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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8100
} | Medical Text: Admission Date: [**2111-10-9**] Discharge Date: [**2111-10-30**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
confusion, change in MS, hypoxia, humeral fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 83 yo man w/ h/o CAD s/p CABG >25 yrs ago, s/p
ICD, Afib not on coumadin, HTN who was admitted after mechanical
fall with proximal left humeral fracture on [**2111-10-9**]. At time of
initial admit, patient had rec'd 2 mg SC morphine, 2 percocets
in the emergency room with subsequent dramatic change in mental
status, but was noted to be clear and oriented prior to
administration. He denied head trauma or LOC during fall. Has
been having "almost" falls lately with some frequency.
.
Since admission, patient has been having waxing and [**Doctor Last Name 688**]
mental status, worsened by narcotics and benzos, as above. Xray
showed comminuted, displaced fracture of left proximal humerus.
Seen by ortho, given sling, and told to be non-weight bearing.
PT consult obtained. Had transient low bp on [**10-9**] to 80's/60's,
thought to be due to wrong medication/antihypertensive doses
(family unsure of doses/ meds). This improved with dose
adjustments. Cr also elevated during admission, thought to be
mostly chronic per notes (but no baseline), given hydration.
.
Past Medical History:
information limited- no records here
CAD s/p CABG [**31**] years ago
CHF
ICD
early/mild dementia per medical record this admission
CRI? baseline unclear
Afib not on coumadin
cataracts w/ ?left sided blindness
Social History:
visiting from berkshires; wife having surgery here;
Family History:
not elicited
Physical Exam:
T 101.1 BP 113/76 P 134 AF? Vpaced R 24 sat 93% 4L
gen: elderly, dysarthric, garbled speaking man, agitated,
calling out
HEENT: MM dry; NC in place, left surgical pupil, right is 2 mm
and reactive, EOMI intact but not to command, tongue midline
NECK: JVP flat; supple
CV: ICD palpated, midline scar; tachy, regular
CHEST: poor effort/cooperation; decreased breath sounds at bases
w/ some crackling; no wheeze
ABD: soft, non tender, nabs
EXTRM: thin; non edematous, left shoulder with severe
ecchymoses; tender to palpation and any movement. In sling.
NEURO: babbling, incoherent, responsive to voice/command/pain;
CN exam limited [**2-25**] selective-command following but tongue
midline, EOMI but not to command (spontaneous), slight left
sided facial droop; down going toes bilaterally w/ withdrawal to
pain, slightly rigid lower extremities- no clonus; hyper
reflexive achilles, patellar, biceps (3+) bilaterally, squeezes
hands and wiggles toes to command, moving all extrm
spontaneously, speech is garbled with intact comprehension to
some extent but unable to formulate meaningful sentences. Able
to give one word answers.
Pertinent Results:
2 views left shoulder: Comminuted, displaced fracture of the
left proximal humerus.
[**10-11**] CT head: There is no intraaxial hemorrhage. There is no
shift of normally midline structures, acute fractures, loss of
the [**Doctor Last Name 352**]-white matter differentiation, or major vascular
territorial infarct. The ventricles and sulci are prominent
consistent with mild brain atrophy. There is low attenuation of
the centrum semi-ovale consistent with chronic microvascular
ischemia. There is a low attenuation in the left basal ganglia
consistent with an old lacunar infarct. This study is degraded
secondary to patient motion and streak artifact. There are
prominent low density extra-axial spaces over the right
convexity and in the left parafalcine region, most likely
representing subdural hygromas or chronic subdural collections.
There is no evidence of an acute subdural hematoma. There is no
mass effect.
[**2111-10-12**] B/L LE dopplers:Negative bilateral lower extremity
Doppler examination.
.
[**2111-10-12**] CT head: 1. No evidence of intracranial hemorrhage or
edema.
2. Cerebral atrophy.
3. Widening of the right extra-axial space likely secondary to
atrophy and/or a subdural hygroma.
.
[**2111-10-12**] CXR:Mild pulmonary edema has developed accompanied by
numerous small right pleural effusion. Severe cardiomegaly is
stable. Atrial biventricular pacer leads are in standard
placements. No pneumothorax.
.
[**2111-10-12**]: EF 15-20% Mild pulmonary edema has developed
accompanied by numerous small right pleural effusion. Severe
cardiomegaly is stable. Atrial biventricular pacer leads are in
standard placements. No pneumothorax.
.
[**2111-10-14**] CT OF THE LEFT SHOULDER WITHOUT CONTRAST: A reference is
made to a prior radiograph dated [**2111-10-8**]. There is a
complex, comminuted fracture through the surgical neck of the
left humerus with anteromedial angulation of the humeral shaft.
A small fracture involving the distalmost aspect of the clavicle
is likely also present. The acromioclavicular joint is
preserved. The humeral head is normally seated within the
glenoid, without evidence of dislocation. An unusual dense ovoid
bony "nodule" is present adjacent to the fracture site and is of
unclear etiology. ? sclerotic focus within the bone (e.g. bone
island which was "released" by the fracture or possibly a dense
loose body in the joint space. There is surrounding soft tissue
hematoma and effusion. Incidental note is made of a 3.3 x 1.7 cm
lipoma along the lateral aspect of the proximal humeral shaft.
IMPRESSION: Comminuted, displaced fracture through the surgical
neck of the left humerus as above. Small distal clavicular
fracture. Unusual ovoid density, as described.
.
[**2111-10-16**] RIGHT UPPER EXTREMITY ULTRASOUND: Grayscale, color, and
Doppler son[**Name (NI) 1417**] of the right internal jugular, right
subclavian, right axillary, right brachial, right basilic, and
right cephalic veins were performed. The most superiorly located
brachial vein is noncompressible and does not demonstrate any
wall to wall color or venous waveforms. These findings are
suggestive of thrombosis involving the superior brachial vein.
The remaining veins otherwise appeared normal with wall-to-wall
color flow, normal waveforms, and normal compressibility.
IMPRESSION: Noncompressibility of the superior right brachial
vein, with lack of color flow and absent venous waveforms,
findings consistent with venous thrombosis.
.
[**2111-10-16**] Renal ultrasound: Large left renal cyst with a thick
septation with calcification falling in the Bosniak II F
category. A four to six month followup is recommended. There is
no evidence of hydronephrosis or renal stones.
.
[**2111-10-19**] RIGHT UPPER QUADRANT ULTRASOUND: This examination was
extremely limited due to altered mental status. No ascites is
seen. This study should be repeated when the patient is more
able to cooperate with the exam
.
[**2111-10-19**]: ABDOMINAL ULTRASOUND WITH LIVER DOPPLER EXAMINATION:
The gallbladder is not visualized. The common bile duct is not
dilated at 3 mm. The liver parenchyma is normal in echo texture
without focal nodules or masses. There is a moderate right-sided
pleural effusion. The right kidney measures 11.4 cm. There is an
exophytic 2.9 x 2.8 x 2.5 cm simple cyst off the lateral aspect
of the right kidney. The left kidney measures 12.4 cm, with a
7.5 x 6.2 x 6.9 cm cyst, which a thin septation and mild
calcifications. The spleen is not enlarged. The pancreas is
poorly visualized secondary to overlying bowel gas.
Doppler examination reveals normal flow and phasicity within the
main and right portal veins, demonstrating hepatopetal flow.
Normal flow and phasicity is seen within the main hepatic
artery. All hepatic veins are patent, with appropriate flow.
Increased phasicity is consistent with underlying right heart
failure.
IMPRESSION:
1. All hepatic vessels are patent with normal directional flow.
Increased phasicity within the hepatic veins is consistent with
underlying right heart failure.
2. Normal appearing liver parenchyma without focal nodules or
masses identified.
3. No evidence of hydronephrosis bilaterally. Simple cyst in
right kidney. Cyst with internal calcification and thin
septation within left kidney.
4. Moderate right-sided pleural effusion.
.
[**2111-10-21**] CXR: 1. Mild congestive heart failure.
2. Increasing atelectasis or pneumonia in the left lower lobe.
.
[**2111-10-22**] CXR: Low lung volumes have worsened; there is more
consolidation at both lung bases, worrisome for pneumonia.
Moderate cardiomegaly is stable. Upper lungs show pulmonary
vascular congestion but no edema. Tip of the right PIC catheter
is in the SVC. Right atrial and left ventricular pacers and
right ventricular pacer defibrillator leads are unchanged in
their respective positions. No pneumothorax.
.
[**2111-10-28**] Successful placement of a 37-cm 4 French single-lumen
PICC by way of the right brachial vein with tip at the superior
vena cava-right atrial junction. The catheter may be used
immediately.
.
[**10-15**] blood cx: [**1-25**] with gram positive cocci
[**10-18**]: blood cultures: [**1-25**] with gram positive cocci
R femoral line tip for culture: final - no growth
[**10-20**]: Blood culture off PICC - no growth
[**10-21**]: Blood culture off PICC - no growth
[**10-22**]: Blood culture peripheral - no growth
[**10-23**]: Blood cultures: no growth
[**10-21**]: urine culture - no growth
.
EKG: most recent from 23:37 with AF rate 138 normal axis;
intermittent V pacing spikes; S1 QIII TIII present. IVCD, no
ischemic changes.
[**2111-10-9**] 06:30PM CK(CPK)-94
[**2111-10-9**] 06:30PM CK-MB-3 cTropnT-0.03*
[**2111-10-9**] 07:45AM GLUCOSE-121* UREA N-43* CREAT-1.8* SODIUM-143
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13
[**2111-10-9**] 07:45AM PLT COUNT-139*
[**2111-10-9**] 07:45AM PT-14.0* PTT-27.3 INR(PT)-1.3
Brief Hospital Course:
83 M with multiple medical problems after mechanical fall with
proximal humerus fracture complicated by delirium.
.
1. Altered Mental status: Patient initially presented to
medicine service with opiate induced delirium as he had been
given 2 Percocet tablets and 4mg of Morphine for pain control
before being seen by medicine service. His delirium, likely
exacerbated by pain from recent fracture, hypoxia/infection from
pneumonia, also may have some degree of uremia from rising
creatinine and persistent renal failure.
Fat emboli syndrome was also high on the differential given his
elevated LFTs and worsening renal failure. PE was also on the
differential, however this was felt to be less likely given the
other reasons for hypoxia and delirium, and given his poor renal
function, CTA was not done during admission. He was also ruled
out for MI. Patient was intermittently agitated. He was
hypotensive at 1 point and had limited IV access and was sent to
the ICU, but did not require intubation. Opiates were avoided as
much as possible. A pain consult was obtained hoping that pain
control would help with his delirium. However, due to his
multiple medical problems they felt that aggressive intervention
would not be possible. They recommended Ultram and standing
Tylenol. His delirium persisted and he became progressively more
tachypneic and looked uncomfortable. Tiny doses of morphine were
give (total of about 2 mg in 24 hours). He remained tachypneic
and then became hypoxic and went into respiratory failure on
[**10-22**]. He was intubated and sent back to the ICU. From a
respiratory status he improved and it was felt that he could be
extubated, however he remained heavily sedated after fentanyl
and versed were discontinued. It was unclear if he would do well
on extubation given his mental status, however he tolerated it
well and sats were in high 90's in 4 L NC. He remained delirious
only answering to what his name is, but otherwise was
disoriented. A family meeting was held in the ICU, and it was
decided that the patient would want to be DNR/DNI but medical
management would be continued. Although they did not make him
comfort measures only, the family stressed that he should be
made as comfortable as possible. He occasionally became agitated
and seemed somewhat uncomfortable when he returned to the floor.
Ultram was restarted with hopes of controlling his pain without
giving morphine and Zyprexa was ordered PRN.
Geriatrics followed the patient throughout his hospital stay
and they agreed that we should treat all of his medical issues
and control his pain, given this was likely contributing to his
delirium. Would continue scopolamine patch for secretions and
suction PRN, continue aspiration precautions until mental status
clears, ultram and tylenol for pain.
.
2. ID: Patient developed pneumonia most likely secondary to
aspiration given his altered mental status he was treated with
12 days of levofloxacin, 8 days of Flagyl and 10 days of
vancomycin. His blood cultures from [**10-15**] and [**10-18**] grew coag
negtaive staph sensitive to vancomycin. However, on [**10-22**] he
spiked a fever to 104 and became hypoxic, chest x-ray looked
like worsening pneumonia most likely to continued aspiration. He
went into respiratory distress, was intubated, brought to the
[**Hospital Unit Name 153**] where he was also on pressors and was started on Zosyn, He
received a full 7 days of Zosyn, was afebrile with improving
respiratory status, was extubated and began maintaining his sats
at 98-100% on 4 L NC. At discharge, he was on no antibiotics and
all cultures from [**10-20**] on were negative.
.
3. Respiratory failure: It was thought that his respiratory
failure was due to pulmonary edema along with pneumonia. It is
likely that he was continuously aspirating. On serial CXR there
was pulmonary edema and O2 sats did improve with diuresis. On
[**10-22**] his respiratory status rapidly declined, blood gas showed a
metabolic acidosis. CXR revealed worsening pneumonia and patient
was tachypneic and hypoxic and eventually began having apneic
episodes. He was intubated, sedated and taken to the ICU where
he was started on pressors and Zosyn for pneumonia. It was
thought that his rapid decline was secondary to worsening
pneumonia and mucous plugging. He was extubated and was satting
98-100% on 4 L NC after treatment with 7 days of Zosyn.
.
4. Access: Multiple attempts were made to get IV access
including PIV in his foot, central lines and femoral lines. Lone
placement was limited by his agitation, edema, pacemaker, right
brachial artery thrombus, and fractured left arm. A femoral line
was briefly placed as patient was in desperate need of
hydration, but was discontinued after 2 days after which time a
PICC line was place. However, patient was bacteremic and PICC
was pulled and he was treated with antibiotics and then a PICC
was replaced. At discharge he has a right PICC which was left in
place given all of his issues with IV access.
5. Renal: Probably ARF on CRF. Patient had rising creatinine
from PCP's office: Cr 1.7->2.2 (rising on 4 consecutive readings
every 2-3 weeks) prior to admission. His creatinine peaked at
2.9, He did not receive any contrast, but has gotten some
ibuprofen. No signs of active sediment with muddy brown casts
consistent with ATN as well, good UOP and renal u/s showed no
signs of obstruction. Urine lytes c/w prerenal etiology.
Creatinine improved with hydration, but his fluid status was
precarious given his low EF. He did have worsening pulmonary
edema after hydration and responded well to 40 of IV Lasix. He
was positive about 10 liters during admission but appears
euvolemic on discharge.
Also, patient was hypernatremic to 157 during the time it
was difficult to gain IV access. A renal consult was obtained
and agreed with our management of replete his free water. His
free water deficit was estimated at 4-5 liters. He received 5
liters D5W and his sodium was within normal limits and remained
normal for the rest of his hospital stay.
His HCO3 remained about 18 throughout most of his hospital
stay. The reason for this is unclear. It is possible that he has
an RTA, but renal was not re consulted. Can consider further
work up after resolution of his acute medical problems.
.
6. Humerus fx/Pain control: Orthopedic consulted and had no plan
for surgery and to follow as outpatient. They recommended
continuing sling with swath for 6 weeks and non-weight bearing
of left arm. His arm remained edematous and ecchymotic thorough
out admission and the patient was reevaluated for possible
compartment syndrome, but Ortho did not think this was likely.
Pain control with Tylenol 1000 mg Q 6H and Ultram [**Hospital1 **]. He should
follow up with orthopedics as an outpatient.
7. Cardiac: Patient has CAD and is s/p CABG and had an ICD
placed for unknown reasons but likely due to low EF. Patient
also has known ECHO in [**2109**] with EF of 30% (as per PMD)with
ischemic changes including enlarged left ventricle and mitral
and aortic regurgitation. On this admission ECHO was repeated
and revealed EF 15-20%. He was ruled out for MI on admission as
he complained of some mild substernal chest pain. Cardiac
enzymes were negative and EKG revealed no ischemic changes. He
had no further episodes throughout admission. His blood pressure
medications were held for hypotension and renal failure.
However, given his low EF and valvular disease would recommend
titrating captopril as blood pressure tolerates.
.
8. Heme: Patient's INR was 1.2 on admission and on HOD#3, INR
peaked at 2.2; on HOD#[**5-3**] A hematology consult was obtained to
evaluate for possible DIC/TTP picture given anemia and
thrombocytopenia. However, there were no schistocytes on smear
and these abnormalities began to normalize, therefore no further
work up was pursued. it has been steady in the 1.8-2.0 range.
.
9. Elevated LFTS: LFTS began to elevate on HOD#9. Abdominal
ultrasound was negative and there was no other reason to explain
this. He did become hypotension, but not to a significant extent
and enzymes are not high enough to indicate shock liver. It was
thought this may have been to an overall inflammatory response
due to fat emboli syndrome. His LFTs continued to improve over
the course of hospitalization.
.
10. FEN: Patient was hypernatremic as mentioned above, but this
has since resolved. Currently has NG in place with TF as 600
cc/hr and D5 1/2 NS at 50 cc/hr. Given his CHF and renal failure
his fluid status had to be closely monitored. On discharge he
appeared euvolemic.
.
11. Code: DNR/DNI. Family would like complete medical
management, but also think comfort is very important so would
consider pain medications even if this worsened his mental
status.
Medications on Admission:
levoflox 250 mg qd IV today day 1
metoprolol 12.5 qd changed to 5 mg IV q6 hr when made NPO
isosorbide 40 mg po bid
bisacodyl
protonix 40 mg qd
asa 162 po qd
oxybutynin 5 mg tid
lipitor 10 mg qd
quinine 260 mg qod
magnesium oxide 280 qd
donepezil 10 mg qd
heparin sc tid
psyllium
colace 100 mg [**Hospital1 **]
doxepin 25 qd
MVI
tylenol 1 g q 4hr
Discharge Medications:
1. Doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
6. Donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO QHS QOD
().
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO 2 CAPLETS DAILY ().
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
14. Isosorbide Dinitrate Oral
15. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
1. Doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
6. Donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO QHS QOD
().
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO 2 CAPLETS DAILY ().
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
14. Isosorbide Dinitrate Oral
15. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary
1. Humeral fracture
2. Delirium
3. Acute renal failure
4. CHF
Secondary
1. A. fib
2. cataracts
Discharge Condition:
Delirium, oriented to self only, respiratory status stable,
afebrile, NGT in place
Discharge Instructions:
Please take all of your medications as directed.
You should follow up with orthopedics for your humeral fracture.
Followup Instructions:
Call the orthopedics clinic for a follow up visit 4-6 weeks.
ICD9 Codes: 5849, 4280, 2760, 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8101
} | Medical Text: Admission Date: [**2154-10-19**] Discharge Date: [**2154-10-30**]
Date of Birth: [**2097-2-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
CC:[**CC Contact Info 75294**]
Major Surgical or Invasive Procedure:
cerebral angiogram x 2
History of Present Illness:
HPI: 57 y/o male in previously good health who was walking
outside his house when he noted a sudden, severe headache unlike
other headaches he had ever experienced. He described the
experience as characterized by severe pressure in his head which
also began to cause posterior neck pain. He was unable to flex
or extend his neck without pain. He also noted feeling of
nausea, but this was mild. He was taken to an outside hospital
where CT of head revealed subarachnoid hemorrhage. He was
transferred to [**Hospital1 18**] ER for neurosurgery eval.
Past Medical History:
PMHx:
sleep apnea
gum infection
Social History:
Social Hx: denies tobacco or IVDU, moderate EtOH use
Family History:
Family Hx:noncontributory
Physical Exam:
on arrival
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**1-18**] bilaterally EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-19**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-23**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2154-10-20**] CT HEAD: Again seen is extensive subarachnoid hemorrhage
involving the basal cisterns and the sylvian fissures as well as
extending down to the pre-pontine cistern and also involving the
sulci of the right frontal and occipital lobes bilaterally.
Again seen is layering blood within the occipital horns of the
lateral ventricles as well as within the fourth ventricle. The
extent of the hemorrhage is not significantly changed. The
ventricles are unchanged in size. The [**Doctor Last Name 352**]/white matter
differentiation is maintained with no areas of infarcts by CT.
The visualized orbits, paranasal sinuses, and mastoid air cells
are clear. No suspicious bony abnormalities are seen.
There is a periapical lucency around the roots of the left
maxillary first molar. There is also a bony defect of the
lateral wall of the left maxillary sinus which may represent a
prior [**Location (un) 51681**]-[**Doctor Last Name **] procedure. There is minimal mucosal
thickening of the left maxillary sinus.
CTA HEAD: No aneurysms, stenoses, occlusions, or vascular
malformations were seen.
IMPRESSION: No aneurysms or vascular malformations.
Extensive subarachnoid hemorrhage and intraventricular
hemorrhage is not significantly changed compared to [**2154-10-19**].
Brief Hospital Course:
Pt was admitted through the emergency room for c/o headache with
noted SAH. Cerebral angiogram was done and was negative for
aneurysm. On [**10-20**] he underwent MRI and CTA. Based on those
results he was maintained in the ICU with close observation and
an angiogram was set up for [**10-25**]. His exam remained stable and
his bp was kept at a range of 90-130. His second angiogram
showed no aneurysm on [**10-25**]. The patient continued to complain of
neck pain and he had nuchal rigidity. He was allowed to start
Motrin for the pain, which did not help. The patient was given
oxycodone and fioricet which improved his pain. On [**10-27**] he was
transferred to the step-down unit. He had a TCD on [**10-28**] which
showed mild vasospasm. He was asymptomatic and was given fluids.
He had a repeat TCD on [**10-29**] which showed that the vasospasm
had resolved. A repeat TCD on [**10-30**] was also negative. The
patient was neurologically stable and was cleared to go home by
PT. He was ambulating, taking in food PO, voiding and his pain
was under control prior to discharge. His nimodipine was
pre-ordered at his pharmacy so it will be ready for him when he
goes there tomorrow.
Medications on Admission:
Medications prior to admission:
penicillin 500mg po QID
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**11-20**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 9 days.
Disp:*108 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
subarachnoid hemorrhage
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
??????Have a family member check your incision daily for signs of
infection
??????Take your pain medicine as prescribed
??????Exercise should be limited to walking; no lifting, straining,
excessive bending
??????You may wash your hair only after sutures and/or staples have
been removed
??????You may shower before this time with assistance and use of a
shower cap
??????Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
??????If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
??????Clearance to drive and return to work will be addressed at your
post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A FOLLOW UP ANGIOGRAM with Dr. [**First Name (STitle) **] IN 6 WEEKS.
Call [**Telephone/Fax (1) 1669**] to schedule an appointment.
Completed by:[**2154-10-30**]
ICD9 Codes: 431, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8102
} | Medical Text: Admission Date: [**2180-10-9**] Discharge Date: [**2180-10-12**]
Date of Birth: [**2115-10-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Concern for cholangitis and need for urgent ERCP
Major Surgical or Invasive Procedure:
ERCP x2
History of Present Illness:
64 y/o M with PMH of CABG, DMII, and recent CCY on [**2180-9-24**] at
[**Hospital1 **] for biliary colic who was transferred to [**Hospital1 18**]
from [**Hospital3 **] with fever and concern for cholangitis. The
patient was initially discharged home following the CCY in
stable condition. On [**10-7**] he was eating breakfast when he
developed RUQ abdominal pain similar in character to his prior
biliary colic. Associated with N/V, loose stools and
diaphoresis. Not relieved by tylenol. He presented to [**Hospital1 **] on [**2180-10-7**] where initial labs revealed a
rising bili, elevated WBC and an elevated lipase. Diagnosed
with gallstone pancreatitis and started on unasyn. Seen by GI
team who recommended ERCP. On the morning of [**2180-10-8**], the
patient spiked a fever to 101.0. Decision was made to transfer
the patient to [**Hospital1 18**] for semi-urgent ERCP given concern for
developing cholangitis.
.
On arrival to [**Hospital1 18**] the patient appeared stable with initial
vitals 99.9 159/65 104 22 94%RA. He reports feeling generally
well and denies any pain at present.
Past Medical History:
- s/p CCY [**2180-9-26**]
- CAD s/p CABG [**2172**]
- DM
- HTN
- HL
- urinary retention s/p cyst removal
Social History:
Works part-time as a CPA. Lives at home with his wife. Former
[**Name2 (NI) 1818**] but quit 13 years ago. Occasional EtOH. No other drug
use.
Family History:
Father and brother with CAD. Brother had lymphoma. Father had
lung CA
Physical Exam:
ADMISSION EXAM:
Vitals: 99.9 159/65 104 22 94%RA
General: Alert, oriented, no acute distress
HEENT: PERRLA, EOMI, icteric sclera, 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, soft I/VI systolic
murmur
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. Mild TTP in RUQ and
also in LUQ. Surgical wounds without surrouning erythema.
Skin: Jaundiced
Ext: No gross deformity or edema
Neuro: Awake, alert and oriented. CN II-XII intact, strenght [**4-13**]
throughout.
DISCHARGE EXAM:
General: Alert, oriented, no acute distress
HEENT: PERRLA, EOMI, icteric sclera, MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, soft I/VI systolic
murmur
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly.
Skin: Jaundiced
Ext: No gross deformity or edema
Pertinent Results:
ADMISSION LABS:
[**2180-10-9**] 04:31AM BLOOD WBC-17.7* RBC-3.72* Hgb-11.9* Hct-34.6*
MCV-93 MCH-32.1* MCHC-34.4 RDW-13.6 Plt Ct-286
[**2180-10-9**] 04:31AM BLOOD Neuts-89.0* Lymphs-6.2* Monos-4.4 Eos-0.1
Baso-0.3
[**2180-10-9**] 04:31AM BLOOD PT-14.9* PTT-29.0 INR(PT)-1.3*
[**2180-10-9**] 04:31AM BLOOD Glucose-187* UreaN-14 Creat-0.9 Na-136
K-4.3 Cl-101 HCO3-24 AnGap-15
[**2180-10-9**] 04:31AM BLOOD ALT-239* AST-107* AlkPhos-198*
Amylase-397* TotBili-2.9*
[**2180-10-9**] 04:31AM BLOOD Lipase-642*
[**2180-10-9**] 04:31AM BLOOD Albumin-3.3* Calcium-8.2* Phos-1.8*
Mg-1.8
[**2180-10-9**] 08:44AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2180-10-9**] 08:44AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2180-10-9**] 08:44AM URINE RBC-4* WBC-16* Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
.
MICROBIOLOGY
[**2180-10-9**] 8:44 am URINE Source: CVS.
**FINAL REPORT [**2180-10-10**]**
URINE CULTURE (Final [**2180-10-10**]): NO GROWTH.
.
IMAGING:
LENI: IMPRESSION: No evidence of DVT.
.
CXR: FINDINGS: No previous images. Cardiac silhouette is at the
upper limits of normal in size in the patient with intact
midline sternal wires after CABG procedure. Opacification at the
right base medially most likely represents atelectasis and
fibrous scarring. However, the lower right heart border is not
sharply seen, and the possibility of supervening pneumonia would
have to be considered in the appropriate clinical setting.
Remainder of the study is within normal limits with no evidence
of vascular congestion.
.
ERCP [**10-10**]:
Impression: Normal Pancreatogram
A 4cm by 5FR pancreatic stent was placed initially to facilitate
cannulation. Cannulation of the bile duct was then successful.
The main bile duct appeared normal. The intrahepatic ducts
appeared to have smaller than expected caliber
Sphincterotomy was extended in the 12 o'clock position using a
sphincterotome over an existing guidewire.
Multiple stone fragments and sludge were extracted successfully
using a balloon. No pus noted.
The pancreatic stent was then removed by using a snare.
.
ERCP [**10-9**]:
Impression: Esophagitis was noted in the lower third of the
esophagus
Edema and distortion of the duodenal wall secondary to
pancreatitis was noted
An impacted stone was noted at distal CBD
Normal pancreatogram
Extremely stenotic papilla with impacted stone at distal CBD.
Therefore, a small precut sphincterotomy was performed. Drainage
of bile and small amount of sludge noted after sphincterotomy.
No pus noted.
Deep cannulation of bile duct was not achieved due to the edema
Otherwise normal ercp to third part of the duodenum
LE DOPPLER: No evidence of DVT.
DISCHARGE LABS:
[**2180-10-12**] 03:21AM BLOOD WBC-7.4 RBC-3.39* Hgb-10.8* Hct-30.9*
MCV-91 MCH-31.8 MCHC-34.9 RDW-13.4 Plt Ct-283
[**2180-10-11**] 04:15AM BLOOD Neuts-81.1* Lymphs-10.6* Monos-6.2
Eos-1.6 Baso-0.5
[**2180-10-11**] 04:15AM BLOOD PT-12.7 PTT-26.6 INR(PT)-1.1
[**2180-10-12**] 03:21AM BLOOD Glucose-174* UreaN-11 Creat-0.6 Na-129*
K-3.3 Cl-95* HCO3-25 AnGap-12
[**2180-10-12**] 03:21AM BLOOD ALT-73* AST-34 AlkPhos-160* TotBili-1.3
[**2180-10-12**] 03:21AM BLOOD Calcium-7.9* Phos-2.5* Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname 90500**] is a 64 y/o M with PMH of CABG, DMII, and recent
CCY c/b likely retained stone and gallstone pancreatitis who was
transferred to [**Hospital1 18**] due to concern for developing cholangitis
and need for urgent ERCP.
#. Abdominal pain - The patient most likely had a retained stone
following CCY that lead to gallstone pancreatitis. There was
initially some concern for developing cholangitis given fever to
101.0 and worsening LFTs; however he remained relatively pain
free, normotensive and without mental status changes making this
condition less likely. Pt had ERCP with sphincterotomy but was
unable to canulate bile duct due to edema. He had repeat ERCP
that showed only stone fragments and sludge. He was continued on
unasyn and his LFTs and WBC trended downward. He was discharged
on a course of augmentin for total 8 day antibiotic course.
#. CAD - Pt is on lisinopril, aspirin and statin at home. These
were initially held at the outside hospital and resumed here
following successful ERCP. He was also started on metoprolol
tartrate before transfer to ICU and this was continued while in
ICU at 50mg po TID for rate control. Unclear if he was on
metoprolol at home but given his CAD, he would likely benefit
from long term beta blocker and has remained stable with the
addition of this to his regimen. Recommend follow up with PCP.
# hypertension: resumed home meds. Also started metoprolol
tartrate 50mg po TID while in house to control heart rate and BP
and patient remained stable with this addition to his regimen.
Recommend follow up with PCP to cont to optimize HTN regimen.
#. Dysuria - Patient describes dysuria on ROS. Had [**Last Name (un) **] on
arrival to OSH which resolved with fluid resucitation. Initial
urine culture negative. Pt was on antibiotics for cholecystitis
so this would treat UTI as well.
# diarrhea: developed diarrhea on day of discharge. unable to
get stool sample before discharge. Thought to be secondary to
cholecystitis but recommended follow up with PCP
# hyponatremia: sodium low to 129 on day of discharge. thought
to be secondary to recent resumption of po intake and subsequent
water consumption. recommended recheck and follow up with PCP
#. DM II: held oral meds and managed with SSI while in house,
restarted home meds on discharge
TRANSITIONAL ISSUES:
1. follow up repeat sodium labs to evaluate hyponatremia
2. follow up BP now that pt has been started on metoprolol
3. follow up diarrhea
Medications on Admission:
amlodipine 5mg
glipizide 5mg [**Hospital1 **]
niaspan 100mg daily
lisinopril 10mg daily
ASA 81mg daily
fish oil
vitamin C
vitamin D
multivitamin
simvastatin 80mg
actos 45mg
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
6. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
7. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day.
9. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.
10. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Gallstone pancreatitis
SECONDARY:
CAD
diabetes
HTN
hypercholesterolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 90500**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for pancreatitis, likely
caused by a gallstone and an infection in your biliary tract.
You had an ERCP which showed an impacted stone at the common
bile duct. We were unable to remove the stone initially, so you
had a repeat ERCP which showed that the stone had disolved. We
were able to advance your diet and you tolerated food well.
You've had some diarrhea which here, that we feel is likely due
to your recent cholecystectomy but you should be seen by your
PCP for [**Name9 (PRE) 702**]. Your sodium was slightly low on the day you
were discharged.
.
Please make the following changes to your medications:
1. START Amoxicillin-Clavulanic Acid 875 mg by mouth every 12
hours for 4 days.
Take all other medications as prescribed.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Apartment Address(1) 33524**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 26774**]
[**2180-10-13**] at 11:45 am
*** please have your electrolytes and blood counts check at this
appointment. Also, please inform your PCP about your diarrhea
***
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2761, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8103
} | Medical Text: Admission Date: [**2199-4-8**] Discharge Date: [**2199-4-16**]
Date of Birth: [**2138-9-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
overdose, suicide attempt
Major Surgical or Invasive Procedure:
None
History of Present Illness:
60 M with PMH of Depression, Parkinson's, suicidal ideation/
attemps was found down face down by friends down since Saturday
by report. He began taking colchicine 5-6 days ago and developed
diarrhea as a side effect. On Saturday, he attempted suicide by
overdose with Xanax and "parkinson's med". He took ~6 xanax, [**2-27**]
pills of 5 mg percocet, 4 vicodin unknown strength, 2 colchicine
0.6 mg tabs, [**3-1**] acetaminophen tabs. He was found by his friends
2 days later who brought him to the ED.
.
In the ED, initial vs were: T 99.8 P:103 BP:137/75 RR:16 O2 sat
100% 2L. He smelled of EtOH, was soaked in urine and had the
following pill bottles: Tramadol (empty), Colchicine (empty),
Allopurinol (empty), Tylenol (empty), Sinemet (empty), Naproxen,
Statin, Indomethacin, Flomax, Carbidopa, Keflex,
Cyclobenzaprine, Urelle, Paroxetine, and some unlabeled pill
bottles in possession.
The following pills were unlabeled but were found by pill
finder: Vicodin, Ambien. Physical exam was notable for pill
rolling tremor, pressure sores on face, chest, knees. He was
somnolent but following commands, answering questions,
protecting airway but some with some gurgling of secretions. On
rectal exam, he had decreased rectal tone, flecks of blood,
empty vault. There was no clonus, asterixis, or hyperreflexia.
Labs were notable for WBC 15.7 with 90% neutrophils, CK 5963,
ALT 60, AST 117, Alk Phos 66, LDH 359, negative acetominophen
level. His CXR, CT head and neck were negative. His EKG revealed
EKG: ST@107 QRS 84 QTc 426. He was given NAC 150 mg IV over 1
hour. On transfer to the [**Hospital Unit Name 153**], his most recent VS were P: 105,
BP: 153/85, RR: 18, O2 sat 100% on 5L NC.
.
.
Review of sytems:
(+) Per HPI, also occasional 'Parkinson's pain'. denies pain
currently, + diarrhea after taking colchicine
(-) Denies fever, chills, night sweats. Denies rhinorrhea or
congestion. Denied cough, shortness of breath. Denied bloody or
black stools. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Depression with hx of past suicidal ideation
Parkinson's
Hyperlipidemia
Chronic Back Pain- managed on oxycodone
Social History:
Patient lives by himself. He is disabled and not currently
working. He previously worked in contruction. He is divorced.
Patient denies tobacco use. He states he drinks very rarely,
drinking [**11-25**]- 1 glass of wine on those occasions. He smokes
marijuana ~2x/month. He has used cocaine and heroine in the
remote past. Patient states this is his first suicide attempt
although he has had suicical ideations in the past.
Family History:
unable to obtain on admission
Physical Exam:
Admission:
Vitals: T: 99.2, BP: 158/82 P: 109 R: 14 O2: 100% on 2L NC
General: lethargic but arouable, oriented to person, place,
month, year but not to day of the week or date, no acute
distress, affected blunted, somewhat tearful during interview
HEENT: Sclera anicteric, dry MM, dried blood on the lips,
pressure ulcer on his chin
Neck: supple, in cervical collar, no cervical pain
Lungs: loud upper respiratory noises over anterior chest,
otherwise CTAB, no wheezes, rales, rhonchi
CV: tachy, 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, erythema
over bilateral ribs
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: exam somewhat limited by lethargy, CNII- surgical defect
of right pupil, left pupil reactive, CN III/ IV- somewhat
limited movements, CNV-XII intact; 4+ strength in bilateral
upper/ lower extremities, sensation intact throughout to light
touch; 2+ biceps, patellar, no dystonia, no rigidity, no tremor,
patient unable to complete finger to nose exercise [**12-26**]
inattention
Pertinent Results:
CXR [**4-8**]
Bibasilar atelectasis, left greater than right.
CT head [**4-8**]
No acute intracranial process.
CT C-spine [**4-8**]: No acute process
Elbow x-ray [**4-8**]: No evidence of acute fracture
[**2199-4-8**] 11:58AM BLOOD WBC-15.6*# RBC-4.70 Hgb-14.7 Hct-41.7
MCV-89 MCH-31.2 MCHC-35.1* RDW-13.7 Plt Ct-276#
[**2199-4-13**] 07:15AM BLOOD WBC-8.4 RBC-3.98* Hgb-12.2* Hct-35.6*
MCV-89 MCH-30.7 MCHC-34.3 RDW-13.4 Plt Ct-220
[**2199-4-8**] 11:58AM BLOOD PT-13.1 PTT-22.0 INR(PT)-1.1
[**2199-4-8**] 11:58AM BLOOD Glucose-131* UreaN-22* Creat-1.1 Na-142
K-4.4 Cl-106 HCO3-24 AnGap-16
[**2199-4-10**] 05:55AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-140
K-3.8 Cl-108 HCO3-26 AnGap-10
[**2199-4-8**] 11:58AM BLOOD ALT-60* AST-117* LD(LDH)-359*
CK(CPK)-5963* AlkPhos-66 TotBili-0.7
[**2199-4-9**] 04:38AM BLOOD ALT-43* AST-71* LD(LDH)-208 CK(CPK)-2559*
AlkPhos-54 TotBili-0.6
[**2199-4-10**] 05:55AM BLOOD CK(CPK)-1121*
[**2199-4-11**] 06:00AM BLOOD CK(CPK)-861*
[**2199-4-13**] 07:15AM BLOOD CK(CPK)-451*
[**2199-4-10**] 05:55AM BLOOD Calcium-8.6 Phos-2.2* Mg-1.8
[**2199-4-8**] 05:30PM BLOOD Acetmnp-NEG
[**2199-4-8**] 11:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2199-4-8**] 12:20PM BLOOD Glucose-131* Lactate-2.1* Na-142 K-4.3
Cl-103 calHCO3-25
[**2199-4-9**] JOINT FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL INPATIENT
[**2199-4-8**] URINE URINE CULTURE-FINAL INPATIENT
[**2199-4-8**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2199-4-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2199-4-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
Brief Hospital Course:
60 yo male with PMH of Parkinson's disease, depression, hx of
suicical ideation who presents after being being found down for
~2 days after an intentional overdose
Patient took excessive doses of several medications including
benzodiazepines, opiates, tylenol, colchicine, carbidopa. Pt
was found down after 2 days with pressure ulcers on chin, ribs
and knees. Patient admitted that this was an attempt to "end it
all." His CK was elevated and peaked at 6000 and he was volume
depleted; he received 3L of IV normal saline in the ED and 1.2 L
in the ICU for rhabdomyolysis. Given his significant elbow
pain, elbow x-ray was done which showed no fracture and a
moderate effusion. Joint was tapped with grossly bloody fluid,
sent for culture and cell count. Psychiatry and social work
were consulted for suicide attempt, he was monitored with a 1:1
sitter. He was noted to have a leukocytosis with WBC 15, and
pulmonary infiltrate that may have been due to aspiration, but
no fevers or other localizing symptoms, and his WBC decreased to
8.4. His sinemet for parkinson's disease was restarted (had
missed 2 days), and the dose was adjusted by his outpatient
Neurologist. He was started on Remeron on evening [**2199-4-15**] per
psychiatry recs given complaints of insomnia.
He has chronic back pain at SI joints for which he was taking
opiates as an outpatient. Pt admitted to misuing the opiates
prior to his suicide attempt. His back pain was managed with
alternative agents to avoid narcotics. He was started on
scheduled tylenol, naproxen, lidoderm patch, and warm packs. He
was encouraged to ambulate and maintain activity, as bed rest
will only make pain worse. He was noted to "inflate" his
ratings of his pain, which he admitted when challenged about his
reports of [**2198-7-2**] pain, then saying, "I exaggerate, may be more
like a [**5-3**]."
Pt was noted to have some mild hypertension, with SBP generally
in mid-140's. He was started on low-dose HCTZ. He should have
lytes, BUN, Cr check on [**2199-4-23**] to ensure he tolerates, and he
should be monitored to ensure that he has sufficient po intake
considering his depression so that he does not become
dehydrated.
He also complained of constipation, for which he has been
started on a bowel regimen, and he will receive an enema.
He is being discharged to an inpatient psychiatric facility for
further treatment of his depression.
Medications on Admission:
Allopurinol 300 mg PO daily
Tramadol 50 mg PO QID PRN
Oxycodone 5 mg PO QID PRN
Ambien 10 mg QHS PRN
Colchicine 0.6 mg PO BID PRN
Alprazolam 2 mg PO TID PRN
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. thiamine HCl 100 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).
6. naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. carbidopa-levodopa 25-250 mg Tablet Sig: 1.5 Tablets PO TID
(3 times a day): 8am, 12pm, 4pm.
9. carbidopa-levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): 8pm
.
10. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
12. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily): Please check lytes, BUN/Cr on [**2199-4-23**] to ensure
tolerates.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
14. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
Depression
Suicide Attempt by Ingestion
Parkinson's Disease
Chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the intensive care unit following ingestion
of multiple medications. You were found to have significant
muscle breakdown (rhabdomyolysis) and a collection of fluid
around your elbow. You were treated with IV fluids and your
symptoms slowly improved. Your dose of Sinemet was also adjusted
during this hospitalization. You are being discharged to a
psyhiatric facility for further treatment of your depression.
Followup Instructions:
Please follow up with your PCP and your Neurologist upon
discharge from your psychiatric facility.
ICD9 Codes: 2749, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8104
} | Medical Text: Admission Date: [**2156-12-28**] Discharge Date: [**2157-2-4**]
Date of Birth: [**2104-10-25**] Sex: F
Service: MEDICINE
Allergies:
Talwin Nx
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
Abdominal Pain
Anasarca
Transplant evaluation
Major Surgical or Invasive Procedure:
Ultrasound guided paracentesis [**2156-12-29**]
Central Line Dialysis Catheter Placement
History of Present Illness:
52-year-old female with history of alcoholic and hepatitis B
cirrhosis, who was recently discharged from [**Hospital 1474**] hospital on
[**12-15**] folling treatment for spontaneous bacterial
peritonitis. She was seen in clinic today and was found with
large ascites, profoundly distended, and notably jaundiced and
in pain. She was admitted for a diagnostic and therapeutic
paracentesis and further work up.
.
Recently she has had slightly worsening abdominal pain,
increased [**Location (un) **] and some nausea and 1 episode of non-bloody
emesis. Reports with weight gain 15 lbs.
Past Medical History:
# Alcoholic liver cirrhosis diagnosed in [**2134**] with ascites and
esophageal varices.
# Hepatitis B cirrhosis, which the patient states she
contracted from her husband. Does not appear to have been
completely treated in the past. The patient does report being
enrolled in an interferon clinical trial at [**Hospital1 2025**] many years ago
but was deemed to not be a "non-responder."
# COPD.
# Hypothyroidism.
# Depression.
# Status post cholecystectomy.
# Sciatica status post back surgery x2
Social History:
The patient has currently quit smoking for 2 weeks. She was
previously smoking one pack per day for a total of 40 years.
The patient is a former drinker with her last drink being on
[**2155-3-29**]. She was drinking approximately four to six packs of
beer per week along with binge-drinking with 40 beers on the
weekends. She was drinking for a total of 30 years. Her last
cocaine use was last year. Last marijuana use two years
ago. She denies a history of IV drug abuse. She is not
currently in substance abuse counseling or support, but states
that she has not had any temptation to use illicits again.
Family History:
The patient reports alcoholism in both sides of
her family. Mother deceased from bladder cancer at the age of
51. Father with heart disease and angina, but no history of
myocardial infarction or coronary artery bypass grafts. The
patient has three children with two girls at the ages of 23 and
21 with hepatitis B. the oldest son does not have hepatitis B
Physical Exam:
98.6 112/69 72 20 94%RA
GEN: illappearing, tearfull, obese
HEENT: icteric sclera, jaundiced skin
CV: rrr s1, s2, no M/g/R
RESP: diffuse wheezing bilaterally
ABD: tender to palpation, obese, +bs, site of paracentesis is
still draining fluid
EXT: tense pitting edema bilaterally
Neuro: AAOx3, 5/5 strength, sensation intact, no flap.
Pertinent Results:
PARACENTESIS DIAG. OR THERAPEUTIC [**2156-12-29**] 4:45 PM
PARACENTESIS DIAG. OR THERAPEU
Reason: DIAGNOSTIC AND THERAPEUTIC paracentesis please send cell
cou
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with hep B/ETOH cirrhosis
REASON FOR THIS EXAMINATION:
DIAGNOSTIC AND THERAPEUTIC paracentesis please send cell count
and differential, fluid for culture
PARACENTESIS ON [**12-29**]
CLINICAL HISTORY: ETOH cirrhosis. Diagnostic tap requested.
PROCEDURE AND FINDINGS: A full discussion of pertinent risks,
benefits, and alternatives to the procedure was performed,
informed consent was obtained. Preprocedure timeout documents
proper patient, site, and procedure.
Using aseptic technique and ultrasound guidance, a 5 French [**Last Name (un) 11097**]
centesis catheter was passed through anesthetized tissues in the
left flank, to the peritoneal cavity from which approximately 1
liter of clear, straw-colored fluid was removed and sent for the
requested labs.
Hemostasis was then obtained, patient tolerated the procedure
well without any immediate post-procedure complications.
Dr. [**Last Name (STitle) 4401**] performed the procedure.
IMPRESSION: Successful ultrasound-guided paracentesis.
.
CT ABDOMEN W/CONTRAST [**2157-1-1**] 5:41 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: assess for loculation
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with cirrhosis with large ascites, tap with
only 1L removed, assess for loculation
REASON FOR THIS EXAMINATION:
assess for loculation
CONTRAINDICATIONS for IV CONTRAST: not needed
INDICATION: 52-year-old female with cirrhosis and large ascites
with recent 1 liter of fluid removed via paracentesis. Assess
for loculation.
COMPARISON: [**2156-11-3**].
TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis
were obtained with IV contrast. Multiplanar reformations were
performed.
CT ABDOMEN WITH IV CONTRAST: There is a moderate right pleural
effusion with associated atelectasis. There is airspace opacity
within the left lung base, likely atelectasis.
The liver is small and nodular consistent with cirrhosis.
Metallic clips are present within the gallbladder fossa,
consistent with prior cholecystectomy. The previously seen early
enhancing lesions within the liver are not well demonstrated,
given the lack of arterial phase timing. The pancreas and
adrenal glands are unremarkable. The spleen is bulky, measuring
13 cm. The small bowel is filled with oral contrast with no
evidence of obstruction. The large bowel is unremarkable. The
rectum and sigmoid colon are stool filled.
There is moderate amount of ascites located primarily along the
pericolic gutters and extending down into the deep pelvis. There
are no obvious septations or collection surrounded by soft
tissue to suggest loculation.
This examination is limited due to artifact created from the
patient's body habitus, particularly on the right of the abdomen
and pelvis.
There is diffuse anasarca throughout the subcutaneous tissues of
the abdomen and pelvis.
CT PELVIS WITH IV CONTRAST: The uterus and adnexa are
unremarkable. The urinary bladder is collapsed and contains a
Foley catheter.
There is no appreciable lymphadenopathy in the abdomen and
pelvis.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. No loculation. Majority of fluid within the pericolic gutters
and extending down into the deep pelvis.
2. Moderate right pleural effusion.
3. Cirrhotic liver and splenomegaly.
.
Echo: The left atrium is mildly dilated. The estimated right
atrial pressure is 0-5 mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%) Transmitral Doppler and tissue velocity imaging are
consistent with normal LV diastolic function. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. An eccentric, posteriorly
directed jet of Mild to moderate ([**12-15**]+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
The pulmonic valve leaflets are thickened. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Normal left ventricular function. Normal right
ventricular function. Moderately elevated estimated pulmonary
pressures.
Compared with the prior study (images reviewed) of [**2156-11-3**],
the estimated pulmonary pressures are moderately elevated and
the severity of mitral regurgitation has increased.
.
US ABD LIMIT, SINGLE ORGAN [**2157-1-7**] 9:16 AM
US ABD LIMIT, SINGLE ORGAN
Reason: EVAL FOR ASCITES AND MARK THE SPOT FOR PARACENTESIS
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with EtOH, Hep B cirrhosis, refractory
ascites.
REASON FOR THIS EXAMINATION:
Please assess for degree of ascites. Anasarca vs. ascites.
LIMITED ABDOMEN ULTRASOUND
COMPARISON: None.
HISTORY: Ascites.
FINDINGS: Limited [**Doctor Last Name 352**]-scale imaging of the abdomen was
performed to assess for underlying ascites. Minimal amounts of
fluid are seen in all four quadrants and midline pelvic view.
Subsequently, no spot was marked due to limited quantity of free
fluid.
IMPRESSION: Minimal amount of abdominal ascites, unable to mark
spot for paracentesis.
.
These findings were discussed with Dr. [**Last Name (STitle) 656**] at the time of
review.
Brief Hospital Course:
# Cirrhosis: The patient reported recent onset of jaundice and
acute exacerbation of peripheral edema and abdominal ascites. An
ultrasound guided paracentesis was performed but could only
drain 1L. CT abdomen showed ascites fluid in difficult to reach
locations, along paracolic gutters and in pelvis. In addition,
it showed much of the fluid was in her subcutaneous tissues.
Hepatitis B was thought to be a precipitating factor. A viral
load was checked and came back at 6700 copies. She was thus
started on entecavir. On initial presentaiton her sodium was low
at 123 and her creatinine was elevated to 1.3. She was placed on
a fluid restriction and her diuretics were held. Her creatinine
improved but her urine output and peripheral edema remained
unchanged. In an effort to mobilize her fluid, she was
adminstered 50g of albumin daily followed by IV lasix. Her
creatinine, sodium, and urine output remained unchanged.
.
She was titrated up to albumin 25g [**Hospital1 **] followed by lasix 80mg
[**Hospital1 **] 30 minutes after giving albumin, and she began to respond
with increased urine output, increased sodium, and decreased
creatinine. The patient also reported feeling less edematous.
Her nadolol, lactulose, and midodrine were continued. Her cipro
was continued for SBP prophylaxis.
.
The team attempted to aggressively diurese her with albumin
cover, and was successful; unfortunately she then went into
renal failure, and was oliguric. HD (ultrafiltration) was
attempted in order to take off more fluid but her blood
pressures did not tolerate much fluid loss. Eventually after
much discussion with the team, the patient, and the patient's
family, we decided to send the patient to the MICU where she
could get CVVH and potentially be able to tolerate a greater
degree of fluid removal over 24 hour fluid removal cycles. She
did not tolerate the CVVH secondary to hypotension and after
further family meetings she was made comfort measures only and
transferred back to the medical floor for placement in an
inpatient hospice setting. In terms of pain and discomfort,
morphine solution was given with good effect.
.
#Dyspnea:Patient reporting increased dyspnea when changing
position from lying down to sitting up. Reporting mild
exertional dyspnea as well. CXR showed vascular congestion. She
also had a mild O2 desaturation 97 to 95 with sitting up. Her
history and presentation was suggestive of hepatopulmonary
syndrome. She reported improvement with increased diuresis. She
had stable oxygenation on room air.
.
#Hyperkalemia: Earlier in admission, in setting of hyponatremia.
She did not have a history of DM, not on NSAIDS, ACEI, or
spironolactone. A morning cortisol was measured and was found to
be normal. Her ekg did not show changes consistent with
hyperkalemia. She was given kayexalate to keep her potassium
under 5.0; this was not an issue later in the admission. Once
she was made comfort measures only her labs were no longer
obtained.
.
# Transplant workup: To be finished during hospitalization. Much
of her workup was completed at outside hospitals. She recived a
transplant workup and psychiatry consult during this
hospitalization. A colonoscopy is being considered. The
ultimate problem are two issues, as above: pulmonary function,
and BMI. Thus because the fluid issues above influenced both, we
saw diuresis and then CVVH as one way to bring the patient
towards the possibility of going onto the transplant list. Given
she did not tolerate CVVH she was made comfort measures and was
comfortable on time of discharge.
.
#:Anemia: Patient reported chronic BRBPR since her hemmorrhoid
surgery 1 month ago, and she ocntinued with brbpr here. No
vomiting, no hematemesis, no melena. She received 1 unit prbcs
he day of admission, and received 2 units of prbc's a week
later. Through most of her admission, despite ongoing BRBPR, she
had stable Hcts. The source of the BRBPR was not clear, since
she sometimes also had maroon stool; the possibility existed
that some food dye or medicine could have been responsible for
some of the color; however, a colonoscopy and workup for GI
bleeding was secondary to trying to see if the patient might
become eligible for a liver. Her hematocrit was stable at last
check before suspending lab draws.
.
# Goals of care: the patient became more discouraged during this
lengthy admission, and frustrated by the experience of waiting
for an uncertain and potentially grim outcome. She decided to
change her code status and a family meeting affirmed her
decision to be DNR/DNI in the presence of her children,
ex-husband and current partner. She eventually decided to give
CVVH a try as one last strategy to attempt to advance towards
transplant, but with the understanding that if this did not work
she might be more interested in trying to move to the goal of
comfort care. Given the ineffect of CVVH she was made CMO and
transferred to inpatient hospice.
Medications on Admission:
Lasix 40 mg daily
spironolactone 100 mg daily
midodrine 10 mg t.i.d.
nadolol 20 mg daily
lactulose t.i.d.
folic acid 1 mg daily
ferrous sulfate 300mg po BID
Multivitamin
Thiamine 100mg daily
Magnesium Oxide 400mg po TID with meals
levothyroxine 25 mcg daily
combivent 2 puffs every four hours
oxycodone 5 mg Q4 p.r.n.
ciproflox 250mg PO Daily
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed.
3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
9. Morphine Concentrate 20 mg/mL Solution Sig: 5-20mg PO Q2H
(every 2 hours) as needed for pain.
10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
11. Senna 8.6 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. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center Wedgemere
Discharge Diagnosis:
Liver Failure
Cirrhosis
End Stage Renal Disease
Depression
Discharge Condition:
Fair, Hemodynamically Stable
Discharge Instructions:
You were admitted for your liver failure. Medical therapies
were initiated and you also had hemodialysis which was
ineffective.
You are being discharged to a hospice center.
If you experience increased pain, shortness of breath, nausea,
vomitting or any other concerning symptom please contact your
primary care doctor
Followup Instructions:
ICD9 Codes: 5849, 5990, 2761, 5119, 2875, 2767, 2859, 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8105
} | Medical Text: Admission Date: [**2196-6-28**] Discharge Date: [**2196-7-1**]
Date of Birth: [**2122-7-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12722**]
Chief Complaint:
Hyperkalemia with loss of access for hemodialysis
Major Surgical or Invasive Procedure:
AVF thrombectomy
History of Present Illness:
73 year old Albanian speaking only male with hx of CAD, HTN, HL,
CVA, PVD, and ESRD on HD T/Th/S was sent in from [**Location (un) **]
[**Hospital **] [**Hospital **] clinic with concern for a clotted right UE HD AV
graft. He recently had a thrombectomy to this graft about two
weeks ago after the graft thrombosed. He had a usual session of
HD on Saturday. He returned today for dialysis where they were
unable to access the graft. Per Dr. [**Last Name (STitle) **] at AV Care, there was
still a problem at the venous anastomosis of the graft.
Presently has no numbness, tingling, pain in the RUE; denies any
fever, chill, night sweats, CP or SOB.
Of note, he is currently anticoagulated with aspirin and plavix.
He was seen by cardiology in [**11/2192**] for atrial fibrillation,
when at that time they recommended aspirin and warfarin instead
of plavix. Note was made that he would need a PCP and [**Name Initial (PRE) **]
[**Hospital 197**] clinic to manage his INR's but then it is unclear from
the records thereafter if he ever used warfarin.
In the ED, admission vitals: 96.7 60 137/63 18 100% RA. Exam
was notable for a palpable radial pulse and axillary pulse in
RUE. No bruit or thrill was noted over graft. Cardiac exam
notable for irregular rhythm. Renal was contact[**Name (NI) **]. [**Name2 (NI) **]
returned with hyperkalemia of 6.9 and EKG was notable for peaked
T's. He was given Dextrose 50% 25gm IV ONCE, insulin 10 unit IV
once, lasix 20mg IV once, and Kayexalate 30gm PO/NG ONCE.
Transplant Surgery recommend a fistulagram and thrombectomy with
IR. Femoral access was requested if urgent dialysis is required.
Most Recent Vitals prior to transfer: 97.7 52 122/58 18 97% on
RA.
In the IR suite, he was noted to brady into the 30's
transiently. His BP's were stable and he denied any CP or SOB
throughout the procedure.
On arrival to the MICU, he denies any pain or discomfort. He
reports being thirsty and has to move his bowels.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-ESRD on HD T/Th/Sat since [**2190**]
-Right AV graft placed [**2194-7-25**] s/p thrombectomies and
revisions
-Left AV graft placed [**4-/2193**], s/p several clots, thrombectomies,
angioplasties, revision, and infection with MSSA s/p excision of
graft. Not used since clotted 2/[**2193**]. Dialyzed through right IJ
until R AV graft was mature in late [**2193**].
-Previous failed L AV graft w/ thrombosis and angioplasty
[**7-/2192**], [**9-/2192**], and 1/[**2192**].
-Hypertension
-Hyperlipidemia
-Hyperthyroidism, not on medications
-CAD
-CVA [**85**] with residual left-sided weakness, managed with
aspirin/plavix
-Atrial Fibrillation
-Aortic Atheroma
-PVD
--left-to-right femoral-femoral bypass with 6-mm PTFE graft in
[**4-21**]
--percutaneous angioplasty and stenting of left common iliac and
external iliac arteries [**3-21**]
-Left carotid endarterectomy [**4-21**]
-Left Nephrectomy for hydronephrosis in [**Country 38213**] in [**2173**]'s
Social History:
Lives with wife. [**Name (NI) **] [**Name (NI) **] lives in NJ and works as a GI fellow.
No current smoking but has 30 year history 1 ppd. He quit in
[**2185**] after his stroke. Last drink was about 15 days prior to
admission and he reportedly drinks very little because of
"kidney problems". [**Name2 (NI) **] recreational drug use.
Family History:
Non contributory
Physical Exam:
On Admission:
Vitals: 97.3 64 (40-64) 134/65 16 97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular, bradycardic, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: bibasilar crackles, crackles at right base clear with
inspiration
Abdomen: +BS, soft, non-tender, non-distended, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace LE edema, RUE AV
graft site without thrill or bruit. Left femoral catheter in
place, dressing clean, dry, intact, no erythema.
Neuro: CNII-XII intact and symmetric, strength 4/5 throughout
upper and lower left extremities, [**3-19**] upper and lower right
extremities.
Discharge Exam:
VS: T 98.4 BP 114/55 HR 70 RR 18 O2 100% RA
Extr: Left femoral catheter removed, dressing clean, dry,
intact, no erythema or swelling or ecchymoses.
Exam otherwise unchanged from admission
Pertinent Results:
[**Month/Day (1) **] on Admission:
=========================
[**2196-6-28**] 10:40AM BLOOD WBC-7.3 RBC-3.60* Hgb-11.5* Hct-34.6*
MCV-96 MCH-31.8 MCHC-33.2 RDW-14.1 Plt Ct-191
[**2196-6-28**] 10:40AM BLOOD Neuts-70.4* Lymphs-21.8 Monos-4.7 Eos-2.5
Baso-0.4
[**2196-6-28**] 10:40AM BLOOD PT-10.2 PTT-26.6 INR(PT)-0.9
[**2196-6-28**] 10:40AM BLOOD Glucose-131* UreaN-93* Creat-10.2*#
Na-139 K-6.9* Cl-99 HCO3-21* AnGap-26*
[**2196-6-29**] 08:32AM BLOOD ALT-11 AST-12 TotBili-0.4
[**2196-6-28**] 05:45PM BLOOD Calcium-8.5 Phos-5.0* Mg-3.2*
Studies/Procedures:
Uncomplicated AV fistulagram with extensive intervention as
above including
chemical and mechanical thrombectomy, balloon dilatation of
central venous
strictures, dilatation and stenting of venous anastomosis, and
removal of
organized thrombus at the arterial anastomosis.
Following the procedure the graft had a palpable thrill and may
be used for
dialysis immediately.
[**Month/Day/Year **] Prior to Discharge:
==========================
[**2196-7-1**] 07:05AM BLOOD WBC-7.0 RBC-2.89* Hgb-9.0* Hct-27.1*
MCV-94 MCH-31.2 MCHC-33.3 RDW-14.4 Plt Ct-112*
[**2196-7-1**] 07:05AM BLOOD Glucose-126* UreaN-77* Creat-10.7*#
Na-136 K-5.0 Cl-98 HCO3-19* AnGap-24*
[**2196-6-29**] 08:32AM BLOOD ALT-11 AST-12 TotBili-0.4
[**2196-7-1**] 07:05AM BLOOD Calcium-6.8* Phos-9.4*# Mg-2.4
Brief Hospital Course:
Assessment and Plan
73 year old Albanian speaking only male with hx of CAD, HTN, HL,
CVA, PVD, and ESRD on HD T/Th/S sent in from [**Location (un) **] [**Hospital **] [**Hospital **]
clinic with concern for a clotted right UE HD AV graft.
# Thrombosed AV graft: No palpable thrill or bruit noted on
exam, with inability to access graft at HD. This graft has had
multiple thrombectomies and revisions, including 10 days prior
to admission. He has limited options for dialysis access as his
left UE AV graft has been thrombosed since [**2193**]. Successful
fistulogram and thrombectomy with palpable thrill afterward,
restarted HD successfully in RUE.
# Hyperkalemia: K 6.9 on initial lab draw in the setting of no
HD for 3 days. Received insulin, glucose, lasix, and kayexalate
in the ED and then improved with HD. Discharge K 5.0 with HD
scheduled tomorrow.
# ESRD: Nephrectomy done in mid [**2173**]'s for obstruction and
hydronephrosis. ESRD was present by the time he immigrated to
the US and was seen by nephrology. He was considered for
transplant but was noted to have poor vascular disease and
therefore was not a transplant candidate. He has been on HD
since [**2190**]. He has had multiple problems with access sites
including clotted and infected sites. Temporary femoral HD line
placed on [**6-28**] for access until long term plan is decided.
# Bradycardia: Slow afib during and after IR procedure. [**Month (only) 116**]
have been vagal response vs metoprolol overload. Improved to 60s
with holding Metoprolol. He maintained blood pressure and mental
status at all times despite HR's in the 30's. Pt had no further
events on tele and metoprolol was held for duration
# HTN: Pressures remained stable except briefly hypotensive at
the end of HD on day of discharge, improved with fluid
replacement at end of HD. Discharged on metoprolol ER 50mg
daily.
# PVD: Hx of fem-fem bypass with iliac stenting, continued on
ASA, Plavix 75mg, and simvistatin 20mg.
# Atrial fibrillation: CHADS2 = 3 with prior CVA. Not on
warfarin for concern for intracranial hemorrhage. Rate
controlled with metoprolol at home, with some bradycardia
evident on exam. Metoprolol resumed when reinitiated HD.
Monitored on tele with no events, continued ASA 81 mg.
Transitional Issues:
Medication Changes: None
Continuity of Care: Will see nephrology at [**Hospital **] clinic tomorrow.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Lanthanum 1000 mg PO TID W/MEALS
5. Nephrocaps 1 CAP PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Lanthanum 1000 mg PO TID W/MEALS
5. Nephrocaps 1 CAP PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
End stage renal disease
Arterial-venous fistula thrombosis
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 68499**],
It was a pleasure participating in your care at [**Hospital1 771**].
You were admitted because your potassium was very high and at
the same time your right arm dialysis access clotted and was
unusable.
In the intensive care unit your potassium was normalized. A
temporary dialysis access point was made in your left groin, and
the clot in your right arm was cleaned out. After the clot was
cleaned out, it was used to resume your dialysis treatments and
the temporary line in your thigh was removed.
Physical therapy evaluated you and determined that you need a
visiting nurse assistant to work with you a few times weekly.
Do not lift more than 5 pounds for one week.
MEDICATION CHANGES:
None
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Appointment: Friday [**2196-7-15**] 11:40am
[**Location (un) **] [**Location (un) **]
Phone: [**Telephone/Fax (1) 5972**]
Nephrologist-[**Name6 (MD) 4102**] [**Name8 (MD) 4090**],MD
Schedule-T/TH/S
*Dr. [**Last Name (STitle) 4090**] will follow up with you at your next diaylsis day
for your hospitalization. Any questions or concerns please call
the office.
Department: CARDIAC SERVICES
When: TUESDAY [**2196-8-9**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2196-8-26**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30470**], MD [**Telephone/Fax (1) 1803**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BWD
ICD9 Codes: 5856, 2767, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8106
} | Medical Text: Admission Date: [**2155-10-15**] Discharge Date: [**2155-10-25**]
Date of Birth: [**2081-7-29**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 74-year-old gentleman
with a history significant for coronary artery disease,
status post CABG times four in [**2147**], status post DDD,
pacemaker placement in [**2155-7-27**], negative Persantine mibi
test in [**2155-7-27**] and recent catheterization of his heart on
[**2155-10-8**] showing an EF of 38%, three vessel disease, moderate
aortic stenosis, moderate mitral regurgitation and moderate
[**Date Range 16631**] and diastolic ventricular dysfunction, CHF, insulin
dependent diabetes mellitus, hypertension,
hypercholesterolemia and GI bleed with a recent admission
between [**10-4**] and [**10-9**] for shortness of breath. The patient
was discharged home on Lasix and now returns with increasing
shortness of breath on exertion, greater than right, no chest
pain, no nausea, vomiting, some abdominal pain, some
lightheadedness and fatigue, no orthopnea, no PND, slight
headache and decreased appetite. Patient's stools are
chronically dark.
In the Emergency Room the patient was found to be guaiac
positive and with a blood pressure of 74/39, pulse of 80. He
was started on Dopamine drip and given one liter of IV
fluids. His urine output was 1.2 liters in 6 hours. The
Dopamine was started at 5 mcg/kg/min. and then decreased to
2.5 mcg/kg/min. and then stopped, but his blood pressure did
not tolerate this and dropped to 68/49 so he was restarted on
the drip at 5 mcg/kg/minute. After he was transferred to the
unit, right radial A line was placed, PA catheter was floated
through his right IJ and initial pressures were CVP of 14, RV
of 78/20, PA 60/25, wedge pressure of 33, PVR was calculated
3.3. Cardiac index 3.03, cardiac output 7, SVR between 500
to 800 on Dopamine drip. The patient was started on
Dobutamine drip in the CCU on the night of admission but his
blood pressure dropped within 20 minutes and this was stopped
and he remained on only the Dopamine drip. He was also given
two units of packed red blood cells on the night of admission
with Lasix after each unit.
PAST MEDICAL HISTORY: 1) Coronary artery disease status post
CABG times four in [**2147**], status post DDD pacemaker placement
[**2155-7-27**], Persantine mibi in [**2155-7-27**] showing no perfusion
defects, EF of 56%, history of AS and possible prior MI
catheterization in [**2155-12-27**] showing LVEF of 38%,
anterolateral hypokinesis, apical dyskinesis, inferior
akinesis, 3+ mitral regurgitation and aortic calcification.
2) CHF stage II. Echocardiogram in [**2155-5-27**] showed EF of 55%
with regional wall motion abnormalities, moderate AS and
moderate to severe mitral regurgitation. An echocardiogram
in [**9-27**] showed septal and apical inferoapical hypokinesis,
moderate MR, TR and 45% EF with moderate AS. 3) Insulin
dependent diabetes mellitus diagnosed in [**2132**]. 4) Recurrent
gastrointestinal bleed with extensive work-up including
colonoscopy in [**2155-5-27**] and [**2155-7-27**] showing sigmoid
diverticulosis and GI hemorrhoids. He is H. pylori negative.
EGD in [**2155-5-27**] and [**2155-9-27**] showed Barrett's esophagus
and mild gastritis. Abdominal CT in [**2155-7-27**] showed
vascular calcifications and he recently had admission on
[**9-27**] through [**2155-10-1**] for GI bleed leading to
orthostasis. He also has a possible history of porcelain
gallbladder. 5) Atrial fibrillation on Coumadin in the past,
now with pacemaker in place and on Amiodarone. 6)
Hypertension. 7) Hypercholesterolemia. 8) Peptic ulcer
disease. 9) Iron deficiency anemia. 10) Cholelithiasis.
11) Peripheral vascular disease with neuropathy.
MEDICATIONS: At home, Insulin NPH 34 units q a.m., 24 units
q p.m., Insulin regular 10 units q a.m., Amiodarone 200 mg q
d, Aspirin 81 mg q d, Cimetidine 400 mg q d, Lipitor 40 mg q
d, Reglan 10 mg tid, Univasc 30 mg q d, Iron 65 mg tid, Lasix
40 mg q d, Imdur 30 mg q d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Mother passed away from a brain tumor, no
history of coronary artery disease or diabetes.
SOCIAL HISTORY: The patient is a widow since [**2146**]. Patient
did have a daughter who died in a train accident many years
ago. He lives alone in [**Location (un) 2251**]. He has a brother and
sister-in-law who he is in contact with and he does have a
girlfriend. [**Name (NI) **] is an ex-smoker, quit smoking many years ago.
He has a 60 pack year history and he does not drink alcohol.
PHYSICAL EXAMINATION: Vital signs, temperature 96.8, blood
pressure 80/45, pulse 80 and regular, respiratory rate 18, O2
saturation 99% on three liters nasal cannula. General,
elderly gentleman in no apparent distress. HEENT:
Normocephalic, atraumatic. Pupils equal, round and reactive
to light. Extraocular movements intact. Oropharynx clear.
Dry mucus membranes. Neck, no lymphadenopathy, jugulovenous
distension to 14 cm. Cardiovascular, regular rate and
rhythm, [**4-1**] late peaking [**Month/Day (4) 16631**] ejection murmur at left
sternal border radiating to the aorta, [**3-4**] holosystolic
murmur at the apex. Pulmonary, bilateral sided basilar
crackles [**1-29**] to [**1-28**] way up. Abdomen, soft, non distended,
nontender, normoactive bowel sounds, no hepatosplenomegaly.
Rectal, guaiac positive. Extremities cool, 2+ pitting edema
to upper calves, left dorsalis pedis 1+, right dorsalis pedis
2+. Neuro, alert and oriented times three, non focal exam.
LABORATORY DATA: White blood cell count 8.5, hematocrit
25.8, platelet count 227,000, PT 13.2, PTT 26.9, INR 1.1,
differential with 82% neutrophils, 11% lymphocytes, 4.5%
monocytes, 1.8% eosinophils, .7% basophils. Sodium 135,
potassium 4.5, chloride 99, CO2 24, BUN 34, creatinine 1.4,
glucose 168, anion gap 17, calcium 8.7, magnesium 2. TSH
from [**10-7**] 1.8, cholesterol panel from [**2155-5-27**], total
cholesterol 21, HDL 24, LDL 76, triglycerides 107, troponin
less than .3. CK #1 48, CK #2 39, CK #3 34. Urinalysis
negative. Urine culture negative. ABG, PH 7.43, PCO2 36,
PO2 73, 96% on four liters nasal cannula. Laboratory data
from [**2155-9-27**], iron 46, ferritin 141, haptoglobin 287, LDH 187,
retic count 3.5, TIBC 261. Chest x-ray, worsening CHF,
satisfactory position of PA cath. Chest x-ray [**9-27**], mild
CHF, small bilateral pleural effusions. EKG, AV paced at 80,
left bundle branch block pattern.
Catheterization [**2155-10-8**], right dominant three vessel coronary
artery disease (RCA/CO middle segment, LAD proximal 60% and
mid 70%, circumflex proximal 60%, mid 100%, distal 100%),
patent grafts (LVMA to LAD, SVG to D1, OM1, PDA) moderate AS,
moderate MR, moderate [**Month/Day/Year 16631**] and diastolic ventricular
dysfunction, EF 38% (increased right sided intracardiac
pressures, increased LVED pressure 21), aortic valve area .9
cm sq going to 1.2 cm sq with Dobutamine infusion, mean
gradient 27 mmHg going to 39 mmHg with Dobutamine infusion
and cardiac index 2.5 liters per minute per meter sq going to
3.7 liters per minute per meter sq with Dobutamine infusion.
Catheterization pressures, right atrium 16/12 with a mean of
15, RV pressure 39/14, PA pressure 39/28 with a mean of 31.
Pulmonary wedge pressure 22/23 with a mean of 29. LV
pressure 134/17 and 169/20 and aortic pressure 103/57 with
mean of 77 and 120/50 with a mean of 73.
IMPRESSION: 74-year-old gentleman with a history of CAD,
CHF, diabetes mellitus, hypertension, hypercholesterolemia
and recurrent GI bleed with recent catheterization on [**2155-10-8**]
showing patent graft, moderate severe AS, moderate MR [**First Name (Titles) **]
[**Last Name (Titles) 16631**] and diastolic left ventricular dysfunction with an
EF of 38% with improvement in AV area mean gradient and
cardiac index with Dobutamine infusion, admitted with
progressive dyspnea refractory to Lasix and guaiac positive
stool.
HOSPITAL COURSE:
1. Cardiovascular:
A) Coronary artery disease - patient with patent graft on
catheterization. He ruled out on this admission for a
myocardial infarction with negative enzymes. The patient was
continued on Aspirin and Lipitor.
B) Contractility - a) Preload, patient has a complicated
clinical picture with the aim to maintain preload for the
aortic stenosis but at the same time avoiding fluid overload.
The patient was transfused two units of packed red blood
cells for hematocrit of 26. Each unit was followed by Lasix
40 mg IV. IT was decided to diurese him gently with Lasix
with prn IV doses. His O2 sats and urine output were
followed and improved. His goal net fluid balance initially
was negative 500 to negative 1 liter. He had decreased
requirement of oxygen over time, eventually being on room air
on discharge. The patient was started on Aldactone during
this admission. On [**10-19**] he was started on Lasix 40 mg po q d
with addition of prn Lasix IV for maintaining his goal urine
output. This was changed to 40 mg [**Hospital1 **] the following day. On
[**8-21**] this was changed to 40 mg IV bid with prn Lasix in
addition and then on [**10-23**] it was changed to 60 mg po q d and
then finally upon discharge was changed to 60 mg po qid as a
maintenance dose. Closer to discharge his Lasix dose was
changed to lower equivalent dose of po Lasix because his BUN
and creatinine bumped a little bit, giving us the impression
that he had reached his threshold for Lasix diuresis.
b) Inotropic - the patient was initially on a Dobutamine drip
to maintain a map of greater than 55 and heart rate of less
than 120. This was started because it had been shown to
improve his aortic stenosis on his recent catheterization,
however, his blood pressure did not tolerate Dobutamine drip
and dropped dramatically so this was stopped and he was
instead maintained on the Dopamine drip. This was weaned off
by hospital day #2. On [**10-17**] the patient had a TEE to
evaluate his valves and this showed LVEF of 45-50% mildly
depressed LV [**Month/Year (2) 16631**] function, RV function normal, simple
atheroma in the descending thoracic aorta, aortic valve
heavily calcified with restricted motion, mild AS, trace AR,
severe 4+ mitral regurgitation, no pericardial effusion. It
was decided that his mitral regurgitation was most likely the
most significant cause behind his CHF. On [**10-19**] the patient
was started on Digoxin .125 mg q d. His PA catheter was
removed and he was transferred to the floor on [**8-18**]. On [**8-22**]
his Digoxin level was .6 and his Digoxin was therefore
increased to .25 mg q d. c) Afterload - patient also had a
complicated balance between decreasing his afterload to
improve his mitral regurgitation without decreasing it too
much because of his aortic stenosis. His home afterload
reducers were held off initially. He had a low SVR and
sepsis was ruled out with blood cultures. His a.m. Cortisol
level was also normal. His low SVR could also be due to
diabetic autonomic dysfunction. TSH on recent testing was
also within normal limits. Urine culture was negative.
Sputum culture was negative. LFTs were within normal limits.
The patient did have a low grade fever on [**8-15**] with an
increase in white blood cell count. Differential was added
without bands. The patient's SVR came up by itself on [**10-17**],
even off of the Dopamine drip. His hypotension was thought
also to perhaps be due to his increased ACE inhibitor dose at
home. On [**10-18**] the patient was restarted on ACE inhibitor, he
was started on Captopril 12.5 mg tid. This was further
increased to 25 mg tid on [**8-18**].
C) Conduction - patient is AV paced. His lytes were
followed. He did not have any arrhythmias on the Dopamine or
Dobutamine drip. The possibility for the future may be to
decrease the rate of his AV pacemaker to less than its
present setting of 80. He was continued on his regular dose
of Amiodarone throughout his hospital stay.
D) Valves - On admission it was decided that once the patient
was hemodynamically stable and the source of the GI bleed
elucidated, that perhaps surgery with mitral valve and aortic
valve replacement would be an option. On echocardiogram on
[**8-16**] TEE showed severe mitral regurgitation, mild to moderate
aortic stenosis. It was felt that he may still benefit from
at least mitral valve replacement, however, his mortality and
morbidity risks from the surgery were extremely high given
his comorbid state up to 20% mortality. This was discussed
with the patient and he was willing to undergo CT surgery
evaluation. On [**10-18**] CT surgery fellow evaluated the patient
and indicated that they would be willing to operate on the
patient if his cardiologist approved and despite his GI
bleed. It was decided by Dr. [**Last Name (STitle) **], the patient's
primary cardiologist, that he should be medically treated,
first given the high risks of operation and at that time
aggressive diuresis was implemented. The patient had a PT
and social services consult.
2. Pulmonary: On admission the patient was in CHF by exam,
PA catheter numbers and chest x-ray showing failure.
Initially he was gently diuresed with prn Lasix and his O2
sats were followed as well as his urine output and both
improved over time. When the question of sepsis came up, the
question of pneumonia also was brought up. Sputum culture
was negative. In addition, there was a low suspicion for a
PE in the patient. There was no evidence of pneumonia on
chest x-ray.
3. GI: The patient has a history of chronic recurrent GI
bleed. He was guaiac positive on admission with a hematocrit
dropped to 24 from 30 a few days previously as an outpatient.
He was transfused two units on his first night and it was
decided to maintain his hematocrit above or equal to 27. His
hematocrit was initially checked every 8 hours. Given the
possibility of CT surgery for valvular replacement, a
valvuloplasty, a GI consult was requested despite his recent
extensive negative GI work-up including colonoscopy, EGD and
small bowel follow through showing small lesions which could
be intermittently bleeding but not explaining his anemia.
His hematocrit had a good response to the transfusions. He
was started on Protonix. The iron was briefly discontinued
for one day because of the thought that GI might want to
evaluate him but then restarted once it was clear that GI
would not do anymore procedure to evaluate his GI bleed. On
[**8-15**] the GI team commented on the patient's GI bleed, that
there was no more work-up to be done for him and that the
next step would be an outpatient small bowel capsule
enteroscopy. They believe that the source of his bleeding is
probably a small bowel source and believe that his GI bleed
does not preclude him from having CT surgery although he may
bleed with Heparinization. The patient required one unit of
transfusion also on the second day of admission. The patient
did have small elevation in his total bilirubin of 1.7 with
direct being .4 and indirect being 1.3. This was probably
thought to be due to his chronic cholelithiasis. The history
of porcelain gallbladder may be precancerous and this should
be reviewed on ultrasound if and when he should go to
surgery. On [**8-17**] his total bilirubin was rechecked and was
within normal limits. The patient was initially constipated
but this was resolved with Dulcolax suppositories. He was
guaiac positive. On [**8-21**] the patient did complain of some
nausea and he was started back on his Reglan home regimen.
4. Heme: The patient's hematocrit was initially checked q 8
hours and he was transfused to maintain hematocrit of greater
or equal than 27. He required a total of 3 units of packed
red blood cells with good response. Despite his guaiac
positive stools, his stable hematocrit indicated that he was
probably not actively bleeding.
5. Infectious Disease: On the second day of admission the
patient had an increase in his white blood cell count and low
grade temperature. Differential was added which showed no
bands. He had clammy, diaphoretic skin, feeling cool to the
touch. The question of sepsis came up with a low SVR and his
hypotension and blood culture, urine culture, sputum culture
and chest x-ray as well as urinalysis were all negative. It
was felt maybe to start empiric antibiotics but initially
this was held off. He did not require antibiotics throughout
this admission. On the third day of admission he became
afebrile, his white blood cell count came down and sepsis
seemed an unlikely explanation for his hypotension and low
SVR.
6. Endocrine: The patient was continued on his home regimen
of NPH and regular insulin with sliding scale of regular
insulin for back-up. His fingerstick blood glucoses were
checked qid. Recent TSH on [**10-7**] was 1.8, within normal
limits. On [**10-17**], because of the patient's poor po intake, it
was decided to have his NPH and regular insulin dose. On
[**10-22**], because of his improved appetite and increased po
intake, his regular insulin NPH doses were increased back to
his preadmission doses. His blood glucose remained stable
throughout his hospital stay.
7. Renal: The patient was admitted with an increased BUN
and creatinine of 34 and 1.4. This was thought to be
prerenal azotemia secondary to his CHF with a component of
increased BUN secondary to his GI bleed. It was decided to
gently diurese him on admission, to follow his urine output.
His BUN and creatinine continued to improve and resolved
within a few days. Aggressive diuresis was started once it
was decided to treat him medically rather than surgically.
The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] was calculated at 2%. This is in the
setting of Lasix so this was deemed not to be accurate.
8. Fluids, Electrolytes & Nutrition: The patient was gently
diuresed initially and this became aggressive diuresis once
medical management was chosen. Fluid balance initially was
negative 500 to negative 1 liter. His electrolytes were
followed carefully. He was placed on a diabetic and cardiac
diet. His initial PA catheter goal for wedge pressure was
20-25. When the patient was being aggressively diuresed with
Lasix, his goal fluid balance was negative two liters and he
met this well with successful response to aggressive Lasix.
9. Psychiatry: On [**10-17**] the patient was started on Celexa 20
mg po q d after it was noted that this is what he had been on
for the last four days at home. The patient did appear
depressed while in the hospital, especially given his status
of living alone and dealing with his medical problems and
frequent hospital stays. On [**10-22**] the patient had a
psychiatry consult who recommended that he be continued on
the same dose as Celexa given the delay in its effectiveness
being felt by patient may take up to weeks.
10. Code: Full.
The patient was transferred to the floor on [**10-19**] and did
well. Physical therapy saw him and ambulated with him and
recommended that he go to rehab center short-term after being
discharged from the hospital.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To [**Hospital3 **] Center.
DISCHARGE INSTRUCTIONS:
1. Please check BUN, creatinine and potassium three times a
week and adjust Lasix and Aldactone accordingly.
2. Please weigh patient every day and aim to maintain
current weight and adjust Lasix accordingly.
3. Please check qid fingerstick blood glucose.
4. Consider changing Captopril to Zestril 10 mg q day if
patient is stable.
5. Please check Digoxin level three days after discharge and
change the medication accordingly.
6. [**Doctor First Name **] cardiac diet q day physical therapy.
7. Please have patient follow-up with his cardiologist, Dr.
[**Last Name (STitle) **], [**Telephone/Fax (1) 25135**] within 1-2 weeks after discharge.
DISCHARGE MEDICATIONS: Lasix 60 mg po bid, Digoxin .25 mg po
q d, Regular insulin 10 units subcu q a.m., NPH 34 units q
a.m., 24 units q p.m., enteric coated Aspirin 325 mg po q d,
Captopril 25 mg po tid, Reglan 10 mg po tid, Colace 100 mg po
bid, Iron Sulfate 325 mg po tid, Aldactone 25 mg po q d,
Celexa 20 mg po q d, Amiodarone 200 mg po q d, Lipitor 40 mg
po q h.s. and Protonix 40 mg po q d.
DISCHARGE DIAGNOSIS:
1. Congestive heart failure.
2. Coronary artery disease.
3. Aortic stenosis.
4. Mitral regurgitation.
5. GI bleed.
6. Diabetes mellitus.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2155-10-24**] 14:38
T: [**2155-10-24**] 15:45
JOB#: [**Job Number 25136**]
cc:[**Hospital6 25137**]
ICD9 Codes: 4280, 5789, 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8107
} | Medical Text: Admission Date: [**2105-2-21**] Discharge Date: [**2105-2-24**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
chest pain, transferred from OSH for STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization s/p Cypher stenting of LCX and OM1
History of Present Illness:
83 y/o man with "on and off" chest pain for several weeks who
presented to [**Hospital 882**] Hospital today complaining of pain that
was persistent. His ECG showed inferior ST elevations with
reciprocal changes. While at [**Hospital1 882**], his exam was consistent
with CHF, as well as CXR. He was given IV lasix, heparin,
integrelin, plavix loaded. He was additionally noted to be
bradycardic to HR 39. He was given atropine 1 mg twice without
response. His BP was 74 systolic, so peripheral dopamine was
started, and he was sent to [**Hospital1 **] for intervention.
.
In cath here he was found to have 90% occlusion of the L Cx, as
well as diffuse disease of a dominant OM1 - cypher stents to
both. There was also 90% mid vessel RCA lesion (non-dominant
vessel).
.
PCWP was 25.
Past Medical History:
- CVA (hemorrhagic) X 2: [**7-29**] and [**2099**] - not on ASA due to this;
no known residual deficits
- Retroperitoneal fibrosis with mult SBO from this and chronic
pain
- DM2 on oral agents only
- HTN
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Blood pressure was 132/64 mm Hg while supine. Pulse was 73
beats/min and regular, respiratory rate was 20 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person only.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 8 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+
Left: Carotid 2+ Femoral 2+ DP 2+
Pertinent Results:
[**2105-2-21**] 11:00AM CALCIUM-7.9* PHOSPHATE-4.1 MAGNESIUM-1.6
[**2105-2-21**] 11:00AM cTropnT-2.73*
[**2105-2-21**] 11:00AM CK(CPK)-534*
[**2105-2-21**] 11:00AM estGFR-Using this
[**2105-2-21**] 11:00AM GLUCOSE-310* UREA N-32* CREAT-1.4*
SODIUM-131* POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-18* ANION GAP-18
[**2105-2-21**] 06:58PM PLT COUNT-312
[**2105-2-21**] 06:58PM CK-MB-291* MB INDX-11.5*
[**2105-2-21**] 06:58PM CK(CPK)-2535*
[**2105-2-21**] 06:58PM POTASSIUM-4.6
[**2105-2-21**] 08:54PM PT-11.4 PTT-22.3 INR(PT)-1.0
[**2105-2-21**] 08:54PM PLT COUNT-302
[**2105-2-21**] 08:54PM WBC-17.0* RBC-3.54* HGB-10.0* HCT-29.9*
MCV-85 MCH-28.3 MCHC-33.5 RDW-14.1
.
IMAGING/STUDIES:
[**2105-2-21**] CARDIAC CATHETERIZATION: COMMENTS: 1. Coronary
angiography in this right dominant system demonstrated an LMCA
with mild proximal disease. The LAD had minimal luminal
irregularities. The LCX was a dominant vessel with diffuse
disease; the mid-LCX had an average 90% stenosis with evident
thrombus, the dominant OM had severe diffuse disease and evident
thrombus as well; both the LCX and OM had TIMI II slow flow. The
RCA was a small nondominant vessel wtih a 90% lesion in its mid
segment. 2. Limited resting hemodynamics revealed normal
systemic arterial pressure (on dopamine gtt). Right sided
filling pressures were mildly elevated. 3. Peripheral
angiography demonstrated a 95% lesion in the right external
iliac artery at the bifurcation with the internal iliac artery.
4. PCI: Successful PTCA and stenting was performed of the AV CX
with a 3.5x18 mm Cypher stent postdilated to 3.75 mm with an NC
balloon. Successful PTCA and stenting was performed of the OM1
with a 3.0x33 mm Cypher stent which was postdilated with a 2.5
mm NC balloon. Final angiography revealed 0% residual stenosis,
no dissection, and TIMI 3 flow in both vessels. (see PTCA
comments). FINAL DIAGNOSIS: 1. Two vessel coronary artery
disease. 2. Acute inferior myocardial infarction, managed by
acute ptca of the LCX. 3. Successful PTCA and stenting of the AV
CX and OM1 was performed with drug eluting stents.
.
[**2105-2-23**] ECHOCARDIOGRAM: The left atrium is normal in size.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. No masses or thrombi are
seen in the left ventricle. Overall left ventricular systolic
function is mildly depressed with inferior and infero-lateral
akinesis, EF = 40-45%. There is no ventricular septal defect.
There is focal hypokinesis of the apical free wall of the right
ventricle. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is severe pulmonary artery systolic
hypertension, PASP = 63. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 19371**] is an 83 year old male with a past medical history
significant for HTN, DM II, hemorrhagic CVA x 2, and
retroperitoneal fibrosis who presented with STEMI.
.
1. STEMI: Mr. [**Known lastname 19371**] presented to an OSH with chest pain. He was
found to have ST elevations in the inferior leads with
reciprocal changes. He was transferred to [**Hospital1 18**] for cardiac
catheterization. His troponin peaked at 2.73
pre-catheterization. He underwent successful Cypher stenting of
the LCX and OM1. Catheterization also demonstrated 90% lesion of
the RCA mid-segment which was nondominant and a 95% lesion in
the right external iliac artery at the bifurcation with the
internal iliac artery. Echocardiography demonstrated an EF of
40-45%, mild dilatation of the left ventricular cavity is mildly
dilated with inferior and infero-lateral akinesis. His
post-catheterization course was complicated by a bump in
creatinine and CHF, as well as hematemesis in the setting of
Integrilin, heparin, Plavix and aspirin use (see below). He was
continued on his beta-blocker which was increased for improved
heart rate and pressure control. High-dose statin therapy was
initiated. At home, he is on an ACE inhibitor which was held in
the setting of rising creatinine.
.
2. CHF: Volume overload was likely secondary to recent STEMI
with mildly depressed LV function. CHF was managed with
aggressive diuresis and his beta blocker was continued. He had
no oxygen requirement at discharge. Echo as above.
.
3. CREATININE ELEVATION: Mr. [**Known lastname 72329**] creatinine increased from
1.4 to 1.9 post-catheterization. Baseline was unknown. This
acute rise was most likely secondary to contrast nephropathy.
His ACE inhibitor was held, but can be restarted as an
outpatient. Mr. [**Known lastname 19371**] was instructed to have lab work after
discharge. His PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 35888**] will monitor the results.
.
4. UGIB: The patient had one episode of Guiaic (+)
maroon-colored emesis that occurred post-catheterization in the
setting of Integrilin, Plavix, ASA and recent heparin bolus.
Colostomy contents were Guiaic negative. Integrilin was stopped
and aspirin was decreased to 81mg. Plavix was continued given
his recent stenting. His pre-transfer HCT at the OSH was 35.2.
Post-emesis HCT dropped to 26.7. He received 1 unit of PRBCs
with an appropriate response in HCT and remained stable for the
remainder of his hospitalization. Repeat HCT was 29.9, then 26.7
post-cath and post-emesis. He was instructed to have a CBC after
discharge. Results will be faxed to Dr. [**Last Name (STitle) 35888**]. He is scheduled
for outpatient GI follow up in 2 weeks.
.
5. DM II: Glyburide and metformin were initially held. He was
managed with sliding scale insulin only until the day prior to
discharge when Glyburide was restarted. We continued to hold
metformin given his elevated creatinine, but this may be
restarted on an outpatient basis after blood work is reviewed by
Dr. [**Last Name (STitle) 35888**].
.
6. RP FIBROSIS: Fentanyl patch was continued per home regimen.
Medications on Admission:
Atenolol 100
Lisinopril 10
HCTZ 25
Metformin
Glipizide 5mg daily
Fentanyl patch 100 mcg
Zantac
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 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for heartburn.
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. STEMI
2. CHF
3. acute renal failure
4. upper GI bleed
.
Secondary:
1. HTN
2. DM II
3. retroperitoneal fibrosis s/p colostomy
4. hemorrhagic CVA x 2
Discharge Condition:
Stable. Afebrile. Tolerating PO. Ambulates with assistance.
Chest pain free.
Discharge Instructions:
You were admitted to the hospital because you had a heart attack
and required cardiac catheterization. You should return to the
ER or call your doctor if you experience any of the following
symptoms: fever > 101.4, chest pain, shortness of breath,
numbness/weakness/dizziness or any other concerning symptoms.
.
Please take all medications as prescribed. You should not take
your metformin (also called Glucophage) until you follow up with
Dr. [**Last Name (STitle) 35888**].
.
Please follow up with all appointments as instructed.
.
During this admission, you underwent cardiac catheterization and
stenting. Please carry the stent information card in your wallet
at all times.
Followup Instructions:
1. CHEM-7 and CBC check on Wednesday (to be drawn by VNA),
results should be sent to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35888**] (Fax: [**Telephone/Fax (1) 14391**],
Phone: [**Telephone/Fax (1) 13745**]). Metformin and ACE-I to be restarted as
indicated by laboratory data.
2. The following appointment with Gasteroenterology at [**Hospital1 18**]
([**Hospital Ward Name 516**], [**Hospital Ward Name 452**]-[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Location (un) **]) has been made for you.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2105-3-10**]
2:00.
3. A Cardiology follow up appointment has been made for you.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2105-3-25**]
9:40
ICD9 Codes: 4280, 5849, 5789, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8108
} | Medical Text: Admission Date: [**2134-8-20**] Discharge Date: [**2134-9-8**]
Date of Birth: [**2053-12-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 yo Armenian-speaking F with a history of multiple myeloma,
hypertension, and [**First Name3 (LF) 2320**], who was discharged two days prior from
[**Hospital1 18**] after being admitted for constipation, now with nausea and
vomiting.
.
She was admitted here from [**Date range (1) 85266**] for constipation, thought to
be due to chronic narcotic use (fentanyl patches, dilaudid pca,
tramadol, and oxycodone in recent past) for her multiple myeloma
pain. She was started on an aggressive bowel regimen and oral
naloxone. Of note, she was admitted to [**Hospital1 2177**] for similar symptoms
from [**Date range (1) 33692**].
.
Since being discharged to rehab two days ago, she has had
persistent nausea and vomiting. According to her grandson, she
has attempted to drink juices and Ensure, and has vomited it all
soon after drinking. Last night there was some brown clots in
the vomit. She has not had a BM since being discharged. She
denies abdominal pain or feeling bloated.
.
In the ED her vitals were 98.4, 136/80, 90, 18, 98%RA. She
received Zofran for nausea. An NG tube was placed with 700cc of
bilious output. She was guaiac negative. A CT was done, and she
was started on heparin gtt for a R common femoral vein DVT.
.
On ROS, she endorses weakness in her LE bilaterally. She denies
fevers, chills, night sweats, recent weight changes, rinorrhea,
confusion, chest pain, SOB, urinary retention or dysuria, rash
or joint pain.
Past Medical History:
1. Kappa light chain multiple myeloma. Diagnosed approximately
one and a half years ago, and has been treated with
velcade/bortezomib and dexamethasone. She has significant pain
and is on chronic narcotics. Oncologist: Dr. [**Last Name (STitle) 85264**] at
[**Hospital6 **], phone [**Telephone/Fax (1) 63775**].
2. Hypertension
3. HLD
4. [**Telephone/Fax (1) 2320**]
5. Cataracts
6. Arthritis
7. Recent oral candidiasis
Social History:
Lives with daughter and grandson. She does not smoke, drink or
use illicit drugs.
Family History:
Both parents were ~age [**Age over 90 **] years when they died and were healthy.
Her sister has Type II DM. Also a family history of cataracts.
Physical Exam:
ADMISSION:
VS 97.2 122/64 100 18 100/2LNC
Gen: Fatigued-appearing, speaks quietly with grandson
[**Name (NI) 4459**]: NC/AT, NGT to wall suction w/ dark brown fluid draining
Neck: Supple, no LAD
CV: Tachy w/ regular rhythm, nl S1/S2
Pulm: Auscultated anteriorly, CTAB
Abd: Soft, nontender, nondistended, striae present, hypoactive
BS
Ext: Warm, 2+ pitting edema to mid-calf
Pertinent Results:
Chemistries:
- [**2134-8-20**] 02:10AM GLUCOSE-115* UREA N-12 CREAT-1.3*
SODIUM-142 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-29 ANION GAP-12
LACTATE-1.5
- [**2134-8-27**] 07:12AM BLOOD Glucose-102* UreaN-11 Creat-1.1 Na-137
K-4.1 Cl-104 HCO3-24 AnGap-13
- [**2134-8-31**] 09:20AM BLOOD TSH-3.4
Hematology:
- [**2134-8-20**] 02:10AM WBC-10.0 (NEUTS-78.9* LYMPHS-15.8*
MONOS-3.8 EOS-1.1 BASOS-0.3) RBC-3.71* HGB-10.2* HCT-32.7*
MCV-88 MCH-27.5 MCHC-31.2 RDW-17.6* PLT COUNT-201
- [**2134-8-27**] 07:12AM BLOOD WBC-6.0 RBC-3.43* Hgb-9.5* Hct-30.9*
MCV-90 MCH-27.7 MCHC-30.8* RDW-17.3* Plt Ct-303
Coagulation Studies:
- [**2134-8-20**] 02:10AM PT-11.4 PTT-25.6 INR(PT)-0.9
[**2134-8-16**] CT Abdomen without IV contrast:
IMPRESSION:
1. Diffuse gaseous distension and borderline dilation of small
bowel without evidence of obstruction. Findings could represent
ileus secondary to narcotic use.
2. Subtle nodularity and bronchial wall thickening in the RLL
suggestive of aspiration.
3. Bilateral femoral head lucencies may represent multiple
myeloma lesions. Correlate with prior imaging if available.
4. Cholelithiasis.
[**2134-8-20**] CT Abdomen with IV contrast:
1. Left pelvic sidewall mass extending through the left
obturator foramen is concerning for plasmocytoma.
2. Clot in the right common femoral vein. The thrombus does not
extend into the iliac vein. The distal extent of this thrombus
is not visualized however.
3. Gallstone within the gallbladder, but no evidence for
cholecystitis.
[**2134-8-24**] KUB:
Slight progression of diffuse gaseous distention of small bowel
with increasingly collapsed colon distally, suggestive of ileus
versus early or partial small-bowel obstruction. No free air.
[**2134-8-26**] Upper Extremity CT:
1. Large destructive lesion in the left humeral head extending
into the
diaphysis of the humerus as well as large external soft tissue
component as described above. Numerous additional lesions with
and without soft tissue component, including incompletely imaged
lesions in the cervical spine. Findings are consistent with
stated history of multiple myeloma.
2. Small left pleural effusion.
[**2134-8-30**] CXR:
No evidence of pneumonia.
Small left pleural effusion and erosion of the right humeral
head.
[**2134-8-30**] Echo:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
moderate global left ventricular hypokinesis (LVEF = 35-40 %).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined.
Brief Hospital Course:
Ms. [**Known lastname 85265**] was admitted to the floor with n/v on [**2134-8-20**]; an
NGT suctioned ~1000cc bilious fluid in the ED.
#Nausea and Vomiting: The abdominal CT revealed no mechanical
obstruction; her ileus was presumed to be due to the high dose
of narcotics she was on for her bone pain. On the floor, the
patient's NGT remained in for 24 hours, with minimal residuals.
Her PO fluid intake were minimal initially, thought to be due to
remaining ileus. Her hospital course was marked by increasing
nausea/vomiting when her narcotics were provided, and a KUB on
hospital day 4 revealed an ileus consistent with medications.
When she ultimately transitioned to standing tylenol for her
pain, her PO remained poor. Because of malnutrition, her family
maintained a strong interest in having her start TPN. They were
counseled about the challenges of TPN, including the lack of an
end point, but wanted to have it started. A double lumen PICC
was placed on [**9-4**] and TPN was started. TPN will continue and
should be adjusted based on daily chem 10s by nutrition.
#DVT: On admission CT scan she was found to have a R common
femoral vein DVT. She was started on heparin gtt. Discussion of
an IVC filter was postponed until after this hospitalization. On
[**2134-8-22**] there was difficulty obtaining blood draws and
monitoring her PTT. She was transitioned to lovenox. Her lovenox
was held on [**9-3**] and [**9-4**] out of concern for a LGIB (? LGIB
versus bleeding hemorroid), but was restarted on [**9-5**]. Hct 26 on
discharge and stable.
#Pain Control: On admission she had a 100mcg/hr fentanyl patch
on her arm dated [**2134-8-17**]. In an attempt to decrease her potential
for narcotic-related ileus, the patch was not replaced; she was
placed on oxycodone for pain. On [**2134-8-22**], the patient (through
her family) reported a significant increase in her joints where
she is known to have lytic lesions. A 50mcg/hr fentanyl patch
was placed. However, her ileus persisted, and she was
transitioned to standing tylenol with ultram for breakthrough
(which she had been on before) with good response.
.
Given her continued nausea and poor PO intake, a KUB was done
and revealed an ileus. Her fentanyl patch and oxycodone were
again discontinued; she was left on standing tylenol. Ultram was
written for breakthrough pain, but she did not require it.
Rad-onc and heme-onc were consulted for palliative radiation and
chemotherapy, in an effort to wean her off pain meds. A CT of
her shoulder revealed significant lytic lesions, and rad-onc
felt it was amenable to XRT as an outpatient (started [**9-2**]). The
family reported on [**9-3**] that they would like to hold the XRT
while she starts getting the TPN and will resume as an
outpatient.
.
#Multiple myeloma: The abdominal/pelvic CT revealed a mass
concerning for a plasmacytoma. Her outpatient oncologist at [**Hospital1 2177**]
reported that this was an amyloidoma, and has been known since
her diagnosis 1.5 years ago. No further workup on this mass was
done. The patient's family expressed an interest in having a
second opinion by [**Hospital1 18**] oncologists and her oncology care
transferred to [**Hospital1 18**]. An appointment was made to be seen as an
outpatient by Dr. [**Last Name (STitle) **] in [**Hospital1 18**] oncology, but her new
medical problems during this hospitalization prompted
involvement of the inpatient heme-onc consult service. Their
advice was solicited to help establish goals of care. A family
meeting was held on [**9-6**] with oncology, after they had time to
review her [**Hospital1 2177**] records. It was felt that she currently is not a
good candidate for more aggressive chemotherapy given her
clinical status and ongoing medical issues. The family decided
they will consider a outpatient opinion once she spends time at
rehab to regain strength. Palliative care was also involved in
the discussions with the family and the family is not ready at
this time to begin a palliative approach. The patient would also
like to be aggressive at this time. The plan on discharge was to
continue TPN to improve the patients nutritional status/strength
and the family would like time to see how she progresses and get
ongoing further treatment options.
#Hypertension: On admission her BP was 122/64 and she was
continued on her home medications of metoprolol, amlodipine and
lasix. Her lasix and amlodipine was held on [**8-21**] after a BP of
99/38 and poor PO intake. Her metoprolol was continued given
her a.fibb and the dose was adjusted to keep her BP stable and
HR under control. She was discharged on 12.5mg PO q6.
#[**Month/Year (2) 2320**]: She was hypoglycemic on the floor initially, requiring
dextrose 50% and glucagon per hypoglycemia protocol. Subsequent
AM glucose were 90-115, and her finger sticks were d/c'ed. They
were restarted on [**9-3**] because of starting TPN. She was
subsequently started on Lantus 6U qhs with ISS. This should be
adjusted based on daily fingersticks with sliding scale.
#Anemia: At the time of her [**2134-8-18**] discharge her Hct was 34.4,
thought to be due to her chronic disease. When she arrived on
this admission it was 32.7, and trended down to 27.8 one day
after being admitted. There was a question of heme-positive
residuals from her NGT, but this could not be verified. Her Hct
rebounded and stablized in the low 30s, before dropping to 24.8
on [**9-2**]. Because she was on lovenox and noted to have dark
maroon stools, it was suspected that she had a LGIB. Her lovenox
was held. Her hct then stabilized and her bleeding was thought
to be due to her hemorrhoid. She was transfused 1U on [**9-3**], with
appropriate increase in her hct. Her Hct susbequently remained
stable around 26-28.
#Wound care: Noted on admission to have a clean wound on coccyx.
