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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8000 }	Medical Text: Admission Date: [2130-1-12] Discharge Date: [2130-1-22] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: subarachnoid hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ]yo woman with history of Alzheimer's dementia fell from standing position and hit head on a bed post at her ALF the night prior to admission. At the time of the fall, the nursing aid denies LOC. Did not fall to ground. Per report patient initally complained of head and right hip pain after the fall. She was initially evaluated at [Location (un) 620] and found to have a subarachnoid hemorrhage on head CT. VS at [Location (un) 620] were T 98.4/HR88/RR15/BP134/73/O296%RA with GCS of 13. She was loaded with Dilantin x 1g and was transferred to [Hospital1 18] for further evaluation. . In the [Hospital1 18] ED, she was seen by Neurosurgery who did not feel there was any surgical intervention. Hip, femur, and knee films were negative. VS in our ED were BP 130's - 160's/50's to 80's, HR 69-90, RR 13-22, GCS 15. . During her MICU course, she was minimally alert and nearly unresponsive. She was described to variably answer simple yes and no questions. She had f/u head CT, which demonstrated stable subarachnoid hemorrhage, and she was followed by Neurosurgery. She was treated with Dilantin for seizure prophylaxis, and she was given Morphine IV prn for pain; nursing reports that she had pain behavior consisting of moaning and grimacing that responded well to prn Morphine. The primary MICU team held extensive discusssion with the caregiver/health care proxy in regards to her poor prognosis. Additionally, she developed an inferior ST elevation MI with markedly positive cardiac biomarkers and associated bradycardia/hypotension. The caretaker was informed of all this, and decision was made to only provide minimal supportive care. Specifically, there would be no aggresive therapy (ASA, heparin, etc) for her STEMI given her overall poor prognosis and also her intracranial hemorrhage. Past Medical History: Alzheimer's Dementia - baseline MS alert to person only Hypothyroidism Right hip replacement Social History: Lives at [Hospital3 ] Family History: Unknown Physical Exam: Vitals (on transfer to floor): T 96.3, BP 90/62, HR 43, RR 16, 96% RA General: Sleepy but arousable, NAD; opens eyes to command, pupils small, minimally reactive HEENT: hematoma over right temple CV: RRR, 2/6 systolic murmur Lungs: Clear bilaterally (anteriorally) Abdomen: Soft, nondistended, nontender, +BS Extremities: warmth/erythema/edema in RUE at previous IV site Neuro: arousable to voice and painful stimuli; moves all 4 extremities to painful stimuli, not giving verbal answers to questions. Pertinent Results: [2130-1-12] 05:13PM GLUCOSE-137* UREA N-22* CREAT-0.8 SODIUM-139 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14 [2130-1-12] 07:33AM LACTATE-2.3* [2130-1-12] 07:32AM WBC-15.5* RBC-4.10* HGB-13.1 HCT-36.6 MCV-89 MCH-32.0 MCHC-35.9* RDW-13.7 [2130-1-12] 07:32AM PLT COUNT-236 [2130-1-12] 07:32AM PT-11.1 PTT-18.9* INR(PT)-0.9 [2130-1-12] 07:32AM FIBRINOGE-420* . EKG (admission)- NSR @ 78 bpm, 1mm ST depressions in 1 and avL. Repeat EKG demonstrates several mm ST elevation in inferior leads w/ reciprocal changes. . Imaging: . [2130-1-12] cxr: Mild cardiac enlargement consistent with systemic hypertension but no evidence of CHF or acute infiltrates . [2130-1-12] Head CT - right frontal subarachnoid hemorrhage; right temporal bone fracture . [2130-1-13] Head CT - 1. Stable appearance of subarachnoid blood, subdural blood, and intraventricular blood as described. No new blood noted. 2. Revisualization of multiple opacified right mastoid air cells and nondisplaced right longitudinal temporal bone fracture. Increased air-fluid level as described. . [2130-1-12] Right Knee - No evidence of fracture or dislocation. Right total hip replacement. . [2130-1-12] Right Femur - No evidence of fracture or dislocation. Right total hip replacement. . [2129-1-12] Right Hip - No evidence of fracture or dislocation. Right total hip replacement. . Micro data: . URINE CULTURE (Final [2130-1-14]): NO GROWTH. Brief Hospital Course: [Age over 90 ] yo with Alzheimer's dementia initially treated in the MICU for subarachnoid hemorrage and inferior ST elevation MI, called out to the floor, was kept comfortable with basic measures, eventuall died on [2130-1-22] at 6.20 AM. HCP and PCP were informed. HCP decided against an autopsy. . 1. SAH/s/p fall: Pt has suffered a significant intracranial hemorrhage, and has severe impairments on account of this. Overall, her prognosis was very poor soon after the event, and Neurosurgery has indicated that there is no role for surgical intervention. Her poor/critical prognosis has been extensively communicated with her only family, namely her guardian [Name (NI) ]. It was decided not to do further imaging, to continue Dilantin for seizure prophylaxis and prn Morhpine for pain control. Pt eventually died while being kept comfortable. . 2. STEMI: Pt had ST elevation in inferior distribution and marked cardiac enzyme elevation. No further intervention given her intracranial hemorrhage and per discussion with guardian. . 3. FEN: NPO. . 4. Code status: DNR/DNI. Medications on Admission: . Discharge Medications: . Discharge Disposition: Expired Discharge Diagnosis: Pt died. Discharge Condition: . Discharge Instructions: . Followup Instructions: . [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] ICD9 Codes: 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8001 }	Medical Text: Admission Date: [2183-10-10] Discharge Date: [2183-10-15] Date of Birth: [2103-6-11] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 11040] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation, arterial line placement History of Present Illness: This is an 80 year old female with history of bronchiectasis and COPD as well as cardiomyopathy secondary to cardiac contusion and atrial fibrillation who was transferred for persistent hypoxic respiratory failure after an admission to [Hospital ] Hospital. The patient's history this year has been marked for starting amioadarone in [Month (only) 958] for persistent atrial fibrilllation (also had TEE and cardioversion) and had stayed in sinus rhythm. Unfortunately, in [Month (only) ] the patient developed worsening cough and dyspnea and her amiodarone was stopped due to concern for early pulmonary toxicity. On [9-23] the patient was admitted to [Location (un) ] Hospial with worsening respiratory symptoms, including dyspnea, cough, and hypoxia. She had a chest CT on [9-25] that revealed diffuse GGO on a background of bronchiectasis and emphysema. She started empiric treatment with abx and steroids for concern of AIP. Given progressive respiratory failure she was intubated. At the time of bronchoscopy she had bloody secretions and there was concern for pulmonary hemorrhage. Therefore she was taken off anticoagulation. She was continued on antibiotics (amp-sublactam and azithromycin) and steroids, her anticoagulation was stopped, and she was also diuresed gently to keep steadily negative fluid balances. She had mild improvements and was extubated on [10-2]. Unfortunately, since extubation she had progressive supplementary O2 requirements and spent the last few days prior to transfer bouncing between 100% NRB mask and CPAP. She has had no positive cultures and bronchoscopy revealed no organisms and no pathognomonic findings for a particular diagnosis. OSH course was also notable for persistent and difficult to control afib with RVR so that on transfer she was on high doses of diltiazem, metoprolol, and digoxin. Given her ? pulmonary hemorrhage the patient's primary pulmonologist strongly felt she should not be anticoagulated again and wanted transfer partially to pursue AV nodal ablation or other more advanced RVR management by our EP service. On arrival, vital signs were 96.1 (axillary), HR 88 (afib), 131/65, and satting 95% on non-rebreather. The patient was awake, alert, responding appropriately to questioning. Reports that her breathing is "a little labored," but feels better than she had at the OSH. Past Medical History: - Cardiomyopathy after chest contusion with former EF 30%, now normalized at 55% - CAD, s/p BMS to RCA in [10/2181] - Upper lobe bronchiectasis attributed to severe pneumonias in the [2132]. Typically has 2-3 episodes of exacerbation bronchiectasis each year. - COPD with moderately severe centrilobular emphysema on CT - Hypertension - T2DM - Mitral Valve Prolapse - R breast nodularites (stable on subsequent mammograms) - Plantar Fasciitis - s/p partial hysterectomy in [2142] - Bladder suspension - GERD - Multinodular goiter Social History: Former smoker, x 30 years at about two packs/day. Stopped seven years ago. Occasional social alcohol. Lives at home alone, is independent in ADLs. Two children are involved in her health care. Family History: There is a family history of premature coronary artery disease or sudden death (three brothers who died of CAD and one sister with CHF). Physical Exam: VS: Temp:96.1 BP:131/65 HR:88 (afib) RR:28 O2sat: 95% on NRB GEN: pleasant, speaking in [3-17] word sentences with NRB in place. Not using accessory neck muscles. Awake, alert, oriented, responding appropriately. HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, +mild thyromegaly RESP: Bibasilar crackles bilaterally, no wheeze CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. 4/5 strength throughout, with limited effort. No sensory deficits to light touch appreciated Pertinent Results: ==================== LABORATORY RESULTS ==================== On Admission: WBC-12.0* RBC-5.29# Hgb-13.3 Hct-39.4 MCV-75* RDW-17.7* Plt Ct-274 ---Neuts-91.0* Lymphs-6.8* Monos-1.1* Eos-0.7 Baso-0.4 PT-11.8 PTT-23.9 INR(PT)-1.0 Glucose-150* UreaN-33* Creat-0.5 Na-139 K-5.9* Cl-103 HCO3-27 Calcium-8.5 Phos-3.5 Mg-2.4 ABG: 7.49/ 38 / 61 ================= OTHER STUDIES ================= Admission ECG: Chest Radiograph [2183-10-10]: IMPRESSION: Dense bilateral reticular opacities. This may represent an acute process superimposed on background chronic changes. The differential diagnosis includes drug-related pneumonitis (by report, the patient is on amiodarone), interstitial edema, and interstitial infection. Edema is considered less likely given the absence of effusions. Bilateral Lower Extremity Ultrasounds [2183-10-11]: IMPRESSION: Bilateral lower extremity DVTs, more extensive on the right involving the common femoral vein, proximal and distal superficial femoral veins and posterior tibial and peroneal veins. Partially occlusive thrombus within the distal left superficial femoral vein. Brief Hospital Course: 80 y/o F with likely emphysema and bronchiectasis as well as Afib w/ RVR and history of cardiomyopathy presenting with worsening respiratory symptoms and hypoxia in the context of bilateral ground glass infiltrates of uncertain etiology. Hypoxic respiratory failure: The patient presented with very high oxygen requirements and desatting with minimal exertion or very short periods off the high flow oxygen masks. Unclear ultimate etiology though diffuse findings on CT were thought to be concerning for AIP on baseline lung disease with pulmonary hemorrhage thought much less likely given reports of bleeding. Patient had already received a fairly high pulse of steroids leaving the benefit of another course questionable but given tenuous respiratory status limiting ability to perform further diagnostic work-up (particular any attempts to pursue tissue diagnosis) a dose of 1 gram methylprednisolone daily was initiated for three days followed by 1 mg/kg daily. She was also started on vancomycin and cefepime given neither vancomycin nor psuedomonas had been covered by here previous antibiotics and those could be established in her altered airways as a not uncommon cause of pneumonia. Also patient was found to have DVT's as described elsewhere, which were treated in hopes of helping hypoxia. Patient received levalbuterol and ipratroprium nebulizers. Eventually a bronchoscopy was done and did not show evidence of pulmonary hemorrhage. However, the patient's oxygenation became more and more problem[Name (NI) 115] and she was intubated for hypoxemic respiratory failure. Her ventilator requirements continued to escalate. Intracranial hemorrage: While on a heparin drip for DVT, the patient was noted to have anisocoria. Head CT revealed large parenchymal hemorrhage apparently centered in the right corona radiata or that caudate nucleus, with transependymal dissection into both lateral ventricles, and the third and fourth ventricles. The patient's poor prognosis was explained to her family. The decision was made to pursue comfort measures only. Deep Vein Thromboses: On presentation given patient's refractory hypoxia an lack of good options decision was made to pursue some work up for VTE given she was thought to be too unstable for CT Scan but this could contribute to hypoxia. Lower extremity ultrasounds revealed DVT and she was started on heparin gtt. Presumably, DVT's were developed during OSH course after warfarin was stopped. Atrial fibrillation: Patient was well rate controlled at arrival on dilt 90 QID, metoprolol tartrate 50 TID and dig, given some pauses (2-2.5 seconds) on the night after admission and generally good rate control. Later in her course her rate became more rapid and she briefly requiring diltiazem gtt. Heparin drip was continued as above. CAD, Cardiomyopathy: Patient had an EF of 30 with a cardiac contusion per past reports but now normalized to 55. Echo showed normal biventricular cavity sizes with preserved global and regional biventricular systolic function and biatrial enlargement. Pulmonary artery systolic hypertensionShe was continued on her aspirin, simvastatin, and beta blocker for her history of CAD. . Hypotension: Initially normotensive on rate control agents. Also on daily furosemide. On the day of intubation, she also became hypotensive requiring initiation of norepinephrine . Diabetes Mellitus Type II: Mildly hyperglycemic on arrival. On oral agents at home, fingersticks with ISS at OSH. SS insulin was continued. . Code status: initially full, later comfort measures only Medications on Admission: - Metformin 1000 mg PO BID - Zocor 10 mg PO QHS - Aspirin 81 mg PO daily - Amiodarone 200 mg PO daily - Warfarin 3 mg alternating with 6 mg PO daily - Amlodipine 10 mg PO daily - Ca++/Vit D - HCTZ 25 mg PO daily - Glimepiride 2 mg PO daily - Metoprolol 50 mg PO BID - Prilosec 20 mg PO BID . Meds on transfer: simvastatin 10 mg PO QHS senna 10 ml PO QHS Aspirin 325 po daily docusate 100 mg po BID guaifenesin 1200 mg PO BID omeprazole 40 mg PO BID digoxin 0.25 po daily diltiazem 90 po q6H metoprolol 50 mg po tid SCH 5000 units Q8 insulin glargine 10 units daily & SS levalbuterol NEB QID methylprednisolone 40 mg IV daily ipratropium neb QID furosemide 40 mg iv daily acetaminophen 650 mg PO Q4H prn polyethylene glycol po daily diphenhydramine 25 mg PO HS MR1 PRN metoclopramide 10 mg IV Q6H PRN ondansetron 4 mg IV Q6H PRN metoprolol 5 mg IV Q6H PRN bisacodyl 10 mg PR daily PRN lorazepam 1 mg IV Q6H PRN morphine 2 mg IV Q4H PRN miconazole topical TID PRN Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: respiratory failure Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[2183-10-17] ICD9 Codes: 496, 4240, 4168, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8002 }	Medical Text: Admission Date: [2146-4-10] Discharge Date: [2146-4-23] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 68839] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right great toe amputation History of Present Illness: This is a [Age over 90 ] year old male with MDS, CAD, CHF, and CKD as well as multiple recent admissions for bacteremia secondary to a gangrenous toe who presented yesterday with fever and hypotension. The patient reports "a couple" of days of feeling generally unwell with malaise and a fever. He is not able to endorse any localizing symptoms like cough, chest pain, dysuria/hematuria, or abdominal discomfort. He also endosres some loose stools over the past few days but no [Age over 90 ] diarrhea. No other abdominal symptoms and he denies abdominal pain, nausea, or vomiting. He was sent to the ED after his daughter noted him rigoring at rehab and demanded he be sent to the hospital. In the ED, initial vs were: T 99.1 P 120 BP 132/80 R 26 O2 sat 99% on NRB but temperature then spiked to 104.2 rectally. As the patient has had multiple admissions for bacteremia related to his toe gangrene vascular and podiatry were consulted regarding management. The patient was given levofloxacin, acetaminophen, vancomycin, and ceftriaxone in the ED. He became hypotensive (SBP's in the 90's) and thus received 2L of NS without much effect before before being started on norepinephrine and sent to the ICU. Overnight the patient was weaned off norepinephrine. He also defervesced and has been afebrile today. He received one unit Plt and one unit pRBC's as was worse than baseline. ID consulted and are recommending daptomycin (patient was on course as an outpatient) and pipercillin-tazobactam as well as discontinuing PICC and scan to r/o abscess. Plan was for podiatry to amputate toe in AM but patient's daughter and HCP requested vascular to perform this operation so timing is currently unclear. [Name2 (NI) ] report blood cultures from [Hospital 100] Rehab are growing gram positive cultures in pairs and clusters as well as gram negative rods. Currently, he reports feeling fatigued but denies specific complaints. Past Medical History: -Stage 3 Chronic Kidney Disease with baseline Cr of 2 -Coronary Artery Disease (PTCA in [2123] w/o stents) -Sick sinus syndrome --> s/p pacemaker [2118], [2128], [2139]; no history of pacemaker infections -Transient Ischemic Attack in [2135] -Myelodysplastic syndrome with anemia, thrombocytopenia and leukopenia -Pseudogout -Benign prostatic hypertrophy -Cryptogenic cirrhosis and ? of hepatitis B (chronic bilateral upper extremity edema) -Polymyalgia rheumatica on chronic prednisone (5mg >1 yr) -GI bleed:Gastric varices; GAVE -Hiatal hernia -Enterococcal endocarditis [2140] -Group G Strep bacteremia, [1-/2144] (tx 6 weeks with amp/sublactam) -Group G Strep bacteremia + R hallux cellulitis, [10/2144] (tx 4 weeks with Ceftriaxone) -MRSA septicemia without endocarditis, [2-/2146] (original tx plan 4 weeks of vancomycin through [4-8]) -MRSA, VRE, multiple strains of Streptococcus bacteremia, [3-/2146] (tx daptomycin x 6 weeks to end [5-6]) Social History: He lives at [Hospital 100] Rehab and has been there for the past month but was living with his daughter prior to that. He was a smoker at one point but has not smoked since [2088]. He is a retired foreign service officer with previous postings in [Location (un) ], [Country 3992], and most recently northern [Country 2559]. He was [Initials (NamePattern4) ] [Last Name (NamePattern4) 68836] Scholar. Family History: Father, mother, brother all died of "heart disease" Physical Exam: Vitals: T: 97.3 BP: 122/38 P: 105 R: 21 O2: 99% on 2L NC General: Alert, oriented, no acute distress, speaks very slowly HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles at the right base posteriorly, no wheezes or ronchi CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses. Forearms with chronic skin changes bilaterally, purple color. Lower legs bilaterally with shiny skin, no hair. Right great toe swollen with darker color and open wound at over the first MTP joint. Pertinent Results: LABORATORY RESULTS ==================== On Presentation: WBC-5.8# RBC-3.02* Hgb-8.8* Hct-26.9* MCV-89 RDW-16.1* Plt Ct-44* ----Neuts-90.2* Lymphs-7.9* Monos-1.7* Eos-0.2 Baso-0 PT-16.1* PTT-30.9 INR(PT)-1.4* Glucose-187* UreaN-32* Creat-1.9* Na-131* K-4.0 Cl-96 HCO3-25 AnGap-14 ALT-28 AST-54* CK(CPK)-32* AlkPhos-236* TotBili-1.1 Lactate-2.6* MICROBIOLOGY ============= [2146-4-10] Blood Cultures: 2/2 Bottles with Staph Aureus SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| DAPTOMYCIN------------ S ERYTHROMYCIN---------- =>4 R GENTAMICIN------------ 2 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>8 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S [2146-4-12]: Bone tissue and swab from amputation with Staph Aureus Pathology from Amputation: DIAGNOSIS: 1. Bone, right first toe, excision (A): A. Bone with changes consistent with acute and chronic osteomyelitis with osteonecrosis. B. Dense fibroconnective tissue with chronic inflammation. 2. Toe, right first, amputation (B): A. Skin with ulceration and necrosis, present at resection margin. B. Bone with marrow fibrosis compatible with chronic osteomyelitis OTHER RESULTS ============== Chest Radiograph [2146-4-10]: IMPRESSION: No acute pulmonary process. EKG [2146-4-10]: Sinus tachycardia. Right bundle-branch block. Possible anterior wall myocardial infarction of indeterminate age. Compared to the previous tracing of [2146-3-8] heart rate is significantly increased. CT Abdomen and Pelvis [2146-4-11]: IMPRESSION: No CT evidence to explain recurrent bacteremia. Transthoracic Echocardiogam [2146-4-13]: IMPRESSION:Prior (stable) antero-apical myocardial infarction with mild to moderately depressed LVEF. No valvular vegetations seen. Right Upper Extremity Ultrasound [2146-4-13]: IMPRESSION: No right upper extremity DVT. Brief Hospital Course: This is a [Age over 90 ] year old male with a history of multiple bacteremias due to gangrene of the right great toe (initially precipitated by anatomical abnormality), myelodysplastic syndrome, coronary artery disease, and chronic kidney disease presenting from rehab with fever and hypotension and found to be bacteremic again. 1) Bacteremia/Sepsis: Patient was clearly septic at presentation with hypotension requiring norepinehprine on the night of admission and positive blood cultures for MRSA. On presentation to the ICU the patient received his daptomycin as well as a dose of pipercillin-tazobactam for broad coverage. Outside hospital blood cultures revealed MRSA, pan-sensitive klebsiella, and two kinds of streptococcus. After spending one night in the ICU the patient defervesced and was able to be quickly weaned off norepinephrine. He was transferred to the floor on his second hospital day and remained hemodynamically stable and afebrile. The most likely etiology of his recurrent bacteremia was considered to be his right great toe, which was status post multiple debridements, so this was amputated on [2146-4-12]. In order to rule out other sources of infection the patient had a CT abdomen and pelvis on recommendation on the infectious disease consult team, which showed no clear etiology of bacteremia though this was a suboptimal study due to the lack of IV contrast. Given bacteremia with a PICC line in place the patient's PICC was discontinued on the recommendation of the ID consult service. Surveillance cultures were persistently negative except for one set on [2146-4-13], which showed S. aureus raising concern for a persistent source of infection. Given the patient has a pacemaker in place and had MRSA bacteremia there was concern for seeding, therefore TEE was considered necessary. TEE did not show evidence of vegetations, but showed fibrous changes along the leads of Mr [Known lastname 68840] pacemaker. Despite being on Daptomycin for MRSA and Ceftriaxone for Klebsiella, the pt continued to have positive blood cultures following amputation of the toe and TEE. The infectious disease service recommended removal of the pacemaker, but after discussion with Mr [Known lastname 3012] and his health care proxies (daughter [Name (NI) 1022] [Last Name (NamePattern1) ] and her husband [Name (NI) ] [Name (NI) ]), it was clear that the pt did not desire this aggressive approach to the treatment of his bacteremia. Mr [Known lastname 3012] accepted the fact that without pacemaker extraction his life expectancy would likely be limited to weeks (according to the ID service) and the decision was made for the pt to go home with hospice, on antibiotics for comfort. The pt was discharged on vancomycin 1g daily and rifampin on the recommendation of the ID service. . # Great toe gangrene: The patient has had chronic infection of his right great toe and he and his daughter had previously been unwilling to go through with amputation. After he became bacteremic once again, however, they agreed to amputation. This was performed by the vascular surgery service on [2146-4-13] without incident. Pathology on bone specimens revealed changes consistent with chronic osteomyelitis. . # Myelodysplastic syndrome / thrombocytopenia: Patient has history of transfusion dependent thrombocytopenia and chronic anemia. He was transfused in the hospital to maintaine Hct >25 and Plt >50 (prior to surgery) and Hct >25 thereafter. . # CKD: The patient has CKD with a baseline Cr of 1.7-1.9. This improved throughout his hospitalization and was simply followed. . # CAD/CHF: Patient has a historical diagnosis of chronic systolic CHF with EF of approximately 40%. He appeared euvolemic during this hospitalization. Initially, his home furosemid dosing was held but then was restarted with stable blood pressures. Despite a history of CAD the patient is not on aspirin, statin, or beta blocker. . # Delerium: The patient was initially with waxing and [Doctor Last Name 688] mental status presumed to be multifactorial and due to his infection and perhaps an element of ICU delirium. This improved with transfer to floor and resolution of hypotension as well as treatment of infection. The patient would continue to have short periods of confusion even on the floor but these were always brief, worse at night, and more consistent with sundowning, which was not considered concerning given the patient's advanced age. He always responded well to reorientation. . # Depression: The patient's mirtazapine was initially held given hypotension but then was restarted with good effect. . # BPH: The patient initially had a foley catheter in place and tamsulosin was held given his hypotension. He was restarted on tamsulosin after 24 hours of normal blood pressures and his foley was discontinued without incident. Prostate exam was performed as part of an infectious work up and revealed no tenderness and UA's were persistently benign. The pt was discharged with a condom catheter for urinary incontinence. . # Polymyalgia rheumatica: The patient has chronically (>1yr) been on prednisone for PMR. He received stress dose IV hydrocortisone on presentation but was transitioned back to his baseline prednisone dose on the day after his surgery. . # Code status: Following the patient's decision not to remove the pacemaker, the pt elected to be DNR DNI. The pt was discharged to his home, with [Hospital 3005] Hospice. Medications on Admission: 1. Omeprazole 20 [Hospital1 ] 2. Prednisone 5 mg DAILY 3. Pyridoxine 50 mg DAILY 4. Tamsulosin 0.4 mg PO HS 5. Albuterol Sulfate 1 NEB TID 6. Cyanocobalamin 500 mcg DAILY 7. Ferrous Sulfate 325 mg (65 mg Iron) DAILY 8. Fluticasone 50 mcg/Actuation [Hospital1 37062], 2 sprays DAILY 9. Folic Acid 1 mg PO DAILY 10. Lidocaine 5 %(700 mg/patch) 1 DAILY 11. Senna 8.6 mg Tabs, 2 Tabs PO BID 12. Docusate Sodium 100 PO BID 13. Furosemide 40 mg PO DAILY 14. Remeron 15 mg PO DAILY 15. Daptomycin 400 mg IV Q48H for 5 weeks: end date [2146-5-6]. 16. Regular ISS Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation three times a day as needed. Disp:qs qs Refills:0 5. Cyanocobalamin 100 mcg Tablet Sig: Five (5) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:80 Tablet(s) Refills:2 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). Disp:180 Tablet, Chewable(s) Refills:2 13. Fluticasone 50 mcg/Actuation [Month/Day/Year 37062], Suspension Sig: Two (2) Nasal once a day. Disp:qs qs Refills:2 14. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g Intravenous Q 24H (Every 24 Hours). Disp:30 g Refills:2 16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 17. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:2 18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical once a day. Disp:30 Adhesive Patch, Medicated(s) Refills:2 19. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 20. Roxanol Concentrate 20 mg/mL Solution Sig: 0.5-1 ml PO q1h as needed for pain. Disp:120 ml Refills:0 Discharge Disposition: Home With Service Facility: Season's Hospice Discharge Diagnosis: Primary Diagnosis: -Methicillin Resistant Staphylococcus Aureus Bacteremia -Osteomyelitis of the right great toe Secondary Diagnoses: Myelodysplastic syndrome Chronic systolic heart failure Chronic Kidney Disease Discharge Condition: Pt breathing comfortably on room air. Discharge Instructions: Mr. [Known lastname 3012]: You were admitted because you had a bloodstream infection. We think the source of this infection was your infected toe. We treated you with antibiotics and you had an amputation to remove the source of the infection. It was then evident that you had not cleared the infection as your blood continued to grow the bacteria, and this was thought to be due to your pacemaker wires. You opted to not have aggressive treatment and leave your pacemaker in place. You decided to continue to take antibiotics, knowing that your life expectancy on an antibiotic regimen may be short. . During this admission your home medications were continued. You were started on two IV antibiotics that you will continue to take at home. The medications that were STARTED are: Vancomycin and Rifampin. . If you develop chest pain, shortness of breath, dizzyness, bleeding or any other concerning symptom, please return call your primary care doctor. Followup Instructions: Vascular surgery follow up: Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] . Dermatology follow up: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8157], M.D. Phone:[Telephone/Fax (1) 1971] Date/Time:[2146-4-19] 10:45 . Gerontology follow up: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 13171], MD Phone:[Telephone/Fax (1) 719] Date/Time:[2146-5-11] 11:30 . Infectious disease follow up: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2146-5-13] 10:00 ICD9 Codes: 2930, 4280, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8003 }	Medical Text: Admission Date: [2191-11-24] Discharge Date: [2191-12-7] Date of Birth: [2155-12-17] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: Pedestrian vs. car + LOC Major Surgical or Invasive Procedure: s/p IMF and tracheostomy History of Present Illness: Mr. [Known lastname 16408] is a 35 yo pedestrian who was struck by a car. GCS of 3 at scene. + LOC. + ETOH. He was transferred to [Hospital1 18] for further management. Past Medical History: ^lipid Social History: ETOH use Family History: non-contributory Physical Exam: On discharge: Patient is afebrile, VSS Gen: NAD, A+O x3, unable to fully verbalize secondary to fixation of mandible, sitting upright in chair HEENT: Lip laceration scabbed over, appears stable CV: RRR Resp: CTAB Abd: Soft, NT/ND Pertinent Results: Admit hct: 44.6 Discharge hct: 37.9 [11-24] CT head: Posterior parafalcine SDH with associated foci of subarachnoid and intraventricular hemorrhage. [11-24] CT sinus/[Last Name (un) ]: Right subcondylar mandible fx, left parasymphyseal mandible fx, Minimally displaced L maxillary fx [11-24] CT c-spine: no fx seen, possible osteophyte fx [11-24] CT chest: Aspiration of all lung lobes [11-24] CT abd/pelvis: no injury [11-30] CT head: Slight interval evolution of previously seen subdural hematomas. No new hemorrhage. No evidence of communicating hydrocephalus. [12-3] CT Sinus/Max: No change as compared to before, stable hardware Brief Hospital Course: After being transferred to the ED at [Hospital1 18], the patient was emergently intubated given his GCS score. However following intubation, the patient vomitted and desaturated into the 70's. The ETT was promptly removed and the patient was suctioned. Reintubation was successful with saturations in the high 90's. The patient's injuries consist of a SDH, chin and lip lacerations, and pan-facial fractures. Neurosurgery, plastics, and OMFS were consulted. Neurosurgery requested repeat head CT's which showed stable SDH, thus the patient was non-operative. Plastics sutured the chin lacerations. After being scanned and deemed hemodynamically stable in the ED, the patient was transferred to the TSICU. His C-collar was discontinued given his negative scans. On [11-26] (HD 3), the patient underwent a tracheostomy such that OMFS could repair his pan-facial fractures the next day. On [11-27], the patient underwent IMF of his b/l mandibular fractures. A Dobloff was placed on [11-29] and he was started on TF. The patient was successfully extubated on [11-29] and maintained his saturations on trach mask at 40%. Multiple attempts by speech and swallow were made however the patient was too sedated to participate. On [12-2], the patient was transferred from the ICU to the floor. On the floor the patient was agitated and required restraints. Psychiatry was consulted for his agitation and the patient was given Haldol PRN. On the floor PT saw the patient and suggested rehab. In addition, the patient pulled out his dobloff. Attempts to replace the dobloff were unsuccessful. A repeat S/S trial was done, however the patient was too sedated to participate again. On [12-3] the patient fell out of his bed despite being on restraints and landed on the right side of his face. Dr. [First Name (STitle) ] was called regarding this fall and a repeat CT Max/Sinus was performed to evaluate the extent of his injuries. His hardware was found to be intact and there were no new fractures. Because of this fall, a 1:1 sitter was initiated. His tracheostomy tube was downsized to a 8. It was capped and the patient did well from a respiratory standpoint. On [12-4], the trauma team saw the patient and decided he would be capable starting on full liquids, which the patient did well on. On [12-5], his 1:1 sitter was discontinued. On [12-5] his tracheostomy tube was discontinued. On [12-7] the patient will be discharged to rehab. Medications on Admission: Unknown Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Pedestrian vs. car, +LOC, s/p IMF and tracheostomy Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Followup Instructions: Follow up with Dr. [Last Name (STitle) 2866] in 5 days for removal of wires. Please call [Telephone/Fax (1) 81467] to make an appointment. Follow up with Neurosurgery in one month. Please call [Telephone/Fax (1) 1669] to make an appointment. Follow up in general trauma clinic in one week. Please call [Telephone/Fax (1) 6429] to make an appointment. Completed by:[2191-12-7] ICD9 Codes: 5070
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8004 }	Medical Text: Unit No: [Numeric Identifier 70741] Admission Date: [2109-1-4] Discharge Date: [2109-1-9] Date of Birth: [2109-1-4] Sex: F Service: Neonatology HISTORY: The patient is a term infant transferred to the Neonatal Intensive Care Unit from regular nursery at one day of age with respiratory distress. Patient was born a 2210 gram product of a 37-4/7 week gestation born to a 35 year-old gravida V, para III to IV mother with estimated date of completion [2109-1-22]. Her prenatal laboratories were notable for a mother with B positive blood type, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, Rubella immune and GBS positive. Patient was delivered by repeat cesarean section without labor or rupture of membranes. No risk factors identified, mother without intrapartum antibiotics. The patient vigorous with Apgars of 8 and 9 and was admitted to the regular nursery. The patient had mild grunting and retractions with intermittent tachypnea, was overall comfortable. She was evaluated once by neonatology in the delivery room and again in newborn nursery and then transferred on day of admission. Chest x-ray revealed patchy oximetry consistent with retained fetal lung fluid, and linear lucency was investigated with a right decubital view which showed no pneumothorax. SUMMARY OF CLINICAL COURSE BY SYSTEM: Respiratory: Patient received nasal cannula oxygen on day of life 3, and this was discontinued 48 hours prior to discharge. No apneic or bradycardic spells during admission. Patient currently on room air with respiratory rate 30 to 50 and oxygen saturation greater than 95%. Cardiovascular: No issues. Mild I/VI systolic ejection murmur at left lower sternal border without radiation. Good perfusion of femoral pulses, no concern at this time. Fluid, electrolytes and nutrition. Patient ad lib breast- feeding, with regular stooling and voiding. Weight on day of discharge is 3005 grams. GI: Stool was consistently heme negative, no current issues. Not jaundiced. Bilirubin on day of life 3 yielded a total level of 8.3 with direct component of 0.3. Hematology: Initial CBC unremarkable for infection. White blood count of 21,000, hematocrit of 37, platelets of 451. White blood cell differential 65 polys, 0 bands, 36 lymphs. Infectious disease: See above. Blood culture negative. Ampicillin and gentamicin were given for the first 48 hours of admission and discontinued with negative blood culture at 48 hours. Neurology: Not applicable. Sensory: Audiology: Hearing screen performed with automated auditory brain stem responses and passed prior to discharge. Ophthalmology: Not applicable. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) 636] [Last Name (NamePattern1) ] at [Hospital 5344] Pediatrics. CARE RECOMMENDATIONS: Feeds at discharge: Ad lib p.o. breast feeding. MEDICATIONS: None. CAR SEAT POSITION SCREENING: Not applicable. STATE NEWBORN SCREENING: Performed prior to discharge. IMMUNIZATIONS: Hepatitis B vaccine given on [2109-1-7]. Immunizations recommended: Synagis RSV prophylaxis should be recommended from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: 1) born at less than 32 weeks, 2) born between 32 and 35 weeks with 2 of the following - day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings or 3) with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOW UP APPOINTMENT: On Friday, [2109-1-11] with Dr. [First Name (STitle) ] at [Hospital 5344] Pediatrics. DISCHARGE DIAGNOSES: 1. Transient tachypnea of the newborn. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 55780] Dictated By:[Name8 (MD) 70742] MEDQUIST36 D: [2109-1-9] 10:52:26 T: [2109-1-9] 11:59:21 Job#: [Job Number 70743] ICD9 Codes: V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8005 }	Medical Text: Admission Date: [2191-7-7] Discharge Date: [2191-8-13] Date of Birth: [2115-8-16] Sex: F Service: CCU CHIEF COMPLAINT: Acute anterior myocardial infarction. HISTORY OF PRESENT ILLNESS: This is a 75 year old white female with a past medical history significant for diabetes mellitus, hypertension and peripheral vascular disease, who now presents with acute anterior myocardial infarction. The patient presented to her primary care physician yesterday complaining of mild aches between her breasts and dyspnea on exertion. EKG at that time revealed new onset atrial fibrillation and the patient was sent home with instructions for follow-up with Cardiology today. She presented to [Hospital1 69] Emergency Department at 5 a.m. today with acute respiratory distress with tachypnea to the 30s, decreased blood pressure, diaphoresis and chest pain. EKG with ST elevations in the anterior leads. She was soon intubated and taken emergently to the Catheterization Laboratory. There, she was found to have a total occlusion of the mid- left anterior descending, subtotal mid occlusion of the left circumflex, and 95% mid right coronary artery with cardiogenic shock. Three stents were placed and the patient was started on a dopamine drip secondary to decreased blood pressure. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus, adult onset. 3. Peripheral vascular disease. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q. day. 2. Calcium carbonate 500 mg p.o. q. day. 3. Univasc 30 mg p.o. q. day. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient has a positive tobacco history, no next of [Doctor First Name ], and lives in a group home. FAMILY HISTORY: Unknown with no next of [Doctor First Name ]. REVIEW OF SYSTEMS: Significant for dry mouth and urinary frequency. PHYSICAL EXAMINATION: Temperature 97.2 F.; blood pressure 178/44; heart rate 79; breathing 16; 100% on room air. Ventilator settings, SMIV at total volume of 500, respiratory rate of 16, PEEP of 5 and pressure support of 5. 100% O2. Telemetry showing normal sinus rhythm with multi-focal atrial tachycardia. In general, this is an intubated and sedated patient, pale, frail, elderly female. HEENT: Endotracheal tube in place. Mucous membranes were moist. Unresponsive. Neck examination: No jugular venous distention and no carotid bruits. Lungs are clear to auscultation bilaterally. Cardiovascular examination is irregularly irregular, tachycardic with no murmurs, rubs or gallops. Abdominal examination is soft, nontender, nondistended, normal bowel sounds. No hepatosplenomegaly. Extremities with no edema, cool extremities with no palpable lower extremity pulses. One plus radial pulses bilaterally. No unusual rashes. LABORATORY: White blood cell count 23.7, hematocrit 34.6, platelets 565. Sodium 134, potassium 4.1, chloride 101, CO2 18, BUN 21, creatinine 1.3. Glucose 410. Calcium 8.0, magnesium 1.7, phosphorus 6.4. Urinalysis was negative. Creatinine kinase was taken at 9 a.m. with a value of 3,063, an MB fraction of 66. Arterial blood gas revealed a pH of 7.27, pCO2 of 43 and a pO2 of 162. Chest x-ray revealed increased interstitial markings, perihilar air space opacities, upper zone redistribution consistent with congestive heart failure, status post myocardial infarction. EKG revealing normal sinus rhythm with a ventricular rate of approximately 110, normal axis, ST elevations in V3 through V5. HOSPITAL COURSE: In summary, this is a 75 year old white female with a history of diabetes mellitus, hypertension, peripheral vascular disease, now with an acute anterior myocardial infarction status post stent times three via catheterization. 1. CARDIOVASCULAR: The patient was initially placed on Integrilin with heparin and started on aspirin and Plavix as well as Pravachol. Her initial hypotension did not allow a beta blocker or ACE inhibitor at the time. Her pump function on admission revealed cardiogenic shock. She was placed on an intra-aortic balloon pump. Her rhythm of atrial fibrillation was attempted to cardiovert on hospital day #2, but continued to alternate between a multifocal atrial tachycardia and normal sinus rhythm. Her Levophed and Dopamine were eventually weaned on hospital day number four. Her balloon pump was discontinued on hospital day number five. An echocardiogram performed on hospital day number five revealed a mildly dilated left atrium, apical akinesis with basal hypokinesis and distal septal dyskinesis, two plus mitral regurgitation and mild PA systolic hypertension, possible small pericardial effusion and an ejection fraction of approximately 20 to 25%. A low dose beta blocker and low dose ACE inhibitor was added on hospital day number six. All pressors were off at this time but the patient continued to revert into atrial fibrillation. She was placed on a heparin drip for anti-coagulation for her atrial fibrillation. On hospital day number ten, she was noted to have a profound drop in her blood pressures. A Swan-Ganz catheter was placed and pressors were once again started to maintain a normotensive blood pressure. Her beta blocker and ACE inhibitor were discontinued at this time. Her Swan-Ganz data revealed fluid overload at the time and she was gently diuresed. She was pulled off pressors on hospital day number 16 once again and a low dose ACE inhibitor was added. On hospital day number 19, due to labile blood pressures her pressors were restarted. Her rhythm seemed to fluctuate between normal sinus rhythm, multi-focal atrial tachycardia and supraventricular tachycardia, which was all managed conservatively. She was eventually placed on a low dose Metoprolol in attempts to control her rhythm and her ACE inhibitor was discontinued. She had a repeat echocardiogram performed on hospital day #34 which revealed continued ejection fraction of less than 25%. She was also noted to have a seven-beat run of nonsustained ventricular tachycardia on hospital day #36, however, after discussion with her guardian in regards to placing an AICD, it was determined that the guardian did not want an AICD placed and also suggested to discontinue the Telemetry which would be of no use if she did go into a life threatening rhythm. Telemetry was discontinued. The patient had no further episodes of cardiovascular events that were noted and her rhythm was no longer monitored. This dictation will be continued at a later date as a Discharge Summary Addendum. DR.[First Name (STitle) ],[First Name3 (LF) 734] 12-944 Dictated By:[Name8 (MD) 5406] MEDQUIST36 D: [2191-9-25] 22:07 T: [2191-9-28] 17:07 JOB#: [Job Number 26156] ICD9 Codes: 4280, 5185, 5789, 2760
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8006 }	Medical Text: Admission Date: [2144-5-26] Discharge Date: [2144-6-3] Date of Birth: [2073-2-18] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 11839] Chief Complaint: Upper back and bilateral rib pain, metastatic rectal cancer. Major Surgical or Invasive Procedure: 1. C7 bilateral hemilaminotomy. 2. T1 laminectomy for removal biopsy tumor neoplasm. 3. T2 bilateral hemilaminotomy. 4. Posterolateral fusion C7-T1. 5. Posterolateral thoracic fusion T1-T2. 6. Iliac crest bone graft harvest for fusion. 7. Posterior instrumentation C7, T1, T2. History of Present Illness: Mr. [Known lastname 14502] is a 71yo man with HTN, COPD, and metastatic rectal cancer to the bones admitted from clinic for upper back and bilateral rib pain. His pain has worsened over the last one week since restarting capecitabine. It is worse with movement and inspiration. He also has similar pain in the front of his chest. Fentanyl patch was increased from 100mcg/hr to 200mcg/hr [2144-5-20]. In addition, he has been needing hydromorphone 4mg every 3hrs for a few days, but this has been inadequate. He was in the [Hospital 878] Clinic due to a prerequisite for enrollment in the Mersana clinical trial. PET/CT [2144-4-17] showed progression of disease. . ROS: He notes anorexia and night sweats. He denies fever, chills, N/V, wght loss, headache, dizziness, dyspnea, cough, abdominal pain, constipation, diarrhea, hematochezia, melena, hematuria, other urinary symptoms, weakness, or rash. He has chronic numbness in his feet. All other ROS were negative. Past Medical History: ONCOLOGIC HISTORY: # Early stage lung cancer status post right upper lobectomy and mediastinal lymph node dissection in [2134-9-6] without evidence of recurrence. # Rectal Cancer: T3N2M0; diagnosed in 10/[2140]. - [2141-9-6]: the pt develops abdominal pain and lower GI bleed, further investigation by colonoscopy reveals an ulcerated 4-5 cm mass in the mid rectum at 10cm, the pathology examination of the biopsies shows poorly differentiated carcinoma. - [2142-3-7]: the patient undergoes low anterior resection and diverting loop ileostomy and mesenteric and periaortic lymphadenectomy (T3N2M0, [8-17] lymph nodes involved, with a distal margin that was clear by < 1 mm, k-RAS wild time) after completion of neo-adjuvant capecitabine-based chemoradiation - [5-14] the patient started adjuvant therapy with FLOX (5-FU + leucovorin 500 mg/m2 on day 1, 8, and 15 and oxaliplatin 85 mg on day 1,5 of four-week cycles). - On [6-13] a nonocclusive thrombus was demonstrated in the left renal vein and the patient was started on anticoagulation. - On [2142-8-21], he started cycle #4 of FLOX at reduced dose of 5-FU 400 mg/m2 only on D1,15 and oxaliplatin at 85 mg/m2 on D1,15. He subsequently completed two more cycles, the last one being on [2142-10-16]. Therapy was also complicated by the developments on oxaliplatin-related neuropathy involving the palms, feet and distal calves. - [2142-7-7] bone scan and spine MRI showed multiple bone metastasis, in [2143-6-6] a bone scan and now CT scan torso showed progression of bone metastates, but no evidence of other site of metastatic disease. - [2143-7-24] start palliative chemotherapy with single [Doctor Last Name 360] Irinotecan (350 mg/m2 q21d). - [2143-10-9] CT TORSO showed increased sclerotic bony metastatic disease unclear if due to disease progression or response to treatment. . Treatment History: 06/09,16,23: C1 FLOX (5-FU 500 mg/m2 D1,8,21 + Oxaliplatin 85 mg/m2 D1,15). [2142-6-13]: C2 FLOX. C2D1 changed from [6-10] to [6-12] due to development of abdominal pain and nausea. Urgent CT demonstrated nonocclusive thrombus of left renal vein and interval enlargement of sclerotic focus in left aspect of T12. Hospitalized [Date range (1) 101702] for neutropenic fevers (100.5, ANC 500,) LLQ pain, and dehydration. CT demonstrated small bowel thickening suggestive of enteritis. Stool and blood cultures negative. Discharged on course of Cipro + Flagyl. [2142-7-16]: C3 FLOX. Hospitalized [Date range (1) 101703] for weakness, abdominal pain, and increased ostomy output and dehydration. CT revealed epiploic appendagitis. [2142-8-21]: C4 FLOX (5-FU 400 mg/m2 D1,15 + Oxaliplatin 85 mg/m2 D1,15). [2142-9-18]: C5 FLOX. [2142-10-16]: C6 FLOX. [2143-7-24]: Start Irinotecan (350 mg/m2 q21d) x7 cycles. [1-/2144]: Cetuximab added to irinotecan. [5-/2144]: Restarted capecitabine. . OTHER PMHx: Hypertension. COPD. Depression/Anxiety disorder. Arthritis. Gastritis. Non-occlusive left renal vein thrombus, [6-13] on enoxaparin. BPH. Social History: He is married with 12 children. He lives in [Location (un) 538] and is currently unemployed. He previously worked as an auto mechanic. He quit smoking ~20yrs ago. He rarely drinks alcohol and denies illicit drug use. Family History: Unremarkable for colorectal or other malignancy. Physical Exam: Admission Physical Examination: VS: T 97.0F, BP 102/68, HR 117, RR 18, O2 Sat 98% RA. GEN: A&O, NAD, ill appearing, thin. HEENT: Sclerae non-icteric, EOM intact, CNs normal, o/p clear, dry MM. Neck: Supple, no thyromegaly, no JVD. Lymph nodes: No cervical, supraclavicular, axillary, or inguinal LAD. CV: S1S2, reg rate and rhythm, no MRG. Chest pain not reproducible by palpation. RESP: Good air movement bilaterally, no added sounds. CHEST: Markedly tender bilateral ribs, large asymmetry/mass at right posterior ribs at thoracotomy scar. ABD: Soft, non-tender, non-distended, no HSM. EXTR: No edema, calf tenderness, or finger clubbing. DERM: No rash. Neuro: Strength 5/5, sensation to touch diminished at feet, down-going plantar reflexes, no focal deficits. PSYCH: Appropriate and calm. Pertinent Results: ADMISSION LABS: [2144-5-26] 06:00PM BLOOD WBC-10.8 RBC-3.97 Hgb-10.4* Hct-31.6* MCV-80* MCH-26.3* MCHC-33.0 RDW-16.7* Plt Ct-360 [2144-5-26] 06:00PM BLOOD Neuts-80.7* Lymphs-8.9* Monos-9.5 Eos-0.6 Baso-0.2 [2144-5-26] 06:00PM BLOOD PT-14.3* PTT-36.7* INR(PT)-1.2* [2144-5-26] 06:00PM BLOOD Glucose-119* UreaN-12 Creat-0.9 Na-134 K-4.4 Cl-97 HCO3-25 AnGap-16 [2144-5-26] 06:00PM BLOOD Albumin-3.6 Calcium-9.0 Phos-2.7 Mg-1.9 [2144-5-26] 06:00PM BLOOD ALT-9 AST-42* AlkPhos-395* TotBili-0.4 . [2144-5-26] MRI T-SPINE: IMPRESSION: 1. Significant progression of metastatic lesions involving the thoracic and visualized lumbar spine since the previous MRI from [2142-7-30]. Multiple sclerotic deposits are demonstrated throughout the thoracic spine with diffuse involvement at multiple sites. 2. Large epidural deposit causing cord compression is demonstrated at T1 level. Several other epidural deposits are seen, most prominent at T9 and T12 levels. . [2144-5-27] CT C/A/P: IMPRESSION: 1. Interval worsening of extensive osseous metastasis, most prominently noted along the right rib cage, with expansile osseous and soft tissue components. Small right pleural effusion. Worsening of multilevel osseous metastases in the spine as described. No acute pathologic fracture. 2. Unchanged small parastomal hernia, but without bowel obstruction at the loop ileostomy in the right lower quadrant. 3. Stable presacral soft tissues. . [2144-5-27] MRI C/L-SPINE: IMPRESSION: 1. Multiple sclerotic metastases in the cervical, visualized thoracic and lumbar spine. 2. Large epidural mass at T1 causing severe cord compression as seen on the earlier thoracic spine study. 3. Small epidural deposit at T12 level indenting the dorsal aspect of the distal cord as seen on the recent thoracic spine study. 4. Small posterior epidural deposits at L2-3 and L3-4 levels without canal compromise. 5. Minor degenerative changes in the lower lumbar spine with disc bulges, small protrusions and facet arthropathy causing foraminal narrowing. . [2144-5-28] MRI BRAIN: IMPRESSION: Sclerotic bony metastatic lesions are identified in both frontal bones and left temporal bone with dural enhancement adjacent to the bony metastases in the right frontal and left temporal regions. Sclerotic metastatic disease to the spinous process of C2 is also noted, which was observed on the cervical spine MRI of [2144-5-27]. No brain parenchymal metastasis is seen. . [2144-5-29] CXR: IMPRESSION: Lung volumes are slightly lower, but lungs are clear of any focal abnormality. Blastic bone lesions in the ribs and the thoracic spine have increased substantially. There is no pneumonia or pulmonary edema or even appreciable pleural effusion. ET tube is in standard placement, right subclavian infusion port ends low in the SVC and a nasogastric tube ends in the mid stomach. No pneumothorax. . DISCHARGE LABS: Brief Hospital Course: 71yo man with HTN, COPD, and metastatic rectal CA admitted for back and bilateral rib pain. Pain improved with IV hydromorphone. MRI T-spine confirmed T1 cord compression. Neurosurgery and Radiation Oncology were consulted. Dexamethasone was started. He went for neurosurgical decompression at T1 [2144-5-28]. After surgery, he developed atrial fibrillation, which was controlled with metoprolol. He was not anticoagulated because of the recent neurosrugery. Radiation Oncology planned radiation to the remaining T-spine regions at risk and pt scheduled to start as an outpt. # Back and rib pain and T1 cord compression: MRI T-SPINE showed severe T1 cord compression. Dexamethasone started. Consulted Neurosurgery and Radiation Oncology. He went for neurosurgical decompression of T1 [2144-5-28].Palliative care was also consulted for pain control.Fentanyl patch was increased to 250 mcg /hr. In addition hydromorphone was added for breakthrough pain. Scheduled acetamoniphen was also state [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 101706] gabapentin increased to 600 mg. Pain wa soverall well ocntrolled with this regimen. . # Rectal CA, KRAS wild-type: Hold capecitabine. Mr. [Known lastname 14502] did not qualify for this recent clinical trial. He plans to pursue other trials or chemo agents after discharge. . # Atrial fibrillation: Developed after surgery and controlled with increased doses of metoprolol. Not anticoagulated because of recent neurosurgery.A chest CTA was done and was neagtive fo ra PE. . # Anemia: Likely chemo-induced. Stable. . # Renal vein clot: Mr. [Known lastname 14502] had decided in the past to discontinue enoxaparin, so this was not restarted during this admission. . # HTN: Changed metoprolol XL to short-acting and increased dose to 25mg [Hospital1 ] to improve BP, tachycardia, and prep for surgery. . # COPD: Continued albuterol/ipratropium and fluticasone/salmeterol. . # BPH: Continued tamsulosin. . # Depression: Continued citalopram. . # FEN: Regular diet. IV fluids given for decreased PO and clinical dehydration. Repleted hypophosphatemia. . # GI PPx: PPI and bowel regimen. . # CODE: FULL. Medications on Admission: ALBUTEROL SULFATE BENZONATATE 200mg PO TID PRN CITALOPRAM 10mg PO daily ENOXAPARIN 80 mg/0.8 mL daily (was not taking) FENTANYL 200mcg/hr Patch Q72hr FLUTICASONE PROPIONATE FLUTICASONE-SALMETEROL [ADVAIR DISKUS] 500mcg-50mcg/Dose 2 puffs inhaled [Hospital1 ] GABAPENTIN 300mg PO TID HYDROMORPHONE 4mg Tablet PO Q3HR PRN IPRATROPIUM-ALBUTEROL [COMBIVENT] 18mcg-103mcg (90 mcg)/Actuation Aerosol - 1-2 puffs inhalation QID PRN LORAZEPAM 2-4mg PO QHS PRN anxiety METOPROLOL SUCCINATE 25mg Extended Release PO daily METRONIDAZOLE [METROGEL] 1% Gel apply on face [Hospital1 ] OMEPRAZOLE 40mg PO daily ONDANSETRON HCL 8mg PO Q12HR DAYS 2 AND 3 after chemotherapy POTASSIUM CHLORIDE [KLOR-CON M20] 20 mEq ER Particles/Crystals PO BID (not taking) TAMSULOSIN [FLOMAX] 0.4mg PO QHS BENZOCAINE [ORABASE-B] 20% Paste apply locally 2-3 times daily prn mouth sores Discharge Medications: 1. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [12-8] Puffs Inhalation Q6H (every 6 hours) as needed for Dyspnea, wheeze. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation: over the counter. 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 4. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 6. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Transdermal Q72H (every 72 hours). Disp:20 patches Refills:0 10. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Transdermal every seventy-two (72) hours: total dose of fentanyl 250 mcg/hr. Disp:10 patchs Refills:0 11. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply for 12hrs every 24 hrs. Disp:30 Adhesive Patch, Medicated(s) Refills:0 13. hydromorphone 4 mg Tablet Sig: Four (4) Tablet PO every four (4) hours as needed for Pain. Disp:120 Tablet(s) Refills:0 14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Disp:60 Capsule(s) Refills:0 16. lorazepam 2 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. Discharge Disposition: Home With Service Facility: art of care Discharge Diagnosis: 1. Back and rib pain. 2. Metastatic rectal cancer to the bones. 3. T1 spinal cord compression. 4. Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for back and rib pain due to metastatic rectal cancer to the bones.You were found to have cord compression at the the level of T1 and underwent neurosurgical decompression. You tolerated the surgery well. After surgery you had a rapid heart rate ( atrial fibrillation) and metoprolol dosing was changed. Your pain medications were also adjusted for better pain control. You should keep the surgical incisional wound open to air, but cover during showers and then pat to dry. Do not take baths or swim until further instructed by Dr [Last Name (STitle) 1007]. Change in medications: 1.Fentanyl patch dose increased to 250 mcg 2.metoprolol succinate chanegd to metoprolol tartate 25 mg po tid 3.Night time gabapentin increasd to 600 mg 4.Tylenol 650 mg four times dailyx7 days 5.lidocaine patch 6.Hydromprophone increased to 16mg as needed every 4 hrs. 7. Docusate and senna as needed for constipation Followup Instructions: Radiation oncology:[6-9] ,8:00 [Hospital Ward Name 23] building [Location (un) 442]. tel [Telephone/Fax (1) 9710] Department: ORTHOPEDICS When: WEDNESDAY [2144-6-24] at 3:25 PM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SPINE CENTER When: WEDNESDAY [2144-6-24] at 3:45 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 3736] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2144-7-1] at 11:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2144-7-1] at 11:30 AM With: [Name6 (MD) 5145] [Name8 (MD) 5146], MD, PHD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8007 }	Medical Text: Admission Date: [2115-4-6] Discharge Date: [2115-4-9] Date of Birth: [2050-12-27] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Headache, left sided numbness and left sided vision loss Major Surgical or Invasive Procedure: Infusion of TPA History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 1 minutes Time (and date) the patient was last known well: 15:15 (24h clock) NIH Stroke Scale Score: 7 t-[MD Number(3) 6360]: Yes Time t-PA was given bolus;19:26 and infusion;19:27(24h clock) I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. NIH Stroke Scale score was 7: 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 2 4. Facial palsy: 1 5a. Motor arm, left: 1 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 1 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 2 NEUROLOGY RESIDENT CONSULT NOTE Reason for Consult:CODE STROKE HPI: Mr [Known lastname 47097] is a 64 year old right handed man presenting as a code stroke after sudden development of right eye pain and left sided numbness. He was playing solitaire today at 15:15, when he started having left sided visual problems and left sided numbness. He drove himself to [Hospital3 26615] hospital and was having some pain behind his right eye. He went to [Hospital3 26615] hospital and his finger stick was 101, temp 97.3, pulse 98, resp 18, bp 191/87, o2 sat of 98%. He got a bag of normal saline, fentanyl, and zofran. He has a history of aneurysm s/p clipping at [Hospital1 2025] in [2107] without subsequent problems. [Name (NI) ] was evaluated by neurosurgery who did not feel an intervention or tpa was currently indicated and was transferred to [Hospital1 ]. While in transit he got a bag of normal saline, fentanyl, and zofran. Upon initial evaluation he had an NIHSS of 7 (2 for left visual field loss, 1 for mild facial palsy, 1 for left pronator drift, 1 for mild hemisensory loss, and 2 for inattention to the left). Currently he states he has a headache but is unaware of any deficits or why things are occuring. On ROS patient states he had nausea and vomiting and diarrhea for the past week, and went to the ED at [Hospital3 26615] this past Wednesday but has been feeling better the past 2 days. He denies any other weakness, numbness, dysarthria, or neurologic symptoms just pain behind his right eye. Besided the recent fevers, nausea, vomiting, he denies any other SOB, CP, or other general symptoms. Past Medical History: HTN, aneurysm in [2107] s/p cliping Social History: lives alone, no children, smoke [1-7] pack per day, drinks socially, no illict drug use. Family History: no family history of strokes or aneurysms Physical Exam: Physical Exam: Vitals 97.3, pulse 98, resp 18, bp 191/87, o2 sat of 98% : General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, no masses or organomegaly noted. Extremities:warm and well perfused Skin: no rashes or lesions noted. . Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Inattentive requring frequent redirection. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. had no anomia if object placed in right visual field. Able to read right half of sentenses without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. +neglect to the left hemispace. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. left hemianopsia, appears worse in the inferior quadrant III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: mild left facial at time of presentation but resolved after CT VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. . -Motor: Normal bulk, tone throughout. initial left pronator drift that resolved after CT scan. Delt Bic Tri WrE FFl FE IP Quad Ham TA L 5 5 5 5 5 5 5 5 5- 5- R 5 5 5 5 5 5 5 5 5- 5- . -Sensory:left hemibody sensory deficit to pinprick. left leg completely desensitized to pinprick, left upperextremity can feel the pin but less than the right side. He has agraphestesia in the left hand. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response was flexor bilaterally. . -Coordination: No dysmetria on FNF . -Gait: defferred Pertinent Results: Admission Labs: [2115-4-6] 06:15PM BLOOD WBC-15.4* RBC-4.55* Hgb-14.5 Hct-44.3 MCV-97 MCH-31.9 MCHC-32.8 RDW-12.9 Plt Ct-428 [2115-4-6] 06:15PM BLOOD PT-10.6 PTT-25.8 INR(PT)-1.0 [2115-4-6] 06:15PM BLOOD Fibrino-252 [2115-4-7] 06:39AM BLOOD Glucose-94 UreaN-17 Creat-1.1 Na-140 K-4.4 Cl-111* HCO3-21* AnGap-12 [2115-4-7] 06:39AM BLOOD ALT-34 AST-18 LD(LDH)-165 CK(CPK)-31* AlkPhos-53 TotBili-0.3 [2115-4-6] 06:15PM BLOOD cTropnT-<0.01 [2115-4-7] 06:39AM BLOOD CK-MB-1 cTropnT-<0.01 [2115-4-7] 06:39AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.8 Mg-2.7* Cholest-137 [2115-4-7] 06:39AM BLOOD %HbA1c-5.5 eAG-111 [2115-4-7] 06:39AM BLOOD Triglyc-94 HDL-28 CHOL/HD-4.9 LDLcalc-90 [2115-4-6] 06:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2115-4-6] 08:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2115-4-6] 08:15PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.039* [2115-4-6] 09:28PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [2115-4-6] 8:15 pm URINE URINE CULTURE (Final [2115-4-8]): NO GROWTH. Discharge Labs: [2115-4-9] 04:50AM BLOOD WBC-12.0* RBC-4.41* Hgb-13.3* Hct-42.4 MCV-96 MCH-30.2 MCHC-31.4 RDW-12.6 Plt Ct-429 [2115-4-9] 04:50AM BLOOD Glucose-111* UreaN-19 Creat-1.2 Na-139 K-4.3 Cl-107 HCO3-25 AnGap-11 [2115-4-9] 04:50AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.4 Reports: EKG: Baseline artifact. Non-specific ST-T wave change. Compared to tracing #1 no diagnostic change. Rate PR QRS QT/QTc P QRS T 72 202 92 358/379 57 12 18 Chest Film: Single AP portable view of the chest was obtained. No focal consolidation, pleural effusion, or pneumothorax is seen. The cardiac silhouette was not enlarged. The aortic knob is calcified. No displaced fracture is seen. IMPRESSION: No acute cardiopulmonary process. CT/CTP/CTA Head/Neck: Increased mean transit time with decreased cerebral blood volume and blood flow on the right occipital lobe, consistent with infarction in the right posterior cerebral artery vascular territory as described in detail above. The patient is status post aneurysm clipping via left frontotemporal craniotomy. There is no evidence of acute intracranial hemorrhage or mass effect. Atherosclerotic calcifications are visualized in the carotid cervical bifurcations, causing severe narrowing at the origin of the right internal carotid artery. Echo: The left atrium and right atrium are normal in cavity size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is 0-5 mmHg. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is high normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION:Trace aortic regurgitation with mild aortic valve sclerosis. No definite structural cardiac source of embolism identified. Carotid U/S: Right ICA 70-79% stenosis, Left ICA 60-69% stenosis. MRI Head: Subacute infarction in the right PCA territory without evidence of hemorrhagic transformation with a possible involvement of the choroidal anterior artery territory. Brief Hospital Course: Me. [Known lastname 47097] was examined emergently in the ED of [Hospital1 18] and was found to have a dense left homonymous hemianopia. Preliminary STAT CT imaging showed the presence of hypoperfusion in a right PCA distribution. His case was discussed with the attending Stroke Neurologist and informed consent was obtained for TPA administration, for which there were no apparent contraindications. TPA was administered without any acute complications, and he was admitted to the ICU for post-TPA monitoring with q1hr neuro checks, etc. As he remained hemodynamically stable and with stable neurologic examinations, he was transferred out of the ICU. His left visual field cut became less dense over time, but at the time of discharge, he still had quite a significant visual field cut. Several studies were done to work up his stroke. We obtained the make/model number of his aneurysm clips from [Hospital1 2025] (he has a history of a left ICA and left ACOMM aneurysm clipped by [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 1128] from [Hospital1 2025]), and with this information, we were able to obtain an MRI of his head, which identified a single area of restricted diffusion in the right PCA distribution. Several days of telemetry monitoring did not identify any evidence of atrial fibrillation. His CTA done on admission did identify scattered atherosclerotic lesions in his intra and extracranial blood vessels, including the internal carotid arteries. A carotid US did show right ICA stenosis of 70-79% and left ICA stenosis of 60-69%. However, these bilateral stenoses were not the cause of his posterior circulation infarct. These bilateral ICA stenoses will need to be monitored for plaque progression in the future. His LDL returned elevated and he was started on statin therapy, and was of course also placed on a daily aspirin as secondary prophylaxis against future strokes. He was counseled extensively on the importance of quitting smoking cigarettes. An echocardiogram was performed which did not reveal any obvious embolic source and no obvious valvular pathology. Given his left visual field cut, he was strictly advised NOT to drive prior to having a formal OPHTHALMOLOGICAL examination with visual field testing. In addition, he was given information about the [Hospital1 18] Drivewise program, which is a comprehensive evaluation of one's driving abilities following a variety different physical and neurologic disabilities. At the time of discharge, he was able to ambulate independently, had no focal neurologic signs (other than a resolving left visual field deficit) and was cognitively intact. Transitional Issues: - HOLTER MONITOR - Neurology Follow Up - Eye examination with formal visual field testing Medications on Admission: Cozaar 50mg [Hospital1 ] Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for headache. Disp:20 Tablet(s) Refills:0 3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:1 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:60 Tablet, Chewable(s) Refills:1 5. Cozaar 50 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Ischemic stroke Hypertension Tobacco Abuse History of brain aneurysm s/p clipping Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Neurological Examination: Slight anisocoria (L>R), full EOM, left homonymous hemianopia with intact sensation and strength throughout Discharge Instructions: Dear Mr. [Known lastname 47097], It was a pleasure taking care of you during this hospitalization. You were admitted to the neuro-intensive care unit and the neurology wards of the [Hospital1 827] for symptoms of headache, left sided numbness and left sided visual loss that you experienced while playing solitaire. Through a series of interviews, physical examinations, laboratory tests and neuroimaging studies, we determined that you sustained a stroke in the right OCCIPITAL region of your brain. The cause of this stroke was likely related to atherosclerosis or plaques in the arteries of your brain that be caused by risk factors such as high blood pressure, high cholesterol and smoking. As we were able to identify your stroke relatively quickly, you received TPA or tissue plasminogen activator therapy (a "Clotbusting" medication) that at times can improve the symptoms of stroke. - We have made some changes to your medications as listed below. Please take your medications as prescribed, and do not hesitate to contact us should you have any questions or concerns. We have started on you a daily ASPIRIN and a CHOLESTEROL lowering medication called ATORVASTATIN. For your headache, we have prescribed you OXYCODONE. Oxycodone can sometimes cause constipation, for which we have prescribed you a stool softener called DOCUSATE. Continue to take COZAAR as you were previously doing. - We expect that your headache will get better over time. To reduce the impact of these headaches, we ask that you stay well hydrated, eat regular meals, have regular sleep cycles and avoid pain medications on a daily basis. - Some strokes, such as the one you sustained, can affect your ability to drive. We have referred you to a program at [Hospital1 18] called DRIVEWISE, which is a comprehensive assessment conducted by skilled therapists who are able to certify your ability to drive safely. Please be sure to follow up with them. Their phone number is [Telephone/Fax (1) 110357], and they will contact you to set up an appointment. - Please come to the nearest ED should you have any of the below listed unexplained symptoms. - We have organized a follow up appointment for you to see Dr. [First Name (STitle) 5846], who is your primary care physician. [Name10 (NameIs) ] ask that you take these records with you as well as ALL your current medications at that time. We have asked Dr.[Name (NI) 110358] office to set up a referral for you to see a neurologist closer to your home town. Please be sure that this is set up at your next visit with Dr. [First Name (STitle) 5846]. - Smoking is an important modifiable risk factor for strokes. Please try to cut down or quit smoking. Your PCP can talk with you further about tips or medications that can help with this. Followup Instructions: Please follow up with Dr. [First Name (STitle) 5846], your primary care physician [Last Name (NamePattern4) ]: [Telephone/Fax (1) 110359] Fax: [Telephone/Fax (1) 110360] [2115-4-19], 3:45PM [Apartment Address(1) 110361] [Location (un) 5028], MA: [Numeric Identifier ] Completed by:[2115-4-9] ICD9 Codes: 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8008 }	Medical Text: Admission Date: [2177-1-6] Discharge Date: [2177-1-11] Date of Birth: [2123-12-15] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [2177-1-6] Coronary Artery Bypass Graft x 3 (Left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) History of Present Illness: 52 year old man with increasing chest pain, nausea, vomiting over the past 6 weeks. A subsequent catheterization revealed multi-vessel coronary artery disease. Transferred for surgical evaluation Past Medical History: s/p Myocaridial Infarction in '[75] Hypertension Hyperlipidemia Tobacco use chronic hip and shoulder pain s/p right ankle injury s/p right leg injury requiring plating and screws s/p discectomy Social History: Occupation: construction supervisor Tobacco: Quit [2176-12-12] ETOH:3-6 packs of beer per week quit [2176-12-12] Family History: father with CAD age 70 Physical Exam: Height: 5'8" Weight: 205lbs General:NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema 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:- Brief Hospital Course: Admitted same day surgery and underwent coronary artery bypass graft surgery. See operative report for further details. He received cefazolin for perioperative antibiotics and Ciprofloxacin for cystoscopy in operating room due to false passage with foley placement by urology. Post operatively he was transferred to the intensive care unit for management. In first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. He was transferred to the floor on post operative day one. Physical therapy worked with him on strength and mobility. Chest tubes and pacing wires were discontinued without complication. Foley was discontinued and the patient voided successfully. Ace inhibitor was not started because blood pressure would not tolerate it. He was discharged home in good condition on POD 5. He will follow up with his personal urologist, Dr. [Last Name (STitle) 20222], on discharge. Medications on Admission: Aspirin, plavix, zocor, lopressor Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 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). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:70 Tablet(s) Refills:0 6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:qs Refills:2 8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:qs Refills:0 9. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 1 weeks. Disp:14 Tablet(s) Refills:0 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA, [Hospital1 1559] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Acute on chronic systolic heart failure False channel s/p cystoscopy for catheter placement Past medical history: s/p Myocaridial Infarction in '[75] Hypertension Hyperlipidemia Tobacco use chronic hip and shoulder pain s/p right ankle injury s/p right leg injury requiring plating and screws s/p discectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with dilaudid prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: [Hospital1 ] heart center [Telephone/Fax (2) 6256] Dr [Last Name (STitle) ] [Name (STitle) ] [2177-1-30] at 9am Heart center [Hospital1 ] [Location (un) ] [Telephone/Fax (1) 6256] Dr [Last Name (STitle) 20222] Tuesday [2177-1-28] at 1130am Please call to schedule appointments Primary Care Dr.[First Name (STitle) ] in [11-30] weeks [Telephone/Fax (1) 84156] Completed by:[2177-1-11] ICD9 Codes: 4280, 412, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8009 }	Medical Text: Admission Date: [2200-12-19] Discharge Date: [2200-12-30] Service: MEDICINE Allergies: Ace Inhibitors / Angiotensin Recp Antg&Calcium Chanl Blkr Attending:[First Name3 (LF) 663] Chief Complaint: Stridor Major Surgical or Invasive Procedure: [2200-12-19] - Intubation and arterial line placement History of Present Illness: Mr. [Known lastname 25788] is an 85 yo with hx of copd who presented to the [Hospital1 18] ED today complaining of sob x 5-6 hours and stridor. He reports it was unlike any previous COPD episodes. Per his caretaker, he had increased work of breathing all night preceeding his visit to the ED with audible wheezing. His wife [Name (NI) 25789] that and said that he was in his previous state of health prior to last night. She did say that he seemed to have problems swallowing, but he never complained. She denied any change in his diet the night before that may suggest anaphylactic response. His daughter mentioned that he felt his cough was worse. In the ED, his symptoms did not improved with bronchodilators. ENT was consulted in the ED who felt that the upper airway was patent and suspected a subglottic problem. Because it was felt his airway was in danger and there was concern of tracheal deviation by imaging, he was intubated. Despite the concern for subglottic airway obstruction, the ET tube passed without problem. A CT neck and chest was ordered and he was admitted to the MICU for further workup. Labs were notable for negative CEs. BNP 9800. Cr 1.2 (BL 1.2). 7.37/46/342. HCT 40. Past Medical History: COPD HTN s/p stroke ? L lacunar infarct [2196] right BKA for thrombosed artery in right leg EtOH abuse wandering atrial pacemaker Social History: [2-12] PPD smoking for past 50-60 years, drinks several shots of ETOH per day, lives with wife and has additional caretaker at home Family History: Unable to obtain Physical Exam: vitals: 56 160/80 spo2 98% gen: intubated, sedated, paralyzed heent: ncat, no obvious neck masses/deformities. no elevated jvd pulm: mild bronchial breath sounds, o/w ctab, no w/r/r cv: hrrr, no m/r/g abd: s/nt/nd/hypoactive bs extr: no c/c/e 2+ peripheral pulses neuro: intubated, sedated, paralyzed Pertinent Results: TRANSTHORACIC ECHOCARDIOGRAM - [2200-12-19] Conclusions: 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. The ascending aorta is moderately 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. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Aortic sclerosis without stenosis. Dilated thoracic aorta. CHEST (PORTABLE AP) [2200-12-19] IMPRESSION: 1. Left lower lobe atelectasis and right small to moderate pleural effusion. No radiographic evidence of pneumonia. Sclerotic focus within the left proximal humerus also noted on prior remote study from [2191] which is not fully characterized and may represent an enchondroma. CT CHEST W/CONTRAST [2200-12-19] IMPRESSION: 1. Endotracheal tube cuff overinflated. 2. Findings compatible with mild interstitial pulmonary edema. Moderate right-sided pleural effusion. 3. Probably reactive precarinal and subcarinal lymphadenopathy. 4. Dilated and fluid-filled esophagus, an aspiration risk. No evidence of aspiration at the current time. 5. Increase in the size of the abdominal aortic aneurysm, incompletely imaged on this study, since [2198]. Dedicated abdominal imaging of this is recommended. 6. Cholelithiasis. 7. Diverticulosis. CT HEAD W/O CONTRAST Study Date of [2200-12-23] IMPRESSION: 1. No acute intracranial hemorrhage. Please note, MRI is more sensitive for the detection of acute ischemia and can be considered if there is high suspicion for acute stroke. 2. Mild-moderate dialtion of ventricles can be due to diffuse parenchymal volume loss with superimposed Alzheimer's disease; to correlate clinically. UNILAT UP EXT VEINS US LEFT Study Date of [2200-12-23] IMPRESSION: Incomplete and suboptimal study secondary to patient noncompliance while in restraints. No evidence of DVT in the vessels interrogated as detailed above. If suspicion persists, consider repeat performance when patient compliance may be achieved. VIDEO OROPHARYNGEAL SWALLOW Study Date of [2200-12-24] IMPRESSION: Evidence for aspiration with thin liquids. Remainder of the study demonstrated mild oral and pharyngeal swallowing dysfunction as detailed above. VIDEO OROPHARYNGEAL SWALLOW Study Date of [2200-12-29] IMPRESSION: 1. Continued laryngeal penetration with nectar-thickened liquids and thin liquids, however, previously appreciated aspiration was not noted on today's study. 2. Otherwise, no interval change in mild oropharyngeal swallow dysfunction. SELECTED LABORATORY RESULTS: [2200-12-19] 06:42AM BLOOD WBC-6.6 RBC-4.12* Hgb-12.9* Hct-40.0 MCV-97# MCH-31.4# MCHC-32.3 RDW-14.7 Plt Ct-351 [2200-12-30] 07:55AM BLOOD WBC-13.7* RBC-4.30* Hgb-13.7* Hct-40.0 MCV-93 MCH-31.9 MCHC-34.4 RDW-14.7 Plt Ct-224# [2200-12-19] 06:42AM BLOOD Glucose-93 UreaN-16 Creat-1.2 Na-141 K-4.6 Cl-105 HCO3-27 AnGap-14 [2200-12-29] 09:05AM BLOOD Glucose-106* UreaN-19 Creat-1.2 Na-137 K-3.7 Cl-97 HCO3-28 AnGap-16 [2200-12-24] 07:40AM BLOOD ALT-50* AST-43* LD(LDH)-250 AlkPhos-70 TotBili-0.5 MICROBIOLOGY: [2200-12-29] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL (NEGATIVE) [2200-12-28] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL (NEGATIVE) [2200-12-20] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL (MIXED OROPHARYNGEAL FLORA) [2200-12-20] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [2200-12-20] URINE URINE CULTURE-FINAL (NO GROWTH) [2200-12-20] BLOOD CULTURE Blood Culture, Routine-FINAL (NO GROWTH) [2200-12-19] MRSA SCREEN MRSA SCREEN-FINAL (NO MRSA ISOLATED) Brief Hospital Course: MICU COURSE: Mr. [Known lastname 25788] was admitted to the MICU with respiratory distress s/p intubation. His respiratory status improved and he was extubated on [2200-12-18]. He had received steroids for possible pharyngeal swelling and was being tapered upon transfer. His CT of the neck showed possible epiglottitis vs. post-intubation inflammation. After being extubated, he did well from a respiratory standpoint. However, his mental status was not at baseline. [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-pysch consult was called and recommended changing his zyprexa to haldol and evaluating his R facial droop. He was ordered for a head CT to evaluate for possible stroke. He was already being treated with aspirin and aggrenox for previous CVAs. He failed his speech and swallow study and an NG tube was placed and tube feeds started. He was transferred to the floor on [2200-12-23]. FLOOR COURSE: #. Dyspnea / Stridor: Once arriving to the floor the patient had only mild expiratory stridor and typically only while awake. He was continued on a prednisone taper for presumed airway inflammation of unknown etiology and he finished his steroid course prior to discharge. His pulmonary exam at discharge revealed some rhonchi, dry and barking non-productive cough, and bibasilar crackles. He was slightly tachypneic to the low 20s, but denied dyspnea and had an oxygen saturation of 96% on room air. He was receiving albuterol and ipratropium nebs and was started on Advair while hospitalized. #. Hypertension: Patient was removed from home regimen of valsartan due to small chance that angioedema could be cause of his stridor. He was started on HCTZ and then switched to amlodipine with good result and was discharged on amlodipine. #. Diarrhea: Patient noted to have diarrhea last two days of admission; however, clostridium difficile toxin was negative in two stool samples prior to discharge. The diarrhea was slowing, but not resolved at discharge. Report from home caregiver to nurse was that patient has been incontinent of loose stool at home. #. Leukocytosis: WBC count was 13.7 at discharge; however, patient had no fever, chills or other systemic or localizing signs or symptoms of infection and was felt to be safe for discharge with PCP [Name9 (PRE) 702] of this leukocytosis. #. Facial droop: Patient was noted to have a right facial droop in the MICU, this was though to be reexpression of prior reported L lacunar stroke; however, we felt that we should rule out acute intracranial process. Obtained head CT shortly after patient hit floor on [2200-12-23] and was read as no acute intracranial process. We felt that patient did not need MRI at this time. As his aggrenox could not be crushed per speech and swallow recs, this medication was discontinued during the hospitalization; however, the patient was continued on aspirin. #. Left arm swelling: Left arm edematous (appeared dependent) without obvious cause at presentation to floor, but non-tender. A left upper extremity ultrasound was obtained and although it was a limited exam, revealed no etiology of the swelling. This improved throughout hospital course and was resolved at discharge. #. Delerium / Sundowning: Patient with waxing and [Doctor Last Name 688] mental status throughout hospitalization, and although in restraints and receiving haldol nightly as needed while in MICU, once transferred to the floor and once he had his feeding tube removed, he was easily redirected and through several days leading up to discharge did not require restraints or haldol. He typically brightened and became more alert and less dysarthric throughout the day. His family was consulted regarding his baseline and they felt that although he waxed and waned, he was close to his pre-hospital mental status. #. Dysphagia: While patient was in the MICU, speech and swallow was consulted and rec that patient be NPO and no meds by mouth. A nasogastric feeding tube was place which the patient removed several times once arriving to the floor despite restraints and redirection. On [2200-12-24], the speech and swallow consult performed a video swallow and modified his diet recs such that an NG tube was no longer needed. He had a video swallowing study again on [2200-12-29] and the final recs for his nutrition care were for him to be on aspiration precautions and receive ground solids, thin liquids, and crushed meds. #. EtOH abuse: No need for actiavation of CIWA in MICU as delerium appeared unresponsive to benzodiazepine administration. Upon arriving to floor, patient was outside window of conern for delirium tremens and the CIWA was discontinued. Medications on Admission: Meds per caretaker: lipitor 10mg qday folic acid 1mg paroxetine 20mg qday aggrenox qday diavan 80 mg qday B1 100mg ASA 81mg qday prednisone taper finished 2 weeks ago MVI Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. Acetaminophen 160 mg/5 mL Solution Sig: Three [Age over 90 ]y (320) mg PO Q6H (every 6 hours) as needed for fever or pain. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary Diagnosis 1) Stridor 2) Chronic Obstructive Pulmonary Disease Secondary Diagnoses 3) Hypertension 4) Delerium 5) Prior Cerebrovascular Accident Discharge Condition: Stable with decreased shortness of breath Discharge Instructions: You were admitted with difficulty breathing and there was concern that you had an obstruction in your throat, so you were intubated when you arrived. After the breathing tube was removed, we gave you steroids to reduce inflammation in your airway. You finished the course of steroids while you were hospitalized. We noted in the hospital that you had some high blood pressure. We discontinued your valsartan due to concern that it was causing your breathing difficulty. We started you on a new medication for high blood pressure called amlodipine. For your shortness of breath, we have you on a new medication called Advair, which you should use twice a day. You had a couple of days of diarrhea and we checked two samples of stool to make sure that you did not have an infection called clostridium difficile causing your diarrhea. You have a follow-up appointment with Dr. [First Name (STitle) ] on [2201-1-5] at 10:30 AM. Should you have any fever, chills, shortness of breath, increased wheezing, lightheadedness, loss of consciousness, or any other symptoms that are concerning to you or your family, please contact your physician or report to an emergency department immediately. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 250] Date/Time: [2201-1-5] 10:30 Completed by:[2200-12-31] ICD9 Codes: 2930, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8010 }	Medical Text: Admission Date: [2157-12-23] Discharge Date: [2158-1-9] Service: CARDIOTHORACIC Allergies: Iodine Containing Multivitamin / Shellfish Derived Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2157-12-23] - 1. Emergent coronary artery bypass grafting x3 on intra-aortic balloon pump with left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to the first obtuse marginal coronary artery; as well as reverse saphenous vein single graft from the aorta to the posterior descending coronary artery. History of Present Illness: Chronic angina that has been increasing over last several weeks. Had positive stress test and was referred for cardiac cath that showed severe left main disease. Now referred for emergent CABG Past Medical History: HTN, DM2, hyperlipidemia, Arthritis, Chronic renal insufficiency, Osteoarthitis, Hard of hearing Social History: Race:Caucaisian Last Dental Exam: Lives with: wife [Name (NI) 29633] [Name (NI) 6934] with Cane Occupation: retired pharmacist and stock broker Tobacco: none ETOH: social Family History: non contributory Physical Exam: Pulse: 92 Resp: 21 O2 sat: 99% 2LNP B/P Right: 121/78 Left: Height: 5' 10" Weight: 97Kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally []scattered rhonchi Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [] Varicosities: Edema: 1+ bilat pedal edema None [] Neuro: Grossly intact[x] non-focal, MAE follows commands Pulses: Femoral Right: cath site Left: 2+ DP Right: 1+ Left: 1+ PT [Name (NI) 167]: Left: Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [2158-1-9] INR 1.6- 3mg coumadin BUN 61/creat 1.7, HCT 28 [2157-12-23] - Cardiac Catheterization Successful placement of an intra-aortic balloon pump. [2157-12-23] - ECHO Pre Bypass: The left atrium is moderately dilated. The left atrium is elongated. A patent foramen ovale is present. There is mild symmetric left ventricular hypertrophy. There is moderate to severe regional left ventricular systolic dysfunction with severe hypokinesis of the entire anterior and anteroseptal walls. There is akinesis of the inferior wall with a possible basal aneurysm. Remaining segments are all hypokinetic. LVEF 20-25%. . The right ventricular cavity is mildly dilated with normal free wall contractility. There are complex (>4mm) atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is a moderate calcifed aortic valve with an aortic valve area which averages 1.8-2.2 cm2 representing borderline mild aortic stenosis.. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([11-26]+) mitral regurgitation is seen and is central and dynamic, vena contracta 4.5 mm. There is no pericardial effusion. IABP seen in descending aorta 8 cm below the Left subclavian- surgeons notified of position. Post Bypass: Patient is AV paced on epinepherine 0.07 mcg/kg/min and phenylepherine 2mcg/kg/min. The anterior and Anteroseptal wall motion is improved. The septal wall motion is consistent with AV pacing. The inferior wall remains akinetic. Overall LVEF 35%. Mitral regurgitation remains [11-26]+. There is mild TR. Aortic contours intact. IABP is readjusted to a position 1-1.5 cm below the left subclavian takeoff. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [2157-12-28] Upper Extremity Ultrasound Cephalic vein thrombus and no evidence of deep vein thrombosis. Brief Hospital Course: Mr. [Known lastname 85873] was admitted to the [Hospital1 18] on [2157-12-23] via transfer from [Hospital3 ] for surgical management of his coronary artery disease. Ipon arrival he had 10/10 chest pain. A Nitro drip was started and an emergent intra-aortic balloon pump was placed in the cardiac catheterization laboratory. He was then taken to the operating room where he underwent urgent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring on serveral vasoactive infusions: esmolol, vasopressin, milrinone, epinephrine and an insulin drip. IABP and vasoactive medications were slowly weaned off once hemodynamic stability was achieved. He remained intubated for acute CHF and PNA. He was aggressively diuresed with a lasix drip and treated with a 10 day course of vanco/zosyn which was completed on [2158-1-9]. He was extubated on POD#5 but remained in the ICU for aggressive pulmonary tiolet and NT suctioning. Mr.G was confused post-op requiring short term haldol prn. He is presently clear and cooperative. His chest tubes and wires were removed per protocol. On POD#5 he was noted to have LUE swelling and an ultrasound revealed cephalic vein thrombus for which a heparin drip was started. Enteral feedings via a dobhoff tube were intitiated for nutritional support which have since been d/c'd and Mr. G has a healthy appetite. He was noted to have a sternal click on POD# 11 which has remained stable and does not [Doctor Last Name ]. He NEEDS STRICT STERNAL PRECAUTIONS. He was transferred to the stepdown unit on POD#14. Mr. [Known lastname 85873] developed rapid afib which was treated with betablockers and amiodarone and has converted to sinus with brief periods of atrial fibrillation which is rate controlled. He was on a heparin drip bridge to coumadin. He has been receiving low dose coumadin while on amiodarone- Most recent INR 1.6 on [2158-1-9]- and recieved 3mg coumadin. He has failed repeated voiding trials -most recently [2158-1-8]- foley remains in place. Of note, he has a stage 1 area on his coccyx. His post operative course was complicated by Afib, coag +Staph PNA, respiratory failure and sternal click. Medications on Admission: Diovan 80', Lipitor 10', Amlopidine 5', Glyburide 5", Tramadol 50 TID, Isorbide 60', Atenolol 50', Celebrex 200' Discharge Medications: 1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing/sob. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED). 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: Dose couamdin based on INR goal 2-2.5 for Afib. 15. Outpatient Lab Work Draw INR daily until on stable coumadin dose Draw Sma7 twice weekly. Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Coronary artery disease s/p CABGx3 on IABP Currently has sternal click Discharge Condition: Alert and oriented x3 nonfocal Pivot stand - CANNOT use walker for full weight bearing due to HIGH RISK for sternal dehissence Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call to schedule appointments Surgeon Dr. [Last Name (STitle) 914] in 4 weeks [Telephone/Fax (1) 170] Primary Care Dr. [Last Name (STitle) ] in [11-26] weeks Cardiologist Dr. [Last Name (STitle) 85874] in [11-26] weeks Completed by:[2158-1-9] ICD9 Codes: 5119, 5859, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8011 }	Medical Text: Admission Date: [2133-12-3] Discharge Date: [2133-12-8] Date of Birth: [2072-9-12] Sex: M Service: CARDIOTHORACIC CHIEF COMPLAINT: The patient is a 61-year-old man with a history of hypertension, borderline diabetes, and hyperlipidemia, who came to the emergency room at 11:30 after developing substernal chest pain and interscapular pain associated with nausea and vomiting about 8:30 on the evening of admission while watching TV. The EKG at that time showed ST-elevations in the inferior leads, ST depressions in V2-3, lead 1 and AVL. The patient was treated with IV Lopressor, nitroglycerin, aspirin, and Heparin. The patient was taken to the cardiac catheterization laboratory, where he was found to have three-vessel disease. Please see catheterization report for full details. In summary, the catheterization showed total occlusion of the proximal RCA, for which the procedures of PTCA and stenting had been performed. Also, mid and distal RCA lesions, LAD with 70% to 80% lesion in the left circumflex with a 95% lesion, PDA and PDL diffusely diseased, and OM with 95% lesion. The PA pressures were 22/12 with wedge of 8. The patient transiently dropped his blood pressure to the 70s during the RCA intervention requiring dopamine times one hour. Upon return from the catheterization laboratory, the patient was pain free with no shortness of breath. PAST MEDICAL HISTORY: The patient's past medical history, as stated previously, is significant for hypertension, hyperlipidemia, and diabetes mellitus. He had a positive ETT in [2131]. MEDICATIONS PRIOR TO ADMISSION: 1. ....................(no dose given). 2. Aspirin 81 mg every other day. ALLERGIES: No known drug allergies. FAMILY HISTORY: History is significant for coronary artery disease in several relatives. SOCIAL HISTORY: The patient lives with his wife; occasional alcohol use. No tobacco use. No intravenous drug use. He is a retired hospital worker. PHYSICAL EXAMINATION: The patient's physical examination, at the time of admission, revealed the temperature 94.8; heart rate 83; blood pressure 123/77; respiratory rate 16; O2 saturation 100% on two liters nasal prongs. Fingerstick blood sugar 333. GENERAL: The patient is a pleasant man in no acute distress. HEENT: Pupils equal, round, and reactive to light with extraocular muscles are intact. NECK: No JVD. CORE: Regular rate and rhythm, S1 and S2, no murmur. PULMONARY: Clear to auscultation anteriorly and laterally. ABDOMEN: Soft, nontender, and nondistended, positive bowel sounds, guaiac negative per the ER examination. EXTREMITIES: No clubbing, cyanosis or edema; 2+ dorsalis pedis pulses and posterior tibial pulses bilaterally. Right femoral sheath in place, oozing with a small hematoma. NEUROLOGICAL: The patient is alert, oriented times three; grossly nonfocal examination. SKIN: No rashes. LABORATORY DATA: Data on admission revealed the white count of 6.6; hematocrit 41.3; platelets 442; PT 12.7; PTT 23.3; INR 1.1; sodium 136; potassium 4.9; chloride 99; CO2 27; BUN 16; creatinine 1.0; glucose 351; CPK 82. Chest x-ray revealed no infiltrates, edema, or effusions, no congestive heart failure. The EKG showed sinus rhythm at a rate of 90 with a normal axis, intervals 184/144/12; 2-mm ST elevation in leads 2, 3 and AVF; ST depression ??????-mm to 1-mm with biphasic T waves in lead 1L, ST depression 1-mm in V2, T wave inversions in V5 and V6. Following catheterization, Cardiothoracic Surgery was consulted. The patient was accepted for coronary artery bypass grafting. On [12-4], the patient was brought to the operating room, where he underwent coronary artery bypass grafting times four. Please see the operative report for full details. In summary, the patient had a CABG times four with a LIMA to the LAD and SVG to OM, SVG to PDA and SVG to diagonal. The patient tolerated the operation well. The patient was transferred to the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient had an arterial line, CVP line, two ventricular, and two atrial pacing wires, two mediastinal and a left pleural chest tube. He had a heart rate of 97 beats per minute, normal sinus rhythm, with a mean arterial pressure of 74, CVP of 6 and he was on propofol at 10 mcg per kg per minute, as well as Neo-Synephrine infusion between .25 and .75 mcg per kg per minute to maintain adequate systemic blood pressure. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and extubated. He did well throughout the initial postoperative day. The patient stated in the Intensive Care Unit on postoperative day #1 as he continued to require Neo-Synephrine to maintain adequate blood pressure. On postoperative day #2, the patient continued to progress from his coronary artery bypass grafting. The Neo-Synephrine was weaned off during the overnight period. His chest tubes were removed. Foley catheter was removed. He was transferred to Far 6 for continuing postoperative care and cardiac rehabilitation. For the next several days, the patient remained hemodynamically stable. He continued to progress from an activity standpoint with the assistance of physical therapy. On postoperative day #5 it was deemed that he was stable and ready for discharge to home. At the time of discharge, the patient's physical examination was as follows: VITAL SIGNS: Temperature 98; heart rate 100 sinus rhythm; blood pressure 109/66; respiratory rate 18; O2 saturation 97% on room air. Weight, preoperatively, is 86.3 kg; on discharge 84.4 kg. LABORATORY DATA: Laboratory data revealed the white count of 5.3, hematocrit 25.8; platelets 435; sodium 140; potassium 4.0; chloride 104, CO2 28; BUN 15; creatinine 0.9; glucose 165. PHYSICAL EXAMINATION: The patient was alert and oriented times three. The patient moves all extremities and follows commands. Respiratory was clear to auscultation bilaterally. Heart sounds regular rate and rhythm, S1 and S2, with no murmur. Sternum is stable. Incisions were closed with staples, open to air, clean, and dry. Abdomen was soft and nontender, nondistended, positive bowel sounds. Extremities are warm and well perfused with no clubbing, cyanosis or edema. The right lower extremity incisions are open to air, clean and dry, closed with Steri Strips. DISCHARGE MEDICATIONS: 1. Lopressor 50 mg b.i.d. 2. Aspirin 81 mg q.d. 3. Plavix 75 mg q.d. 4. Lipitor 10 mg q.d. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post CABG times four with LIMA to the LAD and SVG to OM; SVG to PDA and SVG to diagonal. 2. Noninsulin dependent diabetes mellitus. 3. Hypercholesterolemia. 4. Hypertension. FOLLOW-UP CARE: The patient is to have followup with his primary care physician in three to four weeks. The patient is to followup with Dr. [Last Name (STitle) ] in four weeks and followup in the wound clinic in three weeks. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2133-12-8] 11:58 T: [2133-12-8] 14:07 JOB#: [Job Number 109786] eoD: [2133-12-8] 11:58 T: [2133-12-8] 15:18 JOB#: [Job Number 109786] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8012 }	Medical Text: Admission Date: [2170-10-12] Discharge Date: [2170-10-19] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 12131] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: Radiation Treatments History of Present Illness: 88yo M with history of SC lung cancer s/p RLL lobectomy [2164], recent hospitalization with low back pain found to have new lesions in spine and hip, delerium, [Doctor First Name 48] improved with IVF, MSSA bacteremia/PNA discharged on Nafcillin to be completed [10-9], presents with sudden onset hypoxia this morning, with O2 sat dropping to 81% at rehab and associated shortness of breath. He was placed on 4L NC at that time. Notably patient also had some urinary retention yesterday when at the hospital to have radiation tattooing done, had a Foley placed yesterday, and he has had gross hematuria since. He was taken to [Hospital1 ] today where he was found to be anemic as well as to have a UTI, and an elevated troponin to .4 in the setting of atrial flutter/sinus tachycardia. Hct was also noted to drop from 27-24. H receved asa 162 mg, oxycodone 5mg, zofran 4mg and dilaudid 0.5 mg IV there. . Baseline sats at rehab have been 95-08 on 2L intermittently per patient. Today sat to 79-80 on 2L. Notes show right leg swelling U/S two days ago negative. . Initial Vitals/Trigger: 97.6 114 179/95 19 97%6L. He denies chest pain or abdominal pain, however he does endorse shortness of breath which has somewhat resolved since he's been placed on a nasal cannula at 4 L. . EKG showed atrial flutter. He was guiaic negative. Ceftriaxone was given at 1245. Potassium was also give 1230 as well as Oxycodone. CTA showed b/l subsegmental PEs. CT head with old lesions. . VS on transfer: afebrile 94 121/94 24 94% 2L. . On the floor, he denies ever having any shortness of breath, and attributes his recent symptoms to anxiety which has resolved. He denies any chest pain, and endorses a chronic cough which is unchanged with occasional sputum production. His hematuria began 2 days ago, prior to that, he did not have dysuria. He denies any f/c/n/v/diarrhea. Also has bilateral LE edema which is new. Denies any new problems since transfer. Past Medical History: -Squamous cell lung cancer: In remission for 10yrs. s/p RLL resection, no chemo, radiation. -Head and neck cancer: Remote hx. Details unknown. -HTN -mild COPD -mild carotid stenosis -Recent echo shows mild-moderate mitral valve stenosis/aortic stenosis with preserved EF -hx of cardiac myxoma s/p resection with CVA Social History: Lives with daughter in [Name (NI) 21318]. Also has common law wife who is a former nurse's aide. Retired boat captain. Former 50pack year smoker, quit 10 years ago. Denies EtOH, drug use. Family History: Daughter with breast cancer. Denies history of other cancers or heart disease. Physical Exam: ON ADMISSION: Vitals: 98.9, 97, 111/59, 65-90s, 18, 94/4L General: Alert, oriented, no acute distress, comfortable appearing HEENT: Sclera anicteric, MMM, oropharynx dry Neck: supple, JVP elevated to earlobe Lungs: b/l diffuse end expiratory high pitched wheeze loudest in upper lobes 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, b/l LE edema pitting in R leg, greater than left Neuro: CNS in tact, sensation and strength in tact upper and lower extremities, strength in left leg limited by left hip pain. . ON DISCHARGE: Vitals: 96.5-97.6, 150-168/60-72, 76-83, 18-22, 94-97% 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, OP clear Neck: supple, JVP elevated to earlobe Lungs: b/l diffuse wheezing CV: tachycardic rate and reg rhythm, normal S1 + S2, 3/6 SEM Abdomen: soft, non-tender, non-distended, bowel sounds (+) no rebound or guarding, no HSM GU: foley Ext: warm, well perfused, 2+ pulses, b/l LE edema pitting in R leg, greater than left Neuro: CNS in tact, sensation and strength in tact upper and lower extremities, strength in left leg limited by left hip pain. Pertinent Results: Admission Labs: [2170-10-11] 11:48AM BLOOD WBC-15.4* RBC-3.19* Hgb-9.4* Hct-27.1* MCV-85 MCH-29.6 MCHC-34.8 RDW-15.1 Plt Ct-527* [2170-10-11] 11:48AM BLOOD Neuts-80.7* Lymphs-11.4* Monos-6.1 Eos-1.1 Baso-0.7 [2170-10-12] 12:00PM BLOOD PT-16.3* PTT-25.0 INR(PT)-1.4* [2170-10-11] 11:48AM BLOOD UreaN-22* Creat-1.5* Na-138 K-3.3 Cl-95* HCO3-31 AnGap-15 [2170-10-11] 11:48AM BLOOD ALT-14 AST-21 AlkPhos-97 TotBili-0.4 [2170-10-11] 11:48AM BLOOD TotProt-6.9 Albumin-3.2* Globuln-3.7 Calcium-8.9 [2170-10-11] 11:48AM BLOOD CEA-200* Discharge Labs: [2170-10-19] 07:05AM BLOOD WBC-8.8 RBC-3.31* Hgb-9.9* Hct-29.3* MCV-89 MCH-29.8 MCHC-33.6 RDW-15.8* Plt Ct-399 [2170-10-19] 07:05AM BLOOD Glucose-147* UreaN-11 Creat-1.1 Na-135 K-4.2 Cl-96 HCO3-33* AnGap-10 [2170-10-19] 07:05AM BLOOD ALT-19 AST-28 LD(LDH)-265* AlkPhos-80 TotBili-0.6 [2170-10-19] 07:05AM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.3 Mg-1.7 Imaging: CT Chest: IMPRESSION: 1. Pulmonary emboli in the subsegmental branches of the left lower lobe and anterior left upper lobe with no evidence of right heart strain or pulmonary infarction. 2. New patchy consolidation in the dependent portion of the right upper lobe likely represents pneumonia or aspiration. Ground glass opacities in a bronchovascular distribution in the left upper lobe may represent multifocal pneumonia or significant aspiration event. . CT Head: IMPRESSION: 1. No brain metastases identified. 2. There is no evidence of intra- or extra-axial hemorrhage; however, subtle subarachnoid hemorrhage cannot be excluded on this study due to circulating intravenous contrast. . CXR: FINDINGS: As compared to the previous radiograph, the right PICC line was removed. Status post right lower lobe resection with subsequent volume loss of the right lung. Presence of a minimal right pleural effusion cannot be excluded. No newly appeared parenchymal opacities. No pulmonary edema. No pneumonia. Unchanged asymmetry of the tracheal course through the mediastinum. . LENI: IMPRESSION: Peroneal calf veins not visualized in either lower extremities. Otherwise, no DVT present . CXR: Cardiomegaly and widened mediastinum are unchanged. Patient is status post right lower lobectomy. The lungs are grossly clear with the surgical clips projecting in the right medial upper hemithorax. Unchanged right apical pleural thickening and blunting of the right CP angle are likely postoperative changes. Aeration of the right lung has improved. Brief Hospital Course: 88yo M with history of SC lung cancer s/p RLL lobectomy [2164], recent hospitalization with low back pain found to have new lesions in spine and hip, delerium, [Doctor First Name 48] improved with IVF, MSSA bacteremia/PNA discharged on Nafcillin to be completed [10-9], presented with sudden onset hypoxia found to have bilateral subsegmental PEs, PNA and fluid overlead. . ACTIVE ISSUES: # HYPOXIA: Initial deterioration was likely [3-7] PE and aspiration PNA. Patient was initially started heparin gtt then bridged to lovenox and was initially placed on Vanco/Zosyn. As patient became afebrile, he was placed on Augmentin and remained afebrile. *LAST DAY OF ANTIBIOTICS WILL BE ON [10-24].* Hypoxic continued despite adequate PE and PNA coverage; exam revealed hypervolemic state. Patient was diursed with IV lasix 20mg. Serum Bicarbonate started raising patient and diuresis terminated. Patient was briefly off oxygen however then restarted o2 at 2 liters. This remaining hypoxia was attributed to PE. Patient will remain on lovenox indefinitely. . # LOWER EXTREMITY WEAKNESS/HIP PAIN/URINARY RETENTION: Symptoms were attributed bony metastasis. Patient started radiation therapy and will compelte treatments on Monday [10-22]. Patient was started on steroids to help with inflammation. Patient will remain on this dose of steroids until [10-22] then he can began taper (2mg Q12h for 3 days then 2mg Q24h then off). Outpatient oncology will reassess him to see if further treatments are necessary. Physical therapy saw patient and recommended rehabilitation for strength training. Foley holiday was attempted however patient continued to have retention of urine upto 1L. Foley was then replaced resulting in hematuria, likely [3-7] trauma v. radiation cystitis. Hematocrit was stable and patient was hemodynamically stable. . # HYPERTENSION: Patient was markedly hypertensive during this admission and amlodipine was started with better control of BP . # ELEVATED TROPONIN: Patient had initial troponin leak on admission likely [3-7] tachycardia and PE; there was associated EKG changes. No changes made to medications and no further interventions were needed. . # ATRIAL FLUTTER: On initially presentation, patient was elevated HR to 120s however with treatment of PE and continued use of metoprolol, patient had HR returned to [Location 213]. . # CODE STATUS: DNR/DNI Medications on Admission: Medications: [First Name8 (NamePattern2) ] [Location (un) 582] referal form Lasix 20mg daily, last [10-11] KCl 20meq daily, last 0/8 Asa 81 mg daily, last [10-11] Oxycontin 20mg [Hospital1 ], last 6am [10-12] Hydralazine 50 mg [Hospital1 ], last [10-11] Calcium carbonate 1250mg PO TID last [10-11] Oxycodone 5mg PO Q3H prn, last [10-11] 3pm Ativan 1mg PO Q8H prn last [10-8] lidoderm 5% patch topically to left hip last [10-12] at 7am iron 325mg daily metoprolol tartrate 25 mg Tab [Hospital1 ] colace 100mg [Hospital1 ] prn senna 1 tabe [Hospital1 ] prn insulin humalog starting at 200 increase by 2 units every 50 up to 400 House regular Texture, Necture thick liquid hydrochlorothiazide 25 mg daily (stopped [10-9]) nafcillin in D2.4W 2 gram/100 mL IV Piggy Back (stopped [10-9]) plan to change to Dicloxacillin 500 mg qid through [10-11] Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. hydralazine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Last dose on [10-24]. 5. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q8H (every 8 hours). 6. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for anxiety. 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 8. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. enoxaparin 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 12. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 14. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 15. insulin lispro 100 unit/mL Solution Sig: One (1) bottle Subcutaneous QACHS: For FS 150-200 give 2 units; if 201-250 give 4 units, if 251-300 give 6 units, for 301-350 give 8 units, if > 350 alert MD; At bed time, give 1 unit [Unit Number ]-250, give 2 units for 251-300, give 3 units for 301-350, alert MD for > 350. 16. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Discharge Disposition: Extended Care Facility: [Hospital ] Hospital - [Hospital1 8] Discharge Diagnosis: Pulmonary Emboli Aspiration Pneumonia Metastatic Lung Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted because you were having shortness of breath. When you were admitted you were found to have blood clots in your lungs. You were started on a blood thinning medication to help stabilize the clots. You will remain this medication indefinitely. You were also diagnosed pneumonia and placed on antibiotics. You also have fluid in your lungs which we used lasix to help remove the fluid. You however still require oxygen which may be a result of your the lung clots. You began your radiation treatments while you were in the hospital for your hip pain and urinary retention. You had 4 of the 5 treatments and will return on Monday for your final treatment. You will be followed by your oncologist to determine if you need treatment. We are expecting you to start feeling better in [3-8] weeks. In the mean time you will be going to an excellent rehabilitation center to get stronger. You continue to have urinary retention likely from your cancer. A catheter remains in your bladder to help drain the urine. There is some blood in your urine from the catheter insertion and should resolve within a few days. Please see the attached sheet for your medications. Please take them as directed Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2170-11-15] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [2170-11-15] at 10:00 AM With: DR. [First Name8 (NamePattern2) 2801] [Last Name (NamePattern1) ] [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2170-10-20] ICD9 Codes: 5070, 5990, 4019, 496, 2859, 4241
