was checked and found to not be toxically elevated. He
was continued on this medication. He received versed and
fentanyl while intubated then low dose ativan as needed for
anxiety and agitation post-extubation.
.
7.) Multiple Sclerosis: The patient has advance multiple
sclerosis. He has a neurogenic bladder and chronically foley
dependent. Urine output was monitored with foley catheter in
place
.
8.) PPx. PPI, Heparin SC, hold bowel reg/has colostomy
.
9.) FEN. He recieved tube feeds via his gastrostomy tube. His
electrolytes were repleted as necessary.
.
10.) Thrombocytosis: The patient had an elevated platelet count
which was thought to be a reactive process secondary to his
resolving pneumonia exacerbated by the diuresis that was
required to resolve the pulmonary edema. This lab value should
be follow-up to insure resolution.
.
11.) Full Code. Confirmed in NH records and with sister who is
legal guardian.
.
12.) Dispo: The patient was monitored in the intensive care unit
while in the hospital. He was transferred back the the MAC unit
where he was a resident.
.
13.) Access: He had a subclavian central venous catheter placed
for volume resusitation. He was discharge with PICC line for
the IV antibiotics.
.
14.) Comm: Sister [**Name (NI) **] [**Name (NI) 1726**] [**Telephone/Fax (1) 104993**], [**Telephone/Fax (1) 104994**];
Brother [**Name (NI) 4036**] [**Name (NI) 104995**] [**Telephone/Fax (1) 104996**]
PCP [**Name Initial (PRE) **] [**Telephone/Fax (1) 608**]
Medications on Admission:
- Augmentin 500 mg q12 started [**9-28**]
- Ativan 0.5 prn
- Synthroid 50 mcg daily
- Pepcid 20 mg daily
- MVI daily
- Desipramine 75 mg daily
- G-tube Jevity 1.2 cal
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Pneumonia
Sepsis
.
Secondary:
Multiple sclerosis
schizoaffective disorder
neurogenic bladder
hypothyroidism
Anemia
c. dif colitis s/p colectomy with mucous fistula
Discharge Condition:
stable. afebrile. stable vital signs. tolerating tube feeds at
goal.
Discharge Instructions:
You have been evaluated and treated for pneumonia. You will
continue to receive antibiotics for the next 7 days according to
the prescriptions.
Followup Instructions:
Per extended care facility routine
ICD9 Codes: 5070, 0389, 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7994
} | Medical Text: Admission Date: [**2148-3-27**] Discharge Date: [**2148-3-28**]
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
woman with a history of hypertension and peripheral vascular
disease who presented to her primary care physician in
[**2147-11-25**] with a complaint of cough and chest
tightness. The symptoms persisted and the patient had a
chest x-ray done on [**2148-3-6**], which showed a large right
sided [**Location (un) 21851**] in the paratracheal region.
On review of systems, the patient reports slow progression of
exertional dyspnea, fatigue, anorexia and hemoptysis times
several weeks. The patient presented to the Emergency Room
on [**2148-2-26**], with significant worsening of dyspnea,
wheezing and cough. CT scan was done which showed a large
right upper lobe mass extending into the mediastinum, 7.2
centimeters by 7.7 centimeters, associated with right upper
lobe collapse. There was extensive right hilar and
sub-carinal lymphadenopathy with an 8 millimeter nodular
density in the right posterior middle lobe and small right
pleural effusion.
The patient was discharged and had an outpatient bronchoscopy
performed which showed tumor invasion in the distal tracheal,
right main-stem bronchus was patent at that time. Unable to
do biopsy secondary to patient coughing, discomfort and
difficulty visualizing the bronchus. Repeat bronchoscopy was
done on [**2148-3-15**], which showed complete obstruction of the
main stem bronchus. Biopsies taken indicated poorly
differentiated carcinoma infiltrating bronchial sub-mucosa.
The patient was admitted on [**2148-3-16**], to [**Hospital3 20445**] for worsening shortness of breath. The patient was
started on Solu-Medrol which was subsequently changed to
Prednisone. The patient underwent a staging work-up with
abdominal CT scan which showed no metastases. The patient
was sent for mapping to initiate XRT to large lung mass.
While lying flat, the patient became more dyspneic with
increasing coughing and obvious cyanosis. The patient
underwent an emergency CT scan which showed progression of
disease and compression of the trachea and main [**Last Name (un) 2435**]
bronchus. The patient was sent to [**Hospital1 190**] for emergent XRT and then sent back to
[**Hospital3 1196**] for chemotherapy. The patient
received one cycle of Carboplatin and Taxol on [**2148-3-24**],
and has had a total of five cycles of XRT (last cycle on
[**2148-3-22**]).
The patient reportedly developed increasing cough with
periods of bronchospasm and cyanosis despite increasing doses
of steroids, nebulizer treatments and heated face mask. The
patient was referred to [**Hospital1 69**]
for stenting of her trachea and right main stem bronchus.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Severe peripheral vascular disease on Coumadin status
post bilateral femoral-popliteal bypass in [**2127**].
3. Status post left below the knee amputation in [**2128**]
secondary to obstructing clot and left foot ischemia.
4. In [**2140**], the patient underwent a redo right axillary
shunt to lower extremity bypass which was complicated by
postoperative pulmonary embolus treated with Coumadin and IVC
filter placement.
5. Non-small cell lung cancer as above.
The patient's Oncologist is Dr. [**Last Name (STitle) 6099**] and Dr. [**First Name8 (NamePattern2) 3551**] [**Last Name (NamePattern1) 8631**].
Her Pulmonologist is Dr. [**Last Name (STitle) 40217**].
MEDICATIONS AT HOME:
1. Coumadin 2 mg p.o. q. h.s.
2. Maxzide.
MEDICATIONS ON TRANSFER:
1. Diltiazem 60 mg p.o. q. day.
2. Albuterol and Atrovent nebulizers q. four hours.
3. Decadron 4 mg intravenous q. four hours.
4. Levaquin 250 mg p.o. q. day.
5. Robitussin and Tessalon Pearls p.r.n.
SOCIAL HISTORY: The patient is widowed for seven years.
She has three children. She lives independently and
ambulates with a cane. She has 40 pack year history of
smoking; quit in [**2127**].