Subsequently noted to have ecchymotic perianal tissue, described
as 2 small open areas at 3 and 7 o'clock, also 0.2 cm pink ulcer
on large external hemorrhoid. Wound care was consulted.
Recommended gentle foam cleaner and dry patting. On hospital day
11 she wound care noted significant blistering in the skin folds
of her breast and groin, as well as an ulcerous periurethral
lesion. Through a translator, these were neither painful nor
pruritic. Dermatology was consulted, and recommended nystatin
and zinc oxide for suspected contact vs irritant dermatitis.
Derm did not suspect HSV for her periurethral lesion.
.
#Afib: Was tachycardic on [**8-30**], thought to be due to dehydration
in the setting of poor PO intake. She remained asymptomatic,
denying chest pain or shortness of breath. Telemetry suggested
that she was in afib with RVR. Her metoprolol was increased to
25mg TID. The next day her HR was intermittently in the 160s. An
EKG revealed no ischemic changes or R heart strain. A CXR
revealed no focal consolidation. She was given IVF and her
metoprolol was increased to 37.5mg TID. Her HR decreased to 80s
and 90s. An echo showed moderate LV hypokinesis (LVEF = 35-40%),
increased LV filling pressure (PCWP>18mmHg), and no evidence of
R ventricular strain or wall motion abnormalities. Rate control
was obtained with metoprolol 12.5mg PO QID. This should be
adjusted as needed.
.
#ACS/Demand Ischemia: Elevated troponins x 2. No EKG changes
suggestive of MI; elevated enzymes thought to be due to
new-onset afib. Cardiology was consulted, recommended medical
management. ASA and statin were started, as she was already on
lovenox and metoprolol at the time. The ASA and lovenox were
held on [**9-3**] and [**9-4**] out of concern for a LGIB (? LGIB versus
bleeding hemorroid), but restarted on [**9-5**]. Lisinopril was
started given low EF.
.
#hyponatremia- Pt noted to have Na 126 and remained stable;
initially thought to be hypovolemic hyponatremia but did not
respond to IVF. Pt had urine lytes which showed an SIADH
picture. Pt was not taking in much PO; and given diffuse
anasarca trial of Lasix was done (20mg IV on [**9-6**]) which she
responded to well. She should continue to get Lasix as needed.
Her Na on discharge was 128.
.
#Decreased urinary output: On [**9-2**] she was noted to have
decreased urine output, thought to be due to decreased
intravascular volume in the setting of poor PO intake. A foley
was placed (rather than having to repeatedly straight cath her
given her periurethral lesion), and she had adequate UOP
following IVF.
#Arthritis: Stable. Her pain was addressed with the standing
tylenol described above.
#Social: Several conversations were held with the family (most
often the grandson) about their goals for her long term care. He
stated that they remain optimistic for her, and would like to
pursue rehab for physical therapy and further outpatient
oncology opinions relative to future treatment.
Medications on Admission:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
3. Nystatin 500,000 unit Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
7. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
8. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. Insulin Glargine 100 unit/mL Solution Subcutaneous
10. Lantus 100 unit/mL Cartridge Sig: 15 units Subcutaneous at
bedtime.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
20. Prochlorperazine Maleate 5 mg Tablet Sig: 1-2 Tablets PO Q6H
(every 6 hours) as needed for nausea/vomiting.
21. Fentanyl 100 mcg/hr Patch 72 hr Sig: [**2-13**] Patch 72 hrs
Transdermal Q48H (every 48 hours).
22. Naloxone 1 mg/mL Syringe Sig: One (1) 3mg Injection TID (3
times a day): Please give 3mg PO TID. .
23. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation: hold for >2 BM
daily.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*112 Tablet(s)* Refills:*0*
7. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea,
before meals.
Disp:*42 Tablet, Rapid Dissolve(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO
BID:PRN as needed for constipation.
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
11. 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.
12. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO every
six (6) hours.
19. Insulin Glargine 100 unit/mL Cartridge Sig: 6 units
Subcutaneous at bedtime.
20. Insulin Regular Human 100 unit/mL Cartridge Sig: Sliding
scale Injection once a day: Please see sliding scale per
attached.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Primary: N/V secondary to narcotic-related ileus, R common
femoral DVT, perianal wound
Secondary: Multiple myeloma, HTN, diabetes II, anemia
Discharge Condition:
Ms. [**Known lastname 85265**] is being discharged from the hospital in stable
condition, at normal mental status (per her family) and in a
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 85265**],
You were admitted to the hospital with concern for your nausea
and vomiting. After an evaluation consisting of a history,
physical exam, imaging and blood tests, it was suspected that it
was due to your high levels of pain medications. These can cause
your stomach and digest food slowly. The CT scan showed no
physical obstruction. We decreased the doses of your pain
medications, and it appeared that your nausea and vomiting
improved. You should continue to try to take the Boost shakes
and eat whatever you can tolerate.
The CT of your abdomen also showed a blood clot in your right
leg. We are treating this with the appropriate blood-thinning
medication called Lovenox. You should continue to take this
until you follow-up with your outpatient doctor.
During your hospitalization your heart rate was noted to be in
an irregular rhythm called atrial fibrillation. Your Metoprolol
was changed to help control the heart rate. You were also found
to have a silent heart attack, which may have been due to the
demand on your heart from the fast heart rate. You were seen by
the cardiology team and started on new medications to help
manage this.
You were also not eating very well during your hospitalization
and the decision was made with your family to begin nutrition
through an IV, called TPN. You will continue TPN until you get
your strength back and your nausea improves enough for you to
eat by mouth.
Medications that were changed during this admission are:
1. STARTED Acetaminophen (Tylenol) 325mg, you can take this
every 8 hours as needed for pain.
3. STARTED Zofran 4mg PO - This is another medication for your
nausea. You should take this before your meals as needed.
4. STARTED Lovenox injections - This is a medication for the
blood clot in your leg.
5. STOPPED Amlodipine
6. STOPPED Oxycodone
7. STOPPED Fentanyl Patch
8. STOPPED Furosemide
9. CHANGED Metoprolol to 12.5 mg four times/day
10. STARTED Simvastatin 80mg daily
11. Started aspirin 325mg daily
12. Started Miconazole powder for a rash
13. Started Tramadol 50mg as needed for pain
14. CHANGED Lantus to 6units every evening
15. Stopped Compazine
Followup Instructions:
We understand that you would like to transfer your oncology care
from [**Hospital6 **] to our hospital. Once you complete
your stay at rehab and make a decision regarding further desire
for chemo or radiation, please call [**Hospital1 18**] for an appointment in
oncology. You will be seen by the oncologist at the rehab which
you are going.
ICD9 Codes: 5789, 5070, 5845, 5990, 4275, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8109
} | Medical Text: Admission Date: [**2194-10-24**] Discharge Date: [**2194-11-4**]
Date of Birth: [**2127-3-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Diagnosis and therapeutic thoracentesis
Flexible bronchoscopy
History of Present Illness:
67M with h/o chronic lymphangioma s/p debulking of lymphangioma
mass engulfing R hilum and much of the right mid chest and
mediastinum presents with complaints of SOB for several days. Pt
was seen by PCP for SOB. A CXR was obtained suspicious for
pneumonia. Pt. was admitted to the OSH and a CT scan was
obtained showing a cavitated density in the superior segment of
the LLL with narrowing of the airway. Pt is transferred to
[**Hospital1 18**] for bronchoscopy and possible stenting. Pt denies fevers,
chills. Positive cough with white mucous production.
Past Medical History:
Lymphangioma s/p debulking
HTN
atrial flutter s/p ablation
Social History:
Fomerly smoked 1.5-2 packs/day x 5 years but does not smoke
anymore. Is a retired electrician and lives with wife .
Family History:
Father died of MI @ 50yoa
Pertinent Results:
[**2194-10-29**] 10:33 pm CATHETER TIP-IV Source: R-IJ.
WOUND CULTURE (Pending):
[**2194-10-28**] 6:03 pm PLEURAL FLUID PH.
GRAM STAIN (Final [**2194-10-28**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2194-10-26**] 12:33 pm PLEURAL FLUID
GRAM STAIN (Final [**2194-10-26**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2194-10-29**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2194-10-28**] 06:03PM PLEURAL WBC-5556* RBC-4667* Polys-88* Lymphs-1*
Monos-8* NRBC-2* Macro-1*
[**2194-10-26**] 12:33PM PLEURAL WBC-1175* RBC-375* Polys-81* Lymphs-6*
Monos-0 Macro-13*
[**2194-10-28**] 06:03PM PLEURAL TotProt-3.4 Glucose-89 LD(LDH)-1263
[**2194-10-26**] 12:33PM PLEURAL TotProt-4.0 Glucose-94 LD(LDH)-1257
Albumin-2.1
[**2194-10-31**] 09:51AM BLOOD WBC-17.9*
[**2194-10-30**] 06:41AM BLOOD WBC-16.4* RBC-4.13* Hgb-13.5* Hct-39.0*
MCV-95 MCH-32.7* MCHC-34.6 RDW-14.0 Plt Ct-429
[**2194-10-29**] 10:20AM BLOOD WBC-20.2* RBC-4.19* Hgb-13.5* Hct-39.1*
MCV-93 MCH-32.3* MCHC-34.6 RDW-13.9 Plt Ct-406
[**2194-10-28**] 06:38AM BLOOD WBC-21.0* RBC-4.09* Hgb-13.1* Hct-38.4*
MCV-94 MCH-32.0 MCHC-34.0 RDW-14.0 Plt Ct-453*
[**2194-10-27**] 03:05AM BLOOD WBC-22.1* RBC-4.15* Hgb-13.1* Hct-39.3*
MCV-95 MCH-31.7 MCHC-33.4 RDW-14.1 Plt Ct-446*
[**2194-10-26**] 03:11AM BLOOD WBC-19.3* RBC-4.34* Hgb-14.0 Hct-40.9
MCV-94 MCH-32.2* MCHC-34.2 RDW-14.0 Plt Ct-422
[**2194-10-29**] 10:20AM BLOOD Neuts-84* Bands-0 Lymphs-4* Monos-8 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-4*
[**2194-10-30**] 06:41AM BLOOD Glucose-79 UreaN-28* Creat-0.8 Na-139
K-4.7 Cl-102 HCO3-30 AnGap-12
[**2194-10-29**] 10:20AM BLOOD Glucose-86 UreaN-32* Creat-0.9 Na-140
K-4.7 Cl-102 HCO3-32 AnGap-11
[**2194-10-28**] 12:17PM BLOOD Glucose-153* UreaN-37* Creat-0.9 Na-139
K-4.8 Cl-101 HCO3-31 AnGap-12
[**2194-10-26**] 03:11AM BLOOD TSH-0.81
Brief Hospital Course:
Mr. [**Known lastname 19205**] was admitted to Dr.[**Name (NI) 14680**] service in Interventional
Pulmonology at the [**Hospital1 69**] on
[**2194-10-24**] for further evaluation of a cavitated density in the
superior segment of the LLL with narrowing of the airway. On
[**2194-10-26**], he underwent a diagnostic and therapeutic thoracentesis
for a large left pleural effusion for which cytology was
negative for malignant cells. The next day, he underwent a
flexible bronchoscopy to assess for airway patency. During the
procedure, moderate tracheomalacia, moderate to severe left
bronchomalacia, and a right main stem endobronchial lesion was
found. For details of each procedure, please see dictations.
For his airway compromise, he was started on a prednisone taper
at 60mg for two days to decrease by 10mg every two days until he
reaches 5mg. (At discharge, [**2194-11-3**], he took the second/last
dose of 30mg).
Mr. [**Known lastname 19205**] course was complicated by atrial fibrillation the
night of his admission (HR as high as 160s bpm) which
forestalled his bronchoscopy. A cardiology consult was
obtained. the decision by the consulting team was for rate
control given his history of ablation for atrial flutter. Also,
given his history of hemoptysis and current disease, no
anticoagulation and only aspirin was deemed appropriate
currently.
Mr. [**Known lastname 19205**] was deemed appropriate to be discharged to a rehab
facility on [**2194-10-31**]. He is to continue his course of
prophylactic Unasyn for presumed pneumonia. Lastly, he is to
follow-up with Dr. [**Last Name (STitle) **] in 3 weeks by calling his office for an
appointment. As his WBC was elevated during his stay and at
discharge, a CBC with differential is to be drawn on [**2194-11-3**]
and the result paged to Dr. [**Last Name (STitle) **] (Fellow-Interventional
Pulmonology): [**Telephone/Fax (1) 9986**], pager [**Numeric Identifier 34656**].
Medications on Admission:
Lopressor 25"
Hydrochlorthiazide 25'
Motrin 800'''
Discharge Medications:
1. Hydromorphone 2 mg/mL Syringe Sig: [**11-25**] Injection Q6H (every
6 hours) as needed.
Disp:*qs 1* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Disp:*qs ML(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Disp:*qs 1* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*30 Tablet, Chewable(s)* Refills:*0*
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q2H as needed for copd.
Disp:*qs 1* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for Bowel regimen.
Disp:*30 Tablet(s)* Refills:*0*
9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): 0-60....[**11-25**] amp D50;
61-120....0 Units;
121-160....2 Units;
161-200....4 Units;
201-240....6 Units;
241-280....8 Units;.
Disp:*qs 1* Refills:*2*
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*0*
14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Disp:*qs ML(s)* Refills:*0*
15. Ampicillin-Sulbactam [**12-25**] g Recon Soln Sig: 3 grams Recon
Solns Injection Q6H (every 6 hours) for 17 days.
Disp:*qs Recon Soln(s)* Refills:*0*
16. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO Qday () for 2
doses: taper as follows:
30mg x2days
20mg x2days
10mg x2days
5mg x2days.
Disp:*4 Tablet(s)* Refills:*0*
17. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every [**2-27**]
hours.
Disp:*30 Tablet(s)* Refills:*0*
18. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day) as needed for afib.
Disp:*30 Tablet(s)* Refills:*0*
19. Diltiazem HCl 30 mg Tablet Sig: Four (4) Tablet PO QID (4
times a day) as needed for Afib.
Disp:*30 Tablet(s)* Refills:*0*
20. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1263**] Hospital - [**Hospital1 **] unit
Discharge Diagnosis:
Moderate tracheomalacia
Moderate to severe left bronchomalacia
Right main stem endobronchial lesion
Left-sided pleural effusion
Atrial fibrillation
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
Be sure to your course of intravenous antibiotics.
You may have a low-fat, heart healthy regular diet as tolerated.
You may resume all of your previously prescribed medications.
You may take showers.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Call his office at
[**Telephone/Fax (1) 3020**] for an appointment and to arrange the following:
bronchoscopy, CT scan and Radiation Oncology follow-up plans.
Please make an appointment to see your Primary Care Doctor (Dr.
[**Last Name (STitle) **], [**Telephone/Fax (1) 58696**]) regarding your atrial fibrillation and
new heart medications. He will decide on whether you need to
follow-up with a Cardiologist.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
ICD9 Codes: 5119, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8110
} | Medical Text: Admission Date: [**2141-12-31**] Discharge Date: [**2142-1-9**]
Date of Birth: [**2065-5-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain, transfer for STEMI
Major Surgical or Invasive Procedure:
[**2142-1-1**] Cardiac Cath
[**2142-1-4**] Coronary artery bypass grafting x4, with the left
internal mammary artery to the left anterior descending artery
and reversed saphenous vein grafts to the posterior descending
artery and first and second diagonal arteries.
History of Present Illness:
76 year old male who presented to OSH for ED with sudden onset
of [**9-19**] chest pressure, similar to prior chest pain. Attempted
to fall asleep however could not and so called EMS who brought
him to [**Hospital3 **]. At OSH, EKG revealed ST elevations in
anterior leads. Pt was started heparin gtt and transferred to
[**Hospital1 18**] emergently for further evaluation. Code STEMI was called
after EKG showed ~2mm ST elevations in V3-V4. Labs were
significant for mild troponin of 0.09. He was found to have two
vessel disease and he is now being referred to cardiac surgery
for revascularization.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
2 stents at [**Hospital1 3278**] in [**2129**] (not on plavix because of CVA)
Atrial fibrillation not on Coumadin because of CVA
MCA stroke with hemorrhagic conversion s/p craniectomy in [**2132**]
at Southshore
B12 deficiency
BPH
s/p craniectomy in [**2132**]
Social History:
Race:Caucasian
Last Dental Exam:>1 year ago
Lives with:wife, Wheelchair bound. Wife is primary caretaker
Contact: [**Name (NI) 18380**] (wife) Phone #[**Telephone/Fax (1) 85652**]
Occupation:retired business man
Cigarettes: Smoked no [] yes [x] Hx:quit 20 years ago, has a
greater than 20 pack year history of smoking
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-16**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
No premature coronary artery disease- Father had an MI at age 70
Physical Exam:
Pulse:97 Resp:26 O2 sat:96/2L
B/P 109/66
Height:65" Weight:83kgs
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x] Contracted left knee
Neuro: Grossly intact []
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Discharge Exam:
VS: T: 97.6 HR: 65-100 SR BP: 105-125/60-70 Sats: 96% RA
General: 76 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,.S2 no murmur
Resp: diminished breath sounds bilateral with fine crackles
right 1/4 up, no wheezes
GI: obese, bowel sounds positive, abdomen soft
Extr: warm no edema
Incision: sternal and left lower extremity clean, dry margins
well approximated with no erythema
Skin: ecchymosis right hip, Left papula rash left upper, lower
and groin region.
Neuro: awake, alert, oriented to person, place and time. Mild
left facial droop
Strengths R 3-3/4, Left 0-/4 (old CVA)
Pertinent Results:
[**2142-1-1**] Cardiac Cath: 1. Selective coronary angiography in this
right dominant system demonstrated two vessel CAD. The LMCA was
patent. The LAD had diffuse plaquing throughout and tapers to
90% beyond the patent proximal to mid LAD stent and the D2
takeoff. The D2 is diffusely diseased with 40% at ostium and 50%
proximally. The D1 is a substantive bifricating vessel with 70%
ostial stenosis (partially jailed by the LAD stent). The LCx had
mild plaquing throughout. The proximal OM1 and mid OM2 (both
small vessels) have focal 70% stenosis with normal flow. The RCA
was subselectively engaged due to ostial stent and
calcifications. The ostial stent was patent with instent
restenosis (mild, nonflow-limiting). Serial focal stenosis (1st
65-70%) just beyond the acute marginal takeoff and second (90%)
about 2 cm downstream. The PL has 70-80% ostially but overall
this is a small diffusely diseased vessel. The R-PDA is patent.
2. Limited resting hemodynamics revealed moderately elevated
systemic arterial systolic pressures with an SBP of 150 mmHg. 3.
Abdominal aortography was performed using a pigtail catheter via
power injection and showed diffuse plaquing in the infra-renal
aorta, possible moderate L renal artery stenosis, calcific right
common iliac artery stenosis (difficulty passing the wire
through the common iliac into the aorta).
.
[**2142-1-3**] Carotid U/S: Right ICA <40% stenosis. Left ICA no
stenosis.
.
[**2142-1-4**] Echo: Pre-CPB: The patient is in A.Fib. No spontaneous
echo contrast is seen in the left atrial appendage. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
right ventricular cavity is mildly dilated with mild global free
wall hypokinesis. The ascending aorta is mildly dilated. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed. There
is moderate aortic valve stenosis (valve area 1.0-1.2cm2). In
the face of more modest peak and mean gradients across the
valve, a discussion led to the decision to not replace it. Dr.
[**Last Name (STitle) 4901**] offered his opinion also. Trace aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion. Post-CPB: The patient is on an AV-Pacer, though there
is no atrial response. No inotropes. Preserved biventricular
systolic fxn. 1+MR, trace AI. Aorta intact.
.
[**2142-1-9**] WBC-10.4 RBC-3.14* Hgb-9.3* Hct-27.7* MCV-89 MCH-29.6
MCHC-33.5 RDW-13.9 Plt Ct-308
[**2141-12-31**] WBC-11.5* RBC-4.95 Hgb-14.6 Hct-43.0 MCV-87 MCH-29.6
MCHC-34.0 RDW-13.0 Plt Ct-205
[**2142-1-9**] Glucose-136* UreaN-23* Creat-1.0 Na-140 K-4.5 Cl-103
HCO3-32
[**2141-12-31**] Glucose-172* UreaN-21* Creat-0.9 Na-141 K-4.4 Cl-106
HCO3-22
[**2142-1-3**] ALT-27 AST-29 LD(LDH)-260* AlkPhos-61 TotBili-0.4
Micro:
[**2142-1-3**] URINE CULTURE (Final [**2142-1-4**]): <10,000
organisms/ml.
MRSA SCREEN NASAL SWAB. MRSA SCREEN (Final [**2142-1-6**]): No MRSA
isolated
PICC line [**2141-1-7**]:
Right jugular line has been removed. Tip of the new right PIC
line is in the right atrium. It should be withdrawn 3.5 cm to
position it low in the SVC.
Mild pulmonary edema has developed, most readily appreciated in
the right
lower lung. Severe cardiomegaly is longstanding, but mediastinal
and hilar
vascular engorgements have worsened. There is greater
consolidation at the
left lung base, presumably atelectasis though pneumonia is not
excluded, and an increase in small-to-moderate left pleural
effusion. There is no
pneumothorax.
CXR: [**2142-1-6**] There is a questionable tiny left pneumothorax.
The pulmonary edema has almost resolved. There are persistent
low lung volumes with bibasilar atelectasis. Cardiomediastinal
silhouette is unchanged. Right IJ catheter remains low in the
right atrium and can be withdrawn 3-4 cm for more standard
position. If any there are small bilateral pleural effusions.
The sternal wires are aligned.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 47059**] was transferred from
outside hospital with an ST-elevation myocardial infarction. He
underwent a cardiac cath on [**1-1**] which revealed severe three
vessel coronary artery disease. He then underwent appropriate
surgical work-up while awaiting Plavix to wash-out. On [**1-4**] he
was brought to the operating room where he underwent a coronary
artery bypass graft x 4. Please see operative note for surgical
details. Following surgery he was transferred to the CIVCU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one he was started on beta-blockers and diuretics
and diuresed towards his pre-op weight. On post-op day two he
was transferred to the telemetry floor for further care. Chest
tubes and epicardial pacing wires were removed per protocol. On
post-op day three he had episode of rapid atrial fibrillation
IV/PO amiodarone was started. He converted to sinus rhythm
(pre-op history of AF but not on Coumadin d/t hemorrhagic
stroke). A Non-heparin PICC line was placed for IV access. His
Foley was removed and a condom cath was placed for incontinence.
He was bladder scanned for 300. He continued to make good
progress while working with physical therapy. On post-op day 5
he was discharged to rehab with the appropriate medications and
follow-up appointments.
Medications on Admission:
Medications at home:
metoprolol tartarte 50mg [**Hospital1 **]
lisinopril 10mg daily
simvastatin 20mg daily
tamsulosin 0.4mg daily
escitalopram 20mg daily
finasteride 4mg
senna-docunsate 1 tab TID
NPH/Novolin 10 units SC daily
NPH 15 units SC at dinner
ascorbic acid 500mg daily
folic acid-vit b2-vit b6-vit b 1 tab [**Hospital1 **]
ergocalciferol 1000 units daily
trazodone 50mg daily
aspirin 81mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours).
11. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation Q6H (every 6 hours).
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
14. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 7 days
then 400 mg daily x 7 days then 200 mg daily.
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
16. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash: apply to rash.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for PAIN/TEMP.
18. PICC Line
Non-Heparin: FLUSH with 10 mL of Normal Saline
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Past medical history:
Diabetes
Dyslipidemia
Hypertension
2 stents at [**Hospital1 3278**] in [**2129**] (not on plavix because of CVA)
atrial fibrillation not on Coumadin because of CVA
MCA stroke with hemorrhagic conversion s/p craniectomy in [**2132**]
at
Southshore
B12 deficiency
BPH
s/p craniectomy in [**2132**]
Discharge Condition:
Alert and oriented with Left Hemi-paresis
Ambulating with Max assist
Incisional pain managed with Tramadol
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 cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2142-2-8**] at 1:15PM in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) 10357**] [**Hospital Unit Name **]
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10165**] [**Name (STitle) 31187**] [**2142-1-22**] 12:00
**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:[**2142-1-9**]
ICD9 Codes: 2930, 4280, 4019, 2724, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8111
} | Medical Text: Admission Date: [**2133-2-8**] Discharge Date: [**2133-2-11**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
CODE STROKE (@[**Hospital1 18**] ED, called for right facial droop, right
hemiparesis and receptive aphasia)
Major Surgical or Invasive Procedure:
IV-tPA
History of Present Illness:
Ms. [**Known lastname **] is an 88 year-old right handed woman with a history
including dementia with delusions, hypertension, and
hyperlipidemia who presented about one hour after the acute
onset
of right facial droop, right hemiparesis and receptive aphasia
for whom a code stroke was called.
.
According to the [**Hospital 228**] nursing home, she was in her usual
state of health until this afternoon. She was in the dining
room,
enjoying dinner. She was apparently chatty, wishing everyone a
happy new year. She was last known well at about 4:30 pm.
Between 4:45 and 5 pm, she developed sudden onset right sided
weakness. She also devloped slurred speech and was making
non-sensical statements. Concerned she was having a stroke, the
patient was transferred to the [**Hospital1 18**].
.
Upon arrival, a code stroke was called. Glucose was 122.
Although the examination fluctuated, initial NIH stroke scale
score was 12 for inability to answer month and age (2), failure
to follow commands (2), right facial droop (1), decreased
movement of both lower extremities - likely a function of
comprehension difficulties (2, 2), severe aphasia characterized
by relatively fluent non-sensical speech and poor comprehension
(2), and dysarthria (1). Within about 20 minutes, she her right
upper extremity was completely paretic. Although a stat CT scan
was unrevealing, the examination findings were considered
concerning for a left MCA stroke. After discussions with her
health care proxy about the benefits and risks of the therapy,
t-pa was administered.
.
Past Medical History:
PMH:
# Senile Dementia with Delusional Features
# Osteoporosis
# Osteoarthritis
# Recurrent UTIs: 2 since [**1-13**].
# Hypertension: +fluctuations in BP with spells of anxiety
# Spinal stenosis
# Anxiety
# S/p rheumatic fever as a child
# Congestive heart failure
# Depression and Anxiety
Social History:
SOCIAL HISTORY: Lives close to nephew in [**Hospital3 **]
facility Falls at Cordingly [**Doctor Last Name **] ([**State 55056**], [**Location (un) 745**], MA.
Tel. [**Telephone/Fax (1) 55057**], primary nurse: [**Doctor First Name **]) with private nursing
staff/aides. Social EtOH, denies tobacco and illicits. Born in
[**Country 4754**] - moved here in [**2068**].
Family History:
FAMILY HISTORY:
-Mother died of complications of tuberculosis in
her 30s.
-Father died in his 80s.
-She had 2 brothers and 1 sister all of whom died of childhood
diseases including scarlet fever and diphtheria.
- 1 remote relative w/ early CVA o./w no premature CAD/ CVA/
- no familia malignancies
Physical Exam:
PHYSICAL EXAMINATION <<on admission>>:
Vitals: P: 74 R: 15 BP: 152/68 SaO2: 97 RA
General: Awake, NAD
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
Neck:
No carotid bruits appreciated.
Cardiac: Regular rate, normal S1 and S2 - some occasional extra
beats.
Pulmonary: Lungs clear to auscultation bilaterally anteriorly.
Abdomen: Round. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: Alert.
* Language: Language is fluent but non-sensical. Unable to
follow
verbal commands, can mimic some actions.
.
Cranial Nerves:
* I: Olfaction not evaluated.
* II: very difficult to perceive response - pupils 2mm. blinks
to threat with possible restriction on right
* III, IV, VI: EOM grossly intact
* VII: right facial
* VIII: Hearing intact to voice (turns head to speaker)
Motor:
* Tone: possible cogwheeling at left elbow, seems slightly
decreased in right extremities
Strength:
* Left Upper Extremity: lifts at least versus gravity
* Right Upper Extremity: initially lifts versus gravity -->
completely paretic
* Left Lower Extremity: lifts at least versus gravity
* Right Lower Extremity: able to withdraw at least in plane of
bed
Reflexes:
* Left: brisk throughout Biceps, Triceps, Bracheoradialis,
Patella
* Right: brisk thoughout Biceps, Triceps, Bracheoradialis,
Patella
* Babinski: toes tonically up given structure of foot
.
Sensation:
* Nailbed pressure: withdraws all limbs purposefully
Coordination
* difficult to evaluate
Gait:
* Description: deferred
Pertinent Results:
[**2133-2-11**] 07:10AM BLOOD WBC-7.6 RBC-4.21 Hgb-12.7 Hct-36.8 MCV-87
MCH-30.2 MCHC-34.5 RDW-14.0 Plt Ct-230
[**2133-2-10**] 02:20AM BLOOD WBC-8.4 RBC-3.98* Hgb-11.8* Hct-34.7*
MCV-87 MCH-29.7 MCHC-34.0 RDW-13.8 Plt Ct-219
[**2133-2-9**] 05:10AM BLOOD WBC-8.1 RBC-4.02* Hgb-11.9* Hct-35.0*
MCV-87 MCH-29.7 MCHC-34.1 RDW-13.8 Plt Ct-219
[**2133-2-8**] 09:37PM BLOOD WBC-9.0 RBC-4.11* Hgb-12.5 Hct-36.2
MCV-88 MCH-30.4 MCHC-34.6 RDW-14.2 Plt Ct-237
[**2133-2-8**] 06:05PM BLOOD WBC-8.1 RBC-4.37 Hgb-13.4 Hct-38.7#
MCV-88 MCH-30.6 MCHC-34.6 RDW-14.3 Plt Ct-233
[**2133-2-8**] 06:05PM BLOOD PT-12.9 PTT-25.8 INR(PT)-1.1
[**2133-2-11**] 07:10AM BLOOD Glucose-91 UreaN-7 Creat-0.5 Na-138 K-3.3
Cl-104 HCO3-24 AnGap-13
[**2133-2-10**] 02:20AM BLOOD Glucose-88 UreaN-12 Creat-0.7 Na-136
K-3.4 Cl-103 HCO3-26 AnGap-10
[**2133-2-9**] 05:10AM BLOOD Glucose-97 UreaN-16 Creat-0.6 Na-133
K-4.2 Cl-101 HCO3-24 AnGap-12
[**2133-2-8**] 09:37PM BLOOD Glucose-122* UreaN-19 Creat-0.7 Na-137
K-3.3 Cl-99 HCO3-27 AnGap-14
[**2133-2-8**] 06:05PM BLOOD UreaN-19 Creat-0.7 Na-138 K-3.6 Cl-101
HCO3-22 AnGap-19
[**2133-2-9**] 05:10AM BLOOD CK-MB-2 cTropnT-0.04*
[**2133-2-8**] 09:37PM BLOOD CK-MB-2 cTropnT-0.02*
[**2133-2-8**] 06:05PM BLOOD cTropnT-0.04*
[**2133-2-11**] 07:10AM BLOOD Calcium-9.4 Phos-2.3* Mg-1.8
[**2133-2-10**] 02:20AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.8
[**2133-2-9**] 05:10AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.3
[**2133-2-8**] 09:37PM BLOOD Calcium-10.1 Phos-4.6* Mg-1.5*
Cholest-190
[**2133-2-8**] 06:05PM BLOOD Calcium-10.4* Phos-3.7# Mg-1.7
[**2133-2-8**] 09:37PM BLOOD %HbA1c-5.9 eAG-123
[**2133-2-8**] 09:37PM BLOOD Triglyc-124 HDL-59 CHOL/HD-3.2
LDLcalc-106
[**2133-2-8**] 06:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
ECG on admission:
Cardiology Report ECG Study Date of [**2133-2-8**] 6:54:46 PM
Sinus rhythm and frequent atrial ectopy. Diffuse ST-T wave
changes
as recorded [**2133-1-10**]. The rate has slowed and the ST-T wave
changes are
somewhat less prominent. Frequent atrial ectopy has appeared.
Otherwise, no diagnostic interim change.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 160 102 462/479 104 -16 152
CXR on admission:
UPRIGHT AP VIEW OF THE CHEST: The heart size remains mildly
enlarged. The
aorta is tortuous and calcified, but the mediastinal contours
are unchanged from prior. Low lung volumes are again noted.
There is mild atelectatic changes noted in the left lung base.
The right lung is grossly clear. Degenerative changes are seen
within the left glenohumeral joint. There are no pneumothoraces
or pleural effusions.
IMPRESSION: Mild left basilar atelectasis.
NCHCT on admission:
FINDINGS: There is no acute intracranial hemorrhage. The
[**Doctor Last Name 352**]-white matter
differentiation is largely preserved. The ventricles and sulci
appear
prominent due to involutional change but not overtly changed
from prior study and likely appropriate given the patient's age.
There is no edema or mass effect. The paranasal sinuses and
mastoid air cells are clear. In the left parotid gland, there is
a hypodense round mass that measures 19 x 17 mm (2;3) which has
increased in size from the prior study.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or mass effect.
If clinical concern for stroke persists, MR is more sensitive in
detecting acute ischemia.
2. Left parotid mass which has increased in size since [**2127**];
nonemergent MR imaging is recommended with contrast.
MRI/MRA [**2133-2-9**]:
MRI BRAIN: There is a moderate to large acute infarct in the
left middle
cerebral artery territory, involving the parietal lobe and
insula. Gradient echo images demonstrate increased
susceptibility artifact in a small left parietal portion of the
infarct, consistent with blood products. There is unchanged
severe ventricular enlargement and moderate sulcal enlargement,
most likely due to atrophy with central predominance. There are
multiple foci of T2 hyperintensity in the supratentorial white
matter, suggesting chronic small vessel ischemia.
The known left parotid mass is poorly assessed due to motion.
MRA BRAIN: Motion artifact severely degrades image quality.
There is flow in the internal carotid and vertebral arteries,
without evidence of occulsion. The anterior and middle cerebral
arteries appear patent proximally. Flow within these arteries
appears diffusely attenuated, possibly due to motion, but it is
not possible to accurately assess for stenoses. Evaluation for
aneurysms is suboptimal.
IMPRESSION:
1. Acute left middle cerebral artery territory infarct,
involving the left parietal lobe and insula, with hemorrhagic
transformation.
2. Motion-degraded head MRA with limited diagnostic utility. No
evidence of occlusion of the left internal carotid or proximal
left middle cerebral
artery. Limited evaluation for stenoses or aneurysms.
3. Unchanged severe ventricular and moderate sulcal enlargement,
likely due to central atrophy. However, please correlate
clinically whether the patient may have symptoms of
communicating hydrocephalus.
Carotid duplex doppler U/S bilateral [**2133-2-9**]:
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On the right there is mild heterogeneous plaque in the
ICA. On the left there is mild heterogeneous plaque seen in the
ICA.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 56/13, 60/13, 53/9
cm/sec. CCA peak systolic velocity is 55 cm/sec. ECA peak
systolic velocity is 71 cm/sec. The ICA/CCA ratio is 1.1. These
findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 36/7, 42/11, 33/9 cm/sec. CCA peak
systolic velocity is 55 cm/sec. ECA peak systolic velocity is 47
cm/sec. The ICA/CCA ratio is .76. These findings are consistent
with <40% stenosis.
Right vertebral antegrade artery flow.
Left vertebral antegrade artery flow.
Impression: Right ICA stenosis <40%.
Left ICA stenosis <40%.
Brief Hospital Course:
Overall, the patient remained comfortable and HDS, with normal
and unremarkable VS. By system:
Neuro:
Patient had a stroke, Left M2-inferior division, as evidenced by
DWI/MRI (see report, above). Her initial exam findings improved
after receiving IV-tPA (right arm regained nearly full
strength). She was started on aspirin 81mg. Her LDL was 106, and
it was decided at this level, the risks of statin Tx probably
outweight the benefits. Donepazil was cont'd for
dementia/cognitive Sx.
Her current deficit, c/w the location of her stroke, is a
predominantly receptive Wernike's-type aphasia (preserved
repetition) with frequent made-up words and paraphasic
word/syllable substitutions.
Echocardiogram was not pursued at this time. Carotid imaging was
relatively clean (see above). HbA1c was wnl. LDL cholesterol was
106.
CV:
Home BP meds were held on admission for permissive hypertension
post-stroke. 3d later, after her SBPs ranged up into the 180s
(yet as low as 110s), her labetalol was restarted at home-dose
(150mg [**Hospital1 **]) and her HCTZ was re-started initially at half-dose
(12.5mg daily). Her amlodipine was not as yet restarted, to
avoid causing hypotension / hypoperfusion of the brain. Please
monitor her BPs and re-start this medication if needed for
hypertension (>140/90).
Pulm:
Inh Tx for COPD (Advair) was cont'd.
GU:
Also, Ms. [**Known lastname **] was found to have a UTI on admission (her UA
showed leukocytosis to >50 WBC, +nitrites, moderate
leuk.esterase, many bacteria). Pt had h/o several prior UTI with
3x pan-sensitive E coli and very recently a partially-resistent
Proteus sp., and was initially started on IV cefepime by ICU
team. Her UCx revealed a multi-drug-resistant E coli species
(resistant to Bactrim, Cipro, Ampicillin). It was sensitive to
cefazolin, cefepime, ceftazidime, ceftriaxone, gent/tobra,
nitrofurantoin (Macrobid). Macrobid not started [**3-11**]
recommendation against use in geriatrics pt [**Name (NI) 2793**] risk), and
instead she was switched to PO Cefpodoxime to finish a 7d total
course ending [**2133-2-16**].
Of note, pt. had been on Bactrim DS PO bid, presumably for
chronic/recurrent UTI. Given that her current E coli infection
is Bactrim-resistant, this plan should be re-evaluated by her
PCP (Bactrim was not re-started).
Of note, oxybutinin was not continued (anti-cholinergic
medication in a patient with dementia who is being actively
treated with a cholinesterase inhibitor). Please re-assess the
symptomatic risks/benefits of this medication in this patient.
Endo:
Evista was continued. VitD/Ca++ continued. Prednisone 5mg daily
was continued (per the ICU team, pt's [**Hospital1 1501**] said it was "for COPD"
-- the indication was not substantiated; please verify and
re-assess the need for this medication.
GI:
PPI and bowel regimen (senna/colace) were continued. No active
issues.
Other: other home meds were continued, except as above.
Also, there was an incidental parotid-gland finding on her MRI
(see report, above). This can be followed up with repeat imaging
in the future at the discretion of her PCP.
Medications on Admission:
- ensure 120 ml po bid
- amlodipine 5 mg po daily
- evista 60 mg po daily
- ferrous 325 mg po daily
- hctz 25 mg po daily
- kcl 10 meq po daily
- citalopram 20 mg po daily
- prednisone 5 mg po daily
- apap/codeine 300.30 mg po bid
- oxybutinin ER 5 mg po bid
- ca 500 mg po bid
- vit d 200 mg po bid
- labetalol 150 mg po bid
- advair 250/50 1 p q 12h
- protonix 40 mg po bid
- donepezil 10 mg po bid
- bactrim DS po bid
- bowel reg
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constip.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. raloxifene 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 0.5 Tablet
PO BID (2 times a day).
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
10. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily) as needed for stroke.
13. labetalol 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day) as needed for hypertension/heart (home med).
14. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day as needed for htn.
15. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) as needed for UTI with MDR-E coli sp.
16. potassium chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day: potassium
repletion while on HCTZ (previous home medication).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Nursing Care Center
Discharge Diagnosis:
Primary diagnoses:
- Stroke (ischemic Left-inferior-M2 division of MCA), s/p tPA
with improvement
- Urinary tract infection (multiple-drug-resistant E coli sp.),
s/p IV cefepime, now finishing 7d PO abx course
Secondary diagnoses:
- Senile Dementia with Delusional Features
- Osteoporosis
- Osteoarthritis
- Recurrent UTIs: 2 since [**1-13**].
- Hypertension: +fluctuations in BP with spells of anxiety
- Spinal stenosis
- Anxiety
- S/p rheumatic fever as a child
- h/o Congestive heart failure
- h/o Depression and Anxiety
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted because you had a stroke. You were given an
intravenous clot-busting medicine called tissue plasminogen
activator (tPA), and your symptoms improved somewhat afterwards,
particularly the strength in your Right arm. You were started on
aspirin to prevent future strokes. You were also treated for a
UTI, with antibiotics to continue for 5 days longer. Most of
your previous medications were continued, and your PCP can start
the rest as needed.
It was a pleasure caring for you. Best of luck, Ms. [**Known lastname **]!
Followup Instructions:
1. With your Nursing-home PCP, [**Name10 (NameIs) 3**] soon as able (per protocol,
after inpatient admission)
2. With Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **], stroke/Vascular Neurology attending
physician:
[**Name10 (NameIs) 766**], [**4-13**] at 2:00pm in the [**Hospital1 18**] [**Hospital Ward Name 23**] Clinical
Center, [**Location (un) 442**] (at [**Hospital1 1426**] and [**Location (un) **] Aves.) [**Telephone/Fax (1) 2574**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2133-2-11**]
ICD9 Codes: 5990, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8112
} | Medical Text: Admission Date: [**2124-3-1**] Discharge Date: [**2124-3-9**]
Date of Birth: [**2054-3-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Atenolol
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest pain, shortness of breath.
Major Surgical or Invasive Procedure:
cardiac catheterization
PICC line placed and removed
History of Present Illness:
69 year old female with CAD s/p MI and CABG '[**09**] presents with
intermittent chest pain x 1 week, worse in last 3 days with
shortness of breath, lower extremity swelling. Patient was
recently seen by PCP and aldactazide was d/c'ed on [**12-19**] and
lasix was d/c'ed on [**2124-1-19**] (in setting of worsening renal
function -lasix d/c'ed). In past couple weeks she notes
increasing SOB, 10-lb wt gain and increasing dyspnea on
exertion. She also noted intermittent chest pain during this
period but worse in past 3 days. She has slept sitting up for
the past 8 months. She came to ED after becoming very short of
breath on morning of admission. EKG q wave anterior ?ST
elevation in III. She was started on heparin gtt and nitro gtt.
She went to cath lab and found to have 90%lesion in OM which was
ballooned opened (couldn't stent). In the recovery area, patient
SOB lying flat (likely h/o OSA although none diagnosed). She was
on a non-rebreather satting 97%.
.
She was transferred to the CCU for further management. ABG in
the holding area on NRB was 7.29/57/148. On arrival to the CCU
she was placed on BiPAP, PS 10 PEEP 5, FiO2 50%. Her ABG on
noninvasive ventilation was 7.36/53/146. After approximately [**12-14**]
hours, she was feeling sufficiently less short of breath to be
weaned to nasal cannula, at which point her ABG was 7.39/49/67.
.
Initial vitals in the ED: 97.8, 98, 152/72, 20, 88% on RA. She
was given ASA, heparin gtt, lasix and sent to the cath lab.
.
On review of systems, + for non-productive cough X 3 weeks, and
post-nasal drip. She has gained 10 pounds over the past 2 weeks.
She denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, hemoptysis, black stools or red stools.
She denies recent fevers, chills or rigors. All of the other
review of systems were negative.
Past Medical History:
1. Coronary artery disease status post MI in [**2101**] and CABG in
[**2109**]
2. Diabetes mellitus type II, requiring large amounts of insulin
(last HgA1c 7.9)
3. CHF, last EF per echocardiogram 55%
Hypertension
4. Hypercholesterolemia
5. History of metastatic left-sided infiltrating ductal breast
cancer s/p chemo/XRT (post-CABG) dx'ed [**2111**]
6. Hypothyroidism
7. UTIs (h/o recurrent Ecoli UTI in past)
8. COPD
9. Anxiety
10. Postmenopausal bleeding status post D&C procedure on
[**2120-5-28**]
11. Obesity
Social History:
+70 pack-year history but quit in [**2101**], no EtOH or other drug
use. Widowed 5 years ago. Three grown children. Lives in her own
apt in her son's townhouse. Her daughter has helped her with her
ADLs over the past couple of days and does help her with her
shopping.
Family History:
No family history of premature coronary artery disease or sudden
death. Brother with both multiple myeloma and "thyroid
problems." [**Name2 (NI) **] mother had ?oral cancer.
Physical Exam:
VS - 120/64, 86, 19, 100% on CPAP 50% FiO2
Gen: Obese, elderly female in NAD. Oriented x3. Mood, affect
appropriate. On CPAP
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple, unable to appreciate JVD [**1-14**] obesity
CV: Unable to palpate PMI. RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
Chest: Midline surgical scar. Resp were unlabored, no accessory
muscle use. CTAB, no crackles, wheezes or rhonchi anteriorly.
Radiation skin changes to L breast.
Abd: Obese, soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: 2+ Bilateral LE edema to mid-shins. No femoral bruits. R
femoral sheath with minimal ooze.
Skin: no ulcers, rash
Pulses: Dopplerable dp/pt pulses
Pertinent Results:
Labwork on admission:
[**2124-3-1**] 09:40AM WBC-14.3* RBC-4.00* HGB-10.6* HCT-33.3*
MCV-83 MCH-26.4* MCHC-31.8 RDW-16.7*
[**2124-3-1**] 09:40AM PLT COUNT-273
[**2124-3-1**] 09:40AM PT-13.2* PTT-23.9 INR(PT)-1.2*
[**2124-3-1**] 09:40AM NEUTS-83.7* LYMPHS-12.2* MONOS-3.1 EOS-0.3
BASOS-0.7
[**2124-3-1**] 09:40AM GLUCOSE-277* UREA N-41* CREAT-1.2* SODIUM-141
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-18
[**2124-3-1**] 09:40AM CK(CPK)-159*
[**2124-3-1**] 09:40AM cTropnT-.48*
[**2124-3-1**] 09:40AM CK-MB-33* MB INDX-20.8* proBNP-6666*
.
Pertininent labs:
Creatinine: baseline 1.1, peak 6.1, on discharge 2.0
Hct: Baseline 26-27, Hct on discharge 24 (prior to receiving
1UPRBCs)
.
IMAGING
.
CHEST (PORTABLE AP) [**2124-3-1**]
This AP bedside radiograph is limited by patient's large size.
The heart is probably enlarged with previous CABG. No vascular
congestion. I doubt the presence of consolidations. I cannot
exclude effusions particularly on the right. Other than the
equivocal pleural changes on current examination there is a
little change from more satisfactory bedside exam [**2123-10-11**].
IMPRESSION: Suboptimal exam. No pneumonia and I doubt the
presence of CHF.
.
[**2124-3-1**] CARDIAC CATH: report pending
.
[**2124-3-2**] ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. No
masses or thrombi
are seen in the left ventricle. Overall left ventricular
systolic function is
moderately-to-severely depressed (30 percent) secondary to
global hypokinesis
with regional variation (the inferior and posterior walls appear
more
hypokinetic). There is no ventricular septal defect. Right
ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve
prolapse. Mild to moderate ([**12-14**]+) mitral regurgitation is seen.
[Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly
UNDERestimated.] There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2122-2-24**], the left ventricular ejection fraction now appears
reduced, but the
technically suboptimal nature of both studies precludes
certainty.
Brief Hospital Course:
69 year old female with CAD s/p MI and CABG, DMII, obesity, CHF
p/w NSTEMI in setting of CHF exacerbation.
.
#. Congestive heart failure. Ejection fraction on this admission
30% from 45% on last stress test [**2121**]. The patient was volume
overload on admission and soon became oliguric as below despite
escalating doses of lasix. The patient's oxygen saturations
remained stable. The patient was followed by Renal and may need
dialysis if urine output does not improve. The patient's
ACE-inhibitor was held for renal failure. The patient has not
tolerated a beta-blocker in the past and had one episode of
junctional bradycardia during admission. The patient should have
a repeat echocardiogram in two months for consideration of ICD
placement.
.
#. Acute renal failure. The patient remained oliguric/anuric and
volume overloaded but oxygen saturations remained stable. The
renal failure is likely contrast nephropathy. Her Diovan and
HCTZ were stopped given renal failure. The patient was followed
by Renal during admission, and creatinine gradually improved
from 6.1 to 2.0 on day of discharge. She will need to follow-up
with PCP one week after discharge to have kidney function
evaluated and further address resuming [**Last Name (un) **] and/or diuretics.
.
#. Coronary artery disease. The patient is status post CABG in
[**2109**] and admitted with NSTEMI on this admission now status post
cardiac catheterization on [**2124-3-1**] with no obvious source for
STEMI. The patient received PCTA to 90% stenosis of OM2. The
NSTEMI was likely demand ischemia from CHF exacerbation in
setting of discontinuation of diuretics. The patient was
continued on ASA, plavix, statin. The patient received
integrilin and heparin gtt on admission. The patient's
ACE-inhibitor was held for renal failure. The patient has not
tolerated a beta-blocker in the past and had one episode of
junctional bradycardia during admission.
.
#. Rhythm. Sinus rhythm. The patient hd one episode of
junctional bradycardia of unclear etiology but no subesequent
episodes. Electrophysiology followed the patient during
admission.
.
#. Hypoxemia, hypercarbic respiratory failure. Now resolved. The
patient has a 70 pack year smoking history with COPD and likely
restrictive defect secondary to obesity. The patient had an
additional element of pulmonary edema in the setting of anxiety
post-cath/lying flat/copious fluids peri-cath. The patient was
continued on albuterol/atrovent nebs.
.
#. Anemia. Stable. Iron studies consistent with iron-deficiency.
The patient also has a history of ACD and mild B12 deficiency.
The patient was started on iron supplementation, and prior to
discharge, she was transfused 1U PRBC for Hct 24 given her
extensive cardiac history. After discharge, she was monitored
for several hours for SOB, worsening DOE. She was able to
ambulate and dress herself with baseline shortness of breath,
oxygenation remained 97%.
.
#. Diabetes mellitus, type 2. Not well-controlled based on last
HgA1c. The patient was continued on lantus and HISS.
.
# Urinary tract infection. The patient was given a dose of
levaquin in the ED, but this was changed to ceftriaxone and then
cefpodoxime as the patient had a history of quinonlone-resistant
UTI in the past. Urine culture on this admission showed
sensitivity to quinolones and cephalosporins.
.
# Hypothyroidism. TSH 3.1 during this admission. The patient was
continued on her outpatient levothyroxine.
.
#. FEN : cardiac/[**Last Name (un) **] diet
.
#. Access: R PICC was placed for blood draws and d/c'd on
discharge
.
#. PPx:
- heparin sc
.
#. Code: FULL (confirmed with patient but would not want
prolonged intubation)
.
Post Discharge Follow-up by PCP [**Name Initial (PRE) 105948**]:
1) Repeat creatinine, hct one week post discharge
2) Address whether to restart Diovan 160, HCTZ 25, and/or other
diuretics
3) Repeat echo in 2 months to reassess EF and need for ICD
placement
Medications on Admission:
diovan 160mg po qday
aspirin 325
simvastatin 80 mg qday
LANTUS 100 U/ML--155 units sq every morning
LEVOTHYROXINE 150 MCG--One every day
HCTZ 25mg qday
levothyroxine 150mcg qday
metformin 1000mg po bid
lantus 155u sc qam
HISS sliding scale
FLONASE 50 mcg/Actuation--2 sprays each nostril once a day
lasix 40mg qod (on hold on [**2124-1-19**])
spironolactone 25mg po qday (D/c'ed on [**2123-12-19**])
cranberry tablets (UTI prevention)
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
4. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Cyanocobalamin 100 mcg Tablet Sig: 0.25 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Insulin
Please continue your outpatient insulin (Lantus) regimen as
before
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
coronary artery disease
Non ST segment elevation myocardial infarction
congestive heart failure
acute renal insufficiency
urinary tract infection
.
Secondary:
diabetes mellitus
obesity
hypothyroidism
iron deficiency anemia
Discharge Condition:
stable, saturating at baseline on room air
Discharge Instructions:
You had a heart attack as well as congestive heart failure.
During cardiac catheterization, you had an occlusion in one of
your coronary arteries which was subsequently opened. After
this, you also had renal failure, which is now improving
significantly.
You will need to have your kidney function checked regularly
until it returns to baseline.
Please continue to take all of your medications as prescribed.
Please weight yourself every day, maintain a low salt diet and
call your doctor if you have a greater than 3 pound weight gain
in [**12-14**] days, worsening swelling in your feet, or shortness of
breath.
Please call 911 or go to the emergency room if you have chest
pain, chest pressure, shortness of breath, fever, chills,
nausea/vomiting, or any other concerning symptoms.
Followup Instructions:
Please call [**Hospital3 **], [**Telephone/Fax (1) 250**], and schedule an
appointment with your primary care physician or [**Name Initial (PRE) **] nurse
practioner, to have your kidney function (creatinine) rechecked
early next week.
You already have to following appointments scheduled:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2124-3-28**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2124-5-16**] 10:00
ICD9 Codes: 496, 5859, 5845, 412, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8113
} | Medical Text: Admission Date: [**2134-3-2**] Discharge Date: [**2134-3-14**]
Date of Birth: [**2065-12-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
congestive heart failure
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
This is a 68yo M with h/o IPF(on 4L home O2), h/o PE/DVT,
diastolic heart failure with EF 55% who was admitted to the [**Hospital Unit Name 196**]
service on [**3-5**] for severe CHF. According to the patient, he
gained 10lbs and has increasing orthopnea despite increased
lasix dose. On admission, pro-BNP noted to be 23K. Patient did
not tolerate lasix and natrecor gtt secondary to hypotension.
Patient also did not tolerate dopamine gtt secondary to
tachycardia. Patient was evaluated by the CHF service and was
electively cathed to evaluate right sided pressure.
Catheterization showed mild pulmonary hypertension(34/20) with
minimal improvement with 100% O2 and NO(38/22 and 32/19
respectively). ALso RA 19, RVEDP 19, PCWP 19 suggestive of
restrictive cardiomyopathy. CI 1.8(4LO2) to CI 2.09(NO)
cath completed by right femoral arterial sheath with minimal
bleeding.
Of note, patient had atrial fibrillation responding to beta
blockade
Past Medical History:
1. Idopathic pulmonary fibrosis, followed by Dr. [**First Name (STitle) **] and
undergoing pulmonary rehab. Chronic home O2, 4 L.
2. htn
3. Pulm embolism '[**31**]
4. DVT '[**29**]
5. hyperlipidemia
6. CRI, baseline creat at 1.5
7. depression
8. diastolic CHF: EF 50-55%
9. hearing loss
10. macular degeneration
11. cholelithiasis
12.?sarcoidosis
Social History:
Retired in [**2127**]. Worked at [**Company 2676**] for 20 years as metal
worker. social EtOH. one pack-year tobacco history. quit 35
years ago. Lives with wife.H as 1 son and 1 grandson. They live
25 minutes away.
Family History:
Mother passed from CAD, father from brain tumor.
Physical Exam:
T96.6 P90 RR11 BP 95/84 100% on 4L
Gen- NAD caucasian gentleman
HEENT-unremarkable, no carotid bruit
CV_RRR, no r/m/g
resp-crackles [**1-21**] bilaterally
[**Last Name (un) 103**]-soft, nontender/nondistended
ext-right groin swan in place, no hematoma, no femoral bruit,
2+pitting edema
Pertinent Results:
pro BNP 23, 485
bilateral LENI -no DVT
TTE [**3-4**]
EF50%2+TR 2+MT
pMIBI [**10-22**]:normal without perfusion defects
Brief Hospital Course:
This is a 68yo M with h/o IPF(4L home O2), h/o PE/DVT, diastolic
heart failure with EF 55%, now has restrictive cardiomyopathy.
He was admitted in CCU for tailored diuresis.Despite aggresive
diuresis with natrcor, lasix drip, bumex and metolazone, he
fails to diurese. A search for the cause of restrictive
cardiomyopathy included fat pad biopsy of the heart to rule out
amyloidosis which was negative. Pyrophosphate scan and cardiac
MRI was impossible since patient was unable to lie flat. Renal
team was consulted for renal biopsy. According to them, since
there is no protein in the urine, this is not consistent with
renal amyloidosis and hence biopsy was not indicated.
ULtrafiltration was considered but this is not a long term
solution. Goal of care was discussed extensively with patient
and family. Patient opted for comfort measures and hence was
sent home with hospice.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed: titrate to patient comfort.
Disp:*QS QS* Refills:*0*
4. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal
q 3 days as needed for secretions: may place more than one patch
to control secretions as needed.
Disp:*30 30* Refills:*0*
6. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed: titrate to patient comfort.
Disp:*30 Tablet(s)* Refills:*2*
8. Bumex 2 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*QS ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
restrictive cardiomyopathy
Idopathic pulmonary fibrosis, followed by Dr. [**First Name (STitle) **] and
undergoing pulmonary rehab. Chronic home O2, 4 L.
hypertension
Pulm embolism '[**31**]
DVT '[**29**]
hyperlipidemia
Chronic renal insufficiency, baseline creat at 1.5
depression
diastolic congestive heart failure
hearing loss
macular degeneration
cholelithiasis
sarcoidosis
Discharge Condition:
poor
Discharge Instructions:
This patient's goals revolve around comfort. All reasonable
efforts should be made to relieve pain or shortness of breath or
whatever other discomforts the patient experiences.
To this end, his ativan, scopolamine patch, and morphine should
be titrated accordingly.
Followup Instructions:
PCP: [**Name10 (NameIs) 1576**],[**Name11 (NameIs) 1575**] [**Telephone/Fax (1) 1144**]
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
Completed by:[**2134-3-14**]
ICD9 Codes: 4280, 4254, 9971, 4271, 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8114
} | Medical Text: Admission Date: [**2166-11-8**] Discharge Date: [**2166-11-13**]
Date of Birth: [**2103-10-1**] Sex: F
Service: [**Hospital1 **]
CHIEF COMPLAINT: Hypotension
HISTORY OF PRESENT ILLNESS: This is a 63-year-old woman with
a history of hypertension, admitted to the Emergency
Department after a fall. The patient states that she had
about three-fourths of a glass of wine earlier in the night.
She said she got out of bed to urinate, did not feel
intoxicated, but did feel sleepy and tired. She was also
walking in the dark. The patient then fell to the ground,
and she believes she had loss of consciousness. She did not
remember falling. She hit her left upper face and left elbow
on the furniture. She denied any nausea, vomiting, diarrhea,
lightheadedness, headache, weakness. She did not have any
chest pain, palpitations, or sweating. After falling, the
patient could not pick herself up. Every time she tried to
pick herself up, she continued to fall again. She described
her feeling as generalized weakness. The patient was then
found by her daughter, sitting on the floor and unable to
move.
The daughter described her mother as being very short of
breath and staring off into space. EMS was called, who
brought the patient to [**Hospital1 69**].
In the Emergency Department, the patient's pressure was
initially 90/60, which then dropped to 60/palp. Heart rate
continued to stay in the 80s. Initial laboratories revealed
white blood cells of 29.4, with a low-grade temperature.
Sodium 118. She was treated with aggressive intravenous
fluids and dopamine. She was also noted to have elevated CK,
MB and troponin, with ST elevations in V2 through V4 in the
Emergency Department. Echocardiogram performed in the
Emergency Department did not demonstrate any wall motion
abnormalities. The patient was transferred to the Intensive
Care Unit, and she received a dose of stress-dose steroids.
She was weaned off the dopamine. She was given a presumptive
diagnosis of adrenal insufficiency, and transferred to the
floor.
PAST MEDICAL HISTORY:
1. Hypertension of several years' duration
2. Glaucoma
3. Status post cholecystectomy [**96**] years ago for cholangitis
MEDICATIONS:
1. Candesartan 60 mg by mouth once daily
2. Lorazepam 0.5 mg by mouth daily at bedtime as needed
3. Timolol 0.5% one drop to both eyes twice a day
ALLERGIES: Eggs - diarrhea and fever.
FAMILY HISTORY: Father died at age 61 with coronary artery
disease, myocardial infarction, question of arrhythmia.
Mother had gastric cancer, bleeding ulcers, diabetes, died at
82. Sister died at age 38 with cancer of unknown origin. A
brother died of lung cancer at age 67. A brother died of
cancer at 58 with question of bone cancer. Her brother is
living at 73 with prostate and bladder cancer.
SOCIAL HISTORY: The patient lives in a house with her
husband. She has been married since [**2127**]. She has a
daughter and a son who help care for her husband because he
is physically challenged. The patient has six children, all
of whom are healthy. She used to smoke approximately 67 pack
years, but quit recently. She drinks occasional alcohol, up
to three glasses of wine on the weekends. She states that
she feels safe at home, and denies any history of domestic
violence.
PHYSICAL EXAMINATION: In the Medical Intensive Care Unit,
general is quiet, pleasant, in no acute distress. Head,
eyes, ears, nose and throat: Ecchymosis and swelling at the
left periorbital area. Visual acuity roughly intact,
oropharynx dry, no lymphadenopathy, wasting of cheeks,
temporal area, prominent forehead. Heart: Regular rate and
rhythm, no murmurs, gallops or rubs. Lungs: Coarse breath
sounds throughout. Abdomen: No hepatosplenomegaly, no
inguinal lymphadenopathy. Extremities: No cyanosis,
clubbing or edema. Neurologic: Grossly intact.
LABORATORY DATA: White blood cells 29.4, hematocrit 41,
platelets 405. Differential: 92 neutrophils, 0 bands, 4.6
lymphs. Urinalysis: Large blood, nitrate negative, 30
protein, white blood cells [**11-19**], 0 red blood cells. Chem 7:
Sodium 115, potassium 5.1, chloride 79, bicarbonate 17, BUN
8, creatinine 0.8, glucose 80, anion gap 19. CK ranging from
468 to 875 to 933, MB of 12 and 32, MB index of 2.6 and 3.7,
troponin 2.8 and 8.5. Toxicology screen: Ethanol 32. Serum
osmolality 257.
HOSPITAL COURSE:
1. Endocrine: The patient was initially admitted to the
Medical Intensive Care Unit. After her blood pressure was
unresponsive to a few liters of intravenous fluids and
dopamine, the patient was given a stress dose of steroids,
with rapid correction of her blood pressure. An initial
diagnosis of adrenal insufficiency was made. However, after
being transferred to the floor, the patient's cortisol, which
was drawn prior to starting on the steroids, came back at 25.
Endocrine consult was obtained, and they felt this was
inconsistent with adrenal insufficiency. The patient was
taken off her stress-dose steroids, and her blood pressure
remained stable. Although it appears that the initial
cortisol was drawn prior to getting the steroids, the patient
will be referred for outpatient ACTH stim test to ensure the
patient does not have any underlying adrenal insufficiency.
2. Cardiac: The patient had elevated cardiac enzymes and ST
elevations in the setting of hypotension. The patient likely
had a small myocardial infarction secondary to decreased
blood supply in the setting of hypotension. The patient had
initial echocardiogram in the Emergency Department, which was
read as mildly depressed systolic function with apical
akinesis to hypokinesis. The patient was sent for repeat
echocardiogram three days after admission, which revealed an
ejection fraction of greater than 50%, a left-to-right shunt
across the intra-atrial septum, consistent with a
secundum-type atrioseptal defect. Right ventricle was mildly
dilated, aortic valve mildly thickened, mitral valve mildly
thickened, trivial mitral regurgitation, mild pulmonary
artery systolic hypertension. The patient remained stable,
with no events on telemetry. Her electrocardiogram continued
to demonstrate T wave inversions laterally. The patient was
referred for ETT echo. The patient had normalization of her
T wave inversions laterally, with mild 0.5 mm of ST segment
depression which returned to [**Location 213**] after stopping. This
occurred at a high double product. These were not felt to be
significant. Echocardiogram final report is unavailable, but
preliminary report revealed no wall motion abnormalities,
consistent with ischemia. It is unlikely that the patient
had a myocardial infarction precipitating her hypotension.
3. Hypotension: The exact cause of the patient's
hypotension remains unclear. Should the patient turn out to
be adrenally insufficient, this would provide an explanation.
This does, however, appear unlikely. Her history is
inconsistent with a seizure or cerebrovascular accident. The
patient did receive 1 gram of ceftriaxone in the Emergency
Department. It is possible she had some type of infection
which this treated and allowed her immune system to recover.
Again this is not clear to have occurred. It is possible the
patient took more substantial doses of her medications than
she stated. However, she appears to be a good historian and
denies doing this. The patient was observed in-house for
five days, and had normal to hypertensive blood pressures.
The patient was restarted on her candesartan, and was started
on Lopressor 12.5 mg by mouth twice a day, which the patient
remained on and had high normal blood pressures. She
remained stable and was ready for discharge. Of note, the
patient also had a CT of the chest with contrast which
demonstrated extensive emphysematous changes, small bilateral
pleural effusions, and a multi-nodular goiter. No evidence
of pulmonary embolism was seen. She had a CT of the abdomen
and pelvis which did not reveal any evidence of hemorrhage.
She had a cervical spine film which did not reveal fracture.
She had a head CT which did not reveal acute intracranial
bleed. It did show an old left caudate head lacunar infarct.
4. Elevated liver enzymes: The patient's liver enzymes
initially went up into the several hundreds. This was
believed to be the result of her hypotension and the patient
having shock liver. Her liver function tests continued to
decrease throughout her admission. Hepatitis serologies were
drawn, but these are pending at the time of discharge.
5. Fluids, electrolytes and nutrition: The patient was
volume depleted on admission. She was given intravenous
fluids with some improvement in her symptoms. This may have
occurred from decreased oral intake and alcohol use.
6. Alcohol use: The patient admits to drinking up to three
glasses of wine on a weekend day. She was advised about the
risks of drinking excessive amounts of alcohol, and its
possibility to include fall, liver damage.
7. Weight loss: The patient notes a 60 pound weight loss
over the past many months. She states this is unintentional,
but she has noticed a decrease in her appetite. She had
negative head CT, chest, abdomen and pelvis CT, and has had
negative colonoscopy in the past year. There is no clear
etiology to her weight loss, and this needs to be followed up
as an outpatient.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home with
her family. She will follow up on the day after discharge to
have ACTH stim test performed. She will then follow up with
her primary care physician in one week.
DISCHARGE DIAGNOSIS:
1. Hypotension of unclear etiology
2. Myocardial infarction secondary to hypotension
3. Shock liver
4. Volume depletion
5. Multi-nodular goiter
6. Hypertension
7. Weight loss
DISCHARGE MEDICATIONS:
1. Candesartan 60 mg by mouth once daily
2. Lopressor 12.5 mg by mouth twice a day
3. Lorazepam 0.5 mg by mouth daily at bedtime
4. Timolol 0.5% one drop to both eyes twice a day
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Name8 (MD) 17420**]
MEDQUIST36
D: [**2166-11-13**] 21:32
T: [**2166-11-14**] 02:44
JOB#: [**Job Number **]
ICD9 Codes: 4589, 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8115
} | Medical Text: Admission Date: [**2153-7-15**] Discharge Date: [**2153-8-10**]
Date of Birth: [**2070-7-21**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 17197**]
Chief Complaint:
Left Lower Quadrant pain s/p fall
Major Surgical or Invasive Procedure:
[**2153-7-18**]:Endovascular repair of abdominal aortic aneurysm
History of Present Illness:
82F w/ h/o chronic LE venous stasis disease w/ LLE swelling and
multiple falls s/p mechanical fall two days ago that caused LUE
injuries including possible regional hand/wrist fracture, elbow
lac and hand/arm ecchymosis/pain. She
was attempting to get up from chair but felt weak and couldn't
support herself. She denies head trauma/LOC. Presented to [**Hospital1 18**]
[**Location (un) 620**] ED and was discharged after negative work-up. The
patient also c/o LLQ/flank pain that had started shortly after
fall but this has been persistently intermittent and worse with
movement. She is unable to definitively state if she had hit her
LLQ/flank w/ fall. She returned to the [**Hospital1 18**] [**Location (un) 620**] ED earlier
today. She denies F/C/N/V/SOB/CP/changes in bowel/bladder
function. On w/u a CT torso w/ contrast was performed that
demonstrated incidental finding of 6x5.6cm infrarenal AAA w/o
any evidence of extravasation. We are consulted for AAA.
Past Medical History:
Hypertension
Hypothyroidism
LLE DVT
Dementia
Chronic LLE edema/rash
Multiple falls
Frontal hematoma
cholecystectomy
Social History:
lives in senior housing, lives alone and
ambulates w/ walker, has remote smoking history, denies
ETOH/IVDU
Family History:
NC
Physical Exam:
PHYSICAL EXAM
Vital Signs: Temp: 96.8 RR: 16 Pulse: 70 BP: 190/91 O2 Sat:
96%3L
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, Obese, +LLQ/flank TTP mostly
localized to ASIS/lat abdomen, no ecchymosis, no TTP otherwise,
no guarding/rebound.
Rectal: Not Examined.
Extremities: Abnormal: LLE edema/erythema/scaling w/ venous
stasis changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE Femoral: P. Popiteal: D. DP: D. PT: N.
LLE Femoral: P. Popiteal: D. DP: D. PT: N.
Pertinent Results:
[**2153-7-15**] 06:38AM BLOOD WBC-7.8 RBC-3.95* Hgb-12.1 Hct-35.9*
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.5 Plt Ct-153
[**2153-8-4**] 03:28AM BLOOD WBC-8.1 RBC-3.16* Hgb-9.4* Hct-29.3*
MCV-93 MCH-29.8 MCHC-32.2 RDW-16.6* Plt Ct-204
[**2153-8-5**] 12:26AM BLOOD WBC-7.1 RBC-2.78* Hgb-8.5* Hct-25.7*
MCV-93 MCH-30.5 MCHC-33.0 RDW-16.8* Plt Ct-189
[**2153-8-6**] 03:41AM BLOOD WBC-6.3 RBC-2.76* Hgb-8.6* Hct-26.0*
MCV-94 MCH-31.2 MCHC-33.1 RDW-16.9* Plt Ct-156
[**2153-8-7**] 02:21AM BLOOD WBC-5.9 RBC-2.74* Hgb-8.4* Hct-26.0*
MCV-95 MCH-30.8 MCHC-32.5 RDW-17.1* Plt Ct-163
[**2153-8-8**] 04:00AM BLOOD WBC-5.7 RBC-2.75* Hgb-8.2* Hct-25.5*
MCV-93 MCH-29.9 MCHC-32.2 RDW-17.2* Plt Ct-136*
[**2153-8-9**] 04:35AM BLOOD WBC-5.9 RBC-2.58* Hgb-8.0* Hct-24.3*
MCV-94 MCH-31.1 MCHC-33.0 RDW-17.3* Plt Ct-139*
[**2153-8-10**] 06:42AM BLOOD WBC-4.9 RBC-2.84* Hgb-8.9* Hct-26.5*
MCV-93 MCH-31.3 MCHC-33.6 RDW-17.4* Plt Ct-129*
[**2153-8-9**] 04:35AM BLOOD PT-13.0 PTT-63.6* INR(PT)-1.1
[**2153-8-10**] 06:42AM BLOOD Plt Ct-129*
[**2153-7-15**] 06:38AM BLOOD Glucose-111* UreaN-26* Creat-1.1 Na-142
K-3.9 Cl-104 HCO3-28 AnGap-14
[**2153-8-4**] 03:28AM BLOOD Glucose-117* UreaN-41* Creat-1.4* Na-146*
K-3.9 Cl-104 HCO3-35* AnGap-11
[**2153-8-5**] 12:26AM BLOOD Glucose-112* UreaN-40* Creat-1.3* Na-144
K-3.7 Cl-103 HCO3-34* AnGap-11
[**2153-8-6**] 03:41AM BLOOD Glucose-110* UreaN-36* Creat-1.4* Na-139
K-3.9 Cl-100 HCO3-33* AnGap-10
[**2153-8-7**] 02:21AM BLOOD Glucose-122* UreaN-38* Creat-1.3* Na-138
K-4.1 Cl-99 HCO3-34* AnGap-9
[**2153-8-8**] 04:00AM BLOOD Glucose-122* UreaN-43* Creat-1.3* Na-139
K-4.5 Cl-100 HCO3-34* AnGap-10
[**2153-8-9**] 04:35AM BLOOD Glucose-243* UreaN-59* Creat-1.4* Na-140
K-4.0 Cl-101 HCO3-31 AnGap-12
[**2153-7-18**] 06:41PM BLOOD CK(CPK)-78
[**2153-7-19**] 03:59AM BLOOD CK(CPK)-146
[**2153-7-19**] 12:27PM BLOOD CK(CPK)-651*
[**2153-7-20**] 03:07AM BLOOD CK(CPK)-1134*
[**2153-7-20**] 10:32AM BLOOD CK(CPK)-952*
[**2153-7-21**] 03:06AM BLOOD CK(CPK)-1518*
[**2153-7-30**] 02:59AM BLOOD ALT-18 AST-20 AlkPhos-92 TotBili-0.3
[**2153-8-5**] 12:26AM BLOOD ALT-23 AST-23 LD(LDH)-193 AlkPhos-92
TotBili-0.4
[**2153-7-18**] 06:41PM BLOOD CK-MB-4 cTropnT-<0.01
[**2153-7-19**] 03:59AM BLOOD CK-MB-4 cTropnT-<0.01
[**2153-7-19**] 12:27PM BLOOD CK-MB-7 cTropnT-<0.01
[**2153-7-20**] 03:07AM BLOOD CK-MB-6
[**2153-7-21**] 03:06AM BLOOD CK-MB-14* MB Indx-0.9
[**2153-7-27**] 02:09AM BLOOD calTIBC-190* Ferritn-285* TRF-146*
[**2153-7-28**] 02:09AM BLOOD calTIBC-196* Ferritn-270* TRF-151*
[**2153-8-4**] 06:41PM BLOOD %HbA1c-5.5 eAG-111
[**2153-7-17**] 04:15PM BLOOD T4-8.2
[**2153-8-9**] 09:15PM BLOOD T4-5.4 T3-46*
[**2153-8-3**] 05:50AM BLOOD Vanco-26.5*
[**Known lastname **],[**Known firstname 95**] [**Medical Record Number 97044**] F 83 [**2070-7-21**]
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2153-8-4**]
9:19 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] CSRU [**2153-8-4**] 9:19 AM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 97045**]
Reason: eval for stroke
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with left sided weakness
REASON FOR THIS EXAMINATION:
eval for stroke
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: AFSN SAT [**2153-8-4**] 12:56 PM
Somewhat limited study by motion. Acute right periventricular
subcortical
infarct is seen. Other hyperintensities on diffusion images
could be due to
shine through or subacute infarcts. Severe changes of small
vessel disease
are seen. Also noted is a 2-cm mass partially visualized on
diffusion images
within the right parotid. This can be further evaluated with CT
of the neck
or MRI of the neck as clinically appropriate.
Final Report
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with left-sided weakness.
TECHNIQUE: T1 sagittal and FLAIR T2 susceptibility and diffusion
axial images
of the brain were acquired. Correlation was made with CT of
[**2153-7-24**].
FINDINGS: Diffusion images demonstrate an area of acute
subcortical
periventricular infarct in the right periventricular region
adjacent to the
posterior portion of the body of the right lateral ventricle.
Subtle
hyperintensities in the left periventricular region and right
occipital region
on diffusion images appear to be T2 shine through or could be
due to subacute
infarcts. Diffuse small vessel disease is identified in the
white matter.
Several subcortical lacunes are seen in both basal ganglia
region. Thalami
also demonstrate chronic infarcts. There is mild to moderate
brain atrophy
seen. Vascular flow voids are maintained.
IMPRESSION: Somewhat limited study by motion. Acute right
periventricular
subcortical infarct is seen. Other hyperintensities on diffusion
images could
be due to shine through or subacute infarcts. Severe changes of
small vessel
disease are seen. Also noted is a 2-cm mass partially visualized
on diffusion
images within the right parotid. This can be further evaluated
with CT of the
neck or MRI of the neck as clinically appropriate.
[**Known lastname **],[**Known firstname 95**] [**Medical Record Number 97044**] F 83 [**2070-7-21**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2153-8-5**] 1:22
PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] CSRU [**2153-8-5**] 1:22 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 97046**]
Reason: please eval interval change
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with s/p EVAR, post-op course c/b
respiratory failure
REASON FOR THIS EXAMINATION:
please eval interval change
Final Report
HISTORY: Status post EVAR, respiratory failure.
CHEST, SINGLE AP PORTABLE VIEW.
A stent overlies the midline in the upper abdomen, presumably an
aortic stent.
An oral-type tube is present, extending beneath diaphragm,
overlying stomach.
Right IJ central line is present, tip over distal SVC.
There is mild cardiomegaly. The left hemidiaphragm is slightly
elevated, with
patchy opacity at the left base with possible minimal pleural
effusion. Upper
zone redistribution, without overt CHF. Minimal atelectasis
right base. No
focal consolidation or pleural effusion on the right.
? background COPD.
[**Known lastname **],[**Known firstname 95**] [**Medical Record Number 97044**] F 83 [**2070-7-21**]
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of
[**2153-8-9**] 1:10 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] FA5 [**2153-8-9**] 1:10 PM
VIDEO OROPHARYNGEAL SWALLOW Clip # [**Clip Number (Radiology) 97047**]
Reason: video swallow eval
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with swallowing difficulty
REASON FOR THIS EXAMINATION:
video swallow eval
Wet Read: [**First Name9 (NamePattern2) **] [**Doctor First Name **] [**2153-8-9**] 1:40 PM
1. Mild penetration with thin barium.
2. Difficulty and delay in bolus formation in the oral cavity at
the
initiation of the oropharyngeal phase of swallowing.
Wet Read Audit # 1
Final Report
HISTORY: 83-year-old woman, with swallowing difficulty.
COMPARISON: None.
TECHNIQUE: Swallowing oropharyngeal fluoroscopy was performed in
conjunction
with the speech and swallow division. Multiple consistencies of
barium were
administered.
FINDINGS: The patient continues to demonstrate difficulty in
initiation of
bolus formation. There is also reduced hyolaryngeal excursion.
Minimal
penetration is noted with thin barium, but there is no frank
aspiration.
There is no induced gag reflex or cough.
IMPRESSION:
1. Mild penetration with thin barium.
2. Difficulty and delay in bolus formation, and reduced
hyolaryngeal
excursion.
Please refer to the speech therapist's report for detailed
evaluation and
recommendation.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 95**] [**Hospital1 18**] [**Numeric Identifier 97048**]TTE (Complete)
Done [**2153-7-23**] at 11:48:27 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**], Division of Vascular [**Last Name (un) **]
[**Hospital Unit Name 22682**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2070-7-21**]
Age (years): 83 F Hgt (in): 67
BP (mm Hg): 149/53 Wgt (lb): 173
HR (bpm): 77 BSA (m2): 1.90 m2
Indication: New atrial fibrillation. ?thrombus.
ICD-9 Codes: 427.31, 424.0, 424.2
Test Information
Date/Time: [**2153-7-23**] at 11:48 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2011W000-0:00 Machine: Vivid q-1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 2.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.8 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.4 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.1 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Left Ventricle - Stroke Volume: 71 ml/beat
Left Ventricle - Cardiac Output: 5.46 L/min
Left Ventricle - Cardiac Index: 2.87 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.14 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 10 < 15
Aorta - Sinus Level: 3.5 cm <= 3.6 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 25
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Pressure Half Time: 553 ms
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - E Wave deceleration time: 219 ms 140-250 ms
TR Gradient (+ RA = PASP): *36 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Elongated LA. No LA mass/thrombus (best excluded by
TEE).
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). Estimated cardiac
index is normal (>=2.5L/min/m2). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
The patient appears to be in sinus rhythm. Frequent atrial
premature beats.
Conclusions
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). 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 leaflets are mildly thickened. Mild [1+]
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Pulmonary artery systolic
hypertension. Mild mitral regurgitation. No intra-atrial
thrombus seen (best excluded by TEE).
Brief Hospital Course:
[**7-17**]- Cleared by Medicine team for OR. Underwent emergent EVAR
that evening for worsening abdominal pain.
[**7-18**]- Intubated for resp distress and pressors started.
Transferred to CVICU. Underwent emergent Bronch for RLL collapse
[**7-19**]- Intubated, sedated. CTA done, negative for PE. LENIs neg
for clot.
[**7-20**]- Started Vanc and Zosyn for VAP. Continue diuresis
[**7-21**]- Tube feeds started via dobhoff. Continue diuresis.
[**7-22**]- Extubated. Tube feeds at goal. Antibiotics discontinued.
[**7-23**]-Amiodarone gtt started for intermittent rapid atrial
fibrillation. Continue diuresis.Echo done- EF >60%.
[**7-24**]-Continue aggressive pulm toilet. Continue Tube
feeds.Geriatrics consulted for lethargy/ICU delirium.CT head
negative.
[**7-25**]- Converted to Sinus rhythm. Reintubated overnight for
somnolence, inability to clear secretions.
[**7-26**]-Intubated. Started on Vanc/Zosyn for hospital aquired
pneumonia, GNR in sputum. Bronchoscopy showed left pleural
effusion, BAL with GN diplococci and Staph auresu coag +..
[**7-27**]-Continue lasix with diamox.
[**7-28**]-mental status improving. Extubated.
[**7-29**]-SVT. Vancomycin discontinued. Requiring bipap PRN and NT
suctioning. Family meeting
[**7-30**]-
[**7-31**]-Bursts of Afib.Episode of emesis with turning, concerning
for possible aspiration. Tube feeds held. Bedside swallow eval
done-pt made NPO. CXR done. Still lethargic with minimal left
arm movement. Neurology consulted and recommended MRI brain and
to continue aspirin.
[**8-1**]- Pt more awake. Back in atrial fibrillation- titrated
lopressor and continue amiodarone.
[**8-2**]-Improving mental status. Bedside swallow re-eval: continue
NPO.
[**8-3**]- Amiodarone changed to 400mg po BID. No Coumadin secondary
to fall risk. PT eval.
[**8-4**]-MRI:acute right periventricular subcortical infart. Likely
embolic per Neuro. with left sided weakness. Heparin gtt started
per Neurology recomendations as not a coumadin candidate given
history of falls. Aspirin d/c'd.
[**8-5**]- Tube feeds restarted.
[**8-6**]- Antibiotics discontinued. Statin started. Carotid
ultrasound done- <30% [**Doctor First Name 3098**], [**Country **] cannot be seen due to presence
of dressing. PT re-eval. Speech and swalllow: ground solids/thin
liqs. Nutrition consult.
[**8-7**]-Neurology signed off. Dobhoff removed. Diet advanced.
Heparin gtt continues.Continue diuresis. OT eval.
[**8-8**]-Continues on Heparin gtt. Calorie counts for poor po
intake. Speech and Swallow recommended ground solids and thin
liquids, meds crushed in applesauce.
[**8-9**]-Transferred to floor. ? aspirated while eating breakfast.
Speech and Swallow re-eval with video swallow: rec nectar thick
liqs and moist soft diet with 1:1 supervision. Transfused 1unit
of PRBCs for hct 24.3.
[**8-10**]-Heparin gtt discontinued. Started on 325mg of Aspirin for
embolic stroke.Hct stable at 26
Medications on Admission:
amlodipine 10', levothyroxine 112mcg', valsartan [Diovan] 320',
vit B1'
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Year (2) **]: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheeze.
2. ipratropium bromide 0.02 % Solution [**Month/Year (2) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze.
3. docusate sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: Fifty (50) mg PO BID
(2 times a day): Hold for loose stools.
4. levothyroxine 112 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
5. acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. valsartan 160 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
8. amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times
a day) for 1 weeks.
9. amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day
for 1 weeks: Start after 400 [**Hospital1 **] taper finished.
10. amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day:
Continue after 200mg [**Hospital1 **] taper until follow up with PCP.
11. simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
12. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
13. hydralazine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO q6H PRN as
needed for SBP>140.
14. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for yeast.
15. dextrose 50% in water (D50W) Syringe [**Hospital1 **]: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
16. glucagon (human recombinant) 1 mg Recon Soln [**Hospital1 **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
17. Regular Insulin Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
0-70 Proceed with hypoglycemia protocol
71-150 0Units 0Units 0Units 0Units
151-200 3Units 3Units 3Units 3Units
201-250 6Units 6Units 6Units 6Units
251-300 9Units 9Units 9Units 9Units
301-350 12Units 12Units 12Units 12Units
> 350 Notify M.D. Notify
18. aspirin 325 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day: for stroke
prophylaxis as coumadin contraindicated.
19. heparin [**Hospital1 **]: 5000 (5000) units Subcutaneous three times a
day: For DVT prophylaxis. [**Month (only) 116**] discontinue when ambulating TID.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Abdominal Aortic Aneurysm
Respiratory Failure
Embolic CVA
Atrial Fibrillation
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**3-22**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**5-23**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20205**], MD Phone:[**Telephone/Fax (1) 20206**]
Date/Time:[**2153-9-14**] 12:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2153-9-14**] 11:30
Completed by:[**2153-8-10**]
ICD9 Codes: 5185, 5070, 2930, 5180, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8116
} | Medical Text: Admission Date: [**2143-4-14**] Discharge Date: [**2143-5-13**]
Date of Birth: [**2143-2-17**] Sex: M
Service: NBB
Interim summary covering [**2143-4-8**] to [**2143-5-13**].
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: He had
no apnea or bradycardia during the time covered in this
interim dictation. He did have some desaturations associated
with feeding, but none were associated with color change. He
did have 1 desaturation on [**5-8**], not associated with a
feeding. At the time of his discharge, he was free of
desaturations or apnea greater than 5 days prior to his
discharge.
Cardiovascular: He was cardiovascularly stable during this
interim period.
Fluids, Electrolytes and Nutrition: He was decreased in his
calories to Similac 20 calories per ounce. He was taking ad
lib feedings with a minimum of 130 ml/kg/day. His discharge
weight was 3585 g.
Hematology: His most recent hematocrit from the [**5-17**]
was 27.6%. He will be discharged home on iron
supplementation.
Neurology: He had a left subgaleal shunt placed at [**Hospital3 18242**] on the [**5-8**]. He stayed at [**Hospital3 18242**] for 1 week after that. He came back to [**Hospital3 **]
Hospital and was managed with neurosurgical removal of fluid
around the shunt intermittently at the bedside. At the time
of his discharge, he had had 3 stable head ultrasound without
interval removal of fluid. Head ultrasound findings were
summarized as follows - he continued to have asymmetric right
ventricle and left ventricle with normal amount of
cerebrospinal fluid, no ventriculomegaly on the left, small
area of cystic development in the periventricular white
matter on the left, evidence of bilateral subgaleal shunt
placement. His resistive indices remained elevated with
compression, but were otherwise normal. He has been seen
frequently by Neurosurgery and Neurology and will have follow-
up on Thursday, [**5-16**] with Neurosurgery as an outpatient
with ultrasound to be performed at that time. He will also
have close follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in Pediatric
Neonatal Neurology in [**3-1**] weeks' time. Referral has been made
to Neonatal [**Hospital 878**] Clinic and they will contact parents
with appointment information. Neurosurgical clinical
coordinator, [**Female First Name (un) 60451**], will also be contacting the parents for
appointments. Her contact phone number is [**Telephone/Fax (1) 60452**].
Audiology: He passed his hearing screening.
Ophthalmology: Most recent ophthalmological examination
showed mature retinas. He will need follow-up in [**6-5**] months'
time with Pediatric Ophthalmology.
Immunizations: He received hepatitis B vaccination.
His car seat position testing was passed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], phone number
[**Telephone/Fax (1) 37802**], fax number [**Telephone/Fax (1) 38332**], [**Hospital 1426**] Pediatrics.
CARE AND RECOMMENDATIONS: Feeds at Discharge: Similac 20 ad
lib.
Medications: Ferrous sulfate 0.35 ml by mouth daily.
DISCHARGE DIAGNOSES: Prematurity at 28 2/7 weeks,
respiratory distress syndrome, resolved, staph aureus sepsis
status post 30 day course of oxacillin, patent ductus
arteriosus status post indomethacin, post-hemorrhagic
hydrocephalus status post bilateral subgaleal shunt
placement.
HEALTH CARE MAINTENANCE: [**Known lastname **] was circumcised on [**5-10**]. There
is a small amount of swelling without evidence of induration or
infection at the inferior incision.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2143-5-13**] 12:37:28
T: [**2143-5-13**] 13:08:09
Job#: [**Job Number 60453**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8117
} | Medical Text: Admission Date: [**2136-2-26**] Discharge Date: [**2136-3-14**]
Date of Birth: [**2136-2-26**] Sex: M
Service: Neonatology
HISTORY: [**Known lastname **] [**Known lastname 49913**], Twin #1 was born at 35-1/7
weeks gestation by cesarean section for onset of labor and
known breech presentation of Twin #2. The mother is a
37-year-old gravida 4, para 3, now 5 woman. Prenatal screens
were blood type O+, antibody negative, rubella immune, RPR
nonreactive, and hepatitis surface antigen negative, and
group B Strep positive. This was a spontaneous twin
pregnancy.
The pregnancy was complicated by anemia. The rupture of
membranes occurred at the time of delivery. There was no
antepartum fever. This twin emerged vigorous. Apgars were
eight at one minute and eight at five minutes.
Birth weight is 2,410 grams, birth length 47.5 cm, and birth
head circumference 32 cm.
ADMISSION PHYSICAL EXAMINATION: Vigorous, nondysmorphic
preterm male infant. Anterior fontanel is soft and flat.
Positive bilateral red reflex, intact palate. Positive
substernal intercostal retractions and grunting, decreased
air entry, but breath sounds equal. Heart with regular,
rate, and rhythm, no murmur. Pink and well perfused.
Femoral pulses +2. Abdomen is soft and nontender without
masses. Three vessel umbilical cord. Testes descending,
patent anus. Sacrum without dimples. Stable hip examination
and age appropriate tone and reflexes.
HOSPITAL COURSE BY SYSTEMS:
Respiratory status: The infant was intubated soon after
admission to the NICU for respiratory distress. He received
one dose of surfactant and then weaned to room air within the
first 24 hours and has remained on room air since that time.
He had occasional episodes of apnea and bradycardia never
requiring any methylxanthine treatment. His last episode of
bradycardia occurred on [**2136-3-9**]. On examination his
respirations are comfortable. Lung sounds are clear and
equal.
Cardiovascular status: He has remained normotensive
throughout his NICU stay. There are no cardiovascular
issues.
Fluids, electrolytes, and nutrition status: Enteral feeds
were begun on day of life #1, advanced without difficulty to
full volume feedings by day of life #3. At the time of
discharge, he is eating Enfamil 20 calories per ounce on an
adlib schedule. At the time of discharge, his weight is
2,585 grams. His length is 45 cm and his head circumference
is 33 cm.
Gastrointestinal status: His peak bilirubin occurred on day
of life #4, total was 10.4, direct 0.3. He never required
any phototherapy.
Hematocrit: His hematocrit done on day of life #1 was 46.5.
He has never received any blood product transfusions during
his NICU stay.
Infectious disease status: [**Known lastname **] was started on
ampicillin and gentamicin at the time of admission for sepsis
risk factors. The antibiotics were discontinued after 48
hours when the infant was clinically well and the blood
cultures were negative.
Sensory status: Audiology: Hearing screening was performed
with automated auditory brain stem responses and the infant
passed in both ears.
Psychosocial: Parents have been very involved in the
infant's care throughout his NICU stay. His sibling preceded
him home by several days.
CONDITION ON DISCHARGE: The infant is discharged in good
condition home with his parents.
PRIMARY PEDIATRIC CARE: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital1 **],
[**Last Name (LF) 49914**], [**First Name3 (LF) **], [**Numeric Identifier 49915**], telephone #[**Telephone/Fax (1) 47371**].
CARE AND RECOMMENDATIONS AFTER DISCHARGE:
1. Feedings: Enfamil 20 cal/oz with iron on an adlib
schedule.
2. The infant is discharged on no medications.
3. The infant passed a car seat position screening test.
4. State screens were sent on [**2-29**] and [**2136-3-12**].
5. The infant received his first hepatitis B vaccine on
[**2136-2-26**].
RECOMMENDED IMMUNIZATIONS:
1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: 1) Born at less than 32 weeks, 2) born between 32
and 35 weeks with plans for daycare during RSV season, with a
smoker in the household, or with preschool siblings, or 3)
with chronic lung disease.
2. Influenza immunization should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age, the family
and other caregivers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSES:
1. Status post prematurity 35-1/7 week gestation.
2. Twin #1.
3. Status post respiratory distress syndrome.
4. Sepsis ruled out.
5. Status post apnea of prematurity.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 49916**]
MEDQUIST36
D: [**2136-3-14**] 03:44
T: [**2136-3-14**] 04:16
JOB#: [**Job Number 49917**]
ICD9 Codes: 769, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8118
} | Medical Text: Admission Date: [**2114-4-10**] Discharge Date: [**2086-4-15**]
Date of Birth: [**2056-10-30**] Sex: F
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 57 year-old female
with a history of inflammatory breast cancer, morbid obesity,
obesity hypoventilation syndrome, obstructive sleep apnea,
systolic and diastolic heart failure, hypertension,
gastroesophageal reflux disease and anemia who felt short of
breath on the morning of [**2114-4-10**]. The patient reports that
at baseline she has shortness of breath, however, on the day
of admission the patient's shortness of breath did not
resolve with supplemental oxygen. She reports low grade
fevers with chills and sweats with reported temperature to
100.1 with increased fatigue. She reports cough occasional
production of clear sputum. She denies chest pain, abdominal
pain, diarrhea, nausea or vomiting. She denies urinary tract
infection like symptoms. Denies recent sick contacts, travel
or varying from her routine. She reports medical compliance
with her medications. Consequently she was brought to the
Emergency Department this a.m. where she was found to be
hypoxic with O2 sats in the approximately 75%, hypotensive
with blood pressure 90/50 and was treated with supplemental
oxygen, intravenous fluids, broad spectrum antibiotics
initially on Dopamine drip and started on a sepsis protocol.
PAST MEDICAL HISTORY:
1. Asthma.
2. Obesity hypoventilation syndrome.
3. Obstructive sleep apnea.
4. Morbid obesity.
5. Congestive heart failure systolic and diastolic
dysfunction with an EF of approximately 30 to 35%.
6. Inflammatory breast cancer recently treated with
Herceptin and Navelbine.
7. Hypertension.
8. Gastroesophageal reflux disease.
9. Anemia.
10. Depression.
MEDICATIONS:
1. Lisinopril 40 q.d.
2. Aspirin 325 q.d.
3. Lasix.
4. Flovent.
5. Protonix.
6. Lactulose.
7. Toprol XL 12.5 q.d.
8. Epogen.
ALLERGIES: Penicillin causes hives.
SOCIAL HISTORY: Smoked one pack per day times 10 to 15
years. She quit approximately 20 years ago.
PHYSICAL EXAMINATION: The patient was afebrile on Intensive
Care Unit evaluation. Tachycardic to 106. Blood pressure
92/50, 25, 96% on 2 liters. She was comfortable. She was
described as mild tachypneic with some accessory muscle use.
JVD was difficult to assess. She had coarse breath sounds
anteriorly with moderate air flow throughout. Heart
tachycardic, regular rhythm, normal S1 and S2. No audible
murmurs, rubs or gallops. Belly was soft, nontender,
nondistended with active bowel sounds. She had 1 to 2+ edema
peripherally and evidence of chronic venostasis. No rash was
present.
LABORATORY: White blood cell count 2.9, 59 polys, 32
lymphocytes, hematocrit 23.9, platelets 404. Her chem 7 was
within normal limits. CKs of 167, troponin 0.07. She had a
chest x-ray, which showed a question of a retrocardiac
opacity. She had a CTPA, which was a poor quality study, but
was negative for any obvious signs of PE. She had an
electrocardiogram that was alternating between normal sinus
rhythm and ventricular bigeminy. No acute changes or
ischemia were noted.
HOSPITAL COURSE: In summary this is a 57 year-old female
Jehovah's witness with a history of morbid obesity,
obstructive sleep apnea requiring BiPAP at night, congestive
heart failure, hypertension, anemia and inflammatory breast
cancer who was originally admitted [**4-10**] from her nursing home
for hypoxia and hypotension and treated in the Intensive Care
Unit. The patient was initially treated with Levofloxacin
for pneumonia, BiPAP and noninvasive pressure ventilation for
hypoxia without intubation. She was subsequently transferred
to the floor to continue treatment for pneumonia and hypoxia.
CTPA was negative for evidence of PE. She was doing well on
the floor until [**4-14**] when the patient was again noted to
become dyspneic with oxygen saturations into the 80%. Repeat
chest x-ray showed worsening shortness of breath. She was
treated with Lasix for diuresis and moderate improvement of
respiratory status. Given her complex medical history she
was transferred to the Intensive Care Unit for closer
monitoring. On representation to the Intensive Care Unit
[**2114-4-15**] the patient spiked a fever to 104, developed
significant respiratory distress and was then emergently
intubated semiemergently admitted and initially treated with
broad spectrum antibiotics for her continued respiratory
distress.
1. Respiratory failure: The patient is currently being
treated for multifactorial respiratory failure in the setting
of congestive heart failure, marked obesity, obesity
hypoventilation syndrome and obstructive sleep apnea who was
semiemergently intubated [**3-/2039**] for progressive hypercarbic
respiratory failure and a newly developing sepsis. The
patient's blood gas prior to intubation was 7.23, 68 and 385.
The patient was intubated and continued on her settings. She
ultimately had tracheostomy performed on [**2114-4-26**] per the ENT
Service. The goal had been to attempt a trial of extubation
on the patient on recovery of her MRSA/sepsis. However, she
remained difficult intubation and exacerbated primarily by
her recurrent congestive heart failure and over 30 liters
positive, fluid balance since her admission. At this point
in time she remains trached on pressure support ventilation
and has been doing quite well. The goal would be to continue
diuresis gently approximately 500 cc to negative one liter
per day in order to avoid intravascular of the patient and
acute renal failure. Additionally the patient was treated
aggressively for her MRSA sepsis. She completed a course of
antibiotics for presumed pneumonia and subsequent treatment
for urinary tract infection as well. She continues with
trach care and nebulizers prn and aggressive suctioning as
needed.
2. Congestive heart failure: The patient has known
congestive heart failure with an EF of approximately 30 to
35% with no systolic and diastolic dysfunction. She was
approximately 30 liters positive for fluid following
treatment for MRSA sepsis and remains volume overloaded at
this time. Goal has been for gentle diuresis. She was
initially started on a Lasix drip and subsequently developed
acute renal failure and that was discontinued and the patient
was started on Nesiritide with minimal effect on diuresis.
Ultimately Nesiritide was discontinued minimizing her fluid
intake and she responded to Lasix intravenously prn as needed
for goal as stated above. She was seen on the CH Service by
Dr. [**First Name (STitle) 2031**] and upon resolution of her hypotension the patient
was started on low dose beta blocker and treatment of her
congestive heart failure.
3. MRSA/sepsis: On readmission to the Intensive Care Unit
the patient had a temperature of 104 and blood pressures in
the 70s. She ultimately had a positive right IJ culture tip
for MRSA and positive blood cultures from the [**2-12**] for MRSA bacteremia 4 out of 4 bottles. The patient
was treated with Vancomycin and subsequent surveillance
cultures were negative. The patient's antibiotics course
will be extended for a minimum of four to six weeks
intravenous Vancomycin for an underlying right IJ clot that
is being followed serially. The patient was enrolled in the
sepsis protocol. She was given intravenous fluids, starting
on intravenous Hydrocortisone 50 gallop or murmur
intravenously q.i.d. and required Dopamine for blood pressure
support. As stated the patient's sepsis resolved and
surveillance cultures were negative. She will be continued
on Vancomycin for approximately one month.
4. Urinary tract infection: The patient had a urinary tract
infection from the 28th that was positive for E-coli that was
sensitive to Ceftazidine. The patient was treated with a
seven day course of Ceftazidine. Repeat urine cultures were
negative.
5. Hypotension: The patient had known hypotension in
relation to her sepsis, however, her hospital course was
complicated by persistent hypotension following resolution of
her sepsis. Empirically while the patient did not
demonstrate evidence of adrenal insufficiency removal of
intravenous steroids complicated the patient's picture and
she subsequently became hypotensive. In addition, the
patient responded poorly to Natrecor requiring Dopamine for
blood pressure support in attempt for diuresis. With
subsequent discontinuation of the Natrecor and continuing of
the intravenous Hydrocortisone the patient was effectively
diuresed and continued to be diuresed at the time of this
dictation without significant hypotension.
6. Acute renal failure: The patient has a baseline
creatinine of .5 to .7 and subsequently developed acute renal
failure with a creatinine rising to 2.1 with diuresis
presumed to be prerenal. With gentle diuresis her creatinine
slowly improved and it was approximately 1.3 at the time of
this dictation. Goal was to continue diuresis gently in
order to avoid acute renal failure.
7. Right IJ thrombus: The patient has a known right IJ
thrombus as a presumed complication from right IJ line
placement in the setting of sepsis. The clot is being
followed serially with weakly ultrasound with noticeable
resolution in the proximal right subclavian clot that is no
more seen as of the ultrasound from [**2114-4-30**]. The patient was
not anticoagulated given her Jehovah's witness status and
will be continued to follow serially with ultrasounds.
8. Inflammatory breast cancer: The patient is a patient of
Dr. [**First Name (STitle) **]. She has a recent history of inflammatory breast
cancer and had been receiving weekly Navelbine and Herceptin.
The plan was to try to reduce the size of her left breast
mass so she could become a candidate for a mastectomy.
However, given her repeated decline in her physical condition
her chemotherapy has been changed multiple times. She is
unable to be staged appropriately because of her weight.
However, recent CTPA did not show any obvious metastatic
disease. There was some concern that her preexisting lower
extremity edema prior to this admission was secondary to a
carcinous meningitis, however, that seems to be unfounded and
neurology was unable to obtain LP for diagnostic purposes.
Consequently the plan at this point in time is that the
patient will be reconsidered for additional chemotherapy if
she is able to become discharged from the hospital and
improves her performance status.
9. Anemia: The patient is a known Jehovah's witness and
would significantly benefit from blood transfusions. On
presentation her hematocrit was approximately 23 had
decreased to 19. Heparin products had been avoided and she
has not been anticoagulated. She continues on Epogen and
iron and her hematocrit seems to stabilize between the 23 and
26 range.
10. Vaginal spotting: During her hospitalization in the
Intensive Care Unit the patient had repeated vaginal spotting
with an associated drop in her hematocrit. Gynecology was
consulted and it was thought that this bleeding was unrelated
to her anemia. She does have multiple risk factors for
endometrial cancer and the goal would be to image her with a
transvaginal ultrasound to sample her endometrium again,
however, at this point in time any additional studies were
deferred and she is to be contact[**Name (NI) **] for follow up in the
[**Hospital 111518**] Clinic as her condition improves and she
becomes an outpatient.
11. Rectal fistula: The patient had a noticeable perirectal
fistula on examination with concern that this may have been
contributing to her fever and sepsis. Surgery was consulted
and determined this unlikely as the nidus of infection based
on clinical examination findings. No perirectal cellulitis
and no obvious abscess formation. Unfortunately imaging
studies were unable to be obtained given the patient's body
habitus. Perirectal swab was polymicrobial in nature
including MRSA, however, it was thought that this was
unlikely to be the source of the patient's MRSA bacteremia
though should be considered if the patient has recurrent
event without additional line placement. The patient
continues to be followed serially with examinations with no
obvious signs of infection.
12. FEN: The patient remained NPO and during the initial
part of her hospitalization was started on tube feeds. The
patient continues with tube feeds at this time. She
unfortunately was not a candidate for PEG or open G tube
placement given her [**Doctor Last Name **] habitus and potential surgical
risks. She continues on her tube feeds at this time.
13. Code status: The patient is a Jehovah's witness and
remains full code at the time of this dictation.
DISPOSITION: The patient's disposition is pending based upon
improvement in her respiratory status with a goal for
subsequent transfer to a nursing facility for continued trach
care and pulmonary rehabilitation.
The remainder of this dictation will be completed by the next
medical Intensive Care Unit intern.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 1303**]
MEDQUIST36
D: [**2114-5-5**] 04:08
T: [**2114-5-7**] 08:28
JOB#: [**Job Number 111519**]
ICD9 Codes: 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8119
} | Medical Text: Admission Date: [**2131-1-14**] Discharge Date: [**2131-1-19**]
Date of Birth: [**2131-1-14**] Sex: M
Service: NB
HISTORY: This twin infant was born at 33 1/7 weeks to a 44 year
old gravida III, para I mother with [**Name2 (NI) **] type A negative,
antibody negative, unknown group B stress status, hepatitis
B surface antigen negative and RPR nonreactive. Prenatal
course notable for in [**Last Name (un) 5153**] fertilization conception with
donor eggs. The mother was admitted in the beginning of
[**Month (only) **] from [**12-11**] to [**12-15**] for cervical shortening. She
received magnesium sulfate and betamethasone at that time.