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8013 }	Medical Text: Admission Date: [2145-12-11] Discharge Date: [2145-12-15] Date of Birth: [2066-12-10] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 11892] Chief Complaint: found down Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 79 yo F with history of hypertension, hyperlipidemia, NIDDM and pituitary mass that presents having been found down. It is unclear how long the patient was down. She states she think that she fell after veterans day. She thinks she fell trying to sit on her kitchen chair. She states she has felt lightheaded for up to several months and had a cold for the past week but otherwise she reports no specific symptoms. She denies vertigo, chest pain, palpitations, nausea, vomiting. Her closest contact is her [First Name9 (NamePattern2) ] [Name (NI) 44286] who was the one who called the police. [First Name8 (NamePattern2) ] [Last Name (un) 44286], she has been "this close" to her needing to be in an asissted living facility. He hasn't been feeling well for the past year. He picks up her medications. He last saw her a week ago and las talked to her today when she said she was on the floor. He talked to her prior to then several days before. Today, she seemed "groggy" to him. He confirmed that she did not drunk. In the ED, she was hypothermic to 94. BP was 88/45, HR 97, oxygen 98 on room air. She was given 2L NS. She had one episode of hypotension to the 70/40 which responded to an additional 1L of NS. She was also started on [1-24] NS for hypernatremia. Vitals on transfer were P 79 Bp 125/35 14 100% 2L Past Medical History: Hypertension Hyperlipidemia Diabetes Memory Loss Unsteady gait pituitary macroadenoma Social History: lives at home. reports that her son beats her if she doesnt give him money. prior h/o etoh but quit in [2125] and quit smoking in [2125] Family History: nc Physical Exam: ADMISSION EXAM: General Appearance: No acute distress, Thin Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing Skin: Warm, No(t) Rash: Neurologic: Attentive, Responds to: Not assessed, Oriented (to): place, year, month, Movement: Purposeful, Tone: Not assessed, neuro non focal On discharge: Exam stable, with ability to walk to bathroom with assistance and mild ear congestion. Vital signs stable, with normal blood pressure. Pertinent Results: ADMISSION LABS: [2145-12-11] 12:30PM BLOOD WBC-12.2* RBC-4.64 Hgb-13.7 Hct-41.9 MCV-90 MCH-29.6 MCHC-32.7 RDW-12.9 Plt Ct-286 [2145-12-11] 12:30PM BLOOD Neuts-68.6 Lymphs-26.2 Monos-2.6 Eos-2.2 Baso-0.3 [2145-12-11] 03:05PM BLOOD PT-15.9* PTT-33.7 INR(PT)-1.4* [2145-12-11] 09:20PM BLOOD Glucose-142* UreaN-124* Creat-3.0* Na-146* K-3.8 Cl-111* HCO3-20* AnGap-19 [2145-12-11] 09:20PM BLOOD ALT-19 AST-26 LD(LDH)-264* CK(CPK)-107 AlkPhos-50 TotBili-0.3 [2145-12-11] 03:05PM BLOOD cTropnT-0.04* [2145-12-11] 09:20PM BLOOD Albumin-3.4* Calcium-8.5 Phos-4.8* Mg-2.4 [2145-12-11] 04:18PM BLOOD Type-ART Temp-36.4 Rates-/14 pO2-157* pCO2-28* pH-7.40 calTCO2-18* Base XS--5 Intubat-NOT INTUBA Comment-GREEN TOP [2145-12-11] 12:43PM BLOOD Glucose-151* Lactate-3.3* Na-155* K-4.2 Cl-114* calHCO3-16* On discharge: [2145-12-15] 06:15AM BLOOD Glucose-87 UreaN-27* Creat-1.1 Na-143 K-3.8 Cl-111* HCO3-24 AnGap-12 URINE: [2145-12-11] 12:30PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.014 [2145-12-11] 12:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG MICRO: [2145-12-11] BCx: pending on discharge [2145-12-11] UCx: negative [2145-12-11] MRSA screen: negative [2145-12-11] Legionella: negative STUDIES: [2145-12-11] CT head: 1. No evidence of acute intracranial process. 2. Small left basal ganglia lacune. 3. Age-related involution and small vessel ischemic disease. 4. Findings suspicious for pituitary adenoma with erosion of sellar floor. Correlation with clinical history recommended. MRI can help for further assessment as clinically indicated. 5. Complete opacification of the sphenoid sinus with extension of disease into posterior ethmoidal air cells. [2145-12-11] CT Cspine: No acute cervical spine injury. Erosive changes are seen in clivus. Please see head CT for further details. [2145-12-11] CXR: Possible aspiration in the bases. Large gallstone. [2145-12-12] MR Pituitary: MR EXAMINATION OF THE BRAIN AND PITUITARY GLAND WITHOUT CONTRAST, [2145-12-12]. HISTORY: 79-year-old female with history of "pituitary mass" presents with fall; "stroke protocol" for subacute stroke and evaluate pituitary lesion. TECHNIQUE: Routine [Hospital1 18] non-enhanced MR examination of the brain and sella turcica was performed. N.B. Given the patient's severe renal insufficiency (BUN 124, creatinine 3.0 with eGFR 13 mL/min), no intravenous gadolinium contrast material was administered. FINDINGS: The study is compared with the recent NECT of the head dated [2145-12-11]. As on that study, there is a markedly abnormal appearance to the sella turcica, which is markedly expanded with much of the cortex of its floor, completely eroded. The normal pituitary tissue is replaced by an ill-defined and somewhat heterogeneous mass, roughly isointense-to-normal [Doctor Last Name 352] matter. Though its precise borders are difficult to delineate, this process measures at least 17 (AP) x 22 (TRV) x 18 mm (CC) and likely represents a large macroadenoma, occupying much of the sella and transgressing its floor and possibly anterior wall. Of note, no definite posterior pituitary "bright spot" is identified. The process within the sella blends into the contents of the largely opacified sphenoid sinus, which is nearly completely filled with abnormal soft tissue material, with only its most superior-anterior portion apparently aerated, as on the CT. The sphenoid air cells contain foci of relative [Name (NI) ] and more marked T2-hypointensity, with "blooming" susceptibility artifact, which likely represent secretions with various degrees of inspissation. The extent of intrasphenoidal extension of the sellar mass is very difficult to assess. Allowing for the lack of intravenous contrast, a normal-caliber infundibular stalk is identified, and slightly deviated to the right with a grossly normal appearance. Though there is effacement of the suprasellar cistern, there is no contact with or mass effect upon the optic chiasm or the hypothalamus. Based on the coronal T2-weighted sequence, there is no evidence of cavernous sinus invasion, and the normal cavernous carotid arterial flow voids are preserved. The limited whole brain imaging is notable for moderate global atrophy. There is relatively mild [Name (NI) ]/FLAIR-hyperintensity, largely limited to bifrontal periventricular white matter, likely the sequelae of chronic small vessel ischemic disease. There is no focus of slow diffusion to suggest an acute ischemic event and the principal intracranial vascular flow voids, including those of the dural venous sinuses, are preserved. There is no evidence of intra- or extra-axial hemorrhage, including in the sella, itself. Incidentally noted is a likely Tornwaldt cyst in the midline nasopharynx, as well as relatively mild chronic-appearing inflammatory changes in the maxillary sinuses and anterior ethmoidal air cells, bilaterally, as on the recent CT. IMPRESSION: 1. Limited study, in the absence of intravenous contrast (which could not be given, due to the patient's profound renal insufficiency), redemonstrates a markedly abnormal appearance to the sella turcica. In conjunction with the recent NECT, this suggests an aggressive pituitary macroadenoma with marked erosion and frank dehiscence of the sellar floor, as well as the anterior aspect of the clivus. 2. Markedly abnormal appearance to the sphenoid air cell, which, as on the CT, is virtually-completely opacified with heterogeneous-signal contents, most suggestive of differing degrees of inspissation. However, the full extent of transgression of sphenoid by the sellar mass is impossible to assess without contrast enhancement. Additionally, fungal colonization cannot be excluded, with this appearance. 3. Though there is effacement of the suprasellar cistern, there is no definite mass effect upon the optic chiasm or invasion of the cavernous sinuses. 4. No finding to suggest an acute ischemic event, with no evidence of previous territorial infarction. 5. Global atrophy. . ECHO: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The estimated cardiac index is high (>4.0L/min/m2). Right ventricular cavity size and free wall motion are normal. The ascending aorta and aortic arch are mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal regional/hyperdynamic global systolic function. Mild aortic regurgitation.Borderline pulmonary artery hypertension. Dilated thoracic aorta. CLINICAL IMPLICATIONS: Based on [2141] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: Ms. [Known lastname 39602] is a 79 yo F with h/o hypertension, hyperlipidemia, diabetes mellitus and pituitary macroadenoma presenting found down. # Found down: Differential includes acute illness (h/o cold symptopms and ?infiltrate on cxr), vs stroke, vs encephalopathy [2-24] renal failure vs cardiogenic syncope. Treated for CAP with Azithromycin. MR head did reveal a clear reason for fall. ECHO was equally unremarkable.. Cardiac enzymes were negative. Given constellation of bradycardia, hypothermia, and known pituitary mass, possible endocrinopathy as well. TSH and cortisol were both normal. Physical therapy evaluated the patient who was very deconditioned--a simple mechanical fall may have been the culprit as no other etiology was identified. # PNA: No risk factors for resistant organisms, treated for CAP with Azithromycin. Urinary Legionella was negative. # Acute kidney injury: improved with hydration, creatinine 1.1 upon discharge. HCTZ, lisinopril, and metformin held during stay, with metformin started on discharge. Creatinine should be checked after discharge at which time, if blood pressure can support and creatinine remains stable, lisinopril 20mg and then HCTZ 25mg can be reinitiated daily. # Diabetes: on insulin sliding scale # Elevated inr: INR 1.4 on admission, possibly [2-24] poor nutrition. Should be rechecked as outpatient. # Pituitary mass: No evidence of endocrine abnormality on labs, but imaging demonstrated possibility of slightly larger mass versus prior images. Will need primary care followup. Transitional issues # Please follow creatinine/electrolytes to ensure safe reinitiation of lisinopril and HCTZ. # Please follow INR as well and encourage good nutrition. # Follow-up imaging on pituitary macroadenoma. Medications on Admission: LISINOPRIL 20 MG TABS 1 tab po every day METFORMIN HCL 500 MG TABS 1 tab po daily in the morning SIMVASTATIN 40 MG TABS 1 tab by mouth QHS HYDROCHLOROTHIAZIDE TAB 25MG 1 tab po every day Discharge Medications: 1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 599] Senior Healthcare of [Location (un) 55] Discharge Diagnosis: Primary diagnoses: Renal failure Mechanical fall Domestic violence 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 39602], It was a pleasure caring for you at the [Hospital1 827]. You came to the hospital after a fall. You were found to be weak and to have failure of your kidneys. You improved with IV fluids. Medication changes: START azithromycin for your infection, for only 1 more day. STOP lisinopril and hydrochlorothiazide for now. The doctors at your facility will restart these slowly to control your blood pressure. You should continue taking the rest of your medications as prescribed Followup Instructions: Please follow up with your primary care physician [Last Name (LF) ],[Name9 (PRE) ] [Telephone/Fax (1) 798] after leaving your rehab. Your [Hospital1 778] social worker will help coordinate your living situation. You also have the following appointments already scheduled: Department: [Hospital3 1935] CENTER When: WEDNESDAY [2146-1-5] at 9:00 AM With: EYE IMAGING [Telephone/Fax (1) 253] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 1935] CENTER When: WEDNESDAY [2146-1-5] at 9:20 AM With: [First Name11 (Name Pattern1) 354] [Last Name (NamePattern4) 3013], M.D. [Telephone/Fax (1) 253] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DO 12-BDU ICD9 Codes: 5849, 486, 2760, 2762, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8014 }	Medical Text: Admission Date: [2126-7-30] Discharge Date: [2126-8-4] Date of Birth: [2066-3-20] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2126-7-30] Coronary Artery Bypas Graft x 1 (SVG to RCA), Aortic Valve Replacement with 29mm CE Pericardial Tissue Valve History of Present Illness: 60 y/o male with known bicuspid aortic valve who continues to experience progressive dyspnea on exertion. Most recent echo revealed severe aortic stenosis with preserved LVEF. He had an abnormal ETT and then underwent cardiac cath. Cath revealed single vessel coronary artery disease and was then referred for surgery. Past Medical History: Aortic Stenosis/Bicuspid Aortic Valve, Hypertension, Hypercholesterolemia, Gastroesophageal Reflux Disease, h/o Pericarditis, s/p T&A Social History: Office worker, Quit smoking 12 years ago. Drinks 1-2 beers/wk. Live with wife. Family History: Father did of MI at age 52. Physical Exam: VS: 76 12 142/80 149/73 67" 178# General: WDWN male in NAD Skin: Warm, dry -lesions HEENT: EOMI, PERRL, NCAER, OP benign, sclera anicteric Neck: Supple, FROM, -JVD Chest: CTAB -w/r/r Heart: RRR, 4/6 SEM w/ transmitted murmur to carotids Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema, -varicosities, 2+ pulses throughout Neuro: A&O x 3, CN2-12 intact, MAE, non-focal Pertinent Results: Echo [7-30]: Pre Bypass: There is a tiny pfo with left to right flow. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%). There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. There is mild anterior leaflet mitral valve partial prolapse. Trivial mitral regurgitation is seen. The main pulmonary artery is borderline dilated. Post Bypass: Biventricular function is preserved, LVEF >55% no wall motion abnormalities. There is a 29 mm bioprosthetic valve in place. There is trace Aortic insufficiency originating between the left and right coronary cusps. There is no Aortic stenosis (peak gradient 8 mm Hg, calculated [Location (un) 109] 3.6 cm2). There are no perivalvular leaks. CXR [8-1]: Persistent left lower lobe atelectasis with possible small left pleural effusion. [2126-7-30] 12:16PM BLOOD WBC-17.6# RBC-3.15# Hgb-9.9# Hct-27.2# MCV-86 MCH-31.6 MCHC-36.6# RDW-13.8 Plt Ct-136# [2126-8-2] 06:14AM BLOOD WBC-15.0* RBC-2.57* Hgb-7.9* Hct-22.5* MCV-88 MCH-31.0 MCHC-35.3* RDW-14.3 Plt Ct-170 [2126-7-30] 12:16PM BLOOD PT-16.1* PTT-39.8* INR(PT)-1.5* [2126-8-2] 06:14AM BLOOD PT-12.3 PTT-26.3 INR(PT)-1.1 [2126-7-30] 12:58PM BLOOD UreaN-19 Creat-0.8 Cl-112* HCO3-25 [2126-8-2] 06:14AM BLOOD Glucose-122* UreaN-25* Creat-0.9 Na-136 K-4.3 Cl-99 HCO3-31 AnGap-10 Brief Hospital Course: Mr. [Known lastname ] was a same day admit after undergoing all pre-operative work-up as an outpatient. On [7-30] he was brought to the operating room where he underwent a coronary artery bypass graft x 1 and an aortic valve replacement. Please see op report for surgical details. Patient tolerated the procedure well and was tranferred to the CSRU for invasive monitoring in stable condition. Later on op day patient was weaned from sedation, awoke neurologically intact and then extubated. He did require multiple transfusions post-operatively with FFP and RBC's secondary to bleeding. He was transferred to the cardiac surgery telemetry floor on post-op day one. He was also started on beta blockers and diuretics and he was gently diuresed towards his pre-op weight. Chest tubes were removed on post-op day two. A PICC line was also placed on this day d/t poor venous access. On post-op day five his epicardial pacing wires were removed. He was discharged home on POD 5 tolerating a regualr diet, ambulating with physical therapy, and his pain well controlled with po pain medication. Medications on Admission: Zoloft 100mg qd, Lipitor 10mg qd, Lisinopril 10mg qd, Protonix 40mg qd, Excedrin [2-4]/d, Sinex nasal inh Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:1 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:20 Tablet(s) Refills:0 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day) for 10 days. Disp:40 Capsule, Sustained Release(s) Refills:0 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypas Graft x 1 Aortic Stenosis/Bicuspid Aortic Valve s/p Aortic Valve Replacement PMH: Hypertension, Hypercholesterolemia, Gastroesophageal Reflux Disease, h/o Pericarditis, s/p T&A Discharge Condition: Good Discharge Instructions: You may take shower. Wash incisions and gently pat dry. Do not take bath. Do not apply lotion, creams, ointments or powders to incisions. Do not lift more than 10 pounds for 2 months. Do not drive for 1 month. If you develop a fever or notice drainage from chest incision, or redness around incision, please contact office immediately. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in 4 weeks Dr. [Last Name (STitle) ] (cardiologist) in [2-1] weeks Dr. [Last Name (STitle) 410] (PCP) in [12-31] weeks ICD9 Codes: 4241, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8015 }	Medical Text: Admission Date: [2136-8-6] Discharge Date: [2136-8-29] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Aortic valve replacement (25-mm [Doctor Last Name ] Magna E pericardial),aortic endarterectomy7/19/10 emergency re-exploration [2136-8-8] sternal washout/advance pectoralis flaps and closure [2136-8-10] PICC line placement [8-23] History of Present Illness: This 87 year old male with severe aortic stenosis and recent admission for congestive heart failure exacerbation was admitted with worsening renal failure and hyponatremia. Cardiac surgical consultation was obtained to evaluate for aortic valve replacement. he was admitted now for elective surgery. Past Medical History: Aortic Stenosis chronic atrial fibrillation h/o gastrointestinal bleed Hypertension Systolic and diastolic congestive heart failure Hyperlipidemia chronic Anemia Benign Prostatic Hypertrophy Moderate pulmonary Hypertension Chronic Kidney Disease s/p cataract surgery s/p basal cell CA excision from face s/p Tonsillectomy Social History: Race:Caucasian, primarily Italian speaking Last Dental Exam:many years, poor dentition Lives with:wife and daughter Occupation:previous factory worker Tobacco:40 pack year history ETOH:2 glasses wine/day Family History: Sister on dialysis, hypertension. Mother died suddenly at 65 years old, also with hypertension. Father died at 89yo of old age. There is no family history of premature coronary artery disease or sudden death. Physical Exam: admission: Pulse: Resp: O2 sat: B/P Right: Left: Height:5'3" Weight: General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur III/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema +2 Varicosities: 0 Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +1 Left: +1 PT [Name (NI) 167]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit Right: Left: Pertinent Results: [2136-8-6] Echo: PRE BYPASS The left atrium is markedly dilated. The left atrium is elongated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricle displays normal free wall contractility. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area = 0.6cm2). Mild to moderate ([1-21]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. Dr. [Last Name (STitle) 914] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is being v-paced. There is normal biventricular systolic function. The interventricular septum shows dyssynchronous motion consistent with pacing. There is a bioprosthesis located in the aortic position. It is well seated and displays normal leaflet motion. No significant aortic regurgitation is appreciated. The maximum gradient across the aortic valve is 14 mmHg with a mean of 7 mmHg at a cardiac output of 4.2 liters/minute. The effective orifice area of the valve is 1.4 cm2. The mitral regurgitation is somewhat improved - now moderate in severity. The tricuspid regurgitation is somewhat improved - now mild. The thoracic aorta appears intact after decannulation. Brief Hospital Course: Mr. [Known lastname ] was a same day admit and on [8-6] was taken to the Operating Room where he underwent aortic valve replacement and ascending aortic endarterectomy. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in unstable condition on Neo Synephrine. he subsequently stabilized and was weaned from sedation, awoke neurologically intact and extubated. On [8-8] he underwent a right thoracentesis for 1200cc of straw colored fluid. He later that day was found to have a significant hematocrit drop. A chest tube was placed for about 2 liters of dark blood and he suffered a cardiac arrest. Closed, then open massage were performed and he returned to the Operating Room. He was returned to the ICU on Epinephrine, Neo Synephrine and Nitroglycerin infusions with an open chest. He stabilized, and on [8-10] returned to the operating Room for chest washout and closure. He remained on multiple pressors. He became severely oliguric and CVVH was instituted with renal consultation. Fluid was removed gradualy and he weaned from pressors. Tube feeding was instituted and he gradually awoke. He was transitioned to hemodialysis and as renal function stabilized he was given a holiday from dialysis and remained stable. He was extubated with some stridor which responded to racemic Epinephrine. he improved, was able to swallow and tube feeds were discontinued. He should have nectar-thick foods with ground solids for dysphagia. He become progressively more alert and was intact. Physical Therapy worked with him for strengthening and he was screened for transfer to a rehabilitation facility. He completed abx therapy today. Sternal wound should be washed with hydrogen peroxide when showered. He is to return to [Hospital Ward Name 121] 6 in 7 days for wound check and removal of remaining sutures. Foley may be removed tomorrow [8-30]. Cleared for discharge to [Hospital1 ] at [Hospital1 ] on [8-29]. Follow up appts were advised. Medications on Admission: 1. Docusate Sodium 100 mg Capsule [Month/Year (2) ]: One (1) Capsule PO BID (2 times a day). 2. Doxazosin 1 mg Tablet [Month/Year (2) ]: Two (2) Tablet PO HS (at bedtime). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [Month/Year (2) ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Simvastatin 10 mg Tablet [Month/Year (2) ]: Two (2) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable [Month/Year (2) ]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet [Month/Year (2) ]: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr [Month/Year (2) ]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): Hold for sbp<100, hr<50. Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Month/Year (2) ]: One (1) neb Inhalation Q6H (every 6 hours). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) [Month/Year (2) ]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) ]: One (1) neb Inhalation Q6H (every 6 hours). 5. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: 5000 (5000) units SC Injection TID (3 times a day). 6. Simvastatin 20 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO at bedtime. 7. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day): hold for HR <55 or SBP <90 and call provider. 8. Docusate Sodium 100 mg Capsule [Last Name (STitle) ]: One (1) Capsule PO BID (2 times a day). 9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 10. Magnesium Hydroxide 400 mg/5 mL Suspension [Last Name (STitle) ]: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Hospital1 ] Discharge Diagnosis: Aortic Stenosis chronic atrial fibrillation Hypertension Systolic and diastolic congestive heart failure Hyperlipidemia anemia-chronic Benign Prostatic Hypertrophy Moderate pulmonary Hypertension s/p Aortic Valve Replacement s/p ascending aortic endarterectomy s/p postop cardiac arrest with mediastinal exploration chest reclosure coronary artery disease Chronic Kidney Disease s/p cataract surgery s/p basal cell carcinoma excision from face s/p Tonsillectomy post operative acute renal failure dysphagia Discharge Condition: Alert and oriented x3 nonfocal uses lift; does not ambulate Incisional pain with tylenol prn mild BLE edema Incisions: Sternal - healing well, no erythema or drainage Discharge Instructions: Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Please shower daily including washing incisions gently with mild soap,STERNAL INCISION TO ALSO BE WASHED WITH HYDROGEN PEROXIDE; no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage FOLEY [Month (only) ] BE REMOVED TOMORROW [8-30] Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: Wound check and suture removal [Hospital Ward Name 121] 6 Wed [9-5] @ 10:30 AM Surgeon: Dr. [Last Name (STitle) 914] ([Telephone/Fax (1) 170]),on Tuesday, [9-18] at 1:00 PM Please call to schedule appointments with: Primary Care: Dr. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] ([Telephone/Fax (1) 2205]in [1-21] weeks Cardiologist: Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] in [1-21] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2136-8-29] ICD9 Codes: 4241, 4275, 5845, 5185, 2851, 5859, 2875, 4240, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8016 }	Medical Text: Admission Date: [2117-6-30] Discharge Date: [2117-7-9] Date of Birth: [2039-1-12] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1145] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: cardiac catheterization, w/ placement of 6 stents to the LAD Intra-aortic Balloon Pump Internal Jugular Central Venous Catheter placement, with Swan-Ganz catheter insertion History of Present Illness: HPI: 78 yo woman with h/o breast CA presented with sudden onset of [10-18] chest pressure radiating to back while sitting up in chair. + associated dyspnea, nausea, emesis x 1, This started at 5:30 pm. After about 4 hours of persistent pain, EMS was called. Found to have STE in anterior leads on EKG en route to hospital and given 4 baby aspirin. In ED, repeat EKG still with anterior STEMI. Also had intermittent RBBB and NSVT in ED. Started on heparin, nitro and integrillin gtt, loaded with 300 mg plaix, given lopressor 5 mg IV x 3, and brought urgently to cath lab. About 20-30 minutes into procedure, patient rapidly developed pulmonary edema and was intubated for respiratory distress. Bloody, frothy fluid suctioned from ET tube. Given lasix 20 mg IV. Also developed hypotension and dopamine started. . The cath revealed 3VD, with multiple stenoses in LAD (thought to be distal embolization from proximal plaque) with 6 bare metal stents to LAD. In addition, patient had chronic total occlusion of RCA. Right heart cath (on dopa) with RA 17, RV 46/12, PA 46/20 (35), PCWP 30, CO 3.15 L/min, CI 1.82 L/min/m2. During procedure patient developed small b/l groin hematomas, so integrillin stopped and hematomas stable. Patient brought to CCU on dopamine gtt with balloon pump (1st attempted in L groin but iliac artery thrombosed) and swan in place, both in R groin. Past Medical History: PMH: - breast cancer s/p L mastectomy - hypercholesterolemia - schizophrenia Social History: denies alcohol and tobacco use Family History: noncontributory Physical Exam: PE: T 96.5, 107/60, 84, 100% on AC 500x24, 1.0, 5 GEN - intubated and sedated HEENT - PERRL, mucosa moist NECK - supple LUNGS - rales at L base, R clear anterolaterally HEART - nl s1s2, RRR, II/VI SEM at RUSB ABD - soft, NT/ND, NABS EXT - no edema, dopplerable DP/PT pulses b/l (not palpable) Pertinent Results: [2117-6-30] 11:45PM WBC-9.7# RBC-3.36# HGB-10.0# HCT-30.4# MCV-90 MCH-29.8 MCHC-33.0 RDW-12.8 [2117-6-30] 10:30PM GLUCOSE-158 UREA N-15 CREAT-0.6 SODIUM-148* POTASSIUM-2.0* CHLORIDE-127* TOTAL CO2-12* ANION GAP-11 [2117-6-30] 10:30PM CK(CPK)-130 [2117-6-30] 10:30PM CK-MB-10 MB INDX-7.7* EKG [6-30] (pre-procedure): NSR at 90 bpm, nl axis, nl intervals, 2 mm STE V1, 7 mm STE V2, 2 mm STE V3, [Street Address(2) 2051] depressions I, L, V5-V6. . EKG [7-1] (post-procedure): Sinus tach at 123 bpm, anterior Q waves with persistent STE anteriorly (1-2 mm in V1,V2 and 5 mm V3,V4) with TWI V1-V6. . Echo in cath lab (post-procedure): poor windows. Anterior, anteroseptolateral akinesis. EF 15-20%, nl RV function. [1-10]+ MR, [1-10]+ TR. . Cath [2035-6-29]: -LMCA: normal -LAD: severe disease with multiple 80% stenoses with an occlusion distally -> stented -> left 40-50% origin stenosis and distal diffuse disease with normal flow -LCX: 90% -RCA: occluded, fills by collaterals Brief Hospital Course: 1)STEMI: Mrs. [Known lastname 28660] was brought to [Hospital1 18] with a large anterior STEMI and was taken to the cath lab for revascularization, and received 6 stents to the LAD. She was eventually started on ASA, beta blocker, Plavix, and [First Name8 (NamePattern2) ] [Last Name (un) ] for [Hospital 64052] medical management. 2)CHF: Mrs. [Known lastname 28660] was left with an EF of 20% after her MI. Her hospital course was complicated by cardiogenic shock and pulmonary edema. She required an IABP and pressor support for a while but was eventually weaned off successfully. She was started on the cardiac medications listed above, as well as Coumadin for apical akinesis. She has had no evidence of ongoing ischemia by EKG or enzymes. 3)VT: On admission, she had fascicular VT and the team was concerned for possible development of CHB (as she had evidence of septal ischemia and had a fascicular rhythm from R post fascicle). This resolved w/ PCI. Then 2 days later she had sustained VT originating from anterior apex and was IV loaded with amiodarone. She did not require defibrillation as she remained hemodynamically stable. Per EP, this was still in peri-MI period, and amiodarone use could possibly progress to CHB so it was stopped. She has had no further recurrence of VT. 4) Respiratory distress - She initially had difficulty breathing secondary to pulmonary edema in the setting of MI and depressed EF. She was agressively diuresed using PA cath #s for guidance. She had daily episodes of desaturation while in the CCU, felt to be due to bronchospasm. She had no obvious infiltrate on CXR. She has a residual O2 requirement, and will need to go to rehab with supplemental O2. 5) FEN - She was kept NPO while intubated, and then switched to a heart healthy diet when she began taking po. She has needed potassium repletion frequently during this admission due to aggressive diuresis with Lasix. She appears euvolemic upon discharge. 6) Schizophrenia- Mrs. [Known lastname 28660] stated to the team that she was diagnosed with schizophrenia as a child and has been taking Mellaril for over 25 years. She has had no psychotic symptoms during this admission. She was restarted on her outpatient dose of Mellaril during this admission. She would benefit from having psychiatry follow-up after discharge for reassessment of diagnosis and medicine regimen. 7) Code status- The patient was full code throughout this admission. 8) Dispo- Mrs. [Known lastname 28660] is being discharged to a temporary rehabilitation facility for physical therapy and regain of function. Medications on Admission: -Femara -Mellaril Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Pravastatin Sodium 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 9. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO qd (). 10. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Thioridazine 100 mg Tablet Sig: One (1) Tablet PO QD (). 12. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:3 2 Refills:2 13. Pneumococcal 7-[First Name5 (NamePattern1) ] [Last Name (NamePattern1) 24419] Vacc Intramuscular Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: s/p ST elevation myocardial infarction with 6 stents to the left anterior descending coronary artery Congestive Heart Failure, EF 20-30% by TTE ([7-1]) Discharge Condition: stable Discharge Instructions: Please take all medications as instructed. Please follow up at your scheduled appointments. If you experience fever, chills, chest pain, or shortness of breath, please call your doctor or go to the emergency room. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 4022] Date/Time:[2117-7-19] 2:15 Completed by:[2117-7-29] ICD9 Codes: 2720, 4280, 9971, 4271, 2875, 4241, 2859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8017 }	Medical Text: Admission Date: [2137-9-19] Discharge Date: [2137-9-25] Date of Birth: [2060-9-10] Sex: M Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: Patient, well known to our Neurology service for his myasthenia [Last Name (un) 2902], is a 77-year-old gentleman, who was recently discharged from our inpatient service. He comes to us because of increased secretions in his airway. Patient's diagnosis of myasthenia [Last Name (un) 2902] was made in [2136-8-26], when he was in the hospital for back pain and leg weakness as well as difficulty ambulating. At that time, Neurology service was consulted and they found patient to have fatigable dysphonia, dysphagia, and weakness of his neck flexors. Tensilon test was equivocal, but EMG showed postsynaptic neuromuscular junction defect, which was later confirmed by single fiber analysis. He was given Mestinon, which resolved his problem. He came back shortly after his discharge with increased secretions in his airways and some bulbar weakness. At that time, his Mestinon dose was reduced to 30 mg q.8h. In addition, he received CellCept 1 gram b.i.d. and prednisone 60 mg q.d. Three days after discharge, he was readmitted again because of a choking episode. His Mestinon was then increased to 60 mg p.o. six hours and no changes were made on his CellCept and prednisone. After 13 days stay in the hospital, he was discharged to rehab facility with Mestinon 90 mg q.6h. and prednisone 80 mg q.d. and CellCept 1 gram b.i.d. Ten days later he was hospitalized again with increased anxiety. His CellCept was increased to 1,500 mg IV b.i.d. and Mestinon 75 mg p.o. q.4h. and prednisone 100 mg q.d. One month later, [2137-8-29], he came back because of changes in his voice, apparently patient was talking more nasally, and he was complaining of weakness, as well as dysphagia. He received plasmapheresis and IV IG as well as CellCept 1,500 b.i.d. and prednisone 100 mg b.i.d., and his Mestinon was changed to 75 mg q.6h. and 180 mg extended release every night and cyclosporin 100 mg q.12h. The patient was discharged to rehab facility and he was there for seven days before coming again complaining of increased tracheal secretions as well as dysphagia and problems with talking. PAST MEDICAL HISTORY: 1. Myasthenia [Last Name (un) 2902]. 2. Diabetes. 3. Radiculopathy. 4. Glaucoma. 5. Hypercholesterolemia. 6. Hypertension. 7. Benign prostatic hypertrophy. MEDICATIONS: 1. Calcium carbonate. 2. Glyburide. 3. Metformin. 4. Protonix. 5. Lisinopril. 6. Paxil. 7. Zocor. 8. Flomax. 9. Nystatin swish and swallow. 10. Lumigan. 11. Ativan. 12. Insulin. 13. CellCept. 14. Prednisone. 15. Mestinon. ALLERGIES: None. FAMILY AND SOCIAL HISTORY: Lives with wife. [Name (NI) ] family history of myasthenia [Last Name (un) 2902]. No alcohol or smoking history. He has been in rehab facility in and out since Spring of [2136]. PHYSICAL EXAMINATION: Vital signs: 96.8, 101, 134/65, blood pressure ranged 120-160/50-80. NIF 30 and 28. Vital capacity 2.4 and 2.2 in measurements twice today. NEUROLOGICAL EXAMINATION: Patient was oriented and awake x3. No problems with attention deficits consistent with months of the year backwards and days of the week backwards. Cranial nerves were mostly intact except for weak palate elevation and lack of gag reflex. Motor examination showed no pattern of upper motor neuron disease. Sensory examination was grossly intact to pin prick and light touch as well as vibration. Reflexes were symmetric bilaterally. Coordination was normal. His gait was not assessed. He could get out of bed with assistance and sit in a chair without any problems. PERTINENT IMAGING AND LABORATORY FINDINGS AT ADMISSION: Chest x-ray shows small left pleural effusion, unchanged in the interval. It also showed that the previously discovered left lower lobe consolidation and collapse had been resolved. No other imaging studies were done. Laboratory tests showed an elevated white count of 12.7, hematocrit 31.1, hemoglobin 10.2, and platelets of 322. His INR was 1.0 with PTT of 26.2. Urinalysis was negative. His electrolytes were all normal except for a high glucose level at 300 range. His liver enzymes were all normal. His cyclosporin level was 72 at 10 a.m. on [424-9-21] at [9-21] at 3:10 p.m., and 65 and 386 on [9-24] 6 a.m. and 11 a.m. respectively. HOSPITAL COURSE: Patient received 5x IV IG, the last one on [Last Name (LF) 766], [9-23]. The patient was admitted to the Intensive Care Unit from the day of admission until [9-21]. He received frequent suctioning of his tracheal secretions. Nutrition services suggested Probalance at 70 cc which provides 2,016 kilocalories with 90 grams of protein. His GI examination was monitored for feeding intolerance, which did not occur. Neuromuscular team followed the patient daily and made recommendations on his medications. His Mestinon dose was readjusted and the last dose which was found to be effective was 30 mg and 45 mg of Mestinon interchangeably in total 4x a day. Please see the rest of the medications below. With this current dose of Mestinon, the patient's NIF and vital capacity remained satisfactory. His last NIF was -40 and vital capacity 3.6 with IC of 1.25. His oxygen saturation remained over 97%. Patient subjectively reported much relief from his symptoms prior to admission. Specifically, he did not have much tracheal secretions, and he did not report subjective feeling of fatigue and weakness except for his baseline deconditioned status. FOLLOW-UP APPOINTMENT: Meeting with Dr. [Last Name (STitle) 557] at 4 p.m. Neurology CC8, [10-7]. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: Discharged to [Hospital ] Rehab. DISCHARGE DIAGNOSIS: Myasthenia [Last Name (un) 2902]. DISCHARGE MEDICATIONS: All the medications to be given through the PEG tube: 1. Cyclosporin 150 mg q.12h. 2. Lansoprazole 30 mg q.d. 3. CellCept 1,500 mg b.i.d. 4. Peroxetine 20 mg q.d. 5. Neutra-Phos one packet t.i.d. 6. Ascorbic acid 500 mg b.i.d. 7. Tylenol 325 mg 1-2 tablets q.4-6h. 8. Sodium chloride 0.65% spray [12-27] sprays nasally q.i.d. 9. Heparin 5,000 units injection every 12 hours subcutaneously. 10. Prednisone 50 mg tablets two tablets q.d. 11. Mestinon 45 mg, 30 mg, 45 mg, 30 mg every day. 12. Lorazepam 1 mg tablet every day as needed for anxiety. Patient's nutritional status remains NPO. He will continue to receive tube feeding through PEG, as advised by Nutritional services described above. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 12114] Dictated By:[Last Name (NamePattern1) 728] MEDQUIST36 D: [2137-9-25] 13:09 T: [2137-9-25] 13:32 JOB#: [Job Number 94215] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8018 }	Medical Text: Admission Date: [2179-2-12] Discharge Date: [2179-2-17] Date of Birth: [2101-5-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 1257] Chief Complaint: Bright red blood per rectum, NSTEMI. Major Surgical or Invasive Procedure: Colonoscopy. History of Present Illness: 77 yo M with h/o HTN, HL, multiple falls transferred from [Hospital1 3325] with NSTEMI in setting of anemia. Pt is poor historian but reports several hours of gross blood per rectum several days ago that resolved spontaneously. He described this similar to prior episodes thought to be hemorrhoidal, but lasting longer. He denied SOB, CP, lightheadedness at that point but later, while walking to get the mail, felt weak, dizzy, dyspneic, nauseated. He also had a fall, which he describes as mechanical, but does not remember any surrounding symptoms other than vomiting (bilious nonbloody). Pt was unable to get up for many hours. Pt did have residual left shoulder pain, and describes dislocation. He did not get evaluated until the following day as he takes care of his wife with [Name (NI) 11964] who was having a difficult day yesterday. In the OSH [Name (NI) ] pt was found to have troponin of 9.8, CK 692, Hct 22. Pt was hypertensive to 190s/90s. He received ASA, Plavix, metoprolol and was transferred to [Hospital1 18]. In our ED, BP 180/90, trop 1.4, CK 600, MB 13, Hct 22 from unknown baseline and very positive guaiac stools. BP was treated with nitro drip, pt transfused 2U pRBCs, imaging all without abnormalities (CT torso, CXR, shoulder x-ray). EKG here has LVH w/ ST depressions that are 3 mm in V5-V6 and possibly some in I and aVL. ROS: Denied chest pain. No SOB although breathing was not at baseline. No lightheadedness, dizziness, headaches, abd pain. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: 3. OTHER PAST MEDICAL HISTORY: Unknown Social History: Lives with wife who has [Name (NI) 2481] in [Location (un) 39908]. Never had any children. -Tobacco history: Former, quit 40yrs ago Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=...BP=180/87 HR=78 RR=14 O2 sat= 100% RA GENERAL: WDWN male in NAD. Oriented x3, mediocre historian. 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 without JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Systolic murmur at apex and diastolic decrescendo murmur at left USB. LUNGS: Ecchymosis on left chest. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. 1+ pulses Pertinent Results: Labs at Admission: [2179-2-12] 08:30PM BLOOD WBC-14.2* RBC-2.43* Hgb-7.9* Hct-22.1* MCV-94 MCH-32.6* MCHC-34.8 RDW-16.7* Plt Ct-415 [2179-2-12] 08:30PM BLOOD PT-13.7* PTT-24.0 INR(PT)-1.2* [2179-2-12] 08:30PM BLOOD Glucose-83 UreaN-40* Creat-1.0 Na-141 K-3.8 Cl-105 HCO3-26 AnGap-14 [2179-2-12] 08:30PM BLOOD CK-MB-13* MB Indx-2.2 [2179-2-12] 08:30PM BLOOD Calcium-8.5 Phos-3.1 Mg-2.3 [2179-2-15] 05:11AM BLOOD calTIBC-278 Ferritn-275 TRF-214 Labs at Discharge: [2179-2-17] 05:20AM BLOOD WBC-13.4* RBC-3.23* Hgb-10.2* Hct-29.4* MCV-91 MCH-31.4 MCHC-34.6 RDW-16.8* Plt Ct-336 [2179-2-17] 05:20AM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-139 K-4.3 Cl-101 HCO3-33* AnGap-9 Cardiac Enzymes: [2179-2-12] 08:30PM BLOOD CK-MB-13* MB Indx-2.2 [2179-2-12] 08:30PM BLOOD cTropnT-1.38* [2179-2-13] 04:31AM BLOOD CK-MB-11* MB Indx-2.3 cTropnT-1.55* Imaging Studies: CT CAP ([2179-2-12]): 1. Several osseous fragments in left shoulder joint, which is also distended with fluid. While no overt or displaced fracture is seen, if there is recent trauma with resulting pain to the left shoulder, MRI may be considered for assessment for occult fracture. Age-indeterminate anterior/superior subluxation of the left glenohumeral joint, likely related to chronic rotator cuff injury. 2. Extensive atherosclerotic disease involving the entire aorta and its major branches, and the coronary arteries. CT Head ([2179-2-12]): 1. No acute intracranial process. 2. Marked left maxillary sinus mucosal thickening. TTE ([2179-2-15]): The left atrium is mildly dilated. A left-to-right flow is seen on color Doppler across the interatrial septum c/w a small secundum atrial septal defect. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate global left ventricular hypokinesis (LVEF = 40 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with mild global hypokinesis suggestive of a diffuse process (toxin, metabolic, etc. - cannot exclude multivessel CAD if clinically suggested). Moderate pulmonary artery systolic hypertension. Increased PCWP. Small secundum atrial septal defect. Brief Hospital Course: 77 year old man with history of HTN, HL, multiple falls who presented with lightheadedness, found to be anemic, hypertensive and have had an NSTEMI. # Type II MI (Demand Ischemia): Known troponin leak to 9 at OSH, trending down. EKG with ST depressions laterally unclear if related to hypertrophy or laterally distributed ischemia. This was thought to be largely due to his high amount of blood loss from his GI bleed. He was started on heparin gtt for initial presumption of NSTEMI; heparin gtt was discontinued the next morning. He was initially started on aspirin, plavix and statin. He was transfused a total of 4 units of PRBCs for his anemia. Plavix was stopped and aspirin decreased to 81 mg daily. TTE showed global LV hypokinesis. There was no cardiac intervention during this admission. His medicines have been changed to include baby aspirin, beta-blocker, and ace-inhibitor. He can continue on hydrochlorothiazide for blood pressure control and statin for cholesterol control. Amlodipine has been added to his blood pressure regimen; this could be discontinued or weaned down if he has better blood pressure control after discharge. He has follow-up scheduled in cardiology clinic. # Anemia: The patient had an aggressive bleed (brbpr) several days prior to admission. He was transfused 4 units, started on IV famotidine, which was then changed to omeprazole [Hospital1 ] and was then colonoscoped on [2179-2-15]. During the prep the patient had a large amount of maroon blood. The colonoscopy showed blood throughout the entire length of the patient's colon, with significant sigmoid diverticulosis. The cecum was entered and there was no evidence of blood that would signify an upper GI bleed. His hematocrit was 30.1 on [2179-2-16] and remained stable until discharge. He has follow-up scheduled in [Hospital ] clinic. He can continue ranitidine as outpatient should he have any reflux-type symptoms; the omeprazole has been discontinued at time of discharge. # Leukocytosis: 14, trended down. Afebrile, no localizing symptoms. UA negative, CXR negative. Likely stress reaction. # Hypertension: 180s/90s on presentation. He was started initially on nitroglycerin drip in ED for blood pressure control because medications were unknown. He was then given labetalol overnight to help with BP control and to wean nitro drip. After calling [Location (un) 535] in [Location (un) 18825], Mass, patient's home medications were restarted for BP and nitro drip was turned off; started on Imdur, Lisinopril, HCTZ. His home dose verapamil was switched to carvedilol. He continued to be hypertensive, and was started on amlodipine on [2179-2-16]. # Failure to thrive: The patient and wife live alone together, although his wife has advanced [Name (NI) 2481] and was found wandering by the neighbors. Since then she has been admitted to the dementia unit at [Hospital1 ]. The patient himself has reported to have had multiple falls at home, and per the HCP the home was in a shambles after his admission. Social work was involved in speaking with the healthcare proxy [Name (NI) ] [Name (NI) ] ([Telephone/Fax (1) 86456] to try and either provide home services or place both Mr. [Known lastname 86457] and his wife in a long-term [Hospital3 ] facility. Medications on Admission: Verapamil 240 mg [Hospital1 ] Isosorbide mononitrate 60 mg qday Hydrochlorothiazide 25 mg qday Lipitor 20 mg qday Flomax 0.4 mg qhs Discharge Medications: 1. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for reflux. Disp:30 Tablet(s) Refills:2 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital 671] Healthcare Discharge Diagnosis: Primary: Elevated troponin GI bleed Diverticulosis 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 [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1675] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] because you had stress on your heart. This was due to your severe gastrointestinal bleed, which caused your heart to not receive enough blood to function. You received several blood transfusions to help improve your blood counts. You have been scheduled to follow up with your cardiologist Dr. [Last Name (STitle) ] at the date and time below. During your admission, you also had a colonoscopy. This showed that you had severe diverticulosis, or outpouchings in your colon. This is the most likely cause of your gastrointestinal bleeding. You have been scheduled with a follow-up appointment with the gastroenterologists. Finally, you fell once during your admission while trying to pick up your remote control. You had a CT scan of your head which showed no bleeding in the brain. However, we were concerned that you have also been falling at home and have been having difficulty taking care of yourself and your wife while there. You were evaluated by our physical therapists who determined that you would benefit from going to rehab. You have been started on several new medications while here: -Amlodipine 10mg daily, which helps control your blood pressure. -Lisinopril 40 mg, for blood pressure control -Aspirin 81 mg, for prevention of heart attack and stroke -Ranitidine 150 mg as needed, for stomach discomfort -Carvedilol 25 mg twice daily, for blood pressure control -Isosorbide Mononitrate 60 mg, for blood pressure control -Verapramil was stopped during this admission Followup Instructions: You have a follow-up appointment with your cardiologist, Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 73315] on [3-5] at 9:30. Also, you have a follow up appointment with the gastroenterologists here at [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1675] [Last Name (NamePattern1) ]: [2179-3-3] 03:30p [Name6 (MD) ] [Name8 (MD) ], MD RA [Hospital Unit Name ] ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX), [Location (un) ] ([Telephone/Fax (1) 2233] Completed by:[2179-2-17] ICD9 Codes: 2851, 2724, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8019 }	Medical Text: Admission Date: [2107-11-1] Discharge Date: [2107-12-8] Date of Birth: [2047-8-17] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6169] Chief Complaint: presenting for elective surgery Major Surgical or Invasive Procedure: total abdominal hysterectomy and bilateral salpingo-oopherectomy endotracheal intubation central venous catheter placement arterial line placement History of Present Illness: The patient is a 60 year old female, with no significant past medical history, recently referred to gynecology-oncology for a diagnosis of ovarian cancer. She initially presented to [Hospital ] Hospital with a complaint of progressive shortness of breath. She also reported a 20-30 pound weight loss, gradual abdominal distention and bilateral lower extremity swelling. She was found to have a large right pleural effusion and underwent a 2.5 L thoracentesis, with negative cytology. The patient also had a paracentesis with negative cytology at the OSH. CT torso on [10-20] showed bilateral pulmonary opacities, diffuse lymphadenopathy, ascities, and ovarian masses. Ultrasound on [2107-10-21] showed bilateral pelvic soft tissue masses with ascites and normal uterus. CA-125 was elevated at greater than 2500. She was then transferred to the gyn-onc service for further management. . Patient underwent TAH/BSO, and ascites drainage. Right pelvic lymph node was sent for frozen section which was found to be consistent with lymphoma. The right ovarian mass was found to be benign. Multiple enlarged lymph noes were found, the largest was over 5 cm. Intraoperatively, she received 1 L IVF and was bolused subsequently for low UOP and for post-operative hypotension. Patient was transferred to the [Hospital Unit Name 153] for ongoing treatment. . Upon arrival to the [Hospital Unit Name 153], patient was intubated and mildly sedated, VS: BP 84/52 MAP 65 HR 88 O2 sat 95% on AC. Central line was placed under ultrasound guidance in the right IJ. While in the ICU, she was put on up to 3 pressors for her hypotension. She went into acute renal failure (thought to be from hypotension-related ATN with a possible component of tumor lysis syndrome from steroid-induced lysis) requiring CVVH and rasburicase. She was successfully taken off CVVH and extubated. She was diuresed aggressively for a 20L net positive fluid status since her ICU admission. Her abdominal wound was draining up to 1L/day. Also while in the ICU, she was noted to have an EF of 20%,; it is unclear if this is from an MI in the setting of hypotension or if it is just "shocked" myocardium. . After her acute issues stabilized, the patient was transferred to 7 [Hospital Ward Name 1826] for further management. Past Medical History: none Social History: The patient smoked one pack per day for 30 years, but currently does not smoke. She drinks occasionally. She is married and has two daughters and one son from a previous marraige. Family History: colon cancer Physical Exam: Upon arrival in [Hospital Unit Name 153]: GEN: sedated, intubated. not responsive to voice or noxious stimuli HEENT: PERRL CV: distant heart sounds, nl s1, s2, no m/r/g Pulm: CTA anteriorly Abd: midline abdominal dressing clean and intact. obese, nontender, hypoactive bowel sounds. Ext: warm, trace edema, no cyanosis. pedal pulses present neuro: not responsive to voice or noxious stimuli [3-3] sedation. Pertinent Results: [2107-10-31] 09:05AM PT-11.4 PTT-23.1 INR(PT)-1.0 [2107-10-31] 09:05AM WBC-6.5 RBC-4.24 HGB-11.3* HCT-34.3* MCV-81* MCH-26.7* MCHC-33.0 RDW-14.7 [2107-10-31] 09:05AM PLT COUNT-453* [2107-10-31] 09:05AM TOT PROT-5.9* ALBUMIN-3.9 GLOBULIN-2.0 CALCIUM-9.3 MAGNESIUM-2.3 [2107-10-31] 09:05AM ALT(SGPT)-6 AST(SGOT)-14 ALK PHOS-84 AMYLASE-87 TOT BILI-0.5 [2107-10-31] 09:05AM GLUCOSE-78 UREA N-22* CREAT-0.7 SODIUM-139 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-27 ANION GAP-20 [2107-11-1] 03:52PM PT-12.0 PTT-23.7 INR(PT)-1.0 [2107-11-1] 03:52PM PLT COUNT-390 [2107-11-1] 03:52PM WBC-10.9# RBC-3.56* HGB-9.7* HCT-28.4* MCV-80* MCH-27.2 MCHC-34.0 RDW-14.9 . CT scan [2107-11-4] for lymphoma staging: There is mildly heterogeneous and enlarged thyroid gland with a small 1-cm hypodense nodule within the right lobe. There are multiple nodes present within the mediastinum, the largest of which is seen within the paraesophageal space measuring 16 mm in diameter. There are bilateral enlarged hilar lymph nodes which cannot be definitely measured given lack of IV contrast. There is marked axillary lymphadenopathy with a representative node on the right measuring 20 x 18 mm and is seen on series 2, image 6. A representative node within the left axilla is seen on series 2, image 8, measuring 16 x 12 mm. There are multiple tiny nodules seen within the breasts bilaterally, the largest on the left hand side measuring 12 x 15 mm, seen on series 2, image 16. There are bilateral large pleural effusions. The lungs are otherwise clear. Along the right thorax just below the scapula, there is a moderate amount of air within the subcutaneous and intramuscular space, probably sequelae from prior thoracentesis. The heart and great vessels are unremarkable. There is a 27 x 15 mm node along the right pericardium measuring 15 x 27 mm, seen on series 2, image 36. The patient is intubated and has a nasogastric tube extending with tip in the post-pyloric region. CT ABDOMEN WITHOUT IV CONTRAST: There is a moderate amount of ascites. The liver is unremarkable. The gallbladder wall is thickened likely secondary to third spacing. The pancreas is not clearly defined but appears grossly unremarkable. The spleen is prominent, slightly displacing the stomach medially 12 x 7 cm. The adrenal glands are not well visualized secondary to an extensive amount of retroperitoneal lymphadenopathy extending from the level of the SMA inferiorly and encasing the aorta and IVC. A representative size of this conglomeration is seen on series 2, image 74 measuring 86 x 52 mm. There is extensive lymphadenopathy within the mesentery with a conglomerate of nodes measuring 57 x 40 mm, seen on series 2, image 85. There is a moderate amount of ascites. The small and large bowel are unremarkable and opacified with oral contrast extending to the rectum. There is no evidence of obstruction. CT PELVIS WITH IV CONTRAST: The urinary bladder is catheterized. The rectum is unremarkable. The uterus is not well visualized. There are no adnexal masses with the exception of extensive lymphadenopathy that extends into the deep pelvis bilaterally inferiorly from the above-mentioned retroperitoneal lymphadenopathy along the iliac nodal chains. The largest bulk of this lymphadenopathy measures 94 x 47 mm along the left iliac nodal chain seen on series 2, image 105. There is extensive inguinal lymphadenopathy, the largest nodal conglomerate seen on the left measuring 49 x 62 mm. Also noted within the subcutaneous tissue in the midline of the abdomen are a few pockets of air seen along a linear soft tissue defect likely secondary to prior surgical intervention. BONE WINDOWS: No suspicious lytic or sclerotic bony lesions. . Echo ([2107-11-2]): The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular systolic dysfunction with near akinesis of the distal 2/3rds of the ventricle. Basal segments contract well. The apex is milldy aneurysmal and akinetic, but no masses or thrombi are seen in the left ventricle, though the apex is trabeculated. Right ventricular chamber size is normal. There is focal akinesis of the apical half of the RV free wall. The aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Repeat echo prior to R-CHOP ([12-5]): The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular systolic dysfunction with near akinesis of the distal 2/3rds of the ventricle. Basal segments contract well. The apex is milldy aneurysmal and akinetic, but no masses or thrombi are seen in the left ventricle, though the apex is trabeculated. Right ventricular chamber size is normal. There is focal akinesis of the apical half of the RV free wall. The aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Abdominal Ultrasound ([11-24]): There are again identified bilateral pleural effusions, partially imaged. There is a moderate-to-large amount of ascites present in all four quadrants, best appreciated in the left lower quadrant. In the left lobe of the liver there are two uniformly hyperechoic lesions, the largest of which measures 2.0 x 1.6 x 1.7 cm with appearance consistent with hemangiomas. No other focal abnormalities are demonstrated within the liver. The gallbladder is collapsed with likely wall thickening again, which could be secondary to third spacing of fluid. A shadowing gallstone is demonstrated within the gallbladder lumen. The spleen is stable in size measuring 11 cm in its longest length. A small roughly 1 cm anechoic lesion, without blood flow is demonstrated within the spleen, not fully characterized on this study, though possibly a cyst. The previously described extensive mesenteric or retroperitoneal adenopathy is not well assessed on this study. Color flow and Doppler evaluation of the hepatic vasculature was performed given history of ascites. The hepatic veins, hepatic arteries main portal vein and its branches are patent with appropriate direction of flow and normal waveforms. The inferior vena cava is generally narrowed without intraluminal filling defects. This appearance could be secondary to fluid status or secondary to ascites. . CTA ([12-2]): 1. There is a large right pleural effusion with complete passive collapse of the right lung. There is a small left pleural effusion. 2. Again seen is mediastinal and pericardial lymphadenopathy, which is not significantly changed in comparison to the prior study. 3. A large amount of ascites. 4. Three hypodensities are seen within the visualized portion of the liver which are not completely characterized. . . CYTOLOGY: Pleural Fluid: By immunohistochemical stains, the lymphocytes are a mixture of CD20 positive B-cells along with CD3 positive (B greater than T). Although definite co-expression of CD5 amongst B-cells could not be discerned, a subset of weak CD5 expressing cells is seen amongst the brighter CD5 positive T-cells. Scattered CD10 positive lymphocytes are seen. Bcl-1/cyclin D1 is expressed in a minor subset. Overall, the findings indicate involvement by the patient's known Mantle cell lymphoma. Peritoneal Fluid: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. Abnormal/lymphoma cells comprise 5% of lymphoid gated events. B cells demonstrate a monoclonal Lambda light chain restricted population. They co-express pan-B cell markers CD19 along with CD5 and FMC-7. They do not express any other characteristic antigens including CD10, CD23. A subset express CD20. T cells express mature lineage antigens. INTERPRETATION Findings are of involvement by a Lambda restricted, CD5-positive B cell lymphoproliferative disorder, immunophenotypically consistent with patient's known mantle cell lymphoma. Given the small percentage of involved B-cells, peripheral blood contamination cannot be ruled out. Brief Hospital Course: 1. See HPI for MICU course . 2. Mantle Cell Lymphoma: Received 300mg/m2 of Cytoxan twice a day for six doses, with high-dose Decadron. The decadron was discontinued after the patient developed psychotic paranoia. She developed tumor lysis syndrome with elevated uric acid, and initially requiring CVVH. Her counts dropped in response to chemotherapy and she was neutropenic for several days. The patient was treated with neupogen until her counts normalized, and she remained afebrile. Her effusions (below) continued to re-accumulate after taps, and ultimately the decision was made to treat the patient with the first round of R-CHOP. She tolerated the regimen very well, and had no issues completing the prednisone portion of the therapy. The patient was transfused to keep her hematocrit above 25 and platelets above 10. . 3. Malignant effusion: The patient originally presented with shortness of breath from a right pleural effusion and ascites. Her ascites fluid was drained in the operating room, and not sent for studies. Her right pleural effusion was tapped twice, both large volume. Cytology was positive for lymphoma. The patient had reaccumulation of both fluid collections, which were unintervenable while she was neutropenic. Once her counts recovered, the patient underwent therapeutic paracentesis of 3 liters, which demonstrated malignant cells. The patient remained short of breath after this procedure and underwent a 1.6 liter thoracentesis by interventional pulmonary. She tolerated the procedure well with immediate symptomatic improvement. On a post-procedure x-ray, however, her right lung remained [Last Name (un) 57454]-out. She underwent CTA which demostrated a very large right pleural effusion with right lung collapse. The patient, however, had an improvement in her symptoms and decrease in her oxygen requirement. She underwent R-CHOP in an effort to treat the underlying cause of her effusions. She was discharged on 40 po Lasix to take daily, to which she responded well in the hospital. . 4. s/p TAH-BSO: The patient was originally thought to have ovarian cancer, and she underwent TAH-BSO on [2107-11-1]. The diagnosis of lymphoma was made on an intraoperative lymph node biopsy. Her ovarian pathology was cystadenofibroma. . 5. Cardiomyopathy: In the ICU, her ejection fraction was found to be 20%, which is likely ischemic in origin from "shocked" myocardium. Repeat TTE, when her critical illness resolved revealed an ejection fraction of 55%, but persistent right sided failure. Prior to beginning treatment with R-CHOP, the patient again had an echocardiogram which demonstrated resolution of the right heart failure and 2+ MR. . 6. ID: the patient had asymptomatic pyruia on [11-14], and was treated for 7 days with Zosyn for a Citrobacter UTI. Repeat urine culture was negative. She remained afebrile while neutropenic. . 7. Chronic back pain: MRI demonstrated no spinal or vertebral involvement of her lymphoma. She was maintained on narcotics for pain control. As her ascites reaccumulated, her pain medication requirement increased. She was discharged on 10 mg Oxycontin [Hospital1 ] and 5 mg Oxycodone q4 prn. MRI revealed no spinal involvement of her lymphoma . 8. Disposition: The patient will go to rehabilitation to assist her after her prolonged hospitalization and very low functional status at this point. Patient had a port placed by surgery on [2107-11-17], which was functional through the hospitalization. She was full code. Medications on Admission: hnone Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 2. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day) as needed. 3. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for SOB, wheeze. 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 13. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO twice a day. 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed. 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 18. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Ten (10) ML Intravenous DAILY (Daily) as needed. 19. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: Mantle cell lymphoma Malignant pleural effusion Malignant ascites s/p TAH/BSO Tumor lysis syndrome Cardiogenic shock Chronic low back pain Discharge Condition: afebrile, hemodynamically stable. On 2L NC Discharge Instructions: Please return to the ED with chest pain, shortness of breath, fevers, chills, or vomiting. . Please keep all follow up appointments and take all medications as prescribed. Followup Instructions: Provider: [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 6175], MD Phone:[Telephone/Fax (1) 3237] Date/Time:[2107-12-13] 10:30 ICD9 Codes: 5845, 9971, 2762, 4280, 5990, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8020 }	Medical Text: Admission Date: [2134-10-7] Discharge Date: [2134-10-31] Date of Birth: Sex: F Service: VASCULAR SURGERY HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female with a rapidly increasing asymptomatic abdominal aortic aneurysm who presented to the Vascular Surgery Service for elective repair admitted on [2134-10-7], one day prior to surgery. PAST MEDICAL HISTORY: Asymptomatic abdominal aortic aneurysm. Hypertension. Hypercholesterolemia. History of cerebrovascular accident. Gastroesophageal reflux disease. Coronary artery disease. History of angina with myocardial infarction. History of pneumonia. Hiatal hernia. Irritable bowel syndrome. Esophagitis. History of urinary tract infection. PAST SURGICAL HISTORY: Cataract surgery. MEDICATIONS ON ADMISSION: Nitroglycerin 0.2 mg, Isosorbide Dinitrate 40 mg p.o. t.i.d., Sular 20 mg p.o. b.i.d., Nitrofurantoin 1 tab p.o. b.i.d., Lipitor 40 mg p.o. q.d., Toprol 50 mg p.o. q.d., Plavix 75 mg p.o. q.d., Micro-K 8 mEq 1 tab q.d., Hydrochlorothiazide 50 mg p.o. q.d., Prilosec 20 mg p.o. q.d., Ambien 10 mg p.o. q.d., Prednisone 10 mg p.o. q.d., Nitrostat 0.2 mg [12-31] as needed for chest pain, Hydrocodone 750 mg 1 tab 3 times a day as needed. PHYSICAL EXAMINATION: Vital signs: Afebrile. Vital signs stable. General: The patient was in no apparent distress. She was alert and oriented times three. Head: Normocephalic. Nonicteric. Neck: Soft and supple. Chest: Clear to auscultation bilaterally. Heart: Regular, rate and rhythm. Abdomen: There was a pulsatile abdominal mass. Rectal: Guaiac negative. HOSPITAL COURSE: The patient was admitted on [2134-10-7], for preoperative work-up of open abdominal aortic aneurysm repair. On [2134-10-8], the patient was taken to the Operating Room for open abdominal aortic aneurysm repair by Dr. [Last Name (STitle) 1391]. Please see operative report for more details. Postoperatively the patient went to the Vascular Intensive Care Unit. The patient remained intubated and sedated. Urine output was marginal in the immediate postoperative period with 30-40 cc/hr requiring fluid boluses. The patient was extubated on postoperative day #2 and required 2 U packed red blood cells for a hematocrit of 27. On postoperative day #3, the patient was found to be hypotensive into the 200 systolic which was treated with Lopressor 10 mg IV q.4 hours as needed. Later on that day, on postoperative day #3, the patient was complaining of chest pain with heart rate increasing to the 150-160s, oxygen saturations dropping to the 70%, the patient was emergently intubated. Upon intubation, the patient was found to have frothy pink sputum in the endotracheal tube. On postoperative day #3, the patient was thought to have had an episode of flash pulmonary edema requiring reintubation. The patient was transferred to the Trauma Surgical Intensive Care Unit. CT scan on [2134-10-11], displayed no pulmonary emboli, diffuse ground glass opacities throughout the pulmonary parenchyma, moderate sized bilateral pleural effusions, large hiatal hernia, and Swan-Ganz catheter in the right pulmonary artery. On [2134-10-12], the patient had a chest x-ray which revealed a large left pneumothorax with left-to-right mediastinal shift. A left chest tube was placed in the standard surgical fashion. On postoperative day #5, the patient's status was left pneumothorax, hemodynamic lability, On [2134-10-13], the patient continued to progress into an unstable atrial fibrillation rhythm with hemodynamic compromise. Chest x-ray was normal. The patient was given 150 mg Amiodarone and cardioverted with 100 joules electrocardioversion. On postoperative day #6, the patient was now on Vancomycin, Fluconazole, Levofloxacin and Flagyl. Vent weaning commenced. The patient was started on TPN on [2134-10-14]. On [2134-10-16], the patient was found to be acidemic with slightly rising creatinine, and the patient was planned to have line placement and hemodialysis that day. The patient remained in atrial fibrillation. On postoperative day #9, the patient continued to require judicious sedation. The patient was found to have lower filling pressures; however, the patient was still volume overloaded. She also continued to require hemodialysis. On [2134-10-13], the patient also had a CT scan which showed a 5.7 x 4.4 cm retroperitoneal hematoma adjacent to the ................... site of surgical repair with no evidence of active extravasation. The patient was noted to also have dense ascites suggestive of blood. There was no evidence of pulmonary embolus, worsening bilateral pulmonary ground-glass opacities. On postoperative day #11, the patient remained intubated. Renal function appeared to be improving and responded to intravenous Lasix but still required dialysis. The patient was still on TPN, as well as intravenous Heparin. In addition, the patient was also on intravenous Insulin. On postoperative day #18, the patient remained in congestive heart failure and in acute renal failure with increase in hypertension, requiring Hydralazine and Lopressor IV. On postoperative day #18, the patient was noted to have worsening congestive heart failure, increased oxygen requirement and increasing pulmonary edema requiring diuresis. In addition, acute renal failure was worsening with increasing creatinine despite hemodialysis. The remainder of the patient's postoperative course remained unstable with continued heart failure and renal failure. On [2134-10-31], the staff discussed her condition with the family, and they agreed to make the patient comfort measures only. On [2134-10-31], the patient's pressors were discontinued at 6 p.m. per the family's wishes. At 6:15 p.m., the patient went into asystole with no recordable blood pressure. No resuscitation was carried per the family's wishes. No heart rhythm was detectable. The patient was pronounced at 6:16 p.m. The family declined postmortem autopsy. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 4417] Dictated By:[Name8 (MD) 7190] MEDQUIST36 D: [2135-1-18] 14:40 T: [2135-1-18] 14:58 JOB#: [Job Number 42204] ICD9 Codes: 5845, 5185, 0389, 4275
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8021 }	Medical Text: Admission Date: [2153-8-20] Discharge Date: [2153-8-22] Date of Birth: [2089-9-10] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: fevers Major Surgical or Invasive Procedure: Intubation Resuscitation for cardiac asystole History of Present Illness: 63 year-old Chinese-speaking man with a history of rheumatic heart disease status post prosthetic MVR & [First Name3 (LF) 1291], afib/flutter s/p MAZE on coumadin, who presents with fevers x 2days. Interpretation provided by family member. Mr. [Known lastname ] had been in his USOH until two days prior to admission, when he devloped chills & subjective fevers. These persisted and his wife noted some confusion on the day of presentation, noting that he would not answer her questions appropriately. He was brought to the ED for further evaluation. . In the ED, vitals were rectal Temp 105, BP 99/58, then dropped in to 80s systolic, HR 90s O2sat 93%RA. Bld cx were sent. UA showed possible UTI ([5-29] WBC & Mod bacteria). Crt was elevated at 1.4. K was 2.9. CXR showed no infiltrates. He received 4L IVF, vanc & zosyn as well as tylenol and potassium. He is being admitted . ROS: Positive for for fevers, chills. Pt reports feeling generally weak. He denies cough, SOB, CP, although he does have chronic R shoulder/upper back pain. No abdominal pain, nausea, vomiting, diarrhea, melena, hematochezia, hematemesis, dysuria. No HA/dizziness/paresthesias or weakness. Past Medical History: -Rheumatic heart diseaseStatus post [First Name8 (NamePattern2) 1495] [First Name5 (NamePattern1) 923] [Last Name (NamePattern1) 1291] & MVR, and MAZE [2150-3-12], on Coumadin -Atrial fibrillation (previously on amiodarone [2149]-[2150]) -Pericardial effusion, status post pericardial window. -Peri-op pleural effusion. -[2150-3-10] Cath: LMCA, LAD, RCX, and RCA showed mild irregularities w/o flow limiting stenoses. 2+ MR. 2+ AR. Mild global hypokinesis. EF 43% Social History: immigrated to the US in [2147]; family live in area Family History: NC Physical Exam: VS: T 100.5, 88, 82/51 RR 19, 96% RA GEN: slightly tired appearing, NAD HEENT: NCAT, EOMI, PERRL, oropharynx clear and without erythema or exudate or hemorrhagic lesions NECK: Supple, no LAD, no appreciable JVD CV: RRR, metallic S1S2, [1-24] syst murm at LUSB and apex-->axilla, no rubs or gallops PULM: CTAB, though slightly decreased at b/l bases, good air movement bilaterally ABD: Soft, NTND, normoactive bowel sounds, no organomegaly, no abdominal bruit appreciated EXT: Warm and well perfused, full and symmetric distal pulses, no pedal edema Skin: Osler's Node on L big toe; ? few petechiae on RLE & L foremarm NEURO: alert and orient to self, [Hospital1 ], [2153-8-20], says he's here b/c he's sick, CN 2-12 intact; moving all limbs; sensation grossly intact to light touch Pertinent Results: CT head [2153-8-21] Extensive bilateral subarachnoid hemorrhage without significant mass effect, edema, or shift of normally midline structures on the current study. There is also no definite evidence of intraventricular blood at this time. Brief Hospital Course: 63 year-old man w/ a history of rheumatic heart disease s/p St. [First Name5 (NamePattern1) 923] [Last Name (NamePattern1) 1291] & MVR in [2149] with MAZE for afib, who presented with fever (as high as 105 rectal) and found have staph bacteremia. Patient with sepsis with fever, elevated WBC (11.1), and hypotension. Treated for endocarditis as source of sepsis although TEE showed no vegetations with vanco, cefepime, and gentamycin. Physical examination revealed osler's node on L big toe. He has [1-24] syst murmur both at LUSB & apex-->axilla (?new). Pt also does not have e/o other infections. CXR overall clear. Urine only has [5-29] WBC so less likely that this is source. Lactate improving w/ IVF. Pt mentating clearly & making urine until [2153-8-21] when he had acute event at approximately 6:30pm when he became acutely unresponsive, had flaccid paralyis, was noted to have vomited and have been incontinent of stool, left blown pupil, b/l not constricting to light. Emergently intubated and head scanned, showed large subarachnoid hemorrhage. On arrival back to the floor was tachycardic. Rapidly became hypotensive became asystolic, coded, perfusing rhythm re-established. Heparin and INR reversed. Cardiac [Doctor First Name ] called, agreed with full reversal in this situation. Neurosurgery consulted. Recommended mannitol, no current indication for acute surgery. Pt maxed out on 5 pressors, received 13+ L IVF, given bicarb for profound acidemia, also given FFP, factors, vitamin K and protamine. Family meeting was held, family informed of gravity of pt's prognosis and expectation that he may not survive the night. Decision was made to continue aggressive care but to make pt DNR. PEEP increased as pt persistently difficult to oxygenate. On [2153-8-22], as patient did not regain any neurologic function and continued to be hypotensive despite maximal pressor support, and with O2 sat in 70s despite intubation, family meeting was called to discuss goals of care and patient was made comfort measures only. Pressure support was withdrawn, patient extubated, and he had a quick decline but was comfortable at time of death at 4:45pm [2153-8-22] with family at bedside. Medications on Admission: metoprolol 12.5 mg b.i.d., Coumadin 2-3.5mg daily MVI Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired ICD9 Codes: 5990, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8022 }	Medical Text: Admission Date: [2107-5-6] Discharge Date: [2107-5-19] Date of Birth: [2039-10-18] Sex: F Service: MEDICINE Allergies: Percocet / Darvocet-N 100 / Vicodin Attending:[First Name3 (LF) 2758] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: Endotracheal intubation Central venous line placement Open reduction of ankle dislocation Placement of multiplane external fixation system Closed reduction fibular fracture. History of Present Illness: 67F who was transferred from OSH with open right ankle fracture sustained at the OSH. She had been admitted after feeling short of breath just prior to a scheduled EGD. Blood glucose was found to be 34 after having been NPO for the procedure and she was admitted for workup during which PE was ruled out. Overnight she fell in the bathroom (at the OHS) and sustained an open ankle fracture. At time of admission she had a significant increase in oxygen requirement and blood glucose was noted to be high. The medicine service was consulted and she was taken emergently to the OR for washout of the open ankle fracture and placement of external fixator. Past Medical History: # DM # Htn # Cirrhosis with evidence of ascites and esophageal varices, recent GI bleed (hg [9-21]) # CHF # CAD # Anemia # Cirrosis (states never required paracentesis but is aware of ascites)- hx of alcohol abuse, pcp [Name Initial (PRE) 72520]'t think is still drinking # Bipolar # copd Social History: Denies tobacco or EtOH use. Living in [Hospital3 ] Family History: Non-contributory Physical Exam: ICU ADMISSION EXAM: Vitals: T: 100.2 BP: 120/47 P: 114 R: 25% O2: 96% on 50% FiO2 General: Lethargic but arousable to voice HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, 4/6 SEM, rubs, gallops Abdomen: soft, non-tender, + fluid wave, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley with clear urine Ext: external fixator in place on RLE, 2+ LE edema bilaterally . DISCHARGE PHYSICAL EXAM: Vitals: 99.2 97.8 118/58 (107-118)/(43-66) 88 88-96 22 95%3L I/O: 8H 80/300 24H 1240/1500, + 3BM's General: lying in bed, awake, appears comfortable, pleasant, smiling, making jokes HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, unable to appreciate JVP given body habitus Lungs: anterior lung fields clear, no use of access mm of breathing, laying flat CVS: Regular rate and rhythm, normal S1 S2, 3/6 systolic murmur best heard at RUSB without apparent radiation to carotids, no rubs, gallops Abdomen: Obese, +BS, distended, non-tender, soft, non-tender, + fluid wave, no rebound tenderness or guarding Ext: external fixator in place on RLE, 2+ pitting edema to knee b/l Neuro: A&Ox3, no gross deficits Pertinent Results: ADMISSION LABS: [2107-5-6] 01:46PM BLOOD WBC-6.4 RBC-3.02* Hgb-8.9* Hct-28.2* MCV-94 MCH-29.4 MCHC-31.4 RDW-18.2* Plt Ct-139* [2107-5-6] 01:46PM BLOOD PT-15.4* PTT-24.4 INR(PT)-1.3* [2107-5-6] 01:46PM BLOOD Glucose-209* UreaN-16 Creat-0.4 Na-140 K-3.5 Cl-99 HCO3-36* AnGap-9 [2107-5-6] 01:46PM BLOOD CK(CPK)-55 [2107-5-6] 01:46PM BLOOD CK-MB-3 cTropnT-<0.01 [2107-5-6] 01:46PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.9 [2107-5-6] 05:00PM BLOOD Lactate-1.3 . OTHER LABS: [2107-5-6] 05:00PM BLOOD Type-ART pO2-64* pCO2-68* pH-7.38 calTCO2-42* Base XS-11 Intubat-NOT INTUBA [2107-5-6] 07:52PM BLOOD Type-ART Rates-0/16 FiO2-70 O2 Flow-4 pO2-97 pCO2-94* pH-7.26* calTCO2-44* Base XS-11 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2107-5-7] 04:44AM BLOOD Albumin-3.2* Calcium-8.1* Phos-4.5 Mg-1.7 [2107-5-7] 04:44AM BLOOD ALT-24 AST-31 CK(CPK)-41 AlkPhos-60 TotBili-0.8 [2107-5-6] 01:46PM BLOOD WBC-6.4 RBC-3.02* Hgb-8.9* Hct-28.2* MCV-94 MCH-29.4 MCHC-31.4 RDW-18.2* Plt Ct-139* [2107-5-7] 04:44AM BLOOD Neuts-71.7* Lymphs-17.4* Monos-8.3 Eos-2.2 Baso-0.4 . MICROBIOLOGY: [2107-5-8] Blood Cx, x 2: NO GROWTH [2107-5-8] Urine Cx: NO GROWTH [2107-5-8] Peritoneal Fluid Cx: NO GROWTH [2107-5-9] Sputum: MRSA [2107-5-10] blood Cx: pending [2107-5-10]: UCx: NO GROWTH [2107-5-10] sputum Cx: MRSA [2107-5-11] c. diff: NEGATIVE [2107-5-12] catheter tip: No significant growth. [2107-5-14] c. diff: NEGATIVE . IMAGING: [2107-5-6] Right Ankle Fluro: Multiple fluoroscopic images of the right foot and ankle from the operating room demonstrates interval placement of external fixation pins within the tibia and calcaneus. Please refer to the operative note for additional details. The total intraservice fluoroscopic time was 8.5 seconds. . [2107-5-6] CXR: No previous images. The low lung volumes may account for some of the prominence of the transverse diameter of the heart. Mild indistinctness of pulmonary vessels could also relate to low lung volumes, though some overhydration cannot be excluded. . [2107-5-7] Echo: There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Grossly preserved biventricular systolic function. Thickened aortic valve leaflets, likely without severe stenosis. Very technically-limited study. . [2107-5-7] CXR: Frontal view of the chest is compared to prior study of the day before. Mild cardiomegaly, vascular congestion, low lung volumes, relatively unchanged from prior study. . [2107-5-8] KUB: Two views of the abdomen, limited in technique although best possible film given the patient did not cooperate with the examination. There continues to be markedly distended small bowel loops with some air in the colon. Could represent ileus or developing obstruction. CT may be helpful for further evaluation. . [2107-5-8] CT Abdomen/Pelvis: 1. Cirrhotic liver and moderate amount of ascites. 2. No evidence of intestinal obstruction. 3. Bilateral pulmonary consolidation at the bases. 4. Mild gallbladder distension - if concern for cholecystitis, suggest ultrasound to further assess. [2107-5-11] KUB: Multiple dilated loops of bowel compatible with ileus or early bowel obstruction. [2107-5-11] CT ABDOMEN: 1. No bowel obstruction. Mildly distended loops of large and small bowel is likely due to ileus. 2. Nodular liver contour in keeping with cirrhosis. Moderate amount of ascites. Splenomegaly. Anasarca. 3. Bibasilar opacities at the lung bases improved compared to prior, likely atelectasis. Small left pleural effusion. [2107-5-11] ABDOMINAL ULTRASOUND: Greatly limited study. Ascites in all four quadrants but predominantly within the left upper and left lower quadrants. Gallbladder is distended. . R ankle X-ray [2107-5-17]: RIGHT ANKLE, THREE VIEWS. External fixation hardware is in place. There is an oblique fracture of the distal fibular metadiaphysis extending into the mortise joint. Due to limitations of positioning, the views are atypical. However, the mortise joint appears congruent with the joint space preserved. No talar dome OCD. No medial malleolar fracture is detected. There is surrounding soft tissue swelling. IMPRESSION: Nondisplaced distal fibular fracture. Mortise and tibiofibular joint remain congruent. Brief Hospital Course: HOSPITAL COURSE: 67 yo F with a past history of DM, Asthma, CHF, CAD, and cirrhosis, transferred from an OSH for repair of an ankle fracture, now s/p washout and external fixator placement, who was subsequently admitted to the ICU for hypercarbic respiratory failure after her sugery. In the MICU, she spiked fevers, and paracentesis was done which was negative for SBP, with SAAG 2 suggestive of portal HTN. Pt continued to spike, and UCx, BCx sent, and pt briefly hypotensive (no requirement of pressors). CT abdomen done which showed moderate ascites but no ileus, obstruction, abscess, or other concerning findings. However, CT suggested basilar infiltrates. Sputum cultures were sent, and concern for HCAP, was initially treated with Vanc/Levaquin/Cefepime. She was diuresed. CXR repeated showed worsening LLL PNA. Sputum Cx were speciated to MRSA, and she was continued on Vancomycin, while Levaquin and Cefepime dc'd. TTE was done which was technically limited but demonstrated preserved EF and no vegetations. Pt continued to have abdominal pain, and repeat CT abdomen on [5-11] demonstrated no evidence of obstruction, and moderate ascites. RUQ U/S showed ascites, distended gallbladder. She was extubated on [5-12]. She was transferred to the medical floors for further management on [2107-5-13]. . Her hospital course on the medical floors was complicated by somnolence, attributed to restarting night-time dose of Seroquel for Bipolar disorder. Psychiatry was consulted and recommended continuing Depakote, and holding Seroquel and Neurontin. She was diuresed with lasix and started on Spironolactone for her cirrhosis and volume overload. Pt symptomatically improved. On discharge she required 3LNC of oxygen. . ACTIVE ISSUES: # Hypercarbic respiratory failure: Multifactorial in origin likely secondary to baseline COPD, on top of post-op atelectasis, volume overload, and restrictive defect. Given elevated bicarbonate, patient likely has a component of chronic respiratory acidosis, with acute respiratory acidosis post-extubation. Additionally, narcotic/benzos medicines intraoperatively may have contributed to decreased respiratory drive. In addition, given obesity and ascites, patient is at high risk of obesity hypoventilation syndrome and restrictive defect. CTA was negative for PE at OSH. No evidence of COPD exacerbation on exam. Echo showed mild LVH but normal EF of 55%. Her mental status finally improved and she was successfully extubated on [5-12] with excellent breathing mechanics. On transfer to the medicine floors she required ~3LNC. She was placed on home lasix dosing of 80mg daily, and started on Spironolactone. Pt was discharged on Oxygen via nasal cannula 2-3L, titrate to O2 sat 92-94%. . # Toxic metabolic encephalopathy: Again multifactorial likely [3-16] hypercarbia initially, sedating pain meds slow to clear given cirrhosis, pain and infection. Patient was poorly responsive post-operatively, felt to be due to a combination of possible hepatic encephalopathy (given positive response to lactulose) versus decreased clearance of narcotics and benzos post-op in setting of advanced liver disease. [Doctor Last Name ] mental status improved, and she was oriented at time of discharge to the medical floors. On transfer to the medicine floors, she initially did well and remained oriented. Her home medications of Seroquel had initially been held given sedation and unable to take po's. This was restarted at lowered dose on the medicine floors. However, she became altered the following morning, and this medication was discontinued. Psychiatry was consulted and recommended continuing Depakote and holding Seroquel and Neurontin. She improved and remained alert & oriented x3 for the 3 days prior to discharge. She did not appear to have hepatic encephalopathy, and lactulose was not continued. . # Ventilator-associated MRSA pneumonia: She had bibasilar consolidations noted on CT abdomen on [5-8], and was covered with vanco/cefepime initially, though she continued to spike fevers to 102 with tachycardia to 110s. Added levaquin [5-10] for added GNR coverage. Sputum cultures grew MRSA from [5-9] and [5-10]. She defervesced [2107-5-13], and she was continued on Vancomycin with Levaquin and Cefepime discontinued. She continued on Vancomycin, and completed an 8 day course on [2107-5-16]. . # Right ankle fracture s/p ORIF: Secondary to mechanical fall at OSH. Her leg was maintained in a brace and ortho followed patient. Pain was controlled with tylenol. She was placed on Lovenox 40mg SC q12h for prophylaxis (weight-based dose). Sutures to be removed POD#21, [2107-5-27]. . # Abdominal Distention: On POD #2 the patient was noted to have decreased stool output and progressively distended abdomen. CT abdomen was negative for ileus or obstruction, though did demonstrate a moderate amount of ascites. Paracentesis was negative for SBP. Her distention worsened over the subsequent 3 days, with elevated bladder pressures to 28 noted on [5-11]. KUB showed concerning bowel dilation, however the CT abdomen showed no evidence of SBO. She likely had a post-operative/narcotic induced ileus. She was made NPO, NGT to suction, discontinued lactulose, and her distention slowly improved by [2107-5-13]. She tolerated a clear diet, and the NGT was discontinued. She was advanced to a regular diet which she tolerated well. She had no pain for several days prior to discharge, and some of prior discomfort attributed to gas from lactulose, as symptoms improved after Lactulose discontinued. . # Cirrhosis: Patient with history of ETOH abuse. Given underlying metabolic syndrome, she is also at high risk for NASH. CT abdomen showing signs of cirrhosis including ascites. There was suggestion pt had a history of esophageal varices, though no formal documentaiton, and pt guaiac negative during this admission. Spironolactone was started for ascites at lowered dose of 50mg daily given low blood pressure, and uptitrated to 150mg daily. She was also discharged on a low sodium diet. . # Acute on chronic diastolic heart failure: Home regimen per report includes lasix, losartan, atenolol. Difficult to determine fluid status given body habitus. CXR does not show much pulmonary edema, though not great film. TTE [5-7] demonstrated preserved EF, with mildly thickened aortic valves, though limited study. Pt symptomatically improved after restarting home lasix. Pt was switched from atenolol to metoprolol tartrate for improved titration, and discharged on Toprol XL 25mg daily. Weight on discharge 325lbs. When she follows up with her PCP, [Name10 (NameIs) ] she does have esophageal varices, her beta-blocker should be switched to a non-selective beta blocker. . # Bipolar disorder: medication changes as above. Pt will follow-up with outpatient Psychiatrist Dr. [Last Name (STitle) 10269] on discharge. . # T2DM: Relatively [Name2 (NI) 26970] with alternatively high and low sugars at OSH. A1c less than 6 at OSH. She was started on decreased amount of insulin on the MICU as she was NPO. As her diet was advanced, her ISS was adjusted. Her med rec showed pt was on Januvia, Actos, in addition to ISS. These were held, and pt placed on insulin and sliding scale. . # Hyperlipidemia: Continued statin. . TRANSITIONAL CARE: 1. CODE: FULL 2. FOLLOW-UP: - PCP (needs an appt after she leaves rehab) - Orthopedics - Psychiatry 3. MEDICAL MANAGEMENT: - STOP Actos, Januvia, Metformin, Klor-con, Tussin, Seroquel, Gabapentin, Losartan - START Spironolactone 150mg daily, Lovenox 40 SC q12h, Toprol XL 25mg daily Pt instructed to follow-up with PCP to discuss beta blockade and consideration of starting Propranolol or Nadolol if pt does in fact have esophageal varices, for prophylactic purposes. - Instructions on low sodium diet, strict I&O's, daily weights Medications on Admission: Medications: rec'd with [Location (un) ] [Doctor Last Name ] [2107-5-14] -fluticasone 50mcg nasal spray 2 sprays each nostril daily -lidoderm patch 5% apply 2 patches to L knee -lactulose 15 mL twice daily as needed for constipation -spiriva 18mcg cap daily -lantus 60 units qam, 10 untis qpm -Advair 250/50 1 puff [Hospital1 ] -Humalog 5units sc tid with meals -Ipratropium/albuterol 2.5-0.5 1 vial in neb q6hrs prn SOB -citrate of magnesium drink [2-13] bottle daily on M,W,F as needed for no BM x3 days -proair HFA 90mcg inhale 2puffs every 4-6hrs as needed for SOB -Tussin DM 1 tsp every 4hrs as needed for cough -furosemide 80mg daily -seroquel 300mg 1 tab by mouth qhs -atenolol 25mg [2-13] tab qam -multivit po daily -januvia 100mg daily -singulair 5 daily chew tab qhs -seroquel 200 mg qam, 200mg qpm, and 300 mg qhs -senna 3 tabs qhs -divalproex ER 250 po am (500 po hs - NOT ON MED REC) -vit c 250 [Hospital1 ] -tylenol X-tra strength 500mg cap 2 tabs po tid -omeprazole 20mg 2 caps [Hospital1 ] -carafate 1 gm qid (before meals and at bedtime) -Klor-Con 20meq tab 2 tabs by mouth daily -iron sulfate 325 [Hospital1 ] -metformin 1 g [Hospital1 ] -gabapentin 600 mg TID -Simvastatin 40 mg daily -losartan 50 mg daily -Actos 15 mg po qam -calcium vit D 600 tid Discharge Medications: 1. montelukast 5 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 2. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 *] (2 times a day). 6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO once a day. 8. Vitamin C 250 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO three times a day. 10. Carafate 1 gram Tablet Sig: One (1) Tablet PO four times a day. 11. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) patch Topical once a day: apply to left knee. 12. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO twice a day as needed for constipation. 13. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous Q12H (every 12 hours). Disp:2400 mg* Refills:2 14. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: Eighteen (18) mcg Inhalation once a day. 15. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) vial Inhalation every six (6) hours as needed for shortness of breath or wheezing. 16. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 17. senna 8.6 mg Tablet Sig: Three (3) Tablet PO at bedtime as needed for constipation. 18. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:60 Capsule, Delayed Release(E.C.)(s) Refills:2 19. Lantus 100 unit/mL Cartridge Sig: As directed units Subcutaneous twice a day: Take 60 units in the morning, and 10 units in the evening. 20. insulin lispro 100 unit/mL Insulin Pen Sig: As directed units Subcutaneous QACHS: As directed. 21. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s) Refills:2 22. divalproex 250 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO QHS (once a day (at bedtime)). 23. divalproex 250 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO QAM (once a day (in the morning)). 24. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain: do not exceed >2g/24h. 25. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:45 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 2857] - Twin Oaks - [Location (un) 4047] Discharge Diagnosis: Primary Diagnoses: 1. Hypercarbic respiratory failure 2. Toxic metabolic encephalopathy 3. Abdominal distension 4. Ventilator-associated MRSA pneumonia 5. Right ankle fracture, surgery Secondary Diagnoses: 1. Cirrhosis 2. COPD 3. Bipolar disorder 4. Acute on chronic diastolic congestive heart failure 5. Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname 89572], It was a pleasure taking care of you during this admission. You were admitted for surgery of your right ankle. The surgery went well, but you had difficulties being extubated after surgery. You were monitored closely in the ICU. You also had some abdominal pain, and several CT scans, which showed fluid in the abdomen, but no other new findings. This pain resolved. You were confused during this admission, and several of your medications were changed (please see below). Your breathing became better and your abdominal pain resolved. You were also seen by Psychiatry, and we have made several changes to your medications as listed below. You were also retaining urine and required a foley catheter. The rehabilitation center will try to take this out after a couple of days once you've been moving around more. The following medications were changed during this admission: -STOP Tussin -STOP Klor-Con tablets This medication increases your potassium. However, we started you on a new medication that can increase your potassium (Spironolactone), so you do not need this medication currently. -STOP Actos -STOP Januvia -STOP Metformin (This medication may be safe to restart in the future, but since you had abdominal pain and loose stools here, do not take this medication for the time being) -STOP Atenolol -STOP Neurontin -STOP Seroquel Both Neurontin and Seroquel were stopped during this admission as your were sleepy on confused when taking Seroquel. For now, please do not resume these medications. Please discuss with your outpatient psychiatrist when/if these may be restarted. -STOP Citrate of Magnesium as needed for constipation -STOP Losartan -START Metoprolol XL 25mg by mouth daily -START Spironolactone 150mg by mouth daily -START Enoxaparin injections 40mg SC every 12 hours Continue to take these injections until speaking with your orthopedic doctors. This needs to be continued for at least one month. -We changed the prescription of Omeprazole from 20mg, 2 tablets, twice daily to 40mg tablet, 1 tablet, twice daily (to decrease the number of pills you need to take). -You can continue to take Tylenol as needed for pain. However, you should limit the amount of Tylenol that you take in order to protect your liver. You should not take more than 2 grams of Tylenol in a 24 hour period. -We have adjusted your insulin regimen. Continue to take Lantus 60units in the morning and 10 units in the evening. We have provided and insulin sliding scale to cover your meal-time insulin. At breakfast, lunch, dinner and before bedtime follow the following schedule: Insulin Dose Blood sugar <100 0 101-150 2 151-200 4 [Telephone/Fax (2) 89573]-300 8 [Telephone/Fax (2) 89574]1-400 12 Please continue all other medications you were taking prior to this admission. Please have your labs checked in 2 days to assess for electrolytes. We changed a couple of your medications, and we want to ensure that your potassium does not get too low or too high. You also required a foley catheter on discharge. This may be attempted to be removed in the next few days. You were also started on a new beta blocker (called Metoprolol XL as above). This medication is similar to other medications that are used for patients with cirrhosis who have esophageal varices. Ideally, other medications in the same class (called Nadolol, Propranolol) are used for this reason. Please discuss this with your doctor. Followup Instructions: Please follow-up with the following appointments: We were unable to make an appointment with your primary care doctor as you were going to rehabilitation. Please call your doctor's office, Dr. [Last Name (STitle) ], at [Telephone/Fax (1) 89575] once you leave rehabilitation for further follow-up of your multiple medical problems. With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10269] Location: Center for Healthy Aging Address: [Location (un) 89576], [Numeric Identifier 76223] Phone: [Telephone/Fax (1) 89577] Appointment: Tuesday [2107-5-31] 3:00pm Department: ORTHOPEDICS When: TUESDAY [2107-6-21] at 8:40 AM With: ORTHO XRAY (SCC 2) [Telephone/Fax (1) 1228] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: TUESDAY [2107-6-21] at 9:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2107-5-19**] ICD9 Codes: 5180, 4019, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8023 }	Medical Text: Admission Date: [2147-2-22] Discharge Date: [2147-2-26] Date of Birth: [2108-7-29] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old diabetes since [2145-8-20] and recurrent admissions for diabetic ketoacidosis who is now presenting in diabetic ketoacidosis. She stated that she was in her usual state of health until yesterday afternoon when she began complaining of fatigue, malaise, and nausea. Her family noticed that she had altered mental status and eventually she was brought to the emergency department. She was found to appear markedly 6.97/12/185. She was given aggressive fluid repletion, started on an insulin drip, and transferred to the medical intensive care unit. It is unclear what precipitated this current episode; although, apparently, her blood sugars are in excess of 300 to 400 at baseline. She denies fever, rigors, cough, shortness of breath, chest pain, abdominal pain or dysuria. PAST MEDICAL HISTORY: 1. Diabetes as above. 2. Diabetic ketoacidosis with admission in [2146-3-21] and [2146-9-21]. 3. Hypertension. 4. Gastroesophageal reflux disease. 5. Status post motor vehicle accident in [2145-6-20]. MEDICATIONS ON ADMISSION: The patient does not remember her medicines clearly but states that she thinks she takes insulin 70/30 70 units q.a.m. and 50 units q.p.m. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Temperature was 97.2, heart rate 140 to 150, blood pressure 130/75, respiratory rate 33 to 40, oxygen saturation 96% on 6 liters nasal cannula. In general, the patient was lethargic but awake and oriented, lying in bed. She was experiencing Kussmaul's breathing. HEENT revealed parched oropharynx, otherwise clear. Tympanic membranes were clear. There was no sinus tenderness. Neck was supple with no lymphadenopathy, and meningismus. Lungs were clear to auscultation bilaterally. Coronary examination revealed regular, tachycardic, with no murmurs, rubs or gallops. Abdomen was soft with normal bowel sounds, vague discomfort to palpation in the lower quadrants bilaterally, but no rebound or guarding. Extremities revealed the patient with myalgias, but no evidence of cellulitis or skin infection. No peripheral edema and strong distal pulses. LABORATORY VALUES ON ADMISSION: White blood cell count 34,600, hematocrit 33.4, platelets 293. INR was 1.6, and PTT 20.9. Sodium was 137, potassium 5.3, chloride 103, bicarbonate less than 5, BUN of 24, creatinine 1.4, and glucose of 689. Free calcium was 1.32. Lactate was 1.7. Phosphate was 6.1, magnesium 2.5, and there were large serum acetones. Urine was negative for urinary chorionic gonadotropin and had greater than 1000 glucose and greater than 80 ketones, negative nitrites, 2 red blood cells, 1 white blood cell, and no bacteria. As mentioned, initial arterial blood gas was 6.97/12/185. Electrocardiogram revealed normal sinus rhythm at 150 with a normal axis, and no ischemic changes. Chest x-ray revealed no infiltrates or effusions. HOSPITAL COURSE: The patient was admitted and treated for diabetic ketoacidosis. She was begun on an insulin drip and eventually weaned to subcutaneous insulin. She received aggressive IV fluid and electrolyte repletion. No precipitating event was elucidated for her diabetic ketoacidosis. A repeat chest x-ray revealed a small right pleural effusion of unclear etiology. She was discharged to home in good condition. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. Anemia. DISCHARGE STATUS: To home. CONDITION AT DISCHARGE: Stable. MEDICATIONS ON DISCHARGE: 1. Insulin 70/30 35 units subcutaneous q.a.m. and q.p.m. before dinner. 2. Humalog insulin to be used for emergency only. 3. Glucagon Kit to be used for emergency only. DISCHARGE INSTRUCTIONS: The patient was to follow up with Dr. [Last Name (STitle) ] at [Last Name (un) ] for a follow-up appointment on [3-10]. The patient was instructed to check her fingerstick blood glucose before meals and before bedtime. She was instructed in diabetic teaching and was instructed in the use of the Humalog insulin and Glucagon Kit for emergency use only. She was instructed to return to the emergency department for any further evidence of episodes of diabetic ketoacidosis. [First Name8 (NamePattern2) 275] [Last Name (NamePattern1) ], M.D. [MD Number(1) 17046] Dictated By:[Last Name (NamePattern1) 111057] MEDQUIST36 D: [2147-3-3] 15:41 T: [2147-3-5] 06:03 JOB#: [Job Number 111058] ICD9 Codes: 2765, 5119, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8024 }	Medical Text: Admission Date: [2145-8-25] Discharge Date: [2145-8-30] Date of Birth: [2087-4-11] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2704] Chief Complaint: CHIEF COMPLAINT: shortness of breath Major Surgical or Invasive Procedure: pericardiocentesis History of Present Illness: EVENTS / HISTORY OF PRESENTING ILLNESS: 58 year old male with metastatic renal ca to lung and bone (last chemo [2145-8-10]), who presented to [Hospital ] clinic on day of admission with 2 days of shortness of breath with occasional mild confusion, found to be hypoxic to high 80's on room air. Wife states that for the past few weeks, he has had dyspnea on exertion, it had been attributed to anemia and he received pRBC trasnfusions, however, shortness of breath became more pronounced over the past 2 days. In clinic, he was placed on 4L nasal canula and O2 sat increased to 93% with resp rate of 40. He denied any chest pain or abdominal pain. He complained of slight cough. Per wife, he had fever to 101F at home the night prior to admission but afebrile in clinic. . ED: He was intubated and sedated with fentanyl/versed. Given sodium bicarb, calcium chloride, insulin with D50 for K 6.8. EKG showed low voltage and bedside Echo with pericardial effusion and tamponade physiology. CXR with pulm edema, bilateral pleural effusions. He was given levofloxacin 750mg iv x 1 for possible pneumonia. Cardiology was consulted and he was taken urgently to cath lab where 1260cc straw colored fluid drained from pericardium. . Review of systems limited by patient intubation/sedation. Per records and discussion with family, there is no prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, hemoptysis, black stools or red stools. All of the other review of systems were negative. . * Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. (+) shortness of breath/DOE . Past Medical History: PAST MEDICAL HISTORY: CAD s/p MI [2136], s/p stent atrial fibrillation HTN hypercholesterolemia gout anxiety right wrist fusion [2133] GERD bilateral hearing loss . Onc Hx: Metastatic Renal Cell 1. Nephrectomy for clear cell carcinoma in 09/[2140]. 2. Resection of a right seventh rib metastasis, which revealed metastatic high-grade renal cell carcinoma. 3. High-dose IL-2 therapy, which was complicated by the development of accelerated angina. He is now status post cardiac catheterization with coronary artery stent placement. 4. CyberKnife therapy to a medial paramediastinal lung lesion. 5. Sutent as a single [Doctor Last Name 360] begun in 09/[2144]. This was complicated by severe GI side effects and dehydration. The dose was reduced and despite this reduction, he was admitted in [Month (only) 956] to a local hospital with rapid atrial fibrillation and associated syncope which resulted in an accident while driving. He sustained several rib fractures as a result. 6. Currently, cycle 8 of Sutent 2 weeks on/ 1 week off, plus Gemzar begun because of disease progression. . Social History: Social History: Married, grown children, lives with wife, 2 dogs, 1 cat, on disability from running shelter for homeless veterans in [Hospital1 392]. Family History: . Family History: Mother, 89 h/o ovarian ca, Aunt w/ ovarian CA, father deceased 83 w/ CAD . Physical Exam: PHYSICAL EXAMINATION: VS: T 96.9F HR 83 BP 122/79 RR 16 100% on AC 600x14/100%/5PEEP ABG on AC settings: 7.31/44/130 Gen: intubated, lightly sedated HEENT: intubated, NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: difficult to assess JVP CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: crackles at left base anteriorly, no wheeze. Pericardial drain with small amount of straw colored fluid Abd: soft, ND/NT, No abdominal bruits. Ext: warm, trace ankle edema bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: 2+ DP Left: 2+ DP Pertinent Results: Admission Labs: ([8-25]) LABORATORY DATA: 130.\|.100.\|.18 121 --------------- 6.5.\|.22.