PHYSICAL EXAMINATION: Temperature 98.6 F.; blood pressure
134/60; pulse 110; saturation of 93% on five liters. In
general, the patient was alert and oriented times three.
Cardiovascular: The patient was tachycardic with no
appreciable murmurs, rubs or gallops. Lungs: Bronchial
breath sounds, left greater than right. Abdomen: Obese,
nontender, not distended, normal bowel sounds. Extremities:
Left below the knee amputation. No cyanosis, clubbing or
edema.
LABORATORY: On admission, white blood cell count 25.0,
hematocrit 32.3, platelets 185. Sodium 129, potassium 5.1,
BUN 39, creatinine 0.9, albumin 2.8, calcium 8.5, magnesium
2.1.
HOSPITAL COURSE: The patient is an 80 year old woman with
poorly differentiated non-small cell lung cancer admitted
with compression of the trachea and right main stem bronchus
by a large right upper lobe tumor.
On hospital day one, the patient underwent a rigid
bronchoscopy with findings of the right upper lobe occluded
by tumor; in addition, distal trachea had a near total
obstruction by tumor. The patient underwent placement of a
stent to the distal trachea and right main stem bronchus.
Repeat bronchoscopy was performed on hospital day number two,
which showed stents to be patent and in good position.
Distal airways were patent as well and mild to moderate
secretions were noted bilaterally.
Post-procedure, the patient maintained O2 saturations of 93
to 98% on a 50% face mask (this was her O2 requirement on
admission). The patient was subsequently transitioned to
shovel mask with three liters nasal cannula, again
maintaining her saturations above 93%. The patient did note
subjectively improvement in shortness of breath
post-procedure. The patient was continued on humidified
oxygen, standing Albuterol and Atrovent nebulizers q. four
hours. In addition, the patient was given Lidocaine
nebulizers to help with continued cough. In addition, the
patient was continued on Decadron to help decrease
inflammation in the bronchus and was continued on
prophylactic antibiotics with Levaquin and Flagyl
post-procedure.
MEDICATIONS AT THE TIME OF DISCHARGE:
1. Diltiazem 60 mg p.o. q. day.
2. Heparin 5000 units subcutaneously twice a day.
3. Decadron 4 mg intravenously q. four hours.
4. Protonix 40 mg p.o. q. day.
5. Levaquin 500 mg p.o. q. day.
6. Flagyl 500 mg p.o. q. eight hours.
7. Albuterol and Atrovent nebulizers q. eight hours.
8. Lidocaine nebulizers 2.5 cc. of 1% Lidocaine q. one hour
p.r.n.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient will be discharged back to
[**Hospital3 1196**] for continuing care.
DISCHARGE DIAGNOSES:
1. Non-small cell lung cancer with compression of trachea
and main stem bronchus status post stent placement.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 1297**]
MEDQUIST36
D: [**2148-3-28**] 13:02
T: [**2148-3-28**] 13:26
JOB#: [**Job Number 40218**]
ICD9 Codes: 4439, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7995
} | Medical Text: Admission Date: [**2201-1-23**] Discharge Date: [**2201-2-2**]
Date of Birth: [**2154-5-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Increasing shortness of breath
Major Surgical or Invasive Procedure:
[**2201-1-26**] Atrial Septal Defect Repair with Bovine Pericardial
Patch, and Atrial Thrombectomy
History of Present Illness:
Mrs. [**Known lastname 20948**] is a 46 yo female with increasing SOB over past 3
weeks, associated with a 20 punds weight gain. She also noted
acrocyanosis one week prior to admission. Echo at outside
hospital reported large atrial septal defect wtih primarily left
to right shunt. There was moderate right ventricular dilatation,
moderate right ventricular hypokinesis with moderate pulmonary
hypertension. Echo also notable for a four centimeter clot in
the right atrium. Prior to surgical intervention, she underwent
cardiac catheterization which revealed normal coronary arteries.
She was transferred to the [**Hospital1 18**] for cardiac surgical
intervention.
Past Medical History:
Atrial Septal Defect with Right Atrial Thrombus
Pulmonary Hypertension
Obesity
History of Atrial Fibrillation
?Obstructive Sleep Apnea
Social History:
Denies tobacco and ETOH. Works as cafeteria worker.
Family History:
Denies premature coronary disease/sudden death.
Physical Exam:
PREOP EXAM:
Vitals: 98.7, 101/60, 92, 18, 95% 3L
NAD lying in bed
Neuro A&O nonfocal exam
Lungs with decreased breath sounds at both bases, fine crackles
Heart Irregular
Abdomen benign, obese
Extrem warm, 2+ BLE edema, Rash on bilateral ankles
Pertinent Results:
[**2201-1-23**] Transthoracic ECHO: The left atrium is mildly dilated.A
left-to-right shunt across the interatrial septum is seen at
rest across a large secundum atrial septal defect. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. The number
of aortic valve leaflets cannot be determined. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
[**2201-1-26**] Intraop TEE: PREBYPASS: A definite large (3.1cmx2cm)
thrombus in the right atrial appendage. There is a bidirectional
shunt across the interatrial septum at rest. A large secundum
atrial septal defect is present. The left ventricular cavity
size is normal. There is mild global left ventricular
hypokinesis (LVEF = 45-50 %). The right ventricular cavity is
markedly dilated with moderate global free wall hypokinesis. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. POSTBYPASS: Pt was removed from cardiopulmonary bypass
on epinephrine and phenylephrine infusions and was AV paced. 1.
The large ASD has been subsequently repaired; there is no
evidence of flow across the intraatrial septum. 2. The RV
remains markedly dilated with moderate global hypokinesis. 3. LV
remains with mild left ventricular hypokinesis without evidence
of regional wall abnormalities. 4. Aortic contours are intact
post decannulation.
[**2201-1-29**] CXR: The cardiomegaly is unchanged. The post-sternotomy
wires are intact. Bibasilar consolidations consistent with
atelectasis are grossly unchanged, still significant. There is
no appreciable pleural effusion, and there is no pneumothorax.
Brief Hospital Course:
She was started on a heparin drips. She was started on cipro for
a UTI. She was taken to the operating room on [**1-26**] where she
underwent an atrial thrombectomy and ASD repair. She was
transferred to the ICU in critical but stable condition on epi
and propofol. She was given 48 hours of vancomycin as she was in
the hospital preoperatively. She was extubated later that same
day. She was started on fluconazole for the rash on her ankles.