Unremarkable course until the morning of delivery on [**2131-1-14**]
for which she was admitted with premature rupture of
membranes. She later developed mild contractions so the
decision was made to deliver the twins by repeat cesarean
section under spinal anesthesia. There was no maternal
fever. Mother did receive intrapartum ampicillin and infant
was born with Apgars were 8 and 9.
PHYSICAL EXAMINATION: On admission weight of 2250 grams,
length of 47 cm, head circumference of 30.5 cm. Examination
was remarkable for well appearing preterm infant with pink
color, soft anterior fontanel, normal facies, intact
palate. No grunting, flaring or retractions. Clear breath
sounds. No murmur. Femoral pulses present. Flat, soft,
nontender abdomen, normal phallus. Testes in scrotum, stable
hips. Normal perfusion. Normal tone and activity.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: Infant without any evidence of respiratory
distress during the entire stay.
CARDIOVASCULAR: Infant without murmur during stay. No
spells noted.
FLUIDS, ELECTROLYTES AND NUTRITION: Infant birth weight of
2250 grams. Weight on [**1-18**] was 2145 grams. Infant started
feedings within 24 hours of age and is currently at Special
Care 20 calories at 110 cc per kilogram per day with total
fluids of 150 cc per kilogram per day, advancing 15 cc per
kilogram B.I.D D-sticks have been stable throughout the
infant's course. Voiding normally. Stooling normally. Had
one set of electrolytes on 24 hours of life. Sodium of 141,
potassium of 3.8, chloride of 109, bicarb of 23.
GASTROINTESTINAL: Infant did have a maximum bilirubin of
10.5/0.4 on day of life number three on [**1-17**] and was
started on single phototherapy. Bilirubin was 9.2 on [**1-18**]
and phototherapy was discontinued in the evening of [**1-18**] to
be rechecked for rebound on [**2131-1-19**].
HEMATOLOGY: Infant's [**Date Range **] type is A positive, Coombs
negative. Infant did not receive any transfusions.
Recent hematocrit on day of life number 1 was 45 percent.
INFECTIOUS DISEASE: Infant had a [**Date Range **] culture and an
initial CBC with a white count of 8.8, 16 polys, 0 bands, 73
lymphs, hematocrit of 45, platelet count of 264. He received
Ampicillin and Gentamicin for 48 hours and with negative [**Date Range **]
cultures, antibiotics were discontinued.
NEUROLOGY: No significant issues during stay.
SENSORY: Hearing screening was not performed and one is
recommended prior to discharge.
OPHTHALMOLOGY: Eyes were not needed to be examined.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To level 2, [**Hospital **] Hospital. Name
of primary pediatrician is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in [**Location (un) 14663**].
CARE RECOMMENDATIONS: A. FEEDS AT DISCHARGE: Continue to
advance Special Care 20, until a total volume of 150 cc per
kilogram per day.
B. MEDICATIONS: None.
C. CAR SEAT POSITION SCREENING: Infant will require car
seat test prior to discharge.
D. STATE NEWBORN SCREENING STATUS: Newborn screens were
sent on day of life number three, will need to be followed.
E. IMMUNIZATIONS RECEIVED: None.
F. 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 - day care during RSV season, a smoker in
the household, neuromuscular disease, airway abnormalities,
or school age siblings, or 3) With chronic lung disease.
1. Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age.
2. Before this age and for the first 24 months of the child's
life, immunization against influenza is recommended for
household contact and out of home care givers.
G. FOLLOW UP APPOINTMENT SCHEDULE RECOMMENDATION: Infant
will follow up with pediatrician after discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 33 1/27 weeks.
2. Twin.
3. Physiologic jaundice.
4. Status post rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern4) 57175**]
MEDQUIST36
D: [**2131-1-18**] 16:00:00
T: [**2131-1-18**] 16:48:54
Job#: [**Job Number 60112**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8120
} | Medical Text: Admission Date: [**2121-9-1**] Discharge Date: [**2121-9-15**]
Date of Birth: [**2064-12-26**] Sex: M
Service: SURGERY
Allergies:
Motrin / Glyburide / Glucophage
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
4cm sessile mass in colon, not biopsied seconday to
anticoagulation
Major Surgical or Invasive Procedure:
Right colectomy, laparoscopy assisted ([**2121-9-4**])
History of Present Illness:
56 yo male with multiple medical problems with 4cm sessile polyp
in mid R ascending colon.
Past Medical History:
IDDM
anemia
Mechanical valve, AVR for MRSA endocarditis
BKA
Toe amp
appy
Social History:
Cig 1ppd -> quit
Pipe 3-4 qd
Currently on disability. Lives at home with his partner, Ms.
[**Name13 (STitle) **]. Denies alcohol, drugs, or tobacco. No pets.
Family History:
Family ALW. No hx of MI, CAD, or DM.
Physical Exam:
Afebrile, HR92 BP162/82 RR16
General: Large black male walking with cane accompanied by
fiance, comfortable
Neck: Normal thyroid, no masses, no LA, nl airway, 4+ carotid,
radiating murmur and mechanical click
Chest: Clear, well healed sternotomy
COR: RRR with 2/6 creshendo/decreshendo SEM and soft mechanical
click
Back: No CVAT, or spine pain
Abd: Indented RLQ appi scar in pannus, floppy pannus (overall
has lost about 100lbs from his max wt, stable over last few
months), ND, soft, no mass palpable, NT, no r/g, no
hepatosplenomegaly
Ext: 4+ femoral pulse b/l, no right popleteal pulse, R foot
brace, no edema, L BKA with prosthesis.
Pertinent Results:
CHEST (PRE-OP PA & LAT) [**2121-9-1**] 4:54 PM
IMPRESSION: Left-sided chest opacity could represent loculated
fluid collection. CT is suggested for further characterization.
CT PELVIS ABD W&W/O CONTRAST [**2121-9-2**] 11:49 AM
IMPRESSION:
1. Large loculated left pleural effusion with a thick rim. The
differential diagnosis includes an empyema or prior hemothorax.
The finding is new since the postoperative studies from aortic
valve replacement as of [**2120-8-20**]. Neoplastic involvement
of the pleura cannot be excluded.
2. Large multilobulated low-density splenic lesion, which
extends up to the posterior wall of the gastric fundus, and may
extend into the gastric wall. The findings would be highly
atypical for metastatic colon cancer given the lack of liver
metastases, although this cannot be excluded. possible
etiologies include prior trauma and embolic disease (including
septic emboli given prosthetic aortic valve/endocarditis).
Pancreas is unremarkable without evidence for pseudocyst
extension into spleen/stomach. Correlate with history of trauma
to this area. MRI may provide additional diagnostic information.
Endoscopy could also be considered for assessment of the gastric
fundal abnormality.
Results and potential recommendations were called to Dr. [**First Name8 (NamePattern2) 96487**]
[**Last Name (NamePattern1) 61028**] at 5:00 p.m. on [**2121-9-2**].
Cardiology Report ECG Study Date of [**2121-9-4**] 9:06:06 PM
Sinus rhythm with 1st degree A-V block
Since previous tracing, no significant change
CHEST PORT. LINE PLACEMENT [**2121-9-5**] 6:25 PM
IMPRESSION: Satisfactorily positioned right internal jugular
central venous catheter, without a pneumothorax seen.
Pathology Examination DIAGNOSIS:
Terminal ileum and right colon, ileocolectomy:
Adenoma of the right colon (3.8 x 2.5 cm) with foci of
high-grade dysplasia, see note.
Separate adenoma of the right colon (0.8 cm).
Ileal mucosa with no diagnostic abnormalities recognized.
Regional lymph nodes with no diagnostic abnormalities
recognized.
Note: No invasive carcinoma is identified. The adenoma is
entirely submitted and an additional level of each block
examined. The findings were discussed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] by Dr.
[**Last Name (STitle) **] [**Last Name (NamePattern4) **] on [**2121-9-12**].
[**2121-9-1**] 03:00PM BLOOD WBC-13.1* RBC-3.81* Hgb-7.9* Hct-25.1*
MCV-66*# MCH-20.6*# MCHC-31.3 RDW-16.1* Plt Ct-564*
[**2121-9-2**] 09:45AM BLOOD WBC-11.9* RBC-3.86* Hgb-8.0* Hct-25.4*
MCV-66* MCH-20.6* MCHC-31.4 RDW-16.2* Plt Ct-493*
[**2121-9-3**] 10:10AM BLOOD WBC-15.6* RBC-4.83# Hgb-11.1*# Hct-33.0*#
MCV-68* MCH-22.9*# MCHC-33.5 RDW-17.5* Plt Ct-535*
[**2121-9-5**] 06:12PM BLOOD WBC-27.7*# RBC-5.20 Hgb-11.8* Hct-37.2*
MCV-72* MCH-22.6* MCHC-31.6 RDW-19.3* Plt Ct-520*
[**2121-9-6**] 02:10AM BLOOD WBC-28.6* RBC-4.57* Hgb-10.4* Hct-32.6*
MCV-71* MCH-22.8* MCHC-32.0 RDW-19.1* Plt Ct-496*
[**2121-9-7**] 02:20AM BLOOD WBC-20.7* RBC-3.71* Hgb-8.5* Hct-26.6*
MCV-72* MCH-22.8* MCHC-31.8 RDW-19.7* Plt Ct-357
[**2121-9-8**] 01:58AM BLOOD WBC-16.9* RBC-3.65* Hgb-8.3* Hct-26.3*
MCV-72* MCH-22.7* MCHC-31.5 RDW-19.8* Plt Ct-361
[**2121-9-9**] 04:42AM BLOOD WBC-11.8* RBC-3.51* Hgb-8.2* Hct-25.2*
MCV-72* MCH-23.4* MCHC-32.5 RDW-19.8* Plt Ct-379
[**2121-9-12**] 01:30AM BLOOD Hct-25.4*
[**2121-9-1**] 03:00PM BLOOD PT-20.4* PTT-31.0 INR(PT)-2.0*
[**2121-9-1**] 03:00PM BLOOD Plt Ct-564*
[**2121-9-2**] 01:00AM BLOOD PTT-39.7*
[**2121-9-2**] 09:40AM BLOOD PT-19.5* PTT-49.0* INR(PT)-1.9*
[**2121-9-2**] 09:45AM BLOOD Plt Ct-493*
[**2121-9-2**] 03:00PM BLOOD PT-18.9* PTT-41.6* INR(PT)-1.8*
[**2121-9-2**] 09:21PM BLOOD PT-18.2* PTT-53.6* INR(PT)-1.7*
[**2121-9-3**] 10:10AM BLOOD PT-17.2* PTT-39.9* INR(PT)-1.6*
[**2121-9-3**] 10:10AM BLOOD Plt Ct-535*
[**2121-9-3**] 07:19PM BLOOD PTT-45.0*
[**2121-9-4**] 12:55PM BLOOD PTT-41.1*
[**2121-9-5**] 06:12PM BLOOD Plt Ct-520*
[**2121-9-6**] 02:10AM BLOOD Plt Ct-496*
[**2121-9-6**] 05:49PM BLOOD PTT-92.6*
[**2121-9-7**] 02:20AM BLOOD PT-16.4* PTT-81.4* INR(PT)-1.5*
[**2121-9-7**] 02:20AM BLOOD Plt Ct-357
[**2121-9-7**] 11:39AM BLOOD PT-16.5* PTT-57.4* INR(PT)-1.5*
[**2121-9-7**] 10:26PM BLOOD PT-15.7* PTT-74.7* INR(PT)-1.4*
[**2121-9-8**] 01:58AM BLOOD Plt Ct-361
[**2121-9-8**] 06:29AM BLOOD PT-15.3* PTT-56.2* INR(PT)-1.4*
[**2121-9-8**] 08:55PM BLOOD PT-13.9* PTT-52.0* INR(PT)-1.2*
[**2121-9-9**] 04:42AM BLOOD PT-15.2* PTT-50.7* INR(PT)-1.4*
[**2121-9-9**] 04:42AM BLOOD Plt Ct-379
[**2121-9-9**] 03:38PM BLOOD PTT-58.5*
[**2121-9-10**] 12:08AM BLOOD PTT-82.2*
[**2121-9-10**] 06:02AM BLOOD PT-17.7* PTT-93.4* INR(PT)-1.6*
[**2121-9-10**] 01:35PM BLOOD PTT-71.9*
[**2121-9-10**] 09:00PM BLOOD PTT-68.5*
[**2121-9-11**] 03:39AM BLOOD PT-21.1* PTT-84.4* INR(PT)-2.0*
[**2121-9-11**] 03:38PM BLOOD PT-22.1* PTT-70.9* INR(PT)-2.2*
[**2121-9-12**] 01:30AM BLOOD PT-22.3* PTT-77.0* INR(PT)-2.2*
[**2121-9-12**] 09:09AM BLOOD PT-21.9* PTT-65.2* INR(PT)-2.1*
[**2121-9-12**] 05:09PM BLOOD PT-22.3* PTT-56.2* INR(PT)-2.2*
[**2121-9-13**] 01:29AM BLOOD PT-23.4* PTT-75.4* INR(PT)-2.3*
[**2121-9-14**] 04:30AM BLOOD PT-23.7* PTT-57.3* INR(PT)-2.4*
[**2121-9-15**] 05:55AM BLOOD PT-26.2* PTT-65.1* INR(PT)-2.7*
[**2121-9-1**] 03:00PM BLOOD Glucose-258* UreaN-28* Creat-1.5* Na-133
K-4.0 Cl-100 HCO3-24 AnGap-13
[**2121-9-2**] 09:45AM BLOOD Glucose-207* UreaN-26* Creat-1.1 Na-134
K-4.1 Cl-100 HCO3-25 AnGap-13
[**2121-9-3**] 10:10AM BLOOD Glucose-206* UreaN-20 Creat-1.3* Na-132*
K-4.3 Cl-98 HCO3-23 AnGap-15
[**2121-9-5**] 06:12PM BLOOD Glucose-160* UreaN-15 Creat-1.1 Na-134
K-4.5 Cl-104 HCO3-20* AnGap-15
[**2121-9-6**] 02:10AM BLOOD Glucose-218* UreaN-20 Creat-1.6* Na-132*
K-5.8* Cl-104 HCO3-21* AnGap-13
[**2121-9-6**] 06:20AM BLOOD Glucose-151* UreaN-19 Creat-1.5* Na-135
K-5.3* Cl-106 HCO3-22 AnGap-12
[**2121-9-6**] 05:49PM BLOOD Glucose-127* UreaN-20 Creat-1.3* Na-138
K-5.1 Cl-107 HCO3-21* AnGap-15
[**2121-9-7**] 02:20AM BLOOD Glucose-117* UreaN-18 Creat-1.3* Na-136
K-4.6 Cl-104 HCO3-25 AnGap-12
[**2121-9-8**] 01:58AM BLOOD Glucose-80 UreaN-14 Creat-1.2 Na-136
K-4.2 Cl-101 HCO3-28 AnGap-11
[**2121-9-9**] 04:42AM BLOOD Glucose-106* UreaN-11 Creat-1.1 Na-136
K-3.9 Cl-102 HCO3-30 AnGap-8
[**2121-9-1**] 03:00PM BLOOD Lipase-31
[**2121-9-1**] 03:00PM BLOOD Albumin-3.4 Calcium-8.7 Phos-2.6*# Mg-2.2
[**2121-9-2**] 09:45AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.0
[**2121-9-3**] 10:10AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
[**2121-9-5**] 06:12PM BLOOD Calcium-9.0 Phos-3.7 Mg-1.7
[**2121-9-6**] 02:10AM BLOOD Calcium-8.7 Phos-4.9* Mg-2.5
[**2121-9-6**] 06:20AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.5
[**2121-9-6**] 05:49PM BLOOD Calcium-8.5 Phos-3.4 Mg-2.4
[**2121-9-7**] 02:20AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.2
[**2121-9-8**] 01:58AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.2
[**2121-9-9**] 04:42AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1
[**2121-9-2**] 09:45AM BLOOD CEA-1.8
[**2121-9-5**] 02:30PM BLOOD Type-ART pO2-160* pCO2-32* pH-7.46*
calTCO2-23 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2121-9-5**] 03:45PM BLOOD Type-ART pO2-172* pCO2-31* pH-7.44
calTCO2-22 Base XS--1 Intubat-INTUBATED
[**2121-9-6**] 02:38AM BLOOD Type-ART pO2-163* pCO2-39 pH-7.32*
calTCO2-21 Base XS--5
[**2121-9-6**] 06:38AM BLOOD Type-ART pO2-136* pCO2-43 pH-7.34*
calTCO2-24 Base XS--2
[**2121-9-7**] 02:32AM BLOOD Type-ART pO2-108* pCO2-44 pH-7.39
calTCO2-28 Base XS-0
[**2121-9-5**] 02:30PM BLOOD Glucose-102 Lactate-0.9 Na-131* K-4.2
Cl-106
[**2121-9-5**] 03:45PM BLOOD Glucose-115* Lactate-1.3 Na-136 K-4.3
Cl-110
[**2121-9-6**] 06:38AM BLOOD Lactate-2.5*
[**2121-9-5**] 02:30PM BLOOD Hgb-9.4* calcHCT-28
[**2121-9-5**] 03:45PM BLOOD Hgb-10.1* calcHCT-30
[**2121-9-5**] 02:30PM BLOOD freeCa-1.11*
[**2121-9-5**] 03:45PM BLOOD freeCa-1.05*
Brief Hospital Course:
56 yo male admitted preop for anticoagulation adjustment
secondary to mechanical valve for a R colectomy scheduled for
HD5. Heparin gtt was started on HD1, and titrated accordingly
for a goal PTT of 60-70 until 4am day prior to surgery. A CXR
was done also for preop work up on HD1, which showed L-sided
chest opacity that could represent loculated fluid collection,
and a follow up CT was performed for further characterization on
HD2. CT revealed new loculated left pleural effusion with a
thick rim; multilobulated low-density splenic lesion, which
extends up to the posterior wall of the gastric fundus, and may
extend into the gastric wall. Cardiothoracic surgery team was
consulted, and a decision not to work up the L lung or splenic
fluid collection further was made as they are highly unlikely to
represent metastatic colon CA, given nl liver and low CEA.
Details of both the CXR and CT are available in the respective
radiology reports elsewhere.
Pt was also transfused with 1u PRBC on HD2, given a Hct of 25.1,
which responded to the treatment, and the hct went up to 33.1.
Cardiology team was consulted, and recommended prophylactic
antibiotics prior to surgery.
On day of surgery, PTT was appropriate at goal, and antibiotics
were given as recommended. Pt [**Month/Day/Year 1834**] R hemicolectomy, the
details of the procedure are available in the operative report
elsewhere. Pt had uncomplicated intraoperative course; was
transferred to the SICU POD0 overnight for monitoring. Pt was
restarted on heparin for mechanical valve; not coumadin.
Insulin gtt was started for better blood glucose control. Pt
was transferred back to the floor on POD3.
Pt's diet was started on sips and advance as tolerated and with
respect to return of bowel function on POD3. Pt had no problems
with n/v throughout his hospital stay. Coumadin was restarted
on POD3, and heparin gtt continued to be titrated appropriately.
INR was followed throughout the rest of the [**Hospital **] hospital
course for a goal INR of 2.5-3.5. By POD10, pt was tolerating
regular diabetic po, had return of bowel function, ambulant,
pain controlled, and was found to have an INR of 2.7.
Pt was d/c home in good condition on POD10, with PT to do home
visits, to have INR checked at the [**Hospital 882**] Hospital on
[**2121-9-17**], and to follow up with Dr. [**Last Name (STitle) **] on [**2121-9-22**].
Medications on Admission:
coumadin 10mg' (tues-[**Last Name (un) **], sat, sun)
coumadin 7.5mg' (m+f)
protonix
FeSO4
ASA 81'
folate 1mg'
colace 100mg"
senna prn
insulin NPH 16u qam, 10u qpm, sliding scale if BS>200
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Omeprazole 20 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*
6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen
(16) units Subcutaneous qAM ().
Disp:*QSx 1 month QS* Refills:*2*
7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10)
units Subcutaneous qPM ().
Disp:*QS x 1month QS* Refills:*2*
8. Lancets & Strips
Lancets and glucose monitoring strips sufficient for 4 times
daily fingersticks please.
2 refills.
9. Outpatient Lab Work
Please have your PT, PTT, INR checked at the [**Hospital 882**] Hospital
on [**2121-9-17**]. Please have the result reported to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], [**Telephone/Fax (1) 8792**].
10. Coumadin 10 mg Tablet Sig: One (1) Tablet PO once a day: On
Tues, Wed, Thurs, Sat, Sunday.
Disp:*30 Tablet(s)* Refills:*2*
11. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: On
Monday and Friday.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Colon mass
Discharge Condition:
Vital signs stable, afebrile, tolerating po, ambulant, pain
controlled, INR at therapeutic range between 2.5-3.5.
Discharge Instructions:
You may resume your pre-hospital medications and activity - just
take it easy in the beginning!
No heavy lifting (greater that 10 pounds!) for 4 weeks after
surgery. This could give you a hernia.
You may shower, but no soaking in a tub for 4 weeks after
surgery.
Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting,
inability to eat, wound redness, swelling, foul smelling
drainage, or anything else that concerns you.
Followup Instructions:
Please call Dr.[**Name (NI) 6218**] office at ([**Telephone/Fax (1) 96488**] to schedule a
follow up appointment for Monday, [**2121-9-22**].
Please follow up at the [**Hospital 882**] Hospital for your INR check on
Wednesday, [**2121-9-17**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2121-9-15**]
ICD9 Codes: 5119, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8121
} | Medical Text: Admission Date: [**2110-11-13**] Discharge Date: [**2110-11-18**]
Date of Birth: [**2045-1-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
exertional chest tightness
Major Surgical or Invasive Procedure:
coronary artery bypass grafting x 3 (LIMA->LAD, SVG->diag,
SVG->OM)
History of Present Illness:
The patient is a 65 year old avid squash player with a six month
history of "walk-through angina". He mentioned this to his PCP
who arranged an ETT for [**2110-11-13**] which was markedly abnormal.
Subsequent cardiac catheterization revealed severe coronary
artery disease. He was referred for consideration of surgical
revascularization.
Past Medical History:
dyslipidemia
gastroesophageal reflux disease
s/p removal of pylonidal cyst
Social History:
tobacco: quit 30 years ago
alcohol: [**12-6**] glasses daily
worked in several different jobs
lives with wife in [**Name (NI) 5169**], [**Name (NI) **]
Family History:
mother with coronary artery disease before 55 years of age
Physical Exam:
Admission:
General: pleasant, appropriate
Skin: unremarkable
HEENT: NCAT, EOMI, PERRL
Neck: supple with full range of motion
Chest: lungs CTAB
Heart: RRR
Abdomen: soft, non-distended, non-tender, +bowel sounds
Extremities: warm, well-perfused, no edema, no varicosities
Neuro: grossly intact
Discharge:
VS: 98.5, 112/68, 79, 18, 95%RA
Gen: NAD
Chest: lungs CTAB
Heart: RRR
Abd: soft, non-tender, non-distended, +BS
Ext: warm, trace edema
Incisions: sternum stable, no erythema or drainage about
incision, EVH c/d/i
Neuro: grossly intact
Pertinent Results:
[**2110-11-17**] 05:19AM BLOOD WBC-7.7 RBC-3.09* Hgb-9.8* Hct-27.9*
MCV-91 MCH-31.8 MCHC-35.1* RDW-12.8 Plt Ct-130*
[**2110-11-17**] 05:19AM BLOOD Glucose-105 UreaN-17 Creat-0.8 Na-136
K-3.9 Cl-98 HCO3-35* AnGap-7*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81622**]TTE (Complete)
Done [**2110-11-13**] at 4:23:11 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2045-1-13**]
Age (years): 65 M Hgt (in): 71
BP (mm Hg): 130/80 Wgt (lb): 183
HR (bpm): 61 BSA (m2): 2.03 m2
Indication: Left ventricular function. Preoperative assessment.
Coronary artery disease.
ICD-9 Codes: 414.8, 424.1, 424.0
Test Information
Date/Time: [**2110-11-13**] at 16:23 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W000-0:00 Machine: Vivid [**6-10**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.7 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.7 m/s
Left Atrium - Peak Pulm Vein D: 0.5 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: *5.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.35 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 9 < 15
Aorta - Sinus Level: *4.0 cm <= 3.6 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Arch: 2.8 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 1.20
Mitral Valve - E Wave deceleration time: 225 ms 140-250 ms
TR Gradient (+ RA = PASP): 14 to 20 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Normal ascending aorta
diameter. Normal aortic arch diameter. No 2D or Doppler evidence
of distal arch coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal LV inflow pattern for age.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. 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 normal. There is no
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No diastolic dysfunction, pulmonary hypertension or
significant valvular disease seen. Dilated aortic sinus.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2110-11-13**] 17:35
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81623**] (Complete)
Done [**2110-11-14**] at 9:28:25 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2045-1-13**]
Age (years): 65 M Hgt (in): 72
BP (mm Hg): 130/80 Wgt (lb): 180
HR (bpm): 64 BSA (m2): 2.04 m2
Indication: CABG
ICD-9 Codes: 786.05
Test Information
Date/Time: [**2110-11-14**] at 09:28 Interpret MD: [**Name6 (MD) 3892**]
[**Name8 (MD) 3893**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW01-: Machine: AW1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Focal calcifications in
aortic root. Mildly dilated ascending aorta. Focal
calcifications in ascending aorta. Normal aortic arch diameter.
Focal calcifications in aortic arch. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
he aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
he aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
he mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) 914**] was notified in person of the results on Mr.[**Known lastname 7356**] at
8:30AM
POST-BYPASS:
Preserved biventricular systolic function.
LVEF 55%.
Intact thoracic aortic contour.
No other new abnormalities seen.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2110-11-14**] 11:57
Brief Hospital Course:
The patient was admitted for coronary revascularization. He was
brought to the operating room on [**11-14**] where he underwent
coronary artery bypass grafting x 3. See operative note for
full details. Overall the patient tolerated the procedure well
and post-operatively was transferred to CVICU in stable
condition for recovery and further invasive monitoring. By POD
1 the patient was extubated, alert and oriented, neurologically
intact and hemodynamically stable. He was found suitable for
transfer to telemetry at this point. Chest tubes and pacing
wires were discontiued without complication. The patient made
excellent progress with physical therapy, showing good strength
and balance before discharge. He was gently diuresed toward his
preoperative weight. By the time of discharge on POD 4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics.
Medications on Admission:
aspirin, protonix
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:*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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
6. Acetazolamide 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 2 doses.
Disp:*4 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 2 days.
Disp:*4 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Interim Home Care
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 6 weeks [**Telephone/Fax (1) 75345**]
Dr. [**Last Name (STitle) 914**] in 2 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 39975**] in 4 weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2110-11-18**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8122
} | Medical Text: Admission Date: [**2192-11-4**] Discharge Date: [**2192-11-19**]
Date of Birth: [**2149-1-1**] Sex: M
Service: [**Last Name (un) **]
ADMITTING DIAGNOSIS: A 43 year-old with HCV cirrhosis,
status post liver transplant [**2192-11-4**].
HISTORY OF PRESENT ILLNESS: The patient is a 43 year-old
male with history of HCV and cirrhosis on transplant list who
now presents for liver transplant. Patient has had several
admissions including the most recent on [**2192-10-8**]
during which time a TIPS procedure was performed for diuretic
resistant ascites and hyponatremia which has helped in
control of his ascites. But eventually he became jaundiced
with the bilirubin rising to 11. The patient was notified on
[**2192-10-30**] that there was a potential liver
transplant. However, it did not occur.
The patient has no episodes of confusion although his wife
does say that he is somewhat drowsy and sleeps quite a bit.
His abdominal pain has improved. His abdominal distention and
ankle edema has improved too. Baseline he is treated with
lactulose. Patient has no recent fevers, chills, nausea,
vomiting.
PAST MEDICAL HISTORY: HCV cirrhosis. History of hemorrhoids,
anal fissure, hyponatremia. Echocardiogram that was performed
in [**2192-3-9**] demonstrated an ejection fraction of 55.
PAST SURGICAL HISTORY: Clubbed foot, repaired when young.
ALLERGIES: Erythromycin, gastrointestinal upset.
MEDICATIONS ON ADMISSION: Quinine 325 mg q day, coprostanol
750 q week, spironolactone 100 mg q day, Lasix 80 mg q day,
Protonix 40 mg q day, lactulose b.i.d. - t.i.d., Senna,
Colace, Gas-Ex, calcium, vitamin D.
SOCIAL HISTORY: Patient is married with three children, no
tobacco. No current alcohol. Patient had a history of alcohol
abuse, quit in [**2172**] and IV drug abuse. Patient does have
_____.
FAMILY HISTORY: Uncle had alcohol abuse-induced liver
cirrhosis.
PHYSICAL EXAMINATION: Patient is afebrile. Vital signs are
stable. Weight 91.3 kilograms, 4 feet 8. Patient is awake,
alert, positive scleral icterus. Extraocular movements are
full. Pupils are equal, round and reactive to light. Lungs
clear to auscultation bilaterally. Cardiovascular: Regular
rate and rhythm. Normal S1 and S2 without murmurs. Abdomen
distended but nontender. No organomegaly palpated. No
hernias. No fluid wave. Extremities: Warm, +1 edema noted.
So patient was admitted. Patient was kept n.p.o. Work up
included chest x-ray, electrocardiogram, laboratories, type
and screen and then patient was ordered for fluconazole,
Unasyn, Cellcept, Solu-Medrol to be on call for the operating
room. Patient did go to the operating room on [**2192-11-4**]. Patient had an orthotopic deceased donor liver
transplant (piggyback, portal vein, portal vein anastomosis,
common hepatic artery (recipient to common hepatic donor,
common bile duct - common bile duct anastomosis over a French
T tube performed by [**Last Name (NamePattern4) 24748**] [**Last Name (NamePattern4) **], [**First Name3 (LF) **] and [**Doctor Last Name **].
Please see the operating room note for detailed information
about the surgery. Postoperatively the patient did go to the
unit. Patient was intubated and sedated. Patient had serial
hematocrits, coagulations x24 hours. Patient received Solu-
Medrol, MMF, subcutaneous heparin, Protonix. Patient had a
nasogastric tube placed. Patient had a central line, triple
lumen placed. Postoperative day #1 patient did have a duplex
liver ultrasound demonstrating unremarkable hepatic
vasculature and transplanted liver perfusion on the right.
[**Last Name (un) **] was consulted because of steroid-induced diabetes
mellitus and had followed patient while patient was an
inpatient. Patient had two J tubes, one medial and one
lateral and a T tube, was on antibiotics postoperatively,
Vancomycin, Zosyn. Patient was started on tacrolimus 2 and 2,
MMF 1,000 b.i.d., Solu-Medrol. Patient had received a total
of 5 doses of _____. On [**2192-11-5**] platelets slowly
dropped. Blood test was sent off which was negative. Patient
was getting out of bed, tolerating p.o. intake. On [**2192-11-9**] patient had a postoperative T tube cholangiogram that
demonstrated that there was no evidence of extravasation.
Luminal narrowing of the anastomosis with delayed passage of
contrast which could be secondary to postoperative edema. So
T tube was capped. One of the [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains because of
decreased output was removed. Physical and occupational
therapy saw the patient. On postoperative day 7 the second
[**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drain was removed because of no output.
Patient's liver function tests were slightly elevated after
capping T tube. Tacrolimus was slowly increased due to the
low level. A duplex ultrasound was performed on [**2192-11-12**] because of slightly elevated liver function tests
demonstrating that there was a 5 x 5.8 x 3.5 fluid collection
adjacent to the right lobe consistent with a biloma. 2) There
was dilation of the common bile duct, common hepatic duct and
central intrahepatic duct consistent with a substantial
obstruction/stenosis. Because patient was distended in the
abdomen a KUB was performed demonstrating:
1. Nonspecific bowel gas patterns which could represent
ileus with many air fluid levels. CT of the abdomen was
obtained the following day on [**2192-11-13**]
demonstrating there is mild central intrahepatic biliary
ductal dilatation and the common duct measures 11 mm to
the level of the T tube. The common duct is collapsed
distal to the T tube.
2. There are patent portal veins, hepatic artery and hepatic
veins.
3. Ascites fluid within the abdomen greatest inferior to the
right lobe of the liver. No discrete fluid collection is
identified. There is also fluid adjacent to the spleen
within the lesser sac and within the pelvis.
4. Possible ileus.
5 Minimal right basilar atelectasis.
This prompted to have a T tube cholangiogram which
demonstrated that there was post liver transplant T tube
cholangiogram demonstrated filling of the native common bile
duct and no opacification of the transplant biliary tree.
Contrast was infused by gravity. Another T tube cholangiogram
was performed on [**2192-11-16**] to evaluate all of the
biliary tree demonstrating that there is post liver
transplant T tube cholangiogram demonstrates prompt filling
of the native common bile duct with prompt drainage into the
small bowel. Filling of the right and possible also left
intrahepatic bile duct in Trendelenburg position demonstrates
normal appearing intrahepatic bile duct. Patient continued to
have a great deal of stool. Patient had increased amount of
stool and placed originally on Flagyl, then this was
discontinued, but on [**2192-11-17**] because he was having
increased stool on tube feeds and although multiple stool
cultures were obtained which demonstrated that there was no C
difficile, but because he improved clinically with his stools
with the frequency of loose stools lessened with Flagyl, it
was decided to place him back on Flagyl. After the
cholangiogram on [**2192-11-16**] T tube was recapped. FK
level ranged from 5.4 to 16.8. 5.4 was when he just started
taking the tacrolimus. While he was an inpatient hepatitis
surface antibody and hepatitis surface antigen were obtained
which were quantitative. On [**2192-11-11**], [**2192-11-14**] and [**2192-11-18**] the hepatitis B surface antigen
were negative and the hepatitis surface antibody had a titer
of greater than 450 MIU per ml. So patient was discharged on
[**2192-11-18**] to home with [**Hospital3 **] VNA. So patient
went home with the following medications:
Aluminum hydroxy gel 600 mg per 5 ml suspension, 10 to 30 ml
p.o. q 8 hours p.r.n. for heartburn.
Protonix 40 mg q 12.
Prednisone 20 mg q day.
Fluconazole 400 mg q day.
Lamivudine 100 mg q day.
Bactrim SS 1 tablet q day.
MMF 500 mg q.i.d.
Oxycodone 5 mg q 4 hours p.r.n.
Tylenol 325 1 p.o. q 6 hours p.r.n.
Tacrolimus 3 mg b.i.d.
Flagyl 500 mg t.i.d. for 12 days.
Valganciclovir 900 mg q day.
Patient was discharged on the insulin sliding scale with
fingersticks.
Patient is to have laboratories drawn every Monday and
Thursday and have the results faxed immediately to [**Telephone/Fax (1) 24749**]. Patient is to call transplant surgery immediately at
[**Telephone/Fax (1) 673**] if any fevers, chills, nausea, vomiting,
abdominal pain, increase in abdominal birth. To call if there
is any change in the incision any discharge to the incision.
Also notify transplant if he has difficulty with appetite,
urination or bowel movements.
FINAL DIAGNOSES:
1. HCV cirrhosis, status post liver transplant [**2192-11-4**].
2. Steroid induced hyperglycemia.
3. Question of C difficile treated with Flagyl.
SECONDARY DIAGNOSIS: Hemorrhoids.
Anal fissure.
Chronic hyponatremia.
Patient is to follow up with transplant surgery next week.
Please call [**Telephone/Fax (1) 673**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2192-11-27**] 13:43:15
T: [**2192-11-27**] 15:48:13
Job#: [**Job Number 24750**]
ICD9 Codes: 5715, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8123
} | Medical Text: Admission Date: [**2112-4-28**] Discharge Date: [**2112-5-8**]
Date of Birth: [**2058-11-17**] Sex: M
Service: SURGERY
Allergies:
Kiwi (Actinidia Chinensis)
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
HCC/HCV cirrhosis, liver failure
Major Surgical or Invasive Procedure:
Liver [**First Name3 (LF) 1326**] [**2112-4-28**]
History of Present Illness:
53 M diagnosed with HCC and HCV cirrhosis in [**6-/2111**], presents
for OLT. He was last seen by Hepatology (Dr [**Name (NI) **]) in
[**Month (only) 404**] at which time his MELD was 28.
Past Medical History:
He was diagnosed with cirrhosis and HCC in [**6-/2111**] for which he
underwent cyberknife therapy in 6/[**2111**]. He has been listed for
liver [**Year (4 digits) **] since 6/[**2111**]. He has had an EGD at an OSH in
[**2110-8-13**] with grade 2 esophageal varices and portal
hypertensive gastropathy. He also had a colonoscopy in [**Month (only) 956**]
[**2110**] which showed rectal varices. He was last seen by
Hepatology on [**2111-11-18**] at which time his MELD was 25 and his
diurectics were increased for ongoing lower extremity edema. He
has also had ongoing issues with poor sleep.
Social History:
Positive for EtOH abuse but sober seven years. Positive for
tobacco. Question of past cocaine use. Lives alone. Not
currently working.
Family History:
Mother - colon cancer
Father - ESRD
Physical Exam:
Afebrile, vitals wnl
Gen - A&O x 3 NAD
Pulm - CTAB
CV - rrr no m/g/r
Abd - +BS, ND, mild TTP near subcostal and midline incisions
Extrem - no c/c/e
Pertinent Results:
[**2112-4-28**] WBC-5.3 Hct-37.6* Plt Ct-92*
[**2112-4-28**] WBC-12.9* Hct-29.4* Plt Ct-105*
[**2112-4-28**] WBC-21.7* Hct-24.5* Plt Ct-77*
[**2112-4-29**] WBC-14.7* Hct-30.6* Plt Ct-89*
[**2112-4-30**] WBC-14.4* Hct-28.7* Plt Ct-78*
[**2112-4-30**] WBC-19.2* Hct-31.0* Plt Ct-72*
[**2112-5-2**] WBC-14.3* Hct-30.3* Plt Ct-81*
[**2112-4-28**] PTT-32.7 INR(PT)-1.3*
[**2112-4-28**] PTT-150* INR(PT)-3.1*
[**2112-4-28**] PTT-150* INR(PT)-2.9*
[**2112-4-28**] PTT-72.1* INR(PT)-2.2*
[**2112-4-29**] PTT-26.2 INR(PT)-1.3*
[**2112-4-29**] PTT-25.9 INR(PT)-1.2*
[**2112-4-30**] PTT-23.6 INR(PT)-1.1
[**2112-5-2**] PTT-23.0 INR(PT)-1.0
[**2112-4-28**] Creat-0.8 Na-139 K-3.7
[**2112-4-29**] Creat-1.5* Na-137 K-4.0
[**2112-4-29**] Creat-1.6* Na-138 K-4.1 Cl-104
[**2112-4-30**] Creat-1.4* Na-138 K-3.6 Cl-102
[**2112-5-2**] Creat-0.8 Na-135 K-4.2 Cl-102
[**2112-4-28**] ALT-226* AST-303* AlkPhos-95 TBili-1.3
[**2112-4-28**] ALT-1444* AST-[**2126**]* AlkPhos-51 Amylase-33 TBili-2.4*
LD(LDH)-3050*
[**2112-4-29**] ALT-1155* AST-1646* AlkPhos-52 TBili-2.6* DBili-1.9*
IBili-0.7
[**2112-4-29**] ALT-749* AST-727* AlkPhos-52 TBili-4.0*
[**2112-4-30**] ALT-621* AST-501* AlkPhos-50 TBili-2.3*
[**2112-5-1**] ALT-485* AST-253* AlkPhos-70 TBili-1.6*
[**2112-5-2**] ALT-399* AST-122* AlkPhos-75 TBili-1.3 LD(LDH)-398*
[**2112-5-3**] ALT-318* AST-105* AlkPhos-74 TBili-1.4
[**2112-5-4**] ALT-316* AST-110* AlkPhos-91 TBili-1.3
[**2112-5-5**] ALT-270* AST-118* AlkPhos-119 TBili-2.5*
[**2112-5-6**] ALT-272* AST-92* AlkPhos-197* TBili-4.5*
[**2112-4-29**] POD 1 Liver U/S - IMPRESSION:
1. Status post liver [**Month/Day/Year **] with patent vasculature.
2. 9-cm hematoma inferior to the porta hepatis and small amount
of free fluid throughout the abdomen and pelvis.
[**2112-5-5**] Liver U/S: IMPRESSION:
1. Status post liver [**Month/Day/Year **] with patent vasculature.
2. Two focal fluid collections adjacent to the left lateral
segment
(measuring 3 cm) and inferior to the right lobe of the liver
(measuring
approximately 1.4 cm) are noted.
3. Two echogenic structures within the transplanted liver may
represent
surgical clips versus calcifications and less likely pneumobilia
and are in unchanged position compared to [**2112-4-29**].
[**5-6**] ERCP - Impression:
The [**Month/Year (2) **] bile duct above the stricture was approximately
5mm and the native CBD was approximately 8mm.
Given the small contrast leak at the anastomosis, balloon
dilation of the stricture was not performed.
A sphincterotomy was performed in 12 o'clock position with a
sphincterotome successfully.
A 10Fr x 9cm Advanix plastic biliary stent was placed across the
stricture with excellent drainage of bile and contrast.
Brief Hospital Course:
The patient was admitted to the [**Month/Year (2) 1326**] surgery service on
[**2112-4-28**] and had an Orthotopic liver [**Date Range **]. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please refer to operative note for further details.
The patient tolerated the procedure well and was transferred
intubated to the SICU for management. On POD 1 he was found to
have a large hematoma near the porta and was taken back to the
OR for washout and evacuation of the hematoma. This procedure
was also well tolerated.
Neuro: Post-operatively, the patient received Fentanyl &
Dilaudid IV with good effect and adequate pain control. When
tolerating oral intake, the patient was transitioned to oral
pain medications.
CV: The patient was hypertensive on beginning POD 1 and
initially required hydralazine IV. Once tolerating Po he was
switched to PO Norvasc and Lopressor. The patient was otherwise
stable from a cardiovascular standpoint; vital signs were
routinely monitored.
Pulmonary: Following extubation, the patient was stable from a
pulmonary standpoint; vital signs were routinely monitored.
GI/GU: IV fluids were given until tolerating oral intake. His
diet was advanced to clears on POD 3 and to a regular diet on
POD 4, which was tolerated well. Patient had lower extremity
edema and rhonchi on auscultation. The lateral JP, located in
the hepatic/diaphragmatic gutter was discontinued on POD [**5-3**]
and the medial JP, located near the porta hepatis was
discontinued on [**5-8**]. He was thought to be fluid oveloaded and
on POD 3, 4, & 6 and was administered Lasix IV. Foley was
removed on POD 4, once his fluid status had stabalized. Intake
and output were closely monitored. The patients LFT's increased
on POD 7&8 and he underwent an unremarkable liver U/S. on POD 8
he had an ERCP that showed a stricture and a small bile leak at
the CBD anastamosis. A plastic stent was placed by GI. The
patient tolerated the procedure well and his LFT's trended down
after the procedure.
Endo: He experienced hyperglycemia from the steroids and
required and insulin drip for several days. This was
transitioned to Glargine and a Humalog sliding scale per the
consulting [**Name8 (MD) **] MD. He was taught how to check his blood
glucose and how to draw up and administer insulin. VNA services
were arranged to assist at home as insulin was new for him.
ID: Post-operatively, the patient was started on Bactrim,
Valcyte, and Fluconazole for PCP, [**Name Initial (NameIs) 1074**]/EBV, and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **]. The
patient's temperature was closely watched for signs of
infection.
Immunosuppression: He received induction immunosuppression
(solumedrol and cellcept). Postop, solumedrol was taperedb by
post op day 6 to prednisone 20mg daily. Cellcept 1 gram [**Hospital1 **] was
well tolerated. Prograf was initiated on postop day 1 and dose
adjusted per daily trough levels.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD [**11-20**], the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.
PT cleared him for home. VNA for medication (newly on insulin)
was arranged.
Medications on Admission:
Pantoprazole 40mg Daily, Nadolol 20mg Daily, Lasix 80mg Daily,
Spironolactone 200mg daily, MVI, Fish oil
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. tacrolimus Oral
10. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. insulin glargine 100 unit/mL Solution Sig: Twenty Nine (29)
units Subcutaneous once a day.
Disp:*1 bottle* Refills:*2*
13. insulin lispro 100 unit/mL Solution Sig: follow sliding
scale units Subcutaneous four times a day.
Disp:*1 bottle* Refills:*2*
14. tacrolimus Oral
15. insulin lispro 100 unit/mL Solution Sig: follow sliding
scale units Subcutaneous four times a day.
Disp:*1 bottle* Refills:*2*
16. FreeStyle Lite Meter Kit Sig: One (1) kit Miscellaneous
four times a day.
Disp:*1 kit* Refills:*1*
17. FreeStyle Lite Strips Strip Sig: One (1) Miscellaneous
four times a day.
Disp:*1 bottle* Refills:*2*
18. FreeStyle Lancets Misc Sig: One (1) Miscellaneous four
times a day.
Disp:*1 box* Refills:*2*
19. insulin syringe-needle U-100 1 mL 26 x [**2-14**] Syringe Sig: One
(1) Miscellaneous four times a day: Low dose syringes.
Disp:*1 box* Refills:*2*
20. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 doses.
Disp:*7 Tablet(s)* Refills:*0*
21. Outpatient Lab Work
Labs for AM Monday [**5-9**]: CBC, Chem 10, LFT's, Tacrolimus level
22. FreeStyle Lite Lancets and Strips
Dispense 2 boxes of sterile lancets and test strips for glucose
monitoring. FreeStyle Lite
Refills: 2
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
HCC
HCV cirrhosis
HA anastomosis bleeding
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the [**Hospital 1326**] Office [**Telephone/Fax (1) 673**] if you have any
of the following:
fever, chills, nausea,vomiting, inability to take any of your
medications, jaundice, increased abdominal/incision pain,
incision redness/bleeding/drainage, constipation or diarrhea
You will need to have blood drawn every Monday and Thursday at
[**Last Name (NamePattern1) 439**] Lab on [**Location (un) 453**]
You may not drive while taking pain medication.
No heavy lifting/straining
You may shower with soap and water, but do not put
powder/ointment or lotion on your incision
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2112-5-18**] 11:20
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-5-12**]
9:30
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2112-5-19**] 2:00
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2112-5-26**] 1:40
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8124
} | Medical Text: Admission Date: [**2187-3-27**] Discharge Date: [**2187-3-29**]
Date of Birth: [**2187-3-27**] Sex: F
Service: NEONATOLOG
HISTORY: Baby girl [**Known lastname 916**] was born on [**2187-3-27**] at full term
to a 33-year-old gravida 2, para 1 mother with unremarkable
prenatal labs and unremarkable pregnancy. Delivery was
spontaneous and vaginal after rupture of membranes for
appropriate 12 hours prior to delivery. Maternal group B
strep status was negative. Amniotic fluid was meconium
stained; infant emerged vigorous and did not require
resuscitation in the delivery room. Apgar scores were 7 and
8. Birth weight was 3305 grams. Infant was initially
admitted to the well-baby nursery, where jitteriness was
noted at the three hours of age; DC at that time was 36,
which did increase to 60 at feeding, but fell again to 41 two
hours after feeding. Infant's temperature was 97 degrees at
two hours of age, 97.3 at four hours of age. The infant was
then transferred to the Newborn Intensive Care Unit for
further evaluation of the hypoglycemia and hypothermia.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: The infant was well appearing and vigorous.
Weight was 3,305 grams which is approximately the 50th to
75th percentile. Head circumference is 34.5 cm, which is
also the 75th percentile. Vital signs were stable in room
air. The infant was nondysmorphic appearing. Fontanelles
were soft and flat; palate intact; nares and ears were
normal. Red reflex was present bilaterally. Chest was clear
without increased work of breathing. Heart was regular rate
and rhythm without murmur of gallop. Abdomen was soft
without hepatosplenomegaly. Genitalia were that of a normal
female. Infant was mildly jittery with appropriate tone and
moving all extremities. Reflexes were intact. Skin was
normal.
HOSPITAL COURSE: Infant was admitted to the newborn
Intensive Care Unit for evaluation and treatment of the
hypoglycemia and hypothermia.
RESPIRATORY: The infant remained stable from a respiratory
standpoint throughout admission. Mild desaturations were
noted on day #1 of life, which had resolved by day #2.
CARDIOVASCULAR: The infant remained hemodynamically stable
with normal blood pressure and heart rate throughout the
admission.
FLUIDS, ELECTROLYTES, AND NUTRITION: The infant was
initially begun on IV fluids of D10 in response to the
hypoglycemia, as well as allowed to feed p.o.ad lib. Over
the two days of admission, the IV fluids were able to be
gradually weaned to off with stable blood sugars as feeding
improved. By day of life #2, the infant was feeding well on
an ad lib basis, breasting feeding and bottle with blood
sugars stable, 58 to 66 off IV fluids. Birth weight of 3305
was followed by weight of 3340 grams on day of life #2.
Urine and sugar level were normal. Electrolytes were checked
on day #1 and were within normal limits, including a calcium
level of 8.7.
GASTROINTESTINAL: The infant had normal stools throughout
admission. Bilirubin of 24 hours of life was 5.3/0.3.
INFECTIOUS DISEASE: Initial CBC revealed a white count of
19.7, hematocrit of 45, platelet count of 277 with a
differential of 66 polys, 0 bands. Blood cultures were sent.
Ampicillin and Gentamicin were begun given the hypoglycemia
and hypothermia pending cultures; these are discontinued
after 48 hours with a benign clinical course and negative
cultures.
SENSORY: The infant passed hearing screen with automated
auditory brain stem responses.
DISPOSITION: The infant is being transferred to the Well
Baby Nursery for further monitoring. If the infant does well
it is anticipated that the infant will be able to be
discharged to home in 24 hours.
CONDITION ON DISCHARGE: Stable.
PEDIATRICIAN: Primary pediatrician is Dr. [**Last Name (STitle) 42007**] at Missing
[**Hospital **] Pediatrics in [**Location (un) 1468**], [**State 350**].
CARE RECOMMENDATIONS: Breast feed with bottle supplements on
an ad lib basis.
MEDICATIONS ON DISCHARGE: None.
NEWBORN SCREENING STATUS: Sent.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccination is pending.
DISCHARGE DIAGNOSES:
1. Term infant.
2. Hypoglycemia resolved.
3. Hypothermia resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern4) 42008**]
MEDQUIST36
D: [**2187-3-29**] 12:46
T: [**2187-3-29**] 12:50
JOB#: [**Job Number 42009**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8125
} | Medical Text: Admission Date: [**2112-5-19**] Discharge Date: [**2112-5-20**]
Date of Birth: [**2076-7-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Suicide attempt - tylenol, effexor overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 35 year old female with a history of depression
on Effexor 150 mg (no prior psych admission, suicide attempt)
who presented to the ED on [**2112-5-18**] after her boyfriend called
EMS after he was unable to reach her multiple times by phone.
The patient was found by the police attempting to cut her right
wrist with a razor and admitted to having drank alcohol (unknown
amount, usually drinks beer + vodka) and took a "whole bottle"
of Effexor 150 mg and an unknown quantity of tylenol pm in an
attempt to take her life, approximately around midnight. The
patient states "I can't take it any more". She denies any
instigating factors but states that she has been depressed for
"a long time". She has no psychiatrist but instead was given
Effexor by her PCP. [**Name10 (NameIs) **] denies feeling unsafe at harm and denies
that she feels threatened by anyone. The patient admits to
feeling very depressed. She admits to trying to cut her right
wrist with a razor but "it hurt too much and I couldn't do it."
There was also a report that she may have taken advil as well.
.
The police were able to restrain her from cutting her wrist and
brought her to the ED where her tylenol level was found to be
74, alcohol level 174, serum and urine toxicology otherwise
negative. LFTs were within normal range.
.
The patient's vitals in the ED were 97.4, P 117, BP 133/91, RR
19, 98% on RA. She was given activated charcoal as well as 8400
mg IV NAC, 2 gm magnesium IV and then placed on NAC 4500 mg PO
Q4. She was transferred to the ICU with a 1:1 sitter for further
monitoring.
.
ROS:
.
Otherwise negative. No CP/SOB/abdominal pain. No
nausea/vomiting.
Past Medical History:
Depression, denies past SI
Cervical cancer s/p radical hysterectomy
.
Past Surgical History:
.
Hysterectomy
Social History:
The patient works as a police dispatcher for the [**Location (un) 1411**] police
department. She has a 17 year old daughter who lives with her at
home and is now staying with her father. The patient has a
boyfriend who called EMS initially. She smokes 1 ppd. Admits to
alcohol use and admits a history of alcohol abuse (vodka + beer)
but says she has been cutting down. Denies drinking on a daily
basis. Denies drug use. Family lives in the area
Family History:
Noncontributory.
Physical Exam:
Tc=97.8 P=104 BP = 132/86 RR= 20 100% on RA
.
Gen - Teary eyed, depressed, alert and oriented x 3
HEENT - PERLA, eyes injected, smells of alcohol
Heart - Increased rate, regular rhythm, no M/R/G
Lungs - CTAB
Abdomen - Soft, NT, ND + BS, no hepatosplenomegaly
Ext - No C/C/E, right wrist 3-4 cm linear superficial laceration
over palmaris longus, positive for ecchymosis along bilateral
shins on lower extremities
Back - no CVAT
Skin - As noted above, otherwise no jaundice
Neuro - CN II-XII intact
Psych - Depressed
Pertinent Results:
[**2112-5-19**] 09:49AM ACETMNPHN-9.5
[**2112-5-19**] 09:49AM PT-12.5 PTT-27.5 INR(PT)-1.1
[**2112-5-19**] 05:00AM ACETMNPHN-50.8*
[**2112-5-19**] 02:25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2112-5-19**] 02:25AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2112-5-19**] 02:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2112-5-19**] 01:50AM GLUCOSE-91 UREA N-9 CREAT-0.8 SODIUM-140
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-19
[**2112-5-19**] 01:50AM ALT(SGPT)-20 AST(SGOT)-21 ALK PHOS-60
AMYLASE-34 TOT BILI-0.5
[**2112-5-19**] 01:50AM ASA-NEG ETHANOL-174* ACETMNPHN-73.9*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2112-5-19**] 01:50AM WBC-7.1 RBC-4.38 HGB-14.0 HCT-39.0 MCV-89
MCH-32.1* MCHC-36.0* RDW-13.7
[**2112-5-19**] 01:50AM PLT COUNT-372
[**2112-5-19**] 01:50AM PT-10.9 PTT-26.9 INR(PT)-0.9
Brief Hospital Course:
The patient is a 35 year old female with a history of depression
status post suicide attempt with tylenol overdose, alcohol and
Effexor ingestion.\ who had no significant liver damage from her
intoxications and did quite well. She is now ready for
discharge to an inpatient psychiatric facility.
Plan:
# Tylenol and Effexor overdose. She was originally given
activated charcoal in the ED and NAC. Continued NAC 4500 mg PO
Q4 until HD #1 when, per toxicology recs and normal LFTs, this
was stopped. Her initial tylenol level was 74 and may have been
within <4 hours after ingestion, suggesting borderline to no
hepatotoxicity. Subsequent Acetaminpophen levels dropped
quickly and LFTs remained quite stable. EKG had normal QRS with
RSR' pattern. She supposedly also overdosed with Effexor 150 mg
- so we monitored QRS for widening which was not apparant. We
continued folic acid, thiamine, MVI given history of alcohol
use. She is now medically stable.
# Depression. Psychiatry followed and recommended inpatient
treatment. We retained a 1:1 sitter throughout the admission.
The patient remained very depressed and admitted on HD #1 that
she made a clear attempt to take her life in the setting of a
breakup with her boyfriend related to her alcohol intake. She
is being discharged for further management at an inpatient
psychiatric facility
# FEN - regular, monitor lytes, IVF
# PPX - She refused Heparin SQ TID and pneumoboots
#Code - FULL code
#Dispo - To an inpatient psychiatric facility
#Communication - with patient and her mother
Medications on Admission:
Effexor 150 mg PO QD
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Drug overdose
Suicidality
Depression
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as prescribed.
You were admitted for depression and an overdose on Tylenol and
Effexror with Benadryl. You are being discharged for further
psychiatric evaluation at an inpatient facility.
Follow up as per below.
Seek medical attention immediately if you experience abdominal
pain, headache, desire to hurt yourself or others.
Followup Instructions:
call [**Last Name (LF) **],[**First Name3 (LF) **] S [**Telephone/Fax (1) 8506**] for an appointment when you
get out of the hospital
ICD9 Codes: 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8126
} | Medical Text: Admission Date: [**2108-2-13**] Discharge Date: [**2108-2-15**]
Date of Birth: [**2042-10-15**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Amoxicillin
Attending:[**First Name3 (LF) 2891**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2108-2-14**] left heart catheterization with bare metal stent placed
in left circumflex
History of Present Illness:
65 year old male w/ PmHx of HTN and longstanding GERD (s/p
Nissen procedure) who presented to OSH with chest pain and found
to have elevated troponin without EKG changes, diagnosed with
NSTEMI and transfered to [**Hospital1 18**] for further evaluation.
Mr. [**Known lastname 73466**] reports that around 10am in the morning he developed
a pressure-like sensation around his sternum. He has prominent
GERD symptoms chronically and takes [**Hospital1 **] omeprazole, but this
felt different than his GERD symptoms and didn't feel like
anything he's ever had before. He devleoped diaphoresis, SOB,
and nausea with dry heaving shortly after the chest discomfort
started. He went to [**Hospital3 **] around 2pm. Initial EKG
showed no ischemic changes but troponin I there was elevated at
3.54. He was given 325mg ASA, 75mg clopidogrel, 2SL nitro, nitro
past, 4mg IV morphine, and 40mg simvastatin. Cardiology at
[**Hospital1 2436**] recommended transfer to [**Hospital1 18**].
On arrival to the [**Hospital1 18**] ED, inital VS: 97.4 67 147/107 18 100%
2L. EKG showed no ischemic changes. Guiac negative and started
on heparin gtt for troponin of 0.47 with CK 144 and CKMB 16.
Since chest pain was still present, was given 5mg IV morphine.
He was chest pain free at transfer to [**Hospital Ward Name 121**] 2 with Vs at transfer
97.8, 71, 162/90, 16, 99%RA.
Currently, symptom free. Only other thing that has been going on
recently is severe lower back/Left SI pain with radiation down
the left leg which got much worse over weekend. Started having
issues with this after hurting his back lifting furniture a few
months back. Has received steroid injections in his back in the
past. Over weekend got so bad his feet became a bit numb and
that he couldn't walk much, but this has resolved. Is in process
of being evaluated by a spinal surgeon for this issue. Also
reports intermittent diarrhea with food for many months.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Hiatal hernia, Nissen fundoplication [**2105-7-16**]
GERD
s/p ACL repair in [**2099**]
HTN
Depression
Peroneal nerve entrapemnt s/p surgical decompression in [**2102**]
B/l inguinal hernia repair in [**2102**]
Anemia
R should rotator cuff tear and biceps tendon tear in [**1-28**]
Social History:
Wroked as a painter, physically active. Divorced, in a
monogamous relationship with girlfriend. [**Name (NI) 1139**] - greater than
30 pack years, quit in [**2088**], began smoking at age 12. Alcohol -
1-2 drinks beer daily, almost never binge drinks. No illicit/IV
drug use.
Family History:
Father died of MI at age 70, mother and siblings are healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.0F, BP 166/99, HR 77, R 18, O2-sat 100% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, no focal deficits, intact sensation in
both LE without areas of numbness or paresthesias
BACK: mild pain to palpation over lower back and left SI joint
.
DISCHARGE PHYSICAL EXAM
VS Tmax 99.5, BP 110-140s/68-96, HR 60s, RR18, sats 100% RA
unchanged
Pertinent Results:
ADMISSION LABS
[**2108-2-13**] 09:50PM BLOOD WBC-6.8 RBC-3.85* Hgb-11.9* Hct-38.6*
MCV-100* MCH-31.1 MCHC-30.9* RDW-11.8 Plt Ct-415
[**2108-2-13**] 09:50PM BLOOD Neuts-87.9* Lymphs-8.8* Monos-2.6 Eos-0.7
Baso-0
[**2108-2-13**] 09:50PM BLOOD PT-10.9 PTT-31.4 INR(PT)-1.0
[**2108-2-13**] 09:50PM BLOOD Glucose-132* UreaN-21* Creat-1.0 Na-132*
K-4.7 Cl-99 HCO3-21* AnGap-17
[**2108-2-14**] 07:20AM BLOOD Calcium-8.9 Phos-2.1* Mg-2.0
.
CARDIAC ENZYMES
[**2108-2-13**] 09:50PM BLOOD CK-MB-16* MB Indx-11.1*
[**2108-2-13**] 09:50PM BLOOD cTropnT-0.47*
[**2108-2-14**] 07:20AM BLOOD CK-MB-11* MB Indx-9.7* cTropnT-0.49*
.
DISCHARGE LABS
[**2108-2-14**] 07:20AM BLOOD WBC-7.1 RBC-3.53* Hgb-11.3* Hct-34.4*
MCV-98 MCH-32.0 MCHC-32.8 RDW-12.1 Plt Ct-322
[**2108-2-15**] 06:30AM BLOOD UreaN-8 Creat-0.9 Na-136 K-4.3 Cl-100
[**2108-2-15**] 06:30AM BLOOD ALT-42* AST-65* AlkPhos-47 TotBili-0.9
[**2108-2-15**] 06:30AM BLOOD Triglyc-241* HDL-70 CHOL/HD-2.7
LDLcalc-71
.
IMAGES
[**2108-2-14**] CARDIAC CATH: COMMENTS:
1) Selective coronary angiography of this right-dominant system
demonstrated two-vessel coronary artery disease. The LMCA and
LAD had
no angiographically-apparent flow-limiting stenoses. The large
OM
branch of the LCx had a 70% stenosis at the bifurcation. The
proximal
RCA had a 50-60% stenoses.
2)
3) Limited resting hemodynamics revealed systemic arterial
normotension,
with a central aortic pressure of 127/78 mmHg.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful BMS to LCx.
3. Aspirin 81 mg daily indefinitely and clopidogrel 75 mg daily
for 1
month minimum, longer if no bleeding.
.
3/38/12 TTE: RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated
RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%). Doppler parameters are indeterminate for LV diastolic
function. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately 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%). Doppler parameters are
indeterminate for left ventricular diastolic function. 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. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation.
.
Brief Hospital Course:
Mr. [**Known lastname 73466**] is a 65 year old male w/ hypertension (HTN) and
difficult to control GERD (s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1358**]) who presented to OSH with
chest pain different from his baseline GERD and found to have
elevated troponin without EKG changes ruling in for NSTEMI and
transfered to [**Hospital1 18**].
.
# Non-ST elevation myocardial infarction (NSTEMI): His chest
pain syndrome was very different from his baseline GERD with a
substernal location, pressure-like pain, and associated
diaphoresis and nausea. Eventually, he became chest pain free
and without shortness of breath, but took hours to achieve this
with morphine and nitro. No heart failure on symptoms or exam.
No prior history of coronary disease nor stable anginal syndrome
and no prior caths but has smoking history and hypertension. He
recieved aspirin 325 mg, clopidogrel loaded 600 mg, heparin gtt,
atorvastatin 80 mg daily, metoprolol tartrate 25 mg [**Hospital1 **], and his
lisinopril was increased to 40 mg daily. He underwent a cath
with placement of a bare metal stent to his left circumflex
artery. After this, his plavix was changed to prasugrel 10 mg
daily because this does not interact with his fluoxetine or
omeprazole. His transthoracic ECHO showed no wall motion
abnormalities, slight mitral regurgitation. He was discharged
on: aspirin 81 mg, prasugrel 10 mg daily, atorvastatin 80 mg
daily, metoprolol succinate 50 mg [**Hospital1 **], and lisinopril 40 mg
daily.
.
# HTN: His systolic pressure on admisson was 169 and so his
lisinopril was increased to 40 mg daily in light of NSTEMI as
would prefer to reduce afterload to reduce myocardial oxygen
demand.
.
# Gastroesophageal reflux disease (GERD): This is chronic and
poorly controlled despite past [**Last Name (un) 1358**]. Has been on 40mg
omeprazole [**Hospital1 **] for some time. Because PPI interacts with
clopidogrel, placed BMS so that anticoagulation time is
minimized. Also, discharged him on prasugrel as 2nd
antiplatelet [**Doctor Last Name 360**] so that omeprazole can be continued.
.
# Depression: Symptoms stable. Has been on high dose
fluoxetine. Fluoxetine also interacts with plavix so again
favored prasugrel in [**Hospital 4820**] medical management of NSTEMI.
.
# Siatica: Again long-standing and difficult to control. His
PCP has reported that he trusts him to have narcotics on a
short-term basis if needed for pain while in house. He is
getting set-up with the spine center for possible surgical
intervention. Was given oxycodone for pain control but this
caused nightmares so he asked to not have this continued.
Avoided NSAIDS because don't want to irritate known gastritis in
the setting of new antiplatelet agents as above.
.
# CONTACT: [**Name (NI) 8214**] [**Name (NI) 83084**] (friend-[**Telephone/Fax (1) 83085**](h) /
[**Telephone/Fax (1) 83086**](w)
.
TRANSITIONAL ISSUES:
- Please discontinue prasugrel after a month if concerns for GI
bleeding
- His AST and ALT were slightly elevated and he was started on a
statin. These should be rechecked
Medications on Admission:
Lisinopril 20mg PO daily
Omeprazole 40mg PO BID
Fluoxetine 40mg PO daily
ASA 81mg PO daily
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
non-ST elevation myocardial infarction (NSTEMI)
.
SECONDARY DIAGNOSIS
hypertension
gastroesophageal reflux disease (GERD)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 73466**],
.
You were admitted to the hospital because you had chest pain
which was concerning for a heart attack. Your blood work showed
that you had a small heart attack and you underwent a procedure
(called cardiac catheterization) where they placed a stent in
one of your blood vessels to open it up again. We also started
some new medications to control your blood pressure and
cholesterol. Finally, there are some new medications to thin
your blood so that new blood clots are less likely to form in
your heart. However, these medications do increase your risk of
bleeding in your stomach slightly so you should monitor yourself
for symptoms such as black stools.
.
The following changes were made to your medications:
- START taking prasugrel 10 mg daily
- START taking metoprolol succinate 50 mg a day
- START atorvastatin 80 mg daily
- INCREASE lisinopril to 40 mg daily
.
You should keep all of the follow-up appointments listed below.
.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Department: [**Location (un) **] PRIMARY CARE
When: TUESDAY [**2108-2-28**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 79306**], MD [**Telephone/Fax (1) 3736**]
Building: [**Street Address(2) 82764**] ([**Location 15289**], MA) [**Location (un) 859**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: [**Hospital3 249**]
When: MONDAY [**2108-2-27**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
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: CARDIAC SERVICES
When: WEDNESDAY [**2108-3-21**] at 1:20 PM
With: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 18267**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8127
} | Medical Text: Admission Date: [**2117-3-30**] Discharge Date: [**2117-4-3**]
Date of Birth: [**2051-5-31**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Bilateral sided burr holes for drainage of subdural hematoma
History of Present Illness:
65M who is a physician from [**Name9 (PRE) 6171**] visiting [**Location (un) 86**] for a
conference. He reports a ski accident in [**Country 6171**] about 5 weeks
ago, he is unsure of the event and not sure why he went down-
syncope vs. traumatic event. A head CT at that time was
negative. He flew into [**Location (un) 86**] for a conference and reports a
headache that
started yesterday but has progressed this morning. He denies any
visual issues, but reports nausea/vomiting. Denies any
anticoagulant medication.
Past Medical History:
HTN
Lung cancer diagnosed 3 years ago with no mets or lymph node
spread. No chemo, s/p lobectomy, side unknown.
s/p cholestectomy
BPH?
Bil shoulder injury years ago, s/p surgical intervention
Social History:
Married, has children and grandchildren. Lives in Nice, [**Country 6171**].
He is a Infectious Disease physician. [**Name10 (NameIs) **], no ETOH, no
recreational drugs.
Family History:
Noncontributory
Physical Exam:
O: T: 97.8 BP: 167/76 HR: 81 R 16 O2Sats 99%
Gen: WD/WN, uncomfortable, NAD.
HEENT: normocephalic
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-3**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Pertinent Results:
[**2117-4-1**] 03:04AM BLOOD WBC-11.7* RBC-3.93* Hgb-12.5* Hct-36.3*
MCV-92 MCH-31.8 MCHC-34.4 RDW-13.1 Plt Ct-169
[**2117-4-1**] 03:04AM BLOOD Plt Ct-169
[**2117-3-30**] 11:50AM BLOOD Neuts-87.0* Lymphs-9.2* Monos-3.4 Eos-0.3
Baso-0.2
[**2117-4-1**] 03:04AM BLOOD Glucose-147* UreaN-22* Creat-1.0 Na-139
K-3.6 Cl-106 HCO3-25 AnGap-12
[**2117-4-1**] 03:04AM BLOOD Calcium-7.2* Phos-1.8*# Mg-2.0
[**2117-3-30**] 12:04PM BLOOD Lactate-1.4 K-3.9
Brief Hospital Course:
Mr [**Name13 (STitle) 90376**] was admitted to the neurosurgery ICU for close
observation after a head CT showed bilateral subdural hematoma.
He was started on seizure prophylaxis and prednisione for
headache pain. He was brought to the OR on [**3-31**] and underwent
bilateral burr hole procedures for evacuation of subdural
hematoma. He tolerated the procedure well and remained
neurologically intact. he was trasnfered to the floor where he
remained stable. On the morning fo 3.5 he was noted to be
slightly febrile and having a productive cough. He had a CXR
which was negative, and a head CT which was stable. He also
complained of RLE pain and LENIS were done to rule out DVT. The
preliminary read was that there was no DVT however a final read
had not been done by the time of discharge. The patient was
given instructions for follow-up and did not require any
prescriptions as he already possessed the necessary medications.
He was instructed to follow-up wtih [**Hospital1 18**] prior to flying to
[**Country 6171**] on Wednesday for the results of his LENIs
Medications on Admission:
Cozaar
Some medication for prostate but name unfamiliar
Discharge Medications:
1. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Cepacol Sore Throat + Coating 15-5 mg Lozenge Sig: One (1)
Mucous membrane prn sore throat as needed for sore throat.
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural Hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow up in 4 weeks with Dr [**First Name (STitle) **] you will need head CT at
that time.
****You are being dischargd prior to a final [**Location (un) 1131**] of your
lower extremity doppler studies to rule out DVT. You must
contact [**Hospital1 18**] at [**Telephone/Fax (1) 90377**] on [**4-4**] to obtain the results of
this study prior to flying*****
Completed by:[**2117-4-3**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8128
} | Medical Text: Admission Date: [**2142-4-13**] Discharge Date: [**2142-4-18**]
Date of Birth: [**2086-10-31**] Sex: M
Service: NEUROSURGERY
Allergies:
Nsaids / bee stings / Zyvox
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Brain mass
Major Surgical or Invasive Procedure:
Right craniotomy for open biopsy of Right parietal brain lesion
History of Present Illness:
This is a 55 yo male patient with metastatic lung CA and right
parietal mass. He was recently seen by Dr. [**Last Name (STitle) **] and me and
his
case was discussed with the brain tumor clinic and a biopsy
prior
to radiation was recommended. He therefor represents for
evaluation.
He denies headaches, nausea, emesis, seizure activity.
He reports to have a productive cough all winter that is
improving. He was recently admitted for tachycardia related to
dehydration.
Past Medical History:
- Paranoid schizophrenia
- NIDDM
- Depression
- Hepatitis C
- Cirrhosis.
- Lung Cancer s/p surgery and chemo-radiation 1 year ago
recently found with mets to parietal lobe
Social History:
He lives in a group home/extended care facility. He used to
work as a
manual laborer. He has 40-pack-year smoking history and prior
heavy drinking.
Family History:
Coronary artery disease and MIs.
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD. Wearing a mask due to cough
HEENT: Pupils: 1-0.5 EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 1 to 0.5
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-2**] throughout. No pronator drift
Coordination: normal on finger-nose-finger
On Discharge:
Gen: WD/WN, comfortable, NAD. Wearing a mask due to cough
HEENT: Pupils: 1-0.5 EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 1 to 0.5
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-2**] throughout. No pronator drift
Coordination: normal on finger-nose-finger
On Discharge:
Motor: mild leftsided 4+/5 weakness. Right side is full
strength.
Pertinent Results:
CT HEAD W/O CONTRAST [**2142-4-13**]
Expected post biopsy changes of pneumocephalus, small amount of
blood, and fluid. No large hemorrhage. No evidence of infarction
MR brain [**2142-4-13**]
Redemonstration of the right parietal lesion measuring 1.8 x 2.3
x 2.4 cm. for surgical planning. Other details as above
CT head noncontrast [**2142-4-13**]: Expected post biopsy changes of
pneumocephalus, small amount of blood, and fluid. No hemorrhage.
No evidence of infarction.
Chest Xray [**4-16**] : no change from [**2142-4-10**]. No focal
consolidation or pleural effusion is seen. The cardiomediastinal
silhouette is within normal limits.
Brief Hospital Course:
This is a 55 year old man with history of metastaic lung CA
presents for open biopsy of R parietal brain lesion. Post
operative head CT was stable. He remained in the ICU overnight
for close monitoring. On [**4-14**], patient remained stable.
Overnight his blood glucose was elevated to 455 and an insulin
gtt was started. On the morning of [**4-14**], his gtt was weaned off
and patient was transferred to the SDU. He had BS over 400
twice and [**Last Name (un) **] was consulted on [**4-15**]. Steroids were lowered.
On [**4-16**] his dexamethasone continued to be weaned and [**Last Name (un) **]
contined to see him titrating his sliding scale. On [**4-17**] he was
deemed fit from a neurosurgical perspective for discharge to
rehab, however after discussion with [**Last Name (un) **] he continued to
require more time to devise an appropriate blood glucose
management regimen so his discharge was placed on hold. He was
transferred to floor status on [**4-17**].
He was seen and evaluated by physical therapy and occupational
therapy who felt that he would benefit from rehab.
At the time of discharge he was tolerating a diabetic diet,
ambulating with a walker, afebrile with stable vital signs.
Medications on Admission:
fluticasone-salmeterol, tiotropium bromide, dexamethasone,
citalopram, clonazepam, olanzapine, trihexyphenidyl, tamsulosin,
aspirin 325, docusate sodium, haloperidol, omeprazole,
metformin, albuterol, gabapentin
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. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
7. olanzapine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. trihexyphenidyl 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
10. haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. gabapentin 400 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhaler Inhalation Q6H (every 6 hours)
as needed for wheezing.
13. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
17. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for Pain.
Disp:*50 Tablet(s)* Refills:*0*
18. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
19. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
21. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-29**]
Tablets PO every 6-8 hours as needed for pain.
22. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for itching .
23. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO twice a day as needed for constipation.
24. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
25. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: per insulin flowsheet per insulin flowsheet Subcutaneous
per insulin flowsheet: Please follow insulin Flowsheet.
26. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13990**] Health Care Center - [**Location (un) 5110**]
Discharge Diagnosis:
Right parietal brain lesion
Hyperglycemia
Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Dressing may be removed on Day 2 after surgery.
?????? If you have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? If your wound was closed with staples or non-dissolvable
sutures then you must wait until after they are removed to wash
your hair. You may shower before this time using a shower cap to
cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Aspirin, prior to your
injury, you may safely resume taking this on [**2142-4-20**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-7**] days(from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**4-23**] at
930am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2142-4-18**]
ICD9 Codes: 496, 4019, 2724, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8129
} | Medical Text: Admission Date: [**2149-5-11**] Discharge Date: [**2149-5-19**]
Date of Birth: [**2089-12-7**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient is a 59-year-old woman,
who had a sudden onset of the worst headache of her life on
[**2149-5-2**] with decreased hearing. CT of the head showed
subarachnoid hemorrhage in the intralimbic fissure. CTA
showed no evidence of aneurysm, question of an azygous
anterior cerebral artery abnormality, and left fetal origin
of the posterior cerebral artery, question of aneurysm.
Angio on [**5-2**] showed no evidence of aneurysm. Patient was
transferred to [**Hospital1 69**] for
further management. On [**5-8**], she had a CTA and CT that
showed no evidence of aneurysm. She was taken to the
angiography suite by Dr. [**Last Name (STitle) 1132**], and was found to have a right
A1-2 junction aneurysm. Dr. [**Last Name (STitle) 1132**] took her to the operating room
that day, which was [**2149-5-13**], and she had a clipping of the
aneurysm without intraoperative complication. Postoperatively,
she was monitored in the Intensive Care Unit. She remained
intubated, but awake and alert, following commands. Her
grasps were full. Her IPs were full. Her EOMs full.
She still had her sheath in. Sheath was pulled on
postoperative day #1. She was extubated. She had a repeat
head CT, which showed good placement of drain and also no
evidence of hydrocephalus. The drain was therefore D/C'd.
The patient remained neurologically stable, and was
transferred to the floor on [**2149-5-15**]. She remained
neurologically intact, following commands with no neurologic
deficit. Her incision was clean, dry, and intact. She was
afebrile. She then underwent a post-clipping angiogram which
confirmed that the aneurysm had been clipped without residual
and no evidence of vasospasm.
She was seen by Physical Therapy and Occupational Therapy,
and eventually cleared for discharge home. She was seen by
Cardiology for a question of a history of prolonged Q-T
interval. Cardiology had no immediate recommendations, just
avoiding all medications, which cause prolongation of the Q-T
interval.
Her condition remained stable, and she was discharged to home
on [**2149-5-19**] in stable condition for followup for staple
removal on postoperative day #10 with Dr. [**Last Name (STitle) 1132**].
MEDICATIONS ON DISCHARGE:
1. Percocet 1-2 tablets p.o. q.4h. prn.
2. Labetalol was D/C'd.
3. Dilantin 100 mg p.o. t.i.d.
4. Lansoprazole 30 mg p.o. q.d.
5. Senna one tablet p.o. b.i.d.
6. Colace 100 mg p.o. b.i.d.
7. Patient was to restart her Toprol XL when she returns home
and follow up with her primary care physician for blood
pressure check.
CONDITION ON DISCHARGE: Her condition was stable at the time
of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2149-5-19**] 10:59
T: [**2149-5-20**] 10:23
JOB#: [**Job Number 11434**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8130
} | Medical Text: Admission Date: [**2128-4-27**] Discharge Date: [**2128-5-5**]
Date of Birth: [**2049-12-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 7835**]
Chief Complaint:
Fever and altered mental status
Major Surgical or Invasive Procedure:
ERCP with placement of biliary stent
History of Present Illness:
78 year old man with h/o Afib on Coumadin, CHF, with recent
admission to [**Hospital1 18**] need/[**Location (un) **] for ascending cholangitis (d/c
[**4-23**]) had ERCP with stent replacement, who presents today from
rehab with elevated white blood count (26 at rehab) and shaking.
Patient was recently admitted to [**Hospital1 18**] from 5/55/12-6/1/12 for
ascending cholangitis and UTI after presenting with AMS, fevers
with abdominal US demonstrating obstruction. He underwent ERCP
which demonstrated gross pus. A previously placed mental stent
was removed. A previously placed plastic stent had migrated into
the right hepatic duct/bilary tree - removal was not attempted
given concurrent cholangitis. He further underwent placement of
a 5cm by 10FR double pig tail biliary stent was placed
successfully for decompression with the proximal end terminating
in the left hepatic duct with good biliary flow. He was
initially treated with zosyn which was subsequently narrowed to
Augmentin for a planned 14 day course (last day [**2128-4-29**]). As
above the patient has a previous history of obstruction with
placement of 2 stents. Plan was originally for removal in summer
of [**2126**] however he was lost to follow-up.
The day of presentation patient was noted to have shaking chills
at rehab, labs were done and demonstrated a white count of 26.
He presented [**Hospital1 **] Needeham from rehab where labs were notable for
elevated WBC,lipase of 42 and bili of 9. CXR demonstrated
pulmonary edema but no PNA. Head CT was negative for an acute
process. He was given IVF, zosyn/ vanc and transfered to [**Hospital1 18**]
for further management.
In the ED, initial VS were: 96.5 86 86/49 92% ra. He was given
2 L of NS with improvement in BP to the 130s. Labs were notable
once again for bili 7.5, ALT/AST in the 100s, alk phos of 949,
WBC 22, CR of 1.4 and Na of 148. RUQ US showed intrahepatic
biliary dilation, penumobilia, bilary sludge, and stable
pancreatic duct dilitation. He was given 10 mg IV vitamin K for
an INR of 3.2. The ERCP fellow was contact[**Name (NI) **] with plan for ERCP
tomorrow. He was admitted to the ICU for further management.
On arrival to the MICU, patient's VS were afebrile 89 141/74 99%
2L NC.He denies any complaint including chest pain, shortness of
breath, abdominal pain, headache, nausea, vomiting.
Review of systems:
on able to obtain
Past Medical History:
CAD, s/p MI [**2095**]
Cardiomyopathy, EF 45%
Afib on Coumadin
HTN
HLD
Mild cognitive impairment
TIA - in the setting of low INR
Biliary obstruction - s/p biliary stent in the past with
migration, replaced by metal stent in [**1-3**], supposed to be
re-evaluated/possibly removed [**5-3**] but was not done
PVD s/p L fem-[**Doctor Last Name **] bypass [**2126**]
s/p bladder repair for tear [**3-4**]
s/p AAA repair [**8-2**]
Prostate ca - s/p radiation
Gout
UTIs
Social History:
Lives with his wife, also has a home in [**Name (NI) 108**]. History of
tobacco use, but quit in [**2114**]. Does not drink alcohol.
Family History:
Father with prostate problems. Mother died at age 89 after hip
fracture, ?clot.
Physical Exam:
96.5 86 86/49 92% ra
General: Alert, oriented to person only, no acute distress
HEENT: Sclera icteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irreg irreg, normal S1 + S2, no murmurs, rubs, gallops
Lungs: crackles at bilateral bases
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, decreased strength throughout, grossly
normal sensation,gait deferred.
Pertinent Results:
ADMISSION LABS ([**2128-4-27**]):
WBC-22.5*# RBC-3.58* Hgb-9.2* Hct-30.5* MCV-85 MCH-25.7*
MCHC-30.2* RDW-16.2* Plt Ct-172 Neuts-96.2* Lymphs-1.8*
Monos-1.1* Eos-0.1 Baso-0.9
PT-32.7* PTT-37.8* INR(PT)-3.2*
Glucose-104* UreaN-33* Creat-1.4* Na-148* K-3.3 Cl-115* HCO3-22
AnGap-14
ALT-123* AST-171* CK(CPK)-168 AlkPhos-949* TotBili-7.5*
Albumin-2.4* Calcium-7.8* Phos-3.3 Mg-1.9
RUQ ULTRASOUND ([**2128-4-28**]):
1. Intrahepatic biliary dilatation and pneumobilia. Stent in
common bile duct with stable dilatation of pancreatic duct.
2. Distended gallbladder with sludge and thickened wall, most
likely due to third spacing.
3. Right pleural effusion and ascites.
ECHO ([**2128-4-29**]):
Suboptimal image quality. There is a small mobile mass which may
represents a small vegetation on the tricuspid valve. If
clinically indicated, a transesophageal echocardiographic
examination is recommended. Decreased biventricular systolic
function with abnormal septal wall motion. Mild aortic
regurgitation. Mild to moderate mitral regurgitation. Moderate
tricuspid regurgitation. Mild pulmonary artery systolic
hypertension. Large left pleural effusion.
RUE ULTRASOUND ([**2128-4-30**]): Clot in the right basilic vein. No DVT
in the right upper extremity.
BIOPSY ([**2128-4-28**]): Periampullary mass, mucosal biopsies:
Adenomatous mucosal fragments, predominantly with low grade
dysplasia; see note. Note: Occasional areas demonstrate nuclei
with disordered polarity and cytologic features worrisome for
high grade dysplasia. No definite carcinoma in these biopsy
samples.
BRUSHINGS ([**2128-4-28**]): POSITIVE FOR MALIGNANT CELLS, consistent
with adenocarcinoma.
CXR [**2128-5-4**]:
Moderately-severe pulmonary edema is unchanged, but moderate
right and small left pleural effusion have both increased
substantially since [**4-28**]. Cardiac silhouette is partially
obscured, but probably still mildly enlarged. Heavy
calcification of the cardiac silhouette along the diaphragmatic
surface is probably left ventricular aneurysm or pseudoaneurysm.
Brief Hospital Course:
78 yo male with recent cholangitis s/p ERCP with stent placement
who presents from rehab with chills, AMS, elevated WBC, elevated
bilirubin, LFTs and concern for recurrent cholangitis.
1. Severe sepsis with septic shock; secondary to:
2. VRE, pseudomonas, and enterobacter septicemia
3. Cholangitis
4. Possible endocarditis
Presented with fever, leukocytosis, confusion, and acute renal
failure. Imaging demonstrated biliary dilitation, pneumobilia,
biliary sludge and stable pancreatic duct dilitation. ERCP
demonstrated frank pus draining from behind an obstructed
proximal stent. The stent was removed, however a more distal
stent in the right hepatic duct was not removed. Initial
treatment for enterococcus was vancomycin, then switched to
daptomycin when noted to be VRE. Initial treatment for GNR was
pip-tazo.
Regarding possible bacterial endocarditis, an echo showed a
small mobile mass which may represents a small vegetation on the
tricuspid valve. While a TEE would provide a more definitive
diagnosis, this was deferred in favor of empiric treatment with
6 weeks of antibiotics. Yet, due to goals of care, antibiotics
were stopped prior to discharge home on hospice.
5. Adenocarcinoma: CT abdomen showed enhancing lesion around
pacreatic head. ERCP showed a 4mm fungating mass at the major
papilla. Brushings were positive for adenocarcinoma. After
discussion with the family, oncology consultation was pursued
but pt's poor performance status as well as significant
comorbidities precludes surgery or aggressive therapy.
6. Acute renal failure: Initially elevated with improvement
after IVF then another increase later in course.
7. Encephalopathy: Family reports waxing and [**Doctor Last Name 688**] mental
status over the past several weeks (especially in hospital
setting). Likely multifactorial.
8. Acute on chronic diastolic CHF: Noted to have pulmonary edema
on CXR in the setting of IVF for hypotension. Lisinorpil was
held due to hypotension and ARF. Metoprolol was restarted prior
to ICU callout. He had persistent HTN so this was titrated up
with response. day prior to discharge he was noted to require
oxygen and repeat CXR showed increased bilateral pleural
effusions. IVFs had been stopped due to no IV access.
9. Atrial fibrillation: On admission he was supratherapeutic and
was given vitamin K for ERCP. After procedure he was restarted
on home dose of warfarin. Given a CHADS2 score of 5 with prior
TIA bridging anticoagulation was used (initially with IV
heparin, then enoxaparin given difficulty obtaining PTT levels
routinely). Enoxaparin (as well as warfarin) based on poor
prognosis and due to goals of care.
10. Peripheral vascular disease: Has difficult to
palpate/doppler DP pulse on the left. Feet are often noted to be
blue (often seen at home from wife's report).
11. Goals of care: Discussion with HCP/family on [**2128-5-1**]
documented in OMR. DNR/DNI. Based on poor overall prognosis
with new diagnosis of pancreatic or biliary adenocarcinoma,
family wanted to avoid further invasive measures or aggressive
treatment as it had been the pt's wish to spend his time at
home. He was discharged home on home hospice.
Medications on Admission:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 13 doses: last day of
antibiotics is [**2128-4-29**].
3. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
4. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. docusate sodium 50 mg/5 mL Liquid Sig: One (1) tab PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
2-20 mg PO q1hr as needed for pain.
Disp:*30 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
1. Severe sepsis and setic shock due to:
* Cholangitis with biliary obstruction, likely secondary to
adenocarcinoma
* Septicemia (VRE; pseudomonas; enterobacter)
* Possible endocarditis
2. Encephalopathy
3. Acute renal failure
4. Hypernatremia
5. Atrial fibrillaton with history of TIA
6. Acute on chronic diastolic congestive heart failure
7. Coronary artery disease
8. Peripheral vascular disease
9. Prostate cancer
10. Right basilic vein thrombus
11. NSVT
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with a severe infection (cholangitis) and well
as bacteria in the bloodstream. These were treated with ERPC
with new stent placement and antibiotics.
Unfortunately, a biopsy performed during ERCP showed evidence of
adenocarcinoma. Due to multiple comorbidities and your overall
status at this time you are not a candidate for surgery or
aggressive treatment. After a discussion with your wife and
sons, the decision was made to get you home so you can spend
time with your family with home hospice services.
Followup Instructions:
None scheduled
ICD9 Codes: 412, 4019, 2724, 2749, 4439, 4254, 5849, 2760, 4271, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8131
} | Medical Text: Admission Date: [**2159-6-6**] Discharge Date: [**2159-6-12**]
Date of Birth: [**2093-7-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ESRD s/s htn and type II DM
Major Surgical or Invasive Procedure:
Cadaver Kidney Transplant [**2159-6-6**]
Hemodialysis
History of Present Illness:
53 y.o African American male with ESRD [**3-14**] HTN and Type II DM.
He has been on hemodialysis for three years. He has a left AVG.
He has h/o Hep B and is followed by Dr [**Last Name (NamePattern4) 105801**]. Liver biopsy [**6-12**]
revealed grade 0-1 inflammation and no fibrosis. He has been
feeling well. Denies fevers, chills, infections. Has chronic
post nasal drip. He coughs and raises clear to white phlegm. He
does experience some chest tightness with coughing. Otherwise
denies sob, cp, palp, indigestin, dizziness, dysuria. He voids
~8 oz per day. +occasional constipation. Left hand has been sore
since MVA yesterday. Denied hitting head, loss of consciousness
or other pain.
He
Past Medical History:
h/o prostate CA and underwent a radical prostatectomy
Hep B
ESRD s/s HTN, Type II DM
Arthritis
Retinopathy
Chronic post nasal drip
L AVF [**1-10**]-failed
L AVG with angioplasty, thrombectomy,
Social History:
Widower. Works full time for [**Location (un) 86**] Symphony. Has 6 children.
Has occasional beer. Drank more years ago. Never smoked. No h/o
recreational drugs.
Physical Exam:
97.9-72-18-192/96, 93.4kg, 5'8", gluc 87
A7O, pleasant, nad
perrla, eomi, anicteric, no eye drg. no sinus tenderness,
pharynx wnl. u/l dentures
2+carotids, no bruits, L submandibular 1cm round, mobile nodule.
NT, no jvd
Lungs clear bilat
Cor-S1S2 nl. no m/r/g
abd-nt/nd/+bowel sounds, no HSM, mild umbilical hernia
Ext-no c/c/e
Neuro-A&o, CNII-XII, strength 5/5 upper/lower. no flap,
sensation intact
Vasc-+bruit/thrill L forearm graft. Carotids2+ bilat, fem
2+bilat, 2+ DPs
Pertinent Results:
[**2159-6-6**] 10:42PM HCT-31.5*
[**2159-6-6**] 06:32PM GLUCOSE-88 UREA N-59* CREAT-9.5* SODIUM-145
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-26 ANION GAP-21*
[**2159-6-6**] 06:32PM ALK PHOS-70 TOT BILI-0.4
[**2159-6-6**] 06:32PM TOT PROT-6.3* ALBUMIN-3.7 GLOBULIN-2.6
PHOSPHATE-5.2* MAGNESIUM-1.8
[**2159-6-6**] 06:32PM WBC-8.8# RBC-3.57* HGB-11.8* HCT-34.8* MCV-98
MCH-33.2* MCHC-34.0 RDW-15.1
[**2159-6-6**] 06:32PM PLT COUNT-131*
[**2159-6-6**] 04:30PM TYPE-ART PO2-80* PCO2-36 PH-7.48* TOTAL
CO2-28 BASE XS-3 INTUBATED-INTUBATED VENT-CONTROLLED
[**2159-6-6**] 04:30PM GLUCOSE-90 LACTATE-1.0 NA+-141 K+-5.0 CL--102
[**2159-6-6**] 04:30PM HGB-11.7* calcHCT-35
[**2159-6-6**] 04:30PM freeCa-1.15
[**2159-6-6**] 10:10AM UREA N-57* CREAT-9.7* SODIUM-144
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-31* ANION GAP-15
[**2159-6-6**] 10:10AM ALT(SGPT)-21 AST(SGOT)-24 LD(LDH)-285*
[**2159-6-6**] 10:10AM UREA N-57* CREAT-9.7* SODIUM-144
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-31* ANION GAP-15
[**2159-6-6**] 10:10AM CALCIUM-10.0 PHOSPHATE-4.8* CHOLEST-93
[**2159-6-6**] 10:10AM TRIGLYCER-61
[**2159-6-6**] 10:10AM WBC-4.5 RBC-3.71* HGB-12.3* HCT-35.9* MCV-97
MCH-33.3* MCHC-34.3 RDW-15.2
[**2159-6-6**] 10:10AM PLT COUNT-156
[**2159-6-6**] 10:10AM PT-13.6 PTT-31.6 INR(PT)-1.2
Brief Hospital Course:
Admitted [**2159-6-6**] for cadaver kidney translant. Received
induction immunosuppression including ATG, Cellcept, and
solumedrol. Received HBIG and lamivudine for h/o chronic
Hepatitis B. See OR report for details. Urine output was low
postop averaging 80-23cc/hour. He required post op hemodialysis
after surgery for low urine output, high bp and difficulty
maintaining O2 sat. A CXR revealed bilateral effusions with
pulmonary edema. A total of 1.5 liters was ultrafiltrated. IV
fluid was heplocked.
On POD 1 an ultrasound was done revealing no perinephric fluid
collections or hematomas,no hydronephrosis. There was flow
within the main renal artery and veins. Resistive indices
measure 0.71 in the lower pole to 0.87 in the upper pole. Brisk
arterial upstrokes were noted. He received hemodialysis. He was
run even on this treatment. Creatinine was 11.8, bun 100,
Potassium 5.4. On POD 2 he was started on HBIG and lamivudine
for his Hepatitis B. He was transfused with 2 units of PRBC for
a hematocrit of 25.8. Dialysis was performed on POD 2 for low
urine output, creatinine of 11.8 and potassium of 5.7. One liter
of utrafiltration was achieved. Prograf was started on POD 2.
On POD3 he received 2 units of PRBC for hematocrit of 25.8. JP
continued to drain bloody drainage. Dialysis was performed again
for delayed graft function. HBIG was discontinued. A HbSAG and
HbSAb were drawn. HBIG was restarted on [**6-12**] after Dr. [**Last Name (STitle) 497**]
reviewed the case.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained for management of hyperglycemia
and insulin sliding scale was continued with recommendations to
increase glipizide to 10mg [**Hospital1 **] as the patient refused to take
insulin at home. Glucoses ranged in the mid 100s to 200s. He
should follow up with his outpatient PCP for DM management.
On POD 5, he was given IV lasix with mild diuresis. He was
discharged home on [**6-12**]. He will have follow up with the
transplant surgeon on [**6-14**] and nephrologist the following week.
Labs will be drawn every Monday and Thursday for cbc, chem 7,
calcium, phosphorus, ast, t.bili, urinalysis and trough prograf
level. He will need to continue on lamivudine 15mg every day
for three months. He will need to follow up with Dr.[**Last Name (STitle) 497**].
Labs on discharge were as follows: creatinine 8.8, bun 98,
potassium 43.9, sodium 135, bicarb 26, chloride 95, wbc 3.1,
hematocrit 28.2, platelets 106 and prograf level of 7.3.
Prograf was increased to 9mg [**Hospital1 **]. He will not require
hemodialysis as an outpatient as his urine output increased. He
has delayed graft function.
Medications on Admission:
nephro cap 1 qd, actos 30mg qd, amlodipine 10mg qd, diovan 160mg
qd, neurontin 100mg [**Hospital1 **], glipizide 10mg qd, glipizide 5mg qprm,
senokot prn
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed: tylenol.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO QOD
().
8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): follow sliding scale.
Disp:*1 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Cadaver Kidney Transplant
Delayed kidney graft function
Type II DM
HTN
Discharge Condition:
stable
Discharge Instructions:
Call if fevers, chills, nausea, vomiting, inability to take
medications, decreased urine output, increased drainage from
drain, bleeding from incision, redness of incision or increased
abdominal pain.
Labs every Monday & Thursday for cbc, chem 7, calcium,
phosphorus, ast, t.bili, urinalysis, and trough prograf level.
Results to be fax'd to Transplant office [**Telephone/Fax (1) 697**]
[**Month (only) 116**] shower.
No driving while taking pain medication
no heavy lifting
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2159-6-14**] 10:10
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2159-6-19**] 8:15
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2159-6-25**] 8:00. f/u for Hepatitis B
check blood sugar control
Completed by:[**2159-6-12**]
ICD9 Codes: 5119, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8132
} | Medical Text: Admission Date: [**2193-4-29**] Discharge Date: [**2193-6-1**]
Date of Birth: [**2140-6-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Epigastric abdominal pain
Major Surgical or Invasive Procedure:
[**2193-5-21**]: Exploratory laparotomy, lysis of adhesions, serosal
repair x5
History of Present Illness:
52M w/HIV last CD4 258 VL undetectable [**3-21**] presents to the ED
c/o epigastric pain. 3 days PTA, the patient experienced severe
epigastric pain with nausea. This pain was not related to food
intake. In fact, his appetite was very poor. He reported no
f/c during those 3 days. Presenting to the ED, his WBC was 16.5
(4.3 previous note before presentation), a BUN of 69 and a
creatinine of 3.0 (baseline 1.2). His amylase and lipase were
significantly elevated to 1204 and 1272. A Lactate level was
3.4.
A CTA/Pancreas was obtained and revealed extensive, severe acute
pancreatitis, with internal pancreatic hypoattenuation that may
represent edema versus necrosis.
Past Medical History:
HIV: diagnosed [**2179**]; c/b PCP, [**Name10 (NameIs) 95264**] zoster; treatment
experienced, good virologic suppression currently
HBV, cleared
HTN, on atenolol and lisinopril
Hyperlipidemia, on fenofibrate
schizophrenia & depression, on Buspar, Loxapine, tranylcypromine
Social History:
paitent was b/r in [**Location (un) 7658**] MA, went to boarding school then
college and some grad work in [**Country 2784**] in art history, stopped
when he "fell on (his) face." He did not want to further expaine
that statment. He has a partner [**Name (NI) **] x 20 years. close relation
with his father. [**Name (NI) **] is on SS for HIV and psych issues. He also
is
an artist.
Denies ETOH/recreational drugs/smoking.
Family History:
No h/o anal, colon, cervical or head/neck ca. Brother with
brain tumor, father with prostate ca, mother with breast ca.
Physical Exam:
On Discharge:
VS: AFVSS
Gen: NAD, A+OX3, supine on bed
CV: RRR, normal S1/S2
Resp: CTAB, no wheezes/crackles/rhonchi
Abd: Slightly distended however soft, NT, +BS, incisional site
is C/D/I, staples intact
Ext: No edema, 2+ radial and pedal pulses
Pertinent Results:
Admit WBC: 16.5
Discharge WBC: 10.4
Admit Amylase: 1204
Admit Lipase: 1272
Discharge Amylase: 55
Discharge Lipase: 76
Admit H/H: 17.3/48.2
Discharge H/H: 9.2/28.6
All urine and blood cultures were negative throughout hospital
course.
C-Diff was negative X 3
CTA (Admit): Extensive, severe acute pancreatitis, with internal
pancreatic hypoattenuation that may represent edema versus
necrosis
CTA ([**5-3**]): Continued pancreatitis without evidence of clearing,
there is now an ileus seen on CT
CTA ([**5-13**]): Interval increase in peripancreatic inflammatory
changes, multiloculated fluid collection extending into the left
pericolic gutter and along the descending colon. SBO seen on CT.
CTA ([**5-29**]): 1. Interval increase in peripancreatic inflammatory
changes and interval unification of some of the multiloculated
fluid collection in the left pericolic gutter and in the lesser
sac. New areas of fluid collection are noted in the anterior
abdominal wall. Percutaneous drainage is not feasible given the
multiple internal septations.
2. No evidence of pancreatic necrosis or venous thrombosis or
pseudoaneurysm.
Brief Hospital Course:
After presenting to the ED, the patient was directly admitted to
the SICU for monitoring. During his short stay in the SICU, his
BPs were stable in the 120-150's, HRs were in the 80-90's (NSR),
and his sats were in the high 90's on 2 L NC. He did not
require intubation nor did he require pressors in the SICU.
After being transferred to the floor, the patient did well. He
was tolerating clears well, did not c/o N/V, and his WBC trended
downwards. His pain was well controlled at first by a PCA then
transitioned to PO pain meds. He did not c/o significant
pain/breakthrough pain.
Psychiatry was consulted given his h/o schizophrenia. ID was
consulted given his h/o HIV. Given these recommendations, the
patient was started on his PO anti-psychotic /depression
medications but did not start on his HIV regimen in fear of
resistance (PO status may change at any minute).
Halfway through his hospital course, the patient suddenly became
distended and had episodes of emesis. He was made NPO and a NGT
was inserted. He stopped passing flatus and required daily
suppositories. Despite being NPO with a NGT, the patient
remained distended. In addition he began to c/o more pain,
located in the epigastric region. He began to spike fevers. His
WBC started to rise. He was continued on IV Abx for empiric
treatment and cultures from his urine and blood were obtained.
Repeat CTAs were performed, showing evidence of non-resolving
and worsening pancreatitis. In addition, the CTA suggested
ileus.
In light of his nutritional status, a PICC was placed and TPN
was started. He remained NPO. Despite numerous attempts in
D/Cing the NGT, the patient became more nauseated and distended.
After failing conservative management for approximately a week,
a repeat CTA was obtained which showed pancreatitis and a SBO.
The patient was then taken to the OR and explored on [**5-21**]. LOA
was performed.
Post-operatively the patient did well. He became less distended
and could tolerate not having a NGT. He was passing flatus had
numerous BM. C-diffs were negative X 3. His abdomen became
much less distended and softer. His diet was advanced.
On the day of discharge, he was cleared by psychiatry and ID.
He was to restart all his home medications. He was afebrile X 24
hours with a normal WBC. He was tolerating a diet and had less
frequent BM. His abdomen was slightly distended but soft. His
Amylase and Lipase levels are WNL.
Medications on Admission:
1) Atenolol 50 mg Tablet one and a half Tablet(s) by mouth once
a day
2) BUSPAR 5MG Tablet 2 BY MOUTH EVERY DAY
3) Darunavir 300 mg Tablet 2 Tablet(s) by mouth twice a day take
with Norvir
4) Emtricitabine-Tenofovir [Truvada] 200 mg-300 mg Tablet 1
Tablet(s) by mouth daily
5) Etravirine [Intelence] 100 mg Tablet 2 Tablet(s) by mouth
twice daily with some food
6) Fenofibrate Micronized 67 mg Capsule 1 Capsule(s) by mouth
once a day take this medication with food/meal
7) Lisinopril 10 mg Tablet 1 Tablet(s) by mouth once a day
8) LOXAPINE 80 MG Capsule ONE BY MOUTH EVERY DAY
9) Ritonavir [Norvir] 100 mg Capsule 1 Capsule(s) by mouth twice
daily take with Darunavir
10) TRANYLCYPROMINE 10 MG TABLET 2 BY MOUTH EVERY DAY
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain for 2 weeks.
Disp:*40 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
4. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Tranylcypromine 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily). Tablet(s)
6. Loxapine Succinate 10 mg Capsule Sig: Eight (8) Capsule PO
DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis, Small-bowel obstruction
Discharge Condition:
stable
Discharge Instructions:
Please call or come to the Emergency Department if you
experience temperature >101.5, chills, persistent nausea or
vomiting, abdominal distension, shortness of breath or
difficulty breathing, chest pain, redness / tenderness /
purulent drainage from your incision, or any other symptoms of
acute concern.
Diet: low-fat
New Medications: Dilaudid (pain medication). No driving while
taking.
Activity: as tolerated. No heavy lifting or strenuous activity.
No swimming or tub bathing until told otherwise. [**Month (only) 116**] shower.
Followup Instructions:
Please call Dr[**Name (NI) 11471**] office ([**Telephone/Fax (1) 2998**]) to schedule
appointment in [**11-14**] week.
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2193-6-12**] 2:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2193-7-17**]
9:30
[**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2193-9-4**] 11:30
Completed by:[**2193-6-3**]
ICD9 Codes: 5849, 486, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8133
} | Medical Text: Admission Date: [**2198-11-2**] Discharge Date: [**2198-11-9**]
Date of Birth: [**2141-8-31**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Liver mass
Major Surgical or Invasive Procedure:
[**2198-11-2**] Right hepatic lobectomy, cholecystectomy,
intraoperative ultrasound.