\|.1.7 Ca: 8.7 Mg: 2.2 P: 4.6 D . [8-25] 3:05 p.m. CK: 119 MB: 4 Trop-T: 0.02 . WBC 9.4 Hct 29.4 Plt 250 MCV 103 N:86.1 L:6.7 M:6.9 E:0.2 Bas:0.2 . PT: 16.5 PTT: 27.2 INR: 1.5 . Studies: EKG: NSR HR 79, Nl axis and slight pr prolongation 208msec. low voltage (although unchanged from [8-13] is lower voltage than [2143]) . CXR: Limited study with marked cardiomegaly, pulmonary edema, and bilateral pleural effusions, new since the [8-13] examination. A focal consolidation, particularly on the left, cannot be excluded. . ECHO ([8-25]): Large pericardial effusion. RV diastolic collapse, c/w impaired fillling/tamponade physiology. Significant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling. Overall left ventricular systolic function is low normal (LVEF 50-55%). RV systolic function appears depressed. . Cardiac Cath/ Pericardiocentesis ([8-25]): 1. Pericardiocentesis revealed initial elevated pericardial pressure of 35mmHg subsequently decreasing to 13mmHg after drainage of 1.4 liters of serosanguinous pericardial fluid. . ECHO ([8-26] - s/p pericardiocentesis) LV wall thicknesses and cavity size are normal. Mild regional left ventricular systolic dysfunction with inferior/inferolateral thinning and hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45%). There is no pericardial effusion. . ECHO ([8-28]): Mild regional LV systolic dysfunction with inferolateral akinesis and inferior hypokinesis. Overall LV systolic function is mildly depressed (LVEF= 40-45 %). RV size normal. Small to moderate sized pericardial effusion. There is significant, accentuated respiratory variation in mitral valve inflows, consistent with impaired ventricular filling. Not right ventricular/right atrial collapse identified. Compared with the prior study (images reviewed) of [2145-8-27], left ventricular wall motion abnormlaity appears similar. Respiratory variation in mitral inflow is unchanged. The pericaridal effusion is now slightly larger. . ECHO ([8-30]): [Name Prefix (Prefixes) ] [Last Name (Prefixes) 3841] dilated. RA pressure is 5-10 mmHg. LV wall thicknesses and cavity size are normal. Mild regional LV systolic dysfunction with focal akinesis of the basal half of the inferolateral wall and hypokinesis of the inferior wall. RV size and free wall motion are nl. No valvular disease. Mild pulmonary artery systolic hypertension. There is a small to moderate sized circumferential pericardial effusion most prominent around the right atrium. Brief right atrial diastolic collapse but normal transmitral Doppler spectra. Compared with the prior study (images reviewed) of [2142-8-29], the size of the effusion is slightly greater around the right atrium, but transmitral Doppler no longer suggests impaired filling. Left ventricular systolic function is similar. Brief Hospital Course: In summary, Mr. [Known lastname 37025] is a 58 year old male with renal cell ca with metastases to the lung, bone, liver and right adrenal who presented with 2 days of increasing shortness of breath. In the ER, he was hypoxic and found to have pericardial tamponade. He got a pericardiocentesis on [8-25] with drainage of 1.2 L. . Tamponade. Patient was known to have a pericardial effusion by CT on [2145-8-9] (2 weeks prior to admission. Echo showed intermittent RV collapse suggestive of tamponade and a significant pericardial effusion. On [8-25], Cardiology drained 1300cc of straw colored fluid, which was sent for cytology. A repeat echo the morning after pericentesis showed resolution of the effusion. Drain output decreased and so the pericardial drain was removed on [2145-8-26]. Serial echocardiograms showed a gradual reaccumulation of pericardial fluid, but no acute signs of cardiac tamponade. Consequently, a pericardial window procedure was not pursued at this time. On the day of discharge, he was asymptomatic, denied chest pain, shortness of breath, or lightheadedness and was displaying normal vital signs. He will go home with repeat echo on Thursday ([9-2]) with close follow-up with his outpatient cardiologist. . Mechanical ventilation. Patient was found to be tachypneic and hypoxic in the ED. He was intubated in the ED. His repiratory failure was thought to be due to pulmonary edema from tamponade in addition to a questionable pnuemonia. Patient had improvement of respiratory status after pericardiocentesis. Patient quickly weaned from vent and extubated within 18 hours. He was requiring oxygen by nasal canula during stay which was titrated down with diuresis. . Pulmonary edema. Patient has CXR consistent with pulmonary edema, likely secondary to decreased cardiac output from pericardial tamponade. Patient was given lasix with good response. . Questionable pneumonia. Patient had a fever to 101 on evening prior to admission and has possible infiltrate on CXR. He was started on levofloxacin on [2145-8-25]. On [8-28], he was febrile to 101, so antibiotics were broadened to aztreonam and flagyl, which was converted to levofloxacin and flagyl as an outpatient. . Atrial fibrillation. Patient went into Atrial fibrillation with RVR on [2145-8-26] with a stable blood pressure. This was intially treated with IV lopressor. He was subsequently started on aspirin and standing metoprolol. He was loaded with IV amiodarone for 24 hours and then started on PO amiodarone. He was started on a heparin drip on [8-29] because he reamined in atrial fibrillation for 48 hours. He converted to normal sinus rhythm on the morning of [8-29*] and remained in such until discharge. . Hyperkalemia. Patient was initially hyperkalemic secondary to ARF. This was treated with calcium gluconate, glucose and insulin, and kayexalate with resolution of hyperkalemia. . Acute Renal Failure. ARF is likely due to decreased cardiac output as a result of tamponade. Baseline creatinine is 1-1.2. Creatinine improved with drainage of pericardial fluid and gentle diuresis. . Metastatic Renal Cell CA. Patient has RCC with metastases to the lung, bone, right adrenal, and liver. Lung metastases were treated with cyberknife. He is currently on Gemzar and Sutent with reportedly good response according to his oncologist. . Anemia. Patient was anemic on admission, likely due to myelosuppressive therapy with gemzar. . Hypercholesterolemia. On Zetia for hypercholesterolemia. Medications on Admission: CURRENT MEDICATIONS: Loperamide 2 mg po qid prn diarrhea Pantoprazole 40 mg PO Q24H Lorazepam 1 mg PO Q8H prn anxiety Clonazepam 2mg PO QHS Quetiapine 400 mg po qhs Zolpidem 5 mg PO HS prn Ezetimibe 10 mg PO daily Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s)* Refills:0 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:15 Tablet(s) Refills:0 11. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablets Sustained Release 24 hrs PO once a day. Disp:45 tablets Refills:2 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: pericardial tamponade atrial fibrillation renal cell cancer pneumonia Discharge Condition: good Discharge Instructions: You were admitted to the hospital with a build up of fluid around your heart which was treated with pericardial drainage. You also had a heart arrhythmia called atrial fibrillation which we are treating with aspirin and a new medication called Amiodarone. . Please continue to take all medicines as prescribed. Your Imdur was held while you were in the hospital due to low blood pressure. Please speak to your cardiologist before restarting this medication. . We are also treating you for pneumonia. You were prescribed two antibiotics - levofloxacin and flagyl, and you will have 5 more days of each to complete the course. . If you have any chest pain, shortness of breath, heart palpitations or lightheadedness please seek immediate medical attention because this could be a sign of arrhythmia or of reaccumulation of fluid around your heart. . Please go to the echocariogram lab on [Hospital Ward Name ] 3 to obtain copies of your echocardiograms before you leave and bring them with you to your cardiology appointment. . You have an echocardiogram scheduled for Thursday ([9-2]) to look at the amount of fluid around your heart, your cardiologist will Dr. [Last Name (STitle) 45513] will follow-up the results with you. Please make sure to follow up with your oncologist and with your cardiologist; we have made appointments for you. Followup Instructions: Please follow-up with your primary care provider [Last Name (NamePattern4) ]. [First Name (STitle) ] within one week of discharge from the hospital - please speak with your PCP about restarting Synthroid and following up thyroid function tests. [2145-9-13] 1:00pm with your Cardiologist Dr. [Last Name (STitle) 45513] [Hospital3 3383] Hospital [Location (un) ]. [Location (un) 686], [Numeric Identifier 60377] Phone: [Telephone/Fax (1) 60378] [2146-9-3] 9:00am Echocardiagram at [Hospital3 3383] Hospital. Dr. [Last Name (STitle) 45513] [Location (un) ]. [Location (un) 686], [Numeric Identifier 60377] Phone: [Telephone/Fax (1) 60378] Other appointments: Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 3150] Phone:[Telephone/Fax (1) 22] Date/Time:[2145-9-8] 1:00 Provider: [First Name8 (NamePattern2) 2191] [Last Name (NamePattern1) ], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2145-9-8] 1:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9402], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2145-9-8] 1:00 ICD9 Codes: 5849, 4280, 486, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8025 }	Medical Text: Admission Date: [2120-1-10] Discharge Date: [2120-1-17] Service: MEDICINE Allergies: Tape II Disposable Liner Adhes / Ciprofloxacin / Glyburide Attending:[First Name3 (LF) 905] Chief Complaint: Mental Status Changes Major Surgical or Invasive Procedure: s/p thrombectomy of AV fistula Tunneled Catheter Placement History of Present Illness: Ms [Known lastname 92981] is a 81 yo female [Known lastname 595] speaking only with history of ESRD on hemodialysis, CHF, CAD / CABG, stroke (Broca's Aphasia) admitted s/p complicated thrombectomy of AV fistula on [1-11]. She was also recently hospitalized at [Hospital1 18] from [11-16] [11-21] for GI bleed and mental status changes but she refused further workup. She is known to have a large rectal mass which she also refuses any workup. During this admission, she was admitted for observation post procedure wheh she became unresponsive with complete right sided hemiparesis, and her blood glucose was found to 54. Given 1 amp of D50 with slow resolution of symptoms. She had a head CT that was unchanged from prior and was also seen by the Neuro team who thought this was secondary to hypoglycemia. She was admitted to the ICU for closer monitoring and started on a D50 drip. Her symptoms resolved, and her blood sugars had been running in the 150s. She is currently of her D50 drip, and her mental status is back to baseline. She also was transfused with 2u PRBC but of note, overnight, she pulled her temporary line. She had a R IJ permanent catheter placed in the OR on Monday [2120-1-15]. Also found to be C diff positive and currently on Flagyl Past Medical History: 1) CAD: s/p NSTEMI, CABG x 3v, [10/2115], course c/b by stroke with aphasia and right hemiparesis, with eventual regain of function. 2) ESRD: hemodialysis on T,Th,Sat, through left arm AV graft 3) h/o GI bleeding 4) Gout 5) Anemia 6) HTN 7) Hypercholesterolemia 8) DM2 9) Stoke in left posterior frontal area [10/2115] 10) CHF: EF 30-40% 11) Depression 12) Colon polyps 13) Hemorrhoids 14) Hyperhomocysteinemia Social History: [Month/Year (2) 595]-born. Moved to US in [2104]. Lives alone at [Hospital 7137]. No children. [Location (un) ] is the health care proxy; no history ETOH or tobacco. [Name (NI) ] (cousin) [Telephone/Fax (2) 92985]Lena ([Telephone/Fax (2) 802]) [Telephone/Fax (2) 92986]Val (son) [Telephone/Fax (1) 92987] Family History: Non-Contributory. Physical Exam: VS: T 98.4, P 72, BP 98/60, RR 12, O2 sat 97% on room air Gen: comfortable, lying in bed, NAD HEENT: PERRLA, EOMI Neck: supple, no JVD noted Lungs: CTA bilateral anteriorly Heart: irregularly irregular, no murmurs, rubs, gallops appreciated Abd: soft, non distended, non tender, no HSM Extrem: no edema, cyanosis, clubbing Pertinent Results: [2120-1-15] 03:46AM BLOOD WBC-19.0* RBC-4.01# Hgb-12.0# Hct-35.2# MCV-88 MCH-30.0 MCHC-34.2 RDW-16.3* Plt Ct-340 [2120-1-15] 03:46AM BLOOD Plt Ct-340 [2120-1-15] 03:46AM BLOOD Glucose-103 UreaN-55* Creat-7.4* Na-131* K-4.7 Cl-95* HCO3-22 AnGap-19 [2120-1-15] 03:46AM BLOOD Calcium-8.2* Phos-4.7* Mg-2.3 Iron-89 Brief Hospital Course: 81 yo [Month/Day/Year 595] speaking female who is being transferred from the ICU after presenting there with MS changes secondary to hypoglycemia in the setting of her glyburide. 1. MS changes - she experienced these changes most likely due re expression of prior stroke in the setting of hypoglycemia given Neuro exam unremarkable, and head CT was unchanged. She was seen by the Neurology team who thought this was from hypoglycemia, and once her sugars improved back to baseline, her MS improved back to baseline as well. 2. Hypoglycemia - likely secondary to glyburide in hemodiaylsis patient as glyburide is contraindicated for patients with a Creat clearance of less than 40. during her hospital course, her fingerstick remained in the low 100s and so we decided to hold off on all oral hypoglycemiscs and cover her with regular sliding scale insulin. Please see attached sheet in d/c paperwork for details of covering for insulin. 3. Anemia - she most likely has anemia secondary to anemia of chronic disease given renal failure. She was transfused with 2u PRBC and her HCT remained stable during the rest of the hospital course. 4. Renal - she has known ESRD and is currently on hemodialysis on Tu, [Last Name (un) ], Sat. Had tunneled catheter placed in the OR on [2120-1-15] and it was used for dialysis during her Tuesday session. 5. Cardiology - she has significant cardiac history but no active issues at this time. We decided to continue on all her outpatient regimen. Also has history of atrial fibrillation for which we are rate controlling and holding off of anticoagulation given history of GI bleed 6. ID - she had some leukocytosis and diarrhea and was found to be C Diff positive. She is being treated with Flagyl 500mg po bid for a total of 2 weeks from discharge. 7. Code - DNR/DNI Medications on Admission: Captopril 100mg po tid Protonix 40mg po daily Lopressor 25mg po tid Clonidine 0.1mg po bid Isosorbide 20mg po tid Aspirin 81mg po daily Colace 100mg po bid Nephrocaps Percocet prn Hydralazine 10mg po q6 Discharge Medications: 1. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for diarrhea. 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED): Please give insulin as per sliding scale attached with discharge paperwork. 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: 1. Hypoglycemia 2. End Stage Renal Disease 3. Coronary Artery Disease 4. Hypertension Discharge Condition: Stable Discharge Instructions: Please take all your medications as directed. Please follow up with your Primary Care Physician [Last Name (NamePattern4) ] [2-3] weeks. Please check fingersticks three times a day and cover with Regular Sliding Scale as shown in the discharge paperwork. Followup Instructions: Please take all your medications as directed. Please follow up with your Primary Care Physician [Last Name (NamePattern4) ] [2-3] weeks [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] ICD9 Codes: 4280, 2851, 5849, 2765, 2720, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8026 }	Medical Text: Admission Date: [2183-7-19] Discharge Date: [2183-8-7] Date of Birth: [2122-3-4] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1406] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: Transesophageal Echocardiogram Cardiac Catherization [2183-7-20] 1. Mitral valve replacement with a 31-mm St. [Male First Name (un) 923] Epic tissue valve, model number E-[Medical Record Number 59354]. 2. His aortic valve replacement with a 21 mm cup, [Last Name (un) 3843] [Doctor Last Name ] pericardial tissue valve, model number 3300 TFX. [2183-8-6] and [7-30] left thoracenteses History of Present Illness: This patient is a 61 year old female who is transferred from outside hospital for dyspnea with known [Doctor Last Name 27210] syndrome and known MR. History is very limited due to her acuity and is mostly from EMS and outside hospital. The patient presented with acute onset dyspnea, tachycardia, and was very tachypneic. Upon arrival to the [Hospital1 18] ER she was intubated and admitted tothe MICU. An ECHO was done this morning revealing 4+ Mitral regurg w/ flail leaflet. She is presently acidotic in cardiogenic shock, intubated, sedated on Levophed and Neo. Cardiac surgery was consulted for emergent MVR. Past Medical History: bicuspid aortic valve aortic stenosis mitral regurgitation s/p emergent aortic valve replacement and mitral valve replacement this admission PMH: diverticulitis, [Doctor Last Name 27210] syndrome, hypothyroid Past Surgical History: s/p sigmoid colectomy w/ [Doctor Last Name 3379] pouch [2178] at [Hospital1 18]. Cervical Laminectomy [2177] Social History: Lives with husband Family History: NOn-contributory. Physical Exam: Pulse:102 ST Resp: AC 100%, peep 20, VT 350 x rate 34 O2 sat: 94% B/P A-line 95/73 Height: Weight: General: Skin: Dry [x] intact [x] HEENT: Pupils pinpoint- sedated. S/P cervical laminectomy [2177]. native dentition without obvious deformity. Neck: Supple [] Full ROM [] Chest: Lungs crackles bilat Heart: tacycardic Murmur V/VI SEM Abdomen: Obese, hypoactive, Soft Extremities: Cool, 4+ pitting edema all extremities Neuro: intubated and sedated Pulses: Doppler pulses lower extremities. Unable to appreciate varicosities d/t edema radial A-line left Carotid Bruit : on vent Right: Left: Pertinent Results: [2183-8-7] INR 1.9 PT 20.5 Mg 2.2 creat 0.9 [2183-8-5] 04:30AM BLOOD WBC-18.4* RBC-3.13* Hgb-9.6* Hct-30.6* MCV-98 MCH-30.7 MCHC-31.4 RDW-20.8* Plt Ct-177 [2183-8-4] 03:04AM BLOOD WBC-24.7* RBC-3.21* Hgb-10.1* Hct-30.8* MCV-96 MCH-31.4 MCHC-32.8 RDW-21.0* Plt Ct-139* [2183-8-3] 01:52AM BLOOD WBC-27.5* RBC-3.24* Hgb-10.0* Hct-31.1* MCV-96 MCH-30.8 MCHC-32.0 RDW-20.2* Plt Ct-120* [2183-8-5] 04:30AM BLOOD PT-25.8* INR(PT)-2.5* [2183-8-4] 03:04AM BLOOD PT-26.1* PTT-30.2 INR(PT)-2.5* [2183-8-3] 01:52AM BLOOD PT-32.9* PTT-36.0* INR(PT)-3.3* [2183-8-2] 02:53AM BLOOD PT-33.3* PTT-33.6 INR(PT)-3.4* [2183-8-2] 02:53AM BLOOD PT-33.3* PTT-33.6 INR(PT)-3.4* [2183-8-1] 04:22AM BLOOD PT-22.7* PTT-57.5* INR(PT)-2.1* [2183-8-1] 12:18AM BLOOD PT-21.8* PTT-63.5* INR(PT)-2.0* [2183-8-5] 04:30AM BLOOD Glucose-182* UreaN-36* Creat-1.0 Na-133 K-4.2 Cl-94* HCO3-28 AnGap-15 [2183-8-4] 03:04AM BLOOD Glucose-138* UreaN-32* Creat-0.9 Na-137 K-4.8 Cl-100 HCO3-33* AnGap-9 [2183-8-3] 01:52AM BLOOD Glucose-158* UreaN-26* Creat-0.8 Na-139 K-4.0 Cl-102 HCO3-30 AnGap-11 [2183-7-19] preop echo Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). No aortic regurgitation is seen. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] The mitral valve leaflets are moderately thickened. There is mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. At least moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Small, hyperdynamic left ventricle. Dilated and hypokinetic right ventricle. Mitral valve prolapse with at least moderate mitral regurgitation. Moderate aortic stenosis. Compared with the report of the prior study (images unavailable for review) of [2178-2-16], severity of mitral regurgitation has probably worsened and right ventricle is now hypocontractile. This study might be significantly UNDERestimating the severity of eccentric mitral regurgitation and if there is clinical concern for acute severe mitral regurgitation, a transesophageal study is recommended. [2183-7-19] Chest CT 1. No evidence of pulmonary embolism or aortic dissection. 2. Cardiomegaly with marked left atrial enlargement. Bilateral diffuse ground glass opacity and interlobular and intralobular septal thickening suggests severe pulmonary edema. More consolidative areas within the lower lobes bilaterally may be due to pneumonia or atelectasis. 3. Small to moderate sized bilateral pleural effusions, left larger than right. [2183-7-19] cardiac cath FINAL DIAGNOSIS: 1. Anomolous coronary arteries with no hemodynamically significant 2. Severely elevated left- and right-sided filling pressures. 3. Successful placement of intra-aortic balloon pump. [2183-7-20] intra-op echo Prebypass No atrial septal defect is seen by 2D or color Doppler. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] with severe global RV free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. Significant aortic stenosis is present (not quantified). Unable to calculate gradients and [Location (un) 109] due to poor doppler alignment in the deep transgastric views. No aortic regurgitation is seen. The mitral valve leaflets are myxomatous. There is partial mitral leaflet flail. Torn mitral chordae are present. Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). Moderate [2+] tricuspid regurgitation is seen. Dr. [Last Name (STitle) ] was notified in person of the results on [2183-7-20] at 1500 hours. Post bypass Patient is in sinus rhythm and receiving an infusion of norepinephrine, epinephrine and milrinone. RV function is slightly improved. LVEF= 35%. The inferior and inferoseptal walls are hypokinetic. Bioprosthetic valve seen on the aortic position. Valve appears well seated and the leaflets move well. Trace central aortic insufficiency present. There is a strut seen in the LVOT. There is a bioprosthetic valve seen in the mitral position. This valve appears well seated and the leaflets move well. Aorta appears intact post decannulation. Intraaortic balloon pump tip seems to be in good position. Echo [2183-7-31] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. 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 ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The transmitral gradient is normal for this prosthesis. There is severe mitral annular calcification. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2183-7-19], the mitral and aortic prostheses are new and are with normal gradients Chest CT, abdomen, pelvis [2183-8-1] IMPRESSION: 1. No evidence of fluid collections or abscess. 2. New right pectoral hematoma. 3. Bilateral moderate-sized pleural effusions with adjacent compressive atelectasis. 4. Small pericardial effusion. 5. Small amount of ascites. Brief Hospital Course: 61 year old female with a history of [Doctor Last Name 27210] syndrome and aortic stenosis with bicuspid aortic valve who presents with respiratory failure and cardiogenic shock. Emergent Cardiac surgery evaluation was requested. Echo revealed severe MR and severe AS with a bicuspid aortic valve. Cath did not reveal any significant coronary disease. She was taken to the operating room on [2183-7-20] where she underwent aortic valve replacement with 21mm [Last Name (un) 3843] [Doctor Last Name ] tissue valve and Mitral Valve replacement with 31mm St. [Male First Name (un) 923] porcine tissue valve. Post-operatively was transferred to the CVICU for further invasive monitoring in critical condition. She left the OR with an intra-aortic balloon pump and on titrated levophed, milrinone and epinephrine. Post-operatively, she developed rapid atrial fibrillation with hemodynamic instability and was electrically cardioverted. She remained in atrial fibrillation, and rate control was achieved with amiodarone. IABP was discontinued and eventually the patient was weaned from inotropic and vasopressor support. A Lasix drip was initiated to aggressively diurese her excessive volume overload. Thrombocytopenia developed and HIT was negative. Platelets would eventually trend up to normal levels. Given the patient's complicated hospital course, and question of vegetation on the mitral valve, ID was consulted for antibiotic recommendations and leukocytosis. Additionally, the patient developed a rash, and was tested for [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9880] Spotted Fever- which would ultimately return negative. She was eventually weaned from the ventilator and extubated on POD 6. Due to right upper extremity swelling a right upper extremity ultrasound was performed and negative for thrombus.Left thoracentesis done on [7-30]. Dobhoff placed for tube feeds for increased nutritional needs and poor intake. She continued to progress and was transferred to the step down unit.On POD#17 A 700cc left pleural effusion was evacuated via repeat thoracentesis. On POD#18 she was cleared by Dr.[Last Name (STitle) ] for discharge to [Hospital ] rehab. All follow up appointments were advised. Target INR is 1.8-2.2 for postop Afib ( per Dr. [Last Name (STitle) ] due to chest hematoma). Blood draws should be Mon-Wed-Fri ( next draw [8-8]) . Coumadin dose today is 1 mg, INR today 1.9.Please recheck BUN / creat [8-8] for IV lasix dosing. Please re-check LFTS to dtermine eligibility for statin therapy. Medications on Admission: unknown Discharge Medications: 1. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: 1 mg today, then 0.5 mg Fri and Sat;then further daily dosing by provider; target INR 1.8-2.2 for postop A Fib . 2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 weeks. 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): 30 minutes prior to IV lasix. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for to affected area. 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day): hold for K+ > 4.5 with IV lasix. 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours): last dose PM [8-8]. 14. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q12H (every 12 hours): 750 mg IV; last dose PM [8-8]. 15. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) 500 mg piggyback Intravenous Q8H (every 8 hours): last dose PM [8-8]. 16. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection [Hospital1 ] (2 times a day): 40 mg IV; please recheck creat [8-8];baseline creat 1.5. 17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush: IV prn line flush and daily for PICC; flush with 10 ml NS. 18. INSULIN fixed dose and sliding scale ( see attached) Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: bicuspid aortic valve aortic stenosis s/p Mitral valve replacement with a 31-mm St. [Male First Name (un) 923] Epic tissue valve, model number E-[Medical Record Number 59354]. 2. His aortic valve replacement with a 21 mm cup, [Last Name (un) 3843] [Doctor Last Name ] pericardial tissue valve, model number 3300 TFX mitral regurgitation s/p emergent aortic valve replacement and mitral valve replacement this admission PMH: diverticulitis, [Doctor Last Name 27210] syndrome, hypothyroid Past Surgical History: s/p sigmoid colectomy w/ [Doctor Last Name 3379] pouch [2178] at [Hospital1 18]. Cervical Laminectomy Discharge Condition: Alert and oriented x3 nonfocal Does not ambulate-using [Doctor Last Name 2598] for lifts Incisional pain managed with tramadol and tylenol Incisions: Sternal - healing well, no erythema or drainage Edema : 2+ BLE 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] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8583], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2183-9-3] 1:30 Please call to schedule appointments Primary Care Dr. [Last Name (STitle) 59355],[First Name3 (LF) 32103] [Telephone/Fax (1) 59356] in [2-15] weeks Cardiologist Dr. [Last Name (STitle) 171] [Telephone/Fax (1) 62] in [2-15] 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 Target INR for this pt is 1.8-2.2 per Dr. [Last Name (STitle) ] for postop A Fib Blood draws Mon-Wed-Fri please Please check BUN/creatinine tomorrow [8-8] ( baseline creat 1.5) re-check LFTs for possible statin therapy in future Completed by:[2183-8-7**] ICD9 Codes: 4280, 5849, 2851, 4240, 2449, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8027 }	Medical Text: Admission Date: [2116-11-28] Discharge Date: [2116-12-10] Date of Birth: [2047-9-3] Sex: F Service: MEDICINE Allergies: Penicillins / Vicodin / Relafen / Diclofenac / Bactrim / Keflex / Voltaren / [Doctor First Name ] Attending:[First Name3 (LF) 106] Chief Complaint: chest pain and SOB Major Surgical or Invasive Procedure: Cardiac cath History of Present Illness: 69 yo female with PMHx of CAD s/p MI 9 year ago, diastolic dysfuction with EF of 65%, IDDM, hyperlipidemia, hypothroirid, COPD on 2L home O2 presented to [Hospital 1474] Hospital with complaints of SOB and chest pain for 2 days and was noted to be pale and diaporhetic and bradycardic at the OSH wirh HR in the 40's and BP in 80's. He was started on nitro gtt, heparin gtt, and atropine was given. SHe was persistantly bradycardic and then required dopamine. She had elevated Ck and troponins and was transferred here for further evalution. She states that over the past few dys she has had increased episodes of jaw pain (her anginal equlivant) with increased DOE and orthopnea. She was told to double her Lasix doses on Friday by PCP and was prescribed an antiobiotic tht she does not know the name of. ROS: Jaw pain, DOE with a few feet, increased orthopnea with 2 pillows, no edema or palpitations. No syncope Past Medical History: Vertigo endocarditis 2 years ago RA gastritis Hypothyroidism Depression Carpal tunnel syndrome Hypertension Hyperlipidimia Heart Failure Social History: Does not smoke of drink. Family History: NC Physical Exam: Vitals: T= 97.8, HR = 59, BP = 124/63, RR =23, SaO2 = 92% on 100% face mask. General: appears uncomfortable, in distress. HEENT: Normocephalic and atraumatic head, no nuchal rigidity, anicteric sclera, moist mucous membranes. Neck: No thyromegaly, no lymphadenopathy, no carotid bruits. Obese neck. JVP difficult to assess Chest: Her chest rose and fell with equal size, shape and symmetry, her lungs had coarse breath sounds bilaterally. CV: PMI appreciated in the fifth ICS in the midclavicular line without heaves or thrills, RRR, normal S1 and S1 no murmurs rubs or gallops. Abd: Normoactive BS, NT and ND. No masses or organomegaly Back: No spinal or CVA tenderness. Ext: NO cyanosis, no clubbing, trace edema with 1+ dorsalis pedis pulses bilaterally Pertinent Results: EKG: 2:1 AV block. ST depression in I, AVL, V4 - 6. increased PR interval CXR: Bilateral pleural effusion and in creased pulm vasculature CATH: 1. Selective coronary angiography demonstrated one vessel coronary artery disease in a left dominant system. The LMCA and LAD had no angiographically apparent CAD. The RCA was a small non-dominant vessel that filled only acute marginal branches. The LCx had a proximal 30% stenosis. The OM1 came off the circumfle distally and was completely occluded. The OM2 came off at the same level as the OM1 and had a 90% proximal stenosis. The distal circumflex was totally occluded. 2. Limited hemodynamics revealed normal left heart filling pressures and a preserved cardiac output. 3. Left ventriculography was not performed due to concerns about excess dye load. 4. Successful placement of 3.5 x 13 mm Cypher drug-eluting stent in the proximal LCx. Final angiography demonstrated no residual stenosis in the proximal vessel, no angiographically apparent dissection, and normal flow (See PTCA Comments). 5. Unsuccessful attempt to treat OM1 branch with balloon angioplasty or stenting due to inability to cross chronically occluded lesion with wire. Final angiography demonstrated no change in the total occlusion and no angiographically apparent dissection (See PTCA Comments). 6. Successful balloon angioplasty of the OM2 branch with a maximal 2.0 mm balloon. Final angiography demonstrated a 20% residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 7. Successful placement of three overlapping Cypher drug-eluting stents in the distal LCx (proximal 3.0 x 8 mm, mid 2.5 x 8 mm, and distal 2.5 x 2) all post-dilated with a 3.0 x 15 mm Quantum Maverick balloon. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). FINAL DIAGNOSIS: 1. One vessel coronary artery disease 2. Normal left heart filling pressures 4. Successful placement of drug-eluting stent in proximal LCx. 5. Unsuccessful attempt to cross totally occluded OM1 branch. 6. Successful balloon angioplasty of OM2 branch. 6. Successful placement of three overlapping drug-eluting stents in distal LCx. ECHO: EF 60-65%, 2+ MR, 1+ TR. Brief Hospital Course: 1. Rhythm: The patient was in new 2:1 heart block with bradycardia to the 30 - 40s and low systolic BP, no urine output, and decreased mental status when admitted. Pacer pads were placed and an emergent cordis was inserted into her right IJ for pacer wires. The patient was paced breifly at a rate of 70 and regained a faster native heart rate by the evening. She began to make urine and her mental status improved with this intervention. As her blood pressure began to increase, her dopamine was weaned off. Pt only required temp pacer for the first few days, and remained in normal rate/tachycardia. Pt developed frequent PVC's and bigeminy's when she was hypertensive/tachycardic, and PO metoprolol was added for rate control and BP control. Pt has remained in normal sinus rhythm with occasional PVC's for rest of the hospital course. 2. CAD: Most likely coronary disease in the setting of new EKG changes and 2:1 block. She was ruled in by enzymes with peak troponin of 1.77. She was started on ASA, statin. Beta-blocker was initially held given bradycardia and heart block, but later re-started. ACEI was also held for ARF prior to cath. She has had recurrent CP which responded to nitro and morphine. Pt was on heparin gtt and nitro gtt when she came in. Heparin gtt was continued. Nitro gtt was initially weaned but re-started for BP control. Cath was postponed due to acute renal failure initially, and also later for respiratory distress from penumonia(febrile)/CHF later. Pt underwent cath once creatinine normalized to her baseline, and her respiratory status improved after antibiotics and diuresis. Cath showed the LMCA and LAD had no angiographically apparent CAD. The RCA was a small non-dominant vessel that filled only acute marginal branches. The LCx had a proximal 30% stenosis. The OM1 came off the circumflex distally and was completely occluded. The OM2 came off at the same level as the OM1 and had a 90% proximal stenosis. The distal circumflex was totally occluded. Successful drug-eluting stents placement in proximal LCx x1 stent, 2 over lapping stents in distal LCx, balloon angioplasty of OM2. 3. Pump: Diastolic CHF with EF 65%. CXR and clinical history are c/w CHF excerbation. Pt has a hx of endocarditis, TTE showed 2+MR but no obvious vegetations. Pt went into flash pulm edema requiring IV lasix for diuresis. Swan was placed since pt remained on NRB/BIPAP for several days despite diuresis. PCWP was in the 20's so pt was aggressively diuresed further with IV lasix until PCWP was 11. Her dry weight when PCWP 11 was 114 kg. Pt was discharged with standing po lasix 60 mg qd (homeo dose)+ potassium supplement. Pt was instructed to weigh herself daily to keep her wt at or below 114 kg. 4. Respiratoy failure: Pt has been using home O2 for unclear reason. Pt has no hx of COPD and no hx of smoking. She was recently diagnosed with a pneumonia by her PCP and was started on levofloxacin prior to admission. When admitted,she was very difficult to oxygenate despite NRB. She was started on levofloxacin but remained febrile, so vancomycin and flagyl were added with improvement in symptoms and WBC. Pt was diuresed neg 1L daily without improvement in her respiratory symptoms. Swan-Ganz catheter was placed which showed PCWP of 20's. Pt was then aggressively diuresed with IV lasix until PCWP of 11. She was eventually weaned off to NC 2.5 L. However, pt still desaturate to mid 80's on 3L NC with ambulation, and also at night while she is asleep. PFT's were done which showed restrictive pattern most likely from obesity. FVC 42%, FEV144%, FEV1/FVC 102%, ERV 1%. Also, pt most likely has sleep apnea component as well and should get an outpatient sleep study. Pt was discharged with home O2 since she destaturated to mid 80's with physical therapy activity. 5. DKA: The paitent missed a dose of insulin the morning of admittance. he had an elevated blood glucose and an anion gap of 19. She was started on an insulin drip requiring up to 28 units per hour. Her gap then normalized and she was started on a sliding scale. Pt resumed her home regimen of NPH and humalog and was stable. 6. Acute renal failure: Cr 3.1 on admission (baseline 1.6 per PCP), most likely secondary to decreased C.O. in a setting of NSTEMI and bradycardia. Pt initially had low UOP but improved after temp pacer was placed to treat bradycardia. Creatinine came down to as low as 1.2. However, after aggressively diuresing her for CHF, her Cr came up to 1.8 at the time of discharge. 7.Anemia: Hct of 29 on admission but drifted down to 26. Pt got 2 units of PRBC but with inappropriate response. Guiac was negative. Iron studies were consistent with anemia of chronic disease. Most likely from her renal disease. Pt needs an outpatient follow up of her anemia since she may benefit from Epogen. Pt would should have her PCP refer her to a nephorologist if her Hct continues to trend down. 8. ID: Pt was diagnosed with pneumonia prior to admission and received levofloxacin by her PCP. [Name10 (NameIs) ] was continued on levofloxacin but continued to have fever and leukocytosis with CXR with no improvement. Vancomycin and flagyl were added with improvement in symptoms. Levo and Flagyl were eventually discontinued. Although none of her cultures grew anything, she was treated with presumed MRSA pneumonia since she responded to Vanc and not Levo. She will complete a 14 day course of IV Vancomycin. Medications on Admission: ASA 325, Avapro 75, Cardizem 300, cyclobenzaoime 10, Fosamax 70, Lasix 60, Isosorbide 40 TID, Levoxyl 150, Lipitor 80, Nadolol 20, Zoloft 100, Insulin NPH 66 ans Humalog 12 qAM, Insulin NPH 70 and Humalog 12 qPM Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. 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 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. 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 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Potassium Chloride 20 mEq Packet Sig: One (1) PO DAILY (Daily). Disp:30 Refills:2 9. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous once a day for 3 days. Disp:3000 mg Refills:0 10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as directed Subcutaneous once a day: 66 units NPH in AM, 70 units NPH in PM. 11. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous twice a day: 12 units in AM and 12 units in PM. 12. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 14. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a day. 15. Avapro 75 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 Pneumonia CAD s/p cath CRI Anemia Discharge Condition: Hemodynamically stable, breathing comfortably on 2.5L NC. Discharge Instructions: Patient was instructed to take all of the medications as indicated. Patient needs to seek medical attention if she develops shortness of breath, chest pain, fatigue, dizziness, increased weight, decrease in urine output. Patient needs to weigh herself daily and seek medical attention (PCP, [Name Initial (NameIs) 2085]) if she has more than 2 kg weight gain. She had a low sodium, cardiac, and diabetic diet instruction and should continue that at home. Followup Instructions: Follow up with PCP [Last Name (NamePattern4) ] [1-3] weeks. Follow up with her cardiologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [2-5] weeks. Provider: [Name10 (NameIs) 1571] BREATHING TESTS Where: [Hospital6 29] PULMONARY FUNCTION LAB Phone:[Telephone/Fax (1) 612] Date/Time:[2117-1-8] 8:55 Provider: [Name10 (NameIs) 1571] EXAM ROOM IS (NO CHARGE) Where: IS (NO CHARGE) Date/Time:[2117-1-8] 9:10 Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 611]/DR. [Last Name (STitle) ] Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 5091] Date/Time:[2117-1-8] 9:10 Completed by:[2116-12-11] ICD9 Codes: 4280, 5849, 4240, 496, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8028 }	Medical Text: Admission Date: [2163-8-18] Discharge Date: [2163-8-23] Date of Birth: [2085-4-19] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / hayfever Attending:[First Name3 (LF) 1505] Chief Complaint: Dypnea on exertion Major Surgical or Invasive Procedure: [2163-8-18] Aortic valve replacement, Coronary artery bypass graft x 1 (saphenous vein graft to posterior descending artery) History of Present Illness: 78 year old male who has been followed with serial echocardiograms for aortic stenosis for several years. He continues to work full-time and walks several miles several days per week. In addition he continues to lift weights, do push-up and pull-ups, and play softball three time per week. However he has noticed more shortness of breath this year than past, particulary early in exercise. He underwent a echocardiogram in [Month (only) 116] which revealed worsening aortic stenosis, now severe ([Location (un) 109] 0.9cm2, pk/mn 81/53), and he was referred for surgical evaluation. Past Medical History: Aortic Stenosis Hypertension Heart murmur Duodenal ulcer 50 years ago Anemia in the distant past RBBB Past Surgical History s/p Appendectomy approximately 65 years ago s/p Tonsillectomy s/p Bilateral Cataract surgery Social History: Race: Caucasian Last Dental Exam: Less than 6 months ago Lives alone Occupation: Lawyer Cigarettes: Smoked no [] yes [X] no cigarette hx Other Tobacco use: Pipes/Cigars ETOH: < 1 drink/week [X] [1-17] drinks/week [] >8 drinks/week [] Illicit drug use: denies Family History: non-contributory Physical Exam: Pulse:70 Resp:16 O2 sat:99/RA B/P Right:173/84 Left:169/76 Height: 5'[61]" Weight: 200 lbs General: Well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade 3/6 systolic 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: Transmitted murmur Pertinent Results: [2163-8-22] 06:05AM BLOOD WBC-13.7* RBC-3.27* Hgb-9.6* Hct-25.8* MCV-79* MCH-29.4 MCHC-37.4* RDW-15.2 Plt Ct-107* [2163-8-18] 12:47PM BLOOD PT-15.7* PTT-36.3* INR(PT)-1.4* [2163-8-21] 04:40AM BLOOD Glucose-110* UreaN-23* Creat-0.9 Na-134 K-3.6 Cl-101 [2163-8-18] 12:47PM BLOOD UreaN-19 Creat-1.0 Na-140 K-4.3 Cl-113* HCO3-21* AnGap-10 [2163-8-23] 06:10AM BLOOD WBC-13.2* RBC-3.37* Hgb-10.2* Hct-26.9* MCV-80* MCH-30.2 MCHC-37.8* RDW-15.0 Plt Ct-154 [2163-8-22] 06:05AM BLOOD WBC-13.7* RBC-3.27* Hgb-9.6* Hct-25.8* MCV-79* MCH-29.4 MCHC-37.4* RDW-15.2 Plt Ct-107* [2163-8-23] 06:10AM BLOOD Glucose-107* UreaN-16 Creat-0.9 Na-136 K-4.0 Cl-100 HCO3-26 AnGap-14 [2163-8-22] 10:44AM BLOOD Na-135 K-3.7 Cl-101 [2163-8-21] 04:40AM BLOOD Glucose-110* UreaN-23* Creat-0.9 Na-134 K-3.6 Cl-101 [2163-8-23] 06:10AM BLOOD PT-15.2* PTT-25.3 INR(PT)-1.3* [2163-8-22] 10:44AM BLOOD PT-14.3* INR(PT)-1.2* Brief Hospital Course: Mr. [Known lastname ] was a same day admit and underwent an aortic valve replacement and coronary artery bypass graft x 1 (#23mm St.[Male First Name (un) 923] porcine valve/ Saphenous vein grafted to distal RCA). Cardiopulmonary Bypass Grafting= 94 minutes, Cross Clamp time=74 minutes. Please see operative report for surgical details. Following surgery he was transferred to the CVICU intubated and sedated in critical but stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated without incident. He weaned off pressors and was started on beta-blocker/statin/aspirin and diuresis. Later this day he was transferred to the step-down floor for further recovery. Chest tubes and epicardial pacing wires were removed per protocol. Physical Therapy was consulted for evaluation of strength and mobility. Postoperatively his rhythm was sinus tachycardia that responded minimally to increased beta-blockers. He was placed on Diltiazem for increased rate control. POD#2 his rhythm went into rate controlled Atrial Fibrillation. Medication dosages were increased. Amiodarone was added, Lopressor was titrated up, Diltiazem was discontinued and an ACE-I was added and titrated up for better rate and blood pressure control. For the remainder of his hospital course he had paroxysmal AFib. Anticoagulation was initiated and he was given Coumadin 2.5 mg on [8-22] and [8-23]. On POD 5 night he had an episode of acute confusion after receiving Ativan for insomnia. He cleared from a mental status stand point the following day and all narcotics and benzodiazepine medications were discontinued. He continued to progress and was cleared for discharge to brother's house with visiting nurse services on POD 5. His Coumadin will initially be followed by the cardiac surgery service and then subsequently by [Hospital6 733] Anticoagulation Management Services - referral form faxed. All follow up appointments were advised. Medications on Admission: Lisinopril 20mg daily Norvasc 5mg daily Simvastatin 10mg daily Aspirin 81mg daily Levitra 10mg prn Coenzyme q10 [Hospital1 ] Omega 3 Fish oil daily Ativan prn Multivitamin daily Vitamin D daily Calcium supplement Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:140 Tablet(s)* Refills:0 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): x 1 week then 200 mg [Hospital1 ] x 1 week then 200 mg daily x 1 month then as directed by cardiologist. Disp:75 Tablet(s) Refills:0 7. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Take 2.5 mg on [8-23] then as directed for INR goal 2.0-3.0. Disp:60 Tablet(s) Refills:0 8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: Do not exceed 4 gm/ day. 9. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: tbd Discharge Diagnosis: Aortic stenosis/coronary artery bypass graft x 1 s/p aortic valve replacement and coronary artery bypass graft x 1 Past medical history: Hypertension Heart murmur Duodenal ulcer 50 years ago Anemia in the distant past RBBB s/p Appendectomy approximately 65 years ago s/p Tonsillectomy s/p Bilateral Cataract surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [Last Name (STitle) ] #[Telephone/Fax (1) 170] on [9-21] at 1:15pm Cardiologist: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 696] - office to call you with future appointment Please call to schedule appointments with your Primary Care Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [3-15] 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 atrial fibrillation Goal INR 2.0-3.0 First draw [2163-8-24] Results to [Telephone/Fax (1) 170] cardiac surgery service to follow until patient set up with [Hospital6 733] Anticoagulation Management Services - referral form faxed Completed by:[2163-8-23] ICD9 Codes: 4241, 4019, 2875, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8029 }	Medical Text: Admission Date: [2125-8-11] Discharge Date: [2125-8-20] Date of Birth: [2049-1-31] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 898] Chief Complaint: Word finding difficulties. Confusion. Major Surgical or Invasive Procedure: None History of Present Illness: Mrs [Known lastname 3175] was admitted to [Hospital1 18] on [2125-8-11]. She is a 76 year-old right-handed woman with a past medical history significant for type 2 diabetes mellitus, HTN, hyperlipidemia, obesity, chronic renal insufficiency, anxiety and spinal stensosis who presented with word finding difficulties. She has been struggling over the last several weeks with generalized, weakness, lethargy, and difficulty getting upstairs (with DOE). Her son visits her every saturday. They did some light shopping and she was last seen normal before a nap at 5:20pm. Then at 6:20 he went to see how she was doing and he noticed a clear language deficit. She was producing "nonsensicle" strings of words, including some simple isolated consonants. Her pronounciation was mildly affected, but it seemed that finding the words was the primary difficulty. There was no facial droop and no appendicular weakness or precipitous change in gait. Her son called EMS. They measured a finger stick of 178. Blood pressure in the field was 230/94. Code stroke was called on [8-11] at 7:30pm. Regarding the workup for her weakness/DOE she has had a normal CXR, normal EKG, and a stress ECHO in late [Month (only) 216] revealed a normal EF, with poor exercise tolerance, but no EKG changes and no focal hypokinesis. . Of note until these recent difficulties with shorness of breath and fatigue arose she was living independently in a [Location (un) 1773] appartment. She doesn't use a walker or cane normally. . Past Medical History: HTN Type 2 diabetes mellitus Hyperlipidemia Anxiety/Depression Obesity Spinal Stenosis. Renal insufficiency of uncertain etiology - thought to be due to HTN, DMII, but then there is a note on [2125-6-21] that suggests here renal insufficiency was getting worse faster than one would expect with those etiologies. Social History: Lives alone in [Location (un) ]. Retired Has 3 children. Is divorced. Has a remote smoking history No ETOH or illicits. Family History: Non-contributory Physical Exam: Physical Exam: Vitals: T:96.7 P:79 R:12 BP:220-265/108 SaO2:100% 2L NC. General: Awake, cooperative, NAD. Somewhat slow to respond. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated - can hear heartbeat in the carotids. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: She has pitting edema in the left lower extremity greater than the right lower extremity. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to person, place, but thought it was [Month (only) ] - self corrected to [Month (only) ], but thought it was the 22nd or 23rd. Unable to do MOTY backwards. She said, "[Month (only) ], [Month (only) ], [Month (only) ]". There is a deficit in fluency, in that her production is slow. She does however make more than 7 words in a sentence. She had difficulty with comprehension. She was unable to understand the visual field testing task. She wasn't able to follow command for formal motor testing. She makes paraphasic errors. These are both semantic and phonemic. She called a chair a table. When registering apple, she said appy. When repeating the word Right Thumb, she said "Light Thrumb". She was suggestible. At one point I asked her son if she was left or right handed. She incorporated my question inappropriately in the middle of another sentence. She was perseverative - saying months when I asked her an unrelated question. She read and repeated normally. She touched her right ear rather than the left ear with the right thumb. Naming was intact for stethoscope, fingers, knuckles, name tag, but she was unable to name the watch, rather calling it a clock. She new [Last Name (un) 2450] was president, and [Last Name (un) 2753] is running, but didn't know [Last Name (un) 101306]. Registered normally other than saying Appy rather than Apple. Recalled only 1 item at 30 seconds. None further with clues. There was no evidence of neglect on interpreting the cookie theft picture. She was not dysarthric per her son. -Cranial Nerves: Olfaction not tested. Pupils surgical. Both do react. Unable to see Fundi. There is no ptosis bilaterally. EOMI without nystagmus. Normal saccades. Facial sensation intact to pinprick. No facial droop, facial musculature symmetric. Hearing intact to finger-rub bilaterally. Palate elevates symmetrically. Tongue protrudes in midline. -Motor: Unable to perform formal motor testing, because she couldn't seem to understand the commands to resist. She had symmetric antigravity strenght in all four limbs. -Sensory: No deficits to light touch, pinprick, cold sensation. vibratory sense diminshed in feet. -Coordination: No intention tremor, dysdiadochokinesia noted. No dysmetria on FNF bilaterally. She didn't understand or wouldn't perform the HKS test. - Reflex: No clonus [Hospital1 ] Tri Bra Pat An Toes C5 C7 C6 L4 S1 CST L1 2 1 3 2 tonic up R1 2 1 3 2 up -Gait: Stood up slowly. Needed some help. Took very small steps. Used sink and wall to support herself at times. She didn't ever seem like she would fall, to me, but she did ask for assistance. Romberg absent. She was unable to tandem. Pertinent Results: [2125-8-11] 07:40PM GLUCOSE-143* UREA N-20 CREAT-2.4* SODIUM-135 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15 [2125-8-11] 07:40PM estGFR-Using this [2125-8-11] 07:40PM CK(CPK)-63 [2125-8-11] 07:40PM CK-MB-NotDone cTropnT-0.02* [2125-8-11] 07:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-13.1 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2125-8-11] 07:40PM WBC-11.7# RBC-3.46 HGB-10.3* HCT-30.3* MCV-88 MCH-29.8 MCHC-34.0 RDW-14.5 [2125-8-11] 07:40PM NEUTS-79.1* LYMPHS-13.8* MONOS-4.7 EOS-2.0 BASOS-0.3 [2125-8-11] 07:40PM PLT COUNT-344 [2125-8-11] 07:40PM PT-12.1 PTT-29.2 INR(PT)-1.0 [2125-8-20] 05:20AM BLOOD WBC-12.7* RBC-2.90* Hgb-8.6* Hct-25.6* MCV-88 MCH-29.7 MCHC-33.6 RDW-14.5 Plt Ct-423 [2125-8-12] 08:54AM BLOOD WBC-17.6# RBC-3.53 Hgb-10.2* Hct-31.1* MCV-88 MCH-28.9 MCHC-32.9 RDW-14.7 Plt Ct-424 [2125-8-12] 08:54AM BLOOD Neuts-94.3* Lymphs-3.9* Monos-1.5* Eos-0.2 Baso-0.1 [2125-8-20] 05:20AM BLOOD Glucose-120* UreaN-25* Creat-2.5* Na-138 K-3.8 Cl-101 HCO3-29 AnGap-12 [2125-8-19] 05:05AM BLOOD Glucose-109* UreaN-28* Creat-2.6* Na-138 K-3.8 Cl-100 HCO3-30 AnGap-12 [2125-8-17] 03:28PM BLOOD Glucose-163* UreaN-34* Creat-2.7* Na-136 K-3.5 Cl-97 HCO3-28 AnGap-15 [2125-8-16] 05:49AM BLOOD Glucose-167* UreaN-34* Creat-2.3* Na-136 K-3.7 Cl-100 HCO3-26 AnGap-14 [2125-8-13] 03:45AM BLOOD Glucose-153* UreaN-27* Creat-2.6* Na-137 K-4.0 Cl-98 HCO3-29 AnGap-14 [2125-8-12] 08:54AM BLOOD ALT-26 AST-30 LD(LDH)-542* CK(CPK)-115 AlkPhos-136* TotBili-1.2 [2125-8-12] 08:54AM BLOOD CK-MB-4 cTropnT-0.03* [2125-8-11] 07:40PM BLOOD CK-MB-NotDone cTropnT-0.02* [2125-8-19] 05:05AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.7 [2125-8-12] 08:54AM BLOOD Albumin-3.3* Calcium-8.9 Phos-4.7* Mg-1.6 Cholest-198 [2125-8-17] 03:28PM BLOOD calTIBC-195* Ferritn-244* TRF-150* [2125-8-12] 08:54AM BLOOD VitB12-497 Folate-GREATER TH [2125-8-12] 08:54AM BLOOD %HbA1c-5.8 [2125-8-12] 08:54AM BLOOD Triglyc-117 HDL-60 CHOL/HD-3.3 LDLcalc-115 [2125-8-12] 08:54AM BLOOD TSH-0.14* [2125-8-17] 03:28PM BLOOD PTH-119* [2125-8-15] 06:10AM BLOOD T4-7.5 T3-99 Free T4-1.4 [2125-8-11] 07:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-13.1 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2125-8-12] 10:15AM BLOOD Type-ART pO2-86 pCO2-33* pH-7.49* calTCO2-26 Base XS-2 [2125-8-12] 10:15AM BLOOD freeCa-1.09* . [2125-8-16] 05:49AM Metanephrines (Plasma) TEST RESULT REFERENCE RANGE ---- ------ --------------- Metanephrines, Fract., Free Normetanephrine, Free 1.23 (High) < 0.90 nmol/L Metanephrine, Free <0.20 < 0.50 nmol/L TEST PERFORMED AT: [Hospital 4534] MEDICAL LABORATORIES, [Street Address(2) ] SW, [Location (un) ], [Numeric Identifier ] Complete report on file in the laboratory. . CXR [8-16]: IMPRESSION: 1. Interval improvement in previously described pulmonary vascular congestion. 2. Slight interval decrease in bibasilar atelectasis and unchanged small bilateral pleural effusions. . [8-17] Renal U/S with dopplers: IMPRESSION: 1. Small kidneys. 2. Non-diagnostic Doppler evaluation. 3. Bilateral pleural effusions. . MRI/MRA: is markedly motion degraded. Within limits of this examination, no aneurysm is seen. There is nonvisualization of the left distal vertebral artery and proximal stenosis or possibly hypoplasia cannot be excluded. I would recommend correlation with MRA of the neck for further evaluation. IMPRESSION: 1. Markedly limited study, essentially nondiagnostic for evaluation of the distal vessels in the brain. No proximal high-grade stenosis is seen. The left distal vertebral artery is not visualized, which may be from proximal hypoplasia or stenosis. 2. No evidence for acute ischemia in the brain or PRES. 3. Mild small vessel ischemic sequelae in the subcortical and periventricular white matter. . Brief Hospital Course: 76 year-old woman with DMII, Hyperlipidemia, obesity, chronic renal insufficiency, anxiety, h/o supressed TSH with cold thyroid nodule, benign essential hypertension who presented with word finding difficulties, SBP 230. She was seen by neurology and felt not a TPA candidate because her score was only 1 and she recoved relatively quickly. She was hypertensive in the ED BP was 196-256/71-136, HR 70's-80's sat 100% 3L NC, T 96.7. She was treated with aspirin 325mg daily, labetolol 20mg iv x2. On arrival to the medical floor her initial vital signs at 2230 were 180/88, 82, 20, 97% RA, temp 96.5. She was cooperative, alert and oriented per report by the neurology resident. Through the night however she was noted by the nursing staff to be confused, pulling at her monitor leads, iv's, etc. Repeat VS at 0400 were 170/75, hr 72, rr 20, 96% on RA. At 0800 she was noted to be 240/120, Hr 117, rr 40, 98% via 8L FM. A trigger was called and she was transferred to the micu for respiratory distress and treated for flash pulmonary edema with 40mg iv lasix x1 with good effect, and albuterol neb. She was then stabilized in the MICU and transferred to the neurology service. Stroke workup was negative, but her blood pressure was not controlled by PO medications. She was given 10 IV hydralazine for SBP>200 q4-6prn. She was then transferred to the medicine service and started on a nitroglycerin drip for BP control. After 2 days she was weaned off the nitro gtt, and eventually her SBP was 130-150 on amlodipine 10 po daily, avapro 150 daily, furosemide 40 po daily and isosorbide dinitrate TID. Looking back in her records there was concern that she was becoming more hypertensive after beta blockers so these were D/C'd and plasma metanepherines were sent to eval for pheochromocytoma. She was seen by the nephrologists for her acute renal failure. They suspected this was due to hypoperfusion [12-23] poor forward flow, hypertension and volume overload. Her creatinine peaked at 2.7 and drifted down slowly with lasix diuresis. She was also evaluated for renal artery stenosis with a renal doppler flow study. However, she couldn't hold her breath long enough so this was non-diagnostic. We recommended she follow this up as an outpatient given the unclear reason for the acute worsening of her blood pressure and kidney disease this year. Her Actos was discontinued in the face of critical illness and she was well controlled on SSI. She needs f/u as an outpatient for diabetes regimen as we did not restart Actos. Three days prior to discharge, she developed a leukocytosis, and her urine grew E. Coli. We started her on a 5 day course of Cipro for urinary tract infection. Last day will be Wednesday [8-22]. We also learned that she had been taking Xanax three times a day prior to admission. She had high anxiety in the hospital and we started ativan PRN, then restarted her sertraline. Given her altered mental status on arrival we did not want to send her out on any benzodiazepines. Medications on Admission: Actos 15mg daily Amlodipine 5mg Daily Valsartan/HCTZ 320/25 ASA 81mg daily Zocor 80mg daily Was previously taking Zoloft (50mg qd)and Xanax, but these are not on her current lists. Her PCP in recent notes seems to want her on the Zoloft. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:2 3. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO QDay () as needed for HTN. 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Do not take your iron pills while taking this medication. Disp:2 Tablet(s) Refills:0 10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing, SOB. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary Diagnosis: Hypertensive Encephalopathy Flash Pulmonary Edema Secondary Diagnosis: Anxiety Chronic kidney disease DM, type II on oral medications Hyperlipidemia surpressed TSH with cold thyroid nodule Discharge Condition: Stable. Discharge Instructions: You came to the hospital with difficulty speaking and confusion. We found that you had very high blood pressure. You were seen by the neurology service who did not find any evidence that you had a stroke. We believe your symptoms were due to high blood pressure. We treated your high blood pressure with antihypertensive medications. We found that your kidney function is worse that your baseline. The nephrologists saw you and believed this was due to poor blood flow to your kidneys. Your kidney function improved with control of your blood pressure. We also found that you had a urinary tract infection and treated you with antibiotics. . We made the following changes to your medications: STOPPED Xanax Stopped Metoprolol Stopped Actos Stopped Lisinopril Changed Amlodipine 10mg daily Changed Furosemide 40mg daily Added Isosorbide Dinitrate Added Ciprofloxacin for total 5 days, until [8-22] Added Ferrous Sulfate (iron supplement) but do not take this until you are done with your antibiotic. . If you have any shortness of breath, confusion, difficulty speaking, difficulty walking, chest pain, swelling in your legs, nausea, vomiting, fever, chills, blood in your urine or any other symptoms that are concerning to you, please call your PCP or come to the emergency room. . Please take your medications as prescribed and follow up with your PCP and your nephrologist as below. . Followup Instructions: Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 1125] Date/Time:[2125-8-28] 9:45 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5340], MD Phone:[Telephone/Fax (1) 1803] Date/Time:[2125-9-4] 10:00 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 1125] Date/Time:[2125-9-18] 9:30 Completed by:[2125-8-26] ICD9 Codes: 5849, 5990, 5859, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8030 }	Medical Text: Admission Date: [2122-2-24] Discharge Date: [2122-3-23] Date of Birth: [2075-12-28] Sex: M Service: [Last Name (un) ] CHIEF COMPLAINT: Fever. HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male status post liver transplant in [2121-11-16] for cryptogenic cirrhosis, hepatitis C, varices with recent admission for hyperkalemia now presents with fever of 103.2, decreased appetite, dehydration. Patient has not eaten or had any fluid for a couple of days. PAST SURGICAL AND PAST MEDICAL HISTORY: Liver transplant [2121-11-16], nutcracker esophagus, elevated prolactin, end- stage renal disease, cryptogenic pneumonia, thoracotomy with right upper lobectomy secondary to cavitary lesion, gastroparesis. ALLERGIES: Penicillin. MEDICATIONS AT HOME: Prograf 1 mg p.o. b.i.d., Rapamune 2 mg p.o. daily, prednisone 5 mg daily, fluconazole 400 mg p.o. daily, Protonix 40 mg b.i.d., Valcyte 450 mg daily, NPH insulin 28 units q.a.m., Epogen 20,000 units every week, nifedipine 10 mg p.o. b.i.d., Carafate 1 gram q.i.d., Bactrim single strength 3 times a week. VITAL SIGNS: Temperature 103.7, heart rate 102, BP 101/78, 97% on room air, respiratory rate 18. LABS: White count 1.6, hematocrit 25.3, platelet count 51. PT 14.2, PTT 30.7, INR 1.3. UA was negative. AST 62, ALT 68, alkaline phosphatase 203, T bilirubin 0.6, amylase 12, lipase 8, creatinine 1.5 with a BUN of 330. PHYSICAL EXAM: In no acute distress, nonjaundiced. Heart rate regular. Lungs are clear to auscultation. Abdomen: Soft, nontender, nondistended. HOSPITAL COURSE: Patient was admitted to the transplant service and started on vancomycin and levofloxacin IV and given a dose of Neupogen. Blood cultures were sent off. Duplex of the liver was done. This demonstrated patent hepatic veins and portal veins with appropriate direction of flow. Patent extrahepatic veins, hepatic artery with improved wave forms. The intrahepatic right and left hepatic arteries were poorly visualized which suggested decreased flow. There was no evidence of hepatic ductal dilatation or ascites. Chest x-ray on admission was stable; postoperative appearance of the right hemithorax. No evidence of acute pneumonia. Blood and urine cultures were sent. Blood cultures was less than 10,000 organisms. Blood cultures demonstrated Enterococcus faecium resistant to vancomycin, ampicillin, and penicillin, sensitive to linezolid. Infectious disease was consulted. Given pancytopenia, he was started on daptomycin in lieu of linezolid. Weekly CKs were monitored. These were normal. An abdominal CT was done. This demonstrated the main hepatic artery was not opacified beyond the origin of the gastroduodenal artery. No intrahepatic arterial flow was noted. The intrahepatic biliary ductal dilatation was noted more severe in the left than in the right lobe. Several bile leaks were noted in the left hepatic lobe. There were patent portal and hepatic veins. Moderate ascites was noted with stable severe splenomegaly and multiple varices. Multiple subcentimeter hypodensities in the spleen was noted. This was felt to represent hemangiomas or other benign entities. A small right pleural effusion was noted. He was sent for a T-tube cholangiogram. There was no evidence of obstruction or leak noted. The biliary anastomosis was widely patent and there was normal contrast opacification of the intrahepatic bile ducts and small bowel. He was then sent on [2122-2-26] for a PTC cholangiogram which demonstrated dilated left-side intrahepatic bile ducts with nondilated right-sided intrahepatic bile ducts and irregularly marginated severe stricture of the extrahepatic common ducts with near complete occlusion was noted. This was angioplastied with an 8 mm x 4 cm angioplasty balloon and then a 10 French left-sided internal/external biliary drainage catheter was placed. His LFTs improved. AST was 21, ALT 43, alkaline phosphatase 129, total bilirubin 0.3. On [2122-2-27], he underwent an angiogram by the cardiologist in the catheterization lab. This demonstrated completely occluded hepatic artery. His PTC drain was left to gravity drainage draining approximately 350- 575 cc of bilious drainage. His vital signs remained stable. He was afebrile. His white blood cell count remained on the low side in the range of 1.9-2.5. His hematocrit was stable on the low side ranging between 26.6-24.6. He continued on IV hydration as well as IV Levaquin and daptomycin. He did receive 1 unit of packed red blood cells as well as Neupogen again with slight improvement in his white blood cell count. He was medicated with oxycodone for discomfort in the right upper quadrant and right lateral abdomen. His EKG demonstrated an ectopic atrial rhythm with diffuse nonspecific ST-wave abnormalities. Heart rate was in the range of mid to high 80s. He underwent a transthoracic echocardiogram to assess for vegetation given bacteremia. It was noted that he had left ventricular wall thickness, cavity size and systolic function were normal with left ventricular ejection fraction of 55%. The regional left ventricular wall motion was normal and there was no evidence of endocarditis. A repeat chest x-ray demonstrated no significant interval change from the prior study. No pneumothorax. He was seen by podiatry service for toenail care. He stated that his left hallux nail was painful. He underwent sharp debridement of nails. Pain diminished after this procedure. Triple antibiotic was applied to the site without further problems. Nutrition followed the patient throughout this hospital course making recommendations that included sugar-free shakes t.i.d. Physical therapy cleared him to go home. Dr. [Last Name (STitle) 724] from infectious disease followed Mr. [Known lastname 1250] recommending that fluconazole 200 mg be continued for 1 year given history of cryptococcal pneumonia. This was reinstituted. He was retransfused with 2 units of packed red blood cells for a hematocrit of 24 on [3-8]. Repeat hematocrit was 30. A repeat PTC cholangiogram was done that demonstrated nondilated intrahepatic biliary tree. There was narrowing of the common hepatic duct, but contrast slowed from the intrahepatic biliary tree to the bowel. His PTC drain was capped. He continued to have low-grade fevers of 100.4 up to 103.4 on [3-11]. Repeat blood cultures were drawn almost on a daily basis for surveillance. These blood cultures were negative. Bioculture demonstrated enterococcus, 2 different species both resistant to vancomycin and both sensitive to linezolid. He remained on IV daptomycin and Levaquin. His T-tube was uncapped for this febrile episode. He remained in the hospital for monitoring and IV daptomycin. For the remainder of the hospital course, he was running low grade temperatures and then he was afebrile. His T-tube was capped again and he tolerated this without further fevers. A repeat chest x-ray was done that demonstrated small right pleural effusion that was unchanged. No findings suggestive of pneumonia. Of note, on [2122-3-5], a PICC line was placed at the cavoatrial junction anticipating that he would need IV daptomycin. On [2122-3-18], his levofloxacin was stopped. He was started on cefepime 2 grams IV q.12h. Flagyl was started 500 mg p.o. q.8., and the daptomycin was discontinued. A CMV viral load was done. This was not detected. Cryptococcal antigen was negative. On [2122-3-19], his PICC line catheter was removed and the tip was cultured. There was no growth. Repeat blood cultures on [2122-3-19] are still pending at this time. He was discharged home on [2122-3-23] on p.o. linezolid, p.o. levofloxacin was restarted, and fluconazole 200 mg daily. Infectious disease recommended repeating an abdominal CT to rule out abscess or bilomas. Of note, gram-positive cocci were noted in [11-19] bottles on the blood culture likely representing contaminant. He was ambulatory. Tolerating a regular diet. DISCHARGE CONDITION: Stable. MEDICATIONS ON DISCHARGE: Colace 100 mg p.o. b.i.d., fluconazole 200 mg p.o. daily, levofloxacin 500 mg p.o. daily, linezolid 600 mg p.o. b.i.d., nifedipine 10 mg p.o. b.i.d., oxycodone 5 mg p.o. p.r.n. q.6h. p.r.n. as needed, Protonix 40 mg p.o. q.12h., Bactrim single strength 1 p.o. daily, Rapamune 3 mg p.o. daily, Valcyte 450 mg p.o. daily, NPH insulin 28 units subcutaneous daily, and regular insulin subcutaneous p.r.n. q.6h. DISCHARGE DIAGNOSES: Vancomycin resistant enterococci bacteremia, vancomycin resistant enterococci in bile, hepatic artery thrombosis status post liver transplant [2121-11-16], stricture of extrahepatic common duct, and percutaneous transhepatic catheter placed. FOLLOW UP: He was scheduled to followup in the outpatient transplant clinic on [2122-3-26] at 10:50 with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 816] and on [2122-3-26] at 11:30 with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 3432] Dictated By:[Name8 (MD) 4664] MEDQUIST36 D: [2122-3-24] 12:22:59 T: [2122-3-24] 13:15:18 Job#: [Job Number 62178] ICD9 Codes: 7907
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8031 }	Medical Text: Admission Date: [2167-2-26] Discharge Date: [2167-3-7] Date of Birth: [2138-8-11] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: palpitations Major Surgical or Invasive Procedure: repair Sinus of Valsalva aneurysm rupture([3-3]) History of Present Illness: 28 yo M who 2 days PTA felt a racing heart rate, presented to ED and was found to be in sinus tach. Cardiac cath at OSH showed a large defect in the right sinus of valsalva with left to right shunt from the aorta to the right atrium. Transferred for surgery. Past Medical History: childhood murmur, palpitations Social History: works in operations for BJs denies toabcco, etoh Family History: NC Physical Exam: NAD Lungs CTAB Heart RRR, tachycardic, [5-17] HSM loudest at apex, heard t/o precordium Abdomen Benign Extrem warm, No edema, 2+ pulses t/o Pertinent Results: [2167-3-7] 07:20AM BLOOD WBC-5.2 RBC-2.79* Hgb-8.3* Hct-23.9* MCV-86 MCH-29.7 MCHC-34.7 RDW-13.4 Plt Ct-166 [2167-3-7] 07:20AM BLOOD PT-13.5* PTT-27.6 INR(PT)-1.2* RADIOLOGY Preliminary Report CHEST (PA & LAT) [2167-3-6] 2:05 PM CHEST (PA & LAT) Reason: eval pneumothoraces [Hospital 93] MEDICAL CONDITION: 28 year old man s/p repair og sinu of valsalva rupture REASON FOR THIS EXAMINATION: s/p thoracentesis INDICATION: 28-year-old status post repair of sinus of Valsalva rupture, status post thoracentesis. PA AND LATERAL CHEST: Compared to [2167-3-5]. There has been interval decrease in the bilateral pleural effusions which remain moderately large on the left and small on the right, with bibasilar atelectasis. No pneumothorax is seen. Median sternotomy wires are intact in midline. IMPRESSION: Slight decrease in bilateral effusions, moderate on the left and small on the right, with bibasilar atelectasis. No pneumothorax. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] DR. [First Name8 (NamePattern2) 1569] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11006] [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname 49107] [Hospital1 18] [Numeric Identifier 49108] (Complete) Done [2167-3-3] at 3:59:21 PM FINAL Referring Physician [Name9 (PRE) ] Information [Last Name (Prefixes) 413], [First Name3 (LF) 412] 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: [2138-8-11] Age (years): 28 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Congenital heart disease. Left ventricular function. Preoperative assessment. Right ventricular function. ICD-9 Codes: 441.2 Test Information Date/Time: [2167-3-3] at 15:59 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 168], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW33-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Diastolic Dimension: 6.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Annulus: 2.4 cm <= 3.0 cm Aorta - Sinus Level: 3.9 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Low normal LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Sinus of Valsalva aneurysm. AORTIC VALVE: Normal aortic valve leaflets (3). Trace AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Conclusions PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque.There is a right coronary sinus of Valsalva aneurysm. A [Location (un) 49109] appears in the RA and there is left to right shunt. It is uncertain if there is involvement of the TV. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. POSTBYPASS: Right ventricular function remains preserved. Left ventricular function remains borderline normal. The tricuspid valve appears normal and there is trace TR. The defect in the right coronary sinus is no longer visualized and there is no longer left to right shunting on color flow Doppler. The remaining study is unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 168], MD, Interpreting physician [Last Name (NamePattern4) ] [2167-3-3] 17:38 Brief Hospital Course: Mr. [Known lastname ] was admitted under cardiac surgery. His creatinine was elevated, PO fluids were encouraged, with improvement in renal function. He remained tachycardic, and his beta blockers were titrated accordingly. On [2167-3-3] he underwent primary closure of sinus of valsalva aneurysm rupture. For surgical details, please see seperate dictated operative note. Following the operation, he was transferred to the ICU in stable condition. He was given 48 hours of Vanocmycin as he was in the hospital preoperatively. He awoke neurologically intact and was extubated later that same day. He was transferred to the floor on POD #1. He went in to rapid atrial fibrillation and was treated with increased beta blockade and Amiodarone. He was also transfused for a hematocrit of 22%. Within 24 hours, he converted back into a normal sinus rhythm. Over the next several days, he continued to make clinical improvements with diuresis. He remained in a normal sinus rhythm without further episodes of atrial fibrillation. He had a moderate L effusion which was tapped on POD#3 for a bloody effusion. His CXR still revealed a mild effusion and he will return for f/u with Dr. [Last Name (STitle) 1290] for a repeat CXR in 1.5 weeks. He was discharged to home in stable condition on POD#4. Medications on Admission: MVI Discharge Medications: 1. 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 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: Decrease dose to 400 mg PO daily for 7 days after [Hospital1 ] dose completed. Then decrease dose to 200 mg PO daily after 400 mg dose completed. Disp:50 Tablet(s) Refills:0 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:50 Tablet(s) Refills:0 9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed: Take with food. Disp:90 Tablet(s) Refills:0 10. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: TBA Discharge Diagnosis: Sinus of valsalva Aneurysm Rupture - s/p surgical repair Postoperative Atrial Fibrillation History childhood murmur Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower daily, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon or while taking pain medicine. Followup Instructions: Make an appointment with Dr. [Last Name (STitle) 1290] for Thurs. [3-19] in [Location (un) 47] and have a repeat chest xray. Call [Telephone/Fax (1) ] to arrange appointment. Dr. [Last Name (STitle) 20222] 2 weeks - call for appt Completed by:[2167-3-7] ICD9 Codes: 9971, 5119
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8032 }	Medical Text: Admission Date: [2121-4-30] Discharge Date: [2121-5-7] Date of Birth: [2053-11-18] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1481] Chief Complaint: intramucosal esophageal adenocarcinoma Major Surgical or Invasive Procedure: [2121-4-30] minimally invasive esophagogastrectomy History of Present Illness: Patient is a 67-year-old gentleman who had a workup for anemia, which included an upper endoscopy with biopsies, which showed at least high-grade dysplasia. Further investigations have shown what appeared to be intramucosal carcinoma. Endomucosal resection was attempted, demonstrating intramucosal carcinoma without invasion into the submucosa. However, the margin of the endomucosal resection was positive. He has had no dysphagia and otherwise feels well. Past Medical History: PMHx: coronary artery disease s/p drug-eluting stent placed [2117], chronic lung disease, Type 2 diabetes, and hypertension. PSurgHx: bilateral inguinal hernia repair Social History: Denies drinking. He has a 70-pack-year history of smoking cigarettes, but quit 10 years ago. He has smoked [3-29] cigar per day for the last three years. He works as a writer. Family History: Mother deceased from lung cancer Physical Exam: post-op exam: T 97.8 HR 67 BP 144/57 RR 14 SpO2 100% on 12L NC gen: NAD cardiac: RRR chest: decreased breath sounds right lower lobe, chest tube to -20 sxn without leak abd: mod distended, tender, middle port site dressing with serosanguinous drainage, other dressings clean Pertinent Results: [2121-4-30] 08:30AM PT-13.5* PTT-24.3 INR(PT)-1.2* [2121-4-30] 08:30AM PLT COUNT-280 [2121-4-30] 08:30AM WBC-5.6 RBC-4.44* HGB-10.3* HCT-33.1* MCV-74* MCH-23.2* MCHC-31.2 RDW-16.1* [2121-4-30] 08:30AM ALBUMIN-4.6 CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-1.9 URIC ACID-5.0 [2121-4-30] 08:30AM GLUCOSE-91 UREA N-15 CREAT-0.8 SODIUM-139 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-31 ANION GAP-11 Pathology [2121-4-30]: pT1a pN0 adenocarcinoma of lower thoracic esophagus, margins clear CXR [2121-5-5]: As compared to the previous radiograph, there is no relevant change. The appearance of the right lung, including the site of surgery, is unchanged, the monitoring and support devices are constant. A second line along the nasogastric tube appears to be exterior to the patient. The small right pleural effusion and the postoperative opacities in the right lung have not increased in size. Unchanged small left pleural effusion and retrocardiac atelectasis. [2121-5-5] UGI: 1. No evidence of leak or obstruction. 2. Small amount of oral contrast material is seen tracking into the airway, consistent with aspiration. [2121-5-6] video oropharyngeal swallow: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There is no gross aspiration or penetration. For more details, please refer to the speech and swallow division note in OMR. Brief Hospital Course: Patient was admitted [2121-4-30] for a minimally invasive esophagogastrectomy. Refer to operative notes from Drs. [Last Name (STitle) ] and [Name5 (PTitle) ] for further detail. Patient was transferred stable and extubated to the ICU with an NG tube, right [Doctor Last Name 406] chest tube, J-tube, Foley, and neck JP drain. Pain was well-controlled on PCA. On [2121-5-1] chest tube was changed from suction to water seal and patient was transferred from the ICU to the floor. Tube feeds were started and advanced to goal of 115 mL/hr over 16 hours. Since his surgery, patient maintained a persistent oxygen requirement, likely related to his chronic lung disease, and would desaturate to the mid-80s, though as low as 60s-70s, on room air. Chest xrays were checked daily and showed L>R atelectasis and no evidence of pneumothorax. On [5-5] patient underwent esophogram, which showed no evidence of leak but a question of aspiration, which in retrospect appear to have been artifactual. NG tube, chest tube, and Foley were discontinued. Patient was continued on NPO status until [5-6] when video oropharyngeal swallow study was performed, which showed no evidence of aspiration or penetration. Patient was started on a full diet and tube feeds were advanced to goal. On [5-7] JP was removed as output was minimal. Patient was evaluated by physical therapy over his stay and found to have good function. Oxygen therapy was attempted to be weaned multiple times, but patient was still requiring 3L NC as of discharge. Patient was tolerating a full diet, ambulating, and was receiving good pain control. He was discharged home on home oxygen and tube feeds via J-tube. Medications on Admission: atorvastatin 80', carvedilol 6.25', clopidogrel 75', glyburide 2.5', lisinopril 10', metformin 850', nitroglycerin 0.4 SL, omeprazole 40", vit C 1000', ASA 81', vit D3 1000U', vit B12', iron 325' Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Colace 60 mg/15 mL Syrup Sig: Twenty Five (25) mL PO twice a day. Disp:750 mL Refills:1 3. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:150 ML(s) Refills:0 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metformin 850 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. home oxygen therapy indication: room air SpO2 <88% 3L/min continuous for portability pulse dose system 13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: esophageal intramucosal adenocarcinoma Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the West 3 surgery service for minimally-invasive esophagectomy. Please call your doctor or go to the emergency department if: You experience new chest pain, pressure, squeezing or tightness. You develop new or worsening cough, shortness of breath, or wheeze. 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 an unusual discharge. Your pain is not improving within 12 hours or is not under control within 24 hours. Your pain worsens or changes location. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. You steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Continue to use home oxygen as directed until your oxygen saturation improves. Followup Instructions: Call ([Telephone/Fax (1) 1483] to make an appointment to see Dr. [Last Name (STitle) ] 10-14 days after your discharge. Call ([Telephone/Fax (1) 1483] to make an appointment to see Dr. [Last Name (STitle) ] 10-14 days after your discharge. ICD9 Codes: 5180, 496, 412, 4019, 2859, 2724, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8033 }	Medical Text: Admission Date: [2184-6-23] Discharge Date: [2184-6-26] Date of Birth: [2126-9-4] Sex: M Service: OTOLARYNGOLOGY Allergies: Ace Inhibitors / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / [Last Name (un) ]-Angiotensin Receptor Antagonist Attending:[First Name3 (LF) 4181] Chief Complaint: Throat/neck swelling Major Surgical or Invasive Procedure: Awake fiberoptic intubation History of Present Illness: 57yo M presented to ED with 2 hours of progressive tongue and floor of mouth swelling. It started suddenly and steadily worsened prior to presentation. He was unable to speak, could not tolerate his secretions. Upon arrival his tongue and floor of mouth were severely swollen and he was drooling. He was breathing easily without stridor, wheeze, or tachypnea. He notes he had a dental cleaning recently, but no tooth extractions. He does take an ace inhibitor at home. Due to rapidly worsening edema, the decision was made to electively intubate the patient in the OR. An awake fiber optic intubation was performed successfully. The patient was subsequently transferred to the ICU for recovery. Past Medical History: Gout HTN Hypercholesterolemia Erectile dsyfunction Angioedema secondary to ace inhibitor Social History: lives with girlfriend/wife, looking for a job but was in banking, no children, doesn't smoke, drinks occasional wine Family History: noncontributory Physical Exam: On admission: Vital Signs: in ED afebrile, VSS General: sitting up, drooling, unable to speak OP: severely swollen tongue with superior displacement, firm floor of mouth, drooling Neck: firm, swollen submandibular areas bilaterally with pitting edema Respiratory Effort: No stridor or stertor FLEXIBLE FIBEROPTIC EXAM ‎ ‎‎Nasal Cavity: normal mucosa Nasopharynx: normal mucosa Oropharynx: severely narrowed AP diameter, swollen base of tongue Hypopharynx: No masses or lesions in vallecula, piriform sinuses, or post-cricoid area; mild edema; no pooling of secretions Larynx: epiglottis crisp; arytenoids no edema/erythema; true vocal cords symmetric with nml movement b/l ‎‎ On Discharge: Vital signs stable, afebrile General: sitting up, NAD, AAOx3 OP: No signs of swelling or edema Neck: soft, swelling greatly improved Respiratory Effort: No stridor or stertor, CTAB Pertinent Results: [2184-6-25] 02:06AM BLOOD WBC-7.0# RBC-4.02* Hgb-13.4* Hct-38.4* MCV-96 MCH-33.2* MCHC-34.7 RDW-12.9 Plt Ct-172 [2184-6-24] 02:24AM BLOOD WBC-4.4 RBC-4.21* Hgb-13.9* Hct-39.7* MCV-94 MCH-33.0* MCHC-35.0 RDW-12.6 Plt Ct-184 [2184-6-23] 01:40PM BLOOD WBC-5.6 RBC-4.90 Hgb-16.1 Hct-46.2 MCV-94 MCH-33.0* MCHC-34.9 RDW-12.8 Plt Ct-234 [2184-6-23] 01:40PM BLOOD Neuts-59.7 Lymphs-33.5 Monos-4.9 Eos-1.3 Baso-0.6 [2184-6-23] 01:40PM BLOOD PT-10.8 PTT-32.6 INR(PT)-1.0 [2184-6-23] 01:40PM BLOOD Plt Ct-234 [2184-6-25] 02:06AM BLOOD Glucose-182* UreaN-14 Creat-0.8 Na-134 K-4.0 Cl-101 HCO3-25 AnGap-12 [2184-6-23] 01:40PM BLOOD Glucose-119* UreaN-21* Creat-0.9 Na-138 K-3.8 Cl-100 HCO3-25 AnGap-17 [2184-6-24] 02:38PM BLOOD TotProt-6.2* UricAcd-2.8* [2184-6-24] 02:38PM BLOOD PEP-AWAITING F IgG-1040 IgA-347 IgM-87 IFE-PND [2184-6-24] 02:38PM BLOOD C3-144 C4-37 [2184-6-23] 01:40PM BLOOD C4-45* [2184-6-23] 10:03PM BLOOD Type-ART Temp-36.6 Rates-16/ Tidal V-600 PEEP-5 FiO2-60 pO2-178* pCO2-35 pH-7.42 calTCO2-23 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [2184-6-23] 10:03PM BLOOD Lactate-1.0 [2184-6-23] 01:44PM BLOOD Lactate-1.6 Brief Hospital Course: 57yo M presented to ED with 2 hours of progressive tongue and floor of mouth swelling. It started suddenly and steadily worsened prior to presentation. He was unable to speak, could not tolerate his secretions. Upon arrival his tongue and floor of mouth were severely swollen and he was drooling. He was breathing easily without stridor, wheeze, or tachypnea. He notes he had a dental cleaning recently, but no tooth extractions. He does take an ace inhibitor at home. Due to rapidly worsening edema, the decision was made to electively intubate the patient in the OR. An awake fiber optic intubation was performed successfully. The patient was subsequently transferred to the ICU for recovery. The patient was then extubated in the ICU when swelling improved after starting IV benadryl and steroids. Patient was evaluated by ENT and allergist who attributed this episode to likely a reaction to his ace-inhibitor. He was advised to never take ACE-I again, along with [Last Name (un) ] for possible cross-reactivity. Furthermore, the Allergy team recommended avoid NSAIDs as they can worsen angioedema. Post extubation he was tolerating a regular diet without dsyphagia or food getting stuck and was discharged directly from the ICU to home. Medications on Admission: 1. Atenolol 100 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. NIFEdipine CR 30 mg PO DAILY 5. Trandolapril 4mg PO BID 6. indomethacin 25mg PO BID PRN 7. Viagra 50mg PO PRN Discharge Medications: 1. Atenolol 100 mg PO DAILY Hold for SBP <100 or HR <60 2. Atorvastatin 20 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. NIFEdipine CR 30 mg PO DAILY 5. Viagra 50mg PO PRN Discharge Disposition: Home Discharge Diagnosis: Angioedema due to ace inhibitor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for swelling of your throat and tongue. You were intubated with a fiberoptic scope in the OR in order to secure your airway. You are recovering well your swelling/allergic reaction and are being discharged home now that you have been extubated (tube removed from your throat) and you are breathing and eating well. ACTIVITY: You may resume normal activity. You may bathe and shower normally. HOW YOU [Month (only) ] FEEL: You may have a sore throat because of a tube that was in your throat. This is normal and should get better. If at any point you feel you are having trouble speaking or swallowing, contact your doctor. If you have difficulty breathing at any point, go directly to the emergency room. MEDICATIONS: You may resume your previous home medications EXCEPT any ace inhibitors, aspirin, ibuprofen, or other NSAIDs. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3031], M.D. Phone:[Telephone/Fax (1) 2010] Date/Time:[2184-6-28] 10:00 Please follow up with Dr. [Last Name (STitle) ] (ENT), clinic number [Telephone/Fax (1) 9312] Please follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9313] (Allergy) ICD9 Codes: 4019, 2749, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8034 }	Medical Text: Unit No: [Numeric Identifier 71650] Admission Date: [2109-1-24] Discharge Date: [2109-2-14] Date of Birth: [2109-1-24] Sex: M Service: NB This is an interim summary, dictated on [2109-2-8]. HISTORY OF PRESENT ILLNESS: The patient was born at 33 and 4/7 weeks and was admitted to the Neonatal Intensive Care Unit for prematurity, rule out sepsis and dermatologic work- up. PHYSICAL EXAMINATION: On admission, baby was [2006] [Name2 (NI) ], which is 50th percentile. Length was 46 cm which was 75th percentile and head circumference was 31 cm which was 50th percentile. Otherwise, physical examination was notable for a large erythematous patch on the anterior central forehead, consistent with port wine stain. HOSPITAL COURSE BY SYSTEMS: Respiratory: Baby did not have significant respiratory distress and was on room air from the time of delivery. Apgars were 8 and 9. No significant resuscitation was required. Cardiovascular: The infnat has remained hemodynamically stable, and has been monitored for duration of stay. No significant apneic or bradycardiac spells. Fluids, electrolytes and nutrition: Patient began feeds on day of life 2 and was on full volume feeds on day of life 5, with calories increased to 26 kilocalories per ounce at the time of discharge. The patient is feeding breast milk supplemented with HMF and MCT oil. Weight on [2109-2-8] was 2,055 [Date Range ] with 55 [Date Range ] of birth weight over the past 2 days, averaging 32.5 [Date Range ] per day or approximately 15 [Date Range ] per kg. Gastrointestinal: Feeds were tolerated well without significant spits or aspirates. Peak bilirubin was 13.5 on day of life 3 for which phototherapy was initiated. Rebound bilirubin of 8.4 on day of life 11 obtained. Patient is not clinically jaundiced. Hematology: The infant has received iron and vitamin E at the time of discharge. The last hematocrit was 49 which was obtained at birth. Infectious disease: The patient was ruled out for sepsis. Antibiotics were discontinued at 48 hours for negative cultures. Neurology: Not applicable. Sensory: Hearing screening was performed with automated auditory brain stem responses. Infant passed. Ophthalmology: Screening for ROP was not indicated based on gestational age. Psychosocial: Not applicable. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. NAME OF PRIMARY PEDIATRICIAN: [Hospital 1426] Pediatrics, phone number [Telephone/Fax (1) 37802]. CARE RECOMMENDATIONS: Feeds at discharge: Breast milk 26 kilocalories per ounce, ad lib p.o. MEDICATIONS: Iron and vitamin E. CAR SEAT POSITION SCREENING: Pending. STATE NEWBORN SCREENING STATUS: Sent, prior to discharge. IMMUNIZATIONS: Hep B given prior to discharge. 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. FOLLOW UP: Appointment to be scheduled with [Hospital 1426] Pediatrics. Pediatrician called on [2109-2-8] for likely discharge over week-end. DISCHARGE DIAGNOSES: 1. Prematurity, resolved. 2. Rule out sepsis, resolved. 3. Port wine stain versus hemangioma on anterior central scalp; evaluated by dermatology and recommended for outpatient follow-up at one month of age. Reviewed By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 53043], [MD Number(1) 53044] MEDQUIST36 D: [2109-2-8] 17:09:21 T: [2109-2-8] 17:52:07 Job#: [Job Number 71651] ICD9 Codes: 7742, V053, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8035 }	Medical Text: Admission Date: [2184-2-20] Discharge Date: [2184-3-17] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Penicillins / Clindamycin / Tetracycline / Cozaar / Zestril / Coreg / Toprol Xl Attending:[First Name3 (LF) 7202] Chief Complaint: abdominal pain, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: This is a 87 year old man with multiple medical problesm including coronary artery disease status post coronary artery bypass graft, congestive heart failure with ejection fraction of 20-30%, status post pacemaker for sick sinus syndrome, atrial fibrillation on coumadin, chronic lower back pain who was transferred from [Hospital3 7571]Hospital to the vascular service with concern for aortic dissection. . The patient reports that he began to develop diarrhea several weeks prior to admission. This diarrhea is only during the day, not related to eating. Per the nurse, the patient's stool is liquid, brown, no bright red blood per rectum. The patient also developed nausea and epigastric pain one week prior to admission. The epigastric pain is sharp, constant, unrelated to eating and without exacerbating or alleviating factors. The patient denies emesis, recent travel, or recent antibiotic use. . The pt presented to [Location (un) ] emergency department on [2184-2-15] for these symptoms, and was noted to have an abdominal aorta aneurysm at the level of the renal artery as well as a short aortic dissection on CT. Repeat CT here revealed a 2 cm aortic dissection at level of renal arteries, with possible chronicity. The patient is transferred to medicine for blood pressure management given patient's systolic blood pressure was up to 198 on day of admission. . On review of systems, patient denies fever, decreased appetite. He complains of worsened sciatica down his right leg. Past Medical History: 1. coronary artery disease 2. pacemaker for sick sinus syndrome, right bundle branch block 3. cardiomyopathy with ejection fraction 20-30% 4. congestive heart failure 5. osteoarthritis 6. severe low back pain 7. gastroespophageal reflux disease 8. orthostatic hypotension 9. atrial fibrillation with cardioversion 10.peripheral neuropathy 11.degenerative joint disease 12.chronic pain 13.pulmonary embolus x2 [92].atrial appendage clot 15.depression 16.hypercholesterolemia 17.history of campylobacter PSH: CABG x2 [66] / 98, Left subclavian [Name (NI) ], PTCA [69], anterior scalenectomy, lap CCY, b/l carpal tunnel, multiple hernia repair Social History: Lives in a room in a monastery. Drinks one alcoholic beverage every couple of weeks. Quit smoking 30 years ago. No illicit drug use. Family History: NC Physical Exam: Vitals: Tm 99.1 Tc 98.1 P 45-77 BP 118-198/50-85 Sat 95-96%RA General: thin man laying flat in bed, NAD HEENT: PERRL, NCAT, conjunctivae anicteric and noninjected, dry MM, scale and erythema noted in nasolabial folds Neck: no JVD, supple CV: mostly RRR but occasional PVCs per monitor, Grade 2/6 SEM LUSB, PCM palpable in L chest wall, median sternotomy scar well healed Lungs: bibasilar rales, decreased breath sounds, hyperresonant to percussion Abd: soft, NABS, tender to palp in epigastric region without rebound tenderness Extrem: no c/c/e, full dp/pt pulses Neuro: a and ox 3, CNII-XII grossly intact Pertinent Results: [2178] cath: COMMENTS: 1. Coronary angiography in this right dominants system revealed severe left main and three vessel CAD. The left main coronary artery was diffusely diseased with a 70% distal stenosis. The LAD was totally occluded proximally. The left circumflex artery had a 70% mid-vessel stenosis and the first obtuse marginal branch was totally occluded. The RCA was occluded immediately distal to its origin. 2. Graft angiography revealed patent SVGs. The SVG to the LAD was widely patent. The skip SVG to the first and second diagonal branchs had moderate luminal irregularities throughout its course. The SVG to the obtuse marginal branch was patent. The SVG to the rPDA was patent and the native posterolateral branch beyond the anastamosis was diffusely diseased. 3. Resting hemodynamic studies revealed normal right and left sided filling pressure. The mean RA pressure was 3 mmHg, teh mean PCWP was 5 mmHg, and the LVEDP was 6 mmHg. The cardiac index was marginally depressed at 2.4 L/min/m2. 4. Left ventriculography revealed global hypokinesis with more severe apical hypokinesis and inferior wall akinesis. The estimated LVEF was 30-35%. FINAL DIAGNOSIS: 1. Severe left main and native three vessel coronary artery disease. 2. Patent SVGs to the LAD, skip diagonals, obtuse marginal and rPDA. 3. Severe systolic ventricular dysfunction. Labs on admission: WBC 7.1 Hct 39.5* MCV 81* Plt Ct 206 Neuts 66.9 Lymphs 23.7 Monos 6.2 Eos 2.5 Baso 0.7 . Glucose 103 UreaN 10 Creat 1.6* Na 141 K 3.5 Cl 104 HCO3 26 AnGap 15 Albumin 4.1 Calcium 9.0 Phos 2.9 Mg 1.8 . ALT 8 AST 20 LD(LDH) 191 47 AlkPhos 59 Amylase 42 Lipase 24 TotBili 0.7 PT 39.1* PTT 38.4* INR(PT) 4.4* . Lactate 1.2 TSH 0.42 Digoxin 0.5* . UA negative . Additional Labs: [2184-2-27] 02:40PM CK(CPK) 73 cTropnT <0.01 [2184-2-27] 09:00PM CK(CPK) 49 cTropnT <0.01 [2184-2-28] 06:40AM CK(CPK) 43 cTropnT <0.01 . [2184-2-29] 08:33AM BLOOD Cortsol 27.1* . [2184-2-27] 06:49AM URINE Color Yellow Appear Clear Sp [Last Name (un) ] 1.013 Blood NEG Nitrite NEG Protein NEG Glucose NEG Ketone NEG Bilirub NEG Urobiln NEG pH 5.0 Leuks NEG RBC 0 WBC [3-28] Bacteri FEW Yeast NONE Epi 0 CastHy [3-28]* Mucous OCC Eos NEGATIVE . [2184-2-22] 12:55PM URINE Osmolal 356 UreaN 433 Creat 159 Na 33 . STOOL CULTURE x2: neg C diff: neg OVP x2: negative URINE CULTURE x2: neg BLOOD CULTURE x2: neg . C diff: PENDING OVP x2: PENDING . Studies: . CXR [2184-2-20]: 1. Cardiac pacer leads terminate in the right atrium and the right ventricle. 2. Elevated left hemidiaphragm. . CT abdomen [2-21]: 1. No evidence of thoracic aortic dissection. 2. Emphysema. 3. A 13 mm vague nodular density in the right middle lobe, which should be evaluated further within three months (as well as a 7 mm nodular density at the left base as well, which can be re-evaluated at he same time). 4. Severe stenosis at the origin of the left renal artery with relative atrophy of the left kidney compared to the right. 5. Short 2cm dissection of the aorta at the level of the renal arteries. Although of uncertain chronicity, the appearance may be chronic. 6. Small abdominal aortic aneurysm. 7. Right common iliac aneurysm. 8. Compression fracture of T12, probably chronic. . EKG [2184-2-25]: A-V sequential pacemaker pacemaker rhythm Intervals Axes Rate PR QRS QT/QTc P QRS T 60 0 168 450/450 0 -73 103 . CHEST (PORTABLE AP) [2184-2-28]: The portable erect AP radiograph of the chest is reviewed, and compared with the previous study of yesterday. . The patient has prior CABG and median sternotomy. Pacemaker leads remain in place. There is increase in mild congestive heart failure with cardiomegaly with small right pleural effusion. There is increase in bibasilar patchy atelectasis. . Again, note is made of marked tortuosity of the thoracic aorta with calcification. No pneumothorax is identified. [2184-3-4] Echo: Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is difficult to assess but is moderately depressed. Overall left ventricular EF cannot be reliably assessed. 3. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. INDICATION: 87-year-old male with throat pain, equivocal bedside evaluation. Video oropharyngeal swallow. FINDINGS: Note is made of moderate amount of pharyngeal residue after multiple swallowing attempts. Note is made of penetration at thin barium swallow, more with straw than cup sip. No evidence of aspiration is seen. Please also refer to the official report by speech and lung pathologist available on CareWeb. [2184-3-10] Echo Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%); the apex appears hypokinetic. Due to suboptimal technical quality, another focal wall motion abnormality cannot be fully excluded. Right ventricular contracrtile function appears normal; there is abnormal septal activation suggestive of intraventricular conduction delay. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The aortic root 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. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2184-3-4], no major change is evident. [2184-3-13] AXR Oral contrast is present within the distal rectosigmoid region, possibly related to contrast administered during a video swallow study of [2184-3-9], unless a more recent contrast study has been performed elsewhere in the interval. Again demonstrated are numerous air filled loops of small and bowel, likely related to an ileus. If there is strong clinical suspicion for an obstructive process, additional upright view may be considered for more complete assessment if warranted clinically. CXR [3-8]: COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared with the previous study of [2184-3-6]. There is continued mild-to-moderate congestive heart failure with cardiomegaly, which is superimposed on patient's underlying severe emphysema. There is increased opacity in the right lower lobe indicating superimposed pneumonia or aspiration. The patient has prior CABG and median sternotomy. Uppermost cerclage wires of the sternum has been broken. Pacemaker leads remain in place. There is continued tortuosity of the thoracic aorta with calcification. No pneumothorax is identified. . CT ABD: IMPRESSION: 1. No evidence of thoracic aortic dissection. 2. Emphysema. 3. A 13 mm vague nodular density in the right middle lobe, which should be evaluated further within three months (as well as a 7 mm nodular density at the left base as well, which can be re-evaluated at the same time). 4. Severe stenosis at the origin of the left renal artery with relative atrophy of the left kidney compared to the right. 5. Short 2cm dissection of the aorta at the level of the renal arteries. Although of uncertain chronicity, the appearance may be chronic. 6. Small abdominal aortic aneurysm. 7. Right common iliac aneurysm. 8. Compression fracture of T12, probably chronic Brief Hospital Course: This 87 yo man with history of CAD s/p CABG, CHF EF 20-30%, s/p PCM for SSS, A fib on coumadin, chronic [Hospital 16825] transferred from [Hospital3 ]hospital [2184-2-20] initially to Vascular service with concern for aortic dissection now having hypoxia. The pt presented to [Location (un) ] ER with diarrhea and cramping and was noted to have an AAA at the level of the renal artery as well as a short aortic dissection on CT. Repeat CT here 2 cm aortic dissection at level of renal arteries, with possible chronicity. Surgery had no plan to intervene on him so pt was transferred to medicine for BP management given pts SBP up to 198. His BP was controlled with hydral and imdur then his BP dropped so these were held. His cardiologist advised conversion from atrial fibrillation. He was electrically cardioverted and treated with Amiodarone and Digoxin. He remained in NSR. . On the night of [2184-3-2] a "trigger" was called as he was found to be hypoxic, 78% on 5L NC. ABG 7.39/44/78 on NRB, lactate 1.6. He was treated with Lasix and his hypoxia resolved. Later that evening he was having chest pain, NTG given and BP dropped to 78/p, improved with fluid. Today was sent down for V/Q scan. Upon return from V/Q scan he was hypoxic to the 80s. He was placed on NRB and his sats went to 94%. MICU was called to evaluate him given the need for closer monitoring. . MICU course: For his hypoxia, he was treated for pulmonary edema by diuresis with IV lasix, as well as cont treatment for his CAP. V/q scan was low prob for PE. Started on lasix gtt MICU d #3, placed on vancomycin for nosocomial PNA, pt to recieve 7 more days. Changed to lasix 60 mg IV on [3-8]. Pt complained of chest pain on [3-8], relieved with 1 SL NTG, became hypoxic with sats 86%, placed on NRB. Increased lasix to 100 mg tid, d/c afterload reduction. Speech and swallow [Month/Year (2) ] without aspiration, ? silent asp. Began txt for thrush. Narcotics held [2-26] low BP. Pt was transferred to [Hospital Unit Name 196] service for further CHF mgmt. . Pt has had a long history of ischemic heart disease with h/o cath + CABG. During the [Hospital 228] hospital course, he was having several episodes of L sided pleuritic chest pain which was alleviated with a lidocaine patch. There were no ekg changes during the episodes of the chest pain. Several sets of cardiac enzymes were taken during the chest pain episodes and were negative each time. Due to the patient's high risk profile, the patient was resterted on aspirin 325. No further coronary intervention was undertaken during his hospital stay. .. PUMP: BNP 1301 on transfer to [Hospital Unit Name 196]. systolic function is low normal (LVEF 50%) by recent echo; the apex appeared hypokinetic. In the MICU, the patient was unresponsive to lasix gtt and standing dose of lasix. Patient was gently diuresed with HCTZ and PO lasix once on the floor with limited efficacy. When BUN/Cr contined to climb, a decision was made to scale back the diuretic dosing. While at rehab, volume status should be At rehab, please hold the captopril dosing for SBP < 90. Pt always runs higher blood pressures on the R arm, since has a h/o subclavian stenosis on the L side. Also, pt tends to run low blood pressures while sitting up although he is asymptomatic. The blood pressure returns up to 100 once the patient is back in bed. . Hypoxia: [2-26] CHF and potential nosocomial PNA. Patient has bibasilar infiltrates on CXR. Was treated empirically in the MICU for aspiration pneumonia, completed 7 days of vancoomycin. While on the floor, WBC count was trending down. PNA appears resolving, WBC trending down, pt afebrile. ID consulted and recommended d/c abx. The patient has passed his speech and swallow [Last Name (LF) ], [First Name3 (LF) ] aspiration events were less likely. CXR done on [3-15] did not show any change from previous while the patient's oxygen dramatically improved. When the patient left the MICU, he was on a high flow O2 mask. While on the floor, he was weaned down to 4L by NC, sating 93-94%. -cont CHF mgmt as above . AF: Pacer, s/p DCCV in past, on amiodarone and anticoagulation. Patient had paced rhythm on his EKG w/o any changes with chest pain epidoses. He was continued on amiodarone. The patient was anti-coagulated with coumadin. During the last few days of his hospitalization, coumadin was held due to elevated INR. While at rehab, the patient's INR should be carefully monitored, checked at least 3 times per week and as needed, and coumadin dosing should be adjusted as necessary. . CRI: patient has had a chronic h/o CRI with baseline Cr 1.6-1.7. His Cr bumped with aggressive IV diuresis, so diuretics were switched to PO and decreased dosing. On discharge, the patient's Cr was 2.2 (close to baseline). It was recommended that the patient follows up with his PCP or his nephrologist for his renal issues. . Abdominal Pain: patient was found to be full of stool on AXR/vs contrast from prior speech/swallow study. Pt given enemas and felt better, responding with lots of stool. More aggressive bowel regimen was started. Abdominal pain was monitored carefully since the patient does have an infrarenal AAA. Should the patient have more severe abdominal or back pain or drop in his Hct, an urgent evaluation for progression of AAA or dissection should be considered. . AAA: patient was originally admitted to the surgical service to evalute his AAA and abdominal aortic disection. After thorough evaluation, he was deemend not a surgical candidate and optimal BP control was recommended. The patient was also started on a statin. While on the medical service, the blood pressure remained well controlled. Surgical service recommends re-imaging CT scan of the abdomen to document the progression or stability of his disease. . Medications on Admission: [Last Name (un) 1724]: midodrine 7.5 tid, digoxin 0.125 qod, lasix 40, coumadin 2.5, mevacor 20, prevacid 30, norvasc 2.5, nuerontin 200 "', xanax prn, nitroquick 0.4, oxycontin 20 ", oxycodone 5 prn, colchicine 0.6 . Meds on Transfer: Xanax 0.5 mg po TID prn, amlodipine 2.5 mg po qd, atorvastatin 20 mg po qd, bisacodyl prn, colchicine 0.6 qd, dig 0.125 mg qod, colace, anzemet prn, Lasix 40 mg po qd, nuerontin 200 mg TID, dilaudid prn, hydral 20 mg IV q6 hr, Lansoprazole 30 mg po qd, levothyroxine 88 ug, day, midodrine 7.5 mg po tid, NTG patch, senna, percocet Discharge Medications: 1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 6. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Ten (10) ML Mucous membrane QID (4 times a day) as needed. 8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) inj Subcutaneous ASDIR (AS DIRECTED): please refer to the attached sliding scale. 14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for chronic pain: apply to Left upper chest as needed for chest pain/pressure. 18. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 20. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 22. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 23. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): please hold [2184-3-17] and [2184-3-18] dosing. 24. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 25. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: Life Care Centers of [Location (un) ] Discharge Diagnosis: primary diagnosis: 1. chronic type III aortic dissection 2. paroxysmal atrial fibrillation s/p cardioversion 3. epigastric hiatal hernia 4. Congestive heart failure 5. failure to thrive . secondary diagnosis: Discharge Condition: stable, ambulatory, satting 100% on 3L O2 by nasal cannula Discharge Instructions: Please take medications as prescribed. . Please keep follow-up appointments. . If you have acute worsening abdominal or back pain, lightheadedness, fever/chills or any other concerning symptoms please call your primary care physician or return to the emergency room. . Staff: please follow patient's INR. Patient is anti-coagulated with coumadin for afib and SSS. INR level should be [2-27]. Patient will need his INR checked daily. Please hold [3-17] and [3-18] dosing of coumadin. Re-check INR on [3-19]. Restart warfarin as needed to keep INR [2-27]. . Please check pt's blood pressures. Please do not administer captopril if SBP < 90 . please ambulate the patient and get the patient out of bed as tolerated. Followup Instructions: You must ask your primary care physician to order [Name Initial (PRE) ] noncontrast cat scan of your chest within 3-6 months to follow-up on a nodule in the right middle lobe of your lung that was incidentally found on your cat scan. . call your PCP [Name9 (PRE) 16826],[Name9 (PRE) ] [Name Initial (PRE) ]. [Telephone/Fax (1) 16827] to make a follow up appointment to discuass your heart condition . Please call your primary care physician to arrange [Name9 (PRE) 702] in coumadin clinic for managment of your INR and proper dosing of your coumadin. Completed by:[2184-3-17] ICD9 Codes: 4280, 5070, 5849