She was started on coumadin. She was transferred to the floor on
POD #1. Over the next several days the patient was gently
diuresed, she was started on Bblockers and was anticoagulated.
She has been in AFib with a rapid ventricular rate, up to the
140's with activity. By POD #7, after her Lopressor had been
increased, her heart rate was better controlled. She was also
started on Keflex for an IV site phlebitis. She is now stable,
and ready to be discharged home. Her Coumadin will be followed
by the [**Hospital 40198**] [**Hospital **] Clinic ([**Telephone/Fax (1) 77855**]), [**Doctor Last Name **] has been
notified, and records faxed to her there.
Medications on Admission:
Home: Aspirin, MVI
Transfer: Lisinopril 2.5 qd, Aspirin 81 qd, Lasix IV 40 bid,
Nexium 40 qd, IV Heparin, Metoprolol 50 tid, Silver Sulfa Cream,
Colace, KCL 40 qd, Digoxin 0.125 qd, Vitamin C, Zinc
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): take
1 tablet (5 mg) daily for 2 days, then as directed by [**Hospital 40198**]
Health Care Center ([**Telephone/Fax (1) 77856**].
Disp:*30 Tablet(s)* Refills:*0*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Please take two 200mg tablets once daily for 7days. Then one
200mg once daily until stopped by cardiologist.
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 40198**] VNA
Discharge Diagnosis:
Atrial Septal Defect with Right Atrial Thrombus - s/p Repair
Acute Right Heart Failure
Preoperative Urinary Tract Infection
Lower Extremity Rash
Obesity
History of Atrial Fibrillation
?Obstructive Sleep Apnea
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call for redness or drainage from surgical wounds
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
6)Monitor PT/INR every Mon, Wed, and Friday until INR stablizes.
[**Hospital1 40198**] Health Clinic will manage Coumadin dosing as outpatient.
VNA should call or fax results to clinic. Goal INR is between
2.0 - 3.0.
Followup Instructions:
[**Hospital 40198**] Health Care Center for INR check/Coumadin dosing on Weds
[**2-4**] at 10:00 am
Dr. [**Last Name (STitle) **] in [**2-21**] weeks, call for appt
Dr. [**Last Name (STitle) 77857**] 2-3 weeks, call for appt
Dr. [**First Name (STitle) 437**], call for appt
Completed by:[**2201-2-2**]
ICD9 Codes: 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7996
} | Medical Text: Admission Date: [**2149-1-29**] Discharge Date: [**2149-2-5**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
OP CABGx4(SVG-LAD,SVG-Diag,SVG-OM,SVG-PDA)[**1-31**]
History of Present Illness:
89 year old man with h/o HTN, admitted to OSH [**1-27**] with severe
[**10-21**] substernal chest pain, non-radiating. This occured after
the patient had gotten in an argument as well as had been
shoveling some snow prior to the onset of chest pain. Patient
usually does not have any anginal symptoms. He had some
associated SOB, no N/V, lightheadedness of diaphoresis. The pain
had improved to [**4-20**] with sublingual nitro he received by EMT en
route to the hospital. At the OSH an EKG revealed very mild ST
elevation V1-V3 and peaked T's. Initial troponin 0.064 with
subsequent troponin .350. CK 76. He receved Lopressor and nitro
in the ED. He was subsequently transferred to [**Hospital1 **] where he
underwent cardiac cath which revealed 3 vessel disease with a
tight proximal LAD lesion with thrombus, moderate stenosis of
the ostial RCA, OM2 with tight lesion. Post-cath course
complicated by a right groin hematoma 6"long x 1" wide. Hct 40.7
upon transfer (47 on admission). Patient was transfered here for
evalution for CABG. He came in on a heparin and integrillin gtt.
Past Medical History:
hypertension
kidney stones
polymyalgia [**Hospital1 23389**]
[**Hospital1 **] 7 years ago
s/p hernia repair
Social History:
Patient currently works as a constable for the town of [**Location (un) 1110**].
He lives at home with his wife whom he cares for. He formerly
smoked (15 pack year history) but quit 50 years ago, denies ETOH
or drug use.
.
Family History:
Family history notable for CAD in his brother and sister.
[**Name (NI) 6961**] died from cancer.
Physical Exam:
VS - 98.7 128/66 66 18
Gen: Elderly male in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. SEM heard over entire precordium.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Skin:Ecchymosis on right forearm and 2cm ecchymotic area of left
lower lip.
Pertinent Results:
[**2149-2-5**] 09:20AM BLOOD WBC-12.0* RBC-3.38* Hgb-10.6* Hct-31.9*
MCV-94 MCH-31.5 MCHC-33.3 RDW-14.3 Plt Ct-135*
[**2149-2-5**] 09:20AM BLOOD Plt Ct-135*
[**2149-2-3**] 08:05AM BLOOD PT-15.1* PTT-30.4 INR(PT)-1.3*
[**2149-2-5**] 09:20AM BLOOD Glucose-116* UreaN-26* Creat-1.2 Na-135
K-4.2 Cl-101 HCO3-24 AnGap-14
CHEST (PORTABLE AP) [**2149-2-3**] 8:57 AM
CHEST (PORTABLE AP)
Reason: evaluate for ptx s/p ct removal
[**Hospital 93**] MEDICAL CONDITION:
89 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate for ptx s/p ct removal
REASON FOR EXAMINATION: Chest tube removal in a patient after
CABG. Evaluation for pneumothorax.
Portable AP chest radiograph compared to [**2149-1-31**].
The patient was extubated in the meantime interval with removal
of the Swan- Ganz catheter, NG tube, chest tube, and mediastinal
drains. The cardiomediastinal silhouette is stable.
Post-sternotomy wires are unremarkable. Lungs are clear. Minimal
bilateral pleural effusion is present. There is no pneumothorax.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 76630**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76631**]
(Complete) Done [**2149-1-31**] at 8:48:55 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2059-8-10**]
Age (years): 89 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Aortic valve disease. Chest pain.
Coronary artery disease. Hypertension.