History of Present Illness:
The patient is a 57-year- old female with no history of
underlying liver disease who underwent a CT scan of the chest on
[**2197-5-24**], for evaluation of chest pain to rule out a
pulmonary embolus. However, the visualized portion of the liver
demonstrated an arterial hyper-enhancing lesion measuring 3.2 x
2.9 cm in segment VI of the right lobe of the liver. On [**6-28**], an MRI demonstrated a 3.5-cm lesion in the posterior aspect
of segment VII. She underwent an ultrasound-guided liver biopsy
on [**2197-8-1**], demonstrating benign liver parenchyma
with focal bile duct proliferation, minimal portal mononuclear
inflammation, scattered lobular histiocytes
consistent with resolving injury. At that time, her AFP was
2.5. CEA was 2.4, and hepatitis serologies were negative. A
follow-up MRI on [**2198-10-5**], demonstrated the mass lesion
had increased in size, and now measured 7.6 x 6.5 cm. Her AFP
had increased to 874.5. A chest CT demonstrated a 4- mm, solid,
noncalcified nodule in the left lower lobe that is stable since
[**2196**], and presumably benign. There were no other abnormalities.
The patient presents for elective exploratory laparotomy, right
hepatic lobectomy and cholecystectomy.
Past Medical History:
PMH:
1. Hypertension
2. Benign enlargement of the thyroid
3. Liver mass
PSH:
1. Tonsillectomy
Social History:
Married with three children. Homemaker. Denies A/T/D use.
Bachelor's degree.
Family History:
Mother deceased at age 84 with CAD and Alzheimer's dementia.
Father deceased
at age 77 with lung cancer.
Physical Exam:
Discharge physical exam:
VS: 98.8 86 100/55 20 97% RA
Gen: mildly anxious, alert and oriented, not in distress
Cor: regular rate and rhythym without murmurs rubs or gallops
Res: clear to auscultation bilaterally
Abd: Soft, appropriately TTP near incision, no guarding no
rebound, nondistended
Wound: Clean, dry, and intact; steri strips in place.
Drains: JP drains x2, one with bilious output
Extremities: Warm and well perfused without edema
Pertinent Results:
[**2198-11-8**] 05:20AM BLOOD WBC-12.5* RBC-3.42* Hgb-9.7* Hct-28.9*
MCV-85 MCH-28.2 MCHC-33.4 RDW-14.3 Plt Ct-216
[**2198-11-8**] 05:20AM BLOOD PT-13.4* INR(PT)-1.2*
[**2198-11-8**] 05:20AM BLOOD Plt Ct-216
[**2198-11-8**] 05:20AM BLOOD Glucose-99 UreaN-12 Creat-0.5 Na-137
K-3.7 Cl-102 HCO3-32 AnGap-7*
[**2198-11-8**] 05:20AM BLOOD ALT-123* AST-38 AlkPhos-95 TotBili-0.7
[**2198-11-8**] 05:20AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.1
Brief Hospital Course:
The patient was admitted to the surgical intensive care unit
following an uncomplicated exploratory laparotomy, right hepatic
lobectomy, and cholecystectomy with intraoperative ultrasound.
The procedure was notable for 1300cc of blood loss and
intraoperative administration of 2 units of packed red blood
cells. She tolerated the procedure well with no complications
and was brought to the surgical intensive care unit extubated
and on minimal pressor support. She stayed in the intensive
care unit overnight, was weaned off pressors, and was
transferred to the floor on POD1 in stable condition. Her care
was managed in accordance with the [**Hospital1 18**] Hepatobiliary Surgery
Clinical Pathway. She recieved perioperative doses of
antibiotics. On POD1 she was started on sips. On POD2 she was
started on clear liquids. Her drain output was observed to be
somewhat darker though not frankly bilious at that point. She
recieved ativan for anxiety and lasix for low urine output. On
POD3 her foley catheter was discontinued. She was tolerating
clear liquid diet, and her oxygen was weaned. On POD4 she
recieved 20mg of lasix. She was started on a regular diet and
oral pain medications. On POD5 her J-P drain output had become
frankly bilious. She was otherwise tolerating a regular diet,
ambulating, voiding, but did not yet have return of bowel
function. On POD6 she was given milk of magnesia and dulcolax
suppositories. She was given lasix with good effect. Her
potassium was repleted. On POD7 she had return of bowel
function, her pain was well controlled, she was tolerating a
regular diet, and she was discharged home with [**Location (un) 1110**] VNA for
drain care. Her drains will remain in place at least until she
is seen in follow up.
Medications on Admission:
1. Citalopram 10mg daily
2. Vitamin D 50,000 units po weekly
3. Ativan 0.5mg PRN, prescribed for the week preceding surgery
4. Losartan 100mg daily-prescribed, but the patient did not wish
to start this medicine until she had recovered from surgery
5. Diovan 160mg daily-Continues to take this medicine, but she
will switch to Losartan at some point.
Discharge Medications:
1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*40 Capsule(s)* Refills:*0*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 month.
Disp:*60 Tablet(s)* Refills:*0*
6. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
s/p Right hepatic lobectomy, cholecystectomy, intraoperative
ultrasound, final pathology pending
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
[**Location (un) 1110**] Visiting Nurse Services have been arranged.
Liver Resection
WHAT YOU SHOULD KNOW:
Liver resection is surgery to remove an area of your liver. Your
liver is an organ that lies in the upper right side of your
abdomen (stomach). Your liver has many functions including
removing waste products from your blood. It breaks down your
blood so your body can better use the nutrients. Your liver also
helps control your blood clotting. The liver has a right and a
left lobe, and can be divided into eight segments. The liver is
the only organ in your body that can renew itself.
The most common reason for a liver resection is to remove liver
cancer or liver metastases. Metastases are cancer cells that
have spread to your liver from another area of your body. Liver
resection also may be done for noncancerous liver problems.
Before having a liver resection, imaging tests are done to help
plan your surgery. You also will need tests to check the
function of your liver. The amount of your liver that will be
removed depends on where the diseased areas are found. Because
the liver can renew itself, over half of your liver can be
removed if needed. During surgery, your caregiver will check for
other diseased areas not found before surgery. Having a liver
resection may decrease symptoms of liver problems such as
abdominal pain and yellowing skin.
AFTER YOU LEAVE:
Take your medicine as directed: Call your primary healthcare
provider if you think your medicine is not working as expected.
Tell him if you are allergic to any medicine. Keep a current
list of the medicines, vitamins, and herbs you take. Include the
amounts, and when, how, and why you take them. Take the list or
the pill bottles to follow-up visits. Carry your medicine list
with you in case of an emergency. Throw away old medicine lists.
Antibiotic medicine: Antibiotic medicine is given to fight or
prevent infection caused by germs called bacteria. Always take
your antibiotics exactly as ordered by your caregiver. [**Name (NI) **]
taking this medicine until it is completely gone, even if you
feel better. Never save antibiotics or take leftover antibiotics
that were given to you for another illness.
Pain medicine:
You may need medicine to take away or decrease pain.
Learn how to take your medicine. Ask what medicine and how much
you should take. Be sure you know how, when, and how often to
take it.
Do not wait until the pain is severe before you take your
medicine. Tell caregivers if your pain does not decrease.
Pain medicine can make you dizzy or sleepy. Prevent falls by
calling someone when you get out of bed or if you need help.
Follow-up visits:
You may need to have many follow-up visits with your caregiver
for the first year after your surgery. You may need blood tests
to check the function of your liver. If your surgery was done to
remove cancer, tests may be needed to check if it has returned.
These tests include an abdominal ultrasound, computed tomography
(CT) scan, or magnetic resonance imaging (MRI). You may need a
chest x-ray to check for the spread of cancer to your lungs. You
also may need a colonoscopy to make sure your colon is free from
disease. Keep all appointments. Write down any questions you may
have. This way you will remember to ask these questions during
your next visit.
Activity: Ask your caregiver about when you can return to your
normal activities such as work and school. Please take it easy
until you are seen in follow up. This means that you should try
and walk around and participate in routine activities, but do
not do any heavy lifting or straining.
Deep breathing and coughing: This breathing exercise helps to
keep you from getting a lung infection after surgery. Deep
breathing opens the tubes going to your lungs. Coughing helps to
bring up sputum (mucus) from your lungs for you to spit out. You
should deep breathe and cough every hour while you are awake
even if you wake up during the night.
Hold a pillow tightly against your incision (cut) when you cough
to help decrease the pain. Take a deep breath and hold the
breath as long as you can. Then push the air out of your lungs
with a deep, strong cough. Put any sputum that you have coughed
up into a tissue. Take 10 deep breaths in a row every hour while
awake. Remember to follow each deep breath with a cough.
You may be asked to use an incentive spirometer. This helps you
take deeper breaths. Put the plastic piece into your mouth and
take a very deep breath. Hold your breath as long as you can.
Then let out your breath. Use your incentive spirometer 10 times
in a row every hour while awake.
Preventing deep vein thrombosis: Deep vein thrombosis (DVT) is a
condition where blood clots form inside your blood vessels. This
can easily happen after having surgery. Ask your caregiver for
more information about deep vein thrombosis. The following can
help prevent clots from forming inside your veins:
Compression stockings: Your caregiver may have you wear
compression stockings. These are tight elastic stockings that
put pressure on your legs after your surgery. The pressure is
highest in the toe area and decreases as it goes toward your
thighs. Wearing pressure stockings helps push blood back up to
your heart and keeps clots from forming. Ask your caregiver for
more information about compression stockings.
Walking: Walking may help prevent blood clots and decrease your
risk for a lung infection. Walking helps prevent blood from
pooling in your legs and causing clots to form inside your
veins.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
Wound care:
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medication. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
For more information: Liver resection surgery, and your recovery
may be scary for you and your family. These feelings are normal.
Talk to your caregivers, family, or friends about your feelings.
If you have liver disease or cancer, you may also want to join a
support group. This is a group of people who also have liver
disease or cancer. Contact the following for more information:
American Liver Foundation
[**Last Name (NamePattern1) 99028**]
[**State 531**] , [**Numeric Identifier 99029**]
Phone: 1- [**Telephone/Fax (1) 99030**]
Phone: 1- [**Telephone/Fax (1) 99031**]
Web Address: [**URL 99032**]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2198-11-14**] 1:40
Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD Phone:[**Telephone/Fax (1) 2205**]
Date/Time:[**2198-11-28**] 4:40
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2199-10-4**] 10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2198-11-9**]
ICD9 Codes: 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8134
} | Medical Text: Admission Date: [**2164-5-31**] Discharge Date: [**2164-6-16**]
Date of Birth: [**2081-5-21**] Sex: M
Service: NEUROSURGERY
Allergies:
Nifedipine / Lisinopril
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
[**2164-5-31**]- Cerebral angiogram with coiling of ruptured Left
Pcomm artery aneurysm
[**2164-5-31**]- EVD placement
[**2164-6-8**] EVD replaced
History of Present Illness:
This ia an 80 year old man with history of DM, HTN, on [**Month/Day/Year **] 81,
found down by his wife at 2:30 am. On arrival to ED, GCS was 5
and he was intubated in the ED. CT head revealed bilateral SAH
and Neurosurgery was consulted.
Past Medical History:
DM, HTN, HL
Social History:
He is married and lives with his wife. [**Name (NI) **] was tobacco free for
>12 months and he occasionally used ETOH.
Family History:
non-contributory
Physical Exam:
At Admission:
V: intubated Motor: withdraws to pain, posturing
O: T: BP: 163/91 HR:65 R O2Sats: 100%
HEENT: Pupils: 2-1.5 EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Intubated
Orientation: Intubated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
Motor/Sensory: localizes to pain in B LE; withdraws in B UE
Toes downgoing bilaterally
PHYSICAL EXAM UPON DISCHARGE:
expired
Pertinent Results:
CSF studies:
[**2164-6-14**] 09:47AM CEREBROSPINAL FLUID (CSF) WBC-5800 HCT,Fl-14*
Polys-77 Lymphs-8 Monos-0 Eos-3 Macroph-12
[**2164-6-14**] 09:47AM CEREBROSPINAL FLUID (CSF) TotProt-1150*
Microbiology: Positive Cultures
[**2164-6-6**] Sputum
GRAM STAIN (Final [**2164-6-6**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2164-6-9**]):
MODERATE GROWTH Commensal Respiratory Flora.
ENTEROBACTER AEROGENES. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/Tazobactam sensitivity testing performed
by
Microscan.
[**2164-6-13**] Sputum
GRAM STAIN (Final [**2164-6-11**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2164-6-13**]):
SPARSE GROWTH Commensal Respiratory Flora.
ENTEROBACTER AEROGENES. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 13424**]
([**2164-6-6**]).
IMAGING:
[**2164-5-31**]: CTA Head/Neck: IMPRESSION:
1. Extensive subarachnoid hemorrhage with a large 1-cm sized
aneurysm arising at the junction of the left posterior cerebral
artery and posterior communicating artery as described above.
2. Intraventricular extension of hemorrhage with mild
hydrocephalus.
3. Duplicated origin of the left vertebral artery with one of
the left
vertebral arteries arising directly from the aortic arch and the
second left vertebral artery arising from the left subclavian
artery.
[**5-31**] CT Cspine- IMPRESSION:
1. No evidence of acute fracture or malalignment. Multilevel
degenerative
joint changes, as described above.MRI would be more sensitive
for ligamentous injury.
2. Nasogastric tube is coiled in the oropharynx.
[**5-31**] CT head- IMPRESSION:
1. Expected post-EVD changes.
2. Slightly increased size of lateral ventricles when compared
to the most
recent prior study performed six hours earlier with increased
subarachnoid
hemorrhage layering in the occipital horns of the lateral
ventricles.
3. Unchanged extensive bilateral subarachnoid hemorrhage with
intraventricular extension.
4. Stable small parafalcine and right temporal subdural
hematomas.
5. Generalized loss of [**Doctor Last Name 352**]-white matter differentiation
suggesting diffuse cerebral edema slightly increased from six
hours earlier.
[**5-31**] Cerebral Angio-
[**6-1**] ECHO- Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: Limited study. Normal global and regional
biventricular systolic function. No major valvular disease seen.
[**6-1**] Head CT-
1. New focus of hemorrhage measuring 27 x 25 mm along the
superior track of the EVD without mass effect or edema involving
the right frontal lobe.
2. Bilateral subdural hematomas extending along the posterior
convexity at
the cerebral hemispheres bilaterally has layering along the
tentorium,
increased significantly from 21 hours prior.
3. Decreased size of lateral ventricles compared to the most
recent prior
studies.
4. Unchanged extensive bilateral subarachnoid hemorrhage with
evidence of
redistribution from [**2164-5-31**].
5. Generalized loss of [**Doctor Last Name 352**]-white matter differentiation
consistent with
diffuse cerebral edema.
[**2164-6-1**] TCD
Abnormal TCD evaluation. Below normal velocities of the
bilateral middle cerebral arteries, anterior cerebral anteries,
posterior cerebral arteries, and internal carotid artery siphons
may have been due to poor temporal and ophthalmic windows.
Mildly increased P.I. indices have a differential of increased
intracranial pressure or possibly distal stenosis, including
from small vessel disease. There was no evidence of
vasospasm. Recommend repeat TCD on [**2164-6-4**].
[**6-2**] EEG
This is an abnormal continuous ICU monitoring study because
of the presence of a severe diffuse encephalopathy manifest by
diffuse
voltage suppression and loss of fast frequencies over all head
regions
but showing asymmetry in the right occipital pole. The
background
itself is dramatically abnormal with a frontal central rhythmic
theta
and virtually no posterior rhythms. No clear seizure discharges
were
identified.
CTA Head [**6-4**]
1. Expected evolution of subarachnoid blood products with no
evidence of new hemorrhage.
2. Stable parenchymal hemorrhage along the ventriculostomy tract
with stable position of catheter and decrease in size of
ventricles. This is associated with more prominent subdural
collections bilaterally, likely reative to
shunting.
3. No evidence of infarct following coiling of the left PCom
aneurysm.
4. Small caliber of left posterior cerebral artery as well as
the bilateral A1 segments which is unchanged from [**5-31**] and
thus unlikely to represent vasospasm.
TCD [**2164-6-5**]
Mildly abnormal TCD evaluation. Above normal
velocities of the proximal right middle cerebral artery and the
left posterior cerebral artery. There was no evidence of
vasospasm. Recommend repeat TCD on [**2164-6-6**].
TCD [**2164-6-6**]
Mildly abnormal TCD evaluation. Above normal
velocities of the proximal right middle cerebral artery and the
left posterior cerebral artery. There was no evidence of
vasospasm. Recommend repeat TCD on [**2164-6-7**].
CXR [**2164-6-6**]
ET tube and right subclavian line are in standard placements and
a nasogastric tube can be traced to the upper stomach but the
tip is indistinct. Upper lungs are clear. Heterogeneous
opacification in both lower lungs is either atelectasis or
pneumonia. The involvement at the right base is the greater of
the two, and it is essentially unchanged since [**6-1**]. Heart
size is normal. Mediastinal veins are mildly engorged. No
pneumothorax.
TCD [**2164-6-7**]
Mildly abnormal TCD evaluation. Above normal
velocities of the proximal right middle cerebral artery. There
was no evidence of vasospasm. Recommend repeat TCD on [**2164-6-8**].
CXR [**2164-6-7**]
Unchanged appearance. Probably left basal atelectasis and/or
effusion
CXR [**2164-6-8**]
Lines and tubes are in standard position. There are persistent
low lung
volumes. Mild cardiomegaly is accentuated by low lung volumes.
Bibasilar
opacities, larger on the left side, are unchanged, consistent
with
atelectasis. The upper lungs are grossly clear. There are no new
lung
abnormalities, pneumothorax or enlarging pleural effusions.
TCD [**2164-6-8**]
Abnormal TCD evaluation. Severe vasospasm of the
right proximal middle cerebral artery. This represents a marked
worsening compared to the TCD results from [**2164-6-7**]. Clinical
correlation is needed
CTA head [**2164-6-8**]
1. Moderate vasospasm of the intracranial vessels including the
basilar,
distal M1 segment of the right MCA and M2 and M3 segments of the
bilateral MCA increased from [**2164-6-4**] with persistent
narrowing/vasospasm of the bilateral A1 and A2 segments of the
ACAs, unchanged from [**2164-6-4**].
2. Status post coiling of large left PCOM aneurysm with expected
redistribution of subarachnoid hemorrhage and no evidence of new
hemorrhage.
3. Slightly resolved intraparenchymal hemorrhage within the
right frontal
lobe along the superior EVD tract with unchanged position of EVD
and stable size of ventricles from [**2164-6-4**].
4. Slightly increased bilateral hypodense subdural hematomas
along the
anterior cerebral convexities without significant change in mass
effect and no shift of normally midline structures.
5. Stable posterior hyperdense subdural hematoma.
CTA head [**2164-6-9**]
1. New hyperdense focus at the tip of the external ventricular
drain, which may represent a focus of acute hemorrhage or clot.
2. Minimal increase in ventricular size from 23 to 26 mm.
3. Otherwise, unchanged exam with subarachnoid hemorrhage and
bilateral
subdural collections
CXR [**2164-6-9**]
Compared to the exam from the prior day, there is no significant
interval change.
CT head [**2164-6-10**]
1. Interval evolution of a right frontal parenchymal hemorrhage
along the
shunt catheter. Interval decrease in the intraventricular
hemorrhage. No new change in the size of the ventricles.
2. Bihemispheric subdural hematomas and subarachnoid hemorrhage,
not
significantly changed since the prior study.
3. Pansinus opacification relates to the endotracheal
intubation.
EEG [**2164-6-11**]
This is an abnormal continuous ICU monitoring study because
of a severe diffuse encephalopathy. Superimposed upon this
encephalopathy are some subtle lateralizing features suggesting
greater
damage to the right hemisphere. There are multifocal paroxysmal
sharp
transient suggesting irritability. These tended also to have
right
hemisphere predominance.
TCD [**2164-6-11**]
Abnormal TCD evaluation. Moderate vasospasm of the
right proximal middle cerebral artery. This was not markedly
different from the TCD results of [**2164-6-8**]. The left MCA had
below
normal velocities but this was probably due to technical
factors.
Clinical correlation is needed. Recommend repeat TCD on [**2164-6-12**].
CXR [**2164-6-11**]
As compared to the previous radiograph, there is no relevant
change. The monitoring and support devices are in constant
position. The
lung volumes have minimally decreased. The diameter of the
vascular
structures is at the upper range of normal, potentially
indicative of mild
fluid overload, but no overt pulmonary edema is present.
Moderate
retrocardiac atelectasis. No new parenchymal opacities in the
ventilated
areas of the lung parenchyma.
CT head [**2164-6-11**]
1. Right transfrontal external ventricular drain with blood
products along
the EVD track and decreased post-operative right frontal
pneumocephalus from [**2164-6-10**].
2. Stable intraventricular hemorrhage with blood products in the
anterior
[**Doctor Last Name 534**] of the right lateral ventricle and layering posteriorly
within the
occipital horns of the lateral ventricles.
3. Evidence of redistributed subarachnoid hemorrhage, unchanged
in extent.
4. Stable frontal hypodense and posterior hyperdense subdural
hematomas.
5. No evidence of acute hemorrhage or large vascular territorial
infarct
EEG [**2164-6-12**]
This is an abnormal continuous ICU monitoring study because
of severe diffuse encephalopathy with subtle features suggesting
great
right hemisphere pathology. There are a number of paroxysmal
sharp
features to the record. No clear interictal epileptic discharges
were
noted. The right side tends to predominate in terms of the sharp
features. Compared to the prior day's recording, there were no
significant changes.
CXR [**2164-6-13**]
There are low lung volumes. Mild cardiomegaly is accentuated by
the low lung volumes. Bibasilar atelectases have minimally
improved. ET tube is in the standard poition. NG tube is out of
view below the diaphragm. A right PICC line catheter tip is in
the upper SVC.
CT head [**2164-6-13**]
Unchanged position of the right frontal approach internal
ventricular drain catheter with slightly increased adjacent
pneumocephalus. Multicompartmental hemorrhage and some degree
of edema unchanged compared to recent study. Bil. subdural fluid
collections, increased since the initial study of [**2164-5-31**]-?
superimposed intracranial hypotension. Correlate clinically and
followup.
CXR [**2164-6-14**]
As compared to the previous radiograph, there is no relevant
change. The monitoring and support devices are constant. There
is unchanged appearance of the low lung volumes and the moderate
retrocardiac atelectasis as well as the mildly enlarged cardiac
silhouette. No larger pleural effusions. No newly appeared focal
parenchymal opacities.
[**6-14**] MRI brain: IMPRESSION:
1. Multicompartmental hemorrhage and bil. subdural fluid
collections as
described above, better characterized on the prior CT head
studies.
2. Scattered small foci of increased DWI signal with decreased
ADC signal,
related to ischemic/infarction-related changes. The etiology of
this is
unclear and it is also unclear if these explain the patient's
quadriplegia. Correlate clinically to decide on the need for
further workup.
3. Bil. mastoid fluid and mucosal thickening.
[**6-14**] MRI C-spine:
1. Multilevel, multifactorial degenerative changes with [**Last Name (un) 13425**]
changes and
moderate canal stenosis at C3-4 from disc extrusion and bulge
and ligamentum flavum thickening and deformity on the cord at
this level.
2. Evaluation for marrow edema from trauma or ligamentous
injury or cord
signal intensity changes is limited given the lack of sagittal
STIR and axial T2-weighted sequence. These were not done due to
technical issue. The patient will be brought back, for the
additional sequences, which will be performed as a separate
study.
3. Multilevel moderate foraminal narrowing with deformity of
the nerves in these locations.
[**6-15**] CXR: The left lower lobe atelectasis is unchanged.
Vascular congestion is unchanged but no overt edema is seen.
Right central venous line tip is at the level of mid SVC. ET
tube and the NG tube are in appropriate location, unchanged
since the prior study.
[**6-16**] CT Head- IMPRESSION:
1. Right frontal approach shunt catheter has an
extraventricular course,
terminating at the septum pellucidum.
2. Mild increase in the parenchymal hemorrhage surrounding the
shunt catheter in the right frontal lobe.
3. Bihemispheric subarachnoid and intraventricular hemorrhage,
subdural
hematomas have not significantly changed since the prior study.
[**6-16**] CT Head- IMPRESSION:
1. Status post ventriculostomy catheter placement from right
frontal approach without a definitive intraventricular course as
described on prior report.
2. Similar appearance of bilateral subdural collections with
similar to
slightly increased subarachnoid hemorrhage and definite increase
in
intraventricular hemorrhage. This finding was discovered at
9:39 a.m. and
discussed with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 9:43 a.m. on [**2164-6-16**] by Dr.
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 11623**] over the phone.
3. Similar appearance of air and blood products around the
course of the
ventriculostomy catheter within the right frontal parenchyma.
Brief Hospital Course:
The patient was admitted to the Neurosurgery ICU for Q1
Neurochecks and Vital Signs. She was started on Nimodipine 60mg
Q 4 hours and Seizure Prophylaxis. Strict SBP less < 130
parameters was initiated and she was kept NPO. An EVD was placed
at 15cm h20 and a CT was performed which confirmed good
placement. In the am of [**5-31**] she underwent a cerebral angiogram
and coiling of a left Pcomm artery aneurysm. She was transferred
back to the SICU post procedure. A portable Head CT was
performed in the AM [**6-1**] which revealed a new hemorrhage along
the EVD track and increased SDH. Baseline TCD's were performed.
An Echo and EEG were also requested. The Echo showed LVEF>55%,
and the EEG showed diffuse encephalopathy with no evidence of
clinical seizures. On [**6-2**] his collar was cleared, and on [**6-3**]
his IVF were decreased from 100cc/hr to 75cc/hr. On [**6-4**] his EVD
was raised to 20, he had a CTA that showed more porminent
hygromas and no vasospasm. Overnight, ICPs were stable [**9-16**] and
EVD draining adequately.
On [**6-6**], patient w/d BUE and triple flexes BLE. His drain remains
at 20 and TCDs are negative for vasospasm.
On [**6-7**], TCDs with no evidence of vasospasm. IVF were
discontinued and Lasix ws given for diuresis with goal of 2L
negative.
On [**6-8**], The External Ventricular Drain was at 20 H2O CM above
the tragus. The patient had a low grade fever of 100. ICP were
[**11-17**]. Family meeting****. A CTA was performed which was
consistent with spasm R MCA & basilar arteries.
On [**6-9**], The External Ventricular Drain stopped draining. A NCHCT
was performed which was stable and did not show any
hydrocephalas. The patient was tachypneic and hypertensive. On
exam the patient withdrew to noxious stimulous in all 4
extremities.
On [**6-10**], The external ventricular catheter was clamped 0800. Teh
clamping trial failed at 1130 am whe the patient ICP elevated
to 27-29. The serum BUN was noted to be 40 which was elevated
from the mid 20s on [**6-4**]. Ancef 2 gm TID was added for empiric
EVD coverage as the EVD site was slightly edematous and warm on
palpation. WBC was slightly elevated at 13.4.
On [**6-11**]: The EVD site appearance was improved. There was no
erythema and improved edema. The IVF 100 at cc/hr wa
sdiscontinued. The EVD stopped draing at 0600, 1200, and 4pm
and each time TPA was instilled in the line for 20 mints to
obtain patency.A NCHCT was performed which was stable. On exam
the patient opened the left eye to noxous stimuli,minimal
withdrew to noxious in the Bilateral Upper Eextremities, and
triple flexion was exhibited in the bilateral lower extremities.
The serum BUN was improved to 33. The WBC improved to 12.3 A
TCD was performed which showed right MCA spasm which was stable
when compared to [**6-8**]. The External Ventricular Drain was lowered
to 10 H2O mmhg above the tragus. An EEG was ordered to evaluate
for seizure activity and to evaluate the further requirment of
keppra. The EEG was consistent with no seizures. His ICP
waveform was dampened at 011 on [**6-12**] and it was flushed with
return of waveform. On [**6-12**] his exam remained poor overall, his
drain output began to slow and tPA was instilled at 1430,
clamped for 30 mins, and when re-opened there was brisk drainage
of CSF.
During the day of [**6-13**], his EVD was functioning well. In the
evening it was no longer draining and flushing did not help. The
tubing was pulled back a bit then began draining. Head CT to
confirm placement was performed. On [**6-14**] CSF was sent and MRI
head and C-SPINE imaging was done. MRI revealed multiple small
infarcts but nothing to explain mental status. The results were
discussed in a family meeting as well as goals of care. It was
decided to proceed with trach and peg planning. On [**6-15**] the EVD
continued to be tenuous with periods of non-drainage requiring
flushing and TPA. His neurological exam remained unchanged. On
[**6-16**] in the early AM the EVD required TPA infusion again for
non-drainage. This was infused after a Head CT was performed and
stable. At approx 8:30AM the patients blood pressure rose to
over 200, ICP increased to 70's with a wave form. It was also
noted to have new blood around the EVD dressing. Neurological
exam was stable but the patient was taken for a stat Head CT. CT
revealed new acute IVH. The findings were discussed with the
SICU staff and family. At this time it was recommended that care
be withdrawn and not proceeding with trach and peg. The family
was in agreement with this plan and asked for EVD and ET tube to
be removed as soon as possible. He was started on a morphine gtt
and these were both performed. The patient passed away of
respiratory failure with the family at the bedside in the
afternoon of [**2164-6-16**].
Medications on Admission:
allopurinol 100qD, [**Last Name (LF) 13426**], [**First Name3 (LF) **] 81, atenolol 50qD, lipitor 20 qD,
avandia, colchicine 0.6, losartan, NTG prn
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
aneurysmal subarachnoid hemorrhage
intraventricular hemorrhage
hydrocephalus
encephalopathy
cerebral vasospasm
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2164-6-16**]
ICD9 Codes: 5849, 431, 5859, 2767, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8135
} | Medical Text: Admission Date: Discharge Date: [**2199-11-13**]
Date of Birth: [**2199-11-3**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 57578**] was born to a 33
year old, Gravida VIII, Para III to IV mother, with prenatal
laboratory studies significant for blood type AB positive,
hepatitis B surface antigen negative; RPR nonreactive;
Rubella immune; antibody screen negative; GBS status unknown.
This pregnancy was complicated by preterm labor. There was
no maternal fever and rupture of membranes was at the time of
delivery, as this was an elective repeat cesarean section, in
the setting of preterm labor. Apgars were eight and nine at
one and five minutes respectively and birth weight was 2,490
grams.
FAmily hx. notable for mother and her son having balanced
translocation of chromosomes 4 and 13; mother also has
daughter with unbalanced translocation of chromosomes 4 and
13. This daughter ([**Name (NI) 57579**]) is followed by genetics and
neurology at [**Hospital3 1810**].
PHYSICAL EXAMINATION: Her admission physical examination
revealed a well appearing, slightly preterm, female infant;
consistent with her history of gestation 35 and 4/7 weeks.
Her birth weight was 2490 grams; her length was 46 cm and her
head circumference was 33 cm. Her head and neck examination
was significant for anterior fontanel that was open and flat
and a palate that was intact. Her chest was clear to
auscultation bilaterally. Heart revealed a regular rate and
rhythm with no murmur. Her femoral pulses were 2 plus and
her capillary refill time was less than 2 seconds. Her
abdomen was soft, nondistended, without hepatosplenomegaly
and with bowel sounds present. Her genitourinary examination
revealed a normal preterm female external genitalia with a
patent anus. Her back was without clefts, [**Hospital1 **] or dimples.
Her neurologic examination was normal for her gestational
age.
HOSPITAL COURSE:
1. Respiratory: Baby Girl [**Known lastname 57578**] was briefly on nasal cannula
oxygen but transitioned to room air by about eight hours
of life and has remained stable on room air since that
time. She had only one apnea and bradycardia event, which
occurred on day of life four, [**11-7**], and one
desaturation which occurred on day of life seven, during a
period of periodic breathing. She has never been on
caffeine therapy. She will need to be monitored for at
least five days without further desaturations prior to
discharge.
1. Cardiovascular: Baby Girl ([**Known lastname 57580**]) [**Known lastname 57578**] has been
cardiovascularly
stable throughout her hospital course. She has never had
a murmur or abnormal blood pressures.
1. Fluids, electrolytes and nutrition: Baby Girl [**Known lastname 57578**] was
initially held n.p.o. on total fluids of 60 cc per kg per
day. Within the first 24 hours of life, she was allowed
to begin enteral feeds of [**Known lastname 57581**] and her total fluids were
gradually advanced to the present level of 140 cc per kg
per day. Over the first five days of life, the patient
would take only minimal p.o. feeds. At most, 5 to 10 cc
orally per feeding. She received the remainder of her
feeds by gavage. She was fed with [**Known lastname 57581**] in light of a
family history of cow's milk allergy in other siblings,
but due to the parents concern that she did not like the
taste of [**Known lastname 57581**], she was also tried on Similac. This
failed to improve her ability to bottle feed so she was
again switched to [**Known lastname 57581**]. She has never demonstrated
feeding intolerance, but it was quite concerning that she
had such an inability to take oral feeds at her
gestational age, so further work-up was proceeded. This
included a neurology consult, who felt that her
examination was normal and did not recommend further
evaluation. A feeding team consult was attempted, but
they were unable to see her in the initial days of
difficult p.o. feeding and then her oral intake
spontaneously improved. She was also seen by the genetics
team in light of her sister's history of unbalanced
chromosomal translocation and chromosomes are pending at
the time of this summary.Preliminary report from
cytogenetics lab at [**Hospital1 18**] is that there is an abnormality of
the chromosomes, but does not appear to be the same as that of
the mother and sib of this patient. FISH evaluation is
pending. We will forward results to [**Hospital1 **], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19371**],
and Genetics when final results are knowm. Baby Girl [**Known lastname 57582**]
weight at the
time of discharge is 2300 grams. She spontaneously
improved her p.o. intake and, at the time of transfer, is
taking about [**2-1**] volume feeds p.o. (30cc/feed). ~50cc/feed
would be considered full volume per feed.
1. Gastrointestinal: Baby Girl [**Known lastname 57578**] had one bilirubin
checked on day of life three which was 8.2 with a direct
component of 0.3. She did not show clinical evidence of
jaundice, thereafter, so this was not rechecked.
1. Hematology: Admission hematocrit was 51.4 percent. The
patient has not required any blood products during her
hospitalization.
1. Neurology: Baby Girl [**Known lastname 57578**] does not fit criteria to
require screening head ultrasounds. She was seen by the
neurology team as described above, for inability to p.o.
feed. A head ultrasound was done at the time of the
neurology consult, which was normal.
1. Genetics: Baby Girl [**Known lastname 57578**] has a family history of a
balanced translocation of chromosomes four and 13 in her
mother. [**Name (NI) **] 9 year old sister has an unbalanced
translocation, as she is missing chromosome 13 and has
pulmonary stenosis, epilepsy and cleft palate resulting.
She has a healthy brother who also has a balanced
translocation. In light of her family history and because
of her difficulties feeding, chromosomes were sent on her
on [**11-8**] and are pending at the time of transfer.
Other than chromosomes, the genetic team did not recommend
any further work-up.
1. Sensory: At the time of transfer, Baby Girl [**Known lastname 57578**] has not
had her hearing screen.
1. Health Care Maintenance: Patient received hepatitis B
vaccine on [**2199-11-6**]. She is to undergo a car seat
test prior to discharge.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To [**Hospital3 3765**], level II
nursery.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57583**], M.D., [**Location (un) **].
CARE RECOMMENDATIONS: Baby Girl [**Known lastname 57578**] is feeding [**Known lastname 57581**] 20
at 140 cc per kg per day po/pg and advancing on p.o. feeds.
She is on no medications at the time of transfer.
She still needs car seat testing prior to discharge.
A state screen has been sent.
She received her hepatitis B vaccine on [**2199-11-6**] and
does not quality for Synagis RSV prophylaxis.
DISCHARGE DIAGNOSES: Prematurity at 35 and 4/7 weeks.
Immature feeding.
Rule out sepsis, resolved.
[**Name6 (MD) 1154**] Cold, MD [**MD Number(2) 56585**]
Dictated By:[**Name6 (MD) 57584**]
MEDQUIST36
D: [**2199-11-11**] 16:44:56
T: [**2199-11-11**] 17:14:19
Job#: [**Job Number 57585**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8136
} | Medical Text: Admission Date: [**2127-7-21**] Discharge Date: [**2127-7-30**]
Service: MED
Allergies:
Bactrim / Amiodarone / Quinine / Codeine / Zithromax
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Abdominal Discomfort
Major Surgical or Invasive Procedure:
ERCP x 2
Endotracheal Intubation
History of Present Illness:
The patient is an 85 year old woman with PMH of ESRD on HD, HTN,
and DM, who presented to the [**Hospital1 18**] ED on [**7-21**] with complaint of
nausea, vomiting, abdominal pain, and diarrhea x 3 days. The
patient also reported recent fever and chills. In the ED,
patient had a low grade temperature of 100.5 degrees. Her
abdomen was slightly distended, with no rigidity or rebound.
Admission laboratory data were notable for WBC 6.2, elevated
transaminases, and INR 3.7. Right upper quadrant ultrasound
disclosed a 5 mm gallstone in the neck of the gallbladder.
There was also a 5mm gallstone in the common bile duct, without
ductal dilatation. The patient was evaluated by surgery for her
choledocholithiasis. The patient was also seen by the ERCP
fellow. The patient was not acutely ill last night, so she was
admitted to the Medicine team, with plan for ERCP today. She was
kept NPO and was administered IVF overnight.
This morning, she was administered 4 U FFP to reverse her INR.
After receiving 2 U FFP, she became hypoxic, with O2 sats
dropping to the 70s. She was placed on 100% NRB with
improvement in her O2 sats to the 90s. Prior to dialysis, she
was given 100 mg IV Lasix, with urine output (non measured). At
1:50 PM, she was transferred to the Hemodialysis Unit for
initiation of hemodialysis. Approximately 1 L was removed, yet
the patient remained in respiratory distress, with O2 sats in
the low 90s on NRB. At 2:30 PM, a respiratory code was called
since patient's O2 sats dropped to 70s on the NRB. The patient
was emergently intubated. ABG prior to intubation was
7.21/55/55. EKG disclosed new ST segment depressions in the
inferior and lateral leads. Following intubation, the patient's
SBP dropped to 80s. She was administered approximately 500 cc
NS bolus, and required Dopamine transiently. The patient was
transferred to the MICU for further management.
Past Medical History:
1. End stage renal disease, on hemodialysis via RIJ tunnelled
portacath. h/o failed left arm fistula.
2. History of crescente glomerulonephritis by renal biopsy,
likely related to underlying vasculitis.
3. Vasculitis, ANCA positive, treated with chronic steroids.
Currently on steroid taper.
4. Chronic obstructive pulmonary disease.
5. Steroid induced diabetes mellitus.
6. Chronic anemia related to end stage renal disease.
7. History of hemorrhoids.
8. Atrial fibrillation, status post transesophageal
echocardiography and cardioversion, currently on Atenolol and
Coumadin with an ejection fraction of over 55 percent on
echocardiogram in [**2126-3-2**].
9. Gastroesophageal reflux disease with a normal EGD [**2126-6-2**].
10. Hypothyroidism.
11. Hypertension.
Social History:
Prior tobacco history over twenty years ago. She denies any
alcohol use. She
lives with her daughter, [**Name (NI) **] [**Name (NI) 46**], who is her health
care proxy. The patient is full code. Primary care physician is
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**].
Family History:
Non-contributory
Physical Exam:
General: Elderly female lying in bed, ETT in place.
VS: T: 100.7 BP: 104/48 initially, 68/34 at 4 PM HR: 128
Resp: AC 550x14/100%/5 O2sat: 95%
HEENT: Sclerae anicteric. PERRL. MMM. OP clear.
Neck: Obese. Supple. Difficult to assess JVP.
CVS: RRR. S1, S2. No m/r/g.
Lungs: Crackles in bases bilaterally.
Abd: Slightly distended. +BS.
Ext: Cold. No clubbing, cyanosis, or edema. L AVF.
Neuro: Intubated, sedated. Moving all extremities.
Pertinent Results:
[**2127-7-21**] 08:00AM WBC-6.2 RBC-4.25 HGB-12.7 HCT-40.4 MCV-95
MCH-29.9 MCHC-31.5 RDW-16.3*
[**2127-7-21**] 08:00AM NEUTS-80.5* LYMPHS-12.4* MONOS-4.6 EOS-2.2
BASOS-0.3
[**2127-7-21**] 08:00AM PLT COUNT-284
[**2127-7-22**] 03:52AM BLOOD WBC-3.7* RBC-3.78* Hgb-11.8* Hct-35.8*
MCV-95 MCH-31.2 MCHC-33.0 RDW-16.2* Plt Ct-217
[**2127-7-21**] 08:00AM BLOOD PT-23.5* PTT-40.1* INR(PT)-3.7
[**2127-7-22**] 12:15PM BLOOD PT-12.7 PTT-26.8 INR(PT)-1.1
[**2127-7-21**] 08:00AM BLOOD Glucose-138* UreaN-18 Creat-2.7* Na-135
K-3.3 Cl-100 HCO3-23 AnGap-15
[**2127-7-22**] 03:52AM BLOOD Glucose-109* UreaN-9 Creat-2.0* Na-141
K-3.4 Cl-104 HCO3-28 AnGap-12
[**2127-7-21**] 08:00AM BLOOD ALT-65* AST-36 AlkPhos-506* Amylase-54
TotBili-0.4
[**2127-7-22**] 03:52AM BLOOD ALT-41* AST-21 AlkPhos-393* Amylase-40
TotBili-0.3
[**2127-7-21**] 08:00AM BLOOD Lipase-43 GGT-558*
[**2127-7-22**] 03:52AM BLOOD Lipase-23
[**2127-7-22**] 03:52AM BLOOD Albumin-3.2* Calcium-8.1* Phos-2.7 Mg-1.6
[**2127-7-22**] 01:28PM BLOOD Type-ART pO2-79* pCO2-56* pH-7.27*
calHCO3-27 Base XS--1
[**2127-7-22**] 02:40PM BLOOD pO2-55* pCO2-55* pH-7.21* calHCO3-23 Base
XS--6 [**2127-7-22**] 01:28PM BLOOD Lactate-2.6*
EKG:
(2:47 PM) Sinus tachycardia 118 bpm. Nl intervals, nl axis. ST
segment depressions in II, III, avF, V3-V6. Poor R wave
progression. These changes are new compared to previous EKG
([**3-5**]).
(16:33 PM)
Radiology:
RADIOLOGY Final Report **ABNORMAL!
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2127-7-21**] 1:20 PM
LIVER OR GALLBLADDER US (SINGL
Reason: RUQ PAIN AND NAUSEA, RO CHOLECYSTITIS
[**Hospital 93**] MEDICAL CONDITION:
85 year old woman with hx diabetes, renal failure, on tapering
prednisone for ANCA-positive vasculitis with known gallstone by
abd CT last month, and intermittent vomiting but no abd pain.
r/o acute cholecystitis or abscess.
REASON FOR THIS EXAMINATION:
acute cholecystitis or abscess
INDICATION: Intermittent vomiting without abdominal pain. Known
gallstone by abdominal CT last month.
COMPARISON: CT scan, [**2127-6-23**], is not available on line for
comparison.
FINDINGS: There is a 5-mm gallstone within the gallbladder neck,
but there is no evidence of gallbladder wall edema or
pericholecystic fluid to suggest acute cholecystitis.
Additionally, a 5-mm flat stone is seen within the common duct,
but there is no evidence of ductal dilatation. The common duct
measures 3-4 mm proximally. There is no intrahepatic ductal
dilatation. The portal vein is open, and flow is hepatopetal.
The pancreas appears echogenic, consistent with fatty
infiltration. There is no free fluid.
IMPRESSION: Cholelithiasis and choledocholithiasis without
evidence of acute cholecystitis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2368**]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: MON [**2127-7-21**] 10:09 PM
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2127-7-22**] 1:21 PM
CHEST (PORTABLE AP)
Reason: ?volume overload
[**Hospital 93**] MEDICAL CONDITION:
85 year old woman with chf and decreasing sats after FFP
infusion
REASON FOR THIS EXAMINATION:
?volume overload
INDICATION: Decreasing oxygen saturation after FFP
administration.
COMPARISON: [**2127-7-21**].
CHEST, AP PORTABLE RADIOGRAPH: There is stable cardiac
enlargement. The mediastinal and hilar contours are
unremarkable. There is bilateral pulmonary vascular
redistribution, perihilar haziness and interstitial opacities.
There is unchanged small left pleural effusion. The right
internal jugular central venous catheter is again noted with tip
in the proximal right atrium. The osseous structures are
unremarkable.
IMPRESSION: New pulmonary edema.
DR. [**First Name11 (Name Pattern1) 2369**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2370**]
DR. [**First Name (STitle) 2371**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2372**]
Brief Hospital Course:
1. Respiratory Failure: On HD#2, the patient developed acute
respiratory distress. The patient had recieved IVF in the ED
the nigtht before and that monring had recieved 4 units of FFP
for planned ERCP, the last two within one hour of respiratory
distress. CXR demonstrated acute developement of bilateral
pulmonary infiltrates. Ddx included cardiogenic pulmonary edema
versus TRALI. The patient was taken for emergent HD; however,
depspite succesful diuresis, the patient required intubation for
respiratory failure. TRALI work-up is pending at the time of
discharge. The patient remained intubated in the MICU and
succesfully extubated on the second attempt.
2. Hypotension: After intubation, the patient became hypotensive
in the MICU requiring initiation of pressors. She was found to
be adrenally insufficent by cortisyn stimulation test and
started on stress-dose hydrocortisone and fludircortisone. In
addition, she required pressors and continued IV Unasyn for
possible sepsis, though blood cultures were negative. The
patient's blood pressure improved and stablized.
3. Choledocholithasis: Demonstrated on admission RUQ US on
admission without transaminitis but with low-grade fever and
left-shift. The patient was evaluted by Surgery and ERCP
service. She was started on IV Unasyn. Patient underwent ERCP
in MICU while intubated, which demonstrated dilated CBD but no
stones. Patient had spinchterotomy. The patient completed a 10
day course of IV Unsyn and will be discharged on two days.
Consideration should be given to possible outpatient
cholecystetomy.
4. GI Bleed: Post-ERCP, the patient dropped Hct and was foudn to
be guiac postitive. Patient underwent repeat ERCP which
demonstrated spincterotomy bleed. This required epiniephrine
injection. Hct remained relatively stable, though she had a
possible rebleed several days later which stablized without
repeat scope. ASA and coumadin were held [**2-3**] bleed and may be
safely restarted on [**2127-8-4**]. The patient's Hct remained stable
for the rest of her hospital course. The patient will continue
on her PPI.
5. Coronary Artery Disease: During the patient's MICU stay, EKG
was noted to have
poor R wave progression. An echocardiogram was obtained which
demonstrated regional LV dysfunction suggesting CAD. Cardiac
enzymes demonstrated non-diagnostic elevated Tropnin T, felt
either secondary to demand or ESRD. ASA was held [**2-3**] GI bleed
and the patient's beta-blocker was continued. The patient will
need an outpatient evaluation of her coronaries, likely with ETT
MIBI when she is stable. Again, ASA will be started [**2127-8-4**].
6. ESRD: The patient did well on her hemodilyasis schedule. The
patient's prednisone was continued for her history of renal
vascultitis.
7. Hypothryoidism: Patient stable on levothyroxine.
Discharge Medications:
1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day:
Take four tablets on day #1, two tablets on day #2, one tablet
on day #3, then resume 1 mg per day.
Disp:*7 Tablet(s)* Refills:*0*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO twice a day.
4. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
5. Lidocaine 5 % Adhesive Patch, Medicated Sig: One (1) Adhesive
Patch, Medicated Topical QD (once a day).
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-3**]
Puffs Inhalation Q6H (every 6 hours) as needed.
7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 tube* Refills:*2*
9. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
10. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day:
Start after higher-dose prednisone complete.
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithasis
Spinchterotomy
Upper GI bleed
ESRD
Coronary Artery Disease
Diarrhea
Anemia
Hypothryoidism
Respiratory Failure
Diabetes Mellitus
Discharge Condition:
Good
Discharge Instructions:
1. Please follow-up with your PCP
2. Your primary doctor will obtain a medical alert braclet for
you, indicating that you have adrenal insufficency.
3. You will restart your coumadin and start aspirin on [**Hospital1 766**]
after seeing your PCP.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1683**] on [**Last Name (LF) 766**], [**8-4**] at 10:15
Completed by:[**2127-8-11**]
ICD9 Codes: 0389, 5185, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8137
} | Medical Text: Admission Date: [**2144-12-30**] Discharge Date: [**2145-1-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Percutaneous aortic valvuloplasty
Placement of a bare metal stent in the saphenous vein graft
History of Present Illness:
This is an 86 yo male with a history of CAD (s/p CABG), chronic
Afib, CHF, critical AS who was transferred to [**Hospital1 18**] for
evaluation for aortic valvular repair. In early [**Month (only) 404**], he was
at [**Hospital6 **] for an acute CHF exacerbation, where
he ruled in for an MI by enzymes. At [**Hospital1 **] on [**2144-12-28**], he
underwent catheterization which showed 85% stenosis of his
SVG-OM1, but a patent LIMA-LAD. He was transferred to the [**Hospital1 18**]
for aortic valve replacement.
.
In preparation for surgery, he was being followed by nephrology
for chronic kidney disease. It was felt that the patient had a
20% chance of needing dialysis following CABG. He was also
being followed by Heme-onc for chronically elevated INR, which
was felt to be secondary to chronic warfarin use.
.
On the morning of admission, he became tachypneic, the rate of
his AFib increased and he developed substernal chest pain. His
O2 requirement increased to 92% on 2L (98% RA yesterday). Over
the past few days, he has been on a decreased dose of lasix,
only receiving 40 PO daily when his home regimen was 40mg po
BID.
.
On transfer to the CCU he converted to sinus rhythm after
receiving lasix, metazolone, and metoprolol 7.5 mg IV. He
reported improved SOB and CP after converting.
.
Past Medical History:
CAD - MI & CABG [**2127**]
CHF -- systolic dysfunction (EF 35 - 40%)
Chronic Afib
critical AS
NSVT s/p AICD [**1-28**]
HTN
DM
LBBB
CRI
TIA & CVA
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Patient is a former
barber.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAM
.
VS: T: 96.7 , BP: 91/61 , HR: 110s (Afib) -> 80s , RR:20 , O2
94% on 3L NC
.
Gen: WDWN elderly male with obvious respiratory distress with
some difficulty speaking. Pleasant.
HEENT: NCAT. Sclera anicteric. OP clear.
Neck: Supple with JVP to mid neck with bed at 45%.
CV: irregularly irregular. Murmurs difficult to appreciate.
Chest: Poor air movement ~ 1/3 up bases. No wheezing.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: 2+ pretibial edema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
[**2144-12-30**] 04:50PM BLOOD WBC-8.4 RBC-3.45* Hgb-10.4* Hct-30.9*
MCV-90 MCH-30.0 MCHC-33.5 RDW-14.0 Plt Ct-164
[**2144-12-30**] 04:50PM BLOOD PT-17.7* PTT-75.8* INR(PT)-1.6*
[**2144-12-30**] 04:50PM BLOOD Plt Ct-164
[**2144-12-30**] 04:50PM BLOOD Glucose-160* UreaN-84* Creat-3.2* Na-136
K-4.8 Cl-97 HCO3-30 AnGap-14
[**2144-12-30**] 04:50PM BLOOD ALT-33 AST-28 LD(LDH)-300* AlkPhos-95
Amylase-83 TotBili-0.5
[**2144-12-30**] 04:50PM BLOOD Albumin-3.2*
[**2144-12-31**] 07:30AM BLOOD Calcium-9.1 Phos-5.0* Mg-3.0*
[**2144-12-30**] 04:50PM BLOOD %HbA1c-6.9*
.
IMAGING:
[**2144-12-30**] Admission CXR-- PA & Lateral
Mild atelectasis at the left lung base with moderate
cardiomegaly
.
[**2145-1-15**] Cardiac Catheterization (see cath report for further
details)
1. Three vessel coronary artery disease. Patent LIMA.
SVG->OM/PDA
stenosis.
2. Pulmonary edema.
3. Critical aortic stenosis.
4. Successful stenting of the SVG-OM/PDA with a bare metal
stent.
5. Successful aortic valvuloplasty.
Brief Hospital Course:
AORTIC STENOSIS
On admission, Mr. [**Known lastname 94178**] EF was ~35-40% with moderate mitral
regurgitation and critical aortic stenosis (valve area of 0.6
and mean gradient of 58). Surgical aortic valve replacement was
deferred on this admission because of the patient's worsening
renal function and multiple comorbidities, placing him at high
risk for complications with an open heart surgery. A
percutaneous aortic valvuloplasty was performed on [**2145-1-15**]
without complication.
ATRIAL FIBRILLATION
He has known chronic atrial fibrillation, with a baseline LBBB.
Upon arrival to the CCU, Mr. [**Known lastname **] was found to be in AFib with
a rapid ventricular rate, which induced hypoxia and chest pain.
After intravenous furosemide and metoprolol, the patient quickly
returned to his baseline rhythm of atrial fibrillation with a
rate in the 70's, and his shortness of breath and chest pain
improved. A chest X ray showed pulmonary edema, which slowly
improved over the hospital course with continued diruesis. He
was kept on heparin throught the admission for anticoagulation
and was bridged to Coumadin at the end of his hospital stay.
CORONARY ARTERY DISEASE
Mr. [**Known lastname **] had a CABG in [**2127**] with SVG to the OM1 and LIMA to
the LAD. His cath on [**2145-1-15**] showed patent LAD and 85% stenosis
of the SVG; thus, a bare metal stent was placed in the SVG to
OM1. He was continued on aspirin and plavix for anti-platelet
therapy.
HYPERTENSION
He was continued on metoprolol succinate and amlodipine with
good control of his blood pressure. His home ACE inhibitor was
held in the setting of ARF.
ACUTE ON CHRONIC RENAL FAILURE
Although his baseline Cr is unknown, his Cr was 3.2 on
admission, elevated from the 2.2 - 2.4 that he was running at
the outside hospital prior to transfer. The aucte on CKD was
likely secondary to contrast nephropathy and a pre-renal state.
The renal service was consulted and felt there was no indication
for acute dialysis. His kidney function improved somewhat by
the time of discharge with management of his CHF and volume
status (see above). His home ACE inhibitor was held in the
setting of ARF.
URINARY TRACT INFECTION
Mr. [**Known lastname **] was found to have Klebsiella in is urine cultures
from [**2143-12-31**], which was treated with cirpofloxacin. Repeat urine
culture on [**2145-1-13**] grew Klebsiella and Enterococcus; he was
again treated with ciprofloxacin (shown to be sensitive on
culture). The foley catheter was pulled on [**1-20**] prior to
discharge.
Medications on Admission:
Medications pateint was on prior to admission to [**Hospital1 **]:
toprol XL 100mg
lisinopril 40mg daily
glyburide 10mg daily
hydralazine 20mg TID
furosemide 40mg [**Hospital1 **]
norvasc 5mg daily
doxazosin 4mg daily
ASA 81mg daily
warfarin 5mg daily
hectorol 0.5mcg daily
.
medications on Transfer to ICU:
-metoprolol xl 100mg daily
-doxasozin 4mh qhs
-doxercalciferol 0.5mcg dialy
-colace 100mg [**Hospital1 **]
-lasix 40mg Po daily
-insulin ss
- glipizide 10mg [**Hospital1 **]
-epoietin alpha 4000U SC MWF
-IV heparin
-diltiazem 30mg PO QID
-ipratropium Q6hr
Discharge Medications:
1. Doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, headache, pain.
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Dosage to be adjusted according to INR (goal 2.0 - 3.0).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: Continue through [**2145-1-24**].
10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Insulin Lispro 100 unit/mL Solution Subcutaneous
17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Dosage will need to be adjusted according to daily
weights to keep his weight even.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary Diagnoses:
Aortic Stenosis, s/p percutaneous valvuloplasty
Systolic congestive heart failure
Atrial fibrillation
Acute on chronic renal failure
Urinary tract infection
Secondary Diagnoses:
Hypertension
Diabetes
Coronary Artery Disease
Discharge Condition:
Stable-- patient less short of breath than on admission; still
with some fatigue but also improved. Patient deconditioned from
prolonged hospital stay, but able to work with physical therapy
and being discharged to a rehab facility.
Discharge Instructions:
Please follow the rehabilitation program at the rehab facility
that you are going to after your discharge from the hospital.
You should call your primary care doctor if you develop fever,
pain with urination, worsening shortness of breath, or fluid
retention.
Your fluid levels need to be closely monitored while you are at
the rehab facility and then later when you go home. They should
adjust your lasix dosage so that you do not gain weight and do
not become short of breath.
Subcutaneous insulin dosage to be adjusted according fingerstick
glucose.
Followup Instructions:
Please see your cardiologist and primary care doctors within the
next 1 - 2 weeks for follow-up of your heart problems.
ICD9 Codes: 4241, 5849, 5990, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8138
} | Medical Text: Admission Date: [**2179-11-16**] Discharge Date: [**2179-11-26**]
Date of Birth: [**2098-10-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Quinidine;Quinine Analogues
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Vomiting, malaise, increasing LE edema
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
Mrs. [**Known lastname 63845**] is a 80 year-old female with a history of chronic
AF, diastolic CHF, DM, hyperlipidemia, CRI, who presents with
increasing LE edema and erythema, x 10days. In addition to the
erythema, the pt had blisters that burst b/l. Pt was started on
Levo 10 days ago for LE cellulitis. Pt also had vomiting,
decreased PO intake. + fatigue, malaise, and abd distention.
Some MS changes over past few days along with some LLE thigh
ache/stiffness. Some DOE and lightheadedness. + baseline
orthopnea. No PND. No CP. Pt denies fevers, palpitations,
diarrhea, hemetemesis.
During an admission for N/V/D on [**10-20**], pt was also found to
have prolonged QT 700ms and her Amiodarone was d/c. She was
started on Atenolol 12.5 [**Hospital1 **].
In the ER the patient was found to be in acute on chronic RF
with
Cr from baseline 1.6-1.9 to 4.4, Bun 130, mild CHF, K of 6.5.
bradycardic to 20s with stable BP,w/ relative [**Name (NI) 63846**] SBP
80s. INR 3.0. Pt got atropine, glucagon, kayexalate. Temporary
transvenous pacer was placed.
Past Medical History:
1. Diabetes mellitus
2. CHF (diastolic)
3. Hypothyroidism
4. Gout
5. Hyperlipidemia
6. H/O bilateral DVT
7. Atrial fibrillatin
8. B12 deficiency
9. OP
10.Carotid artery stenosis: CEA on left (2-3 years prior)
11. CRI (baseline SCr of 1.6)
Social History:
Lives with daughter; former fish packer
Tobacco: quit >20 years ago
EtOH: denies
Family History:
NC
Physical Exam:
vital signs: T 97.5, BP 114/40, HR 60, RR 13, O2 sat 100% 3L
GEN: obese female lying in bed
HEENT: PERRL, MM very dry, poor dentition, no OP lesions, no LAD
CV: brady; distant heart sounds; II/VI systolic murmur
PULM: diffuse crackles b/l, no rhonchi or wheezes.
ABD: soft, non-tender, obese, ventral hernia on exam; reducible,
superficial epidermal abrasion under pannus on R.
EXT: warm, + erythema bilaterally to knees, and evidence of
previous ulcerations; no current ulcers noted
Neuro: oriented x 2. No focal deficits.
Pertinent Results:
Laboratory Results:
[**2179-11-16**] 09:00AM BLOOD WBC-9.9# RBC-4.19* Hgb-12.4 Hct-36.5
MCV-87 MCH-29.5 MCHC-33.9 RDW-15.3 Plt Ct-197
[**2179-11-17**] 05:49PM BLOOD WBC-9.2 RBC-3.65* Hgb-11.2* Hct-31.2*
MCV-86 MCH-30.6 MCHC-35.8* RDW-15.5 Plt Ct-149*
[**2179-11-22**] 04:41AM BLOOD WBC-9.7 RBC-3.25* Hgb-9.9* Hct-28.1*
MCV-86 MCH-30.6 MCHC-35.4* RDW-15.7* Plt Ct-125*
[**2179-11-25**] 06:15AM BLOOD WBC-8.6 RBC-3.22* Hgb-9.7* Hct-29.3*
MCV-91 MCH-30.2 MCHC-33.2 RDW-16.4* Plt Ct-162
[**2179-11-16**] 09:00AM BLOOD Glucose-167* UreaN-132* Creat-4.4*#
Na-119* K-8.8* Cl-86* HCO3-23 AnGap-19
[**2179-11-16**] 09:30PM BLOOD Glucose-129* UreaN-135* Creat-4.3*
Na-125* K-5.4* Cl-90* HCO3-22 AnGap-18
[**2179-11-18**] 08:00AM BLOOD Glucose-142* UreaN-126* Creat-3.8*
Na-132* K-3.6 Cl-96 HCO3-21* AnGap-19
[**2179-11-21**] 05:24AM BLOOD Glucose-129* UreaN-120* Creat-2.9* Na-134
K-4.5 Cl-102 HCO3-22 AnGap-15
[**2179-11-23**] 06:12AM BLOOD Glucose-107* UreaN-102* Creat-2.0* Na-140
K-4.0 Cl-106 HCO3-24 AnGap-14
[**2179-11-25**] 06:15AM BLOOD Glucose-120* UreaN-85* Creat-1.5* Na-145
K-4.3 Cl-111* HCO3-26 AnGap-12
[**2179-11-16**] 09:00AM BLOOD PT-28.7* PTT-37.1* INR(PT)-3.0*
[**2179-11-16**] 09:30PM BLOOD PT-22.5* PTT-35.5* INR(PT)-2.2*
[**2179-11-18**] 08:00AM BLOOD PT-26.7* PTT-36.8* INR(PT)-2.7*
[**2179-11-25**] 06:15AM BLOOD PT-15.6* PTT-40.4* INR(PT)-1.4*
[**2179-11-16**] 09:00AM BLOOD ALT-37 AST-94* CK(CPK)-155* AlkPhos-80
Amylase-84 TotBili-0.7
[**2179-11-16**] 10:50AM BLOOD ALT-31 AST-43* CK(CPK)-121 AlkPhos-92
Amylase-88 TotBili-0.7
[**2179-11-16**] 09:00AM BLOOD CK-MB-4 cTropnT-0.04* proBNP-5442*
[**2179-11-17**] 06:19AM BLOOD CK-MB-8 cTropnT-0.09*
[**2179-11-16**] 09:00AM BLOOD Calcium-8.9 Phos-6.0* Mg-5.4*
[**2179-11-20**] 05:29AM BLOOD Calcium-8.5 Phos-5.0* Mg-4.5*
[**2179-11-25**] 06:15AM BLOOD Calcium-8.8 Phos-3.2 Mg-3.6*
[**2179-11-18**] 08:00AM BLOOD Free T4-1.7
[**2179-11-21**] 05:24AM BLOOD Cortsol-28.0*
EKG: ventricular escape rhthm at 45. RBBB. TWI III, AVF (new).
Relevant Imaging:
1)Cxray ([**11-16**]): Limited study. No obvious pneumonia,
pneumothorax, or pleural effusion detected in these conditions.
Apical redistribution of pulmonary blood flow. A repeat chest
radiograph in a true AP projection is recommended for better
delineation, as well as to better assess heart size.
2)Lower extremity U/S ([**11-16**]): No evidence of bilateral lower
extremity deep venous thrombosis.
3)ECHO ([**11-17**]):The left atrium is moderately dilated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. The right ventricular cavity is mildly dilated. Right
ventricular systolic function is normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
No aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is no mitral valve prolapse.
Moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Severe [4+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
4)RUE U/S ([**11-20**]): Limited study of the right upper extremity,
without intraluminal thrombus is identified. The right internal
jugular and medial right subclavian veins were not examined as
described.
5)Cxray ([**11-23**]):There was considerable rotation of the patient
to the right, thereby making difficult comparisons of heart size
with prior films. The left-sided pacemaker with its single
ventricular lead seems unchanged in position. There has been
interval placement of a right-sided PICC line, with its tip at
the level of the mid or central portion of the superior vena
cava. Bibasilar small pleural effusions are present, left worse
than right.
Brief Hospital Course:
Ms. [**Known lastname 63845**] is a 80 yo female with a history of CRI, chronic
AF on Coumadin, diastolic CHF who presents in ARF, bradycardia,
hyperkalemia, uremic symptoms, and possible LE cellulitis.
Hyperkalemia resolved and renal failure improving slowly with
IVFs. Had been 100% transvenous paced, now s/p permanent
pacemaker placement.
1) Rhythm: Patient has history of Chronic AF and became
bradycardic in the setting of severe renal failure and
hyperkalemia. Patient was discharged on Atenolol on her last
admission, which is renally excreted, and became bradycardic as
her creatinine increased. In the ED, she was given Atropine with
a minimal response and a temporary pacer was placed in the EP
lab. Her anti-hypertensives, diuretics, and Coumadin were held.
Her pacer rate was initially set at 60 but slowly increased to
80, which she tolerated. Heparin gtt was started for
anti-coagulation but was held because she had significant
epistaxis and hematuria. She was followed closely by EP and a
permanent single chamber pacemaker was placed with no
complications. She was treated with 3 days of Vancomycin, per
EP. She will need follow-up with EP and the device clinic. Would
recommend no atenolol given h/o renal dysfunction, instead give
metoprolol if requires restart of beta-blocker.
2) Pump: Patient has EF >55%, severe tricuspid regurgitation,
likely diastolic dysfunction. She takes Lasix and Spironolactone
at home, both of which were stopped given her renal failure and
dehydration. She is extremely edematous on exam but is likely
intravascularly depleted given her elevated BUN and dry mucous
membranes on clinical exam. Patient was started on maintenance
fluids several times during her hospital stay given her poor
intake. She also required multiple fluid boluses to maintain her
blood pressure. Would recommend to continue holding all
diuretics for now despite peripheral edema given intravascularly
deplete and extremely poor PO intake.
3) Acute-on-chronic renal failure: Patient initially came in
with a creatinine of 4.4 and a potassium of 8.8, secondary to
decreased PO intake, nausea, vomiting, and diuretics. Baseline
creatinine is 1.6. Her BUN was elevated at 132 from dehydration.
She did not require dialysis. In the ED she was given Kayexalate
and glucagon. She was followed closely by renal during her stay.
Her creatinine slowly improved to 1.5 on discharge. Her
potassium quickly resolved as well. Recommend IV NS 1L @ 75cc/hr
qod while PO intake poor to maintain intravascular volume.
4) Diabetes: Patient on Avandia and Glyburide at home. These
were stopped given her renal failure and she was placed on a
insulin sliding scale with sugars checked QID. Discontinued
glyburide and avandia given h/o renal dysfunction, started on
glipizide prior to discharge.
5) Lower extremity edema: Patient presented with skin changes,
initially thought to be cellulitis. As her swelling improving it
was thought that she had extensive venous stasis instead. Daily
pressure dressings were done. The patient was started on
Vancomycin for presumed MRSA cellulitis but was d/c'ed given
that this was not the case. Completed 10 day course.
6) Elevated INR: Patient initially presented with an INR 3.0 on
admission. Unlikely related to her dose of Coumadin. Secondary
to poor PO intake. She was given several doses of Vitamin K to
decrease her INR in preparation for her pacemaker placement.
7) Hyperlipidemia: Continue outpatient regimen of Lipitor.
8) Yeast infection: Miconazole cream to vaginal area.
9) Hypothyroidism: TSH initially elevated but now normalized.
Started Synthroid.
Medications on Admission:
1. Warfarin 2/3 mg PO QAM QOD
2. Docusate Sodium 100 mg Capsule PO BID
3. Montelukast 10 mg PO DAILY
4. Aspirin 81 mg Tablet, Chewable PO DAILY
5. Atorvastatin 10 mg PO DAILY
6. Donepezil 5 mg Tablet PO HS
7. Fluticasone 50 mcg/Actuation Aerosol, Spray Nasal DAILY
8. Levothyroxine 112 mcg Tablet PO DAILY
9. Nitroglycerin 0.4 mg Tablet,
10. Atenolol 12.5 mg Tablet PO once a day.
11. Alendronate 70 mg PO QFRI
12. glyburide 5mg Qpm
13. Furosemide 160 mg PO DAILY
14. Spironolactone 25 mg PO DAILY
15. Metolazone 2.5 mg PO once a week.
16. Avandia 2mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal DAILY (Daily).
7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
9. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): sliding scale.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
11. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
13. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 3 days.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
16. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
17. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
18. Megestrol 40 mg/mL Suspension Sig: Ten (10) ml PO DAILY
(Daily).
19. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
20. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
bradycardia
congestive heart failure exacerbation
hyperkalemia
hyponatremia
acute renal failure
uremia
Discharge Condition:
good
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please adhere to a 2gm sodium diet and 1.5L fluid
restriction.
3. Please measure your weight daily and call your doctor if your
wt increases > 3 pounds as you may need to restart some of your
diuretics.
4. You have been started on several new medications: calcium
acetate, megesterol, insulin, miconazole, percocet, anzemet,
robitussin.
5. We have discontinued several medications including atenolol,
spironolactone, metolazone, glyburide, avandia.
6. Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, sweating, fevers, chills, bleeding, or other
concerning symptoms.
Followup Instructions:
You are scheduled for the following appointments. Please contact
the [**Name2 (NI) 11686**] provider with any questions or if you need to
reschedule.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2179-11-29**]
2:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2179-12-6**] 11:30
Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2180-1-13**] 1:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 4280, 5849, 2767, 2761, 2449, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8139
} | Medical Text: Admission Date: [**2126-2-21**] Discharge Date: [**2126-3-2**]
Date of Birth: [**2057-3-8**] Sex: M
Service: [**Last Name (un) **]
ADMITTING DIAGNOSIS: Alcoholic cirrhosis and HCC admitted
for liver transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 68 year old
male with a history of alcoholic cirrhosis and hepatocellular
carcinoma. Cirrhosis discovered after episode of esophageal
varices bleeding approximately five years ago. Asymptomatic
until two years ago when he had another episode of bleeding.
In [**2125-5-26**] he was noted to have a 4 cm mass in the liver
which was an hepatocellular carcinoma. Had radiofrequency
ablation [**6-29**]. Presents today for liver transplant.
PAST MEDICAL HISTORY: Alcoholic cirrhosis, hepatocellular
carcinoma, esophageal varices with bleeding, history of
tuberculosis approximately 18 years ago. Mild hypertension,
coronary artery disease, status post coronary artery bypass
graft 13 years ago.
PAST SURGICAL HISTORY: Coronary artery bypass graft one
vessel and hernia repair.
MEDICATIONS ON ADMISSION: Aspirin 81 mg q day, isosorbide 50
mg q day, propranolol 40 mg B.I.D., spironolactone 25 mg q
day, folic acid 400 mg q day, iron 325 mg B.I.D. Fish oil 2
grams B.I.D.
ALLERGIES: Penicillin.
SOCIAL HISTORY: Widowed, high school teacher in [**Hospital3 **].
Two children. Drank greater than 12 beers per day for 30
years but he quit some years ago.
REVIEW OF SYSTEMS: No cough, sore throat, upper respiratory
illness. No change in appetite or weight. No change in
bowel or bladder habits.
PHYSICAL EXAMINATION: The patient has a heart rate of 60,
temperature 96.1, blood pressure 140/70, breathing 18, pulse
oximetry 98 percent on room air. General: In no acute
distress. Awake, alert, friendly, conversant. Head, eyes,
ears, nose and throat: Normocephalic, atraumatic.
Extraocular movements are full. Cardiovascular: Regular
rate and rhythm. Negative murmur, rub or gallop. Distant
sounds. Pulmonary: Clear to auscultation bilaterally.
Chest midline, coronary artery bypass graft scar upper chest.
Abdomen soft, nontender, not distended, no masses, no rebound
or guarding. Extremities: No edema, warm, well perfused.
Dorsalis pedis and posterior tibial 1 plus bilaterally right
leg with scar from vein harvesting.
LABORATORY DATA: WBC of 10., hematocrit of 29.4, PT of 16.8,
PTT of 150 and platelets of 70. Patient has a sodium of 141,
3.2, 107, 26, BUN/creatinine of 17/0.9. ALT on the 28th was
61, AST 361, total bilirubin 1.8, direct bilirubin 0.6.
Patient had an electrocardiogram demonstrating sinus
bradycardia, 56 with questionable first degree AV block.
Slipped T waves in V6. Chest x-ray showed no acute
cardiopulmonary disease.
HOSPITAL COURSE: The patient was admitted to Transplant
Surgery, given MMF, 20 mg times 1, Solu-Medrol 1,000 mg times
one, fluconazole 400 mg times 1, Vancomycin 1,000 mg times 1,
Levaquin 500 mg times 1. Patient was typed and crossed.
Patient went to the operating room on [**2126-2-22**] and transplant
was performed by Dr. [**First Name (STitle) **] and Dr. [**First Name (STitle) 2523**] with no
complications. Patient went to the Intensive Care Unit still
intubated, sedated. On [**2126-2-22**] patient had a transplant
Doppler ultrasound postoperatively and report demonstrated
liver texture appears normal. No focal hepatic or
perihepatic masses seen. Portal vein appears normal and
patent. Inferior vena cava is patent as well as the main
hepatic vein and conclusion was normal liver, normal
vasculature. Patient had a chest x-ray on [**2126-2-23**] for
placement of right internal jugular and that demonstrated
that the right internal jugular was in the superior vena cava
and no pneumothorax. Density at the right base may represent
some pleural fluid. Left upper lung opacity consistent with
prior tuberculosis. Patient was doing well on postoperative
day two. Doing well. Pain well controlled. No nausea or
vomiting. Tolerating clears. Patient was still continuing
Solu-Medrol taper, cyclosporin and MMF. Patient was out of
bed on [**2126-2-24**] and transferred here to the floor. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 1661**] [**Last Name (NamePattern1) 1662**] medial on [**2126-2-24**], put out 65, lateral 70 and T
tube 393. Physical therapy was consulted. Patient was out
of bed. Tacrolimus levels were closely monitored. On [**2126-2-26**]
T tube cholangiogram was performed demonstrating that there
is rapid inflow drainage into the small bowel, some reflux
into the hepatic ducts. A second canalicular structure next
to the distal bile duct must likely represent the remnant of
the cystic duct. On [**2126-2-27**] the patient T tube was capped.
Patient was placed on cyclosporin drip to increase the
cyclosporin level. His platelets were decreased slightly to
99. He continued to do well, urinating and ambulating
without difficulty. On [**2126-3-1**] he was continued on Bactrim,
fluconazole and ganciclovir. His propranolol was held which
is a medication that he takes at home because his heart rate
was in the low 50s. Electrocardiogram was performed
demonstrating no ST changes.
Patient is possibly going home on [**2126-3-2**] if patient does well
overnight. Patient should call Transplant Service
immediately at [**Telephone/Fax (1) 56342**] if any fevers, chills, nausea,
vomiting, inability to take medications, jaundice or
lethargy. Patient should have his dry sterile gauze to
capped T tube every day, observe the site for redness,
drainage or pus. [**Hospital3 **] [**Hospital6 407**] to
follow the patient. Glucose monitoring and logs every Monday
and Thursday with results faxed to Transplant Office at [**Telephone/Fax (1) 21087**]. He has an appointment with Dr. [**Last Name (STitle) **] on [**2126-3-6**] at
11:40 and also an appointment on [**2126-3-13**] at 10:30 A.M.,
[**2126-3-20**] at 10:40 and again patient should get laboratory work
every Monday and Thursday which includes the CBC, chem-10,
AST, ALT, alkaline phosphatase, albumin, total bilirubin and
cyclosporin level.
Patient is being discharged on the following medications:
Fluconazole 400 q 24 hours, aspirin 81 mg q day, cyclosporin
300 and 300 q 12 and it will be adjusted per transplant
coordinators if needed, ferrous sulfate 325 mg q day.
Patient is going to go home on Ganciclovir 400 q 24 hours,
heparin 5,000 units subcutaneously t.i.d. Patient is going
to home on MMF 1,000 B.I.D., Percocet 1 to 2 P.O. q 4 hours
PRN, Protonix 40 q 24, guaifenesin 20 mg q day and Bactrim
SSI 1 tablet P.O. q day.
Patient should follow up with his cardiologist because
medications have been held due to a low heart rate.
Otherwise patient will be discharged to home with [**Hospital6 3429**].
FINAL DIAGNOSIS: Alcohol related cirrhosis with
hepatocellular carcinoma.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2126-3-1**] 17:53:01
T: [**2126-3-1**] 18:54:19
Job#: [**Job Number 56343**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8140
} | Medical Text: Admission Date: [**2112-2-28**] Discharge Date: [**2112-3-17**]
Date of Birth: [**2049-5-31**] Sex: F
Service: [**Hospital Unit Name 153**]
THIS DISCHARGE SUMMARY COVERS THE [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13533**] FROM
[**2112-3-9**] THROUGH [**2112-3-17**].
CHIEF COMPLAINT: Hypoxia.
HISTORY OF PRESENT ILLNESS: This is a 62 year old female
with pancreatic carcinoma originally admitted to the hospital
on [**2112-2-28**], with complaints of nausea, vomiting and
dizziness. She was found to have left hydronephrosis. On
the Floor, she became more hypoxemic to 93% on non-rebreather
and was transferred to the Intensive Care Unit on [**2112-3-1**] and was intubated there.
She had been started on Ampicillin, Gentamicin and Flagyl for
Klebsiella urosepsis versus cholangitis on [**2-29**].
During her Intensive Care Unit course, the patient had four
out of four blood cultures positive for Klebsiella and had a
percutaneous nephrostomy to relieve left hydronephrosis and
an Emergency Room CT scan which was negative for cholangitis.
The patient was treated for Klebsiella bacteremia in the
Intensive Care Unit and had a left lower lobe pneumonia, and
was started on Ceftriaxone and Flagyl. She was extubated on
[**2112-3-4**].
She received aggressive chest Physical Therapy and nebulizers
to allow for this but had a persistent O2 requirement upon
transfer back to the floor on [**3-6**]. Her oxygen
requirement there increased daily as well as her white blood
cell count. On [**3-7**], her antibiotics were changed to
a broader spectrum, Zosyn/Vancomycin, and she continued to
become more hypoxemic. Her oncologist, Dr. [**Last Name (STitle) 150**] saw
her on the floor and was reluctant to start palliative
chemotherapy until her infection issues were resolved.
She was febrile on the floor up to 101.7 F., on [**3-8**].
On the day of transfer to the Intensive Care Unit she looked
worse clinically with a saturation down to 91% on 50 liter
face mask, on 90 to 93% on nonrebreather, and the Medical
Intensive Care Unit team was asked to evaluate.
MEDICATIONS ON TRANSFER:
1. Heparin 5000 units subcutaneously three times a day.
2. Protonix 40 mg p.o. q. day.
3. Regular insulin sliding scale.
4. Vancomycin one gram intravenous q. 12, day three.
5. Zosyn 4.5 mg intravenously q. six, day three.
6. MSIR 50 mg q. four to six hours p.r.n.
7. Ativan 0.5 mg p.r.n.
8. Zofran 4 mg intravenously q. six hours p.r.n.
9. Benadryl p.r.n.
10. Tylenol.
11. Atrovent.
12. Albuterol p.r.n.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Klebsiella pneumonia.
3. Urinary tract infection.
4. Osteopenia.
5. Pancreatic cancer with liver metastases.
6. Thyroid disease.
SOCIAL HISTORY: One half pack per day smoker times many
years.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: No history of cancer.
REVIEW OF SYSTEMS: The patient denies dyspnea, chest pain,
shortness of breath or any other pain. She wishes to have
all possible medical interventions.
PHYSICAL EXAMINATION: Vital signs upon transfer are
temperature 100.8 F.; pulse 107; blood pressure 97/50;
saturation of 93% on 100% nonrebreather; respiratory rate 25;
arterial blood gas was 7.48, 30, 8, 58. Fingerstick was 109.
In general, an thin elderly female on a nonrebreather,
tachypneic, alert and oriented times three. Head:
Extraocular movements are intact. Dry mucosal membranes.
Neck with right internal jugular catheter in place.
Cardiovascular: Tachycardic, S1, S2, no murmurs, rubs or
gallops. Abdomen soft, nontender, nondistended, positive
bowel sounds. Back with no costovertebral angle tenderness;
left nephrostomy in place. Pulmonary: Bronchial breath
sounds in left base with egophony and dullness to percussion
in the left base; otherwise clear to auscultation.
Extremities with no cyanosis, clubbing or edema, warm, well
perfused. [**2-29**] dorsalis pedis pulses bilaterally.
Neurological intact.
LABORATORY: White blood cell count 33.4, hematocrit 25.8,
platelets 386, INR 1.4. Chem 7 was sodium 138, potassium
3.9, chloride 97, bicarbonate 28, BUN 8, creatinine 0.5,
glucose 94. ALT 15, AST 28, LD 557, alkaline phosphatase
203, total bilirubin 2.0, amylase 75, lipase 44. Calcium
7.5, phosphorus 2.6, magnesium 1.6, albumin 2.3.
Repeat chest x-ray showed a left lower lobe consolidation,
patchy bilateral infiltrates versus pulmonary edema.
Micro-data was unrevealing since four of four blood cultures
positive on [**3-1**] for Klebsiella.
CT scan of the abdomen on [**3-8**] revealed left lower
lobe atelectasis, small bilateral pleural effusions and
numerable liver metastases and spleen metastases and interval
resolution of left hydronephrosis.
Initial impression was a 62 year old female with pancreatic
cancer metastatic to liver, left hydronephrosis, status post
left nephrostomy, status post recent Klebsiella pneumonia
bacteremia with worsening hypoxia and infiltrate on chest
x-ray; slightly elevated total bilirubin and leukocytosis.
MEDICAL INTENSIVE CARE UNIT COURSE BY PROBLEM:
1. ACUTE RESPIRATORY FAILURE: The patient was initially
hypoxemic believed to be secondary to congestive heart
failure in the setting of aggressive volume resuscitation
with sepsis. Initially, the patient was brought to the
Intensive Care Unit and started on the MUST protocol. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]
stim test was negative. The patient's initial lactates were
in the 2 range and she was given one unit of packed red blood
cells for her low hematocrit. The patient initially had
AmBisome started, however, this was discontinued after she
was afebrile for 24 hours.
She had a persistent O2 requirement in the Intensive Care
Unit and was on a nonrebreather mask for two days, however,
with diuresis and antibiotics she was able to avoid
intubation and in fact be weaned on her high flow face mask
very slowly.
The patient was initiated on aggressive chest Physical
Therapy as well as suctioning. She was able to provide
sputum which did not grow out anything and after diuresis she
did well. An echocardiogram was performed which showed a
normal left ventricular ejection fraction with impair left
atrial relaxation and so it was assumed that the diastolic
congestive heart failure could be related to her respiratory
failure.
The patient also had Gentamicin initially started upon
transfer to the unit, however, this was discontinued along
with AmBisome on [**3-11**] and the MUST protocol was
discontinued on [**3-10**] as she was afebrile, her blood
pressure stable and her lactate was only 1.2.
2. HYPOTENSION: The patient was initially hypotensive upon
transfer to the Unit. This improved upon diuresis. The
patient was noted to become hypotensive acutely after
morphine administration. A Fentanyl patch was started for
pain control with p.r.n. MSIR p.o. around the clock which
seemed to hold her blood pressure up better. The patient was
not on any pressors in the unit.
3. PANCREATIC CANCER: The patient achieved pain control
with morphine p.r.n. as well as a Fentanyl patch. Palliative
chemotherapy was not an option given her infectious issues
and the patient's family initially wanted her to be a full
code with aggressive care.
However, upon multiple discussions with the family and the
patient, the family is now resolved to having the patient be
a "DO NOT RESUSCITATE" "DO NOT INTUBATE" and transfer to
Hospice; however, the patient herself wished to remain a Full
Code and these issues remained unresolved at the time of
transfer out of the unit today.
Her bilirubin was rising in the unit to a high of 2.4,
however, it had started to fall after this and no other
interventions were done. Her INR was elevated to a high of
1.6, however, dropped back down to 1.3 after 5 mg of Vitamin
K subcutaneously. Other liver function tests were stable in
the unit.
4. NUTRITION: The patient was initially kept NPO, however,
she was able to tolerate clear liquids. By the time of
discharge, the patient was started on TPN and was kept on TPN
throughout the unit stay.
5. LEFT PICC LINE AND A-LINE: Right IJ triple lumen
catheter was pulled once a left PICC line was placed and tip
sent for culture which never grew out anything. The patient
had A-line discontinued upon transfer back to the floor.
6. ENDOCRINE: Regular insulin sliding scale, fingerstick
four times a day.
7. INFECTIOUS DISEASE: Urine culture positive for yeast on
[**3-9**]; the Foley catheter was replaced and a recheck of
urinalysis was negative. Repeat urine cultures did not grow
out anything and so she was not started on any anti-fungals
for this. However, she did have a positive yeast infection
by clinical examination and was on three days of miconazole
intravaginal suppositories.
8. DEPRESSION / ANXIETY: The patient was actively going
through the acceptance stages for dying as she had been told
that she has a very grave prognosis; angry at house staff at
times, refusing to participate in getting out of bed or chest
Physical Therapy at times, however, does it with
encouragement. The patient was started on Ritalin
empirically to treat depression and fatigue and malaise while
in the Intensive Care Unit.
The rest of her hospital stay should be dictated by the Floor
Team accepting her.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-207
Dictated By:[**Name8 (MD) 6867**]
MEDQUIST36
D: [**2112-3-17**] 14:30
T: [**2112-3-17**] 15:29
JOB#: [**Job Number 97006**]
/
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8141
} | Medical Text: Admission Date: [**2182-4-25**] Discharge Date: [**2182-5-1**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Right Upper Quadrant Abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic Cholecystectomy
ERCP
History of Present Illness:
89M with PMH HTN p/w 2 days RQU pain, +chills, +N/V, yellow
stool, tea colored urine. Initially presented to OSH, found to
have WBC 25 with left shift, elevated TBili 12.2 DBili 7.5,
Lipase 1017, AST/ALT 92/58. Patient also found to be in new
onset Afib.
Past Medical History:
HTN
Elevated cholesterol
Gout
CAD
Social History:
Denies EtOH, Denies tobacco
Lives at home with wife
Family History:
Non-contributory
Physical Exam:
(On Admission)
97.3 74 112/58 18 96RA
NAD, A&OX3
HEENT: scleral icterus
CV: Irreg irreg, II/VI holosystolic mumur, loud S2
LUNGS: Scattered mild expiratory wheeze
ABD: RUQ pain, distended, no rebound/guarding
EXT: no edema
SKIN: jaundice
NEURO: grossly intact
Pertinent Results:
[**2182-4-25**] 10:08PM WBC-30.6*# RBC-3.88* HGB-13.3* HCT-38.1*
MCV-98 MCH-34.2* MCHC-34.8 RDW-14.7
[**2182-4-25**] 10:08PM PLT COUNT-229
[**2182-4-25**] 08:47PM GLUCOSE-99 UREA N-35* CREAT-1.3* SODIUM-139
POTASSIUM-3.1* CHLORIDE-108 TOTAL CO2-21* ANION GAP-13
[**2182-4-25**] 08:47PM ALT(SGPT)-34 AST(SGOT)-49* CK(CPK)-40 ALK
PHOS-247* AMYLASE-125* TOT BILI-11.4*
[**2182-4-25**] 08:47PM LIPASE-81*
[**2182-4-25**] 08:47PM CK-MB-NotDone cTropnT-<0.01
[**2182-4-25**] 08:47PM ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-2.4*
MAGNESIUM-1.7
[**2182-4-25**] 08:47PM PT-17.0* PTT-34.8 INR(PT)-1.6*
[**2182-4-25**] 09:10AM GLUCOSE-81 UREA N-34* CREAT-1.1 SODIUM-137
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17
[**2182-4-25**] 09:10AM ALT(SGPT)-44* AST(SGOT)-64* CK(CPK)-30* ALK
PHOS-330* AMYLASE-277* TOT BILI-12.9*
[**2182-4-25**] 09:10AM LIPASE-294*
[**2182-4-25**] 09:10AM CK-MB-NotDone cTropnT-<0.01
[**2182-4-25**] 09:10AM ALBUMIN-2.9* CALCIUM-9.5 PHOSPHATE-3.3
MAGNESIUM-2.0
[**2182-4-25**] 09:10AM WBC-2.8*# RBC-4.78 HGB-15.7 HCT-46.9 MCV-98
MCH-32.9* MCHC-33.5 RDW-14.6
[**2182-4-25**] 09:10AM PLT COUNT-234
[**2182-4-25**] 09:10AM PT-15.2* PTT-23.4 INR(PT)-1.4*
[**2182-4-25**] 12:00AM GLUCOSE-106* UREA N-30* CREAT-1.1 SODIUM-135
POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-29 ANION GAP-12
[**2182-4-25**] 12:00AM estGFR-Using this
[**2182-4-25**] 12:00AM ALT(SGPT)-42* AST(SGOT)-53* ALK PHOS-320*
AMYLASE-394* TOT BILI-12.1*
[**2182-4-25**] 12:00AM LIPASE-408*
[**2182-4-25**] 12:00AM ALBUMIN-3.0*
[**2182-4-25**] 12:00AM ACETONE-NEGATIVE
[**2182-4-25**] 12:00AM WBC-22.7* RBC-4.26* HGB-14.6 HCT-40.8 MCV-96
MCH-34.2* MCHC-35.7* RDW-14.8
[**2182-4-25**] 12:00AM NEUTS-90* BANDS-4 LYMPHS-3* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2182-4-25**] 12:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2182-4-25**] 12:00AM PLT SMR-NORMAL PLT COUNT-251
[**2182-4-26**] 04:41AM BLOOD WBC-29.7* RBC-3.92* Hgb-13.0* Hct-38.5*
MCV-98 MCH-33.2* MCHC-33.8 RDW-15.0 Plt Ct-253
[**2182-4-27**] 01:40AM BLOOD WBC-15.6* RBC-3.72* Hgb-12.0* Hct-36.5*
MCV-98 MCH-32.3* MCHC-33.0 RDW-14.9 Plt Ct-204
[**2182-4-28**] 02:08AM BLOOD WBC-12.3* RBC-3.63* Hgb-11.9* Hct-34.6*
MCV-95 MCH-32.7* MCHC-34.2 RDW-15.1 Plt Ct-175
[**2182-4-28**] 05:16PM BLOOD WBC-11.5* RBC-3.94* Hgb-13.2* Hct-37.0*
MCV-94 MCH-33.6* MCHC-35.8* RDW-15.0 Plt Ct-206
[**2182-4-29**] 04:05AM BLOOD WBC-11.1* RBC-3.43* Hgb-11.4* Hct-33.1*
MCV-97 MCH-33.3* MCHC-34.5 RDW-15.1 Plt Ct-186
[**2182-4-30**] 03:48AM BLOOD WBC-16.0* RBC-3.64* Hgb-11.8* Hct-35.0*
MCV-96 MCH-32.5* MCHC-33.8 RDW-14.8 Plt Ct-212
[**2182-5-1**] 06:55AM BLOOD WBC-14.1* RBC-3.66* Hgb-12.3* Hct-34.9*
MCV-96 MCH-33.5* MCHC-35.1* RDW-14.9 Plt Ct-272
[**2182-4-26**] 04:41AM BLOOD Plt Ct-253
[**2182-4-27**] 01:40AM BLOOD PT-14.9* PTT-32.5 INR(PT)-1.3*
[**2182-4-27**] 01:40AM BLOOD Plt Ct-204
[**2182-4-28**] 02:08AM BLOOD PT-12.5 PTT-32.0 INR(PT)-1.1
[**2182-4-26**] 04:41AM BLOOD Glucose-90 UreaN-38* Creat-1.0 Na-139
K-3.7 Cl-109* HCO3-20* AnGap-14
[**2182-4-27**] 01:40AM BLOOD Glucose-88 UreaN-40* Creat-1.2 Na-140
K-3.2* Cl-110* HCO3-22 AnGap-11
[**2182-4-28**] 02:08AM BLOOD Glucose-94 UreaN-31* Creat-1.1 Na-137
K-3.1* Cl-108 HCO3-23 AnGap-9
[**2182-4-28**] 05:16PM BLOOD Glucose-92 UreaN-28* Creat-0.9 Na-139
K-3.8 Cl-108 HCO3-23 AnGap-12
[**2182-4-29**] 04:05AM BLOOD Glucose-110* UreaN-23* Creat-0.8 Na-138
K-3.8 Cl-107 HCO3-27 AnGap-8
[**2182-4-30**] 03:48AM BLOOD Glucose-115* UreaN-19 Creat-0.9 Na-136
K-4.2 Cl-104 HCO3-27 AnGap-9
[**2182-5-1**] 06:55AM BLOOD Glucose-104 UreaN-15 Creat-0.9 Na-137
K-3.4 Cl-102 HCO3-30 AnGap-8
[**2182-4-26**] 04:41AM BLOOD ALT-34 AST-48* CK(CPK)-40 AlkPhos-239*
Amylase-95 TotBili-11.1*
[**2182-4-28**] 02:08AM BLOOD ALT-24 AST-29 LD(LDH)-140 AlkPhos-191*
Amylase-90 TotBili-5.3*
[**2182-4-28**] 05:16PM BLOOD ALT-26 AST-29 LD(LDH)-141 AlkPhos-210*
Amylase-134* TotBili-4.9*
[**2182-4-29**] 04:05AM BLOOD ALT-22 AST-26 AlkPhos-190* Amylase-134*
TotBili-4.5*
[**2182-4-30**] 03:48AM BLOOD ALT-30 AST-57* LD(LDH)-245 AlkPhos-183*
Amylase-150* TotBili-4.2*
[**2182-5-1**] 06:55AM BLOOD ALT-30 AST-40 AlkPhos-196* Amylase-189*
TotBili-3.5*
[**2182-4-26**] 04:41AM BLOOD Lipase-63*
[**2182-4-28**] 02:08AM BLOOD Lipase-161*
[**2182-4-28**] 05:16PM BLOOD Lipase-208*
[**2182-4-29**] 04:05AM BLOOD Lipase-240*
[**2182-4-30**] 03:48AM BLOOD Lipase-208*
[**2182-4-26**] 04:41AM BLOOD Albumin-2.3* Calcium-8.2* Phos-2.5*
Mg-2.7*
[**2182-4-27**] 01:40AM BLOOD Calcium-8.5 Phos-2.1* Mg-2.4
[**2182-4-28**] 02:08AM BLOOD Albumin-2.0* Calcium-8.2* Phos-2.5*
Mg-2.1
[**2182-4-28**] 05:16PM BLOOD Albumin-2.3* Calcium-8.5 Phos-1.8* Mg-1.9
[**2182-4-29**] 04:05AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.8
[**2182-4-29**] 06:24PM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2
[**2182-4-30**] 03:48AM BLOOD Albumin-2.0* Calcium-8.3* Phos-3.4 Mg-2.0
Brief Hospital Course:
Patient was admitted to the General Surgery floor from the
Emergency Department. On HD1 the patient underwent ERCP where
three stones, sludge, and pus were extracted as well as a
sphincterotomy was performed without complication. In the
recovery room the patient had a hypotensive episode to the 60's
systolic - was transfered to the ICU and responed to fluid
resusication as well as low dose pressors. On post-procedure
day two the patient was weaned off of pressors and was in stable
condition when transfered to the regular general surgery [**Hospital1 **] on
hopspital day 4. On HD5 the patient underwent a laparoscopic
cholecystectomy without complication - please refer to the
operative note for full details. The patient was also evaluated
by cardiology for the new-onset atrial fibrillation who
recommeded holding all beta blockers and starting
anticoagulation when hemostatically stable post-operatively and
s/p sphincterotomy. At the time of discharge the patient was
doing well, tolerating a regular diet and was without
complaints.
Medications on Admission:
Corgard 160
HCTZ 50
ASA 325
Nitro PRN
MVT
Zocor 20
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a
day.
Disp:*90 Capsule(s)* Refills:*2*
6. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Nitroglycerin SL PRN
8. MVT
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Gall stone pancreatitis with cholangitis
Atrial Fibrillation
Discharge Condition:
Stable
Discharge Instructions:
Please call physician or return to the Emergency Department if
any of the following occur:
1. Fever >101.5
2. Increased abdominal pain
3. Intractable nausea/vomiting
4. Redness or swelling or discharge from incision sites
5. Any other concerning symptoms
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] within one to two weeks. Call
[**Telephone/Fax (1) 6429**] for appointment.
Please follow-up with your primary care provider within one to
two weeks for follow-up of your atrial fibrillation. Current
[**Hospital1 18**] Cardiology recommendation are to start anticoagulation
when sufficient time has elapsed from surgery/ERCP (1-2 weeks).
It is my impression however that the patient is at significant
fall risk. Thus considering the low rate of embolic events from
AFib (probably ~5% per year) and the patient's age, the primary
physician might consider avoiding warfarin therapy, as the
increased risk from trauma (especially intra-cranial bleeding)
may exceed the embolic risk.
Completed by:[**2182-5-1**]
ICD9 Codes: 0389, 4280, 2749, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8142
} | Medical Text: Admission Date: [**2169-11-1**] Discharge Date: [**2169-11-20**]
Date of Birth: [**2100-4-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
black stools
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Anterior gastrotomy.
3. Submucosal resection of gastric neoplasm, likely lipoma.
4. Two-layer gastrorrhaphy.
History of Present Illness:
The patient is a 69-year-old gentleman who was admitted to the
medical service on [**11-1**] with anemia and melena. He has a
history of end-stage
renal disease secondary to complications from diabetes and is
on hemodialysis. He reported 2 prior significant episodes of GI
bleeding, one in [**2168-10-17**] for which he received 5 units and
no source was found, and another in [**Month (only) 956**] of this year in
which no source was found. At the time of this GI bleed, upper
endoscopy was performed, and this revealed evidence of a 6 cm
submucosal mass in the
antrum of the stomach with central ulceration and stigmata of
recent bleeding. This was felt to be consistent with a GI
stromal tumor or leiomyoma and was felt to be the source of
bleeding. No other abnormality was noted in the esophagus,
stomach or first 2 portions of the duodenum.
Preoperative CT scans of the chest, abdomen and pelvis showed
a well-defined mass in the antrum with attenuation consistent
with fat. On further questioning, the patient does note a
recent history of early satiety without weight loss. He
states that this has progressed over the last several months
Past Medical History:
1. ESRD on HD
2. HTN
3. Hypercholesterolemia
4. DM
5. Diastolic CHF, EF >55%
6. COPD
7. h/o GI bleeding
8. unilateral kidney
9. s/p cataract surgery
Social History:
Pt is a retired medical record coder at the VA. He is widowed
with 4 children and 5 grandchildren. Quit smoking 14 years ago.
Smoke [**2-17**] ppd for 40+ years. No EtOh. No drug use. Pt was in the
army from [**2118**]-[**2142**].
Family History:
Family History:
M: Died at 64 of MI; DM
F: Died at 41 of MI
Aunts maternal and paternal with DM.
Physical Exam:
At admission, Mr. [**Known lastname **] was pale, but non-diaphoretic, and
non-distressed. There was no JVD. His heart was regular rate
rhythm with a [**1-22**] holosystolic murmur, best heard at the apex.
His abdomen was soft, non-tender, non-distended with normal
bowel sounds. He was guaiac positive. There was no edema in
his extremities. Distal pulses were diminished. The left upper
extremity fistula had good thrill and bruit.
Pertinent Results:
[**2169-11-1**] 12:35PM BLOOD WBC-11.1* RBC-2.35*# Hgb-7.6*# Hct-20.9*#
MCV-89 MCH-32.3* MCHC-36.3* RDW-15.9* Plt Ct-149*
[**2169-11-8**] PATHOLOGY REPORT: Submucosal gastric lipoma.
Brief Hospital Course:
Upon admission, the patient was made NPO and given IV fluids.
He was then transfused several units of pRBC's to maintain his
hematocrit to be near 30. A CT scan of this abdomen revealed a
48 x 38 mm rounded, well-defined mass in the antrum of the
stomach. He was then taken to the operating room to have the
mass removed, which was confirmed to be mucosal lipoma by
pathology. He tolerated the surgery, but post-operatively, he
had several bouts of nausea and vomiting. An upper GI with
small-bowel follow through showed no obstruction up to the
mid-portion of the jejunum. It was decided that the study was
sufficient because inorder to study up to the terminal ileum,
the patient had to swallow a much greater amount of barium at
the risk of aspiration. Although slow, the patient's nausea and
vomiting did eventually resolved and he was able to tolerate a
regular, low salt diet. While in hospital, he maintained his
hemodialysis schedule of M/W/F. At time of discharge, he was in
stable/good condition.
Medications on Admission:
ASA 81mg
Calcium acetate 667mg po TID
docusate 100 [**Hospital1 **]
nephrocaps qD
omeprazole 20 qD
NPH Insulin 22U HS
lovastatin 20mg HS - d/c'd by PCP
metoprolol [**Name9 (PRE) **] 25
diltiazem 180 qD (on M,W,F,Sa only)
sevelamer 800 2 tabs TID
flovent
ambien
monopril 20mg
vit E 400qD
Pred-forte gtt OD qid
Advair
Spiriva
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed.
Disp:*100 Tablet(s)* Refills:*0*
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
3. Protonix 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*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
5. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4-6HRS () as needed.
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
11. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
15. Insulin per outpatient regiment
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Gastric Lipoma
Discharge Condition:
Stable
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1924**] in his office in 2 weeks.
Please call the office ahead of time to make an appointment
([**Telephone/Fax (1) 55864**]
Completed by:[**2169-11-23**]
ICD9 Codes: 5789, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8143
} | Medical Text: Admission Date: [**2175-11-15**] Discharge Date: [**2175-11-21**]
Date of Birth: [**2113-3-30**] 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:
[**2175-11-17**] Four Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending,
with vein grafts to the diagonal, obtuse marginal and PDA.
History of Present Illness:
Mr. [**Known lastname **] is a 62 year old male with recent complaints of
worsening chest pain. He describes the pain as anterior chest
pain radiating to his left shoulder and arm at rest. EKG
revealed inferolateral T wave inversion on ETT. Subsequent
cardiac catheterization revealed severe three vessel coronary
artery disease. Given the above results, he was transferred to
the [**Hospital1 18**] for cardiac surgical intervention.
Past Medical History:
Hypertension
Dyslipidemia
Type II Diabetes Mellitus
Low Back Pain
History of Retinal Detachment
Tonsillectomy
Social History:
Unemployed, lives with his sister. Denies tobacco history.
Admits to [**12-28**] ETOH drinks per month.
Family History:
Father died of diabetic complications, no premature coronary
disease.
Physical Exam:
Admission
VS - 98.2, 65, 122/74, 18, 100% RA
Gen: WDWN male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple, No LAD, no JVP appreciated
CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: clear bilaterally
Abd: Soft, NT, ND. No abdominial bruits appreciated.
Ext: Warm. No edema or cyanosis.
Skin: unremarkable
Pulses: 1+ bilaterally, no carotid or femoral bruits noted
Discharge
VS T 98.5 HR 102ST BP 111/66 RR 18 O2sat 99%RA
Gen NAD
Neuro Alert, nonfocal exam
Pulm CTA-bilat
Cor RRR, no murmur. Sternum stable-incision CDI.
Abdm soft, NT/+BS
Ext warm, trace edema. Palpable pulses bilat
Pertinent Results:
[**2175-11-15**] 03:32PM BLOOD WBC-7.3 RBC-3.94* Hgb-11.8* Hct-34.5*
MCV-87 MCH-30.0 MCHC-34.3 RDW-12.8 Plt Ct-319
[**2175-11-15**] 03:32PM BLOOD PT-12.1 PTT-23.7 INR(PT)-1.0
[**2175-11-15**] 03:32PM BLOOD Glucose-219* UreaN-14 Creat-1.0 Na-139
K-4.6 Cl-101 HCO3-29 AnGap-14
[**2175-11-15**] 03:32PM BLOOD ALT-16 AST-18 LD(LDH)-139 AlkPhos-59
Amylase-64 TotBili-0.3
[**2175-11-15**] 03:32PM BLOOD CK-MB-2 cTropnT-<0.01
[**2175-11-15**] 03:32PM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.7 Mg-2.0
[**2175-11-15**] 03:32PM BLOOD %HbA1c-9.0*
[**2175-11-20**] 05:46AM BLOOD WBC-7.7 RBC-3.13* Hgb-9.6* Hct-27.2*
MCV-87 MCH-30.7 MCHC-35.4* RDW-13.4 Plt Ct-165
[**2175-11-20**] 05:46AM BLOOD Plt Ct-165
[**2175-11-20**] 05:46AM BLOOD UreaN-8 Creat-0.7 Na-138 K-4.0
[**2175-11-16**] Transthoracic ECHO:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60-70%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. There are focal calcifications in
the aortic arch. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
[**2175-11-17**] Intraop TEE:
PRE BYPASS The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is no pericardial effusion. Dr. [**Last Name (STitle) **]
was notified in person of the results in the operating room at
the time of the study. POST BYPASS Normal biventricular systolic
function. Thoracic aorta intact. No changes from pre-bypass
study.