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8036 }	Medical Text: Admission Date: [2195-11-27] Discharge Date: [2195-12-3] Date of Birth: [2130-10-1] Sex: F Service: MEDICINE Allergies: Statins-Hmg-Coa Reductase Inhibitors / Reglan / Pravastatin Attending:[First Name3 (LF) 38277] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname 10528] is a 65 year old woman with diabetes, hypertension, hyperlipidemia, and prior remote left circumflex MI transferred from OSH to our CCU for evaluation and treatment of CHF exacerbation. Two weeks ago she was admitted to OSH for treatment of DKA associated with significant nausea and vomiting and involving a 5 day ICU stay. On transfer to the floor, her family states she got lots of IV and PO fluids out of concern for dehydration and was discharged, by their thoughts, prematurely. According to her family, she entered the hospital weighing 160lbs and left weighing 180lbs. When at home she felt very short of breath and noticed significant lower extremity swelling. She returned to the hospital 3 days later in what was assessed as an acute CHF exacerbation. . She was initially admitted to the floor and was given IV furosemide. Cardiac biomarkers were cycled. Her troponin reached a high of 0.41. Her CK-MB reached a high of 8. Her renal function gradually climbed from 1.5 -> 2.6. UOP decreased and started on dobutamine with improved UOP. She also had a few episodes bradycardia to the 30's which required atropine. This occured in the setting of using the bedpan. On [11-26] she received two units of pRBC's without any diuretics for a drop in hematocrit from 25 to 21. There were no obvious areas of bleeding. She was on [3-6] L nasal cannula prior to her transfer. . On arrival to the CCU, she was on a non-rebreather. She had been transferred on a dobutamine and furosemide drip. She had 300 cc in her foley. She reported her breathing was slightly better than the past few days. . On review of systems, she reports some constipation. She denies any blood in her stools. She still has episodes of nausea. . Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. Past Medical History: CHF Hypertension Diabetes mellitus Chronic Kidney Disease (recent baseline 1-1.5) Episodes of Nausea and Vomiting Hyperlipidemia 1. Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: [2178] left circumflex angioplasty without stent - PERCUTANEOUS CORONARY INTERVENTIONS: Social History: No tobacco or illicits. Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM GENERAL: appears slightly uncomfortable Oriented x3. HEENT: NCAT. Sclera anicteric. Pupils equal. NECK: Supple with JVP of to earlobes. CARDIAC: RRR, no murmurs, rubs, or gallops although difficult to assess given loud lung findings LUNGS: Respirations were unlabored, no accessory muscle use. Diffuse rales mixed with rhonchi in all lung fields. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 1+ clubbing to mid shin SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ DISCHARGE EXAM: Unchanged, except as below General: Comfortable, A&Ox3 Neck: JVP below the clavicle Lungs: CTAB with no crackles in the lung bases Cardiac: RRR, no m/r/g Extremities: No edema, no clubbing or cyanosis Pertinent Results: ADMISSION LABS: [2195-11-27] 06:45PM BLOOD WBC-19.2* RBC-3.46* Hgb-10.3* Hct-30.2* MCV-87 MCH-29.8 MCHC-34.1 RDW-14.7 Plt Ct-183 [2195-11-27] 06:45PM BLOOD Neuts-91.8* Lymphs-6.0* Monos-1.9* Eos-0.1 Baso-0.1 [2195-11-27] 06:45PM BLOOD PT-14.6* PTT-25.3 INR(PT)-1.3* [2195-11-27] 06:45PM BLOOD Plt Ct-183 [2195-11-27] 06:45PM BLOOD Ret Aut-2.6 [2195-11-27] 06:45PM BLOOD Glucose-223* UreaN-50* Creat-2.2* Na-140 K-4.2 Cl-101 HCO3-25 AnGap-18 [2195-11-27] 06:45PM BLOOD ALT-148* AST-63* LD(LDH)-382* CK(CPK)-144 AlkPhos-81 Amylase-44 TotBili-1.8* DirBili-0.7* IndBili-1.1 [2195-11-27] 06:45PM BLOOD Lipase-6 [2195-11-27] 06:45PM BLOOD Albumin-3.7 Calcium-9.3 Phos-4.4 Mg-1.6 [2195-11-27] 06:45PM BLOOD Hapto-267* [2195-11-27] 06:56PM BLOOD Type-ART pO2-83* pCO2-36 pH-7.48* calTCO2-28 Base XS-3 [2195-11-27] 06:56PM BLOOD Lactate-1.4 [2195-11-27] 06:56PM BLOOD O2 Sat-94 PERTINENT LABS AND STUDIES: [2195-11-27] 06:45PM BLOOD CK-MB-7 cTropnT-0.45* [2195-11-28] 04:49AM BLOOD CK-MB-4 cTropnT-0.56* proBNP-9288* [2195-11-28] 03:10PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2195-11-27] BLOOD CULTURE staph coag neg 1/5 bottles [2195-11-28] BLOOD CULTURE ENTEROCOCCUS FAECALIS AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S PENICILLIN G---------- 4 S VANCOMYCIN------------ 1 S [2195-11-29] BLOOD CULTURE ENTEROCOCCUS FAECALIS AMPICILLIN------------ <=2 S DAPTOMYCIN------------ S PENICILLIN G---------- 2 S VANCOMYCIN------------ 1 S [2195-11-30] URINE CULTURE ENTEROCOCCUS SP. 10,000-100,000 ORGANISMS/ML AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S [2195-11-30] URINARY LEGIONELLA ANTIGEN NEGATIVE [2195-11-30] CATHETER TIP CULTURE NEGATIVE [2195-11-29] BLOOD CULTURE X3 PENDING * [2195-11-27] CXR New right PIC line passes to the mid SVC, where the tip is partially obscured by a nasogastric tube that is looped in the stomach and ends at the level of the carina in the esophagus. Nasogastric tube was removed on subsequent radiograph available at the time of this dictation, so I made no attempt at position verification. Heart is moderately enlarged. Lungs are filled with multiple nodules and moderately severe pulmonary edema and/or consolidation. Right pleural effusion is small. No pneumothorax or appreciable left pleural effusion. [2195-11-27] ABDOMEN XRAY AP view of the chest and left decubitus frontal view of the abdomen show marked fecal impaction of most of the colon and a nasogastric tube is looped in the stomach returning to the level of the carina, subsequently removed on chest radiograph performed on [2195-11-28] at 7:50 p.m. and available at the time of this dictation. The absence of appreciable distention of bowel proximal to the impacted colon corroborates an intact ileocecal valve. There may also be a right femoral or inguinal hernia, without evidence of incarceration or obstruction. [2195-11-28] CXR Nasogastric tube has been removed. Right PIC line ends close to the superior cavoatrial junction. Widespread pulmonary opacification, has worsened appreciably, obscuring the margins were previously well defined lung nodules. Pleural effusions may also have increased and cardiomegaly worsened. No pneumothorax. [2195-11-28] ABDOMEN US GALLBLADDER OR LIVER The liver echotexture is coarse. There is no focal intrahepatic lesion or intrahepatic bile duct dilation. A 5-mm calcified granuloma lies within the right lobe. The main portal vein is patent, demonstrating proper hepatopetal flow. The CBD is not dilated, measuring 2 mm. The gallbladder is normal. No ascites is detected. The spleen is not enlarged, measuring 8.7 cm. Bilateral pleural effusions are present. IMPRESSION: 1. Coarsened liver echotexture, suggestive of underlying liver disease. Clinical correlation is recommended and advanced disease such as cirrhosis or fibrosis cannot be excluded with this technique. 2. No intra- or extra-hepatic bile duct dilation. 3. Bilateral pleural effusions. [2195-12-2] CXR Cardiomegaly is stable. Now mild-to-moderate pulmonary edema has improved. There is no evidence of pneumothorax or increasing pleural effusions. The pleural effusions are small and bilateral. There are no new lung abnormalities, lung nodules are not appreciated, and continued followup is recommended until resolution of acute findings of CHF. Brief Hospital Course: 65F with hx of remote LCx MI in [2178], CAD, IDDM, and [Hospital 2091] transferred from OSH for further evaluation and management of acute diastolic CHF exacerbation. ACTIVE ISSUES: # Acute Diastolic CHF Exacerbation: Her echo shows depressed EF 45-50% with inferior wall hypokinesis which does not appear to new finding for her given records of old ECHO's and likely related to her remote LCx infarct. On exam at time of admission she was grossly volume overloaded in her neck, lungs, and extremities. She also has an elevated BNP of 2900 at OSH. This was likely a result of the volume resuscitation she received during a recent admission to an OSH for DKA. She was initially placed on a Lasix drip and was then transitioned back to her home dose of torsemide 20mg daily. She was diuresed to a dry weight of 161 lbs. Her oxygen requirement was weaned and she was able to ambulate without difficulty. Her CXR showed improved edema at the time of discharge and her exam showed resolution of peirpheral edema, JVD and crackles in the lungs. # Concern for NSTEMI/CAD: Ms. [Known lastname 10528] had a previous LCx MI in [2178]. Her anginal symptoms at that time included nausea and vomiting (similar to what she was having at admission). Her troponins were elevated in the context of renal insufficiency and MB's peaked at 8. This is likely a demand ischemia pattern given her lower grade enzyme leak and lack of ischemic findings on CXR although it is concerning because N/V was her prior anginal equivalent. Her CKMB remained not elevated at 7 and then 4. She was treated with Aspirin 325mg PO daily. Restarted on home metoprolol. Did not receive heparin or plavix due to hematocrit drop with unclear source. #Positive BCx and leukocytosis: WBC of 19 on admission with GPC??????s in blood, these subsequently speciated to pan-sensitive Enterococci. Prior CXR showed nodules vs abscess, which were hard to evaluate in setting of prior volume overload, but repeat CXR after diuresis showed absence of nodules. WBC improved and afebrile. BCx from [11-28] shows Enterococcus which is sensitive to amp. She was initially treated with vanc and cefepime, but narrowed to ampicillin when sensitivities returned. At discharge, she will continue on Augmentin 875/125 q12h for a total course of 2 weeks (finish on [12-12]). # Acute on Chronic Renal Failure. Patient has elevated baseline creatinine. During this recent admission her creatinine had increased to 2.6 while her urine output decreased. Cr here on admission is 2.2 and her urine output so far is robust following 100mg IV lasix @ ~100cc/hr. [Last Name (un) ] likely related to prior diuresis and poor forward flow. Her creatinine improved to 1.0 at time of discharge. # Nausea/Transaminitis: As discussed above, patient's anginal equivalent appears to be nausea. It appears that her presentation last week was reported to be in the setting of hyperglycemia and DKA. Has mild-moderate transaminitis on admission labs but negative lipase and amylase. Ultrasound revealed coarse liver echotexture. The patient's symptoms improved throughout her hospital course. # Anemia. Patient has baseline hematocrit of 28-30. Her hematocrit at the OSH decreased from 25 to 21. She received to units of pRBC today but without any lasix chaser per report. Crit 30 here on admission. No active signs of bleeding and she refuses rectal with guiaic. Her hematocrit was stable around 27-32 prior to admission. INACTIVE ISSUES # HTN: She is on metoprolol as an outpatient. We restarted home metoprolol XL 12.5mg daily, lisinopril 10mg daily. # HLD: Intolerant of statins. Restarted home zetia. . # Diabetes: Mildly hyperglycemic to the 200's. Will place on home glargine and insulin sliding scale in-house. Home dose of insulin is 28units AM and 32 units PM; Glargine was increased to 30 units PM and 24 units AM yesterday. ISSUES OF TRANSITIONS IN CARE: CODE: Full Code (confirmed) COMM: daughter PENDING STUDIES AT TIME OF DISCHARGE: blood cultures Medications on Admission: lisinopril 20 daily metoprolol xl 12.5 daily aspirin 81 mg colace 200 mg [Hospital1 ] Lantus 15 units qAM and 25 units qPM insulin sliding scale novolog omeprazole 20 mg TID vitamin D 1000 units daily colestipol 1 gm daily 94 hours away from all other meds) erythromycin 250 mg TID ferrous sulfate 325 mg daily ? percocet prn pain ? torsemide 20 mg daily trazodone 50 mg QHS senna 2 tablets QHS Discharge Medications: 1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: [1-4] Capsules PO BID (2 times a day). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lantus 100 unit/mL Solution Sig: Twenty Eight (28) units Subcutaneous qam. 9. Lantus 100 unit/mL Solution Sig: Thirty Two (32) units Subcutaneous qpm. 10. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: Two (2) Tablet PO once a day. 11. cod liver oil Capsule Sig: Two (2) Capsule PO once a day. 12. multivitamin Tablet Sig: One (1) Tablet PO once a day. 13. insulin aspart 100 unit/mL Solution Sig: solution units Subcutaneous three times a day: Please resume home sliding scale. 14. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 10 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: acute diastolic heart failure, acute on chronic renal failure, anemia secondary diagnosis: hypertension, hyperlipidemia, diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 10528], You were admitted for fluid overload due to your congestive heart failure. You received Lasix and torsemide to help you to remove the fluid. Please weigh yourself every morning, call the CCC hotline if your weight goes up by more than 2 pounds in one day or more than 4 pounds in one week. We have changed some of your medications, as described below. Please discuss these changes with your outpatient providers at your follow-up appointment. There was also some bacteria in your blood and urine, we have started an antibiotic which you will continue for 10 days at home, as outlined below. Please note the following changes to your medications: - START: Augmentin 875/125mg every 12 hours for 10 days (last dose on [12-12]) - STOP: trazodone, erythromycin, colestipol, - INCREASE: aspirin from 81mg to 325mg daily - DECREASE: lisinopril from 20mg to 10mg daily - Continue your other medications as prescribed, as outlined on your medication list Please be sure to follow up with your physicians as outlined below. Followup Instructions: Name: [First Name8 (NamePattern2) ] [Last Name (un) ], PA (works with Dr [Last Name (STitle) ] Location: [Location (un) 2274]-[Location (un) ] -Primary Care Address: 111 [Doctor Last Name ] DR, [Location (un) ],[Numeric Identifier 17464] Phone: [Telephone/Fax (1) 17465] Appt: [12-8] at 11:30am Name: Come, [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Location (un) 2274] [Location (un) ], Cardiology Address: [Location (un) ], [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 2258] *THe office is working on an appt for you in the next two weeks and will call you at home with the appt. IF you dont hear from them in the next two business days, please call them dircectly to book. Department: DIGESTIVE DISEASE CENTER When: TUESDAY [2195-12-15] at 10:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 100114], MD [Telephone/Fax (1) 85583] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3202] Campus: EAST Best Parking: Main Garage Department: ENDO SUITES When: TUESDAY [2195-12-15] at 10:15 AM Name: [First Name8 (NamePattern2) ] [Last Name (un) ], PA (works with Dr [Last Name (STitle) ] Location: [Location (un) 2274]-[Location (un) ] -Primary Care Address: 111 [Doctor Last Name ] DR, [Location (un) ],[Numeric Identifier 17464] Phone: [Telephone/Fax (1) 17465] Appt: [12-8**] at 11:30am ICD9 Codes: 5856, 5849, 4280, 3572, 2859, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8037 }	Medical Text: Admission Date: [2121-5-20] Discharge Date: [2121-5-24] Date of Birth: [2064-1-4] Sex: F Service: CARDIOTHORACIC Allergies: Ciprofloxacin / Demerol / Latex / Sulfa (Sulfonamide Antibiotics) / Shellfish Derived Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2121-5-20] - Aortic Valve Replacement (21mm St. [Male First Name (un) 923] Mechanical Valve) History of Present Illness: 57 year old female with shortness of breath and chest tightness on exertion. She reports an episode of syncope after climbing one flight of stairs at a quick pace and occasional paroxysmal nocturnal dyspnea, orthopnea and a sensation of palpitations while lying in bed. She completed an ECHO on [2121-2-24] revealing left atrial enlargement with mild MR, severe AS with moderate AI and a globally preserved LV function of 60-65%. Past Medical History: Hypertension Asthma Depression Gastric esophageal reflux disease Aortic Stenosis Hypothyroid Fatigue Neuropathy Irritable bowel syndrome C6-C7 and L4-L5 back surgery Social History: Last Dental Exam: > 1 year will set up outpatient appointment Lives with: son Occupation: works as rehab specialist with work placement Tobacco: denies ETOH: denies Family History: brother s/p AVR, other brother s/p CABG mother s/p stents Physical Exam: Pulse: 89 Resp: 16 O2 sat: 100% RA B/P Right: 153/80 Left: 149/74 Height: 5'7" Weight: 68kg General:no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] anterior Heart: RRR [x] Irregular [] Murmur 3/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema trace Varicosities: multiple spider veins bilateral lower extremities Neuro: alert and oriented x3 non focal Pulses: Femoral Right: cath site - mynx closure Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: murmur Left: murmur Pertinent Results: [2121-5-20] ECHO: Pre-bypass: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal(LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([12-21]+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post-bypass: The patient is receiving no inotropic support post-CPB. There is a well-seated bileaflet mechanical prosthesis in the aortic position with good leaflet excursion. There are two small transvalvular regurgitant jets consistent with washing jets. There is no paravalvular regurgitation. The mean transvalvular gradient is 5 mm Hg. Biventricular systolic function is preserved and all other findings are consistent with pre-bypass findings. The aorta is intact post-decannulation. All findings discussed with the surgeon intraoperatively. [2121-5-21] CXR: As compared to the previous radiograph, all monitoring and support devices have been removed, except for the right-sided jugular vein catheter. There is no visible pneumothorax. Unchanged appearance of the lung parenchyma, unchanged minimal retrocardiac atelectasis. No pleural effusions. No overhydration, no pneumonia. Normal size of the cardiac silhouette. [2121-5-20] 01:26PM BLOOD WBC-7.1# RBC-2.63# Hgb-8.3# Hct-24.3# MCV-93 MCH-31.5 MCHC-34.0 RDW-12.7 Plt Ct-161 [2121-5-23] 05:08AM BLOOD WBC-8.0 RBC-2.43 Hgb-7.6* Hct-22.6* MCV-93 MCH-31.3 MCHC-33.6 RDW-12.9 Plt Ct-155 [2121-5-20] 01:26PM BLOOD PT-15.3* PTT-33.8 INR(PT)-1.3* [2121-5-22] 08:44AM BLOOD PT-18.7* PTT-31.0 INR(PT)-1.7* [2121-5-23] 05:08AM BLOOD PT-26.9* INR(PT)-2.6* [2121-5-20] 02:56PM BLOOD UreaN-11 Creat-0.6 Cl-110* HCO3-26 [2121-5-23] 05:08AM BLOOD Glucose-103* UreaN-13 Creat-0.5 Na-135 K-3.5 Cl-98 HCO3-30 AnGap-11 [2121-5-22] 04:23AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7 Brief Hospital Course: Ms. [Known lastname 85213] was admitted to the [Hospital1 18] on [2121-5-20] for surgical management of her aortic valve disease. She was taken directly to the operating room where she underwent an aortic valve replacement using a 21mm St. [Male First Name (un) 923] Mechanical Valve. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Over the next several hours, she awoke neurologically intact and was extubated. On postoperative day two, she transferred to the step down unit for further recovery. Coumadin was started for anticoagulation for her aortic valve. She was gently diuresed towards her preoperative weight. Chest tubes and epicardial pacing wires were removed per protocol. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She continued to improve will awaiting INR to be in therapeutic range (2.5-3.5). On post-op day four she appeared suitable for discharge home with VNA services and the appropriate medications and follow-up appointments. She was cleared for discharge by Dr. [Last Name (STitle) ] for Dr. [Last Name (STitle) ]. Coumadin with be followed by PCP [First Name11 (Name Pattern1) 1494] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1492] with goal INR 2.5-3.5. Medications on Admission: ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA Aerosol Inhaler - 2 puffs four times per day as needed BUPROPION HCL [WELLBUTRIN XL] - (Prescribed by Other Provider) - 300 mg Tablet Sustained Release 24 hr - one Tablet(s) by mouth daily BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - (Prescribed by Other Provider) - 50 mg-325 mg-40 mg Tablet - one Tablet(s) by mouth daily as needed for migraines DIPHENOXYLATE-ATROPINE [LOMOTIL] - (Prescribed by Other Provider) - 2.5 mg-0.025 mg Tablet - one Tablet(s) by mouth daily as needed for IBS ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 50,000 unit Capsule - one Capsule(s) by mouth weekly GABAPENTIN - (Prescribed by Other Provider) - 800 mg Tablet - one Tablet(s) by mouth three times a day HYDROXYZINE HCL - (Prescribed by Other Provider) - 25 mg Tablet - one Tablet(s) by mouth daily as needed for itch LEVOTHYROXINE [LEVOXYL] - (Prescribed by Other Provider) - 100 mcg Tablet - one Tablet(s) by mouth daily LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - one Tablet(s) by mouth up to three times a day as needed METOCLOPRAMIDE [REGLAN] - (Prescribed by Other Provider) - 10 mg Tablet - one Tablet(s) by mouth as needed for migraines with nausea MONTELUKAST [SINGULAIR] - (Prescribed by Other Provider) - 10 mg Tablet - one Tablet(s) by mouth daily NORTRIPTYLINE - (Prescribed by Other Provider) - 10 mg Capsule - one Capsule(s) by mouth daily at bedtime OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth daily TRIAMTERENE-HYDROCHLOROTHIAZID - (Prescribed by Other Provider) - 50 mg-25 mg Capsule - one Capsule(s) by mouth daily VERAPAMIL - (Prescribed by Other Provider) - 240 mg Cap,24 hr Sust Release Pellets - one Cap(s) by mouth daily ZOLMITRIPTAN [ZOMIG] - (Prescribed by Other Provider) - 5 mg Tablet - one Tablet(s) by mouth daily as needed for migraines CALCIUM CARBONATE [CALCIUM 600] - (Prescribed by Other Provider) - 600 mg (1,500 mg) Tablet - one Tablet(s) by mouth daily CYANOCOBALAMIN - (Prescribed by Other Provider) - 1,000 mcg Tablet, Sublingual - 1 tab sublingually qam 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. 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 4. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:30 Capsule(s) Refills:1 5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:180 Capsule(s) Refills:1 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 7. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:60 Tablet Sustained Release(s) Refills:1 8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours). Disp:1 Refills:2 12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Indication: Mechanical Aortic Valve Goal INR 2.5-3.5 PCP: [First Name8 (NamePattern2) 1494] [Last Name (NamePattern1) 1492] will follow INR and adjust dose accordingly. Disp:60 Tablet(s) Refills:2 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 5 days. Disp:5 Tab Sust.Rel. Particle/Crystal(s) Refills:0 15. Coumadin 2 mg Tablet Sig: One (1) Tablet PO sunday [2121-5-25] for 1 doses. Discharge Disposition: Home With Service Facility: VNA Carenetwork Discharge Diagnosis: Aortic stenosis s/p aortic valve replacement Past medical history: Neuropathy Hypertension Gastroesophageal reflux Depression Irritable bowel syndrome Hypothyroidism Asthma s/p cervical laminectomy s/p lumbar laminectomy Discharge Condition: Alert and oriented x3, nonfocal. Ambulating with steady gait. Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema: trace LE edema Discharge Instructions: Shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. No lotions, cream, powder, or ointments to incisions. Each morning you should weigh yourself and then in the evening take your temperature, These should be written down on the chart . No driving for approximately one month, until follow up with surgeon. No lifting more than 10 pounds for 10 weeks. Please call with any questions or concerns ([Telephone/Fax (1) 170]). Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge of sternal wound. Please call cardiac surgery office with any questions or concerns ([Telephone/Fax (1) 170]). Answering service will contact on call person during off hours. Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 170]) on [6-19] at 1PM Please call to schedule appointments with: Primary Care: Dr. [First Name11 (Name Pattern1) 1494] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1492] ([0-0-]) [6-3] at 1215 PM Cardiologist: Dr. [Last Name (STitle) ] [Name (STitle) 4922] in [12-21] 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 ?????? for mechanical aortic valve Goal INR: 2.5-3.5 First draw: [2121-5-26] Results to: PCP, [First Name11 (Name Pattern1) 1494] [Initial (NamePattern1) ] [Last Name (NamePattern4) 1492] (spoke with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 22771]) phone: [0-0-] fax: [Telephone/Fax (1) 85214] Last several Coumadin doses and INR: [5-24]: Dose 2mg INR 2.3 [5-23]: Dose 1mg INR 2.6 [5-22]: Dose 2.5mg INR 1.7 [5-21]: Dose 2.5mg INR not drawn Completed by:[2121-5-24] ICD9 Codes: 4241, 4019, 2449, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8038 }	Medical Text: Admission Date: [2160-7-7] Discharge Date: [2160-7-15] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Fatigue/Dyspnea on exertion Major Surgical or Invasive Procedure: [2160-7-9] - Coronary artery bypass graft x3 (free left internal mammary artery from vein graft to left anterior descending coronary artery, reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery and reverse saphenous vein graft from the aorta to the distal right coronary artery). History of Present Illness: Very nice 82 year old gentleman with episode of CHF in [Month (only) 116] and admitted to the [Hospital ] Hospital for diuresis. He underwent a s stress test which was suggestive for ischemia. He underwent a cardiac catheterization which rvealed three vessel diesase and he was referred for surgical management. Past Medical History: lipids, HTN, DM2, BPH, Gout, CHF, Afib, malaria, pna, PPM Social History: works as Rabbi no tobacco for 15 years rare etoh Family History: father deceased from MI @ 75 Physical Exam: 74 126/75 69" 175lbs GEN: WDWN in NAD SKIN: Warm, dry, no clubbing or cyanosis. Multiple solar/actinic kertosis and nevi. HEENT: PERRL, Anicteric sclera, OP Benign NECK: Supple, no JVD, FROM. Pacer pocket in right upper chest. LUNGS: CTA bilaterally, mild kyphosis. HEART: RRR, Paced rhythm, No M/R/G ABD: Soft, ND/NT/NABS EXT:warm, well perfused, no bruits, no varicosities, mild peripheral edema NEURO: No focal deficits. Pertinent Results: [2160-7-9] ECHO PREBYPASS 1.No atrial septal defect is seen by 2D or color Doppler. 2. There is mild regional left ventricular systolic dysfunction. Overall left ventricular systolic function is mildly depressed (LVEF= 40=45 %). 3. There is mild global right ventricular free wall hypokinesis. 4.The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate (2+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-11]+) mitral regurgitation is seen. 7.There is a trivial/physiologic pericardial effusion. POST BYPASS 1. Patient is v paced and receiving an infusion of phenylephrine. 2. Biventricular systolic function is unchanged. 3. Mild mitral regurgitation persists. 4. Aorta intact post decannulation [2160-7-14] 06:10AM BLOOD WBC-9.6 RBC-3.26* Hgb-10.2* Hct-30.0* MCV-92 MCH-31.4 MCHC-34.1 RDW-15.8* Plt Ct-174 [2160-7-15] 06:00AM BLOOD PT-20.2* PTT-35.5* INR(PT)-1.9* [2160-7-14] 06:10AM BLOOD PT-18.6* PTT-33.7 INR(PT)-1.8* [2160-7-13] 04:50AM BLOOD PT-16.2* INR(PT)-1.5* [2160-7-12] 08:12AM BLOOD PT-14.9* PTT-32.7 INR(PT)-1.3* [2160-7-15] 06:00AM BLOOD Glucose-128* UreaN-46* Creat-1.5* Na-142 K-4.5 Cl-106 HCO3-24 AnGap-17 [2160-7-14] 06:10AM BLOOD Glucose-120* UreaN-51* Creat-1.7* Na-141 K-5.0 Cl-106 HCO3-23 AnGap-17 [2160-7-13] 04:50AM BLOOD Glucose-81 UreaN-37* Creat-1.4* Na-142 K-4.1 Cl-107 HCO3-23 AnGap-16 Brief Hospital Course: Rabbi [Known lastname ] was admitted to the [Hospital1 18] on [2160-7-7] for surgical management of his coronary artery disease. Heparin was started as his INR was allowed to normalize. On [2160-7-9] Rabbi [Known lastname ] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the SICU for monitoring. On postoperative day one, he awoke neurologically intact and was extubated. He was transfused with packed red blood cells for postoperative anemia. The electrophysiology service interrogated his pacemaker and programmed it to VVI at 80-100. Coumadin was resumed for his chronic atrial fibrillation. On [2160-7-12], Rabbi [Known lastname ] fell while in the bathroom. Fortunately no injury was sustained. On postoperative day three, Rabbi [Known lastname ] was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Rabbi [Known lastname ] continued to make steady progress and was discharged to rehabilitation on postoperative day 6. He will follow-up with Dr. [Last Name (STitle) 1290], his cardiologist and his primary care physician as an outpatient. Dr. [Last Name (STitle) ] will resume his coumadin management as per preoperatively upon discharge from rehabilitation. His Goal INR is 2.0-2.5 for atrial fibrillation. Medications on Admission: Enalapril 10mg QD Atenolol 50mg QD Coumadin 7.5mg QD Lipitor 20mg QD Glipizide 10mg QD Actos 30mg QD Colchicine 0.6mg PRN Lasix 20mg QD FLomax 0.4mg QD Diovan 80mg QD Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:4 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for 1 months. 6. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: Two (2) Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily). 7. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. Discharge Disposition: Extended Care Facility: Brookview Discharge Diagnosis: Hyperlipidemia HTN Diabetes Mellitus Type 2 BPH Gout CHF AF PPM in situ Discharge Condition: Good. Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Coumadin to be taken daily. Goal INR is 2.0-2.5 for atrial fibrillation. Please resume coumadin follow-up with Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 73689]. 8) Take lasix and potassium once daily for 5 days then stop. Monitor and replete electrolytes as needed. 9) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 1290] in 1 month. ([Telephone/Fax (1) 1504] Follow-up with cardiologist Dr. [Last Name (STitle) ] in [12-11] weeks for routine appointment and immediately after discharge from rehab for coumadin management. ([Telephone/Fax (1) 73689] Follow-up with pcp [Last Name (NamePattern4) ]. [First Name (STitle) 48684] in 2 weeks for routine appointment ([Telephone/Fax (1) 73690] Please call all providers for appointments. Completed by:[2160-7-15] ICD9 Codes: 4280, 2851, 4019, 2720, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8039 }	Medical Text: Admission Date: [2142-9-9] Discharge Date: [2142-9-18] Date of Birth: [2080-10-27] Sex: M Service: SURGERY Allergies: Tetracycline / Percocet Attending:[First Name3 (LF) 668] Chief Complaint: end stage renal disease Major Surgical or Invasive Procedure: 1) s/p cadaveric kidney transplant History of Present Illness: Mr. [Known lastname 9201] is a 62-year-old male with end-stage renal disease who underwent pretransplant evaluation and after risk-suitable workup is now ready for transplantation after a donor organ became available. The crossmatch was negative and the ABO compatibility was confirmed. He has had no recent changes in his health status, including no recent cough, chest pain or shortness of breath, or fevers. Please see the results section of this discharge summary for the results of his pre-op work-up. Past Medical History: 1) Coronary artery disease, status post CABG in the year [2136], s/p multiple PCI's 2) End-stage renal disease secondary to polycystic kidney disease and is on hemodialysis. 3) Status post failed renal transplant. 4) GERD. 5) Peptic ulcer disease 6) Mitral regurgitation. 7) Diabetes mellitus type 2. 8) Hypertension. 9) Hyperlipidemia. 10) Peripheral vascular disease. 11) Gout. 12) Status post appendectomy. 13) Depression and anxiety. Social History: Lives at home with his wife and one of his children. Family History: Notable for CAD, diabetes mellitus, hypertension, and a sister with kidney disease. Physical Exam: A+O x 3. Afebrile, vital signs stable in the pre-operative holding area. Cor: systolic murmur Lungs: bil. rales. Abd S/NT/ND. His prior kidney transplant incision has healed nicely without evidence of wound breakdown or discharge. LE His femorals are 2+ and equal bilaterally. Pertinent Results: [2142-9-9] 11:30PM WBC-5.7 RBC-4.37* HGB-13.6* HCT-40.9 MCV-93 MCH-31.1 MCHC-33.2 RDW-15.0 PLT COUNT-146* [2142-9-9] 11:30PM UREA N-74* CREAT-10.1# SODIUM-141 POTASSIUM-5.5 CHLORIDE-98 TOTAL CO2-19* ANION GAP-30* [2142-9-9] 11:30PM CALCIUM-9.6 PHOSPHATE-7.8# CHOLEST-130 [2142-9-9] 11:30PM ALT(SGPT)-8 AST(SGOT)-9 LD(LDH)-144 [2142-9-9] 11:30PM TRIGLYCER-101 [2142-9-9] 11:30PM PT-14.5 PTT-27.7 INR(PT)-1.4 CMV (-) EBV (-) Sinus rhythm Left atrial abnormality Low limb lead QRS voltages Probable right ventricular conduction delay Consider prior inferolateral myocardial infarct Clinical correlation is suggested also for possible in part RV overload Since previous tracing of [2142-9-10], tachyarrhythmia absent Renal Transplant Ultrasound [9-11] 1. Normal perfusion with normal RI of 0.8 of transplanted kidney. 2. A complexed superficial fluid collection in the left lower quadrant inferior to the transplanted kidney, probably representing hematoma, seroma, or lymphocele. 3. Empty bladder with Foley catheter, which cannot be further evaluated. Echo [9-11] Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the inferior and inferolateral walls. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.]The aortic valve leaflets (3) are moderately thickened. Aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Severe (4+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior report (tape unavailable for review) of [2140-4-27], the severity of mitral regurgitation is increased. And pulmonary artery systolic hypertension is now identified. KUB [2142-9-17] There are gas-filled loops and non-dilated small bowel gas in the colon, and no obvious evidence for intestinal obstruction or free intraperitoneal gas on the suboptimal film. Brief Hospital Course: This 61 year old male was admitted for cadaveric kidney transplant. He underwent a successful transplant [9-10] along with a left inguinal hernia repair. Given his significant cardiac history he was monitored in the PACU then transferred to the SICU after extubation. He required pressor support following the surgery. Immunosuppressants were started intra-operatively per the standard protocol. He also required an intermittent insulin drip to tightly control his blood glucose. Cardiology was consulted to help in management of the patient post-operatively given his hypotension and pre-op history. They recommended a temporary hold on plavix and to hold aggrenox. Aspirin was continued. He initially made 25-35cc of urine per hour but this decreased to 189 cc for the 24 hrs on POD 3. This was due to delayed graft response. On POD 4 the patient received a treatment of hemodialysis for fluid overload-- this decreased his weight from 79.9 to 76.0 kg (pre-op weight 64). On POD [4-21] the patient's diet was advanced to full. His urine output rose to 990 cc for the day on POD 7. His Cr dropped to 5.1 from over 8 previously. The renal transplant service (following) felt he would no longer need hemodialysis. He complained of nausea and vomiting while taking [Last Name (LF) 9202], [First Name3 (LF) ] this was discontinued. In addition, his Cellcept was tapered to 500 [Hospital1 ]. LFT's and an EKG were also checked to r/o any biliary or cardiac disease, and these were at baseline. He was started on levoquin x 7 day course for a UTI on POD 5, sensitivities pending at time of discharge. Otherwise, his home medications were restarted, with the exception of aggrenox as cardiology could find no reason to continue this. He was tolerating a regular diet and he remained afebrile. Before discharge the patient's foley was reinserted for urinary retention. This should be continued for 2 weeks, when a voiding trial can be conducted. His immunosuppressive regimen was maintained per protocol throughout his hospital course. Daily Prograf levels were checked and his doses adjusted accordingly. His Prograf level was stable at approximately 10 on 4 mg [Hospital1 ]. He received ATG x 4 doses per protocol. His Cellcept was tapered to 500 mg [Hospital1 ] for nausea and vomiting. Medications on Admission: ASA325, folate, prilosec 30, lopressor 100, plavix 75, Dig.125 MWF, aggrenox 75 [Hospital1 ], neurontin 100TID, isosorbide 40 TID, trazadone 50 QHS, lactulose 30. Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 6. Diphenhydramine HCl 25 mg Capsule Sig: [12-17] Capsules PO Q12H OR QHS PRN () as needed for sleep. 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection [Hospital1 ] (2 times a day). 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO MON/WED/[Female First Name (un) ] (). 10. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) syringe Subcutaneous ASDIR (AS DIRECTED): Bedtime Glargine 6 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-50 mg/dL [12-17] amp D50 [12-17] amp D50 [12-17] amp D50 [12-17] amp D50 51-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-160 mg/dL 2 Units 2 Units 2 Units 0 Units 161-200 mg/dL 4 Units 4 Units 4 Units 0 Units 201-240 mg/dL 6 Units 6 Units 6 Units 2 Units 241-280 mg/dL 8 Units 8 Units 8 Units 3 Units 281-320 mg/dL 10 Units 10 Units 10 Units 4 Units . 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 13. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold for SBP < 100, HR < 60. 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 17. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 18. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 20. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 4 doses. 21. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Last Name (un) ] Center - [Location (un) 701] Discharge Diagnosis: End stage renal disease s/p cadaveric kidney transplant. Discharge Condition: Stable. Discharge Instructions: 1) Please call Dr.[Name (NI) 670] office or return to the ED if you have increasing abdominal pain, fevers > 101.5 F, redness around or drainage from your wound, or a drop-off in urine output. 2) Sponge bath only until staples come out at your first follow-up visit. The incision may get wet but do not soak or scrub it. Followup Instructions: 1) Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2142-9-20] 1:10 PM 2) Provider: [Name10 (NameIs) 2105] [Name11 (NameIs) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2142-9-25] 3:40 PM 3) Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2142-10-1] 3:20 PM Completed by:[2142-9-18] ICD9 Codes: 4240, 5990, 2762, 5845, 3572, 4439, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8040 }	Medical Text: Admission Date: [2167-8-21] Discharge Date: [2167-9-1] Date of Birth: [2100-11-15] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 465] Chief Complaint: Fever, altered mental status Major Surgical or Invasive Procedure: Lumbar Puncture Transesophageal Echocardiagram History of Present Illness: HPI: Patient unable to give good history on his own; hx per daughter. Daughter found pt. when she returned home in evening [8-20] lying on the ground, awake; lying there approx. 4 hrs per pt report. Pt states he had "passed out" and couldn't rise. Positive mental status changes at the time and was not able to answer his daughter's questions appropriately. He had not been incontinent of stool or urine. She called her mother and the ambulance and the patient was then brought in to the ED. . The daughter says the patient had not been feeling well the previous day. He was complaining of not feeling well, but could not specify symptoms. Prior to admission, complained of intermittent nausea and insomnia. . At baseline, the patient has L sided weakness, both UE and LE, from a previous stroke. He also has speech difficulties from his most recent strokes in [12-24]. He understands some English. He is able to ambulate around their house with a cane. . ED: L IJ catheter placed. Concern for ischemia (EKG ? ST change in V6 -> cards felt LVH not acute MI, received ASA and lopressor IV), meningitis (LP done) or other infection (given tylenol, vanc, ceftriaxone, acyclovir, and gentamicin). He was transferred to [Hospital Ward Name 121] 3 and begun on dialysis for a Ca of 12. . On floor, pt. underwent HD; renal eval - AVF site warm and swollen, not tender. [8-21] evening, pt had episode hypotension - txf to unit for evaluation - pt tx'd for bacteremia, pt bp stabilized, tx'd with genta/vanco. . ROS: daughter denies any fevers, URI sx, diarrhea, chest pain or SOB; thinks that the patient did have some vomiting yesterday (day PTA). . Past Medical History: 1. Coronary artery disease s/p MI in [12/2164], status post 2 stents to the LAD. Cath in [1-/2165] revealed re-stenosis of both stents. He is status post 3-vessel CABG on [2165-2-20] with LIMA to LAD, saphenous vein to RCA, saphenous vein to OM. 2. ESRD on HD since [2161](MWF), felt secondary to HTN 3. Status post CVA in [2149] with residual left-sided hemiparesis 4. Hypertension 5. UGIB after cardiac cath on [12/2164] 6. Gout 7. Pancreatitis 8. Diverticulosis 9. History of multiple E coli bacteremias 10. Anemia of chronic disease (10.9Hgb [11-22]) 11. Hypercholesteremia 12. COPD 13. Afib/Aflutter, not on anticoagulation secondary to history of GI bleed. 14. [12-24] TEE: LVEF >55%, small ASD, complex (>4mm non-mobile) atheroma in the descending thoracic aorta, ([12-21]+) AR, tr MR. 15. H/O Hepatitis B Social History: The patient lives at home with his wife & daughter in a [Location (un) 6332] apartment with an elevator. Family History: Mother with hypertension No history of no strokes, seizures, or heart disease Physical Exam: PE: Tm 99.1, Tc 96.9, HR 90-103, BP 111-142/49-62, RR 18-22, O2 sat 100% NC 2l, 90% ra; CVP 3-5, I: 1400 in, O: none Gen: elderly man appears sleepy, speaks slowly HEENT: PERRL, OP clear, dry MM, neck veins flat CV: RRR, + [2-22] early systolic murmur Lungs: b/l basilar crackles, no wheezes Abd: soft, NT, ND Ext: L arm - fistula, no tenderness. No erythema noted, no drainage Pertinent Results: MICRO: [2167-8-21] bctx - G+ cocci pairs/clusters ([3-23]) [2167-8-20]: CSF cx pending, gram stain neg for PMNs/microorg . RADS: [2167-8-20]: CXR - No consolidation. L costophrenic angle blunting c/w effusion/chronic thickening. Evidence of CABG/stents . [2167-8-20]: CT head - No hemorrhage, no mass effect, no hydrocephalus, chronic L parietal infarct . [2167-8-21]: ECHO - no vegetations [2167-8-21] 11:15PM CORTISOL-53.7* [2167-8-21] 10:34PM CORTISOL-36.0* [2167-8-21] 10:02PM TYPE-MIX TEMP-37.3 COMMENTS-MEDIAL POR [2167-8-21] 10:02PM LACTATE-2.7* [2167-8-21] 10:02PM O2 SAT-90 [2167-8-21] 09:59PM GLUCOSE-144* UREA N-31* CREAT-4.9* SODIUM-142 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-29 ANION GAP-14 [2167-8-21] 09:59PM CALCIUM-11.9* PHOSPHATE-3.9 MAGNESIUM-2.0 [2167-8-21] 09:59PM WBC-11.7* RBC-3.87* HGB-11.3* HCT-33.9* MCV-88 MCH-29.2 MCHC-33.2 RDW-18.8* [2167-8-21] 09:59PM NEUTS-78* BANDS-14* LYMPHS-7* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2167-8-21] 09:59PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [2167-8-21] 09:59PM PLT SMR-VERY LOW PLT COUNT-64* [2167-8-21] 09:59PM PT-14.0* PTT-33.2 INR(PT)-1.3 [2167-8-21] 06:39PM LACTATE-4.9* [2167-8-21] 06:22PM GLUCOSE-175* UREA N-27* CREAT-4.8# SODIUM-144 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-29 ANION GAP-20 [2167-8-21] 06:22PM CK(CPK)-68 [2167-8-21] 06:22PM CK-MB-NotDone cTropnT-0.19 [2167-8-21] 06:22PM ALBUMIN-4.1 CALCIUM-12.3* PHOSPHATE-4.3 MAGNESIUM-2.0 [2167-8-21] 07:15AM GLUCOSE-131* UREA N-58* CREAT-8.7* SODIUM-139 POTASSIUM-3.1* CHLORIDE-92* TOTAL CO2-31 ANION GAP-19 [2167-8-21] 07:15AM CK(CPK)-65 [2167-8-21] 07:15AM cTropnT-0.20* [2167-8-21] 07:15AM CK-MB-NotDone [2167-8-21] 02:30AM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-497* POLYS-30 LYMPHS-14 MONOS-26 MACROPHAG-30 Brief Hospital Course: A/P: 1. Bacteremia - Given hypotension, pt. in septic shock. Etiology of bacteremia includes possible AV fistula infxn vs. endocarditis. Pt has hx MSSA bacteremia c possible cardiac emboli involvement (d/c summ [2-21]) - at this time, no clinical signs of endocarditis, all ECHOs neg for vegetations. LP results look like viral meningitis (WBC persist to 4th tube, high protein, neg gram stain). Could be UTI but patient is virtually anuric. He was sent to the MICU for a brief period because of hypotension likely secondary to septic shock, adrenal insufficiency was considered but cosyntropin stimulatory test was normal. He also became normotensive with hydration, and did not require pressors. His chest xrays show left sided pleural effusions but no indications of pneumonia. He Received gentamicin and vancomycin while the blood cultures were pending to cover for endocarditis, the vancomycin was changed to oxacillin when cultures grew MSSA. A TTE did no show vegetations and no indications of endocarditis, a followup TEE also indicated no evidence of endocarditis, thus he was treated for bacteremia with a five day course of gentamicin and a ten day course of oxacillin. He remained afebrile for at least the last week of his hospital course, with no evidence of infection. . 2. ESRD - Secondary to hypertenson on hemodialysis. During his hospital course HD was unable to access HD, a LUE ultrasound showed patent brachial artery and vein, but very narrowed flow in AVF, a fistulagram was ordered to followed up. His AVF was ballooned during the fistulagram and was functioning. His electrolytes remained unchanged during the delay in his hemodialysis, although he developed a slight decline of mental status from his baseline, which was attributed to uremia, as the patient was two days past his scheduled dialysis. He was never clinically fluid overloaded on exam. He received HD and his mental status dramatically improved. He continued on sensipar 60 mg po qd dinner and his medications were renally dose meds . 3. Mental status changes were likely due to uremia. He received a lumbar puncture which did not show indications of infection, his viral cultures were negative. His bacteremia may have caused presentation of his prior strokes. Hypercalcemia may have also contributed to his mental status changes. During his hospital course he waxed/waned in mental status, with correlation to his dialysis status. He was noted to have improvements after hemodialysis. . 4. PAF-He was maintained on ASA and rate controlled with a beta blocker, but kept off coumadin secondary to a history of hematochezia. . 4. Elevated troponin/?EKG changes: He had EKG changes and elevated troponins on admission, which trended down. Cardiology was consulted and felt the EKG changes are due to LVH, not acute MI. He was ruled out for a myocardial infarction, and the elevated troponin was likely due leak combined with chronic renal insufficiency. His enzymes were trended and were negative for MI. . 5. Hypercalcemia: This was attributed to ESRD and he was continued on sensipar and hemodialysis during his hospital course . 6. HTN: Well controlled currently. Monitored BP and continued on metoprolol. . 7. Anemia: Etiology unknown, but likely due to ESRD. Will trend Hct over time to make sure anemia is not new finding. He hematocrit remained at a baseline anemia. It slowly trended down his hospital course, with no indications of active bleeding. His epogen received during dialysis was increased and he his hematocrit was followed. . 8. Mental status changes/? syncope: Unclear story. Has prior strokes, so infection could cause reactivation of old deficits. His MS improved with dialysis at the change was attributed to likely uremia. He did receive a lumbar puncture during his hospital course which did not indicate infection, and HSV cultures were negative. . 9. PPX - heparin SC, pantoprazole, bowel regimen . 10. Dispo - The patient agreed to physical therapy, but declined rehabilitation although recommended, in lieu of going home. . 12. Code - presumed FULL . Medications on Admission: Metoprolol 100 mg [Hospital1 ] Clonidine 0.1mg [Hospital1 ] po Enalapril 2.5 mg qd Norvasc 5mg qd Renagel 1 po tid (vs ca acetate? -- has both) Ranitidine 150 mg po bid ASA 325g po qd Nephrocaps 1 po qd Cinacalcet ? dose qd Lipitor 10mg po qd Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO QD (). Disp:60 Tablet(s) Refills:2 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Sepsis MSSA bacteremia Discharge Condition: Afebrile, Good Discharge Instructions: You had an infection,sepsis, in your bloodstream and were treated with antibiotics. Please take your medications as instructed You are scheduled to follow up with your Nurse Practioner on [2167-9-14] at 9:40am. If you experience, fever, chills, shortness of breath, chest pain, please call your PCP, [Name10 (NameIs) ] go to the Emergency Room. Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] within one week. Followup Instructions: Provider [First Name8 (NamePattern2) 1238] [Last Name (NamePattern1) 1239] [Name8 (MD) ], [MD Number(3) 3670]: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2167-9-14] 9:40 Provider: [First Name4 (NamePattern1) 247] [Last Name (NamePattern1) 248], MD Where: [Hospital6 29] [Hospital ] Phone:[Telephone/Fax (1) 250] Date/Time:[2167-9-29] 10:40 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6925],MD Where: [First Name8 (NamePattern2) ] [Hospital Ward Name ] BUILDING ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX) ENDOSCOPY SUITE Phone:[Telephone/Fax (1) 463] Date/Time:[2167-10-15] 9:30 Provider: [First Name8 (NamePattern2) 1238] [Last Name (NamePattern1) 1239] [Name8 (MD) ], [MD Number(3) 3670]: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2167-9-14] 9:40 Provider: [First Name8 (NamePattern2) 1238] [Last Name (NamePattern1) 1239] [Name8 (MD) ], [MD Number(3) 3670]: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2167-9-14] 9:40 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472] ICD9 Codes: 496, 0389, 2875, 2720, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8041 }	Medical Text: Admission Date: [2145-2-27] Discharge Date: [2145-3-11] Date of Birth: [2064-10-12] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4095] Chief Complaint: GNR bacteremia Major Surgical or Invasive Procedure: Continuous Bladder Irrigation Central Line Placement History of Present Illness: 80M history of DM2, HTN, prostate CA 8 yrs ago sp brachytherapy, recent admission to NEBH on [2145-2-8] for TKR for osteoarthritis who presents from rehab for a fever to 103 this morning and was subsequently sent to the [Hospital1 18] ER. In the ED inital vitals were, 07:56 10 101.8 116 115/63 18 96% RA. There has been no swelling or drainage at the surgical site. He endorses feeling fine but did have chills and sweats. Patient had HR in 150s initially on monitor that then decreased after 45 seconds. EKG (per ED read) showed sinus tachycardia with frequent PACs, no overt ischemic changes. His rate subsequently decreased, but then while he spiked a fever, his HR went to 140-150s with subsequent drop in blood pressure to 90/50s and then consistent SBP 80s despite IVF. They then discovered Tele showed new onset A fib HR 140-150s. He was give 10mg IV dilt once and HR improved to 120s. Also given 4 L NS. UA was positive and CBC showed WBC 12 with 93 Neuts. He was then started on vancomycin 1 gm IV and zosyn 4.5 g IV in addition to acetaminophen 1000 mg. R IJ was placed for hypotension despite IVF rescusitation with initiation of levophed infusion at 0.1 to maintain BPs. CXR showed Right internal jugular catheter tip terminates at the approximate level of the cavoatrial junction. Very slight increase in pulmonary vascular prominence is consistent with interval intravenous hydration. No pneumothorax detected. Labs were significant for initial lactate 2.5 --> 2.3 (after 3 L IVF). UA: SG 1.014, LE large, blood large, protein 100, RBC 38, WBC > 182, many bacteria, 0 epi with many WBC clumps. Chem significant for BUN 34, Cr 3.0 (pre-op Cr at NEBH was 1.9). AG 18. WBC 11.7, Hct 30.7, Plats 500. Ortho was consulted in the ED regarding the knee, they recc imaging. Most recent Vitals prior to transfer: 98.3, HR 140, RR 33, 96% RA, 117/63 on levophed 0.1mcg/kg/min. Admit to [Hospital Unit Name 153] for urosepsis. On arrival to the ICU, pt is tachy to 150s, dyspneic, able to talk in sentences. Says he feels "great." Denies any history of A fib with RVR. Says he has been drinking normally, thinks his urine ouput is normal. Denies any difficulty starting his stream. No abd pain, no diarrhea, no chest pain, no pneumonia. Past Medical History: Prostate CA sp brachytherapy - 8 yrs ago HTN DM2 osteoarthritis sp TKA Social History: non smoker, no ETOH. Lives in [Initials (NamePattern4) ] [Last Name (NamePattern4) ] alone. WIdow. 1 daughter, 5 grandchildren. Family History: no FH of heart disease of cancer Physical Exam: Admission Exam: Vitals: afebrile, HR 144, 134/67, RR 22, 100%2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, pale appearing Neck: supple, JVP not elevated, no LAD Lungs: Anteriorly: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining cloudy urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge Exam: AVSS breathing comfortably on room air Lungs: Anteriorly: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear urine Pertinent Results: =================== LABORATORY RESULTS =================== Admission Labs: WBC-11.7* RBC-3.54* Hgb-10.6* Hct-30.7* MCV-87 RDW-12.9 Plt Ct-500* --Neuts-93* Bands-4 Lymphs-1* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 PT-15.7* PTT-24.7* INR(PT)-1.5* Glucose-218* UreaN-84* Creat-3.0* Na-133 K-3.6 Cl-94* HCO3-21* ALT-32 AST-39 AlkPhos-262* TotBili-0.8 Lipase-24 cTropnT-0.04* CK-MB-3 cTropnT-0.06* Calcium-8.5 Phos-3.8 Mg-2.2 TSH-0.90 Lactate-2.5* ============= MICROBIOLOGY ============= Micro: Blood Culture, Routine (Final [2145-3-3]): ESCHERICHIA COLI. FINAL SENSITIVITIES STRAIN 1. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. ESCHERICHIA COLI. FINAL SENSITIVITIES STRAIN 2. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. ESCHERICHIA COLI. FINAL SENSITIVITIES STRAIN 3. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ESCHERICHIA COLI \| \| ESCHERICHIA COLI \| \| \| AMPICILLIN------------ 4 S 4 S 4 S AMPICILLIN/SULBACTAM-- 4 S 4 S 4 S CEFAZOLIN------------- <=4 S <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S PIPERACILLIN/TAZO----- S S S TOBRAMYCIN------------ <=1 S <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S Aerobic Bottle Gram Stain (Final [2145-2-27]): Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] @ 2202 ON [2-27] - 4I. GRAM NEGATIVE ROD(S). URINE CULTURE (Final [2145-3-1]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Blood Cultures ([2-28] and [3-1]): NGTD ============== OTHER STUDIES ============== Imaging: [2-27] CXR: Portable chest radiograph demonstrates interval placement of a right central venous line with tip terminating at the cavoatrial junction. No pneumothorax evident. Otherwise, exam is unchanged with persistence of the left lower lung faint opacity, morel likely atelectasis although developing consolidation/pneumonia not excluded. [2-27] knee xray: No acute fracture or dislocation. Possible small suprapatellar joint effusion. Status post right knee replacement without evidence of hardware complication. [3-1] Renal U/S: FINDINGS:The kidneys measures 11cm. There is no evidence of hydronephrosis, renal masses or nephrolithiasis bilaterally. The corticomedullary differentiaion is well preserved. The bladder is collapsed around a Foley catheter. IMPRESSION: No evidence of hydronephrosis. [3-1] LENI: IMPRESSION: No evidence of deep venous thrombosis in bilateral lower extremities. [3-1] ECHO: The left atrium is elongated. The estimated right atrial pressure is 5-10 mmHg. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. Preserved global biventricular systolic function. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Mild mitral and tricuspid regurgitation. Borderline pulmonary hypertension. [2-28]: RUQ U/S: IMPRESSION: Normal right upper quadrant ultrasound. CT Head W/O Contrast [2145-3-7]: IMPRESSION: No evidence of hemorrhage or infarction. If there are concerns for intracranial infection an MR with contrast will be far more sensitive. Discharge Labs: [2145-3-11] 03:29AM BLOOD WBC-6.0 RBC-3.08* Hgb-9.0* Hct-27.4* MCV-89 MCH-29.3 MCHC-32.9 RDW-15.9* Plt Ct-150 [2145-3-11] 03:29AM BLOOD PT-17.8* INR(PT)-1.7* [2145-3-11] 03:29AM BLOOD Glucose-101* UreaN-22* Creat-1.8* Na-140 K-3.1* Cl-108 HCO3-22 AnGap-13 [2145-3-5] 07:05AM BLOOD ALT-534* AST-74* LD(LDH)-258* CK(CPK)-58 AlkPhos-291* TotBili-0.6 [2145-3-10] 05:37AM BLOOD Mg-1.5* Brief Hospital Course: 80M with history of DM2, HTN, prostate CA sp brachytherapy, recent admission to NEBH on [2145-2-8] for TKR for arthritis who presented from rehab for a fever, tachycardia, hypotension, consistent with septic shock. ACTIVE ISSUES BY PROBLEM: # Septic Shock secondary to E. Coli septicemia: leukocytosis, fever, tachycardia, and hypotension requiring pressors, and elevated lactate and creatinine on admission, consistent with septic shock. Urine looked grossly infected, so urosepsis suspected. He was started on cefepime and vancomycin for broad coverage. Levophed was started in the ED, however this was changed to neosynephrine on arrival in the ICU in order to better control atrial fibrillation with RVR (see below). Multiple fluid boluses were given, however blood pressures continued to remain low, so neo was uptitrated. Lactate rose from 2.3 to 7.2 within hours of arrival. Blood cultures grew GNRs in [5-5] bottles within 12 hours, and urine culture also grew GNRs (e.coli), confirming high grade bacteremia from urosepsis. Pressors were able to be discontinued on [2-28]. Blood pressures remained acceptable afterward, with intermittent need for fluid boluses during ICU stay. After speciation of the blood and urine, we changed ciprofloxacin. Ciprofloxacin transitioned to ceftriaxone on [2145-3-7] out of concern ciprofloxacin could be contributing to delirium. This should continue through [2145-3-14]. A PICC line was placed on [2144-3-9]. . # Chest Pain/ Melena/ Black Esophagus/ Candidal esophagitis: Patient had one episode of melena in the ICU but no further and Hct stable. He did, however, report chest pain worse with eating and thus on transfer to floor there was concern for ulcer or other acute GI process. EGD on [2145-3-5] showed black esophagus, likely due to ischemia in the context of hypotension and hypoperfusion while he was septic. He was managed supportively with [Hospital1 ] PPI, sucralfate, and fluconazole for likely [Female First Name (un) ] esophagitis. He did well and chest pain resolved. He had no signs of bleeding with advancement of diet back to full (he was made NPO) or with initiation of anticoagulation. His fluconazole was changed to po on [2145-3-8] with plan to continue this through [2145-3-14]. He should continue on oral nystatin swish and swallow x 2 weeks after cessation of systemic antibiotics. He should have a repeat EGD in [5-7] weeks. - When odynaphagia improves, transition from IV to PO PPi # Acute toxic metabolic encephalopathy: The patient had confusion in the ICU with disorientation that was thought attributed to critical illness. He showed gradual improvement. Head CT showed no acute injury (concern for watershed infarcts given other signs of hypoperfusion injury) and work up for other sources of infection including UA and repeat blood cultures was negative. MRI was discussed with patient's HCP/daughter but it seemed unlikely to change management as hypoperfusion injury would be largely supportive and patient would require sedation for MRI which may further worsen his delirium. - At the time of discharge, the patient was at his mental baseline per his daughter. # Atrial fibrillation: No previous history of afib, acute development likely secondary to sepsis. Troponin slightly elevated, however likely due to demand ischemia from tachycardia and renal failure, no new ST changes on ECG. On arrival in the ICU, levophed was stopped in case this was contributing/driving the Afib with RVR. He was also given verapamil 2.5 mg IV then metoprolol 5 mg IV with good control of heart rate (dropped from 130s-->80s), however remained in atrial fibrillation. Given his CHADS score of 3, he was started on a heparin gtt for anticoagulation which was stopped after he developed melena and hematuria. After several days of improvement his heparin drip was restarted without overt bleeding and warfarin was restarted. Given ongoing use of abx, fluconazole and poor po intake, his warfarin/INR will need to be checked/followed VERY carefully. Goal INR [3-5]. Last dose of 1mg given on [3-10]. Recommend increasing to 2mg daily starting [3-11]. - Given the AF was in the setting of sepsis, the patients new B-blocker and Calcium Channel blocker could be titrated down and his home SBP meds restarted (once his Cr is close to baseline) # Hematuria: Thought to be related to UTI in a patient with a friable bladder post-radiation and anti-coagulation. Required foley placement with CBI, which clotted a few times. Eventually transitioned off CBI with plan for outpatient urology followup. Urology was consulted and they recommended outpatient cystoscopy with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 770] and proceding with systemic anticoagulation despite "pink colored" urine. They stated if patient again developed clots to reconsult them and they would reconsider inpatient cystoscopy. Foley was continued due to skin excoriation in perineum. - Urine was clear on [2145-3-11]. Consider discontinuation of foley later on [3-11] or on [3-12]. # Acute Renal Failure: Likely acute on chronic as baseline Cr 1.9 per NEBH records and he had protein in UA. Cr was 2.3 at rehab on the day of admission, was elevated to 3.0 on presentation. Likely etiologies include pre-renal hypovolemia vs ATN from sepsis vs post-obstructive process in pt with hsitory of prostate CA. Renal US showed no acute pathology. After transfer to floor patient had progresive improvement of his Cr as likely acute tubular necrosis resolved. On discharge Cr is 1.8 # Anion gap then non-anion gap metabolic acidosis: Anion gap 19 on admission, likely secondary to lactic acidosis and acute renal failure. His gap closed but remained with hyperchloremic metabolic acidosis likely secondary to normal saline volume resuscitation. *This resolved after fluid resuscitation stopped and patient able to eat. On discharge was # Shock liver: Patient had markedly elevated LFTs at presentation likely due to hypoperfusion and shock liver. These dramatically improved after hemodynamics were corrected. # Malnutrition/Poor po's: With acute illness, odynophagia in the acute setting (with necrotic esophagus) though this latter seems to have resolved, patient's po intake has been very poor. His diet was liberalized to allow for him to eat whatever suited him. He requires encouragement to take any po's. INACTIVE ISSUES BY PROBLEM: # Anemia: HCT 31, although appears to be higher then recent 27. Likely reflective of recent ortho surgery and blood loss. Hct on d/c is 27 # S/p TKR: Ortho saw pt in ED, felt knee healing well, signed off. Knee film unremarkable. # DM2: Held glipizide 10mg. Started on glarine 10U and ISS # HTN: Given hypotension, held home antihypertensives while in house (amlodipine 10mg) as pt was being treated with b-blocker and calcium channel blockers. # Prostate CA: appears to be in remission, sp brachytherapy. . TRANSITIONAL ISSUES: Full Code Daughter ([Doctor First Name ]) [Telephone/Fax (1) 50108] Verbal signout over the phone was given to the patients PCP prior to discharge to rehab. Pt will need to be followed for new onset of AF in regards to anticoagulation. Medications on Admission: HCTZ 25mg Glargine 10 U ISS at rehab with humalog MVT Amlodipine 10mg tylenol 1000mg simvastatin 20mg colace bisacodyl MOM [Name (NI) ] Discharge Medications: 1. CeftriaXONE 1 gm IV Q24H Switched from ciprofloxacin on [2145-3-7]. End date: [2145-3-14] 2. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 3. verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 4. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 5. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Last day [3-14]. 7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): swish and swallow last day [2145-3-28] . 8. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 12. Ondansetron 4-8 mg IV Q8H:PRN nausea Discharge Disposition: Extended Care Facility: [Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnoses: Urosepsis complicated by bacteremia with E. coli Shock Liver Acute Renal failure likely secondary to acute tubular necrosis Acute toxic/metabolic encephalopathy Hematuria Atrial Fibrillation Secondary Diagnoses: Diabetes Mellitus type 2 History of prostate cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with a severe bloodstream infection that originated in the urine. You were treated with antibiotics, fluids, and drugs to help your blood pressure and you improved. While your blood pressure was low you sustained injury to your liver, kidneys, and esophagus that are all improving. You will need time to recover from this severe illness and to continue to rehabilitate from your knee surgery. You will be discharged to a rehabilitation facility to complete this recovery. Your medications have been changed. Please take all medications as prescribed and keep all discharge appointments. Followup Instructions: Please make an appointment to follow-up with your PCP post discharge ICD9 Codes: 5845, 5990, 2930, 2762, 2851, 2768, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8042 }	Medical Text: Admission Date: [2186-11-21] Discharge Date: [2186-11-22] Date of Birth: [2171-9-20] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: Gunshot wound to abdomen Major Surgical or Invasive Procedure: Exploratory laparotomy Abdominal Washout Right lower extremity fasciotomy Placement of Swann-Ganz catheter Placement of central venous catheters History of Present Illness: Mr. [Known lastname 18937] is a 15-year-old male who was shot in the right lower quadrant at approximately 0300 on [2186-11-21]. He was taken to [Hospital 40576] by EMS where he evidently had a GCS of 15, positive FAST, and hemorrhagic shock. He was taken to the operating room and I (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]) have discussed the details of this with Drs. [Last Name (STitle) ] and [Name5 (PTitle) ] of [Hospital3 ]. He evidently had a stapled repair of a cecal injury as well as ligation of the right iliac vein. He also had a segmental loss of external iliac artery for which he had an external iliac to common femoral artery inter-position graft. The bullet was reported to remain in the right iliac fossa. He was then transferred here due to blood bank depletion and need for critical care. During transfer (helicopter), he evidently had a systolic pressure between 30 and 90 mmHg. . On arrival, his pressure was 50 systolic. He had had approximately 30 units of packed cells, 2 units of platelets, 23 liters of crystalloid, and 6 units of plasma prior to arrival. His blood loss had been estimated at 18 liters and his urine output had been 100 mL. He was hypothermic (initial temperature here was 88 degrees Fahrenheit), profoundly acidotic (pH of 6.7, Base deficit of 29, Lactate of 20), and profoundly coagulopathic (INR reported at 7, would later increase to 22). CXR from referring hospital demonstrates no pneumothorax or effusion by attending surgeon read. . Upon his arrival to the TSICU, massive transfusion protocol was initiated and the patient was taken emergently to the operating room for exploration of his open (covered) abdominal wound. Past Medical History: Reportedly in good health prior to admission . Past Surgical History: Appendectomy, date unspecified. Social History: Per report from his mother, the patient has been a "runaway" since [2186-11-14]. Parents are divorced. Mother lives locally, Father lives in [State 108]. No other social history obtained. Family History: Noncontributory Physical Exam: Pt expired. Pertinent Results: [2186-11-22] CXR: FINDINGS: In comparison with the study of [11-21], there is probable progression of the diffuse bilateral alveolar opacifications presenting a bat-[Doctor First Name 362] pattern. Although most consistent with noncardiogenic pulmonary edema, the possibility of diffuse hemorrhage or even infection or ARDS must be considered. Swan-Ganz catheter has been pulled back to the tip of the pulmonary outflow tract. Endotracheal tube remains in place, as does the nasogastric tube. . [2186-11-21] XR PELVIS: Tubing and a balloon device overlies the pelvis. Multiple other iatrogenic devices are seen. Skin staples are present. Of note, there is a bullet overlying the soft tissues of the medial proximal right thigh. Although bony detail on this image is quite limited, no obvious fracture is identified. . [2186-11-21] KUB PORTABLE: HISTORY: Critical gunshot. No other clinical indication available to me at this time. Single AP portable view obtained in the OR of the abdomen. An NG tube is present, tip over stomach. Two drains are present. Additional surgical instrumentation and skin staples and overlying artifact are present. Assessment of fine detail in the abdomen is limited -- ? fluid in abdomen. No bullet is detected in the abdomen on this film. At the periphery of these films, there are findings raising the question of increased density at the lung bases. . [2186-11-22] 12:00AM GLUCOSE-47* UREA N-12 CREAT-1.8* SODIUM-145 POTASSIUM-6.4* CHLORIDE-110* TOTAL CO2-19* ANION GAP-22* [2186-11-22] 12:00AM CALCIUM-10.1 PHOSPHATE-6.8* MAGNESIUM-2.2 [2186-11-22] 12:00AM WBC-1.6* RBC-3.01* HGB-9.8* HCT-26.7* MCV-89 MCH-32.5* MCHC-36.5* RDW-14.2 [2186-11-22] 12:00AM PLT COUNT-96* [2186-11-22] 12:00AM PT-18.8* PTT-48.6* INR(PT)-1.7* [2186-11-21] 10:11PM TYPE-ART PO2-143* PCO2-44 PH-7.24* TOTAL CO2-20* BASE XS--8 [2186-11-21] 10:01PM WBC-1.5* RBC-3.26* HGB-10.2* HCT-28.9* MCV-89 MCH-31.4 MCHC-35.4* RDW-14.0 [2186-11-21] 10:01PM PT-22.0* PTT-67.5* INR(PT)-2.1* [2186-11-21] 08:13PM ALT(SGPT)-446* AST(SGOT)-783* LD(LDH)-1099* ALK PHOS-49 AMYLASE-143* TOT BILI-0.7 [2186-11-21] 08:13PM LIPASE-89* [2186-11-21] 08:13PM ALBUMIN-2.4* CALCIUM-10.5 PHOSPHATE-5.3* MAGNESIUM-1.7 Brief Hospital Course: Upon his arrival to the TSICU, massive transfusion protocol was initiated and the patient was taken emergently to the operating room for exploration of his open (covered) abdominal wound by Dr. [Last Name (STitle) ]. (see op note for detail) After leaving the operating room, Pt arrived to TSICU with tenuous blood pressure. Pt arrested multiple times and was resuscitated with blood/platelets/plasma and pressor support. Pt received 90+ units of blood products, was on vasopressor support throughout, multiple amps of bicarb, Factor 7. On postoperative day 1, the patient was hyperkalemic, continued to be acidotic, coded multiple time for bradycardic arrest, ventricular fibrillation, asystole, profound hypotension. Right lower extremity fasciotomies were performed by the Vascular Surgery team. Muscle appeared to be somewhat viable but did not bleed well. Pt. again arrest approximately at 515 PM and expired. Medications on Admission: None Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Gunshot wound to abdomen Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None - Patient Expired ICD9 Codes: 2851, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8043 }	Medical Text: Admission Date: [2167-6-1] Discharge Date: [2167-6-2] Date of Birth: [2110-8-10] Sex: M Service: NEUROLOGY Allergies: Fentanyl Attending:[First Name3 (LF) 618] Chief Complaint: Left sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: 56yo M with HTN, afib, pacer implantation, CAD s/p CABG x 2, presents with headache L sided weakness found to have R ICH on OSH CT. Found by son on ground this am after hearing a thud upstairs. Pt was conversant according to EMS records complaining of severe headache and Left sided weakness. At OSH he was intubated for ? reasons. Head CT revealed large R basal ganglia hemorrhage with extensive intraventricular spread, + blood in 4th ventricle, 1cm midline shift. INR at OSH was 3.4. He was given Vit K, FFP x 3 units, loaded with dilantin, nitroprusside for BP control. Transferred to [Hospital1 18] for further care. Past Medical History: Paroxysmal Atrial Fibrillation [2159] Tachybrady Syndrome s/p PPM [11-4] Stroke [1-4] Upper GI bleed Hepatitis C in the setting of IV drug use Diabetes Hpertension Oesity Social History: He is a prior smoker. He is currently self-employed as an exterminator. He used to use IV drugs but does not use them anymore. Family History: There is a family history of diabetes and early stroke in his mother. Physical Exam: T 98, HR 100, BP 190/90, R 18, 100% intubated Gen- critically ill, intubated, off propfol x 15 minutes prior to exam. HEENT: NCAT, anicteric sclera Neck: no carotid bruits, no nuchal rigidity. CV- RRR, no MRG Pulm- soft crackles bilat, Adb- soft, nd, BS+ Extrem- 1+ bilat LE edema Neurologic exam: MS- no response to deep noxious stimuli. CN- pupils 6mm and unreactive to light bilaterally, absent oculocephalic reflex laterally and vertically, no blink to threat, absent corneal response, + gag. Motor/Sensory- no arm movement to noxious, activates quads bilaterally to deep noxious in legs but otherwise no actual leg movement. Reflexes- absent throughout Plantar response- upgoing on left, mute on right. Pertinent Results: CT head [2167-6-1] 1. Massive right temporoparietal hemorrhage, centered within the right basal ganglia, with intraventricular extension and subfalcine, uncal, transtentorial and tonsillar herniation. 2. Diffuse subarachnoid hemorrhage and diffuse brain edema. 3. Entrapment of the left lateral ventricle with hydrocephalus. CXR [2167-6-1] IMPRESSION: 1. Bibasilar ill-defined patchy opacities, right greater than left, which could represent areas of infection or atelectasis. 2. Small amount of fluid within the right minor fissure. 3. Appropriate positioning of lines and tubes. [2167-6-1] 06:33PM TYPE-ART RATES-/14 TIDAL VOL-700 PEEP-5 O2-100 PO2-348* PCO2-43 PH-7.41 TOTAL CO2-28 BASE XS-2 AADO2-342 REQ O2-60 INTUBATED-INTUBATED [2167-6-1] 05:34PM GLUCOSE-221* UREA N-13 CREAT-0.9 SODIUM-140 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15 [2167-6-1] 05:34PM CK(CPK)-159 [2167-6-1] 05:34PM cTropnT-<0.01 [2167-6-1] 05:34PM CALCIUM-9.6 PHOSPHATE-2.7 MAGNESIUM-1.9 [2167-6-1] 05:34PM ASA-NEG ETHANOL-NEG ACETMNPHN-9.6 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2167-6-1] 05:34PM WBC-12.4* RBC-5.25# HGB-13.6# HCT-41.5# MCV-79# MCH-25.9# MCHC-32.8 RDW-15.0 [2167-6-1] 05:34PM NEUTS-74.9 LYMPHS-18.2 MONOS-5.9 EOS-0.5 BASOS-0.5 [2167-6-1] 05:34PM PLT COUNT-236 [2167-6-1] 05:34PM PT-21.3* PTT-33.8 INR(PT)-2.0* Brief Hospital Course: 56yo male with mult vascular risk factors, CAD, HTN, afib on coumadin presents with a large R putaminal hemorrhage. His exam off sedation at present is very poor with loss of brainstem reflexes except for gag. Motor exam only notable for vague activation of quadriceps bilaterally. CT from outside hospital with extensive intraventricular spread of hemorrhage with dissection of the brainstem and blood in the 4th. Given his examination and imaging this is a grade IV intraventricular hemorrhage with very poor prognosis. He had serial brain stem examinations, and in his second brainstem exam, he met the criteria for brain death. His family were aware of the situation and his family agreed to an organ donation on [2167-6-2]. Medications on Admission: Medications (per chart review): ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - 40 units by injection once a day INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - Dosage uncertain LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL TARTRATE - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth twice a day SOTALOL - (Prescribed by Other Provider) - 80 mg Tablet - 1.5 Tablet(s) by mouth twice a day WARFARIN - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth as directed 5 mg M,T,TH,F,Sat and 7.5 mg (1 [1-30]) tabs Sun, Wed Medications - OTC ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth twice a day ASPIRIN [ENTERIC COATED ASPIRIN] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - one Tablet(s) by mouth daily OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - (Prescribed by Other Provider) - 20 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Stroke (large right putaminal hemorrhage with extensive intraventricular spread) Discharge Condition: Not applicable Discharge Instructions: None Followup Instructions: None [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2167-6-3] ICD9 Codes: 431, 4589, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8044 }	Medical Text: Admission Date: [2168-7-19] Discharge Date: [2168-8-2] Date of Birth: [2121-6-20] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1505] Chief Complaint: SOB Major Surgical or Invasive Procedure: Cardiac cath History of Present Illness: 47 year old female with known aortic stenosis was seen at OSH ED for recent development of shortness of breath. In the days preceding her ED visit the patient developed shortness of breath when walking distances or up stairs. Her SOB was associated with chest tightness, dizziness, changes in vision, and on one occurence, loss of urine. There has not been any syncope with these episodes. She saw her PCP the day of her admission where CXR showed CHF and she was then sent to the ED for further work up and diuresis. ECHO in the ED showed critical aortic stenosis. Patient was transferred to [Hospital1 18] for cardiac cath in preparation for future valve surgery. Cath showed mild disease in coronaries and critical AS with an aortic valve area of 0.27 and gradient of 26.63. She was also noted to have [1-10]+MR, severe pulmonary HTN, LV diastolic heart failure with LVEF of 45-50%. Pressures: RA - 14, RV - 71/19, PA - 71/37, PCWP - 32, AO - 100/54, CO - 2.29, CI - 1.19. Past Medical History: Anxiety Alcohol abuse Back pain Anemia secondary to chronic alcohol use Aortic stenosis Social History: Patient lives with her husband and two sons. She has a 30 ppy tobacco hx, and recurrent alcohol abuse. She has presenty been sober for 8 months, is involved in AA and therapy. Family History: Father - aortic stenosis, bovine valve replacement, multiple CABGs, CHF, CEA Mother - hx of silent MI 3 Siblings - healthy Physical Exam: Vit: T 97.3 HR 85 BP 136/59 RR 20 PO2 95%RA 2L Gen: milddle aged woman, lying flat on bed, in NAD HEENT: MM slightly dry, PERRLA, EOMI Neck: soft, + JVD CV: RR, [3-13] blowing holosystolic murmur radiating to the carotids, early diastolic murmur Pulm: CTAB anteriorly, no w/c/r Abd: + BS, soft, NT, ND Ext: no peripheral edema Skin: + telangectasias on face Neuro: AAO x 3, CN II-XII grossly intact Pertinent Results: [2168-8-2] 06:10AM BLOOD WBC-7.7 RBC-3.50* Hgb-11.3* Hct-33.9* MCV-97 MCH-32.2* MCHC-33.3 RDW-15.6* Plt Ct-104* [2168-8-2] 06:10AM BLOOD PT-21.3* PTT-74.9* INR(PT)-3.0 [2168-8-2] 06:10AM BLOOD UreaN-11 Creat-0.8 K-4.3 Brief Hospital Course: Taken to OR on [2168-7-21] for AVR (mechanical), found to have significant MAC, therefore, MVR was also done at that time. Post-op course stable, transferred to telemetry floor on POD # 2, started on Coumadin, lopressor and lasix. Heparin gtt initiated on POD # 3. On POD # 6, INR was elevated to 3.5 (from 1.8), but on the following day, she dropped to < 2.0, and heparin was restarted. She remained in the hospital waiting for therapeutic INR. During that time, her lasix and KCl were d/c'd, she progressed with PT, and she is now [Last Name (un) ] to be discharged home. Her INR today is 3.0. SHe will receive 5 mg on Coumadin today and tomorrow, then have her INR checked, and called to Dr. [Last Name (STitle) 656] who will continue dosing for a target INR 3.0-3.5. Medications on Admission: Folate MVI Remeron ASA 81 mg Vit B12 shots 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 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 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 4. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: 5 mg on [8-2] & [8-3],then INR to be checked and called to Dr.[Name (NI) 42421] office for continued dosing (target INR 3.0-3.5). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: Severe AS, MAC s/p AVR(), MVR()-mechanical Etoh abuse anxiety Discharge Condition: Good. Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 2 lbs in one day or five in one week Call with temperature greater than 100.5, redness or drainage froim incision. No driving or lifting more than 10 pounds until follow up appointment. [Month (only) 116] shower, wash incision with mild soap and water, pat dry, do not aply lotions, creams or powders, no baths, keep out of the sun. Adhere to 2 gm sodium diet Followup Instructions: Dr. [Last Name (STitle) ] 4 weeks Dr. [Last Name (STitle) 656] 2 weeks Dr. [Last Name (STitle) ] 2 weeks Completed by:[2168-8-2] ICD9 Codes: 4168, 4019, 3051, 2724, 2768
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8045 }	Medical Text: Admission Date: [2130-2-9] Discharge Date: [2130-2-21] Date of Birth: [2071-10-16] Sex: F Service: MEDICINE Allergies: Percocet Attending:[First Name3 (LF) 4095] Chief Complaint: Altered mental status, respiratory failure Major Surgical or Invasive Procedure: Endotracheal Intubation Bronchoscopy Central Venous Cannulation Arterial Line Placement History of Present Illness: 58 yo female who at [Hospital3 ] facility was noted to have changes in mental status, eye rolling, gait instability at home. Had also reported to outside providers that she was coughing and low grade temps for several weeks -> started on augmentin [1-12]. Call to PCP reported some pain from abdominal incision, fatigue and depression. Brought to ED on [2130-2-9] and was found to have fever and hypoxia and respiratory distress. She was started on NIPPV. She was eventually intubated upon transfer to ICU for somnolence and no significant improvement in terms of respiratory status. Started on levo, vanco, cefepime. [Hospital ] facility reported [1-4] pills missing from trazadone bottle. Toxicology consult obtained but it turned out the facility was mistaken and was referring to another patient, so erroneous. MICU course ([Date range (1) 33280]) was significant for mucus plugging s/p bronchoscopy on [2-10] showing thin secretions, sputum cx growing H flu, oliguria responsive to IVF, bradycardia from Precedex, development of HTN while on steroids. Was extubated on [2-16]. HCT also showed frontal lobe hypodensities of unclear chronicity, family declined MRI for now. At this point, leukocytosis, hypercapnia, mild transaminitis have all improved. She has some paranoid thoughts about her health care which are new. Denies any suicidal or homicidal thoughts. Reports that breathing is "at 100%" and reports no pain. Past Medical History: - COPD/asthma - "throat disorder" ("not GERD or Barrett's...throat closes if I don't take protonix") - depression with suicide attempts in past - sleep apnea - colonic polyps - no h/o HTN, no anti-HTN meds in OMR Past Surgical History: - cholecystectomy [2124] c/b subsequent incarcerated hernia with bowel compromise requiring small bowel resection with primary anastamosis @ OSH - ventral hernia repair Social History: - Tobacco: still actively smoking up until admission per niece (per patient quit 2 weeks ago) - Alcohol: negative - Illicits: negative Family History: HTN diffusely in family Physical Exam: Admission Exam (in MICU): General Appearance: Intubated, sedated. Wakes up when stimulated, starts choking on tube. Can occasionally squeeze hands Eyes / Conjunctiva: left pupil s/p cataract surgery. 5 mm L, 2 mm R pupil. ERRL Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube Lymphatic: Cervical WNL Cardiovascular: RRR, normal S1,S2. No m/g/r Respiratory / Chest: Good bilateral air entry, coarse upper respiratory sounds/rhonchi, but no wheezes or crackles. Significant sputum production. Abdominal: Soft, Non-tender, Obese, mid-line ventral hernia scar, well-healed Extremities: Warm, well perfused. 2+ peripheral pulses. No edema Exam on transfer ([2-17] PM): Gen well appearing female in NAD VS afebrile 170/90 95 95% 2L Neck JVD unable to be appreciated CV RR no mrg Pul poor air movement, scant end-inspiratory wheezes, no rales Abd soft NT ND, midline scar well healed, no palpable hernia Ext without edema, cold but not cyanotic Neuro "[Hospital1 18]," "you're a doctor," "I'm here for pneumonia." Could only do 4 digits immediate recall. CN 2-12 intact, VFFTC, sensation intact to light touch, DTRs present and symmetric in upper extremities and knees. Psych reported "someone is trying to download files about that person who died in the ICU" and "they are after me" Exam on discharge AVSS with SBPs 110-120s. Desaturation to 88% transiently on ambulation on room air. NAD, hoarse voice No wheezes, good air movement CNII-XII intact, normal gait, normal affect. Pertinent Results: ==================== LABORATORY RESULTS =================== On Admission: WBC-18.4# RBC-4.89 Hgb-12.6 Hct-40.2 MCV-82 RDW-15.1 Plt Ct-271 --Neuts-87.1 Lymphs-6.9* Monos-5.6 Eos-0.2 Baso-0.2 PT-11.4 PTT-25.3 INR(PT)-1.1 Glucose-157* UreaN-19 Creat-0.9 Na-133 K-4.4 Cl-97 HCO3-24 ALT-105* AST-133* CK(CPK)-100 Calcium-8.2* Phos-3.7 Mg-2.1 Albumin-4.1 Lactate-1.1 VitB12-802 Osmolal-280 TSH-0.48 Blood Tox: ASA-NEG EtOH-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Urine: Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.013 RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 CastGr-2* CastHy-30* bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG On Discharge: [2130-2-21] 07:24AM BLOOD WBC-7.8 RBC-4.91 Hgb-12.8 Hct-39.4 MCV-80* MCH-26.0* MCHC-32.4 RDW-16.3* Plt Ct-503* [2130-2-21] 07:24AM BLOOD Glucose-146* UreaN-21* Creat-0.6 Na-133 K-3.9 Cl-99 HCO3-23 AnGap-15 [2130-2-19] 06:05AM BLOOD %HbA1c-6.2* eAG-131* Other Significant Labs: [2130-2-9] 04:48PM BLOOD CK-MB-7 cTropnT-0.06* [2130-2-9] 11:45PM BLOOD CK-MB-6 cTropnT-0.02* ============== MICROBIOLOGY ============== Urine Culture [2130-2-9]: URINE CULTURE (Final [2130-2-10]): PROBABLE ENTEROCOCCUS. ~1000/ML. Sputum Culture [2130-2-9]: GRAM STAIN (Final [2130-2-9]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2130-2-11]): SPARSE GROWTH Commensal Respiratory Flora. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE. MODERATE GROWTH. BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN. All blood cultures negative ============== OTHER STUDIES ============== EKG on Presentation [2130-2-9]: NSR, NI, LAD, TWI in V1-V3, transition point V5. Similar to prior dated [2128-8-31]. CXR [2130-2-9]: Impression: 1. Pulmonary vascular congestion. 2. Area of increased opacity lateral right upper lung could be due to overlying vascular and osseous structures, although underlying consolidation may be present, due to infection or aspiration. CT Head [2130-2-9]: Impression: 1. Loss of [Doctor Last Name 352]-white matter differentiation and subtle hypodensities in the left frontal lobe, inferior putamen, and subinsular region . The etiology is unclear. Would recommend MRI for further evaluation. 2. Small air-fluid levels in the right maxillary sinus and sphenoid sinuses may be related to intubation. TTE [2-13]: The left atrium is elongated. The left ventricular cavity size is normal. Regional wall motion abnormalities could not be excluded due to suboptimal imaging. However, overall left ventricular systolic function is probably normal (LVEF>55%). 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. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Regional wall motion abnormalities could not be excluded due to suboptimal imaging. However, overall left ventricular systolic function is probably normal. No significant valvular regurgitation/stenosis. CXR [2-17]: FINDINGS: In comparison with the study of [2-15], the endotracheal tube and nasogastric tube have been removed. Continued hyperexpansion of the lungs with substantial decrease in opacification at the right base. Pulmonary vascularity is within normal limits, and there is no definite pneumonia. Mild atelectatic changes at the bases. CT Head [2130-2-18]: IMPRESSION: Previously seen vague hypodensities in the left insular region are less apparent on today's examination. No acute hemorrhage detected. MRI Head/ MRA Head/ MRA Neck [2130-2-18]: IMPRESSION: 1. Findings involving the parieto-occipital subcortical white matter, bilaterally, without significant mass effect or associated diffusion abnormality or hemorrhage. These findings are most suggestive of so-called PRES (posterior reversible encephalopathy syndrome) and should be closely correlated with history of significant hypertension (including "relative" hypertension) and/or implicated pharmaceutical agents. 2. Discrete and confluent FLAIR-hyperintensity in bihemispheric subcortical and periventricular and central pontine white matter, unchanged since [2129-5-18], and likely representing chronic small vessel ischemic disease, perhaps related to underlying hypertension. 3. Unremarkable cranial MRA, with no flow-limiting stenosis. N.B. The cervical MRA could not be completed. Brief Hospital Course: 58F asthma/COPD with recent hospitalization for pneumonia/COPD exacerbation at [Hospital1 ] in [11-26], sleep apnea, depression with prior SI, tobacco abuse brought in by ambulance for altered mental status, found to have pneumonia and continuing altered mental status thought to be secondary to PRES syndrome. ACTIVE ISSUES: # Hypercarbic and hypoxemic respiratory failure/ COPD with exacerbation/ Acute bacterial pneumonia (H. Influeza): Pt placed on BiPAP in ED, but intubated on arrival to the ICU for respiratory acidosis, hypoxemia and failure of bipap trial, copious secretions found on intubation. Etiology likely multifactorial: ? COPD/asthma exacerbation with pneumonia. PE thought unlikely. CXR showed RLL PNA. Bronchoscopy showed significant mucous production with airway mucous plugs occasionally. Patient was started on cefepime, vanco, levofloxacin (D1= [2-9]) for PNA coverage and given Prednisone 60mg for 3 day course with standing MDIs for possible COPD exacerbation. H. influenza came back positive in the sputum. Patient was continued on cefepime and levofloxacin (Vanc d/c'd [2-12]) until sensitivities returned and then converted to levofloxacin alone and finished 10 days of therapy for acute bacterial pneumonia. She still had considerable wheezing so standing bronchodilators continued. Prednisone was stopped on [2130-2-18] after development of PRES and patient was started on fluticasone inhaler for better control of COPD/Asthma. - Pt ambulating with 02 saturations to 88% on room air that promptly return to >90% upon rest. # Sepsis secondary to Bacterial PNA: Patient met SIRs criteria on admission (fever, tachycardia, leukocytosis) with suspected pulmonary source (pneumonia). CXR showed RLL PNA. Affected organs are lungs (respiratory failure) and altered mental status. Urine output initially poor but Cr remained stable. Lactate remained WNL. No other apparent sources ?????? UA not suggestive of infection, does not seem to have any pain w abdominal palpation, no diarrhea. Had initially questioned meningitis, however this seemed less likely given her clear pulmonary source. Continued antibiotics for PNA as above and septic physiology resolved. # Acute Encephalopathy: Per reports, patient had gait instability and was "groggy." There is some concern for ? toxidrome given numerous psychiatric medications. Other considerations include septic encephalopathy, hypercarbia, primary CNS process such as SDH or meningitis. Toxicology consulted re: possible trazadone ingestion ?????? recommended benzos for agitation and monitoring of ECG for QRS/QTc prolongation, as patient is also on effexor. CT scan showed findings concerning for some hypoxic injury, however unclear if this was acute or chronic. TSH and Vit B12 normal and on arrival to the floor pt no longer acutely encephalopathic . # Posterior reversible encephalopathy Syndrome/Seizures: On the day after transfer out of the MICU the patient intially appeared well and respiratory status was stable. She then developed a sudden episode of unresponsiveness where she was noted to have choking sounds but no abnormal movements were noted. She began to respond in less than a minutes but was unable to speak and could only follow commands on left side of the body. A code stroke was called. Head CT benign but already exam had returned to nearly baseline suggesting more likely seizure. Prior to going for MRI patient had an additional seizure, which was convulsive and consisted of face and eye clonic movements to the right. This lasted less than three minutes and resolved on its own with post ictal period following. The patient received lorazepam and went to MRI where imaging consistent with PRES thought likely contributed to by relative hypertension (SBPs in 170's from baseline of normotensive) and possibly prednisone. As it was day 8 of prednisone taper this was stopped and patient was loaded with levetiracetam. . *She had no further seizures. She was discharged with plan to follow up with neurology in one month and repeat MRI in two months to document resolution. She should be seizure free for six months prior to driving again, which was emphasized by the primary team and neurology* - Final EEG still pending at the time of discharge - Patient discharged on Keppra 1000mg [Hospital1 ] - Pt to follow-up with neurology in 1 month time. She will need a repeat MRI to evaluate PRES in ~ 2 months. . # Hypertension: Patient with hypertension noted in the ICU and thought likely secondary to prednisone. Captopril was started but SBPs still running in 150s-170s on transfer out of the MICU. Dose increased after PRES diagnosis but later when SPB in 90's was decreased back to 6.25 mg po tid. At discharge she was transitioned to lisinopril 10mg with SBPs in the 110s-120s (based on Captopril dosing) . # OSA: She was continued on CPAP after extubated with no acute issues. . # Depression: Held home effexor while intubated, as this cannot be crushed. Concern for trazadone overdose contributing to AMS on presentation but then concern for empty pill bottles appears to have been inappropriate as report of empty bottle actually referred to another patient. Patient was re-initiated on her home psychiatric medication regimen with normal mental status prior to discharge. Psychiatry followed her throughout the admission. Although remeron and clonazepam were recommended being discontinued on discharge, the patient stated that she had these medications at home and would likely take them for sleep and anxiety once at home. A message was left with the patients outpatient prescribing physician (Dr. [First Name (STitle) 6164] to call back the Hospitalist pager at [Telephone/Fax (1) 9472] and was pending at the time of discharge. A ECG was checked prior to d/c with the pt's QTC <400 prior to d/c. . Transitional Issues: - Coordination was made with the [Company 191] transitions team on discharge - A visiting nurse was set up to provide medication teaching, orthostatic checks and pulmonary evaluation on discharge. - The patient is to follow-up with Dr. [Last Name (STitle) ] on [2130-2-28] - A medication reconcillation was attempted over the phone with the [First Name4 (NamePattern1) 5279] [Last Name (NamePattern1) ], but the staff member stated the medication list was a "few years old" ([2130-2-21]) - A medication reconcillation was performed with the [Company 4916] on [Location (un) ] St in [Location (un) 745] over the phone on ([2130-2-21]). Attempts were made to reconcile the above list as best possible. Potential issues include pt prescribed 2 B-agonists (albuterol and pivoablbuterol), addition of Keppra, low SBPs with Lisinopril 10mg. -Patient should not drive until seizure free for six months -She will need close monitoring of her depression while on levetiracetam as this medication can worsen depression -She should follow up with Dr. [Last Name (STitle) ] in neurology in one month -She should have repeat head MRI in two months to document resolution of PRES Medications on Admission: - risperdal 2 mg PO qAM - baclofen 10 mg PO TID - oxybutynin ER 15 mg PO BID (Pt reported takes 20 mg QAM and 10 mg QPM) - remeron 45 mg PO qHS - trazadone 200 mg PO qHS - [Doctor First Name 130] 60 mg 2 tab PO qD - ibuprofen 800 mg [1-16] tab PO prn - Gabapentin 600 mg PO qHS - singulair 10 mg PO qD - doc-q-lace 100 mg PO 2 tab qD - Effexor XR 75 mg PO qD - Effexor XR 150 mg 2 tab PO qD - Protonix 40 mg PO BID - topamax 200 mg PO BID - albuterol sulfate INH prn SOB - prednisone taper [1-20*] Tablet(s) by mouth daily as directed 60 mg daily x 3 days then 40 mg daily x 3 days then 20 mg daily x 2 days then 10 mg daily x 2 days (unclear if started) Discharge Medications: 1. risperidone 1 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 2. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. oxybutynin chloride 5 mg Tablet Extended Rel 24 hr Sig: Three (3) Tablet Extended Rel 24 hr PO twice a day. 4. trazodone 100 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for insomnia. 5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 6. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Five (5) Capsule, Ext Release 24 hr PO DAILY (Daily). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. topiramate 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO once a day. 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for shoulder pain or fever. 12. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s)* Refills:2 13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 14. Remeron 45 mg Tablet Sig: One (1) Tablet PO once a day. 15. clonazepam 2 mg Tablet Sig: One (1) Tablet PO once a day. 16. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) Inhalation once a day. 17. [Doctor First Name ] 60 mg Tablet Sig: One (1) Tablet PO once a day. 18. Astelin 137 mcg Aerosol, Spray Sig: One (1) Nasal once a day. 19. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 20. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: [1-16] Inhalation every 4-6 hours. Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Primary Diagnoses: -Hemophilus Influenza Pneumonia -Chronic obstructive Pulmonary Disease Exacerbation -Hypercarbic and Hypoxemic Respiratory Failure -Posterior Reversible Leukoencephalopathy Secondary Diagnoses: -Depression -Obstructive Sleep Apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with shortness of breath and found to have a severe pneumonia as well as a worsening of your chronic obstructive pulmonary disease. You were treated with antibiotics and medicines to help open your lungs but you still required a machine to support your breathing. You were eventually weaned off this machine. You also developed a condition called posterior reversible leukoencephalopathy (PRES), likely related to relatively high blood pressures and the prednisone medicine used to treat your chronic obstructive pulmonary disease. This caused you to have seizures. You were treated with an anti-seizure medicine and your blood pressure controlled and you had no further seizures. This should completely resolve but you will need to follow up with neurology and should not drive for six months. Your medications have been changed. Please take all medications as prescribed. Followup Instructions: Department: [Hospital3 249] When: TUESDAY [2130-2-28] at 10:00 AM With: DR [First Name (STitle) ] [First Name (STitle) ]/[Company 191] POST [Hospital 894] CLINIC Phone: [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [Name10 (NameIs) 616] this visit, you will see your regular primary care doctor in follow up. Department: NEUROLOGY When: WEDNESDAY [2130-4-5] at 3:00 PM With: [First Name8 (NamePattern2) ] [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 3445], MD [Telephone/Fax (1) 2574] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 0389, 2762, 2930, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8046 }	Medical Text: Admission Date: [2192-6-26] Discharge Date: [2192-7-4] Date of Birth: [2108-7-8] Sex: F Service: MEDICINE Allergies: Prinivil / Keflex Attending:[First Name3 (LF) 10842] Chief Complaint: L leg hematoma Major Surgical or Invasive Procedure: none History of Present Illness: 83 yo F with CDIP s/p IVIG and atrial fibrillation on coumadin admitted to [Hospital1 18] with diaphoresis and hypotension. At her nursing home she injured her left leg during tranfer from shower to chair. She was transferred initially to an OSH, SBPs were noted to be in the 60s resolving spontaneously and she was transferred to [Hospital1 18]> ON admission her labs were notable from a Hct of 24 (baseline 30-33) and INR of 5.1. There was concern for RP bleed. She received to [Location 16678] and Vit K in the evening of [6-27] and 1 unit of pRBCS with appropriate increase but lost her IV access. Multiple attempts on the floor to place an EJ and PIVs were unsuccessful and she was transferred to the MICU for closer monitoring of hematocrit and placement of central access. BP on transfer was 120/60. In the ICU, RIJ was placed. CT abdomen showed no evidence of an RP bleed, instead a left thigh hematoma without extension was seen. Lowest noed Hct was 18.5 on [6-28] in the AM. She received an additional 4 units of pRBCS and 2 units FFP that evening. Hct stabilized at 27. She was never hemodynamically stable. Hcts are now being cycled [Hospital1 ]. Vascular was consulted for concern of compartment syndrome due to poor function of lower extremities due to baseline neurological disease. However this exam finding was not acute and patient has good peripheral pulses, without significant pain. Patient also had a new complain of left arm pain where a bruise and left upper extremity edema was noted. LUE ulstrasound noted no DVT, but did suggest hematoma or synovial swelling. Review of systems: (+) constipation (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: CIDP, getting monthly IVIG last [2192-6-7] - Asthma, ?COPD - Arthritis - Heart murmur/aortic stenosis - Left carotid plaque (unknown severity; exam performed at OSH) - HTN - Hypercholesterol - ?H/o DVT 20-30 years ago - Sciatica - Esophagitis - Tinnitus - afib , on coumadin briefly, but then stopped [3-13] falls, with later successful cardioversion->now back on coumadin Social History: Retired funds manager of health/welfare for Teamsters [Hospital1 ], lives with husband and son in [Name (NI) 4628]. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Mother had a MI at 63, uncles with heart disease. Sister and oldest son with DM type II. Physical Exam: On admission: Vitals: 99.3 71 130/84 16 94% on RA General: elderly F Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, small ecchymoses/hematoma over R SCM Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: large LLE thigh noticeably larger than RLE thigh with ecchymoses over the L thigh and L back. toes slightly decreased in temperature bilaterally. wiggles toes. PTs, DPs moderately dopplerable bilaterally. Pertinent Results: Labs on Admission: [2192-6-26] WBC-11.4# RBC-2.55 HGB-8.2* HCT-24.5* MCV-96 RDW-15.0 NEUTS-85.4* LYMPHS-10.5* MONOS-2.9 EOS-1.0 BASOS-0.1 PT-47.2* PTT-27.3 INR(PT)-5.1* HAPTOGLOB-196 CK-MB-NotDone cTropnT-0.02* LD(LDH)-163 CK(CPK)-51 TOT BILI-0.2 ABG PO2-202* PCO2-38 PH-7.41 TOTAL CO2-25 Left femur fx: [2192-6-26] There is no fracture or dislocation. Tricompartmental degenerative changes are seen within the knee with joint space narrowing, subchondral cystic and sclerotic changes, and osteophyte formation. Moderate hip osteoarthritis is also seen on the left with osteophytic spurring, joint space narrowing and subchondral sclerosis. No focal lytic or sclerotic osseous abnormality is present. No fracture or dislocation is present. CT abdoman/ pelvis w/o contrast: [6-28] 1. Large left thigh hematoma, without active extravasation or underlying fracture. 2. Multiple renal cysts, with questionable hyperdense lesion in left mid pole. Recommend ultrasound for further evaluation. Left Elbow lateral/AP [6-29]: Technically limited study with no true frontal view. No evidence of a fracture, dislocation, or posterior fat pad indicating joint effusion. Unilateral LUE u/s: No DVT CXR [7-2]: As compared to the previous radiograph, there is no relevant change. No overhydration. No focal parenchymal opacity suggesting pneumonia. Moderate tortuosity of the thoracic aorta. No hilar or mediastinal lymphadenopathy. Brief Hospital Course: 83 yo F with CDIP and AF on coumadin transferred to the MICU for monitering of acute blood loss in the setting of a L thigh. On admission it was unclear what the source of her blood loss was, thought ot be RP bleed. Given the rapidity of the blood loss, she was transferred to the ICU. Pt was noted to be supratherapeutic. There was no evidence of GIB. RIJ triple lumen was placed as patient has poor access. She was given Vitamin K and FFP to maintain an INR <1.5. CT non contrast of abdomen pelvis showed left thigh hematroma, without pelvic or hip fracutre and without RP bleed. There was initially concern for compartment syndrome due to the increased firmness of the left leg. Vascular was consulted. Pt continued to have palpable DP pulses with function of her lower extremity and recommended q4h neuro and vascular checks to ensure stability. Pt eperienced some low grade fevers in the setting of hematoma and truma. She was pan cultured but there was no evidence of infection. She remained asymptomatic and prior to transfer to the medical floor her fevers stopped. She was given a total of 5 units of pRBCs and 4 units FFP in the ED and ICU. Her Hct was relatively stable prior to transfer to the floor. Given a slow drift of hematocrit she was again transfused two additional units. After which her respiratory status worsened. She was also generally edematous due to the volume she had received. She was given IV lasix with improvement of her respiratory status. She was also given an incentive spirometer to reduce atelectasis. At time of discharge her Hct was 32.5 and stable for 48 hrs. #Atrial fibrillation: Patient was s/p TEE cardioversion in [11/2191], and rate controlled. Her CHADS-2 score is 2, warranting anticoagulation She was continued on her metoprolol and amiodarone, but given active bleeding resuming anticoagulation and aspirin therapy will be deferred for outpt as discussed with Dr. [Last Name (STitle) ] on day of discharge. # Troponin leak: Patient with mild troponin leak of 0.02 on admission (baseline troponin leak of 0.02 back in 3/[2192]). No chest pain or SOB. However, patient has new LBBB on EKG, although she has had intermittent LBBB in the past. Thought to be secondary to stress from injury. She was continued on BB and statin. ASA treatment was deferred given bleed. # Asthma/COPD: continue ipratropium, q6h, standing # Constipation: Pt is chronically constipated. It is very important to uptitrate bowel regimen as needed to ensure regular bowel movements. #Pain - Pt on oxycodone for pain given hematoma. Given constipating effect of this medication. Please down titrate narcotics in favor of naprosyn or other non constipating medication to control pain. #Back and leg pain: Pt on standing Tylenol and # Prophylaxis: pneumoboots # Access: R IJ # Communication: Patient # Code: Full (discussed with patient) To do: - regular bowel regimen - pain control with tylenol and oxycodone, please discontinue narcotics in favor of tramadol when pain has improved - if patient appears clinically volume overloaded has done well with 40mg po lasix - pt to resume ASA and/or coumadin per her PCP as [Name9 (PRE) 84417], currently holding per PCP's wishes - pt has a smal tear near the perineal region, care instructions below: cleanse ulcer with wound cleanser, foam cleanser or NS then pat dry apply thin layer of critic aid clear to ulcer and peri ulcer tissue daily- reapply if having frequent BM's Pressure ulcer care per guidelines: Turn and reposition off back q 2 hours and prn Limit sit time to 1 hour at a time using a pressure redistribution cushion Medications on Admission: Amiodarone 200 mg PO DAILY Amlodipine 2.5 mg PO DAILY Metoprolol Tartrate 12.5 mg PO BID Rosuvastatin 5 mg PO DAILY Lidocaine 5 % Patch, DAILY as needed for back pain. Tramadol 50mg PO q8 PRN Aspirin 81 mg PO DAILY Hydrochlorothiazide 25 mg PO DAILY Coumadin 1mg PO daily Senna/Colace Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for SOB. Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Rosuvastatin 5 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 back pain. 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day: hold for loose stools . 10. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day: hold for loose stools. 11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. Discharge Disposition: Extended Care Facility: [Hospital1 4860] - [Location (un) 4310] Discharge Diagnosis: Primary Active Diagnoses Anemia secondary to blood loss Left thigh hematoma COPD/Asthma Secondary Diagnoses: CIDP Hypercholesterolemia HTN Arthritis Sciatica Esophagitis Cellulitis Dysphagia Hiatal Hernia Discharge Condition: -Mental Status: Clear and coherent. -Level of Consciousness: Alert and interactive. -Activity Status: Bedbound. Left thigh edemetous and tense. Able to move all toes. Palpable DP pulses. Sensation intact. No pallor or allodynia. O2 sat 98% RA. Discharge Instructions: Ms. [Known lastname ] - It was a pleasure to care for you during your hospitaliztaion. You were admitted to [Hospital1 18] for blood loss/anemia that you developed after trauma to your left leg. When you arrived here, you had a very low blood pressure, and your blood count (hematocrit) was low. We gave you red blood cells as well as vitamin k and platelets to help you stop bleeding, because we found that your blood was very thin from coumadin. You were transferred to the medical ICU because you needed a different type of IV access. While in the ICU your blood count (hematocrit) dropped to a low of 18.5. You were given a total of 7 units of red blood cells while hospitalized before stabilizing your blood count. While here, we also followed the swelling in your left leg to make sure you didn't continue to lose blood into your left thigh. You were evaluated by the vascular surgeons to make sure that you didn't have a dangerous complication of this swelling known as compartment syndrome (which you did not). Finally, we have worked to address your pain and shortness of breath--two chronic problems you had before your fall that we have worked to treat while you have been here. Your pain seems to now be well-controlled with a combination of acetaminophen and oxycodone. Your breathing improved with nebulizer use, breathing exercise with the incentive spirimeter, and lasix after receiving large volume of blood products. Medications changed during this hospitalization: STOP Tramadol STOP Aspirin due to increased risk of bleeding, readdress at your next doctor's visit STOP Coumadin due to risk of bleeding, readdress at your next doctor's visit. START Oxycodone for pain START Miralax as needed for constipation START Tylenol 1000mg tid for pain Followup Instructions: Provider: [Name10 (NameIs) 1248],BED FIVE [Name10 (NameIs) 1248] ROOMS Date/Time:[2192-7-30] 9:15 Provider: [First Name8 (NamePattern2) 539] [Last Name (NamePattern1) 540] MD (Neurologist) Phone:[Telephone/Fax (1) 541] Date/Time:[2192-7-31] 1:30 Provider: [Name10 (NameIs) 1248],BED FIVE [Name10 (NameIs) 1248] ROOMS Date/Time:[2192-8-27] 9:15 You should follow up with your Primary Care Physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 1147], about setting up a follow up appointment. If you do not hear from them by this Friday, [7-6], you should call ([2192] Completed by:[2192-7-5] ICD9 Codes: 2851, 4280, 4019, 2720, 4241