ICD-9 Codes: 786.51, 440.0, 424.1
Test Information
Date/Time: [**2149-1-31**] at 08:48 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2007AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Mild-moderate regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Normal RV wall thickness. Normal RV chamber size.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic root. Normal ascending aorta diameter. Simple
atheroma in ascending aorta. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (AoVA 1.2-1.9cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Calcified tips of papillary
muscles. Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
Conclusions
1. The left atrium is mildly dilated. No spontaneous echo
contrast is seen in the body of the left atrium or left atrial
appendage. No mass/thrombus is seen in the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild to
moderate regional left ventricular systolic dysfunction with
anteroseptal inferior hypokinesis. Apical akinesis.
3. . Right ventricular chamber size and free wall motion are
normal. Right ventricular chamber size is normal.
4. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is limited mobility of
the RCC. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7. There is a trivial/physiologic pericardial effusion.
On infusions of Levo, epi, phenylephrine during coronary
occlusions. Post CABG lvef =35-40%. Inferoseptal, anterior and
anteroapical hypokinesis. MR remains 1+.
Brief Hospital Course:
He was seen by cardiac surgery. His platelet count was low, and
HIT ab was negative. He was taken to the operating room on [**1-31**]
where he underwent an off pump CABG x 4. He was transferred to
the ICU in critical but stable condition on epi, phenylephrine
and propofol. He received 48 hours of prophylactic vancomycin as
he was in the hospital preoperatively. He was extubated on POD
#1. He was transferred to the floor late on POD #1. He was
started on plavix for his off pump CABG. Chest tubes and wires
were pulled without incident. He did well postoperatively and
was ready for discharge to rehab on POD #5.
Medications on Admission:
CURRENT MEDICATIONS on Transfer:
Asa 325mg
prednisone 9mg daily
lopressor 25mg twice a day
protonix 40 mg daily
colace
heparin gtt
Integrellin gtt
.
Medication at home:
HCTZ 25mg daily
Diltiazem ER 120mg daily
Prednisone 9mg daily
Potassium 200mEq daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. PredniSONE 1 mg Tablet Sig: Nine (9) Tablet PO DAILY (Daily):
9 mg daily.
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 weeks: then reassess need for diuresis.
Disp:*qs Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day)
for 1 weeks: while on lasix
.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours). Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
CAD now s/p CABG
NSTEMI
HTN, kidney stones, polymyalgia [**Last Name (LF) 23389**], [**First Name3 (LF) **] 7 years ago,
s/p hernia repair
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 32255**] 2 weeks
Dr. [**Last Name (STitle) 70216**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2149-2-5**]
ICD9 Codes: 9971, 2762, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7997
} | Medical Text: Admission Date: [**2158-8-23**] Discharge Date: [**2158-8-27**]
Date of Birth: [**2089-3-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
asymptomatic with heart murmur
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **].Inv. MVR (29mm [**Company 1543**] Mosaic porcine)
History of Present Illness:
69 yo female with long history of heart murmur. recent echo
showed worsening MR with increased PA pressures. Pt. is
currently asymptomatic and remains very active. Referred for
valve surgery.
Past Medical History:
mitral valve prolapse/regurg.
HTN
PSH: c- sections x3
bil. vein strippings
Social History:
grandmother, lives alone
never used tobacco, occasional ETOH
Family History:
father died at 55 of complics. of DM
Physical Exam:
WDWN in NAD
skin/HEENT unremarkable
neck supple with full ROM, no carotid bruits appreciated
CTAB
Irregular HR with 4/6 systolic murmur best heard at LLSB
soft, NT, ND, + BS
extrems warm, well-perfused, no edema
bil. vein stripping scars
neuro grossly intact
2+ bil. fem/DP/PT/radials
Pertinent Results:
[**2158-8-26**] 04:55AM BLOOD WBC-7.0 RBC-2.60* Hgb-8.3* Hct-24.3*
MCV-94 MCH-32.0 MCHC-34.1 RDW-13.6 Plt Ct-129*
[**2158-8-24**] 12:45PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2158-8-26**] 04:55AM BLOOD Plt Ct-129*
[**2158-8-26**] 04:55AM BLOOD Glucose-92 UreaN-16 Creat-0.7 Na-137
K-4.0 Cl-104 HCO3-26 AnGap-11
[**2158-8-23**] 01:00PM BLOOD ALT-9 AST-14 AlkPhos-39 TotBili-0.4
[**2158-8-23**] 01:00PM BLOOD %HbA1c-5.8
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 95**] [**Hospital1 18**] [**Numeric Identifier 71608**] (Complete)
Done [**2158-8-24**] at 2:46:52 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2089-3-31**]
Age (years): 69 F Hgt (in):
BP (mm Hg): 110/60 Wgt (lb):
HR (bpm): 72 BSA (m2):
Indication: mitral valve prolapse
ICD-9 Codes: 424.0, 440.0
Test Information
Date/Time: [**2158-8-24**] at 14:46 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.2 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Moderate/severe MVP. Moderate to severe (3+) MR.
TRICUSPID VALVE: Mild to moderate [[**11-29**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%)
Right ventricular chamber size and free wall motion are normal.
There are 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.
There is moderate/severe mitral valve prolapse of posterior
leaflet with myxomatous disease of the posterior leaflet.
Moderate to severe (3+) mitral regurgitation is seen.
There is no pericardial effusion.
Post_Bypass:
Biventricular normal systolic function. LVEF 55%.
There is a bioprosthesis in the mitral location with normal
function and stability. Mean transmitral gradient is 5mm of Hg.
Thoracic aortic contour is intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2158-8-26**] 8:21 AM
CHEST (PORTABLE AP)
Reason: r/o PTX, interval change
[**Hospital 93**] MEDICAL CONDITION:
69 year old woman with s/p Minimally Invasive MVR(porcine) s/p
chest tube to water seal
REASON FOR THIS EXAMINATION:
r/o PTX, interval change
HISTORY: Mitral valve replacement.
Single portable radiograph of the chest demonstrates similar
cardiomediastinal contour when compared with [**2158-8-25**]. The
right internal jugular Swan-Ganz catheter and introducer sheath
have been removed. A prosthetic cardiac valve is again seen and
is unchanged. There is mild bibasilar atelectasis and a small
left-sided pleural effusion. No pneumothorax. Trachea is
midline. No consolidation is evident. No pneumoperitoneum.
IMPRESSION:
Interval removal of support lines.