[**Known lastname **],[**Known firstname **] A [**Medical Record Number 81585**] M 62 [**2113-3-30**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2175-11-19**]
12:25 PM
[**Hospital 93**] MEDICAL CONDITION:
62 year old man s/p chest tube removal
Final Report
CLINICAL HISTORY: Status post removal of left chest tube.
CHEST:
Mediastinal chest tubes, endotracheal tube and nasogastric tube
have all been removed. Some atelectasis is present at the left
base. No pneumothorax is identified. There are low lung volumes.
Air-filled loops of large and small bowel are seen. There is no
free air
under either hemidiaphragm.
IMPRESSION: Tubes removed. No pneumothorax.
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Approved: MON [**2175-11-20**] 2:52 PM
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation. Workup was rather
unremarkable and he was cleared for surgery. Given his inpatient
stay was greater than 24 hours prior to surgery, Vancomycin was
used for perioperative coverage.
On [**11-17**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting surgery. For surgical details, please see seperate
dictated operative note. Following the operation, he was brought
to the CVICU in stable condition for invasive monitoring. Within
24 hours, he awoke neurologically intact and was extubated
without incident. Given postoperative anemia, he was transfused
with packed red blood cells to maintain hematocrit near 30%. He
otherwise maintained stable hemodynamics and transferred to the
SDU on postoperative day one. On postoperative day two, he
experienced atrial fibrillation which was initially treated with
beta blockade and Amiodarone. He converted back to a normal
sinus rhythm within 24 hours. The remainder of his hospital stay
was uneventful, his activity level was gradually advanced and on
POD4 he was discharged home. He has follow up in 1 week at wound
clinic [**Hospital1 18**].
Medications on Admission:
Lisinopril 10 qd, Toprol 100 qd, Metformin 1000 [**Hospital1 **], Simvastatin
40 qd, Aspirin 162 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
coronary artery disease s/p CABGx4
PMH DM, ^chol, HTN, Retinal detatch, LBP, 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**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr. [**First Name (STitle) **],[**First Name3 (LF) **] in 1 week please call for appointment
Dr. [**Last Name (STitle) 29070**] in [**1-29**] weeks; please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 next week([**Telephone/Fax (1) 3071**])
Completed by:[**2175-11-21**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8144
} | Medical Text: Admission Date: [**2168-12-13**] Discharge Date: [**2168-12-23**]
Date of Birth: [**2168-12-13**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**Known lastname 46860**] number three is the former 32 [**1-4**]
week 1690 gram in [**Last Name (un) 5153**] fertilization triplet number three,
born by cesarean section for unstoppable pre-term labor to a
23-year-old GI P0-III. Pregnancy complicated by pre-term
labor and cervical shortening, on terbutaline at home for
delivery. On admission, aggressively treated with magnesium
sulfate and betamethasone. Ruptured at delivery, emerged
with spontaneous respiratory effort and good cry. Received
blow-by oxygen, and transferred to the Newborn Intensive Care
Unit. Apgars of 7 at one minute and 8 at five minutes.
Prenatal screens: B positive, antibody negative, rubella
immune, RPR nonreactive, hepatitis B surface antigen
PHYSICAL EXAMINATION: On admission, birth weight 1690,
length 30 cm, head circumference 42 cm. Examination notable
for inspiratory crackles and significant grunting, flaring
and retracting. Unable to maintain saturations without
facial CPAP. Non-dysmorphic, regular rate and rhythm, no
murmur, well perfused. Anterior fontanel flat and soft,
normal facies. Abdomen soft, three vessel cord, straight
spine, no dimples, stable hips.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: Chest x-ray showed low lung volumes, air
bronchograms, ground-glass appearance, consistent with
surfactant deficiency. Baby was intubated, received two
doses of surfactant, weaned to extubatable settings. Initial
blood gas was 7.31, 70. Repeat gas of 7.39, 50. By day of
life one, was on extubatable settings, was extubated to nasal
cannula oxygen, which she required until day of life four,
when she transitioned to room air. She has had no further
respiratory distress. She has had an occasional episode of
apnea and bradycardia, has not required any methylxanthine
treatment.
2. Cardiovascular: Did not require any pressor support.
Has had no murmur. Baseline heart rate 130s to 150s, and
stable blood pressure. No issues.
3. Fluids, electrolytes and nutrition: Baby initially was
nothing by mouth, and was started on maintenance intravenous
fluid. Her initial dextrose stick was 30, received a 2 cc/kg
bolus of D-10-W. Subsequent dextrose stick was 68, with
other dextrose sticks all greater than 60. Did not require
any further boluses. Enteral feedings were introduced on day
of life one, and advanced without issue. Is currently
feeding 150 cc/kg of PE or breast milk 26 calories/ounce plus
promod via
gavage. Baby is voiding and stooling. Last electrolytes on
[**12-17**] were 142, 6.3, 110, 24. Previous electrolytes on [**12-14**]
were 140, 4.6, 101, 28. Wt=1750g.
4. Gastrointestinal: Baby did require single phototherapy
for physiologic jaundice. Peak bilirubin on day of life
three was 9.7/0.3/9.4. Lights were turned off on day of life
six, and her rebound bilirubin on day of life seven, [**12-20**],
was 4.9/0.2.
5. Hematology: The baby did not require any blood
transfusions during this admission. Admission hematocrit was
52.2.
6. Infectious Disease: Because of her initial respiratory
distress, the baby had a blood culture and a CBC sent, and
was started on antibiotics. Her initial white count was 8.9,
with 3 polys, 0 bands, 72 lymphs, platelets of 279,000,
hematocrit of 52.2. At 48 hours, the baby was clinically
well. Cultures remained negative. Ampicillin and gentamicin
were discontinued. She has had no further issues with
infection.
7. Neurology: The baby is appropriate for gestational age.
No head ultrasound was done based on gestational age of
greater than 32 weeks.
8. Sensory: Audiology: Hearing screen would be recommended
prior to discharge. Has not been done to date.
Ophthalmology examination not indicated, as baby greater than
32 weeks.
9. Psychosocial: The parents are involved, and look forward
to transitioning closer to home and ultimately home, are
quite pleased with the triplets.
CONDITION AT TRANSFER: Stable.
DISCHARGE DISPOSITION: To [**Hospital6 33**].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) 46867**], [**Location (un) 38**],
[**State 350**], telephone number [**Telephone/Fax (1) 46862**].
CARE RECOMMENDATIONS:
1. Feedings: Continue ad lib feedings of breast milk 24 or
PE 24. Encourage oral feeds.
2. Medications: Iron 2 mg/kg/day.
3. Car seat position screening not done to date. Would
recommend prior to discharge.
4. State newborn screening status: Initial screen sent on
[**12-16**]. Repeat due on [**12-27**].
5. Immunizations received: None to date, as baby is less
than 2 kg.
6. Immunizations recommended: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation; (2) Born
between 32 and 35 weeks, with plans for day care during
respiratory syncytial virus season, with a smoker in the
household, or with preschool siblings; or (3) With chronic
lung disease.
Influenza immunization should be considered annually in the
fall for pre-term infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
7. Follow-up appointments: With primary care provider per
routine.
DISCHARGE DIAGNOSIS:
1. Former 32 [**1-4**] premature triplet
2. Status post respiratory distress syndrome
3. Apnea and bradycardia of prematurity
4. Status post physiologic jaundice
5. Status post rule out sepsis with antibiotics
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**]
Dictated By:[**Last Name (NamePattern1) 36144**]
MEDQUIST36
D: [**2168-12-20**] 22:29
T: [**2168-12-21**] 00:54
JOB#: [**Job Number 46868**]
ICD9 Codes: 769, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8145
} | Medical Text: Admission Date: [**2103-4-11**] Discharge Date: [**2103-5-4**]
Date of Birth: [**2050-1-17**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Tracheostomy and GJ feeding tube placements
Total abdominal colectomy with end ileostomy ([**2103-5-3**])
History of Present Illness:
52 yo female with history of [**Location (un) 805**] Syndrome, atrial
fibrillation, CHF (? diastolic, last EF 70%), history of MVR s/p
valvuloplasty [**2100**], recent recurrent PNAs (last [**1-12**] w/MSSA PNA
s/p intubation), and severe COPD, who presents with shortness of
breath. Has had body aches for the last 2 days. She reports
increased SOB, but denies cough, sputum, fever, chills,
abdominal pain, nausea, vomitting, diarrhea, or dysuria.
Normally, she is on oxygen at rehab on [**1-4**] LNC. Because of the
shortness of breath and fever, she was sent to the ED.
.
In the ED, the patient had the following vital signs: 98.6 120
92/60 18 97% NRB. She was noted to be in a fib with RVR with
rates up to the 140s, however, she was not rate controlled for
fear of patient being periseptic. The patient was given
levofloxacin 750mg IV ONCE, ceftriaxone 1gm IV ONCE. The patient
was given 2L of NS thinking she was tachycardic from
dehydration. She was also given combivent, and morphine 2mg IV x
2 and tylenol 1gm PO ONCE for body pain and dyspnea. Last set of
vitals were: 98.1 131 106/61 22 90%5LNC.
.
In the MICU, she arrived in acute respiratory distress and
tachypneic with heart rate in the 130s in a fib with RVR, and
hypoxic to the 80s on 6LNC. She was given morphine 1mg IV x 2,
lasix 20mg IV x 1 (leading to 300cc of urine in [**1-4**] hrs), a
trial of bipap for 15 minutes with significant improvement in
her symptoms. She was also given 5mg and 10mg IV dilt for HR in
140s, followed by dilt 60mg PO QID with improvement in her rate
down to 110s.
Past Medical History:
PMH: [**Location (un) 805**] syndrome, developmental delay, steroid-induced
diabetes, afib with left atrial clot, diastolic CHF, COPD,
diverticulitis, MR, malnutrition
PSH: mitral valvuloplasty ([**2100**] - [**Hospital1 112**])
Social History:
She was at Bostonian [**Hospital1 1501**] after last discharge. Generally, lives
in [**Hospital1 **] with 2 brothers. [**Name (NI) **] brothers, no longer able to walk
or take care of ADLs; decline in last few months since recurrent
PNAs. Not working. Former smoker, smoked [**12-3**] PPD for 30 years,
quit 2 years ago. No EtOH or ilicit drugs.
Family History:
Coronary artery disease. No other congenital abnormalities in
the family
Physical Exam:
On admission:
GEN: Small, pale, woman with [**Last Name (un) **] facies, tachypneic, using
excessory muscles to breath
HEENT: Anisocoria (old), anicteric, dry MM, op without lesions,
mildly elevated jvd,
RESP: Bibasilar rales R>L, moderately reduced airflow, no
wheezes, positive egophony at right base
CV: Tachycardic, irregular, 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.
Pertinent Results:
[**2103-5-4**] 10:47AM BLOOD WBC-26.0* RBC-2.91* Hgb-7.6* Hct-25.2*
MCV-87 MCH-26.3* MCHC-30.3* RDW-19.5* Plt Ct-86*
[**2103-5-4**] 10:47AM BLOOD ALT-4019* AST-5755* LD(LDH)-PND
AlkPhos-57 TotBili-4.5*
[**2103-5-4**] 10:58AM BLOOD Type-ART pO2-81* pCO2-45 pH-7.11*
calTCO2-15* Base XS--15
[**2103-5-4**] 10:58AM BLOOD Lactate-14.6*
CXR [**4-11**]: COMPARISON: [**2103-2-22**].
FINDINGS: Frontal and lateral views of the chest are obtained.
Patient is
status post median sternotomy. The lungs are hyperinflated,
consistent with chronic obstructive pulmonary disease. Since the
prior study, there has been development of bibasilar, right
greater than left opacities, worrisome for pneumonia. There is
also blunting of the bilateral costophrenic angles concerning
for small pleural effusions with possible pleural thickening.
Cardiac and mediastinal silhouettes are stable. Minimal
superimposed pulmonary vascular congestion may also be present.
IMPRESSION:
1. Large right base opacity and possible small left base
opacity, worrisome for pneumonia. Possible small bilateral
pleural effusions and/or pleural thickening.
2. COPD.
.
CXR [**4-12**]: Comparison is made with prior study performed a day
earlier.
Cardiomegaly is stable. The lungs are hyperinflated consistent
with patient's known COPD. Pneumonic consolidations, right
greater than left are unchanged. There are no new lung
abnormalities. Probable small bilateral pleural effusions are
stable. There are no other interval changes.
.
CXR [**4-30**]:
A tracheostomy tube and left-sided PICC are in unchanged
positions.
Cardiomediastinal silhouette is stable. The lungs are stable in
appearance
with background emphysema, bilateral pleural effusions and
extensive
consolidations which are greater on the right.
.
EKG [**4-23**]:
Diffuse artifact. Probable atrial fibrillation with moderately
controlled
ventricular response. Low QRS amplitude in the limb leads. RSR'
pattern in
lead V1 is probably a normal variant. Compared to the previous
tracing
of [**2103-4-11**] the ventricular response is more controlled.
Non-specific ST-T wave changes persist.
.
ECHO [**4-23**]:
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). There is no ventricular septal
defect. The right ventricular cavity is moderately dilated with
borderline normal free wall function. There is abnormal septal
motion/position. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. A mitral valve annuloplasty ring is present.
The mitral annular ring appears well seated with normal
gradient. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
Brief Hospital Course:
53 yo female with history of [**Location (un) 805**] Syndrome, atrial
fibrillation, CHF (? diastolic, last EF 70%), history of MVR,
recent recurrent PNAs, and severe COPD, who presents with
shortness of breath, leukocytosis, bandemia, and RLL infiltrate.
.
#Lactic acidosis: Patient developed abd pain and required
pressors overnight on [**5-3**]. Her lactate rose and her cdiff toxin
returned positive. WBC rose. She was started on pressors at
times maxed levofed and neo. Flaygl was started and surgery was
consulted and determined need for emergent OR for colectomy.
.
#. Dyspnea/hypoxia: Patient with a white count of 29 with
bandemia, and dense RLL consolidation, which raises the concern
for acute bacterial pneumonia. She has a history of MSSA but
also given her stay at a rehab facility, healthcare associated
pneumonia and hospital acquired pneumonia were also considered.
Also there was a component of acute pulmonary edema and COPD. PE
is unlikely given clear precipitant for dyspnea/hypoxia and that
patient has been therapeutic on coumadin. Patient treated with
Vanc/cefepime/levofloxacin given her recent hospitalization
within 90 days, her stay at rehab, and severity of illness as
well as MRSA positive in her Nares. She was put on standing
albuterol and ipratropium nebulizers and home dose of steroids.
Patient was diuresed with 20 IV lasix daily. Over the first 5
days of admission the patient required 60-80% high flow to
maintain sats in the 90s. Due to lack of clear improvement and
concern for increasing sputum, she had a bronch (awake) which
showed minimal secreations but significant airway collapse. BAL
fluid sent for culture and grew sparse coag + staph and spare
yeast. On [**4-19**], the patient desaturated throughout the morning
and on ABG was found to have pCO2 >80. She was intubated for
hypercarbic respiratory failure and afterwards, significant
secretions suctioned out. Her abx were stop and she was given a
bust of methylpred again with plans for long taper. It is
possible she mucus plugged or aspirated on her secretions in the
morning prior to being intubated. Of note, the patient's CT
chests document very little apical parenchymal reserve and
significant blebs. The patient tolerated mechanical ventilation
well and was switched from assist control to pressure support.
Spontaneous breathing trial on [**4-22**] was uneventful and patient
was extubated on [**2103-4-22**]. On [**4-23**], she was weaned down to 5 L
nasal cannula, but that same night, she developed an increasing
O2 requirement.Intermittantly she was having mucuous plugging.
All the while, discussions were held with the family about if
she needed reintubation that she would require trach. Acapella
devicse used to help with chest PT. Her steroids were down
titrated. On [**4-25**], the patient developed incrasing hypoxia and
was reintubated. WBC was noted to rise to 23.8 and abx were
restarted to cover VAP with Linezolid/tobra and zosyn.
Interventional pulmonology performed a tracheostomy on [**4-26**].
However, interventional pulmonology was unable to place a PEG
due to esophageal stenosis. She underwent IR placement of JG
tube on [**4-27**]. She was put on pressure support once trached which
she tolerated initially but would pull low tidal volumes and
needs resting at night or after oxycodone. Her prednisone was
down titrate. She tolerated 2 hours of trach collar on [**4-28**]. On
[**4-26**], she tolerated trach collar for many hours but became
hypercarbic to pCO2 of 57 and was put on the vent to let her
rest. Plan was initiated to use trach collar during the day and
vent at night. She completed 8 day course of zosyn on [**5-2**] and
will complete 10 day course of linezolid on [**5-4**].
- Continue linezolid 600mg twice daily until [**5-4**] (day [**9-10**])
- Continue albuterol nebs every 6 hours, ipratropium 6 puffs QID
and Flovent 6 puffs twice daily
.
#Fungal UTI: s/p 4 days of fluconazole with resolution of
symptoms.
.
# Nutrition: Patient with very poor PO intake during
hospitalization, albumin low at 2.9. Nutrition was consulted and
the patient started on TPN. [**Month (only) 116**] consider eventual esophageal
motility testing for CREST syndrome component to [**Location (un) 805**]
Disease. A Dobhoff was placed on [**2103-4-19**], with placement
confirmed by x-ray. Tube feeds were started on [**2103-4-19**] although
the Dobhoff then clogged. NGT was placed instead, which the
patient tolerated well and maintained during intubation. The
patient received tube feeds during this time. Interventional
pulmonology attempted to place a PEG on [**2103-4-26**] but was
unsuccessful due to esophageal stenosis. Tube feeds started
through G-J tube on [**4-27**].
- Continue tube feeds:
Nutren 2.0 Full strength;
Starting rate: 30 ml/hr; Advance rate by 10 ml q12h Goal rate:
30 ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 30 ml water q6h
- Continue multivitamin, Vitamin B12 50mcg daily and Vitamin D
400mg daily
- Continue lansoprazole, simethicone and zofran for GI upset,
nausea
.
#. Hypotension: Patient became hypotensive overnight on [**4-30**]
likely related to escalating doses of metoprolol amd small doses
of narcotics and ultram which she seems sensitive to. She
required levophed for a brief term. Cortisol levels could not be
checked in setting of recent prednisone. Her blood pressures
were monitored through her arterial line. BPs ranged from
hypotensive (thought [**1-3**] meds) to hypertensive (possibly pain
related) and normalized on their own.
- Continue home digoxin and metoprolol per below
- Limited narcotic medications for pain (oxycodone 2.5mg q8
hours if absolutely necessary). Use acetaminophen for pain.
.
#. Atrial fibrillation with RVR: Most likely precipitant is
infection, hypoxia, and dyspnea. Rate well controlled on PO
diltiazem and home digoxin - this was later decreased to 30mg
QID and her metoprolol decreased from 12.5 mg TID to [**Hospital1 **] given
bradycardia into HR50s (asymptomatic), especially when
intubated. Coumadin was held for supratherapeutic INR and the
patient started on lovenox bridge. Metoprolol was uptitrated
again briefly for BP and HR control, but subsequently was
downtitrated due to bradycardia. Diltiazem was stopped on
[**2103-4-26**]. She was bridged back to coumadin after her procedures.
Metoprolol was increased to 25 mg [**Hospital1 **] on [**4-29**] but held for
hypotension and then decreased to 12.5mg [**Hospital1 **].
- Continue Digoxin 0.125mg daily
- Continue Metoprolol 12.5mg twice daily
- Check INR daily as supratherapeutic on discharge. Resume home
coumadin 5mg daily when INR <2.5
.
#. History of dCHF: Patient with MVR s/p valvuloplasty in [**2100**].
Lasix was initially used for aggressive diuresis and beta
blockers given judiciously. The patient was felt to be overly
diuresed eventually and received a few small fluid boluses while
intubated, for lower urine output. Gentle diuresis was resumed
when she developed lower extremity edema ([**12-3**]+). ECHO was
obtained with showed 3+TR and severe pulmonary hypertension.
- Continue gentle diuresis with Furosemide 20mg daily PRN
(previous home dose was 20mg daily)
.
#. Diabetes Type II: Steroid exacerbated. Patient continued on
lantus and SSI both of which were increased/tightened throughout
hospital course. As the patient's steroids were tapered, her
insulin requirement decreased. Glargine was stopped on [**4-29**] for
hypoglycemia and her sliding scale was made more conservative to
only cover glucose >200.
- Continue low insulin sliding scale (fingersticks every 6
hours, 2 units for BS>200, 4 units for BS>250, 6 units for
BS>300). The patient can possibly be transitioned off insulin
now that she is off steroids.
.
#. COPD: Patient on recent long steroid taper since [**Month (only) 956**]
[**2102**]. Patient is on long acting advair and spiriva. Patient quit
smoking >2 years ago but has >40 pack year history. She was
continued on standing nebs and advair, as well as steroids
(intermittently home 10mg or 30mg vs. IV solumedrol). In
particular, the patient was on IV solumedrol during intubation
and slowed tapered to PO steroids. Her spiriva was ultimately
restarted and atrovent was discontinued.
- Continue albuterol nebs every 6 hours, ipratropium 6 puffs QID
and Flovent 6 puffs twice daily
.
Contact: [**Name (NI) 53228**] (brother and HCP): [**Telephone/Fax (1) 95244**], [**Name (NI) 2092**] (brother)
[**Telephone/Fax (1) 95246**].
Code: DNR, okay to intubate (trach/PEG)
The above discharge summary was dictated by the MICU service.
On [**2103-5-3**] her care was taken over by the surgical team. She
developed fulminant c.difficuile with a dramatically elevated
WBC (18), INR (6.1) and lactate (14) with an increasing pressor
requirement and concern for abdominal compartment syndrome. She
was taken emergently to the OR for a total abdominal colectomy
with end ileostomy. She was taken to the SICU intubated and on
pressors post-operatively. Echo findings demonstrated dramatic
pulmonary hypertension and left-sided heart failure. She
required CVVH for anuric renal failure and dramatic volume
overload. Her liver enzymes increased and she developed shock
liver. She was difficult to ventilate and began having
arrythmias. She was treated with zosyn, flagyl and vanco enemas
for her rectal remanant but remained floridly septic with
hypotension, hypothermia and profound acidosis. After
discussion with her two brothers the decision was made to make
her CMO as her chance of recovery was thought to be very slim
and she had previously expressed a desire that no extraordinary
measures be taken to extend her life. Medications were
discontinued and she expired shortly thereafter.
Medications on Admission:
1. senna 8.6 mg Tablet Sig: One Tablet PO BID PRN Constipation.
2. bisacodyl 2 5 mg Tablet TabletPO DAILY PRN Constipation.
3. docusate sodium 50 mg/5 mL 10cc PO BID
4. digoxin 125 mcg Tablet PO DAILY
5. montelukast 10 mg Tablet One Tablet PO DAILY
6. therapeutic multivitamin 5cc PO DAILY
7. cholecalciferol (vitamin D3) 400 unit Two TAB PO DAILY
8. cyanocobalamin (vitamin B-12) 500 mcg 2 TAB PO DAILY
9. guaifenesin 600 mg Tablet Extended Release PO BID
10. tiotropium bromide 18 mcg Capsule INH DAILY.
11. levalbuterol HCl 0.63 mg/3 mL Q4hrs as needed for wheezing,
12. trazodone 50 mg PO HS as needed for insomnia.
13. lorazepam 0.5 mg PO Q8H (every 8 hours) as needed for
anxiety.
14. metoprolol tartrate 25 mg PO QID
15. diltiazem HCl 60 mg Tablet PO QID
16. fluticasone-salmeterol 250-50 mcg/dose Disk [**Hospital1 **] (2 times a
day).
17. polyethylene glycol 3350 17 gram PO DAILY
18. warfarin 5 mg PO Once Daily
19. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20)
units Subcutaneous at bedtime
20. furosemide 20 mg PO daily
.
Allergies: NKDA
Discharge Medications:
Not applicable
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Respiratory distress (COPD, pneumonias) s/p intubation and
tracheostomy, malnutrition, steroid-induced diabetes, atrial
fibrillation on anticoagulation, diastolic CHF, fulminant c.diff
with ensuing sepsis
Discharge Condition:
Death
Discharge Instructions:
Death
Followup Instructions:
Death
ICD9 Codes: 5845, 4280, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8146
} | Medical Text: Admission Date: [**2180-3-13**] Discharge Date: [**2180-3-25**]
Date of Birth: [**2113-2-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hmg-Coa Reductase Inhibitors (Statins)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Redo-Coronary Artery Bypass Graft x
4(SVG-LAD,SVG-OM1,SVG-OM2,SVG-PDA), Mitral Valve repair (28 mm
band) [**3-13**]
History of Present Illness:
67 yo M s/p CABG in [**2172**] and PCI in [**2178**], now s/p admission for
acute pulmonary edema and cardiac catheterization showing 2
occluded grafts. Referred for redo surgery.
Past Medical History:
- CAD with 5vCABG in [**2172**]
- MI with PCI [**2172**], PCI in [**5-/2179**] (DES to RCA)
- left renal artery stenosis on [**2180-1-10**], nuclear scan showed 82%
function on R and 16% function on L. 99% stenosis on renal
angiogram with BMS X 1
- CRI ([**2180-1-18**] Cr 2.2)
- HTN
- hemmorhoids
- hypercholesterolemia (LDL 98)
- PVD
- h/o liver lesions
- s/p rectal prolapse repair
- known carotid disease 16-49% stenosis on R, 50-79% on left
- s/p herniorrhaphy
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: CABG, in [**2172**] anatomy as follows: LIMA->LAD,
SVG to PDA, OM1, OM2, and diag.
.
Percutaneous coronary intervention, in [**2177**] anatomy as follows:
total occlusion of native vessels and LIMA, with patent SVG to
diag which backfilled LAD. 40% stenosis in SVG to OM.
.
Social History:
Social history is significant for current tobacco use (52 pack
year smoking history). There is no history of alcohol abuse.
Family history was not elicited.
Family History:
NC
Physical Exam:
hr 61 BP 115/72 RR 16
NAD
Lungs CTAB
Well healed sternal incisions
Heart RRR, HSM
Abdomen Benign
Pertinent Results:
[**3-13**] [**Month/Year (2) **]: PRE-BYPASS: 1. The left atrium is [**Month/Year (2) 5660**] dilated.
No atrial septal defect is seen by 2D or color Doppler. 2. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
moderate hypokinesis of the inferior and inferolateral walls. An
area of akinesis is also seen in the mid to basal inferior wall.
Overall left ventricular systolic function is [**Month/Year (2) 5660**]
depressed (LVEF= 40%). 3. Right ventricular chamber size and
free wall motion are normal. 4. There are focal calcifications
in the aortic arch. There are simple atheroma in the descending
thoracic aorta. 5. There are three aortic valve leaflets. There
is no aortic valve stenosis. No aortic regurgitation is seen. 6.
The mitral valve leaflets are mildly thickened. An eccentric,
postero-lateral directed jet of Severe (4+) mitral regurgitation
is seen. POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and
epinephrine and is being paced. 1. A well-seated mitral
annuloplasty ring is seen with normal leaflet motion (mean
gradient = 5 - 7 mmHg). There is no valvular systolic anterior
motion ([**Male First Name (un) **]). Trivial mitral regurgitation is seen. 2. RV
function is slightly depressed, LV function is [**Male First Name (un) 5660**]
depressed. Specifically the inferior wall appears akinetic. 3.
Aorta is intact post decannulation.
[**3-23**] CXR: Allowing for patient positional differences, the
right-sided pleural effusion distributes in a different pattern,
however, the overall extent of the pleural effusion is not
significantly changed from prior. Smaller left pleural effusion
is also again identified. Median sternotomy wires, cardiac and
mediastinal contours appear unchanged. No new focal
consolidations are identified.
[**2180-3-13**] 12:32PM BLOOD WBC-17.1*# RBC-2.28*# Hgb-6.9*#
Hct-19.4*# MCV-85 MCH-30.1 MCHC-35.4* RDW-15.2 Plt Ct-174
[**2180-3-16**] 03:54AM BLOOD WBC-21.2* RBC-3.11* Hgb-9.2* Hct-27.9*
MCV-90# MCH-29.6 MCHC-33.0 RDW-16.6* Plt Ct-114*
[**2180-3-24**] 05:25AM BLOOD WBC-13.3* RBC-3.07* Hgb-9.1* Hct-27.9*
MCV-91 MCH-29.6 MCHC-32.5 RDW-16.1* Plt Ct-347
[**2180-3-13**] 12:32PM BLOOD PT-15.7* PTT-59.0* INR(PT)-1.4*
[**2180-3-13**] 02:06PM BLOOD UreaN-31* Creat-2.2* Cl-116* HCO3-22
[**2180-3-16**] 03:54AM BLOOD Glucose-193* UreaN-60* Creat-4.4* Na-138
K-6.1* Cl-105 HCO3-19* AnGap-20
[**2180-3-24**] 05:25AM BLOOD Glucose-116* UreaN-76* Creat-3.5* Na-144
K-4.6 Cl-106 HCO3-26 AnGap-17
[**2180-3-14**] 12:52AM BLOOD Calcium-8.1* Phos-2.1* Mg-2.7*
[**2180-3-21**] 08:40AM BLOOD Calcium-8.5 Phos-5.2* Mg-2.7*
Brief Hospital Course:
Mr. [**Known lastname 105222**] was a same day admit after having a cardiac cath and
surgical work-up in late [**Month (only) 958**]. He was taken to the operating
room on [**2180-3-13**] where he underwent a redo-sternotomy, CABG x 4
and MV Repair. Please see operative report for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. Postoperatively he had asystole
followed by complete heart block. He remained intubated for
acidosis and was extubated the morning of post-op day two,
neurologically intact. He was restarted on Plavix for his renal
stent. Chest tubes and epicardial pacing wires were removed per
protocol. He continued to have some episodes of heart block and
nodal agents were held. He then had rapid atrial fibrillation
which converted with amiodarone. He was started on Coreg. He was
seen by renal for oliguria and hyperkalemia. His urine output
improved as did his creatinine with time and holding diuretics.
He was transferred to the telemetry floor on post-op day seven
for further management. Over the next several days he worked
with physical therapy for strength and mobility. His creatinine
trended down and he appeared to be suitable for discharge on
post-op day ten with the appropriate follow-up appointments.
Medications on Admission:
Alprazolam, Plavix 75', Fenofibrate 45', Metoprolol 100",
Nifedipine 30', ASA 325', Iron 325'
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 DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. 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*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*0*
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please take 200mg [**Hospital1 **] for 7 days. Than 200mg QD until
stopped by cardiologist.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease, Mitral Regurgiataion now s/p
Redo-Coronary Artery Bypass Graft x 4, Mitral Valve Repair
Acute on chronic renal failure
PMH: Coronary Artery Disease s/p PCI-RCA, Chronic Renal
Insufficiency, Hypertnesion, Hypercholesterolemia, Peripheral
Vascular Disease
PSH: CABG '[**72**], L renal stent, hernia repair, Prolapse Rectum
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**First Name8 (NamePattern2) 5987**] [**Last Name (NamePattern1) 3236**] 2 weeks
Cariologist in [**12-19**] weeks
Dr. [**Last Name (STitle) **] 4 weeks
Nephrologist in [**12-19**] weeks
Completed by:[**2180-3-25**]
ICD9 Codes: 4240, 4275, 9971, 5849, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8147
} | Medical Text: Admission Date: [**2175-11-20**] Discharge Date: [**2175-12-12**]
Date of Birth: [**2109-4-9**] Sex: M
Service: SURGERY
Allergies:
Meperidine
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Status post motor vehicle collision.
Major Surgical or Invasive Procedure:
1. Anterior pelvic ring external fixator.
2. Left posterior ring fixation with sacroiliac screw.
3. Suprapubic catheter placement
History of Present Illness:
Mr. [**Known lastname 4894**] is a 68 y/o male who was "T" boned, struck on drivers
side, by a car at an unknown speed, requiring prolonged
extraction with Jaws of Life. He was conscious at the scene but
on arrival to the emergency department at [**Hospital 8641**] hospital in New
[**Location (un) **], he was disoriented and found to have a ruptured
spleen. He was brought to the OR at [**Location (un) 8641**] for a splenectomy. He
also had an open book fracture of his pelvis and ruptured
urethra, as well as a left humerus fracture. Per report he had
bilateral frontal contusions. He was transferred to [**Hospital1 18**] for
further care.
Past Medical History:
Prostate CA s/p radical prostatectomy [**2165**], XRT [**2173**]; GERD,
hiatal hernia, [**Last Name (un) 865**] esophagus, colon polyps, TKA [**8-/2174**]
Family History:
Noncontributory.
Physical Exam:
VS: 92.1--> 94.8, 100 (ns), 136/77, 20, 99% AC 0.6/600x14/5
GEN: intubated, sedated
SKIN: scrotal swelling and hematoma, diffuse mottling at
hands/feet, no other appreciable skin breaks
BACK: no step-offs, no ecchymoses, no skin breaks
HEENT: no scalp compromise, EOMI, PERRL bilat 4-->2mm, MMM, soft
neck, +c-collar
CARDIAC: RRR, no m/r/g
LUNGS: CTAB
ABD: +BS, soft, distended, dressings c/d/i, no appreciable
ecchymoses.
PVASC: mottled cool feet/hands. +doppler PT/DP pulses bilat.
MSK: L humerus fracture, displaced.
NEURO: deferred.
Pertinent Results:
[**2175-11-20**] 11:42PM TYPE-ART PO2-298* PCO2-47* PH-7.16* TOTAL
CO2-18* BASE XS--11
[**2175-11-20**] 11:42PM LACTATE-7.6*
[**2175-11-20**] 11:42PM O2 SAT-99
[**2175-11-20**] 11:42PM freeCa-1.12
[**2175-11-20**] 11:30PM GLUCOSE-153* UREA N-17 CREAT-1.1 SODIUM-143
POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-17* ANION GAP-17
[**2175-11-20**] 11:30PM CALCIUM-7.3* PHOSPHATE-5.2* MAGNESIUM-1.4*
[**2175-11-20**] 11:30PM WBC-16.7* RBC-4.88 HGB-15.4 HCT-43.8 MCV-90
MCH-31.7 MCHC-35.3* RDW-14.0
[**2175-11-20**] 11:30PM PLT COUNT-131*
[**2175-11-20**] 11:30PM PT-13.6* PTT-25.2 INR(PT)-1.2*
[**2175-11-20**] 11:30PM FIBRINOGE-178
----------------
PELVIS (AP ONLY) PORT Clip # [**Clip Number (Radiology) 44491**]
IMPRESSION:
Diastasis of the pubic symphysis with associated fractures
through the
bilateral superior and inferior pubic rami and left sacral ala
are better seen on subsequent CT examination.
Subcutaneous emphysema involving the soft tissues overlying the
low pelvis.
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 44492**]
FINDINGS: Portable radiograph of the chest. Endotracheal tube
is
appropriately positioned with its tip approximately 4.1 cm from
the carina. NG tube is seen with its tip within the stomach and
a side port below the diaphragm. Of note, the left costophrenic
angle and many of the left-sided ribs are cut off from this film
and therefore the rib fractures on the left side that are
identified on later radiographs are not seen on this film.
However, we are seeing pleural thickening possibly representing
hemorrhage
extending up the lateral costal pleural margin. Possible left
apical pleural cap, with a generally widened mediastinum and
rightward deviation of the trachea is identified. There is a
possibility of mediastinal
hemorrhage/aortic injury. This was discussed with the team
caring for this
patient according to a dictation performed for a later chest
radiograph on
[**11-21**]. Opacification in the left mid lung zone may
represent contusion versus edema.
HUMERUS (AP & LAT) LEFT PORT Clip # [**Clip Number (Radiology) 44493**]
IMPRESSION:
Old fracture of the left mid humeral diaphysis. Bridging callus
formation is present and there is residual lateral displacement
and varus angulation of the distal fracture fragment.
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 44494**]
IMPRESSION: Ovoid hyperdense focus is present in the right
anterior frontal lobe that may represent hemorrhage or
mineralization. Followup is
recommended.
Note added at attending review: The prior study is now available
for review. The right frontal high density is slightly larger
than the prior study. The left frontal high density is slightly
more diffuse and less evident. There are no definite new
findings. There is a left posterior subgaleal hematoma.
CTA CHEST W&W/O C &RECONS Clip # [**Clip Number (Radiology) 44495**]
IMPRESSION:
1. No evidence of aortic dissection or pulmonary embolus.
2. Multiple left-sided rib fractures post motor vehicle
accident.
3. Bilateral pleural effusions and atelectasis in intubated
patient. Mild
interstitial edema. Subcentimeter mediastinal lymphadenopathy.
----------------
CT L-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 44496**]
IMPRESSION:
1. Left sacral and iliac fractures with diastasis of the left
sacroiliac
joint. Left eleventh rib fracture.
2. Severe chronic degenerative changes at the L5-S1 level with
moderate
degenerative changes at the upper lumbar spine.
------------------
CT T-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 44497**]
IMPRESSION:
1. Multiple left-sided rib fractures posteriorly.
2. Left transverse process fracture T6 vertebra.
3. Bilateral pleural effusion and atelectasis.
-----------------
CT PELVIS W/O CONTRAST Clip # [**Clip Number (Radiology) 44498**]
IMPRESSION:
1. Suprapubic tube in the bladder, which demonstrate signs
consistent with a bladder rupture, most likely extraperitoneal.
Extravasation of contrast along the urethra, which may be
consistent with urethral injury
2. Multiple pelvic fractures in relation to the superior and
inferior ramus on the left, the left sacrum, the left iliac
bone.
3. Multiple clips in the pelvis, which may be consistent with
patient's
status post prostatectomy.
4. Free fluid in the right paracolic gutters.
-------------------
RENAL U.S. Clip # [**Clip Number (Radiology) 44499**]
IMPRESSION: No evidence of hydronephrosis or significant
interval change.
-------------------
BILAT LOWER EXT VEINS Clip # [**Clip Number (Radiology) 44500**]
IMPRESSION: No evidence of venous thrombosis in the bilateral
lower
extremities.
------------
WRIST, AP & LAT VIEWS LEFT PORT [**2175-12-5**] 5:44 PM
IMPRESSION: Marked degenerative changes of the carpal bones and
at the radiocarpal joint, in a distribution which is atypical
for osteoarthritis. Query post- traumatic arthritis or
seronegative spondyloarthropathy.
------------
CT PELVIS W/O CONTRAST [**2175-12-9**] 10:59 AM
IMPRESSION:
1. Evidence of active contrast extravasation into the patient's
perineum and scrotal sac as described above.
2. New subcutaneous emphysema along the dorsum of the penis -
while this may be related to injection of contrast, an
underlying infection should be considered.
------------
Brief Hospital Course:
Mr. [**Known lastname 4894**] was trasnferred to [**Hospital1 18**], s/p splenectomy, with a
left humerus fracture, a complicated open-book pelvic fracture,
a urethral disruption, and a presumed bladder rupture. He was
intubated, sedated. He was admitted to the Trauma Surgical
Intensive Care Unit where he was shortly seen by the orthopedics
and urology services. On hospital day #1, a suprapubic catheter
was placed and he was started on ampicillin/gentamicin. He was
evaluated by neurosurgery for report from OSH of bilateral
frontal contusions, which were felt to be stable. Mr. [**Known lastname 4894**]
initially had issues with low urine output and his initial
pigtail SPC was replaced with a larger catheter to facilitate
drainage of urine and decompression of the bladder. A chest tube
was placed on hospital day 4 for a right pleural effusion. On
hospital day 5, he returned to the OR with orthopedics for
external fixation of his pelvic fractures. Urology recommended
against attempt for immediate urethral repair given his scar
tissues/clips from his prostatectomy. Mr. [**Known lastname 4894**] was extubated
successfully post-operatively and continued to improve. His
cervical collar was cleared when his mental status improved. He
was transferred to the floor on hospital day 11 where he
continued to improve. Recognizing the need for continued DVT
prophylaxis, Mr. [**Known lastname 4894**] was evaluated by vascular surgery for an
IJ-approached IVC filter. The procedure was cancelled, however,
as the day of surgery Mr. [**Known lastname 44501**] creatinine unexpectedly rose
to 3.
He was evaluated by the urology and nephrology services. A renal
ultrasound was negative for frank obstruction and/or
hydronephrosis. He persistently had adequate urine output. His
creatinine bump was felt to be related to hypovolemia and he was
started on a strict regimen of IV fluids. At the same time, Mr.
[**Known lastname 4894**] was noted to be febrile, with a rising WBC. His groin
erythema worsened during this time and spread to involve his
lower back. A fever workup resulted in a negative chest xray and
no positive blood cultures. He was treated empirically with
broad spectrum antibiotics and improved.
On [**2175-12-6**], Mr. [**Known lastname 4894**] was noted to have significant pain and
swelling over his left wrist. Upon examination, the wrist was
red, swollen, and exquisitely tender to palpation. An aspiration
of the joint revealed frank pus and rhomboid crystals. Hand was
consulted and he was started on vancomycin for presumed septic
joint and taken to the OR the next morning for a formal washout.
He was started on colchicine for pseudogout and he readily
improved. Final cultures were negative for any organism.
Mr. [**Known lastname 4894**] had a repeat CT cystogram on [**2175-12-9**], revealing
persistent small extravasation from his bladder rupture. In
discussion with urology, this extravasation was consistent with
his previous scan and they recommended continuation of the
suprapubic catheter until definitive repair in [**6-15**] weeks from
the date of injury.
On hospital day 22 ([**2175-12-11**]), Mr. [**Known lastname 4894**] had an IVC filter
placed by the vascular surgery service via a right IJ approach,
necessitated by his pelvic fixation. He tolerated the procedure
well and should no longer require anticoagulation.
Mr. [**Known lastname 4894**] will require daily pin care at his external fixator
as well as [**Hospital1 **] flushing of his suprapubic tube to avoid
obstruction. He has made great strides in transfers with
physical therapy but will need extensive rehabilitation given
his prolonged immobility secondary to his injuries.
Medications on Admission:
celecoxib, lansoprazole
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
1. Status post motor vehicle collision.
2. Bifrontal contusions
3. L humerus fx.
4. grade IV splenic lac s/p splenectomy at OSH
5. complicated pelvic fx.
6. ruptured urethra
7. ruptured bladder
8. multiple L rib fx. (>6)
9. R pleural effusion
10. Left wrist infection.
11. Left septic extensor tenosynovitis.
Discharge Condition:
Stable.
Discharge Instructions:
You are being discharged to an extended care facility for
further care and rehabilitation of your injuries. If you have
any new or concerning symptoms, please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 3584**]
housestaff immediately. Call if you experience fever, nausea or
vomiting that precludes eating or drinking, chest pain,
worsening abdominal pain, or any new or concerning symptom.
Followup Instructions:
You will need to follow up with urology, Dr. [**Last Name (STitle) 44502**], in 3 weeks;
call ([**Telephone/Fax (1) 10941**] for an appointment.
You will also need to be seen by orthopedics, Dr. [**Last Name (STitle) 1005**], in
[**3-11**] weeks. Call [**Telephone/Fax (1) 1228**] for an appointment.
Please schedule an appointment with the Trauma Surgery clinic in
two weeks; call [**Telephone/Fax (1) 6429**] for an appointment.
Finally, you will need to call the plastics and reconstructive
surgery hand clinic for a follow up appointment in one to two
weeks; call [**Telephone/Fax (1) 4652**] for an appointment.
ICD9 Codes: 5849, 5119, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8148
} | Medical Text: Admission Date: [**2166-1-19**] Discharge Date: [**2166-1-20**]
Date of Birth: [**2126-5-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
s/p suicide attempt/ overdose
Major Surgical or Invasive Procedure:
Intubation [**2165-1-19**], extubation [**2165-1-20**].
History of Present Illness:
The patient is a 39 year-old male with PMHx of depression
presenting with overdose @ 4am on [**1-19**]. Patient was involved in a
argument with his girlfriend, after which he took ambien,
benadryl, and paroxetine of unknown quantity (by girlfriend's
report).
The patient was unresponsive in ED and history was obtained from
his girlfriend. In [**Name2 (NI) **], VS were T 98.1 BP 200/110 --> 127/74
upon moving to the floor HR in 100s. His pupils were dilated at
4 mm and reactive to 2 mm. The patient was intubated in the ED
and started on propofol gtt. Toxicology consult was obtained. He
was given 60 mg of Charcoal. UTox was positive for EtOH and
cocaine, and negative for tylenol. His labwork, including his
EKG was unremarkable with nl QTc.
Past Medical History:
Depression: significant for attempted suicide 7 years ago, OD
with [**Last Name (un) 77141**] oven cleaner, resulted in inpatient hospitalization x 1
month. Denies regular SI, HI
Social History:
Patient was born in the [**Country 13622**] Republic, moved her 11 years
ago, lives with a girlfriend, cleans [**Name2 (NI) 77142**] for work
EtOH: 7 beers 2x a week, denies history of or withdrawal sx
Tob: 15 cig/day x 20years
Denies marijuana and IVDU use, reports cocaine x 1 "many years
ago"
Family History:
brother and paternal uncles with depression and SA
Physical Exam:
T: 95.8 BP:122/83 P: 89 RR: 18 O2 sats: 95% 40% CPAP [**5-26**]
Gen: NAD, young male sedated
HEENT:NCAT, PERRL 5 mm -> 3 mm, anicteric
Neck: no masses, flat
CV: RRR no MRG, nl S1, S2
Resp: CTAB/l
Abd: NABS, soft, NT, ND, no guarding/rigidity/rebound
Ext: no edema, no cyanosis,
Neuro: intubated, light sedation, closes eyes, squeezs hands
Pertinent Results:
LABS:
.
[**2166-1-19**] 05:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2166-1-19**] 05:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2166-1-19**] 05:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2166-1-19**] 05:30AM WBC-9.0 RBC-4.08* HGB-14.0 HCT-39.6* MCV-97
MCH-34.2* MCHC-35.3* RDW-13.4
[**2166-1-19**] 05:30AM PLT COUNT-190
[**2166-1-19**] 05:30AM NEUTS-61.7 LYMPHS-25.8 MONOS-10.5 EOS-1.6
BASOS-0.4
[**2166-1-19**] 05:30AM ASA-NEG ETHANOL-128* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2166-1-19**] 05:30AM GLUCOSE-116* UREA N-10 CREAT-1.1 SODIUM-141
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-17
[**2166-1-19**] 05:30AM ALBUMIN-4.1 CALCIUM-8.7 PHOSPHATE-3.3
MAGNESIUM-2.0
[**2166-1-19**] 05:30AM ALT(SGPT)-74* AST(SGOT)-62* LD(LDH)-231 ALK
PHOS-65 TOT BILI-0.4
[**2166-1-19**] 05:30AM LIPASE-41
[**2166-1-19**] 11:19AM ACETMNPHN-NEG
.
[**2166-1-19**] EKG: Sinus tachycardia at 101bpm. Nml axis, nml
intervals, no ischemic ST/T wave changes
.
[**2166-1-19**] CXR: IMPRESSION: No focal consolidation.
Brief Hospital Course:
The patient is a 39 year-old male with depression with 1
previous suicide attempt presenting with a suicide attempt via
overdose on ambien, benadryl, and paxil in setting of +EtOH and
cocaine on admission tox screens.
.
# Overdose: The patient was unresponsive upon presentation to
the ED and intubated for airway protection. CXR was clear, EKG
was without evidence of QT prolongation. He was monitored for
evidence of anticholinergic effects with benadryl and
serotinergic effects of paroxetine with no issues. The patient
was successfully extubated with return of mental status to
baseline by HD2. The patient was continued on 1:1 sitting with
no further suicide attempts while inhouse.
.
# SA/ Depression: The patient was evaluated by psychiatry while
inhouse. He was found to meet criteria for section 12, and he
will require inpatient psychiatric hospitalization for further
evaluation / treatment of depression.
.
# Transaminitis: The patient presented with a transaminitis
which was trending down to baseline by the time of discharge.
.
# Code: Full
Medications on Admission:
none
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Other- Psych
Discharge Diagnosis:
Suicide attempt by overdose.
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted due to an overdose of several medications. You
are now being transferred to an inpatient psychiatric facility
for further care.
.
Please take all of your medications as prescribed. Please attend
all of your follow-up appointments.
Followup Instructions:
Please contact a PCP to initiate care.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8149
} | Medical Text: Admission Date: [**2112-11-14**] Discharge Date: [**2112-11-23**]
Date of Birth: [**2062-6-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2112-11-17**] Left heart catheterization, coronary angiogram
[**2112-11-18**] Off-pump coronary artery bypass graft x
2(LIMA-LAD,SVG-DG)
History of Present Illness:
50 yo man 2 weeks s/p BMS stent placement to OM2 on [**2112-10-28**]
for NSTEMI at [**Hospital1 2025**] (admitted [**Date range (3) 20020**]) now here with left
chest pain radiating to left jaw, left eye, with associated with
sweatiness and SOB.H as been taking his plavix and all his meds.
Positive stress at [**Hospital1 18**] on [**2112-11-15**]. Cardiac enzymes negative,
no EKG changes per report. CP free with morphine. Per report
patient refused CABG at [**Hospital1 2025**] choosing medical management. Patient
now amendable to surgical revascularization.
Past Medical History:
Coronary artery disease s/p coronary stent (BMS to OM2 [**2112-10-28**])
Hypertension
Diabetes Mellitus Type 2 (insulin 72/25) poor control due to non
compliance
Polysubstance abuse
Myocardial Infartcion [**10-24**]
Hypercholesterolemia
Multiple hospital admissions for ileus
Gastroesophageal Reflux Disease
Rt shoulder SLAP tear s/p steroid injection
Rib fracture
pancreatitis secondary to ETOH abuse
MRSA bacteremia/PNA
C4/5 fusion
rotator cuff surgery
Social History:
Reports that he lives in [**Hospital1 8**] in a shelter. Is single and
has no children. Smokes 0.5-1ppd X 40+ yrs. Denies current
alcohol use - reports he has not had anything to drink in 5
months, admits to crack use 5 months ago. Denies IVDU. Of note,
patient uses different names in hospitals around [**Location (un) 86**] and has
a history of leaving AMA.
Family History:
non-contributory
Physical Exam:
Pulse:74 reg Resp: 18 O2 sat:96% RA
B/P: 98.3
Height: Weight:195lbs
General: comfortable
Skin: Dry [x] intact [x]
HEENT: PERRLA [] 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
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact. R handed, moves 4 ext. follows commands
Pulses:
Femoral Right:palp Left:palp
DP Right:palp Left:palp
PT [**Name (NI) 167**]: Left:
Radial Right:palp Left:palp
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2112-11-17**] Cardiac Cath: 1. Selective coronary angiography of this
right-dominant system revealed two-vessel coronary artery
disease. The LMCA had no significant stenoses. The LAD had a
50-70% stenosis after D1, which itself had a 70% mid-vessel
stenosis. The distal LAD tapers and had an 80% stenosis. The
LCX had a widely patent prior stent in a large OM2. The RCA had
severe diffuse proximal and mid-vessel disease up to its
bifurcation. The RPL and RPDA branches were small and without
significant stenoses, with distal filling via LAD collaterals.
2. Limited resting hemodynamics demonstrated normal central
aortic pressures.
[**2112-11-18**] Echo: Off Pump CABG:1. The left atrium is mildly
dilated. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No thrombus is seen in the left atrial
appendage. 2. No atrial septal defect is seen by 2D or color
Doppler. 3. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. 4. Right ventricular
chamber size is normal. 5. There are simple atheroma in the
descending thoracic aorta. 6. There are three aortic valve
leaflets. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. 7. The mitral valve appears structurally normal with
trivial mitral regurgitation. 8. There is no pericardial
effusion. The LV systolic function was preserved at the end of
the case.
[**2112-11-14**] 11:00AM BLOOD WBC-6.1 RBC-3.67* Hgb-11.1* Hct-34.9*
MCV-95 MCH-30.3 MCHC-31.8 RDW-15.5 Plt Ct-428
[**2112-11-17**] 05:10PM BLOOD WBC-6.0 RBC-2.96* Hgb-9.6* Hct-28.3*
MCV-96 MCH-32.3* MCHC-33.8 RDW-15.3 Plt Ct-293
[**2112-11-23**] 05:00AM BLOOD WBC-6.3 RBC-2.68* Hgb-8.4* Hct-25.6*
MCV-95 MCH-31.3 MCHC-32.8 RDW-15.5 Plt Ct-271
[**2112-11-14**] 11:00AM BLOOD PT-12.1 PTT-25.8 INR(PT)-1.0
[**2112-11-18**] 11:46AM BLOOD PT-13.0 PTT-34.3 INR(PT)-1.1
[**2112-11-14**] 11:00AM BLOOD Glucose-95 UreaN-28* Creat-2.0* Na-140
K-5.8* Cl-105 HCO3-27 AnGap-14
[**2112-11-17**] 07:15AM BLOOD Glucose-198* UreaN-18 Creat-1.3* Na-140
K-5.1 Cl-105 HCO3-27 AnGap-13
[**2112-11-21**] 06:40AM BLOOD Glucose-190* UreaN-27* Creat-1.6* Na-141
K-4.6 Cl-105 HCO3-25 AnGap-16
[**2112-11-20**] 01:00PM BLOOD ALT-13 AST-27 LD(LDH)-277* AlkPhos-78
Amylase-20 TotBili-0.4
[**2112-11-15**] 07:20AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0
Brief Hospital Course:
Following admission he ruled out for acute infarction. Cardiac
cath on [**11-17**] showed severe left anterior descending coronary
disease. Having previously refused surgical intervention
elsewhere, he now consented to surgery. On [**11-18**] he went to the
operating Room where an off pump bypass was performed. See
operative note for details. He tolerated the procedure well and
was transferred to the CVICU for invasive monitoring in stable
condition. Plavix was administered as he was done off pump.
Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one he was
transferred to the telemetry floor.
He was admonished to the necessity of taking medications as
prescribed, smoking cessation and compliance with glucose
control. Beta blockade was resumed and diuresis begun. Chest
tubes were removed on the first day after surgery. Physical
Therapy was consulted for mobility and strength. Insulin was
begun, both fixed dose and sliding scale, as this had previously
been his regimen when compliant. He was evaluated by the pain
service regarding his pain medication regimen due to his history
polysubstance abuse. The remainder of his post-op course was
uneventful and on post-op day four he appeared suitable for
discharge to rehab with the appropriate medications and
follow-up appointments.
Medications on Admission:
Outside: Plavix 75mg daily
Medications in hospital: as of [**2112-11-15**]
Metoprolol XL 100mg in am 50mg HS
Ranolazine 500mg [**Hospital1 **]
Insulin SSR
Gabapentin 300mg three times a day
Tramadol 50mg po q6hr ; prn
NTG 0.3mg SL PRN
Ranitidine 150mg po BID
aimtriptyline 100mg po at night
ASA 325mg po daily
Plavix 75 mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Outpatient Lab Work
Please go to lab to have labs drawn on Friday [**2112-11-18**] (Chem 7).
Results should be faxed to your primary care physician, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1887**] at [**Telephone/Fax (1) 6309**].
5. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*1*
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
11. humalog insulin 75/25
18 units every morning subcutaneously
20 units every evening subcutaneously
Dispense 2 vials and 2 refills
12. humalog insulin
dose according to sliding scale finger sticks
dispense 2 vials with 2 refills
13. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*15 Patch 24 hr(s)* Refills:*2*
14. Oxycodone 5 mg Tablet Sig: 2-4 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Coronary artery disease s/p off pump coronary artery bypass x 2
Past medical history
s/p coronary stent (BMS to OM2 [**2112-10-28**])
Hypertension
Diabetes Mellitus Type 2 (insulin 72/25) poor control due to non
compliance
Polysubstance abuse
Myocardial Infartcion [**10-24**]
Hypercholesterolemia
Multiple hospital admissions for ileus
Gastroesophageal Reflux Disease
Rt shoulder SLAP tear s/p steroid injection
Rib fracture
pancreatitis secondary to ETOH abuse
MRSA bacteremia/PNA
C4/5 fusion
rotator cuff surgery
Discharge Condition:
Ambulatory, normal mental staus.
Wounds healing well.
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 Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital Ward Name 121**] 6 wound clinic ([**Telephone/Fax (1) 20021**] [**First Name (Titles) **] [**Last Name (Titles) **]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13959**] in [**12-18**] weeks ([**Telephone/Fax (1) 250**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]- [**Company 191**] Post [**Hospital **] Clinic
Date/ Time: [**2112-11-29**] 1:10pm
Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) 895**]
Central Suite, [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 250**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2112-11-23**]
ICD9 Codes: 5845, 3572, 4111, 2767, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8150
} | Medical Text: Admission Date: [**2159-2-14**] Discharge Date: [**2159-2-24**]
Date of Birth: [**2089-6-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
SOB/angina for 18 months
Major Surgical or Invasive Procedure:
CABG x 4 [**2159-2-20**] (LIMA to LAD, SVG to DIAG, SVG to RAMUS, SVG
to PDA)
History of Present Illness:
69 yo male with SOB and angina to left arm with moderate
exertion. Has had sx for approx. 1 1/2 years. Cath at [**Location (un) **]
revealed LM and occluded RCA, as well as severe right external
iliac stenosis. Transferred here for CABG.
Past Medical History:
CAD
inferior myocardial infarction
hyperlipidemia
hypertension
renal calculi ( 10 years ago)
bilat. LE claudication
PSH: appy, tonsillectomy, 2 back surgeries
Social History:
lives with wife
retired [**Name2 (NI) **] worker
actively smokes one ppd
one ETOH per week
Family History:
mother with multiple MIs/CVA, died at age 82
Physical Exam:
5'9" 89.3 kg
HR 50 RR 18 136/62
well-appearing
skin unremarkable
PERRL
lower partial and imcomplete dentition
neck supple, full ROM
CTAB
RRR no murmur
soft, NT, ND, + BS
warm, well-perfused, no edema
left groin cath site c/d/i, no hematoma
neuro grpossly intact
2+ bil. fem/DP/PT/radials
no carotid bruits appreciated
Pertinent Results:
Conclusions
PRE-CPB:1. The left atrium is normal in size. No thrombus is
seen in the left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %). Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) LV diastolic dysfunction.
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is mildly dilated. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of phenylephrine, a-pacing. Preserved
biventricular systolic function post-cpb. Trivial mr, ai. Aortic
contour is normal post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2159-2-20**] 16:43
?????? [**2153**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Mr. [**Known lastname 496**] was admitted from [**Hospital **] Hosp. on [**2-14**]. Heparin
was started during a plavix washout while awating surgery. He
underwent CABG with Dr. [**Last Name (STitle) **] on [**2-20**]. He tolerated the
procedure well and was transferred in critical and stable
condition to the surgical intensive care unit. His phenylephrine
and propofol drips were weaned. He was extubated that evening
and his chest tubes were removed. He was transferred to the
floor on POD #1 to begin increasing his activity level. He was
seen in consultation by physical therapy. On POD #3 his wires
were removed. By the following day he was ready for discharge
to home.
Medications on Admission:
atenolol 50 mg daily
zetia 10 mg daily
simvastatin 80 mg daily
ASA 325 mg daily
plavix 75 mg daily
prednisone 20 mg TID x 1 day for cath prophylaxis only
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 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:*2*
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
CAD s/p CABG
inferior myocardial infarction
hyperlipidemia
hypertension
renal calculi ( 10 years ago)
right external iliac stenosis
bilat. LE claudication
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. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 8579**] in [**2-6**] weeks
Follow up with Dr. [**Last Name (STitle) 40075**] in [**1-5**] weeks
Completed by:[**2159-2-24**]
ICD9 Codes: 4111, 5180, 2724, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8151
} | Medical Text: Admission Date: [**2148-9-6**] Discharge Date: [**2148-9-17**]
Date of Birth: [**2072-2-26**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Code stroke: found by wife in the morning to be unresponsive,
non-communicative and to have left sided weakness.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 76 yo M with history of pAfib on coumadin, CHF (EF
10-15%), Prostate CA, stroke, who presents with acute onset left
sided weakness, drowsiness and inability to speak.
Over the past several weeks, he had been experiencing increased
SOB and difficulty climbing stairs. He has been followed by his
cardiologist who had scheduled a cardiac cath for this morning.
In that setting he had been holding his coumadin since Monday
and was not taking other anticoagulation or antiplatelets.
This morning his wife woke him up around 5am to come in for the
catheterization and found him unresponsive. He was also
apparently not moving his left side. She tried to waken him up
but he would not open his eyes. He did not interact purposefully
at that time and apparently could not communicate.
EMS was called and he was brought to the ED at which time code
stroke was called. His NIHSS was calculated to be 15, he
underwent CT/CTA/CTP which revealed extensive clot from R ICA
above the bifurcation to the R MCA with area of hypodensity.
Given the time course of the time of last known well >8hrs, tPA
was not given; interventional thrombectomy/lysis was considered
and extensively discussed but given the time course and the
unfavorable risk/benefit assessment ultimately was not pursued.
While awaiting assessment in the ED, the patient's respiratory
status became tenuous with shallow breathing. He was responsive
only to vigorous sternal rub. He was therefore intubated and
sedated for airway protection.
ROS was not possible in this setting.
Past Medical History:
1. CAD status post MI in [**2136-3-24**], [**2136-8-24**], [**2137**]. He
has known 3VD. He is status post PTCA of the left circ and OM1
in 4/00. He is status post PTCA stent of the ramus in 5/00. In
[**8-/2136**] he had restent of the ramus and stent in the proximal LAD.
In 11/00 he had PTCA of the left circ. His last stress was in
[**11/2136**]. He exercised four minutes, 48% exercise capacity, no
anginal symptoms, no EKG changes. He had a fixed defect in the
anterior septal region.
2. History of obstructive jaundice status post ERCP in [**Month (only) 547**]
[**2135**] with sphincterotomy and extraction of common bile duct
stone.
3. Hypertension.
4. Hypercholesterolemia.
5. Depression.
6. Paroxysmal atrial fibrillation.
7. CVA: ischemic left middle cerebral artery territory infarct
in his posterior frontal lobe with subsequent right hemiparesis.
Suspected cardioembolic source. On long-term Coumadin.
8. Systolic HF, last EF 25% on TTE [**12-27**].
9. Prostate CA
[**45**]. Right inguinal hernia repair
Social History:
Came here from [**Country 532**] in [**2132**]. Russian speaking only. He lives
with his wife. [**Name (NI) **] does not smoke tobacco or drink alcohol.
Denies illicit drugs.
Family History:
Coronary artery disease
Physical Exam:
Physical Exam:
On admission:
Vitals: T: afebrile P: 92 R: 20 BP: 150/100 SaO2: 97%
General: responsive only to sternal rub, eyes closed, able to
follow simple commands,
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: irregular, S1S2S3 systolic murmur,
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
(If applicable)
NIH Stroke Scale score was 14:
1a. Level of Consciousness: 2
1b. LOC Question: 2
1c. LOC Commands: 2
2. Best gaze: 1
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 2
5b. Motor arm, right: 0
6a. Motor leg, left: 1
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 3
10. Dysarthria: 0
11. Extinction and Neglect: 1
-Mental Status: Drowsy, eyes closed, responds only to vigorous
sternal rub. ? neglect of left side. No spontaneous speech,
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: Forced conjugate deviation towards the right that
can be overcome with VOR
VII: No clear facial droop, facial musculature symmetric when
grimacing
VIII: VOR intact
IX, X:+ gag
-Motor: Normal bulk, decreased tone in the left upper extremity
No adventitious movements, such as tremor, noted. No asterixis
noted.
Level of arousal limited accurate assessment of motor strength
but appeared to have full strength in the right upper and lower
extremities. Left upper extremity demonstrated [**2-26**] at the
deltoid
and flaccid paralysis distal to the deltoid.
Left lower extremity was at least [**2-26**] in all muscle groups, tone
was not decreased, no external rotation,
-Sensory: withdrawal to noxious in all extremities
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 mute
R 2 2 2 2 mute
Plantar response was extensor bilaterally.
-Coordination/Gait: defered
Physical Exam on Discharge:
expired
Pertinent Results:
[**2148-9-9**] 04:05AM BLOOD WBC-6.9 RBC-4.18* Hgb-12.5* Hct-37.3*
MCV-89 MCH-30.0 MCHC-33.6 RDW-14.2 Plt Ct-160
[**2148-9-7**] 02:12AM BLOOD WBC-7.8 RBC-4.26* Hgb-12.9* Hct-38.6*
MCV-91 MCH-30.2 MCHC-33.3 RDW-14.2 Plt Ct-163
[**2148-9-6**] 03:00PM BLOOD WBC-6.3 RBC-4.23* Hgb-12.8* Hct-38.0*
MCV-90 MCH-30.3 MCHC-33.8 RDW-14.4 Plt Ct-178#
[**2148-9-6**] 05:40AM BLOOD WBC-6.7 RBC-4.02* Hgb-12.4* Hct-36.3*
MCV-90 MCH-30.8 MCHC-34.1 RDW-14.6 Plt Ct-365
[**2148-9-5**] 08:24AM BLOOD WBC-5.4 RBC-4.36* Hgb-13.2* Hct-40.5
MCV-93 MCH-30.3 MCHC-32.7 RDW-14.7 Plt Ct-185
[**2148-9-9**] 04:05AM BLOOD Plt Ct-160
[**2148-9-8**] 02:03AM BLOOD PT-13.0* PTT-35.0 INR(PT)-1.2*
[**2148-9-7**] 02:12AM BLOOD PT-13.1* PTT-32.2 INR(PT)-1.2*
[**2148-9-5**] 08:24AM BLOOD PT-15.2* INR(PT)-1.4*
[**2148-9-6**] 05:40AM BLOOD Fibrino-350
[**2148-9-9**] 04:05AM BLOOD Glucose-145* UreaN-20 Creat-0.6 Na-143
K-3.5 Cl-107 HCO3-28 AnGap-12
[**2148-9-8**] 02:03AM BLOOD Glucose-104* UreaN-15 Creat-0.6 Na-141
K-3.5 Cl-106 HCO3-26 AnGap-13
[**2148-9-7**] 02:12AM BLOOD ALT-19 AST-33 AlkPhos-79
[**2148-9-9**] 04:05AM BLOOD Calcium-8.7 Phos-2.2* Mg-1.9
[**2148-9-7**] 02:12AM BLOOD CK-MB-6 cTropnT-0.03*
[**2148-9-6**] 05:40AM BLOOD cTropnT-<0.01
[**2148-9-7**] 02:12AM BLOOD Triglyc-60 HDL-43 CHOL/HD-3.2 LDLcalc-83
[**2148-9-6**] 05:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2148-9-6**] 05:54AM BLOOD Glucose-153* Lactate-3.3* Na-138 K-7.3*
Cl-107 calHCO3-16*
[**2148-9-6**] 05:54AM BLOOD Hgb-13.3* calcHCT-40 O2 Sat-94 COHgb-5
MetHgb-0.3
HEAD AND NECK CTA [**9-6**]
Thrombus within the right intracranial ICA extending over the
supraclinoid ICA
and bifurcation with thrombus in the right M1 segment of the
middle cerebral
artery. The right ICA is not opacified through the petrous
segment, but this
may reflect decreased flow due to the distal thrombus rather
than thrombosis
of this segment of the vessel as there is no hyperdense thrombus
visualized in
this segment of the artery. Corresponding decreased cerebral
blood flow and
blood volume in the right middle cerebral artery distribution.
There is distal
collateral flow. Origin of the thrombus may be from extensive
soft plaque in
the proximal cervical internal carotid artery.
Occluded right vertebral artery from its origin through the V4
segment, where
it is distally reconstituted.
No intracranial hemorrhage.
HEAD AND NECK MRI [**9-6**]
FINDINGS: There is slow diffusion within the entire right
middle cerebral
artery territory, compatible with acute/subacute ischemia.
Hyperintense
signal is seen within the right internal carotid artery
extending from the
distal cervical portion through the bifurcation and also in the
middle
cerebral artery on the right, which may reflect combination of
slow flow
and/or thrombus. There is no hemorrhage.
Elsewhere, there is confluent and punctate FLAIR signal
hyperintensity in
periventricular and subcortical white matter bilaterally, which
likely reflect
sequela of moderate microvascular disease. The visualized
portions of the
paranasal sinuses, mastoids, and orbits are unremarkable. Fluid
is noted
within the nasopharynx.
IMPRESSION:
1. Acute infarct involving nearly the entire right middle
cerebral artery
territory.
2. Thrombus and/or slow flow within the right internal carotid
artery
extending from the distal cervical portion through the
bifurcation of the
internal carotid artery and into the right middle cerebral
artery.
3. No intracranial hemorrhage.
TTE [**9-11**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.7 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Right Atrium - Four Chamber Length: *7.2 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 15% to 20% >= 55%
Left Ventricle - Stroke Volume: 35 ml/beat
Left Ventricle - Cardiac Output: 3.22 L/min
Left Ventricle - Cardiac Index: *1.67 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': *0.02 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.02 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *50 < 15
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Ascending: *3.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 10
Aortic Valve - LVOT diam: 2.1 cm
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - E Wave deceleration time: *101 ms 140-250 ms
TR Gradient (+ RA = PASP): *45 to 48 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 0.7 m/sec <= 1.5 m/sec
Findings
This study was compared to the prior study of [**2147-6-5**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. No ASD or
PFO by 2D, color Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Severe regional LV systolic dysfunction. No LV mass/thrombus. No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion. There is
an anterior space which most likely represents a fat pad, though
a loculated anterior pericardial effusion cannot be excluded.
GENERAL COMMENTS: Contrast study was performed with 1 iv
injection of 8 ccs of agitated normal saline at rest. Patient
was unable to cooperate with maneuvers. Echo contrast was
administered by the clinical nurse. [**First Name (Titles) 2325**] [**Last Name (Titles) **] effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is markedly dilated. The right atrium is
markedly dilated. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. There is severe global
and regional left ventricular systolic dysfunction with akinesis
to dyskinesis of the basal to mid inferior wall and apex, and
global hypokinesis in the remaining segments (EF 15-20%). No
masses or thrombi are seen in the left ventricle. Mild right
ventricular systolic dysfunction. The ascending aorta is mildly
dilated. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: No left ventricular thrombus. No PFO or ASD by
resting saline injection. Severe regional left ventricular
systolic dysfunction. Mild mitral regurgitation. Moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2148-8-1**], the
findings are similar.
CT Head [**9-7**]:
FINDINGS: The patient's head is turned to the right at
approximately 45
degrees, making evaluation slightly difficult.
There is cytotoxic edema in essentially the entire territory of
the right
middle cerebral artery, representing evolution of the known
thromboembolic
infarction. There is no evidence of hemorrhagic transformation.
The right
lateral ventricle is partially effaced. The third ventricle is
minimally
shifted to the left, without significant compression. The left
lateral
ventricle is stable in size. There is no uncal herniation and
no cerebellar
tonsillar herniation. There is persistent hyperdensity in the
distal right
internal carotid artery and proximal right middle cerebral
artery,
corresponding to the known embolus. Calcifications are again
noted in
bilateral intracranial vertebral arteries, as well as cavernous
and
supraclinoid portions of bilateral internal carotid arteries.
Hypodensities
are again noted in the white matter of the left cerebral
hemisphere, likely
corresponding to sequela of chronic small vessel ischemic
disease.
The imaged paranasal sinuses and mastoid air cells are well
aerated.
IMPRESSION:
1. Continued expected evolution of the acute infarction in the
right middle
cerebral artery territory, with only mild mass effect at this
time. No
hemorrhagic transformation.
2. Persistent embolic occlusion of the distal right internal
carotid artery
and proximal right middle cerebral artery.
3. No intracranial hemorrhage.
Brief Hospital Course:
The pt is a 76 yo M with history of pAfib on Coumadin, off
Coumadin for 5 days as he was planned to undergo cardiac
catheterization because of recent worsening of his cardiac
function and CHF (EF 10-15%) who was transported to the hospital
after his wife found him lethargic, non-communicative and with
left side weakness. He was found on CTA and CT perfusion to have
thromboembolic occlusion of [**Country **]-RMCA c/b ischemia in the RMCA
distribution. His limited neurological exam demonstrated R
hemiparesis (arm>leg), left sided neglect and forced eye
deviation towards the right. The patient was not given tPA
because of the time course; he was last seen well at 10 or 11 PM
and was found at 5 AM. The patient was intubated in ED for
airway protection and transferred to the ICU. After extubation
transferred to the floor [**9-8**]. On [**9-12**], pt was again transferred
to ICU based on initiation of heparin gtt for acute limb
ischemia, concern about hemorrhagic conversion of large CVA, new
HAP, advanced CHF. Given poor prognosis, patient was
transitioned to comfort measures only.
1. Ischemic stroke: An MRI was performed and confirmed acute
infarct in the entire right MCA territory and large thrombus in
the right carotid extending from the distal cervical portion,
through the bifurcation of the internal carotid and into the
right MCA. Given the size of stroke and risk of bleeding he was
not started on heparin drip or anticoagulation for AFib. Stroke
risk factors: A1c (5.2), lipid profile (TChol 138, LDL 83, HDL
43, TG 60). CMO as above.
2. Cardiovascular: hx of CHF: In ICU, cardiology service got
involved and recommended preventing volume overload, started
betablocker drip for heart rate control and will perform TTE.
On floor, initiated CHF/AFib regimen of metoprolol 25 mg PO q6h
and lisinopril 5 mg daily.
On [**9-12**], pt was found to have a cold, mottled, pulseless left
leg. Vascular surgery consulted urgently. Stat CTA LE was
obtained, pt started on heparin gtt. Found to have aortoiliac
thrombus. Would need amputation of leg, however, not operative
candidate given cardiac. If no surgery, would progress to
ischemic necrosis of the leg and sepsis. Given poor prognosis,
transitioned to CMO as above.
3. Pulmonary: The patient was extubated successfully. However,
on floor was noted to be tachypneic with [**Last Name (un) 6055**] [**Doctor Last Name **]
respirations. On [**9-11**], received 20 mg furosemide IV in light of
tachypnea, crackles, JVD, congestion on CXR. On [**9-12**], continued
to be tachpneic, with worsening CXR infiltrates and new
leukocytosis, was started on antibiotic therapy for HAP.
Discontinued once transitioned to CMO.
4. GI: failed speech/swallow. NG tube placed, and was receiving
nutrition. Scheduled for PEG placement.
Medications on Admission:
Medications - Prescription - pt was only taking warfarin.
WARFARIN - (Prescribed by Other Provider) - warfarin 5 mg
tablet
one tablet(s) by mouth once a day or as directed last dose
Monday
[**2148-9-2**]
ATENOLOL - (Not Taking as Prescribed) - atenolol 25 mg tablet
one Tablet(s) by mouth once a day
LISINOPRIL - (Not Taking as Prescribed) - lisinopril 5 mg
tablet
one Tablet(s) by mouth once a day
ASPIRIN; 81 MG po DAILY
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
ischemic stroke
left aortoiliac thrombus
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2148-9-17**]
ICD9 Codes: 486, 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8152
} | Medical Text: Admission Date: [**2107-8-16**] Discharge Date: [**2107-8-22**]
Date of Birth: [**2055-5-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2107-8-16**] Aortic Valve Replacement(23mm ON-X mechanical valve),
Replacement of Ascending Aorta(26mm Gelweave Graft), and Closure
of Atrial Septal Defect.
History of Present Illness:
Mr. [**Known lastname 9907**] is a 52 year old male with heart murmur since
childhood. He has known aortic valve disease and has been
followed by serial echocardiograms. His most recent ECHO
revealed severe aortic insufficiency, and severe aortic stenosis
with a peak gradient of 97mmHg and mean of 62mmHg. The [**Location (un) 109**] was
estimated at 0.7cm2. The LVEF was estimated at 60%. Cardiac
catheterization confirmed severe aortic insufficiency and aortic
stenosis with evidence of moderately dilated ascending aorta.
His coronary arteries were angiographically normal. Based upon
the above results, he was referred for cardiac surgical
intervention.
Past Medical History:
Mixed Aortic Valve Disease
Dilated Ascending Aorta
History of ETOH abuse
GERD
Anxiety
Prior Foot Surgery
Social History:
Denies history of tobacco. Employed as a chef. He is married,
and lives in [**Location 701**].
Family History:
Denies premature coronary artery disease.
Physical Exam:
BP 150-160/80-90, HR 84 regualr, RR 12
Well developed, well nourished male in no acute distress
Oropharynx benign, full dentures
Neck supple, with FROM, no JVD, no carotid bruits
Lungs CTA bilaterally
Heart regular rate and rhythm, normal s1s2, mixed diastolic and
systolic murmurs noted
Abdomen benign
Extremities warm, well perfused, no edema
Distal pulses 2+ bilaterally
Alert and oriented, CN 2-12 intact, 5/5 strength, no focal
deficits
Pertinent Results:
[**8-16**] Echo: Prebypass: 1. A left-to-right shunt across the
interatrial septum is seen at rest. A small secundum atrial
septal defect is present. 2. There is mild symmetric left
ventricular hypertrophy. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is low
normal (LVEF 50-55%). 3.Right ventricular chamber size and free
wall motion are normal. 4.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 moderate to severe aortic valve
stenosis (area 0.8-1.0cm2). Moderate to severe (3+) aortic
regurgitation is seen. 5.Trivial mitral regurgitation is seen.
Post bypass: 1. Mechanical aortic valve is well seated and the
leaflets move well. Trace aortic regurgitation seen. Peak
gradient across the valve is 19 mmHg. 2. Ascending aortic graft
is noted. 3. No flow detected across the intra-atrial septum. 4.
Preserved biventricular function.
[**8-21**] CXR: Small to moderate bilateral pleural effusion, left
greater than right, has increased since [**8-18**]. Moderate left
lower lobe atelectasis is stable. Right lung is clear.
Cardiomediastinal silhouette has a normal postoperative
appearance, unchanged. No pneumothorax.
[**2107-8-16**] 12:00PM BLOOD WBC-15.3*# RBC-2.71*# Hgb-8.1*#
Hct-23.9*# MCV-88 MCH-30.1 MCHC-34.1 RDW-13.7 Plt Ct-210
[**2107-8-22**] 07:00AM BLOOD WBC-10.7 RBC-3.62* Hgb-10.7* Hct-30.7*
MCV-85 MCH-29.5 MCHC-34.7 RDW-14.5 Plt Ct-292#
[**2107-8-16**] 12:00PM BLOOD PT-15.1* PTT-56.4* INR(PT)-1.4*
[**2107-8-20**] 05:15AM BLOOD PT-16.0* INR(PT)-1.5*
[**2107-8-21**] 01:50AM BLOOD PT-29.8* PTT-38.8* INR(PT)-3.1*
[**2107-8-21**] 09:20AM BLOOD PT-32.4* INR(PT)-3.5*
[**2107-8-22**] 06:00AM BLOOD PT-26.1* PTT-37.4* INR(PT)-2.7*
[**2107-8-16**] 12:53PM BLOOD UreaN-15 Creat-1.0 Cl-109* HCO3-31
[**2107-8-22**] 07:00AM BLOOD Glucose-110* UreaN-17 Creat-0.9 Na-137
K-4.3 Cl-101 HCO3-28 AnGap-12
[**2107-8-19**] 06:35AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 9907**] was a same day admit and was brought directly to the
operating room where he underwent a mechanical aortic valve
replacement along with replacement of his ascending aorta and
closure of an atrial septal defect. For surgical details, please
see separate dictated operative note. Following the operation,
he was brought to the CSRU for invasive monitoring in stable
condition. Initially coagulopathic, he required multiple blood
products with much improvement. Within 24 hours, he awoke
neurologically intact and was extubated without incident. He
transiently required Labetalol drip for hypertension. He
otherwise maintained stable hemodynamics and transitioned to PO
beta blockade. Given his history of anxiety and ETOH abuse, he
was maintained on Ativan. His CSRU course was otherwise
uneventful, and he transferred to the SDU on postoperative day
two. Chest tubes and epicardial pacing wires were removed per
protocol. Coumadin was initiated on post-op day three and
Heparin was used as a bridge until INR was therapeutic. He
continued to improve well over the next several days while
working with physical therapy for strength and mobility. Once
his INR was therapeutic he was discharged home with VNA services
and the appropriate follow-up appointments. Dr. [**Last Name (STitle) **] (his
cardiologist) will manage his Coumadin.
*****Of note, Mr. [**Known lastname 9907**] is enrolled in the ON-X trial.*****
Medications on Admission:
Ativan prn
Zoloft 75 qd
Zantac 150 [**Hospital1 **]
MVI
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 BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
8. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
please take 2 mg [**8-22**] and [**8-23**] - lab draw [**8-24**] and further
dosing by Dr [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*0*
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Aortic Valve Disease, Dilated Ascending Aorta, Atrial Septal
Defect s/p Aortic Valve Replacement, Asc. Aorta Replacement, ASD
Closure
PMH: Anxiety, Gastroesophageal Reflux Disease, History of ETOH
abuse
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**]
Take Warfarin as directed by Dr. [**Last Name (STitle) **] . INR goal is around 2.5-3.
INR should be first checked on this Wednesday. Future blood
draws on Monday, Wednesday, Friday or per Dr. [**Last Name (STitle) **].
Followup Instructions:
Dr. [**Last Name (STitle) 68853**] in [**4-14**] weeks, please call for appt [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**9-19**] at 4:45pm. Appt. has already been set up
for you. Please call if there are scheduling conflicts.
Dr. [**Last Name (STitle) 3321**] in [**2-12**] weeks, please call for appt [**Telephone/Fax (1) 3183**]
Wound check please schedule with RN [**Telephone/Fax (1) 3633**]
Completed by:[**2107-8-22**]
ICD9 Codes: 9971, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8153
} | Medical Text: Admission Date: [**2203-3-22**] Discharge Date: [**2203-3-26**]
Date of Birth: [**2168-10-6**] Sex: F
Service: [**Hospital Unit Name 153**]
THE PATIENT SIGNED OUT AGAINST MEDICAL ADVICE 0N [**2203-3-26**].
HISTORY OF PRESENT ILLNESS: The patient is a 34 year old
female who is admitted to the Intensive Care Unit with an
episode of diabetic ketoacidosis, nausea and vomiting. Her
past medical history is notable for multiple hospital
admissions for diabetic ketoacidosis with nausea and vomiting
and she now presents with an approximately one to two days of
nausea and vomiting and some episodes of chest pain with her
vomiting. She states that she had been taking her usual
insulin regimen of 22 units of Lantus at night but has
stopped taking her Lantus the past one to two days because of
this persistent nausea and vomiting and decreased p.o.
intake.
On history she also notes occasional blood tinged vomitus
with her vomiting. She decided to come to the Emergency
Department because of her continued nausea and vomiting and
continued chest pain. In the Emergency Department, she was
noted o have several episodes of blood tinged vomitus, but no
NG tube lavage was performed. She was noted to have a
glucose of over 500 with an anion gap of 19 and was felt to
be in diabetic ketoacidosis.
On further review of systems, she notes several years of
fecal incontinence and continued diarrhea. She denies any
abdominal pain. She has also had intermittent episodes of
lower extremity edema previously that were treated with Lasix
and felt to be due to her renal failure.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 1 with over 80 episodes of
diabetic ketoacidosis in the past. She has neuropathy,
nephropathy and retinopathy.
2. Chronic renal insufficiency with baseline creatinine of
between 2.4 and 2.9.
3. History of gastroparesis, with episodes of nausea and
vomiting.
4. Atypical chest pain.
5. Hypertension.
6. Asthma.
7. Chronic right foot ulcer being followed by Dr. [**Last Name (STitle) 108352**] of
[**Last Name (STitle) **].
8. Chronic diarrhea.
ALLERGIES: To aspirin, codeine and peanuts.
SOCIAL HISTORY: She lives in [**Location 686**] with her husband.
MEDICATIONS: (per medical record)
1. Lantus 22 units at night.
2. Humalog insulin sliding scale.
3. Protonix 40 mg once a day.
4. Phenergan p.r.n.
5. Atenolol 75 mg once a day.
6. She had previously taken Lisinopril as well as an
antibiotic given by [**Location **], the exact antibiotic could not
be identified.
PHYSICAL EXAMINATION: Vital signs on admission were
temperature of 98.7 F.; blood pressure 126/62; heart rate 86;
respiratory rate 14; saturation of 97% on room air. General
appearance: The patient was somnolent but in no apparent
distress. Head and Neck examination: She was nonicteric.
Mucosa seemed moist. No jugular venous distention was noted.
Lungs were clear to auscultation anteriorly and laterally.
Cardiac examination is regular rate and rhythm; II/VI
systolic ejection murmur that appeared to radiate to the
carotids. Abdomen with some decreased bowel sounds, mild
periumbilical discomfort. Nondistended, no rebound noted.
Extremities had no lower extremity edema. Her right foot
ulcer did not have significant areas of erythema or
tenderness with clean margins. Neurologic: Pupils equally
round and moderately reactive. The patient seemed somnolent,
otherwise nonfocal examination.
LABORATORY: On admission notable for a white blood cell
count of 12.0, with 24% neutrophils, zero bands, 6%
lymphocytes. Hematocrit 32.4, platelets 424, normal
coagulation studies.
Initial Chem-7 was notable for sodium of 140, potassium of
4.1, chloride 102, bicarbonate 19, BUN and creatinine were 50
and 3.2 with a glucose of 490, anion gap of 19. Calcium,
magnesium and phosphorus were within normal limits. One set
of negative cardiac enzymes. Normal liver function tests.
Large acetone in the blood. HCG negative. Urinalysis
notable for over 1000 glucose, 50 ketones.
Arterial blood gas with a pH of 7.41, CO2 of 30, O2 of 129.
Chest x-ray with no evidence of pneumonia or pneumothorax.
Previous echocardiogram done in [**2202-3-2**] had an left
ventricle with an ejection fraction of over 75%.
HOSPITAL COURSE:
1. DIABETIC KETOACIDOSIS / DIABETES MELLITUS: The patient
was initially placed on an insulin drip with D5 half normal
saline for an episode of diabetic ketoacidosis. Her anion
gap closed within 12 hours of admission. She was not given
subcutaneous insulin however for several days because of her
continued nausea and vomiting and inability to take a regular
p.o. diet.
On the 23rd, she was able to take p.o. and was given Lantus
22 Units at night as well as a Humalog sliding scale.
2. FOOT ULCER: She had a history of a chronic foot ulcer
being followed by [**Year (4 digits) **], which was not fully treated in
the past because of a long history of noncompliance. No
clear source of her diabetic ketoacidosis was found on
admission so it was presumptively thought to be related to
her foot ulcer.
[**Year (4 digits) **] evaluated the ulcer and felt that it looked fairly
clean and recommended a foot x-ray as a definitive test for
osteomyelitis which was negative. A follow-up bone scan was
not recommended.
She was initially placed on Zosyn which was later
discontinued because of her concomitant infection with
Clostridium difficile. She was urged to follow-up with
[**Year (4 digits) **].
3. CLOSTRIDIUM DIFFICILE INFECTION: Her Clostridium
difficile culture came back positive on [**3-24**] and she
was initially placed on intravenous Flagyl which was then
changed to p.o. Flagyl when she was able to tolerate pills.
This was thought to be the etiology of her nausea and
vomiting. Although the patient was initially placed on Zosyn
for her foot ulcer, it was discussed with [**Month (only) **] if she
could discontinue this medication as she had an unchanged
physical examination, negative foot x-ray, history of
noncompliance and there was concern that the Zosyn may effect
her treatment of Clostridium difficile.
Prior to resolution of her treatment for her foot ulcer, the
patient signed out Against Medical Advice but was given a
prescriptions for Flagyl to complete a two week course.
4. ACUTE RENAL FAILURE: The patient's creatinine was
initially elevated at 3.2, which fell to 2.9, which is the
high end of her baseline. Her ACE inhibitor was held during
her admission as she had previous episodes of lower extremity
swelling and had some facial swelling during her hospital
course. Her sodium intake was restricted as she was likely
fluid overloaded from her renal failure. She was not given
Lasix during her hospital stay as she did not have any
shortness of breath or decreased O2 saturations.
5. CARDIOVASCULAR: She had an elevated blood pressure
during her hospital course and initially placed on
intravenous hydralazine because of her nausea and vomiting.
She was then given her usual p.o. atenolol dose of 75 mg
after she could tolerate pills. Given her hypertension,
history of chest pain and lower extremity edema and notable
systolic murmur, an echocardiogram was done showing fairly
unchanged echocardiogram from her previous in [**2201**]. She had
some mild left ventricular hypertrophy and an ejection
fraction of over 75%.
6. HEMATEMESIS: The patient has had multiple episodes of
hematemesis with her numerous bouts of nausea and vomiting
which is associated with her chest pain and presumed to be
from [**Doctor First Name **]-[**Doctor Last Name **] tears. On the 24th, her hematocrit
dropped from 29.8 to 26.5 but was later rechecked and was
29.0. She had guaiac positive stools and there was concern
for an upper gastrointestinal bleed. It was explained that
she should have an esophagogastroduodenoscopy to better
evaluate for a possible bleed, however, the patient declined
and subsequently signed out Against Medical Advice.
7. AGAINST MEDICAL ADVICE: The patient signed out Against
Medical Advice. The patient refused further
esophagogastroduodenoscopy and left the hospital against
medical advice.
It was urged that she follow-up with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as well as Dr. [**Last Name (STitle) **] of [**Last Name (STitle) **] in
the future and that she should continue with full course of
her Clostridium difficile treatment and obtain a future
evaluation for possible upper GI bleed.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 6289**]
MEDQUIST36
D: [**2203-3-30**] 15:23
T: [**2203-3-30**] 18:06
JOB#: [**Job Number 108353**]
ICD9 Codes: 2765, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8154
} | Medical Text: Admission Date: [**2134-2-9**] Discharge Date: [**2134-2-18**]
Date of Birth: [**2067-9-19**] Sex: F
Service:
PROCEDURE PERFORMED: Abdominal wall split thickness skin
grafting, donor site left thigh.
OVERT DIAGNOSES:
1. History of an aortic aneurysm rupture requiring multiple
abdominal explorations for mesenteric and pancreatic
ischemia.
2. She has also undergone a takedown of a colostomy in the
past that developed a small dehiscence.
3. Ventral hernia repaired with Marlex.
4. She also has a cerebral aneurysm that has been coiled.
5. Atrial fibrillation.
6. Chronic kidney disease.
7. Hypertensive disease.
8. Coronary artery disease.
HOSPITAL COURSE: Ms. [**Known lastname **] was admitted to the hospital
where she underwent split thickness skin grafting on the
19th. A back dressing was placed on the wound. Her
postoperative course was uneventful. On day 3, we took the
vac dressing down. The skin graft had near 100% take, and we
were able to at this point convert her management to
bacitracin and adaptic.
PLAN: She was discharged home on [**2134-2-12**] to followup with
Dr. [**First Name (STitle) **] in one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Dictated By:[**Last Name (NamePattern4) 3433**]
MEDQUIST36
D: [**2134-6-15**] 18:52:31
T: [**2134-6-15**] 21:07:03
Job#: [**Job Number 46115**]
ICD9 Codes: 4271, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8155
} | Medical Text: Admission Date: [**2142-12-18**] Discharge Date: [**2142-12-24**]
Date of Birth: [**2078-3-18**] Sex: M
Service: NEUROSURGERY
Allergies:
Amitriptyline
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64M with h/o frequent falls presents to ED with obvious head
trauma s/p fall from standing. + EToH. Head CT showing
intraventricular blood and "material layering within the
hypopharynx. The patient is obtunded per clinical history and
clinical correlation is advised for possible aspiration."
Therefore, we were consulted to evaluate his oral and pharyngeal
swallowing ability to r/o aspiration. Nurses reported some
coughing after swallowing pills whole w/water.
Past Medical History:
#) Diabetes - w/neuropathy; uses a cane
#) PVD -- sees Dr. [**First Name (STitle) **]
#) Cardiac aflutter/a tach
#) Colon Ca -- s/p partial colectomy [**2125**], no rad or chemo; on 5
yr follow-up schedule now -- due [**2143**].
#) Neuropathy -- progressing to R arm now; legs unchanged, uses
cane for balance since proprioception almost totally gone; motor
strength fine.
#) Wt Loss -- has subsided, and pt has actually gained wt again.
#) Spinal Stenosis -- MRI done [**5-/2141**], no emergent issues, but
some retrolisthesis of L4-5.
#) 4x MI's as per HPI, last 6 yrs ago
#) HTN
#) Hyperlipidemia
Social History:
pt is retired on SS and SSDI. He has a live-in companion who
helps around the house and with medical and personal care.
Smokes 2ppd. Drinks 2-3 drinks of hard alcohol per day.
Family History:
No hx of CAD or DM
Physical Exam:
PHYSICAL EXAM: on admission
O: T:96 BP:137/67 HR:82 R:20 O2Sats: 96
Gen: thin, coverd with dried blood,NAD.sleeping but able to
arouse with effort. Participates with exam.
HEENT: Pupils:5->4.5 bilat EOMs full, right ear
laceration sutured by plastics
Neck: in hard collar
Extrem: Warm and well-perfused. multiple abrasions, dried blood
Neuro:
Mental status: Awake and alert, cooperative with exam, blunted
affect.
Orientation: Oriented to person and date "[**2142-12-6**]". Place
stated "My apartment"
Language: Speech somewhat garbled but good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 to 4.5
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength grossly full throughout. No pronator drift
appreciated.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Pertinent Results:
[**2142-12-19**] 04:52AM BLOOD WBC-5.5 RBC-3.34* Hgb-12.2* Hct-33.7*
MCV-101* MCH-36.4* MCHC-36.1* RDW-13.7 Plt Ct-180
[**2142-12-18**] 06:10AM BLOOD Neuts-54.0 Lymphs-38.1 Monos-5.8 Eos-1.7
Baso-0.4
[**2142-12-19**] 04:52AM BLOOD Plt Ct-180
[**2142-12-19**] 04:52AM BLOOD PT-11.5 PTT-24.8 INR(PT)-1.0
[**2142-12-19**] 04:50PM BLOOD Na-131*
[**2142-12-19**] 04:52AM BLOOD Glucose-200* UreaN-6 Creat-0.4* Na-131*
K-3.6 Cl-93* HCO3-18* AnGap-24*
[**2142-12-18**] 11:00AM BLOOD Glucose-266* UreaN-8 Creat-0.6 Na-126*
K-3.7 Cl-92* HCO3-16* AnGap-22*
[**2142-12-19**] 12:45PM BLOOD CK(CPK)-76
[**2142-12-19**] 04:52AM BLOOD ALT-39 AST-44* LD(LDH)-188 CK(CPK)-86
AlkPhos-77 Amylase-44 TotBili-0.8
[**2142-12-19**] 04:52AM BLOOD Lipase-24
[**2142-12-19**] 12:45PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2142-12-19**] 04:52AM BLOOD CK-MB-6 cTropnT-<0.01
[**2142-12-19**] 04:52AM BLOOD Albumin-3.5 UricAcd-3.8
[**2142-12-18**] 10:00PM BLOOD Calcium-8.2* Phos-2.3* Mg-1.6
[**2142-12-19**] 04:52AM BLOOD TSH-1.2
[**2142-12-18**] 11:00AM BLOOD Ethanol-203*
[**2142-12-18**] 06:10AM BLOOD ASA-NEG Ethanol-314* Acetmnp-5.7
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT HEAD W/O CONTRAST [**2142-12-20**]
IMPRESSION: No evidence of interval progression. Stable
appearance of the intraventricular hemorrhage
CT HEAD W/O CONTRAST [**2142-12-19**]
IMPRESSION:
1. Extension of the intraventricular hemorrhage with involvement
of third and fourth ventricle. This could be due to
redistribution of prior hemorrhage, however, slow persistent
intraventricular bleed cannot be excluded. No hydrocephalus.
2. Disruption of the cortex adjacent to the occipital condyle as
described above, which could be a possible non displaced
fracture. Soft tissues changes secondary to trauma as described
above.
3. Unchanged appearance of the air-fluid level within the right
sphenoid sinus, with evidence of cortical irregulaity,
suggesting a potential right inferolateral sinus wall fracture.
CT C-SPINE W/O CONTRAST [**2142-12-18**]
IMPRESSION:
1. No fracture or malalignment. Degenerative changes as
described.
2. Material layering within the hypopharynx. The patient is
obtunded per clinical history and clinical correlation is
advised for possible aspiration.
3. Right sphenoid sinus opacification with partial opacification
of the right middle ear cavity. Recommend correlation with
subsequently performed CT sinus and temporal bone.
4. Biapical emphysema.
Brief Hospital Course:
64M with h/o falls presents s/p fall while intoxicated (EToH
314) and Head CT showing intraventricular blood.
[**2142-12-18**] Na/K/Mg were repleted, and foley was placed, pt was
lethargic.
[**2142-12-18**] he had a cardiac event, this was monitored and
corrected.
[**2142-12-20**] he underwent a swallow eval, and the recommendations
were to advance his diet to a thickened diet. His current diet
is regular and well tolerated.
[**2142-12-20**] CT of head on shows no evidence of interval progression
and stable appearance of the intraventricular hemorrhage.
[**2142-12-22**] patient became lethargic, with head CT demosntation
fairly severe hydrocephallus. He was transferred to sICU for a
bediside EVD; however his symptoms resolved spontaneously.
[**2142-12-23**] he is transferred to the floor, and he remained stable.
[**2142-12-24**] repeat CT of head is stable and improved.
[**2142-12-24**] PT recommends d/c with home PT.
[**2142-12-24**] Pysical exam was non-focal, neurologically stable, we
will proceed with discharge.
Medications on Admission:
Aspirin EC 81 mg--1 tablet(s) by mouth once a day
Bupropion 75 mg--1 tablet(s) by mouth once a day
CYMBALTA 60 mg--1 capsule(s) by mouth once a day
FOLIC ACID 1 mg--1 tablet(s) by mouth once a day
HUMALOG 100 unit/mL--as directed
HUMULIN N 100 unit/mL--as directed
LIPITOR 40 mg--1 tablet(s) by mouth once a day
Lyrica 100 mg--1 capsule(s) by mouth once a day
OMEPRAZOLE 20 mg--1 capsule(s) by mouth once a day
PLAVIX 75 mg--1 tablet(s) by mouth once a day
SOTALOL 120 mg--1 tablet(s) by mouth twice a day
TOPROL XL 100 mg--1 tablet(s) by mouth twice a day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed: do not exceed 4000 mg of Acetaminophen in 24
hour period.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: do not exceed 4000 mg of
Acetaminophen in 24 hour period.
Disp:*20 Tablet(s)* Refills:*0*
3. Bupropion 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 * Refills:*2*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
use while on percocet.
Disp:*40 Capsule(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
IVH
Discharge Condition:
neurologically stable
Discharge Instructions:
?????? 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
Completed by:[**2142-12-24**]
ICD9 Codes: 3572, 4019, 412, 3051, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8156
} | Medical Text: Admission Date: [**2158-7-22**] Discharge Date: [**2158-8-28**]
Date of Birth: [**2074-7-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / aspirin
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Altered mental satus
Major Surgical or Invasive Procedure:
Left frontal Temporal Craniotomy for Subdural Hematoma
History of Present Illness:
The patient is an 84 year old female with history of
hypertension and GERD who was visiting her daughter and grandson
from [**Country 26467**] when she experience a mechanical fall 3 days
prior to admission after slipping on wet grass and landing on
her right shoulder. She denied hitting her head at the time,
denied loss of consciousness, and had no report of neck pain.
She was initially brought to the ED at [**Hospital6 2561**] for
evaluation of her right shoulder pain and decreased range of
motion. She was diagnosed with shoulder dislocation, and the
shoulder was re-located with no imaging of the head or torso
obtained. The patient was subsequently discharged home from the
ED with a sling for the right upper extremity. She initially did
well until the night before admission when she began
experiencing increasing confusion, altered mental status, and
another fall. She returned to [**Hospital6 2561**] where a CT
of the head was obtained which demonstrated a significant
(1.9cm) left sub-dural hematoma and 7mm midline shift. The
patient was then transferred to [**Hospital1 18**] for Neurosurgical
intervention.
Past Medical History:
HTN
GERD
Social History:
Lives in [**Country 26467**], No Tobacco or ETOH.
Family History:
Non-contributory.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T: 99.6 BP: 191/100 HR:138 R 14 O2Sats 99 2L
Gen: WD/WN, comfortable, NAD.
HEENT: NCNT
Neck: Hard collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake, not following commands or answering
questions.
Language:Garbled speech
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: UA
[**Doctor First Name 81**]: UA.
XII: UA.
Motor: Right arm in sling, bruised. moving right lower with
stim,
moves left upper and lower spontaneously.
Handedness Right
PHYSICAL EXAM ON DISCHARGE:
VS: 97.9, 149/87 (130s-140s/70s-80s), 97, 18, 97% RA
General- NAD, well-appearing in bed
HEENT- Sclera anicteric without injection or erythema, MMM.
Recent craniotomy scar, incision c/d/i.
Lungs- CTA bilaterally, without wheezes, rales
CV- Regular rhythm with tachycardia, normal S1 + S2, no m/r/g
Abdomen- soft, non-tender, non-distended, (+)BS, no rebound or
guarding
GU- diaper, incontinent to urine
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, RUE in sling
Neuro- CN II-XII grossly intact, moving all extremities, AOx3
this morning
Pertinent Results:
ECG [**2158-7-22**]
Sinus tachycardia with premature atrial contractions. No
previous tracing
available for comparison.
ECG [**2158-7-22**]
Sinus tachycardia. Compared to tracing #1 ectopy is not seen.
CT head [**2158-7-22**]
1. Expected postoperative changes, status post left craniotomy
and evacuation of the previously large subdural hematoma.
Larger than expected quantity of pneumocephalus with
displacement of underlying parenchyma - correlate clinically
to decide on further mngt. /followup.
2. Significant resolution with persistent small amount of left
sided subdural hemorrhage as above.
X-ray shoulder [**2158-7-22**]
There is again seen a complex fracture involving the right
proximal humerus with fracture line predominantly through the
surgical neck. There is a displaced greater tuberosity fracture
and there is varus angulation at the fracture. There is no
glenohumeral joint dislocation. There is generalized
demineralization.
LENIS [**2158-7-24**]
No deep vein thrombus in the left or right lower extremity
Right Tib/Fib X-ray [**2158-7-25**]
No evidence of bone or soft tissue abnormality. Superior
patellar
spurring and patellofemoral spurring noted. Vascular
calcification is seen posterior to the distal femur
[**2158-7-27**] Chest Xray: As compared to the previous radiograph,
pre-existing signs of mild fluid overload have improved. There
currently is no evidence of pneumonia. Borderline size of the
cardiac silhouette. Moderate hiatal hernia. No pleural
effusions. A previously visualized right humeral fracture is
less evident than on the previous image.
[**2158-7-30**]: As compared to the previous radiograph, there is no
relevant
change. Constant signs of mild fluid overload. No evidence of
pneumonia. Borderline size of the cardiac silhouette. No
pleural effusions.
[**2158-8-1**] CT head: no new hemorrhage. Improving pneumocephalus,
improving cerebral edema, improving subdural collections.
[**2158-8-1**] LENIS: No lower extremity DVT
[**2158-8-4**] U/S Abd: Cholelithiasis in a contracted gallbladder. No
intrahepatic or extra-hepatic biliary ductal dilatation. Normal
son[**Name (NI) 493**] appearance of the liver without focal lesions.
[**2158-8-11**] CT Head: In comparison to [**2158-8-7**] exam, there is no
significant change inpostoperative changes related to left
parietal craniotomy. Left extra-axial collection is not
significantly changed since prior. No new intracranial
hemorrhage.
[**2158-8-11**] Xray Shoulder: Healing complex fracture involving the
right proximal humerus through the surgical neck. No new acute
fractures or dislocations.
[**2158-8-21**] CT Head: In comparison to the [**2158-8-11**] exam, there
is no significant change in the postoperative changes related to
left parietal craniotomy. Left extra-axial collection is not
significantly changed since prior and likely represents a
hygroma. No new intracranial hemorrhage.