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8047 }	Medical Text: Admission Date: [2155-4-6] Discharge Date: [2155-4-11] Date of Birth: [2132-1-9] Sex: M Service: [Hospital1 212] HISTORY OF PRESENT ILLNESS: This is a 23-year-old male with a history of type I diabetes for over 20 years, hypertension, cardiopathy, chronic kidney disease who was hospitalized here about one month ago for diabetic ketoacidosis. The patient at that time had a creatinine of 8.1 and a BUN of 116. Patient has never been dialyzed, but preparations to start have been ongoing in the past month. In the interim, liver donor for renal transplant is also being worked up. Patient has been on Lasix 80 mg po b.i.d. and Zaroxolyn 2.5 mg po q.d. with initial weight and lower extremity edema decreasing, but over the past three to four days, the patient has had increasing lower extremity edema. Patient was feeling well until the night prior to admission when he was noted to have a non-productive cough over the past few days and awoke with severe dyspnea on the morning of admission. The patient denies sore throat, chills, fever, diarrhea, hematuria, abdominal pain. The patient did vomit without hematemesis. The patient took his Lasix and Zaroxolyn medication, however, in the Emergency Room he was also given an additional 80 mg intravenous of Lasix and 2.5 mg po Zaroxolyn, as well as his antihypertensive medicines. Patient was also given Ceftriaxone 1 gram intravenous and Zithromax 500 mg po q.d. In addition, he was given a subsequent dose of Lasix 40 mg intravenously. He had a chest x-ray that was consistent with a pneumonia. PAST MEDICAL HISTORY: 1. Congestive heart failure. Cardiologist Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 2031]. Echocardiogram in [2155-3-1] with an ejection fraction of 35%, global hypokinesis, septal akinesis and 1+ mitral regurgitation. 2. Diabetes type 1 diagnosed at age 18 months with retinopathy, neuropathy, nephropathy, status post multiple laser surgeries, as well as bilateral vitrectomies, and chronic kidney disease. 3. Chronic kidney disease followed by Dr. [First Name8 (NamePattern2) ] [Name (STitle) 805] in Nephrology with plans underway to consider transplant versus Dialysis. 4. Depression. 5. Severe hypertension. 6. Migraine headaches. 7. Charcot foot. 8. [Doctor First Name ]-[Doctor Last Name ] tears diagnosed post hematemesis after severe gastroenteritis in [2155-3-1]. ALLERGIES: Zestril which causes lightheadedness. SOCIAL HISTORY: Positive for alcohol, one pack a day of tobacco and marijuana occasionally. FAMILY HISTORY: Significant for two sisters and a mother with type 1 diabetes. HOME MEDICATIONS: 1. Lantus 20 units q.d., Humalog sliding scale per carbohydrate count. 2. Norvasc 10 mg po q.d. 3. Labetalol 600 mg po b.i.d. 4. Lasix 80 mg po q.d. 5. Phos-Lo. 6. Procrit 5000 units weekly. 7. Zaroxolyn 2.5 mg po q.d. 8. Hydralazine 25 mg po q.i.d. 9. Protonix 40 mg po q.d. 10. Isosorbide 10 mg po t.i.d. 11. Reglan 10 mg po q.i.d. PHYSICAL EXAMINATION: Temperature 97.8. Pulse 92. Blood pressure 205/105, decreased to 137/71. Oxygen saturation 80% on room air. Head, eyes, ears, nose and throat exam: Oropharynx clear. Mucous membranes dry. Neck supple, no lymphadenopathy. Cardiovascular regular rate, normal S1, S2, 2-3/6 small systolic murmur at the apex, no rub. Lungs: Crackles at the bases bilaterally. Abdomen: Normal active bowel sounds, soft, nontender, nondistended. Extremities: Warm, [1-2]+ edema bilaterally lower extremities to the knees. Neurological: Appropriate, no asterixes. LABORATORY DATA AT THE TIME OF ADMISSION: White blood cell count 15.1, hematocrit 30.9, platelet count 475,000, INR 1.1, PTT 25.2, sodium 131, potassium 3.9, chloride 88, bicarbonate 20, BUN 132, creatinine 8.2, glucose 582, CK 448, troponin I less than .3. Albumin 3.9, CK-MB 6, calcium 6.8, magnesium 2.5, phosphorus 8.0. Urinalysis: Specific gravity 1.011, small blood, 100 protein, 1000 glucose, arterial blood gas on a nonrebreather was 7.37, 40, 97. Patient had a lactate of 1.9. HOSPITAL COURSE: 1. Hypoxemic respiratory failure: Patient with good ventilation, but hypoxia. Patient was placed on supplemental oxygen and initially admitted to the Medical Intensive Care Unit. Patient's respiratory failure was ascribed to volume overload with congestive heart failure, probably a combination of known decreased ejection fraction plus worsening renal failure. In addition, the patient had a left lower lobe infiltrate on his chest x-ray and history of a dry cough. This was treated with Ceftriaxone and azithromycin while in the Intensive Care Unit. Patient was gradually less hypoxic and was taken off his supplemental oxygen after being treated with antibiotics and aggressive diuresis. Patient had a follow-up chest x-ray on [4-9] that showed marked resolution of his bibasilar pulmonary consolidations and congestive heart failure. He had some residual small bilateral pleural effusions and small atelectasis at the left base, but resolution of the previously seen right lower lobe infiltrate. 2. Diabetes mellitus: The patient was initially on an insulin drip without any clear evidence for diabetic ketoacidosis. He was then changed to subcutaneous insulin and after [Last Name (un) ] Consult was obtained, patient was changed to his home dose glargine at 20 units in the morning and a carefully titrated Humalog sliding scale. Subsequently, he had initially excellent glycemic control with blood sugars ranging from 54 to 209, however, on the next hospital day, the patient had an episode of hypoglycemia with a fingerstick of 16, as well as elevated blood sugars in the setting of a strict Humalog sliding scale and glargine while patient unable to tolerate a full diet and mild emesis. Patient's sliding scale was adjusted [First Name8 (NamePattern2) ] [Last Name (un) ] recommendations and eventually patient was placed on his home dose glargine and as an outpatient will only continue on carbohydrate counting. 3. Hypertension: Patient had blood pressures controlled with his home dose regimen including labetalol, hydralazine, Isordil and Norvasc. Patient's blood pressures ran anywhere between mostly 120s to 150s during his hospital admission. 4. Renal: End stage kidney disease: Patient had evidence of volume overload, but no acute indications for hemodialysis. The patient had a PD catheter placed by Transplant Surgery. Subsequent to this, he had considerable pain that required multiple doses of intravenous morphine which was then switched to Percocet for his outpatient regimen. Patient will have peritoneal Dialysis initiated in the next three to four weeks as an outpatient. Patient will have further evaluation for transplant as an outpatient. Patient was placed on increasing EPO doses at 10,000 units subcutaneously twice a week. He was initially on amphojel, calcium carbonate and calcium acetate while in the Intensive Care Unit and this was switched to calcium acetate 2 tablets t.i.d. with meals and calcium carbonate 500 mg t.i.d. after meals. Patient was also started on iron polysaccharide complex. Patient's diuresis was maintained on Zaroxolyn 2.5 mg po q.d. with Lasix 80 mg po b.i.d. which is a double units dose of Lasix from admission. DISPOSITION: Patient will follow-up in [Hospital ] Clinic and will call for an appointment as per his usual regimen. Patient has an appointment with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 805] in Renal on [2155-4-15]. DISCHARGE DIAGNOSES: 1. Congestive heart failure secondary to volume overload and decreased ejection fraction. 2. Pneumonia. 3. End stage renal disease; to start perineal Dialysis in the next two weeks. DISCHARGE MEDICATIONS: Please resume all home medications with the following changes: 1. Reglan decreased to 5 mg po q.i.d. 2. EPO increase to 10,000 units biweekly. 3. Lasix increase from 80 mg q.d. to 80 mg b.i.d. 4. Addition of iron. 5. Calcium acetate 2 tablets t.i.d. with meals and calcium carbonate 500 mg tablets t.i.d. after meals. 6. Percocet total of 8 tablets to be used prn abdominal discomfort from peritoneal dialysis catheter placement. [Name6 (MD) 251] [Last Name (NamePattern4) 11865], M.D. [MD Number(1) 11866] Dictated By:[Name8 (MD) 231] MEDQUIST36 D: [2155-4-11] 06:36 T: [2155-4-12] 13:08 JOB#: cc:[Last Name (NamePattern1) 28589] ICD9 Codes: 486, 4280, 4240, 4254
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8048 }	Medical Text: Admission Date: [2199-2-8] Discharge Date: [2199-2-12] Date of Birth: [2156-9-22] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 78] Chief Complaint: s/p trauma to head Major Surgical or Invasive Procedure: None History of Present Illness: 42 y/o F with history of ETOH abuse presents s/p being kicked in the head by her boyfriend approximately 48 hours ago. Her boyfriend awoke this morning to see her having a seizure and brought her to an OSH ED. Head CT was done which revealed a R frontal SDH 6mm in size with no midline shift. On transfer to [Hospital1 18], she continued to seize and was sedated and intubated. She arrived on propofol gtt. Past Medical History: None per OSH records Social History: ETOH abuse Family History: NC Physical Exam: On Admission: Intubated and sedated No EO +cough, gag, and corneals Brisk localization with RUE W/D BLE w/d LUE to noxious On Discharge: Pertinent Results: CT HEAD W/O CONTRAST [2199-2-9] 1. Stable appearance of the small right frontal subdural hematoma measuring up to 7 mm. 2. No new intra- or extra-axial hemorrhage. No obstructive hydrocephalus or acute large territorial infarction. 3. No evidence of transtentorial or subfalcine herniation CXR [2-9] The NG tube tip is in the proximal stomach with proximal port just above the GE junction. This can be advanced slightly. The ET tube is not visualized. There is a new right lower lobe hazy infiltrate. There is also volume loss in the left lower lung. The heart is upper limits normal in size. There is some mild pulmonary vascular re-distribution. CXR [2-10] Previous mild pulmonary edema and mediastinal vascular engorgement have cleared. New or newly apparent heterogeneous opacification in the right mid lung could be new pneumonia. There is no pleural effusion or evidence of central adenopathy. Heart size is normal. Brief Hospital Course: 42 y/o F s/p being hit in head by boyfriend 48 hours ago presents to OSH with new onset seizure activity. Patient was intubated and sedate. Head CT revealed a 7mm R frontal acute SDH with no midline shift and a small nondisplaced parietal skull fracture. Patient was transferred to [Hospital1 18] for further neurosurgical evaluation. Patient arrived sedated and intubated. She was purposeful on the R and w/d on the L side, PERRL. She was then admitted to the ICU and SW was consulted for domestic violence. Once in the ICU, neurology was consulted for seizures and EEG lead were place for monitoring. No seizure activity was seen on EEG. On [2-9], patient was extubated. On exam, she was intact. She has a history of EOTH abuse, she was placed on a CIWA scale and monitored closely. On [2-10], patient remained intact. She was transferred to the SDU. The evening of [2-10] she attempted to leave AMA but was convinced to stay. On the morning of [2-11] her exam was nonfocal and she again wished to leave AMA. She was evaluated by the psychology team to determine competence to make her own medical decisions and they felt that she was medically competent. She was also evaluated by OT who felt she required no services. Radiology noted a possible RML PNA and as such she was placed on a course of PO levaquin. Despite conversations with the patient regarding her medical needs she expressed intentions to be discharged against medical advice. She was instructed explicitly to not drink alcohol as well as this could react poorly with her current clinical status and medication regimen. Ultimately she agreed to stay overnight on [2-11] into [2-12] with hopes she would be afebrile. Overnight into [2-12] she was febrile to 102.1 and she again expressed her intentions to leave against medical advice. Patient left on [2-12] against medical advice. She stated that she would follow up with her PCP in regards to the fevers and treatment for her pneumonia. Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: R frontal acute SDH R parietal skull fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Patient left AMA Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[2199-2-12] ICD9 Codes: 486
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8049 }	Medical Text: Admission Date: [2183-9-26] Discharge Date: [2183-9-28] Date of Birth: [2127-7-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1990] Chief Complaint: cocaine/opiate intoxication Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 56 yo man with h/o polysubstance abuse (heroin, crack cocaine), depression/anxiety who presents with acute cocaine and opiate intoxication. Patient went to the ED and reportedly stated that "I took too much cocaine". Per report from the ED, he took [12-5] ounce intranasally a couple hours before coming in. He was reportedly very anxious and agitated as well as diaphoretic. His initial vs were T 97.3, BP 180/120, HR 120-130s and RR 35. He was given a total of 10 mg of IV ativan, 5 mg IV haldol and 2 mg IV versed and was very sedated when he came to the [Hospital Unit Name 153]. Initial vs in ICU were BP 134/73, P 91O2 sat 95% on RA. Patient exhibiting periods of apnea which appears to be from possible obstructive sleep apnea as he is trying to breathe against a closed glottis. Past Medical History: 1. Depression 2. Polysubstance abuse 3. Anxiety 4. BPH 5. h/o ARF after rhabdo [1-3] cocaine ingestion in [2180], needed to be previously dialyzed. Last creatinine in [2180] was 1.9. 6. Hep B core ab positive on last admit and Hep C ab pos with neg viral load Social History: smoker [10-3] ppd, occ etoh, h/o abuse in past. Uses cocaine weekly. H/o IVDA but not now. Family History: non-contrib Physical Exam: GEN: sleeping, arousable with painful stimuli and sternal rub HEENT: anicteric, pupils 2 mm and equally reactive, MM dry, OP clear NECK: no tenderness, suppple SKIN: no lesions or track marks CV: RRR no m/r/g PULM: CTAB ABD: soft, NT, ND, no masses or HSM, +bs EXT: no cce, pedal pulses 2+ b/l NEURO: DTRs 2+ and equal throughout, toes upgoing to babinski but no [Doctor Last Name 6671], withdrew feet b/l, unable to assess strength or cranial nerves Pertinent Results: [2183-9-26] 11:24AM URINE HYALINE-[2-3]* [2183-9-26] 11:24AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [2183-9-26] 11:24AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2183-9-26] 11:24AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.019 [2183-9-26] 11:24AM PLT COUNT-189 [2183-9-26] 11:24AM NEUTS-89.0* LYMPHS-6.8* MONOS-3.3 EOS-0.7 BASOS-0.1 [2183-9-26] 11:24AM WBC-12.0* RBC-5.24# HGB-14.7# HCT-42.9# MCV-82 MCH-28.0 MCHC-34.2 RDW-14.7 [2183-9-26] 11:24AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [2183-9-26] 11:24AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2183-9-26] 11:24AM CK-MB-22* MB INDX-2.7 [2183-9-26] 11:24AM cTropnT-<0.01 [2183-9-26] 11:24AM LIPASE-17 [2183-9-26] 11:24AM ALT(SGPT)-28 AST(SGOT)-55* LD(LDH)-320* CK(CPK)-823* ALK PHOS-85 AMYLASE-72 TOT BILI-0.9 [2183-9-26] 11:24AM GLUCOSE-98 UREA N-27* CREAT-1.4* SODIUM-142 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-17* ANION GAP-24* [2183-9-26] 06:07PM OSMOLAL-297 [2183-9-26] 06:07PM CK-MB-22* MB INDX-2.2 cTropnT-<0.01 [2183-9-26] 06:07PM CK(CPK)-1011* [2183-9-26] 06:13PM LACTATE-0.8 [2183-9-26] 06:13PM TYPE-ART PO2-82* PCO2-36 PH-7.40 TOTAL CO2-23 BASE XS--1 Brief Hospital Course: 56 year old with substance abuse, here s/p cocaine use and resulting combativeness. . # Cocaine/opiate intoxication -[Doctor Last Name ] scale followed with 2 g ativan for [Doctor Last Name ] > 10 -on day of discharge, pt. had not scored on [Doctor Last Name ] scale, felt well, VSS, eating, ambulatory. . # HTN - resolved after agitation was treated with benzos. Has no previous history of HTN. Pt had 2 sets of negative cardiac enzymes, refused the third. BP stable at time of d/c without treatment. . # Elevated CK - initial ck 800. CK trended down to <300 at time of d/c. . # Renal failure with AG acidosis- likely pre-renal on presentation. Resolved with hydration. At time of discharge had resolved, cr. normal. . # Depression- resumed home SSRIs and trazodone, hydoxyzine. At time of d/c denied depressed mood, suicidality. . # BPH- resumed finasteride. Medications on Admission: Called pt.s pharmacy to confirm: Hydroxazine 50 [Hospital1 ] prn Finasteride 5mg qday Trazodone 100mg qhs Cymbalta 40mg daily Citalopram 20 mg daily Discharge Medications: No changes: 1. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Discharge Disposition: Home Discharge Diagnosis: Cocaine intoxication/overdose Discharge Condition: Stable Discharge Instructions: Take all medications as prescribed. Return to the [Hospital1 18] Emergency Department for: Chest pain Suicidal thoughts Lightheadedness Followup Instructions: Call your primary doctor for a follow up appointment within two weeks of leaving the hospital: PCP: [Name10 (NameIs) ],[Name11 (NameIs) 53457] [Name Initial (NameIs) ] [Telephone/Fax (1) 14315] ICD9 Codes: 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8050 }	Medical Text: Admission Date: [2184-3-5] Discharge Date: [2184-3-9] Date of Birth: [2138-2-26] Sex: M Service: SURGERY Allergies: Lithium Attending:[First Name3 (LF) 3223] Chief Complaint: bilateral foot pain and swelling Major Surgical or Invasive Procedure: none on this admission History of Present Illness: Mr. [Known lastname 66333] is a 46-year-old man who claims to have been trimming tree branches while barefoot and fell out of the tree into a thorn [Last Name (un) ]. He sustained multiple abrasions and then went with a friend to use cocaine, after which he felt bilateral foot pain and walked to [Hospital 1474] Hospital for evaluation. His aunt, with whom he lives, describes finding him in the garage, wrapped only in a blanket, near a pile of broken glass. He had scratches all over his body and complained of foot pain, so she took him to [Hospital 1474] Hospital. Past Medical History: bipolar disorder multiple inpatient psychiatric admissions self-inflicted stab wound to chest requiring emergent sternotomy Social History: +MJ, +cocaine 2 year h/o cigarette smoking lives with aunt, unemployed Family History: NC Physical Exam: 98.9 95 172/124 20 95%RA A&Ox3 agitated, uncomfortable sick-appearing HEENT: PERRL, EOMI. minor scratches on face chest: multiple abrasions. CTAB. Midsternal wound healed. CV RRR abd: multiple abrasions including on genitals. NTND, soft, +BS UE: multiple scratches b/l arms concentrated at dorsal/volar forearms. Erythema b/l hands R>L. SILT M/R/U/A. +TTP throughout R hand. Necrotic R small digit tip. LE: multiple scratches b/l LE extending from upper inner thighs to feet. All leg compartments soft but b/l feet significantly more tense. Weeping excoriations L foot. Able to express small amount of pus from excoriation plantar foot. Erythema extending just distal to knees b/l. 2+ DP pulses. Great and 2nd toes cold and dusky bilaterally Pertinent Results: [2184-3-5] 11:45AM WBC-14.3* RBC-4.52* HGB-13.8* HCT-38.3* MCV-85 MCH-30.5 MCHC-36.0* RDW-13.9 [2184-3-5] 11:45AM NEUTS-78.9* BANDS-0 LYMPHS-17.4* MONOS-3.4 EOS-0.1 BASOS-0.2 [2184-3-5] 11:45AM PT-13.4* PTT-26.7 INR(PT)-1.1 [2184-3-5] 11:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2184-3-5] 11:45AM GLUCOSE-114* UREA N-51* CREAT-2.1* SODIUM-135 POTASSIUM-5.9* CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [2184-3-5] 11:45AM CALCIUM-8.2* PHOSPHATE-4.1 MAGNESIUM-2.4 [2184-3-5] 11:45AM CK(CPK)-[Numeric Identifier 11094]* [2184-3-5] 02:32PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [2184-3-5] 09:18PM WBC-11.4* RBC-4.37* HGB-13.2* HCT-37.1* MCV-85 MCH-30.2 MCHC-35.6* RDW-13.8 [2183-3-9]: WBC=8.0, Cr=0.9, CK=794 Brief Hospital Course: Pt was evaluated by multiple services in the ED. He was admitted to the trauma ICU with a presumed diagnosis of rhabdomyolysis, acute renal failure, and cellulitis. He was started on aggressive hydration and his CK and renal assays normalized. ID was consulted and he received IV Vancomycin/Zosyn for 5 days. He was maintained on a 1:1 sitter throughout his hospitalization. He was followed by multiple surgical services but no surgical intervention was deemed necessary. He was initially somnolent but his mental status gradually improved. The erythema, edema, and tenderness to palpation of his extremities gradually improved with elevation and antibiotics. His lower extremities were wrapped in compressive dressings with good resolution of the edema. On hospital day 2 he was improving. He was transferred to the surgical floor. Psychiatry was consulted given his extensive psychiatric history. On hospital day 3 he was advanced to a regular diet and was able to ambulate. Per ID, a hepatitis panel and HIV test were sent. All hepatitis tests were negative. The HIV test was still pending at the time of discharge and will need to be followed as an outpatient. By hospital day 5 the patient was greatly improved and stable for discharge. He had stable necrotic tips of the first and 2nd digits of each foot as well as the small digit of the right hand on discharge. He will follow-up with Podiatry and Plastic Surgery for these. Psychiatry agreed that he was stable for discharge to home. He will follow-up with the TriCity Mental Health Clinic on Friday. It is possible that he will need vascular surgery intervention at a later date, although at this point he has only single digit necrosis on his hands and feet and bilaterally palpable pulses at his feet. His blood pressure was also elevated throughout this admission, althought he was asymptomatic. He was started on Metoprolol 25mg PO BID, which he will continue at home. He was given the information for the [Hospital3 ] internal medicine group and he will follow-up with his new primary care doctor regarding this issue. Medications on Admission: depakote (although blood levels extremely low) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 2 weeks: take while taking narcotic pain medication. Disp:28 Capsule(s) Refills:0 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 1 weeks. Disp:25 Tablet(s) Refills:0 3. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO at bedtime. Disp:30 Tablet, Delayed Release (E.C.)(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 Discharge Disposition: Home Discharge Diagnosis: rhabdomyolysis acute renal failure cellulitis frostbite bipolar disorder Discharge Condition: stable Discharge Instructions: You may resume your usual diet and activities as you feel able. When you are sitting or lying down you should keep your feet elevated above the level of your heart. You should keep all scratches and skin breaks clean and dry, do not scratch or pick at the scabs. You should not drive while taking pain medications. Keep all follow-up appointments. Call your doctor or go to the ER if you experience: -chest pain or shortness of breath -fevers or chills -increased pain, redness, or drainage from your hands or feet -anything else that concerns you Followup Instructions: Follow-up with the TriCity Mental Health clinic on [2-8] at 3pm. Follow-up with Podiatry in 2 weeks. Call ([Telephone/Fax (1) 21608] to schedule your appointment. Follow-up with Plastic Surgery Hand Clinic in [2-2] weeks. Call [Telephone/Fax (1) 4652] to schedule your appointment, appointments are Tuesdays only. Follow-up with [Hospital3 ] to get a new primary care doctor. They are located in the [Hospital Ward Name 23] Atrium ([Location (un) ]) on the [Hospital Ward Name 516]. Call ([Telephone/Fax (1) 56960] to schedule your appointment. An HIV test was sent on this admission. You can get the results from your new primary care doctor. In addition, your blood pressure was elevated throughout this admission. A new medication, metoprolol, was started which you should take every day. You should have your blood pressure followed as an outpatient. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 520] MD, [MD Number(3) 3226] ICD9 Codes: 5849
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8051 }	Medical Text: Admission Date: [2165-11-12] Discharge Date: [2165-11-18] Date of Birth: [2103-12-29] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This 61 year old female was seen originally by the Cardiac Surgery team on [2165-11-1], prior to her admission. She was status post myocardial infarction in [2152] with DCA of her left circumflex. She was recathed in [2157] which showed subtotal LAD occlusion. She was treated medically at that time. She now reports one year history of dyspnea, exertion. Stress test in [2165-1-17] showed an apical ischemia of EF of 67 percent. She has had ongoing symptoms and was referred for cath on [2165-11-1] which showed left vein 70 percent lesion, LAD 100 percent occluded, RCA 50 percent, ostium 70 percent mid lesion. She was referred to Dr. [First Name (STitle) ] [Name (STitle) ] for coronary artery bypass graft. She reports angina symptoms since [2152], worse lately with DOE and edema. She denies nausea, vomiting, diarrhea, or syncope. PAST MEDICAL HISTORY: Myocardial infarction with coronary artery disease. Status post DCA of left circumflex. Insulin dependent diabetes mellitus. Hypertension. Hyperlipidemia. Gastroesophageal reflux disease. Obesity. Psoriasis. PAST SURGICAL HISTORY: Cesarean sections. Tonsillectomy and right eye cataract removal. ALLERGIES: Codeine which causes vomiting but stated that Percocet was OK to use. MEDICATIONS: Medications prior to admission are as follows: 1. Procardia XL 90 mg po daily. 2. Atenolol 50 mg po daily. 3. Lipitor 80 mg po daily. 4. Aspirin 81 mg po daily. 5. Zantac 150 mg po daily. 6. Zestril 40 mg po daily. 7. Hydrochlorothiazide 25 mg daily. 8. Halobetasol prn for psoriasis. 9. Novolin insulin 24 units [Hospital1 ]. 10. Humalog 12 units [Hospital1 ]. 11. Glucophage 50 mg po daily. SOCIAL HISTORY: The patient lives alone in [Location (un) 4444] with three children in the area. She works full time as a legal secretary. She quit smoking 13 years ago with a 30-year pack a day history. She has rare alcoholic drinks. Her mother had a coronary artery disease at age [Age over 90 ]. The patient's weight was stable. She did have a history of psoriasis. PHYSICAL EXAMINATION: VITAL SIGNS: Height was 5'2", weight 210, sinus rhythm at 68, respiratory rate 16, blood pressure 160/74 and oxygen saturations 97 percent on room air. She is lying flat in bed in no apparent distress. She is alert and oriented x 3 and appropriate. HEENT: Neck was supple with no carotid bruits. LUNGS: Clear bilaterally anteriorly with distant sounds. HEART: Regular rate and rhythm with S1 and S2 tones and no murmur, rub, or gallop. ABDOMEN: Soft, obese and nontender, nondistended with positive bowel sounds. EXTREMITIES: Warm and well perfused with no edema or varicosities. Pulses were 2+ bilaterally for radials, 1+ DP on the right, 2+ on the left and 2+ PT bilaterally. PREOPERATIVE LABORATORY DATA: Preop labs are as follows: White blood cell count 6.6 hematocrit 33.3, platelet count 294,000, sodium 138, K 4.2, chloride 102, bicarb 23, BUN 13, creatinine 0.8 with a blood sugar of 163, PT 12.6, PTT 30.4, INR 1.0, ALT 24, AST 24, alkaline phosphatase 88. Amylase 54. Total bilirubin 0.3, albumin 4.4. Urinalysis was negative preoperatively. Additional labs were vitamin B12 level 229, triglycerides 159, HDL 57, cholesterol HDL ratio 2.9, LDL 78. Preop chest x-ray showed no acute cardiopulmonary process. On [2165-11-12], the patient underwent coronary artery bypass graft x 3 with left internal mammary artery to the LAD and vein graft to the RCA and vein graft to the ramus. The patient was transferred to the cardiothoracic Intensive Care Unit in stable condition on an insulin drip at 3 units an hour and propofol drip at 15 ug/kg per minute. The patient had some inferior ST elevation status post her coronary artery bypass graft; related to that Cardiology was called to do a TTE. TTE was attempted but without windows clean enough to judge wall motion. The patient was pain free with a blood pressure of 111/60 and heart rate of 104 at the time of echo on 40 ug of nitroglycerine and 45 ug of Neo-Synephrine. Please refer to the Cardiology note. The patient was extubated on the early morning hours of [2165-11-13]. On postoperative day 1, the patient started some epinephrine. The patient continued to improve in sinus rhythm in the 90's with blood pressure of 127/59, epi was on at 0.02 ug/kg/minute, insulin drip remained on at 3 units an hours and a small amount of Neo-Synephrine drop at 0.75 ug/kg/minute. POSTOPERATIVE LABORATORY DATA: Postoperative labs are as follows: White blood cell count 14.1 hematocrit 31.5, platelet count 293,000, K 4.5, BUN 12, creatinine 0.9 with a blood sugar of 81. Examination was unremarkable. The lungs were clear bilaterally with 1+ peripheral edema. Beta blockade was held. Lasix intravenous 6 began, epi was discontinued later in the day and Neo-Synephrine was continued. The patient remained on Intensive Care Unit on postoperative day 2. The patient received one dose of Lasix overnight and remained only on Neo- Synephrine drip at 0.21. She was stable hemodynamically with a pressure of 92/46 and in sinus rhythm in the 80's, saturating 93 percent on 4 liters nasal cannula. Chest tubes remained in place with no air leak. Examination was unremarkable. Creatinine was stable at 1.0, hematocrit dropped slightly at 25.6. Chest tubes and Foley were discontinued. The patient was transferred out to the floor. Lasix diuresis was continued and beta blockade with Lopressor 12.5 mg po b.i.d. was started. The patient was also seen by the [Last Name (un) ] consult followed at the request of the Cardiac Surgery team and was evaluated by physical therapy. The patient was switched over to PO Percocet for pain. On postoperative day 3, she was also started on her vitamins and iron. Glucophage was restarted. The patient had some volume overload with dyspnea. Hematocrit was rechecked. This dropped to 24.3. The patient continued with Lasix diuresis intravenous and was transfused 1 unit of packed red blood cells with additional Lasix and also prn nebulizer treatments were ordered. [Last Name (un) ] consult recommendations were appreciated. The patient was also seen by case management. On postoperative day 4, the patient had decreased breath sounds bilaterally, was stable hemodynamically in sinus rhythm, oxygen saturations 96 percent on 2 liters nasal cannula. The patient continued diuresis and aggressive physical therapy with respiratory therapist also. Incisions were cleaned, dry and intact. Examination was otherwise unremarkable. The patient was receiving Percocet and Motrin po with good effect for pain management. [Last Name (un) ] follow up was also done on [2165-11-17]. The patient was also encouraged to continue ambulating to her maximal abilities and postoperative day 6, the day of discharge, the patient was in sinus rhythm at 80 with blood pressure of 147/71. The weight was down 0.2 kg from preoperative and hematocrit was stable at 28.5, K 3.9, magnesium 1.5, saturating at 96 percent on room air. The examination was unremarkable. In addition the patient was discharged in stable condition with the following discharge diagnoses. 1. Status post coronary artery bypass graft x 3. 2. Status post myocardial infarction with coronary artery disease and prior PTCA of circumflex. 3. Insulin dependent diabetes mellitus. 4. Hypertension. 5. Hyperlipidemia. 6. Gastroesophageal reflux disease. 7. Obesity. 8. Status post cesarean section. 9. Status post tonsillectomy. 10. Status post right eye cataract removal. DISCHARGE MEDICATIONS: 1. Colace 100 mg po bid. 2. Percocet 5/325 one tablet po prn q 4 to 6 hours for pain. 3. Enteric coated aspirin 81 mg po once daily. 4. Lipitor 80 mg po once daily. 5. Metformin 1000 mg po twice daily. 6. Ferrous sulfate 325 (65 mg tablet) one tablet po daily. 7. Vitamin C 500 mg po twice a day. 8. Ibuprofen 600 mg po q8 hours prn. 9. NPH insulin - human recombinant 100 units per ml suspension 12 units subcutaneously [Hospital1 ]. The patient will adjust according to the blood sugars [First Name8 (NamePattern2) ] [Last Name (un) ] protocol. 10. Lasix 40 mg po bid x 7 days. 11. Metoprolol tartrate 50 mg po bid. 12. Potassium chloride 20 milliequivalents po bid x 7 days. 13. Humalog 100 units per ml solution prn units subcutaneous per q day as directed by Dr. [Last Name (STitle) 174] of [Hospital ] Clinic. The patient was instructed to follow with Dr. [First Name (STitle) ], her primary care physician, [Last Name (NamePattern4) ] 2 to 3 weeks, and follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], the cardiologist, in 2 to 3 weeks, to follow up with Dr. [Last Name (STitle) 174] of [Hospital ] Clinic as needed and to make appointment to see Dr. [First Name (STitle) ] [Name (STitle) ], M.D. in the office postoperatively 4 weeks for postoperative surgical visit. The patient was discharged home in stable condition on [2165-11-18]. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2165-12-13] 15:28:38 T: [2165-12-13] 17:19:23 Job#: [Job Number 26663] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8052 }	Medical Text: Admission Date: [2169-6-14] Discharge Date: [2169-6-21] Date of Birth: [2096-3-22] Sex: M Service: MEDICINE Allergies: morphine Attending:[First Name3 (LF) 7333] Chief Complaint: Dizziness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 73 yo man with a h/o rheumatic heart disease s/p bioprosthetic AVR, non-ischemic cardiomyopathy with an EF of 20%, and s/p AICD in [2168] who presented to [Hospital3 ] Hospital on [2169-6-12] with dizziness. Per the patient's daughter, the patient was in his normal state of health until approximately one week ago, when he began to experience periodic episodes of dizziness associated with tachycardia, nausea, weakness, and urinary incontinence. The day of admission, Mr. [Known lastname 99580] was noted by his daughter to be "grey" during one of these episodes, so EMS was called and he was brought to [Hospital3 ] Hospital for further evaluation. . At [Hospital3 ] Hospital, his AICD was interrogated and demonstrated sustained monomorphic VT, the longest of which lasted for 19 minutes. This rate was apparently slower than the VT detect rate on his defibrillator, so he was not shocked. His pacemaker was reprogrammed to a slower rate, and he was thereafter cardioverted once in the ED. He was started on an amiodarone gtt and was admitted to the CCU. . In the OSH CCU, he was started on Lopressor IV and was continued on the amiodarone gtt to suppress his arrythmia. He then became febrile to 104.9, hypotensive to 81/35 and was found to have [5-8] bottles of GPCs in chains in his blood. He was started on CTX/Vancomycin and was transferred to [Hospital1 18] for further evaluation. . On arrival to the CCU, the patient was very uncomfortable with his foley in place, and he was occasionally speaking in Polish. He stated that he had occasional nausea and dizziness but otherwise had no acute complaints. Of note, he was alert and oriented to person, place, and date but did not demonstrate insight into his condition. . On review of systems, he denied any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denied recent fevers, chills or rigors. He denied exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems was notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: - PACING/ICD: VVI [Company 1543] pacer/AICD, placed in [2168] - Non-ischemic cardiomyopathy with EF of 20% - Rheumatic Heart Disease (in childhood) s/p bioprosthetic AVR [68] years ago in FL - paroxysmal atrial fibrilation on Coumadin (confirmed by phone by his [State 108] cardiologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 99581] (Holywood, [Numeric Identifier 99582]) - Ventricular tachycardia 3. OTHER PAST MEDICAL HISTORY: - Gout - Hypothyroidism - Traumatic injury to his left arm 30 years ago Social History: The patient's girlfriend lives in FL. He lived in [State 108] up until recently, when he moved to [Location (un) ] to live with his daughter. [Name (NI) ] does not smoke cigarettes. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GENERAL: Restless, oriented x3 HEENT: NCAT. Sclera anicteric. Pin-point pupils, round, reactive to light b/l; EOMI. Clear oropharynx without exudates. NECK: Supple, no JVD. LYMPH: No cervical, axillary, or inguinal lymphadenopathy. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Soft systolic ejection murmur (Grade II/VI) at RUSB. No r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: Well-healed scar around left ante-cubital fossa, with large circumferential bulbous area of erythema distally; non tender, no crepitus, but warm to touch. Area of discoloration and mild erythema w/o tenderness on extensor surface of left arm. No c/c/e. Several toes b/l with onychomycosis. No splinter hemorrhages, no Osler nodes/[Last Name (un) 1003] lesions. SKIN: Well-healed surgical incision near ICD/pacer. Pacemaker pocket without erythema, exudate, fluctuance, or tenderness. No stasis dermatitis, ulcers, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ . On Discharge: HEENT: NCAT. Sclera anicteric. pin point pupils, round, reactive to light b/l; EOMI. Clear oropharynx w/o exudates. NECK: Supple, no JVD. LYMPH: no cervical, axillary, or inguinal lymphadenopathy CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. soft systolic ejection murmur (Grade II/VI) at RUSB. No r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: Well healed scar around left ante-cubital fossa, with large circumferential bulbous area of erythema distally; non tender, no crepitus, minimal warmth. Area of discoloration and mild erythema w/o tenderness on extensor surface of left arm. No c/c/e. Several toes b/l with onychomycosis. No splinter hemorrhages, no Osler nodes/[Last Name (un) 1003] lesions. SKIN: Well healed surgical incision near ICD/pacer. Pacemaker pocket without erythema, exudate, fluctuance, or tenderness. No stasis dermatitis, ulcers, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: OSH: - OSH Cx - blood: pansensitive beta hemolytic GAS - urine: pansensitive e.coli enterococcus faecalis: levofloxacin R ciprofloxacin R tetracycline R . On Admission: [2169-6-14] 04:00PM WBC-7.9 RBC-5.07 HGB-13.5* HCT-40.1 MCV-79* MCH-26.7* MCHC-33.7 RDW-15.8* [2169-6-14] 04:00PM NEUTS-68.0 LYMPHS-21.6 MONOS-6.7 EOS-3.2 BASOS-0.5 [2169-6-14] 04:00PM PLT COUNT-171 [2169-6-14] 04:00PM GLUCOSE-92 UREA N-16 CREAT-1.1 SODIUM-135 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13 [2169-6-14] 04:00PM CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-2.1 [2169-6-14] 04:00PM ALT(SGPT)-15 AST(SGOT)-28 LD(LDH)-203 ALK PHOS-78 TOT BILI-0.5 [2169-6-14] 04:00PM TSH-0.74 [2169-6-14] 04:14PM LACTATE-1.7 [2169-6-14] 04:00PM PT-30.9* PTT-34.1 INR(PT)-3.0* . Micro: [2169-6-17] 5:56 am STOOL CONSISTENCY: LOOSE Source: Stool. FINAL REPORT [2169-6-18] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2169-6-18]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . Blood cxs: NGTD . TTE [6-15] The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis (LVEF = 25-30 %) with akinesis of the basal inferior, inferolateral and lateral segments. The right ventricular cavity is moderately dilated with depressed free wall contractility. The aortic root is moderately dilated at the sinus level. A bioprosthetic aortic valve prosthesis is present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: No echocardiographic evidence of endocarditis with suboptimal visualization of valvular structures and of the prosthetic aortic valve. If clinically indicated, a transesophageal echocardiogram may better assess for valvular vegetations. Basal inferior/inferolateral and lateral akinesis with moderate hypokinesis of the other segments. Mild pulmonary artery systolic hypertension. . TEE [6-15] The left atrium is dilated. Mild to moderate spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. LV systolic function appears depressed. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch and descending thoracic aorta. A bioprosthetic aortic valve prosthesis is present with normal appearing aortic valve prosthesis leaflets and normal leaflet motion. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. There is no aortic valve stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is no pericardial effusion. . IMPRESSION: No discrete vegetations on the valves or ICD lead wires seen. Image quality of pacer wires was suboptimal due to patient agitation. Well seated aortic bioprosthesis with normal leaflet motion. Depressed left ventricular global systolic function. . CT Head [6-15] IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. If there is a high clinical concern for septic emboli, MRI can be considered as a more sensitive test if not contra-indicated. 2. Difference in the attenuation of the bones as mentioned above- consider follow up to confirm if this is artifatual/real and further work up to be based on the follwo up study and clinical correlation for metabolic /metastatic disease. . Chest US: IMPRESSION: No evidence of fluid collection to suggest abscess or hematoma. . Upper extremity US: IMPRESSION: 1. No deep venous thrombosis within the right upper extremity. 2. Partially occlusive thrombus within the right cephalic vein. 3. Superficial thrombophlebitis of a right forearm vein, at the site of prior IV attempt. 4. Asymmetry of the left subclavian waveforms compared to the right is likely due to the presence of pacing leads within the left subclavian vein . On Discharge [2169-6-19] 07:15: . WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 5.1 5.49 14.4 43.9 80* 26.2* 32.7 15.4 199 . Glucose UreaN Creat Na K Cl HCO3 AnGap 99 15 1.2 136 4.7 100 30 11 . INR: 1.9 . TSH: 0.74 Brief Hospital Course: Mr [Known lastname 99580] is a 73 year old man with h/o rheumatic heart disease s/p bioprosthetic AVR, non-ischemic cardiomyopathy with an EF of 20%, and s/p AICD in [2168] transferred from OSH for management of group A strep bacteremia in the setting of ventricular tachycardia/ICD firing and prosthetic aortic valve. . # Group A strep bacteremia: On arrival, the patient was broadly covered with vanco/CTX/clinda. OSH microbiology data returned with pansensitive group A strep and was narrowed to ceftriaxone 2gm IV Q24hrs with plan to complete a 6 week course. Work-up here largely negative as surveillance cultures NGTD, TTE and TEE w/o evidence of vegetations on valves or ICD wires. CT head was negative for obvious embolic events. Pacemaker pocket ultrasound negative for fluid collection. The source was most likely thought to be from the arm cellulitis which was slowly starting to improve prior to discharge. At time of discharge patient afebrile with WBC wnl. Continued CTX 2 g IV q24hr for 6 week course. PICC line placed on [6-19]. . OUTPATIENT ISSUES: -- Follow-up with ID (see appts); weekly BUN/creatinine, LFTs, CBC . # Ventricular tachycardia/ICD firing: No evidence of vegetations on leads or fluid collection in pacemaker pocket. Reset on [6-16] with permanent pacing at 3V both from RV and LV. Patient with intermittent runs of symptomatic VT lasting seconds. Decision made to repeat amiodorone load and continue with 200mg PO TID for one week then 400mg daily subsequently in additional to home mexilitine. . OUTPATIENT ISSUES: -- Continue amiodarone 200 mg TID for one week (day 1 = [6-17]) and then 200 mg [Hospital1 ] for 1 week then 200 mg daily subsequently. -- Close outpatient EP follow-up (see appts) . # Left arm erythema: On arrival patient with evidence of left forearm cellulitis around site of old traumatic injury. Seen by surgery; wrapped and elevated arm, physical exam without evidence of necrotizing fascitiis. Patient started on antibiotics and upper extremity cellulitis slowly improved. . OUTPATIENT ISSUES: -- Monitor upper extremity closely . # Non-ischemic Cardiomyopathy per OSH records: Echo on [6-15] demonstrated mildly dilated left ventricular cavity, severe global left ventricular hypokinesis (LVEF = 25-30 %) with akinesis of the basal inferior, inferolateral and lateral segments; moderately dilated right ventricular cavity with depressed free wall contractility. In house patient continued on home carvedilol 25 mg PO BID, digoxin 0.125mg daily, as well as coumadin for anticoagulation at 5 mg daily (home dose is 7.5, but given amiodarone drip and interaction are going lower for now), INR at time of discharge: 2.0. Patient without signs of volume overload during hospital stay and continued on home lasix. Lisinopril 2.5 mg daily was started for afterload reduction. OUTPATIENT ISSUES: -- monitor K on new Lisinopril and [Month (only) ] Lasix dose . # Paroxysmal atrial fibrilation - continued coumadin and carvedilol, was also reloaded with amiodarone as outlined above. . OUTPATIENT ISSUES: -- monitor INR and adjust coumadin dose to goal INR [3-9] . # Restless Leg Syndrome: Patient with worsening complaints in-house. Improved with higher dose of home requip (0.5mg -> 1.0mg qhs). . # CAD: No known CAD per OSH. Patient contined on aspirin for primary prevention as well as home carvedilol. He was without complaint of chest discomfort in-house. . # Hypothyroidism: Admission TSH wnl at 0.74. Continued on home levothyroxine. . # Gout: Continue on home colchicine. . CODE: Full during this admission Medications on Admission: Protonix 40 mg daily Requip 0.5 mg qhs ASA 81 mg daily Coumadin 7.5 mg daily Amiodarone 200 mg daily Carvedilol 25 mg PO BID Colchicine 0.6 mg daily Lasix 40 mg daily Digoxin 0.25 mg daily Klor-Con 20 mEq daily Levothyroxine 25 mcg daily Mexiletine 250 mg [Hospital1 ] Roxicet prn for pain Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO see other instructions: Take one tablet three times daily for 3 days, then one tablet twice daily for 7 days, then continue taking 1 tablet once daily. . 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 9. ropinirole 0.5 mg Tablet Sig: Two (2) Tablet PO once a day. 10. mexiletine 250 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 11. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 13. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: One (1) dose Intravenous Q24H (every 24 hours) for 34 days. 14. Klor-Con 20 mEq Packet Sig: One (1) PO once a day. 15. Outpatient Lab Work CBC with diff, Chem-7, LFT's, ESR and CRP weekly starting on [2169-6-26], please fax results to Infectious disease R.Ns. at ([Telephone/Fax (1) 1353]. Discharge Disposition: Extended Care Facility: [Hospital1 2670] Discharge Diagnosis: Primary: Ventricular tachycardia Bacteremia Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory with assitance Discharge Instructions: Dear Mr [Known lastname 99580] it was a pleasure taking care of you. . You were admitted to [Hospital1 18] for management of bacteremia (infection in the blood) and urinary tract infection in the setting of ventricular tachycardia/ICD firing. The abnormal heart rhythm as well as ICD firing was attributed to your underlying infection, the source of which is thought to be the skin on your left arm. Close inspection of your heart valves as well as ICD pocket was negative for infection. You were treated with IV antibiotics to treat the underlying infection. You were also started on an anti-arrhythmic to better control your heart rate and rhythm. . CHANGES TO YOUR MEDICATIONS: To treat your infection: Start taking CeftriaXONE 2 gm IV Q24H . To better control your heart rhythm: Take Amiodarone 200 mg tablet. Take one tablet three times daily for 3 days, then 1 tablet twice daily for 7 days, then continue taking 1 tablet once daily. . To treat your restless legs: Your Requip 0.5mg tablet dose was increased from one to two tablets once daily. . For anti-cooagulation: Your Warfarin (Coumadin) dose was decreased from 7.5mg once daily to 5mg once daily. Please take one 5mg tablet once daily. . For you heart function: - Digoxin was decreased from 250 mcg to 125 mcg tablet. Please take one 125 mcg tablet once daily. - Lisinopril 2.5mg tablet was started to help your heart pump better. Please take one tablet once daily. Followup Instructions: EP: Department: CARDIAC SERVICES: Electrophysiology When: THURSDAY [2169-7-6] at 3:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 11899], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: INFECTIOUS DISEASE When: MONDAY [2169-7-10] at 10:10 AM With: [Name6 (MD) ] [Name8 (MD) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: THURSDAY [2169-7-27] at 11:00 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10000], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2169-6-21] ICD9 Codes: 5990, 4280, 2749, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8053 }	Medical Text: Admission Date: [2130-10-3] Discharge Date: [2130-10-7] Date of Birth: [2051-2-12] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1363] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None: <BR><H3>PENDING ISSUES/FOLLOWUP:</H3> <b>1. BLOOD PRESSURE:</B> The patient's systolic blood pressure ranged 85-115. She was low even on 25 of metoprolol QID (at home was on Toprol XL 200). She is being discharged on Toprol XL 100mg daily. <br><b>2. CHF:</b> Her repiratory status was stable and she had sats in the high 90s on her home O2 level of 2 lpm via NC. We gave her fluids only very gently and did not diurese her. She was fluid positive about 2L over the course of her hopital stay but after transfer to the floor she had relatively equal Is and Os with good urine output (around 1L on day prior to discharge). We discharged her on her home dose of torseminde but held the metolazone. She will see Dr. [First Name (STitle) 437] in clinic on [2130-10-16]. <br><b>3. Recurrent pleural effusion:</b>She is at her baseline respiratory status. She will be seen in the interventional pulmonology clinic to have a pleurex catheter placed to facilitate <br><b>4. Cancer:</b> The cells in the pleural fluid are more likely breast than uterine. She was followed by her primary oncologist, Dr. [Last Name (STitle) ]. She was restarted on Arimidex, an aromatase inhibitor. She will see Dr. [Last Name (STitle) ] on [2130-10-13].<br> History of Present Illness: 79 yo F with h/o chronic L pleural effusion, breast and uterine CA in remission admitted from ED with AF with RVR, SBO and leukocytosis. Patient was found to be hypotensive at [Hospital3 ] facility and was brought in to ED. She was asymptomatic at the time. In the ED, initial vs were: 98.8 118 109/63 16 96. Patient was given 2L IVF. CT torso showed known pleural effusion and new SBO. Surgery was consulted and recommended ex-lap for LOA which patient refused. See surgery note for full details. Repeat VS prior to transfer: 97.8 109 96/54 100% 2l 26. On transfer to the unit, patient reports that she has some worsening SOB over the last few days, but feels well now. On 2l nc at baseline for restrictive lung disease. States she is passing gas, last BM yesterday. Denies CP, fever, chills, nausea, dysuria, HA, vision change or [Location (un) ]. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: H/o Stage 3 breast CA in [2122] H/o endometrial CA s/p hysterectomy Afib not on coumadin [2-20] falls Restrictive lung disease on 2-3L nc at home DCHF s/p Pelvic Fx in [5-/2130] Osteoporosis w multiple compression fx OA PPM for tachy/brady syndrome H/o Non-sustained VT Recurrent, refractory pleural effusions of unknown cause, thought to be secondary to radiation. last tap on [9-22] showed adeno Hypothyroidism Social History: Lives alone in [Hospital3 ]. Home health aide comes three times per week. Remote tobacco use. Drinks two glasses of wine each night to help her sleep. Family History: Two nieces with breast cancer, mother died of CAD, father had emphysema. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2130-10-3] 10:55PM GLUCOSE-88 UREA N-19 CREAT-0.8 SODIUM-126* POTASSIUM-4.1 CHLORIDE-87* TOTAL CO2-31 ANION GAP-12 cTropnT-0.03* proBNP-4913* URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-NEG WBC-19.9# RBC-4.61 HGB-15.6 HCT-45.1 MCV-98 MCH-33.9 MCHC-34.6 RDW-13.8 NEUTS-95.0* LYMPHS-2.0* MONOS-2.3 EOS-0.4 BASOS-0.2 ALBUMIN-3.3* CALCIUM-8.6 PHOSPHATE-2.5* MAGNESIUM-1.8 GLUCOSE-90 UREA N-25* CREAT-1.0 SODIUM-126* POTASSIUM-3.7 CHLORIDE-70* CT CHEST/A/P IMPRESSION: 1. Moderate sized left pleural effusion and small right pleural effusion, with enhancing pleural margins on the right, which may be secondary to an inflammatory or infectious process, though this appears similar to prior study. 2. Dilated small bowel loops, with decompressed and tethered small bowel loops in the pelvis, concerning for a small-bowel obstruction. Locules of extra-luminal air are noted in the mid abdomen. 3. Moderate amount of free fluid in the abdomen with new nodular appearance of the peritoneum, concerning for peritoneal carcinomatosis. 4. Subacute right inferior pubic ramus fracture, with insufficiency fractures of the sacral ala bilaterally. 5. Stable multiple compression deformities of the thoracolumbar spine, as detailed. KUB ([10-5]): IMPRESSION: 1. Unchanged bowel gas pattern consistent with partial SBO 2. Ascites. 3. Bilateral pleural effusions. Pleural fluid (collected [2130-9-22]): POSITIVE FOR MALIGNANT CELLS. Consistent with adenocarcinoma. -Tumor cells are immunoreactive for Keratin AE1/AE3/CAM 5.2, B72.3 and [Last Name (un) ]-31. -Calretinin and WT-1 stain mesothelial cells in the background. - No immunoreactivity is seen for CEA, absorbed, Leu M1, mammoglobin or GCDFP. -CK20 and TTF-1 show no immunoreactivity. Tumor cells are positive for CK7 Brief Hospital Course: 79 yo F with h/o Afib, breast CA, uterine CA both in remission admitted from ED with Afib with RVR, SBO, leukocytosis, and also with pleural fluid results from prior admission showing adenocarcinoma. # SBO: Unclear etiology but appears on CT to be [2-20] adhesions vs peritoneal nodules suspicious for carcinomatosis. Pt denies N/V before admission. She was seen by surgery and made it very clear that she was not interested in surgery. When transferred to the floor, she was passing flatus and has minimal output for her NGT. It was removed on [10-5] and the patient tolerated a liquid diet which was advanced and the patient had a bowel movement on day of discharge. She did not have any nausea or vomiting. # Leukocytosis: Though the patient was afebrile, she had an elevated WBC count on admission and was started on levofloxacin, vancomycin and metronidazole. Cultures were negative, there was no evidence of infection and the WBC count trended down. Her antibiotics were discontinued on [10-6] and her white count continued to trend down and she remained afebrile. # Atrial fibrillation: Has h/o paroxysmal AF, not on coumadin given fall risk. She was rate controlled with IV fluids and small amounts of beta blockers until she was taking POs and then she was started on PO metoprolol. # Hypovolemia: Patient was on torsemide and metolazone. She had contraction alkalosis, hyponatremia and a concentrated appearing CBC that resolved with IVF. She also was net fluid positive at least 2L and was at her baseline respiratory status with balanced Is and Os over the two days prior to discharge. # Hypotension: The patient's systolic blood pressure ranged 85-115. She was low even on 25 of metoprolol QID (at home was on Toprol XL 200). She is being discharged on Toprol XL 100mg daily. # CHF, chronic diastolic: Her repiratory status was stable and she had sats in the high 90s on her home O2 level of 2 lpm via NC. We gave her fluids only very gently and did not diurese her. She was fluid positive about 2L over the course of her hopital stay but after transfer to the floor she had relatively equal Is and Os with good urine output (around 1L on day prior to discharge). We discharged her on her home dose of torseminde but held the metolazone. She will see Dr. [First Name (STitle) 437] in clinic on [2130-10-16]. # Recurrent pleural effusion: She is at her baseline respiratory status. She will be seen in the interventional pulmonology clinic to have a pleurex catheter placed to facilitate # Malignant Pleural Effusion: Effusion is chronic and recurrent ?????? but last tap on [9-22] had adenocarcinoma, staining pending. Pt seen by Dr. [Last Name (STitle) ] and aware of presence of malignant cells. The cells in the pleural fluid are more likely breast than uterine. She was followed by her primary oncologist, Dr. [Last Name (STitle) ]. She was restarted on Arimidex, an aromatase inhibitor. She will see Dr. [Last Name (STitle) ] on [2130-10-13]. # Elevated Troponin: Likely demand, trop flat in first 2 sets at 0.03 with normal CK. EKG without changes. Troponin trended down to 0.02. Medications on Admission: 1. Levothyroxine 50 mcg 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. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Take through [2130-10-1]. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime. 7. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO twice a day. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed for constipation. 10. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Medications: 1. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:1 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). Disp:30 Tablet(s) Refills:2 5. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day. 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 599] of [Location (un) 55] Discharge Diagnosis: Primary: Small bowel obstruction Secondary: malignant pleural effusion Discharge Condition: Good Discharge Instructions: Dear Ms. [Known lastname 109973], It was a pleasure taking care of you again. You were admitted because you may have had an obstruction in your bowel. This resolved on its own. Your blood pressure was low and we are sending you home on a lower dose of your blood pressure medication. The following changes were made to your medications: START Arimidex STOP Metolazone STOP Toprol XL 200mg daily START Toprol XL 100mg daily Please take all other medications as prescribed. Please take stool softeners and laxatives to maintain regular bowel movements and prevent obstruction. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Call your doctor or 911 if you have severe nausea/vomiting, shortness of breath, or for any other concern. Followup Instructions: Provider: [First Name4 (NamePattern1) 488] [Last Name (NamePattern1) 6401], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2130-10-13] 3:00 Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 7634], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2130-10-13] 3:00 Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 62] Date/Time:[2130-10-16] 1:30 [10-20], 9AM in Interventional Pulmonology Clinic on [Hospital1 ] 1, Dr. [Last Name (STitle) 109974]. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 1368] ICD9 Codes: 4280, 496, 4589
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8054 }	Medical Text: Admission Date: [2165-11-18] Discharge Date: [2165-12-12] Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: This 86-year-old female was struck by an SUV with significant damage to the SUV's front end on [2165-11-18]. The patient had a loss of consciousness after this collision and was taken to an outside hospital where her systolic blood pressure was in the 60s. She was intubated and transfused. She was subsequently transferred to [Hospital1 69] where she was hemodynamically unstable in the trauma bay. She received 6 units of packed red blood cells and 5 liters of crystalloid. Status post this treatment her blood pressure improved to about the 120s systolic. The patient was taken to the CT scan for scanning of her head, neck, chest and belly but this scan was aborted once her systolic blood pressures again fell to the 70s. She was then taken to the intensive care unit where bedside echocardiogram was performed and was negative for tamponade. A DPL was also performed which was negative. A chest x-ray showed widened mediastinum and this was followed up by the patient being taken to the angiography suite where no bleeding from the aortic arch or pelvic vessels was demonstrated. As the patient was hemodynamically stable she was taken back to the intensive care unit where a repeat echocardiogram was performed. This study was consistent with significant pericardial fluid. Other physical findings in this patient included a right scalp laceration which was closed with staples. Her belly was soft but her left thigh was tense on examination with an obvious open left tibia-fibula fracture. Admission laboratory studies were significant for an initial hematocrit of 41.0 which fell to 25.8 over the course of a four-hour period. Admission electrolytes were largely unremarkable and her initial blood gas was 7.51, 24, 599, 20 and -1. After her hypotensive episodes the gases changed to 7.10, 92, 359, 30 and -3. Pelvic x-ray showed no obvious fracture or dislocation and left tibia-fibula film showed an open displaced and comminuted fracture of the tibia and fibula. The orthopedic service was consulted while the patient was in the intensive care unit and their recommendation was that the patient be taken to the operating room on the following day for external fixator placement and open fracture washout of the open fracture. HOSPITAL COURSE: In the intensive care unit the plan consisted of aggressive fluid resuscitation including packed red blood cells, fresh frozen plasma and platelets. The respiratory plan was for assisted ventilation. Serial hematocrits were checked q. 1 hour. Her neurological status was maintained under sedation. Bladder pressures were controlled and Protonix was initiated. On hospital day two the patient was maintaining her blood pressures at 87/45 with a heart rate of 119. Her morning hematocrit was 21.8 which had decreased from 30.2 and 25.8 the previous night. On examination the patient was intubated and sedated, unresponsive in a hard cervical collar. The patient was taken to the operating room early on hospital day two for exploratory laparotomy and pericardial window. This procedure was performed with no complications and a blood loss of approximately 100 cc. There was no obvious source of bleeding identified with either of these procedures. On hospital day two the hematology service was also consulted and their recommendations for fluid resuscitation for this patient included fresh frozen plasma to keep the PT and PTT within normal limits, vitamin K 2 mg intravenous, transfusion of platelets to maintain the platelet count close to 100,000, repletion of calcium, repeat of fibrinogen levels and a search for the patient's source of bleeding. These recommendations were followed by the intensive care unit team. On hospital day three/postoperative day two status post an open tibia-fibula washout, exploratory laparotomy and pericardial window the patient was in stable condition and her hematocrit had increased to 30.4. Her blood pressure was 118/65 with a heart rate of 85. The patient was awake but sedated with notable bilateral periorbital edema. She had notable left expiratory wheezes and her abdomen was distended and edematous. She was moving all four extremities spontaneously. The patient was started on levofloxacin for her open fractures until the patient's condition was stabilized sufficiently for closure of her open fractures. On [2165-11-21], the orthopedic service took the patient to the operating room where an incision and drainage of her open left tibia-fibula fracture and intramedullary rod fixation was performed. Postoperative orders included nonweight-bearing status on the left lower extremity and Levaquin intravenous to be continued in light of the patient's previously open fracture. Plastic surgery was also consulted and the patient was seen and examined with the plastic surgery attending. Recommendation was for bedside debridement. Also notable was a vacuum-assisted closure dressing which was in place on the left lower extremity. On postoperative day three the patient was in stable condition with an hematocrit of 32. Plastic surgery, orthopedics and interventional radiology services continued to follow and were pleased with the recovery from their respective procedures. The plan from the standpoint of the intensive care unit team was for continued close monitoring of the patient's cardiovascular status, and continuation of the antibiotics for the patient's previously open fracture. On [2165-11-24] the patient was alert and following commands. Her cervical collar was still in place and her cardiovascular status was regular with a chest examination that was clear to auscultation bilaterally. The patient's condition continued to improve in the intensive care unit over the subsequent days. On postoperative days six and four the vacuum-assisted closure dressing was still in place but was scheduled to be changed and the plastic surgery service suggested a soleus flap once the patient's condition stabilized. The vacuum-assisted closure dressing was indeed changed on this day by the orthopedic service and per their description the underlying skin was red and warm with a necrotic edge. There was a large seroma in the lateral aspect of the thigh and palpation of the wound easily expressed a small amount of brownish fluid. In light of the appearance of the wound Ancef was added to the antibiotic regimen for broader antibiotic coverage. Over the subsequent three intensive care unit days the patient's condition continued to improve including her mental status where she was awake and responsive and following commands. On [2165-11-29] the patient was taken to the operating room by plastic surgery where a soleus flap to her left leg defect was performed by Dr. [Last Name (STitle) 13797] with the assistance of Dr. [First Name (STitle) ]. The patient was noted to have a significant amount of oozing despite normal coagulations and a platelet count of 96,000. Postoperatively the patient recovered well and was weaned to pressor support and CPAP. The left leg was bandaged with a moderate amount of serosanguinous oozing. The patient was returned to the surgical intensive care unit for management consistent and appropriate with the patient's postoperative condition. On [2165-11-29] bilateral pleural effusions were noted in this patient and bilateral chest tubes were placed which were immediately productive of 200-300 cc of serosanguinous fluid. These tubes continued to have high output until approximately [2165-12-3] when the left chest tube was discontinued as its output had diminished considerably. The right chest tube was continued and the patient was extubated and was saturating well on four liters of oxygen by nasal cannula. On [2165-12-4] the patient's Foley catheter was discontinued and the patient was evaluated by physical therapy who commented that the patient's knee range of motion was still limited and questioned institution of a continuous passive motion therapy. On [2165-12-5] the patient was transferred to the floor where she received a video swallow evaluation that initially showed aspiration. However repeat video swallow examination showed no overt signs of aspiration and the patient was placed on a diet consisting of honey-thickened liquids with supervised p.o. intake. As the patient's right chest tube output had declined the patient's right chest tube was discontinued on hospital day 17, which was [2165-12-5]. Plastic surgery continued to follow the patient and on [2165-12-5] the patient was taken to the operating room with the plastic surgery service for a STSG. This procedure was performed by Dr. [Last Name (STitle) 13797] and was more specifically a STSG to the left soleus flap and left lower extremity lateral wound. The procedure also included a wound debridement, evacuation of hematoma of bilateral thighs with wound debridement. The estimated blood loss from this procedure was minimal and the patient was transferred in stable condition to the recovery room. One day after this procedure the plastic surgery service noted that the vacuum-assisted closure on the soleus flaps was outputting minimal amounts of fluid and the setting was changed to 75 mmHg. Wet-to-dry dressings were continued at the sites of the hematoma evacuation. On [2165-12-6] the patient was in stable condition and the plan from the standpoint of the trauma service was to continue pulmonary toilet, to assist the patient out of bed to chair with the assistance of the physical therapy service, continuing the tube feeds, and discontinuing her antibiotics which consisted of vancomycin after her sputum culture had been positive for methicillin-resistant Staphylococcus aureus. Over the subsequent days the patient was evaluated by physical therapy who commented that the patient's range of motion on her left side was improving but that transfer to an appropriate rehabilitation center for further assistance before resuming her activities of daily living would be necessary. Over the subsequent days the patient's condition continued to be stable and as the flap care per the plastic surgery service was followed the patient was assessed to be suitable for discharge on [2165-12-12]. On [2165-12-12] the patient was discharged to an appropriate rehabilitation center in stable condition. STATUS AT DISCHARGE: Approved. CONDITION ON DISCHARGE: Good. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) ] Dictated By:[Last Name (NamePattern1) 13717] MEDQUIST36 D: [2165-12-12] 10:33 T: [2165-12-12] 10:42 JOB#: [Job Number 46934] ICD9 Codes: 2851, 5119
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8055 }	Medical Text: Admission Date: [2201-4-2] Discharge Date: [2201-4-8] Date of Birth: [2152-12-30] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: Myocardial infarction/Unstable angina Major Surgical or Invasive Procedure: [2201-4-2] - CABGx4 (Left internal mammary artery->Left anterior descending artery, saphenous vein graft(SVG)->obtuse marginal artery, Saphenous vein 'Y' graft to distal circumflex artery and posterior descending artery.) History of Present Illness: This 48-year-old patient with exertional chest pain was investigated and an angiogram showed very tight lesion in the circumflex and severe triple- vessel disease with 100% blockage of the right coronary artery and critical stenosis of the left anterior descending artery. He had persistent chest pain and hence was transferred urgently for emergency coronary artery bypass grafting. Intraoperative transesophageal echocardiogram showed the ejection fraction to be about 45%. Past Medical History: Hyperlipidemia Myocardial infarction Social History: Works in a restaurant in food prep. Current heavy smoker. Mild alcohol use. Family History: Brother with CABG at 53. Father with MI at age 75 Physical Exam: GEN: WDWN in NAD SKIN: Warm, dry, no clubbing or cyanosis. HEENT: PERRL, Anicteric sclera, OP Benign NECK: Supple, no JVD, FROM. LUNGS: distant breath sounds anteriorly HEART: RRR, No M/R/G ABD: Soft, ND/NT/NABS EXT:warm, well perfused, no bruits, no varicosities NEURO: No focal deficits. Pertinent Results: [2201-4-2] ECHO PRE-CPB:1. The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. 2. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 6. The mitral valve leaflets are structurally normal. Mild to moderate ([2-6]+) mitral regurgitation is seen. 7. There is no pericardial effusion. There was an episode of inferior wall akinesis with 3+ MR, occasional PVC's and elevation of the PA pressures. After treatment with phenylephrine and nitroglycerine there was resolution of the RWMA and improvement of the MR. POST-CPB: On infusion of phenylephrine. A-pacing. Preserved biventricular systolic function post-cpb. MR is now 1+. The aortic contour is normal post decannulation. [2201-4-2] 11:14AM %HbA1c-5.8 [2201-4-8] 05:10AM BLOOD WBC-6.8 RBC-3.04* Hgb-8.6* Hct-24.9* MCV-82 MCH-28.4 MCHC-34.7 RDW-13.7 Plt Ct-269 [2201-4-8] 05:10AM BLOOD Glucose-92 UreaN-15 Creat-0.7 Na-139 K-4.0 Cl-103 HCO3-26 AnGap-14 Brief Hospital Course: Mr. [Known lastname 80822] was admitted to the [Hospital1 18] on [2201-4-2] via transfer from [Hospital6 ] for urgent coronary artery bypass grafting. He was taken from the intensive care unit to the operating room where he underwent four vessel coronary artery bypass grafting. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. He later awoke neurologically intact and was extubated. Beta blockade, aspirin and a stain were started. On postoperative day one, he was transferred to the step down unit for further recovery. Mr. [Known lastname 80822] was gently diuresed towards his preoperative weight, the physical therapy service was consulted for assistance with his postoperatve strength and mobility. His chest tubes and wires were removed. On the evening of post operative day two he was found to have increased work of breathing with desaturation so he was returned to the indensive care unit. Multiple sputum and blood cultures were sent to the laboratory in response to a very wet chest radiograph with questionable infiltrates. He was placed on Vancomycin and zosyn originally for the same findings, and then switched to levofloxacin as cultures began to return negative. He was treated aggressively with bronchodilators and his respiratory status improved markedly. By post-operative day five he was no longer symptomatic and his chest radiograph had cleared. The patient continued to progress and was discharged home with VNA services on POD6 in good condition. Medications on Admission: None Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 4. 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 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s) Refills:0 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:60 Tablet(s) Refills:0 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:0 11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts Myocardial infarction Hyperlipidemia Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [First Name (STitle) ] in 1 month. ([Telephone/Fax (1) 1504] Please follow-up with Dr. [Last Name (STitle) 1295] in 2 weeks. Please follow-up with Dr. [Last Name (STitle) 80823] (PCP) in [3-10] weeks. [Telephone/Fax (1) 45333] [Hospital Ward Name 121] 6 wound clinic in 2 weeks please call for appointments [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2201-4-8] ICD9 Codes: 486, 2724, 412, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8056 }	Medical Text: Admission Date: [2171-9-14] Discharge Date: [2171-9-23] Date of Birth: [2088-7-26] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: fevers, hypotension Major Surgical or Invasive Procedure: [2171-9-14] Esophagastroduodenoscopy History of Present Illness: The patient OPCABG x 4 on [2171-7-29]. Post-op course was lengthy and complicated. He initially was hemodynamically unstable, requiring vasopressor support. EP saw the patient for ventricular ectopy. PPM/AICD was not recommended. He continued to be bradycardic, and would receive a temporary pacer. This was removed, EP did not feel a PPM was indicated. He developed a sternal wound infection and was taken to the operating room by plastic and reconstructive surgery for sternal plating and bilateral pectoralis flaps. The patient required re-intubation several times during the [Hospital ] hospital course, and eventually received a trach and PEG on [2171-8-30]. EVH site was debrided, and he received a 10 day course of vancomycin. He was transferred to rehab on POD 45, [2171-9-12]. He returned on [2171-9-13] with fever and hypotension. During this hospitalization he was found to have CDiff in the stool and was placed on appropriate antibiotics. His hypotension resolved Past Medical History: Coronary Artery Disease s/p off pump coronary artery bypass grafts Respiratory failure- s/p Tracheostomy/PEG Loculated left sided pleural effusion s/p Pigtail toracentesis Sternal dehiscence s/p sternal debridement,plating,pectoral flap advancement Endoscopic vein harvest infection [Date Range ] decubitus ulcer Ischemic cardiomyopathy Chronic atrial fibrillation Peripheral vascular disease Hypertension chronic obstructive pulmonary disease Hypercholesterolemia Social History: Family History: Race: Caucasian Last Dental Exam: edentulous Lives with: wife (in-law apartment- daughter +fam live nearby) uses Canadian crutches for ambulation ([3-12] OA of knees) Occupation: retired Tobacco: 1ppd x 64yrs. ETOH: occasional Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS - T 102.6, 93/50, HR 70's (atrial fibrillation, Vent - SIMV TV 500, FIO2 50% Rate 14 PEEP 10 Gen: Eldery male, ill appearing HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: No clear JVD CV: PMI located in 5th intercostal space, midclavicular line. Irregularly irregular. normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: Wheezing b/l. sternum stable Abd: distended, patient does not react to deep palpation Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: GJ TUBE CHECK. One view of the abdomen. There is motion artifact. Contrast material has been injected via a gastrostomy tube. Contrast has accumulated in a small area in the left upper quadrant, presumably within the gastric lumen. The bowel gas pattern is not remarkable. There are degenerative changes in the lumbar spine. IMPRESSION: Limited study demonstrating findings consistent with placement of the gastrostomy tube in the stomach. See procedure note. Admission: [2171-9-13] 08:45PM URINE RBC-[7-18]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[4-12] [2171-9-13] 08:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2171-9-13] 08:45PM PT-13.4 PTT-26.7 INR(PT)-1.1 [2171-9-13] 08:45PM PLT COUNT-345 [2171-9-13] 08:45PM WBC-14.3# RBC-3.46 HGB-10.5* HCT-32.3* MCV-93 MCH-30.3 MCHC-32.5 RDW-16.5* [2171-9-13] 08:45PM CALCIUM-9.3 PHOSPHATE-4.9* MAGNESIUM-2.5 [2171-9-13] 08:45PM cTropnT-0.11* [2171-9-13] 08:45PM LIPASE-107* [2171-9-13] 08:45PM ALT(SGPT)-67* AST(SGOT)-158* LD(LDH)-327* ALK PHOS-241* AMYLASE-97 TOT BILI-1.2 [2171-9-13] 08:45PM GLUCOSE-135* UREA N-74* CREAT-1.3* SODIUM-142 POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-22 ANION GAP-15 [2171-9-13] 08:51PM LACTATE-1.2 K+-4.1 Discharge: [2171-9-23] 02:54AM BLOOD WBC-8.8 RBC-2.86* Hgb-8.6* Hct-26.4* MCV-93 MCH-30.1 MCHC-32.5 RDW-17.6* Plt Ct-228 [2171-9-23] 02:54AM BLOOD Plt Ct-228 [2171-9-15] 03:17AM BLOOD PT-14.1* PTT-29.8 INR(PT)-1.2* [2171-9-23] 02:54AM BLOOD Glucose-86 UreaN-36* Creat-1.0 Na-144 K-4.4 Cl-112* HCO3-22 AnGap-14 [2171-9-19] 03:59AM BLOOD ALT-24 AST-23 AlkPhos-124 Amylase-53 TotBili-1.3 [2171-9-18] 01:36AM BLOOD Lipase-38 [2171-9-16] 5:00 am STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT [2171-9-16] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2171-9-16]): REPORTED BY PHONE TO [Doctor First Name 66866],D @ 16:19, [2171-9-16]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). Radiology Report CHEST (PORTABLE AP) Study Date of [2171-9-22] 10:34 AM [Hospital 93] MEDICAL CONDITION: 83 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pleural effusions Final Report REASON FOR EXAMINATION: Evaluation of the patient after CABG for pleural effusions. Portable AP chest radiograph was compared to [2171-9-18]. Tracheostomy tube is in the midline, approximately 7.5 cm above the carina. There is no change in the sternal fixation devices appearance. Cardiomegaly is severe. Retrocardiac consolidations are bilateral, accompanied by bilateral pleural effusions. There is no interval worsening of the overall appearance of the chest. DR. [First Name4 (NamePattern1) 2618] [Last Name (NamePattern1) 2619] Brief Hospital Course: The patient was admitted for workup and management of fever and hypotension. He was empirically treated with vancomycin and zosyn. There was question of malposition of G-tube on CT scan, so urgent EGD was performed. Tube was re-positioned without complication. Contrast study was negative for extravasation. Tube feeds were resumed. Wound care was consulted for evaluation of [Last Name (NamePattern1) 85030] pressure ulcer (present prior to admission). Pan cultured for fever workup, sputum culture would grow gram negative rods and stool was positive for c-diff. The patient was treated with flagyl and zosyn. After several days on Flagyl the patient continue to have watery stool and PO Vancomycin was added for treatment of CDiff infection. Pulmonary status remains tenuous, attempts to wean ventilator to pressure support ventilation with 5 Peep and 5 Pressure support were unsucessful. The patient would quickly have an episode of tachypnea requiring increased pressure support. Interventional pulmonary was consulted, an ultrasound of pleural space showed small loculated effusion that was not amendable to drainage. On hospital day 10 the patient was transferred to rehabilitation at [Hospital1 ]-[Hospital1 8]. Medications on Admission: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). 13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [7-18] Puffs Inhalation Q4H (every 4 hours). 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 4-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 15. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 18. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 19. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed for SBP>130. 20. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 21. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 22. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 23. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [Hospital1 ] (2 times a day) as needed for COPD. 24. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous twice a day for 10 days. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day) as needed for prophylaxis. 2. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day) as needed for ----. 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for prevent thrush. 4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 6-10 Puffs Inhalation Q4H (every 4 hours). 5. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 6. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Inhalation [Hospital1 ] (). 7. Collagenase Clostridium hist. 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily): to [Hospital1 85030] decub. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q 8H (Every 8 Hours). 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold sbp<100 hr<60. 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 14 days: end date [9-30]. 12. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 14 days: end date [10-6]. Disp:qs Capsule(s) Refills:0 13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Tablet(s) 14. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times a day). 17. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Intravenous daily and PRN: Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. . 18. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection once a day. Discharge Disposition: Extended Care Facility: [Hospital6 85] TCU - [Location (un) 86] Discharge Diagnosis: Coronary Artery Disease s/p off pump coronary artery bypass grafts Respiratory failure- s/p Tracheostomy/PEG Loculated left sided pleural effusion s/p Pigtail toracentesis Sternal dehiscence s/p sternal debridement,plating,pectoral flap advancement Endoscopic vein harvest infection [Location (un) ] decubitus ulcer Ischemic cardiomyopathy Chronic atrial fibrillation Peripheral vascular disease Hypertension chronic obstructive pulmonary disease Hypercholesterolemia Discharge Condition: Tracks, Moves upper extremities Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Left Lower leg endoscopic vein site open->pack wet to dry [Hospital1 ] 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] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [First Name (STitle) ] ([Telephone/Fax (1) 170]) on [2171-10-21] at 1:00PM Please call to schedule appointments: Primary Care: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 17859] ([Telephone/Fax (1) 40171]in [4-11] weeks Cardiologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 5424]) in [4-11] weeks Plastic Surgery: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 1416] in [4-11] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2171-9-23] ICD9 Codes: 5119, 4439, 4019, 2720, 496, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8057 }	Medical Text: Admission Date: [2136-3-4] Discharge Date: [2136-3-13] Date of Birth: [2056-6-26] Sex: M Service: MEDICINE Allergies: Penicillins / Nsaids / Magnesium / Meperidine / Paroxetine / Famotidine / Indomethacin Attending:[First Name3 (LF) 2009] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy Interventional Radiology Artery Coiling Central Line Place EGD History of Present Illness: 79 y/o M with history of ESRD on HD, RCC and prostate cancer who presented from nursing home via OSH on day of admission with BRBPR. For the 2 weeks prior to admission, he had loose bowel movements although without blood. At 4PM on day of admission he was noted by the nursing home to have large amount of BRBPR with passage of clots. He was brought into [Hospital3 ] were initial vitals were 106/67 with heart rate 96 although he reportedly had an episode of systolic blood pressures to the 80s. He reportedly had an episode of syncope. Hematocrit was 21. He was transfused 2 units of PRBC at the OSH and transferred to [Hospital1 18] for further management. Of note, he has not had a colonoscopy in > 10 years. No recent NSAID or prednisone use. He does take plavix daily for what appears to be carotid disease. In the ED, initial vs were: 96.8 139/72 97 17 100%2L. He passed large red clots with some bright red blood and dark black stool. Hematocrit here was 30.7. He was transfused an additional 1u PRBC. Access with 3PIV (16,18,20 gauge). Transferred to MICU for further management. On floor, passed small amount of dark clot. Past Medical History: 1. ESRD on HD (MWF) 2. DM 3. renal cell CA 4. prostate CA 5. hyperlipidemia 6. gout 7. HTN 8. depression 9. cognitive dysfunction Past Surgical History: 1. s/p prostatectomy '[18] 2. s/p right nephrectomy '[23] 3. s/p R AVF '[32] 4. s/p LIH repair Social History: Patient has lived in nursing home (Radius in [Location (un) 3320]) for the past three months. Prior to this wife assisted with most [Name (NI) 5669]. Currently with limited ambulation. He has an approximately [4-9] year pack history of smoking, quit in [2114]. He denies ETOH and illicit drug use. Family History: There is no family history of colon cancer. Physical Exam: Vitals: 97/5 146/79 92 15 100%RA General: Sleeping, responds to loud voice, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, non-tender GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2136-3-4] 11:51PM TYPE-[Last Name (un) ] COMMENTS-GREEN TOP [2136-3-4] 11:51PM LACTATE-2.1* [2136-3-4] 11:40PM HCT-31.6* [2136-3-4] 08:50PM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.017 [2136-3-4] 08:50PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [2136-3-4] 08:50PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [2136-3-4] 08:50PM URINE RBC->50 WBC->50 BACTERIA-MOD YEAST-NONE EPI-0 [2136-3-4] 08:50PM URINE GRANULAR-0-2 [2136-3-4] 07:59PM LACTATE-3.2* K+-4.7 [2136-3-4] 07:59PM HGB-10.7* calcHCT-32 [2136-3-4] 07:45PM GLUCOSE-163* UREA N-45* CREAT-5.5* SODIUM-143 POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-30 ANION GAP-17 [2136-3-4] 07:45PM estGFR-Using this [2136-3-4] 07:45PM ALT(SGPT)-27 AST(SGOT)-17 CK(CPK)-23* ALK PHOS-67 TOT BILI-0.9 [2136-3-4] 07:45PM LIPASE-93* [2136-3-4] 07:45PM CK-MB-NotDone cTropnT-0.19* [2136-3-4] 07:45PM ALBUMIN-3.1* [2136-3-4] 07:45PM WBC-19.5* RBC-3.37* HGB-10.1* HCT-30.7* MCV-91 MCH-30.0 MCHC-33.0 RDW-16.9* [2136-3-4] 07:45PM NEUTS-88.1* LYMPHS-9.1* MONOS-1.7* EOS-0.8 BASOS-0.3 [2136-3-4] 07:45PM PLT COUNT-194 [2136-3-4] 07:45PM PT-12.6 PTT-23.1 INR(PT)-1.1 CXR (portable) [2136-3-5]: INDICATION: Leukocytosis, questionable pneumonia. COMPARISON: No comparison available at the time of dictation. FINDINGS: The lung volumes are low. No pleural effusions. Borderline size of the cardiac silhouette without evidence of pulmonary edema. Moderate tortuosity of the thoracic aorta. No focal parenchymal opacities suggesting pneumonia. Brief Hospital Course: 79 yo male with ESRD on HD, RCC and prostate cancer, h/o dementia who was transferred from [Hospital3 3583] for evaluation and treatment of a lower GI bleed. . #) GI BLEED: Mr. [Known lastname 86684] initially presented to [Hospital3 ] with a BRBPR, and was then transferred to [Hospital1 18] for further management. He was initially managed in the MICU for closer monitoring, where he required blood transfusions but remained hemodynamically stable, so he was transferred to the floor. On [2136-3-5] he was started on a bowel prep for EGD and colonoscopy on [2136-3-6], he was able to tolerate the prep well. The EGD showed normal mucosa in the esophagus, antral gastritis, patchy duodenitis in the duodenal bulb, and an otherwise normal EGD to third part of the duodenum. Colonoscopy showed a 10 cm area of erythema, ulceration and diffuse oozing/friability from cecum to proximal ascending colon. The mucosa in the terminal ileum appeared normal. Two areas of erythema and ulcerations were noted in the transverse colon with an intermediate normal mucosa. The proximal of those two areas was about 10 cm. A single sessile polyp of benign appearance of 1.5 cm was found in the transverse colon. He went back to the floor post procedure, but that night he redeveloped a GI bleed and was transferred back to the MICU. At that point he was evaluated by IR and underwent angiogram with coil embolization of a foci of angiodysplasia near the cecum. After discussion with the MICU team, the patient and his family decided that he would not wish to pursue further surgical treatment. In total over his course he received 9 units of PRBC's. The bleeding slowed, and on [2136-3-9] he started to have brown bowel movements. His hematocrit remained stable, so he was transferred to the general medicine floor. While the floor he did not have any further BRBPR, and remained hemodynamically stable. His protonix was transitioned to po dosing, and he did not require any further blood products while on the floor. . #) LEUKOCYTOSIS: White count on admission was elevated at 19.5, given his loose stools prior to admission there was concern for a GI source of bleeding. His stool was sent for multiple studies, due to concern for possible infection that could have led to a GI bleed. However, infection with shigella, E.coli 0157 considered although timecourse of over two weeks with sudden change to hemorrhage and absence of constiutional symptoms or abomdinal pain appreared less consistent with is current presentation. In the work up for his leukocytosis urine and blood cultures were sent, the urine grew Strep viridans and he was found to have coagulase negative staph growing in his blood cultures. He was started on treatment with vancomycin and completed a 7 day course. All surveillance blood cultures drawn after that point were negative. He also had a CT scan that showed colitis, for which he completed a 7 day course of ciprofloxacin. Over the course of his hospital stay his leukocytosis improved. . #) ESRD on HD: Patient on M/W/F schedule with access being R. fistula, last performed on 3 days prior to admission at Fresenius ([Telephone/Fax (1) 86685]). He was follwed by the renal team and dialyzed according to his stability at their discretion during this admission. His regular renal medications were continued, but when his phosphorus became low at the time of discharge it was suggested that his calcium acetate be decreased to twice daily administration. . #) ELEVATED TROPONIN: Given the [Initials (NamePattern4) 228] [Last Name (NamePattern4) 47] risk factors of DM and HTN, cardiac enzymes were trended. Elevated troponin persisted at 0.17-0.19, with flat CK and CK-MB. These troponins were therefore felt most likely secondary to ESRD rather than an ischemic event, especially in the setting of no EKG changes. . #) HYPERTENSION: Antihypertensives were initially held in setting of GIB. Once his bleed had stablized he was first restarted on labetalol prior to discharge. We recommend that his nifedipine be restarted the day after discharge and that it be held the morning of dialysis since he has had some episodes of low blood pressure while at dialysis. . #) HYPERLIPIDEMIA/CAD: Patient's statin was initially held while in the MICU, and his aspirn and plavix were also held in the setting of his GI bleed. His statin was restarted after he left the MICU, and his aspirin can be restarted on [2136-3-16]. His plavix was not restarted due to concern about the increased risk of bleeding on dual anti-platelet therapy, and we would recommend continuing to hold his plavix given the severity of his GI bleed, this issue can be readdressed by his primary care physician after discharge. . #) GOUT: Patient's home dose of allopurinol was initially held but was restarted on hospital day 1 and then continued throughout his admission. He did not have any signs of a gout flare during his stay. . #) COGNITIVE DECLINE: Patient was continued on his home dose of donepizil and risperdal, attempted to maintain his day/wake cycle as best as possible to help prevent concurrent delirium while in the hospital. Medications on Admission: - Lutein 20mg daily - Allopurinol 100mg daily - Asa 81mg daily - Plavix 75mg daily - Ranitidine 150mg [Hospital1 ] - Phoslo 3 caps TID - Labetolol 200mg daily - Aricept 5mg daily - Simvastatin 40mg daily - Nifedipine 60mg [Hospital1 ] - Xanax 0.5mg prn - Risperidone 1mg daily - Calcium acetate 667mg TID w/ meals - Claritin 10mg daily - Allopurinol 100mg daily - Bisacodyl prn - Polyethylene glycol PRN Discharge Medications: 1. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Labetalol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 11. Lutein 20 mg Capsule Sig: One (1) Capsule PO once a day. 12. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 14. Miralax 17 gram/dose Powder Sig: One (1) capful PO once a day as needed for cold symptoms. Discharge Disposition: Extended Care Facility: [Hospital1 11057] Nursing & Rehabilitation Center - [Location (un) 3320] Discharge Diagnosis: Primary: 1. Lower Gastrointestinal Bleed 2. Coagulase Negative Staph Bacteremia 3. End Stage Renal Disease on Hemodialysis Secondary: Atrial fibrillation Hypertension Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Mr. [Known lastname 86684], it was a pleasure taking care of you at [Hospital1 18]. You were transferred to [Hospital1 18] from [Hospital3 3583] with bleeding from your GI tract. During your stay you needed to be cared for in the Intensive Care Unit for closer monitoring. The gastroenterologists did a colonoscopy that showed a large ulcer in part of your small intestine, but they could not stop the bleeding. Then you were taken to interventional radiology and had a coil put in the bleeding artery to help slow down the bleeding. You required a lot of blood transfusions, but the bleeding slowed down and you were able to be transferred out of the intensive care unit. Also during your stay you were found to have a positive blood culture, which we think was due to a line infection, and you were found to have a urinary tract infection. Both of these infections were treated with antibiotics that were given at dialysis. After your blood counts had been stable for a few days we were able to restart your blood pressure medications. . Changes made to your medication regimen: 1. STOPPED Plavix 75mg daily due to the increased risk of bleeding 2. STOPPED Ranitidine 150mg [Hospital1 ] 3. STARTED Protonix 40mg daily Please continue to take all other medications as previously prescribed Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2136-4-18] at 2:00 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) 10314], 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: 5856, 7907, 5990, 2851, 2749, 2724, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8058 }	Medical Text: Admission Date: [2153-11-5] Discharge Date: [2153-11-8] Date of Birth: [2094-10-13] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 59-year-old gentleman with metastatic renal cell carcinoma to the brain with left parietal metastases. The patient had right nephrectomy on [12/2152] and chemotherapy in [2153-2-1]. He had stereotactic radiosurgery in [2153-5-1]. The patient had difficulty walking and difficulty talking. He had increased lethargy with headaches for the last week. The patient became incontinent of urine times one and one half months. Weakness of the right side became progressively worse. The patient was obtunded in the emergency room. Pupils were equal and reactive to light. Chest was clear to auscultation. Cardiovascular: S1 and S2, no murmur, rub or gallop. Extremities: No clubbing, cyanosis or edema. Neurologically: The patient is awake, alert, and oriented times three with some speech receptive and expressive aphasia and right hemiparesis. Head CT shows left parietal lesion with a large amount of swelling around the tumor. HOSPITAL COURSE: The patient was admitted to the Surgical Intensive Care Unit. The patient was started on Decadron 20 mg IV, Mannitol and Zantac. On hospital day #2, the patient was taken to the OR and underwent left frontal parietal craniotomy for removal of left frontal tumor. Vital signs were stable. Postoperatively, neurologically, he was awake and alert, oriented times three. Speech is improving daily. Naming is improved. He continues to have a right hemiparesis, upper extremity worse than the lower extremity, but improving. Incision is clean, dry, and intact. Vital signs have been stable. He is afebrile. He will be followed by Drs. [First Name (STitle) ], [Name5 (PTitle) 724], and [Doctor Last Name ] in the Brain [Hospital 341] Clinic. He will be followed up there two weeks' postoperatively. Staples will be removed on postoperative day #10. MEDICATIONS ON DISCHARGE: 1. Norvasc 10 mg p.o.q.d. 2. Zantac 150 mg p.o.b.i.d. 3. Dilantin 400 mg p.o.q.d. 4. Percocet 1-2 tabs p.o.q.4h.p.r.n. pain. 5. Decadron to be tapered to 2 b.i.d. Vital signs remained stable. The patient is afebrile and neurologically continues with right hemiparesis, which is improving. FOLLOW-UP CARE: The patient will followup in the Brain [Hospital 341] Clinic in two weeks' time. Staple removal in ten days. CONDITION ON DISCHARGE: Stable. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2153-11-8] 10:10 T: [2153-11-8] 10:10 JOB#: [Job Number 23339] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8059 }	Medical Text: Admission Date: [2171-11-18] Discharge Date: [2171-11-25] Date of Birth: [2092-8-4] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1666] Chief Complaint: subdural hematoma/ subarachnoid hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 79F with a h/o hypercholesterolemia who presented to an OSH after an unwitnessed fall on [11-18] and was found to have a 7mm left sided SDH and SAH on CT. She does not remember the fall, and was found by a neighbor who reported she was unconscious at first but then arousable. The patient denies any preceding events/ movements/ auras to her knowledge. She denies any CP, SOB, dizziness, tongue biting, incontinence, weakness/ motor deficits, sensory deficits, and change in speech or vision before or after the time of fall. The patient was very confused upon arousal and reports a severe throbbing HA and neck pain with flexion after the fall. She denies any other recent falls. . The patient was transferred from the OSH to [Hospital1 18] on [11-18] where CT showed a 5mm left-sided subdural hematoma (possibly acute on chronic) and a small L temporal subarachnoid hemorrhage with no evidence of acute infarct. Vital signs were stable and exam was nonfocal on admission. The patient was admitted to the trauma ICU for frequent neurochecks, where she was started on dilantin for seizure prophylaxis. Repeat CT on [11-19] was unchanged, and the patient was transferred to the floor on telemetry. . Of note, the patient does report word-finding difficulties that the daughter reports are intermittent since the fall. Previous documentation notes word finding problems for the last 1 and [1-22] years that were attributed to Zoloft, but the patient's daughter notes that these symptoms are far more pronounced than usual. Past Medical History: Hypercholesterolemia Depression Question early dementia - recent forgetfulness Hypothyroidism treated with Synthroid The patient also reports a cardiac catheterization at the [Hospital1 112] 6yrs ago which was normal. The cath was done for a "lab abnormality". She also had a normal carotid ultrasound about 2 yrs ago after her sister was diagnosed with a carotid stenosis. Social History: lives in group home- [Hospital1 ] House in [Hospital1 6687], no tobacco, no Etoh; adult children live in the area as well and are very supportive. The patient is independent in her ADLs and drives on her own. Family History: father CAD, MI at age 66yrs, sister with carotid stenosis at age 76 Physical Exam: VS: Tc/m 101.4 BP 122/70 (118-136/60-72) HR 86 (74-86) RR 18 O2sat 97%RA (93-97%RA) Gen: pleasant elderly female sitting in chair in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT, PERRL, EOMI, sclera anicteric. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. OP clear Neck: Supple, JVP not elevated, no carotid bruit CVS: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. Very mild systolic [1-26] murmur best over RUSB. No r/g/ thrills. No S3 or S4. Chest: normal respiratory effort, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: +BS, Soft, NT, ND. No HSM or tenderness. No abdominial bruits. No suprapubic tenderness. Ext: No c/c/edema. Pneumoboots in place. 2+ distal pulses Skin: stasis dermatitis, no ulcers or scars. Neuro: AAOx3. CN II-XII intact, 5/5 strength throughout in proximal and distal muscle groups. 2+ biceps, triceps, and patellar reflexes. Sensation to light touch intact throughout. [3-23] registration and recall. Patient can name days of week and months of year backwards without difficulty. + occasional word finding difficulties. Appropriate behavior throughout. Pertinent Results: LABS: [2171-11-18] 04:30PM WBC-10.5 RBC-4.53 HGB-13.6 HCT-40.8 MCV-90 MCH-30.0 MCHC-33.3 RDW-13.5 [2171-11-18] 04:30PM PLT COUNT-210 [2171-11-18] 04:30PM PT-11.5 PTT-24.1 INR(PT)-1.0 [2171-11-18] 04:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2171-11-18] 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2171-11-19] 05:10AM BLOOD Glucose-106* UreaN-14 Creat-0.9 Na-141 K-4.5 Cl-105 HCO3-29 AnGap-12 [2171-11-19] 05:10AM BLOOD CK(CPK)-129 [2171-11-19] 05:10AM BLOOD CK-MB-4 cTropnT-<0.01 [2171-11-19] 04:29PM BLOOD CK(CPK)-129 [2171-11-19] 04:29PM BLOOD CK-MB-4 cTropnT-<0.01 [2171-11-20] 12:35AM BLOOD CK(CPK)-117 [2171-11-20] 12:35AM BLOOD CK-MB-4 [2171-11-21] 05:30AM BLOOD VitB12-367 Folate-11.6 [2171-11-21] 05:30AM BLOOD TSH-2.9 . EKG: SR, Left axis consistent with LAFB, LVH, normal intervals . [11-18] CT head: Left-sided suboccipital subdural hematoma about 5mm in greatest thickness. Small L temporal subarachnoid hemorrhage. No evidence of acute infarct. Findings not significantly changed compared to OSH CT. . [11-19] CT head: IMPRESSION: Unchanged L convexity subdural hematoma and small subarachnoid hemorrhage . [11-19] CXR (port AP): FINDINGS: Opaque tubes somewhat obscure the right lower lung. The cardiac silhouette is mildly enlarged and there is some tortuosity of the aorta. However, no evidence of vascular congestion, pleural effusion, or acute pneumonia. . [11-20] carotid U/S: IMPRESSION: Less than 40% right ICA stenosis. 40% to 59% left ICA stenosis. . [11-20] Echo: IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function (LV EF > 55%). Mild mitral regurgitation. No structural cardiac cause of syncope identified. . [11-22] CT head w/o contrast: IMPRESSION: 1. Unchanged subdural hematoma along the left convexity, left anterior falx and left tentorium. 2. Probable evolving contusion in the left posterior/inferior temporal lobe. An evolving infarction may also be considered. The planned brain MRI will be helpful for further evaluation. . [11-22] MRI brain & neck w/o contrast: IMPRESSION: 1. Left temporal abnormality visualized on the recent CT consistent with hemorrhagic contusion and not with recent infarction. 2. Irregularity of the left posterior cerebral artery may be due to trauma from impact onto the nearby tentorium or alternatively could relate to intrinsic arterial disease such as atherosclerosis. Given the lack of evident arterial disease elsewhere, in context, the former seems more likely. 3. Small multifocal subdural hematomas, probably unchanged, allowing for differences in technique between CT and MR. 4. Old lacunar infarct in the left caudate. . [11-23] MRA neck: FINDINGS: Neck MRA demonstrates normal flow signal in the carotid and vertebral arteries. No evidence of stenosis or occlusion seen. . [11-24] EEG: IMPRESSION: This is an abnormal routine EEG in the waking and drowsy states due to intermittent bursts of focal slowing arising in the left temporal and left fronto-temporal regions suggesting a region of subcortical dysfunction in that area. Vascular disease would be among the common causes for such a finding. There were no epileptiform features. No electrographic seizures were noted. Micro: [11-19] UA: neg, [1-22] UCx: 10-100K enterococcus URINE CULTURE (Final [2171-11-21]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S . [11-19] BCx neg x 2 [11-20] BCx: neg x 4 . Brief Hospital Course: A/P: 79 yo with hypercholesterolemia and depression who presents after an unwitnessed fall possibly secondary to a syncopal episode with subsequent SDH/SAH. . # SDH/SAH: The patient was initially admitted to the Neuro ICU, where she remained neurologically intact with stable findings on serial CT scans. She was started on dilantin for seizure prophylaxis and was transferred to the floor in stable condition. The patient's daughter expressed concern that existing word-finding difficulties had worsened from her baseline, and during admission the patient complained of intermittent episodes of emesis and headaches. There were no meningeal signs on exam and neurologic exam remained unchanged. A repeat CT head was negative for rebleed and expansion of bleed. An MRI was performed, with findings consistent with hemorrhagic concussion and surrounding edema. Neurology was consulted and felt that symptoms were consistent with a post-concussive syndrome. Symptoms resolved prior to discharge, with return of mental status to baseline per the patient's daughter. Dilantin was tapered off prior to discharge with no evidence of seizures during admission. The patient's aspirin was held for 7 days per neurosurgery, and this was restarted upon discharge. . # Syncope: The patient presented after an unwitnessed fall that she does not recall. The patient denies any preceding symptoms consistent with mechanical fall, vasovagal event, or orthostatis; however, details are unclear. The patient was ruled out for MI with cardiac enzymes negative x 3 with no concerning EKG changes for ischemia. The patient was monitored on telemetry during admission with no significant events. The patient has a very mild systolic heart murmur on exam with no history of syncope, chest pain or dyspnea suggestive of severe valvular disease. Echo showed normal heart function and no evidence of valvular stenosis. Carotid US and MRA of the neck were without significant stenosis on both sides. EEG was negative for epileptiform foci. The patient was ambulating well with no symptoms of orthostasis during admission. Circumstances surrounding fall still remain unclear, but syncope workup was negative with no further evidence of syncope. . # Fever: During the admission the patient spiked a temperature to 101.4 with no leukocytosis and no localizing symptoms. Urinalysis was negative but cultures were positive for 10-100K enterococcus without urinary symptoms. The possibility of drug fevers was entertained given new addition of dilantin, but this was felt to be unlikely per neurology. The patient was started on a 7 day course of ampicillin for UTI and was afebrile by the time of discharge. . # Possible dementia: The patient was evaluated by neurology and was found to have evidence of word-finding difficulties intermittently during admission. Symptoms were felt by the primary medical team and neurology consult service to be consistent with sundowning and/or post-concussive syndrome. Patient also exhibited evidence of early mild-cognitive impairment, given word-finding difficulties and finger apraxia on exam which may be more pronounced after recent head trauma. However, these symptoms could also be secondary to edema surrounding contusion in left temporal lobe on CT. Metabolic/ infectious workup was negative, with negative RPR and TSH, B12, and folate within normal limits. The neurology service recommended that alternative medications to amytriptyline may be considered upon discharge, and the patient may benefit from Aricept. . # Hypothyroidism: The patient was continued on her outpatient dose of Synthroid. . # CVS/Hyperlipidemia: The patient has no cardiac history by recent cath. Echo with normal cardiac function and LV EF > 55%. During admission the patient was continued on Simvastatin and Zetia with ASA held, as above, for SDH/SAH. . # Code: During this admission the patient's code status was FULL. . # The patient was discharged to home in good condition; afebrile, VSS, ambulating and taking PO well with return of mental status to baseline. She was given instructions to follow-up with Dr. [Last Name (STitle) 739] in 4wks with a head CT prior to the appointment. Medications on Admission: Zocor 80 mg PO DAILY Synthroid 50mcg PO DAILY Ezetimibe 10 mg PO DAILY Zoloft 50mg PO DAILY (per psychiatrist) Acetaminophen 325-650 mg PO/PR Q6H:PRN Oxycodone-Acetaminophen [1-22] TAB PO Q6H:PRN pain Amitriptyline HCl 25mg PO HS Prilosec OTC 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. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:10 Tablet(s) Refills:0 5. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig: One (1) ML Injection ASDIR8 (ASDIR). 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 3 days. Disp:24 Capsule(s) Refills:0 9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 6X/D (). Disp:1 tube Refills:2 11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital3 ] vna Discharge Diagnosis: Primary: L sided subdural hematoma and subarachnoid hemorrhage, post-concussive syndrome Secondary: Hypercholesterolemia Depression Hypothyroidism treated with Synthroid Discharge Condition: Neurologically stable with resolution of headaches. Low-grade fever (100.0) without source of infection upon workup with other VSS. Ambulating well and taking po well. Mental status at baseline. Discharge Instructions: You were transferred to [Hospital1 18] after sustaining head trauma from a fall. No clear cause for the fall was found. You were found to have a small amount of bleeding called a subdural and subarachnoid hemorrhage on admission. This was found to be stable on CT scans throughout your hospital course. During your hospitalization your aspirin was held because this increases the risk of bleeding immediately following the fall. This should be restarted upon discharge from the hospital. You were also diagnosed with a urinary tract infection for which you should complete a course of ampicillin. . Please continue to take all of your medications as prescribed. Please attend all of your follow-up appointments. . DISCHARGE INSTRUCTIONS FOR HEAD INJURY ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? 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. . 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 Followup Instructions: Please contact your PCP upon discharge for a follow-up appointment within 1-2 weeks. Please call [Telephone/Fax (1) 1669] to schedule an appointment with Dr. [Last Name (STitle) 739] (Neurosurgery) to be seen within 4 weeks. You will need a CT scan of the brain with or without contrast prior to this visit. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1672] MD, [MD Number(3) 1673] ICD9 Codes: 5990, 2720, 2449, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8060 }	Medical Text: Admission Date: [2194-6-23] Discharge Date: [2194-7-1] Date of Birth: [2122-8-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 10493] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Right femoral HD line [2194-6-23] Bone marrow biopsy [2194-6-25] Left percutaneous nephrostomy tube placement [2194-6-25] History of Present Illness: presented to the ED with weakness and repeated falling. Per report, family unable to care for patient at home and patient resistant to MD follow-up and treatment. Patient was section'd 12 by PCP today as there was a question of competency and sent to the ED. Per patient, he reports diarrhea recently off and on over the last 2 weeks, no BRBPR/melena/hematochezia. Complete ROS negative for h/a, vision changes, CP/SOB/palpitations, abd pain, n/v, dysuria, current diarrhea, LE edema, weakness/numbness/tingling. . In the ED, initial VS were Tc 98.8 BP 164/47 HR 71 RR 16 SaO2 100%/RA. Labs significant for K 8.2, BUN/Cr 150/12.3. Renal was consulted, urgent HD line placed. K treated with 1 amp bicarb, 1 amp Calcium gluconate, 30 gm kayexelate, 1 amp D50, 10 U regular insulin. Past Medical History: PMH 1. ? CKD - documented by PCP at least one year, last Cr here 5.7. 2. s/p right inguinal hernia [2169] 3. Seborrheic dermatitis 4. h/o diastolic murmur 5. Basal cell carcinoma of upper lip Social History: SH - Retired messenger. Lives at home with his sister. [Name (NI) ] tobacco/EtOH. Family History: NC Physical Exam: PHYSICAL EXAM - VS: Tc 97.0, BP 138/44, HR 88, RR 18, SaO2 99%/RA General: Disheveled thin male in NAD, AO x 3 HEENT: NC/AT, PERRL, EOMI. MM dry, OP clear Neck: supple, no LAD or JVD Chest: CTA-B, no w/r/r CV: RRR s1 s2 normal, [2-25] diastolic murmur loudest at LUSB, no radiation Abd: soft, NT/ND, NABS, no HSM Ext: no c/c/e, wwp Neuro: AO x 2 (person, place, but not time). No asterixis. No focal deficits. Skin: multiple excoriations on extremities Pertinent Results: [2194-6-23] CXR CHF with interstitial edema. Subsegmental atelectasis, without focal consolidation. . [2194-6-24] CT Abdomen and Pelvis W/O Contrast Moderate-to-severe left hydronephrosis, with abrupt transition at the ureteropelvic junction. Although no definite obstructing mass is seen, evaluation is limited due to absence of intravenous contrast. If there is continued clinical concern for obstructing mass, evaluation would be best performed with MR urography. Marked splenomegaly, displacing the left kidney anteromedially. Cardiomegaly, anemia, and evidence of chronic lung disease. . [2194-6-24] Renal U/S Echogenic kidneys consistent with chronic medical renal disease. Massive left hydronephrosis, cause not identified by this study (bladder collapsed about Foley catheter). Differential diagnosis includes a stone or potentially distal tumor. Further evaluation with CT or MR urography would be the next step in evaluation if clinically indicated. Massive splenomegaly. Potential right renal artery stenosis. . [2194-6-24] TTE The left atrium is mildly dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate global left ventricular hypokinesis (ejection fraction 40 percent). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with at least Grade I (mild) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated athe sinus level. The ascending aorta is moderately dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild to moderate ([1-21]+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . [2194-6-25] CTA Chest No pulmonary embolism. Ascending aortic aneurysm. Continuous followup is recommended. Progression of consolidation at the left lung base concerning for aspiration/pneumonia. Nodular opacities in the right upper lobe, one with a small cavity concerning for infection. . [2194-6-25] CT Head No acute abnormality. . [2194-6-23] WBC-2.7* RBC-1.85# Hgb-5.3# Hct-16.1# Plt Ct-78 [2194-6-30] WBC-3.0* RBC-2.52* Hgb-7.7* Hct-22.6* Plt Ct-71* [2194-6-23] Glucose-108* UreaN-150* Creat-12.3# Na-137 K-8.2 Cl-106 HCO3-10* [2194-6-30] Glucose-107* UreaN-59* Creat-6.5# Na-138 K-4.2 Cl-98 HCO3-29 [2194-6-30] ALT-14 AST-21 LD(LDH)-229 AlkPhos-50 TotBili-0.3 [2194-6-30] Albumin-3.1 Calcium-8.0* Phos-4.3 Mg-2.5 [2194-6-24] VitB12-300 Folate-8.6 [2194-6-23] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2194-6-24] HIV Ab-NEGATIVE [2194-6-23] HCV Ab-NEGATIVE . Bone marrow biopsy Immunophenotypic findings consistent with involvement by: a CD5 positive B-cell lymphoproliferative disorder. . Correlation with morphology (see separate report) and other ancillary testing (immunohistochemical stains, cytogenetics etc) is needed for further subclassification. . Pathology consistent with mantle cell lymphoma. Brief Hospital Course: 71 y/o male resistant to medical care who presented with acute renal failure and hyperkalemia. The following issues were addressed during this admission. The patient was initially admitted to the MICU for closer monitoring and transferred to the medical floor prior to discharge to rehab. . 1. Acute Renal failure The pt was admitted to the ICU after he was found to be in severe acute renal failure accompanied by hyperkalemia. U/A was significant for muddy brown casts and FeNa of 8%. In addition, he had large left-sided hydronephrosis secondary to anatomic displacement of the left kidney by an enlarged spleen. No stones or other causes were identified for the obstructive picture. He was initiated on HD on admission for hyperkalemia after a right femoral HD line was placed on [2194-6-23], which improved with one session. He underwent an IR placement of a left percutaneous nephrostomy tube on [2194-6-25] for relief of the hydronephrosis. A tunneled HD cath was placed on [2194-6-27]. Pt will need to have continued HD via the tunneled line that was placed by IR. The pt was followed by the renal team during this admission and will continue to follow the pt at [Hospital 100] Rehab. He will resume a MWF HD schedule upon discharge to [Hospital 100] Rehab. . 2. Pancytopenia/Splenomegaly There was concern for a hematologic malignancy given the leukopenia. Hepatitis viral serologies were negative, parvovirus IgM, and HIV AB's negative. He was transfused during admission. He was also given 1 bag of platelets and 2 doses of dDAVP given his uremic platelets. Hemolysis labs on admission were negative, no evidence of TTP on peripheral smear. Pt had oozing from his temporary HD catheter, tunneled line catheter as well as hematuria which caused no appropriate bump in his hct. He was given DDAVP, plts, and PRBC for blood loss. His oozing from lines resolved eventually and his hct remained stable for 24 hours prior to transfer to the floor. Heme-onc has been following and a bone-marrow bx was performed on [2194-6-25]. In addition, flow cytometry has been sent and is consistent with mantle cell lymphoma. FISH analysis confirmed mantle cell lymphoma. Extensive discussion took place with the pt and his sister regarding the diagnosis. The pt will follow up with Dr. [Last Name (STitle) 2148] in one week for further management of his mantle cell lymphoma. Given that his splenomegaly will not resolve without treatment, his left nephrostomy tube will stay in place until he follows up with urology in 3 months. Rehab will perform routine nephrostomy care. If pt elects to have treatment, it would be 3 or more weeks after discharge. . 3. Lung lesions Patient underwent a CTA on [2194-6-25] to r/o PE as he developed sudden-onset tachycardia and hypoxia. This was negative for PE and his symptoms were likely [2-21] volume overload from blood products. However, the CTA demonstrated nodular opacities in the RUL and opacities in the LUL. This was reviewed the MICU attending who did not feel an active infection was present. He has not had any symptoms of fever, cough, or productive sputum. A sputum cx was also ordered, but the patient has not produced any to give an adequate sample. Given these abnormal findings and the fact that the patient will need chemotherapy, he will likely need a bronch prior to proceeding with treatment for his lymphoma. . # Hematuria - patient developed persistent hematuria with few clots beginning on [2194-6-25] after changing his foley. On [2194-6-28], his foley stopped draining any urine but his bladder scan demonstrated 400 cc, foley did not flush. Blood was noted around the meatus at that time. Foley was removed and changed to a cudet with good drainage. Urology saw the patient and did not have any other additional recs. # Elevated troponin - likely in setting of severe renal failure, CK-MB flat. EKG with [Date Range ], lateral depressions - per PCP, [Name10 (NameIs) ] old. Troponin has remained elevated but stable with repeated sets, no new EKG changes. Patient was started on a low-dose BB. TTE demonstated global hypokinesis, AI, MR, and an EF of 40%. He was also started on an ACE-I. ASA is being held given the thrombocytopenia and dysfunction platelets and oozing blood from lines and hematuria. . # Positive U/A - patient is on day 3 of ciprofloxacin, urine cx grew staph, however without significant growth. His antibiotics were discontinued. . # Capacity - patient was initially sectioned 12 by his PCP as he has been resistant to medical care and there was concern for whether he had capacity to make his decisions. He has been cooperative with all medical treatments since his admission. Psychiatry saw the patient and deemed him to have capacity to make his decisions; however, if he becomes uncooperative with medical treatments, they need to be [Name (NI) 653], as there is some concern whether the patient has full understanding of the situation. His sister is also involved in his care. Social work has also been involved. . # F/E/N - renal diet . # PPx - pneumoboots . # Access - 2 PIV, right femoral HD cath . # Code - FULL . # Communication - [Telephone/Fax (1) 107444] sister, [Name (NI) 107445] [Name (NI) 107446] . # Dispo - to floor as stable Medications on Admission: None Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Renal failure Mantle Cell Lymphoma . Secondary: Hypertension Discharge Condition: The patient was discharged to rehab hemodynamically stable afebrile with appropriate follow up. Discharge Instructions: You were admitted to the hospital for renal failure. You were started on hemodialysis. You were also diagnosed with mantle cell lymphoma after your spleen was found to be very large which was not allowing the urine to drain from your kidney. You were discharged to a rehab center in order to improve your strength and receive dialysis. . Please keep all follow up appointments. They are listed below. You will need to follow up with oncology in 1 week. You will also need to follow up with urology regarding the tube in your back which drains your left kidney. You will also need to follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 1007] in [2-23] weeks. . Please take all medications as directed. Followup Instructions: Please follow up with urology: DR. [First Name (STitle) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 274] Date/Time:[2194-10-2] 9:00 . Please follow up with oncology: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9561], M.D. Phone:[Telephone/Fax (1) 457] Date/Time:[2194-7-8] 9:30 . Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 1007] in [1-21] weeks by calling [Telephone/Fax (1) 10492] for an appointment. . The kidney doctors [Name5 (PTitle) ] [Name5 (PTitle) 788] [Name5 (PTitle) ] at [Hospital 100] Rehab, Dr. [Last Name (STitle) ], while you are having dialysis there. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 10491] MD, [MD Number(3) 10495] Completed by:[2194-7-2] ICD9 Codes: 5845, 2767, 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8061 }	Medical Text: Admission Date: [2141-7-29] Discharge Date: [2141-7-30] Date of Birth: [2083-5-14] Sex: F Service: MEDICINE Allergies: Lorazepam / Ultram Attending:[First Name3 (LF) 99] Chief Complaint: upper GI bleed Major Surgical or Invasive Procedure: endoscopy [2141-7-30] Placement of left femoral central venous catheter [2141-7-30] History of Present Illness: This was a 58F with history of seizure disorder, BPAD, frontal and cerebellar atrophy but no prior history of liver disease or GIB who presented to the ED by ambulance after a syncopal episode at home. She reported having taken zolpidem and then walked to the kitchen. Unclear actual mechanism of fall as patient unable to remember but noted to have blood on her face, which was attributed to striking her face on the sink as she fell. EMS reported observing two possible focal seizures with fixed gaze and arm posturing with incontinence. She has a history of seizures with tramadol in the past but had not taken this in some time. In the ED she had a SBP in the 50s in triage while awake and mentating. 18g IV placed and she received 4L NS with improvement of SBP to 80-90s. She had an episode of stool incontinence with a melena. NG lavage with 1L fluid showed copious coffee grounds that cleared followed by bright red blood. At that point lavage was stopped. Labs notable for Hct 31.7 from a distant baseline of 38 in [2135] and a Cr 1.7 from baseline of 1.1. Head CT was without acute change. She received 1 unit pRBCs in the ED and was started on pantoprazole drip after an 80 mg bolus. A second unit of pRBC's was started just prior to transfer to the ICU. . After arrival to the ICU the patient when asked more about her history noted decreased appetite with early satiety x1 month as well as epigastric pain, which she attributed to her diabetes and reportedly improved with sugar. Her husband endorsed at least one episode of emesis a day, but he was not sure if this was bloody. She endorsed occasional falls, which were a longstanding issue. Of note, patient did endorse taking meloxicam daily for arthritis pain. She denied any abdominal pain at time of arrival to the ICU and denied any heartburn, chest pain, F/C, dizziness, or dysuria. Past Medical History: - Type II DM (not on meds) - HTN - HL - Insomnia - Chronic Gait instability with falls - Cerebellar atrophy - Frontal atrophy - Bipolar disorder - Seizure disorder (not on meds) - Osteoarthritis - Cervical Spondylosis Social History: Retired. Lives separately from husband [Name (NI) 4468]. History of smoking. She denied any EtOH or drug use. Family History: Father with diabetes Physical Exam: At admission: VS: T 96.9 ??????F, HR 65, BP 107/62, RR 23, O2 Sat 100% on RA General Appearance: No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, poor dentition Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: Nl S1 and S2, RRR, no M/R/G, peripheral pulses at radials and DP's present and normal Respiratory / Chest: Clear to auscultation bilaterally with equal chest expansion bilaterally Abdominal: Soft, Non-tender, normoactive bowel sounds, mild tenderness with deep palpation of the epigastrum and RUQ Extremities: Warm and well perfused with no lower extremity edema appreciated Skin: Warm Neurologic: Alert and oriented 3. Responding to questions appropriately. Child-like affect. Pertinent Results: =================== LABORATORY RESULTS =================== At Admission: WBC-13.4 Hgb-10.9* Hct-31.7* MCV-91 RDW-12.9 Plt Ct-349# ----Neuts-60.4 Lymphs-31.9 Monos-4.7 Eos-2.3 Baso-0.7 Glucose-167* UreaN-37* Creat-1.7* Na-137 K-4.6 Cl-97 HCO3-23 PT-12.7 PTT-19.8* INR(PT)-1.1 Lipase-70* Calcium-10.3 Phos-4.8# Mg-2.4 Lactate-2.6 Prior to demise: WBC-9.7 RBC-1.28# Hgb-4.1# Hct-12.1# MCV-94 RDW-14.3 Plt Ct-86 ---PT-28.1* PTT-150* INR(PT)-2.7* Glucose-105* UreaN-13 Creat-0.5 Na-147* K-3.2* Cl-129* HCO3-8* Calcium-3.5* Mg-1.2* ABG: Temp-35.6 pO2-79* pCO2-49* pH-6.98* calTCO2-12* Lactate-7.1* Hct Trend: [2141-7-29] 02:30AM Hgb-10.9* Hct-31.7* [2141-7-29] 10:30AM Hgb-10.9* Hct-31.9* [2141-7-29] 03:30PM Hct-30.2* [2141-7-29] 09:50PM Hct-26.9* [2141-7-30] 02:30AM Hct-25.9* [2141-7-30] 03:44AM Hgb-4.1# Hct-12.1# ============================ RADIOLOGY AND OTHER RESULTS ============================ EKG [7-29]: NSR at 60bpm. LAD, poor R wave progression. TWI in V1, TWF in V2-V3. No prior for comparison. CT head [7-29] FINDINGS: There is no evidence of acute intracranial hemorrhage, discrete masses, mass effect or shift of normally midline structures. The ventricles and sulci are prominent which is not typical for the patient's age, however it is unchanged since [2134-5-3]. There is pronounced cerebellar atrophy bilaterally. No acute fractures are identified. Bilateral mastoid and paranasal sinuses are clear. IMPRESSION: No acute intracranial pathology. CXR [7-29] PORTABLE AP CHEST RADIOGRAPH: Prominence of the right hilum and upper mediastinum may represent technique and rotated position. Both lungs are clear with no focal consolidation, pleural effusion or pneumothorax. Recommend a repeat PA and lateral chest radiograph for further evaluation. The study and the report were reviewed by the staff radiologist. Upper Endoscopy [2141-7-30]: Impression: Immediately upon entering the esophagus there was a large amount of active bleeding obscuring the view. At approx 45cm there was an area without any blood, ?if this was peritoneum, reflecting a massive perforation. Procedure aborted, surgical team at the bedside. Otherwise normal EGD to unknown Brief Hospital Course: 58F with history of seizures and bipolar disorder presenting with syncope, hypotension, melena and coffee grounds on lavage. Patient was admitted to the medical ICU for concern of hematemasis. She was started on a pantoprazole drip and NSAIDs were held. 2 large PIV were placed. As Hct's were initially stable and hemodynamics were stable, endoscopy was initially defered until [7-31]. At approximately 2:30am on [7-30], patient became unresponsiveness, hypotensive, with hematemesis. Palpable pulse, anesthesia called for intubation and then Code Blue called. ETT and OGT and oropharynx with copious blood. PEA arrest. 2 rounds epi, chest compressions, L groin cordis placed by surgery, NS wide open and PRBC running. Regained pulse after ~10-15 minutes down time with MAPs >60. Massive transfusion protocol activated, GI, surgery, IR consulted. R groin Aline placed by MICU attending. Liters of blood continuing pour from OGT and oropharynx. Hypoxemia requiring FiO2 1.0 and PEEP 10 for sats > 90, CXR with ETT in place, no PTX, no obvious free air. acidosis pH 6.85 Ca < assay, PTT>150, INR 5, Progressive massive abdominal distention. Received 22 U PRBC 6 FFP 4 Plt. GI arrived for endoscopy, concerning for perforation; surgery / anesthesia planned to take pt to the OR. While preparing patient for transfer, Aline tracing dampened, pulse initially not palpable ?????? then thready. Repeat episode of massive hemoptysis around yankauer / OGT, decorticate posturing. Decision made at bedside to not initiate CPR and cease further resuscitative efforts; discussed with surgery, nursing, medical housestaff. Communicated with her husband the severe nature of her illness and that further resuscitation would not be performed. PRBC/pressors/Vent D/c??????d and patient died shortly thereafter. Medications on Admission: Medications: - lisinopril 5mg daily - atenolol 25mg daily - niacin 500mg daily - aspirin 81mg daily - ambien 10-20mg QHS - Calcium-Vit D - Mobic 15mg daily - Fish Oil 1000mg caps daily . Allergies: Lidocaine Lorazepam Ultram Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased ICD9 Codes: 5070, 2851, 4275, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8062 }	Medical Text: Admission Date: [2200-2-4] Discharge Date: [2200-2-12] Date of Birth: [2170-12-9] Sex: M Service: Surgical This 59-year-old man with a history of esophagectomy for esophageal cancer, was brought in for repair of an incisional hernia. His past medical history is notable for the above mentioned esophageal cancer, status post no invasive esophagectomy. He does have some underlying lung disease, COPD. He was admitted for routine hernia repair. HOSPITAL COURSE: Patient was admitted, underwent repair of a small incisional hernia. During the operation he was complicated by aspiration and aspiration pneumonitis. The patient was then admitted to the hospital. At that time he was intubated and sedated still on the ventilator. Lungs sounds were coarse, especially at the left base, the abdomen soft and the wounds were fine. An arterial blood gas has shown reasonable oxygenation on the ventilator. He had bilateral patchy infiltrates on chest x-ray, which is consistent with aspiration pneumonitis. He was admitted to the Intensive Care Unit where he was continued on the ventilator with a fever. Antibiotics were not started initially. He had small improvement in his oxygenation and clinical status. He was extubated on [2200-2-6]. He remained on fairly high levels of supplemental oxygen in a face tent. He continued to have fever which was consistent with a lung injury. Because of findings on his gram stain he was placed on vancomycin and cefepime for continued fever. A CT scan of the chest was performed to rule out pulmonary embolism which was negative. He eventually grew out Haemophilus influenzae and E. coli from his sputum and remained on cefepime and the vancomycin was discontinued. He made a slow but steady recovery from this event, continued with physical therapy. He was then discharged on [2200-2-12]. FINAL DIAGNOSIS: 1. Incisional hernia. 2. Aspiration pneumonitis and pneumonia. SURGICAL PROCEDURES: Incisional hernia repair with mesh [2200-2-4]. DISCHARGE MEDICATIONS: Omeprazole, ciprofloxacin, home oxygen. DISPOSITION: Patient discharged. He will go home with services and followed as an outpatient. [First Name11 (Name Pattern1) 333] [Last Name (NamePattern4) 366], [MD Number(1) 367] Dictated By:[Last Name (NamePattern4) 24987] MEDQUIST36 D: [2200-12-31] 12:50:34 T: [2200-12-31] 13:17:54 Job#: [Job Number 67089] ICD9 Codes: 5070
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8063 }	Medical Text: Admission Date: [2182-8-23] Discharge Date: [2182-8-27] Date of Birth: [2112-9-7] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 358] Chief Complaint: bright reg blood per rectum Major Surgical or Invasive Procedure: upper endoscopy colonoscopy History of Present Illness: 69 F w/ DM, HTN, chronic back pain who presented to the ER with c/o BRBPR. She reports that she had 3 seperate episodes of blood associated with her bowel movement this am, present in toilet bowl & not just covering stool. Denies any associated dizziness, diaphoresis, abd. pain, N/V or palpitations. She also denies melena or any hx of BRBPR. She was recently started on Naprosyn 2 months ago, and has been taking 2tabs twice daily for chronic back, hip & ankle pain. . Past Medical History: Diabetes II, oral [Doctor Last Name 360] controlled. Hypertension History of DVT in [2170] TAH-BSO Depression Social History: Lives in [Location 686]. 3 daughters, is primary caretaker for a daughter with cerebral palsy. No EtOH, no tobacco, no illicits. Originally from Mobile, [State 9512], married. Family History: Noncontributory. Physical Exam: Afebrile, mildly hypertensive but otherwise normal vitals signs including sat greater than 90% on room air Gen -- very pleasant black female in NAD HEENT -- unremarkable Heart -- regular Lungs -- clear Abd -- soft, nontender, nondistedend with appropriate bowel sounds Ext -- no edema, lesion or rash Pertinent Results: [2182-8-27] 06:40AM BLOOD WBC-6.3 RBC-3.76* Hgb-11.2* Hct-31.9* MCV-85 MCH-29.9 MCHC-35.2* RDW-15.4 Plt Ct-188 [2182-8-23] 01:25PM BLOOD WBC-6.9 RBC-3.97* Hgb-11.5* Hct-32.4* MCV-82 MCH-29.0 MCHC-35.5* RDW-15.2 Plt Ct-232 [2182-8-27] 06:40AM BLOOD Glucose-129* UreaN-5* Creat-0.6 Na-142 K-3.6 Cl-106 HCO3-26 AnGap-14 Brief Hospital Course: 1. bright red blood per rectum -- Admitted to [Hospital Unit Name 153], with gastroenterology consultation. Hematocrit remained stable in the low 30% range, although she had several heme positive stools in the first 24 hours of admission. She had fluid resucitation but was not hypotensive or orthostatic. She did not require transfusion. She was transferred to the hospital medicine service on 12 [Hospital Ward Name 1827], and underwent colonoscopy and endoscopy Monday, [8-26]. Please see the procedure reports for details of each. Briefly, endoscopy was normal throughout, and colonoscopy showed diverticulosis with one diverticulum with some inflammation and clot formation, likely the culprit of the gastrointestinal bleed. 2. hypertension -- home medications were held until after evaulation with endoscopy and colonoscopy. She remained mildly hypertensive throughout her stay, which improved with reinitiation of home medications. 2. diabetes mellitus II -- She was managed on sliding scale insulin and scheduled accuchecks. Home medications were reinitiated prior to discharge without difficulty. 3. chronic back pain -- Ms. [Known lastname 13461] is regularly followed by an orthopedic surgeon for chronic lumbar back pain, and used NSAIDs as well as Percocet prior to admission for GI bleed. She was advised to discontinue use of NSAIDs, use Tylenol and Percocet prn for pain. Medications on Admission: ASPIRIN 81MG--One by mouth every day ATENOLOL 150 mg daily GLUCOPHAGE 1000 mg qam, 500mg at noon, 1000mg qpm GLYBURIDE 10MG twice a day HYDROCHLOROTHIAZIDE 25 mg daily MOEXIPRIL HCL 30 mg daily MULTIVITAMINS PERCOCET 5 mg-325 mg q 8 hours as needed for pain RANITIDINE HCL 150 mg twice a day . Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:30 Capsule(s) Refills:0 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): ** this is a new medication, meant to replace ranitidine. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Atenolol 100 mg Tablet Sig: 150 mg Tablets PO once a day. 7. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: gastrointestinal bleeding, likely from a diverticulum diabetes mellitus type II hypertension Discharge Condition: stable, without continued bleeding, tolerating a full diet Discharge Instructions: You were hospitalized with gastrointestinal bleeding, most likely from a diverticulum. You should continue to watch for blood in your stool, and call your doctor or return to the hospital if you experience more bleeding, have abdominal pain, fever greater than 101, or any other concerns. Avoid NSAIDs (including Motrin, aspirin, ibuprofen, naproxen or medications including those names). You can continue to take Percocet and tylenol, but do not exceed 4000 mg of acetaminophen (Tylenol) in 24 hours. You can resume taking your baby aspirin in 10 days. Followup Instructions: Provider: [First Name11 (Name Pattern1) 177] [Last Name (NamePattern4) 5500], M.D. Phone:[Telephone/Fax (1) 1228] Date/Time:[2182-8-28] 2:15 Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2182-8-29] 8:50 Provider: [Name10 (NameIs) 13978] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2182-8-29] 9:10 Provider: [Name10 (NameIs) 100045], [Name11 (NameIs) 2048] (primary care provider) [Telephone/Fax (1) 250] on [9-4] at 8:30 AM. ICD9 Codes: 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8064 }	Medical Text: Admission Date: [2112-11-8] Discharge Date: [2112-11-21] Date of Birth: [2039-7-28] Sex: F Service: VASCULAR SURGERY CHIEF COMPLAINT: Cellulitis, dorsum of the left foot and anterior shin. HISTORY OF THE PRESENT ILLNESS: The patient is a 73-year-old nondiabetic white female with CAD, status post MI in [10-30], hypertension, hypercholesterolemia, steroid-dependent COPD, who developed mild cellulitis over the dorsum of her left foot and lower shin ten days prior to admission. Over the previous four days the cellulitis has worsened in spite of being on Keflex. The patient denied fevers, chills, nausea, or vomiting. The patient returned to see Dr. [Last Name (STitle) ] in the office and was admitted for further evaluation and treatment. PAST MEDICAL HISTORY: 1. CAD: Non-ST elevation MI in [2111-10-30]. 2. Hypertension. 3. Hypercholesterolemia. 4. Asthma/emphysema, steroid-dependent. 5. Peptic ulcer disease. 6. Osteoporosis. 7. Osteoarthritis. PAST SURGICAL HISTORY: 1. Right total knee replacement. 2. Laminectomy in [2107]. FAMILY HISTORY: Mother had hypertension, arrhythmia, and died of a stroke at the age of 89. Father had asthma and died of a stroke at age 69. One sister is living. Three brothers are deceased. SOCIAL HISTORY: The patient lives in senior housing. She uses a walker, a wheelchair, or scooter for ambulation. She has a 150 pack year smoking history. She quit tobacco several years ago. She has not used alcohol since [2095]. The patient is a psychiatrist. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Prednisone 5 mg p.o. q. 48 hours. 2. Prednisone 6 mg p.o. q. 48 hours. 3. Enalapril 5 mg p.o. q.d. 4. Estratest 0.625 mg p.o. q.d. 5. Prilosec 20 mg p.o. q.d. 6. Atrovent. 7. Albuterol. 8. Niacin 500 mg p.o. b.i.d. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.4, pulse 70, respirations 18, blood pressure 176/91, 02 saturation equals 97% on room air. General: Alert, cooperative white female in no acute distress. Chest: Lungs clear bilaterally. Heart: Regular rate and rhythm without murmur. Abdomen: Soft, nontender, nondistended. Extremities: Dorsum of left foot and lower shin cellulitic. No ulcerations. Pulse examination: Radial, femoral pulses are palpable bilaterally. Popliteal pulses are nonpalpable. Right pedal pulses-exam not noted. Left dorsalis pedis has no Doppler signal. Left PT pulse has a Doppler signal. LABORATORY/RADIOLOGIC DATA: WBC 14.1, hemoglobin 14.8, hematocrit 46.3, platelets 232,000. PT 12.6, PTT 26.6, INR 1.1. Sodium 140, potassium 4.4, chloride 100, bicarbonate 32, BUN 23, creatinine 1.0, glucose 97. Calcium 9.3, phosphorus 3.5, magnesium 1.7. The urinalysis was negative. Chest x-ray showed severe upper lobe bullous emphysema and a large hiatal hernia. No acute pulmonary disease. X-ray of the left foot showed no focal destruction, periosteal reaction, or radio-opaque foreign body. No subcutaneous emphysema. EKG showed a normal sinus rhythm at a rate of 79 with premature ventricular contractions and supraventricular extrasystole. Right bundle branch block complete since previous tracing and new left anterior fascicular block. HOSPITAL COURSE: The patient was admitted to the hospital on [2112-11-8]. She was started on vancomycin, levofloxacin, and Flagyl. Cardiology was consulted for preoperative clearance. They recommended a Persantine MIBI study preoperatively, increasing the patient's Enalapril from 5 mg p.o. q.d. to b.i.d., and also starting a statin after lipid profile. The patient underwent a left lower extremity angiogram via a right femoral approach on [2112-11-9] by Dr. [Last Name (STitle) ]. Postoperatively, the patient had a right groin hematoma. Pressure was held approximately 45 minutes in total and the hematoma resolved. On the following day, while the patient was out of bed to chair, the patient started to bleed from the right groin puncture site again. This was resolved with holding pressure. The patient's Persantine MIBI study was normal with an ejection fraction of 63%. The Cardiology Service cleared her for surgery. The patient was reluctant to start a statin without first consulting her local cardiologist, Dr. [Last Name (STitle) 103712] and this was deferred. On [2112-11-15], the patient underwent a left femoral to popliteal bypass graft with nonreverse saphenous vein. Postoperatively, she had a palpable left anterior tibial pulse. Immediately postoperatively, the patient had an episode of hypotension which was treated with an IV fluid bolus. The patient developed some oozing from her left groin incision. Her hematocrit was 26 with a PTT of 150. The patient received several units of fresh frozen plasma, packed red blood cells, and lactate Ringer's solution. On postoperative day number one, [2112-11-16], the patient was brought to the Operating Room again for evacuation of left thigh hematoma. Postoperatively, she was treated with fresh frozen plasma and DDAVP (desmopressin), for oozing which was successful. On [2112-11-17], the Hematology Service was consulted regarding the patient's apparent coagulopathy which had been successfully treated with the fresh frozen plasma and DDAVP. After reviewing the [Hospital 228] medical records, it appeared that the patient had an episode of a right groin hematoma following her cardiac catheterization in [2111-10-30]. After careful review, it appeared that the patient was extremely sensitive to heparin. After stopping all heparin, the patient's coagulations returned to [Location 213]. On [2112-11-17], Cardiology was reconsulted because the patient had developed extrasystoles which had also occurred preoperatively. Cardiology started the patient on Diltiazem 30 mg q.i.d. and recommended titration to keep the heart rate less than 100. They also noted that the patient was 9.5 liters up and 8 kilograms up from her preoperative weight. they recommended gentle diuresis with Lasix and keeping her hematocrit greater than 30. The patient was again transfused for a hematocrit of 27. Post transfusion hematocrit was 34. The patient's Diltiazem was titrated to keep the heart rate less than 80 and systolic blood pressure greater than 100 with Diltiazem SR 120 mg p.o. q.d. The patient will follow-up with her local cardiologist, Dr. ..................... At the time of dictation, the patient's left leg incision is clean, dry, and intact. She has a palpable graft. The cellulitis had improved. She had been ambulating with physical therapy who suggested a [Hospital 3058] rehabilitation stay. The patient will be discharged to [Hospital 3058] rehabilitation on two more weeks of levofloxacin. She will follow-up with Dr. [Last Name (STitle) ] in the office for surgical staple removal in two weeks. DISCHARGE MEDICATIONS: 1. Levofloxacin 500 mg p.o. q.d. times two more weeks. 2. Prednisone 5 mg p.o. q. 48 hours. 3. Prednisone 6 mg p.o. q. 48 hours. 4. Enalapril 5 mg p.o. b.i.d. 5. Diltiazem SR 120 mg p.o. q.d., hold for systolic blood pressure less than 110 and heart rate less than 55. 6. Aspirin 81 mg p.o. q.d. 7. Omeprazole 20 mg p.o. b.i.d. 8. Multivitamin one p.o. q.d. 9. Niacin SR 500 mg p.o. b.i.d. 10. Risedronate 35 mg p.o. q. week. 11. Pulmicort .................... three puffs inhalation b.i.d., the patient taking own medications. 12. Estratest h.s. one tablet p.o. q.d., patient taking own medication. 13. Calcium carbonate 500 mg p.o. b.i.d. 14. Albuterol one to two puffs q. six hours p.r.n. 15. Ipratropium MDI two puffs q.i.d. 16. Percocet one to two tablets p.o. q. four to six hours p.r.n. 17. Glycerine suppositories one per rectum p.r.n. 18. Miconazole powder 2% one application topically p.r.n. CONDITION ON DISCHARGE: Satisfactory. DISPOSITION: To [Hospital 3058] rehabilitation facility. PRIMARY DIAGNOSIS: 1. Ischemic infected right leg. 2. Left femoral to popliteal bypass graft with nonreverse saphenous vein on [2112-11-15]. SECONDARY DIAGNOSIS: 1. Postoperative left thigh hematoma: Evacuation left thigh hematoma on [2112-11-16]. 2. Post angio right groin hematoma, resolved. 3. Extreme sensitivity to heparin causing prolonged coagulopathy; treated with fresh frozen plasma and DDAVP. 4. Blood loss anemia, status post multiple transfusions. 5. Steroid-dependent chronic obstructive pulmonary disease. 6. MAT: Treatment with medication initiated. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], M.D. [MD Number(1) 6223] Dictated By:[Last Name (NamePattern1) 3954] MEDQUIST36 D: [2112-11-21] 02:57 T: [2112-11-21] 16:44 JOB#: [Job Number 103713] ICD9 Codes: 2851, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8065 }	Medical Text: Admission Date: [2116-7-27] Discharge Date: [2116-8-6] Date of Birth: [2040-11-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4153] Chief Complaint: chest discomfort, dyspnea Major Surgical or Invasive Procedure: Intubated [Date range (1) 11879] Central line placed Dialysis History of Present Illness: 75 y/o male with HTN, DM2, CAD s/p PCI to distal RCA with Cypher stent([2116-4-28]), ESRD on HD, presented for HD and had SSCP. In the ED, during procedure to place central line, he was put into trendelenburg and he became dyspneic, with desat and required intubation. He was dialyzed and became hypotensive, briefly required dopamine. Transferred to CCU for management of decompensated CHF. Past Medical History: 1. HTN 2. DM2 (IDDM, triopathy) 3. Nephrolithiasis, s/p bilateral ureteral stents in [2110] 4. ESRD on HD (M,W,F) since [2114-12-16] 5. Atrophic L kidney 6. Possible sarcoidosis (Liver biopsy c/w granulomatous hepatitis, bilat hilar mediastinal adenopathy, LUL scarring) 7. h/o infected R IJ permacath s/p removal [1-17] 8. L forearm AVG [1-17] 9. OA Left knee, back 10. Recurrent UTIs Social History: Haitian immigrant. Denies alcohol, smoking, or drug use. Married to second wife. Family History: non-contributory Physical Exam: Vitals Stable and afebrile. Intubated and sedated. Bleeding from mouth and puncture sites. Good air entry bilaterally. Heart tahcycardic without murmurs, extra heart sounds, or rubs. Abdomen with good bowel sounds, soft, NT, ND, no organomegaly. Extremities cool with weak distal pulses. Neuro exam limited by sedation. Pertinent Results: Admission Labs: [2116-7-27] 12:30PM WBC-11.3* RBC-3.93* HGB-13.4* HCT-40.2 MCV-103* MCH-34.1* MCHC-33.3 RDW-14.5 [2116-7-27] 12:30PM NEUTS-71.6* LYMPHS-20.4 MONOS-5.7 EOS-1.9 BASOS-0.4 [2116-7-27] 12:30PM PLT COUNT-275 [2116-7-27] 12:30PM PT-12.2 PTT-27.2 INR(PT)-1.0 [2116-7-27] 12:30PM GLUCOSE-359* UREA N-42* CREAT-7.8# SODIUM-119 POTASSIUM-7.3* CHLORIDE-81* TOTAL CO2-22 ANION GAP-23* [2116-7-27] 04:11PM K+-6.6* [2116-7-27] 04:11PM TYPE-ART PO2-375* PCO2-44 PH-7.31* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED [2116-7-27] 07:15PM LACTATE-2.6* [2116-7-27] 07:15PM TYPE-ART PO2-128* PCO2-53* PH-7.33* TOTAL CO2-29 BASE XS-1 INTUBATED-INTUBATED [2116-7-27] 08:28PM PT-15.6* PTT-150* INR(PT)-1.7 [2116-7-27] 08:28PM WBC-18.0# RBC-3.94 HGB-13.5* HCT-39.8* MCV-101* MCH-34.3* MCHC-34.0 RDW-14.5 [2116-7-27] 08:28PM PLT COUNT-274 [2116-7-27] 12:30PM CK-MB-6 cTropnT-0.06* [2116-7-27] 08:28PM CK-MB-7 cTropnT-0.25* [2116-7-27] 08:28PM ALT(SGPT)-65* AST(SGOT)-46* CK(CPK)-232* ALK PHOS-245* TOT BILI-0.7 [2116-7-27] 08:28PM GLUCOSE-181* UREA N-24* CREAT-5.1# SODIUM-134 POTASSIUM-4.1 CHLORIDE-92 TOTAL CO2-21* ANION GAP-25* [2116-7-27] 10:52PM FIBRINOGE-491* [2116-7-27] 10:52PM PT-13.8* PTT-60.9* INR(PT)-1.3 [2116-7-27] 11:57PM CORTISOL-27.8* [2116-7-28] CT ABD and Pelvis IMPRESSION: 1. Findings consistent with right lower lobe pneumonia. There are also bilateral pleural effusions 2. There are bilateral hilar lymphadenopaties, which is increased in size when compared to [2113]. Largest lymph node in the right hilum measures 1.7 x 1.7 cm. At minimum this requires follow up, since possibility of lymphoma or metastatic malignancy cannot be excluded. 3. Multiple mesenteric and retroperitoneal lymphnodes. 4. Bilateral renal stones (right greater than left without evidence of hydronephrosis). The stones on the right are probably unchanged when compared to the prior study. 5. No intraabdominal abscess is identified. 6. Mild thickening of the colon is likely due to collapsed colon, but possibility of mild colitis cannot be excluded. Echo([2116-7-28]): Ejection Fraction: 20% to 25% moderate symmetric left ventricular hypertrophy severe global left ventricular hypokinesis with some preservation of basal posterior wall motion Overall left ventricular systolic function is severely depressed [2116-8-1] CT Head IMPRESSION: 1. No evidence of intracranial hemorrhage or edema. 2. Findings consistent with chronic small vessel ischemic changes and cerebral atrophy. [2116-8-3] LENIS IMPRESSION: No acute deep vein thrombosis. Likely subacute or chronic thrombus inhibiting wall to wall blood flow within the right superficial femoral vein. [2116-8-3] VQ Scan IMPRESSION: low likelihood ratio for recent pulmonary embolism. Brief Hospital Course: 75 y/o male came into hospital because of need for dialysis. Complained of substeranl chest pain and was sent to the emergency room where he was placed in trendelenberg to have central line placed. During procedure had severe dyspnea and desaturation requiring intubation. Admitted to CCU service where he was emergently dialysed for elevated potassium and volume overload. While on dialysis he became hypotensive and shortly developed a fever. He was found to have a right lower lobe pneumonia for which he was started on antibiotic treatment. In the CCU he was dialysed and volume status was watched closely as he was known to have both systolic and diastolic cardiac dysfunction. He was shortly extubated and after several sessions of dialysis was stable for transfer to step down floor. Throughout his stay he had periods of sinus tachycardia, of which the cause was not discovered. He continued to have tachycardia on the step down floor and so work up for PE was undertaken. Evidence of chronic, non-occlussive clot in superficial femoral vein was found on doppler of legs, but VQ scan showed low probability of pulmonary embolus. His workup for sinus tachycardia was negative and he eventually was discharged with without tachycardia, on coumadin for prevention of PE, with follow up of his INR, regularly scheduled diayisis, and follow up with a cardiologist. Medications on Admission: Per OMR records Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:5 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:5 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:5 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:5 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:5 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:5 7. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:5 9. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 10. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:60 Tablet(s) Refills:0 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:7 Tablet(s) Refills:0 13. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) 23 units Subcutaneous once a day. 14. Outpatient Lab Work Check PT, PTT, INR. The pt is taking Coumdain. Please have results reviewed by a nurse practitioner [First Name (Titles) ] [Last Name (Titles) 11880]n at Dr.[Name (NI) 11881] clinic Discharge Disposition: Home With Service Facility: [Hospital1 ] Family & [Hospital1 1926] Services Discharge Diagnosis: Decompensated CHF Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Less than 1.5L total daily of juices, water, soda Pls take all meds as prescribed Resume dialysis on Friday [8-7]. Pls call dialysis center to confirm. . Please make sure to check your blood sugar 4 times a day. If your blood sugar is low and does not rise with taking [Location (un) 2452] juice, please call your doctor. Followup Instructions: Saturday, [8-8] Come in during the morning(before 1pm) to have your blood check, since you started coumandin. Sister [Name (NI) ], NP at [Hospital1 7975] ST. INTERNAL MEDICINE Phone:[Telephone/Fax (1) 7976]. . [8-12] 2:30 with Sister [Name (NI) ], NP at [Hospital1 7975] ST. INTERNAL MEDICINE Phone:[Telephone/Fax (1) 7976]. . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10134], MD Where: [Hospital1 7975] INTERNAL MEDICINE Phone:[Telephone/Fax (1) 7976] Date/Time:[2116-9-2] 2:00 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD Where: LM [Hospital Unit Name 3126] CENTER Phone:[Telephone/Fax (1) 673] Date/Time:[2116-9-17] 2:00 . Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] TRANSPLANT SOCIAL WORK Where: TRANSPLANT SOCIAL WORK Date/Time:[2116-9-17] 3:00 [Name6 (MD) ] [Last Name (NamePattern4) 4156] MD, [MD Number(3) 4157] Completed by:[2116-9-11] ICD9 Codes: 4280, 486, 4240, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8066 }	Medical Text: Admission Date: [2176-10-14] Discharge Date: [2176-10-17] Date of Birth: [2119-6-11] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) / Penicillins / Ivp Dye, Iodine Containing / Latex / Codeine / Tylenol/Codeine No.3 / Vancomycin Attending:[First Name3 (LF) 2777] Chief Complaint: right leg infection Major Surgical or Invasive Procedure: right below knee guillotine amputation [2176-10-16] History of Present Illness: 57 F with c/o one week of foot pain and distal wound, purulence out of medial and lateral malleoli Past Medical History: ESRD: on hd x5 years, not able to recall what it is due to, tunnelled rij placed with transplant surgery [1-22], HD t/t/sat Congestive heart failure - last tte [2171] with ef 65% Type II diabetes Hypertension Paranoid schizophrenia/delusions s/p right tmt amputation Social History: She lives with her husband and her son. Retired high school teacher. She denies alcohol, tobacco, or recreational drugs. Family History: DM Physical Exam: Deceased Pertinent Results: [2176-10-16] 11:20PM BLOOD WBC-40.0* RBC-3.06* Hgb-9.5* Hct-35.1* MCV-115* MCH-31.2 MCHC-27.2* RDW-19.1* Plt Ct-147* [2176-10-16] 08:30AM BLOOD Neuts-73* Bands-6* Lymphs-8* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-3* NRBC-23* [2176-10-16] 08:30AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-NORMAL Polychr-2+ Spheroc-1+ Burr-2+ [2176-10-16] 11:20PM BLOOD PT-43.3* PTT-150* INR(PT)-4.6* [2176-10-16] 02:52PM BLOOD Glucose-98 UreaN-40* Creat-5.2* Na-150* K-4.3 Cl-94* HCO3-10* AnGap-50* [2176-10-16] 11:20PM BLOOD ALT-330* AST-1369* CK(CPK)-1598* AlkPhos-321* TotBili-1.0 [2176-10-16] 11:29PM BLOOD Type-ART pO2-113* pCO2-32* pH-6.99* calTCO2-8* Base XS--23 [2176-10-16] 11:29PM BLOOD freeCa-1.47* [2176-10-14] 4:15 pm SWAB Site: ANKLE RIGHT ANKLE. GRAM STAIN (Final [2176-10-14]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [2176-10-17]): SERRATIA MARCESCENS. HEAVY GROWTH. STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE. SERRATIA MARCESCENS \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Brief Hospital Course: Pt admitted for pedal sepsis. Stat antibiotics were intiated. The team recommend a stat guillatine amp. Pt refused. A psych consult was obtained. cxs taken. Psychiatry met patient and concluded that patient was not able to make decisions in her own best interest at this time. The family was notified. No health care proxy. The [Hospital1 18] lawyer was notified. The process was begun to make son the health care proxy to make medical decisions. [First Name8 (NamePattern2) 714] [Last Name (NamePattern1) 9449] from [Hospital1 1388] legal department notified. A Social consult was obtained. SW began to coordinate Guardianship information sheet and [Name (NI) ] signatures from patient's son. SW then met with patient's two [Initials (NamePattern4) ] [Last Name (NamePattern4) ] and Rowan who have agreed to be co-guardians and had them sign the [Last Name (NamePattern4) ] necessary to begin court proceeding for emergency guardianship. Am rounds nurse [First Name (Titles) 13431] [Last Name (Titles) 98435] breathing and lethargy. Pt only responded to painfull stimuli. Anesthesia was called to intubate patient. Anesthesia intubated patient. Transfered to the CVICU. Family notified. Family agreed to stat guillatine AMP. Pt taken emergently to the OR for Right pedal sepsis. Guillotine right below-the-knee amputation was performed. No intra op complications. Pt then transfered to the CVICU. There it was noticed that the pt abd distention. A general surgery consult was obtained. Bladder pressures, NPO/IV resuscitation. Serial labs were drawn. Multisystem organ failure from sepsis occured. Pt put on multiple pressors. Family notified. Made CMO. Pt deceased shortly aferwards. Medications on Admission: Norvasc 5', Sevelamer 800''', Tylenol, Aspirin, Minopehn [Telephone/Fax (1) 1999] PRN, Colace, NPH, Hexavitamin, Senna Discharge Medications: [Male First Name (un) ] - deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased Completed by:[2176-10-17] ICD9 Codes: 0389, 5856, 2762, 4280, 4240, 3572
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8067 }	Medical Text: Admission Date: [2146-12-9] Discharge Date: [2146-12-13] Date of Birth: [2084-12-7] Sex: F Service: NEUROLOGY Allergies: Aspirin / Cephalexin / Hydromorphone / Ativan Attending:[First Name3 (LF) 618] Chief Complaint: Right sided weakness, ?seizure Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [Known lastname ] is a 62 year old woman with a history of a left cea one week ago for an asymptomatic 90% stenosis. She was doing well until yesterday afternoon when she had the sudden onset of rt sided weakness and right sided "twitching" both in the arm alone. By report she was responding normally when EMS arrived but began to have slurred speech and declining alertness enroute. At OSH she had myoclonic jerks of the right arm and was given 5mg valium, 200mg PB, and 1gm PHT. She was transferred to [Hospital1 18], paralyzed and intubated on propofol. Overnight she was extubated and noted to be confused and unable to speak. Past Medical History: Hypertension, coronary artery disease with an MI in [2139], angioplasty with stent placement to the right coronary artery in [2139], a second MI in [2144], with a re-stenting of the right coronary artery at that time. Social History: +smoker, no hx of EtOH or drug use Family History: N/C Physical Exam: General Exam: Vitals: afebrile BP: 150/70s P: 90s R: 12 Gen: obese, distraught Head: NC/AT, non-icteric, MMM, equal pulses Neck: supple, left CEA scar, no carotid bruits CV: nl S1, S2 regular Ext: no edema nor rashes Neurological Exam: Mental Status: Awake, alert, and attentive. Non fluent aphasia with little comprehension and impaired repetition that fits technical criteria for global aphasia but with more comprehension than usually. Tries to repeat but unable. Sparse output. Perseverative. Says "Scared" repeatedly. 50% midline commands, <25% axial. Cranial Nerves: II. visual fields intact to threat. pupils normal, round and reactive to light, no rAPD III, IV, VI. Extraocular movements intact and without nystagmus, V, VII. Normal facial sensation. No facial droop. Strength full and symmetric. VIII. Hearing intact to voice bilaterally IX, X, XII. Normal oropharyngeal movemement. Tongue midline without fasciculations. Sternocleidomastoid and trapezius normal bilaterally Motor: Left side with full strength but motor impersistance. repeatedly extends left arm and hand toward examiner or railing and often lifts left leg in the process. Left arm with 4 to 4+/5 range UMN weakness, Left leg sustained antigravity Appears to have either proprioceptive difficulty or motor planning problems. Sensory: grossly intact Reflexes: Tri [Hospital1 ] Br Pat Ach Toes L 2 2 2 2 0 down R 3 3 3 3 0 down Pertinent Results: [2146-12-9] 01:05PM BLOOD WBC-17.9# RBC-4.47# Hgb-13.7 Hct-41.8# MCV-93 MCH-30.7 MCHC-32.9 RDW-13.0 Plt Ct-434# [2146-12-13] 04:45AM BLOOD WBC-11.8 RBC-4.15* Hgb-12.8 Hct-37.7 MCV-91 MCH-30.8 MCHC-33.9 RDW-13.4 Plt Ct-353 [2146-12-9] 01:05PM BLOOD PT-13.1 PTT-28.4 INR(PT)-1.1 [2146-12-9] 01:05PM BLOOD Glucose-237* UreaN-12 Creat-0.8 Na-142 K-3.8 Cl-99 HCO3-34* AnGap-13 [2146-12-10] 04:27AM BLOOD ALT-36 AST-22 LD(LDH)-264* AlkPhos-97 Amylase-69 TotBili-0.4 [2146-12-10] 04:27AM BLOOD Lipase-41 [2146-12-10] 04:27AM BLOOD %HbA1c-5.8 [2146-12-10] 04:27AM BLOOD Triglyc-115 HDL-68 CHOL/HD-2.9 LDLcalc-103 [2146-12-13] 04:45AM BLOOD Phenyto-11.5 [2146-12-9] 01:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Stool: positive for C. dif toxin Urine Cx: positive for proteus and E. coli Brief Hospital Course: 62 yo s/p endarterectomy last week for 90% stenosis of left ICA who presents to the ED after acute right sided weakness followed by accounts of shaking of the RUE. She was given large doses of valium, phenobarb, and dilantin at an OSH and was intubated in the [Hospital1 18] ER for airway protection. Was extubated, transfered to floor [12-10]. Head CT showed evidence of subacute left frontal infarct which likely served as the focus for her seizure. CTA demonstrated patent cervical and intracranial vasculature. EEG showed intermittent low amplitude sharp activity seen over the left centro-temporal region confirming an area of focal irritability which may have led to her seizure. She was loaded with dilantin and levels were therapeutic at the time of discharge. Dilantin will be continued for the next six months. She has remained seizure free during her hospitalization. She was continued on Plavix for secondary stroke prevention (has asa allergy). She had a carotid duplex which showed less than 40% stenosis right extracranial internal carotid artery, no significant stenosis was seen in the left extracranial internal carotid artery. Echocardiogram was done to r/o cardioembolic source. It showed no cardiac source of embolus. On admission she was noted to have an elevated WBC. She was found to have a UTI with cultures positive for both P. mirabilis and E. coli. Her stool was also positive for C. diff. She was started on Levofloxacin and Flagyl and will finish 7 and 14 day courses, respectively, of these antibiotics. Vascular surgery evaluated her with regard to her recent CEA and felt that she was healing well. Her exam improved over the course of her admission, no aphasia, mild right sided weakness and ataxia. She will be discharged with primary care, vascular surgery and neurology follow up appointments. She will also have outpatient PT/OT to improve right UE mobility. Medications on Admission: protonix [Doctor First Name 130] xanax 0.5 prn lescol 80 avapro 300 Discharge Medications: 1. Fluvastatin Sodium 20 mg Capsule Sig: Four (4) Capsule PO qd (). Disp:120 Capsule(s) Refills:2 2. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO qd (). Disp:30 Tablet(s) Refills:2 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:10 Tablet(s) Refills:0 4. 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 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 12 days. Disp:90 Tablet(s) Refills:2 9. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:90 Capsule(s) Refills:2 10. Dilantin 30 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 11. Occupational Therapy Sig: One (1) as needed: S/P acute stroke, please do OT to improve right upper extremity function. Disp:1 1 Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 537]- [Location (un) 538] Discharge Diagnosis: 1. Seizure 2. Stroke -left frontal lobe infarct 3. HTN 4. C. diff colitis 5. Urinary tract infection-Proteus and E. coli Discharge Condition: Stable: Right UE weakness and ataxia. Discharge Instructions: Please follow up with Dr. [Last Name (STitle) ] next week. Please take your medication as directed. You will need to be on dilantin for six months for seizure prevention. You cannot drive for the next six months. You will take two antibiotics: Levofloxacin and Flagyl. You should take the Levofloxacin for 4 more days (to complete 7 days) and the Flagyl for 12 more days (to complete 14 days). Followup Instructions: 1. Dr. [Last Name (STitle) ] ([Telephone/Fax (1) 42057]. Have bloodwork done next week to check dilantin level. The target dilantin level is [1-20]. Please have your blood pressure checked. You will also need a repeat UA and Urine culture after you have completed the course of antibiotics. 2. [Hospital ] CLINIC: Dr. [Last Name (STitle) 7994]/ Dr. [Last Name (STitle) ]. ([Telephone/Fax (1) 8951] TIME: [3-12] at 1:00PM. WHERE: [Hospital Ward Name 23] Bldg 3. Outpatient Occupational Therapy [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 5990, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8068 }	Medical Text: Admission Date: [2107-6-3] Discharge Date: [2107-6-9] Service: MEDICINE Allergies: Univasc Attending:[First Name3 (LF) 5755] Chief Complaint: vomiting, hemoptysis Major Surgical or Invasive Procedure: fluoro-guided PICC placement History of Present Illness: [Age over 90 ] yo G6P2 woman, with recent history of endometrial cancer diagnosed on exploratory laparotomy with bilateral salpingo-oophorectomy on [5-13] and discharged to [Hospital3 2558] on [5-23], presents with vomiting undigested food, hematemesis vs hemoptysis, and confusion. The patient had been doing well at rehab until yesterday per notes and her report. She tells me that she vomited yesterday; per records sent with her, it appears as though the patient vomited undigested food and then had episodes of "spitting up blood-tinged sputum." She had one episode of coughing up bright red blood. Per report, her initial blood pressure was in the 60s systolic. The patient's mental status had been improving since her discharge, but today she was noted to be more confused and less oriented. . In the ER, the patient had abdominal imaging which showed ileus without obstruction. She was evaluated by both the General Surgery and the Gyn-Onc teams. She had an NG lavage with small amounts of pink fluid which cleared; she was guaiac positive on rectal exam per ER exam but remained hemodynamically stable throughout her ED course. She was transfused with 2 U PRBCs as well as 2 U FFP for INR 3.4. Repeat Hgb at 0100 was 32.6 from 25.8. She also received 1 L NS. Head CT was without bleed or mass effect. She was also evaluated by the GI team. . In the ED, she was also found to have a right middle lobe pneumonia in conjunction with WBC count of 13.8 (92% neutrophils). She was treated with one dose of levofloxacin. Blood cultures were sent and are pending. . At the present time, the patient denies abdominal pain. She cannot remember exactly why she was brought to the hospital; she does remember that she vomited "yesterday" and that she has been feeling poorly since that time though she cannot elaborate. She denies cough, chest pain, coughing up blood, and shortness of breath. She cannot tell me whether or not she has been having bowel movements or whether her abdomen is distended. Past Medical History: PMHx: * Endometrial carcinoma with torsion - s/p exploratory lapartomy, bilateral salpino-oophorectomy, and bowel disimpaction on [5-13] complicated by postoperative delirium * Partial SBO (admission [5-7]) thought due to mechanical obstruction from ovarian mass (now s/p removal) * Catheter-associated DVT (R IJ) * Coronary artery disease, status post MI in [2070]. * Hypertension. * Breast cancer [2061], status post right radical mastectomy. * Iron deficiency anemia, baseline HCT 36-39 * Diverticulosis. * Carpal tunnel syndrome. * Osteoarthritis. * Chronic Renal Insufficiency (baseline 1.5-1.7 --> GFR 30cc/min) . PSH: 1. Appendectomy 2. Right radical mastectomy 3. Cone biopsy 4. [2107-5-13] ex lap/BSO/bowel disimpaction for endometrial Ca Social History: She is widowed and previously lived alone. Prior to recent admission was able to take care of self overall: was ambulating, toileting, dress. No history of alcohol use. She has smoked two packs per week for over sixty years. >120 pkyr hx. Has several children, all except one lives in state. Recently was discharged to [Hospital3 2558] on [5-23]. Family History: Mother lived to age [Age over 90 ]. Otherwise unknown. Physical Exam: PE: T 99.6 BP 146/78 HR 98 RR 14 O2Sat 100% RA Gen: Patient awake and cooperative Heent: OP clear, MMM Neck: no palpable lymphadenopathy Cardiac: RRR S1/S2 grade III/VI SEM heard throughout precordium Lungs: slight crackles in right midlung/base, otherwise clear to auscultation Abd: surgical scar at midline below umbilicus well-healed, distended abdomen but soft and nontender to palpation. Normoactive bowel sounds. Ext: Right UE larger in size than left UE. Anasarcatous. Neuro: Awake, pleasant. Oriented to self, year, location (building). Not oriented to month, name of hospital. Pertinent Results: [2107-6-2] CT ABD/PELVIS: 1. Findings consistent with ileus. No evidence of small bowel obstruction. 2. Ascites, small pleural effusions, and anasarca. These findings are likely related to the patient's recent operation, and volume-related hemodilution could contribute to the apparently "decreased hematocrit." . [2107-6-2] CT HEAD: No acute intracranial hemorrhage or mass effect. . [2107-6-2] CXR: Right middle lobe pneumonia. Small bilateral pleural effusions. . [2107-6-2] KUB: Prominent loops of small bowel may be related to ileus, early or partial small bowel obstruction cannot be excluded. . [2107-6-2] ECG: Sinus rhythm. Borderline low limb lead voltage. Leftward axis. Lead V2 is technically difficult. Since the previous tracing of [2107-5-13] the Q-T interval is shorter. . [2107-6-3] CXR: 1. Re-identification of patchy right middle lobe pneumonia. 2. Increased left lower lobe atelectasis. 3. Resolving small bilateral pleural effusions with probable mild interstitial remaining edema. . [2107-6-4] CT CHEST: 1. Left upper lobe cavitary lesion concerning for primary lung cancer or metastatic disease. An infectious process is less likely. 2. Redemonstration of right middle and upper lobe pneumonia. 3. Moderate right and small left pleural effusions. . [2107-6-7] CXR: There is now a small right pleural effusion. The patient's CHF has essentially cleared. There is some patchy linear atelectasis at the right base. . blood cx [2107-6-2]: no growth . [2107-6-5] 5:00 pm SPUTUM Source: Induced. GRAM STAIN (Final [2107-6-6]): [12-1] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2107-6-8]): RARE GROWTH OROPHARYNGEAL FLORA. YEAST. SPARSE GROWTH. ACID FAST SMEAR (Final [2107-6-6]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): . [2107-6-6] 3:40 pm SPUTUM Source: Induced. ACID FAST SMEAR (Final [2107-6-7]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): . [2107-6-7] 3:40 pm SPUTUM Site: INDUCED induction verified. ACID FAST SMEAR (Final [2107-6-8]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): . [2107-6-2] 08:20PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.016 [2107-6-2] 08:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2107-6-2] 01:35PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 [2107-6-2] 01:35PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2107-6-2] 01:35PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-[7-17] . [2107-6-2] 12:45PM BLOOD WBC-13.8# RBC-2.84 Hgb-8.4* Hct-25.8* MCV-91 MCH-29.7 MCHC-32.8 RDW-15.6* Plt Ct-293 [2107-6-2] 12:45PM BLOOD Neuts-91.5* Bands-0 Lymphs-4.8* Monos-3.2 Eos-0.3 Baso-0.2 [2107-6-2] 12:45PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [2107-6-2] 12:45PM BLOOD Plt Smr-NORMAL Plt Ct-293 [2107-6-2] 12:45PM BLOOD PT-31.9* PTT-33.5 INR(PT)-3.4* [2107-6-2] 03:45PM BLOOD Glucose-116* UreaN-25* Creat-1.4* Na-136 K-4.8 Cl-103 HCO3-27 AnGap-11 [2107-6-2] 12:45PM BLOOD Glucose-106* UreaN-25* Creat-1.5* Na-132* K-7.4* Cl-100 HCO3-26 AnGap-13 [2107-6-2] 12:45PM BLOOD Calcium-8.1* Phos-3.9 Mg-2.4 [2107-6-2] 04:10PM BLOOD K-4.8 [2107-6-2] 12:55PM BLOOD Lactate-2.2* K-6.3* [2107-6-2] 12:55PM BLOOD Hgb-8.9* calcHCT-27 . [2107-6-3] 07:45PM BLOOD Hct-31.7* [2107-6-3] 11:41AM BLOOD Hct-32.0* [2107-6-3] 02:46AM BLOOD WBC-15.8* RBC-3.67# Hgb-10.9# Hct-33.5# MCV-91 MCH-29.7 MCHC-32.5 RDW-14.9 Plt Ct-237 [2107-6-3] 02:46AM BLOOD Plt Ct-237 [2107-6-3] 02:46AM BLOOD PT-26.2 PTT-33.7 INR(PT)-2.7* [2107-6-3] 01:00AM BLOOD PT-26.6* PTT-32.2 INR(PT)-2.7* [2107-6-3] 02:46AM BLOOD Glucose-82 UreaN-22* Creat-1.3* Na-136 K-4.5 Cl-100 HCO3-27 AnGap-14 [2107-6-3] 01:00AM BLOOD Glucose-88 UreaN-21* Creat-1.3* Na-135 K-5.3* Cl-102 HCO3-25 AnGap-13 [2107-6-3] 02:46AM BLOOD Lipase-14 [2107-6-3] 02:46AM BLOOD Albumin-3.3* Calcium-9.0 Phos-3.2 Mg-2.1 Iron-80 [2107-6-3] 02:46AM BLOOD calTIBC-285 Ferritn-113 TRF-219 [2107-6-3] 02:46AM BLOOD TSH-3.2 [2107-6-3] 02:46AM BLOOD Free T4-1.3 [2107-6-3] 12:57AM BLOOD Lactate-1.5 [2107-6-3] 12:57AM BLOOD Hgb-10.6* calcHCT-32 . [2107-6-8] 06:55AM BLOOD WBC-6.8 RBC-3.36* Hgb-9.8* Hct-31.0* MCV-92 MCH-29.1 MCHC-31.6 RDW-14.5 Plt Ct-267 [2107-6-8] 06:55AM BLOOD Plt Ct-267 [2107-6-8] 06:55AM BLOOD PT-14.4* INR(PT)-1.3* [2107-6-8] 06:55AM BLOOD Glucose-85 UreaN-11 Creat-1.3* Na-138 K-3.7 Cl-102 HCO3-31 AnGap-9 [2107-6-8] 06:55AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.9 . Brief Hospital Course: # Right middle and upper lobe pneumonia: Suspect nosocomial, given recent hospital admission. Micro unrevealing. Blood cultures were negative. Remained stable on room air and will complete a 10 day course of zosyn/vancomycin for treatment. Given pneumovax and influenza vaccine prior to discharge. Nebs prn. . # Hemoptysis: INR therapeutic. [Month (only) 116] be secondary to pneumonia or left upper lobe lesion which is likely malignant. Ruled out for TB with AFB negative x 3 induced sputums. Hematocrit and oxygen stable. Daughter states she and her mother wish to defer biopsy. They are aware this is a probable malignancy but do not wish further treatment. . # Ileus: Concern for obstruction last admission. S/p intraabdominal surgery [2107-5-13]. CT this admission showed ileus but no obstruction. NGT placed for decompression and has since been discontinued. Patient's diet was advanced. She is currently tolerating a regular diet without nausea, vomiting, bloating, or abdominal pain. . # Anemia: HCT 25 on admission (down from baseline 29-30). Suspect contribution from chronic kidney disease + acute infection. Guaic positive on admission but hematocrit stabilized with 2 units PRBC and has remained 29-30 x days. Thus, consider outpatient C-scope and EGD for further work-up, if patient wishes (discussed with daughter). Of note, iron studies at this time, do not reflect iron deficiency. TSH, vitamin B12 also normal. Folate added on on the day of discharge and will be pending. . # History of right IJ clot: Restarted on anticoagulation in house (lovenox to bridge given subtherapeutic on coumadin). Please check Factor Xa level tonight (4 hours after dose of lovenox) and adjust as needed. Lovenox can be d/c once coumadin level therapeutic (INR 1.2 on day of discharge). . # Atrial fibrillation: Rate stable on beta blocker. On anticoagulation. . # Hypertension: Blood pressure high in house, but patient was not receiving her minitran. Nifedipine and metoprolol doses have been increased since admission. Minitran restarted at discharge. . # Delirium: Resolved with treatment of pneumonia. Zyprexa prn. . # Chronic kidney disease: Creatinine at baseline (1.4 on day of discharge). Recommend outpatient follow-up with renal to consider epo given chronic anemia. . # FEN: low sodium . # PPX: sacral decub care, PPI . # Full code . # Dispo: discharged to [Hospital3 2558] Medications on Admission: Meds at recent discharge/per [Hospital3 2558] records Docusate Sodium 100 mg PO BID Aspirin 81 mg daily Prilosec 40 mg PO daily Valsartan 40 mg PO daily Nifedipine 60 mg PO daily Minitran 0.1 mg/hr Patch (on during day, off at night) Coumadin 3 mg PO daily Nitroglycerin 0.1 mg/hr Patch (on during day, off at night) Olanzapine 5 mg PO QHS (discontinued [5-19]) Olanzapine 2.5 mg PO TID prn agitation Acetaminophen 650 mg PO Q8H pain Metoprolol Tartrate 50 mg PO BID Discharge Medications: 1. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 3. Minitran 0.1 mg/hr Patch 24 hr Sig: One (1) patch Transdermal once a day: APPLY TO CHEST EACH DAY, OFF AT BEDTIME. 4. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO twice a day. 5. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day for 1 days: DOSE DAILY, BASED ON DAILY INR. 6. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) MG Subcutaneous Q24H (every 24 hours): PLEASE CHECK FACTOR Xa TONIGHT, AS REQUESTED. 7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation, delerium. 8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours as needed for pain. 9. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q48H (every 48 hours) for 3 days. Disp:2 gram Refills:0 15. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 3 days. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: primary: ileus nosocomial pneumonia hemoptysis with underlying left upper lobe lesion - suspect malignancy (ruled out for TB with AFB negative x 3; family deferred biopsy for definitive diagnosis) secondary: history of right IJ thrombus atrial fibrillation chronic kidney disease chronic anemia Discharge Condition: good: stable on room air, hematocrit stable, taking good po Discharge Instructions: Please monitor for temperature > 100.5, worsening hypoxia, vomiting, abdominal pain, or other concerning symptoms. Followup Instructions: 1. Provider: [First Name4 (NamePattern1) 247] [Last Name (NamePattern1) 248], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2107-6-16] 11:00. [Telephone/Fax (1) 250] ICD9 Codes: 486, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8069 }	Medical Text: Admission Date: [2130-7-3] Discharge Date: [2130-7-5] Date of Birth: [2083-8-25] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1257] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 3012] is a 46 y/oM who presents to the [Hospital1 18] ED for shortness of breath. He has had previous admissions for EtOH in the past. He reports 2-3 days of feeling ill with a diarrheal illness (nonbloody, awakens him from sleep) accompanied by some left sided abdominal pain and some vomiting, also non-bloody. This morning, he developed shortness of breath and was tachypneic. He has reported some cough with phlegm which is above baseline and some runny nose in the recent past. No chest pain. He made his way from the [Hospital1 ] Shelter to the neareast "T" station where he called 911, and was brought by EMS to the [Hospital1 18]. He reports his last alcoholic drink approximately on Saturday. Of note, he had blunt violent trauma to his head in [Month (only) 958], and had fracture of C6-C7. He has been mainly in a [Location (un) 2848] J since then, and states that Dr. [Last Name (STitle) 363] is planning on operating once he has been away from cigarettes for one month. He has had repeat head imaging for concern of intracranial bleed as he has had interval ED visits for EtOH and head abraisons, but no ICH seen. In the ED, his triage vitals were 97.7 141/101 HR 103 RR 24 Sat 100% on NRB. He was later weaned to 97% on room air. His shortness of breath improved over time. He had a chest xray that was unremarkable. For his nausea/vomiting, he had a normal lipase. He had an abdominal/pelvis CT scan that was unremarkable without evidence of pancreatitis. He was given 3mg of ativan, zofran, and 2L of normal saline. Past Medical History: - Hepatitis C per patient history, immunized A and B. Past HIV neg - Alcohol Abuse - previous withdrawal seizures, DT's - Depression - C6/7 spinal cord contusion [4-17] admission - Thrombocytopenia, since [4-17] - Anemia - Leukopenia - [2129-4-7] Fracture of the lamina papyracea/medial wall of the left orbit. Social History: Lives in shelters or at his families home in [Location (un) ]. on SSDI. Smokes 1/2ppd. No other drug use. Family History: NC Physical Exam: Vitals: T: 98.1, BP: 117/88, P: 55, RR: 18, O2: 98% RA. PE: Gen: A & O x3, nervous affect, in C-collar CV: RRR, no MGR RESP: CTAB ABD: ND, +BS, vol guarding, marked LLQ tenderness, no reboud tenderness, liver edge 3-4cm below rib. Extr: No edema Neuro: Reports decreased sensation to no sensation in both arms across multiple dermatomal distributions, [5-14] motor strength throughout both arms, nl motor strength in all other major muscle groups, nl EOM, nl cerebellar tests, mild tremor on had extension. Pertinent Results: Admission labs: [2130-7-3] 02:40AM WBC-6.1 RBC-4.21* HGB-13.4* HCT-37.5* MCV-89 MCH-31.8 MCHC-35.7* RDW-15.8* [2130-7-3] 02:40AM NEUTS-68.2 LYMPHS-22.4 MONOS-8.6 EOS-0.6 BASOS-0.4 [2130-7-3] 02:40AM GLUCOSE-120* UREA N-13 CREAT-0.9 SODIUM-131* POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-19* ANION GAP-23* [2130-7-3] 02:40AM ALT(SGPT)-157* AST(SGOT)-236* ALK PHOS-61 TOT BILI-1.0 [2130-7-3] 02:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG\ Imaging: Portable CXR: COMPARISON: [2130-7-3]. SINGLE PORTABLE SUPINE CHEST RADIOGRAPH: The right middle lobe opacification seen only on the lateral view on the prior study cannot be evaluated by this study. Cardiomediastinal silhouette is unchanged. There is no focal consolidation, large effusion, or pneumothorax. Pulmonary vasculature is within normal limits. Osseous structures are grossly normal. IMPRESSION: In order to compare with the initial exam, a lateral radiograph is needed. PA and lateral upright chest radiograph was compared to [2130-7-4] obtained at 05:35 a.m. The heart size is normal. Mediastinal position, contour and width are unremarkable. Lungs are clear. There is no abnormality seen on the lateral view that might correspond to previously suspected abnormality in the right middle lobe. There is no pleural effusion or pneumothorax. There is diminishing of the neutral lordosis of the thoracic spine a finding that in combination with relatively straight orientation of the ribs might be consistent with straight back syndrome. The AP diameter of the trachea is relatively [Name2 (NI) 15015], about 10 mm compared to 20 mm of the AP diameter better appreciated on the lateral view. There is also questionable narrowing of the upper trachea at the level of the clavicular heads compared to the areas below with some upper mediastinal thickening, findings that might be consistent with thyroid enlargement. Findings better partially imaged on the CT of the spine obtained on [2130-4-27]. Correlation with thyroid ultrasound is recommended. Discharge labs: [2130-7-5] 06:15AM BLOOD WBC-3.8* RBC-4.13* Hgb-13.0* Hct-36.4* MCV-88 MCH-31.5 MCHC-35.8* RDW-15.3 Plt Ct-41* [2130-7-5] 06:15AM BLOOD Plt Ct-41* [2130-7-5] 06:15AM BLOOD Glucose-122* UreaN-12 Creat-0.8 Na-134 K-3.7 Cl-98 HCO3-26 AnGap-14 [2130-7-5] 06:15AM BLOOD ALT-168* [2130-7-5] 06:15AM BLOOD Phos-3.2 [2130-7-3] 10:10AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [2130-7-3] 10:10AM BLOOD HCV Ab-POSITIVE* [2130-7-3] 10:10AM BLOOD calTIBC-408 Ferritn-247 TRF-314 Brief Hospital Course: 46 y/o man with EtOH abuse p/w acute shortness of breath after a few days of nausea, vomiting, and diarrhea. #) SOB: He required NRB at arrival but he was weaned to RA over minutes implying no seriously ongoing pulmonary pathology. Differential diagnosis is unclear given the rapid resolution of symptoms on arrival. Initial CXR findings were more c/w atelectasis. He had no oxygen requirement during his stay and no further episodes. Repeat PA/LATERAL CXR showed no consolidation. SOB was likely due to anxiety or panic attack. #) Nausea/Vomiting: No intraabdominal pathology was seen on CT such as diverticulitis. LLQ tenderness appears to be chronic. He was found to be C. diff negative. #) Anion Gap: Present on admission along with a venous lactate of 2.7. Both of which resolved with hydration. C/w volume depletion from GI losses vs ETOH abuse. #) EtOH Withdrawal: CIWA, diazepam 10mg PO q2h as needed. Has only required 40mg Valium total dose over 24 hours. S/p banana bag administration. He only needed 50mg diazepam total. # Thrombocytopenia/Anemia. Likely related to Alcohol. Retic count low given anemia which is c/w marrow suppression from ETOH. Iron studies showed no iron deficiency. Could also be marrow suppression secondary to GI infection. #) C6-C7 spinal canal stenosis: to be managed by spine surgery electively. His current exam suggests no changes. Dr. [Last Name (STitle) 739] was contact[Name (NI) ] during the stay. Sensory exam and motor exam were not convincing for any sensory deficit or motor deficit related to C6-7 contusion. A follow up appointment was scheduled with his neurosurgeon, Dr. [Last Name (STitle) 65103] on [7-19] at 9AM at [Hospital Unit Name ]. #) Hepatitis C: likely not an active problem, but checked hepatitis serologies (Hehp B surface and [Last Name (un) ] antibody negative, HAV antibody positive, HCV antibody positive). CT showed steatosis, no focal lesions. Advise outpatient followup. #) CXR finding of tracheal stenosis: Pt not SOB, no stridor, no thyromegaly, no history of intubation. This will need PCP follow up. Medications on Admission: Fluoxetine 20 mg Capsule Two (2) Capsule by mouth DAILY Lamotrigine 100 mg Tablet Two (2) Tablet by mouth DAILY Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Paroxetine HCl 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: gastroenteritis Hepatitis C Alcohol abuse C6-7 spinal canal stenosis Discharge Condition: Stable, afebrile. Discharge Instructions: You were admitted to the hospital with complaints of shortness of breath. Your shortness of breath resolved quickly and you were achieving high oxygen saturations on room air. You also had ongoing diarrhea. You were found not to have a bacterial illness called Clostridium Difficile. There was also concern about you going into alcohol withdrawal, so you were given a medicine called diazepam to stop you from going into serious withdrawal. You were discharged in stable condition. Please follow up with your primary care doctor within two weeks to discuss your general health, alcohol abuse issues, and hepatitis C. Please follow up with your neurosurgeon, Dr. [Last Name (STitle) 65103] on [7-19] at 9AM at [Hospital Unit Name ] about your C6-7 contusion. You can call ([Telephone/Fax (1) 88]) if you have any problems with this appointment. Please seek medical attention if you have a fever over 102 degrees F, if you feel dizzy or faint, if you vomit profusely or vomit blood, or if you have any blood in your diarrhea. Followup Instructions: Please follow up with your primary care doctor within two weeks to discuss your general health, alcohol abuse issues, and hepatitis C. Please follow up with your neurosurgeon, Dr. [Last Name (STitle) 65103] on [7-19] at 9AM at [Hospital Unit Name ] about your C6-7 contusion. You can call ([Telephone/Fax (1) 88]) if you have any problems with this appointment. Completed by:[2130-7-5] ICD9 Codes: 5180
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8070 }	Medical Text: Admission Date: [2126-10-28] Discharge Date: [2126-11-20] Date of Birth: [2077-5-7] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 371] Chief Complaint: epigastric pain x 16 hrs Major Surgical or Invasive Procedure: laparoscopic cholecystectomy History of Present Illness: Pt is a 49M with sharp, continuous epigastric pain for the 16hrs prior to presenting to [Hospital1 18] ED. No prior episodes. Vomitted once without relief 12hrs PTP. Last BM/flatus 8hrs PTP. Pain does not radiate. Also reports chills (did not check temperature), but denies urinary s/s. + chest pain night PTP. No SOB. Last meal chinese food/chicken fingers. Past Medical History: HTN CRI Social History: no EtOH. No tobacco. Married with 4 children Physical Exam: Afebrile 92 175/112 19 98% 2L AOx3, + distress from pain anicteric RRR CTA b/l Abd: decreased BS, distended, diffuse tenderness. + [Doctor Last Name ], -gret-[Doctor Last Name 4862] guiac neg. - CVA tenderness Ext: WWP, no CCE Pertinent Results: [2126-10-28] 10:05AM BLOOD WBC-12.2# RBC-5.54 Hgb-16.1 Hct-44.7 MCV-81 MCH-29.1 MCHC-36.1* RDW-13.7 Plt Ct-226 [2126-10-28] 10:05AM BLOOD Neuts-90* Bands-5 Lymphs-2* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2126-10-28] 10:05AM BLOOD PT-12.8 PTT-19.0* INR(PT)-1.1 [2126-10-28] 10:05AM BLOOD Plt Ct-226 [2126-10-28] 10:05AM BLOOD Glucose-195* UreaN-29* Creat-1.7* Na-144 K-4.2 Cl-103 HCO3-25 AnGap-20 [2126-10-28] 10:05AM BLOOD ALT-168* AST-269* LD(LDH)-489* CK(CPK)-620* AlkPhos-106 Amylase-2452* TotBili-1.9* DirBili-0.9* IndBili-1.0 [2126-10-28] 10:05AM BLOOD Lipase-3380* [2126-10-28] 10:05AM BLOOD CK-MB-5 [2126-10-28] 10:05AM BLOOD cTropnT-<0.01 [2126-10-28] 10:05AM BLOOD Calcium-10.0 Phos-3.4 Mg-1.7 RADIOLOGY Final Report ABDOMEN U.S. (COMPLETE STUDY) [2126-10-28] 12:45 PM IMPRESSION: 1. Gallbladder wall thickening with no evidence of distention or pericholecystic fluid. These findings are not typical of acute cholecystitis and likely represent an etiology outside of the gallbladder, such as the pancreas. 2. Nonobstructing gallstones. 3. Diffuse fatty liver-see above for. Brief Hospital Course: # Gallstone Pancreatitis: The patient was admitted to the SICU for agressive IV hydration, pain control, serial exams, and close monitoring. The patient continued to be stable with normal vital signs and good urine output. Liver/pancreatic enzymes steadily improved; On HD3 the patient was transfered to the floor. Pain and liver/pancreatic enzymes continued to improve. Vital signs/UO were normal. A CT scan was obtained on [2126-11-2] when the abdominal pain had not improved and there was increased abdominal distension. Imipenem was started [11-6] and a repeat CT was obtained when the patient was persistently febrile without postive cultures. It was negative for pseudocysts, phlegmon, or reasons for fever. Imipenem was discontinued after a 7-day course. On [2126-11-18] the patient underwent a laparoscopic cholecystectomy. Post-op Amylase/Lipase were much improved and he was advanced to full liquids on POD1. On POD2 the patient was tolerating a low fat diet. He was discharged home after nutrition teaching for a low fat diet. . # Nutrition: A PICC line was placed on [10-30]; TPN was started and continued throughout his hospital course. Of note Mr. [Known lastname ] showed signifcant insulin resistance while on TPN requring approximately 150 units of insulin per bag of TPN to keep his blood surgars less than 120. Sips were started on [11-1]. Clear liquids as tolerated was started on [2126-11-15] when there was resolution of his abdominal pain. . # Chronic renal insuffiency: slight increase from baseline creatinine despite agressive hydration upon presentation. BUN/Cr/UO monitored and Cr slowly returned to baseline. . # Enterococcus UTI: treated with a 5-day course of IV Ciprofloxacin. [2052-11-1] Medications on Admission: tylenol prn, lasix 20 mg daily Discharge Medications: 1. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed. Disp:45 Tablet(s) Refills:0 3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Gallstone pancreatitis Discharge Condition: good Discharge Instructions: Restart you home medications as usual. Low Fat diet. You may resume activity as tolerated. You may shower, then pat-dry incision. Do not rub incision. No tub baths or swimming for 3-4 weeks. You may leave the incision uncovered or use a light dressing for comfort. Keep the white strips until they fall off. * Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink * Pain/redness/drainage from wound * Other symptoms concerning to you Followup Instructions: 1. Call Dr.[Name (NI) 1863] office for a follow-up appointment [Telephone/Fax (1) 1864] 2. Call Dr. [Last Name (STitle) 18991] office for follow-up appointment regarding your chronic renal insufficiency ([Telephone/Fax (1) 817] ICD9 Codes: 5990, 5859, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8071 }	Medical Text: Admission Date: [2187-1-11] Discharge Date: [2187-2-1] Date of Birth: [2106-12-3] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 613] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: -Intubation while in intensive care unit -Placement of right internal jugular central venous line while in intensive care unit -Placement of a right arm mid-line PICC for additional IV access History of Present Illness: This is an 80 year of female NH resident with a past medical history of chronic aspiration (on precautions, puree diet), severe dementia, HTN, DM2, recurrent UTIs, systolic CHF (EF 40%), stable gout and chronic anemia (mixed ACD & iron-deficiency) who presented initially for acute onset altered mental status, hypotension and bradycardia. She was noted to be non-verbal and non-responsive to visual stimuli by her nursing home so she was sent to the [Hospital3 ] ED and then to [Hospital1 18] emergency room. At baseline she is verbal but intermittently confused; mostly A&Ox1. She does not walk on her own and is bed bound. On arrival to [Hospital1 18] she was hypotensive to 90/60 range and bradycardic to 30s. FSG was 114, afebrile, and saturating fiarly well at 98% on RA. Of note, per NH report, she was diagnosed with a UTI on [1-8] and started on levofloxacin. Labs on that day also noted an increased BUN to 52 and was started on IVF at her NH. She was then transferred to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. . At [Hospital1 ], HR initially remained in the 30s to 40s and blood pressures were initially stable at 102/59. However, she then dropped to the 70s systolic. She was given 1mg atropine with little effect. Received only 500cc of NS out of concern for possible pulmonary edema on CXR. BNP 391. Also noted some questionable left facial droop but initial non-contrast CT head was negative for acute process. Initial cardiac enzymes were all negative at time of her initial emergency transfer and workup. Due to persistent hypotension she was started on peripheral dopamine, given IVFs and transferred to ICU for monitoring. For safety, she needed intubation for several days in ICU while hemodynamics stabilized and then she was extubated. . Ms. [Known lastname 15569] MICU course was notable for low platelets and hematology/oncology service was consulted. Ultimately given diagnosis of HIT after PF4 Abs returned positive and all heparin being avoided since that time. She also had transient ARF which resolved over several days and worse rhonchi on lung exam with some opacities on serial CXRs so she was treated for VAP alongside antibiotics for her urosepsis coverage. Once stable, she was transferred to medical floor where she was noted to have some RUE edema and asymmetry. Follow-up RUE ultrasound showed DVT so she is now on course of Coumadin therapy after being bridged with fondaparinux . Team needed to adjust/hold occasional doses, give PRN vitamin k to aim for INR goal [2-28]. Past Medical History: -Recent admit to [Hospital1 ] [11-3] for sepsis/aspiration pneumonia -Severe Dementia -Chronic back pain -Chronic gait disorder with multiple falls / mainly bed bound -Hypertension -Diabetes Mellitus type 2 -Frequent UTIs -Gout; no recent flare-ups Social History: Patient had been semi-independent with help of her son a few months prior to recent nursing home placement after sepsis/aspiration pneumonia. She was living in nursing home in [Hospital1 ] and mostly bed bound prior to this admission per her son ( [Name (NI) ] [Name (NI) ]). No significant alcohol, smoking or illicit drug use history. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: . Vitals - <96, 42, 100/40, 99% 2L GENERAL: Awake, agitated but non verbal HEENT: PERRL, dry MM CARDIAC: bradycardic, no MRGs appreciated LUNG: CTAB ABDOMEN: Soft, NT/ND, +BS EXT: no edema NEURO: moving all 4 extremities DERM: no rash, unstagable pressure ulcer on R heel, stage 2 on R buttock . DISCHARGE PHYSICAL EXAM: . GEN: NAD EYES: conjunctiva clear, anicteric ENT: dry mucous membranes, dried blood along lips 2/2 episodes of hemoptysis NECK: supple CV: RRR s1, s2. No m/r/g. PULM: coarse BS throughout GI: + BS, ND, soft, nontender EXT: warm, no edema RUE edema and dependent ecchymosis much improved since my last exam on [1-28] SKIN: no rashes NEURO: alert, oriented x 1, answers some questions appropriately (mostly yes/no), follows some commands (lifts arms, squeezes my hands, wiggles toes, too weak to lift legs) PSYCH: appropriate ACCESS: PIV Pertinent Results: ========== Labs ========== . On Admission: [2187-1-12] 12:04AM BLOOD WBC-9.3 RBC-4.19* Hgb-9.5* Hct-31.3* MCV-75* MCH-22.7* MCHC-30.5* RDW-17.6* Plt Ct-172 [2187-1-12] 12:04AM BLOOD Neuts-88.0* Lymphs-9.2* Monos-2.2 Eos-0.3 Baso-0.2 [2187-1-12] 12:04AM BLOOD PT-13.6* PTT-46.1* INR(PT)-1.2* [2187-1-14] 12:35PM BLOOD HEPARIN DEPENDENT ANTIBODIES- POSITIVE . On Discharge: WBC: 7.4, Hgb: 7.3, Hct: 23.1, Plt: 261. Na: 144, K: 3.8, Cl: 109, Bicarb: 29, BUN: 14, Creatinine: 0.9, Glucose: 67. Ca: 8.2, Phos: 2.7, Mg: 1.6 . PLATELET FACTOR ANTIBODIES / HIT WORKUP [2187-1-14] - ----- HEPARIN DEPENDENT ANTIBODIES POSITIVE COMMENT: POSITIVE PF4 HEPARIN ANTIBODY BY [Doctor First Name ] . ========= Radiology ========= . [1-12] Renal ultrasound 1. Irregular fluid collection around the upper pole of the right kidney, concerning for perinephric abscess. Collection measures roughly 2.4 x 3.5 cm. 2. Moderate amount of fluid in the pelvis. 3. Normal left kidney. . [1-12] TTE - The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis (LVEF = 30-40 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. . [1-13] CT Torso - 1. Gall bladder wall edema. In case of clinical concern for cholecystitis right upper quadrant ultrasound is recommended. 2. Limited evaluation due to lack of IV contrast however no definite perinephric fluid collection. Small amount of fluid in the right perinephric space is nonspecific but does not have the appearance of an abscess. 3. Moderate-volume intra-abdominal ascites. 4. Colonic diverticulosis, mostly in the ascending colon, with no evidence of diverticulitis. 5. Cardiomegaly and severe coronary artery calcifications. 6. Bilateral small pleural effusions with associated atelectasis. Severe emphysema. . RUQ U/S Severely thickened gallbladder wall. Differential diagnosis is broad and includes underlying liver disease and fluid overload. Clinical correlation is recommended. Echogenic liver may represent fatty deposition. Please note that other liver disease such as fibrosis or cirrhosis cannot be excluded . LENIs IMPRESSION: No lower extremity deep venous thrombosis bilaterally. . [1-18] RUE Doppler US - FINDINGS: Grayscale and Doppler son[Name (NI) 1417] of the right subclavian, internal jugular, axillary, paired brachials, cephalic, and basilic veins were performed. Within the right internal jugular vein, a focal approximately 1.2 cm in length area of non-occlusive thrombus was identified with flow preserved within the right internal jugular vein. The right internal jugular vein was not fully compressible. There is normal flow and compressibility of the right axillary, paired brachials, cephalic, basilic, and subclavian veins. Note is made of a variant with two axillary veins noted. IMPRESSION: Non-occlusive thrombus within the right internal jugular vein. . [1-21] CXR - FINDINGS: As compared to the recent radiograph, there has been worsening of interstitial edema and slight increase in size of a small right pleural effusion. Lower lobe collapse may have slightly worsened, and is accompanied by a small-to-moderate left pleural effusion. . [1-21] CT HEAD W/O CONTRAST - IMPRESSION: 1. No acute intracranial abnormality. 2. Paranasal sinus disease, not significantly changed from prior. Recommend clinical correlation. . [2187-1-27] CXR - FINDINGS: Comparison is made to prior study from [2187-1-21]. Cardiac silhouette is upper limits of normal but stable. There is again seen a left retrocardiac opacity. There are new airspace opacities within the right lung, mostly within the upper and mid lung fields which are new since the [2187-1-21] study. Since the vascular pedicle is not widened, these findings are more likely related to some infectious/inflammatory etiologies as opposed to pulmonary edema. There is also a right-sided pleural effusion. There is a catheter with the distal tip in the axilla on the left side, which is unchanged from prior. . ========= Micro ========= URINE CULTURE (Final [2187-1-17]): PROVIDENCIA STUARTII. >100,000 ORGANISMS/ML.. GENTAMICIN & TOBRAMYCIN sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROVIDENCIA STUARTII \| ENTEROCOCCUS SP. \| \| AMIKACIN-------------- <=2 S AMPICILLIN------------ <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R <=16 S PIPERACILLIN/TAZO----- 8 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ S TRIMETHOPRIM/SULFA---- 8 R VANCOMYCIN------------ <=1 S Brief Hospital Course: 80 year old female with hx of DM2, HTN, dementia, systolic CHF (EF 40%), and frequent UTIs presented with altered mental status, hypotension, and bradycardia and found to have urosepsis, ARF and thrombocytopenia which have now all resolved. Hospital course complicated by additional ventilator acquired PNA and RUE DVT in addition to ongoing chronic aspiration for which she was placed on aspiration precautions and safe protocol diet. Also had intermittent hypothermia to the low 90s with no other abnormal vital signs, leukocytosis or other clinical change. The patient's ongoing aspiration and new areas of pneumonia were discussed with the patient's son [Name (NI) 382]. We had a family meeting discussing goals of care, and it was ultimately agreed that aggressive interventions, including a feeding tube, would not be consistent with the patient's goals. He changed her code status to DNR/DNI. After further discussion with family members, he decided to shift focus to management of symptoms and optimization of quality of life. He agreed to hospice care. Please see outlined hospital course below for additional details. #. Sepsis: Initial sepsis felt to be most likely secondary to UTI. She had fevers, leukocytosis to peak 17 range, and positive urinalysis at presentation. BP improved with 2 units of packed red blood cells and IVFs. She was also transiently on pressors through [2187-1-14]. Urine culture grew Providencia stuartii and Enterococcus species. Patient was treated in the ICU with Ceftriaxone starting on [1-12] for a planned 14 day course, and Ampicillin was added on on [1-17]. Antibiotics were changed to Vancomycin/Cefipime on [1-18] to provide concomitant ID coverage for her suspected aspiration PNA/VAP on CXRs. LFTs increased in the setting of hypotension, but improved without intervention. Also, she had initial concerning RUQ ultrasound that showed severe gallbladder wall thickening, though patient denied abdominal pain. Surgery was consulted, but they did not feel this was c/w cholecystitis. All blood cultures have been negative through this admission; 2 sets done [1-12] and 2 more sets done [1-20] all with no growth. Post extubation on [1-17], patient had brief period of worsening leukocytosis and was hypothermic which is what prompted search for additional sources of infection and led to CXR that demonstrated RLL opacification / VAP. As mentioned above, her antibiotic regimen was changed/broadened to Vancomycin and Cefepime to cover for Ventilator Associated Pneumonia/UTI with completion on [2187-2-1] prior to discharge. CXR on [2187-1-27] with worsening right sided opacities, which we attributed to recurrent aspiration, and after discussing with son, we began shift of care to symptom management. Aspiration is likely to continue with worsening of symptoms. . #. Hypernatremia: Na peaked at 150 and intermittently improved with free water repletion but returned to the mid to high 140s. She was likely hypovolemic in the setting fluid loss on initial presentation and she was calculated to have a free water defecit of several liters in the ICU. She received 2.5 L of D5W in the ICU over 2 days, and was eating and drinking before leaving the ICU. By time of transfer back to the floor free water deficit was still near 1 L. She was given cautious amounts of D5 1/2 NS as recent TTE showed EF 40% and CXR also had some small effusions on [1-21] so did not want to push her into acute CHF exacerbation. Given gentle IVFs on medical floor with fluctuation in sodium levels. At time of discharge her Na was 144. . # Acute renal failure: Cr peaked at 1.4. Likely had ATN from hypotension and patient improved Cr to 0.9 prior to transfer from the ICU. She remained on medical floor for over a week with cretinine levels mostly in the 0.8-0.9 range with no recurrence of her renal dysfunction after aggressive antibiotics and IVFs for her sepsis management. . # Right internal jugular thrombosis: Non occulusive. Patient's RUE >LUE size and she had a lot of edema noted on physical exam on [1-18]. Patient had RIJ central line placed on this side which was adjacent to clot site and felt to be the etiology of her newly diagnosed DVT that was confirmed on ultrasound on [1-19]. Patient was started on [1-19] on Fondaparinux and Coumadin given that she was HIT positive. Although serotonin assay was negative, per Hematology she is still at moderate risk for true HIT so she was treated as such and all heparin products were avoided. She became therapeutic >2 INR so Fondaparinux was discontinued but there was some overlap of effects and she had several days of supratherapeutic INR. Plan per hematology was to continue her Coumadin for a total of 3 months, but in setting of supratherapeutic INR and recent decision by son to shift goals of care to symptom management, will need to readdress coumadin reinitiation with hospice team. She was discharged off coumadin. She will follow-up with PCP, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 84084] after discharge for additional management. . # Anemia, thrombocytopenia: Initially attributed to bone marrow suppression due to infection. No signs of hemolysis on labs. DIC labs negative. HIT Ab positive so heparin induced thrombocytopenia was felt to be main cause of her dropping platelets. Levels returned to [Location 213] ranges after heparin discontinued which further corroborates this diagnosis. However serotonin release assay was negative. Per hematology she still had moderate likelihood of true HIT so she should therefore avoid all heparin products in future. Patient had briefly been on argatroban in the MICU while team sorted out her diagnosis. On the medical floor she was placed on pneumoboots for LE DVT prevention but as noted above she unfortunately developed a RUE DVT. Briefly bridged with Fondaparinux and started Coumadin. All platelet levels remained normal prior to discharge. Anemia baseline unclear as she had never before been hospitalized here at [Hospital1 18] so no labs to compare to. However, iron studies done and she likely has mixed picture of anemia of chronic disease alongside some accompanying iron deficiency with MCV in high 70s and low iron levels. Due to constipation, opted to continue her multivitamin with low level iron at discharge with no additional supplements. HCT has been been slowly trending down, likely secondary to supratherapeutic INR following coumadin, causing intermittent episodes of blood-tinged sputum and occult blood positive stools. With shift of care to symptom manangement, will need to discuss with hospice team in regards to transfusions. Continue PPI as an outpatient. . # Hypertension: She has baseline HTN and had been on home 5mg PO lisinopril and metoprolol. These were held in setting of her sepsis presentation as she had hypotension for several days. Only recently, on [1-25] when her blood pressures consistently back to 140s systolic range was she restarted on her usual low dose 5mg lisinopril daily but beta blocker will continue to be held due to her low HRs. Normotensive and stable at time of discharge. . # Nutrition: She has been evaluated twice on this admission by speech and swallow specialists regarding her aspiration risks. Particularly in the setting of her new VAP diagnosis. Placed on strict aspiration precautions with baseline diet of honey thick liquids and pureed food. Asked to have 1:1 sitter with meals, head of bed >80 degrees and on q4 hour mouth cleaning and suctioning when needed. . # Sinus Bradycardia: EKG shows mild 1st degree AV block, unsure of prior baseline as she is a new [Hospital1 18] patient. Team felt this may have developed in setting of illness. Rate now improved markedly and she has been in the high 50-70s ranges. She had been on metoprolol at baseline but due to low HRs and low BPs this was held, can perhaps be restarted as outpatient at later date. Cardiac markers negative. EKG without ischemia. TTE with reduced global function but no focal WMA. . # Hypothermia: She had intermittent readings from axillary thermometers on the medical floor in the low 90s at times. Accuracy questioned as several repeat values and actual temperature rectal probe re-checks usually several degrees warmer. She was placed on warming blankets several times with improvement to 96-97 but she tends to run in 94-96F PO range. Given that she had no leukocytosis or hemodynamic instability in setting of these episodes an infectious pre-sepsis picture was unlikely. Moreover, she was being covered with broad IV antibiotics as well. Team also did workup to assess endocrinologic causes and her TSH and AM cortisol were WNL. Medications on Admission: Trazadone 25mg PO qhs MVI Vicodin 1 tab PO BID ASA 81mg Po daily lisinopril 5mg PO daily Metoprolol 12.5mg PO BID Allopurinol 300mg PO daily Glyburide 2.5mg Po daily Lovenox 40mg SC daily Miralax Colace 100mg PO BID Senokot 2 tabe PO qhs Tylenol PRN Vitamin C 500mg PO daily Zinc sulfate 220mg PO daily MOM 30mL PO qhs PRN Maalox PRN Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Lisinopril 5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet [Hospital1 ]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Insulin Lispro 100 unit/mL Solution [Hospital1 ]: AS DIRECTED Subcutaneous ASDIR (AS DIRECTED): please take per sliding scale provided . 5. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 7. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 8. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. Zinc Sulfate 220 (50) mg Capsule [Last Name (STitle) ]: One (1) Capsule PO once a day. 11. Multivitamin Capsule [Last Name (STitle) ]: One (1) Capsule PO once a day. 12. Vitamin C 500 mg Tablet Sustained Release [Last Name (STitle) ]: One (1) Tablet Sustained Release PO once a day. 13. Aspirin 81 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 14. Maalox 200-200-20 mg/5 mL Suspension [Last Name (STitle) ]: One (1) PO TID: PRN. Discharge Disposition: Extended Care Facility: [Hospital ] healthcare Discharge Diagnosis: Primary: -Sepsis secondary to urinary tract infection -Ventilator acquired pneumonia -Recurrent aspiration with intermittent hypoxia -Thrombocytopenia (secondary to HIT / Heparin induced thrombocytopenia) -Right upper extremity Deep Vein Thrombosis -Hypothermia at baseline -Dementia -Bradycardia . Secondary: -systolic CHF ( EF 40%) -Hypertension -Diabetes Mellitus type II -Frequent UTIs -Anemia (chronic disease and iron deficiency) -Gout (no recent attacks) Discharge Condition: Mental Status: Waxing and [Doctor Last Name 688] confusion. Alert and oriented to person only. Level of Consciousness: Alert and minimally interactive Activity Status: Bedbound Discharge Instructions: It was a pleasure taking care of you here at [Hospital1 771]. You were admitted with worsening changes in your baseline mental status and confusion in the setting of a urinary tract infection. You were admitted to the intensive care unit for this bladder infection which spread to your blood. Poor blood flow to the kidneys also caused some transient renal failure which has now resolved back to baseline function. . You were treated with IV antibiotics, IV fluids and several medications to help stabilize your blood pressure. To protect your airway and breathing while you were less responsive the medicine team needed to place a breathing tube into your lungs to help you maintain good oxygenation for a few days, this is called intubation. After the breathing tube was taken out you had some change on your chest x-ray concerning for pneumonia so you were started on additional antibiotics and your cough improved and repeat chest x-ray looked better. Your confusion slowly improved and so did your infections so you were sent to the general medical floor after the ICU to continue to recuperate. . While in the hospital you had some abnormal labs (low platelet count) which were felt to be secondary to a reaction to heparin, a common blood thinning medication. It is very important that you avoid heparin products in the future due to an increased risk of bleeding. . You also developed a blood clot in your right upper extremity. You will need to discuss with the hospice team in regards to completing coumadin therapy for 3 months. It is currently being held due to INR > 4. Should coumadin be started, goal INR would be [2-28]. . MEDICATION INSTRUCTIONS/CHANGES: -Do not take any heparin products or Lovenox after discharge -Your usual 5mg lisinopril for blood pressure control was restarted -At discharge, continue taking your bowel regimen of Bisacodyl, Colace and Senna to prevent constipation. -You have been placed on albuterol and ipratropium nebulizers to help with any shortness of breath/wheezing secondary to recent pneumonia and recurrent aspiration issues -Continue taking Lansoprazole dissolving oral tablets for GI prophylaxis -Continue taking other multivitamins, Vitamin C, Zinc and Tylenol home medications as previously prescribed -STOPPED glyburide in favor of a more controlled sliding scale insulin regimen; please continue this at nursing home -STOPPED allopurinol for gout prevention as it can contribute to kidney dysfunction and you are recovering from recent acute renal failure -STOPPED trazodone -STOPPED vicodin -STOPPED metoprolol due to slow heart rates and low blood pressure . If you develop any fevers, persistent hypothermia, chills, nausea, vomiting, low blood pressures, dizziness, diarrhea, dark or malodorous urine, urine retention, or any other health concerns please seek medical attention. . Please monitor weight as you have also been given diagnosis of congestive heart failure. If gain > [2-28] pounds please notify M.D. Adhere to cardiac low sodium diet. You were given mild amounts of IVFs in hospital but need to be cautious with your overall fluid intake as you are prone to volume overload. Followup Instructions: 1)Please follow-up with your primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 84084] at [Hospital1 ] /[Doctor Last Name 68902] [Location (un) 38], [Numeric Identifier 84085]. Appointment is [2187-2-19] at 2:20pm. Phone # [Telephone/Fax (1) 84086]. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] ICD9 Codes: 0389, 5845, 5185, 5070, 5990, 5180, 4019, 4280, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8072 }	Medical Text: Admission Date: [2172-4-5] Discharge Date: [2172-4-18] Date of Birth: [2093-5-6] Sex: F Service: CARDIOTHORACIC Allergies: Tape Attending:[First Name3 (LF) 1505] Chief Complaint: left shoulder and chest pain Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: Ms. [Known lastname 20598] is a 78 year old with a past medical history of hypertension and remote tobacco abuse who presents with 8/10 substernal chest pain with the onset at rest at 7AM while eating breakfast. She called EMS within 1 hour of developing this pain and en route to hospital in aspirin and 2 sublingual nitroglycerines were administered. Her pain then decreased to [3-5]. In the outside hospital emergency department, she was found to have an inferior STEMI with initial vital signs of 110/82, 77 and 100% on 4 L. She was started on heparin, integrellin, and nitro drips and transferred directly to the [Hospital1 18] cath lab. There she was found to have 3 vessel disease with a culprit RCA lesion. Her RPL branch was stented. On hemodyamic evaluation, she was found to have tall V waves concering for MR. However, once her stent was placed, the tall V waves resolved. Additionally, to rule out shunt pathology as the etiology for the tall R waves, her oxygen saturations were assessed. She had no step up with PA sat 83 and SVC sat 83. CT [Doctor First Name ] was consulted in the cath lab and they are working her up for possible CABG. Her cardiac output post cath was 6.4 and her index was 3.73. Past Medical History: fibromyalgia glaucoma bilaterally right eye surgery, right pupil does not respond to light Social History: 2 children, married and lives with son quit EtOH 25 years ago, recovered alcoholic smoked 1 PPD for 35 years and quit 15 years ago Family History: father with CAD no DM Physical Exam: afebrile, BP 118/65, HR 93, 97% on 4L Gen: loquacious, NAD HEENT: maxillary and mandibular gums with blood oozing Cor: RRR, no M/R/G Pulm: CTAB no W/R/R anteriorly Abd: soft NT ND + BS Ext: WWP DP 2+ bilaterally, right groin with catheters in place, dressings, C/D/I, no pedal edema Pertinent Results: [2172-4-5] 03:21PM CK-MB-59* MB INDX-12.6* [2172-4-5] 03:21PM CK(CPK)-470* [2172-4-5] 10:45AM GLUCOSE-150* UREA N-28* CREAT-0.7 SODIUM-142 POTASSIUM-3.1* CHLORIDE-116* TOTAL CO2-16* ANION GAP-13 [2172-4-5] 10:45AM ALT(SGPT)-17 AST(SGOT)-26 CK(CPK)-64 ALK PHOS-44 TOT BILI-0.4 [2172-4-5] 10:45AM ALBUMIN-3.2* [2172-4-5] 10:45AM WBC-17.3* RBC-4.37 HGB-13.6 HCT-41.3 MCV-95 MCH-31.2 MCHC-33.0 RDW-12.6 [2172-4-5] 10:45AM PT-17.8* PTT-150* INR(PT)-2.0 ECHO: The left ventricular cavity size is normal. Left ventricular systolic function appears grossly preserved but regional wall motion could not be fully assessed. The inferior wall and apex were not well visualized. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Brief Hospital Course: Ms. [Known lastname 20598] is a 78 year old woman who presented with an inferior STEMI on [4-5]. She has 3VD with placement of a cypher stent in the RCA RPL branch as culprit lesion. She was started on plavix and aspirin. She did appear to have ischemic MR since she had tall V waves which resolved after stent placement in the RPL which supplies the posterior leaflet of the mitral valve. Her repeat echo showed an EF of 55% and 2+ MR. Cardiac surgery was consulted for operative revascularization. She was taken to the operating room with Dr. [Last Name (STitle) ] on [4-9] for CABGx3, LIMA-LAD, SVG-OM1, SVG-PDA. The mitral regurgitation was found to be mild in the operating room by TEE and the MVR was not replaced. She tollerated the procedure well and was transfered to the CSRU in stable condition. Upon arrival to the CSRU she was found to have ST changes on her EKG. A TEE was performed which showed mild inferior hypokinesis which was not thought to be significant. She was weaned and extubated from mechanical ventillation without difficulty and remained hemodynamically stable with a good cardiac index. She developed atrial fibrillation on POD#2 and was started on amiodarone. She was transfered to the floor on POD#3 where she began working with physical therapy. She quickly progressed with physical therapy, but repeatedly complained on feeling short of breath with ambulation. Her lasix was increased and a CXR did not show significant effusions or infiltrate. On POD#7 she was noted to have an elevated WBC. Medications on Admission: atenolol, nifedipine, aspirin 81, evista, elavil PRN Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 7. 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 8. 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 9. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a day for 1 months. Disp:60 Tablet(s) Refills:0 11. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 12. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 932] Area VNA Discharge Diagnosis: s/p ST elevation myocardial infarction s/p CABG hypertension glaucoma s/p eye surgery anxiety Discharge Condition: good Discharge Instructions: you may take a shower and wash your incisions with mild soap and water do not swim or take a bath for 1 month do not drive for 1 month do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 10 pounds for 1 month Followup Instructions: follow up with Dr. [Last Name (STitle) 32296] in [1-26] weeks follow up with Dr. [Last Name (STitle) 60853] in [1-26] weeks follow up with Dr. [Last Name (STitle) ] in [3-27] weeks ICD9 Codes: 4240, 4280, 9971, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8073 }	Medical Text: Admission Date: [2187-5-8] Discharge Date: [2187-5-10] Date of Birth: [2101-6-24] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2880] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: DDD pacemaker implantation History of Present Illness: Mr [Known lastname 4020] is an 85 year old male with history of CAD s/p CABG x2 and s/p AVR with bioprosthetic valve (not on anticoagulation), transferred from [Hospital1 ] [Location (un) 620] with complete heart block. He has been experiencing recurrent episodes of lightheadedness upon standing and falls for the past two weeks. He has been generally asymptomatic when lying still, but repeatedly feels lightheaded when standing. Has not had any nausea, diaphoresis, or chest pain. Hit head softly one week ago, but denies loss of consciousness. . On presentation to [Hospital1 ] [Location (un) 620], initial VS were 97.3, 152/73, 37, 16, 100% 2l NC. Labs there showed hct 39.3, BUN/creat 54/1.4, INR 1.1, Alk phos 234, AST 147 (ALT 51), and normal CK/MB/trop. ECG showed complete heart block with wide-QRS complex escape beats. CXR showed no acute processes. He was seen by cardiology who recommended transfer to [Hospital1 18]. . In the ED, initial VS were 98.0, 132/63 22 100% 2L NC. Ventricular rate was consistently in the 30s. ECG showed complete heart block, with ventricular escape beats, rate in the 30s. Labs revealed hct 34.7 (baseline high 20s-low 30s), elevated BUN/creat 56/1.2, negative troponin, and normal potassium, magnesium, and other electrolytes. Pacer pads were placed on his chest but were not employed. . Upon arrival to the CCU, the patient is without significant complaints. He is awake, alert, and appears comfortable. He is persistently bradycardic to the 30s, with occasional runs of hemodynamically insignificant NSVT. . On review of systems, he endorses only chronic polyarticular arthralgias. He denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, or ankle edema. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: [2177-8-19]: CABG x4: -in-situ LIMA to diagonal -reversed SVG to distal LAD -reversed SVG to OM1 -reversed SVG to PDA [2184-1-15]: -Redo CABG x2: SVG to LAD, SVG to PDA -AVR with 23 mm Biocor porcine valve. -Endoscopic vein harvesting -c/b post-operative atrial fibrillation requiring amiodarone . OTHER PAST MEDICAL HISTORY: - Unresponsive episode in [2187-3-6] believed [2-7] TIA vs seizure - L3-L4 spinal stenosis - L basilic vein thrombosis [8-6] - Parkinson's disease - BPH - diverticulosis - arthritis - s/p cataract surgery - s/p tonsillectomy Social History: Retired engineer. Denies any tobacco history or significant alcohol intake. Wife passed away in [2179]. Lives home alone, but has several children and friends visit him daily. Family History: - No family history of arrhythmia, cardiomyopathies, or sudden cardiac death - Mother: [Name (NI) 5895] disease - Father: Alcoholism, ?MI at age 40 - Son: tourette's disease Physical Exam: VS: T=97.1 BP=132/108 HR=43 RR=16 O2 sat=99% 4L NC GENERAL: Elderly caucasian gentleman with Parkinsonian features. NAD. Oriented x3. Mood, affect appropriate. HEENT: Masked facies. NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 7 cm H20. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Regular rhythm, bradycardic. Absent S1, prominent S2. +Holosystolic murmur most prominent at LUSB. No rubs or lifts. LUNGS: CTAB, no W/R/R. No accessory muscle use ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: +High frequency, low amplitude upper extremity tremor, which decreases with purposeful movements. No c/c/e. No femoral bruits. SKIN: No rashes PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . VS: T=97.1 BP=128/88 HR=56 RR=16 O2 sat=98%2L GENERAL: Elderly caucasian gentleman with Parkinsonian features. NAD. Oriented x3. Mood, affect appropriate. HEENT: Masked facies. NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 7 cm H20. CHEST: Pacemaker site without tenderness or erythema CARDIAC: PMI located in 5th intercostal space, midclavicular line. Regular rhythm, bradycardic. Absent S1, prominent S2. +Holosystolic murmur most prominent at LUSB. No rubs or lifts. LUNGS: CTAB, no W/R/R. No accessory muscle use ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: +High frequency, low amplitude upper extremity tremor, which decreases with purposeful movements. No c/c/e. No femoral bruits. SKIN: No rashes PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Lab Trends: . CBC: [2187-5-8] 06:00PM BLOOD WBC-7.4 RBC-3.57* Hgb-11.8# Hct-34.7# MCV-97 MCH-33.2* MCHC-34.2 RDW-13.4 Plt Ct-161# [2187-5-9] 02:24AM BLOOD WBC-7.6 RBC-3.51* Hgb-11.5* Hct-34.0* MCV-97 MCH-32.9* MCHC-34.0 RDW-13.2 Plt Ct-143* [2187-5-10] 12:40AM BLOOD WBC-8.0 RBC-3.60* Hgb-11.8* Hct-34.2* MCV-95 MCH-32.8* MCHC-34.5 RDW-13.3 Plt Ct-163 . INR [2187-5-8] 06:00PM BLOOD PT-13.8* PTT-27.7 INR(PT)-1.2* . Chemistry: [2187-5-8] 06:00PM BLOOD Glucose-93 UreaN-56* Creat-1.2 Na-141 K-4.5 Cl-107 HCO3-27 AnGap-12 [2187-5-9] 02:24AM BLOOD Glucose-105* UreaN-54* Creat-1.3* Na-140 K-4.7 Cl-107 HCO3-26 AnGap-12 [2187-5-10] 12:40AM BLOOD Glucose-91 UreaN-38* Creat-1.2 Na-139 K-4.7 Cl-107 HCO3-26 AnGap-11 . LFTs: [2187-5-8] 06:00PM BLOOD ALT-60* AST-125* CK(CPK)-90 AlkPhos-171* TotBili-0.4 [2187-5-9] 02:24AM BLOOD ALT-34 AST-105* AlkPhos-160* TotBili-0.6 [2187-5-10] 12:40AM BLOOD ALT-22 AST-66* AlkPhos-146* TotBili-0.5 . CXR [5-10] FINDINGS: Sternotomy wires are midline. The first sternotomy wire is fractured, but unchanged since [2184-2-6]. A left pacemaker device is noted with leads terminating appropriately in the right atrium and right ventricle. Mediastinal surgical clips are noted. Bilateral lungs show changes consistent with chronic lung disease; however, no focal consolidation, pleural effusion, or pneumothorax is noted. The cardiac, mediastinal and hilar contours are within normal limits. IMPRESSION: No consolidation, pleural effusion, or pneumothorax. . ECG [5-8]: Sinus rhythm with complete heart block and ventricular escape rhythm. Compared to the previous tracing of [2184-2-4] complete heart block is new. TRACING #1 - Prior ECG ([2184-2-4]): Sinus rhythm. Left bundle-branch block. Baseline artifact. Compared to the previous tracing of [2184-1-20] the lateral T waves are upright. The inferior T waves are still inverted. These changes may be non-specific but clinical correlation is suggested . ECG [5-9]: Ventricular paced rhythm. Compared to the previous tracing pacing is now present. TRACING #2 Brief Hospital Course: 85 y/o M with hx CAD s/p CABG x2, AS s/p AVR, LBBB, Htn, HL, presenting with several episodes of presyncope and syncope over the past several weeks, found to be in complete heart block now s/p successful pacemaker placement . ACTIVE ISSUES: . # Complete heart block/syncope: Presenting EKG showed complete heart block. The patient underwent placement of PPM without complication. The etiology of the patient's heartblock was thought to be sick-sinus syndrome; CEs were serially negative and there were no ischemic changes on serial EKGs although a missed ischemic event was considered; TSH was within normal limits; lyme serologies were negative. BB was initially held in the acute setting then restarted after PPM placement when the patient became hypertensive. The patient was discharged on 12.5mg daily metoprolol succinate at his home dose and follow-up with the device clinic as well as antibiotics for 48h. . # HTN: Became hypertensive after placement of PPM in the setting of holding BB. Became normotensive after restarting home dose metoprolol as above. . # Elevated LFTs: LFTs were found to be mildly elevated from baseline, in particular the patient's AP. Further work-up was deferred for the outpatient setting. . # Delirium: The patient had an episode of delirium after placement of PPM attributed to medical stressors and environmental change in the setting of low cognitive reserve due to Parkinson's and advanced age. The episode resolved with Trazodone. There was no clear toxic-metabolic etiology of the delirium; he remained hemodynamically stable. . INACTIVE ISSUES: . # CAD s/p CABG: Presented with symptoms of ACS. Continued outpatient regimen. Became hypertensive off of BB, which was then restarted at home dose. . # Parkinsons disease: Continued on sinemet, ropinorole . # Spinal stenosis: Presented with chronic paresthesias and tingling in lower extremities; no changes were made to home regimen. . # BPH: Remained stable. No changes were made to home regimen. . TRANSITIONAL ISSUES: . # PPM: Follow-up with device clinic as detailed below. . # Elevated LFTs: Patient will require further work-up after discharge, starting with a RUQ ultrasound. Medications on Admission: -metoprolol 12.5 mg PO daily -simvastatin 20 mg PO daily -aspirin 325 mg PO daily -docusate 100 mg PO BID -ropinorole 1 mg PO QID -carbidopa-levodopa 25-100 PO 5x/day -vitamin C, E, B12, D, Calcium Discharge Medications: 1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 4. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO 5X/DAY (5 Times a Day). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for post-pacemaker for 2 days. Disp:6 Capsule(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital 38] Rehab Hospital at [Hospital1 ] Discharge Diagnosis: Third degree AV block 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 Mr [Known lastname 4020] it was a pleasure taking care of you. . You were admitted due to weakness and repeated episodes of fainting in recent weeks. You were found to have very slow heart rate. A pacemaker was implanted in your chest in order to help your heart beat at a normal rate. . You are discharged with the following new medication: . Cephalexin 500 mg Capsule, take One (1) Capsule PO Q8H (every 8 hours) for 2 days to prevent infection. . No other changes were made to your medications, please continue to take your regular medications as prescribed. . For the next week please avoid lifting or other strenous activity involving your left arm. Also avoid raising your left arm about above the level of the shoulder. Followup Instructions: please keep the following appointments: . Name: [Last Name (LF) ],[First Name3 (LF) 35386] I. MD Location: [Location (un) ] [University/College ] FAMILY MEDICINE Address: [Street Address(2) ], [Apartment Address(1) 35387], [Location (un) 35388],[Numeric Identifier ] Phone: [Telephone/Fax (1) 17203] Appointment: Wednesday [2187-5-16] 10:30am Department: CARDIAC SERVICES When: THURSDAY [2187-5-17] at 10:00 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) 900] [Last Name (NamePattern1) 2882] MD, [MD Number(3) 2883] ICD9 Codes: 2930