Persistent bibasilar atelectasis and small left-sided pleural
effusion.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: SAT [**2158-9-2**] 12:19 AM
?????? [**2153**]
Brief Hospital Course:
Admitted [**8-23**] for cath which revealed nl. cors. and EF 75% with
4+ MR.[**First Name (Titles) **] [**Last Name (Titles) **]. invasive MVR with Dr. [**First Name (STitle) **] on [**8-24**] and
was transferred to the CVICU in stable condition on titrated
propofol and phenylephrine drips.Extubated later that afternoon
and transferred to the floor on POD #1 to begin increasing her
activity level. She was gently diuresed toward her preoperative
weight. Ibuprofen started for anti-inflammatory effect and
low-dose beta blockade also started. Chest tube removed without
incident and cleared for discharge to home on POD #3 with VNA
services. Pt. is to make all follow up appts. as per discharge
instructions.
Medications on Admission:
lisinopril 40 mg daily
HCTZ 25 mg daily
ASA 81 mg daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 2 weeks: then TID prn pain.
Disp:*90 Tablet(s)* Refills:*0*
8. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day:
WHILE ON IBUPROFEN.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
MR s/p [**Hospital1 **]. inv. MVR
HTN
Discharge Condition:
good
Discharge Instructions:
may shower, no swimming or bathing for 1 month
no creams,lotiions or powders to any incisions
Followup Instructions:
with Dr. [**Last Name (STitle) 26909**] in [**12-31**] weeks
Dr. [**Last Name (STitle) **] in [**12-31**] weeks
with Dr. [**First Name (STitle) **] in 4 weeks
Please call for appts.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2158-9-12**]
ICD9 Codes: 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7998
} | Medical Text: Admission Date: [**2113-7-23**] Discharge Date: [**2113-8-23**]
Date of Birth: [**2040-6-19**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Thoracentesis.
Thallium myocardial viability study.
Intubation.
Central line placement.
Echocardiogram.
History of Present Illness:
Mr. [**Known lastname 44755**] is a 73 year old man transfered from an outside
hospital with chest pain and ecg changes.
Patient has past medical history of ESRD on HD for 5 years, PAF,
CVA, anemia, CAD s/p MI, Aortic stenosis. Patient was admitted
to [**Hospital3 4107**] last month with an MI. His hospital course
was complicated by bradycardic arrest, MRSA pneumonia, C diff
colitis. He was discharged to NESH 3.5 weeks ago. Since this
admission he has had worsening mental status with dementia.
On the day of admission he complained of chest pain [**9-20**]
radiating to his right shoulder. This was relieved only after 3
NTG. BP was stable; HR was 105-113 during this episode. He was
transfered to [**Hospital3 417**] Hospital where ECG showed
intermittant rate related RBBB and LVH with strain. Patient was
pain free on arrival and remained pain free. He was given one
aspirin. TnI was 0.2 and the patient was transfered here for
management of ACS.
On arrival here the patient had 10/10 chest pain. ECG showed
sinus tachycardia with LVH and strain. Pain resolved with one
sublingual nitroglycerin. TnT here 0.6, and CK is 51.
Currently the patient denies chest pain, shortness of breath,
abdominal pain, nausea, vomiting. He reports frequent diarrhea.
He has h/o orthopnea, PND but denies pedal edema. He has SOB
with ambulation.
Past Medical History:
1. ESRD on HD for 5 years
2. diverticulosis
3. GI bleed
4. PAF
5. CVA 2 years ago, with residual left sided weakness
6. CAD s/p MI (echo [**5-19**] with inferior hypokinesis)
7. Anemia
8. Cardiac arrest
9. GERD
10. OSA on CPAP 16 cm with 1 L oxygen
11. Moderate Aortic stenosis (echo in [**Month (only) 547**] at OSH)
Social History:
Lives at home with his wife. Stopped smoking in [**2105**].
Family History:
non contributory
Physical Exam:
T 98.0 HR 110 BP 138/59 RR 24 O2 sat 99% on 4L
Gen: elderly gentleman, appearing older than stated age, lying
in bed, in NAD.
HEENT: PERRL, EOMI, sclera anicteric, MM dry.
Neck: No JVD, no LAD.
Lungs: coarse BS bilaterally, anteriorly and posteriorly.
Expriatory wheezes.
CV: Regular with no MRG appreciated.
Abd: soft, distended, tender in the RUQ with guarding, no
rebound. active bowel sounds.
Ext: no clubbing, cyanosis or edema. Weak pulses bilaterally.
Neuro: sleepy but arousable. Follows commands. oriented to self,
place, but states date is [**2012**]. Strength 5/5 on the right and
4+/5 on the left lower extremity (can resist minor force) and
[**6-15**] on the right upper extremity and [**5-16**] on the left upper
extremity (cannot resist any force). Reflexes are 2+ in the left
patella and bicepts and 1+ on the right. Toes downgoing on right
and equivocal on left.
Pertinent Results:
OSH: 18.7\ /593 [**Age over 90 **]|95|25 /108 CK 30 MB 2.5 TnI 0.2 BNP >
5000
/40.3\ 5.3|30|5.9\
INR 2.5 DDimer 1409
LABS HERE:
[**Age over 90 **] |93|32 / 99 AGap=23
4.9 |26|6.4\
8:30p CK: 38 MB: Notdone Trop-*T*: 0.63
7:45p CK: 51 MB: Notdone Trop-*T*: 0.62
Ca: 10.0 Mg: 2.2 P: 3.7
ALT: 16 AP: 93 Tbili: 0.6 Alb:
AST: 22 LDH: 172 Dbili: TProt:
[**Doctor First Name **]: 54 Lip: 46
TSH:Pnd
MCV 92
17.7\12.1/569
/37.8\
N:87.5 Band:0 L:8.7 M:2.5 E:0.8 Bas:0.5
Hypochr: 1+ Anisocy: 1+ Polychr: 1+
Plt-Est: High
PT: 20.9 PTT: 28.5 INR: 2.9
ECG: 8:20 Sinus tachycardia at 107 bpm, LAD, RBBB, Q in III,
AVF. TWI in V1-V4, III, AVF. No STE or depression.
14:09 Sinus at 95 bpm. First degree AV block. LAD. Q in III,
AVF. Flat TW in I, AVL, V5-6. LVH with strain pattern.