[**2158-8-22**] V/Q (Lung) Scan: Low probability for a pulmonary embolus.
Admission Labs:
[**2158-7-22**] 10:20AM BLOOD WBC-15.7* RBC-3.59* Hgb-12.7 Hct-36.6
MCV-102* MCH-35.4* MCHC-34.7 RDW-12.3 Plt Ct-213
[**2158-7-22**] 10:20AM BLOOD Neuts-93.8* Lymphs-3.0* Monos-2.8 Eos-0.1
Baso-0.2
[**2158-7-22**] 10:20AM BLOOD PT-10.8 PTT-25.7 INR(PT)-1.0
[**2158-7-22**] 10:20AM BLOOD Glucose-137* UreaN-16 Creat-0.7 Na-127*
K-4.8 Cl-89* HCO3-23 AnGap-20
[**2158-7-24**] 01:00PM BLOOD CK(CPK)-270*
[**2158-7-24**] 01:00PM BLOOD CK-MB-5 cTropnT-0.07*
[**2158-7-22**] 02:38PM BLOOD Calcium-7.7* Phos-3.1 Mg-1.6
[**2158-7-22**] 01:21PM BLOOD Type-ART Temp-37.4 Rates-/8 Tidal V-630
PEEP-3 FiO2-50 O2 Flow-1.0 pO2-262* pCO2-32* pH-7.47* calTCO2-24
Base XS-1 Intubat-INTUBATED Vent-CONTROLLED
Microbiology:
URINE CULTURE (Final [**2158-8-13**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
[**2158-8-17**] 7:06 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2158-8-18**]**
C. difficile DNA amplification assay (Final [**2158-8-18**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
Discharge Labs:
Patient did not have further laboratory results after [**2158-8-16**],
attempted to minimize routine/unnecessary lab work in the
setting of no concerning complaints, signs, or symptoms [**First Name8 (NamePattern2) **]
[**Doctor First Name **] protocol.
Brief Hospital Course:
The patient is an 84 year old female with history of
hypertension and GERD presenting after a mechanical fall with
resultant subdural hematoma and evacuation on the neurosurgical
service, subsequently transferred to the medical service for
management of persistent tachycardia, UTI, and delirium.
.
ACTIVE ISSUES and HOSPITAL COURSE:
On the surgical service:
Ms. [**Known lastname **] was evaluated in the ED on [**7-22**]. After review of her
outside cranial CT she was taken to the operating room for an
emergent left craniotomy for SDH evacuation.
.
She was followed by Orthopedics for her right upper extremity
fracture and a sling was recommended. On [**7-23**] she had a Temp of
101.5 F. Fever work up was initiated, which unrevealing. On [**7-24**]
she was tachycardic to 130. EKG demonstrated sinus tachycardia.
LENIs to evaluate for DVT were negative. Troponins were obtaine
and trended down from 0.07 to 0.05. On [**7-25**] A corrected
Dilantin level was 10.2. She had a brief mom[**Name (NI) **] of confusion in
the afternoon but this self resolved.
.
Patient continued to actively work with PT for rehabilitation.
As patient is originaly from [**Country 26467**], and her the maximum of
her travelers' insurance reached, she was not a candidate for
inpatient rehabilitation in the US. The Australian consulate
was consulted and stated that they were willing to pay for
transportation to [**Country 26467**]. However, the neurosurgery service
deemed patient unable to fly for 30 days after her surgery.
.
On [**7-27**], patient was febrile to 101. The UA was normal and the
CXR demonstrated no evidence of pneumonia.
.
On [**7-28**], patient's continued tachycardia and fevers prompted a
medicine consult. The primary service institued their
recommendations to obtain orthostatics, obtain blood and urine
cultures, bolus the patient 1000 mL of normal saline, place
water at the bedside for patient to drink at liberty, and
discontinue percocet and replace with standing tyelenol and
oxycodone.
.
Tachycardia continued to persist on [**7-29**], a TSH was obtained to
rule out thyroid disease as potential cause, it was normal.
Patient's electrolytes were repleted as they were observed to be
low.
.
On [**7-30**], patient suffered increased confusion when examined
during morning rounds. Her blood cultures came back came back
as normal and her urine cultures from [**7-28**] demonstrated
lactobacillus. Levofloxacin was initiated. Repeat urine
cultures were obtained for speciation and sensitivities. As
part of confusion work-up, CXR, EKG, troponins x1, and
orthostatics were obtained. CXR revealed mild fluid
overloading; strict ins and outs were instituted and the patient
received lasix. All other confusion work-up remained negative.
Patient's confusion cleared briefly later in the afternoon.
.
On [**7-31**] she remained stable and on [**8-1**] she continued to have
confusion. Head CT was obtained and was stable, no new
findings.
.
Upon transfer to the medical service:
.
# Altered mental status: The patient came to the medical service
with waxing and [**Doctor Last Name 688**] mental status, concern for infection vs.
delirium. CXR from admision and on repeat were negative for a
pneumonia. The patient was not experiencing fevers, and no blood
cultures were positive. A toxic metabolic workup by LFTs and
electrolytes was normal. All sedating medications, including
oxycodone, tramadol, and benzos were discontinued. Given head
bleed, patient was at high risk for delirium and seizure. Head
CT was repeated to rule out any further acute bleeding.
Geriatrics was consulted who recommended starting venlafaxine
for depression and for its activating effects. Excess lines and
tethers were removed at all times to avoid further contribution
to delirium. Patient was found to have a positive UTI (coag
negative staph) and was treated with nitrofurantoin. Her mental
status cleared about one week prior to discharge.
.
#Subdural Hematoma: Patient is s/p mechanical fall which was
complicated by subdural hematoma evacuated by neurosurgery on
[**7-30**]. Patient was on levetiracetam 750mg for seizure
prophylaxis. Repeat CT scans demonstrated no change.
.
#Tachycardia: Patient was found to be tachycardic from 95-115
throughout hospital stay. Patient remained asymptomatic. The
tachycardia was fluid-responsive, but would reoccur within hours
administration. Patient was screened for infections, found not
to have pneumonia. The patient did have a UTI, but the
tachycardia persisted despite resolution. Concern for PE arose
given benign tachycardia. Patient had multiple lower extremity
ultrasounds performed which did not reveal DVT. A V/Q lung scan
was performed which demonstrated she was low probability for PE.
Patient's tachycardia was trended and patient was monitored.
.
# Rectal bleeding: Patient had one episode of BRBPR while
inpatient. She remained normotensive, with no further elevation
of her heart rate. Stool found to be guaiac positive, brown. Her
hematocrit remained stable, and no further episodes occurred.
.
TRANSITIONAL ISSUES:
Patient had foley catheter inserted prior to discharge for
flight to [**Country 26467**]. Foley should be discontinued upon arrival
to reduce risk of UTI.
Medications on Admission:
Nexium
BP med-name unknown
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
SDH
Humerus fracture
Hypokalemia
Hypocalcemia
Hypophosphatemia
UTI
Secondary Diagnoses:
Hypertension
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
ICD9 Codes: 5990, 2761, 2768, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8157
} | Medical Text: Admission Date: [**2201-8-18**] Discharge Date: [**2201-8-23**]
Date of Birth: [**2156-8-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lidocaine / Novocain
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue, occasional chest pressure
Major Surgical or Invasive Procedure:
[**2201-8-18**] - Redo sternotomy, Aortic valve replacement with 23mm
St. [**Male First Name (un) 923**] mechanical valve
History of Present Illness:
Mr. [**Known lastname 8508**] is a 44-year-old gentleman who underwent a prior type
A emergency dissection repair in [**2200-5-20**]. Since that time, he
has been followed with serial echocardiograms for 4+ aortic
insufficiency. He has been undergoing further preoperative
evaluation for a redo operation. Most notably, he underwent a
cardiac catheterization in [**2201-4-20**], which revealed normal
coronary arteries. He also underwent repeat echocardiogram,
which confirmed 4+ aortic insufficiency with 1+ mitral
regurgitation and normal left ventricular function. He also
underwent a chest CT scan, which showed status post dissection
repair with flap extending into the arch. His root did appear
to be somewhat dilated. In review of his studies at this time,
it is recommended that he proceed with a redo sternotomy and
will most likely require a Bental procedure. The risk of this
operation was discussed fully with the patient, and he wishes to
proceed his tentative operative date as [**2201-8-18**].
Past Medical History:
Past Medical History
- Hypertension
- Dyslipidemia
- Fatty Liver
Past Surgical History
- [**2200-5-20**] Replacement of Ascending Aorta with Resuspension of
Aortic Valve
- [**Last Name (un) 8509**] surgery
- Tooth Extractions
Social History:
Lives alone. Works as an attorney. Reports occasional alcohol
use and no tobacco use.
Family History:
Father has hypertension.
Physical Exam:
Physical Exam
Pulse: 92 Resp: 16 O2 sat: 98% ra BP: 135/72
Height: 69 inches Weight: 192lbs
General: WDWN male in no acute distress
Skin: Dry [x] intact [x] - well healed sternotomy and groin
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [**2-23**] diastolic murmur best
heard along the right and left sternal borders
Abdomen: Soft[x] non-distended [x]non-tender[x]bowel sounds +
[x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact
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 Left/Right: trans murmur
Pertinent Results:
[**2201-8-18**] ECHO: PREBYPASS: No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thicknesses are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. A mobile
density is seen in the distal aortic arch consistent with an
intimal flap/aortic dissection. There are three aortic valve
leaflets. Severe (4+) aortic regurgitation is seen. Mild (1+)
mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person
of the results on [**2201-8-18**] at 1000am.
Post bypass: Patient is AV paced and is receiving an infusion of
phenylephrine. Biventricular systolic function is slightly
depressed. The septal and anterior septal walls are mildly
hypokinetic. Mechanical valve seen in the aortic position.
Leaflets move well and the valve appears well seated. Washing
jets typical for this type of valve present. Peak gradient
across the valve is 20 mm Hg and mean gradient is 10 mm Hg.
Brief Hospital Course:
Mr. [**Known lastname 8508**] was admitted to the [**Hospital1 18**] on [**2201-8-18**] for surgical
management of his aortic insufficiency. He was taken to the
operating room where he underwent a redo sternotomy with
replacement of his aortic valve using a mechanical prosthesis.
Please see operative note for details. Postoperatively he was
taken to the intensive care unit for invasive monitoring in
stable condition. Within 24 hours he was weaned from sedation,
awoke neurologically intact and extubated. On post-op day one he
was transferred to the telemetry floor for further care. Chest
tubes and epicardial pacing wires were removed per protocol.
Coumadin was initiated on post-op day one with Heparin bridge
until therapeutic. Heparin was d/c'd and INR was 2.8 on day of
discharge. He was given 3mg coumadin and his INR and coumadin
dosing will be folowed by DR. [**Last Name (STitle) **]. Of note, Mr. [**Known lastname 8508**] did
have an elevation in his LFTS. His abd exam was benign. He will
have follow up LFT's drawn by the VNA and called to Dr. [**Initials (NamePattern4) 6149**] [**Last Name (NamePattern4) 8510**] this week.
Medications on Admission:
Aspirin 81 qd, Metoprolol 50 qd
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Warfarin 1 mg Tablet Sig: as directed by Dr. [**Last Name (STitle) **] Tablet
PO DAILY (Daily): goal INR 2-3.0.
Disp:*90 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
INR check on [**2201-8-24**] and Fax to Dr.[**Last Name (STitle) 8511**] office
[**Telephone/Fax (1) 8512**]
Goal INR 2-3.0
Also check LFT's this week and call results to Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 170**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA
Discharge Diagnosis:
Aortic insufficiency s/p Redo aortic valve replacement
Past Medical History
- Hypertension
- Dyslipidemia
- Fatty Liver
Past Surgical History
- [**2200-5-20**] Replacement of Ascending Aorta with Resuspension of
Aortic Valve
- [**Last Name (un) 8509**] surgery
- Tooth Extractions
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please contact your [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with all wound issues.
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 date of
surgery.
5) No driving for 1 month.
6) Call with any questions or concerns.
7) Coumadin will be followed by coumadin clinic ([**Name8 (MD) 8513**] RN) at
Dr.[**Name (NI) **] office. Goal INR is 2.0-3.0 ([**Telephone/Fax (1) 8514**] fax ([**Telephone/Fax (1) 8515**]. Blood can be drawn by VNA.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**First Name8 (NamePattern2) 8516**] [**Last Name (NamePattern1) **] in [**12-23**] weeks.
Please follow-up with Dr. [**Last Name (STitle) **] in [**12-23**] weeks.
Call all providers for appointments.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2201-11-27**] 11:20
Completed by:[**2201-8-25**]
ICD9 Codes: 4241, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8158
} | Medical Text: Admission Date: [**2178-7-22**] Discharge Date: [**2178-8-3**]
Date of Birth: [**2118-12-13**] Sex: F
Service: SURGERY
Allergies:
Percocet / Ceftriaxone / Flagyl / Levofloxacin / Iodine Strong /
Unasyn / Bactrim / Vancomycin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Left Abdomen Cellulitis of 5 days duration
Weight loss and anorexia x 1 month
Major Surgical or Invasive Procedure:
Incision and drainage of abdominal abcess
Small bowel resection secondary to fistula in communication with
abcess
History of Present Illness:
Patient with known Hep C Cirrhosis (last paracentesis 4 months
ago) presents with 4-5 day history of Left side abdominal
cellulitis. Denies nausea or vomiting, although she notes weight
loss and anorexia over the last month. Denies abdominal pain, no
change in bowel habits.
Past Medical History:
1. Hepatitis C: She is followed in liver clinic, but declined
any interventions. She has evidence of cirrhosis and ascites.
This is believed to have resulted from transfusion 20 years ago
following an ectopic pregnancy
2. Hypertension
3. Cryoglobinemia diagnosed in [**3-23**]
4. Varicose veins status post stripping in [**5-27**] and [**12-29**]
5. Vasculitis: Leukocytoblastic diagnosed on biopsy from [**2-21**]
following 3 year history of difficulty walking and leg pain and
swelling.
6. Hypothyroidism
7. Cholecystectomy in [**2174**] that is thought to be due to chronic
vasculitis from untreated Hepatitis C.
Social History:
She came to the US from [**Country 532**] about 15 years ago. She lives
with her ex-husband, son, and daughter. She requires assistance
in walking to the bathroom and ADLs. She denies alcohol or
tobacco use.
Family History:
Her mother died of coronary arterty disease and hypertension at
the age of 72
Physical Exam:
On Admission:
VS: 101 HR 120's, BP100/50
Cardiac: Tachy
Lungs: clear bilaterally
Abd: Distended with ascites. NT, Left side of abdomen with
cellulitis, desqaumation.
Pertinent Results:
Labs on Admission:
[**2178-7-22**] 03:55AM
GLUCOSE-87 UREA N-16 CREAT-0.5 SODIUM-131* POTASSIUM-3.4
CHLORIDE-97 TOTAL CO2-19* ANION GAP-18
ALT(SGPT)-11 AST(SGOT)-30 ALK PHOS-79 AMYLASE-60 TOT BILI-1.4
LIPASE-28
ALBUMIN-2.3* CALCIUM-7.6* PHOSPHATE-3.3 MAGNESIUM-1.3*
WBC-16.2*# RBC-3.90* HGB-9.4* HCT-28.4* MCV-73* MCH-24.0*
MCHC-33.0 RDW-16.8*
NEUTS-94.2* BANDS-0 LYMPHS-4.1* MONOS-1.5* EOS-0.1 BASOS-0
PLT COUNT-171#
LACTATE-2.9*
FreeCa-1.29
PT-19.8* PTT-50.3* INR(PT)-1.9*
Brief Hospital Course:
59 y/o female with known history of Hep C/cirrhosis and ascites
requiring intermittent paracentesis presents with 4-5 day
duration of abdominal cellulitis.
CT of abdomen/pelvis revealed a large left anterior abdominal
subcutaneous abscess.
She also has a large amount of ascites, as well as moderate
right and small left pleural effusions. Surgical drainage of the
abcess and exploratory laparotomy was performed on [**7-22**] and was
complicated by the need for a small bowel resection due to an
intracutaneous fistula. Patient also underwent lysis of
adhesions and ileoileostomy with repair of abdominal wall
defect. Initially the patient had 2 abdominal JPs and was
started on Vanco and Aztreonam. These were D/C'd and Meropenem
started, then Vanco re-added as well as Fluconazole. Patient
extubated on [**7-24**]. Patient continued to require RBC's, PLts and
FFP. (History of cryoglobulinemia)
Wound Vac started on [**7-25**] to abdominal wound. Strep Viridans
isolated from the abdominal wound. Biopsy of Segments of small
bowel taken during surgery showed Focal necrotizing arteritis.
Focal perforation with surrounding necrosis, acute inflammation,
and serosal reaction, as well as focal villous flattening with
architectural distortion and metaplastic change consistent with
chronic injury.
TPN was started for nutritional support.
On [**7-28**] patient experienced approxiamtely 50 cc BRBPR, receiving
platelets and PRBCs. Hct as low as 23%, on discharge Hct 24.8%,
platelets 146
Wound VAC remained in place, being changed q 3 days. Wound is
reported to be free of any S&S of infection and granulation
tissue is noted.
Patient required detailed explanations of any procedure or
medication she was to receive, and this was better managed with
the use of the Russian interpreter. Patient had not been taking
any medications at home, and used limited ones while at the
hospital. Initially PT was refused, however patient has been
encouraged by many disciplines of the importance of ambulating,
and being OOB. Psych consult was obtained, and the
recommendation to have a translator available when reviewing
procedures and need for medications was made. Treatable
etiologies of dementia were ruled out, and patient was
encouraged to follow up with Social work or other mental health
provider to work out issues of trust with medical system.
TPN continued until discharge, patient should be given
supplements to PO intake with breakfast lunch and dinner.
Appointments as indicated.
Medications on Admission:
None,
refuses to take
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q3-4H
(Every 3 to 4 Hours) as needed.
6. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Focal necrotizing arteritis
S/P small bowel resection
intracutaneous fistula, abdomen
Discharge Condition:
Stable
Discharge Instructions:
Please call [**Telephone/Fax (1) 673**] to notify if patient experiences fever,
chills, change in abdominal wound, difficulty with wound vac, or
other problems concerning to you
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2178-8-6**]
8:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-8-13**] 4:00
Call [**Telephone/Fax (1) 673**] for follow up appointment with surgeon
Completed by:[**2178-8-3**]
ICD9 Codes: 5715, 5119, 5789, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8159
} | Medical Text: Admission Date: [**2139-3-15**] Discharge Date: [**2139-3-20**]
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Mechanical Fall
Major Surgical or Invasive Procedure:
Right hip hemiarthroplasty
History of Present Illness:
This is a [**Age over 90 **] year-old woman with a history of hypertension who
presents with a right hip fracture. The patient was walking with
a nurses aide at home and fell at 8pm last night. Unclear if it
was mechanical fall, but no loss of conciousness and no head
trauma. This AM she was unable to ambulate to breakfast and was
taken to [**Hospital1 **] [**Location (un) 620**] for further eval. She was found to be
tachypneic ith scattered wheezes. She had an eleavted WBC of
14.8 and lactate of 4.0. She was given 2L IVF and given
Vancomycin and Zosyn. She also had a troponinT of 0.1, CK 216,
CK-MB 5.2 and creatinine of 1.4. She was started on heparin gtt.
The patient was oriented x2-3.She remained normotensive and
transferred to the [**Hospital1 **] ED.
.
In the ED, T: 99.6, 86 144/70 18 98% 2L NC. The patient had
plain films that showed "Right basicervical femoral neck
fracture with proximal and lateral displacement of the distal
fracture fragment." She was evaluated by ortho and the family
reversed her code status from DNR/DNI to full code. The family
would like her to undergo surgery. She also underwent a CTA of
her chest that did not show evidence of a PE. Her Trop 0.11, CK
233, MB 6. Cardiology was consulted and recommended d/c heparin
gtt given likely demand in the setting of her hip fracture. The
patient's peripheral lactate was 4.2. The patient became
confused and combative in the ED and was given 2.5mg IV Haldol.
On transfer her vital signs were HR: 82, BP 127/76 RR: 25-30 O2
sat 100% 2L.
.
On arrive the patient denied pain and had no further complaints.
The patient's daughter was present and was able to give a
history. She stated her mother had not been complaining of an
fevers, chills, cough, urinary complaints or symptoms of
illness. She states her mother is usually oriented x2 and is
able to ambulate independently.
Past Medical History:
hypertension
Mild Dementia
Social History:
Lives with her daughter at home. She has VNA and a nursing aide
at home.
Remote smoking history. No EtOH or drug use.
Family History:
non-contributory
Physical Exam:
Admission Exam:
GEN: no acute distress, oriented x1
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dry MM
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
[**Hospital1 **]: No C/C/E, right leg shortened and externally rotated
distal pulses present, but diminished b/l
NEURO: oriented to person only. CN II ?????? XII grossly intact.
Moves all extremities [**Hospital1 **] right leg secondary to pain. Patellar
DTR +1. Plantar reflex downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission Labs:
[**2139-3-15**] 06:35PM PT-13.3 PTT-150* INR(PT)-1.1
[**2139-3-15**] 06:35PM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-1.7
[**2139-3-15**] 06:35PM CK-MB-6
[**2139-3-15**] 06:35PM cTropnT-0.11*
[**2139-3-15**] 06:35PM CK(CPK)-233*
[**2139-3-15**] 06:35PM GLUCOSE-165* UREA N-24* CREAT-1.0 SODIUM-138
POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-18* ANION GAP-23*
[**2139-3-15**] 06:39PM HGB-11.6* calcHCT-35
[**2139-3-15**] 06:39PM GLUCOSE-122* LACTATE-4.2* NA+-140 K+-4.8
[**2139-3-15**] 06:59PM WBC-13.8* RBC-4.63 HGB-13.7 HCT-41.5 MCV-90
MCH-29.7 MCHC-33.1 RDW-13.5
.
Cardiac Enzymes
[**2139-3-15**] 06:35PM BLOOD cTropnT-0.11*
[**2139-3-16**] 04:51AM BLOOD CK-MB-6 cTropnT-0.11*
[**2139-3-16**] 03:17PM BLOOD CK-MB-7 cTropnT-0.07*
.
Discharge Labs
[**2139-3-20**] 05:22AM BLOOD WBC-6.1 RBC-3.26* Hgb-9.9* Hct-29.9*
MCV-92 MCH-30.3 MCHC-33.2 RDW-13.8 Plt Ct-176
[**2139-3-20**] 05:22AM BLOOD Glucose-113* UreaN-19 Creat-0.7 Na-142
K-4.0 Cl-110* HCO3-26 AnGap-10
[**2139-3-20**] 05:22AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.9
.
[**2139-3-15**] Chest CT
IMPRESSION:
1. No pulmonary embolus or aortic dissection.
2. Extensive mural thrombus within the thoracic aorta,
particularly within
the aortic arch.
3. Evidence of prior granulomatous disease.
4. 7 mm nodule in the right lower lobe. If clinically indicated,
a chest CT in six months can be performed.
5. T10 compression deformity of uncertain age.
.
[**2139-3-15**] Hip Xrays
IMPRESSION: Right basicervical femoral neck fracture with
proximal and
lateral displacement of the distal fracture fragment.
.
[**2139-3-15**] Femur Xray
IMPRESSION: Right basicervical femoral neck fracture with
proximal and
lateral displacement of the distal fracture fragment.
.
[**2139-3-15**] Chest xray
IMPRESSION: Mild bibasilar atelectasis.
.
[**2139-3-17**] Femoral Pathology
Report not finalized.
Assigned Pathologist [**Last Name (LF) **],[**First Name3 (LF) **] L.
Please contact the pathology department, [**Name (NI) **] [**Numeric Identifier 1434**]
PATHOLOGY # [**Numeric Identifier 51824**]
femoral head.
.
[**2139-3-17**] Hip films intra-op
Single AP radiograph of the right hip obtained in O.R. Since
exam two days
ago, the fractured and displaced right femoral neck and head
have been
replaced with a bipolar hemiarthroplasty with non-cemented
femoral stem. The distal tip of the stem is not imaged and a
single cerclage wire is present.
.
[**2139-3-17**] Chest xray
The ET tube tip is 4.5 cm above the carina. Cardiomediastinal
silhouette is stable. There is interval development of left
lower lobe opacity, consistent with atelectasis with obscuration
of the left hemidiaphragm. The rest of the lungs are essentially
clear. No pleural effusion or pneumothorax is present.
Brief Hospital Course:
Ms. [**Known lastname 51825**] is a [**Age over 90 **] year old woman with a history of hypertension
who presented with a right hip fracture.
.
#. Hip Fracture: She had a witnessed mechanical fall at home.
She underwent a right hip hemiarthroplasty on [**3-17**]. Her dressing
was changed on [**3-19**]. She was started on enoxaparin on [**3-19**]. She
is to continue enoxaparin for a total of four weeks. Last day is
[**4-14**]. Her weight bearing status was advanced to weight bearing
as tolerated by the orthopedic team. She has follow up scheduled
with the orthopedic service.
# Hypotensive episode: Follwoing her procedure she became
hypotensive. This was thought likely secondary to anesthesia
medications. She improved after brief treatment with levophed.
.
#. Demand Ischemia: On admission Ms. [**Known lastname 51825**] had an elevated
troponin of 0.11. However, CK was 233 which trended to 182 (MB 6
-> 6). Cardiology felt that this event was likely demand and not
an acute thrombus. She was initially started on a heparin gtt,
but this was discontinued on the advice of cardiology. She was
continued on aspirin and started on metoprolol.
.
#. Leukocytosis: She presented with an elevated white blood cell
count. She was intially treated with vancomycin and Zosyn
empirically. No evidence of infection was found. Her white count
gradually normalized. Her antibiotics were discontinued prior to
discharge.
.
#. Fall: Ms. [**Known lastname 51825**] had a witnessed fall while walking with
nurses aide. There was no head trauma and no evidence of
syncope.
.
#. Delerium: Ms. [**Known lastname 51825**] has dementia at baseline. Her mental
status was worsened in the MICU. Her delirium was improved with
pain control and maintenance of sleep wake cycles.
.
#. Hypertension: She was continued on home lisinopril ans
started on metoprolol as described above.
.
# Nutrition: She was evaluated by the speech and swallow out of
concern for aspiration. A diet of soft solids and thin liquids
was recommended. A discussion was held with the daughter about
the risks of aspiration. The decision was made by her daughter
to allow her to eat despite the risk of aspiration.
.
# s/p Bowel Obstruction: Ms. [**Known lastname 51825**] was seen by the wound care
nurse [**First Name (Titles) **] [**Last Name (Titles) **] of her ostomy. There was concern over the
low output from the ostomy. However, Ms. [**Known lastname 51826**] daughter had
changed the bag. She was having good output at the time of
discharge.
.
# Code status: Ms. [**Known lastname 51825**] was admitted with a DNR/DNI order.
However, this was changed during the procedure. Following
recovery from her surgery, it was changed back to DNR/DNI.
Medications on Admission:
Lisinopril 20mg daily
ASA 81mg daily
Colace
Prevacid
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous DAILY (Daily) for 24 days: Please continue until
[**4-14**].
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
13. Metoprolol tartrate 25 mg tablet Sig: 1 tablet PO every
eight hours. Please hold for HR<60 or SBP<95.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Primary Diagnosis:
Right Hip Fracture
Demand Ischemia
Delirium
Secondary Diagnosis:
Hypertension
Anemia
Dementia
s/p bowel obstruction with ostomy
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital because you had a mechanical fall at
home. You fractured your right hip. While you were in the
hospital, you were admitted to the intensive care unit because
there was concern about your heart function.
We started several new medications while in the hospital.
We started metoprolol, a medication to control your heart rate
and blood pressure.
We also started enoxaparin or Lovenox, a blood thinner that you
will take during the next month to reduce your risk of blood
clots.
We also started medication to help control your pain and help
move your bowels.
Followup Instructions:
We scheduled a follow up appointment for you with the orthopedic
department. Your appointment is scheduled on Tuesday, [**4-7**]
at 10:20. This is located at the [**Hospital Ward Name 23**] building, [**Location (un) 1773**].
ICD9 Codes: 2762, 5180, 2930, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8160
} | Medical Text: Admission Date: [**2144-10-15**] Discharge Date: [**2144-10-24**]
Date of Birth: [**2068-3-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Transferred from [**Hospital 61603**] Hospital in NY for treatment of
Tracheoesophageal Fistula
Major Surgical or Invasive Procedure:
[**10-15**] 1. Rigid bronchoscopy at the yellow Dumon bronchoscope,
Flexible bronchoscopy with therapeutic aspiration,
Bronchoalveolar lavage of the left lower lobe, Balloon
dilatation, left main stem, Stent placement. Ultraflex 40 x 14
covered stent, left main stem, Silicone Y-stent placement.
[**10-16**] Flexible bronchoscopy, Stent revision, Therapeutic
aspiration of secretions
[**10-16**] Thoracentesis under thoracic ultrasound.
[**10-18**] Flexible bronchoscopy, Therapeutic aspiration of
secretions.
Placement of A-line, CVL R IJ (both removed)
History of Present Illness:
The patient is a 76 yo non-smoker with NSCLCA, dx'd 1 year ago
s/p chemo/XRT, believed to be in remission who was [**2144-9-23**] for a
TIA who was found to have a tracheo-esophageal fistula (large
defect in esophagus, two small defects
in distal trachea lateral to LMS and carina) who underwent
Esophageal stent 1 wk ago but remained intubated on vent with
difficult weaning. Bronch one week ago demonstrated erosion of
stent thru posterior tracheal membrane. The patient was
transferred per the family's request for further management of
the TEF.
Past Medical History:
HTN, AFib
NSCLCA: originally treated with tarceva only, then LAD
progressed and treated with chemo/XRT. LUL opacity developed
after XRT and attributed to post rad changes (per son) - PET
negative and has subsequently decreased in size,
Vertigo, h/o hemoptysis while AC, B TKR, ccy, breast ca s/p
lumpectomy
Social History:
Strong family support, married with two sons
Family History:
noncontributory
Physical Exam:
Upon discharge:
NAD A and Ox3
PERRL, dry mucus membranes, no JVD, R CVL dressing IJ in place
irreg irreg ? sys murmur at URSB
coarse bs at bases b/l
soft NT/ND
Foley in place
no c/c slight edema LE 2+ DP b/l
L PICC UE
R arm severe ecchymoses
Pertinent Results:
[**2144-10-23**] 02:42AM BLOOD WBC-5.9 RBC-2.70* Hgb-7.9* Hct-23.8*
MCV-88 MCH-29.2 MCHC-33.1 RDW-19.6* Plt Ct-118*
[**2144-10-15**] 11:09AM BLOOD WBC-7.0 RBC-2.94* Hgb-8.8* Hct-26.6*
MCV-90 MCH-29.9 MCHC-33.1 RDW-20.6* Plt Ct-95*
[**2144-10-23**] 02:42AM BLOOD Plt Ct-118*
[**2144-10-15**] 11:09AM BLOOD PT-12.7 PTT-53.3* INR(PT)-1.1
[**2144-10-23**] 02:42AM BLOOD Glucose-148* UreaN-22* Creat-0.4 Na-136
K-3.5 Cl-99 HCO3-29 AnGap-12
[**2144-10-15**] 11:09AM BLOOD Glucose-81 UreaN-47* Creat-0.7 Na-145
K-4.4 Cl-109* HCO3-29 AnGap-11
[**2144-10-18**] 02:27AM BLOOD ALT-31 AST-18 LD(LDH)-402* AlkPhos-118*
TotBili-0.6
[**2144-10-23**] 02:42AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.7
[**2144-10-15**] 11:09AM BLOOD Albumin-2.9* Calcium-7.9* Phos-4.2 Mg-2.1
[**2144-10-23**] 02:41AM BLOOD Vanco-12.3
[**2144-10-23**] 11:49AM BLOOD Type-ART pO2-106* pCO2-31* pH-7.56*
calTCO2-29 Base XS-6
[**2144-10-15**] 11:17AM BLOOD Type-ART pO2-213* pCO2-48* pH-7.39
calTCO2-30 Base XS-3
Brief Hospital Course:
PROCEDURES DURING ADMISSION
[**10-15**] 1. Rigid bronchoscopy at the yellow Dumon bronchoscope,
Flexible bronchoscopy with therapeutic aspiration,
Bronchoalveolar lavage of the left lower lobe, Balloon
dilatation, left main stem, Stent placement. Ultraflex 40 x 14
covered stent, left main stem, Silicone Y-stent placement.
[**10-16**] Flexible bronchoscopy, Stent revision, Therapeutic
aspiration of secretions
[**10-16**] Thoracentesis under thoracic ultrasound.
[**10-18**] Flexible bronchoscopy, Therapeutic aspiration of
secretions.
Placement of A-line, CVL R IJ
# TRACHEOESOPHAGEAL FISTULA
The patient was transferred intubated from [**Hospital 61603**] Hospital
in NY on [**10-15**] for stent revision to a tracheo-esophageal
fistula.
On [**10-16**] she underwent a CT scan that revealed collapse of the
left lung with partial sparing of the lingula. Left main
bronchus stent was seen in place and was patent, although there
was diffuse attenuation of the airways distal to the stent on
the left, with moderate pleural effusions b/l.
That day she underwent rigid and flexible bronchoscopy with
therapeutic aspiration, BAL of left lower lobe, Balloon
dilatation, left main stem Ultraflex 40 x 14 covered stent, and
left main stem Silicone Y-stent placement. THe patient
tolerated the procedure well, although she remained with copious
secretions, and so underwent stent revision on [**10-16**] and again
on [**10-18**].
On [**10-17**] she was extubated, which she tolerated well although
with need for frequent suctioning, chest PT, and required
therapeutic bronchoscopy for secretions on [**10-18**]. She was also
maintained on scheduled nebulizers and prednisone.
On [**10-21**] she underwent a Barium swallow to assess for the TEF,
but the patient was unable to complete the study as she
aspirated the Barium during the study. However, contrast was
seen within the left main stem bronchus and distal airways, most
likely reflecting aspiration although without lateral views,
persistent tracheoesophageal fistula could not be excluded.
On [**10-22**] she had a follow up CXR that revealed: The stent,
central venous access line, and abdominal drain are in unchanged
position. The right-sided basal consolidation has decreased in
extent. The left retrocardiac atelectasis is unchanged. Also
unchanged is still moderate cardiomegaly. Unchanged mediastinal
widening and increase in mediastinal diameter. No newly occurred
focal parenchymal opacities.
# VENTILATOR ASSOCIATED PNEUMONIA
The BAL on [**10-18**] revealed MRSA > 100K, and so the patient was
started on IV vancomycin for a total therapy duration of two
weeks. She remained afebrile and hemodynamically stable
throughout her stay.
#PLEURAL EFFUSION
On [**10-16**] the patient underwent thoracentesis given radiologic
and clinic findings that was transudative in nature, with
Glucose 214, LDH 170, and total protein of 2.5. She was also
started on lasix for diuresis.
# HYPERTENSION
The patient's hypertension was eventually controlled through a
combination of clonidine patch, enalapril, labetolol, and
metoprolol.
# ATRIAL FIBRILLATION
The patient has a history of Atrial fibrillation and was
initially placed on IV diltiazem and esmolol for rate control,
which was then converted to PO meds via the PEG; however, her
rate was not controlled until she was digoxin loaded on [**10-19**] and
her rate slowed from AF in the 120s to the 80s. She was then
placed on her home dose of digoxin 0.125 mg/day, which
controlled her rate throughout her stay.
# ATRIAL THROMBUS
The CT on [**10-16**] revealed a filling defect along posterosuperior
wall of left atrium could represent direct extension of tumor or
intraluminal thrombus. Given this finding in the presence of
Atrial Fibrillation, she underwent an echocardiogram that
revealed a possible 1.1cm mass in the body of LA,Mild-moderate
mitral regurgitation, Mild pulmonary artery systolic
hypertension, mild symmetric left ventricular hypertrophy, but
normal cavity size and global systolic function (LVEF>55%).
She was then placed on therapeutic lovenox for the fibrillation
and the thrombus, and given her history of a TIA, even though
she is at a risk for falls.
# DYSPHAGIA
The patient had a PEG tube placed by IR on [**10-16**] given that she
was intubated for feeding. She was started on tube feeds [**10-17**],
which she tolerated, and she was kept NPO given that she
aspirated during her [**10-21**] Barium swallow.
# C DIFFICILE
The patient was transferred from [**Location (un) 61603**] with a history of C
difficile diarrhea, and so she was kept on her PO vancomycin.
# ANEMIA
The patient was admitted from [**Location (un) 61603**] with anemia (Hct 26.6),
which has slowly trended down to 23.8, likely secondary to
phlebotomy. This should be followed in the future, and her
baseline anemia is of unknown etiology.
Medications on Admission:
catapres TTS qwed, nexium 40 qday, solumedrol 10 qday, reglan 10
q6, enalapril 1.35 q4, haldol 1 q4prn, vanc 250 q6, xopenex
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Location (un) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Vancomycin 250 mg Capsule [**Location (un) **]: One (1) Capsule PO Q6H (every
6 hours).
3. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Ointment [**Location (un) **]: One
(1) Appl Topical [**Hospital1 **] (2 times a day) as needed.
4. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day): Hold for loose stool.
5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day): Hold for loose stool.
6. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID
(3 times a day): Hold for SBP < 110, HR < 60.
7. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1)
Injection ASDIR (AS DIRECTED).
8. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: One (1) ML
Miscellaneous Q6H (every 6 hours).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours).
10. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO BID (2 times
a day).
11. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H
(every 6 hours).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Diltiazem HCl 90 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day) as needed for atrial fibrillation: Hold for HR <
60, SBP < 110.
15. Enoxaparin 80 mg/0.8 mL Syringe [**Last Name (STitle) **]: One (1) Subcutaneous
Q12H (every 12 hours).
16. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times
a day): Decrease pending creatinine levels.
17. Enalapril Maleate 10 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO DAILY
(Daily) as needed for HTN: Hold for SBP <110.
18. Clonidine 0.3 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
19. Hydrochlorothiazide 12.5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily): Hold for SBP < 110.
20. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Last Name (STitle) **]: Five
(5) ML PO BID (2 times a day).
21. Digoxin 250 mcg/mL Solution [**Last Name (STitle) **]: One (1) Injection DAILY
(Daily).
22. Labetalol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times
a day): Hold for SBP < 110, HR < 60.
23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
24. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q 24H (Every 24 Hours) for 7 days: Last day [**10-30**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 686**]
Discharge Diagnosis:
Tracheo-esophageal Fistula, HTN, Atrial Fibrillation, Atrial
Thrombus, dysphagia
PMx:
Non-small cell lung cancer s/p chemo, XRT, Atrial Fibrillation,
HTN, Vertigo, h/o hemoptysis while AC, B TKR, ccy, breast ca s/p
lumpectomy
Discharge Condition:
Stable
Discharge Instructions:
1. Give medicines as prescribed (through the J tube unless
otherwise specified); adjust
2. q2 hour chest PT and suction
3. Oxygen therapy to maintain saturations 90-95%
4. Physical therapy
5. Check CBC, electrolytes once weekly; transfuse as needed
6. Check digoxin level in one week
Followup Instructions:
1. Follow-up with Dr [**Last Name (STitle) **]; call office for appointment
2. Follow up with your primary care physician
3. [**Month (only) 116**] reconsider your lovenox therapy in future as determined
by safety given your atrial thrombus but also your fall risk
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2144-10-24**]
ICD9 Codes: 5119, 5180, 4240, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8161
} | Medical Text: Admission Date: [**2196-2-1**] Discharge Date: [**2196-2-18**]
Date of Birth: [**2138-7-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ancef / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2-1**] Redo-sternotomy, Aortic Valve replacement (23mm St. [**Male First Name (un) 923**]
tissue), Ascending aorta and hemi-arch replacement (28mm
Gelweave), Aortic Endarterectomy
[**2-4**] Temporary screw in lead
[**2-16**] permanent pacemaker insertion
History of Present Illness:
57 year old female with history of bioprosthetic aortic valve
replacement in [**2182**] with serial echocardiograms that have shown
worsening aortic valve gradients. Currently complaining of
dyspnea on exertion with recent admission in [**Month (only) **] for heart
failure.
Past Medical History:
Ascending aortic aneurysm, Bicuspid aortic valve s/p aortic
valve replacement [**2182**], Bilateral breast cancer s/p
Lumpectomy/XRT/Chemotherapy, Chronic lymphocytic leukemia s/p
chemotherapy, h/o Active tuberculosis [**2159**], Splenomegaly,
Cholelithiasis, s/p repair of cerebral AVM [**2169**]
Social History:
[**Name6 (MD) 1403**] as RN on oncology unit
Lives with spouse
[**Name (NI) 1139**] quit 30 year ago
ETOH denies
Family History:
Mother and father both died of cardiac disease suddenly
Physical Exam:
VS: 90 16 90/70 5'3" 125#
Gen: No acute distress
Skin: Unremarkable with well-healed sternotomy incision
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Clear lungs bilat.
Heart: Regular rate and rhythm with 2/6 systolic murmur
radiating to carotids
Abd: Soft, non-tender, non-distended +bowel sounds
Ext: Warm, well-perfused, -edema
Neuro: Grossly intact, alert and oriented x 3
Pertinent Results:
[**2196-2-18**] 05:52AM BLOOD WBC-7.0 RBC-3.17* Hgb-9.4* Hct-27.4*
MCV-87 MCH-29.5 MCHC-34.1 RDW-15.9* Plt Ct-278
[**2196-2-1**] 01:12PM BLOOD WBC-16.8*# RBC-2.16*# Hgb-6.8*#
Hct-20.2*# MCV-93 MCH-31.5 MCHC-33.8 RDW-14.3 Plt Ct-103*
[**2196-2-18**] 05:52AM BLOOD Plt Ct-278
[**2196-2-18**] 05:52AM BLOOD PT-13.2 PTT-26.1 INR(PT)-1.1
[**2196-2-17**] 04:45AM BLOOD PT-12.9 INR(PT)-1.1
[**2196-2-1**] 01:12PM BLOOD PT-16.3* PTT-53.7* INR(PT)-1.5*
[**2196-2-9**] 03:45AM BLOOD Fibrino-646*#
[**2196-2-6**] 02:29AM BLOOD Ret Aut-3.9*
[**2196-2-18**] 05:52AM BLOOD Glucose-92 UreaN-20 Creat-0.4 Na-140
K-4.1 Cl-101 HCO3-31 AnGap-12
[**2196-2-1**] 03:17PM BLOOD UreaN-24* Creat-0.8 Cl-108 HCO3-31
[**2196-2-16**] 05:42AM BLOOD Calcium-9.8 Phos-4.7* Mg-2.0
[**2196-2-2**] 02:00AM BLOOD Phos-3.6 Mg-2.0
[**2196-2-14**] 05:30AM BLOOD TSH-4.0
[**2196-2-14**] 05:30AM BLOOD Free T4-1.2
[**2196-2-10**] 01:54AM BLOOD Cortsol-17.6
[**Known lastname **],[**Known firstname **] [**Medical Record Number 107464**] F 57 [**2138-7-3**]
Cardiology Report ECG Study Date of [**2196-2-17**] 7:52:02 AM
Sinus rhythm with atrial sensing and ventricular pacing.
Ventricular ectopy.
Compared to the previous tracing atrial fibrillation is no
longer present and
pacing is new.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
99 0 140 392/460 0 130 -51
CHEST, PORTABLE
REASON FOR EXAM: 57-year-old woman with CHB status post AVR. New
PM implant.
Rule out pneumothorax, lead location.
Since [**2196-2-11**], left-sided pacemaker was removed and
right-sided
pacemaker was installed, ending in the right atrium and right
ventricle.
There Dobbhoff tube is still in place, ending below the
diaphragm with its tip
not imaged on today's study. A right-sided PICC was also
installed ending in
the mid SVC.
Small right pleural effusion, increased with basilar opacity.
Left lower lobe
atelectasis improved. There is no pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2196-2-16**] 5:52 PM
Provisional Findings Impression: JXRl TUE [**2196-2-9**] 6:02 PM
Findings concerning for right frontal infarct with loss of
[**Doctor Last Name 352**]-white matter
differentiation (2:24-25).
Final Report
HISTORY: 57-year-old woman status post aortic valve replacement
with left
hemiparesis. Assess for CVA.
COMPARISON: Non-contrast head CT from [**2196-2-2**].
TECHNIQUE: Non-contrast head CT was obtained.
FINDINGS: Loss of [**Doctor Last Name 352**]-white differentiation associated with a
subtle region
of hypodensity within the right frontal lobe near the vertex
(2:24-25), new in
comparison to CT [**2196-2-2**], is concerning for relatively
acute
infarction.
There is no intracranial hemorrhage, mass effect or shift of
normally midline
structures. The ventricles and basal cisterns are normal and
unchanged in
size and configuration.
Post-operative changes of the right temporal lobe, with apparent
right
temporal resection and overlying right temporal bone craniotomy
are unchanged.
Bones are otherwise unremarkable without lesions suspicious for
metastases.
Paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION:
1. Findings concerning for relavtively acute right frontovertex
infarct.
2. Unchanged findings of right temporal lobe resection.
COMMENT: The findings were discussed with Mr. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] (NP,
Cardiothoracic Surgery service) by Dr. [**Last Name (STitle) 20059**] on [**2196-2-9**], at
approximately
6pm. Findings can be further evaluated with MRI if clinically
indicated.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
Approved: WED [**2196-2-10**] 9:00 AM
Brief Hospital Course:
Mrs. [**Known lastname 97236**] was a same day admit after undergoing
pre-operative work-up prior to her admission. She was taken
directly to the operating room where she underwent a
redo-sternotomy with an aortic valve replacement as well as an
ascending aorta and hemi-arch replacement. Please see operative
report for surgical details. Postoperatively she was taken to
the intensive care unit for invasive monitoring. She was noted
to be in complete heart block and was paced with epicardial
pacing. She was quite slow to wean from sedation and focal
facial seizures were noted. A neurology consult was obtained and
a CT scan was performed. The CT scan was inconclusive and an MRI
was recommended but unable due to epicardial wires. Extubation
was delayed due to concern for airway protection. An EEG was
performed which was abnormal suggesting a widespread
encephalopathy or a metabolic anoxic or postictal etiology. A
video EEG was performed which did not show any seizure activity
but did show a markedly encephalopathic background. Keppra was
continued for control of seizure activity. The cardiology
service was consulted for her complete heart block. She was
taken to the electrophysiology [**Known lastname **] where a temporary screw in
pacemaker was placed. Tube feed and intravenous vitamins were
started for nutritional support. She slowly became more alert
moving her right side and only responding to painful stimuli on
her left side. The neurology service felt that all her symptoms
were consistent with a brainstem infarct. On postoperative day
five she was successfully extubated without incident. She
continued with left sided weakness however physical and
occupational therapy were consulted to work with her for range
of motion activity. Mrs. [**Known lastname 97236**] developed a fever and was
pancultured. Vancomycin and zosyn were started. Her sputum
culture revealed serratia marcescens and ceftriaxone was
started. She continued to improve from a neurological standpoint
however remained with no spontaneous left sided movement. She
underwent repeat CT scan that had findings concerning for
relavtively acute right frontovertex infarct. Her mental status
also improved where she could answer questions and respond to
commands. Mrs. [**Last Name (STitle) 107465**] was transferred from the ICU on post
operative day thirteen. A permanent pacemaker insertion and
cardioversion on post operative day fourteen. She was started
on coumadin and amiodarone for atrial fibrillation. She has
continued to make slow progression, please see speech,
occupational and physical therapy notes.
Sternal incision no erythema no drainage
no edema
weight preop 55 kg and discharge 52 kg
Medications on Admission:
Lasix 40mg qd, Toporol XL 25mg qd, Femara 25mg qd, Calcium and
multiple vitamins
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2
times a day). ml
2. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Levetiracetam 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day): Continue - if questions please contact Dr [**Last Name (STitle) 107466**]
[**Name (NI) 1693**] (neurology).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
6. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times
a day): 400mg twice a day through [**2-23**] then decrease to 400 mg
once daily through [**3-1**], then decrease to 200mg and follow up
with Dr [**Last Name (STitle) **] .
7. Clindamycin HCl 150 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO Q6H
(every 6 hours) as needed for PM implant for 7 doses.
8. Warfarin 3 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day for 1
days: 3mg [**2-19**] and recheck INR [**2-20**] for further dosing - goal
INR 2-2.5 for atrial fibrillation .
9. Femara 2.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
10. medications
Please consider starting betablocker when blood pressure will
tolerate, then if stable start ace inhibitor, unable to start
during hospitalization due to blood pressure
11. Outpatient [**Name (NI) **] Work
PT/INR for coumadin dosing, goal INR 2-2.5 with first draw [**2-20**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Bioprosthetic aortic stenosis s/p Aortic Valve replacement
Ascending aortic aneurysm s/p replacement
Complete heart block s/p permanent pacemaker placement
Post operative atrial fibrillation
Right frontal infarction
Seizure
Acute on Chronic systolic heart failure
PMH: Bicuspid aortic valve s/p aortic valve replacement [**2182**],
Bilateral breast cancer s/p Lumpectomy/XRT/Chemotherapy, Chronic
lymphocytic leukemia s/p chemotherapy, h/o Active tuberculosis
[**2159**], Splenomegaly, Cholelithiasis, s/p repair of cerebral AVM
[**2169**]
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) 4044**].
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:
Dr. [**Last Name (STitle) **] in [**1-12**] weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] in [**2-10**] weeks
Dr. [**Last Name (STitle) 4390**] after discharged from rehab [**Telephone/Fax (1) 3070**]
Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**] after discharged from rehab ([**Telephone/Fax (1) 22692**]
Dr [**Last Name (STitle) 1837**] - [**Hospital **] clinic - [**3-20**] at 11 am [**Telephone/Fax (1) 41**]
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2196-2-24**]
11:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2196-3-8**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2196-3-8**] 10:00
Completed by:[**2196-2-18**]
ICD9 Codes: 9971, 5185, 4241, 4280, 2859, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8162
} | Medical Text: Admission Date: [**2111-12-29**] Discharge Date: [**2112-1-3**]
Date of Birth: [**2039-10-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
Mitral Valve Repair [**2111-12-29**]
History of Present Illness:
72 y.o. old primary care physician with [**Name Initial (PRE) **] history of severe
mitral regurgitation, new onset acute diastolic congestive heart
failure. He reports occasional palpitations. He denies shortness
of breath, PND, orthopnea, presyncope, or syncope. He reports
mild dependent chronic 1+ bilateral LE edema. TEE revealed
mildly thickened and myxomatous mitral valve leaflets, moderate
to severe MVP with severe 4+MR. [**Name13 (STitle) **] was evaluated by Dr. [**Last Name (STitle) **]
and agreed to proceed with elective mitral valve repair.
Past Medical History:
Mitral Regurgitation/Mitral valve prolapse
Hypertension
SVT/Atrial Tachycardia
Diverticulosis
Nephrolithiasis
Polymyalgia Rheumatica
Osteopenia
Low Back Pain/Sciatica
OSA-compliant with cpap
Left knee arthroscopic knee surgery; case was done under general
anesthesia and patient reports post anesthesia course
complicated
by a bronchospastic reaction along with oxygen desataturation,
which required overnight observation prior to discharge. No
issues with conscious sedation during prior colonoscopy.
Social History:
Lives with wife [**Name (NI) **]
Occupation: PCP
[**Name Initial (PRE) 1139**]: remote- quit 25 yo
ETOH: [**1-22**] drinks a week
Family History:
Non-contributory
Physical Exam:
Pulse: 60SR Resp: 20 O2 sat:
B/P Right: 112/64 Left:
Height: 5'9" Weight: 150lb
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 systolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema- trace
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:
no bruits
Pertinent Results:
[**2111-12-29**]:Conclusions
PRE-CPB:
The left atrium is moderately dilated. No thrombus is seen in
the left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler.
Left ventricular wall thicknesses are normal. Overall left
ventricular systolic function is normal (LVEF>55%).
The RV systolic function is borderline low normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Trivial aortic regurgitation is seen.
The mitral valve leaflets are myxomatous. The portion of the
mitral leaflet between P2 and P3 is flail with ruptured chord.
There is a anteriorly directed jet of severe MR [**First Name (Titles) 151**] [**Last Name (Titles) 96316**]
effect. There is a smaller central MR jet.
POST-CPB:
A mitral valve annuloplasty ring is present. The anterior
leaflet spans the entire length of the mitral annulus, and the
posterior leaflet is minimally visible, consistent with a mitral
valve repair. There is no residual MR. The peak gradient across
the mitral valve is 6mmHg, the mean gradient is 3mmHg.The TR is
now mild.
The LV systolic function is borderline normal with no new wall
motion abnormalities. The RV systolic function appears improved
to normal.
There is no evidence of dissection.
[**2112-1-1**] CXR: FINDINGS: In comparison with the study of [**12-30**],
there is partial clearing of the bilateral atelectatic change,
though opacification persists in the retrocardiac region at the
left base. Blunting of the costophrenic angles is again seen. No
evidence of pneumothorax.
[**2111-12-29**] 11:32AM BLOOD WBC-1.6*# RBC-2.80*# Hgb-8.8*# Hct-25.0*#
MCV-90 MCH-31.4 MCHC-35.1* RDW-13.5 Plt Ct-95*
[**2111-12-29**] 12:10PM BLOOD WBC-4.7# RBC-3.44* Hgb-10.6* Hct-30.6*
MCV-89 MCH-30.8 MCHC-34.7 RDW-13.5 Plt Ct-103*
[**2111-12-29**] 07:15PM BLOOD Hct-32.3*
[**2111-12-30**] 04:16AM BLOOD WBC-6.1 RBC-3.54* Hgb-11.2* Hct-31.6*
MCV-89 MCH-31.6 MCHC-35.4* RDW-13.5 Plt Ct-100*
[**2111-12-31**] 04:16AM BLOOD WBC-7.6 RBC-3.70* Hgb-11.5* Hct-32.5*
MCV-88 MCH-31.0 MCHC-35.3* RDW-13.4 Plt Ct-99*
[**2112-1-1**] 05:05AM BLOOD WBC-5.7 RBC-3.46* Hgb-10.7* Hct-31.1*
MCV-90 MCH-31.0 MCHC-34.4 RDW-13.4 Plt Ct-102*
[**2111-12-29**] 11:32AM BLOOD PT-15.4* PTT-36.1* INR(PT)-1.3*
[**2111-12-29**] 11:32AM BLOOD Plt Smr-LOW Plt Ct-95*
[**2111-12-29**] 12:10PM BLOOD PT-14.4* PTT-38.4* INR(PT)-1.2*
[**2111-12-29**] 12:10PM BLOOD Plt Ct-103*
[**2111-12-30**] 04:16AM BLOOD Plt Ct-100*
[**2111-12-31**] 04:16AM BLOOD Plt Smr-LOW Plt Ct-99*
[**2112-1-1**] 05:05AM BLOOD Plt Ct-102*
[**2111-12-29**] 12:10PM BLOOD UreaN-16 Creat-0.9 Na-142 K-4.3 Cl-112*
HCO3-25 AnGap-9
[**2111-12-29**] 07:15PM BLOOD Na-142 K-4.2 Cl-112*
[**2111-12-30**] 04:16AM BLOOD Glucose-122* UreaN-17 Creat-0.9 Na-140
K-4.5 Cl-109* HCO3-26 AnGap-10
[**2111-12-31**] 04:16AM BLOOD Glucose-128* UreaN-20 Creat-1.0 Na-136
K-3.8 Cl-100 HCO3-31 AnGap-9
[**2112-1-1**] 05:05AM BLOOD UreaN-21* Creat-1.0 Na-138 K-3.9 Cl-100
[**2112-1-1**] 11:12PM BLOOD Glucose-112* UreaN-18 Creat-1.0 Na-137
K-4.2 Cl-99 HCO3-31 AnGap-11
Brief Hospital Course:
The patient was brought to the operating room on [**2111-12-29**] where
the patient underwent mitral valve repair with 28mm ring.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility and cleared
for discharge to home. By the time of discharge on POD 5 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. His home ACE inhibitor was
not added back secondary to hypotension. The patient was
discharged [**2112-1-3**] in good condition with appropriate follow up
instructions.
Medications on Admission:
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
one Capsule(s) by mouth qweek
FUROSEMIDE - 20 mg Tablet - [**11-22**] tab Tablet(s) by mouth once a
day
- No Substitution
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day - No Substitution
SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth as
directed
ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth
daily
CALCIUM CITRATE [CALCITRATE] - (Prescribed by Other Provider) -
200 mg (950 mg) Tablet - 1 (One) Tablet(s) by mouth twice a week
CYANOCOBALAMIN (VITAMIN B-12) - (Prescribed by Other Provider)
-
1,000 mcg Tablet Sustained Release - 1 Tablet(s) by mouth twice
a
week
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - 1,000 unit
Capsule - 1 Capsule(s) by mouth daily
RANITIDINE HCL - (OTC) - 150 mg Tablet - 1 Tablet(s) by mouth
prn as needed for GERD
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
4. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO Q12H (every 12 hours).
Disp:*20 Tablet, ER Particles/Crystals(s)* Refills:*0*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week: Per home routine.
11. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day: Per home routine.
12. Vitamin B-12 1,000 mcg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a week: Per home routine.
13. calcium citrate 200 mg (950 mg) Tablet Sig: One (1) Tablet
PO twice a week: Per home routine.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral Regurgitation/Mitral Valve Prolapse
Hypertension
SVT/Atrial Tachycardia
Diverticulosis
Nephrolithiasis
Polymyalgia Rheumatica
Osteopenia
Low Back Pain/Sciatica
Obstructive Sleep Apnea
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema:2+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Do not resume your lisinopril
Do not resume Viagra
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr.[**Last Name (STitle) **] [**2112-1-21**] @ 1:30pm Phone: [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) **] [**1-19**] @ 1:30pm
Please call to schedule the following:
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-23**] 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:[**2112-1-3**]
ICD9 Codes: 4240, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8163
} | Medical Text: Admission Date: [**2170-1-6**] Discharge Date: [**2170-1-9**]
Service: MEDICINE
Allergies:
Aspirin / Percocet / Codeine / Nutren Pulmonary / Zosyn
Attending:[**First Name3 (LF) 96598**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
89 yo F with COPD, HTN, PVD, PEG tube, presents dyspnic from Heb
Reb. Recently finished steroid taper at end of [**Month (only) **] for prior
COPD exacerbation. The patient recently had a UTI which was
treated with abx (? levoflox). She has been having decreased
MS/po intake over past few days.
.
In the ED, initial vitals were T 103.8 rectal, P 100 BP 128/49 R
40 O2 79% on NRB. Changed to BiPAP with good effect and O2 sat
increased to 100%. ABG on BiPAP 7.38/48/303/29. Received vanc
1g, Ceftaz 2g for consolidation on CXR in the setting of a
nursing home and h/o MRSA. Also received nebs and 10mg dexameth
for COPD exacerbation.
.
On arrival to the unit the patient had decreased responsiveness.
Satting well on BiPAP. (However needed to be on NRB for the
trip). New gas on bipap 7.39/40/159. BP's in the 80's came up to
90's with gentle bolus. Spoke to family who want full code and
invasive measures if necessary.
.
Past Medical History:
1. Steroid induced hyperglycemia with history of
hypoglycemia.
2. Asthma with greater than 5 hospitalizations with history
of intubation complicated by MRSA pneumonia.
3. Hypertension.
4. Peripheral vascular disease, status post left femoral
peroneal bypass in [**2162**].
5. COPD with 51% predicted FEV1.
6. MAT.
7. History of multiple aspirations, status post PEG.
8. Left hilar mass. Workup pending.
9. History of GI bleed, declined endoscopy.
10. Diastolic CHF with preserved EF.
11. Anemia of chronic disease, baseline hematocrit 26.
12. Chronic renal insufficiency, last creatinine 1.2.
13. bell's palsy
Social History:
Daughter involved in the patient's care.
Widowed with 3 children. Denies tobacco use. Previous alcohol
3 times per week. None recently. States significant second
hand exposure from her father until age 21.
Family History:
NC
Physical Exam:
per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9570**]
VS: 98.8 105/60 HR 97 RR 22 99% on 50% BiPAP
GEN - repsponsive only to sternal rub
HEENT - BiPAP on, PERRL
NECK - supple, no LAD
COR - tachy , regular
CHEST - diffuse ronchi, worse in R base
ABD - soft, +BS
EXT - no edema
Skin - decub ulcer on sacrum, stasis changes on legs
Pertinent Results:
Admission CXR - Findings concerning for right pneumonia. Left
retrocardiac opacity, consistent with atelectasis, effusion, or
consolidation.
.
Admission EKG - RBBB tachy 109, no change from prior
.
Admission labs:
ABG: 7.39/40/151
U/A: small leuks, small blood, neg nitr, many bacteria
.
136 104 83
--------------< 192
4.4 26 1.6
Ca: 10.5 Mg: 2.5 P: 4.4
ALT: 55
Tbili: 0.2
AST: 50
[**Doctor First Name **]: 47 Lip: 20
Lactate:1.1
.
7.7
9.9 >----< 279
22.6
N:92.6 Band:0 L:4.0 M:2.9 E:0.4 Bas:0.1
PT: 12.8 PTT: 27.4 INR: 1.1
.
Trends:
CK: 20 - 16
CKMB: 3 - 3
Tropo: 0.18 - 0.10
Iron 17, TIBC 205, B12 982, Folate okay, Ferritin 561
.
Micro:
[**2170-1-7**] 10:06 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2170-1-7**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary): RESULTS PENDING. .
.
[**2170-1-6**] 8:00 am URINE Site: CATHETER
URINE CULTURE (Preliminary):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
2ND ISOLATE. <10,000 organisms/ml.
SENSITIVITIES: MIC expressed in MCG/ML
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- PND
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- PND
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
89 yo woman with severe COPD presents with dyspnea from nursing
home. Hospital course by problem:
.
# Respiratory distress - This was thought likely secondary to
pneumonia +/- COPD exacerbation. Patient with history of ESBL
and MRSA so she was initially covered with meropenem and vanco.
Her sputum grew out 3+ gram positive rods, 2+ gram positive
cocci, and 1+ gram negative rods (with good sample). Further
identification pending upon discharge. We also monitored her in
the ICU and treated her with a BiPAP. She was treated with
standing nebs, chest PT, singulair, advair and [**Doctor First Name 130**]. Her
respiratory status significantly improved with these measures.
We also treated with steroids for a COPD exacerbation (initially
with IV solumedrol on [**1-8**] with transition to prednisone 60mg PO
daily by [**1-9**]). She will need to complete a 10 day course of
vancomycin starting on [**1-6**]. Her troughs were therapeutic.
.
# UTI - Patient with gram negative rods in urine culture from
[**1-6**]. Sensitivites indicate that she has largely resistent
klebsiella which is sensitive to meropenem. We started this on
[**1-6**] and suggest treating for a 10 day course.
.
# Altered mental status: On evening of [**1-8**], the patient
developed altered mental status and garbled speech. This came
on suddenly and improved within 15 minutes. A neuro exam at the
time indicated a right facial droop (which has been previously
documented). She also was alert and oriented to person, place,
date, month, time, and situation (10 min after the change in
mental status was first appreciated). An ABG at the time showed
good oxygenation and no evidence of hypercarbia. Blood glucose
was 400. A head CT preliminarily read as no hemorrhage or
territorial lesion. Her ms improved.
.
# Anemia - below baseline but stable at 22. We transfused her
one unit of pRBC prior to discharge.
.
# ARF - labs were initially c/w dehydration. 500cc boluses were
given for hypotension and poor urine output. This resulted in
improvement in her UOP and stabilization of her blood pressure.
.
# MAT - EKG appears regular. We were cautious with the
verapamil initially given her hypotension but added it back on.
Her HR was well controlled in the 100-110 range. She was placed
on her home verapamil and had good control of her heart rates.
.
# Steroid Induced DM - Continued a RISS but also added glargine
6u qhs. This may be titrated in the future as needed.
.
# HTN - continued verapamil as above.
.
# Diastolic CHF - continued HR and BP control
.
# Hilar Mass - work up once stable as outpt
.
# Decubitus and stasis ulcer - wound care per routine
.
# h/o post herpetic neuralgia - we held her neurontin while
decreased MS [**First Name (Titles) **] [**Last Name (Titles) **]. This was then restarted prior to
dispo.
.
# PPx - hep SC, PPI, bowel reg
.
# FEN - Tube feeds
.
# Code Status - Full code
.
# Contacts - Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2916**] [**Telephone/Fax (1) 96596**]
Medications on Admission:
MEDS:
TF through PEG, flush 200 cc free water q6h
Chronic indwelling foley
Multivitamin
Zantac 150mg po/ng qdaily
Levothyroxine 200mcg po qdaily
Vitamin B12 100mcg po daily
Vitamin C 500mg daily
Neurontin 200mg po tid
Buspar 10mg po daily
Hep SQ 5000 U TID
Lipitor 10mg po daily
Metoprolol tartate 25mg po daily
Humulin sliding scale
Dulcolax 10mg pr prn constipation
Albuterol nebs prn wheezing
Atrovent nebs prn wheezing
Ativan 1mg prn anxiety
Tylenol 650mg po q4-6h prn
Ultram 50mg po q6h prn pain
.
ALLERGIES: Penicillins
Discharge Medications:
1. Gabapentin 300 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO HS (at
bedtime).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1)
Injection TID (3 times a day).
3. Humalog 100 unit/mL Solution [**Telephone/Fax (1) **]: variable Subcutaneous four
times a day: please use sliding scale as previously instructed.
4. Insulin Glargine 100 unit/mL Solution [**Telephone/Fax (1) **]: Six (6) units
Subcutaneous at bedtime.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Telephone/Fax (1) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12h on
and 12h off.
6. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One Hundred (100) mg
PO BID (2 times a day).
7. Nexium 20 mg Capsule, Delayed Release(E.C.) [**Telephone/Fax (1) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Fexofenadine 60 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO once a day.
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Telephone/Fax (1) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Singulair 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
11. Senna 8.6 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
12. Verapamil 120 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a
day.
13. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
14. Zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
15. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
16. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
17. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
18. Meropenem 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 1 weeks: first does was
[**1-6**]. Suggest rx x 10 days.
19. Vancomycin 1,000 mg Recon Soln [**Month/Year (2) **]: One (1) Intravenous
once a day for 1 weeks: first dose was [**1-6**]. suggest renally
dose by level (<20). suggest completion of 10 day course.
20. Prednisone 20 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO once a day:
Please take 60mg per day for 1 week, then 50mg per day for 1
week, then 40mg a day for 1 week, then 30mg a day for 1 week,
then 20mg a day for 1 week, then 10mg a day for 1 week, then 5
mg a day for 1 week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
UTI: klebsiella
COPD exacerbation
Anemia of chronic inflammation and iron deficiency
altered mental status
bell's palsy (documented also in [**11-1**])
.
Secondary:
ARF c/w prerenal azotemia
multifocal atrial tachycardia
steroid induced DM
HTN
diastolic CHF
hilar mass
decubitus and stasis ulcerations
h/o post herpetic neuralgia
PVD
s/p PEG
h/o GI bleed
Discharge Condition:
fair
Discharge Instructions:
You were admitted with a COPD exacerbation, shortness of breath,
altered mental status, and a UTI. Please take your medications
as instructed. Notably, you need to be on antibiotics for a
total of 7 days. These were started on [**1-6**]. You were also
started on Prednisone and should have a slow taper of this
medication. Because your insulin was increased on your
prednisone, you need to be sure to decrease this as you decrease
your steroid dose.
.
Please contact your doctor if you develop worsening shortness of
breath, altered mental status, fevers, chills, abdominal pain.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc/d
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2170-1-18**] 2:10
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2170-1-18**] 2:30
.
Please followup with your PCP within the next two weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(1) 7585**]
ICD9 Codes: 486, 5990, 5849, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8164
} | Medical Text: Admission Date: [**2136-10-6**] Discharge Date: [**2136-12-4**]
Date of Birth: [**2072-5-17**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain with fevers
Major Surgical or Invasive Procedure:
T3-L3 posterior spinal fusion
Iliac crest bone graft
T6-7 corpectomy with T5-8 fusion and strut graft
History of Present Illness:
64F h/o mental retardation, ESRD on HD, DM2, epidural abscess,
p/w GI bleed and resp distress. The pt recently had a
complicated hospital course at [**Hospital1 18**] from [**2136-7-16**] to [**2136-9-1**]
during which she had sepsis and resp failure requiring
mechanical ventilation for roughly 2 weeks. She was found to
have epidural spinal abscesses with spinal cord impingement
treated operativelyt by Orthopedics [**2136-7-26**] and then with abx.
Course was also c/b ATN/ARF requiring HD which the pt required
at discharge. She returned on [**9-16**] to [**9-26**] with fevers from rehab
and was found to have radiographic worsening of the vertberal
osteomyletis which was treated by tailoring abx, without
surgery. The plan was for her to continue a course of linezold
followed by nafcillin at discharge to [**Hospital **] Rehab.
On [**10-5**], the pt was admitted to [**Hospital **] Hospital for tachycardia
and respiratory distress. At [**Hospital1 **], she was tachy to 130, was
diuresed and put on nitro gtt for suspected CHF. WBC 8.1 though
pt was febrile to 101.8. CXR showed CHF and possible infiltrate
so pt was treated broadly for PNA, UA was positive as well. Hct
was noted to be 23 on admission and had h/o coffee grounds
emesis at rehab, though green stool found at [**Hospital1 **]. Pt was
transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
COPD
Mental retardation
DVT [**1-/2130**]
NIDDM
Obesity
Sciatica
Hypertension
Hypercholesterolemia
Anxiety
Psoriasis
Paroxysmal A. fib
Osteomyelitis T6-7
Social History:
Lives in apartment with 24 hour caregiver; has a long term
boyfriend. [**Name (NI) 1403**] part time. Guardian is [**Name (NI) 402**] [**Name (NI) 33801**]
[**Telephone/Fax (1) 33802**].
Family History:
Pt unable to provide
Physical Exam:
VS: Temp: 99.9 BP: 131/69 HR: 114 RR: 44 O2sat: 99% 2L NC
GEN: moderate tachypnea and resp distress, awake, alert,
interactive
RESP: crackles [**1-23**] way up, no wheezes
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
NEURO: moving all extremities, no ankle clonus
Pertinent Results:
[**2136-12-3**] 01:41AM BLOOD WBC-7.2 RBC-2.88* Hgb-9.3* Hct-27.0*
MCV-94 MCH-32.3* MCHC-34.5 RDW-19.8* Plt Ct-278
[**2136-12-2**] 02:03AM BLOOD WBC-5.6 RBC-2.98* Hgb-9.5* Hct-28.1*
MCV-95 MCH-31.8 MCHC-33.6 RDW-19.7* Plt Ct-291
[**2136-12-1**] 02:08AM BLOOD WBC-5.6 RBC-2.95* Hgb-9.2* Hct-27.7*
MCV-94 MCH-31.2 MCHC-33.2 RDW-19.6* Plt Ct-289
[**2136-11-30**] 03:52AM BLOOD WBC-5.4 RBC-3.13* Hgb-9.6* Hct-29.4*
MCV-94 MCH-30.6 MCHC-32.7 RDW-19.4* Plt Ct-328
[**2136-11-28**] 03:05AM BLOOD WBC-6.2 RBC-2.28* Hgb-7.2* Hct-21.1*
MCV-92 MCH-31.7 MCHC-34.4 RDW-20.8* Plt Ct-301
[**2136-11-26**] 03:38AM BLOOD WBC-6.5 RBC-2.36* Hgb-7.5* Hct-22.0*
MCV-93 MCH-31.6 MCHC-34.1 RDW-20.7* Plt Ct-287
[**2136-11-24**] 03:33AM BLOOD WBC-7.3 RBC-2.48* Hgb-7.9* Hct-23.1*
MCV-93 MCH-31.8 MCHC-34.1 RDW-20.4* Plt Ct-233
[**2136-11-22**] 04:00AM BLOOD WBC-15.4* RBC-3.22* Hgb-10.0* Hct-28.9*
MCV-90 MCH-30.9 MCHC-34.5 RDW-20.8* Plt Ct-281
[**2136-11-20**] 02:22AM BLOOD WBC-10.0 RBC-2.39* Hgb-7.4* Hct-21.3*
MCV-89 MCH-31.0 MCHC-34.7 RDW-23.4* Plt Ct-212
[**2136-11-17**] 03:09AM BLOOD WBC-7.9 RBC-2.88* Hgb-8.8* Hct-25.8*
MCV-90 MCH-30.4 MCHC-34.0 RDW-22.1* Plt Ct-282
[**2136-11-15**] 03:26AM BLOOD WBC-8.1 RBC-3.18* Hgb-9.7* Hct-28.2*
MCV-89 MCH-30.5 MCHC-34.4 RDW-20.9* Plt Ct-430
[**2136-11-14**] 06:01PM BLOOD WBC-8.6 RBC-3.23*# Hgb-9.7*# Hct-28.8*#
MCV-89 MCH-29.9 MCHC-33.6 RDW-20.7* Plt Ct-438
[**2136-11-13**] 03:14AM BLOOD WBC-10.9 RBC-2.81* Hgb-8.6* Hct-25.2*
MCV-90 MCH-30.7 MCHC-34.2 RDW-20.3* Plt Ct-560*
[**2136-11-11**] 04:29AM BLOOD WBC-12.1* RBC-3.06* Hgb-9.6* Hct-27.5*
MCV-90 MCH-31.4 MCHC-35.0 RDW-18.9* Plt Ct-609*
[**2136-11-9**] 02:45AM BLOOD WBC-7.8 RBC-3.10* Hgb-9.4* Hct-27.4*
MCV-88 MCH-30.4 MCHC-34.5 RDW-17.6* Plt Ct-541*
[**2136-11-7**] 05:16AM BLOOD WBC-9.2 RBC-2.87* Hgb-8.7* Hct-24.8*
MCV-86 MCH-30.4 MCHC-35.2* RDW-18.1* Plt Ct-446*
[**2136-11-3**] 03:55PM BLOOD WBC-11.9* RBC-3.29* Hgb-10.1* Hct-27.9*
MCV-85 MCH-30.7 MCHC-36.2* RDW-16.2* Plt Ct-206
[**2136-11-2**] 03:15PM BLOOD WBC-7.9 RBC-3.37* Hgb-10.4* Hct-28.5*
MCV-85 MCH-30.8 MCHC-36.3* RDW-16.1* Plt Ct-87*
[**2136-11-1**] 03:05AM BLOOD WBC-8.2 RBC-2.54* Hgb-8.0* Hct-21.9*
MCV-86 MCH-31.6 MCHC-36.6* RDW-21.3* Plt Ct-81*
[**2136-10-29**] 03:10AM BLOOD WBC-7.8 RBC-3.10* Hgb-9.7* Hct-26.8*
MCV-87 MCH-31.4 MCHC-36.3* RDW-21.5* Plt Ct-135*
[**2136-10-26**] 03:00AM BLOOD WBC-7.0 RBC-2.87* Hgb-8.8* Hct-24.7*
MCV-86 MCH-30.8 MCHC-35.8* RDW-23.7* Plt Ct-238
[**2136-10-23**] 02:16AM BLOOD WBC-8.5 RBC-3.21* Hgb-9.5* Hct-28.3*
MCV-88 MCH-29.6 MCHC-33.6 RDW-23.7* Plt Ct-298
[**2136-10-20**] 03:10PM BLOOD Hct-30.0*
[**2136-10-19**] 05:29PM BLOOD WBC-8.8# RBC-4.20# Hgb-12.4 Hct-36.9
MCV-88 MCH-29.6 MCHC-33.6 RDW-24.0* Plt Ct-284
[**2136-10-19**] 12:06AM BLOOD Hct-28.5*
[**2136-10-16**] 06:00AM BLOOD WBC-6.2 RBC-2.53* Hgb-8.3* Hct-25.2*
MCV-100* MCH-32.6* MCHC-32.8 RDW-19.9* Plt Ct-305
[**2136-10-13**] 05:39AM BLOOD WBC-5.9 RBC-2.55* Hgb-8.4* Hct-25.3*
MCV-99* MCH-32.7* MCHC-33.0 RDW-19.5* Plt Ct-303
[**2136-10-11**] 05:46PM BLOOD WBC-6.2 RBC-2.78* Hgb-8.9* Hct-26.5*
MCV-95 MCH-31.8 MCHC-33.4 RDW-19.8* Plt Ct-318
[**2136-11-29**] 03:11AM BLOOD Neuts-70.4* Lymphs-13.3* Monos-6.0
Eos-10.0* Baso-0.2
[**2136-10-16**] 06:00AM BLOOD Neuts-71.0* Lymphs-15.4* Monos-7.1
Eos-6.2* Baso-0.4
[**2136-10-10**] 05:40AM BLOOD Neuts-72.3* Lymphs-14.1* Monos-5.9
Eos-6.9* Baso-0.8
[**2136-10-6**] 08:27PM BLOOD Neuts-71.4* Lymphs-15.8* Monos-5.4
Eos-7.0* Baso-0.3
[**2136-11-30**] 03:52AM BLOOD PT-14.9* PTT-32.5 INR(PT)-1.3*
[**2136-11-23**] 03:31AM BLOOD PT-17.1* PTT-34.0 INR(PT)-1.6*
[**2136-11-17**] 03:09AM BLOOD PT-18.1* PTT-35.5* INR(PT)-1.7*
[**2136-11-13**] 03:14AM BLOOD Plt Ct-560*
[**2136-11-13**] 03:14AM BLOOD PT-19.6* PTT-38.5* INR(PT)-1.9*
[**2136-11-11**] 04:29AM BLOOD PT-17.1* PTT-34.7 INR(PT)-1.6*
[**2136-11-10**] 03:29AM BLOOD Plt Ct-606*
[**2136-11-7**] 05:16AM BLOOD PT-14.8* PTT-34.6 INR(PT)-1.3*
[**2136-11-6**] 03:34AM BLOOD PT-14.1* PTT-35.6* INR(PT)-1.3*
[**2136-11-5**] 02:09AM BLOOD PT-15.1* PTT-39.2* INR(PT)-1.4*
[**2136-11-4**] 03:40AM BLOOD Plt Ct-247
[**2136-11-3**] 03:55PM BLOOD PT-15.2* PTT-31.8 INR(PT)-1.4*
[**2136-11-2**] 12:22PM BLOOD PT-14.9* PTT-34.2 INR(PT)-1.3*
[**2136-10-30**] 02:44AM BLOOD PT-13.1 PTT-31.5 INR(PT)-1.1
[**2136-10-21**] 02:44AM BLOOD PT-17.0* PTT-35.2* INR(PT)-1.6*
[**2136-10-20**] 01:24AM BLOOD Plt Ct-283
[**2136-10-19**] 05:29PM BLOOD Plt Ct-284
[**2136-10-18**] 05:00AM BLOOD PT-15.2* PTT-31.4 INR(PT)-1.4*
[**2136-10-13**] 05:39AM BLOOD PT-14.5* PTT-34.8 INR(PT)-1.3*
[**2136-10-9**] 12:16PM BLOOD PT-15.0* PTT-29.5 INR(PT)-1.3*
[**2136-12-3**] 01:41AM BLOOD Glucose-103 UreaN-47* Creat-1.4* Na-141
K-4.2 Cl-114* HCO3-20* AnGap-11
[**2136-11-30**] 03:52AM BLOOD Glucose-104 UreaN-54* Creat-1.3* Na-144
K-4.7 Cl-116* HCO3-19* AnGap-14
[**2136-11-28**] 03:05AM BLOOD Glucose-117* UreaN-56* Creat-1.5* Na-147*
K-5.1 Cl-119* HCO3-17* AnGap-16
[**2136-11-24**] 03:33AM BLOOD Glucose-116* UreaN-43* Creat-1.2* Na-147*
K-4.2 Cl-117* HCO3-16* AnGap-18
[**2136-11-21**] 05:11AM BLOOD Glucose-118* UreaN-38* Creat-1.4* Na-141
K-4.8 Cl-108 HCO3-19* AnGap-19
[**2136-11-18**] 02:06AM BLOOD Glucose-127* UreaN-27* Creat-1.6* Na-144
K-3.8 Cl-110* HCO3-18* AnGap-20
[**2136-11-16**] 04:23AM BLOOD Glucose-187* UreaN-27* Creat-1.7* Na-146*
K-3.8 Cl-115* HCO3-16* AnGap-19
[**2136-11-14**] 06:01PM BLOOD Glucose-104 UreaN-27* Creat-2.0* Na-147*
K-4.5 Cl-118* HCO3-14* AnGap-20
[**2136-11-12**] 02:40AM BLOOD Glucose-153* UreaN-31* Creat-2.1* Na-144
K-3.1* Cl-112* HCO3-19* AnGap-16
[**2136-11-9**] 02:15PM BLOOD Glucose-76 UreaN-35* Creat-2.3* Na-144
K-3.5 Cl-109* HCO3-22 AnGap-17
[**2136-11-8**] 04:28PM BLOOD Glucose-69* UreaN-39* Creat-2.2* Na-145
K-3.6 Cl-109* HCO3-21* AnGap-19
[**2136-11-5**] 02:09AM BLOOD Glucose-122* UreaN-46* Creat-2.1* Na-141
K-4.0 Cl-107 HCO3-20* AnGap-18
[**2136-10-31**] 02:15AM BLOOD Glucose-134* UreaN-61* Creat-2.5* Na-141
K-3.5 Cl-106 HCO3-18* AnGap-21*
[**2136-10-27**] 03:00AM BLOOD Glucose-109* UreaN-50* Creat-2.8* Na-136
K-3.5 Cl-105 HCO3-17* AnGap-18
[**2136-10-23**] 04:27PM BLOOD Glucose-119* UreaN-40* Creat-2.4* Na-135
K-3.5 Cl-104 HCO3-19* AnGap-16
[**2136-10-20**] 01:24AM BLOOD Glucose-88 UreaN-41* Creat-1.8* Na-143
K-4.0 Cl-116* HCO3-18* AnGap-13
[**2136-10-19**] 04:47AM BLOOD Glucose-144* UreaN-51* Creat-1.9* Na-141
K-4.6 Cl-110* HCO3-23 AnGap-13
[**2136-10-12**] 05:04AM BLOOD Glucose-101 UreaN-16 Creat-1.9* Na-144
K-3.3 Cl-110* HCO3-28 AnGap-9
[**2136-10-9**] 03:16AM BLOOD Glucose-63* UreaN-20 Creat-2.1* Na-154*
K-3.4 Cl-113* HCO3-26 AnGap-18
[**2136-10-10**] 05:40AM BLOOD ALT-5 AST-12 AlkPhos-106 Amylase-17
TotBili-0.4
[**2136-11-24**] 10:28PM BLOOD CK-MB-NotDone cTropnT-0.46*
[**2136-11-24**] 03:07PM BLOOD CK-MB-NotDone cTropnT-0.44*
[**2136-10-16**] 10:50AM BLOOD CK-MB-4 cTropnT-0.30*
[**2136-12-3**] 01:41AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.2
[**2136-12-1**] 02:08AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0
[**2136-11-29**] 03:11AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.0
[**2136-11-14**] 06:01PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0
[**2136-11-13**] 09:12PM BLOOD Calcium-8.1* Phos-0.9* Mg-2.2
[**2136-11-11**] 04:29AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.9
[**2136-11-7**] 05:16AM BLOOD Calcium-7.9* Phos-4.5 Mg-1.9
[**2136-11-4**] 12:19PM BLOOD Calcium-7.2* Phos-4.5 Mg-1.9
[**2136-11-1**] 03:05AM BLOOD Calcium-7.4* Phos-4.3 Mg-1.7
[**2136-10-28**] 07:54PM BLOOD Calcium-6.8* Phos-5.1* Mg-2.0
[**2136-10-24**] 03:15AM BLOOD Calcium-5.9* Phos-5.0* Mg-1.9
[**2136-10-19**] 05:29PM BLOOD Albumin-1.9* Calcium-7.9* Phos-4.3 Mg-1.6
Iron-50
[**2136-10-9**] 03:16AM BLOOD Albumin-1.9* Calcium-7.1* Phos-2.4*
Mg-1.8
[**2136-11-5**] 04:22PM BLOOD calTIBC-48* Ferritn-GREATER TH TRF-37*
[**2136-10-28**] 02:07AM BLOOD Free T4-0.40*
[**2136-10-18**] 04:10PM BLOOD PTH-42
[**2136-10-27**] 05:02PM BLOOD Cortsol-27.7*
[**2136-10-20**] 01:17PM BLOOD Cortsol-42.7*
[**10-6**] CHEST, SINGLE AP VIEW.
There are low inspiratory volumes. Allowing for this, there is
probably underlying cardiomegaly. Marked prominence of pulmonary
vascular markings and vascular blurring most likely reflects the
presence of CHF, but is probably also accentuated by low lung
volumes. There is increased retrocardiac opacity with
obscuration of the left hemidiaphragm and blunting of left
greater than right costophrenic angles. Compared with [**2136-9-24**],
the degree of left lower lobe consolidation is worse. The
inspiratory volumes are lower. A dual lumen right-sided central
line is present with tips over distal SVC and SVC/RA junction.
[**10-9**] CT Pelvis IMPRESSION:
1) Left lower lobe pneumonia with moderate parapneumonic
effusion. Small focus of consolidation/atelectasis in the right
posterior medial lung. Without IV contrast we cannot assess for
empyema.
2) Destructive process involving the T7 and T8 vertebral bodies.
This has progressed markedly compared to the CT of [**2136-8-16**].
Limited assessment on these non-contrast axial images, however
there appears to be associated soft tissue. These findings are
highly concerning for osteomyelitis and potentially epidural
abscess. If the patient is able to cooperate, MRI could better
assess for cord involvement and/or epidural abscess.
[**10-10**] MR [**Name13 (STitle) 2854**] IMPRESSION:
1. Increased retropulsion of T7 vertebral body with increased
kyphotic deformity, destruction of the T8 vertebral body and
continued enhancing anterior epidural tissue. This is associated
with increasingly severe canal narrowing and development of cord
edema at this level.
2. No significant interval change in lumbar spine.
[**10-19**] SINGLE AP PORTABLE VIEW OF THE CHEST: ET tube tip is
located 34 mm above the carina. Right internal jugular vein dual
catheter is in unchanged position. There is no pneumothorax.
There is small left pleural effusion. The lungs are better
expanded. There is a new left chest tube. Patient is post
anterior T5/T8 spinal fusion.
There is a small subcutaneous emphysema in the left chest wall.
[**11-14**] Chest IMPRESSION: No significant change showing moderate
congestive heart failure and stable cardiomegaly.
[**11-27**] FINDINGS: Compared to the prior study, there has been no
significant interval change. There continues to be left lower
lobe volume loss and effusion. There is some mild pulmonary
vascular redistribution. There is no overt failure. Tracheostomy
tube, spinal fixation devices are unchanged. The right lateral
chest is off the film.
[**2136-11-24**] 3:30 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2136-12-2**]**
GRAM STAIN (Final [**2136-11-24**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2136-12-2**]):
RARE GROWTH OROPHARYNGEAL FLORA.
ACINETOBACTER BAUMANNII. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component". AMIKACIN SENSITIVE AT 8
MCG/ML.
ACINETOBACTER BAUMANNII. MODERATE GROWTH. 2ND COLONY
TYPE.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component". AMIKACIN SENSITIVE AT 16
MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
| ACINETOBACTER BAUMANNII
| |
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFEPIME-------------- =>64 R =>64 R
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
IMIPENEM-------------- =>16 R =>16 R
LEVOFLOXACIN---------- =>8 R =>8 R
TOBRAMYCIN------------ 2 S 8 I
TRIMETHOPRIM/SULFA---- I I
[**2136-11-16**] 4:22 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2136-11-16**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2136-11-16**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2136-11-13**] 12:32 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2136-11-18**]**
GRAM STAIN (Final [**2136-11-13**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Final [**2136-11-18**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
ACINETOBACTER BAUMANNII. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
Trimethoprim/Sulfa sensitivity testing available on
request.
AZTREONAM RESISTANT AT >= 64 MCG/ML.
TIGECYCLINE RESISTANT AT >12 MCG/ML BY E-TEST.
EXTRA SENSIS REQUESTED BY DR.[**Last Name (STitle) **]([**Numeric Identifier 21494**]) ON [**2136-11-15**].
ENTEROBACTER CLOACAE. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Trimethoprim/Sulfa sensitivity testing available on
request.
TIGECYCLINE SENSITIVE AT 1.5 MCG/ML BY E-TEST.
AZTREONAM RESISTANT AT >64 MCG/ML.
GRAM NEGATIVE ROD #3. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
| ENTEROBACTER CLOACAE
| |
AMPICILLIN/SULBACTAM-- =>32 R
CEFEPIME-------------- =>64 R 2 S
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
IMIPENEM-------------- =>16 R <=1 S
LEVOFLOXACIN---------- =>8 R =>8 R
MEROPENEM------------- <=0.25 S
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ 4 S 8 I
[**2136-11-6**] 4:54 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2136-11-11**]**
GRAM STAIN (Final [**2136-11-6**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2136-11-11**]):
ACINETOBACTER BAUMANNII. HEAVY GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
ACINETOBACTER BAUMANNII. SPARSE GROWTH STRAIN 2.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
| ACINETOBACTER BAUMANNII
| |
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFEPIME-------------- 16 I 8 S
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 8 I 4 S
IMIPENEM-------------- 8 I 8 I
LEVOFLOXACIN---------- =>8 R 4 I
TOBRAMYCIN------------ 2 S <=1 S
OPERATIVE REPORT
[**Last Name (LF) 2194**],[**First Name3 (LF) 900**] J.
Signed Electronically by [**Last Name (LF) 2194**],[**First Name3 (LF) 900**] on SAT [**2136-11-24**] 2:51 PM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 33886**]
Service: MED Date: [**2136-11-9**]
Date of Birth: [**2072-5-17**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 33887**]
PREOPERATIVE DIAGNOSES:
1. Sepsis.
2. Respiratory failure with prolonged intubation.
POSTOPERATIVE DIAGNOSES:
1. Sepsis.
2. Respiratory failure with prolonged intubation.
ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33888**], RES
PROCEDURE PERFORMED:
1. Tracheostomy.
2. Percutaneous endoscopic gastrostomy.
INDICATIONS FOR PROCEDURE: The patient is an unfortunate
woman who has had a spinal epidural abscess from which she
has manifested prolonged sepsis. She is bedridden and
ventilator dependent. She has been intubated for a
considerable length of time. The patient is quite obese
despite a small body frame, and has been quite difficult to
manage from a respiratory standpoint. Also, she has been
nasogastric tube feed dependent.
DETAILS OF THE PROCEDURE: The patient was brought to the
operating theater and placed on the operating table supine. A
roll was fashioned behind the shoulders and the head was
extended on a jelly roll to the extent possible. This was
somewhat limited. The patient had a very short neck and was
very stout. The patient's breasts were taped, protecting the
nipples, and pulled towards the feet. The neck, face, chest
and abdomen were now prepared sterilely with Betadine and
draped. At this time, a 2-1/2-cm vertical incision was
fashioned between the estimated location of the cricoid and
the sternal notch. This was deepened carefully using [**Last Name (un) 4161**]
cautery through the midline raphe of the neck. The trachea
was encountered with a difficult segment of thyroid over it.
This was elevated from the trachea with right-angle clamps
and suture ligated bilaterally with 2-0 silk suture. At this
point, a right-angle clamp was placed under the thyroid and
it was further elevated, dividing it with cautery. At this
time, there was still residual isthmus which was divided with
cautery, and eventually isolated and suture ligated. Now, the
2 lobes of the thyroid were grasped with right-angle clamps
and elevated off the trachea and dissected from it with
cautery. There was troublesome bleeding behind the right lobe
of the thyroid. This was controlled with Surgicel.
At this time, the trachea was marked for an inferior-based
flap with the incision between the 1st and 2nd tracheal
rings. The anesthesiologist was asked to suction the pharynx
and deflate the balloon, at which point the stay sutures were
placed into the trachea above and the flap below. The balloon
was reinflated and the trachea was elevated using stay
sutures. At this time, once more the balloon was deflated and
a transverse tracheotomy was fashioned. At this point, we
noted that we were well above the balloon and the vertical
arms of the flap were cut. At this time, the endotracheal
tube was withdrawn under direct vision by the
anesthesiologist to a point where the tip was just above the
tracheotomy. A #8 cuffed Portex tracheostomy tube was now
passed into the trachea and connected to the ventilator
circuit. Ventilation through this system was unsatisfactory,
although the patient was able to be oxygenated. Close
inspection revealed that the balloon was herniating outward.
My feeling was that this was too large a balloon for her
trachea. We therefore withdrew it and re-passed the
endotracheal tube from above. The patient was now fully
oxygenated. A 7 Portex tube was brought on the field, and the
tube was once more withdrawn, and the 7 Portex tube passed
without problem into the trachea. The balloon was inflated.
It was attached to the circuit and excellent CO2 and gas
exchange were observed. At this point, the tracheotomy was
slightly closed at the inferior end with a single cutaneous
suture. The tracheostomy was sutured in place with 0 silk
sutures and secured with umbilical tapes. The tracheostomy
part of the procedure was now terminated.
At this point, the previously prepared abdomen, which had
been covered sterilely, was uncovered from its secondary
draping. The gastroscope was passed into the mouth and
carefully passed through the esophagus into the stomach. The
stomach was inflated. Despite the patient's obesity, it was
remarkably easy to isolate the location in the mid stomach
where we saw excellent transillumination and easy dimpling
visible from the scope. A puncture was fashioned at this
point, and the wire was passed into the stomach. At this
point, a snare was passed through the gastroscope, grasping
the wire, and the wire was pulled along with the gastroscope
out through the mouth. Now, an 11 blade was used to incise a
generous skin incision for egress of the gastrostomy. The
gastrostomy tube was attached to the wire and pulled down
until the mushroom was just at the mouth.
At this time, the scope was reattached using the snare to the
gastrostomy tube and the entire assembly was pulled through
the pharynx and into the stomach. The PEG tube came to rest
easily at 4 cm. At this point, the snare was loosened and
disengaged from the PEG tube. The cross piece was placed, the
stomach was suctioned free of air, and the cross piece was
secured to the PEG tube. Dry sterile dressings were placed.
The PEG was placed to gravity suction. The procedure was
terminated. Photo documentation was obtained of the PEG and
tracheostomy position.
COMPLICATIONS: Both procedures went without apparent
complication.
ESTIMATED BLOOD LOSS: Minimal.
The patient was returned to the ICU in unchanged condition.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 33889**]
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] A.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on SAT [**2136-11-10**] 10:12 AM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 33886**]
Service:ORTHO Date: [**2136-11-2**]
Date of Birth: [**2072-5-17**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**], [**MD Number(1) 3192**]
First Assistant: [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) 33890**], MD
PREOPERATIVE DIAGNOSES: Kyphosis and status post
osteomyelitis and epidural abscess.
POSTOPERATIVE DIAGNOSES: Kyphosis and status post
osteomyelitis and epidural abscess.
OPERATIONS:
1. Fusion T3-L3.
2. Multiple thoracic laminotomies.
3. Instrumentation T3-L3.
4. Right iliac crest bone graft.
PROCEDURE: The patient was brought to the operating room and
placed on the table int he supine position. After adequate
general endotracheal anesthesia has been obtained, a Foley
catheter was inserted under sterile conditions. [**Male First Name (un) **] hose and
intermittent compression stockings were applied. The patient
was gently transferred to the [**Location (un) 1661**] table. The arms were
kept at less than 90 degrees to prevent injury to the
brachial plexus. The legs were extended to maintain their normal
natural lumbar lordosis. The back was prepped and draped in
the usual sterile fashion.
The midline incision was made over
the spinous processes from T3 down to L3. Dissection was
carried down through the skin and subcutaneous tissue.
Meticulous hemostasis was obtained using [**Last Name (un) 4161**]
electrocautery. Self-retaining Weitlaner and Gelpi retractors
were applied. Exposure was taken down to the level of the
midline muscle and fascia. This was divided in the midline
and then carried out to the lateral margins of the transverse
processes extending from T3 down to L3. There was significant
scarring from the previous decompression and fibrosis of the
musculature at the T12-L2 levels.
The fascia was divided and a revision laminectomy was
performed at the level of T12, L1, and L2. The
medial border of the pedicle was identified at L1, L2 and L3
and the junction of the superior articular facet and
transverse process was decorticated with [**First Name8 (NamePattern2) **] [**Last Name (un) 30565**] bur and
then using a reamer probe, pedicle screw holes were made.
These were palpated with a ball-tipped probe ensure that
no breach of the pedicle had been performed. Then, a 5.5 x 40
mm screw was inserted at each of these levels. On the
left at L3, a 6.5 mm screw was placed to obtain purchase.
There was moderate osteoporosis encountered. Multiple thoracic
laminotomies were performed after removing the spinous processes
and interspinous ligament from T3-T12 distally.
The inferior articular facets were removed with
[**First Name8 (NamePattern2) **] [**Last Name (un) 30565**] burr and the remaining articular cartilage was
removed as well by the decortication. The multiple laminotomies
were performed by first dividing the midline ligamentum flavum
with an angled curette. The ligamentum was then resected with
Kerrison rongeurs. A claw construct of hooks was placed with a
downward-going hook on the superior lamina at T3 and
an upward going at T4. Simlarly hooks were placed at T6 and T8
on
the left. A downgoing hook was placed on the superior margin of
T4 on the right and upward going hooks were placed at T5 and T7
as well. Sublaminar Atlas cables were applied also at T9 and T10
to enhance the rigidity of the construct. A rod was contoured
into ther appropriate thoracic kyphosis and lumbar lordosis and
attached to the previously placed segmental instrumentation. All
the set caps were applied to the hooks and screws distally and
these were tightened down with gentle distraction of the claw
constructs superiorly with a torque wrench.
Intraoperative x-rays showed accurate location of
the implants. Two transverse connectors were applied after
decorticating all the transverse processes and remaining
lamina with the [**Last Name (un) 30565**] bur.
The patient had a separate skin
incision made over the right iliac crest. Dissection was
carried down through the skin and subcutaneous tissue.
Meticulous hemostasis was obtained using [**Last Name (un) 4161**]
electrocautery. Self-retaining and Gelpi retractors were
applied. Exposure was taken down to the level of the crest
where a subperiosteal dissection was performed. An osteotome and
mallet was used to obtain cortical and cancellous bone graft.
Once adequate bone graft had been obtained, Gelfoam and bone wax
were applied for hemostasis.
The fascia overlying the crest was then closed with #1 Vicryl
suture in a running continuous fashion, after allograft bone
was used to restore the crest. The subcutaneous tissue was
closed with 2-0 Vicryl and the skin was closed with staples.
This bone graft was morselized, mixed with allograft and
packed in the posterior gutters from T3-L3. The
midline muscle and fascia were reapproximated with #1 Vicryl
suture in a running continuous fashion. The subcutaneous
tissue was closed with 2-0 Vicryl and the skin was closed
with interrupted staples. A sterile dressing including 4x4s,
ABDs and Elastoplast tape were applied without tension.
Sponge and instrument counts were correct at the end of the
case x3.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**], [**MD Number(1) 3192**]
Brief Hospital Course:
64 y/o female with DM, MR, ESRD on HD through tunneled catheter
presented to [**Hospital Unit Name 153**] on [**2136-10-6**] with fevers and resp distress. CXR
revealed pneumonia and sputum grew out enterobacter. On
meropenem with improvement in pna. Was also started on vanco for
nosocomial pna and hx MSSA spinal osteo. Sputum has also grown
out acenitobacter (likely colonizer) and 1 blood cx out of many
coag neg staph (likely a contaminant.) PT was spiking temps on
vanco and [**Last Name (un) 2830**]. CT chest/abd/pelvis with pleural effusions and
worsening of osteo at T7-T8. Pleural effusion was tapped and
consistent with transudate. Pt also with diarrhea- though cdiff
negative. Was placed on flagyl. MRI spine with worsening
destruction of T7- T8 with cord compression. Ortho-spine
consulted surgery for T7-T8 destruction and cord compression.
Went to OR [**10-19**] for T6-7 corpectomy with T5-8 strut graft/fusion
for osteomyelitis. In SICU, intubated, on neo. Multiple
hemodialysis treatments with renal function was improving but
now may be having some post-op ATN. Renal following and deciding
whether or not to dialyze.
She had been stable for over a week - pending repeat surgery of
her spine. She was supposed to go to OR- but was nutritionally
depleted -so surgical procedure postponed. She remains
intubated. The only new culture that has grown out is
acinetobacter from the sputum on [**10-20**]. Subsequent sputum
cultures did not grow it out - but we decided since she had
thick yellow sputum - to treat her for a [**7-30**] day course with
Tobra.
[**10-25**] Ms. [**Known lastname **] continued to spike through Tobramycin,
Nafcillin and Fluconazole without an obvious source.
Antibiotics were at appropriate therapeutic levels. At this
time Ms. [**Known lastname **] has been continually ventilated since her
spinal fusion [**10-19**]. Renal recommendation were followed and
dialysis initiated as needed. ID recommendations were followed
and antibiotics were titrated to cover source of fevers.
[**10-28**] 2 units PRBC were tranfused for Hct of 22 in preparation
for posterior spinal fusion with instrumentation. Ms. [**Known lastname **]
was thought to have chronic aspirations and was considered for a
trach and PEG potentially concurrently with the spinal fusion.
Between her thoracolumbar spinal fusion and her posterior spinal
fusion she failed extubation due to respiratory distress.
[**11-2**] Ms. [**Known lastname **] returned to the Operating Room and was fused
posteriorly T3-L3. Her guardian, as with her anterior spinal
fusion, gave her consent. Please see Operative Note for
procedure in detail.
[**11-3**] 2 units PRBC were transfused for post-operative anemia.
She remained intubated; however, began making copious urine and
the hemodyalisis catheter was discontinued.
[**11-9**] Ms. [**Known lastname **] remained intubated and a Trach and PEG was
placed. An attempt to wean off the ventilator failed due to
respiratory distress.
[**11-15**] transfused 2 units PRBC for dropping hematocrit.
Responded accordingly. Fevers persisted with a rare
acinctobacter which is highly resistant persisting. At this
time Linezolid, vancomycin, cefepime and tobramycin.
[**11-20**] posterior midline staples removed and incision clean, dry
and intact without evidence of source of infection.
[**11-21**] Thoracic service was consulted for an air leak around
tracheostomy which was determined to be due to tracheostomy
being too large. Bronchoscopy at bedside performed and they
found the airway without collapse, the cuff was reinflated and
the leak obliterated. Thoracentesis performed for large left
pleural effusion. Antibiotics adjusted to accommodate the
results.
[**11-26**] PICC line changed. Source of fevers still inclear. Fever
curve improving on Nafcillin.
[**12-3**] Rehab screening started and bed found. Planning long term
Nafcillin via PICC.
Fluconazole X 1 week, began [**12-3**].
Medications on Admission:
Paroxetine
Albuterol
Ipratropium
Metoprolol
Pantoprazole
Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
syringe Injection ASDIR (AS DIRECTED).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
7. Epoetin Alfa 4,000 unit/mL Solution Sig: Three (3) syringes
Injection QMOWEFR (Monday -Wednesday-Friday).
8. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
syringe Injection TID (3 times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
14. Nafcillin 2 gm IV Q4H tx of osteomyelitis
15. Fluconazole 100 mg IV Q24H
16. Hydromorphone 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H
(every 4 hours) as needed.
17. Lorazepam 2 mg/mL Syringe Sig: 0.5-2 mg Injection Q2-3H
(every 2-3 hours) as needed.
18. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
19. Levothyroxine 200 mcg Recon Soln Sig: Fifty (50) mcg
Injection DAILY (Daily).
20. Metoclopramide 5 mg/mL Solution Sig: Ten (10) mg Injection
Q6H (every 6 hours).
21. Metoprolol 7.5 mg IV Q4H:PRN HR>100
hold for SBP <100, HR <60
22. Morphine Sulfate 2 mg IV Q2H:PRN pain
23. Outpatient Lab Work
Please draw weekly CBC, BUN/Cr, LFT's and fax to [**Hospital **] clinic [**Telephone/Fax (1) 10739**].
24. Fluconazole
Fluconazole 100 mg IV Q24H QAM X 1 week. Began [**2136-12-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Pneumonia
Epidural abscess/Osteomyelitis
GI bleed
Post-operative fever
Post-operative anemia
Discharge Condition:
Stable
Discharge Instructions:
Please continue current treatment plan. Inspect the surgical
incisions daily for signs of infection.