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8074 }	Medical Text: Admission Date: [2192-11-3] Discharge Date: [2192-11-15] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 77 year old man with a history of diabetes mellitus, coronary artery disease, status post three vessel coronary artery bypass grafting and status post mitral valve replacement, who presented to an outside hospital with ventricular tachycardia, progressing to a ventricular fibrillation arrest, with chronic defibrillation times two. The patient reports he was driving his car when he began to note some lightheadedness. He pulled over to the side of the road and then lost consciousness. Prior to this, he had no symptoms of chest pain, shortness of breath, diaphoresis or any other anginal equivalent at that time. He was found a short time later, he does not know how long. Emergency medical service was called and an electrocardiogram at that time reportedly revealed supraventricular tachycardia at a rate of 200 to 210, although no strips are available for review. The patient was given 6 mg of Adenosine en route to an outside hospital, which had essentially no effect. Upon arrival to the outside hospital, he was found to be in a tachycardia to approximately 200, of unknown etiology. He then rapidly progressed to monomorphic ventricular tachycardia, became pulseless and cyanotic, for which he was rapidly defibrillated at 200 joules, with an immediate resumption of normal sinus rhythm. The patient again went into ventricular tachycardia a short time later, with degeneration into ventricular fibrillation and was again defibrillated, this time with 300 joules, again returning to normal sinus rhythm immediately. At this time, he was given a 100 mg Lidocaine bolus and a 2 mg/minute continuous intravenous drip was started. The patient remained in normal sinus rhythm after that and was transferred to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] for further management. Of note, the patient denies ever having had an anginal equivalent or chest pain in the past. His initial coronary artery disease was picked up on a routine workup for another medical illness that he does not recall, ultimately resulting in stress, cardiac catheterization and then coronary artery bypass grafting. Upon arrival to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ], the patient was without complaint. He had no chest pain or shortness of breath. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post three vessel coronary artery bypass grafting in [2183]; also performed at the same time was a mitral valve repair which failed; patient then had a mitral valve replacement with a mechanical valve approximately in [2184]. 2. Abdominal aortic aneurysm repair. 3. Diabetes mellitus times ten years, controlled with Glynase after diet management failed. 4. Peptic ulcer disease. MEDICATIONS ON ADMISSION: Adalat 30 mg p.o.q.d., Lopressor 50 mg p.o.b.i.d., Lipitor 10 mg p.o.q.d., Glynase 3 mg p.o.q.d., Accupril 20 mg p.o.q.d., Lanoxin 0.125 mg p.o.b.i.d. (patient verifies that his dosing is b.i.d.), Coumadin 2.5 mg p.o.q.d., Prevacid 30 mg p.o.q.d., Zantac 150 mg p.o.q.d. ALLERGIES: Penicillin (rash). SOCIAL HISTORY: The patient does not currently smoke, he quit 20 years ago, and denies any alcohol intake. He lives with his wife in [Name (NI) ]. He is a retired police officer. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On physical examination on admission, the patient had a blood pressure of 143/103, pulse 69 and regular, respiratory rate 18 and oxygen saturation 98% in room air. General: Well appearing, in no acute distress. Head, eyes, ears, nose and throat: Anicteric sclerae, oropharynx clear with moist mucous membranes. Neck: Jugular venous pressure to 6 cm, estimated central venous pressure of approximately 14. Respiratory: Lungs clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, mechanical S1, normal S2, soft crescendo-decrescendo systolic murmur best heard at left sternal border, nonradiating. Abdomen: Old surgical scars, soft, benign. Rectal: Brown guaiac negative stool. Extremities: No cyanosis, clubbing or edema, 2+ pulses bilaterally. LABORATORY DATA: Electrocardiogram on admission showed normal sinus rhythm at 71 beats per minute, normal axis, normal intervals, borderline first degree A-V block, partial right bundle branch block, T wave inversions in II, III, V5 and V6. HOSPITAL COURSE: 1. Cardiovascular: Given the patient's extensive history of coronary artery disease, it was suspected that he had had a primary arrhythmic event and this is what led to his monomorphic ventricular tachycardia and his need for defibrillation. The patient was continued on Lidocaine overnight, which was stopped on hospital day number two, after he had been stable. He was scheduled to go to the electrophysiology laboratory for an electrophysiology study. Cardiac enzymes were cycled and revealed CKs of 187, 228 and 215 with MBs of 14, 18 and 16. We believed that this was a troponin leak secondary to his tachycardia and not a primary event. However, given the patient's extensive history, we could not rule out a primary cardiac vent leading to the arrhythmia. The plan was for the patient to go to the cardiac catheterization laboratory and, following his catheterization, go to the electrophysiology laboratory for an electrophysiology study and, most likely, an ICD placement. On hospital day number two, however, the patient began to develop increasing blood pressure to approximately 200 systolic. He then developed rales bilaterally, approximately one-half way up, and his oxygen requirement began to increase. It was believed that the patient had flashed into pulmonary edema and he was diuresed with Lasix. On hospital day number three, the patient's lungs were clear and his oxygen requirement had returned to [Location 213], however, the patient's BUN and creatinine had risen. His creatinine on hospital day two was in the mid-2s compared with 1.6 on admission. Because of this rise in creatinine, it was believed it was not safe at the current time to send him to the catheterization laboratory, so catheterization was delayed. The electrophysiology service offered, in light of his delayed catheterization, to take the patient to the electrophysiology for an electrophysiology study to see if he had an ablatable focus. On [2192-11-7], the patient was taken to the electrophysiology laboratory. A focus of atrial tachycardia was found, which was ablated during the electrophysiology study. A plan was made for the patient to have a pacemaker and ICD placement after his catheterization. On the same day, an echocardiogram was performed which revealed mild symmetric left ventricular hypertrophy, normal left ventricular cavity size, severely depressed left ventricular function with a left ventricular ejection fraction of 25% to 30% and sever global left ventricular hypokinesis. The patient also showed a depressed right ventricular function, moderate tricuspid regurgitation, mitral valve prosthesis with normal function, no mitral regurgitation. The patient continued to be stable following his electrophysiology study and was transferred to the floor awaiting his catheterization. Catheterization was performed and revealed a 100% occluded right coronary artery, left anterior descending artery and left circumflex. The patient also had three saphenous vein grafts. The superior saphenous vein graft to the obtuse marginal two was patent. Saphenous vein graft to the distal right coronary artery was patent but the saphenous vein graft to the left anterior descending artery was occluded proximally with a mid- left anterior descending artery and distal graft filling via right-to-left collaterals. At the time, the decision was made to do no intervention and that medical management only would be preferred. The patient was sent back to the floor and, the following day, had an electrophysiology study in which an ICD was implanted with DDD mode pacing capabilities. The procedure was uncomplicated and the patient was returned back to the floor in stable condition. Upon returning back to the floor, the patient's Coumadin was restarted, although he was continued on heparin for his mechanical valve. The patient remained in house for four days awaiting his INR to become therapeutic. On the day of discharge, his INR was 2.1 and it was deemed safe to send him home. The patient will have no medications make. I will tell him to return to his 2.5 mg daily of Coumadin and he will follow up with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 24717], the day following discharge. Additionally, per patient's discussion with the electrophysiology team, electrophysiology will see him today before he leaves and then, one month from now, he will be seen by Dr. [Last Name (STitle) 1911] for follow-up on his ICD pacemaker implantation. DISCHARGE DIAGNOSIS: Ventricular fibrillation. Coronary artery disease. Flash pulmonary edema. Anticoagulation for mechanical mitral valve. DISCHARGE MEDICATIONS: Adalat 30 mg p.o.q.d. Lopressor 50 mg p.o.b.i.d. Lipitor 10 mg p.o.q.d. Glynase 3 mg p.o.q.d. Accupril 20 mg p.o.q.d. Lanoxin 0.125 mg p.o.b.i.d. Coumadin 2.5 mg p.o.q.d. Prevacid 30 mg p.o.q.d. Zantac 150 mg p.o.q.d. DISCHARGE STATUS: To home. DISCHARGE CONDITION: Stable. FOLLOW-UP: The patient will follow up with Dr. [Last Name (STitle) 24717], his primary care physician. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], M.D. [MD Number(1) 1014] Dictated By:[Last Name (NamePattern1) 1213] MEDQUIST36 D: [2192-11-15] 10:21 T: [2192-11-19] 07:28 JOB#: [Job Number ] cc:[Numeric Identifier 39461] ICD9 Codes: 4275, 4271, 4280, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8075 }	Medical Text: Admission Date: [2178-8-13] Discharge Date: [2178-8-16] Date of Birth: [2104-11-4] Sex: F Service: MEDICINE Allergies: Dilantin / Depakote / Zoloft / Cyclobenzaprine / Celexa Attending:[First Name3 (LF) 1145] Chief Complaint: chest pain and nausea Major Surgical or Invasive Procedure: Cardiac Catheterization with Drug Eluting Stents to Left Anterior Descending and Right Coronary Artery History of Present Illness: 73 y/o F with htn, dyslipidemia, hx seizure d/o who presents with substernal CP lasting hours. She had subtle inferior ST changes, interpreted as 1mm inferior ST elevations at [Hospital1 ] 1700 [8-13] arrival. Pt was hemodynamically stable, BP 136/82, p83. Recieved asa, plavix, integrillin bolus and heparin medication error, 25k U were bolused. The pt was transferred to [Hospital1 18] for cath, although immediate cath was postponed due to bleeding risk. ST changes were resolved by arrival at [Hospital1 18]. The cardiac enzymes were (-)x3. Pt went to cath [8-14] 0800 for unstable angina. Cypher to LAD and RCA. Past Medical History: htn, dyslipidemia, hx seizure Social History: no alcohol, smoking, drugs Family History: father with MI, sister with [Name2 (NI) ] Physical Exam: 97.7 81 164/78 14 Flat Jugular veins S4 gallop, no murmurs clear lungs bengin abdomen no edema Pertinent Results: EKG: small Q waves in II, III, aVF . Cath [2178-8-14]: LMCA: 20% ostial LAD: 20% ostial, 70% mid-cypher LCX: normal RCA: 90% ostial-cypher . Echo [2178-8-14]: LVEF 75-80% nl LV and LA size. LVOT gradient: peak 40. nl RV size/fxn 1+ MR . Labs on Admission to [Hospital1 18]: [2178-8-13] 08:15PM WBC-7.2 RBC-3.90* HGB-11.8* HCT-32.6* MCV-84 MCH-30.2 MCHC-36.1* RDW-12.6 [2178-8-13] 08:15PM PLT COUNT-280 [2178-8-13] 08:15PM PT-64.6* PTT-150* INR(PT)-34.8 [2178-8-13] 08:15PM GLUCOSE-102 UREA N-9 CREAT-0.7 SODIUM-139 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 [2178-8-13] 08:15PM CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-1.9 [2178-8-13] 08:15PM CK-MB-NotDone cTropnT-<0.01 [2178-8-13] 08:15PM BLOOD CK(CPK)-64 [2178-8-14] 03:19AM BLOOD CK(CPK)-53 [2178-8-14] 04:51PM BLOOD CK(CPK)-43 [2178-8-15] 05:57AM BLOOD CK(CPK)-44 Brief Hospital Course: 73 y/o F with htn, dyslipidemia, hx seizure d/o who presented with unstable angina with subtle ST changes at OSH, cardiac enzymes were negative x3. She had cath with stent to LAD and RCA once her coagulation issue was resloved after recieving supratheraputic heparin dose before transfer to [Hospital1 18]. . 1. Unstable angina: She had subtle inferior ST changes with symptomes of chest pain and nausea. Had catheterization with stents to LAD and RCA. DShe tolerated the procedure well. We treated her with ASA/plavix/statin/toprol XL/lisinopril. To follow up at [Hospital3 1280] with Dr. [Last Name (STitle) ] of Cardiology. Needs Cardiac Rehabilitation. . 2. Hypothyoroid: We continued her synthroid at her home dose. . 3. H/O Seizures: No seizure activity. We coninued her phenobarbital at 100mg QD. . 4. Back Pain: She had one episode of back pain which quickly resolved. We did not believe that this was a retroperitoneal bleed but watched her closely for it. . She was given pneumovax on discharge [2178-8-16]. Medications on Admission: toprol xl 50 QD zestril 20 QD synthroid prevacid 20 QD phenobarb 100 mg QD . All: Dilantin, depakote, zoloft, flexeril, celexa Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please be sure to take every day. Disp:30 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Phenobarbital 100 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:30 Tablet(s) Refills:2 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:90 Tablet Sustained Release 24HR(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Unstable Angina Coronary Artery Disease Discharge Condition: Stable without chest pain or nausea. Discharge Instructions: Please call your doctor and go to the emergency room if you experience return of your chest pain, or worsening nausea or vomiting. Please make an appointment to see your primary care provider this week. Please make an appointment with Cardiologist, [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [Hospital6 3872] [Apartment Address(1) 62525], [Location (un) 1110], [Telephone/Fax (1) 62526] Followup Instructions: Please make an appointment to see your primary care provider this week. Please make an appointment with Cardiologist, [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [Hospital6 3872] [Apartment Address(1) 62525], [Location (un) 1110], [Telephone/Fax (1) 62526] Completed by:[2178-8-18] ICD9 Codes: 4111, 2765, 4019, 2724, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8076 }	Medical Text: Admission Date: [2135-4-6] Discharge Date: [2135-4-11] Date of Birth: [2090-2-1] Sex: F Service: GYN REASON FOR ADMISSION: The patient was admitted postoperatively from a total abdominal hysterectomy. ADMISSION DIAGNOSIS: 1. Status post total abdominal hysterectomy. 2. Status post postoperative hemorrhage, reexploration, and religation of the right uterine artery. 3. Postoperative anemia. DISCHARGE DIAGNOSES: 1. Status post total abdominal hysterectomy. 2. Status post postoperative hemorrhage, reexploration, and religation of the right uterine artery. 3. Postoperative anemia. DISCHARGE MEDICATIONS: 1. Iron. 2. Colace. 3. Percocet. 4. Motrin. HISTORY OF HOSPITALIZATION: The patient was admitted status post total abdominal hysterectomy secondary to uterine fibroids. Please see admission operative note for full details. She is a 45-year-old gravida 2, para 2 with a history of large fibroid uterus and menometrorrhagia. Her fibroid uterus was approximately 20 cm in size. PAST MEDICAL HISTORY: C section x2. She has no medical history. PHYSICAL EXAMINATION: Physical exam is within normal limits. With noting her fibroid uterus, decision was made to proceed with a total abdominal hysterectomy. At the time, this was felt to be uncomplicated, however, when the patient was transferred to the floor, she was dizzy and nauseated. Her blood pressure is found to be 54/palp and the heart rate was in the 100s, the sat was 95%. She was evaluated at that time, placed on Trendelenburg, and given IV bolus until her blood pressures resolved to the 80s-90s/30s-40s. A second drop in blood pressure was noted 67/38. A STAT hematocrit was sent, and a MICU consult was initiated. She had been putting out 200-400 cc urine in each hour, however, the concern was for bleeding, and she was noted to be slightly distended. Decision was made to proceed to the operating room. She was type and crossed for 4 units, and she proceeded to the operating room. The laparotomy revealed bleeding at the right uterine artery pedicle which was ligated. Please see full operative report for details of that procedure. She received 2 units of blood intraoperatively as well as 2 units postoperatively. She was transferred to the MICU postoperatively for immediate postoperative care as she was extubated 8:30 or 9 pm. She was maintained overnight in the MICU. Was found to be hemodynamically stable, and transferred to the floor the following morning. At that time, her hematocrit was noted to be 34.4 and her laboratory values were within normal limits. She was advanced within her diet. Her calcium was noted to be low at 7.1 and was repleted. She was hemodynamically stable with adequate urine output. Her blood pressure was stable. She was maintained on STD prophylaxis, and she was transferred on postoperative day one from the MICU to the floor. At that time, the beginnings of her routine postoperative care were initiated. Her diet was advanced over the following few days, and she was able to tolerate a regular diet. She was noted to be tachycardic on postoperative day one on the late afternoon with a heart rate in the 120s. The chest x-ray was obtained, and she was found to have a small left pleural effusion. Chem-10 was obtained and all electrolytes were noted to be within normal limits. The following day she was monitored, the question of pain medications arose with regard to her tachycardia. She also noted had chest discomfort and CTA was ordered the following day which was read as negative with small bilateral pleural effusions and patient was not thought to have a pulmonary embolus. She was maintained on the next four days. Her diet was advanced. Her pain control improved. Her tachycardia resolved, and she underwent routine postoperative care. On [4-9], two days prior to discharge, she was notably vomiting and had nausea overnight, however, this was self limited, resolved on its own, and on postoperative day five, [2135-4-11], she was greatly improved. She was tolerating regular diet, voiding spontaneously without a Foley catheter. Her tachycardia had stabilized at 90s-100s, and she was discharged home in stable condition on postoperative day five to followup with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. [First Name11 (Name Pattern1) 412] [Last Name (NamePattern4) 108522], M.D. [MD Number(1) 108523] Dictated By:[Dictator Info ] MEDQUIST36 D: [2135-4-13] 21:56 T: [2135-4-18] 06:58 JOB#: [Job Number 108524] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8077 }	Medical Text: Admission Date: [2196-1-29] Discharge Date: [2196-2-17] Date of Birth: [2118-8-17] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Vicodin / Demerol Attending:[First Name3 (LF) 165] Chief Complaint: Worsening Dyspnea on Exertion, Chest Pain Major Surgical or Invasive Procedure: [2196-2-2] Cardiac catheterization [2196-2-8] AVR ( 23 mm CE pericardial)/ MV repair (28 mm [Company 1543] CG Future ring)/ CABG X 2 ( LIMA to LAD , SVG to OM)/aortic endarterectomy Hypertension Moderate Aortic Stenosis - valve area of 1cm in [2188] (last echo in our system) Mild LVH Gout GERD L3-L5 Laminectomy in [2192] Post nasal drips s/p hysterectomy s/p tonsillectomy Pneumonia History of Present Illness: Ms. [Known lastname 30016] is a 77 year old female with a h/o moderate aortic stenosis (valve area 1cm on echo in [2188]), HTN, LVH who presents with a few weeks of worsening dyspnea on exertion. She reports shortness of breath and feeling as though her throat is closing with any amount of activity, about 25 steps, which resolves with rest. She has also had a wet, nonproductive cough that is worse with deep breathing. She denies any orthopnea, LE edema, recent illnesses. She reports the throat tightness being present for past few years, always with exertion and relieved by rest and drinking ice water. She also has been having intermittent jaw pain, usually associated with the throat tightness, never occurs at rest. She denies any associated chest pain, but has been very bothered by her "wet", nonproductive cough which only occurs when she takes a deep breath, which she says is a change from prior. . In the ED, initial vitals were 97.8, 115, 131/73, 20, 95% on RA. Labs and imaging significant for a troponin of 0.02, BNP of 3456, D-dimer of 438, EKG was sinus tachycardia with a LBBB, with no priors for comparison. Cardiology was consulted who felt that she was in heart failure likely due to worsening of her AS but could also be ischemic, her symptoms of throat tightening were concerning for angina given that it resolves with rest. The cardiology fellow felt that her LBBB was likely related to a structural problem, so no need for anti-coagulation at this time. Patient was given aspirin 325 mg. Vitals on transfer were 109, 103/86, 18, 93% on RA. . On arrival to the floor her initial VS were: 98.6, 110/66, 109, 20, 95% on RA, patient currently feels well, says that she only has trouble breathing when she moves around or is coughing for a long period of time. Also, she is concerned about what she thinks is a fungal infection in her groin area, which she has had in the past and is currently somewhat painful. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Moderate Aortic Stenosis - valve area of 1cm in [2188] (last echo in our system) Mild LVH Gout GERD L3-L5 Laminectomy in [2192] Social History: Used to work as an occupational therapist, widowed. -Tobacco history: denies -ETOH: very rare -Illicit drugs: denies Family History: Significant for mother who died of heart disease, father who died of CA of the prostate and also heart disease. She has a son with CAD, an aunt on her mother's side who died of breast cancer. She has three siblings, all of whom are alive; two of them have heart issues. Physical Exam: On admission: VS: T=98.6 BP=110/66 HR=109 RR=20 O2 sat=98% on RA GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, +HJR, JVP CARDIAC: RR, normal S1, S2, systolic murmur best heard at LUSB, No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use, decreased breath sounds at the bases, crackles about [12-27] the way up ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: Admission labs: [2196-1-29] 06:30PM BLOOD WBC-9.4 RBC-4.54 Hgb-13.9 Hct-40.5 MCV-89 MCH-30.7 MCHC-34.4 RDW-14.3 Plt Ct-257 [2196-1-29] 06:30PM BLOOD Neuts-61.5 Lymphs-32.0 Monos-4.0 Eos-1.6 Baso-0.9 [2196-1-29] 06:30PM BLOOD PT-14.2* PTT-23.4 INR(PT)-1.2* [2196-1-29] 06:30PM BLOOD Glucose-119* UreaN-17 Creat-0.8 Na-138 K-4.2 Cl-100 HCO3-22 AnGap-20 [2196-1-29] 06:30PM BLOOD CK(CPK)-54 [2196-1-30] 02:42AM BLOOD CK(CPK)-33 [2196-1-30] 11:20AM BLOOD CK(CPK)-43 [2196-2-2] 10:33AM BLOOD ALT-30 AST-33 AlkPhos-57 Amylase-42 TotBili-0.5 DirBili-0.2 IndBili-0.3 [2196-1-29] 06:30PM BLOOD CK-MB-3 proBNP-3456* [2196-1-29] 06:30PM BLOOD cTropnT-0.02* [2196-1-30] 02:42AM BLOOD CK-MB-2 cTropnT-0.02* [2196-1-30] 11:20AM BLOOD CK-MB-2 cTropnT-<0.01 [2196-1-30] 02:42AM BLOOD Calcium-9.9 Phos-3.9 Mg-2.0 Cholest-156 [2196-2-3] 07:00AM BLOOD %HbA1c-6.2* eAG-131* [2196-1-30] 02:42AM BLOOD Triglyc-88 HDL-43 CHOL/HD-3.6 LDLcalc-95 LDLmeas-106 Carotid U/S: Bilateral calcified plaque slightly greater on the right, but no hemodynamically significant stenosis identified. . CXR [1-29]: Bilateral small pleural effusions with bibasilar atelectasis, unchanged. Background emphysema. . Cath [2-2]: 1. Selective coronary angiography revealed moderate LMCA and multivessel coronary artery disease. The LMCA is heavily calcified with 40-50% stenosis. The LAD is heavily calcified with mid vessel 40-50% stenosis (relative to calcium shell). There is a distal short myocardial bridge with systolic compression. There is mild-moderate diffuse disease apically, a modest D1 and larger D2. The LCx is heavily calcified. There is a tiny OM1 and OM2. There is proximal-mid tubular ulcerated eccentric 70% stenosis before OM3. OM3 has a large lower pole with hazy 85%stenosis. There is a modest OM4 and OM5. OM6/LPL1 has proximal 80% stenosis. There is a small LPL2, patent LPDA and distal AV groove Cx. The RCA is heavily calcified. It is a small, nondominant vessel which is mildly moderately diffusely diseased. It supplies conus and atrial branches. 2. Resting hemodynamics revealed elevated left and right sided filling pressures with RVEDP 9 mmHg and LVEDP 21 mmHg. There is mild pulmonary arterial hypertension with PASP 38 mmHg. The PCWP is moderately elevated at entry at 18 mmHg. The cardiac output is minimally depressed with CI 2.46 L/min/m2 (using an assumed oxygen consumption). There was severe aortic stenosis with a mean gradient of 36 mmHg and a calculated valve area of 0.7 cm2. FINAL DIAGNOSIS: 1. Moderate LMCA and multivessel coronary artery disease in a left dominant system. 2. Severe aortic stenosis 3. Moderate left ventricular diastolic heart failure in setting of newly diagnosed systolic heart failure. 4 .Mild pulmonary arterial hypertension. 5. Vagal reaction to attempts at right antecubital venous access. . CT chest: 1. Thoracic aortic calcifications as described. Severe coronary calcifications. Severe aortic valvular calcifications. 2. 5-mm left lower lobe pulmonary nodule. In the absence of risk factors, a 12-month followup chest CT is warranted. However if risk factors are present then a six-month followup is warranted. 3. Left thyroid nodule, for which an ultrasound could be performed. 4. Incompletely evaluated left adrenal lesion and incompletely evaluated right liver lesion. These could be further evaluated with CT or MRI. 5. Bilateral pleural effusions and atelectasis. 6. Biapical mild centrilobular emphysema. Conclusions Prebypass No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with borderline normal function of the inferior and anterior walls, severe hypokinesis of the inferior and anterior septal and septal walls, dyskinesis of the anterior, apical septum and apical akinesis. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen due to bileaflet tethering. There is no pericardial effusion. Postbypass The patient is on infusions of milrinone and norepinephrine and is A-paced. There is a new mitral annuloplasty ring which appears well-seated. Immediately postbypass, there was a jet of mitral regurgitation moderate in severity originating from the base of the anterior leaflet just inside the annuloplasty ring, likely around the A3 scallop, consistent with a perforation in the base of the leaflet. After discussion with the surgeon, the patient was returned to bypass for repair. After coming off cardiopulmonary bypass for a second time, this regurgitant lesion was now mild in intensity. There was also mild regurgitation from the coaptation point. There is no evidence of systolic anterior motion of the anterior mitral leaflet and there is no stenosis (mean gradient 2 mmHg at a CO of 3.6 L/min). There is also a new bioprosthetic valve in the aortic position which is well-seated without evidence of regurgitation or paravalvular leak. Gradient through this valve is peak/mean [11-28] mmHg at a CO of 3.6 L/min. Left ventricular function is slightly improved (LVEF now 25%) with some improved contractility of the lateral, inferior and anterior walls. The anteroseptal wall continues to be dyskinetic with severe hypokinesis/akinesis of the septum and apex). The thoracic aorta is intact. Dr. [Last Name (STitle) ] was notified in person of the results at the time of the study. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4901], MD, Interpreting physician [Last Name (NamePattern4) ] [2196-2-8] 20:39 Brief Hospital Course: 77 y/o female with a h/o moderate Aortic stenosis with most recent echo in [2188], HTN who presented with progressive dyspnea among other symptoms, 3VD on cath and worsening Aortic stenosis. . # Aortic stenosis - last echo in [2188] with valve area 1cm now with severe Aortic stenosis, area 0.8cm2, [12-27]+ AR. Symptoms of progressive DOE may be related to worsening Aortic stenosis. She was slightly volume overloaded on admission and diuresed with daily IV lasix. She was evaluated by cardiac surgery and found to be a good candidate for AVR; had cath done on this admission which showed 3-vessel disease (see below) and good candidate for concomitant CABG with AVR. CHF: exam, CXR and symptoms consistent with progressive CHF, last echo in [2188] showed EF 55% and echo on this admission shows markedly decreased LVEF (25%) likely in setting of CAD (3-vd on cath). She was cautiously diuresed pre-operatively. Stable Angina: She was ruled out for ACS on admission with negative enzymes. Catheterization was performed and showed moderate LMCA and multivessel coronary artery disease in a left dominant system (see cath report for details). She was on ASA 325mg daily, statin 40mg daily. # Emphysematous changes on CXR - pt is non-smoker, no occupational exposure, no history of asthma. CT chest shows mild changes, which are unlikely to be clinically significant. Pre-op w/u completed and underwent surgery with Dr. [First Name (STitle) ] on [2196-2-8]. See operative note for details. post operatively she was admitted to the CVICU in stable condition on propofol, levophed, and milrinone drips. all drips were weaed off with stable henodynamics. She was started on carvedilol, lasix and lisinopril and maintained on statin therapy. She was extubated on POD #2 and transferred to the floor on POD # 4 to begin increasing her activity level. Went into rapid A Fib and was treated with amiodarone and ultimately DCCV. Coumadin was started. Of note, she developed sacral ulcer treated with mepilex. Medications on Admission: Diovan 80mg daily Dyazide 1 tablet daily Tylenol 1000mg q6h prn pain Omeprazole 40mg daily Naproxen 250mg [Hospital1 ] SL Nitro prn Coenzyme Q10 Glucosamine Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 12. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 13. warfarin 2.5 mg Tablet Sig: as directed for afib Tablet PO once a day: dose based on daily INR until at goal of 2.0-2.5. 14. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day: 400mg [Hospital1 ] x7days then 400mg daily X7days then 200mg ongoing. 15. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 17. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day: until lower extremity resloves- may need to increase to TID. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: postop A Fib- on coumadin coronary artery disease mitral regurgitation Hypertension Moderate Aortic Stenosis - valve area of 1cm in [2188] (last echo in our system) Mild LVH Gout GERD groin fungal rash sacral ulcer L3-L5 Laminectomy in [2192] Post nasal drips s/p hysterectomy s/p tonsillectomy Pneumonia Discharge Condition: Alert and oriented x3 nonfocal requires assist with mobility Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 2+ lower extremity edema bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [First Name (STitle) ] on Monday [3-14] @ 1:15 pm [Hospital Ward Name ] 2A [Telephone/Fax (1) 170] Cardiologist:Dr. [First Name (STitle) ] [Name (STitle) ] [3-31] at 9 AM Please call to schedule appointments with your Primary Care Dr.[First Name (STitle) ] in [3-29] 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 afib Goal INR 2.0-2.5 First draw [2196-2-18] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2196-2-17] ICD9 Codes: 4111, 4271, 9971, 2851, 5990, 4241, 4280, 4019, 2749, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8078 }	Medical Text: Admission Date: [2143-10-23] Discharge Date: [2143-11-4] Date of Birth: [2093-4-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: hypoxic respiratory failure Major Surgical or Invasive Procedure: CVL insertion Mechanical Intubation Bronchoscopy with BAL OG tube insertion [First Name3 (LF) 2793] replacement therapy History of Present Illness: 50 yo M with mixed connective tissue/vasculitis with history of pulmonary hemorrhage and lupus nephritis currently being treating with prednisone and cytoxan who presented to OSH complaining of [3-13] days of worsening SOB. Per report, the patient had no recent fevers, wheezing, coughing, chest pain or nausea but did complain of worsening LE edema. In the ED there he was hypoxic to 76% on RA, RR37, HR 130s, BP 94/65. He was placed on NRP and O2 Sat improved to 88% but he continued to appear cyanotic. He was emergently intubated and intial ABG following intubation was 7.34/32.6/48.6. He was given 80 IV lasix, hydrocortisone 100, phenylephrine 50 mg IV push x 2, ketamine 100 mg IV, Succinylcholine 150 IV, and vecuronium 10 mg IV. He was transferred to [Hospital1 18], where he receives the majority of his care. . On arrival to the [Hospital1 18] ED, the patient's intial vitals were HR 132, BP 109/67, RR 22, SaO2 98%. Initial ABG on 100% FiO2 was 7.14/54/85/19. Labs were notable for WBC of 19.9 with a left shift (11% bands), Hct 31.1 (range in OMR 28-36), Cr of 2.5 from baseline 1.0, and lactate 1.0. Blood and urine cultures were sent, and he was given 2L NS, vanco 1 g IV, zosyn 4.5 mg IV. He was initially started on propofol drip but then changed to fentanyl/versed drip. CXR showed multifocal bilateral pulmonary infiltrates, and ventilator settings changed to ardsnet protocol and admitted to the MICU for further management. . On arrival to the MICU, patient was hypotensive to 80s/60s, HR 120-130s, SaO2 92%, and appeared dyssynchronous with the ventilor. He was started on peripheral neosynephrine and paralyzed with vecuronium. . Notably, patient had a recent [Hospital1 18] admission for hemoptysis ([Date range (1) 41780]). During that admission, he had a cavitaory LUL lesion for which extensive testing failed to identify specific diagnosis. During that admission, he had a CT scan, was ruled out for TB with multiple sputum tests and serologic sputum testing for Nocardia histo, coccidioidomycosis, aspergillosis were all negative. He did have an "indeterminate" quantiferon test at that time, of unclear [Name2 (NI) 41781], and has several AFB cultures still pending currently (from [8-27], [8-28], [8-29]). ANCA testing was negative and lung biopsy was considered and discussed but not done. Past Medical History: - Mixed connective tissue//vasculitis: Characterized by fluctuating lymph nodes, Raynaud's phenomenon, skin ulcerations, neuropathy, arthralgias, alopecia, and prior history of thrombocytopenia, hemolytic anemia - History of chronic inflammatory demyelinating polyneuropathy, status post four plasmapheresis sessions in [2136]. - Bilateral hip avascular necrosis in the setting of steroid therapy, status post bilateral hip replacements. -Hypertension -Hypogonadism -IV-G V lupus nephritis and class V membranous nephritis with [Year (4 digits) ] impairment, high-grade proteinuria and nephrosis -- currently receiving cytoxan/mesna monthly, has received 5 cycles, last dose 9/3 -cavitary LUL lesion with extensive ID workup neg except for indeterminate quantiferon test Social History: He denies cigarette use and uses alcohol very rarely. He denies any recent history of cocaine, IV drug, or marijuana use. Family History: His sister also has an undiagnosed autoimmune condition, currently in remission. He denies any history of diabetes, hypertension, or kidney disease in the family. Physical Exam: General Appearance: Pale, ill-appearing Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Endotracheal tube, alopecia Cardiovascular: tachycardic and regular, no murmur appreciated Peripheral Vascular: (Right radial pulse: Diminished), (Left radial pulse: Diminished), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Breath Sounds: No(t) Rhonchorous: ), coarse and rhonchorus lying flat, improved upright Abdominal: Soft, Distended, hypoactive BS Extremities: Right lower extremity edema: 2+, Left lower extremity edema: 2+, Cyanosis Skin: Cool, multiple deep, prurlent ulcers on LE b/l Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated, Paralyzed, Tone: Not assessed Pertinent Results: CT head: 1. Hemorrhagic transformation of the previously seen right MCA and PCA territorial infarct with significant mass effect causing uncal and subfalcine herniation. 2. New right thalamic infarct. 3. Mass effect effacement of ipsilateral right lateral ventricles with trapping of the left lateral ventricles. [2143-11-1] 9:52 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. FINAL REPORT [2143-11-4] GRAM STAIN (Final [2143-11-1]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2143-11-4]): RARE GROWTH Commensal Respiratory Flora. ASPERGILLUS FUMIGATUS. RARE GROWTH. IDENTIFICATION PERFORMED ON CULTURE # [Numeric Identifier 41782] [2143-10-29]. YEAST. RARE GROWTH. CUNNINGHAMELLA SP.. IDENTIFICATION PERFORMED ON CULTURE # [Numeric Identifier 41782] [2143-10-29]. Brief Hospital Course: 50 yo M with history of vasculitis including prior pulmonary hemorrhage and lupus nephritis being treated with prednisone and cytoxan who presented to [Hospital1 18] on [2143-10-23] with hypoxic respiratory failure and shock. . # Hypoxic Respiratory failure: The differential diagnosis for acute respiratory failure in this significantly immunocompromised patient included bacterial infection, fungal/PCP infection, pulmonary hemorrhage, cytoxan-induced pneumonitis. ID, Rheum, and Nephrology were consulted. The patient was intubated and had an esophageal balloon for transplerual pressure monitoring placed. Rheum thought that a vasculitic process was unlikely given that the patient was on cytoxan and prednisone as an outpatient and there was no benefit from plasmapheresis. He was treated with pulse steroids for 4 days, then tapered back to a standing dose of prednisone, which was later discontinued. [Date Range 2793] initiated CVVH given the [Initials (NamePattern4) 228] [Last Name (NamePattern4) ] and tenuous clinical picture, and this was later discontinued as his [Last Name (NamePattern4) ] function improved. Per ID, the patient was initially started on vancomycin, meropenem, IV bactrim, ambisome, and ciprofloxacin. Cultures and studies to look for CMV, crypto, PCP, [Name10 (NameIs) 41783], and fungi were sent. A sputum culture grew back yeast and mold - later identified as zygomycetes/cunninghamella and aspergillus. . # Stroke: As Mr. [Known lastname 41769] was weaned from sedation, it was noted that his mental status did not improve as expected. Head CT showed a large right MCA and PCA stroke, which was later better characterized with MRI. Stroke team was consulted and provided prognostic information to the family regarding the deficits Mr. [Known lastname 41769] could expect if he recovered from his acute illness. On [2143-11-4], he was noted to have a blown pupil, and repeat head CT showed hemorrhagic conversion of the stroke with uncal and subfalcine herniation. . # Tachycardia/Hypertension - This was thought to be in part from benzo withdrawal and also from heart failure. An echo obtained on admission showed an EF of 20-25% with moderate to severe MR. The patient was diuresed with CVVH as above with improvement in his hypoxia. However, he remained tachycardic and hypertensive. His benzo withdrawal was treated as above, and he was given some fluid back. . # Hct drop: Most concerning for pulmonary hemorrhage in setting of known vasculatis with significant lung lesion. No indication of GI bleed or other source of blood loss, although dilution could certainly be contributing to decreased counts. Stabilized. . # Acute on chronic [Date Range ] failure - The patient's creatinine on admission was 2.5, up from a baseline of 1.0. He was started on CVVH, which was stopped after 4 days. His urine output significantly improved after he was stabilized. . # Goals of care: Multiple family meetings were held with the family and with the primary MICU team as well as consultants from ID, Rheum, and Stroke. The family was clear that Mr. [Known lastname 41769] would not have wanted invasive measures to prolong his life without meaningful hope of recovery, and decided to move to DNR/CMO. He was terminally extubated on [2143-11-4], and passed away shortly thereafter in the presence of his family. His son, the next of [Doctor First Name ], was notified, and requested an autopsy. Medications on Admission: alendronate clotrimazole cyclophosphamide furosemide mesna mvi w/ caffeine nifedpine ondansetron prednisone bactrim testosterone Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: 1. Respiratory failure 2. Invasive fungal infection 3. Brain herniation Discharge Condition: Deceased. Discharge Instructions: - Followup Instructions: - ICD9 Codes: 0389, 5845, 431, 2930, 2760, 4280, 5859, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8079 }	Medical Text: Admission Date: [2155-4-25] Discharge Date: [2155-5-4] Date of Birth: [2155-4-25] Sex: F Service: NEONATOLOGY HISTORY: Baby Girl [Known lastname 42435] is the 3890 gram product of a 40 week gestation, born to a 20-year-old GI P0 now I black married female. Prenatal screens: AB positive, antibody negative, RPR nonreactive, rubella immune, hepatitis surface antigen negative, GBS negative. Pregnancy was uncomplicated. delivery. Assisted vaginal delivery with forceps and vacuum. Nuchal cord x 1 cut before delivery of body. Blow-by oxygen, suctioned. Abrasion of left cheek and under eye noted at delivery. PHYSICAL EXAMINATION: Notable for craniotabes on the left skull. Apgars were assigned at 7 and 8. Weight 3820 grams (95th percentile), head circumference 35.5 cm (90th percentile), length 51 cm (75th to 90th percentile). Anterior fontanel soft, flat, positive "[Doctor First Name 13792]-ponging" of skull and left occipitoparietal region. Positive caput of left parietal region. Abrasions on left cheek and under left eye. Intact palate, clear breath sounds. Grade II/VI murmur. Soft abdomen, three vessel cord, no hepatosplenomegaly. Normal female genitalia, patent anus. No sacral dimple. Mongolian spot on buttocks. Multiple cafe-[Name Prefix (Prefixes) ]-[Last Name (Prefixes) 28584] spots on chest, abdomen, back and buttocks. Active normal tone, symmetric faces, good suck. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: The infant has remained in room air throughout her hospital course, without any respiratory issues. 2. Cardiovascular: Has been cardiovascularly stable throughout the hospital course. 3. Fluids, electrolytes and nutrition: Birth weight was 3890. The infant was initially started on 60 cc/kg of D-10-W, with ad lib feedings for hypoglycemia. The infant remained on intravenous fluids in addition to ad lib enteral feedings until day of life number five. The infant received Enfamil 24 calories with 2 calories of Polycose added to supplement and support glucose needs. Polycose was discontinued on [2155-5-1]. The infant has been ad lib feeding Enfamil 20 calories since the [5-2], with every four hours dextrose sticks, stable 45 to 58 before meals, following 45. Dextrose sticks pc are greater than 80. 4. Hematology: Hematocrit on admission was 36. The infant has not required any blood transfusions. 5. Infectious Disease: CBC and blood culture were obtained on day of life one in light of persistent hypoglycemia. CBC was benign. Antibiotics were not started. On day of life number two, the abrasion on her left cheek remained excoriated, and the edges were becoming suspicious for cellulitis. The infant was started on cefazolin intravenously for a total of 48 hours, then the antibiotics were discontinued. She continues to receive [Known lastname 42436] to her skin abrasion. 6. Neurology: X-rays of the skull showed no fractures. The infant has been appropriate for gestational age, without issue. 7. Audiology: A hearing screen was performed with automated auditory brain stem responses, and the infant passed both ears. 8. Psychosocial: A social worker has been involved with this family, and can be contact[Name (NI) ] at [Telephone/Fax (1) ]. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 42437] [Location 42438]Health Center, telephone number [Telephone/Fax (1) 3581], fax number [Telephone/Fax (1) 37223]. CARE RECOMMENDATIONS: 1. Feedings: Continue ad lib feeding Enfamil 20 calories every three to four hours. 2. Medications: Not applicable. 3. Car seat position screening not applicable. 4. State newborn screens have been sent per protocol, and have been within normal limits. 5. Immunizations received: The infant has not yet received hepatitis B vaccine. Plan to receive prior to discharge. DISCHARGE DIAGNOSIS: 1. Full-term infant with persistent hypoglycemia 2. Rule out sepsis, resolved 3. Hypoglycemia, resolved 4. Left facial skin abrasion, resolving [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36095] Dictated By:[Last Name (NamePattern1) 38294] MEDQUIST36 D: [2155-5-4] 00:19 T: [2155-5-4] 00:25 JOB#: [Job Number 35708] ICD9 Codes: V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8080 }	Medical Text: Admission Date: [2104-10-3] Discharge Date: [2104-10-17] Date of Birth: [2072-6-25] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5883] Chief Complaint: traumatic complete amputation L forearm Major Surgical or Invasive Procedure: 1. Repair of traumatic amputation of forearm with revascularization. 2. ORIF of the radius and ulna, with shortening and placement of allograft bone graft. 3. Repair of median, ulnar and radial nerves. 4. Repair of radial and ulnar arteries. 5. Repair of anterior interosseus vein times 2, ulnar vena comitantes vein times one, superficial dorsal vein times one, and cephalic vein with placement of vein graft, with vein graft harvest from upper extremity 6. Repair of flexor tendons FCR, FCU, FDP 2345, FDS 2345, FPL and brachial radialis. 7. Repair of extensor tendons ECRL, ECRB, EDC, EPB, EPL, ECU, EDM, APL. 8. Decompressive hand fasciotomy of dorsum thenar/hypothenar. 9. Carpal tunnel release. 10. Forearm fasciotomy. 11. Local advancement flap closure. 12.Left forearm debridement with a split-thickness skin graft from left upper thigh History of Present Illness: This is a 32 yo man who was medflighted to [Hospital1 18] after a traumatic complete amputation of the left forearm by a saw at work. The amputated limp was wrapped in guaze, on ice. He arrived at [Hospital1 18] ~20 minutes afte the injury. Plastic surgery was notified and arrived on the Past Medical History: None. Social History: Married. Works as lathe operator. Smoker. Family History: NC Physical Exam: In ED: 98.2 80 141/79 100% NRB NAD RRR, normal S1/S2 CTAB Abd soft NT/ND L forearm wrapped in ACE/sterile gauze; amputated L hand wrapped in towels, on ice GCS 15 Pertinent Results: Admission Laboratory Results: [2104-10-3] 05:43PM BLOOD WBC-7.4 RBC-3.90* Hgb-11.9* Hct-33.6* MCV-86 MCH-30.5 MCHC-35.4* RDW-14.1 Plt Ct-246 [2104-10-4] 05:07AM BLOOD Neuts-81.1* Bands-0 Lymphs-12.5* Monos-5.9 Eos-0.2 Baso-0.4 [2104-10-3] 05:43PM BLOOD PT-13.1 PTT-26.1 INR(PT)-1.1 [2104-10-3] 05:46PM BLOOD Glucose-106* Lactate-1.5 Na-143 K-3.8 Cl-106 calHCO3-25 [2104-10-3] 05:43PM BLOOD UreaN-13 Creat-0.8 [2104-10-3] 05:43PM BLOOD Amylase-36 [2104-10-3] 05:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . FOREARM (AP & LAT) LEFT; AP WRIST & HAND LEFT [2104-10-3] 5:43 PM The left forearm is amputated at the level of the mid radius/ulna. There is a sharp amputation line through both bones with no visible associated fracture fragments. The bony structures proximal and distal to the amputation site appear intact without visible fractures or dislocations. Bony mineralization is normal and joint spaces are preserved. . UPPER EXTREMITY FLUORO FOREARM (AP & LAT) LEFT IN O.R Study Date of [2104-10-3] 8:48 PM Four intraoperative views of the left hand were obtained without a radiologist present. These demonstrate a plate and screws fixating the amputated distal hand and distal radius and ulna to the more proximal radius and ulna. . [2104-10-9] 10:20AM BLOOD WBC-7.6 RBC-2.60* Hgb-8.1* Hct-22.6* MCV-87 MCH-31.3 MCHC-36.0* RDW-15.7* Plt Ct-324 [2104-10-9] 10:20AM BLOOD Plt Ct-324 [2104-10-8] 03:26AM BLOOD Glucose-96 UreaN-7 Creat-0.6 Na-134 K-3.9 Cl-101 HCO3-28 AnGap-9 [2104-10-8] 03:26AM BLOOD Calcium-7.3* Phos-4.2 Mg-2.0 [2104-10-5] 09:49AM BLOOD Lactate-1.7 [2104-10-5] 02:09AM BLOOD freeCa-1.16 Brief Hospital Course: Mr. [Known lastname ] arrived at [Hospital1 18] approximately 20 minutes after the amputation. He was promptly evaluated by Plastic Surgery and emergently taken to the OR for limb replantation. Surgical intervention included ORIF of radius and ulna, repair of median, ulnar, and radial nerves, repair of radial and ulnar arteries, and repair or extensor and flexor tendons. . Postoperatively he was initially monitored in the ICU with continuous pulse oximetry of the replanted forearm. He was called out from the ICU on HD #6, POD #5. His replanted forearm continued to have good perfusion through the hospitalization. On [2104-10-9] Pt. taken back to the operating room for placement of STSG. He was discharged to home on aspirin, dilaudid, with VNA services. He will be followed in the Hand Clinic. . Perioperatively, he received 9 units PRBCs. In total he received 15 units PRBCs. . STSG were placed on Mr. [Known lastname 69614] L arm both anteriorly and medially with bolster dressings bilaterally. On [2104-10-16] bolsters were removed and the STSG exposed. The grafts had good take with no necrosis, seromas, hematoma. His STSG was then dressed with Xeroform, dry dressing, and kerlex. Medications on Admission: None. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for anxiety. Disp:30 Tablet(s) Refills:1 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 10 days. Disp:120 Tablet(s) Refills:0 5. Keflex 250 mg Capsule Sig: One (1) Capsule PO three times a day for 7 days. Disp:21 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Complete traumatic amputation of left forearm Replantation of left forearm Discharge Condition: Stable, with good color, warmth, capillary refill of left forearm. Discharge Instructions: You were hospitalized at [Hospital1 18] after a traumatic amputation of your left forearm. You underwent surgery to re-attach the forearm. . You should keep your left arm in the splint, elevated. You will have visiting nurses change the dressings daily and evaluate your arm. You can passively move your fingers (i.e. use your other hand to move the fingers) as you have been instructed. You will be having occupational therapy coming to your house to help you with your left hand motion . You should take all medications as prescribed. . You should follow-up as indicated below. . You should seek emergent medical care (be seen promptly by a doctor/go to the Emergency Department): -for blue color or coldness of the fingers/hand/arm on your left side -if the VNA nurses difficulty in detecting the pulses in your left arm -if there are signs of infection of your left arm including redness, increased swelling, increased warmth -if you have a significant increase in the amount of pain you are having . You should contact your doctor/be seen by a physician [Name Initial (PRE) ]: -high fevers (>102) -increased pain -increased stiffness/decreased mobility of the joint -chest pain/shortness of breath -persistant nausea/vomiting -other symptoms that concern you. Followup Instructions: You should be seen in the Hand Clinic this Tuesday, [10-21]. Please call [Telephone/Fax (1) 4652] to make an appointment. Completed by:[2104-10-17] ICD9 Codes: 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8081 }	Medical Text: Admission Date: [2161-5-1] Discharge Date: [2161-5-10] Date of Birth: [2093-1-23] Sex: M Service: CARDIOTHORACIC Allergies: Iodine Attending:[First Name3 (LF) 1406] Chief Complaint: exertional dyspnea Major Surgical or Invasive Procedure: left heart catheterization, coronary angiogram, left ventriculogram Coronary artery bypass grafting x4 (internal mammary artery to left anterior descending artery,reverse saphenous vein graft to the right posterior descending artery, second obtuse marginal artery,diagonal artery). 2. Aortic valve replacement with a 25-mm St. [Male First Name (un) 923] left heart catheterization, coronary angiogram, left ventriculogram Coronary artery bypass grafting x4 (internal mammary artery to left anterior descending artery,reverse saphenous vein graft to the right posterior descending artery, second obtuse marginal artery,diagonal artery). 2. Aortic valve replacement with a 25-mm St. [Male First Name (un) 923] mechanical valve reference number [Serial Number 73802]. left heart catheterization, coronary angiogram, left ventriculogram Coronary artery bypass grafting x4 (internal mammary artery to left anterior descending artery,reverse saphenous vein graft to the right posterior descending artery, second obtuse marginal artery,diagonal artery). 2. Aortic valve replacement with a 25-mm St. [Male First Name (un) 923] mechanical valve reference number [Serial Number 73802]. History of Present Illness: This 68 year old gentleman with a history of hypertension and aortic stenosis has a 1 year history of exertional chest burning. It occurs with exertion that occurs after walking his dog 1 block on a slight incline and resolves after 5 minutes of rest. He denies any symptoms occurring at rest. He also denies shortness of breath. He was seen by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 5686] and referred for a stress test done [3-18]. He exercised for 5 minutes and 16 seconds [First Name8 (NamePattern2) ] [Doctor First Name ] protocol. Positive for chest pain. Nuclear imaging negative for ischemia with normal LV function. Past Medical History: Hypertension Hypothyroidism Thyroid cancer s/p resection [2157], radioactive iodine Pulmonary embolus [10-12] postoperative to a thyroid resection Pancreatitis [9-12] ho Skin cancer Social History: Married works as a dispatcher for a cab company Tobacco: yes-[2-7] ppd (just cut down from 1ppd) ETOH: No Contact upon discharge: Wife or daughters. Family History: non-contributory. No history of sudden death or premature coronary artery disease. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS - T: 96.4, BP: 128/70, HR: 77, RR: 16, O2 sat: 96% RA Gen: Elderly male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple. JVP not elevated CV: RRR. III/VI harsh systolic murmur at RUSB. normal S1, S2. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Cardiac cath: 1. Coronary angiography in this right dominant system revealed severe left main coronary artery disease. The LMCA had a moderate proximal narrowing with a tight 80% stenosis in the distal portion, with ventricularization and dampening of the pressure tracing with engagement that limited assessment of other coronary arteries. The LAD and LCX were grossly normal. The RCA had a 60% stenosis in the mid-portion, with a focal 80% stenosis distally. 2. Resting hemodynamics revealed aortic stenosis, with peak gradient of 60 mmHg, mean gradient of 36 mmHg, and estimated aortic valve area of 1.0 cm2. There was no evidence of mitral stenosis. The right- and left-sided filling pressures were normal, with mean RA pressure of 8 mmHg, and mean PCW pressure of 12 mmHg. The resting blood pressure was normal at 134/76. Intra-op Echo [2161-5-5] The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. A patent foramen ovale is present. There is mild 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. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Post Bypass The patient is on a Neo drip@1.5mcg/kg/min with a Cardiac Index -2.5 There is now a well seated 25 [Hospital3 ] Aortic valve the mean gradient across the valve is 8,with no paravavular leak The Ef is preserved at 55% The aorta has no dissection flaps [2161-5-8] 04:50AM BLOOD WBC-9.0 RBC-4.00* Hgb-12.7* Hct-36.1* MCV-90 MCH-31.7 MCHC-35.2* RDW-13.3 Plt Ct-102* [2161-5-9] 06:30AM BLOOD PT-14.5* PTT-30.0 INR(PT)-1.3* [2161-5-8] 04:50AM BLOOD PT-11.8 INR(PT)-1.0 [2161-5-7] 12:20PM BLOOD PT-11.6 PTT-26.7 INR(PT)-1.0 [2161-5-5] 02:34PM BLOOD PT-13.6* PTT-35.4* INR(PT)-1.2* [2161-5-9] 06:30AM BLOOD K-4.0 [2161-5-7] 04:30AM BLOOD Glucose-94 UreaN-15 Creat-0.8 Na-138 K-4.2 Cl-104 HCO3-29 AnGap-9 Brief Hospital Course: catheterization demonstrated significant left main and triple vessel disease with severe aortic stenosis. He was referred for surgery. The ususla preoperative workup was undertaken. The patient was brought to the Operating Room on [2161-5-5] where he underwent coronary bypass and aortic valve replacement adescribed in the operative note utilizing a 25mm St. [Male First Name (un) 923] mechanical valve. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis given his inpatient stay preoperatively of greater than 24 hours. 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. Anti-coagulation for the mechanical valve was initiated with coumadin on POD 2. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. By the time of discharge the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Arrangements will be made for Coumadin management by Dr. [Last Name (STitle) 39375] in th emorning of [5-11] and we will contact the patient. He is to take 5mg of Coumadin [5-10]/ and 5,and have INR chechecked on the 6th. Precautions and medications were discussed at length with him. Medications on Admission: -Levoxyl 175mcg daily -Ranitidine 150mg ??????[Hospital1 ] the day prior and am of procedure -Prednisone 40mg-[Hospital1 ] the day prior to procedure and am of procedure -Benadryl 25mg [Hospital1 ] the day prior and am of procedure as directed. Discharge Medications: Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 weeks. [Hospital1 ]:30 Tablet(s) Refills:0 Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. [Hospital1 ]:50 Tablet(s) Refills:0 Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. [Hospital1 ]:50 Tablet(s) Refills:0 Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [Hospital1 ]:60 Tablet(s) Refills:2 Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). [Hospital1 ]:60 Cap(s) Refills:2 Warfarin 5 mg Tablet Sig: as directed Tablet PO once a day: take as directed by MD. [Last Name (Titles) ]:100 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: coronary artery disease Aortic Stenosis Hypertension Hypothyroidism h/o Thyroid cancer h/o Pulmonary embolus h/o Pancreatitis h/o Skin cancer Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with Percocet 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) ] Wed. [6-10], 1pm [Telephone/Fax (1) 170] Please schedule appointments with: Primary Care in [2-7] weeks Dr. [Last Name (STitle) 39374] [Name (STitle) ] ([0-0-]) Cardiologist in [2-7] weeks Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 11554]) We will call [5-11] morning to let pt. know Coumadin arrangements Completed by:[2161-5-10] ICD9 Codes: 4241, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8082 }	Medical Text: Admission Date: [2120-10-30] Discharge Date: [2120-11-12] Date of Birth: [2043-11-15] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1406] Chief Complaint: recurring dyspnea following community aquired pneumonia Major Surgical or Invasive Procedure: [2120-11-1] Coronary artery bypass grafting x2: Left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the first diagonal artery. History of Present Illness: Mr. [Known lastname ] is a 76 yo male with chronic renal failure who presented to MWMC with recurrent dyspnea following treatment for community acquired pneumonia. On admission, he ruled in for NSTEMI and chest x-ray revealed pulmonary edema. He was also started on hemodialysis for volume control. Since initiation of dialysis and completion of antibiotic therapy, his dyspnea has significantly improved. Recent cardiac catheterization revealed severe single vessel coronary artery disease with depressed LV function. He was therefore transferred to the [Hospital1 18] for surgical revascularization. Past Medical History: Past Medical History: Coronary Artery Disease, recent NSTEMI Acute on Chronic Diastolic CHF End Stage Renal Failure, on hemodialysis Hypertension Dyslipidemia Type II Diabetes History of DVT - right leg Recent Pneumonia- no culture data available, patient states everything was negative Anemia of Chronic Disease, on Epogen every 2 weeks,Constipation History of Shingles - 5 years ago Past Surgical History s/p Placement of Double Lumen Dialysis Catheter [2120-9-29] s/p Left Arm AV Fistula [2120-9-29] s/p Bowel Obstruction Repair/LOA [2112]- no resection required s/p Abd Aortic Aneurysm Repair [2110] s/p Hemorrhoidectomy s/p Right Rotator Cuff Repair Social History: Race: caucasian Last Dental Exam: edentulous Lives with: Wife Occupation: retired computer repairman Tobacco: 15 PYH, quit 40 years ago ETOH: rare, no history of abuse Family History: non contributory Physical Exam: Review of Systems General: 30 pound weight loss over last month which he attributes to poor appetite. Appetite currently improving. No recent fevers. Patient states he and his family has the "swine flu" back in early [Month (only) ] - diagnosis not confirmed. Skin: Eczema [] Psoriasis [] Skin Cancer [] +facial port wine stain HEENT: Hearing aide(s) [] Glasses [x] Other: Denies[] Respiratory: Asthma [] COPD [] Pneumonia [x] Cough [] Sputum [x] Other- Cough/Hemoptysis has resolved Cardiac: Chest pain [] SOB [x] DOE [x] Orthopnea [x] PND [x] GI: Nausea [] Vomiting [] Diarrhea [x] Constipation [x] Heartburn/GERD [] Other: Diarrhea resolved after ABX GU: Dysuria [] Frequency [] Prostate [] GYN [] other: Denies[x] Musculoskeletal: Arthritis [x] - left knee pain Peripheral Vascular: Claudication [] Other: Denies [x] Psych anxiety [] depression [] Other: Denies [x] Endoicrine Diabetes [x] thyroid [] Other: denies [] Heme/ID: + History of DVT, no history of PE Neuro: TIA [] CVA [] Neuropathy [] Seizures (x) Denies Physical Exam T: 98.2 Pulse: 84 B/P: 157/76 Resp: 18 O2 sat: 95% 2L Height: 73 inches Weight: 89.8 kg General: Elderly male in no acute distress, non-toxic appearance Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Bibasilar rales Heart: RRR [x] normal s1s2, no murmur or rub Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds+ [x] - well healed midline and LLQ incisions Extremities: Warm [x], well-perfused [x] Edema - none Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 1 Left: 1 DP Right: 1 Left: 1 PT [Name (NI) 167]: 1 Left: 1 Radial Right: 2 Left: 1 Carotid Bruit Right: none Left: none Pertinent Results: Preop [2120-10-30] 01:10PM PT-14.8* PTT-150* INR(PT)-1.3* [2120-10-30] 01:10PM PLT COUNT-231 [2120-10-30] 01:10PM WBC-9.2 RBC-3.70* HGB-10.2* HCT-32.0* MCV-86 MCH-27.5 MCHC-31.9 RDW-17.1* [2120-10-30] 01:10PM %HbA1c-6.1* [2120-10-30] 01:10PM ALBUMIN-3.2* MAGNESIUM-2.7* [2120-10-30] 01:10PM LIPASE-192* [2120-10-30] 01:10PM ALT(SGPT)-16 AST(SGOT)-27 LD(LDH)-260* ALK PHOS-61 AMYLASE-148* TOT BILI-0.2 [2120-10-30] 01:10PM GLUCOSE-113* UREA N-46* CREAT-6.4* SODIUM-144 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-24 ANION GAP-19 [2120-10-30] 06:13PM URINE RBC-0-2 WBC-[5-8]* BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 RENAL EPI-0-2 [2120-10-30] 06:13PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG post op [2120-11-6] 04:45AM BLOOD calTIBC-139* Ferritn-396 TRF-107* [2120-11-6] 08:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE [2120-11-10] 06:15AM BLOOD WBC-7.5 RBC-3.11* Hgb-8.5* Hct-26.6* MCV-85 MCH-27.2 MCHC-31.9 RDW-18.0* Plt Ct-298 [2120-11-10] 06:15AM BLOOD Plt Ct-298 [Hospital1 18] ECHOCARDIOGRAPHY REPORT: [Known lastname ], [Known firstname 275] Indication: Intraoperative TEE for CABG procedure. Aortic valve disease. Congestive heart failure. Coronary artery disease. Left ventricular function. Preoperative assessment. Right ventricular function. Shortness of breath. Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 45% >= 55% Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Ascending: 3.5 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 10 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 6 mm Hg Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Bidirectional shunt across the interatrial septum at rest. Small secundum ASD. LEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild AS (area 1.2-1.9cm2). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. 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. Left pleural effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass There is a bidirectional shunt across the interatrial septum at rest. A small secundum atrial septal defect is present. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apex, apical and mid portions of the anterior septum. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 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. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). The [Location (un) 109] by planimetry is 2.2 cm2and by continuity equation it is 1.2 cm2. No aortic regurgitation is seen. 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 [2120-11-1] at 0915am. Very poor transgastric views Post bypass Patient is AV paced and receiving an infusion of phenylephrine and epinephrine. Biventricular systolic function is unchanged. There is trivial mitral regurgitation. Aorta is intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 1509] [Name8 (MD) 1510], MD, Interpreting physician [Last Name (NamePattern4) ] [2120-11-1] 13:12 Radiology Report CHEST (PORTABLE AP) Study Date of [2120-11-4] 7:28 AM [Hospital 93] MEDICAL CONDITION: 76 year old man with CABG/ESRD Final Report CHEST RADIOGRAPH FINDINGS: As compared to the previous radiograph, the left-sided pleural effusion and subsequent retrocardiac atelectasis are unchanged. The pre-existing right pleural effusion and subsequent atelectasis are minimally increased. No newly occurred focal parenchymal opacities, no other changes. Unchanged right-sided double-lumen catheter. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] Approved: MON [2120-11-4] 2:46 PM [2120-11-7] 04:50AM BLOOD PT-13.6 PTT-31.4 INR(PT)-1.2* [2120-11-12] 05:15AM BLOOD Glucose-78 UreaN-47* Creat-5.9* Na-140 K-4.3 Cl-103 HCO3-27 AnGap-14 Brief Hospital Course: Mr [Known lastname ] was transferred from MWMC on [2120-10-30] for coronary revascularization. He was dialysed prior to surgery. He was taken to the Operating Room on [2120-11-1] for coronary artery bypass grafting. Please see opertive note for details., in summary he had coronary artery bypass grafting x2 with left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the first diagonal artery. His bypass time was 70 minutes with a crossclamp of 58 minutes. He tolerated the operation well and was transferred to the cardiac ICU intubated and sedated on neosynepherine infusion. He remained hemodynamically stable in the immediate post-op period was weaned from pressors, the ventilator and extubated in stable condition. He had dialysis on POD1 and was transferred from the ICU to the step down unit on POD #3. He was started on betablockers and had several sinus pauses, the Bblockers were stopped and electrophysiology was consulted. Per Dr [Last Name (STitle) 2357] he was cleared for discharge with telemetry monitoring at rehab. He will require follow up with Dr [First Name (STitle) ] at [Hospital3 ]. Once his fistula has matured and he is able to have his temporary dialysis catheter removed, he is to be evaluated for a permanent pacemaker. He is not to start on beta blockers until that time. Additional he had several episodes of nonsustained ventricular tachycardia which were evaluated by the electrophysiology service and given EF 40% not treated at this time. He was maintained on a Tuesday-Thursday-Saturday dialysis schedule. He was evaluated and treated by physical therapy and rehab was recommended. The remainder of his hospital stay was uneventful. He was transfered to telemetry rehababilitation at [Hospital ] Rehabilitation at [Last Name (un) 59835] [Doctor Last Name 3549] in [Location (un) 1110] on POD#11. He requires continued hemodialysis, his last episode of HD was on [2120-11-12]. stopped [11-11] Medications on Admission: Coreg 3.25", ASA 325', Doxazosin 4', Lotrel 10/40"', Lipitor 20', Protonix 40', Hydralazine 20"', Renvela 800 with meals, Nephrocaps 1', Glipizide 2.5', Florastor 250" 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet(s) Refills:2 8. Benazepril 20 mg Tablet Sig: Two (2) Tablet PO once a day. 9. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Saccharomyces boulardii 250 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital1 ]-Northeast-[Location (un) 1110] Discharge Diagnosis: CAD (s/p NSTEMI) s/p CABGx2 Acute on Chronic Diastolic Heart Failure, ESRD, HTN, Dyslipidemia, DM2, DVT, CAP, Recent GI Bleed with tx PRBC, Anemia of Chronic Disease on Epogen, Constipation, s/p Left Arm AV Fistula [2120-9-29], s/p AAA Repair [2110], s/p Hemorrhoidectomy Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Wound: healing well, no drainage or erythema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on Mon [2120-12-11] @ 1PM ([Telephone/Fax (1) 170]) Dr [Last Name (STitle) 84103] [Name (STitle) 67625](Vascular surgeon)[Telephone/Fax (1) 84104] in 1 week. Dr [Last Name (STitle) 67625] will come to [Hospital1 ] to see patient if you call his office to let him know patient has arrived. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 68568] 2 weeks([Telephone/Fax (1) 5835]) call for appointment Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] 2 weeks-please call for appointment Completed by:[2120-11-12] ICD9 Codes: 5856, 4271, 2930, 4280, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8083 }	Medical Text: Admission Date: [2135-2-1] Discharge Date: [2135-2-6] Date of Birth: [2067-3-30] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) / Erythromycin Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: [2135-2-1] Aortic Valve Replacement w/ 23mm St. [Male First Name (un) 923] Epic Porcine Tissue Valve History of Present Illness: 67 y/o female with known aortic stenosis followed by echo's over last several years. now she has been c/o progressively worsening dyspnea on exertion. Aortic valve area has slowly worsened over time with most recent showing [Location (un) 109] of 0.6. Past Medical History: Aortic Stenosis, Hypertension, Hypercholesterolemia, Osteoarthritis, SLE, Peripheral Neuropathy w/ dropfoot, Spinal cyst, Lumbar disc disease, Retinitis, Uveitis, Psoriasis, Eczema, Melanoma s/p removal, s/p Hysterectomy, s/p Appendectomy, s/p Multiple eye surgery, s/p Tonsillectomy Social History: Quit in [2122] after 1ppd x 30yrs. Denies ETOH use. Family History: NC Physical Exam: VS: 76 12 118/78 63" 187# Gen: WDWN female wearing RLA brace and using cane Skin: Healed scar on chest from melanoma removal HEENT: EOMI, PERRL NCAT, OP benign Neck: Supple, FROM -JVD Chest: CTAB -w/r/r Heart: RRR 3/6 SEM with radiation to carotids Abd: Soft, NT/ND +BS Ext: Warm, well-perfused 1+edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [2-1] Echo: PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. The ascending aorta is mildly dilated. 5. The aortic valve is bicuspid. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Trace aortic regurgitation is seen. 6. Mild (1+) mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is being AV paced. 1. A well-seated bioprosthetic valve is seen in the Aortic position with normal leaflet motion and gradients. No aortic regurgitation is seen. 2. Biventricular function is preserved. 3. MR appeared to be slightly worse with AV pacing. No [Male First Name (un) ] physiology noted 4. A slight hypoechoic area noted in the Ascending aorta with no obvious dissection flaps noted. 5. Other findings are unchanged [2-3] CXR: 1) No evidence of pneumothorax following tube removal. 2) Mid sternal lucency at proximal aspect of sternotomy, which can occasionally be seen normally in the early postoperative period. Correlation with physical exam findings and follow up chest radiograph may be helpful to exclude early sternal dehiscence. 3) Worsening left lower lobe atelectasis and new small left pleural effusion. [2135-2-1] 10:04AM BLOOD WBC-5.7 RBC-3.08# Hgb-8.7# Hct-26.6# MCV-86 MCH-28.3 MCHC-32.8 RDW-14.2 Plt Ct-240 [2135-2-4] 06:16AM BLOOD WBC-14.4 RBC-3.32* Hgb-9.4* Hct-29.4* MCV-89 MCH-28.4 MCHC-32.1 RDW-14.1 Plt Ct-191 [2135-2-1] 10:04AM BLOOD PT-14.0* PTT-28.7 INR(PT)-1.2* [2135-2-1] 11:13AM BLOOD UreaN-14 Creat-0.6 Cl-111* HCO3-23 [2135-2-4] 06:16AM BLOOD Glucose-120* UreaN-14 Creat-0.7 Na-135 K-4.0 Cl-99 HCO3-27 AnGap-13 [2135-2-5] 4:54 pm URINE Source: CVS. URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML.. Brief Hospital Course: Mrs. [Known lastname 77160] was a same day admit after undergoing all preoperative work-up as an outpatient. On day of admission she was brought directly to the operating room where she underwent an aortic valve replacement. 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 she was weaned from sedation, awoke neurologically intact and extubated. On post-op day one she was started on beta blockers and diuretics. She was gently diuresed towards he pre-op weight. Later on this day she was transferred to the telemetry floor for further care. On post-op day two her chest tubes were removed. On post-op day three her epicardial pacing wires were removed. She continued to improve quite well post-operatively while working with physical therapy for strength and mobility, which has declined since preoperatively. On post-op day 5, she was discharged to rehab facility for further physical therapy. Medications on Admission: Voltaren 75mg [Hospital1 ], Prednisone 2mg [Hospital1 ], Sular 10mg qd, Toprol XL 25mg [Hospital1 ], Tricor 145mg qd, Sinemet 50/200 q6, Mirapex 25mg qhs, Gluosamine, Levobunolol eye gtts, Alphagan eye gtts, Travatan eye gtts, Premild eye gtts 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. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 4. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig: One (1) Tablet PO QID (4 times a day). 6. Prednisolone Acetate 0.12 % Drops, Suspension Sig: One (1) Drop Ophthalmic once a day. 7. Alphagan P 0.15 % Drops Sig: One (1) Ophthalmic [Hospital1 ] (2 times a day). 8. Levobunolol 0.25 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 9. Travatan 0.004 % Drops Sig: One (1) Ophthalmic Daily (). 10. XIBROM 0.09 % Drops Sig: One (1) Ophthalmic [Hospital1 ] (2 times a day). 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. 13. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO once a day. 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-8] Sprays Nasal 5X/DAY (5 Times a Day) as needed. 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 17. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 2857] - [Location (un) 9188] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement PMH: Hypertension, Hypercholesterolemia, Osteoarthritis, SLE, Peripheral Neuropathy w/ dropfoot, Spinal cyst, Lumbar disc disease, Retinitis, Uveitis, Psoriasis, Eczema, Melanoma s/p removal, s/p Hysterectomy, s/p Appendectomy, s/p Multiple eye surgery, s/p Tonsillectomy 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] [Last Name (NamePattern4) 2138]p Instructions: [Hospital Ward Name 121] 6 for wound check in 2 weeks Dr. [Last Name (Prefixes) ] in 4 weeks Dr. [Last Name (STitle) 77161] in [1-9] weeks Dr. [Name (NI) 77162] in [12-8] weeks Completed by:[2135-2-6] ICD9 Codes: 4241, 5990, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8084 }	Medical Text: Admission Date: [2124-12-2] Discharge Date: [2124-12-8] Service: Neurosurgery HISTORY OF THE PRESENT ILLNESS: The patient is an 88-year-old gentleman transferred from [Hospital6 1597] with a chronic subdural hematoma. The patient has had a history of dizziness and falls for the last two months. There is no history of nausea, vomiting, loss of consciousness, seizures. There was no history of chest pain or shortness of breath. PHYSICAL EXAMINATION: Examination revealed the blood pressure of 96.5, heart rate 50s, respiratory rate 18, blood pressure 132/84, saturations 97% on one liter. PAST MEDICAL HISTORY: History revealed hypertension and congestive heart failure. PHYSICAL EXAMINATION: On physical examination, the patient neurologically is awake, alert, oriented time three with no pronator drift, no facial droop. Motor strength was [4-29] in all muscle groups with the exception of the right deltoid, which was 4+/5. The CT showed a 2-cm subdural hematoma over the right temporal parietal region with compression of the right ventricle and some mass effect. He was admitted to the Surgical Intensive Care Unit for close monitoring. On [2124-12-3], the patient went to the operating room for drainage of the right subdural hematoma, without intraoperative complications. Postoperatively, the patient was monitored in the Surgical Intensive Care Unit. On [2124-12-4] the EKG showed 1-mm to 2-mm S-T depression in the V1 through V6 leads with some complaints of nausea and chest pain with a blood pressure of 170. He was given one sublingual nitroglycerin with gradual decreased in his heart rate down to the 30s and his systolic blood pressure down to the 60s. He required five minutes of IV Neo-Synephrine in African-American female 250 cc bolus saline. His blood pressure recovered along with his heart rate. The Department of Cardiology recommendations were to avoid preload reduction, continue beta blocker for blood pressure and heart rate control and when the patient recovers from the subdural hematoma repeat echocardiogram and cardiac catheterization for further assessment of his aortic stenosis. The patient's subdural drain was discontinued on [2124-12-5]. The patient was awake, alert, and oriented times three. He was following commands with no drift. Face was symmetrical. The patient was transferred to the regular floor with the blood pressure under better control off Nipride. The patient was seen by the Physical Therapy and Occupational Therapy. He was found to require rehabilitation. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o.b.i.d. 2. Zantac 150 mg p.o.b.i.d. 3. Metoprolol 25 mg p.o.q.d. 4. Cozaar 50 mg p.o.q.d. 5. Isosorbide MN 60 mg p.o.q.d. 6. Tylenol 650 p.o.q.4h.p.r.n. 7. Nitropaste ?????? inch q.6h. hold for blood pressure less than 110. The patient was in stable condition at the time of transfer to rehabilitation. The patient will followup with Dr. [Last Name (STitle) 6910] in two to three weeks time. The patient was neurologically stable at the time of discharge with stable vital sign and afebrile. The patient will need to followup with the Department of Cardiology after recovery from subdural hematoma or evacuation, most likely, after he sees Dr. [Last Name (STitle) 6910] in followup. [Name6 (MD) 6911] [Name8 (MD) ], MD [MD Number(1) 6913] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2124-12-8] 14:01 T: [2124-12-8] 14:13 JOB#: [Job Number 36916] ICD9 Codes: 2761, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8085 }	Medical Text: Admission Date: [2125-5-3] Discharge Date: [2125-6-6] Date of Birth: [2060-7-29] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1283] Chief Complaint: Left leg ulcers Major Surgical or Invasive Procedure: s/p Aorto-Innominate artery bypass/aorto-> L common carotid bypass [2125-5-22] s/p L carotid->L subclavian bypass(8 mm PTFE)/Thoracic aortic stent graft [5-23] History of Present Illness: This 64BF has a history of PVD and foot ulcers and was admitted from Dr.[Name (NI) 7257] office for VAC placement and possible angiograms. Past Medical History: -- DM2 -- chronic foot ulcers/PVD -- HTN -- OA -- obesity -- asthma -- leg pain/neuropathy -- depression -- anemia -- h/o MRSA bacteremia [11-18], also septic arthritis treated at [Hospital3 ] . Right thalamic hemorrhage resulting in a gait disorder and incontinence of urine, followed by Dr. [Last Name (STitle) ]. Old CVAs. Neuropathy, peripheral. Anxiety and panic disorder. Status post total abdominal hysterectomy. Hypercholesterolemia. Social History: The patient lives with her daughter [Name (NI) 2048] and her three kids since being d/c'ed from a nursing home last [Month (only) 205]. Has seven children, many grandchildren. Smokes [1-16] to 1 pack per day. Family History: Brother died of an MI in his 30's, she denies diabetes mellitus in the family. Cancer in parents (mother died in 40s, father in 80s), at least two siblings, but unsure what kind. Physical Exam: Discharge General NAD Vitals 98.8, 118/58, 92 SR, 20 RR, 98% RA, 124.2 kg Neuro A/O x3 MAE R=L strength, generalized weakness Pulm CTA but diminished bilat bases no rhochi/wheezes Card RRR no murmur/rub/gallop Abd Soft nontender nondistended obese + BS BM [6-5] Ext warm pulses with doppler no edema IV access midline Rt AC Inc Sternal healing no erythema no drainage staples intact - plan for removal [6-14] Left subclavian incision healing no erythema no drainage staples intact - plan for removal [6-14] Right groin incision - no drainage or erythema covered with DSD staples intact plan for removal [6-14] Left ankle ulcer tissue pink healing no drainage - VAC dc'd and wet - dry dressing [Hospital1 ], area 6cm L x 1.5 cm W x .25 cm D Left calf circular open area that is pink healing no drainage dry dressing Skin care eval [5-28] S/P surgery, she developed a drug rash and has dry desquamation overall body. There are several open blistered sites on her left forearm and one open site on her right forearm. All unroofed blisters are partial thickness ulcers with pink wound beds. There is minimal drainage from the sites. The wound edges are irregular. The periwound tissue has blistered skin and dry exfoliation. There are no s/s of infection. Goals of wound care: resolved skin issues Recommendations: Pressure relief per pressure ulcer guidelines Support surface: BariMaxx II with ETS Turn and reposition every 1-2 hours and prn Heels off bed surface at all times Multipodis Splints to B/L LE's If OOB, limit sit time to one hour at a time and sit on a pressure relief cushion, 4"Foam. Elevate LE's while sitting. Commercial wound cleanser or normal saline to irrigate/cleanse all open wounds. Pat the tissue dry with dry gauze. Apply Aquaphor Ointment to the intact dry skin upper and lower extremities, torso [Hospital1 ] Apply Adaptic (nonadherent dsg) to the open ulcers (unroofed blisters) Cover with dry gauze Secure with netting, no tape on skin. Change dressing daily. Support nutrition and hydration. [5-31] SWALLOWING ASSESSMENT: PO assessment was conducted with ice chips, water and nectar thick liquid via tsp, cup and straw sip, custard, applesauce and whole & crushed meds in applesauce and one bite of ground up [Location (un) ] crackers in custard. Swallows were slow / delayed. Laryngeal elevation felt adequate to palpation. There was no cough, no throat clear and no change in voice quality after eating or drinking. However, the pt. consistently said that she felt like coughing after drinking water. She said she did not feel like coughing after drinking nectar thick liquids. We were unable to obtain a reliable O2 saturation despite trying on her finger, toe or ear. She seemed to swallow ground and pureed solids but did best when she alternated between bites and sips. She could not swallow the whole pill w/nectar or in applesauce. So, we crushed the pill in custard and swallowed it with a sip of nectar to follow. SUMMARY / IMPRESSION: [Known firstname ] [Known lastname 1661] may be aspirating thin liquids because she says she feel like coughing consistently after drinking water. However, she appears safe to drink nectar thick liquids and to eat pureed or ground solids if she alternates between bites and sips. She could not swallow a whole pill today with nectar thick [Location (un) 2452] juice or whole in applesauce, but she swallowed her pill crushed in custard w/a sip of nectar to follow. This swallowing pattern correlates to a Dysphagia Outcome Severity Scale (DOSS) rating of Level 4, Mild to moderate dysphagia with 2 consistnecy restrictions and intermittent supervision/cueing. This dysphagia is likely due to her old strokes. RECOMMENDATIONS: 1. Diet of ground solids and Nectar thick liquids with Pills crushed in puree 2. Supervision w/meals Alternate between bites and sips 3. If there are further concerns about aspiration on this diet, we would be happy to perform a FEES evaluation. She would not be a candidate for a Videoswallow because she is too large to fit into the fluoroscope. These recommendations were shared with the patient, nurse and medical team. ____________________________________ [First Name4 (NamePattern1) 1154] [Last Name (NamePattern1) 19916] [Doctor Last Name 3748], M.S., CCC-SLP Pager # [Numeric Identifier 22568] Pertinent Results: [2125-6-5] 07:23AM BLOOD WBC-10.7 RBC-2.71* Hgb-8.0* Hct-23.9* MCV-88 MCH-29.5 MCHC-33.4 RDW-16.5* Plt Ct-311 [2125-5-6] 06:10AM BLOOD Neuts-95.5* Bands-0 Lymphs-1.9* Monos-1.3* Eos-1.0 Baso-0.4 [2125-5-3] 07:30PM BLOOD WBC-5.5 RBC-4.54 Hgb-12.1 Hct-37.2 MCV-82 MCH-26.7* MCHC-32.5 RDW-14.9 Plt Ct-158 [2125-5-3] 07:30PM BLOOD Neuts-65.6 Lymphs-26.2 Monos-4.7 Eos-3.2 Baso-0.3 [2125-6-6] 05:38AM BLOOD PT-16.4* INR(PT)-1.5* [2125-6-5] 07:23AM BLOOD Plt Ct-311 [2125-5-3] 07:30PM BLOOD Plt Ct-158 [2125-5-3] 07:30PM BLOOD PT-11.4 PTT-26.1 INR(PT)-1.0 [2125-5-30] 03:03AM BLOOD ESR-65* [2125-6-6] 10:41AM BLOOD Glucose-156* UreaN-25* Creat-1.1 Na-140 K-3.7 Cl-109* HCO3-22 AnGap-13 [2125-5-3] 07:30PM BLOOD Glucose-130* UreaN-23* Creat-1.1 Na-142 K-3.8 Cl-107 HCO3-24 AnGap-15 [2125-5-22] 11:20PM BLOOD CK(CPK)-188* [2125-5-18] 04:45AM BLOOD ALT-40 AST-39 LD(LDH)-310* AlkPhos-136* Amylase-52 TotBili-0.3 [2125-5-18] 04:45AM BLOOD Lipase-44 [2125-5-22] 11:20PM BLOOD CK-MB-4 cTropnT-0.02* [2125-6-6] 10:41AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.3 [2125-5-3] 07:30PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.3 RADIOLOGY Final Report CHEST (PA & LAT) [2125-6-5] 8:42 AM CHEST (PA & LAT) Reason: evaluate effusion [Hospital 93] MEDICAL CONDITION: 64 year old woman with R innom. aneurysm REASON FOR THIS EXAMINATION: evaluate effusion PORTABLE UPRIGHT CHEST, 8:52 A.M., [6-5]. INDICATION: Followup effusion. FINDINGS: Compared with 5/16 and with [2125-5-29], haziness at the right lung base is consistent with the right pleural effusion seen on CT of [6-2] and does not appear grossly changed. The left hemidiaphragm is elevated compared with the pre-op study consistent the left lower lobe collapse on CT. The superimposed left pleural effusion appears perhaps slightly smaller. The known right innominate artery aneurysm and recent aortic stent graft are again noted. No overt CHF. IMPRESSION: Overall, no definite/obvious significant interval changes appreciated. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: TUE [2125-6-5] 12:00 PM RADIOLOGY Final Report CTA CHEST W&W/O C&RECONS, NON-CORONARY [2125-6-2] 1:16 PM CTA CHEST W&W/O C&RECONS, NON- Reason: r/o leak [Hospital 93] MEDICAL CONDITION: 64 year old woman with s/p aortic reconstruction REASON FOR THIS EXAMINATION: r/o leak CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 64-year-old woman post aortic reconstruction, evaluate for leak. TECHNIQUE: Multidetector contiguous axial images of the neck and chest were obtained following the administration of intravenous contrast. Delayed images of the neck through the chest were obtained. Non-contrast study of the chest was also obtained. FINDINGS: Compared to prior study of [2125-5-4], there has been repair of the aneurysmal dilatation of the innominate artery. Stent graft is seen extending from the distal portion of the ascending thoracic aorta through the arch and through the proximal portion of the descending thoracic aorta. No leak is identified. Injection of contrast was performed via the left arm, and there are a large amount of collaterals seen extending along the posterior chest wall to the azygos and hemiazygos veins which enter the right atrium via the IVC. The SVC, and proximal left subclavian vein are thrombosed in the interval. There are no filling defects in the pulmonary arterial vasculature. No pulmonary embolism is identified. At the site of surgical clips in the left upper neck, there is a large hematoma measuring 3.6 x 6.8 cm. Lung windows demonstrate atelectasis of the left lower lobe, moderate and to a lesser degree on the right. Small bilateral pleural effusions are present. Few images through the upper abdomen demonstrate a simple cyst arising from the upper pole of the left kidney measuring 5.5 cm in diameter. A calcified granuloma is seen in the spleen. Findings were discussed with Dr. [Last Name (STitle) ]. Bridges on [2125-6-2]. IMPRESSION: 1. No leak post aortic reconstruction. 2. No pulmonary embolism. 3. Left neck hematoma as described above. 4. Interval development of thrombosis of the superior vena cava and proximal left subclavian vein. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] DR. [First Name8 (NamePattern2) 7722] [Last Name (NamePattern1) 7723] Approved: SUN [2125-6-3] 11:13 AM Cardiology Report ECG Study Date of [2125-5-24] 9:25:12 AM Sinus tachycardia with diffuse low voltage. Q waves in leads III and aVF consistent with prior inferior myocardial infarction. Compared to the previous tracing of [2125-5-22] no diagnostic change. Read by: [Last Name (LF) ],[First Name8 (NamePattern2) 2206] [Doctor Last Name ] Intervals Axes Rate PR QRS QT/QTc P QRS T 102 130 80 294/352.85 48 -10 75 Cardiology Report ECHO Study Date of [2125-5-23] PATIENT/TEST INFORMATION: Indication: Intra-op TEE for Aortic stenting Status: Inpatient Date/Time: [2125-5-23] at 11:04 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW07-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] DR. [First Name (STitle) 412] [Last Name (Prefixes) 413] INTERPRETATION: Findings: LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally effusion. Conclusions: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Electronically signed by [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD on [2125-5-24] 07:08. [Location (un) ] PHYSICIAN: Brief Hospital Course: Admitted [5-3] to vascular service for left leg venous stasis ulcers which was infected, she was sterted on IV antibiotics and VAC placed [5-4]. She was worked up for mass that was compressing trachea that revealed innominate artery aneurysm. Cardiac surgery was consulted and she underwent preoperative workup. She underwent recontruction and bypass of aneurysm in two phase on [5-22] and [5-23], see operative report for further details. She was transferred to the CSRU and requiring pressors for blood pressure management. She awoke neurologically intact and over the next few days was weaned off pressors and diuresised. She extubated on [5-28] without complications and continued to progress. She remained in the CSRU for respiratory and blood pressure monitoring. She had swallowing evaluation due to concerns for aspiration that she did well and was cleared for nectar thickended. She was started on anticoagulation for thrombosis Rt subclavian. She continued to do well and was transferred to [Hospital Ward Name ] 2 on [6-4] for continued treatment. She continued to work with physical therapy and was ready for discharge to rehab. Medications on Admission: Remeron 30 mg PO daily Lopressor 50 mg PO BID Mevacor 20 mg PO daily MVI Vicodin PRN Plavix 75 mg PO daily Celexa 10 mg PO daily Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 8. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. 12. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): UNTIL INR 2.0. 13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 14. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 15. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical QID (4 times a day) as needed. 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: each port of midline daily and as needed. 17. insulin sliding scale Insulin SC (per Insulin Flowsheet) Sliding Scale Fingerstick QACHSInsulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 4 oz. Juice 61-100 mg/dL 0 Units 0 Units 0 Units 0 Units 101-130 mg/dL 2 Units 2 Units 2 Units 0 Units 131-150 mg/dL 4 Units 4 Units 4 Units 0 Units 151-180 mg/dL 6 Units 6 Units 6 Units 2 Units 181-210 mg/dL 8 Units 8 Units 8 Units 4 Units 211-240 mg/dL 10 Units 10 Units 10 Units 6 Units Ordered by [Last Name (LF) ],[First Name3 (LF) 2114] M, APN Beeper#: [Numeric Identifier 72690] on [6-4] @ 2112 Acknowledged by RN on [6-4] @ 2140 by [Last Name (LF) ],[Name8 (MD) 674], RN Processed by pharmacy on [6-4] @ 2118 by [Last Name (LF) ],[First Name3 (LF) ] Order #:[Numeric Identifier 94654] 18. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1 doses: for [6-6] only, then MD to order daily dose. Discharge Disposition: Extended Care Facility: [Hospital6 2222] - [Location (un) 538] Discharge Diagnosis: Innominate artery aneurysm PVD HTN NIDDM Depression Iron deficiency anemia CRI s/p breast ca s/p CVA ^chol. vascular dementia Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 10 weeks. Shower daily, let water flow over wounds, pat dry with a towel. Call our office for temp.>101.5, sternal drainage. Do not use creams, lotions, or powders on wounds. Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Make an appointment with Dr. [Last Name (STitle) ] for 2 weeks. (vasc. foot surgeon)[Telephone/Fax (1) 2395] Make an appointment with Dr. [Last Name (STitle) 1290] for 4 weeks.[Telephone/Fax (1) 170] Make an appointment with Dr. [Last Name (STitle) 8499] after discharge from rehab [Telephone/Fax (1) 7976] Completed by:[2125-6-6] ICD9 Codes: 5859, 2875, 5990, 5185, 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8086 }	Medical Text: Admission Date: [2141-5-19] Discharge Date: [2141-5-24] Date of Birth: [2084-3-25] Sex: F Service: CARDIOTHORACIC Allergies: Clindamycin Attending:[First Name3 (LF) 922] Chief Complaint: + Stress Test Major Surgical or Invasive Procedure: [2141-5-19] - CABGx2 (Left internal mammary artery to the left anterior descending artery, vein graft to the right coronary artery) History of Present Illness: Patient is a 58 year old woman who complained of exertional jaw pain. Patient had a stress test which was positive. She underwent cardiac catheterization which demonstrated severe 2 vessel coronary disease involving the proximal LAD as well as subtotally occluded right coronary artery. Percutaneous angioplasty and stenting was attempted on a subtotally occluded right coronary artery which was unsuccessful. She was, therefore, referred for coronary artery bypass grafting. The patient understood the risks and benefits of the procedure including, but not limited to bleeding, infection, myocardial infarction, stroke, death, renal and pulmonary insufficiency, as well as the possibility of a blood transverse and future revascularization procedures and agreed to proceed. Past Medical History: PMHx: DMx10 years on metformin HTN- last week diovan dose was increased Hypercholesterolemia- on lipitor . PSHx: right meniscus rhinoplasty for broken nose tonsillectomy appy Social History: Tobacco- quit 20 years ago (1pack for 15 years). Very active. Exercises on the treadmill regularly. Golf. Works in an office. . Family History: None Physical Exam: 97.5, 120/80, 74, 18, fs155 NAD. JVP 5cm nl s1/s2 CTA soft, nt, nd, +bs no edema, warm, +pulses Pertinent Results: [2141-5-23] 11:29AM BLOOD Hct-26.1* [2141-5-21] 04:37AM BLOOD Plt Ct-240 [2141-5-22] 05:40AM BLOOD K-4.4 [2141-5-21] 04:37AM BLOOD Glucose-188* UreaN-14 Creat-0.8 Na-137 K-4.6 Cl-104 HCO3-27 AnGap-11 [2141-5-21] CXR There is no appreciable left pneumothorax or pleural effusion following removal of the pleural tube. Postoperative widening of the mediastinum has improved. Aside from left middle lobe atelectasis, right lung is clear. No pulmonary edema. [2141-5-19] ECHO PRE-CPB: The left atrium is normal in size. No spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. No left ventricular aneurysm is seen. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There is no mass/thrombus in the right ventricle. The ascending, transverse and descending thoracic [Month/Day/Year 5236] are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No mitral regurgitation is seen. There is no pericardial effusion. Post CPB: Preserved biventricular systolic fxn. Trace AI, no MR. [First Name (Titles) ] [Last Name (Titles) 18350]t. Other parameters as pre-bypass. Brief Hospital Course: Mrs. [Known lastname ] was admitted to the [Hospital1 18] on [2141-5-19] for elective surgical management of her coronary artery disease. She was taken directly to the operating room where she underwent coronary artery bypass grafting to two vessels. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. By postoperative day one, Mrs. [Known lastname ] was awakem neurologically intact and extubated. Beta blockade, aspirin and a statin were started. She was then transferred to the cardiac surgical step down unit for further recovery. Ms. [Known lastname ] was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. Her pacing wires and drains were removed per protcol without complication. Mrs. [Known lastname ] continued to make steady progress and was discharged home on postoperative day five. She will follow-up with Dr. [Last Name (STitle) 914], her cardiologist and her primary care physician as an outpatient. She will return to the nursing floor in 2 weeks for a routine wound check. Medications on Admission: Diovan 160mg (increased from 80 last week) Evista Lipitor 10mg daily ASA 81mg MVI Calcium Nasonex metformin 1000mg [Hospital1 ] loratadine Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: Take twice daily for 7 days then stop . Disp:14 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Take for 1 month then as needed for constipation. Disp:60 Capsule(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:4 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months: Take for 1 month then stop. Disp:30 Tablet(s) Refills:0 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Take for 1 month then stop. Disp:60 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days: Take for 7 days with lasix then stop. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 10. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Gentiva Discharge Diagnosis: s/p CABG(LIMA-LAD, SVG-RCA)[5-19] PMH:HTN, NIDDM, hypercholesterolemia, s/p rhinoplasty, s/p T&A, s/p appy Discharge Condition: good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lifting greater then 10 pounds for 10 weeks from the date of surgery. 5) No driving for 1 month from date of surgery. 6) Take lasix and potassium as instructed for 7 days then stop. 7) You may resume your Evista, nasonex and loratidine medications as per preop at home. 8) Call with any questions or concerns. Followup Instructions: Follow-up with [Hospital Ward Name 121] 2 [Hospital 409] clinic in 2 weeks as instructed by nurse. Follow-up with Dr [Last Name (STitle) 914] in 4 weeks. Call [Telephone/Fax (1) 170] for appointment. Follow-up with primary care physician Dr [First Name8 (NamePattern2) 2048] [Last Name (NamePattern1) ] in 2 weeks. [Telephone/Fax (1) 133] Follow-up with cardiologist Dr. [First Name4 (NamePattern1) 919] [Last Name (NamePattern1) 911] in [12-5] weeks. Call [Telephone/Fax (1) 920] for appointment. Please call all providers to schedule your appointments. Completed by:[2141-5-24] ICD9 Codes: 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8087 }	Medical Text: Admission Date: [2201-4-14] Discharge Date: [2201-4-20] Date of Birth: [2120-10-14] Sex: M Service: MEDICINE Allergies: Alprazolam / Hydrochlorothiazide / Sulfonamides / Iodine / Clindamycin / Amoxicillin / Doxycycline / Cefaclor / Erythromycin Base / Amiodarone / Levofloxacin Attending:[Doctor First Name 1402] Chief Complaint: Shortness of breath, ICD firing Major Surgical or Invasive Procedure: ICD battery replacement History of Present Illness: This is a 80 year old patient with a history of nonischemic cardiomyopathy and cardiac arrest w/AICD placement [2194], DM2 and [Hospital ] transferred from OSH with AICD firing found to be in VT. OSH course: He presented to the OSH on [4-12] w/SOB which was thought to be due to CHF and possible respiratory infection. He was started on levofloxacin and received furosemide(which he tolerated). His sx improved on HD2, but then had episode of rapid VT and AICD firing where pt was shocked 9 times. This was terminated w/300mg IV amiodarone bolus. He then went into V-paced rhythm w/underlying LBBB pattern. He did not have any hypotension during this episode, but did desat transiently requiring NRB. CEs were cycled and negative x 2, bnp 242. He was seen by the cardiology service who recommended no further diuresis with lasix because of concern for potassium depletion being the inciting cause of prior VT arrest in [2194]. Also, Amio was started initially but held b/c thought to have had increased pt's QTc in the past. . Estimated he had approx 34 shocks of AICD. Device interrogated by Dr. [Last Name (STitle) ] which showed battery needs replacement. He was overdrive paced at 95 w improvement in QTc. He was then transferred to [Hospital1 18]. . He was admitted to cardiology with EP service following. On [2201-4-15] he had temporary transvenous pacing and replacement of AICD generator. He returned to the floor in stable confusion, but did have one episode of confusion. . On AM of [2201-4-16], pt had repeat episode of VT with AICD firing. Rhythm was terminated w/lidocaine 20mg and he was started on a lidocaine gtt. Past Medical History: 1. As child, question big heart according to the father. 2. Hypertension. 3. Noninsulin dependent diabetes mellitus . 3. Hiatal hernia. 4. History of left bundle branch block. 5. Status post cardiac arrest [2194] with ICD placement at that time. 6. Status post right epididymectomy in [2163] and right inguinal hernia surgery in [2163]. 