14:20 Sinus at 96 bpm. First degree AV block. LAD. Q in III,
AVF. TW flat in I, avl, V5-6. LVH with strain pattern.
18:47 Sinus at 106 bpm. RBBB. LAD. TW normalization in I, AVL,
V5-6. Q in III, AVF. TWI in V1-V4. No STE or depression.
19:39 Sinus at 104 bpm. LAD. TW flat in I, AVL, V5-6. Q in III,
AVF. LVH with strain pattern.
labs around time of GI bleed.
[**2113-8-17**] 01:25PM BLOOD PT-14.2* PTT-36.6* INR(PT)-1.3
[**2113-8-17**] 08:07PM BLOOD PT-15.4* PTT-80.0* INR(PT)-1.6
[**2113-8-18**] 04:32AM BLOOD PT-14.5* PTT-63.0* INR(PT)-1.4
labs on discharge
[**2113-8-23**] 06:12AM BLOOD PT-21.0* PTT-33.7 INR(PT)-2.9
[**2113-8-23**] 06:12AM BLOOD WBC-10.0 RBC-3.44* Hgb-10.2* Hct-32.5*
MCV-94 MCH-29.7 MCHC-31.5 RDW-20.7* Plt Ct-335
[**2113-8-23**] 06:12AM BLOOD Glucose-79 UreaN-23* Creat-4.5*# Na-145
K-3.6 Cl-105 HCO3-28 AnGap-16
[**2113-8-23**] 06:12AM BLOOD Calcium-9.5 Phos-3.8 Mg-1.7
Brief Hospital Course:
This 73 year old gentleman with a history of ESRD on HD,
ischemic cardiomyopathy, EF 35%, PAF, h/o CVA, h/o CAD s/p MI
who was initially transferred here from [**Hospital3 4107**] on
[**2113-7-23**] with chest pain, intermittent RBBB/LVH, TropI 0.6, CK
51. [**Hospital3 **] course notable for bradycardic arrest, MRSA
pna, C diff colitis and was d/c to rehab. with MRSA pneumonia, C
diff colitis.
.
On admission here, pt thought not to have acute ischemia;
finished course of PO vanco for c diff and IV vanco for MRSA
pna. His mental status was noted to be poor, thought to be [**3-15**]
delerium. Dialysis was continued. Wished for CTA to r/o PE, but
pt has iodine allergy. Had abnl cxr so v/q not pursued either.
Passed swallow study on [**7-25**] and [**7-31**].
.
[**7-25**], pt had resp distress but cxr showed layering pleural
effusions L>R, BNP [**Numeric Identifier 44756**].
.
[**7-26**], patient had another episode of tachypnea, hypoxia at HD
and was transferred to the [**Hospital Unit Name 153**] for further mngt. In [**Hospital Unit Name 153**], he
was rapidly weaned to nasal cannula, CPAP at night (has OSA).
SOB thought to be multifactorial from volume overload, pleural
effusions, AF w/ RVR. Leukocytosis to 13-14 persisted but ID
work up negative besides his previous known infections, as
above. Effusion not tapped since patient's resp status improved
(he also apparently refused per record).
.
[**7-29**] Recurrence of tachypnea, tachycardia, hypotension on [**7-29**]
that was thought [**3-15**] aspiration vs flash pulm edema vs mucous
plugging, again improved w/o intervention. Aggressive chest PT
was initiated. Cards consulted who wished to optimize his CHF
mngt w/ Ace-i, cont amio/bb and stop digoxin. EF now 25% with
new akinesis. Cardiac cath considered for concern of recurring
ischemia (INR elevated [**3-15**] coumadin, so held off for some time).
Vanco was started on [**8-1**] for GPC's in sputum and increased
secretions.
.
[**8-1**] With clinical improvement was transferred to general
medicine [**Hospital1 **]. Cath tentatively planned for [**8-7**], pt started on
heparin today for stroke ppx since INR now.
[**2113-8-5**] Had HD session w/o incident and had acute onset of resp
distress w/ sats 83% approx 30 min after arrival on floor. MICU
team near by and helped evaluate patient. VS at that time were T
96.3 BP 108/60's HR 90's RR 30's sats 83% NRB (was 98% 2L
previous to this). Pt confused but semi-alert, not mentating,
not comuunicative. ABG 7.42/40/49 on NRB. Code blue called for
impending resp arrest. pt w/ pulse; ekg NSR 90's old TWI's in
V1-V5. Intubated and brought to MICU.
.
MICU stay Underwent throacentesis with 1700 cc of serous fluid
removed which was transudative. He was thought to have flash
pulmonary edema. He was initially on a levophed gtt for
hypotension, but with fluid boluses he was weaned off the gtt.
[**8-7**]
-weaned off all pressors,
-seen by cardiology and they decided to defer catherization
until the patient was stable from a respiratory standpoint.
-Patient's stool was positive for C diff. He was started on
Flagyl for a ten day course. He was also
-started on levofloxacin/flagyl for empiric treatment of
aspiration pneumonia.
[**8-8**].
-extubated, transferred to general medicine wards
.
General medicine [**Hospital1 **] stay.
[**Date range (1) 44757**]
This period was characterized by recurrent episodes of chest
pain, respiratory distress, hypotension, and tachycardia. No
EKG changes accompanied these. Aggressive suctioning with O2
therapy successfully resolved all of these episodes, and it was
felt these episodes were secondary to mucus plugging. Chest PT,
nebulizer therapy, and mucolytic therapy were instituted with
success.
.
[**8-16**] Episode of 200 cc coffee ground emesis after HD. Emesis
guiaiac positive, stool guaiac negative. PTT was
supratherapeutic GI consulted, felt endoscopy would not be of
benefit unless catheterization performed.
.
[**8-17**] Thallium viability performed revealed no reversible defects,
as no tissue could be recovered by reperfusion, Cardiology
decided catheterization would not benefit the patient and signed
off. Per there recommendations, beta blocker and ACEi therapy
were titrated up. GI signed off.
[**8-18**] Thoracentesis performed 2L removed transudative negative for
gram stain and culture, largely for respiratory comfort.
Respiratory function notably improved after this, with somewhat
less oxygen requirement, and more vigorous cough reflex. Lungs
clear to auscultation. Pt had only one minor episode of
respiratory distress after this time.