Please draw weekly CBC, BUN/Cr, LFT's and fax to [**Hospital **] clinic [**Telephone/Fax (1) 10739**].
Followup Instructions:
Please follow up with the Orthopedic Spine Clinic in two months.
Call [**Telephone/Fax (1) 11061**] for an appointment.
Provider: [**First Name8 (NamePattern2) 7618**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2137-1-1**]
10:30.
Please draw weekly CBC, BUN/Cr, LFT's and fax to [**Hospital **] clinic [**Telephone/Fax (1) 10739**].
Please follow up with your nephrologist at [**Hospital1 **].
Completed by:[**2136-12-4**]
ICD9 Codes: 0389, 5119, 496, 5856, 5990, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8165
} | Medical Text: Admission Date: [**2159-2-12**] Discharge Date: [**2159-3-1**]
Date of Birth: [**2086-5-29**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 72 year-old
female status post motor vehicle crash, restrained driver
with loss of consciousness and confusion at the scene
intubated by med flight prior to transfer to this facility
for decreased mental status and low blood pressure who
presented to our trauma bay for resuscitation. The patient
has a known past medical history of paroxysmal atrial
fibrillation, hypertension, recent deep venous thrombosis and
recurrent urinary tract infections.
HOME MEDICATIONS: Coumadin 5 mg po q day with an INR goal of
2 to 2.5, Digoxin 0.125 mg po q day, Paxil 20 mg po q.d.,
Diltiazem XT 120 mg po q.d. and Prinzide 10/12.5 mg po q.d.
ALLERGIES: No known drug allergies.
In the trauma bay the patient was found to be intubated, but
responsive. Trauma investigation revealed left frontal small
intraparenchymal hemorrhage, right parietal subarachnoid
hemorrhage also small, bilateral large pulmonary contusions,
tiny bilateral pneumothoraceses for which chest tubes were
not inserted and a left clavicular fracture. The patient's
initial troponins were elevated up to the 30s and the
cardiology consult opinion was the patient's motor vehicle
accident was probably related to a primary cardiac event
causing her pain and disorientation, which resulted in the
crash. Following resuscitation in the trauma bay she was
transferred to the Trauma Intensive Care Unit intubated. She
was maintained on a Propofol drip and was loaded with
Dilantin for her intraparenchymal and subarachnoid
hemorrhage.
On hospital day number two the patient appeared to be in more
respiratory distress. Chest x-ray revealed enlarging
pneumothorax for which a chest tube was placed on the right
side. The patient was also transfused several units of
blood. The patient had a prolonged Intensive Care Unit
course resulting in a very slow ventilator wean due to her
bilateral pulmonary contusions. The patient also developed
ventilator related pneumonia for which she was started on
antibiotics. The patient was also started on total
parenteral nutrition to support her metabolic needs during
this extended Intensive Care Unit stay. Finally after a long
ventilatory wean, the patient was extubated. Pneumonia was
improving and she was restarted on her Coumadin.
After several days the Coumadin was held due to increasing
white count and the suspicion that the patient might have a
calculus cholecystitis, however, after investigation of this
proved not to be the case and she was again restarted on her
Coumadin and prehospitalization medications. By hospital day
seventeen, the patient was afebrile with stable vital signs
working well with physical therapy. Her central line was
removed. Catheter tip sent for culture, which had no growth.
She will complete her antibiotic course, which will be three
additional days of Levofloxacin and is in excellent condition
to be discharged to rehab.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE MEDICATIONS: Heparin subQ 5000 units q 8 hours,
Coumadin 2.5 mg po q day with a goal INR of 2 to 2.5,
Levofloxacin 500 mg po q day for three days, Paxil 20 mg po q
day, Tylenol #3 one to two q 4 to 6 hours prn for pain,
Zantac 150 mg po b.i.d., Albuterol and Atrovent meter dose
inhalers q 4 hours prn, insulin sliding scale and Boost
nutritional supplements one can po t.i.d.
FOLLOW UP: 1. The patient should follow up with her primary
care physician at some point immediately following discharge.
She was not restarted on her prehospitalization Digoxin,
because our in house cardiology staff did not feel it was
necessary and her primary care physician should reevaluate
this as an outpatient. Additionally, the patient was not
restarted on her prehospitalization Diltiazem, because her
blood pressures during her hospitalization were at normal
levels and did not warrant an anti-hypertensive [**Doctor Last Name 360**], nor
did her heart rate warrant rate control with a calcium
channel blocker. Her pulmonary status and volume status did
not appear during this hospitalization to require a diuretic
anti-hypertensive [**Last Name (LF) 360**], [**First Name3 (LF) **] therefore her Prinzide was also
not restarted as an inpatient. Again, this should be
reevaluated by the primary care physician following discharge
as it may be necessary.
2. The patient should follow up with the Orthopedic Surgery
Clinic for her clavicular fracture two weeks after discharge.
3. The patient may follow up with the Trauma Clinic only prn
as necessary and no strict appointment is needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2159-2-28**] 16:30
T: [**2159-3-1**] 07:26
JOB#: [**Job Number 37389**]
ICD9 Codes: 5185, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8166
} | Medical Text: Admission Date: [**2109-8-19**] Discharge Date: [**2109-8-26**]
Date of Birth: [**2053-10-27**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 56 year-old
woman with a significant past medical history for resection
of pituitary adenoma by right frontal craniotomy thirty seven
years ago at age 19. Pathology report was benign.
Postoperatively was significant for double vision, which
history of right sided jaw pain diagnosed with TMJ and fitted
with a prosthesis. She also developed concurrent headaches,
which have increased in severity and frequency in the past
two years. Headaches are now continuous. The patient also
relates a two year history of decreased visual acuity
primarily on the right side with increased loss since two
months. The patient was seen by an ophthalmologist a week
ordered at an outside hospital, which revealed a 4.5 cm right
sided frontal temporal lesion. The patient
was admitted to the [**Hospital1 69**] for
further management.
PHYSICAL EXAMINATION: The patient was awake, alert and
oriented times three. Pupils are equal, round and reactive
to light. Extraocular movements intact. Vision right eye
80/200. Muscle strength is 5 out of 5 in all muscle groups.
Plantar reflexes down and her reflexes in the upper and lower
extremities were 2+.
LABORATORIES ON ADMISSION: White blood cell count 10.4,
hematocrit 44.6, platelets 322, INR 1.1, sodium 136, K 3.1,
chloride 95, CO2 28, BUN 19, creatinine .8. The patient had
an MRI/MRA with and without contrast and also underwent
arteriogram with embolization of this right frontal tumor
without complications.
HOSPITAL COURSE: The patient was then taken to the Operating
Room. On [**2109-8-23**] the patient underwent right frontal
parietal crani for tumor resection without intraoperative
complications. Postoperatively, she was monitored in the
Intensive Care Unit. Her vital signs were stable. She was
afebrile. Pupils are equal, round and reactive to light.
She was transferred to the regular floor on postop day number
one. Her vital signs remained stable. She was seen by
physical therapy and occupational therapy and found to be
safe to discharge to home with outpatient physical therapy.
She was sent home on a Decadron taper off over ten to twelve
days, Zantac 150 mg po b.i.d., Percocet one to two tabs po q
4 hours prn for pain with follow up with Dr. [**First Name (STitle) **] in one month
in the Brain [**Hospital 341**] Clinic and follow up in one week for
staple removal.
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: [**2109-8-27**] 08:33
T: [**2109-8-27**] 09:14
JOB#: [**Job Number 45351**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8167
} | Medical Text: Admission Date: [**2114-2-11**] Discharge Date: [**2114-2-15**]
Date of Birth: [**2038-7-14**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 52898**] is a 75-year-old
female with a prior history of hypothyroidism who presents at
[**Hospital3 **] transferred from [**Hospital3 1443**] Hospital with
an anterior ST elevation myocardial infarction. She has a
prior history of a non-ST elevation myocardial infarction two
weeks prior to this admission.
Cardiac catheterization revealed left main coronary artery
50% stenosed, 100% proximal left anterior descending with
collaterals, 80% mid left circumflex, 100% mid right coronary
artery with bridging collaterals. She had three stents
placed in the left main coronary artery to the left
circumflex.
Post catheterization she had an intra-aortic balloon pump
placed and was transferred to the Coronary Care Unit for
monitoring. Hemodynamics during cardiac catheterization, a
right atrium pressure 13, PA pressure 46/27, wedge 25,
cardiac index was 3.6 on IABP.
Upon arrival to the Coronary Care Unit the patient was
hypotensive. CT abdomen revealed a small retroperitoneal
hematoma. On exam, blood pressure 130 to 140/64, cardiac
output 6.2 with an index of 3.4. Patient was intubated and
ventilated on assist control 500 x 16, PEEP of 5, and FIO2 of
0.6. Exam: Patient had coarse breath sounds bilaterally, a
soft abdomen. A right groin hematoma was present. She had
Dopplerable pulses bilaterally. She was transferred to the
Coronary Care Unit on Vecuronium, Midazolam, Lipitor,
Synthroid, aspirin, and Plavix. Prior to admission the
patient only took Synthroid.
At catheterization hematocrit was 35; post catheterization
dropped to 31 and then was transfused two units to hematocrit
of 33 and then 36.
HOSPITAL COURSE BY PROBLEM:
1. Retroperitoneal bleed: Patient was typed and crossed for
eight units. Serial hematocrits were performed which were
stable throughout her hospitalization. She was consulted on
by Vascular Surgery, who followed her during the course of
her hospitalization. She had a femoral vascular ultrasound
which revealed no pseudo aneurysm and no fistulas. After
pulling her sheets on the left thigh, the patient developed a
left groin hematoma in addition to her right groin hematoma
and retroperitoneal bleed. That hematoma was also stable
throughout her hospitalization and was also ultrasound
showing no pseudo aneurysm and no fistula.
2. Cardiac: Coronary artery disease: Patient was continued
on aspirin, Plavix, and started on a statin. She was weaned
off Dopamine after transfer to the Coronary Care Unit. She
was initially placed on a balloon pump at 1:1 and was
discontinued after 24 hours.
At the time of discharge the patient is taking Toprol XL,
Lisinopril, aspirin, Plavix, Lipitor, and Cardizem.
3. Pump echo showed left atrial mild dilation. Left
ventricle cavity and wall were normal size, moderate left
ventricular systolic dysfunction, severe hypokinesis of the
distal half of the anterior septum, anterior wall, basal
inferior wall and apex.
Patient was started on an angiotensin-converting enzyme. She
maintained a normal sinus rhythm throughout her
hospitalization.
4. Endocrine: Patient was continued on her regular dose of
Synthroid.
DISCHARGE MEDICATIONS:
1. Aspirin 325.
2. Plavix 75 mg p.o. q.d.
3. Levothyroxine 100 mcg p.o. q.d.
4. Lipitor 20 mg p.o. q.d.
5. Lisinopril 20 mg p.o. q.d.
6. Toprol XL 200 mg p.o. q.d.
7. Diltiazem SR 120 mg p.o. q.d.
DISCHARGE CONDITION: Stable.
DISPOSITION: To home with primary care physician and cardiac
follow up.
DISCHARGE INSTRUCTIONS:
1. Patient will go home today. She will be visited by the
VNA nursing service this weekend.
2. She will also have follow up with her primary care
physician within the next seven to 10 days.
3. She has a follow-up appointment with Dr. [**First Name (STitle) 3236**], her new
cardiologist, with [**Location (un) **] River Associates in [**Location (un) 1468**]
scheduled for this month.
4. She will also call Dr.[**Name (NI) 9920**] office to arrange a date
for follow-up catheterization given her left main stent.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 2706**]
MEDQUIST36
D: [**2114-2-15**] 11:58
T: [**2114-2-15**] 11:57
JOB#: [**Job Number 52899**]
ICD9 Codes: 4019, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8168
} | Medical Text: Admission Date: [**2187-5-15**] Discharge Date: [**2187-5-22**]
Date of Birth: [**2132-12-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
OD
Major Surgical or Invasive Procedure:
intubation
TLC placement
History of Present Illness:
54 yof with unclear PMH BIBA to ER with unresponsiveness. Per
EMS, bradycardic and transiently unresponsive enroute where she
was given atropine and narcan. Initial vitals T 97.5 HR 92 BP
143/119, 24, 100%RA. Intubated for airway protection after
etomidate and succcinylcholine. OG was placed and was given
activated charcoal, in the middle of the procedure OG dislodged
but no respiratory compromise per ER report. In the ED, ECG
without ischemic changes. CXR with bilateral infiltrates, so
Given levoflox and Zosyn for aspiration. R IJ placed. CT head
without abnormalities.
.
At time of transfer, patient was awake able to answer questions.
Denied any chestpain, shortness of breath. only complaint is
of throat pain from ET tube. Able to write on a piece of paper.
Wrote "I took the wrog pill wills and I forgot I" took them.
Past Medical History:
HTN
Depression
Social History:
divorced
has been engaged for >10 years to man in [**State **]
denied Etoh, tobacco
Family History:
denies psych history
Physical Exam:
General Appearance: Well nourished, intubated
Eyes / Conjunctiva: sluggishly reactive
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(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) Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Warm
Neurologic: Responds to: Verbal stimuli, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
[**2187-5-15**] 10:25PM cTropnT-<0.01
[**2187-5-15**] 08:55PM LACTATE-2.7*
[**2187-5-15**] 08:40PM GLUCOSE-126* UREA N-16 CREAT-0.7 SODIUM-141
POTASSIUM-4.6 CHLORIDE-114* TOTAL CO2-20* ANION GAP-12
[**2187-5-15**] 08:40PM ALT(SGPT)-14 AST(SGOT)-29 LD(LDH)-232
CK(CPK)-226* ALK PHOS-62 TOT BILI-0.4
[**2187-5-15**] 08:40PM LIPASE-48
[**2187-5-15**] 08:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2187-5-15**] 08:40PM WBC-6.2 RBC-3.84* HGB-10.9* HCT-35.3* MCV-92
MCH-28.4 MCHC-30.9* RDW-13.7
[**2187-5-15**] 08:40PM NEUTS-91* BANDS-3 LYMPHS-4* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
FINDINGS: There is no intracranial hemorrhage, mass effect, or
shift of normally midline structures. [**Doctor Last Name **]-white matter
differentiation is preserved. The ventricles are prominent with
proportionately deepened sulci consistent with mild atrophy.
There is no acute major vascular territorial infarction. The
paranasal sinuses are clear with the exception of a small right
mucoid retention cyst within the maxillary sinus. The right
mastoid air cells are opacified. Osseous and soft tissue
structures are otherwise unremarkable.
IMPRESSION: No evidence of intracranial hemorrhage.
MRI of brain:
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect or acute/subacute territorial infarction. The ventricles
and sulci are slightly prominent, more than expected for the
patient's age. In the brain parenchyma there is no evidence of
focal lesions and the FLAIR sequence demonstrates no evidence of
gliotic areas or demyelinating lesions. Normal flow void signal
is identified in the vascular structures. The orbits appears
within normal limits. The paranasal sinuses demonstrates mucosal
thickening on the right maxillary sinus, there is evidence of
opacities and hyperintensity signal on the right mastoid air
cells.
IMPRESSION: There is no evidence of focal lesions in the brain
parenchyma. Mild prominence of the sulci and ventricles for the
patient's age. Right maxillary mucosal thickening and opacities
noted on the right mastoid air cells as described above.
Brief Hospital Course:
# Drug overdose - It was unclear what medication patient took as
tox screen positive for benzo and opiate which patient does take
at home and may have mistaken. The patient was intubated due to
lack of gag reflex. She was seen by the toxicology team and
admitted to the [**Hospital Unit Name 153**] for further monitoring. All of her psych
meds were initially held and then restarted at a lower dose
prior to discharge. It was felt that this was an unintentional
overdose as the patient took her meds twice out of confusion.
She was followed by psych during her stay and was felt safe for
discharge home and psych follow up the day after discharge. She
had no evidence of SI or SA during this hospitalization.
# Bradycardia ?????? Unclear how bradycardic patient was enroute to
ER. On presentation to the ICU, she had two episodes of pause
on tele lasting 2.5 sec and 5.9 sec. [**Month (only) 116**] have been from
atenolol ingestion or possibly opiates. She had episodes in the
[**Hospital Unit Name 153**] of hypertensive urgency requiring IV labetalol. No further
bradycardia was observed on tele. She was placed back on
atenolol with good control of BP.
.
Anemia: patient was found to have fe deficiency but was guaiac
negative throughout. She was placed on fe supplements and a PPI
and will need a colonoscopy as an outpatient.
Medications on Admission:
Morphine 30 mg Tab Oral 1 Tablet(s) Every morning and at noon,
2 tablets in the evening
Amidrine 325 mg-65 mg-100 mg Cap Oral 1 Capsule prn headache
Diazepam 10 mg Tab Oral 1 Tablet(s) Three times daily
Flexeril 10 mg Tab Oral 1 Tablet(s) Three times daily for 10
days
Cloanapin 1 mg tid
Loratadine
Celexa 20 mg daily
Premarin
Prilosec
seroquel 200 mg daily
ambien 10 mg daily
nortriptylline 200 mg daily
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
2. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
3. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
4. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
5. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)) as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
medication overdose
respiratory failure
hypertensive urgency
depression
anemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a presumed accidental overdose of your
medications that required intubation. You will need to label
all of your medications carefully. Please follow up with your
PCP as described below.
Followup Instructions:
Dr [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 78479**] [**Telephone/Fax (1) 78480**], please call for a follow up
appointment in 2 weeks. We recommend a GI follow up as well
given your persistent normocytic anemia.
You have psychiatry follow up tomorrow, [**5-23**] here at [**Hospital1 18**].
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8169
} | Medical Text: Admission Date: [**2163-1-16**] Discharge Date: [**2163-1-31**]
Service: MEDICINE
Allergies:
Iodine / Cipro / Sulfonamides / Morphine / Codeine /
Levofloxacin
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
left hip pain/concern for sepsis in ED
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 yo F with hx Renal Cell Carcinoma, ovarian CA, arthritis, s/p
right hip replacement with new onset L hip pain for 3 days. pt
has had difficulty ambulating, endorses pain with any movements
at all. Pt has chronic UTI on keflex at home. She presented to
the ED for evaluation of L hip pain. during w/u for possible
pathologic Fx pat was noted to be hypotensive to 70s. She was
found to have a WBC of 14K, a positive U/A, as well as an
elevated creatinine of 2.4 (baseline 1.6-1.8). Her initial
lactate was 2.1. CXR was negative for PNA. She was ordered for
hip/pelvis plain films. A central line was placed, pat was given
zosyn and 3-4L IVF. Started on levophed.
Admitted to ICU for urosepsis.
Past Medical History:
Left renal tumor x2, status post CyberKnife radioablation in
[**2162-5-23**].
h/o ovarian cancer with peritoneal metastases (followed by Dr
[**Last Name (STitle) 19**]
h/o recurrent partial small bowel obstructions
CRI (1.3 to 1.6)
CHF (EF 50% with mod AS, [**11-24**]+AR, 2+MR)
h/o PAD
h/o C. difficile infections
HTN
h/o diverticulitis,
h/o recurrent UTIs
s/p left CEA,
h/o talc pleurodesis
TAH/BSO 19 years ago
Gout
h/o Collagenous colitis
Allergies: Iodine / Cipro / Sulfonamides / Morphine / Codeine /
Levofloxacin
Social History:
Lives by herself; close relatives live [**Name2 (NI) 97184**]. No tobacco,
EtOH, or IV drug use.
Husband died in [**2161-6-23**].
Family History:
Not contributory
Physical Exam:
Gen: lying in bed, non-toxic, well-appearing
HEENT: dry MMM
Neck: supple, JVD 8 cm, no carotid bruits
Chest: CTAB, no wheezes, decreased BS L base
CVS: rrr, Grade II/VI syst murmur LUSB
Abd: soft, + BS, minimal tenderness LLQ, no rebound or guarding,
no masses
Extrem: no c/c; 2+ pitting edema b/l
Neuro: nonfocal, moves all extremities
Pertinent Results:
[**2163-1-13**] UCx: PSEUDOMONAS AERUGINOSA. pan-sensitive
[**2162-2-23**], [**2162-1-26**]: ESCHERICHIA COLI
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CXR:
1. Low-lying new central venous catheter, which should be
partially
withdrawn; no definite pneumothorax.
2. CHF with bilateral pleural effusions.
Hip films (WET READ):
No cortical irregularity or disruption of trabecular lines
detected to suggest acute fracture in the left hip. Right hip
replacement and pelvis similar in appearence to previous. No hip
dislocation. Given osteopenia, dedicated left hip views vs
CT/MRI may be considered if indicated to evaluate subtle
fractures.
MRI Abd [**2162-12-15**]:
1. Two left-sided renal lesions are again identified. Overall,
the size of these lesions is slightly decreased in size since
the aforementioned recent prior MRI.
2. Arterial spin labeling sequence does demonstrate blood flow
within these lesions as noted. However, no prior ASL is
available for comparison.
3. Stable large, cystic lesion within the left adnexa as noted
above.
RENAL U/S: Limited portable ultrasound performed. No
hydronephrosis or stones in the left kidney. The right kidney
which is small could not be visualized given overlying bowel
gas. A CT abdomen and pelvis may be obtained if warranted for
further evaluation.
ECHO [**2162-8-31**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. There is mild global left
ventricular hypokinesis (LVEF = 45%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
0.7cm2). Mild to moderate ([**11-24**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**11-24**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
CT CHEST/ABD/PELV:
1. No evidence of loculated pleural effusion or empyema, though
evaluation is limited without intravenous contrast.
2. New opacification at the right lung base, and posterior
segment of the
right upper lobe, concerning for pneumonia, possibly related to
aspiration.
3. Unchanged appearance of nonspecific focally distended loops
of small
bowel. No specific evidence of bowel obstruction.
4. Unchanged appearance of numerous calcified lesions throughout
the
peritoneum and abdomen, limited evaluation without intravenous
contrast, but suspicious for metastatic foci.
5. Unchanged appearance of predominantly cystic left adnexal
mass.
Brief Hospital Course:
86 y/o F with PMHx of severe AS & CHF admitted with urosepsis,
s/p extubation on [**2163-1-23**], had recurrent A.fib with RVR &
hypotension that responded to repeat IV fluid boluses, made
DNR/DNI on [**1-27**] with continued delirium.
.
# A.Fib/CV: Pt with severe AS & CHF with EF 50%. Pt developped
Afib with RVR c/b hypotension that responded to repeated IVF
boluses. Concern for aggressive fluid resuscitation sending pt
into pulm edema, likely to compromise resp status. Per family
meeting, pt was made DNR/DNI, no lines, no pressors. Pt had
intermittent episodes of hypotension requiring further fluid
boluses. Avoiding aggressive volume boluses due to tenous
volume status. Was on Digoxin 0.125mg every other day to help
control rate.
.
#UTI/Septic Shock: Pt recently completed a 10 day course of
Zosyn for pseudomonas urosepsis, successfully extubated on [**1-23**].
WBC had trended down, afebrile. However, pt developed recurrent
hypotension likely cardiogenic etiology but was restarted on
empiric ABx prior to leaving the ICU (Zosyn/Vancomycin). Upon
arrival to the floor, the patient remained afebrile with WBC
trending down. Culture data was also negative. Therefore,
antibiotics were stopped and the patient was monitored.
.
# RENAL FAILURE, ACUTE on chronic: Pt initially with oliguric
renal failure likely [**12-25**] hypoperfusion vs ATN in setting of
shock. Pt began to naturally diurese on [**2163-1-26**], then UOP dropped
in setting of hypotension on [**1-27**]. Currently, avoiding volume
overload with gentle IVF boluses. Creatinine gradually
increasing after transfer from ICU to medicine floor. Urine
output decreased and urine studies consistent with pre-renal
picture. Patient given intermittent IVF given poor PO intake.
.
# RESP FAILURE: Pt was intubated on [**1-18**] due to worsening
acidosis & MS changes. CXR with bilateral pleural effusions R>L
& pulm edema. CT on [**1-18**] showed possible airspace disease in
RLL vs chronic changes [**12-25**] to right sided pleurodeisis. Pt
extubated successfully on [**1-23**] and has been maintaining sats on
2-3LNC. Was given nebulizer treatments as needed.
.
# MS CHANGES: Pt with delirium likely secondary to intubation,
polypharmacy & prolonged ICU stay. Sleep/wake cycles now very
disturbed. Pt has been pulling out lines overnight, had to
place restraints temporary. Was started on Zyprexa (initially
5mg [**Hospital1 **], then 2.5/5mg, then 2.5mg [**Hospital1 **] w/ PRN doses).
.
# LEFT HIP PAIN: Etiology unclear but unlikely due to infectious
source. CT neg for joint effusion, bone scan neg for pathologic
fracture/metastatic lesion. PT consulted to assist with getting
OOB. Initially received Dilaudid in the ICU, however that was
stopped due to worry for hypotension and clouding mental status.
On transfer to the floor, patient still with significant pain.
In discussing with family, decision made to re-start Dilaudid
(however in PO form) to control pain, with the understanding
that this may cloud mental status.
.
#Thrombocytopenia ?????? pt has baseline plt ct 50-70s, trended down
to 40 & heparin products held [**2163-1-24**]. Plts have been stable.
Suspician of HIT very low and HIT Ab never sent from lab.
Heparin products were held.
.
#Sacral Decub/intertriguinous rash - was seen by the wound care
nurse [**First Name (Titles) **] [**Last Name (Titles) 7219**] implemented for wound care. Also
placed on kinair mattress with regular position changes. Was
given antifungal cream as well.
.
#Nutrition
Pleasure feeds with pureed nectar thickened feeds (maintained on
aspiration precautions).
.
Code status: DNR/DNI, no lines, no pressors
.
On [**1-31**], patient rapidly became hypotensive and unresponsive and
expired. Family was notified.
Medications on Admission:
ALLOPURINOL 100 mg--2 tablet(s) by mouth twice a day
CEPHALEXIN 500 mg--1 capsule(s) by mouth twice a day
DULCOLAX STOOL SOFTENER 100 mg--1 capsule(s) by mouth four times
a day
FUROSEMIDE 40 mg--4 tablet(s) by mouth every day
Fish Oil 1,000 mg--
HYDROCORTISONE 1 %--apply to affected area twice a day as needed
Hydralazine 50 mg--2 tablet(s) by mouth three times a day
ISOSORBIDE DINITRATE 20 mg--1 tablet(s) by mouth three times a
day
MULTIVITAMIN --1 capsule(s) by mouth once a day
Micro-K 10 mEq--2 capsule(s) by mouth daily
OMEPRAZOLE 40 mg--1 capsule(s) by mouth once a day
TAMOXIFEN 10 mg--2 tablet(s) by mouth once a day
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 5185, 486, 2762, 5990, 5849, 2930, 4280, 4241, 5859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8170
} | Medical Text: Admission Date: [**2100-8-6**] Discharge Date: [**2100-8-14**]
Date of Birth: [**2018-3-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
worsening shortness of breath, fatigue and dyspnea
Major Surgical or Invasive Procedure:
[**2100-8-6**]
1. Aortic valve replacement 25-mm Biocor Epic tissue valve.
2. Coronary artery bypass grafting x3: Left internal mammary
artery graft to left anterior descending, reverse saphenous vein
graft to the marginal branch and the posterior descending artery
History of Present Illness:
82 year old male who has been followed for aortic stenosis since
[**2098**] after an echo was performed for a murmur prior to his left
total hip replacement. Echo revealed moderate aortic stenosis
with peak/mean gradient 62/38. Medically managed with serial
echocardiograms over the last several years. He noted a marked
decrease in exercise tolerance with generalized fatigue. He also
complains of dyspnea on exertion. He attributes some of these
symptoms to fairly severe arthritis in his knees and hips. His
most recent echo showed severe AS (similar to echo in [**2099**]),
given his current symptoms he was referred for surgical
evaluation.
Past Medical History:
PMH:
Aortic stenosis
Insulin dependent Diabetes Mellitus
Arthritis
Rheumatic heart disiease
Coronary artery disease
Hypertension
Prostate cancer treated with radiation
PSH:
s/p Left total hip replacement at the [**Hospital3 **] in [**12-15**]
s/p Bilateral knee replacements in [**2096**]
Right shoulder surgery
Prostatectomy [**2075**]
Social History:
Race: Caucasian
Last Dental Exam: [**2-7**] mos. ago
Lives with: wife
Occupation: retired engineer, published his very moving book on
his WWII experiences, keeps very active- builds furniture
Tobacco: never
ETOH: quit 3 yrs. ago
Family History:
non-contributory
Physical Exam:
Preoperative
Pulse: 69 Resp: 18 O2 sat: 98%RA
B/P Right: 128/89 Left: 123/85
Height: 66" Weight 93 kg (205 lbs)
General: NAD, WGWN, appears younger than stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x] fixed pupils (cataracts)
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 systolic
Abdomen: Soft [x] non-distended [x] non-tender [x] + BS [x]
Extremities: Warm [x], well-perfused [x]
Edema: trace pedal edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left:1+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: cath Left:1+
Carotid Bruit -radiated murmur
Pertinent Results:
Admission
[**2100-8-6**] 08:00AM HGB-11.7* calcHCT-35
[**2100-8-6**] 08:00AM GLUCOSE-131* LACTATE-1.0 NA+-141 K+-4.4
[**2100-8-6**] 12:31PM GLUCOSE-178* LACTATE-1.7 NA+-138 K+-4.8
CL--113*
[**2100-8-6**] 12:34PM FIBRINOGE-206
[**2100-8-6**] 12:34PM PT-13.9* PTT-30.9 INR(PT)-1.2*
[**2100-8-6**] 12:34PM PLT COUNT-154
[**2100-8-6**] 12:34PM WBC-15.3*# RBC-2.54*# HGB-8.0*# HCT-23.2*#
MCV-91 MCH-31.5 MCHC-34.5 RDW-13.8
[**2100-8-6**] 02:18PM UREA N-38* CREAT-1.1 SODIUM-143 POTASSIUM-4.6
CHLORIDE-119* TOTAL CO2-22 ANION GAP-7*
Discharge
[**2100-8-14**] 04:40AM BLOOD WBC-10.8 RBC-2.79* Hgb-8.4* Hct-24.9*
MCV-89 MCH-30.2 MCHC-33.8 RDW-13.8 Plt Ct-352
[**2100-8-14**] 04:40AM BLOOD PT-13.5* INR(PT)-1.2*
[**2100-8-14**] 04:40AM BLOOD Glucose-99 UreaN-29* Creat-1.4* Na-136
K-4.6 Cl-100 HCO3-28 AnGap-13
[**2100-8-14**] 04:40AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.2
ECHO [**2100-8-6**]: PREBYPASS: No atrial septal defect is seen by 2D or
color Doppler. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. 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). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
borderline functional mitral stenosis due to mitral annular
calcification (MVA-2.2 cm2) Mild (1+) mitral regurgitation is
seen.
POSTBYPASS: There is preserved biventricular systolic function.
There is a well seated, well functioning bioprosthesis in the
aortic position. There is trace valvular AI. The remaining study
is unchange from prebypass.
Chest x-ray [**8-11**]: PA and lateral chest submitted for review on
[**8-13**] shows a stable postoperative appearance to the enlarged
mediastinum. Aside from mild right basal atelectasis, lungs are
clear. Pleural effusions are small if any. No pneumothorax or
pulmonary edema.
Brief Hospital Course:
Mr. [**Known lastname 50500**] was admitted on [**2100-8-6**] and taken to the operating
room where he underwent Aortic valve replacement and Coronary
artery bypass grafting x3. Please see operative note for
details, in summary he had: Aortic valve replacement 25-mm
Biocor Epic tissue valve and Coronary artery bypass grafting x3
with left internal mammary artery graft to left anterior
descending, reverse saphenous vein graft to the marginal branch
and the posterior descending artery. His bypass time was 129
minutes with a crossclamp of 106 minutes. He tolerated the
operation and immediately post-operatively was admitted to the
ICU intubated and sedated on propofol and on neo for BP support.
Propofol was weaned off readily and patient was extubated
without difficulty on POD #1. On POD#2 he developed rapid afib
which was treated with IV Lopressor and amiodarone and he
continued to require neo for blood pressure support. He
converted to sinus rhythm and Neo-Synephrine infusion was weaned
off. Chest tubes and pacing wires were removed per cardiac
surgery protocol. On POD# 3 he was transferred to the step down
unit for ongoing post-operative care. He was diuresed
postoperatively and developed ATN which improved when Lasix dose
was decreased. Once on the stepdown floor he continued to have
intermittent episodes of rapid afib and his beta blocker was
titrated accordingly, rate control was difficult to achieve. EP
was consulted and he was also started on Coumadin for his atrial
fibrillation. The remainder of his hospital course was
uneventful. He was evaluated by physical therapy for strength
and conditioning and a brief rehabilitation stay was recommended
prior to returning to home. He was discharged to [**Hospital 24806**] rehab on
POD 8.
Medications on Admission:
Insulin Lispro (Humalog) 30 units daily
Insulin Glargine [Lantus]100 unit/mL Solution 30U at 2300 hrs
Latanoprost [Xalatan] 0.005 % Drops, 1 drop(s) both eyes bedtime
Proscar 5mg daily
Ramipril 10mg daily
Aspirin 81mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day for 1
doses: Titrate for a Goal INR 2.0-2.5.
10. guaifenesin 600 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO BID () for 3 days.
11. insulin glargine 100 unit/mL Solution Sig: Thirty Five (35)
Subcutaneous once a day: at breakfast.
12. Insulin sliding scale
Please see attached chart for sliding scale insulin (Humalog)
dosing
13. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): Please take 200mg three times a day for 5 days. Then
take 200mg twice daily for 7 days. Finally, take 200mg daily
until stopped by cardiologist.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 24806**] Care Center - [**Hospital1 1562**]
Discharge Diagnosis:
Aortic Stenosis/Coronary artery disease s/p Aortic Valve
Replacement and Coronary artery bypass graft x 3
PMH:
Diabetes Mellitus
Osteoarthritis
Rheumatic heart disease
Hypertension
Prostate cancer s/p XRT
s/p left total hip replcaement
s/p Bilateral knee replacements in [**2096**]
s/p Right shoulder surgery
s/p Prostatectomy [**2075**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw - day after discharge, [**8-15**]
Rehab to arrange Coumadin follow-up with PCP
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2100-9-2**] 1:00
in the [**Hospital **] Medical office building [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2100-9-21**] 4:00
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 98813**] to be seen in [**5-11**] 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**
Completed by:[**2100-8-14**]
ICD9 Codes: 5845, 5185, 9971, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8171
} | Medical Text: Admission Date: [**2183-8-14**] Discharge Date: [**2183-8-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Fever, rigors
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname 1005**] is an 89yo spanish speaking female with PMH
significant for multiple ESBL UTIs, lumbar osteomyelitis, and
psoas abcess who was admitted to the MICU with a UTI and
transient hypotension concerning for urosepsis. Of note, the
patient was recently hospitalized in [**2183-5-20**] for E coli and K.
pneumo UTI ([**1-17**] BCx + for K. pneumo), tx with
cephalexin/cefpodoxime for 14d. Her osteomyelitis was unchanged
per MRI at this time. In addition, a PICC was placed on [**7-31**] to
administer a 7d course of Imipenem (500mg q8h, [**Date range (1) 50412**]) for an
ESBL E. coli UTI [**2-15**] foley catheter (d/c'd [**7-31**]). The PICC was
kept until f/u urine studies could be performed 1 wk post-abx.
This morning at the patient's NH, she was noted to have fevers
and rigor. Her vitals at this time were T 100.0 BP 160/90 AR 130
RR 30 O2 sat 90% RA. ? if she was on carbapenem for a UTI. She
was then transferred to [**Hospital1 18**] for further work-up.
In the ED, initial vitals were T 99.1 Tmax 101.8 BP 120/80 AR 92
RR 16 O2 sat 99% RA. Foley placed without any complications. She
received Flagyl 500mg, Linezolid 600mg, and Meropenem 500mg. Her
BP dropped to 90/68. She also was given 2L NS.
Upon arrival to the MICU and in the presence of the spanish
translator, the patient denies any acute complaints. She denies
any chest pain, SOB, abdominal pain, or any other concerning
symptoms. She does admit to some low back pain, which is chronic
for her. She was hemodynamically stable in the MICU, and so she
was called out to the floor. She is being followed by ID
in-house and is on meropenem and daptomycin (changed from
linezolid [**2-15**] serotonin syndrome concern).
On the floor, she only c/o generalized weakness.
Past Medical History:
1)VRE stump infection [**1-21**]
2)Klebsiella pneumonia and bacteremia
3)Multiple UTIs including ESBL E. coli [**2183-7-30**] in setting of
foley
4)Lumbar osteomyelitis L2-L3 s/p daptomycin and meropenem x8
weeks; biopsy cultures were negative
5)Psoas/iliacus abscesses [**1-21**]
6)Hypertension
7)Type 2 diabetes
8)Stomach carcinoma s/p resection
9)Hx of gastritis/esophagitis
10)Chronic anemia
11)PVD s/p common femoral to left common femoral bypass with
PTFE in [**2181-6-14**]
12)L AKA in [**12-21**] c/b klebsiella PNA, VRE UTI, presumed c. diff
tx'ed with abx 8 wks
13)Hx urinary incontinence status post collagen injections
to bladder neck
14)s/p hysterectomy
15)s/p oophorectomy 30 years ago
Social History:
She is originally from [**Country 26231**]. She is not employed. She does
not use tobacco. She does not use alcohol nor any drugs. Lives
at NH.
Family History:
n/c
Physical Exam:
VS: 98.9 71 135/44 18 99%RA
Gen: Pleasant female, well appearing, alert and oriented to
person, place day and month (year - [**2145**]).
HEENT: MMM, anicteric sclera
Heart: RRR, no m,r,g
Lungs: CTAB, few scattered crackles at posterior lung bases
Abdomen: Soft, mild tenderness in RLQ, +BS; G-tube in place
without any surrounding erythema or tenderness. No CVAT.
Extremities: L AKA, no edema of RLE, 2+ DP/PT pulses; quarter
sized sacral ulcer with mild surrounding tenderness
Pertinent Results:
[**2183-8-14**] 09:15AM WBC-13.2* RBC-3.71* HGB-10.0* HCT-30.0*
MCV-81* MCH-27.1 MCHC-33.5 RDW-14.8
[**2183-8-14**] 09:15AM PLT SMR-HIGH PLT COUNT-470*
[**2183-8-14**] 09:15AM SED RATE-120*
[**2183-8-14**] 09:15AM CRP-177.7*
[**2183-8-14**] 09:15AM GLUCOSE-106* UREA N-17 CREAT-0.5 SODIUM-130*
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-24 ANION GAP-13
[**2183-8-14**] 09:47AM LACTATE-3.3*
[**2183-8-14**] 10:17AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.008
[**2183-8-14**] 10:17AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2183-8-14**] 10:17AM URINE RBC-[**6-24**]* WBC->50 BACTERIA-MANY
YEAST-FEW EPI-[**3-19**]
[**2183-8-14**] 11:02AM LACTATE-2.2*
URINE CULTURE (Final [**2183-8-17**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I =>32 R
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S 16 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 128 R
PIPERACILLIN/TAZO----- <=4 S 32 I
TOBRAMYCIN------------ 4 S 8 I
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
.
Urine cx ([**8-15**]): negative
Blood cx ([**8-14**]): negative x2
Blood cx ([**8-15**]): NGTD x2
Cdiff toxin neg x1
.
CT abd/pelvis ([**8-14**]):
IMPRESSION:
1. No acute finding to explain source of infection.
2. Stable destruction of L2 and L3 vertebral bodies.
3. No CT evidence of pyelonephritis.
4. No evidence of intraabdominal or pelvic abscess.
.
MRI pelvis ([**8-18**]):
IMPRESSION:
1) Severely limited study for reasons stated above.
[claustrophobia]
2) Bilateral femoral avascular necrosis with severe underlying
osteoarthritis.
3) Prominent bilateral subcutaneous edema and edema tracking
along the
adductor musculature bilaterally.
4) Study not of diagnostic quality to assess the psoas muscles
or exclude deep abscess.
.
MRI T/L spine ([**8-17**]):
Impression:
Essentially no change in the appearance of the inflammatory
changes at L2-L3.
.
KUB with oral contrast via J tube ([**8-16**]):
Single portable radiograph of the abdomen demonstrates oral
contrast within a catheter projecting over the left upper and
lower quadrants. There is oral contrast within the small bowel.
No extravasation is seen. Surgical staples project over the
right upper quadrant. There is a non-obstructive bowel gas
pattern. No pneumoperitoneum is evident. The appearance of the
osseous structures is unchanged compared with [**2183-7-3**].
Surgical staples projecting over the left upper and lower
quadrants remain similar in appearance as well.
Brief Hospital Course:
## UTI/urosepsis:
Patient was initially febrile to 101.8 and hypotensive to 90/68
on admission. She was given flagyl, linezolid, and meropenem in
the ED, as well as 2L NS. Foley was placed with purulent urine
return. She was initially continued on meropenem and linezolid,
but the linezolid was switched to daptomycin on [**8-15**] due to
concern for serotonin syndrome given venlafaxine use. Daptomycin
d/c'd on [**8-18**] as osteo stable (see below). Urine culture grew E
coli and Klebsiella, sensitive to meropenem and bactrim. Due to
this, meropenem was switched to bactrim on [**8-19**] to complete a 14
day course. Pt transitioned from Foley to straight cath q8h due
to retention to help prevent UTI recurrence (no bladder scan at
nursing facility). Since her initial ED presentation, she has
remained without hypotension or fevers. She was restarted on
lisinopril and metoprolol XL after 24hrs w/o hypotension.
## Osteomyelitis: No complaints of back pain. MRI T/L spine
showed stable appearance, so daptomycin was stopped on [**8-18**]. MRI
pelvis was attempted, but pt did not tolerate due to
claustrophobia (even with ativan). CRP was much decreased on
discharge. She will followup in [**Hospital **] clinic.
## Rash
Erythematous unilateral macular flank rash w/ small pustules
noted. No pain, confirms pruritis. No eos on CBC. Started on 7d
course valacyclovir to end [**8-24**] for possible zoster.
## Type 2 DM: Held oral hypoglycemics and had reasonable glucose
control with insulin sliding scale.
## FEN
Pt gets supplemental tube feeds overnight. Her sutures came
loose on [**8-16**], but were reattached by IR. Plain film w/ contrast
showed proper positioning, so feeds resumed.
## Decubitus ulcer
Known prior to admission. Wound care consulted and pt was
repositioned and cleansed per their recs. No e/o communication
w/ osteo on MRI.
## Bilateral AVN of femoral head
Noted on brief images obtained on MRI pelvis study. Pt
asymptomatic and would likely need conservative management. Can
consider bisphosphonates in the outpatient setting.
## Dispo
All other chronic problems remained stable and treated as prior.
She is being discharged back to her [**Hospital1 1501**].
Medications on Admission:
Pioglitazone 7.5mg PO daily
Fluticasone-salmeterol
Omeprazole 20mg PO BID
Tiotropium MDI
Aspirin 81mg PO daily
Metoprolol XL 50 mg PO daily
Docusate 100 mg 100mg PO BID
Senna PO BID
Venlafaxine 25mg PO BID
Oxycodone PO Q6H PRN
Acetaminophen 650mg PO Q6H
Vitamin D PO daily
Lisinopril 20mg PO daily
Immodium PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. Venlafaxine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 5 days: Last day of 7d total course is [**2183-8-24**].
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Actos 15 mg Tablet Sig: [**1-15**] Tablet PO once a day.
13. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
14. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO after each
loose stool as needed for diarrhea.
15. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 8 days: To finish 14d total course on [**2183-8-27**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location 4288**]
Discharge Diagnosis:
Primary:
Urosepsis,
Stage IV decubitus ulcer
Lumbar osteomyelitis.
Secondary diagnoses:
Diabetes mellitus type 2, controlled with complications
Hypertension
Peripheral vascular disease status post left above knee
amputation
Discharge Condition:
Stable hemodynamics, alert and interactive, afebrile.
Discharge Instructions:
You were admitted to [**Hospital1 18**] because of a bladder infection. This
caused you to have low blood pressure, which we fixed with
fluids. We started you on intravenous antibiotics for 14 total
days for the infection. We imaged your spine with an MRI to see
if your previous bone infection had changed, and it looked
stable from your last MRI. We have removed the catheter that
stays in your bladder because this would make treating the
infection difficult. Instead, we will use intermittent
catheters, "straight cath," as needed. Also, you have a rash on
your back that may be herpes zoster, which is a virus. We will
treat you with antibiotics for this as well.
Please take all medications as prescribed and follow-up at all
appointments.
If you notice any problems urinating, fevers, chills, night
sweats, weakness, changes in mental status, or any other
concerning symptoms, please seek medical attention or come to
the emergency department immediately.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD, Infectious Disease
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2183-8-27**] 11:30
Dr. [**First Name (STitle) 17832**] [**Name (STitle) 16365**], Primary Care, Phone:[**Telephone/Fax (1) 17826**]
[**8-22**] at 2:45pm. [**Street Address(2) **] [**Location (un) 577**], [**Numeric Identifier 4544**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2183-8-20**]
ICD9 Codes: 5990, 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8172
} | Medical Text: Admission Date: [**2133-2-9**] Discharge Date: [**2133-2-14**]
Date of Birth: [**2087-1-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2133-2-10**] - CABGx2 (Lima->LAD, SVG->Diag). Mediastinal Lymph Node
Biopsy.
[**2133-2-8**] - Cardiac Catheterization
History of Present Illness:
The patient is a 46-year-old man who presented with angina. He
has had a history of several LAD stents placed with recurrent
thrombosis. This was angioplastied under Dr. [**First Name (STitle) **] with good
flow to the distal vessel. In
addition, the patient has a left upper lobe lung lesion most
likely carcinoma. He now presents for surgical
revascularization.
Past Medical History:
CAD
-s/p LAD stent [**2130**]
-s/p anterolateral MI ([**5-31**]) [**2-19**] stent occlusion (s/p LAD stent)
Hypercholesterolemia
Smoker
Prior knee surgeries
Right arthroscopic rotator cuff surgery ([**2132-5-29**])
Medication non-compliance
Social History:
Patient is single and has a significant other ([**Name (NI) 3742**]). He
works in property maintenance.
Family History:
[**Name (NI) 1094**] mother died of MI at age 54 (had first MI at earlier age).
Father w/ CAD; died [**2-19**] accident. Uncle had CABG in 30s when he
passed away. Oldest brother had angina.
Physical Exam:
Vitals: BP 107/60, HR 72, RR 20, SAT 100% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign, good dental health
Neck: supple, no JVD, transmitted murmur to carotid noted
Heart: regular rate, normal s1s2 II/VI diastolic murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, 1+ LE edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2133-2-9**] 04:45AM PT-12.5 PTT-33.4 INR(PT)-1.0
[**2133-2-9**] 04:45AM PLT COUNT-223
[**2133-2-9**] 04:45AM GLUCOSE-103 UREA N-12 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12
[**2133-2-9**] 04:45AM CK-MB-126* MB INDX-14.2* cTropnT-1.35*
[**2133-2-9**] 09:45AM PLT SMR-NORMAL PLT COUNT-200
[**2133-2-9**] 09:45AM WBC-8.0 RBC-UNABLE TO HGB-12.1* HCT-34.5*
MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO RDW-UNABLE TO
[**2133-2-9**] 09:45AM ALT(SGPT)-32 AST(SGOT)-128* ALK PHOS-57 TOT
BILI-0.5
[**2133-2-9**] 09:45AM GLUCOSE-116* UREA N-10 CREAT-0.8 SODIUM-136
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-22 ANION GAP-11
[**2133-2-9**] 12:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2133-2-13**] 06:45AM BLOOD Hct-23.4*
[**2133-2-12**] 04:45AM BLOOD Plt Ct-120*
[**2133-2-12**] 04:45AM BLOOD Glucose-101 UreaN-18 Creat-1.0 Na-134
K-4.1 Cl-100 HCO3-27 AnGap-11
[**2133-2-9**] Cardiac Catheterization
1. Selective coronary angiography in this left dominant
circulation
demonstrated one vessel coronary artery disease. The LMCA had
mild
luminal irregularities. The proximal LAD had a 30% stenosis. The
proximal LAD stents were totally occluded with some retrograde
filling
of the distal and mid LAD by left to left collaterals. The LCx
was a
large dominant vessel and had mild luminal irregularities. The
OM1 was a
moderate size vessel with moderate diffuse disease. The OM2 was
also a
moderate size vessel without significant obstructive disease.
The L-PDA
was without any significant flow limiting disease. The RCA was
not
engage because it was known to be a diminuitive vessel.
2. Resting hemodynamics from right and left heart
catheterization
demonstrated moderate elevation of right and left heart filling
pressures (RVEDP 20mmHg, LVEDP 23mmHg). There was moderate
pulmonary
arterial hypertension. There was no mitral stenosis appreciated.
There
was no transaortic pressure gradient upon catheter pullback from
the
left ventricle to the ascending aorta. The calculated cardiac
output by
the Fick method was 5.3 L/min with a cardiac index of 2.7.
3. Intravascular ultrasound interrogation of the proximal LAD
verified
that the occlusion was secondary to thrombus formation and that
the
previously deployed stents were well opposed.
4. Successful catheter thrombectomy and balloon angioplasty
using a
3.25 mm balloon in the proximal LAD late stent thrombosis. Final
angiography demonstrated no residual stenosis, no
angiographically
apparent dissection, and normal flow (See PTCA Comments).
[**2133-2-11**] ECHO
The left atrium is normal in size. No spontaneous echo contrast
is seen in the body of the left atrium or left atrial appendage.
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. No left ventricular aneurysm is seen. There is moderate
regional left ventricular systolic dysfunction. Overall left
ventricular systolic function is moderately depressed. Resting
regional wall motion abnormalities include mid anterior,
anterior septum and septum ( moderately hypokinetic). The
inferior wall is mildly hypokinetic.The remaining left
ventricular segments contract normally. Right ventricular
chamber size and free wall motion are normal.
There is simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Post bypass the LV function was unchanged and RV function is
preserved. Aorta was in tact post decannulation.
[**2133-2-9**] CXR
No acute cardiopulmonary process.
[**2133-2-9**] EKG
Sinus rhythm with ventricular premature depolarizations. Low QRS
voltage in the limb leads. Extensive anteroseptal and lateral
myocardial infarction. Compared to the previous tracing of
[**2132-9-5**] multiple abnormalities as previously noted persist
without major change.
Brief Hospital Course:
Mr. [**Known lastname 27427**] was admitted to the [**Hospital1 18**] on [**2133-2-9**] for further
work-up of his chest pain. He underwent a cardiac
catheterization which was significant for severe single vessel
coronary artery disease. Given the severity of his disease, the
cardiac surgical service was consulted for surgical management.
Mr. [**Known lastname 27427**] was worked-up in the usual preoperative manner.
Heparin was continued for anticoagualtion. Given his new history
of a right upper lobe nodule, the thoracic surgery service was
consulted for assistance in his care. A mediastinal lymph node
biopsy was recommended during his bypass surgery. On [**2133-2-10**],
Mr. [**Known lastname 27427**] was taken to the operating room where he
underwent coronary artery bypass grafting to two vessels.
Afterward he was transferred to the Cardiac surgery recovery
unit in stable condition and awakened neurologically intake.
He was weaned from ventilator support, extubated, and pressors
were weaned. On POD 2 he was then transferred to the Stepdown
unit for further recovery. His chest tubes were removed without
complication. He was gently diuresed to his preoperative
weight, beta blockade and aspirin therapy were resumed, and
physical therapy service was consulted to assist with his
postoperative strength and mobility. Electrolytes were repleted
as needed. On POD 3 he his epicardial pacing wires were removed
without complication, he continued to improve his ability to
ambulate including climbing stairs without respiratory distress
or chest pain. A chest xray demonstrated a left lower lobe
consolidation for which he was placed on empiric levaquin. On
POD 4 Mr. [**Known lastname 27427**] was at his preop weight with good exercise
tolerance, no SOB, or chest pain. His blood pressure was
stable. His sternotomy and leg incision were clean, dry, and
intact without evidence of infection. He was discharged home on
POD 4 with services in good condition, levaquind 500mg po qd for
five days, cardiac diet, sternal precautions, and instructed to
follow up with his PCP and cardiologist in [**1-19**] weeks. He will
follow up with Dr. [**Last Name (STitle) 1290**] in four weeks.
Medications on Admission:
ASA 325'
Zocor 20'
Toprol 50'
Lisinopril 5'
plavix 75'
Discharge Medications:
1. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs MDI* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. 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:
[**Location (un) **] vna
Discharge Diagnosis:
Coronary Artery Disease
Anterior STEMI
s/p PTCA and stenting
Hypercholesterolemia
HTN
Lung Mass
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage and increased pain.
2) Report any weight gain of greater then 2 pounds in 24 hours
or 5 pounds in 1 week.
3) Report any fever greater then 100.5.
4) No lifting more then 10 pounds for 10 weeks.
5) No driving for 1 month.
6)
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month.
Follow-up with your cardiologist in [**1-19**] weeks.
Follow-up with your primary care physician [**Last Name (NamePattern4) **] 2 weeks.
Call all providers for appointments.
Completed by:[**2133-2-14**]
ICD9 Codes: 4280, 5180, 2859, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8173
} | Medical Text: Admission Date: [**2172-3-12**] Discharge Date: [**2172-3-17**]
Service: MEDICINE
Allergies:
Lipitor / Amoxicillin / Erythromycin Base / Sulfa (Sulfonamide
Antibiotics) / Procainamide / Zocor
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
Dysuria and hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is an 88 M with a medical history notable for
hormone-resistant prostate cancer and previous urethral trauma
who currently has a chronic indwelling Foley catheter. He was
sent to the ED from his skilled nursing facility as the [**Hospital1 1501**] was
unable to change his Foley. Two days prior to presentation he
noted malaise and urinary discomfort. During these two days, he
also noted subjective fevers, chills and a poor appetite. He
denies vomiting and back pain. His care providers at his [**Hospital1 1501**]
tried to change his Foley, but after multiple attempts were
unable to do so. He then developed worsening bloody discharge
from his urethral meatus.
In the ED, initial vs were: T 98.3, P 77, BP 165/59, R 16, O2
sat 98% RA. Patient was febrile in the ED to 101.4. Urology saw
the patient in the ED and placed a 14F Coude-tip catheter
without difficulty. Approx 200cc of cloudy, foul smelling urine
drained. Blood and urine cx were sent. U/A was positive.
Patient was given vanco and CTX given his h/o MRSA and proteus
UTIs. After which, the patient became hypotensive 70s. Has
received 2L of IVF and SBPs only in 90s. The patient felt
lightheaded with the low BP in the ED. He was also given zofran
and tylenol. He was then admitted to the ICU.
Past Medical History:
Asbestosis with numerous pleural plaques
RUL mass seen on [**8-/2171**] admission, thoracic surgery recommended
repeat CT scan
spinal stenosis, severe C3-C4 and C6-C7
Afib (not on coumadin secondary to falls)
CAD - '[**52**] BMS to mid RCA, '[**64**] DES to mid RCA
Diastolic CHF - [**11-25**] EF 55%, LA mod dilated, mild LVH, RV
normal, aortic root mildly dilated, no AS, no AI, trivial MR,
mod pHTN
PAD - s/p stent to RLE SFA in [**12-25**]
H/o bladder cancer in [**2166**](s/p local resection)
hx of urethral stricture requiring permanent indwelling foley
h/o prostate CA (s/p external beam radiation and Lupron
injections)
Recurrent UTIs - Patient has a h/o of MRSA & Proteus UTI in
[**12-26**] as well as STENOTROPHOMONAS, sensitive to bactrim and
ENTEROCOCCUS SP, [**Last Name (un) 36**] to vanco in [**8-26**]. Multiple pseudomonas
UTIs in past, most were fairly sensitive.
Social History:
Lives at a skilled nursing facility. Denies current alcohol,
IVDU, or
smoking. He smoked cigarettes in the past, but quit 45 years
ago. Admits to asbestos exposure during WWII.
Family History:
Mother: had heart problems
Father: had heart problems
Brother: died from prostate cancer
Brother: died from MI
Physical Exam:
Admission physical exam:
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding
Back: no CVA tenderness
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema, right heal with
pressure ulcer.
Neuro: A&Ox3, CN 2-12 intact, MAE.
Pertinent Results:
Admission Labs:
[**2172-3-12**] 02:25PM WBC-9.6# RBC-3.38* HGB-9.9* HCT-31.1* MCV-92
MCH-29.4 MCHC-32.0 RDW-15.9*
[**2172-3-12**] 02:25PM GLUCOSE-125* UREA N-29* CREAT-1.7* SODIUM-139
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-30 ANION GAP-14
[**2172-3-12**] 04:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
[**2172-3-12**] 02:04PM LACTATE-2.2*
[**2172-3-12**] 02:25PM PT-13.1 PTT-22.6 INR(PT)-1.1
Discharge Labs:
[**2172-3-17**] 07:13AM BLOOD WBC-4.8 RBC-3.21* Hgb-9.7* Hct-28.6*
MCV-89 MCH-30.1 MCHC-33.9 RDW-15.7* Plt Ct-186
[**2172-3-17**] 07:13AM BLOOD Glucose-94 UreaN-17 Creat-1.4* Na-141
K-3.7 Cl-101 HCO3-36* AnGap-8
[**2172-3-17**] 07:13AM BLOOD Calcium-8.6 Mg-2.0
MICROBIOLOGY:
- admission Urine Culture:
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ =>32 R <=2 S
AMPICILLIN/SULBACTAM-- 16 I <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S 8 R
Brief Hospital Course:
Mr. [**Known lastname **] presented to the [**Hospital1 18**] ED with 2 days of malaise and
for a Foley catheter change. On presentation he was found to
have a fever and hypotension. His catheter was changed and he
was found to have a UTI with quinolone-resistant E coli and
Proteus. He initially required admission to the ICU for
fluid-responsive hypotension and was then transferred to the
floor. Due to a difficult Foley catheter change he developed
hematuria. He received 1 unit of packed red blood cells and his
hematuria resolved without intervention.
Active medical problems:
1. Catheter-associated UTI
- initially treated with Vancomycin and cefepime until cultures
returned
- continue cefepime with last dose on [**2172-3-22**] for a total
10-day course
- has scheduled follow-up with Dr. [**Last Name (STitle) **] for a catheter change
at the end of [**Month (only) 958**]
2. Cardiovascular disease including peripheral vascular disease:
- continued patient's home regimen of aspirin and Plavix.
3. Paroxysmal atrial fibrillation
- had bradycardia and fatigue on his home metoprolol while
admitted; this was held but may be restarted after his acute
illness has resolved
4. Congestive heart failure with preserved ejection fraction and
stage III Chronic kidney disease
- required increased doses of Lasix while admitted in the
setting of IV fluids and transfusion
- restarted home Lasix at discharge
- please recheck kidney function and electrolytes on Thursday
[**3-19**] and adjust Lasix accordingly
- discharge weight: 80.2kg
5. Prostate Cancer
- currently being considered for an investigational treatment.
He has follow-up with oncologist, Dr. [**Last Name (STitle) **], to discuss
treatment options.
6. Skin Care:
- for right heel ulcer:
Cleanse wound with wound cleanser then pat dry. Apply aloe vesta
to dry intact tissues and cover wound with Adaptic - nonadherent
dressing. Follow this with dry gauze and ABD pad. Then wrap with
Kerlix or stretch gauze. Change this daily.
Medications on Admission:
Protonix 40mg PO daily
Aspirin 81 mg PO daily
Citalopram 20mg PO daily
Ferrous Sulfate 325mg PO daily
Multivitamin 1 tab po daily
Lasix 40mg po daily
Plavix 75 m PO daily
Vitamin B 12 1000mcg Po daily
Vit D 400 unit s po daily
Calcium Carbonate 500mg PO BID
Gabapentin 300mg PO QHS
metoprolol tartrate 12.5mg PO BID
Tylenol 325mg, 2tabs PO Q6hrs prn
Oxycodone 5-325 1 tab PO Q4hrs prn, does not use regularly
MOM PRN
[**Name (NI) 10687**] 2 tabs PO QHS
Miralax PRN
Bisacodyl PRN
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) cc PO
at bedtime as needed for constipation.
7. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please monitor weight and electrolytes closely; this may need
decreased to 20mg daily.
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
14. [**Name (NI) **] 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
16. acetaminophen 650 mg/20.3 mL Solution Sig: 1-2 tablets PO
Q6H (every 6 hours) as needed for pain.
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for moderate to severe pain.
18. CefePIME 1 g IV Q24H
19. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) dose Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
20. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q2H (every 2
hours) as needed for shortness of breath.
21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing and rehab
Discharge Diagnosis:
Catheter-associated urinary tract infection
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 **],
You presented to the hospital to have your Foley catheter
changed and were found to have a urinary tract infection. You
briefly required admission to the ICU and improved with
antibiotics. We would like you to complete 10 days total of the
antibiotics.
The only other change to your medications was holding your
metoprolol. Taking this medication seemed to make you quite
tired and your heart rates were very low with this medication.
You can continue your other medications as before.
Please follow-up with Dr. [**Last Name (STitle) **] to discuss treatment options for
your prostate cancer.
Please also follow-up with Dr. [**Last Name (STitle) **] to have him change your
Foley catheter at the end of the month.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2172-4-2**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], 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
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2172-4-16**] at 11:30 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 277**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5849, 2851, 5990, 4280, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8174
} | Medical Text: Admission Date: [**2112-10-10**] Discharge Date: [**2112-10-16**]
Date of Birth: [**2041-10-20**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Ace Inhibitors
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
N/V/D
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname **] is a 70 year old man with h/o CAD, dilated
ischemic cardiomyopathy (EF 10%), aflutter on Dabigatran, BiV
ICD, DM, HTN, HLD, CKD, R 4th toe amputation with debridement in
[**2112-6-3**], s/p 6 weeks of Vanc/Ctx for osteomyelitis, who
presents with N/V/D x4 days.
Patient has been having nausea, vomiting, and diarrhea for the
past 4 days. Diarrhea is watery stool, nonbloody. No recent
travel or sick contacts. [**Name (NI) **] abdominal pain. +subjective fevers
and chills. Of note, patient finished 6 week course of Vanc/Ctx
for R foot osteomyelitis on [**2112-9-11**].
In the ED, initial VS were stable. Patient was given Dilaudid
for chronic LE pain, 250cc NS, and Zofran. RUQ U/S with sludge,
negative [**Doctor Last Name 515**], no wall edema. Labs notable for lactate 2.7,
anion gap 19, Cr 2.2, HCO3 9. pH was 7.21 on VBG. Patient has
been relatively hypotensive, SBP 90s. On the Medicine floor, the
patient was treated with IVF boluses (1.5L) and started on
broad-spectrum antibiotics for concern for sepsis. Patient was
altered in the AM, but became more alert in the afternoon. He
was refusing VS and lab draws at times. Lactate and anion gap
improved initially, but then worsened in the early evening.
Given concern for worsening labs, patient was transferred to the
ICU for closer monitoring.
In the ICU, the patient is currently not complaining of nausea,
vomiting, or abdominal pain. He has had no episodes of diarrhea
today. He is c/o L knee pain, new from a few weeks ago.
Past Medical History:
1. CAD, multiple MIs, CABG ([**2101**]) ([**2101**]): SVG-PL, SVG-Diagonal
and LIMA-LAD. He had a PTCA only of the mid Cx with an Apex OTW
2.25x15 mm
2. Dilated ischemic cardiomyopathy with LVEF of 10%.
3. Atrial flutter, status post cardioversion [**2110-11-28**].
4. BiV ICD pacemaker.
5. Diabetes.
6. Dyslipidemia.
7. Hypertension.
8. Stage III chronic kidney disease secondary to hypertension
and diabetes.
9. Retinopathy, neuropathy, and nephropathy from diabetes.
10. Left hip fracture with attempted surgery, which resulted in
a cardiac arrest.
11. History of substance abuse.
12. History of pancreatitis.
13. GERD.
14. Colonic polyps.
15. [**6-6**] Right fourth toe amputation.
16. [**5-/2111**] ORIF left hip with persistent nonunion of his
subtrochanteric femur fracture
17. Left eye vitrectomy
18. [**2112-7-1**]: RLE Balloon angioplasty of tibioperoneal trunk,
Balloon angioplasty of the anterior tibialis artery.
19. [**2112-7-5**]: Debridement of wound down through subcutaneous
tissue and including bone with placement of vacuum-assisted
closure dressing.
20. R foot osteomyelitis, s/p 6 weeks Vanc/Ctx, finished
[**2112-9-11**]
Social History:
- Previously employed as cab driver, now retired. Lives at home
with his wife.
- Tobacco history: 40-50 pack year history, quit 15 years ago
- ETOH: heavy use until [**2090**]
- Illicit drugs: previous heroin/cocaine use
Family History:
Mother and father died in 70's-80s of cancer. Denies any family
history of cardiac disease. No family history of early MI.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.8 BP: 92/55 P: 87 R: 20 O2: 98% RA
General: Alert, orientedx2, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild ttp in RLQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool to touch, palpable/dopplerable distal pulses, no
edema, R 4th toe amputated with dry gauze overlying ulcer, L
knee with effusion, no warmth/erythema, mild tenderness
Neuro: grossly intact
Pertinent Results:
ADMISSION LABS:
[**2112-10-10**] 04:30AM BLOOD WBC-12.8*# RBC-3.88*# Hgb-9.3*#
Hct-30.2*# MCV-78* MCH-24.0*# MCHC-30.9* RDW-16.0* Plt Ct-256
[**2112-10-10**] 04:30AM BLOOD Neuts-91.3* Lymphs-4.5* Monos-3.4 Eos-0.6
Baso-0.2
[**2112-10-10**] 09:36AM BLOOD PT-21.5* PTT-40.6* INR(PT)-2.0*
[**2112-10-11**] 03:04PM BLOOD Fibrino-556*#
[**2112-10-11**] 03:04PM BLOOD ESR-35*
[**2112-10-10**] 04:30AM BLOOD Glucose-156* UreaN-47* Creat-2.2*#
Na-132* K-4.4 Cl-104 HCO3-9* AnGap-23*
[**2112-10-10**] 04:40AM BLOOD ALT-32 AST-37 AlkPhos-330* TotBili-1.4
[**2112-10-10**] 04:40AM BLOOD Lipase-17
[**2112-10-10**] 09:36AM BLOOD CK-MB-4
[**2112-10-10**] 09:36AM BLOOD Calcium-8.7 Phos-4.4# Mg-2.0
[**2112-10-11**] 05:59AM BLOOD CRP-161.1*
[**2112-10-10**] 06:00PM BLOOD Digoxin-1.0
[**2112-10-10**] 08:08AM BLOOD pO2-62* pCO2-38 pH-7.21* calTCO2-16* Base
XS--12 Comment-GREENTOP
[**2112-10-10**] 04:41AM BLOOD Lactate-2.7*
[**2112-10-10**] 06:07PM BLOOD O2 Sat-68
[**2112-10-10**] 11:50AM BLOOD freeCa-1.13
URINE:
[**2112-10-10**] 10:45PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.016
[**2112-10-10**] 10:45PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2112-10-10**] 10:45PM URINE RBC-36* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
[**2112-10-10**] 10:45PM URINE WBC Clm-FEW
[**2112-10-10**] 10:45PM URINE Hours-RANDOM UreaN-92 Creat-124 Na-91
K-25 Cl-63
[**2112-10-10**] 10:45PM URINE Osmolal-312
MICRO:
[**2112-10-10**] BCx: MRSA
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2112-10-10**] UCx: negative
STUDIES:
[**2112-10-10**] ECHO:
Left ventricular hypertrophy with cavity dilatation and severe
global biventricular hypokinesis c/w diffuse process
(multivessel CAD, toxin, metabolic, etc.) Severe pulmlonary
artery hypertension. Tricuspid regurgitation. Mild-moderate
mitral regurgitation.
Compared with the prior study (images reviewed) of [**2110-12-1**],
global and regional left ventricular systolic function is now
more depressed. The severity of tricuspid regurgitation is
slightly increased.
[**2112-10-10**] RUQ U/S:
1. Nondistended gallbladder filled with sludge, negative
son[**Name (NI) 493**] [**Name2 (NI) 515**] sign, and minimal gallbladder wall edema
and pericholecystic fluid. Findings likely due to chronic liver
disease.
2. Mild perihepatic ascites and small left pleural effusion.
3. Normal common bile duct diameter measuring 3 mm.
4. Homogeneous echogenicity of the liver without focal lesion.
[**2112-10-11**] L Knee XR:
1. Incompletely seen intramedullary rod with distal interlocking
screw, with ossification surrounding the head of the screw and
distal lateral femur. No signs of orthopedic hardware loosening.
2. No definite acute fracture or dislocation.
3. Extensive vascular calcified atherosclerotic disease at the
left knee soft tissues.
4. Trace knee joint effusion
[**2112-10-12**] CXR:
Left pectoral CCD with defibrillator leads leading to the right
ventricle and other two leads each terminating into the right
atrium and left ventricle are unchanged in position. Patient is
status post median sternotomy and has intact sternal sutures.
Moderate-to-large cardiomegaly and mediastinal and hilar
contours are stable. Bilateral lung volumes remain low with mild
improvement in the pulmonary edema. No pleural effusion. No
discrete opacities concerning for pneumonia.
Brief Hospital Course:
Mr. [**Known lastname **] is a 70 year old man with h/o CAD, sCHF (EF <20%),
DM, HTN, CKD, s/p R 4th toe amputation and recent Abx, who was
admitted with N/V/D x 4days. He was transferred from the medical
floor to the ICU for sepsis, found to have MRSA bacteremia.
Likely source is from his R foot, where he recently had a toe
amputation and osteomyelitis. Despite treatment with
broad-spectrum antibiotics (Linezolid and Zosyn), the patient
declined rapidly and had multi-system organ failure. The patient
and family declined further invasive lines and treatments. The
family and medical team decided to make the patient comfort
measures only on [**2112-10-13**]. The patient was transitioned to
inpatient hospice on the medical floor. He expired on [**2112-10-16**].
Medications on Admission:
ASA 81mg PO daily
Atorvastatin 40mg PO qhs
Dabigatran 150mg PO BID
Digoxin 0.125mg PO daily
Metoprolol XL 50mg PO daily
Imdur 30mg PO daily
NTG 0.4mg SL q5min prn
Valsartan 80mg PO daily
Spironolactone 25mg PO daily
Torsemide 60mg PO daily
Gabapentin 100mg PO TID
Oxycontin 10mg PO BID
Percocet 2tabs PO q4-6h prn
Oxycodone 5mg PO BID prn
Lorazepam 0.5mg PO q6h prn
Trazodone 25mg PO BID
NPH
Humalog
Ascorbic acid 250mg PO BID
Colace 100mg PO BID
Ferrous sulfate 325mg PO BID
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
MRSA sepsis
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2112-10-18**]
ICD9 Codes: 5849, 2762, 2761, 4254, 3572, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8175
} | Medical Text: Admission Date: [**2123-11-10**] Discharge Date: [**2123-12-3**]
Date of Birth: [**2047-10-15**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / Fruit
Extracts / Nafcillin / cefazolin
Attending:[**Doctor First Name 3298**]
Chief Complaint:
fever, rigor, vomiting
Major Surgical or Invasive Procedure:
TEE [**11-12**], no vegetations, EF 40-45%
DCCV: [**11-16**], converted to NSR
PICC line placed R arm
Temporary HD line placed R IJ [**2123-11-26**], removed [**2123-12-3**]
History of Present Illness:
Mr. [**Known lastname 23**] is a 76 yo M with h/o CAD, CHF, a-fib, AVR, DM, HTN,
HLD, p/w one day of fever, rigor, nausea and vomiting. Pt felt
sudden onset rigor one day ago, with fever to 100, and BP
reportedly to 220/120 at home. He had some valium and was able
to sleep. He Of note, pt did not have recent sickness, no
weight loss, night sweats. He did report some exercise
intolerance recently in the gym, which he attributed to
hypoglycemia. Of note, pt had a PCI with 2 drug eluting stents
placed in LAD and R-PDA. Pt had no recent dental work and never
had colonoscopy.
Pt went to [**Hospital1 **] [**Location (un) **] today, where he had VS: 102.1 HR: 101 BP:
123/49 Resp: 23 O(2)Sat: 100%. Lab showed WBC of 11.3 with 7%
Bands, INR 3.2, Cr 2.4, CK 1400, CK-MB 6, Trop 0.035; and
moderate hepatocellular transaminitis. Pt underwent noncontrast
CT-head, which did not reveal acute intracranial bleed. Blood
culture later grew GPC in pairs and clusters. Pt received 2L IVF
and one dose ceftriaxone / zosyn, and transferred to [**Hospital1 **] [**Location (un) **].
In [**Hospital1 **] [**Location (un) **], patient was switched to nafcillin once cultures
showed MSSA. After starting nafcillin, his urine output
diminished significantly and his creatinine bumped. At this
time, the patient presented to our service.
Past Medical History:
IDDM c/b neuropathy
HTN
HLD
CAD s/p CABG in [**2113**] and [**2119**] and multiple stents
s/p biologic AVR [**2119**] c/b transient heart block post op treated
with
pacer insertion ([**Company 1543**] Sensia dual-chamber pacemaker).
Paroxysmal Atrial Fibrillation (last pacer interrogation
demonstrated no episodes of AF)
Chronic Systolic Heart Failure (EF 35% to 40% in [**2119**])
BPH
Hypothyroidism
CKD
Social History:
Exercises at the gym 2-3 times per week. Has a bachelor's
degree, previously worked as a pharmacist and a small business
owner, and is currently retired. Married and lives with his
wife. [**Name (NI) 4084**] smoked. Rarely drinks a single drink. No illicits
Family History:
Notable for a mother who died at 81 and had a brain tumor and a
sibling with Alzheimer disease. There is also thyroid, lung
cancer in other family members.
Brother: pancreatic and liver cancer in his brother.
[**Name (NI) **] family history of CAD or sudden cardiac death.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals: 97.2, 78, 108/57, 19. 97% on RA
General: Alert & oriented X3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no r/rh/w
CV: Regular rate and rhythm, soft S1, S2, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses bl, no clubbing, cyanosis or
edema, no splinter hemorrhage
NEURO: MMS notable for poor memory and normal attention, CN2-12
grossly intact, slight pronator drift on the right, otherwise no
focal neurological findings, normal strength throughout.
On Discharge:
VS: 97.5, 142/73, 82, 18, 97RA
BG 62, 95, 45
Physical Exam:
General: pleasant this morning, easy to arouse
HEENT: PERRL, EOMI, sclerae anicteric, neck supple, moist mucous
membranes, no ulcers / lesions / thrush
CV: RRR, normal S1, S2,
Pul: CTAB
BACK: no focal tenderness, no costovertebral angle tenderness
GI: normoactive bowel sounds, soft, non-tender, distended, no
hepatosplenomegaly
Extremities: warm and well perfused, 2+ DP pulses palpable
bilaterally, bilateral nonpitting edema of hands and feet
LYMPH: no cervical, axillary, or inguinal lymphadenopathy
SKIN: the original skin reaction to the antibiotic is resolvign
with some lingering drying ulcers. However, there is a new
petechial rash on the back of his right leg . No excoriations.
The same petechial rash is present on the back of his left
elbow, but in a more limited area. I did not notice the rash
there yesterday but I may have missed it.
NEURO: resting tremor in arms bilaterally, awake, slightly
sedated but oriented x3, CN 2-12 intact, 5/5 strength, sensation
in /tact bilaterally, no asterixis
PSYCH: non-anxious, normal affect, frustrated with length of
stay
Pertinent Results:
On Admission:
[**2123-11-10**] 04:15PM BLOOD WBC-9.2 RBC-3.42* Hgb-9.9* Hct-29.7*
MCV-87 MCH-29.1 MCHC-33.5 RDW-13.3 Plt Ct-199
[**2123-11-10**] 04:15PM BLOOD Neuts-42* Bands-40* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-1* Metas-11* Myelos-0 Promyel-2*
[**2123-11-10**] 04:15PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
[**2123-11-10**] 04:15PM BLOOD PT-34.2* PTT-43.1* INR(PT)-3.4*
[**2123-11-10**] 04:15PM BLOOD Glucose-388* UreaN-40* Creat-1.8* Na-136
K-4.2 Cl-102 HCO3-19* AnGap-19
[**2123-11-10**] 04:15PM BLOOD ALT-195* AST-185* CK(CPK)-1240*
AlkPhos-103 TotBili-0.8
[**2123-11-10**] 04:15PM BLOOD CK-MB-7 cTropnT-0.03*
[**2123-11-10**] 04:15PM BLOOD Albumin-3.3* Calcium-8.0* Phos-2.3*
Mg-1.8
[**2123-11-14**] 04:12AM BLOOD Free T4-4.5*
[**2123-11-14**] 04:12AM BLOOD TSH-0.042*
Imaging:
Portable TEE (Complete) Done [**2123-11-12**] Conclusions
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. A patent foramen ovale is
present. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-45 %). Right ventricular chamber size and
free wall motion are normal. There are simple atheroma in the
aortic arch and complex atheroma n the descending thoracic
aorta. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion. No masses or vegetations are seen on the
aortic valve. The mitral valve leaflets are mildly thickened. No
mass or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis or
abscess seen. Normal functioning aortic valve bioprosthesis.
Mildly depressed left ventricular function. Mild spontaneous
echo contrast in the left atrium without evidence of thrombus in
the left atrium or left atrial appendage.
CT HEAD W/O CONTRAST Study Date of [**2123-11-15**] CONCLUSION:
1. No finding to suggest acute vascular territorial infarct; in
this setting, MRI with DWI (if feasible) would be more
sensitive.
2. Evidence of chronic small vessel ischemic disease.
3. Chronic inflammatory disease involving the bilateral sphenoid
air cells
with superimposed acute inflammation involving the left sphenoid
air cell;
correlate clinically.
CHEST (PA & LAT) Study Date of [**2123-11-17**] IMPRESSION:
1. Left lower lobe opacity worrisome for pneumonia in the right
clinical
setting, less likely atelectasis.
2. No pulmonary vascular congestion.
RENAL U.S. Study Date of [**2123-11-23**] IMPRESSION: Normal renal
ultrasound. 2.4 cm exophytic left lower pole renal cyst.
CHEST (PA & LAT) Study Date of [**2123-11-24**] IMPRESSION:
1. Interval development of mild interstitial pulmonary edema and
enlargement of still small layering bilateral pleural effusions.
2. Persistent retrocardiac opacification that could either
represent
atelectasis though pneumonia is also a possibility in the
correct clinical
setting.
ABDOMEN (SUPINE ONLY) Study Date of [**2123-11-24**] IMPRESSION: No
ileus or obstruction.
Labs on Discharge:
[**2123-12-2**] 04:24AM BLOOD WBC-13.0* RBC-2.91* Hgb-8.2* Hct-26.0*
MCV-89 MCH-28.2 MCHC-31.5 RDW-17.1* Plt Ct-630*
[**2123-11-30**] 06:00AM BLOOD Neuts-79* Bands-1 Lymphs-8* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2123-11-30**] 06:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Schisto-OCCASIONAL Burr-OCCASIONAL
[**2123-12-3**] 04:44AM BLOOD PT-19.3* PTT-29.7 INR(PT)-1.8*
[**2123-12-3**] 04:44AM BLOOD Glucose-42* UreaN-138* Creat-5.5* Na-141
K-4.4 Cl-99 HCO3-27 AnGap-19
[**2123-11-28**] 05:06AM BLOOD CK(CPK)-87
[**2123-11-29**] 06:19AM BLOOD CK-MB-7 cTropnT-0.49*
[**2123-12-3**] 04:44AM BLOOD Calcium-8.6 Phos-7.4* Mg-2.6
[**2123-12-3**] 04:44AM BLOOD Vanco-22.8*
Brief Hospital Course:
76 y/o M with a history of CHF, afib, DM2, CAD with a history of
CABG s/p recent PCI in early [**2123-10-19**] with DES to LAD and
distal PDA presented to [**Hospital1 **] with fever, malaise, R arm
weakness and was found to have transaminitis, bandemia, and ARF.
The patient was put on nafcillin for MSSA but developed anuria
and increase in creatinine. The patient was stabilized and
started on steroids, at which point the patient was presented to
our service.
##MSSA Bacteremia presenting as sepsis. Likely source thought
to be due to introduction of skin bacteria during recent
coronary angiogram/PCI. TEE on [**11-12**] did not show vegetation.
Pt was followed by ID with plan to treat with 4 week course of
naficillin until [**12-8**].The patient became anuric and his
creatinine bumped on nafcillin, so he was switched to cefazolin,
on which he developed a rash. It is unclear if the rash was from
the nafcillin or the cefazolin. In any case, we switched him to
vancomycin to be safe. He is to complete his course on [**12-8**].
Goal trough is 15-20. Given his poor kidney function, he will
require daily trough with dosing daily to maintain that trough.
The course will complete on [**12-8**].
.
#Acute renal failure d/t AIN
Pt developed progressive renal failure, which was concerning for
probable AIN due to nafcillin. Nafcillin was discontinued, and
Nephrology was consulted. Due to worsening renal function, pt
became progressively fluid overloaded. Diuresis was attepted
with aggressive diuretics (Metolazone 5 mg followed by Lasix 120
mg IV, BID), with minimal response. Pt became nearly anuric, and
pt subsequently developed uremia with asterixis. Pt was also
symptomatic from volume overload, with mild dyspnea at rest,
cough, nausea, early satiety, and poor appetite (likely d/t
bowel edema). Pt was started on empiric steroids on [**2123-11-25**] for
presumed AIN after discussion with both Nephrology and ID. He
will continue on Prednisone, and will taper over the next 30
days. His discharge dose is 50mg /day and it will be tapered by
5mg every 3 days until the course is completed. Urgent HD access
was obtained by Interventional Radiology, as pt is
anticoagulated on Warfarin for atrial fibrillation, as well as
aspirin and plavix. Pt underwent his first round of HD on
[**2123-11-26**]. The patient required dialysis until [**2123-11-29**] at which
point his urine output increase significantly and we would
evaluate him daily, both in terms of his I/Os, and in terms of
his electrolytes and kidney function labs. The patient did not
require any further HD, and his catheter was pulled and the
patient was discharged. The patient is to have CBC and Chem7
drawn and faxed to the nephrologists on Monday [**12-6**] for follow
up.
#NSTEMI: type 2 MI due to demand in setting of sepsis presenting
with arm discomfort. Troponin peak to 0.46 on [**11-13**].
Cardiology recommended continued medical management of known CAD
with ASA/plavix (recent PCI in early [**Month (only) **]). His dose of
statin reduced in context of use of amiodarone. On discharge,
we decided to increase his statin dose to 80mg (home dose),
given his history of recent MI in [**Month (only) **].
#Diabetes Type 2: uncontrolled with complications (MI): he is on
aggressive insulin regmin including parandial humalog and basal
lantus at home. [**Last Name (un) **] was consulted and helped up titrate his
SS and basal insulin for better glucose control. [**Last Name (un) **]
continued to follow and make recommendations. On 2 occasions,
the patient was found to have a glucose aroudn 50-60. On one
occasion, the patient was difficult to arouse, but was easily
reversed with dextrose. On the second occasion, he was
completely asymptomatic, though dextrose was given anyways. The
patient's sliding scale and daily NPH dose has been adjusted
based on [**Hospital1 4087**] recs. The patient should have his glucose
monitored and his insulin should be adjusted according to his
glucose trends. It is likely that his insulin requirements will
change as his prednisone is tapered.
#Afib: paroxysmal afib known on history with afib and RVR during
ICU stay requiring a combination of betablockers and CCB as well
as initiation of amiodarone. He underwent DCCV on [**11-16**] with
return of NSR. Since then he has been on toprol XL and
amiodarone 400mg TID. As of [**11-21**] he received 9300mg loading
dose of amiodarone and was transitioned to 200mg amiodarone
daily with f/u with cardiology to decide on any further need of
admiodarone. He was anticoagulated with coumadin. His INR
should be trended daily and his coumadin dose should be adjusted
accordingly, as his coumadin requirements may be different now
with his diminished kidney function. He was discharged at a
dose of 3mg per day and INR 1.8.
#Question of stroke: presented to [**Hospital Unit Name 153**] at [**Hospital1 18**] with aphasia and
R upper extremity weakness with old strokes on non-contrast head
CT done at OSH. Seen by neurology in ICU who felt that symptoms
could be due to recrudescence of previous stroke or possibly a
small new stroke in setting of sepsis. An MRI was not possible
because he has a pacemaker. A repeat CT performed 72 h after CT
done at [**Location (un) 620**] did not show evidence of stroke. He reamined on
anticoagulation given afib and high risk of stroke given
CHADS2>=4. His speech returned to baseline and he did not have
further extremity weakness other than L shoulder due to
suspected rotator cuff tear.
#Rotator cuff tear: inability to comfortable move L shoulder
with discomfort in upper arm. Xray showed degenerative joint
disease. Ortho consult suspected partial rotator cuff tear on
physical exam and recommended ROM as tolerated with outpatient
f/u in the sports medicine clinic. His shoulder improved during
the course of the hospitalization.
#Thyroid function abnormalities: PMH documents history of
hypothyroidism and home med included levothyroxine, but dose of
20mcg is very low for someone his size. TSH low at 0.042, free
T4 slightly high at 4.5. Rather than repeat TFTs in acute
setting which could be abnormal for sick euthyroid, his dose of
levothyroxine was discontinued and recommend close outpatient
monitoring of TSH, free T4 as he is now on amiodarone.
#R cephalic vein clot noted on U/S of R upper arm, not a DVT
#Transitional Issues:
Please follow daily INR and vancomycin trough. His vancomycin
and coumadin doses need to be adjusted accordingly. His goal INR
is [**1-21**]. His goal trough is 15-20 until [**12-8**]. If the patient's
trough is less than 16, he is to get a dose of 500mg of
vancomycin. If the trough is greater than 16, the dose is to be
held for that day. He should also have a full CBC/Chem7 done on
Monday [**12-6**] and the results should be faxed to [**Numeric Identifier 4088**].
Thank you
Medications on Admission:
AMITRIPTYLINE 25MG - One every evening
ASPIRIN 81MG - ONE EVERY DAY
ATORVASTATIN 80 mg - once a day
CLOPIDOGREL 75 mg - once a day
DIAZEPAM 5 mg - at bedtime as needed for prn
FUROSEMIDE 20 mg - once a day
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg - one by mouth qd prn
INSULIN GLARGINE - 52 units every AM
INSULIN LISPRO [HUMALOG] - sliding scale
L-THYROXINE 25MCG - ONE EVERY DAY
LISINOPRIL 30 mg - once a day
METFORMIN 500 mg - twice a day
METOPROLOL SUCCINATE 100 mg - twice a day
NEURONTIN 300MG - EVERY EVENING
NITROGLYCERIN 0.4 mg -sublingually qd prn chest pain
TAMSULOSIN 0.4 mg Capsule - 2 Capsule(s) by mouth at bedtime
WARFARIN - as directed by coumadin clinic
CHOLECALCIFEROL 2,000 unit - once a day
MULTIVIT-IRON-MIN-FOLIC ACID [CENTRUM] - 1 Tablet daily
.
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every other
day: give dose at night.
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a
day).
7. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ONCE MR2 (Once and may repeat 2 times).
10. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*100 ML(s)* Refills:*0*
11. 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.
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
14. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
16. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): discontinue once patient is
mobile.
19. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
20. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
21. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
22. vancomycin 500 mg Recon Soln Sig: [**12-20**] Intravenous see
details for 5 days: Please follow vanco trough for goal 15-20
daily. If patient is below 16 vanco trough, please administer
500mg that day.
23. prednisone 5 mg Tablet Sig: 1-10 Tablets PO once a day for
30 days: please start with 10 pills (50mg) for 3 days, then
decrease dose by 5mg (1 pill) every three days for a total of
thirty days.
24. insulin lispro 100 unit/mL Solution Sig: One (1) dose
Subcutaneous as directed by sliding scale: 1 dose as directed by
sliding scale.
25. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
26. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
27. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
28. Lab
Please check CBC and Chem7 and fax results to [**Telephone/Fax (1) 4089**]
(c/o Dr. [**Last Name (STitle) 4090**]
29. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
adjust per INR.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
MSSA bacteremia
NSTEMI
ARF/AIN requiring initiation of hemodialysis
rotator cuff tear
uncontrolled type 2 diabetes
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 hospitalized for a blood stream infection with staph
aureus (MSSA). You will need to complete a long course of
antibiotics ending on [**12-8**]. Please have your INR checked daily
and have the coumadin dose adjusted accordingly. Please also
have your vancomycin trough checked daily and have the
vancomycin dose adjusted daily until your course is complete on
[**12-8**]. Please have full chem7 and CBC with INR checked on
Monday [**12-6**] to make sure that your electrolytes are fine.
[**Month/Year (2) **] changes
start Vancomycin IV until [**12-8**]
start Amiodoarone
start calcium acetate
start prednisone
stop lisinopril
stop metformin
stop diazepam
stop hydrocodone-acetaminophen
.
Dose changes
coumadin
Insulin regimen
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2123-12-28**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], 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: NEUROLOGY
When: FRIDAY [**2124-1-14**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 4092**] [**Last Name (NamePattern1) 4093**], MD [**Telephone/Fax (1) 2574**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: [**Known lastname 23**] Garage
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 2946**] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 2205**]
**Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.**
Completed by:[**2123-12-5**]
ICD9 Codes: 5845, 5849, 2762, 2851, 3572, 4280, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8176
} | Medical Text: Admission Date: [**2192-11-20**] Discharge Date: [**2192-11-22**]
Date of Birth: [**2138-11-23**] Sex: F
Service: MED
PREOPERATIVE DIAGNOSIS:
1. Postmenopausal bleeding status post dilation and
curettage.
2. Congestive heart failure.
3. Hypertension.
4. Diabetes.
5. Postoperative CRFA endometritis.
HISTORY OF PRESENT ILLNESS: This is a 53-year-old woman with
a history of diabetes, chronic hypertension, and congestive
heart failure, who presented originally with postmenopausal
bleeding x1 episode. An ultrasound done as an outpatient
showed an endometrial stripe of 12 mm and normal ovaries. The
decision was made to do a D and C to rule out malignancy.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, CHF with a ejection fraction of 55% on a [**2192-3-28**]
echo, insulin dependent diabetes, atypical chest pain with a
negative work up and a negative MIBI on [**2192-3-28**], asthma,
sleep apnea, anemia, lower extremity edema, GERD, and a PE in
[**2188-9-28**] requiring 12 months of Coumadin
anticoagulation, obesity, hypercholesterolemia, migraines,
colon polyps, depression, hypercholesterolemia.
PAST SURGICAL HISTORY: D and C x3, open cholecystectomy in
[**2161**], right knee arthroscopy bilateral rotator cuff repair
and acromioplasties.
MEDICATIONS:
1. Singulair 10 q day.
2. Prilosec 20 q day.
3. Renodil 800 t.i.d. with meals.
4. Humulin.
5. Seroquel 25 at bedtime.
6. Verapamil 240 q day.
7. Albuterol.
8. Bupropion.
9. Lisinopril 20 q day.
10. Effexor.
11. Lasix 40 q day.
12. Advair.
ALLERGIES: Codeine, aspirin, Augmentin, Trazodone,
ibuprofen, Atrovent, Reglan, Ampicillin, and Lipitor.
SOCIAL HISTORY: She lives alone and ambulates independently.
She denies any type of alcohol or drug use.
FAMILY HISTORY: Significant for heart disease, diabetes, and
colon cancer.
HOSPITAL COURSE: She was admitted on [**11-20**] for an
outpatient procedure of a dilation and curettage for
postmenopausal bleeding. However, during the procedure the
patient was noted to have dis-complete ventilating by
anesthesia. A quick curettage was done. The hysteroscopy
portion was aborted and the patient was too unstable to
extubate, although intraoperative chest x-ray was consistent
with pulmonary edema that was thought to be due to her CHF.
She was brought to the ICU for diuresis and ventilation
weaning. She was given Lasix overnight on postoperative day
#0, and diuresed well. A chest x-ray done 4 hours after the
initial chest x-ray done intraoperatively showed improvement
of the pulmonary edema after IV Lasix. She continued to
diurese well overnight and was extubated on postoperative day
#1. She remained well oxygenated on room air into
postoperative day #2.
Cardiac: Given the flash pulmonary edema, cardiac enzymes
were cycled x3 and were all negative for any evidence of a
troponin leak. An EKG was noted to have a right bundle branch
block, but had been noted at a preoperative EKG.
Hypertension: The patient was started on a nitro drip for the
CHF, which was successfully weaned off by postoperative day
#1. She was started on her home regimen of hypertensive
medications. Her blood pressure ranged in the less than 120's
to 202/60's to 80's. The 202/64 was noted to be an out layer
and on postoperative day #2 it was felt that she was well
controlled on her home regimen.
Diabetes: She was started on a regular insulin sliding scale
with adequate control of her sugars in the 200's. She was
started on her diabetic diet on postoperative day #1, and
started on her home insulin regimen with sugars in the mid
200's.
Asthma: She was started on her home regimen of Albuterol
inhaler, had noticed some productive cough, and this was sent
off for cultures. However, as noted, the chest x-ray that was
done after diuresis did not show any evidence of infiltrates
suggestive of pneumonia.
Postoperative fever: She spiked to 101.3 on postoperative day
#0, and given the chest x-ray with no evidence of infiltrates
beyond pulmonary edema, as well as a negative UA, it was felt
this was most likely consistent with endometritis. She was
started on Gentamycin and Clindamycin until she was 24 hours
afebrile. This was discontinued on postoperative day #2.
After a thorough discussion with the ICU team, it was felt
that she was stable for discharge home. She continued to have
no postoperative issues with regards to her medical
management. The ICU team felt that her current home regimen
was actually adequate for the [**Hospital 228**] medical issues. She
will follow up closely with her primary care physicians, as
well as her respective specialists. She was discharged home
in stable condition on postoperative day #2 from the ICU.
DISCHARGE MEDICATIONS: Continue home regimen. She will also
use extra strength Tylenol at home for pain control, as
ibuprofen causes gastritis.
ATTENDING PHYSICIAN: [**Name10 (NameIs) 34301**] [**Name11 (NameIs) 34302**], MD
CONSULT ATTENDING:[**Last Name (NamePattern1) 94923**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], MD
Dictated By:[**Last Name (NamePattern1) 57757**]
MEDQUIST36
D: [**2192-11-22**] 10:40:13
T: [**2192-11-22**] 11:31:42
Job#: [**Job Number 94924**]
ICD9 Codes: 5185, 4280, 4019, 2720, 2859, 311, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8177
} | Medical Text: Admission Date: [**2123-7-4**] Discharge Date: [**2123-7-28**]
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
AS, PAF
Major Surgical or Invasive Procedure:
[**7-16**] AVR, MVRepair, MAZE
History of Present Illness:
Patient is a 84 year old female with a history of PAF, HTN and
AS who presented to an OSH one day PTA with SOB and
palpitations. SHw was found to be in afib in the 150s. She was
transferred to [**Hospital1 18**] for cardiac catheterization and surgical
evaluation.
Past Medical History:
HTN
AF
s/p TAH [**2099**]
s/p right ORIF [**2121**]
AS
Social History:
retired
No tobacco
No Etoh
No IVDA
Family History:
Non contributory
Physical Exam:
On discharge:
Afebrile, BP 128/88, HR 89, AFib, 93% on RA
Irreg, irreg, no m/r/g
Lungs CTAB, min crackles
+1 BLE edema, some mottling (baseline), large ecchymotic area on
LUE
Neurologically grossly intact
Abdomin soft non tender and nondistended
Midsternal incision clean dry and intact
Pertinent Results:
[**2123-7-27**] 01:12AM BLOOD WBC-9.2 RBC-4.19* Hgb-12.7 Hct-37.4
MCV-89 MCH-30.4 MCHC-34.0 RDW-13.9 Plt Ct-215
[**2123-7-27**] 01:12AM BLOOD PT-16.3* INR(PT)-1.8
[**2123-7-27**] 01:12AM BLOOD Glucose-83 UreaN-30* Creat-0.9 Na-138
K-4.1 Cl-99 HCO3-31 AnGap-12
Brief Hospital Course:
An Echo done on [**7-5**] demonstrated AS with peak gradient 102,
mean gradient of 72, estimated valve area of 0.6cm2, 3+ MR, and
EF of 55%. Held coumadin in prep for cardiac cath, which she
received on [**7-7**], demonstrating AO valve area of 0.4 cm, peak
grad 50; CO/CI of 2.99/1.71 (3.63/2.99 with dobuta); RA 11; RV
38/10; PA 38/30; PCWP 24. LV gram with preserved Ef and inf
apical and mid ant-lat HK. Coronary angiogram revealed nl LMCA,
50-60% small diag off of lad and 40-50% rca without any flow
limiting dz.
After results of the cath were known, cardiothoracic surgery was
consulted for AVR/MVR surgery. She awaited preop workup, and
normalization of INR.
Post operatively she was transferred to the icu in critical but
stable condition on epi, milrinone, norepi, amio and propofol.
She was extubated on post op day 4, and her drips were weaned to
off by post op day 6, however she was placed on natrecor.
She was seen in consultation by electrophysiology for rate
control who recommended diltiazem beta blockade and amiodarone,
with follow up in 6 weeks for possible cardioversion.
She was given a 7 day course of vancomycin and levofloxacin for
sputum cultures positive for MRSA and gram negative rods.
She was HIT + without clinical signs and was anticoagulated with
coumadin already for her atrial fibbrilation.
Medications on Admission:
Digoxin, verapamil, lopressor, colace, levoxyl, coumadin(3 alt
with 4), lasix
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 Inh* Refills:*2*
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Inh* Refills:*2*
11. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO once a
day for 1 doses: Please check INR on [**7-29**], and PRN.
Disp:*30 Tablet(s)* Refills:*0*
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Lifecare of [**Location 15289**]
Discharge Diagnosis:
AS, MR, Afib
PAF
CHF
HTN
Hypothyroid
s/p TAH
s/p hip and leg surgery
Discharge Condition:
Good.
Discharge Instructions:
No driving or lifting more than 10 pounds until follow up
appointment or while taking pain medication.
Call with temperature more than 100.5, redness or drainage from
incision, or weight gain greater than 2 pounds in 1 day or 5 in
1 week.
Shower, wash incision with mild soap and water and pat dry, no
lotions, creams or powders, no baths, keep covered when in the
sun.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 29478**] 1-2 weeks
Dr. [**Last Name (STitle) **] 1-2 weeks
Completed by:[**2123-7-28**]
ICD9 Codes: 5990, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8178
} | Medical Text: Admission Date: [**2157-7-26**] Discharge Date: [**2157-8-1**]
Date of Birth: [**2084-8-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic AS/CAD
Major Surgical or Invasive Procedure:
[**2157-7-26**] - Aortic Valve Replacement(23mm St.[**Male First Name (un) 923**] Epic),
CABGx2(LIMA-LAD,SVG-Dg) - Dr. [**Last Name (STitle) **]
History of Present Illness:
72 year old male with known aortic valve stenosis which has been
followed by serial echocardiograms which most recently showed
severe aortic stenosis. A stress test was also performed however
it was stopped due to hypotension. In preparation for surgery, a
cardiac catheterization was performed which showed two vessel
disease. He is now admitted for surgical management.
Past Medical History:
AS,Gout,HTN,Hyperlipidemia,hypothyroidism,torn RT rotator cuff,
bilat knee sx,lipoma removal,cyst excisions.
Social History:
Accountant attorney. Never smoked. Rare alcohol use. Lives with
wife. [**Name (NI) **] dental exam was Spring [**2156**].
Family History:
Unremarkable
Physical Exam:
76 sr 13 172/82 177/90 69" 210
GEN: NAD
HEENT: Unremarkable, NCAT/PERRL/OP Benign
NECK: Supple, From, No JVD
LUNGS: Clear
HEART: RRR, III/VI SEM
ABD: S/NT/ND/NABS
EXT: Warm, well perfused, trace LE edema. No varicosities. 2+
pulses.
NEURO: Nonfocal. Murmur transmitted to b/l carotids.
Pertinent Results:
[**2157-7-26**] ECHO
PREBYPASS
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No thrombus/mass is
seen in the body of the left atrium. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler. There is
moderate symmetric left ventricular hypertrophy with normal
cavity size. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the abdominal
aorta. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). No aortic regurgitation is seen. Moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion.
POSTBYPASS
Preserved biventricular systolic function. There is a well
seated, well functioning bioprosthesis ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] 23 mm Epic,
supra-annular bio). No aortic valve insufficiency is visualized.
No aortic dissection seen. The mitral regurgitation is now mild
(1+) The study is otherwise unchanged compared to prebypass.
Brief Hospital Course:
Mr. [**Known lastname 11309**] was admitted to the [**Hospital1 18**] on [**2157-7-26**] for elective
surgical management of his aortic valve and coronary artery
disease. He was taken directly to the operating room where he
underwent coronary artery bypass grafting to two vessels and an
aortic valve replacement using a 23mm St. [**Male First Name (un) 923**] epic tissue
valve. Please see operative note for details. Postoperatively he
was taken to the intensive care unit for monitoring. Within 24
hours, Mr. [**Known lastname 11309**] had awoke neurologically intact and was
extubated. Beta blockade, a statin and aspirin were resumed.
Later on postoperative day one, he was transferred to the step
down unit for further recovery. Mr. [**Known lastname 11309**] was gently diuresed
towards his preoperative weight. The physical therapy service
was consulted for assistance with his postoperative strength and
mobility. The patient developed atrial fibrillation on POD 3.
Amiodarone drip was initiated and eventually transitioned to
oral amiodarone. Rate control was established with lopressor.
The patient was anticoagulated with coumadin. By the time of
discharge on POD 6, the patient was ambulating freely, the wound
was healing and pain was controlled with oral analgesics. The
patient was d/c'd to home in good condition.
Medications on Admission:
L
o
v
a
statin40',Lisinopril-Hctz10/12.5',ASA81',MVI,Levothyroxin0.5mcg'
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*60 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. Lovastatin 20 mg Tablet Sig: Two (2) Tablet PO daily ().
Disp:*60 Tablet(s)* Refills:*0*
6. Levothyroxine 50 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
8. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: md
will change dose daily based on inr goal [**12-26**].
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
take in the a.m.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Amio: 400mg 2x/day for 2 weeks, then 200mg 2x/day for 1 week,
then 200mg 1x/day until further instructed.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic Stenosis
Coronary Artery Disease
Hyperlididemia
Hypothyroidism
Gout
s/p tonsillectomy
s/p bilateral knee surgery
torn RT rotator cuff
Discharge Condition:
Good
Discharge Instructions:
No lifting more than 10 pounds for 10 weeks
Shower daily
No swimming, tub baths
No lotion, creams or powders to incisions
No driving
Take all medications as prescribed
report any temperature greater than 101.5 or wound drainage
weigh daily and report any weight gain more than 3 pounds
Followup Instructions:
Followup with Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Follow up with Dr. [**Last Name (STitle) **] in [**11-24**] weeks.
Completed by:[**2157-8-1**]
ICD9 Codes: 4241, 4019, 2724, 2449, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8179
} | Medical Text: Admission Date: [**2157-5-6**] Discharge Date: [**2157-5-8**]
Service: ACOVE-MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
gentleman presenting from the [**Hospital3 **] facility
for altered mental status described as "lethargy" times
approximately four days, as well as question of worsening
anemia. The patient is [**Country 532**] speaking and upon arrival in
was minimally responsive to even noxious stimuli. The eye
position was midposition. The pupils were felt to be
minimally reactive. The patient was not following commands,
even commands in Russian.
The patient in the Emergency Department became increasingly
awake and alert, status post dosing of Narcan although it
Emergency Department was negative for narcotics. On repeat
examination at the time the patient arrived at the floor,
through an interpreter, the patient was awake and alert and
not sure why he was at the [**Hospital1 188**] or really the name of the facility.
Even he denied fever, chills, chest pain, shortness of
breath, headache, abdominal pain, change in vision, change in
strength, change in sensation. He stated he had been
somewhat short of breath approximately seven days ago but had
not experienced the symptoms since that time.
The patient is reported to have had an episode of decrease in
blood pressure on [**2157-5-2**], at the [**Hospital3 **]
Center. He does have a recent history of discharge from the
[**Hospital1 69**] on [**2157-4-30**], for anemia
and transient renal insufficiency.
Additionally, please note that the patient had a recent
admission to the [**Hospital1 69**] between
[**2157-4-13**], and [**2157-4-16**], for atrial fibrillation with hospital
course complicated by an exaggerated response to Lopressor
producing unresponsiveness and hypotension, noting that the
patient's vital signs in the Emergency Department at this
admission were stable at a heart rate of 75, blood pressure
122/90, respiratory rate 20, and pulse oximetry 97% on four
liters.