8. [2194-3-31] echocardiogram with mild left atrial dilatation, mild dilated left ventricular cavity, moderate to severe left ventricular systolic dysfunction, delayed relaxation for c/w left ventricular infiltrate, transaortic regurgitation. 9. CAD: On [2194-3-31], catheterization showed no significant coronary artery disease with hypokinesis of the anterior basal, anterolateral, apical, inferior posterior basal walls with ejection fraction of 25% to 30% and elevated LVEDP at 22. 10. VT/torsades in [2194] in setting of prolonged QTc (approx 70 shocks at that time) Social History: Married. Tobb 36yrs ago. 1 dtr. no etoh. R and D engineer, now retired. Can walk 1 block. Family History: no early CAD Physical Exam: VS: T BP 132/76 HR 95 136 kg 100% AC PEEP 5 TV 700 Gen: intubated, sedated, NAD HEENT: MMM unable to assess, lying flat Cards: RRR nl S1S2 no MGR, PMI displaced laterally Resp: Coarse bilat. no wheezes Abd: BS+ NTND soft, no HSM Back: No CVA tenderness Ext: 2+ DP, PT bilat, no edema Neuro: moving all 4 extremities Skin: no rash Pertinent Results: [2201-4-14] 09:15PM BLOOD WBC-9.1 RBC-4.39* Hgb-13.8* Hct-38.9* MCV-89 MCH-31.4 MCHC-35.5* RDW-13.8 Plt Ct-167 [2201-4-17] 04:48AM BLOOD PT-15.6* PTT-27.7 INR(PT)-1.4* [2201-4-14] 09:15PM BLOOD Glucose-180* UreaN-27* Creat-1.1 Na-138 K-4.8 Cl-100 HCO3-30 AnGap-13 [2201-4-14] 09:15PM BLOOD CK(CPK)-538* [2201-4-16] 10:02AM BLOOD CK(CPK)-284* [2201-4-14] 09:15PM BLOOD CK-MB-5 cTropnT-<0.01 [2201-4-16] 10:02AM BLOOD CK-MB-4 cTropnT-<0.01 [2201-4-14] 09:15PM BLOOD Calcium-9.2 Phos-2.7 Mg-2.5 CXR: 1. More pronounced tortuosity and probable dilatation of the aorta. 2. Bibasilar opacities which might be consistent with aspiration/pneumonia, please correlate clinically. 3. Pacemaker defibrillator lead terminates in right ventricle. TTE: There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 30-40 %) with regional variation; there is relative preservation of contractile function at the base of the left ventricle. The aortic valve leaflets are moderately thickened. Significant aortic stenosis is present (not quantified). There is no pericardial effusion. The right ventricle was not well seen. Compared with the findings of the prior report (images unavailable for review) of [2194-3-31], left ventricular function remains at least moderately reduced. Brief Hospital Course: Mr. [Known lastname 6930] was admitted with VT storm and ICD firing an estimated 30 times. He was noted to be in a paced rhythm upon admission with notable QTc prolongation on EKG. It is likely that his initial VT event was due to recent quinolone-induced QTc prolongation. He was recently treated for pneumonia diagnosed by his PCP. [Name10 (NameIs) ] patient's QTc improved though continued at a top normal range of 450. He underwent uncomplicated ICD generator change on hospital day 2. While going for echocardiogram on hospital day 3 the patient's ICD began firing again. He was found to be in VT storm. He received an estimated 15 shocks from his ICD. Code blue was called. The patient was treated with lidocaine bolus (200mg) then drip and magnesium bolus of 2g. He successfully converted back to paced rhythm however due to mental status changes he was intubated and transferred to the ICU. The patient had an uneventful ICU course. He was rapidly extubated approximately 24 hours later and had no further VT. Echocardiogram revealed significant AS (not quantified) and EF 30-40% with regional variation. The images were of poor quality. He was transitioned to PO mexilitine and was titrated up on beta blocker and calcium channel blocker. His home spironolactone dose was also increased. His home ACEi was discontinued. The patient's home glipizide was discontinued as this can cause QT prolongation. The patient's rhythm was not felt to be amenable for induction/ablation. . The patient will follow-up with Dr. [Last Name (STitle) ] from EP on [2201-4-28] for further management of his rhtyhm issue. He will continue on 150mg toprol-xl, mexilitine 200mg Q8H, 120mg verapamil long acting. He should likely under repeat echo at a time more distant from recent defibrillations. He was also transitioned from glipizide to metformin at discharge. Metformin was chosen, because it is a non-QT prolongating [Doctor Last Name 360]. Metformin is still a less than ideal choice, because if patient has an arrest risk of increased acidosis. He will address further management of diabetes with Dr. [Last Name (STitle) 34488] on [4-23]. All medications should be reviewed w/ PCP with the specific focus on choosing non-QT prolonging agents. . Patient was told that legally he is not allowed to drive or operate heavy machinery given his history of VT. . On the day prior to discharge the patient had a routine portable chest x-ray which raised concern for worsening double contour of the aorta. Non-contrast CT revealed this abnormality to be mediastinal fat captured at changing angles due to patient positioning. Radiology recommended no further evaluation including no need for contrast CT to further evaluate the aorta. Medications on Admission: VS: T BP 132/76 HR 95 136 kg 100% AC PEEP 5 TV 700 Gen: intubated, sedated, NAD HEENT: MMM unable to assess, lying flat Cards: RRR nl S1S2 no MGR, PMI displaced laterally Resp: Coarse bilat. no wheezes Abd: BS+ NTND soft, no HSM Back: No CVA tenderness Ext: 2+ DP, PT bilat, no edema Neuro: moving all 4 extremities Skin: no rash Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:45 Tablet Sustained Release 24 hr(s) Refills:2 7. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:90 Capsule(s) Refills:2 8. Verapamil 120 mg Cap,24 hr Sust Release Pellets Sig: One (1) Cap,24 hr Sust Release Pellets PO once a day. Disp:30 Cap,24 hr Sust Release Pellets(s) Refills:2 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 10. Prescription You are not legally allowed to drive given your history of ventricular tachycardia Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis 1.Ventricular tachycardia 2.ICD change 3.Intubation . Secondary Diagnosis 1.Hypertension 2.DM type 2 3.s/p cardiac arrest [2194] w/ ICD placement at that time 4.Hx of Right inguinal hernia repair in [2163]. Discharge Condition: Stable Discharge Instructions: You were admitted with an unsafe heart rhythm and firing of your implanted defibrillator. Your recent antibiotic (levofloxacin) may have caused this though you are still at risk for further recurrence. You were started on 2 new medications - Verapamil and Mexilitine - to try to prevent recurrence. You should have a repeat echocardiogram in the future. Please discuss this further with your outpatient cardiologist. . Please weigh yourself daily and limit your salt intake to less than 2gm per day. Please notify your cardiologist if you gain more than 3lbs per day. . Please eat a bannana daily or other fruits high in potassium. . Discuss management of your blood sugars with metformin (instead of glipizide) with your primary care doctor. Glipizide was discontinued due to the risk that this medication can cause arrhythmia. It is our recommendation that your endocrinologist consider starting you on insulin, as another cardiac arrest while on metformin can lead to worsening acidosis than otherwise expected. . Take all medications as prescribed. New medications include verapamil sustained release 120mg daily, mexilitine 200mg three times a day and metformin 500mg twice daily. Please take toprol XL 150mg daily and discontinue metoprolol 75mg three times daily that you were taking prior to admission. Increase your home spironolactone to 50mg daily. . Discontinue your home glipizide as this can sometimes cause arrhythmias. Instead take metformin for blood sugar control. Also discontinue your home quinapril that you were taking prior to admission. . Keep all of your followup appointments as listed below. . You had a change in your ICD during this hospital stay. . Please do not shower for the next week, you can change the gauze, around the ICD site, but do not change the steri strips. If you notice, redness or swelling around the site please go to the emergency room or call Dr.[Name (NI) 1565] office [Telephone/Fax (1) 285]. . Your diagnosis of Ventricular Tachycardia legally prevents you from driving or operating heavy machinery. . Call 911 or return to the hospital for any firing of your implanted defibrillator, chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: You are sceduled for electophysiology follow up with Dr. [Last Name (STitle) ] on [2205-4-28]:20 on the [Location (un) 436] of the [Hospital Ward Name 23] building [Hospital Ward Name ] of [Hospital1 18]. If you have to change this appointment please call [Telephone/Fax (1) 285] . You should also be seen by your cardiologist or primary care physician [Name Initial (PRE) 176] 1 week. Follow-up in the device clinic as scheduled. Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2201-4-24] 11:30 . Please follow up with your endocrinologist Dr. [Last Name (STitle) 34488] at [Street Address(2) 34489], [Location (un) 24356] Ma. Ph# [Telephone/Fax (1) 3183]. You are scheduled for a follow up appointment on [4-23] at 1145am. . You are scheduled for a follow up with your primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on 3:15 pm on [2201-4-21]. Office location is 15 Rocat way, [Apartment Address(1) ], [Location ], MA. If you have to change this appointment Dr.[Name (NI) 33490] office number is [Telephone/Fax (1) 8725]. ICD9 Codes: 5070, 4271, 4254, 4275, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8088 }	Medical Text: Admission Date: [2199-1-1] Discharge Date: [2199-1-11] Date of Birth: [2124-11-20] Sex: F Service: MEDICINE Allergies: Levofloxacin / Zithromax / Optiray 300 Attending:[First Name3 (LF) 3016] Chief Complaint: diarrhea, tachycardia, nausea/vomiting and flushing Major Surgical or Invasive Procedure: intubation lumbar puncture PICC placement History of Present Illness: Ms [Known lastname ] is a 74 yo woman with a h/o NSCLC and recent diagnosis of neuro-endocrine tumor with carcinoid syndrome.Pt presented to the ED with severe nausea/emesis and diarrhea x 2days. Also worsening of flushing over the past several days.In the ED exam notable for flushing and sinus tach to 120s. Labs significant for crea 1.8 ( baseline 0.7), bicarb 13 and lactate up to 4.2.\Pt with h/o NSLAC and recently admitted for flushing,diarrhea and tachycardia ( [Date range (3) 32763]). Was diagnosed with carcinoid syndrome ( chromogranin A 4880)and started on octreotide 50 mcg q hrs.Liver biopsy was also done and reportedly is c/w with a primary neuroendocrine tumor. Pt's symptoms did improve initially and diarrhea and flushing resolved, however, over the past two days she has had an increase in dairrhea ( non-stop) and emesis x 10 /24hrs with palpiations and flushing.She has abdominal cramping with BMs. She also reports that over the past few days she has had intermittent chest pain which she has had before when she gets palpitations. Pain not related to exertion adn does not worsen with deep breath.She continues to suffer from chronic DOE , which has started in [9-16] and is being evaluated by cardiology. Of note , pt has recently completed a 7 day course of bactrim for a proteus UTI. She denies fevers/chills/headaches/cough/hematemesis/hematochezia/dysuria. All other ten point ROS is negative. Past Medical History: ONCOLOGIC HISTORY: (per [Date Range ]) 1. Stage I nonsmall cell lung cancer (predominant histology: large cell carcinoma with neuroendocrine features) in [2190-6-15]; 2. Stage I nonsmall cell lung cancer (adenocarcinoma with bronchioloalveolar features) in [2195-5-22]; 3. Stage IV nonsmall cell lung cancer (large cell carcinoma with neuroendocrine features) in [2196-12-22] with liver metastasis (liver biopsy from [2198-5-11] shows adenocarcinoma/large cell carcinoma). 4. [12-18]: Diagnosed with carcinoid syndrome. Liver biopsy poitive for primary endocrine tumor. Started on octreotide. Treatment: 1. Status post right lower lobe lobectomy on [2190-6-8] 2. Status post left upper lobe lobectomy on [2195-5-22] 3. Status post 4 cycles of carboplatin 6->4.5 AUC, paclitaxel 200-> 180 mg/m2, bevacizumab 15 mg/kg. As part of clinical trial DFHCC 07-369 with anamorelin HCl/placebo. Last dose [2197-3-21]. 4. Status post 3 cycles of erlotinib 150 mg/day and ARQ 197/placebo. Part of DFHCC 07-373. Started on [2197-5-18]. Off treatment [2197-9-15] due to disease progression. 5. Status post 2 cycles of carboplatin 3 AUC D1 and etoposide 80mg/m2 IV D1-3. Last dose on [2197-11-14]. 6. Status post 6 cycles of pemetrexed 500 mg/m2. Last dose on [2198-4-17]. 7. Status post 1 cycle of gemcitabine 1000 mg/m2 D1, D8, D15 and oral V1 inhibitor as part of phase I clinical trial DFHCC 08-033. Last dose on [2198-9-19]. OTHER MEDICAL HISTORY: # History of shingles diagnosed in 05/[2197]. # History of recurrent pneumonia in [4-/2189], [2189-10-8] and [2190-4-7]. # Osteoporosis of the spine diagnosed on bone mineral density testing in addition to osteopenia of the femoral neck and hip # Mild pulmonary hypertension: R heart cath in late [2198-11-7] showed normal left and right sided filling presures with an LVEDP of 6mmHg and RVEDP of 8mmHg. There was mild pulmonary hypertension with a PASP of 40mmHg. There was normal estimated cardiac index by Fick of 2.96 L/min/m2. Social History: The patient has never smoked. No history of EtOH use. Did work in a factory with heavy pollution. Lives with her husband, who also does not smoke. Family History: Sister died from lung cancer. Physical Exam: ADMISSION PHYSICAL EXAM VS: Tm:99 BP:126/58 HR:121 RR:22 O2 100Sat % on RA Pain:no pain GEN: Significant flushing of her face and chest, no acute signs of distress HEENT: Pupils equal and reactive, sclerae non-icteric, o/p clear, dry mucus membranes Neck: Supple, No JVD, no thyromegaly. Lymph nodes:No cervical, supraclavicular or axillary LAD CV: S1S2, tachycardic but reg.rhythm, systolic ejection murmur,no rubs or gallops RESP: Good air movement bilaterally, no rhonchi or wheezing ABD: trace ankle edema bilaterally, good pedal pulses DERM: facial and chest flushing Neuro:non-focal. PSYCH: Appropriate and calm . DISCHARGE PHYSICAL EXAM Tm/Tc 99.3/98.8, BP 130/65 (100-130)/(50-60), HR 85 (85-95), RR 20-22, SaO2 98%RA FS 160-200 GEN: NAD HEENT: MMM Cards: RR S1/S2 normal. No murmurs/gallops/rubs. Pulm: No dullness to percussion, crackles at bases bilaterally Abd: BS+, soft, round abdomen but nondistended; no masses palpable and no tenderness to palpation Neuro: face/smile symmetric, sensation to light touch intact throughout extremities, moves all extremities spontaneously, [4-11] upper extremity strength Extrem: upper extremities symmetric Pertinent Results: ADMISSION LABS [2199-1-1]: WBC-10.4# RBC-4.61# Hgb-14.1# Hct-43.5# MCV-95 MCH-30.7 MCHC-32.4 RDW-14.9 Plt Ct-391 WBC-12.3* RBC-4.29 Hgb-13.2 Hct-40.9 MCV-95 MCH-30.8 MCHC-32.3 RDW-15.0 Plt Ct-359 Neuts-91.7* Lymphs-3.4* Monos-4.6 Eos-0.3 Baso-0.1 Glucose-300* UreaN-31* Creat-1.3* Na-136 K-4.5 Cl-111* HCO3-13* AnGap-17 Glucose-420* UreaN-39* Creat-1.8# Na-132 K-4.2 Cl-99 HCO3-12* AnGap-25* ALT-325* AST-382* LD(LDH)-363* AlkPhos-329* TotBili-0.6 pO2-78* pCO2-27* pH-7.33* calTCO2-15* Base XS--9 Lactate-4.2* K-7.3* Lactate-3.0* DISCHARGE LABS [2199-1-11]: WBC 7.7, Hb/Hct 8.6/26.3, Plt 307 Na 140, K 3.8, Cl 104, HCO3 29, BUN 8, Cr 0.6 Ca: 7.7 Mg: 1.8 P: 3.0 ALT: 16 AST: 11 AP: 117 Tbili: 0.3 PT: 13.1 INR: 1.1 ECG [2199-1-1]: sinus tachycardia, no changes compared to previous . CXR [2199-1-1]: 1. No acute cardiac or pulmonary process. 2. Small unchanged right pleural effusion. . KUB [2199-1-1]: no free air, no dilated loops. = = = = = = ================================================================ CT HEAD [2199-1-4] No acute intracranial pathology. MRI HEAD [2199-1-4] No evidence for metastatic disease or acute ischemia. EEG [2199-1-5] There were no pushbutton events during this recording session suggestive of clinical seizures. The detections were artifactual in origin. The routine record shows an encephalopathic EEG and a few sharp epileptiform transients across the right lateral temporal area. LUMBAR PUNCTURE [2199-1-4] Pathology: NEGATIVE FOR MALIGNANT CELLS. WBC-2 RBC-[Numeric Identifier 32764]* Polys-91 Lymphs-5 Monos-4 WBC-1 RBC-[Numeric Identifier 32765]* Polys-92 Lymphs-4 Monos-4 TotProt-47* Glucose-110 HERPES SIMPLEX VIRUS PCR- Negative EBV-PCR- Negative HERPES 6 PCR- Negative TB - PCR-Pending CYTOMEGALOVIRUS - PCR- Negative GRAM STAIN (Final [2199-1-4]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. CRYPTOCOCCAL ANTIGEN (Final [2199-1-5]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. = = = = = = ================================================================ MICRO DATA: [2199-1-1] blood cultures - Negative [2199-1-2] blood culture - Negative [2199-1-3] blood culture - Pending [2199-1-4] blood culture - Pending [2199-1-6] blood culture - Pending [2199-1-7] blood culture - Pending [2199-1-9] blood culture - Pending [2199-1-2] Stool Studies: negative for Salmonella, Shigella, Yersinia, enteric GNRs, Campylobacter, O+P, culture, and C. diff toxin x3.. [2199-1-3] 02:45AM STOOL CLOSTRIDIUM DIFFICILE TOXIN, PCR- Positive [2199-1-5] 1:16 pm URINE [Female First Name (un) ] ALBICANS. >100,000 ORGANISMS/ML. = = = = = = ================================================================ Brief Hospital Course: BRIEF HOSPITAL COURSE: Ms. [Known lastname ] is a 74 y/o lady with h/o NSCLC (large cell with neuroendocrine features) with liver involvement and carcinoid syndrome, who presented with diarrhea, flushing, palpitations, vomiting and lethargy in the setting of infection as well as carcinoid syndrome due to not injecting Octreotide at home. When she was out back on Octreotide, she felt much better. In addition. she was treated for C. diff colitis and yeast UTI. Her course was complicated by one episode of seizure for which she was started on Keppra. She was discharged to rehab with plans for long-acting Octreotide injections in the future. ACTIVE ISSUES: 1. Carcinoid syndrome: Patient was admitted with severe carcinoid symptoms but without blood pressure lability. She was started on octreotide 200mg sc q 4 hrs with close f/u of symptoms. When her diarrhea did not resolve (see below), she was temporarily placed on an Octreotide drip, but was able to be transitioned back to subcutaneous. At the time of discharge, she had no more diarrhea, flushing, palpitations, vomiting or lethargy. She is being discharged to rehab on Octreotide SC TID, but she will follow up in [Hospital ] clinic to have monthly Sandostatin (long-acting Octreotide), to ensure compliance. She will follow up with her Oncologist soon after discharge. 2. Diarrhea: C. diff colitis in addition to carcinoid syndrome. The patient's watery stools did not completely resolve with Octreotide. Though C. diff toxin was negative x3, there was a high index of suspicion due to fevers and leukocytosis, so C. diff PCR was sent which was positive. Given her PPI use as well as recent antibiotic use, she is predisposed to getting C. diff infection. She was started on PO Vancomycin and her stools became more formed. She will complete a 2 week course of this antibiotic; the last day of treatment [2199-1-15]. 3. UTI: [Female First Name (un) 564] albicans. Multiple urinalyses showed yeast UTI; speciation was requested and was found to be [Female First Name (un) 564] albicans. She will continue this for a 2 week course; last day is [2199-1-22]. 4. Altered Mental Status / Seizure: multifactorial in etiology. On the third day of admission, the patient complained of chest pain (see below) and she received Morphine & Ativan. She became progressively lethargic. A head CT was done and was normal. She developed tonic-clonic movements of both arms concerning for seizure and therafter became more lethargic consistent with post-ictal state. She was transfered to the ICU on [2199-1-4] for elective intubation for airway protection and further work-up. Neurology was consulted. Patient loaded with keppra and started on keppra 750mg IV BID for seizure prophylaxis. She did have an elevation in WBC; concern for meningitis prompted antibiotic coverage with empiric vancomycin, cefepime, ampicillin, and acyclovir for empiric meningitis coverage. The patient was intubated to protect her airway in order to perform an MRI and LP. MRI head was negative for any signs of encephalitis as well as any brain mets. LP without sign of infection; the empiric antibiotics were discontinued. EEG was performed and overall was consistent with toxic-metabolic encephalopathy but there was some localized temporal activity so per Neurology she was kept on Keppra. Mental status improved and she was extubated the next day. After that, she remained alert and oriented x3 for the rest of admission and had no further seizure activity. This decompensation was likely a result of her underlying illness with superimposed infections (C. diff, UTI) as well as sedating medications. She is being discharged on Keppra, and will follow up with Neurology. 5. Tachycardia/Chest pain: Most likely due to carcinoid syndrome. During the hospital stay she had an episode of left sided chest pain , which she described as different from previous. No significant EKG changes on admission and pain familiar to pt from the past when she had episodes of tachycardia related to the carcinoid syndrome. ECG did show TWI in V3 only. CE were obtained. CK was elevated but CKmb and trop remained flat. Cardiology was consulted and they did not think that there was any evidence of ischemia based on the EKGs and cardiac enzymes an further evaluation was not recommended. CXR and physical exam reveal no evidence of pericardial effusion. For the rest of her admission, she had no more chest pain. 6. Acute renal failure: Prerenal state, resolved. On admission pt with ARF (Cr 1.8). In the setting of diarrhea and vomiting, this was most likely from prerenal state. This resolved with IV fluid and at the time of discharge her creatinine was 0.6. 7. Transaminitis: resolved. LFTs were slightly higher than baseline (hepatitis B and C negative). Transaminases were in the 300's on admission. This was most likely due to disease progression, meds and dehydration. This was monitored and her LFTs trended downwards and were normal (<20) at the time of discharge. 8. Hyperglycemia: New onset. Could be due to octreotide. Monitored with finger sticks and treated with ISS. However, she had a low insulin requirement so insulin was not continued. She had no polydipsia/polyuria/polyphagia. 9. LUE Swelling: no DVT. She has LUE swelling noted near the site of the PICC line so there was concern for a DVT or a superficial vein thrombosis. Ultrasound was without clot. At the time of discharge, her arms were symmetric. She is being discharged with PICC in place (discussed with outpatient Oncologist). TRANSITIONAL ISSUES: -Patient is full code. She demonstrated understanding about her disease but does not want to make any decisions about code status while her son is still in [Name (NI) 651]. -Chinese speaker; patient requires translator. -IV Access: left upper extremity PICC line placed [2199-1-3]. Medications on Admission: Medications - Prescription LORAZEPAM [ATIVAN] - 0.5 mg Tablet - [12-9] Tablet(s) by mouth at bedtime as needed for insomnia OCTREOTIDE ACETATE - (Prescribed by Other Provider) - 50 mcg/mL Solution - 50 Solution(s) every eight (8) hours PROCHLORPERAZINE MALEATE - 5 mg Tablet - 1 Tablet(s) by mouth as directed as needed for nausea take one tablet twice daily for three days following chemotherapy and then only as needed Medications - OTC ACETAMINOPHEN - (OTC) - 500 mg Tablet - 1 Tablet(s) by mouth as directed take 1 tablet twice daily for three days following chemotherapy and then only as needed FOOD SUPPLEMENT, LACTOSE-FREE [ENSURE] - Liquid - 1 can by mouth twice a day LORATADINE - (OTC) - 10 mg Tablet - 1 Tablet(s) by mouth once a day as needed for post nasal drip MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. octreotide acetate 50 mcg/mL Solution Sig: Fifty (50) mcg Injection Q8H (every 8 hours). 2. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia or anxiety. 3. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for nasuea around chemotherapy doses. 4. acetaminophen 500 mg Capsule Sig: One (1) Capsule PO as directed as needed for pain: 1 tablet twice daily for three days following chemotherapy and then only as needed. 5. Ensure Liquid Sig: One (1) can PO twice a day: Lactose-free Ensure. 6. multivitamin Capsule Sig: One (1) Capsule PO once a day. 7. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 5 days: (14 day course, last day is [2199-1-15]). 8. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 12 days: (14 day course, last day is [2199-1-22]). 9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 10. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): to rash on buttocks. 11. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [Hospital 392] Rehabilitation & Nursing Center - [Hospital1 392] Discharge Diagnosis: carcinoid syndrome C. difficile diarrhea yeast UTI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with diarrhea, flushing, palpitations, vomiting and lethargy. You were found to have a gastrointestinal infection, for which you are being treated with antibiotics. In addition, you have a urinary tract infection. In addition to these infections, your symptoms are also likely due to your underlying cancer and not being able to take the Octreotide injections that were prescribed. We treated you with this medication and your symptoms are much improved. You are being discharged to a rehab facility where you will be able to receive these shots, and the plan is to come back as an outpatient for a formulation of that injection that lasts one month. . Also, during the admission you had a seizure and you were evaluated by Neurology. You have been started on anti-seizure medication. Please follow up with Neurology (appointment listed below). . We made the following changes to your medications: -start Vancomycin oral (14 day course, last day is [2199-1-15]) -start Fluconazole (14 day course, last day is [2199-1-22]) -start Nystatin oral and Miconazole topical as needed -start Keppra Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2199-1-15] at 11:30 AM With: [First Name4 (NamePattern1) 539] [Last Name (NamePattern1) 10603], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2199-1-29] at 9:30 AM With: [Name6 (MD) ] [Name8 (MD) 831], MD [0-0-] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PULMONARY FUNCTION LAB When: THURSDAY [2199-1-31] at 1:10 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: NEUROLOGY When: MONDAY [2199-2-4] at 2:30 PM With: DRS. [Name5 (PTitle) 162] & [Hospital1 ] [Telephone/Fax (1) 44] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) ] [Name8 (MD) 831] MD, [Doctor First Name 3018] ICD9 Codes: 5849
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8089 }	Medical Text: Unit No: [Numeric Identifier 59156] Admission Date: [2103-2-10] Discharge Date: [2103-2-22] Date of Birth: [2103-2-10] Sex: M Service: NB HISTORY: [Known lastname ] [Known lastname ], twin number two, is the 1450 gram product of a 33 and [4-5] week twin gestation, born to a 41 year-old, Gravida II, Para 0, now 2, white female. Prenatal screens reveal blood type A negative, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune, group B strep negative. She was betamethasone complete since [1-12]. Pregnancy was otherwise uncomplicated. The mother presented on the day of delivery with premature rupture of membranes. The infant was delivered by Cesarean section, due to twin gestation. He emerged vigorous and crying. Apgars were 9 at one minute and 9 at five minutes. He was brought to the Neonatal Intensive Care Unit for admission. PHYSICAL EXAMINATION: Physical examination reveals a premature male, who is pink and comfortable in room air. Anterior fontanel open and flat. Clavicle and palate intact. Clear breath sounds with fair aeration. No murmur. Regular rate and rhythm. Good femoral pulses. Abdomen soft, nondistended, no hepatosplenomegaly. Normal male genitalia. Testes descended into the scrotum. Patent anus. Moves all extremities. INITIAL IMPRESSION: Premature, small for gestational age, twin male, without respiratory distress. He is at risk for sepsis, secondary to prematurity only. HOSPITAL COURSE: Hospital course will be discussed by systems: 1. Respiratory: Infant has been stable in room air. He has not had significant apnea of prematurity. He had one apneic and bradycardiac episode on day of life 9, secondary to a spit. 2. Cardiovascular: He has remained hemodynamically stable. There has never been a murmur. 3. Fluids, electrolytes and nutrition: Initially, he was n.p.o. on D10W at 80 ml per kg per day intravenously. He was also started on parenteral nutrition. Feedings were started on day of life one and advanced to full feedings by day of life five. He is currently on breast milk 26 or Similac special care 26, with ProMod at 150 ml per kg per day. He requires a significant amount of gavage feedings and receives his feedings over one hour 20 minutes. His discharge weight is 1645 grams. 4. Gastrointestinal: He had mild hyperbilirubinemia, requiring phototherapy. His peak bilirubin was 6.9 total, 0.3 direct. His rebound bilirubin was 3.4 total 0.5 direct. 5. Hematology: His initial hematocrit was 44.9. He has not required transfusions. His blood type is A negative, Coombs negative. 6. Infectious disease: He had initial CBC which was benign, with white blood cell count of 7.3, 42 polys, 0 bands. Blood culture was sent. He was never started on antibiotics. Blood culture was negative at 48 hours. 7. Neurology: He has a normal neurologic examination. He has not required a head ultrasound. 8. Sensory: Audiology hearing screen was not done. It needs to be performed prior to discharge. Ophthalmology: Eye examination was not done, as he is not at risk for retinopathy of prematurity. 9. Psychosocial: [Hospital1 69] social work is involved with the family, per routine. The contact social worker can be reached at [Telephone/Fax (1) ]. Parents are involved in his care. They desire transfer to [Hospital1 59157] for further care before discharge home. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To [Hospital6 2561] Special Care Nursery for level II care. NAME OF PEDIATRICIAN: not yet chosen CARE RECOMMENDATIONS: The infant is on Special Care 26 or breast milk 26 with promod, at 150 ml/kg/day, mainly by gavage, over 1 hour and 20 minutes. Feedings p.o. are being encouraged, as tolerated. Medications: Fer-in-[Male First Name (un) ] 0.15 ml p.o. daily. Vitamin E 5 International Units p.o. daily Car seat position screening is recommended prior to discharge. State laboratory screen has been sent times one. Results are pending. No immunizations have been given. 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) Born at less than 32 weeks; (2) Born between 32 and 35 weeks with two of the following: Daycare during RSV season , a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or (3) with chronic lung disease. 2. Influenza immunization is recommended annually in the Fall for all infants once they reach six months of age. Before this age, and for the first 24 months of the child's life, immunization against influenza is recommended for house hold contacts and out of home caregivers. Follow up appointments scheduled/recommended: None. On discharge from [Hospital3 ], the infant should have follow up with his pediatrician. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Twin number two. 3. Small for gestational age. 4. Mild apnea of prematurity. 5. Hyperbilirubinemia, treated. 6. Sepsis ruled out without antibiotics. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 54936] Dictated By:[Last Name (NamePattern4) 55464] MEDQUIST36 D: [2103-2-22] 06:47:10 T: [2103-2-22] 07:06:21 Job#: [Job Number 59158] cc:[Last Name (NamePattern4) 55464] ICD9 Codes: 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8090 }	Medical Text: Admission Date: [2181-12-29] Discharge Date: [2182-1-3] Service: [Hospital1 212] HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 103774] is an 84 year-old man with an extensive past medical history including end stage renal disease on hemodialysis, diabetes type 2, gastrointestinal bleed, hyperlipidemia, hypertension, coronary artery disease and congestive heart failure with an ejection fraction of 15 and is status post a cerebrovascular accident who presented to the [Hospital1 188] Intensive Care Unit after an episode of hypotension following dialysis catheter placement. He was also noted to be tachycardic. The patient was rehydrated, but unfortunately his blood pressure remained low in the 80s with a mean arterial pressure in the 40s and 50s. He was treated with Vancomycin, Ceftriaxone and Flagyl for suspected sepsis, however, the patient's blood pressure failed to improve and it was believed this was due to his worsening ischemic cardiomyopathy with a known EF of 14% prior to this presentation. The patient was placed on pressor medications with little improvement in his blood pressure, which remained too low to have hemodialysis performed. After consultation with the family and with the kidney specialist, a family meeting was held and it was determined that the patient's wife Mrs. [Known lastname 103774] requested to have her husband made as comfortable as possible, taken off any pressor medications and made comfort measures only. He was then transferred to the floor where he received morphine prn for pain and for respiratory distress. Over the two days on the floor the patient gradually deteriorate with worsening blood pressure, tachycardia and an increasing respiratory rate. On the evening of [1-3], the patient expired. He remained as comfortable as possible throughout the last few days at the [Hospital1 69]. The patient's wife refused a post mortem examination and Dr. [Last Name (STitle) ] his attending was notified. The patient's wife was at the bedside at the time of death. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[Last Name (NamePattern1) 17270] MEDQUIST36 D: [2182-1-3] 21:07 T: [2182-1-8] 08:39 JOB#: [Job Number ] ICD9 Codes: 0389, 2765, 4280, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8091 }	Medical Text: Admission Date: [2152-11-15] Discharge Date: [2152-11-19] Date of Birth: [2093-6-2] Sex: M Service: ORTHOPAEDICS Allergies: Alcohol Attending:[First Name3 (LF) 11415] Chief Complaint: L ankle pain Major Surgical or Invasive Procedure: ORIF left ankle History of Present Illness: Pt suffered ankle fx, presented to [Hospital1 18]. Social History: Lives with wife. 60 pack year tob hx, quit 15 years ago, no ETOH currently, but hx of ETOH abuse and alcholism 23 years ago. Family History: HTN in father and brother and distant family hx of CAD Physical Exam: swollen ankle on admission, nvi Brief Hospital Course: Pt tolerated surgery well and had an uncomplicated post-op course. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:60 Tablet(s) Refills:0 2. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) syringe Subcutaneous Q 24H (Every 24 Hours) for 2 weeks: 1 40mg syringe daily. Disp:14 40 mg syringes Refills:0 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:60 Capsule(s) Refills:0 4. Quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: right ankle fracture Discharge Condition: Good Discharge Instructions: Keep your incisions clean and dry. Do not bear weight on your right leg. Elevate your leg above your heart as much as possible. Take all medications as prescribed. You need to take lovenox shots for 2 weeks. Please follow-up with Dr. [Last Name (STitle) 1005] in 2 weeks for suture removal. Please return to the emergency room if you notice: -increased swelling or redness -temperature > 101.4 -shortness of breathe Call with any questions Physical Therapy: NWB RLE Treatment Frequency: Please do daily dressing changes until there is no more drainage from wounds. Staples out at follow-up. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 1005] at the [Hospital1 18] orthopaedic clinic in 2 weeks. Call [Telephone/Fax (1) ] to make an appointment. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4450], M.D. Phone:[Telephone/Fax (1) 4451] Date/Time:[2153-1-3] 9:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] Completed by:[2152-11-19] ICD9 Codes: 4019, 2720, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8092 }	Medical Text: Admission Date: [2116-5-19] Discharge Date: [2116-5-26] Date of Birth: [2044-12-17] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Seasonale Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Aortic Valve #23 [Doctor Last Name ] pericardial valve, Coronary artery bypass graft x1 (SVG-dRCA) History of Present Illness: 71 yo female with known aortic stenosis. Recent cardiac catheterization revealed single vessel coronary artery disease. She is now referred for AVR/CABG. Current symptoms include progressive dyspnea on exertion. She has had surgery cancelled recently for a UTI and tpresents today for PATs Past Medical History: - Hypertension - Dyslipidemia - Hypothyroid - Morbid Obesity - Diabetes Mellitus, diet controlled - recent UTI Past Surgical History: R TKR [2110] R cataract [Doctor First Name ] Social History: Lives with:husband Occupation:retired Tobacco:denies ETOH:denies Family History: Family History:non-contrib. Race:Caucasian Last Dental Exam:on emonth ago Physical Exam: Pulse: 79 O2 sat: 97% B/P Right: 122/62 Left: Height: 64 inches Weight: 275 lbs General:has a difficult time lying flat due to back pain, orthopnea Skin: Dry [] intact [x]moist large area of fungal rash right groin HEENT: PERRLA [x] EOMI []ptosis R upper lid; anicteric sclera; OP unremarkable Neck: Supple [] Full ROM []no JVD appreciated Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur- 4/6 SEM radiates to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x];obese Extremities: Warm [x], well-perfused [x] Edema- trace BLE Varicosities: superficial spider veins Neuro: Grossly intact; MAE [4-30] strengths; nonfocal exam Pulses: Femoral Right: 2+ Left:2+ DP Right: NP Left:NP PT [Name (NI) 167]: 1+ Left:1+ Radial Right:2+ Left: 2+ Pertinent Results: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient was initially AV-Pace, then in SR. No inotropes. An aortic tissue-valve is seen to be well-seated with no leak and no AI. Residual mean gradient = 5 mmHg. Preserved biventricular systolic fxn. Aorta intact. MR is now trace. [2116-5-22] 03:01AM BLOOD WBC-10.0 RBC-2.75* Hgb-8.9* Hct-25.3* MCV-92 MCH-32.2* MCHC-35.0 RDW-13.8 Plt Ct-151 [2116-5-19] 01:35PM BLOOD WBC-17.3# RBC-2.90# Hgb-9.2# Hct-26.5# MCV-91 MCH-31.6 MCHC-34.6 RDW-13.6 Plt Ct-165 [2116-5-22] 03:01AM BLOOD Glucose-144* UreaN-27* Creat-1.1 Na-135 K-4.0 Cl-103 HCO3-25 AnGap-11 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 96177], [Known firstname ] [Hospital1 18] [Numeric Identifier 96178] (Complete) Done [2116-5-19] at 11:07:23 AM 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: [2044-12-17] Age (years): 71 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: AVR/CABG ICD-9 Codes: 786.05, 786.51, 424.1, 424.0 Test Information Date/Time: [2116-5-19] at 11:07 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3318], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW1-: Machine: us6 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Ascending: 3.0 cm <= 3.4 cm Aorta - Descending Thoracic: 2.6 cm <= 2.5 cm Aortic Valve - Peak Gradient: 66 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 36 mm Hg Aortic Valve - LVOT diam: 2.0 cm Aortic Valve - Valve Area: 0.6 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Moderate (2+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate (2+) MR. TRICUSPID VALVE: Mild to moderate [[12-29]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient was initially AV-Pace, then in SR. No inotropes. An aortic tissue-valve is seen to be well-seated with no leak and no AI. Residual mean gradient = 5 mmHg. Preserved biventricular systolic fxn. Aorta intact. MR is now trace. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD, Interpreting physician [Last Name (NamePattern4) ] [2116-5-22] 11:11 ?????? [2107] CareGroup IS. All rights reserved. Brief Hospital Course: The patient was brought to the Operating Room on [5-19] where the patient underwent Aortic valve replacement with # 23 [Doctor Last Name ] pericardial valve and coronory artery bypass graft x 1 SVG to dRCA. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring on POD #3. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact hemodynamically stable, weaned from inotropic and vasopressor support by POD#2. 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. Patient is a known diabetic diet controlled she was started on lantus and sliding scale insulin during this admission for optimal blood glucose control. By the time of discharge on POD #7 the patient was ambulating with assist, the wound was healing and pain was mimimal. The patient was discharged to Hellenic Nursing and Rehab in [Location (un) 2624] in good condition with appropriate follow up instructions. Medications on Admission: Medications at home: Folate 1 mg daily Levothyroxine 100 mcg daily Lisinopril 20 mg daily Metoprolol ER 25 mg daily Simvastatin 40 mg daily Aspirin 81 mg daily Allergies: Sulfa - pruritis Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: re-eval need to continue diuretics after 1 week. 15. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. 16. insulin glargine 100 unit/mL Cartridge Sig: Thirty (30) units Subcutaneous once a day for daily days: please 30units q AM. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: aortic stenosis coronary artery disease Hypertension, Dyslipidemia, Hypothyroid, Morbid Obesity, Diabetes Mellitus-diet controlled, recent UTI PSH: Right TKR '[10], Right cataract [Doctor First Name ] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Monitor vitals signs including weight and temperature Concerns - fever of 100.5 degrees Fahrenheit or higher - weight increase more than two pounds in one day or five pounds in a week ?????? Monitor wound healing, teach wound care Care - SHOWER DAILY - including first washing incisions gently with mild soap - NO lotions, cream, powder, or ointments to incisions Concerns - warmth, redness, swelling or increased tenderness/pain - ANY fluid or drainage coming out of incisions ?????? Medication, diet and exercise teaching and compliance ?????? Follow-up appointment assistance and compliance Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [Telephone/Fax (1) 170] Surgeon Dr.[First Name (STitle) ] [Name8 (MD) 6144], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2116-6-18] Cardiologist Dr.[First Name8 (NamePattern2) 518] [Last Name (NamePattern1) 8579] on [6-25] at 11:15 Please call to schedule the following: Primary Care Dr.[Last Name (STitle) ],[First Name3 (LF) ] M. [Telephone/Fax (1) 40076] in [3-31] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2116-5-26] ICD9 Codes: 4241, 4019, 2449, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8093 }	Medical Text: Admission Date: [2135-1-6] Discharge Date: [2135-1-12] Date of Birth: [2049-11-26] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2777] Chief Complaint: Abdominal aortic aneurysm Major Surgical or Invasive Procedure: [2135-1-6] open repair infrarenal AAA [2135-1-7] ex lap/cholecystectomy, Bilat [Doctor Last Name ] embolect, Bilat fasciotomies [2135-1-8] [Doctor Last Name ] cutdown, embolectomy, AT embolectomy [2135-1-9] ex-lap (neg), open abdomen History of Present Illness: 85-year-old female presented for elective repair of an infrarenal abdominal aortic aneurysm initially found on CT chest for routine follow-up of a lung mass. Past Medical History: 5.8-cm abdominal aortic aneurysm, smoker, hypertension, LLE DVT, COPD, arthritis, hammertoe deformities, major depression, a pulmonary nodule in RUL, cataracts, footdrop of the right foot, diastolic dysfunction by echo from [2117], chronic kidney disease stage III, mitral valve prolapse, degenerative disc disease, hearing loss, hyperlipidemia, urge incontinence, osteopenia. PFTs from [2128] showed FEV1 93% predicted and FEV1/FVC ratio 84% predicted. colonoscopy: consistent with colitis/IBD; scoliosis; varicose veins. Social History: Significant history of tobacco use. Denied EtOH abuse. Denied recreational drug use. Family History: Unknown. Physical Exam: Pre-op exam: T 98.9 P 68 BP 137/79 RR 20 O2sat 97% on RA Awake, alert, NAD, anxious Heart RRR Lungs no respiratory distress, normal excursion/effort Abdomen soft, NT, ND Extremities WWP, bilateral hammertoe deformities Brief Hospital Course: On [2135-1-6], the patient was admitted post-operatively after open AAA repair. She produced 2 guaiac positive stools, raising concern for mesenteric ischemia. In addition, dopplerable signals were lost in bilateral lower extremities, raising concern for showered emboli from the aneurysmal thrombus. The patient was taken back to the OR on [2135-1-7] for bilateral popliteal artery exploration with embolectomy of the tibial vessels bilaterally, exploratory laparotomy with cholecystectomy and evacuation of hematoma. The right DP became dopplerable, but signals remained absent on the left DP/PT. Pt was transfused with blood to maintain hematocrit above 30. On [2135-1-8] the patient underwent re-exploration at left popliteal fossa with left anterior tibial artery thrombectomy. The patient was started on an argatroban drip out of concern for HIT. She went into rapid afib and was cardioverted x2. The patient returned to the OR [2135-1-9] for exploratory laparotomy which was unremarkable, and she was left with an open abdomen. She remained intubated and sedated since the initial surgery. She became hypotensive requiring vasopressor drips. She developed anuric renal failure, requiring CVVHD. She developed progressive acidosis and hemodynamic instability requiring pressors. She returned to the OR for exploration on [2135-1-11] at which time diffuse ischemia of all abdominal contents was noted and it was deemed inappropriate to procede with bowel resection based on the patient's previously stated wishes and a discussion with the son. After many family discussions, final decision was to render the patient CMO on [2135-1-11]. Medications were stopped. The patient expired on [2135-1-12] at 0250. Medications on Admission: Atenolol 25 mg daily, Lisinopril 10 mg daily, and Aspirin 81 mg daily. Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Abdominal aortic aneurysm, s/p open repair Bilateral popliteal artery embolism Cholecystitis Bilateral lower extremity ischemia Acute kidney injury, requiring hemodialysis Chronic kidney disease Discharge Condition: Expired. Discharge Instructions: None. Followup Instructions: None. Completed by:[2135-1-12] ICD9 Codes: 5845, 2762, 496, 4240, 2724, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8094 }	Medical Text: Admission Date: [2174-6-6] Discharge Date: [2174-6-10] Date of Birth: [2108-5-10] Sex: M Service: MEDICINE Allergies: Simvastatin Attending:[First Name3 (LF) 2736] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac catheterization status post percutaneous intervention (2 bare metal stents) History of Present Illness: HISTORY OF PRESENTING ILLNESS: Mr. [Known lastname 88506] is a 66 year old M w/ h/o pancreatic CA s/p sphincterotomy [12-15] and chemotherapy with gemcitabine and erlotinib, DM type 2, and CAD s/p MI and PCI/stent [2167] who is transferred from OSH with acute inferior STEMI. Patient presented to [Hospital3 8544] the afternoon of admission with chest pain, onset around noon and radiation to neck and left arm. Pain occurred at rest and was worse with inspiration. Associated with SOB, no nausea or vomiting. Of note, reported some pleuritic symptoms several days prior to this episode, though not as intense. Pain was [9-14] at its worst. Presented to OSH where EKGs were remarkable for STE and small q waves in II, III, aVF with reciprocal ST depressions in I and aVL. Patient was given asa, plavix 300, and started on a heparin drip. He was given nitro x 3 without relief of his symptoms and subsequently started on a nitro drip. He was transferred to [Hospital1 18] for further management. . On arrival at [Hospital1 18] patient was taken straight to cath lab. Vitals at that time were HR 109, BP 128/68 RR 19 O2 sat 99%. Cardiac catheterization showed a right dominant system with total occlusion of RCA, minimal disease in the remaining vessels. The lesion was apparently difficult to cross and behaved more like a chronic TO than an acute lesion. He underwent balloon dilation and then two bare metal stents were placed in the proximal and mid RCA. . In the CCU, patient reported pain improved, but continued pleuritic pain in his upper chest/neck with inspiration and burping. [3-10] in intensity. Denied cough, hemoptysis, hematemesis, nausea, vomiting, abdominal pain, rashes. Reports has been active at home, walking around and driving more than in recent times. ROS is negative for diarrhea, black stools, bloody stools, and fevers. +Chills. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . . Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: CAD s/p PCI in [2167] 3. OTHER PAST MEDICAL HISTORY: Metastatic Pancreatic cancer (currently on gemcitabine qOweek and erlotinib daily) Embolic cerebral infarcts Status post left MCA stroke with left carotid artery stenosis S/p upper and lower GI bleed [12-15] Thrombocytopenia Diabetic retinopathy Cataracts Glaucoma Social History: - Tobacco: currently smokes 1ppd x 40 years - EtOH: previously was a heavy drinker, quit 20 years ago. Denies current EtOH use - Illicits: denies Lives with his wife. [Name (NI) ] 3 children, numerous grandchildren. Family History: The patient's father died of asbestosis and mesothelioma at 75 years. His mother is alive at [Age over 90 ] years. He has three children and two brothers without health concerns. . Physical Exam: On Admission: VS: T= 99.4 BP= 118/65 HR=99 RR=16 O2 sat=99% on 2L GENERAL: thin elderly man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm, positive hepatojugular reflex. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Rub appreciated at LLSB. No m/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 anteriorly. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: No c/c/e. No femoral bruits. Dopplerable DPs. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . On Discharge VSS 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, no JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Rub appreciated at LLSB. No m/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 anteriorly. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: No c/c/e. No femoral bruits. Dopplerable DPs. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: On Admission: [2174-6-6] 09:50PM WBC-9.2 RBC-3.02* HGB-9.2* HCT-27.3* MCV-90 MCH-30.4 MCHC-33.6 RDW-16.9* [2174-6-6] 09:50PM NEUTS-78* BANDS-3 LYMPHS-8* MONOS-10 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2174-6-6] 09:50PM GLUCOSE-347* UREA N-24* CREAT-0.9 SODIUM-134 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-15 [2174-6-6] 09:50PM ALT(SGPT)-55* AST(SGOT)-79* CK(CPK)-363* ALK PHOS-223* TOT BILI-0.6 [2174-6-6] 09:50PM PT-14.1* PTT-46.1* INR(PT)-1.2* . On Discharge: [2174-6-10] 06:45 WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 12.8* 2.96* 9.1* 27.5* 93 30.9 33.2 17.6* 120* . Glucose UreaN Creat Na K Cl HCO3 AnGap 109 27* 1.1 138 4.1 106 22 14 . Cardiac Markers: CK-MB MB Indx cTropnT [2174-6-7] 12:00 20* 7.8* 3.531 [2174-6-7] 04:15 23 6.4* 5.221 . HgA1c: 8.3 . Lipid Panel: [2174-6-7] 04:15 Cholest Triglyc HDL CHOL/HD LDLcalc 136 111 11 12.4 103 . Cardiac Catheerization: PROCEDURE: Percutaneous coronary revascularization was performed using placement of bare-metal stent(s). Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM RIGHT CORONARY 1) PROXIMAL RCA DISCRETE 100 2) MID RCA NORMAL 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA NORMAL 4) R-PDA NORMAL 4A) R-POST-LAT NORMAL 4B) R-LV NORMAL ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD NORMAL 6A) SEPTAL-1 NORMAL 7) MID-LAD NORMAL 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 10) DIAGONAL-2 NORMAL 11) INTERMEDIUS NORMAL 12) PROXIMAL CX NORMAL 13) MID CX NORMAL 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 NORMAL 15) OBTUSE MARGINAL-2 NORMAL 16) OBTUSE MARGINAL-3 NORMAL 17) LEFT PDA NORMAL 17A) POSTERIOR LV NORMAL COMMENTS: 1. Selective coronary angiography of this right dominant system revealed 1 vessel coronary artery disease. The LM, LAD and LCx had minimal disease. The RCA was totally occluded proximally. 2. Limited resting hemodynamics revealed normal systemic arterial pressure of 133/53mmHg. FINAL DIAGNOSIS: 1. Bare metal stents placed in a patient with presumed STEMI with ST elevation in 3 and F. 2. He is still c/o of pleuritic chest pain. A spiral CT must be obtained to r/o PE as this may have been a chronic TO. 3. ASA and clopidogrel for as long as a year if he can tolerate it, but no less than a month. . TTE: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with inferior and inferolateral akinesis, c/w RCA disease. The remaining segments contract normally (LVEF = 40%). The right ventricular cavity is mildly dilated with focal basal free wall hypokinesis. 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. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Dilated and hypokinetic RV in a pattern, consistent with either proximal RCA disease or acute pulmonary hypertension (e.g., PE). Normal estimated pulmonary pressures argue in favor of CAD as a cause of RV dysfunction. . CTA Chest: The pulmonary arterial tree is well opacified and there is no embolic filling defect. The aorta is normal in caliber, and there is no evidence of dissection. Airways are patent to subsegmental levels bilaterally. Note is made of small bilateral pleural effusions with overlying subsegmental atelectasis. In addition, there is more focal consolidation in the left lower lobe (4:67) with the possibility of pneumonia not excluded. The lungs are otherwise clear. The heart and great vessels are notable for extensive coronary arterial calcification as well as coronary arterial stenting. Though there is no hilar, mediastinal or axillary lymphadenopathy by size criteria, note is made of many borderline sized hilar nodes as well as multiple mediastinal nodes, notable in number. The study is not tailored for precise characterization of subdiaphragmatic contents. Nevertheless those included are notable for pneumobilia as well as a metallic common bile duct stent seen on the scout imaging. Osseous structures reveal no suspicious sclerotic or lytic lesions. IMPRESSION: 1. No pulmonary embolism. 2. Small bilateral pleural effusions with overlying atelectasis as well as more confluent opacity at the left lung base. For the latter, the possibility of pneumonia is not excluded and should be correlated to the clinical presentation of the patient. 3. Extensive coronary arterial calcification . RUQ ultrasound [6-9]: IMPRESSION: 1. No intrahepatic biliary ductal dilatation. Small pneumobilia in the CBD, likely introduced by the known biliary stent. 2. Extensive metastatic disease in the liver, better assessed by the prior CT torso on [2174-2-21]. 3. Cholelithiasis without acute cholecystitis. Splenomegaly. No ascites. . Brief Hospital Course: Mr. [Known lastname 88506] is a 66 year old M w/ h/o pancreatic CA s/p sphincterotomy [12-15] and chemotherapy with gemcitabine and erlotinib, DM type 2, and CAD s/p MI and PCI/stent [2167] who was transferred from OSH with acute inferior STEMI. . # STEMI: Patient presented with chest pain to OSH that was severe and sharp in quality and acute in onset at rest. EKG consistent with inferior MI. Total occlusion of RCA on cath, but some suggestion of chronic state. Now s/p PCI with 2 BMS to RCA. Given findings on cath and history of intermittent pleuritic pain prior to today's episode cannot be entirely sure about the timing of the MI. ASA 325mg and clopidogrel 75mg needs to be taken daily for as long as a year if he can tolerate, but no less than one month. No statin was given history of rhabdomyolysis. Pt has f/u appt wtih Dr. [Last Name (STitle) ] at [Hospital1 18] and will f/u with his PCP [Last Name (NamePattern4) ] 1 week. . # Pleuritic chest pain: Thought [3-9] MI related pericardial irritation. Resolved over hospital stay. No pericardial effusion, small pleural effusions noted. Chest CTA showed no evidence of PE. He does have a friction rub noted on exam that persisted. . # Acute Systolic Dysfunction: As of [2174-2-5], intact EF with no evidence of systolic or diastolic dysfunction. ECHO after MI showed EF of 40%, no pericardial effusion. Pt did not have symptoms of CHF during his hospital stay but teaching regarding daily weights, low Na diet and adherance to medicines done at discharge. He was not on diuretics in the past. ACEi was started as an inpatient and should be uptitrated if BP tolerate. . # RHYTHM: Currently in sinus. No history of arrhythmias or syncope. No arrythmias noted on telemetry during hospital stay. . # Pancreatic CA: Followed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1852]. Currently on gemcitabine 1000 mg/m2 days one and 15 of a 28-day cycle in combination with erlotinib 100 mg p.o. daily. This is his off week for gemcitabine. Dr. [Last Name (STitle) 1852] was consulted during pts hospital stay and recommended continuing Tarceva for now with close f/u after discharge to discuss further chemotherapy options. Home dose of Lovenox was continued. . # Hypertension: Currently normotensive. No hypotensive episodes at OSH or in hospital. Lisinopril continued and metoprolol uptitrated to goal HR in 70's. Amlodipine was not continued. . # Diabetes mellitus: On metformin and glipizide at home. Last A1c 8.3. No medication changes were made. . # Bacteremia: Pt developed fevers and found to have Klebsiella in his blood cultures. Urine culture was negative. ID was consulted given pts history of pancreatic CA and recommended a 12 day course of IV Ceftriaxone. This was continued at discharge via new PICC line. The source of bacteremia is unclear with no evidence of secondary infection via CT or ultrasound testing. His leukocytosis resolved and pt remained hemodynamically stable. He will f/u closely wtih ID and his outpatient oncologist. There are 3 more sets of blood cultures pending at the time of his discharge. Medications on Admission: Amlodipine 10 mg daily Lovenox 100 mg SC qHS Erlotinib 100 mg daily Lisinopril 5 mg daily Metoprolol Succinate 200 mg daily Omeprazole 20 mg daily Prochlorperazine maleate 10 mg q6h prn for nausea/vomiting Terazosin 1 mg qHS Zolpidem 5 mg qhs prn for sleep MVI daily Glyburide 5 mg [Hospital1 ] Metformin 1000 mg [Hospital1 ] Discharge Medications: 1. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous once a day. 2. glyburide-metformin 5-500 mg Tablet Sig: Two (2) Tablet PO twice a day. 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:2 4. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: 0.5 Tablet Extended Release 24 hr PO once a day. 5. ceftriaxone 1 gram Recon Soln Sig: One (1) gram Intravenous once a day for 12 days. Disp:12 bags Refills:0 6. Outpatient Lab Work Check Chem-7, LFT's and CBC on Wed [6-15] and Wed [6-22] and call results to Dr. [Last Name (STitle) ] [Name (STitle) ] at Infectious disease clinic: ([Telephone/Fax (1) 4170] or at 617-632-page #[Numeric Identifier 38654] 7. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. terazosin 1 mg Capsule Sig: One (1) Capsule PO at bedtime. 13. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 14. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 15. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes as needed for chest pain: take no more than 2 tablets, call Dr. [Last Name (STitle) ] or 911 for any chest pain. Disp:25 tablets Refills:0 Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: ST Elevation myocardial infarction Diabetes Mellitus Hypertension Dyslipidemia Pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 88506], You were admitted to the hospital because you had a heart attack. You underwent cardiac catheterization and two stents were placed in one of your coronary arteries. You were found to have bacteria in your blood and you were seen by the infectious disease team and started on an antibiotic called ceftriaxone. You will need to get this antibiotic for a total of 2 weeks. As of this time, we do not know why you developed this infection in your blood. You will need to have your blood drawn weekly to check your liver and kidney function on this antibiotic. You will see the infectious disease doctor [First Name (Titles) ] [Last Name (Titles) 766] [6-13]. No lifting more than 10 poounds for one week, no pools or baths for one week. You may shower as usual. No driving for 3 days after you go home. . We made the following changes to your medicines: 1. STOP taking amlodipine and omeprazole 2. START taking clopidogrel (Plavix) every day and aspirin 325 mg for at least one month and possibly longer. Do not stop taking Plavix with aspirin or miss [First Name (Titles) 691] [Last Name (Titles) 4319] unless Dr. [Last Name (STitle) ] tells you to. 3. Decrease Metoprolol to 100 mg daily 4. Start Ceftriaxone intravenously for 2 weeks to treat the bacteria in your blood 5. Start famotidine twice daily instead of omprazole to decrease the acid in your stomach. 6. Stop taking your Tarceva, you can discuss this with Dr. [Last Name (STitle) 1852] at your next appt. Per Dr. [Last Name (STitle) 1852], you will not get your intravenous chemotherapy on [Last Name (STitle) 766] while you are on antibiotics. Followup Instructions: Name: [Last Name (LF) 313],[First Name3 (LF) ] N Location: [Hospital ] HEALTH CENTER Address: 200 [Last Name (un) 12504] DR, [Location (un) ],[Numeric Identifier 18464] Phone: [Telephone/Fax (1) 18462] Appointment: Tuesday [2174-6-14] 1:30pm Department: INFECTIOUS DISEASE When: [Year (4 digits) ] [2174-6-13] at 10:00 AM With: [Name6 (MD) 2323] [Name8 (MD) 2324], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: HEMATOLOGY/ONCOLOGY When: [Hospital Ward Name ] [2174-6-13] at 11:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 6050], MD [Telephone/Fax (1) 8770] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/ONCOLOGY When: [Hospital Ward Name ] [2174-6-13] at 12:00 PM With: [Name6 (MD) 8111] [Name8 (MD) 8112], RN [Telephone/Fax (1) 22] Building: [Hospital6 29] [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Department: CARDIAC SERVICES When: Friday [8-12] at 10:30am With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage The cardiology office will call you in a few days with an earlier appt. Completed by:[2174-9-14] ICD9 Codes: 486, 5849, 7907, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8095 }	Medical Text: Admission Date: [2135-6-6] Discharge Date: [2135-6-14] Date of Birth: [2072-3-28] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 759] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: None History of Present Illness: 63 YO F with Parkinson's and dementia (recent baseline oriented times 1) p/w hypotension, hypoxia and AMS from her NH. Conflicting reports about what happened at NH per the ED but as per EMT notes the patient became pale and diaphoretic then unresponsive with episodes of apnea. Her VS when EMTs arrived where 97.1 90/40 98 14 and 88% on RA. She was placed on a NRB with sat of 91%. She remained intermittently responsive with moaning. . Upon arrival to the ED, VS were: 95 102/62 14 95% on unclear amount of oxygen. Paitent was triggered with a BP of 90. Per report her SBP did decrease to the 80s but was responsive to fluids. A bedside u/s showed dilated RV with strain. She was started on a heparin gtt due to c/f PE. Prior to heparin gtt, rectal exam revealed brown guiac positive stool. Given hypotension and recent surgery the ED was also concerned for sepsis so the patient was given cefepime, vanc and levoflox. A foley was placed with cloudy urine and u/a had >50 WBCs. Blood and urine cultures were drawn. Exam was also notable for purulent drainage and staples from his surgery on [5-19] so [Month/Day (4) ] spine was called. Per report, the ED was unable to express any pus but did obtain a CT neck with contrast which did not show a fluid collection. . Given c/f PE and unclear series of events, a CTA along with CT A/P with contrast were completed and was notable for extensive bilateral pulmonary emboli spanning from the distal main pulm art to the distal segmental and subsegmental arteries along with a LLL wedge-shaped lesion c/w an infarct. Past Medical History: Parkinson's for 15 years. Dementia worse for the last 1 year. Obesity. No history of CVA, cancer, MI or other chronic illnesses. Usually blood pressure is low. She has a history of multiple falls. Social History: Lives at home with husband. Usually walks and plays piano but sometimes dependent on cane also. She is a retired school teacher. No smoking, alcohol or drugs. Family History: Parkinsons - Dad, brother Physical Exam: General Appearance: Well nourished, Overweight / Obese Eyes / Conjunctiva: PERRL, Conjunctiva pale, No(t) Sclera edema Head, Ears, Nose, Throat: Normocephalic, Poor dentition Cardiovascular: S1, S2 regular rhythm, normal rate Respiratory / Chest: CTA bilaterally, unlabored respirations Abdominal: Soft, Non-tender, Obese Extremities: Right lower extremity edema: Trace, Left lower extremity edema: 1+, left second toe purple Skin: Not assessed Neurologic: Responds to voice, MAE antigravity, Pertinent Results: LOWER EXTREMITY U/S: FINDINGS: [Doctor Last Name ]-scale and color Doppler son[Name (NI) 493] evaluation of the bilateral common femoral, superficial femoral, and popliteal veins was performed. There is extensive occlusive thrombus in the left superficial femoral vein extending to the popliteal vein. Right-sided veins are patent with normal compressibility, flow, and augmentation. Calf veins were not visualized due to patient's body habitus. IMPRESSION: DVT throughout the entire left superficial femoral vein extending through the popliteal vein. . CT CHEST: CT OF THE CHEST WITH CONTRAST: There are extensive bilateral pulmonary emboli extending from the bilateral distal main pulmonary arteries into the lobar, segmental and subsegmental branches. There is an area of hypoenhancing wedge-shaped opacity at the left lung base which is most consistent with pulmonary infarct. Small amount of atelectasis is also noted at the left lung base. There is mild bowing of the interventricular septum, concerning for right heart strain. The main pulmonary artery is also mildly enlarged. There is also a trace pericardial effusion. There is no mediastinal, hilar or axillary lymphadenopathy. The airways are patent. CT OF THE ABDOMEN WITH IV CONTRAST: Please note that there is significant artifact from the patient's overlying arms limiting evaluation. The spleen, adrenal glands, pancreas, stomach, and intra-abdominal loops of bowel are within normal limits. Multiple tiny hypodensities are noted in the kidneys bilaterally, too small to characterize. A small cyst is noted within the interpolar region of the left kidney. Gallbladder is distended but otherwise normal in appearance. There is no retroperitoneal or mesenteric lymphadenopathy. No free air or free fluid is present. CT OF THE PELVIS WITH IV CONTRAST: There is a large amount of stool within the rectum. A Foley catheter is noted within a decompressed bladder. Small amount of air within the bladder is likely due to recent instrumentation. There is no free fluid. No pelvic or inguinal lymphadenopathy is present. BONE WINDOWS: No concerning osseous lesions are identified. IMPRESSION: 1. Extensive bilateral pulmonary emboli, spanning from the distal main pulmonary arteries into the lobar, segmental and subsegmental branches. Area of pulmonary infarct in the left lower lobe. Mildly enlarged main pulmonary artery suggests component of pulmonary hypertension. In addition, bowing of the interventricular septum raises concern for right heart strain. Recommend echocardiogram for further evaluation of cardiac function. 2. No acute intra-abdominal or intrapelvic process. 3. Subcutaneous air noted in the right arm, incompletely assessed. . Brief Hospital Course: 63 YO F with Parkinson's and progressive dementia s/p recent hospitalization for fall with 2 c-spine operations now presenting with altered mental status, hypoxia and hypotension found to have submassive pulmonary emboli on imaging. . # Pulmonary embolism: She was found to have extensive bilateral pulmonary emboli on chest CT with evidence of right heart strain and slightly elevated troponin. She was started on a heparin drip for systemic anticoagulation. She remained hemodynamically stable in the ICU and was transferred to the floor. On [6-8], pt was started on Warfarin, and her INR was trended. . # LLE DVT: LENI's done on [2135-6-7] demonstrated DVT throughout the entire left superficial femoral vein extending through the popliteal vein. There was concern that due to her high clot burden in her lungs, pt would not tolerate another PE. Heme/onc was consulted. Through review of the literature it appeared that IVC filters had their greatest benefit in the first few days of DVT (up to 12 days). However, given concern that there would be difficulty in retrieving the filter, we opted to first repeat LENI's to assess for clot progression since it was found on [2135-6-6]. It showed extension into the femoral artery, and the study was unable to visualize extension into the pelvis. Given concern for clot progression, and IVC filter was placed on [2135-6-10] by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Dr. [Last Name (STitle) ] indicated the filter could be retrieved in approx 4 weeks time. Please call to schedule an appointment for this by calling Dr.[Name (NI) 8664] assistant: [First Name5 (NamePattern1) 8665] [Last Name (NamePattern1) 8666] Cardiac Cath Lab Scheduling [Hospital1 69] [Street Address(2) 8667] [Location (un) 86] [Numeric Identifier ] Phone: ([Telephone/Fax (1) 8668] . # Altered mental status: On the morning of [2135-6-10], pt was found to be unresponsive even to sternal rub around 0800. She had been seen earlier that morning around 0630 and had been sleeping, but awakened to voice and was trying to speak. Pt found to have O2 sats 96% on RA; an ABG was done which showed mild respiratory alkolosis but PO2 was normal. Pt had stat head CT without which showed no acute intracranial abnormality. Neuro was consulted, who suggested that some of her mental status changes could be attributed to her severe [Last Name (un) 309] Body dementia. However, seizure was also on the DDx. An EEG was ordered, but there was an equipment failure and it was never performed. In discussing the case with Neurology, they felt seizure was very low on the DDx so it was not pursued further. . # ?Urinary tract infection/Urinary Retention: Pt was found to have a grossly positive UA on admission. She was started empirically on Levofloxacin as well as broad spectrum antibiotics (cefepime and vancomycin) transiently. UCx came back as contaminated. Her levofloxacin was stopped on [2135-6-11]. On [6-14], a repeat U/A (straight cath sample) was sent that showed moderate bacteria, no WBC. Urine culture is pending at the time of discharge. She clinically appears well with no leukocytosis. Her only urinary complaint is new urinary retention. She had had incontinence with frequent bed wetting (? overflow incontinence) till Saturday, [6-11]. Then, on [6-12], she was noted to have diminished/absent urinary output. She was found to have significant urinary retention since and has required intermittent straight catheterization. Dr. [Last Name (STitle) ] discussed this with Neurology who felt that it was unlikely due to her Neurologic or Psychiatric medications as she has been on these medications for some time. Dr. [Last Name (STitle) ] discussed the situation with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007] who felt that the urinary retention may be related to her initial cervical spine injury but that there was not much to be done at this time about it. . # C-spine surgery, Surgical site: Orthopedics spine was consulted and felt that the surgical wound was healing appropriately without evidence of surgical site infection. Her staples were removed on [2135-6-13] and the wound was described by Surgery as looking good. She has follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007] in [Month (only) 216] as outlined. . # Parkinson's disease: She was continued on carvidopa, levodopa. Neurology was consulted given pt's agitation and questions regarding her sinemet. They recommended decreasing her Sinemet to q3hrs and using Seroquel titrating up as needed prn agitation. . FOR FOLLOW UP: 1) INR on [2135-6-15] with warfarin dosing to achieve an INR goal [12-22] Last INR's have been as below: [2135-6-14] 9:20 AM 6.5 [2135-6-14] 5:45 AM 6.9 @ [2135-6-13] 7:30 PM 6.2 [2135-6-13] 6:05 AM 5.2 [2135-6-12] 6:48 AM 2.6 [2135-6-11] 6:05 AM 2.6 [2135-6-10] 5:40 AM 1.8 [2135-6-9] 10:00 PM 1.6 [2135-6-9] 4:54 PM 1.5 [2135-6-9] 7:15 AM 1.5 [2135-6-8] 3:53 AM 1.4 [2135-6-7] 4:26 AM 1.4 [2135-6-6] 8:30 PM 1.1 [2135-6-6] 6:45 PM 2.9 [2135-5-20] 7:15 AM 1.2 [2135-5-17] 11:39 PM 1.2 ===================== warfarin dosing: [6-13] - no warfarin given [6-12] - 2.5 mg warfarin given [6-11] -2.5 mg wafarin given [6-10] - 5 mg wafarin given [6-9] - 5 mg warfarin given [6-8] - 3 mg warfarin given ================================ 2) Please straight cath q8 hours, monitor Post-Void residuals for ongoing need 3) Monitor urine culture results *SHOULD BE BACK on [6-15] or [6-16]. PLEASE ASK DR. [Last Name (STitle) ] TO CHECK ON THESE in the [Hospital1 18] system**** 4) Please call to have IVC filter removal appointment scheduled for 3-4 weeks from now (information as listed above) Medications on Admission: 1. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS 2. Zonisamide 25 mg Capsule Sig: Two (2) Capsule PO QHS 3. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO eight times daily (): Give with each dose of sinemet except with the last dose while awake. 4. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO EVERY 2 HOURS (): Hold during evening hours while patient sleeping. Resume at 8 AM . 5. Lodosyn 25 mg Tablet Sig: One (1) Tablet PO ASDIR (AS DIRECTED): Take with each dose of sinemet. 6. Paxil 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day: with dinner. 8. Namenda 5 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day: with food. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a day: Hold for loose stools. 11. Ativan 2 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week for 12 weeks. Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Memantine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Zonisamide 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation. Disp:30 Tablet(s) Refills:0 5. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 6. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation. Disp:60 Tablet(s) Refills:0 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 9. Lodosyn 25 mg Tablet Sig: One (1) Tablet PO 1 tablet with each dose of sinemet (). 10. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO Q3H EXCEPT WHILE SLEEPING (). Disp:270 Tablet(s) Refills:2 11. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO with each dose of sinemet except for last dose of sinemet (). 12. Miralax 17 gram/dose Powder Sig: One (1) PO once a day: Hold for loose stool. 13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO qhs prn as needed for Constipation: Hold for loose stool. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 15. Warfarin 1 mg Tablet Sig: 1-2 Tablets PO once a day as needed for Please give as per Dr.[Name (NI) 8669] order. INR today [2135-6-14] was 6.5 (down from 6.9 on [6-13]). Do not give warfarin tonight ([6-14]). Check INR on [6-15] and dose warfarin accordingly with goal INR [12-22]. Discharge Disposition: Extended Care Facility: [Hospital1 599] Senior Healthcare of [Location (un) 55] Discharge Diagnosis: ## extensive bilateral pulmonary emboli, pulmonary infarction: hemodynamically stable, therapeutic on heparin, on room air, s/p IVC filter placement [6-10] seconddary to extensive occlusive LLE DVT ## Encephalopathy - likely mulitfactorial ## Parkinson's disease with reported dementia ## moderate pulmonary hypertension ## cervical spine rim-enhancing fluid collection: seroma vs abscess # s/p anterior cervical discectomy & fusion at C3-C4 on [2135-5-20] # s/p C2-C4 decompression and fusion at C2-C5 with grafts on [2135-5-21] # Urinary retention - ? secondary to cervical cord injury # possible UTI - culture pending Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you during this admission. You were admitted with shortness of breath and found to have clots in your lungs. You were in the ICU where they started Heparin to prevent the clots in the lungs from spreading. You did well, and were transferred to the medicine floors. You were continued on Heparin and Warfarin was started as well. You had a large clot in your left leg. You had a filter (IVC filter) placed to prevent the clot in your leg from breaking off and going to your lung. During the stay your shortness of breath improved. You were also seen by the Spine team, who helped to monitor your wound, which looked clean. Neurology also saw you and helped to adjust your medications for Parkinson's disease. . The following changes were made to your medications during this hospitalization: STOP Lorazepam 1 mg by mouth three times daily STOP Carbidopa-Levodopa 25-100 mg Tablet 1.5 tablets every 2hrs except while asleep STOP Quetiapine 200mg by mouth at night . START Lorazepam 1 mg Tablet by mouth every 8 hours as needed for agitation. START Quetiapine 50 mg Tablet once by mouth at bedtime START Quetiapine 50 mg tablet once by mouth three times daily as needed for agitation START Acetaminophen 325mg 2 tablets by mouth every 6 hours as needed for pain START Carbidopa-Levodopa 25-100 mg Tablet 1.5 tablets every 3 hrs except while asleep START Docusate Sodium 50mg/5ml liquid 10 ml by mouth twice daily as needed for constipation . Please continue all other medications you were on prior to this admission. Followup Instructions: Please follow-up with the following appointments below: Department: ORTHOPEDICS When: WEDNESDAY [2135-7-13] at 1:10 PM With: [Year (4 digits) ] XRAY (SCC 2) [Telephone/Fax (1) 1228] . Please call to schedule IVC filter removal. She should have the filter removed in [1-20] weeks from the time of discharge. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] will remove it. To schedule the removal, please call the person below: [First Name5 (NamePattern1) 8665] [Last Name (NamePattern1) 8666] Cardiac Cath Lab Scheduling [Hospital1 69] [Street Address(2) 8667] [Location (un) 86] [Numeric Identifier ] Phone: ([Telephone/Fax (1) 8668] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SPINE CENTER When: WEDNESDAY [2135-7-13] at 1:30 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 3736] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 5990, 2760, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8096 }	Medical Text: Admission Date: [2135-5-1] Discharge Date: [2135-5-8] Date of Birth: [2085-9-30] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 1257] Chief Complaint: seizure Major Surgical or Invasive Procedure: None. History of Present Illness: 49y/o M transfer from OSH for evaluation of possible toxic alcohol ingestion. Patient was brought to OSH by EMS after family found him shaking/foaming at the mouth. Pt reported drinking 6 beers/day x 2 days. He has a history of heavy EtOH in the past however he reports being sober x~1yr. Per EMS report, had had been on a "2-day" binge, stopping yesterday, with prior history of withdrawal seizures. There is also report from EMS and OSH that the patient has hisotry of ETOH abuse and prior seizures. The patient denies this. . He initially went to [Hospital 15405], where he was reported to have an anion gap of 28, and an osmolar gap of 24. His lactate was 6.8, and serum EtOH of 29. No ASA/APAP was detected. An ABG was performed 7.46/37/140. LFT's with AST/ALT 126/75. PCC was contact[Name (NI) ] and recommended fomepazole. Pt was given 15mg/kg of fomepazole (1050mg), as well as a total of 100mg thiamine, 1mg folic acid, 1gm magnesium, 30mg of IV Valium, 1gm of ceftriaxone and 4mg of zofran prior to transfer. . His initial vitals in the ED were 99.4 122 142/88 100% 2L NC. Toxicology was consulted and they will continue to follow. The patient denies ingestionof any other substances. Pt denies F/C, HA, CP, SOB, abd pain, N/V/D, tinitus, visual disturbance. He received additional 5 IV valium. He was tachycardic to 110 and this increased to 140-150 with any movement. vitals on transfer: 150/100 110 18 98 RA 99.4 . On arrival, patient is interviewed with interpreter. He again denies drinking before this current episode since [Month (only) 404]. He denies fever/chills/ cough/chest pain/nausea/vomiting. He had difficulty recalling his girlfriend's phone number and his home phone number. His daughter [Name (NI) 12208] was contact[Name (NI) ] and she stated that he has been drinking chronically for at least a month. Past Medical History: headaches Social History: Lives with two daughters. [Name (NI) 12208], age 19, another daughter age 7. [Name2 (NI) 1403] in construction. Has a wife in [Country ]. denies tobacco and drugs Family History: non-contributory Physical Exam: On Admission: VS: Temp: 99.2 BP: 150/100 HR:115 RR: O2sat 98RA General Appearance: Anxious, Diaphoretic Cardiovascular: (S1: Normal), (S2: Normal), tachy Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Not assessed, Tone: Normal, tremulous On Discharge: VS: Temp: 97.0 m98.0 BP: 124/92 (100-126/72-92) HR: 80 (77-103) RR: 18 O2sat100%RA Tele: 70s-80s; occasional jumps to 120s Gen: NAD HEENT: EOMI, PERRL, clear oropharynx Neck: supple, no LAD CV: nl S1, S2, RRR, no m/r/g Pulm: CTAB, no rhonchi, rales, wheezes Abdominal: Soft, Non-tender, bowel sounds present Extremities: WWP, 2+ DPs, no edema, cyanosis, clubbing Skin: No rashes, lesions Neurologic: Attentive, motor strength and sensation grossly intact; intact FNF, rapid alternating movements, and heel to shin; wide based ataxic gait Pertinent Results: On Admission: [2135-5-1] 06:40PM BLOOD WBC-7.4 RBC-3.95* Hgb-13.2* Hct-37.3* MCV-94 MCH-33.3* MCHC-35.3* RDW-16.1* Plt Ct-106* [2135-5-1] 06:40PM BLOOD Neuts-78.6* Lymphs-14.1* Monos-6.8 Eos-0.2 Baso-0.3 [2135-5-1] 06:40PM BLOOD PT-12.3 PTT-23.4 INR(PT)-1.0 [2135-5-1] 06:40PM BLOOD Glucose-98 UreaN-4* Creat-0.6 Na-141 K-2.8* Cl-99 HCO3-27 AnGap-18 [2135-5-1] 09:51PM BLOOD ALT-68* AST-100* AlkPhos-69 TotBili-1.6* [2135-5-1] 06:40PM BLOOD Calcium-8.2* Phos-3.2 Mg-2.1 [2135-5-1] 06:40PM BLOOD Osmolal-288 [2135-5-1] 06:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2135-5-1] 08:40PM BLOOD Type-[Last Name (un) ] pO2-66* pCO2-32* pH-7.51* calTCO2-26 Base XS-2 Comment-GREEN-TOP [2135-5-1] 07:31PM BLOOD Lactate-1.8 . On Discharge from MICU: [2135-5-4] 05:42AM BLOOD WBC-6.2 RBC-3.78* Hgb-12.7* Hct-36.4* MCV-96 MCH-33.5* MCHC-34.8 RDW-15.8* Plt Ct-132* [2135-5-4] 05:42AM BLOOD PT-11.6 PTT-23.7 INR(PT)-1.0 [2135-5-4] 05:42AM BLOOD Glucose-91 UreaN-6 Creat-0.6 Na-139 K-3.4 Cl-102 HCO3-29 AnGap-11 [2135-5-4] 05:42AM BLOOD ALT-54* AST-69* AlkPhos-61 TotBili-1.5 [2135-5-4] 05:42AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9 . On Discharge: [2135-5-8] 06:30AM BLOOD WBC-8.1 RBC-3.71* Hgb-12.2* Hct-36.6* MCV-99* MCH-32.9* MCHC-33.3 RDW-16.1* Plt Ct-321 [2135-5-8] 06:30AM BLOOD WBC-8.1 RBC-3.71* Hgb-12.2* Hct-36.6* MCV-99* MCH-32.9* MCHC-33.3 RDW-16.1* Plt Ct-321 [2135-5-8] 06:30AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-143 K-3.8 Cl-107 HCO3-29 AnGap-11 [2135-5-4] 05:42AM BLOOD ALT-54* AST-69* AlkPhos-61 TotBili-1.5 [2135-5-8] 06:30AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.8 [2135-5-7] 06:20AM BLOOD VitB12-809 Imaging: [2135-5-2] CXR: Single view of the chest is obtained without the prior study. There is possible bilateral hilar fullness. The lungs are clear. Heart is within normal limits. Comparison with the prior chest x-ray would be helpful. [2135-5-8] MRI Brain: There is mild cerebellar atrophy. The ventricles and cerebral sulci are abnormally large for age, consistent with mild cerebral atrophy. There is no acute infarction. There are scattered foci of high T2 signal in the supratentorial white matter, as well as a focus of high T2 signal in the midline pons and a focus of high T2 signal in the right cerebellar hemisphere, consistent with small chronic infarctions. The major arterial flow voids are preserved. There is no evidence of parenchymal blood products. There is a small focus of polypoid mucosal thickening in the inferior left maxillary sinus. IMPRESSION: 1. Mild cerebellar and cerebral atrophy, abnormal for age. 2. Scattered small chronic infarctions in the supratentorial white matter, pons, and right cerebellar hemisphere. No acute infarction. Brief Hospital Course: 49 y/o with confirmed history of chornic alcohol use (though patient denies) presented to OSH with seizure and transferred here for eval of possible toxic alcohol ingestion and treatment of withdrawal. . # Alcohol withdrawal. Patient had witnessed seizure secondary to ETOH withdrawal. Patient denies ETOH ingestion before two days ago but daughter confirms chronic drinking. Patient was admitted to the MICU and treated agressively with valium and transferred to the floor on [5-4] once requirement decreased to q4hours. He received close to 500 mg of valium during his hospital stay. After he was no longer [Doctor Last Name ] on CIWA, he remained ataxic and tachycardic with movement. Was seen by PT who felt that his ataxia was related to his chronic alcohol abuse and would not benefit from further PT/rehab. Patient treated with thiamine, folate and MVI. . # ? Toxic alcohol ingestion: Received fomepizole x 1 at osh. transferred here for tox eval. seen by tox here. on review of OSH labs, his osmolar gap was accounted for by alcohol and lactate and it has resolved. There was minimal concern for toxic alcohol ingestion and no indication for further fomepizole. . # H/o lactic acidosis: 6.8 at OSH - resolved. Likley [2-16] seizure. . # Ataxia- Patient note to have broad based ataxic gait even after no longer [Doctor Last Name ] on CIWA. Cerebellar exam was otherwise intact and non-focal. B12 level was checked and within normal limits. He underwent MRI brain to assess for cerebellar lesions- this was notable for age advanced global atrophy and scattered chronic small infarcts. Was seen by PT who felt that his deficits were not likely to be improved by further physical therapy and rehab and were more likely chronic in nature secondary to his long standing alcohol abuse. He was felt safe for discharge. . # Social: Patient initialy denied chronic alcohol use though family confirms. Patient was seen by social work and continued to deny use of alcohol and necessity of detox/rehab. Eventually admitted use of alcohol and voiced desire to quit but wanted to do so on his own without rehab. We emphasized to the patient through an interpreter that he puts his life at risk by drinking and that his seizures, ataxia and brain atrophy were directly related to his use of alcohol. We asked him to establish care with a PCP through [Name9 (PRE) 191] or in his home town if more convenient. Medications on Admission: Denies Discharge Medications: 1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 3. multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Seizure Alcohol Withdrawal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 10010], You were admitted to the hospital because you were having a seizure. We believe the seizure was due to withdrawal from alcohol. You were treated with medications and monitored closely in the medical intensive care unit and then transferred to the general medicine floor when your condition improved. You were seen by social work and physical therapy who offered you resources on alcohol abuse and assessed your physical condition. You had an MRI of your head which showed shrinkage of your brain which we believe is related to your use of alcohol. We strongly recommend you STOP DRINKING ALCOHOL as you put your life and the lives of others in danger when you drink. We also recommend you establish care with a doctor who can help manage your health conditions (see below). We have started you on the following medications: - Folic Acid - Thiamine - Multivitamin Please take them as directed. We wish you a speedy recovery. Followup Instructions: Please call [Telephone/Fax (1) 1247] to establish care with a primary care doctor. Completed by:[2135-5-8] ICD9 Codes: 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8097 }	Medical Text: Admission Date: [2191-1-26] Discharge Date: [2191-2-5] Service: MEDICINE Allergies: Codeine / Pravachol / Dimetapp / Clonidine Attending:[First Name3 (LF) 898] Chief Complaint: hyperglycemia, diabetic ketoacidosis, hypotension Major Surgical or Invasive Procedure: central venous line intubation History of Present Illness: 87 yo female with Alzheimer's dementia, DM, h/o aspiration, hypothyroid, hyperlipidemia, CHF with recent admission to [Hospital1 18] [Location (un) 620] for DKA in setting of UTI ([12-22]), who presented to [Hospital1 18] [2191-1-26] after being found unresponsive at her NH, with marked hyperglycemia (FSG>500, given 16U regular + 30U NPH insulin), and sent to [Hospital3 ]. On [Location (un) 620] ED admission, patient had VS of T=99.8, BP 54/28, pulse 130, rr30, and was 94% on a NRB. Her ABG was 6.91/22/95, with a lactate of 10.4. She received a further 10U of insulin and was begun on an insulin drip. She also started on neosynephrine, given 2 amps of sodium bicarbonate, tylenol, and empirically begun on levofloxacin. She was intubated (#7 ETT) and subsequently transferred to [Hospital1 18]. Upon arrival at [Hospital1 18]: her vitals were BP 75/40, pulse 110, and was on mechanical ventilation (AC 500/25/1/5) with ABG 7.20/22/386. Labs were notable for a leukocytosis (WBC 16.3), Anion gap of 23, and an elevated Tn T 1.43. Pt was switched from neo to dopamine and dobutamine. A L IJ central line was placed and she was transferred to ICU after receiving 3L NS in ED. Past Medical History: DM, Alzheimer's, hyperlipidemia, hypothyroidism, known aspiration, tachycardia. S/p Recent admission for DKA [12-22] at [Location (un) 620], thought secondary to UTI. Social History: social:lives in [Location ] in [Doctor First Name ]. No known tobacco exposure Family History: NC Physical Exam: Gen: patient appears stated age, found lying flat in bed, somnolent though easily arousable, in NAD HEENT: Sclera anicteric, conjunctiva uninjected, OD surgical pupil, OS 2mm -> 1mm with direct light, EOMI, MMM, no sores in OP Neck: JPV 7cm H20, no LAD, nl ROM Cor: RRR nl S1 S2 II/VI decrescendo murmur at RUSB Chest: clear to percussion and asculation Abd: soft, NT/ND, +BS. No HSM appreciated. EXT: no calf tenderness. No edema Neuro: Awake, not oriented (place: middle of bed; time: now, unsure of month, year, hospital), answers intermittently with one-word responses, CN II-XII in tact within limits of the exam (patient intermittently cooperates with simple commands), Grip strength 4+, able to wiggle toes, 1+ DTRs, gait not tested. Pertinent Results: [2191-1-26] 10:00PM TYPE-ART TEMP-37.0 RATES-25/ TIDAL VOL-650 PEEP-5 O2-50 PO2-161* PCO2-23* PH-7.44 TOTAL CO2-16* BASE XS--5 -ASSIST/CON INTUBATED-INTUBATED [2191-1-26] 09:28PM GLUCOSE-106* UREA N-31* CREAT-1.3* SODIUM-147* POTASSIUM-3.5 CHLORIDE-119* TOTAL CO2-16* ANION GAP-16 [2191-1-26] 09:28PM CK(CPK)-4126* [2191-1-26] 09:28PM CK-MB-113* MB INDX-2.7 cTropnT-4.48* [2191-1-26] 09:28PM CALCIUM-8.1* PHOSPHATE-0.8# MAGNESIUM-1.3 [2191-1-26] 05:35PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.013 [2191-1-26] 05:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2191-1-26] 05:35PM URINE RBC-[2-19]* WBC-[2-19] BACTERIA-MOD YEAST-NONE EPI-0-2 [2191-1-26] 05:35PM URINE HYALINE-0-2 [2191-1-26] 05:35PM URINE COMMENT-0-2 COARSE GRANULAR CASTS [2191-1-26] 04:30PM TYPE-ART TEMP-35.3 RATES-25/ TIDAL VOL-550 PEEP-5 O2-50 PO2-121* PCO2-23* PH-7.38 TOTAL CO2-14* BASE XS--9 -ASSIST/CON INTUBATED-INTUBATED [2191-1-26] 04:30PM LACTATE-6.3* [2191-1-26] 04:30PM freeCa-1.00* [2191-1-26] 02:34PM TYPE-ART RATES-25/0 TIDAL VOL-550 PEEP-5 PO2-302* PCO2-23* PH-7.38 TOTAL CO2-14* BASE XS--9 -ASSIST/CON INTUBATED-INTUBATED [2191-1-26] 02:34PM LACTATE-6.8* [2191-1-26] 02:34PM freeCa-1.07* [2191-1-26] 02:19PM GLUCOSE-419* UREA N-34* CREAT-1.7* SODIUM-144 POTASSIUM-3.5 CHLORIDE-113* TOTAL CO2-15* ANION GAP-20 [2191-1-26] 02:19PM CK(CPK)-2781* [2191-1-26] 02:19PM CK-MB-77* MB INDX-2.8 cTropnT-2.80* [2191-1-26] 12:48PM TYPE-[Last Name (un) ] PO2-70* PCO2-24* PH-7.29* TOTAL CO2-12* BASE XS--12 [2191-1-26] 12:48PM GLUCOSE-480* LACTATE-8.3* [2191-1-26] 10:55AM TYPE-ART PO2-384* PCO2-24* PH-7.20* TOTAL CO2-10* BASE XS--16 INTUBATED-INTUBATED VENT-CONTROLLED [2191-1-26] 10:55AM GLUCOSE-548* LACTATE-10.4* NA+-141 K+-3.3* [2191-1-26] 10:55AM HGB-9.6* calcHCT-29 [2191-1-26] 10:55AM freeCa-1.08* [2191-1-26] 10:50AM GLUCOSE-595* UREA N-38* CREAT-2.0* SODIUM-144 POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-10* ANION GAP-27* [2191-1-26] 10:50AM ALT(SGPT)-147* AST(SGOT)-232* CK(CPK)-1402* ALK PHOS-87 AMYLASE-53 TOT BILI-0.3 [2191-1-26] 10:50AM LIPASE-27 [2191-1-26] 10:50AM cTropnT-1.43* [2191-1-26] 10:50AM CK-MB-28* MB INDX-2.0 [2191-1-26] 10:50AM ALBUMIN-2.8* CALCIUM-7.6* PHOSPHATE-3.6 MAGNESIUM-1.5* [2191-1-26] 10:50AM WBC-16.3* RBC-3.18* HGB-9.2* HCT-30.6* MCV-96 MCH-28.9 MCHC-30.1* RDW-13.6 [2191-1-26] 10:50AM NEUTS-83* BANDS-5 LYMPHS-10* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 [2191-1-26] 10:50AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL BURR-1+ ELLIPTOCY-OCCASIONAL [2191-1-26] 10:50AM PLT COUNT-340 [2191-1-26] 10:50AM PT-16.4* PTT-33.8 INR(PT)-1.7 Brief Hospital Course: MICU course was notable for resolution of her DKA on insulin drip, with reinitiation of NPH insulin [1-30]. Her BP was supported with saline and pressors, and she has a net fluid balance of +11 liters for her length of stay. She was successfully extubated [1-29]. Patient noted to have elevated cardiac enzymes, with Ck max of 4126, Ck-MB of 113, and MB index of 2.7, and Troponin T, with maximum of 4.48 [2191-1-27]. Bedside echocardiogram demonstrated nl LV systomlic function (EF>60%), with 1+ AR and mild LVH. She was noted to have a transaminitis, with ALT maximum of 200, AST maximum of 361, though alkaline phosphatase and bilirubin were normal. A CT of the Abdomen/Pelvis was notable for diverticulosis without evidence of diverticulitis, multiple peripheral diffusion perfusion defects in the spleen, possibly infarcts (age indeterminate) and pericholecystic fluid with strong enhancement of the gallbladder wall, raising the possibility of cholecystitis. However, RUQ ultrasound revealed cholelithiasis without evidence of cholecystitis, and a gallbladder (HIDA) scan revealed normal gallbladder, without evidence of cholecystitis. CT of the head was negative for any cute process. She has been maintained on empiric antibiotics, including vancomycin, Unasyn, levofloxacin and flagyl empirically, with decrease in WBC from a maximum of 27. Patient was transferred from the ICU to the floor [1-30]. Remainder of her hospital course: DM - patients blood sugars remained well controlled on a regimen of NPH twice daily. She was however not eating (see below). Aspiration - Ms [Known lastname ] was unable to cooperate with a speech and swallow evaluation, and upon empirically advancing her diet to pureed solids and nectar thickened liquids, she was witnessed to aspirate. She was kept NPO until [2-4], when the decision was made by her Durable Power of Attorney (following court hearing) to change the goals of her care to Comfort Measures Only. As such, we have attempted to reinitiate her diet as tolerated. The decision was made by her Power of Attorney not to proceed with PEG or PEJ tubes. CHF- She was initially aggressively diuresed after leaving the ICU, given hypoxia secondary to CHF. However, as her PO intake was limited by aspiration as above, attempts to continue diuresis were limited by intravascular depletion from poor PO intake and hypoalbuminemia. Oral medications had been held (including ACE, Beta-blocker), and as she is now CMO, medications have been discontinued. Transaminitis - was likely secondary to hypoperfusion on admission, and her ALT/AST levels trended downward, approaching their baseline Hypothyroidism - continued to hold levothyroxine, as she has been unable to take PO, and is now CMO. dementia: continue to hold gabapentin, riperidol and exelon, given inability to take POs as above. Code status - per her Durable Power of Attorney, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 20669], Ms. [Known lastname 4946] code status is officially DNR/DNI CMO status - per her Durable Power of Attorney, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 20669], Ms. [Known lastname ] is comfort care only. No PEG/PEJ tube will be placed. She will be allowed to resume her diet of pureed solids/nectar thickened liquids, and should be fed when hungry, in keeping with goals of comfort care. She should not be re-hospitalized (do not hospitalize status). Given goals for comfort care, finger sticks, and therefore insulin dosing, have been discontinued. Medications on Admission: Meds: NPH, lipitor, lasix qod, molexopril, levothyroxine, gabapentin, risperidol, zyprexa, exalon Discharge Medications: none Discharge Disposition: Extended Care Facility: [Location (un) 1036] - [Location (un) 620] Discharge Diagnosis: Diabetic Ketoacidosis Aspiration Pneumonia Hypertension Diabetes Mellitus Alzheimer's Disease Congestive Heart Failure Coronary Artery Disease Hypothyroidism Discharge Condition: fair Discharge Instructions: Per discussion with the patient's Durable Power of Attorney, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 20669], Ms. [Known lastname ] is now DNR/DNI for code status, and her goals of care are Comfort Measures Only. Further decisions regarding her health care should be made between her Durable Power of Attorney, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 20669], and Ms. [Known lastname 4946] physicians (her PCP and at her [Hospital3 ]). Followup Instructions: Patient now CMO Completed by:[2191-2-5] ICD9 Codes: 5070, 4280, 4019, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8098 }	Medical Text: Admission Date: [2142-9-13] Discharge Date: [2142-9-20] Date of Birth: [2072-8-26] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Exertional angina for days. Major Surgical or Invasive Procedure: [9-13] AVR (St. [First Name5 (NamePattern1) 923] [Last Name (NamePattern1) 9041]), Aortic root enlargement History of Present Illness: 70 yo female with history of CAD and known AS, now with worsening exertional chest pain and SOB over past 4 days. Cath done [9-5] prior to planned AVR showed no significant coronary disease. Past Medical History: Critical AS rheumatic fever as a child CAD GI bleed due to gastric polyps NIDDM ^chol. HTN s/p R breast bx s/p R leg fx s/p R ankle fx s/p T+A Depression Social History: Lives with husband. ETOH: none Cigs: none Family History: Father died at 40 from MI, twin sister w/ CVA Physical Exam: 5'3" 220# HR 72 RR 18 149/42 NAD neck supple with full ROM, no carotid bruits appreciated HEENT unremarkable CTAB RRR 4/6 SEM radiating to carotids abd soft, Nt, ND, + BS extrems warm, well-perfused with no varicosities neuro grossly intact 2+ bil. fems/radials 1+ bil. PTs/ trace DP on right, 1+ on left Pertinent Results: [2142-9-16] 04:40AM BLOOD WBC-13.1* RBC-3.65* Hgb-11.3* Hct-32.6* MCV-89 MCH-31.0 MCHC-34.7 RDW-15.1 Plt Ct-100* [2142-9-15] 01:56AM BLOOD PT-15.9* PTT-30.9 INR(PT)-1.4* [2142-9-16] 04:40AM BLOOD Glucose-184* UreaN-30* Creat-1.1 Na-138 K-3.8 Cl-104 HCO3-24 AnGap-14 RADIOLOGY Final Report CHEST (PA & LAT) [2142-9-17] 10:38 AM CHEST (PA & LAT) Reason: eval effusions, atel [Hospital 93] MEDICAL CONDITION: 70 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval effusions, atel TWO-VIEW CHEST X-RAY DATED [2142-9-17]. COMPARISON: Preoperative chest x-ray [2142-9-5] and postoperative portable chest radiograph, [2142-9-13]. INDICATION: Status post aortic valve replacement. The patient is status post median sternotomy and aortic valve replacement. Various lines and tubes have been removed since the most recent radiograph with no evidence of pneumothorax. Cardiac silhouette is upper limits of normal in size and slightly increased compared to the preoperative study, likely due to postoperative changes. Perihilar edema has resolved. Bilateral perihilar areas of discoid atelectasis are present, overall improved. Pleural effusions, left greater than right are present. IMPRESSION: Small pleural effusions, left greater than right. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5785] Cardiology Report ECHO Study Date of [2142-9-13] PATIENT/TEST INFORMATION: Indication: Aortic valve disease. Hypertension. Height: (in) 63 Weight (lb): 220 BSA (m2): 2.02 m2 BP (mm Hg): 155/50 HR (bpm): 77 Status: Inpatient Date/Time: [2142-9-13] at 07:05 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [First Name (STitle) ] R. [Doctor Last Name ] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.6 cm Left Ventricle - Fractional Shortening: 0.43 (nl >= 0.29) Left Ventricle - Ejection Fraction: 60% (nl >=55%) Aorta - Valve Level: 2.1 cm (nl <= 3.6 cm) Aorta - Ascending: 3.0 cm (nl <= 3.4 cm) Aorta - Arch: 2.2 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: 2.2 cm (nl <= 2.5 cm) Aortic Valve - Peak Velocity: 4.9 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 95 mm Hg Aortic Valve - Mean Gradient: 48 mm Hg Aortic Valve - LVOT Peak Vel: 1.00 m/sec Aortic Valve - LVOT VTI: 27 Aortic Valve - LVOT Diam: 1.9 cm Aortic Valve - Valve Area: 0.7 cm2 (nl >= 3.0 cm2) Mitral Valve - Peak Velocity: 1.7 m/sec Mitral Valve - Mean Gradient: 7 mm Hg Mitral Valve - Pressure Half Time: 79 ms Mitral Valve - MVA (P [11-27] T): 2.8 cm2 INTERPRETATION: Findings: LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%). Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Severe AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. No MS. Mild to moderate ([11-27]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally Conclusions: PRE-BYPASS: 1. Left ventricular cavity size, and systolic function are normal (LVEF>55%). Mild LVH. 2. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis with an estimated aortic valve area of 0.7 cm2. Mild (1+) aortic regurgitation is seen. 3. The mitral valve leaflets are mildly thickened. There is mild restriction of motion of the anterior mitral leaflet.There is no mitral valve prolapse. There is mild (1+) mitral regurgitation. 4. There is a heavily calcified structure in the left atrial appendage which is probably a calcified pectinate muscle. (Surgeon made aware) No spontaneous contrast in the LAA or in the LA. Normal LAA ejection velocity (28 cm/s). 5. No atrial septal defect is seen by 2D or color Doppler. 6. Right ventricular chamber size and free wall motion are normal. 7.There are simple atheroma in the descending thoracic aorta. POST-BYPASS: The patient is being AV paced. 1. A bioprosthetic valve is seen in the aortic position. The valve appears well seated with normal leaflet function(The mid esophageal short axis views are limited). Mean gradient across the prosthetic aortic valve is 17-24 mmHg . Peak velocity across the valve is 3.8 m/sec. The surgeon made aware and accepts these gradients. 2. Trace mitral regurgitation present. 3. Aorta is intact post decannulation. Electronically signed by [Name6 (MD) 1509] [Name8 (MD) 1510], MD on [2142-9-13] 15:43. Brief Hospital Course: Admitted [9-13] and underwent AVR and aortic root replacement with Dr. [Last Name (STitle) ]. Transferred to the CSRU in stable condition on a propofol drip. Extubated on POD #1 and beta blockade titrated with gentle diuresis. Transferred to the floor off all drips on POD #2. Chest tubes and pacing wires removed without incident. She was somewhat deconditioned but continued to make good progress on the floor. Cleared for discharge to rehab on POD # 7. Pt. is to make all follow- up appts. as per discharge instructions. Medications on Admission: Protonix 40 mg PO daily Paxil 40 mg PO daily Glucovance 5/500 2 tabs [Hospital1 ] Norvasc 10' Lisinopril 40 mg PO daily Bumex 1 mg PO daily ASA 81 mg PO daily Actos 15 mg PO daily Mevacor 10 mg PO daily Atenolol 25 mg PO daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:60 Capsule(s)* Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Glyburide-Metformin 5-500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 9. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:0 11. 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 12. Bumex 1 mg Tablet Sig: One (1) Tablet PO twice a day: twice a day for one week, then daily as prior to surgery. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: Glenridge - [Location (un) 1468] Discharge Diagnosis: AS GI Bleed Rheumatic fever HTN lipids DM depression tonsillectomy Discharge Condition: Good. Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5)No lifting greater then 10 pounds for 10 weeks. 6)No driving for 1 month. Followup Instructions: Dr. [Last Name (STitle) ] or Dr. [Last Name (STitle) 49171] in [11-27] weeks Dr. [Last Name (STitle) ] in [12-29] weeks Dr. [Last Name (STitle) ] 4 weeks [Telephone/Fax (1) 170] Completed by:[2142-9-20] ICD9 Codes: 4241, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8099 }	Medical Text: Admission Date: [2155-9-5] Discharge Date: [2155-9-11] Date of Birth: [2107-2-1] Sex: M Service: IDENTIFICATION/CHIEF COMPLAINT: This is a 48 year old man with a history of hypertension, Type 1 diabetes and end stage renal disease on hemodialysis (Monday, Wednesday and Friday) who presented to the Emergency Department with hypertensive crisis. PAST MEDICAL HISTORY: 1. Diabetes times 27 years 2. End stage renal disease on hemodialysis, Monday, Wednesday and Friday 3. Diabetic retinopathy 4. Hypertension 5. Nephrolithiasis times two 6. Back surgery 7. Hernia repair MEDICATIONS ON ADMISSION: 1. Cardizem 2. Catapres 3. Insulin 15 units q AM/q PM with sliding scale for meals 4. Phoslo ALLERGIES: Minoxidil causing facial swelling HISTORY OF PRESENT ILLNESS: The patient describes being in his normal state of health until the day of admission when he felt unwell and dizzy while at work. The patient then became confused and disoriented and was given some juice and crackers for presumed hypoglycemia. Glucose was noted to be at 90 when taken by his wife. The patient was also noted to have some slurred speech and then developed some vomiting and a headache which was rated at 9 out of 10. The patient was taken to the Emergency Department by the emergency medical technicians and was found to have a blood pressure of 214/96 with a pulse of 76. In the Emergency Department the patient was treated with enteric coated Aspirin and was started on a Nitroprusside and Labetalol drip. The patient also received 21 units of insulin for his blood sugar over 300. He underwent a computerized tomography scan which demonstrated no intracranial pathology. The patient had a recent echocardiogram on [2154-5-30] which demonstrated left atrial enlargement and left ventricular hypertrophy. He had an ejection fraction of over 50% and trace mitral regurgitation. He also had a stress test in [2152-10-5] which was an exercise stress test which he was able to perform for 11 minutes achieving 80% of his maximum heart rate and had to stop secondary to fatigue. He at that time was also noted to have an ejection fraction of 54% with no wall motion abnormalities. PHYSICAL EXAMINATION: The patient was in no apparent distress and/or somewhat somnolent. He had a temperature of 101.0 with a heartrate of 86 and a blood pressure of 230/90. His respiratory rate was 16 on 5 liters of nasal cannula resulting in an oxygen saturation of 95%. Head and neck examination was unremarkable as his mucous membranes were moist. Extraocular movements intact and pupils were equal and reactive to light. His neck was supple without any lymphadenopathy and he had no meningismus. His lungs had crackles bilaterally a third of the way up from the bases without any wheezes. He had a jugulovenous pressure of 8 to 9 cm and his carotids demonstrated normal volume and upstroke. He did not have any carotid bruits. He had a regular rate and rhythm with normal S1 and S2 and no history of S4. He had a II/VI systolic ejection murmur. His abdominal examination was unremarkable and he had 1+ edema to his ankle. He had the presence of a right bruit in his forearm fistula. His neurological examination showed that he was moving all four extremities spontaneously and that he was somewhat delirious. LABORATORY DATA: The patient had a normal complete blood count and coags. His chem-7 was notable for a BUN of 59 and a creatinine of 7.9 with glucose of 514. He had normal liver function tests and his arterial blood gases was 7.41, 46 and 70. His chest film showed him to be in mild pulmonary edema. His electrocardiogram showed that he was in normal sinus rhythm at 66 with axis of -30 and T wave inversions in lead 1, AVL, V5 and V6. HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit where he was continued on the Nitroprusside and Labetalol infusions. The Neurology Service was consulted after the patient was noted to have some left-sided weakness. In addition to left-sided weakness, the patient was also found to have some left-sided neglect and a left hemianopia. An magnetic resonance imaging scan was recommended at that time which did not demonstrate any distinct lesions. The patient was able to wean off of the Nitroprusside and Labetalol infusion on [2155-9-6]. He was then converted to oral hydralazine and Labetalol. The patient also ruled out for myocardial infarction by enzymes. Due to the nature of the patient's hypertensive crisis the patient was sent for an magnetic resonance imaging scan of his kidneys to rule out renal artery stenosis. This was performed on [9-10] which showed him to have no abnormality in his renal artery stenosis or with his renal arteries. The patient's blood pressure continued to be managed with Hydralazine and Labetalol. With the negative magnetic resonance imaging scan the patient was then started on Lisinopril on [2155-9-11]. The patient's neurologic symptoms resolved two to three days prior to discharge from the hospital. The patient was discharged from the hospital on [2155-9-11] in stable condition. He also underwent an echocardiogram prior to discharge. His echocardiogram demonstrated an ejection fraction of over 60% with mild left atrial enlargement, left ventricular hypertrophy and normal valves. DISCHARGE MEDICATIONS: 1. NPH insulin 15 units q. AM and 15 units q. PM followed by a sliding scale insulin t.i.d. with his meals. 2. The patient also was discharged home on Labetalol 400 mg p.o. b.i.d. 3. Hydralazine 75 mg p.o. q.i.d. 4. Lisinopril 10 mg p.o. q.d. 5. Enteric coated Aspirin 325 mg p.o. q.d. 6. Phoslo 3 packets p.o. t.i.d. with meals 7. Colace 100 mg p.o. b.i.d. 8. Dulcolax 5 to 10 mg p.o./p.r. q.h.s. prn [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) ] Dictated By:[Name8 (MD) 26201] MEDQUIST36 D: [2155-9-11] 16:45 T: [2155-9-11] 17:17 JOB#: [Job Number 39021] ICD9 Codes: 3572

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