[**8-21**] Wife met with attending, Dr. [**Last Name (STitle) **], and elected to change
pt status to DNR/DNI.
In summary this is a 73 year old Caucasian gentleman with a
prior history of coronary artery disease s/p myocardial
infarction, paroxysmal atrial fibrillation on amiodarone and
anticoagulation, ischemic cardiomyopathy EF 25%, end stage renal
disease on hemodialysis. He was admitted for non-ST elevation
MI, since admission his course has been complicated by recurrent
respiratory distress with chest pain and hypotension and
necessitating one intubation, pneumonia, upper GI bleed from
supratherapeutic INR, and C. dificile
on discharge this patients issues are as follows.
Resp distress: Improved s/p thoracentesis and with nebulizer,
chest PT and mucinex therapy. Mucus plugging was likely cause
of his recurrent resp distress. No recent sign of pneumonia.
Prior episode of pneumonia during stay successfully treated with
levofloxacin. No EKG changes have occured during these
episodes.
Ischemic heart disease: EF of 25%, now with new akinesis.
Unfortunately, invasive procedures will no longer benefit the pt
owing to the lack of viable tissue left. We have attempted to
optimize medical management using beta blocker and ace inhibitor
for protection of remainder of myocardium.
PAF: Appears stable, on amiodarone and now transitioned to
Coumadin for anticoagulative therapy last INR: 2.9.
End Stage Renal Disease: On hemodialysis Tuesday, Thursday,
and Saturday. On epogen for anemia. Appreciate work of renal
team in managing fluids.
Sepsis: Pt was septic requiring pressors x 3, resolved in MICU.
h/o MRSA pneumonia.
GI bleed: No further episodes of GI bleed since [**8-16**]; this was
probably secondary to his supratherapeutic INR
C. Dificile: On discharge, he will be on day 10 of 14
DVT prophylaxis: Coumadin
Anemia: Likely from chronic disease, ESRD, on epogen.
Hypothyroid: On replacement.
Code: DNR/DNI per wife as of [**2113-8-21**]
Medications on Admission:
Amiodarone 200 mg po daily
Lipitor 10 mg po daily
Aspirin 81 mg daily
Celexa 20 mg daily
Levoxyl 25 micrograms daily
Prevacid 30 mg daily
Provigil 100 mg daily
Nephrocaps 1 cap daily
Coumadin 2.5 mg daily
Lorazepam 0.5 mg q 8 hr prn
Vancomycin 250 mg po three times a day
colace 100 mg po daily
xopenex q 6 hr
atrovent q 6 hr
epogen 12,000 unit sq M,W, F
lactinex 2 tab po bid
megace 800 mg daily
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Solution
Injection ASDIR (AS DIRECTED).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID
(2 times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
11. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for Oral Thrush.
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: Course to complete 2 weeks of
therapy on [**2113-8-27**].
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours).
16. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): Please do NOT give on hemodialysis days.
17. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
18. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Please do NOT give on hemodialysis days.
20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
21. Warfarin Sodium 1 mg Tablet Sig: 1.5 Tablets PO at bedtime.
22. Compazine 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]
Discharge Diagnosis:
Non-ST elevated MI
Sepsis with hypotension.
End stage renal disease now on hemodialysis.
Congestive heart failure (ischemic cardiomyopathy.
Coronary artery disease.
Clostridium difficile infection.
Recurrent respiratory distress with mucus plugging.
Gastrointestinal bleed.
Paroxysmal atrial fibrillation.
Anticoagulative therapy
Discharge Condition:
Stable.
Stable.Still requiring oxygen 2-3 L by NC or face mask.Chest
pain free.
Discharge Instructions:
Please return to hospital if respiratory distress, chest pain
recurs. Please return if coffee ground or bloody vomiting
recur.
Followup Instructions:
Rehabilitation facility.
Please see PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4469**] in [**8-20**] days.
ICD9 Codes: 5070, 4280, 0389, 5119, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 7999
} | Medical Text: Admission Date: [**2141-6-15**] Discharge Date: [**2141-6-18**]
Date of Birth: [**2073-8-31**] Sex: M
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Fevers, chills.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 67 year old male
with a history of bladder cancer, status post bladder
resection with ileal conduit in [**2112**] who has a history of
nephrolithiasis and multiple urinary tract infections who now
presents with fevers, chills, nausea, vomiting and a recent
urine culture positive for gram negative rods. The patient
was recently admitted to [**Hospital6 256**]
in [**2141-4-23**] for an elective lithotripsy of a left renal
stone which was complicated by Corynebacterium urosepsis for
which he was treated with ten days of Vancomycin. During
that admission he also had multiple bilateral lower lobe
pulmonary emboli and negative lower extremity noninvasive
studies.
The patient was in his usual state of health until four to
five days prior to admission when he experienced fatigue and
fevers to 102 degrees. He presented to his primary care
clinic and was started on Levofloxacin by his primary care
physician on [**6-13**]. On [**6-14**], he developed severe left
flank pain and was sent to the Emergency Department with a
fever of 102.7 degrees. Computerized axial tomography scan
showed severe left hydronephrosis with gas requiring urgent
decompression. The patient was given one unit of fresh
frozen plasma in order to correct his Coumadin-induced
coagulopathy before his interventional radiology procedure,
however, he developed a pruritic rash while receiving his
fresh frozen plasma, so he only received one out of three
proposed units. At Interventional Radiology he had a
temporary inferior vena cava filter placed through his right
jugular and a left percutaneous nephrostomy tube was placed
as well under local anesthesia. Immediately after the
procedure, the patient desaturated to 66% oxygen saturation
which then increased to the 90s of 100% FIO2 with a
nonrebreather mask. The patient was then transferred to the
Medical Intensive Care Unit for further management.
PAST MEDICAL HISTORY: Bladder cancer with bladder resection
in [**2112**] with an ileal conduit. This was transitional cell
carcinoma, diabetes Type 2, hypertension, coronary artery
disease, status post myocardial infarction ten years ago,
status post stent to the left circumflex in [**2140-1-22**], at
which time catheterization showed an ejection fraction of
65%, hypercholesterolemia, left nephrolithiasis with
recurrent urinary tract infection, bilateral pulmonary emboli
in [**2141-4-23**], requiring, anticoagulation, status post
diskectomy.
ALLERGIES: Codeine causing a rash.
MEDICATIONS ON ADMISSION: Vancomycin 1 gm intravenously q.
12, ten day course completed [**2141-5-12**]. Coumadin 2 mg
h.s. alternating with 3 mg h.s., 3 mg on Tuesday and
Thursday, Metoprolol XL 200 daily, iron 150 daily, Senna one
tablet daily, Lisinopril 20/Hydrochlorothiazide 12.5 daily,
Aspirin 325 daily, Nifedipine CR 60 daily, Atorvastatin 10 mg
daily, Tricor 160 mg daily, Humulin N 75/25 36 units q. AM,
52 units q.h.s.
SOCIAL HISTORY: He lives with his wife and does not drink.
He used to smoke, he has a 35 pack year history but he quit
12 to 13 years ago.
FAMILY HISTORY: Non-contributory.
PHYSICAL EXAMINATION: Temperature 103.7 degrees, heartrate
113, blood pressure 119/42, respiratory rate 31, oxygen
saturation 94% on nonrebreather with 100% FIO2. General:
Visibly tachypneic. Head, eyes, ears, nose and throat: Dry
mucosal membranes, extraocular muscles intact. Pupils equal,
round and reactive to light. Supple neck. Cardiovascular
examination: Regular, tachycardiac, S1 and S2 present, no
murmurs, no jugulovenous distension noted. Pulmonary
examination, lungs clear to auscultation bilaterally.
Abdomen, soft, nontender, nondistended, positive bowel
sounds. The patient has a right lower quadrant urostomy and
a left percutaneous nephrostomy tube. Extremities, warm,
trace edema on the right lower extremity, trace to 1+ edema
on the left lower extremity. Dorsalis pedis pulses were
palpable bilaterally. Neurological examination, alert and
oriented times three, answers questions appropriately.
Strength 5/5 bilaterally in upper and lower extremities.
LABORATORY DATA: White blood cell count 9.4, hematocrit
33.6, platelets 271. Sodium 133, potassium 3.8, chloride 97,
bicarbonate 20, BUN 47, creatinine 2.8, glucose 192, INR 2.5.
Urine analysis showed specific gravity of 1.017, large blood,
positive nitrates, moderate leukocytes, 11 to 20 red blood
cells, 50 white blood cells, many bacteria. Urine culture
from [**6-13**], was growing gram negative rods. Arterial blood
gases showed 7.43, 27 pCO2 and pO2 of 81 and lactate of 5.9.
Chest x-ray after his interventional radiology procedure
showed new bibasilar lung opacities in the retrocardiac
region with atelectasis. These are new findings compared to
his chest x-ray from earlier in the Emergency Department.
Computerized axial tomography scan of his abdomen showed
severe left hydronephrosis with gas in the collecting system
around the left ureteral stone. Electrocardiogram showed
normal sinus rhythm with rate of 125, Q wave in II, III and
AVF.
HOSPITAL COURSE: 1. Urosepsis - The patient had a left
percutaneous nephrostomy tube placed for drainage by
Interventional Radiology. He was started on Levofloxacin,
Ampicillin and Flagyl for his urosepsis, however, after 24
hours, it was changed to Zosyn. He was initially borderline
hypotensive with systolic pressures in the 90s, however,
after 24 hours of antibiotics his pressure increased and his
fever broke. The patient was followed by Urology who was
initially planning on treating him with intravenous
antibiotics and continuing the percutaneous nephrostomy tube
for a period of four to six weeks followed by definitive
treatment with an open procedure to extract the stone.
2. Hypoxia - The patient had several episodes of hypoxia
throughout his stay, some points requiring CPAP ventilation.
He was found to have crackles on examination during some of
these episodes of shortness of breath and he was given Lasix
as he was felt to be in failure. His chest x-rays were
consistent with small amount of pulmonary edema. He
responded to the Lasix, however, it was also thought that his
pulmonary emboli may be contributing to his hypoxic episodes.
Despite having his inferior vena cava filter placed for
pulmonary embolism prophylaxis, he was restarted on heparin
on [**6-18**] and a V/Q scan was ordered to assess for pulmonary
emboli. In addition, the patient was scheduled for an
echocardiogram to assess for systolic or diastolic failure as
he has responded to Lasix therapy during some of the episodes
of shortness of breath.
3. History of pulmonary embolism - The patient had an
inferior vena cava filter placed and was initially not given
his daily Coumadin. However, three days after admission the
patient stabilized and was restarted on his heparin therapy.
The plan will include removing the temporary inferior vena
cava filter after the patient is restarted on Coumadin and is
therapeutic with an INR of 2.0 to 3.0.
4. Anemia - The patient had a small amount of blood loss
during his interventional radiology procedure, and he was
initially transfused for a hematocrit of 25 considering his
history of previous myocardial infarction and coronary artery
disease. He received approximately one unit of blood at
which time he became short of breath. This was felt to be
due to fluid overload and transfusion was stopped. The
patient was given Lasix and he responded with improved oxygen
saturation and decreased symptomatic shortness of breath.
After being transfused one unit of blood, his hematocrit
stabilized between 28 and 29%. It was felt that this level
was adequate for the patient as it was over 28 and in light
of his initial reaction to receiving his first transfused
unit.
5. Diabetes mellitus - The patient was placed on insulin
sliding scale and fingerstick glucoses were checked and the
patient's blood sugar was tightly controlled and kept in the
low 100 range.
6. Fluids, electrolytes and nutrition - The patient's
electrolytes were closely monitored and repleted as
necessary. The patient's diet was also advanced. He was
hemodynamically stable.
7. Prophylaxis - The patient was placed on a proton pump
inhibitor for gastrointestinal prophylaxis. He had an
inferior vena cava filter placed and was restarted on heparin
therapy.
8. Hypertension - After he became hemodynamically stable,
the patient eventually developed some mild hypertension. He
should be restarted on his outpatient antihypertensives
before discharge.
CODE STATUS: Full code.
The remaining portion of the discharge summary will be
dictated by the covering house staff.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 9609**]
MEDQUIST36
D: [**2141-6-18**] 17:27
T: [**2141-6-18**] 18:04
JOB#: [**Job Number 27938**]
ICD9 Codes: 4280, 2851, 5990, 5849 |
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