PAST MEDICAL HISTORY:
1. Recent discharge [**2157-4-29**], for anemia.
2. Parkinson's disease.
3. Depression with psychotic features with a history of a
suicide attempt.
4. Colon cancer, status post hemicolectomy in [**2153**].
5. Benign prostatic hypertrophy.
6. Gastroesophageal reflux disease.
7. History of atrial fibrillation.
8. History of C. difficile.
9. History of loculated pericardial effusion with
pericarditis.
10. Alert and oriented times two at baseline.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lasix 40 mg p.o. b.i.d.
2. Neurontin 500 mg p.o. t.i.d.
3. Atenolol 25 mg p.o. q.d.
4. Aspirin 81 mg p.o. q.d.
5. Sinemet 25/100 two tablets p.o. q.i.d. and one tablet
p.o. q.h.s.
6. Ibuprofen 600 mg p.o. t.i.d.
7. Prevacid 30 mg p.o. q.d.
8. Flomax 0.4 mg p.o. q.d.
9. Seroquil 100 mg p.o. b.i.d. (noting that had been
recently decreased from 150 mg p.o. b.i.d.
PHYSICAL EXAMINATION: In the Emergency Department, afebrile
at 98.4, pulse 74, blood pressure 144/63, respiratory rate
12, 97% in room air and 100% on four liters. General -
somnolent, opening eyes to verbal commands, not following
commands, normocephalic and atraumatic. The pupils are
equal, round, and reactive to light and accommodation. The
neck was supple. Chest was clear. Cardiac - regular rate
and rhythm. The abdomen was benign. Rectal examination was
negative for occult blood. There was 1+ edema bilaterally.
The skin was warm and dry. The patient as noted was
somnolent and unable to follow commands.
The examination when the patient arrived on the floor the
night of [**2157-5-6**], the patient was afebrile, blood pressure
148/100, pulse 53, respiratory rate 18, pulse oximetry 93% in
room air. In general, the patient is awake, alert in no
apparent distress. There was a question of jugular venous
distention but the pulsus was 4 to 5 (not elevated). The
oropharynx was exceptionally dry. There was noted to be poor
dentition. There were upper dentures in place with white
exudate versus dry mucus in the posterior aspect of the
oropharynx. The patient was oriented to [**Location (un) 4551**] and the year
[**2156**], with the month being [**2156**], on repeated questioning. He
could pick the type of building as hospital from a list but
could not generate this on his own. The pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. The strength was full and symmetrical
to limited examination in the upper and lower extremity
flexors and extensors. Cardiac examination was unremarkable
with regular rate and rhythm, no murmurs were noted. There
were dry crackles at the bases, right greater than the left,
and otherwise the patient was clear to auscultation
bilaterally. The abdomen demonstrated a well healed midline
scar, soft, nontender abdomen with normal abdominal sounds.
There is no edema noted. The patient was awake and alert in
no apparent distress.
LABORATORY DATA: White blood cell count at the time of
admission was 5.3, hematocrit 28.8, with normal differential.
Platelet count was 317,000. Coagulation studies were
essentially unremarkable. Urine was negative for urinary
tract infection. Chem7 sent at the time of admission on
[**2157-5-6**], at 1:30 p.m. was sodium 139, potassium 3.8,
chloride 98, bicarbonate 28, blood urea nitrogen 20,
creatinine 1.5**a significant value. Glucose 111. Calcium
8.8, magnesium 1.6, phosphate 2.9. Arterial blood gases in
the Emergency Department on [**2157-5-6**], at 3:40 p.m. had a pH
7.47, pCO2 46, pO2 77. Urine culture is pending at the time
of this dictation.
Head CT was performed on [**2157-5-6**], with the following
impression: "No acute intracranial pathology, brain
atrophy". Chest x-ray was performed on [**2157-5-6**], with the
following impression: "Persistent pericardial and pleural
effusions".
HOSPITAL COURSE: The patient was admitted with the above
complaints with having received doses of Narcan in the
Emergency Department. Although the toxicology screen was
negative for narcotics, the patient's mental status improved
markedly although there was no clear cause and effect
relationship for this change.
By the time the patient arrived at the medical floor, his
mental status was apparently more or less at the baseline.
His creatinine was noted to be elevated to 1.5 and the
patient was gently hydrated with 750 ccs of normal saline
overnight with a resultant decrease in the patient's
creatinine to 0.9 the day following admission, noting that
the patient's mouth had been quite dry at the time of
admission and it was moist on the morning following
admission.
The etiology of the patient's mental status change observed
in the Emergency Department with stable vital signs and
unclear precipitant of resolution at this time is still
unclear, but possibilities are felt to include dehydration
which has now been corrected, the possibility of narcotic
ingestion responding to Narcan, the patient's psychiatric or
neurologic problems including depression or [**Name (NI) 5895**]
disease although Parkinson's disease the Sinemet has not
recently changed. The Seroquil has recently been decreased
and is currently being held though these possibilities appear
less likely than others.
Head CT was performed as noted above to rule out acute
intracranial pathology including bleeding. Additionally,
please note that the geriatric fellow raised the possibility
of seizure although the patient is not reported to have had
positive phenomenon including tonoclonic movements or eye
movements consistent with seizure during the period of
unresponsiveness. The possibility of occult seizure is still
open to question and the patient will be observed for
approximately 24 additional hours to insure that such an
episode does not recur.
At this time, the patient's mental status is approximately
baseline and the patient is stable and will be observed for
the forthcoming day with reassessment at that time and
possible discharge back to [**Hospital3 **] Center in
the morning.
MEDICATIONS ON DISCHARGE: (at the time of this dictation)
1. Lopressor 25 mg p.o. b.i.d. (to be changed to Atenolol 25
mg p.o. q.d. prior to the time of the patient's discharge to
[**Hospital3 **]).
2. Flomax 0.4 mg p.o. q.d.
3. Prevacid 30 mg p.o. q.d.
4. Sinemet 25/100 two tablets p.o. q.i.d. and one tablet
p.o. q.p.m.
5. Aspirin 81 mg p.o. q.d.
6. Colace 100 mg p.o. b.i.d.
DISCHARGE DIAGNOSES:
1. Dehydration.
2. Altered mental status possibly secondary to dehydration
or other factors yet to be determined.
Please note that additional diagnoses may be found in past
medical history.
CONDITION AT TIME OF DICTATION: Stable.
DISCHARGE PLAN: The current plan is for discharge back to
[**Hospital3 **] Center. The patient should not have
increased beta blocker without close supervision including
frequent blood pressure monitoring and neurologic checks as
he has a history of unresponsiveness and hypotension because
of sensitivity to beta blockade although he is stable on his
current dosing. Sedating medications should be avoided.
The patient should be closely monitored for signs of
dehydration and creatinine should be checked q.d. to q.o.d.
for one week versus signs for volume overload including pulse
oxygenation measured b.i.d. and on examination as the patient
may either need additional hydration or diuretic to insure
that he does not begin to become dehydrated, nor does he have
worsening of his pulmonary status.
DR.[**Last Name (STitle) **], [**First Name3 (LF) 177**]
Dictated By:[**Name8 (MD) 2058**]
MEDQUIST36
D: [**2157-5-7**] 11:51
T: [**2157-5-7**] 14:03
JOB#: [**Job Number 21687**]
ICD9 Codes: 2765, 2761, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8180
} | Medical Text: Admission Date: [**2107-1-25**] Discharge Date: [**2107-1-29**]
Date of Birth: [**2030-5-5**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 76 year old male with
a known history of coronary artery disease, who reports some
episodes of chest pain with radiation to his jaw, right ear,
and right arm. He also reported progressive shortness of
breath, all occurring a few times over the past couple of
months. He said he also had one episode on [**1-14**] while
at rest. He had a stress test on [**12-29**] which showed
inferior, posterior and lateral infarct, inferoapical lateral
hypokinesis and ejection fraction of 47 percent. He denied
any nausea, vomiting or diaphoresis. His cardiac
catheterization showed ejection fraction of 51 percent, LAD
90 percent lesion, circumflex 90 percent lesion, OM1 80
percent lesion and the RCA 70 percent lesion. His past
medical history includes being hard of hearing,
hypothyroidism, no tendons in his right foot and hepatitis in
[**2052**]. Past surgical history includes appendectomy,
tonsillectomy and left ear surgery at age 6 months. He had
no known drug allergies. Medications preop were
levothyroxine, 100 mcg po daily and ibuprofen, 800 mg po prn.
He is married and lived in [**Hospital1 **]. He is retired. He had no
tobacco history and no use of alcohol.
Preop chest x-ray showed no active lung disease, but
tortuosity of thoracic aorta with calcification. Please
refer to the official report dated [**2107-1-20**]. Preop EKG on
[**2107-1-20**] showed sinus rhythm at 93 with some low amplitude
T waves and LVH. Please refer to the official report dated
[**2107-1-20**].
On exam he is 5 feet 8 inches tall, 152 pounds, in sinus
rhythm at 86 with a blood pressure of 162/97, respiratory
rate 16, sating 98 percent on room air. He was lying flat in
bed in no apparent distress. He was alert and oriented times
three and appropriate. Moving all extremities. His lungs
were clear bilaterally. His heart was regular rate and
rhythm with S1 and S2 tones and a grade 2/6 systolic ejection
murmur. His abdomen was soft, flat, nontender, nondistended
with positive bowel sounds. Extremities warm, dry and well
perfused with no edema or varicosities noted. He had 2 plus
bilateral radial and DP pulses and 1 plus bilateral PT
pulses.
Preop labs are as follows. White count 4.9, hematocrit 30.1,
platelet count 161,000. Sodium 139, potassium 3.3, chloride
108, bicarb 28, BUN 38, creatinine 0.8 with a blood sugar of
158. PT 13.0, PTT 31.2, INR 1.1. AST 13, ALT 15, alkaline
phosphatase 68, total bilirubin 0.5, albumin 3.5. Urinalysis
preop was negative for UTI, but had trace hematuria.
Additional labs as follows: albumin 3.5, cholesterol 142,
anion gap 10, triglycerides 70, HDL 36, cholesterol to HD
ratio 3.9, calculated LDL 92.
The patient went home over the weekend and came back for
surgery on [**1-25**], the day of admission, and underwent
coronary artery bypass grafting times four with LIMA to the
LAD, vein graft to the OM, vein graft to PL and vein graft to
the RCA by Dr. [**Last Name (STitle) **]. He was transferred to the
cardiothoracic ICU in stable condition on a Neo-Synephrine
drip at 0.3 mcg per kg per minute and a propofol drip at 30
mcg per kg per minute. On postoperative day one, the patient
was stable hemodynamically with a blood pressure 106/50 in
sinus rhythm at 97. He remained ventilated with CPAP early
that morning with a white count of 8.1, hematocrit 32.8.
Potassium 4.4, BUN 20, creatinine 0.9. PA pressures of 38/16
with an index of 3.35 and a mixed venous of 80 percent. He
was also evaluated by case management. Later that evening he
was extubated, overnight had some wheezes and got some
racemic epinephrine therapy, kept in the unit on
postoperative day one just to keep an eye on his respiratory
status.
He was evaluated by case management on postoperative day two.
His creatinine remained stable at 0.9. He was
hemodynamically stable with a blood pressure of 136/66 in
sinus rhythm in the 90s. Beta blockade was begun. He was
transferred out to the floor. A swallow study was ordered as
there was some question of some aspiration risk and was to be
re-evaluated during the day. If a swallow study was needed,
it would be ordered for him at that time. His beta blockade
was increased on postoperative day two on the floor. He was
evaluated by physical therapy and was encouraged to increase
his activity level and ambulate with the physical therapist
and the nurses. On [**1-27**] his chest tubes were
discontinued and his wires were discontinued. On
postoperative day three he was alert and oriented. He had
nonfocal exam. His lungs were clear. His heart was regular
rate and rhythm. He remained on Lasix, 20 mg twice a day.
Lopressor was increased to 75. Pacing wires were
discontinued. He was sating 93 percent on 4 liters nasal
cannula. His Foley was removed and he voided successfully.
He had evaluation by orthopedics given the fact that he had
no tendons in his right foot and had a long-standing old
remote injury. He complained of some pain on ambulation.
They recommended possible strength training exercises,
elevating his foot and ankle, only weightbearing as tolerated
and giving him ibuprofen for prn pain control. He was alert
and oriented and steady on his feet. His diet was advanced.
On postoperative day three his creatinine remained stable at
1.0 with hematocrit of 32.8 and white count of 11.5. He was
independently ambulating. Was denying any pain. He appeared
to be sleeping well. He had a T-max of 100.3 on
postoperative day three, but then rapidly became afebrile.
He was ambulating a level 5 and moving all extremities and
doing extremely well.
On the day of discharge his blood pressure was 156/76, sating
97 percent on room air. Heart rate 80. His lungs were clear
bilaterally. His heart was regular rate and rhythm. He was
alert and oriented. His abdomen was soft, nontender,
nondistended. He had some trace bilateral lower extremity
edema. He was doing very well and was discharged to home
with VNA services on [**2107-1-29**] with the following discharge
instructions. He was instructed to see Dr. [**Last Name (STitle) **] in the
office approximately four weeks postop and to see his primary
care physician in approximately two weeks post discharge.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting times four.
2. Hard of hearing.
3. Hypothyroidism.
4. Status post right foot injury with absence of tendons.
5. Remote hepatitis in [**2052**].
DISCHARGE MEDICATIONS:
1. Colace, 100 mg po twice a day.
2. Enteric coated aspirin, 81 mg po once a day.
3. Percocet 5/325, 1 to 2 tablets po prn q4 hours for pain.
4. Levothyroxine sodium, 100 mcg po once daily.
5. Metoprolol, 75 mg po twice a day.
6. Lasix, 20 mg po once a day for 7 days.
The patient was discharged to home on [**2107-1-29**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2107-3-17**] 09:35:56
T: [**2107-3-17**] 12:27:40
Job#: [**Job Number 60022**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8181
} | Medical Text: Admission Date: [**2135-12-1**] Discharge Date: [**2135-12-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
AV fistulogram
Tunneled dialysis catheterization
Hemodialysis
History of Present Illness:
Mr. [**Known lastname 97237**] is an 88 y/o man with PMH notable for stage IV CKD,
afib on coumadin, and CHF who was at his home earlier today when
he noted the onset of nausea. He reports no chest pain,
diaphoresis or abdominal pain at the time. He did have several
episodes of dry heaves. He called EMS and was taken to [**Hospital1 **]. On arrival to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], he was noted to have
acute decompensation. O2 sat on arrival was 77-80% on [**Name6 (MD) 597**] [**Name8 (MD) **] MD
notes. He received lasix 100 mg and bumex 1 mg but made only 100
cc urine over the course of his stay; he then received 50 more
mg of lasix with no response. He was also placed on a nitro gtt
but blood pressures declined to 80s-90s systolic so this was
intermittently stopped. As his primary nephrologist is at [**Hospital1 18**]
and the outside hospital ED was worried about dialysis
initiation, he was then transferred to [**Hospital1 18**] for further
evaluation.
.
In the [**Hospital1 18**] ED, initial VS were T 96.8, HR 62, BP 92/61, RR 17,
99% on bipap. BP transiently dropped to 88/28 and he was given a
250 cc NS bolus X 1. Due to ? infiltrate on CXR, he was given 1
g IV vancomycin and 750 mg IV levofloxacin. He was also treated
with combivent nebs. Eventually, he was placed on a [**Hospital1 597**] but
dropped his O2 sats to 88-92% so was placed back on BiPAP with
improvement in sats. Nitro gtt was also discontinued. Potassium
was found to be 6.8 and he was given calcium gluconate,
insulin/D50 and kayexelate.
.
On the floor, the patient states his breathing has improved
compared to earlier today. He denies any current nausea, chest
pain, abdominal pain, headache, dizziness, or diaphoresis. He
would like to try to take off the BIPAP again. He states he did
have a few canned soups over the past few days but no other
dietary changes. After seeing Dr. [**Last Name (STitle) **] on Tuesday, he held his
lasix on Tuesday afternoon and Wednesday morning per
instructions and then resumed 80 mg Wednesday evening.
.
ROS:
Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Does have dizziness
intermittently, especially with lying down. Denies cough, chest
pain or tightness, palpitations. Denies PND or orthopnea. Uses
CPAP at night chronically. Denies vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. Occasionally has small amounts of bright red
blood in stool but none recently. No dysuria but some difficulty
initiating urination. Slight decrement in urine output. Denies
arthralgias or myalgias.
Past Medical History:
# CAD s/p CABG [**2123**].
# Diabetes Mellitus, type 2
- HbA1C 6.3 [**12/2131**]
# ESRD on HD initiated [**2135-12-9**]
- s/p LUE AV fistula in [**3-/2135**]
# Atrial fibrillation on coumadin
# Chronic systolic CHF, EF 25% [**2135-12-2**]
# Hypertension
# Hyperlipidemia
# chronic venous stasis
Social History:
Married, lives with wife in [**Hospital3 **] facility. Daughter
lives in close proximity. No EtOH or tobacco.
Family History:
Mother with aortic dissection. Father with MI.
Physical Exam:
VS: T 97.2, BP 112/46, HR 61, RR 22, O2 96%
Gen: no distress, pleasant
HEENT: NCAT, EOMI, PERRL. Anicteric, no conjunctival pallor. OP
clear, MMM.
Neck: JVD difficult to assess, no LAD, no thyromegaly
Cor: irregularly irregular, no appreciable murmur
Pulm: no wheezing, + bibasilar crackles
Abd: soft, normoactive bowel sounds, nontender to palpation
Extrem: no peripheral edema, feet cool bilaterally with stigmata
of chronic venous stasis, DP pulses dopplerable bilaterally, LUE
AV fistula
Skin: dry skin bilateral anterior legs with color change
compatible with venous stasis bilaterally but L>R
Neuro: alert, speaking clearly and in full sentences, face
symmetric, moving all extremities without difficulty
Pertinent Results:
Admission:
[**2135-12-11**] 01:50AM BLOOD WBC-9.7 RBC-2.90* Hgb-9.9* Hct-28.0*
MCV-97 MCH-34.0* MCHC-35.3* RDW-18.5* Plt Ct-168
[**2135-12-10**] 03:04PM BLOOD Glucose-219* UreaN-88* Creat-3.1* Na-136
K-4.2 Cl-98 HCO3-26 AnGap-16
[**2135-12-11**] 01:50AM BLOOD Glucose-121* UreaN-54* Creat-2.7* Na-143
K-4.5 Cl-104 HCO3-28 AnGap-16
[**2135-12-1**] 06:20PM BLOOD WBC-13.6*# RBC-3.75* Hgb-12.1* Hct-36.9*
MCV-98 MCH-32.4* MCHC-32.9 RDW-19.0* Plt Ct-167
[**2135-12-1**] 06:52PM BLOOD PT-30.0* PTT-32.3 INR(PT)-3.1*
[**2135-12-1**] 06:20PM BLOOD Glucose-163* UreaN-92* Creat-4.2* Na-137
K-6.5* Cl-103 HCO3-20* AnGap-21*
[**2135-12-1**] 06:20PM BLOOD CK(CPK)-92
[**2135-12-2**] 02:04AM BLOOD CK(CPK)-91
[**2135-12-2**] 08:00AM BLOOD CK(CPK)-102
[**2135-12-1**] 06:20PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2135-12-1**] 06:20PM BLOOD cTropnT-0.20*
[**2135-12-2**] 02:04AM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2135-12-2**] 08:00AM BLOOD CK-MB-4 cTropnT-0.19*
[**2135-12-2**] 02:04AM BLOOD Calcium-9.4 Phos-5.9* Mg-2.4
[**2135-12-1**] 06:35PM BLOOD Glucose-149* Lactate-3.2* Na-138 K-6.8*
Cl-101 calHCO3-20*
[**2135-12-1**] 06:56PM BLOOD Lactate-3.1* K-6.4*
[**2135-12-1**] 10:53PM BLOOD Lactate-3.4* K-6.1*
[**2135-12-16**] 08:00AM BLOOD WBC-10.3 RBC-2.63* Hgb-8.7* Hct-25.3*
MCV-96 MCH-33.0* MCHC-34.3 RDW-18.7* Plt Ct-181
[**2135-12-15**] 05:35AM BLOOD PT-26.6* PTT-38.9* INR(PT)-2.6*
[**2135-12-16**] 08:00AM BLOOD Glucose-192* UreaN-56* Creat-4.0* Na-130*
K-4.4 Cl-95* HCO3-26 AnGap-13
[**2135-12-10**] 10:51AM BLOOD CK(CPK)-85
[**2135-12-10**] 03:04PM BLOOD CK(CPK)-78
[**2135-12-10**] 10:30PM BLOOD CK(CPK)-79
[**2135-12-15**] 11:50AM BLOOD CK(CPK)-45
[**2135-12-10**] 10:51AM BLOOD CK-MB-NotDone cTropnT-0.46*
[**2135-12-10**] 03:04PM BLOOD CK-MB-NotDone cTropnT-0.50*
[**2135-12-10**] 10:30PM BLOOD CK-MB-NotDone cTropnT-0.58*
[**2135-12-15**] 11:50AM BLOOD CK-MB-NotDone cTropnT-0.40*
[**2135-12-16**] 08:00AM BLOOD Albumin-3.3* Calcium-9.5 Phos-3.9 Mg-1.9
[**2135-12-9**] 05:45AM BLOOD calTIBC-268 Ferritn-246 TRF-206
[**2135-12-10**] 03:04PM BLOOD PTH-691*
[**2135-12-10**] 08:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
[**2135-12-9**] 04:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2135-12-9**] 04:15PM BLOOD HCV Ab-NEGATIVE
[**2135-12-10**] 10:54AM BLOOD Type-ART pO2-77* pCO2-55* pH-7.20*
calTCO2-22 Base XS--6 Intubat-NOT INTUBA
[**2135-12-10**] 03:10PM BLOOD Lactate-1.6.
[**2135-12-1**] 06:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2135-12-1**] 06:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2135-12-1**] 06:20PM URINE RBC-0-2 WBC-0 Bacteri-RARE Yeast-NONE
Epi-0
[**2135-12-2**] 02:04AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.018
[**2135-12-2**] 02:04AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-SM
[**2135-12-2**] 02:04AM URINE RBC-21-50* WBC-[**3-9**] Bacteri-MOD Yeast-NONE
Epi-0
[**2135-12-7**] 08:42AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2135-12-7**] 08:42AM URINE RBC-[**6-14**]* WBC-[**3-9**] Bacteri-RARE Yeast-NONE
Epi-0-2
[**2135-12-10**] 01:45PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.026
[**2135-12-10**] 01:45PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-TR Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-SM
[**2135-12-10**] 01:45PM URINE RBC-21-50* WBC-[**11-24**]* Bacteri-MANY
Yeast-NONE Epi-0-2
[**2135-12-11**] 04:41PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2135-12-11**] 04:41PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR
[**2135-12-11**] 04:41PM URINE RBC-[**6-14**]* WBC-[**3-9**] Bacteri-MOD Yeast-NONE
Epi-0
MICRO:
Blood CX: [**12-1**], [**12-1**], [**12-10**], [**12-10**], [**12-10**], [**12-10**]: NO GRWOTH
[**12-14**], 12,10: NGTD
Urine Cx: [**12-2**], [**12-7**], [**12-10**], [**12-11**] NO GROWTH
[**12-2**]: TTE
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis (LVEF = 25 %). No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. There is a minimally
increased gradient consistent with minimal/mild aortic valve
stenosis. Trace 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 moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2134-6-8**], the
LVEF appears slightly lower.
[**12-1**] CXR:
IMPRESSION: Limited evaluation due to low inspiratory volumes.
Retrocardiac
opacity may represent atelectasis but developing infection is
not excluded. A
dedicated PA and lateral views of the chest are recommended when
the patient
is able to take a better inspiration for further evaluation of
the lung bases.
[**12-2**] CXR
IMPRESSION:
Cardiomegaly without evidence of pulmonary edema or focal
infiltrate to
suggest pneumonia. Bibasilar atelectasis.
Unchanged retrocardiac opacity likely reflective of a
moderate-to-large hiatal
hernia. When clinically feasible, this can be better evaluated
with dedicated
repeat PA and lateral radiographs.
[**12-10**] CXR
This film is somewhat obscured by motion. There are patchy
alveolar opacities
that have increased compared to the prior study and retrocardiac
opacity has
probably increased as well. The findings are suggestive of
increased
pulmonary edema although an infectious etiology cannot be
totally excluded.
There is a right IJ line with tip in the SVC/RA junction.
[**12-9**] AV Fistula
PFI: Left AV fistulogram demonstrated mild stenosis at the
proximal venous
portion of the cephalic vein and mild stenosis at the distal
portion of the
cephalic vein near the anastomosis site. Balloon dilation at
both stenosis
sites with both stenoses resolved and improved flow.
Brief Hospital Course:
88 year old male with a history of CAD s/p CABG, CHF (EF 25%),
ESRD newly initiated on [**Hospital **] transferred to the ICU with hypoxia,
pulmonary edema, and lactic acidosis.
.
#Dyspnea/ Hypoxia: Mr. [**Known lastname 97237**] was initially admitted to [**Hospital1 18**]
ICU on [**12-1**] after transfer from an OSH with CHF exacerbation
and hypoxia. A repeat ECHO on [**12-2**] showed slight worsening of
systolic function (EF 25%). He was treated with a lasix gtt (due
to borderline low blood pressures), and was weaned to nasal
cannula. He was transferred to the Cardiology service on [**12-3**].
While on the Cardiology service he was transitioned to bolus
diuretics and was responding well to lasix 60 mg IV BID and
metolazone 5 mg po BID with I/Os 1-1.5 L negative per day.
.
It was eventually decided to initiate HD during this hospital
admission. He had a fistulogram performed [**12-9**] and also had a
tunnelled R IJ HD catheter placed and he had his first run of HD
without ultrafiltration. In the setting of HD initiation it was
requested that his diuretics be held so he did not receive lasix
or metolazone yesterday. The patient became acutely SOB on [**12-10**]
in the morning. O2 sats were in the mid-80s on nasal cannula and
improved to 90% on [**Month/Day (4) 597**]. Prior to episode, patient was
hypertensive with SBP 160 and was tachycardic on telemetry as
high as 140s. CXR c/w pulmonary edema. ABG showed 7.20/55/77
with a lactate of 7.4. The patient's venous lactate was repeated
and was 6.2. The patient also had a leukocytosis of 12.8. Blood
cultures were sent and the patient got a 1gm of Vancomycin. The
patient had a new AG of 21. Cardiac enzymes were eventually
negative x3 (elevated Trop, but flat CK in the setting of renal
failure). He received albuterol and atrovent nebulizers, 80 mg
of IV lasix, and 1 inch of nitropaste with improvement.
.
The patient had HD again on [**12-10**] w/ 1.5kg removed and weaned to
home CPAP overnight and 3L NC in the morning. His AG improved
and lactate normalized. The patient's WBC trended down to 9.7.
The patient's UA was also postive and he was started on cipro,
but urine cx were negative and cipro was discontinued. The
patient was transferred back to the floor on [**12-11**] on 3L NC. He
continuned dialysis with fluid removal and was able to be weaned
to back to room air on [**12-14**]. The patient's repiratory status
improved and he was discharged on [**12-16**]. His home lasix was
held secondary to low blood pressure and having fluid removed at
dialysis and he should be followed up as an outpatient regarding
reinitiation.
.
# ESRD: It was eventually decided to initiate HD during this
hospital admission. He had a fistulogram performed [**12-9**] and also
had a tunnelled R IJ HD catheter placed and he had his first run
of HD on [**12-9**] without ultrafiltration. On [**12-10**] the patient again
had HD with 1.5L removed. The patient continued to have HD with
fluid removal and his respirtroy status improved. He had
hepatitis serologies performed and were negative. Additionally,
he had a PPD placed that was also negative. The patient
continuned HD and was closely followed by the renal team. He
was setup with outpatient HD M/W/F. His last HD session prior
to discharge was [**12-16**] and will have outpatient HD on Monday,
[**12-9**].
# anion gap metabolic acidosis: The patient was transferrred to
the ICU on [**12-10**] with elevated lactate. There was no clear source
of the new lactic acidosis. The patient also had a newly
elevated WBC count but not left shifted so could have been a
stress response from pulmonary edema. The patient did receive
vancomycin 1 gram per HD protocol to cover for possible
bacteremia from line placement, but blood cultures were
negative. However, the patient's lactate rapidly closed and
leukocytosis resolved.
.
# CHF: The patient had an ECHO that showed his EF 25% down from
30-40%. Please see above. The patient was restarted on
metoprolol 6.25mg [**Hospital1 **], but was limited by his low blood
pressure. Additionally, his ACE-I was attempted to be
restarted, but his blood pressures could not tolerate.
.
# AF: The patient has been on coumadin, but was held for his HD
line placement. His coumadin was restarted on his home dose on
[**12-11**] (INR 1.2) . The patient's INR continued to trend upward
and was therapeutic on discharge. He was continued on his home
dose of 4.5mg daily at dischage. The was also continued on
metoprolol 6.25mg [**Hospital1 **] for rate control, but the dose was limited
by low blood pressures.
.
# DM2: The patient was continued on his home NPH dose of 15U in
the AM and 30U in the PM. His blood sugars were well
controlled, however he did have an episode of asymptomatic
hypoglycemia with a AM glucose of 44, repeat FS showed 64 on
[**12-15**]. He was given juice and crackers. The patient's PM NPH
dose was adjusted to 25U and was titrated back to 28U on
discharge given mildly elevated AM sugars 194. He was followed
with QID FS and ISS during his stay.
.
# CAD: s/p CABG. On [**12-10**] the patient had cardiac enzymes drawn
that were eventually negative x3 (elevated Trop, but flat CK in
the setting of renal failure). He also did not have compliants
of chest pain or EKG changes. The patient also had an episode
of chest pain on [**12-15**] after working with PT. The episode
resolved spontaneously and no EKG changes and CE x1 were
negative. The patient was continued on ASA and his BB. The
patient remained chest pain free at discharge.
.
# FEN: cardiac, renal diet
.
# PPx: coumadin, bowel regimen
.
# ACCESS: R tunnelled HD catheter, PIV x2
.
# Code: DNR/DNI, confirmed with patient
Medications on Admission:
Lipitor 10 mg once a day
Zemplar 1 mcg once a day
Aranesp 60 mcg/0.3 mL s/c once a week
Humulin N 100 unit/mL Susp, Sub-Q Inj 15 u in the AM and 30 u in
the PM, humalog 4 U prior to dinner
Aspirin [**Hospital1 1926**] 81 mg once a day
Allopurinol 200 mg once a day
Furosemide 80 mg twice a day
Enalapril Maleate 40 mg once a day
Cozaar 100 mg once a day
Ferrous Gluconate 324 mg once a day
Warfarin 4.5 mg once a day
Toprol XL 50 mg once a day
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
11. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS) as needed for nausea.
Disp:*45 Tablet(s)* Refills:*0*
12. Warfarin 1 mg Tablet Sig: 4.5 Tablets PO Once Daily at 4 PM.
13. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as
directed Subcutaneous twice a day: 15U in the AM
28U in the PM.
14. Humalog 100 unit/mL Solution Sig: Four (4) U Subcutaneous
prior to dinner.
15. Zemplar 1 mcg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary Diagnosis:
1. Acute on chronic renal failure (Stage IV)
2. Chronic systolic congestive heart failure
3. Respiratory distress
Secondary Diagnosis:
1. Coronary artery disease status post coronary artery bypass
grafting in [**2123**].
2. Hypertension.
3. Hyperlipidemia.
4. Chronic venous stasis
5. Type 2 Diabetes
Discharge Condition:
Stable. Breathing comfortably.
Discharge Instructions:
You were admitted for shortness of breath. This was caused by
worsening of your kidney function. You received diuretics during
your admission that helped with your breathing. You also were
initiated with hemodialysis during your hospitalization.
Unless otherwise indicated, you should resume all of your home
medications as presribed. It is very important that you take
your medications as prescribed.
Please Stop:
1) Enalapril Maleate 40mg daily
2) Cozaar 100mg daily
3) Toprol XL 50mg daily
New Medications:
1) Metoprolol 6.25mg [**Hospital1 **]
2) Metoclopramide 5mg po TID w/meals
3) Docusate 100mg [**Hospital1 **]
4) Senna 1 tab [**Hospital1 **]
Please keep all your medical appointments.
If you develop chest pain, shortness of breath, or any other
concerning symptoms, please call your PCP or go to your local
Emergency Department immediately.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**] [**Telephone/Fax (1) 2205**].
Appointment: [**12-20**]. (Tues) 3:30pm
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2135-12-28**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2136-1-17**] 3:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2136-2-24**] 1:40
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2135-12-18**]
ICD9 Codes: 5849, 2762, 5990, 5856, 4280, 2724, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8182
} | Medical Text: Admission Date: [**2101-10-4**] Discharge Date: [**2101-10-7**]
Date of Birth: [**2043-6-3**] Sex: F
Service: General Surgery
HISTORY OF PRESENT ILLNESS: This is a 58 year-old woman with
chronic pancreatitis, status post multiple abdominal
surgeries who presented disoriented. Her History of Present
Illness is obtained from her son. Apparently the patient was
in her usual state of health until five days prior to
presentation when she started having nausea and vomiting of
unclear frequency. She was also noted to have decreased
appetite and increased weakness to the point where she
couldn't ambulate with assistance. She was found to be short
of breath on the day of admission. Abdominal pain is unknown
and whether se was having gas or not was unknown. The
patient denies diarrhea, fever, chills, cough, urinary
symptoms, headaches, photophobia but due to this weakness is
brought to the operating room. In the Emergency Room she was
confused, was afebrile with a heart rate of 90 and blood
pressure of 110/70 initially. Her blood pressure then
dropped into the 70s and she was noted to have a very tender
abdomen. She was given 2 liters of fluid and started on a
Dopamine drip. She was admitted to the Medical Service in
the Intensive Care Unit.
PAST MEDICAL HISTORY: Includes [**Doctor Last Name 14837**] Roux-en-Y in [**2096**], a
laparoscopic cholecystectomy in [**2097**], a sphincterotomy in
[**2099**], splenectomy in [**2079**] secondary to motor vehicle
accident, an appendectomy, a right carotid endarterectomy in
[**2099**] and an aorto-[**Hospital1 **]-femoral graft placement which was
revised secondary to infection and replacement with an ex
[**Hospital1 **]-femoral. She also had chronic pancreatitis, coronary
artery disease with an ejection fraction of 45 percent, an
AICD placement in [**2100-1-13**], gastroesophageal reflux
disease, history of deep venous thrombosis in [**2096**],
hypercholesterolemia and migraines. Her medications at home
included Coumadin, Prilosec, Creon, Atenolol, Celebrex and
folic acid. She was an active smoker but denies alcohol.
FAMILY HISTORY: Her sister died of liver cancer and her
father died of an myocardial infarction at an unknown age.
On the evening of admission the medical Intensive Care Unit
staff consulted surgery for question of abdominal process.
When she was seen by surgery she was 99.5 with a heart rate
of 100, blood pressure of 70/21 on Dopamine at 10 and she was
markedly acidotic with a bicarbonate of 15 and a base deficit
of 7. She was awake but confused. Her abdomen was soft,
distended and diffusely tender, left greater than right side.
She had perfusion tenderness and guarding and she had gross
blood and stool in the rectal vault. Her white count is
16.6. Her hematocrit had fallen from 30 to 28, platelets
268. Her PT was 22.5, PTT 63 and INR of 3.5. Chem-7
135/4.0, 100/16, 11/1.1 and 58. Her urinalysis was positive
for nitrites, had 11 to 20 white cells and many bacteria.
Her ALT was 21, AST 59, alk phos 291 and total bilirubin .6
and amylase of 11, lipase of 16 and lactate level of 3.2.
Her CK was 966. She underwent an abdominal CT which showed
portal venous air and apparently a right colon that was
thickened mid transverse colon consistent with colonic
ischemia. She also had pneumatosis. She was therefore
diagnosed with likely dead bowel and taken to the operating
room where she underwent exploratory laparotomy and found to
have dense adhesions and a frankly necrotic sigmoid and
proximal rectum. She underwent left sigmoid resection and
transverse colostomy and underwent extensive lysis of
adhesions. She was then admitted to the Surgical Intensive
Care Unit in critical condition.
She was initially maintained on a Levophed drip and received
4 units of packed cells and 4 of fresh frozen plasma over her
first day. She was given Levophed and Flagyl for
antibiotics. She was maintained with extreme acidosis with
base deficit in the 10 - 11 range. On postoperative day one
her platelets fell to 28 and her abdomen was very distended
with drains pouring out serosanguinous fluid. A bladder
pressure was obtained with a question of abdominal
compartment syndrome. This was found to be 19 and at that
time she had systolic blood pressure of 119 so no further
treatment was required for that. By postoperative day two
she had deteriorated and required a change of pressors from
Levophed to dobutamine secondary to a low cardiac index. She
was also placed on Pitressin with these maintaining her blood
pressure in the 80/60 range.
Her next problem area was oxygenation with worsening
oxygenation over the night and a low pO2 of 36 with
improvement of pO2 in the 50's on pressure control once she
was paralyzed and sedated. She received 8 more units of
fresh frozen plasma over the night of postoperative day
number two to treat elevated coags. Discussion was
undertaken on postoperative day number two with her sons
given her worsening clinical status, her worsening acidosis.
At this point her lactate was 17 and her sons made it clear
that they did not want to continue treatment and elected for
comfort measures only status when the pressors were
withdrawn. The patient died quickly.
DISPOSITION: Death.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 7589**]
MEDQUIST36
D: [**2101-10-7**] 12:55
T: [**2101-10-11**] 14:44
JOB#: [**Job Number 14838**]
ICD9 Codes: 5849, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8183
} | Medical Text: Admission Date: [**2163-3-5**] Discharge Date: [**2163-3-9**]
Date of Birth: [**2163-3-5**] Sex: M
Service: NB
DISCHARGE DIAGNOSIS: Premature twin A, 33 weeks gestation.
HISTORY OF PRESENT ILLNESS: [**Known firstname **] [**Known lastname 59015**] is the [**2068**]-gram
product of a 33-week IVF-twin gestation born to a 41-year-old
gravida 3, para 1 now 2, living 3 female. Her prenatal
screens revealed she is O positive, hepatitis B surface
antigen negative, RPR nonreactive, rubella immune, and group
B Strep status was unknown. Pregnancy was otherwise
unremarkable.
Because of preterm labor, mom was allowed to deliver. She
delivered twin A by spontaneous vaginal delivery with Apgars
of 9 and 9. Twin had to be delivered by cesarean section
for transverse lie.
Infant was admitted to the [**Hospital3 **] Special Care Nursery.
PHYSICAL EXAMINATION ON ADMISSION: Physical exam on
admission revealed a pink, active infant in room air, and no
murmur heard. Blood cultures and CBC were sent. Dextrostick
62.
PROBLEMS DURING HOSPITAL STAY: Respiratory: Infant remained
in room air throughout the hospital course with a rare
episode of apnea and bradycardia of prematurity.
Cardiac: There were no cardiac issues.
Infectious disease: Infant had initial CBC with a WBC count
of 9.6, 16 polys, 0 bands, and 68 lymphocytes with 298
platelets and 57.8 hematocrit. Ampicillin and gentamicin
were begun, and at 48 hours with negative cultures, the
antibiotics were discontinued.
Feeding and nutrition: At the time of transfer, the infant
is on 100 cc/kg of mother's milk, Special Care 20, mostly pg,
but occasional p.o. partial feedings. His weight at the time
of transfer was grams.
Hematologic: Initial hematocrit was 57.8. His initial
bilirubin on [**3-8**] was 8.5 and on [**3-9**] was
Parents would like the babies to be transferred closer to
home, and for this reason, they are being moved to [**Hospital3 **]. They will be in the care of Dr. [**Last Name (STitle) 59016**] on the Special
Care Nursery.
Upon discharge, they will be followed up at [**Hospital1 **]
[**Hospital1 3494**] Center by Dr. [**Last Name (STitle) 59017**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-393
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2163-3-8**] 09:45:50
T: [**2163-3-8**] 10:10:06
Job#: [**Job Number 59018**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8184
} | Medical Text: Admission Date: [**2119-9-10**] Discharge Date: [**2119-9-15**]
Date of Birth: [**2065-7-31**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Right internal jugular line ([**9-10**])
History of Present Illness:
53 yo M w/ h/o Down's syndrome, non-verbal at baseline,
hypothyroidism, cataracts, dysphagia s/p G-tube, h/o aspiration
pna's, hypoNa on 4Lnc QHS who presents w/ cough and hypoxia from
group home.
Per report, patient with acute on chronic cough found to desat
to 88% on RA this AM. Looked as if he were in respiratory
distress. Per OMR had been empirically treated for pna back in
[**6-/2118**] w/ multiple notes documenting cough.
In the ED, initial VS were: 98.2 74 92/50 28 100% nrb. Tmax
100.2. On exam +crackles L>R. Labs notable for Na 129, Cl 93,
HCO3 28, BUN 11, Cr 0.8, Glu 114, Lactate 1.4, UA neg
leuk/nitr/3wbc/neg bact/epis O, wbc 7.2, HCT 41.3, plt 313. CXR:
gastric distention, bibasilar atelectasis. He received
ceftriaxone and levo, vanc, and Flagyl, 1LNS.
A right IJ was placed and followup chest x-ray showed small
right upper lobe pneumothorax.
On the floor, Abx were narrowed to Zosyn. He became hypotensive
to 76/doppler, thick secretions on nasotracheal suctioning and
increased work of breathing. Mentation was unchanged during
event and held his sats at 100% on 3LNC. CXR showed new
pneumothorax and bilateral infiltrates. He received
albuterol/impratropium and 500cc NS, pressures improved to
83/doppler. He was transferred to the MICU for hypotension.
On arrival to the MICU, the patient is lethargic, awakens to
sternal rub, does not interact. Not in acute distress.
Past Medical History:
Down's syndrome, non-verbal at baseline
-Alzheimer's
-B12 deficiency
-hypothyroidism
-cataracts, legally blind
-dysphagia s/p G-tube
-h/o aspiration pna's
-h/o DVT
-h/o cdiff
Social History:
Lives in a group home, brothers very involved with care.
Family History:
No memory disorders
Physical Exam:
General: Lethargic, arouses to sternal rub, no acute distress
HEENT: Pupils equal, round and reactive
Neck: No LAD
CV: Regular rate and rhythm, no murmurs
Lungs: No accessory muscle use, no retractios. Good air
movement. Diffuse ronchi throughout.
Abd: Soft, Gtube site c/d/i, normoactive BS, nontender
nondistended
GU: Foley in place
Ext: warm, well perfused, 2+ pulses pedal pulses, no clubbing,
cyanosis or edema
Pertinent Results:
Admission Labs:
[**2119-9-10**] 11:02PM URINE HOURS-RANDOM UREA N-59 CREAT-7
SODIUM-127 POTASSIUM-11 CHLORIDE-126
[**2119-9-10**] 11:02PM URINE OSMOLAL-291
[**2119-9-10**] 11:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2119-9-10**] 10:32PM GLUCOSE-96 UREA N-6 CREAT-0.5 SODIUM-135
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-31 ANION GAP-8
[**2119-9-10**] 10:32PM CALCIUM-7.9* PHOSPHATE-2.6* MAGNESIUM-1.8
[**2119-9-10**] 10:32PM TSH-3.0
[**2119-9-10**] 10:32PM WBC-5.9 RBC-3.55* HGB-12.5* HCT-36.9*
MCV-104* MCH-35.3* MCHC-33.9 RDW-13.3
[**2119-9-10**] 10:32PM PLT COUNT-262
[**2119-9-10**] 09:07AM LACTATE-1.4
[**2119-9-10**] 08:55AM GLUCOSE-114* UREA N-11 CREAT-0.8 SODIUM-129*
POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-28 ANION GAP-12
[**2119-9-10**] 08:55AM WBC-7.2# RBC-3.99* HGB-14.0 HCT-41.3 MCV-104*
MCH-35.2* MCHC-34.0 RDW-12.9
[**2119-9-10**] 08:55AM NEUTS-79.7* LYMPHS-13.4* MONOS-4.5 EOS-1.5
BASOS-0.9
[**2119-9-10**] 08:55AM PLT COUNT-313
[**Hospital3 **]:
[**2119-9-12**] 06:36AM BLOOD Albumin-2.9* Calcium-7.9*
[**2119-9-10**] 10:32PM BLOOD TSH-3.0
[**2119-9-11**] 03:28AM BLOOD Cortsol-11.9
[**2119-9-13**] 05:13AM BLOOD Vanco-24.9*
[**2119-9-13**] 09:58PM BLOOD Vanco-19.8
Discharge Labs:
[**2119-9-15**] 05:50AM BLOOD WBC-5.4 RBC-3.71* Hgb-13.1* Hct-39.9*
MCV-108* MCH-35.2* MCHC-32.8 RDW-12.9 Plt Ct-264
[**2119-9-15**] 05:50AM BLOOD Glucose-94 UreaN-7 Creat-0.9 Na-138 K-4.2
Cl-97 HCO3-31 AnGap-14
Microbiology:
[**2119-9-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
FUNGAL CULTURE-PRELIMINARY
[**2119-9-10**] URINE Legionella Urinary Antigen - FINAL
[**2119-9-10**] URINE CULTURE - FINAL
[**2119-9-10**] MRSA SCREEN - POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS
[**2119-9-10**] BLOOD CULTURE - PENDING
Imaging:
CXR [**2119-9-10**]: Two frontal radiographs were obtained. Lung volumes
are low. There is no
focal consolidation, large effusion, or pneumothorax. There are
no abnormal cardiac or mediastinal contours. Basilar
atelectasis is noted.
CXR [**2119-9-11**]: As compared to the previous radiograph, there is
increasing radiodensity in the right lung, predominating in the
right upper lobe. Developing pneumonia cannot be excluded.
CXR [**2119-9-14**]: As compared to the previous radiograph, the
current image is taken in a highly rotated patient position. As
a result, hyperlucency of the left lung apex without definite
signs of pneumothorax is seen. The pre-existing opacity at the
right lung apex is unchanged. Lung volumes have minimally
decreased, but the pre-existing signs suggesting fluid overload
have decreased. No evidence of pleural effusions, interposition
of colon between the liver and the abdominal wall. Unchanged
position of the right internal jugular vein catheter. Unchanged
appearance of the cardiac silhouette.
CXR [**2119-9-15**]: The lungs are now clear. Right upper lobe opacity
has completely resolved. There is only minimal bibasilar
atelectasis. Right jugular line ends in upper SVC. Mediastinal
and cardiac contours are normal. No significant pleural
effusions or pneumothorax.
CT Head without contrast [**2119-9-15**]: pending at time of discharge
Brief Hospital Course:
SUMMARY: 54 yo M w/ h/o Down's syndrome, non-verbal at baseline,
hypothyroidism, dysphagia s/p G-tube, h/o aspiration pna's,
hypoNa on 4Lnc QHS who presents w/ cough and hypoxia from group
home.
# Hypotension: Blood pressure on the floor dropped to 92/50 and
he was transferred to the MICU where his blood pressure
responded to fluid boluses (total 3L). The etiology of his
hypotension is likely secondary to acute infection. On CXR he
has a possible right lobe infiltrate that could represent
infection, pneumonitis or pulmonary edema. He was started on IV
Vanc and Zosyn for coverage of healthcare associated pneumonia
since he lives in a group home. At the time of discharge, his
blood pressure was at baseline (100s/80s) and did not require
pressors.
# Respiratory Distress: Initially hypoxic to 88% at group home.
No evidence of CHF by exam or CXR. No history of CHF in past.
Could be secondary to infiltrate in right lobe that could
represent pneumona, pneumonitis or pulmonary edema. EKG did not
have any ischemic changes. On [**9-10**] patient had RIJ placed and
follow up CXR showed small pneumothorax but there was no change
in the patient's respiratory status. He was put on supplemental
oxygen, and on [**9-11**] CXR showed resolution of the pneumothorax.
He was discharged on a total 14 day course of antibiotics for
his presumed HCAP, due to complete [**9-24**]. At the time of
discharge, his oxygen saturation was high 90s on 2L nasal
cannula.
# pulmonary edema: No cardiac history, but patient developed
findings c/w pulmonary edema on CXR after minimal fluids. EKG
was unconcerning.
# Seizure Disorder: Etiology unclear. Myoclonic jerks observed
after transfer from MICU to the floor, and EEG showed seizure
activity. His home Keppra was increased to 1.5g [**Hospital1 **].
# HypoNa: Chronic per facility records, though hypovolemic this
admission. Resolved with fluid resuscitation.
# Down's syndrome, non-verbal at baseline: Per NH at baseline.
Given his lack of responsiveness, head imaging was performed to
ensure lack of new pathology.
# Hypothyroidism: Continued on home synthroid. TSH was normal.
# Social: Over the last few months that patient's health has
been declining and he was made DNR/DNI by HCP (brother).
Currently in discussion with PCP about making [**Name9 (PRE) 3225**] and moving to
hospice care. During this admission a meeting with the
patient's group home, DMH case worker, [**Hospital1 18**] social work and
case management, [**Hospital 18**] medical staff, and the patient's two
brothers was held to discuss his prognosis and goals of care.
The medical team stated that the patient's overall life
expectancy is in the range of months, but that this could be
much shorter if he has an acute respiratory event. He will
continue to aspirate and may continue to have infections.
However, treating these infections may require him to remain in
a hospital, which his family agrees is not the best setting for
his comfort. His brothers recognized that moving to hospice/DNH
and taking him back to the group home would improve his quality
of life, but they were concerned that this might shorten his
overall lifespan. After discussion of the options, they decided
to complete this course of antibiotics (2 weeks) and then plan
to return him to the group home. They recognized that this
course of treatment may not provide him any long-term benefit,
and that he could die while undergoing the treatment. They
stated that they would consider a DNH order after this current
course of antibiotics.
FOLLOW-UP ISSUES
1. Please follow up on his blood cultures and sputum cultures.
They were pending at the time of discharge.
2. Please evaluate for evidence of seizure-like activity. At the
time of discharge, he was having occasional myoclonic jerks that
did not correspond to epileptiform discharges on EEG. He may
need an EEG at a future time.
3. Please check his sodium and fluid balance, as he presented
initially with hyponatremia, likely secondary to dehydration.
4. Patient tested positive for MRSA, and should be on contact
precautions.
5. Head CT read pending on discharge, may show signs of subacute
pathology that changes his overall prognosis.
6. IV Zosyn and vancomycin planned 14 day course through [**9-24**],
however this may be adjusted by the patient's response and
clinical situation.
Medications on Admission:
- Acetaminophen 650 mg PO Q4H:PRN Pain/Fever
- Atropine Sulfate 1% 2 DROP SL Q4H:PRN Secretions
- Bacitracin Ointment 1 Appl TP [**Hospital1 **]:PRN open wounds
- Bisacodyl 10 mg PO/PR DAILY:PRN constipation
- Denta 5000 Plus *NF* (sodium fluoride) 1.1 % Dental [**Hospital1 **]
- Fleet Enema 1 Enema PR DAILY:PRN constipation
- Haloperidol 0.5-1 mg NG Q4H:PRN agitation
- Kaopectate (bismuth subsalicy) *NF* (bismuth subsalicylate)
- LeVETiracetam 500 mg PO QAM
- LeVETiracetam 1000 mg PO QPM
- Levothyroxine Sodium 88 mcg PO/NG QAM
- Lorazepam 0.5 mg PO/NG Q4H:PRN Anxiety
- Milk of Magnesia 30 mL NG PRN constipation
- Multivitamins 5 mL PO/NG DAILY
- Neutra-Phos 1 PKT PO BID
- OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain/Shortness
of Breath
- Simethicone 40 mg PO Q4H
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain/Fever
2. Bacitracin Ointment 1 Appl TP [**Hospital1 **]:PRN open wounds
Apply to open wounds on coccyx and buttocks
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Fleet Enema 1 Enema PR DAILY:PRN constipation
If dulcolax not effective
5. Haloperidol 0.5-1 mg NG Q4H:PRN agitation
Via G tube
6. LeVETiracetam 1500 mg PO BID
7. Levothyroxine Sodium 88 mcg PO QAM
Via G tube
8. Lorazepam 0.5 mg PO Q4H:PRN Anxiety
Via G tube
9. Milk of Magnesia 30 mL PO PRN constipation
If no BM for 3 days. Give via G tube
10. Multivitamins 5 mL PO DAILY
Via G tube
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN
Pain/Shortness of Breath
12. Simethicone 40 mg PO Q4H
13. Denta 5000 Plus *NF* (sodium fluoride) 1.1 % Dental [**Hospital1 **]
14. Kaopectate (bismuth subsalicy) *NF* (bismuth subsalicylate)
262 mg/15 mL Oral QD:PRN diarrhea
Per G tube
15. Neutra-Phos 1 PKT PO BID
16. Atropine Sulfate 1% 2 DROP SL Q4H:PRN Secretions
17. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 500 mg 1000mg IV twice a day Disp #*44 Each
Refills:*0
18. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5mg IV every 8 hours Disp
#*33 Each Refills:*0
19. Ipratropium Bromide Neb 1 NEB IH Q6H wheezing, dyspnea
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 NEB Every six
hours Disp #*15 Each Refills:*1
20. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea, wheezing
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 NEB Every six
hours Disp #*15 Each Refills:*1
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
- Aspiration pneumonia
Secondary:
- hypvolemia
- Hypotension
- Hyponatremia
- Seizure disorder
- Down's syndrome
- Alzheimer's dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 3291**],
It was a pleasure taking care of you in the hospital. You were
admitted for shortness of breath, and were found to have an
infection of your lungs from chronic aspiration. You were
treated with IV antibiotics and regular suctioning of oral
secretions, and your breathing improved. Your blood pressure was
also occasionally low, and received IV fluids. You were found to
have seizure activity during this hospitalization, and your home
doses of keppra was increased.
Please start taking the following medications:
1. IV vancomycin 1gm twice a day
2. Piperacillin-Tazobactam 4.5 g IV every 8 hours
3. Albuterol 0.083% Neb Soln every 6 hours as needed for
shortness of breath
4. Ipratropium Bromide Neb every 6 hours as needed for shortness
of breath
Please change the dosing on the following medications:
1. Levetiracetam 1500 mg twice a day
Please continue to take your other medications.
Followup Instructions:
Department: PODIATRY
When: MONDAY [**2119-9-18**] at 2:20 PM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2120-5-2**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2119-9-15**]
ICD9 Codes: 5070, 2761, 4589, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8185
} | Medical Text: Admission Date: [**2182-5-16**] Discharge Date: [**2182-5-18**]
Date of Birth: [**2113-12-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14145**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Pacemaker placement ([**2182-5-17**])
History of Present Illness:
68M with h/o diastolic CHF, bradycardia p/w SOB since this
evening, which awoke him from sleep tonight. His symptoms feel
like his previous CHF, and he was last admitted ~1.5mos ago for
same and noted to be bradycardic at which time his BB was
stopped. Currently, he denies cp, fevers, light headedness or
leg swelling.
.
He was admitted for CHF exacerbation [**Date range (1) 34845**] and [**Date range (1) 22380**].
Lasix was increased on this last admission. He was also brady
that admission so they stopped his metoprolol. Saw cardiologist
two weeks ago who increased lasix from 40mg to 60mg. Tuesday
feeling more SOB than normal (even with rest). Last night
breathing heavier and brought in at 2am. He thought this was
similar to prior CHF exacerbations and therefore presented to
the ER.
.
In the ED, initial VS: 95.8 42 101/35 22 98%. A CXR revealed
mild pulmonary edema. He was noted to be in [**Last Name (un) **]. He received
atropine x 1. He was given 1 amp of calcium for concern for
prolonged QT secondary to hypocalcemia. His bradycardia
persisted to the 40s, it was thought to be junctional vs afib
per cardiology and he developed hypotension to the 80s, which
was asymptomatic. He was then given 1L of fluid with improvement
to the high 90s. He refused a rectal guiac. Cr noted to be 2.7
from a baseline of 1.4-1.6. His BNP was 1594 (it was 1362 on
[**4-11**] and was 324 in [**2181-12-15**]). Blood cultures were drawn. CXR
showed mild congestion. EKG showed slow junctional rhythm. EKG
on [**4-12**] was NSR and showed LAD. Echo in [**2174-12-15**] showed EF > 60%
and LVH. On transfer to the floors, HR 60's, BP 121/39, Pox
95RA.
.
On the floor, he denies dizziness. He denies dietary
noncompliance and is not sure what his weight has been doing.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Two stents placed in past. Patient seen by
Dr. [**Last Name (STitle) **] and reportedly had a "normal" stress (as per the
patient) about 6 months ago. Prescribed nitroglycerin but only
uses it twice/year.
-CABG: N/a
-PERCUTANEOUS CORONARY INTERVENTIONS: In [**2174**], ramus was stented
with a 2.5 x 12 mm drug-eluting Taxus stent. In [**2168**], mid LAD
was stented with a 3.5 x [**Street Address(2) 104404**] GFX stent.
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
--Prostate cancer
--Glaucoma
Social History:
Used to work for [**Company 25186**]/[**Company 25187**] in the claims
department. Is married and likes to travel with his wife. One
son who lives in [**Name (NI) 622**]. Smoked 2 PPD for 54 years - recently
quit. Has an occasional shot of ETOH on the weekends. Denies
illicits.
Family History:
Mother and grandmother with DM. Mother died of aneurysm and
father died of "old age."
Physical Exam:
ON admission:
VS: T Afebrile BP 102/31, HR 46, RR 18, Pox 98RA
GENERAL: Well-appearing man in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, JVD slightly elevated.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: bibasilar rales, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
NEURO: Awake, A&Ox3, muscle grossly intact
.
ON discharge:
VS: T 98.5 BP (116-158)/49-74, HR 73-91, RR 20, Pox 92-98%RA
GENERAL: Well-appearing man in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, JVD slightly elevated.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: bibasilar rales, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
NEURO: Awake, A&Ox3, muscle grossly intact
Pertinent Results:
On admission:
.
[**2182-5-16**] 03:10AM BLOOD WBC-6.8 RBC-3.79* Hgb-11.6* Hct-36.1*
MCV-95 MCH-30.6 MCHC-32.2 RDW-16.1* Plt Ct-239
[**2182-5-16**] 03:10AM BLOOD Neuts-51 Bands-0 Lymphs-42 Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2182-5-16**] 03:10AM BLOOD PT-13.2 PTT-22.9 INR(PT)-1.1
[**2182-5-16**] 03:10AM BLOOD Glucose-154* UreaN-82* Creat-2.7*# Na-138
K-4.9 Cl-101 HCO3-22 AnGap-20
[**2182-5-16**] 03:10AM BLOOD cTropnT-0.02*
[**2182-5-16**] 03:10AM BLOOD proBNP-1594*
[**2182-5-16**] 03:10AM BLOOD Calcium-9.9 Phos-5.3*# Mg-2.4
.
CXR: Mild pulmonary congestion
.
[**5-16**] EKG: Probable junctional rhythm with atrial premature beat.
Delayed R wave
progression with late precordial QRS transition is
non-diagnostic. Since the
previous tracing of [**2182-4-12**] probable junctional rhythm has
replaced sinus
rhythm.
.
Pacemaker:
PPM interrogation
AAI-DDD
R - 7.3mV, 584 ohms, 1V @ 0.5 ms
P - 5.5 mV, 496 ohms, 0.5V@0.5ms
.
On discharge:
[**2182-5-18**] 07:45AM BLOOD WBC-6.4 RBC-3.97* Hgb-12.3* Hct-38.4*
MCV-97 MCH-30.9 MCHC-32.0 RDW-16.0* Plt Ct-212
[**2182-5-18**] 07:45AM BLOOD Glucose-117* UreaN-32* Creat-1.4* Na-139
K-4.8 Cl-106 HCO3-22 AnGap-16
.
Blood cultures: NGTD
Brief Hospital Course:
68M with h/o diastolic CHF, CAD s/p RCA and LAD stents,
longstanding DM, and bradycardia p/w SOB since this evening who
now has diastolic congestive heart failure, acute kidney injury,
and bradycardia.
.
#) Bradycardia: Noted on last 2 hospital admissions but had been
attributed to beta-blocker, which was stopped in [**March 2182**]. On
presentation to the ED, HR in 30s-40s showing junctional rhythm
with occasional sinus beats. He was given 1 mg atropine in the
ED. The patient did complain of intermittent lightheadedness at
home. EP was consulted and elected to place a dual chamber
pacemaker on [**2182-5-18**]. He is to follow-up in device clinic in 1
week. He was started on Toprol 25 mg per day.
.
#) Diastolic CHF: Two recent admissions for decompensated CHF in
[**Month (only) **] and [**2182-3-15**]. Lasix had recently been increased by his
outpatient cardiologist to 60 mg per day. On admission, BNP was
elevated to 1594, CXR showed mild congestion, and [**Last Name (un) **] was
present. He was given IV Lasix 20 mg on HD#1. His discharge
lasix dose was 60 mg per day.
.
#) CAD: Last stent in [**2174**], currently on ASA 325 and plavix.
These were continued. Once pacemaker was place, he was started
on metoprolol succinate at 25 mg qday.
.
#) [**Last Name (un) **]: Creatinine elevated to 2.7 from baseline 1.4-1.6. Likely
secondary to poor forward flow in the setting of bradycardia.
Creatinine returned to baseline of 1.6 by HD#1 with gentle
diuresis. Cr was 1.4 on discharge.
.
#) Glaucoma: continued eye drops
.
#) DM: continued novolog and SSI
.
#) HL: continued atorvastatin
.
DVT prophylaxis was with subQ heparin. He remained full code.
Medications on Admission:
1. Novolog Mix 70-30 100 unit/mL (70-30) Solution , 44units [**Hospital1 **]
2. Actos 45 mg Daily
3. Lipitor 40 mg Daily
4. clopidogrel 75 mg Daily
5. aspirin 325 mg Tablet Daily
6. prednisolone sodium phosphate Ophthalmic
7. Azopt Ophthalmic
8. Travatan Z Ophthalmic
9. Lasix 60 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Forty
Four (44) units Subcutaneous twice a day.
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. travoprost 0.004 % Drops Sig: One (1) Ophthalmic qd ().
7. brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] (2 times a day).
8. prednisolone sodium phosphate 1 % Drops Sig: One (1)
Ophthalmic twice a day.
9. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 1 days.
Disp:*4 Capsule(s)* Refills:*0*
10. 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:*1*
11. furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. Sinus node dysfunction
2. Acute on chronic diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you short of breath thought to be due
to slow heart rate. You were noted to have abnormal heart
rhythm which was thought to be from age associated fibrosis. A
pacemaker was implanted to help with your slow heart rate
without any complications.
.
FOLLOWING MEDICATION CHANGES WERE MADE TO YOUR MEDICAL REGIMEN
START METOPROLOL SUCCUNATE 25 mg daily
DECREASE ASPIRIN to 81 mg by mouth once a day
CONTINUE LASIX 60 mg by mouth once a day
.
Should you experience any symtpoms that concern you after
leaving the hospital, please call your cardiologist. Weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3
lbs.
.
Followup Instructions:
Please call your outpatient cardiologist's office on Monday in
order to schedule an appointment within 1 week.
.
Please call Device Clinic at ([**Telephone/Fax (1) 2037**] on Monday in order
to schedule a follow-up appointment in 1 week for wound check.
Please make an appointment with your primary care physician [**Last Name (NamePattern4) **]
[**Telephone/Fax (1) 3581**] within a week.
ICD9 Codes: 5849, 2762, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8186
} | Medical Text: Admission Date: [**2159-2-7**] Discharge Date: [**2159-2-12**]
Date of Birth: [**2078-6-10**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Ciprofloxacin / Zithromax
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal pain, malaise, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 year old female on remicade for Ulcerative Colitis (last dose
[**1-30**]), presents to the ED with 3 days of malaise, low grade
fever to 100.5, anorexia, and mild abdominal pain. She has been
having diarrhea, however this is not unusual for her due to her
colitis. Denies any urinary symptoms, nausea, vomiting, chest
pain, or shortness of breath. Anorexia over the past 2 days. She
was seen by her PCP today and her SBP was in the 80's and she
was instructed to go to the ED. On arrival, she initially
responded to fluid, however her BP continues to run 80's-90's
systolic, and she developed crackles on lung exam. She was given
Zosyn and Ceftriaxone in ED.
Past Medical History:
1. Severe colitis - Thought to be collagenous colitis vs.
medication-induced; on Remicade, last infusion in [**10-10**]. Diarrhea
with some blood in it at baseline.
2. PE
3. Recurrent UTI
4. Hypertension
5. Anemia
6. Hearing loss
7. Hyperparathyroidism
8. Osteoarthritis.
9. Hypercholesterolemia.
10. Osteoporosis
Social History:
Married to a physician from [**Name9 (PRE) 112**], 5 grown children. Still active
in her own business finding homes for international American
medical students. Her husband has retired and is her full-time
care-giver. She does not currently have services at home.
Family History:
Father died of lung ca at 67; mother died of MI at 50 (1st MI in
40s), had eclampsia.
Physical Exam:
On Admission:
VS: 97.4 77 82/53 (95/60 after administration of 2L fluids) 12
99% RA
GEN: A&O x 3, NAD
HEENT: PERRL, EOMI, anicteric
COR: RRR
LUNGS: Mild crackles at bilateral bases
ABD: Soft, distended, normal bowel sounds, mildly tender
suprapubically and in LLQ, no rebound or guarding
RECTAL: guiac +
EXTREM: LE warm, no edema
Pertinent Results:
On ADmission:
[**2159-2-7**] 08:15AM PT-20.4* INR(PT)-1.9*
[**2159-2-7**] 08:15AM PLT COUNT-246
[**2159-2-7**] 08:15AM WBC-20.2*# RBC-4.01* HGB-11.4* HCT-35.6*
MCV-89 MCH-28.4 MCHC-31.9 RDW-14.5
[**2159-2-7**] 08:15AM TRIGLYCER-108 HDL CHOL-82 CHOL/HDL-2.4
LDL(CALC)-89
[**2159-2-7**] 08:15AM CALCIUM-9.0 IRON-16* CHOLEST-193
[**2159-2-7**] 08:15AM ALT(SGPT)-11 AST(SGOT)-14 ALK PHOS-93 TOT
BILI-0.8
[**2159-2-7**] 08:15AM UREA N-22* CREAT-1.1 SODIUM-133 POTASSIUM-3.9
CHLORIDE-97
[**2159-2-7**] 08:15AM GLUCOSE-108*
[**2159-2-7**] 10:00AM CK-MB-NotDone
[**2159-2-7**] 10:00AM cTropnT-<0.010
[**2159-2-7**] 10:00AM LIPASE-33
[**2159-2-7**] 10:12AM LACTATE-1.3
[**2159-2-7**] 11:43AM URINE HYALINE-[**4-6**]*
[**2159-2-7**] 11:43AM URINE RBC-0-2 WBC-[**7-12**]* BACTERIA-FEW
YEAST-NONE EPI-21-50
[**2159-2-7**] 11:43AM URINE BLOOD-SM NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2159-2-7**] 08:06PM URINE RBC->50 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-<1
[**2159-2-7**] 11:43AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2159-2-7**] 10:03PM CORTISOL-34.1*
.
IMAGING:
[**2159-2-7**] ABD/PELVIC CT W/CONTRAST:
1. Sigmoid diverticulitis and microperforation. Follow up
imaging or colonoscopy is recommended after treatment to ensure
resolution.
2. Unchanged left adnexal cyst. Second cystic lesion adjacent to
the known left adnexal cyst may be a secondary additional cyst,
and was present on the prior study. Can consider ultrasound on a
non-urgent basis for further evaluation of adnexa.
.
[**2159-2-7**] CXR:
FINDINGS: Cardiac silhouette is enlarged but unchanged from
[**2158-3-6**]. The mediastinal contours are unchanged.
Atherosclerotic calcifications are once again noted within the
thoracic aorta. The lungs appear clear with no evidence of
consolidation, pleural effusion or pneumothorax. Degenerative
changes are noted within the thoracic spine.
IMPRESSION: No acute cardiopulmonary process.
.
[**2159-2-7**] ECG:
Sinus rhythm. Baseline artifact. Non-specific precordial T wave
inversion. Compared to the previous tracing of [**2158-3-4**] T wave
inversion is new in leads V3-V6.
Intervals Axes:
Rate PR QRS QT/QTc P QRS T
78 158 74 398/429 51 26 98
.
MICROBIOLOGY:
[**2159-2-7**] Blood Cx: No growth to date - Prelim.
[**2159-2-7**] Urine Cx: Contaminant.
[**2159-2-7**] MRSA Screen: Negative.
Brief Hospital Course:
The patient was admitted to the TSICU from the Emergency
Department on [**2159-2-7**] for further evaluation and treatment of
sepsis and hypotension. She was made NPO except medications,
started on IV fluids and empiric IV Zosyn and Flagyl, and a
foley catheter was placed. The patient was hemodynamically
stabilized.
.
Neuro: The patient did not experience any significant pain, and
did not require any pain medications during this admission. She
remained neurologically intact.
.
CV: Upon arrival in the ED, the patient's blood pressure was
82/53; after an initial 2 liter IV fluids, her blood pressure
increased to 95/60. Anti-hypertensives were held. Further
aggressive fluid rescusitation and an infusion of albumin in the
TSICU resulted in resolution of the hypotension. Thereafter, the
patient remained stable from a cardiovascular standpoint; vital
signs were routinely monitored. Home anti-hypertensives were
restarted prior to discharge.
.
Pulmonary: Admission CXR was unremarkable. The patient remained
stable from a pulmonary standpoint; vital signs were routinely
monitored. Good pulmonary toilet, early ambulation and incentive
spirrometry were encouraged throughout hospitalization.
.
GI/GU/FEN: Upon arrival, the patient was made NPO with IV fluids
started. As above, she received aggressive IV fluid
rescusitation and a unit of albumin with good effect, and
resolution of hypotension. She was started on sips of clears on
[**2159-2-9**], which was progressively advanced to a low residue
regular diet by [**2159-2-11**] with good tolerability. At midnight on
[**2159-2-10**], the foley catheter was discontinued. She subsequently
voided without problem. Patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary.
.
ID: Upon admission, the patient was started on empiric IV Zosyn
and Flagyl. Admission urine culture was unremarkable, and blood
culture no growth to date. On [**2159-2-10**], IV Zosyn was discontinued,
and Ciprofloxacin added to the Flagyl. The patient was
discharged home on a total of 14 days of Ciprofloxacin and
Flagyl. The patient's white blood count and fever curves were
closely watched for signs of infection.
.
Endocrine: The patient's blood sugar was monitored throughout
her stay; sliding scale insulin was administered accordingly.
Cortisol stimulation test result was 34.1; prednisone was
discontinued. She was continued on her home dose of synthroid.
.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
.
Prophylaxis: Coumadin prophylaxis for history of PE was intially
continued upon admission, but was discontinued on [**2159-2-11**] for an
INR of 3.0, most likely due to drug-drug interaction with Flagyl
and Ciprofloxacin, which can elevate INR. Upon discharge, she
was restarted on Coumadin 1.5mg daily ([**2-3**] regular dose) with a
home PT/INR draw scheduled for [**2159-2-15**]. The patient PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], has kindly agreed to follow the patient's INR and
manage Coumadin dosing after discharge. Venodyne boots were used
during this stay; was encouraged to get up and ambulate as early
as possible.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a low
residue regular diet, ambulating, voiding without assistance,
and she was not experiencing any pain. She was discharged home
only with home phlebotomy services. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ramipril 5 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
7. WelChol 625 mg Tablet Sig: Three (3) Tablet PO twice a day.
8. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
9. Remicade 100 mg Recon Soln Sig: Three Hundred (300) mg
Intravenous Q3 MONTHS.
10. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 8 days before and 2 days after remicade or as directed.
11. Loperamide 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for diarrhea.
12. Fexofenadine 60 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for allergy symptoms.
13. Calcium 500 500 mg (1,250 mg) Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day.
14. Ferrous Sulfate 134 mg (27 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-8**]
hours as needed for fever or pain.
18. Coumadin 3 mg Tablet Sig: 1 Tablet PO once a day [**Month/Day (3) 766**]
through Saturday; 0.5 tablet PO on Sunday.
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ramipril 5 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
7. WelChol 625 mg Tablet Sig: Three (3) Tablet PO twice a day.
8. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
9. Remicade 100 mg Recon Soln Sig: Three Hundred (300) mg
Intravenous Q3 MONTHS.
10. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 8 days before and 2 days after remicade or as directed.
11. Loperamide 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for diarrhea.
12. Fexofenadine 60 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for allergy symptoms.
13. Calcium 500 500 mg (1,250 mg) Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day.
14. Ferrous Sulfate 134 mg (27 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 12 days.
Disp:*36 Tablet(s)* Refills:*0*
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-8**]
hours as needed for fever or pain.
18. Coumadin 3 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Sigmoid diverticulitis
2. Hypotension
.
Secondary:
1) Colitis
2) History of pulmonary emboli
3) Hypertension
4) Hypothyroidism
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-11**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Please call ([**Telephone/Fax (1) 8105**] to schedule a follow-up appointment
with Dr. [**First Name (STitle) 2819**] (Surgery) in 2weeks.
.
You have an appointment with Dr. [**Last Name (STitle) **] (PCP) scheduled for
Wednesday, [**2159-2-28**] at 1:30PM, [**Hospital Ward Name **] 1B, [**Last Name (NamePattern1) 439**],
[**Hospital1 18**], [**Location (un) 86**]. Please call ([**Telephone/Fax (1) 24024**] if you have any
questions.
.
A phlebotomist from the [**Hospital1 18**] laboratory will come to your home
on Thursday, [**2159-2-15**] in the morning to draw blood for a PT/INR
test. Dr.[**Name (NI) 6844**] office will then contact you with any
Coumadin dose adjustments.
Completed by:[**2159-2-12**]
ICD9 Codes: 4589, 2449, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8187
} | Medical Text: Admission Date: [**2136-9-22**] Discharge Date: [**2136-9-26**]
Date of Birth: [**2090-3-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 yo man with history of HIV (CD4
330, viral load undetectable) with HCV likely cirrhosis who was
transferred to [**Hospital1 18**] from [**Hospital3 22439**] for management of
hyponatremia.
.
Per MICU Admit note, patient's sodium was initially noted to be
120 at his primary care physician's office on [**2136-9-19**] where he
presented with complaints of nausea/vomiting and RUQ abdominal
pain. Patient's nausea had been persistent X 2 months with
nonbloody, nonbiliary emesis. Patient was initially treated at
[**Hospital3 22439**] with IVF and dilaudid for presumed SIADH.
Chest Xray and KUB were negative at the time. Patient was
transferred here for refractory hyponatremia. Of note, patient
was recently started on Lasix 40mg qod and Matolazone
(8/12-14/09)
.
In the ED, initial VS were: T97 HR86 BP122/64 RR16 O2sat98%. He
was mentating well and did not show evidence of seizures. He
appeared euvolemic on exam and was given Kayexalate for
hyperkalemia.
.
In the MICU, he was initially fluid restricted but with
continuing hyponatremia. He was continued on fluid restriction
with hypertonic saline with transient improvement of his sodium
level (122). Renal was consulted and patient started on Lasix
and
Aldactone in addition to fluid restriction <800cc and hypertonic
saline. Heme/Onc was consulted for patient's elevated LDH, low
haptoglobin and reticulocytosis. They did not feel this was
consistent with TTP or DIC (no schistocytes seen on blood
smear).
Thick and thin smears for parasites (babesia) have been
negative.
Patient stated he wished to leave AMA while in MICU with ?SI to
his outpatient case manager by phone; psych consult stated
patient does not have capacity currently to leave AMA (altered
mental status) and recommended head CT. Upon transfer to the
floor, patient's VS: Tm98.7 Tc 98.2 HR 73-107 BP 107/52 RR 16
O295% RA.
.
Review of Systems otherwise negative for 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. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias
or myalgias. No hematochezia, melena, hematemesis.
Past Medical History:
* HIV (most recent CD4 330, viral load undetectable)
* HCV (never treated, unable to biopsy for cirrhosis diagnosis
[**2-27**] thrombocytopenia)
* EtOH abuse (quit in [**Month (only) 116**]/[**2136-6-25**] with
?intermittent/infrequent
binges)
* Concommitant Lyme/Babesia/Erlichiosis treated with
?doxycycline
in [**Month (only) **]/[**2136-7-25**]
* Bipolar disorder vs. personality disorder
Social History:
Lives on [**Hospital1 64171**]in HIV group home. Has
friend support group, no family (h/o sexual abuse by
brother/cousin). Quit smoking/EtOH in [**Month (only) 116**]/[**2136-6-25**] with
?infrequent intermittent EtOH binges. Denied IVDU.
Family History:
Mother with hypertension
Physical Exam:
VS: Tm98.7 Tc 98.2 HR 78 BP 107/52 RR 16 O295%RA.
General: Oriented X3 but lethargic, no apparent distress,
temporal wasting.
HEENT: Normocephalic atraumatic, icteric sclera, moist mucus
membranes, normal oropharynx
Neck: Soft, supple, no JVD or LAD
Lungs: Clear to auscultation bilaterally, no
wheezes/rhonchi/rales
CV: Regular rate and rhythm, normal S1 + S2, no
murmurs/gallops/rubs
Abdomen: +Bowel Sounds, soft, non-tender, mildly distended with
fluid wave ascites, +hepatosplenomegaly
Ext: warm, well perfused, 2+ DP/PT pulses, no
clubbing/cyanosis/edema, dry skin in bilateral lower extremity
Neuro: CN2-12 grossly intact, ?+ asterixis
Pertinent Results:
UreaN:935 FeNa = 70%, FeUrea = 61.97% (?ATN)
Creat:98
Na:74
Osmolal:652
.
Chem 10
122 97 17 93 AGap=10
4.9 20 1.1
.
ALT: 57 AP: 135 Tbili: 7.3 AST: 71 LDH: 208
.
CBC
6.6 > 9.6 < 34
29.4
.
PT: 17.7 PTT: 37.5 INR: 1.6
.
Cortisol 31.3, TSH 4.2
.
DDimer 3055, Fibrinogen 183, Retic 6.3 (h), Haptoglobin <20 (l)
.
Micro: Urine Cx negative
.
Images:
RUQ U/S: 1. Very heterogeneous nodular appearing liver
consistent
with cirrhosis. While no liver lesion is identified it is
difficult to fully assess the hepatic tissue due to the degree
of
heterogeneity. The left lobe in particular could not be
visualized due to overlying bowel gas. A CT or MRI is
suggested for further evaluation.
2. Reversed flow in the main portal vein and right portal vein.
Numerous vessels could not be identified as described above.
3. Splenomegaly.
4. Ascites.
.
CXR ([**2136-9-22**]): No previous images. The heart is normal in size
and the lungs are clear without vascular congestion or pleural
effusion.
.
EKG: Sinus with PACs, no peaked Ts
Brief Hospital Course:
* Patient left AGAINST MEDICAL ADVICE on [**2136-9-26**] after Psychiatry
deemed his mental status improved and patient competent to make
his own medical decisions. *
.
46 yo man with HIV and HCV (?cirrhosis) who
presents with nausea/vomiting and hyponatremia 115-122 that has
been refractory to normal saline, hypertonic saline, fluid
restriction and Lasix/Aldactone. Also notable on admission to
MICU are elvated transaminases, elevated creatinine,
hyperkalemia, mild megaloblastic anemia and thrombocytopenia.
Patient continues to have transaminitis, megaloblastic anemia
and
thrombocytopenia.
.
# Euvolemic hyponatremia: It remains unclear whether patient was
hypo or euvolemic on initial presenation. Differential diagnosis
included SIADH (? due to cirrhosis, pain/nausea) although
patient's sodium remained resistant to treatments, with slight
improvements on the last day of admission. Patient was continued
on fluid restriction upon arrival to CC7 with some questions of
non-compliance. Before Lasix could be re-started per Renal
recommendations, patient's sodium had improved (125 <-- 118) and
patient left against medical advice. CT noncon of chest and CT
with contrast of head ordered to
assess cerebral edema and malignant sources for SIADH on [**2136-9-25**]
were negative. Sodium continued to be checked every 8 hours,
dependent on patient's cooperation and patient was continued on
telemetry without incidence.
.
#. Altered mental status: Patient's physical exam became
concerning by [**2136-9-25**] for altered mental status. While in the
MICU, patient was evaluated by Psychiatry for threatening to
leave AMA in order to "walk into traffic" (passive SI). Psych at
that time deemed patient not competent to make his own medical
decisions. Hepatology evaluated patient with differential
diagnosis of Meningitis vs. Hepatic Encephalopathy (from
hepatitis C, genetic or autoimmune liver disease) vs.
spontaneous bacterial peritonitis. Lumbar puncture and
diagnostic paracentesis were considered to further work patient
up for these possibilities but patient was mentating better on
[**2136-9-26**]. Psychiatry determined patient competent to make medical
decisions and he decided to leave AMA. Anti-smooth muscle
antibody, Ferritin, [**Doctor First Name **], were all pending upon patient's
departure.
.
# ARF: Baseline unknown. Cr 1.1 at OSH. Ample urine output in
MICU and creatinine remained within normal limits the remainder
of this admission.
.
# Hyperkalemia: Received Kayexalate in ED. Potassium was within
normal limits thereafter. Spironolactone was held.
.
# Transaminase elevation, elevated bilirubin, h/o HCV: Elevated
total bilirubin and INR were likely secondary to depressed
synthetic function. Patient had recent transaminitis (with usual
delayed rise in total bili and alkaline phosphatase) after his
triple tick infection. The RUQ ultrasound poorly visualized the
left lobe of the liver (for masses) although veins were patent.
CT/MRI were deferred during this admission. Patient's LFTs were
monitored during this admission with progressive improvement.
.
# Thrombocytopenia: Differential diagnosis includes
hypersplenism/splenic sequestration (from liver cirrhosis) vs
HIV vs TTP (unlikley). Apparently at OSH, patient's Plt 58 and
HCT 32. Patient's thrombocytopenia was monitored during this
admission.
.
# Megaloblastic anemia: Differential diagnosis includes HIV vs
vitamin deficiency. HCT has remained stable. Patient's folate
was 9.0, 11.6 (within normal limits). Patient was continued on
Folate repletion of 2mg daily.
.
# HIV: Patient was continued on Truvada, Norvir, Prezista. His
viral load and CD4 were not repeated during this admission as he
had relatively recent labs and symptoms not suggestive of HIV
encephalopathy or other HIV-based etiology.
.
FEN: Patient's fluid was restricted to <800 although patient did
drink a pitcher of water the evening of [**9-24**].
.
Code: Full (discussed with patient)
.
Medications on Admission:
Medications on admission (confirmed by pharmacy):
Truvada 200 mg-300 mg Daily
Norvir 100 mg Twice Daily
Prezista 600 mg Twice Daily
Spironolactone 50 mg Twice Daily
Omeprazole 20 mg [**Hospital1 **]
Enalapril 10 mg daily
Ativan 1 mg q6-8h prn
Nadolol 20 mg Once Daily
Lactulose 10 gram/15 mL [**Hospital1 **]-TID
Hydroxyzine 25 mg 1-2 tablets q6h prn for itch
KCL 20 mEq TID
Lasix 40mg qod and Metolazone prescribed on [**7-29**]/[**2136**]
.
Allergies:
NKDA
.
Medications on Transfer to CC7: IV
* Lactulose 30 mL PO TID
* Darunavir 600 mg PO BID
* Multivitamins W/minerals 1 TAB PO DAILY
* Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
* Nadolol 20 mg PO DAILY
* FoLIC Acid 1 mg PO DAILY
* Omeprazole 20 mg PO DAILY
* Furosemide 20 mg PO DAILY
* RiTONAvir 100 mg PO BID
* HydrOXYzine 25 mg PO Q6H:PRN itching
Discharge Medications:
* Lactulose 30 mL PO TID
* Darunavir 600 mg PO BID
* Multivitamins W/minerals 1 TAB PO DAILY
* Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
* Nadolol 20 mg PO DAILY
* FoLIC Acid 1 mg PO DAILY
* Omeprazole 20 mg PO DAILY
* Furosemide 20 mg PO DAILY
* RiTONAvir 100 mg PO BID
* HydrOXYzine 25 mg PO Q6H:PRN itching
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Discharge Condition:
Improved
Discharge Instructions:
Patient left Against Medical Advice
Followup Instructions:
Patient left Against Medical Advice but was informed that should
any of his symptoms (nausea, malaise, vomiting) recur, he should
seek medical attention. He was also informed that should he
become more confused, lethargic (signs of cerebral edema), he
should go immediately to the Emergency Room.
ICD9 Codes: 5849, 2767, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8188
} | Medical Text: Admission Date: [**2101-8-7**] Discharge Date: [**2101-8-10**]
Date of Birth: [**2041-1-14**] Sex: F
Service: NEUROSURGERY
Allergies:
Dilaudid / morphine
Attending:[**First Name3 (LF) 5084**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 60 year old RH female who reported sudden onset
headaches 2 days ago that progressed. She took motrin, tylenol
without significant relief. Patient was taken to [**Hospital **]
Hospital where a head CT showed a SDH. She was loaded with
dilantin and sent to [**Hospital1 18**] for further management. At OSH, she
received 1gm phosphenatoin, 8mg morphine total, 4mg zofran.
Today, she complains of headache. She denies any nausea,
vomiting, weakness or paresthesia. Images were shown to patient
and family. Natural history was discussed in detail and the
possible need for surgical intervention.
Past Medical History:
HTN, migraines
Social History:
married with children
Family History:
non contributory
Physical Exam:
On [**2101-8-7**] Admission:
PHYSICAL EXAM:
O: T: 97.9 82 124/78 16 96%
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic, eyes clear, hearing grossly intact, Pupils:
PERRL
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
GCS 15, AOX3, PERRL 5-2mm, face with right nasolabial fold,
tongue midline, no pronator drift, motor [**5-14**] b/l, sensory intact
Toes downgoing bilaterally, no clonus
On Discharge: Intact
Pertinent Results:
CT HEAD W/O CONTRAST Study Date of [**2101-8-7**] 10:41 PM
FINDINGS: Again seen is an acute on subacute subdural hematoma,
with mixed hyper- and hypodense components. This is stable at 1
cm in thickness, and tracks superiorly along the falx cerebri
and inferiorly along the left tentorium cerebelli. There is
subjacent sulcal effacement, with persistent 9 mm rightward
shift and subfalcine herniation. There is also a left uncal
herniation, extending over the tentorium with asymmetric
widening of the left ambient cistern relative to the right.
Cerebellar tonsils are in expected position at the level of the
foramen magnum. There is no intraparenchymal or
intraventricular hemorrhage. There is no evidence of
infarction. Note is made of mild hyperostosis frontalis interna.
There is mild mucosal thickening throughout multiple ethmoid
air cells. Mastoid air cells and middle ear cavities are clear.
Orbits and intraconal structures are symmetric.
IMPRESSION: Stable appearance of subacute subdural hematoma
measuring up to 1 cm, with 9 mm rightward shift, subfalcine
herniation, and early uncal
herniation.
CHEST (PORTABLE AP) Study Date of [**2101-8-7**] 11:45 PM
FINDINGS:
No previous images. There is striking scoliosis of the thoracic
spine convex to the right and centered at approximately T9.
However, there is no evidence of acute pneumonia, vascular
congestion, or pleural effusion.
NCHCT [**2101-8-8**]
1. Stable left subdural hematoma with underlying sulcal
effacement.
2. Midline shift to the right, unchanged compared to prior.
3. No progression of left subfalcine or left uncal herniation.
4. There is a possible fracture immediately anterior to the
left coronal
suture. There is an area of hemorrhage in a biconvex
configuration
immediately below the fracture that may represent an epidural
rather than
subdural location.
Brief Hospital Course:
This is a 60 year old RH female who reported sudden onset
headaches 2 days ago that progressed. The patient was taken to
[**Hospital **]
Hospital where a head CT showed a SDH and was loaded with
1 gram of phosphenatoin and sent to [**Hospital1 18**] for further
management. The patient continued to experience complains of
headache. The patient denied any nausea,
vomiting, weakness or paresthesia. The images were shown to
patient
and family. Natural history was discussed in detail and the
possible need for surgical intervention. The patient was
admitted to the surgical intensive care unit for close
neurological assessment and kept NPO for possible surgical
intervention in case patient decompensated.
On [**2101-8-8**], A repeat NCHCT was performed at 1100 am which was
found to be stable and the images were shown and explained to
the patients and her husband. The patient was transferred to
the Step Down Unit and a regular diet was initiated. The
patient continued to report headache and was given oxycodone and
fioricet for pain. The patient reported that following dilaudid
and morphne doses she experienced pruitis and these medications
were documented as allergies. She had no further issues while in
the hospital. She was discharged home with 24 hour supervision
per OT recs on [**8-10**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or headache, fever
2. Lisinopril 10 mg PO DAILY
3. Hydrocodone-Acetaminophen (5mg-500mg [**1-10**] TAB PO Q6H:PRN pain
RX *Co-Gesic 5 mg-500 mg [**1-10**] tablet(s) by mouth q6 hours Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Sub Dural Hematoma
Discharge Condition:
AOx3. Activity as tolerated.
Discharge Instructions:
Nonsurgical Brain Hemorrhage
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last 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.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
Completed by:[**2101-8-10**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8189
} | Medical Text: Admission Date: [**2190-5-20**] [**Month/Day/Year **] Date: [**2190-5-27**]
Date of Birth: [**2117-9-11**] Sex: F
Service: MEDICINE
Allergies:
Hydralazine / Opioid Analgesics / Compazine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 108904**] is a 72 yo female with PMH significant for ESRD. She
underwent HD on day PTA but presented to the ED with SOB. Per
patient, her breathing has become more difficult over the past 4
days but has not been feeling very well over the past few weeks.
Upon arrival to the ED her BP was 210/104 and O2 sat~68% RA. She
was placed on CPAP and was started on a nitro gtt. She was
transferred to the MICU for emergent dialysis. EKG was unchanged
and cardiac enzymes were negative.
Upon transfer to the MICU her BPs slowly improved with nitro gtt
which was d/c'ed. She was also started on Vancomycin/Levaquin
given her leukocytosis.
She currently denies any fevers, chills, chest pain, dizziness,
abdominal pain. She continues to feel SOB.
Past Medical History:
1. Hypertension
2. Hypothyroidism [**2-5**] thyroidectomy in [**2173**]
3. Type 2 DM
4. ESRD on HD T, Th, Sat; s/p Left loop forearm AV graft in [**2187**]
5. s/p CVA 2 years ago
6. Gait disorder
7. s/p splenectomy in [**2145**] [**2-5**] trauma, never prescribed
prophylactic antibiotics.
8. SVC stenosis
Social History:
Lives at home alone locally. Had 8 children, 1 son died
recently. Daughter comes to see her frequently, helps with
grocery shopping, meds, etc. She is a nonsmoker and no EtOH
Family History:
Noncontributory
Physical Exam:
vitals T 98.4 BP 172/78 AR 60 RR 18 O2 sat 95% on 3L
Gen: Pleasant female, appears tired
HEENT: MMM
Heart: distant heart sounds,
Lungs: scattered crackles posteriorly
Abdomen: soft, NT/ND, +BS
Extremities: [**1-5**]+ bilateral edema
Pertinent Results:
Laboratory results:
[**2190-5-20**] 12:10AM BLOOD WBC-20.1*# RBC-3.81* Hgb-12.7# Hct-37.6#
MCV-99* MCH-33.2* MCHC-33.6 RDW-16.0* Plt Ct-399
[**2190-5-27**] 06:50AM BLOOD WBC-11.2* RBC-3.48* Hgb-11.2* Hct-34.1*
MCV-98 MCH-32.1* MCHC-32.8 RDW-15.8* Plt Ct-348
[**2190-5-27**] 06:50AM BLOOD PT-23.6* PTT-32.0 INR(PT)-2.4*
[**2190-5-20**] 12:10AM BLOOD Glucose-220* UreaN-47* Creat-6.6*#
Na-131* K-5.1 Cl-91* HCO3-27 AnGap-18
[**2190-5-20**] 12:10AM BLOOD cTropnT-0.04*
[**2190-5-20**] 12:10AM BLOOD Calcium-9.3 Phos-3.9# Mg-2.5
Relevant Imaging:
1)Cxray ([**5-19**]): No large pneumothorax. Pulmonary edema.
2)Cxray ([**5-23**]): No radiographic evidence suggestive of volume
overload. Small bilateral pleural effusions and underlying
massive pulmonary arterial hypertension.
3)EKG: sinus @ 64, LAD, nl intervals, TWI II,III,AVF (old),
normalization of T in V5-V6
Brief Hospital Course:
Ms. [**Known lastname 108904**] is a 72yo female with ESRD who presents to ED with
respiratory distress in the setting of hypertension.
1)Respiratory Distress: Patient presented with acute decline in
respiratory status in setting of severely elevated blood
pressures. Initial cxray was consistent with pulmonary edema
which improved with BP control and dialysis. Troponins slightly
elevated in setting of renal insufficiency but no new EKG
changes. She was placed on BIPAP in the ED and this was
continued upon transfer to the MICU. Upon arrival to the floor
she was on NC which was quickly weaned off during the remainder
of her stay. She was followed closely by her nephrologist and
she was dialyzed T, TH, Sat with improvement in her volume
status.
2)Malignant hypertension: Patient presented with extremely
elevated blood pressures on admission. Likely due to fluid
retention with worsening renal function. She was initially
started on a Nitro gtt which was weaned off in the MICU. She was
also started on Clonidine PO and her dose of [**Last Name (un) **] was increased.
Upon transfer to the floor the Clonidine was stopped and she
started on Minoxidil with goal SBP ~140's given her history
vertebral insufficiency. Her blood pressures improved with her
regimen (Lisinopril, Losartan, Clonidine patch, Minoxidil, and
Metoprolol)and dialysis.
3)Leukocytosis: Patient presented with leukocytosis of 20.1
which returned to baseline on [**Last Name (un) **]. She was started on
Levaquin and Vancomycin since she was at risk for an infection
since she has an HD line in place. 1/2 blood culture bottles
grew GPC. She received a 7d course of Levaquin which was stopped
at time of [**Last Name (un) **] and she was given Vancomycin at dialysis.
Surveillance cultures remained negative.
4)ESRD: Patient was followed closely by her primary renal
attending. She was dialyzed 3x/week with improvement in her
blood pressures and volume status.
5)Hypothyroidism: Continued on Levoxyl.
6)Type 2 DM: Patient on Glipizide as outpatient. She was placed
on Glargine and RISS initially on admission since she had been
unable to take adequate PO. Upon transfer to the floor she was
started on Glipizide with appropriate control of her blood
sugars.
7)H/O of SVC stenosis: Anticoagulation was initially held in the
ED but restarted by the MICU team.
Medications on Admission:
Medications at home:
Acetaminophen 325 mg PO Q4-6H
Metoprolol Tartrate 150 mg PO TID
Losartan 25 mg PO DAILY
Lansoprazole 30 mg Tablet DR [**Last Name (STitle) **] DAILY
Levothyroxine 100 mcg PO DAILY
Clonidine 0.3 mg/24 hr Patch QMON
Isosorbide Mononitrate 90 mg Tablet Sustained Release 24 hr PO
DAILY Amlodipine 10 mg PO DAILY
Lisinopril 40 mg PO DAILY
Hexavitamin PO once a day.
Glipizide 2.5 mg Tab,Sust Rel PO once a day.
Coumadin 5 mg Tablet qhs
Calcium Acetate 1334 mg PO TID W/MEALS
Medications on transfer:
Medications:
Vancomycin 1g IV @ HD
Levaquin 500mg PO Q48
Acetaminophen 325 mg PO Q4-6H
Metoprolol Tartrate 150 mg PO TID
Losartan 50 mg PO DAILY
Lansoprazole 30 mg Tablet DR [**Last Name (STitle) **] DAILY
Levothyroxine 100 mcg PO DAILY
Clonidine 0.3 mg/24 hr Patch QMON
Clonidine 0.1mg PO TID
Imdur 90mg PO daily
Amlodipine 10 mg PO DAILY
Lisinopril 40 mg PO DAILY
Hexavitamin PO once a day.
Glipizide 2.5 mg Tab,Sust Rel PO once a day.
Coumadin 5 mg Tablet qhs
Calcium Acetate 1334 mg PO TID W/MEALS
[**Last Name (STitle) **] Medications:
1. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
3. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID
(3 times a day).
4. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime).
5. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
6. Glipizide 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
7. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Minoxidil 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Losartan 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
11. Levothyroxine 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H (every
8 hours) as needed.
14. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO once a day.
15. Clonidine 0.3 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Patch
Weekly Transdermal QMON (every Monday).
16. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO once a day:
please take with 60mg tablet for total of 90mg.
[**Last Name (STitle) **] Disposition:
Home With Service
Facility:
[**Location (un) 1468**] VNA
[**Location (un) **] Diagnosis:
Primary diagnoses:
1) End stage renal disease
2) Malignant hypertension
3) Respiratory failure
Secondary diagnoses:
1)Hypothyroidism
2)Type 2 Diabetes
3)Superior vena cava stenosis
[**Location (un) **] Condition:
Stable
[**Location (un) **] Instructions:
1) Please take all medications as listed in the [**Location (un) **]
instructions.
2)You have been started on several new medications which you
will be given prescriptions for: Norvasc 10mg once daily,
Minoxidil 10mg once daily, and your dose of Losartan has been
increased to 100mg once daily. You should continue all your
other medications as you were taking them at home.
3)Please schedule an appointment with Dr. [**First Name (STitle) 4370**] [**Name (STitle) **] in [**Hospital **] as your new primary care physician. [**Name10 (NameIs) **]
information is listed below.
4) If you experience any fevers, chills, chest pain, SOB,
dizziness or any other concerning symptoms please return to the
emergency room.
Followup Instructions:
Please call Dr. [**First Name (STitle) 4370**] [**Name (STitle) **] at [**Telephone/Fax (1) 250**] to schedule a
follow-up appointment after being discharged from the hospital.
ICD9 Codes: 4280, 5856, 7907, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8190
} | Medical Text: Admission Date: [**2112-11-24**] Discharge Date: [**2112-12-3**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
delta MS, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 yo male, h/o metastatic breast and lung cancer, brain mets,
ICH in the past, presenting with weakness and delta MS x [**4-5**]
days. History obtained via pt and his son. As per family, Mr.
[**Known lastname 13783**] has not been acting like himself for the past 4-5 days.
By report, he has been weak, confused since his last XRT
treatment on friday, [**11-18**]. Pt has known hip, brain mets for
which he is receiving XRT; he just completed a 10-treatment
course for his hip mets and has received 2 treatments for his
head, most recently on [**11-18**]. Son reports that he has had some
episodes of urinary incontinence over the past few days, thought
to be [**2-3**] the fact that he has been too weak to make it to the
bathroom. Pt has not had a bowel movement in [**4-5**] days. He
denies fever/NS/cp/sob/n/v/d; he has had chills, however. Son
denies that he has been more clumsy/denies one-sided weakness or
focal deficits. He walks, at baseline, with a walker, and gait
has been at baseline.
.
In the [**Name (NI) **], pt was A&Ox2, CT of the head showed interval
development of hypodensity within the grey matter of the
bilateral posterosuperior parietal, possibly occipital lobes.
He was also found to be hypertensive with SBP to 180s, HR 40's.
There was some thought that this was [**Location (un) 3484**] reflex [**2-3**]
increased intracerebral pressure. Neurology was consulted and
felt that new stroke/infection could not be excluded; they
recommended ?LP, antibiotics, MRI. EKG had no specific changes,
but had possible new TWI in L, V6; TNT was elevated to 0.46 with
flat [**Name (NI) **] (pt without sx). He was given ASA, Decadron 10 mg IV
x 1, admitted for mgt.
Past Medical History:
PMH:
1. DCIS of right breast, [**2104**], s/p mastectomy, chemo, XRT, neg
LNs (or not examined); mets to left hip (s/p bx [**10-5**]), brain.
Completed 10 radiations for hip, 2 for brain (most recently
[**2112-11-19**])
2. Lung cancer diagnosed radiographically, no rx
3. DM, diet controlled
4. LBP, s/p L4-5 laminectomy [**2108**]
5. s/p Carpal tunnel release
6. ICH, seen at [**Hospital1 112**] [**2111**] (pres with HA, left sided clumsiness)
7. HTN
Social History:
Lives downstairs from son, wife passed away fairly recently; 70+
pack year history (still smoking), no etoh/drugs, retired
electrictian
Family History:
son with NHL, mother died CVA, father died MI age 72
Physical Exam:
Admission PE: 98.8, BP: 183/55, HR: 44, RR: 19, O2sat: 98% 2L
GEn: NAD, pleasant male, sitting in bed
HEENT: CN II-XII grossly intact; some asymmetry of right
eyelid/increased closure
Lungs: CTA bilat, no w/r/r
CV: [**Last Name (LF) 8450**], [**First Name3 (LF) **] S1/s2, 2/6 SEM at LUSB
Abd: soft, nt/nd, nabs
Extr: no c/c/e, PT 2+ bilat
Neuro: moving all 4 extremities, CN as above, weakness of L foot
Rectal: guaiac neg
Skin: no [**Last Name (un) **] lesions, no splinter hemorrhages, no other
stigmata of endocarditis
Pertinent Results:
EKG: 1st degree AV block SR in 40's, with LAD, TWI in I, L,
V4-V6 (?new in L, V6), no other T-wave or ST changes.
.
Imaging:
CT head: interval devpt of hypodensity iwthin [**Doctor Last Name 352**] matter of
bilateral posterosuperior parietal, possibly occipital lobes,
new from [**11-4**]
.
MRI brain: multiple embolic strokes in cerebellar, parietal,
occipital lobes; enhancement of mets, temporal lobes
.
Echo: Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is mildly depressed. Antero-apical hypokinesis
is present.
3. The aortic valve leaflets (3) are mildly thickened. Trace
aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
.
Carotid series:
IMPRESSION: Minimal plaque with bilateral less than 40% carotid
stenosis. However, waveforms in the common carotid arteries may
be indicative of a more proximal disease. Clinical correlation
and potential MRA followup is warranted.
.
[**2112-11-24**] 10:52AM BLOOD WBC-15.8* RBC-4.79 Hgb-13.7* Hct-41.4
MCV-86 MCH-28.6 MCHC-33.1 RDW-16.3* Plt Ct-140*
[**2112-11-29**] 06:05AM BLOOD WBC-11.1* RBC-3.33* Hgb-9.5* Hct-27.4*
MCV-82 MCH-28.5 MCHC-34.6 RDW-16.3* Plt Ct-110*
[**2112-11-24**] 10:52AM BLOOD Neuts-86.1* Bands-0 Lymphs-9.7* Monos-3.7
Eos-0.5 Baso-0
[**2112-11-25**] 02:45AM BLOOD Neuts-91.4* Bands-0 Lymphs-4.0* Monos-3.7
Eos-0.1 Baso-0.1
[**2112-11-25**] 02:45AM BLOOD PT-15.0* PTT-83.7* INR(PT)-1.5
[**2112-11-29**] 04:00PM BLOOD PT-13.0 PTT-37.0* INR(PT)-1.1
[**2112-11-28**] 04:00PM BLOOD Fibrino-290 D-Dimer-1726*
[**2112-11-24**] 11:05AM BLOOD Glucose-145* UreaN-30* Creat-1.3*
[**2112-11-25**] 02:45AM BLOOD Glucose-161* UreaN-32* Creat-1.2 Na-139
K-4.0 Cl-105 HCO3-23 AnGap-15
[**2112-11-29**] 06:05AM BLOOD Glucose-204* UreaN-29* Creat-1.1 Na-136
K-4.2 Cl-106 HCO3-20* AnGap-14
[**2112-11-24**] 11:05AM BLOOD ALT-21 AST-28 CK(CPK)-47 AlkPhos-113
TotBili-0.8
[**2112-11-24**] 11:05AM BLOOD CK-MB-NotDone cTropnT-0.46*
[**2112-11-24**] 06:45PM BLOOD CK-MB-NotDone cTropnT-0.42*
[**2112-11-25**] 02:45AM BLOOD CK-MB-4 cTropnT-0.43*
[**2112-11-24**] 11:05AM BLOOD Calcium-10.0 Phos-3.9 Mg-1.8
[**2112-11-28**] 07:45AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
[**2112-11-29**] 06:05AM BLOOD CEA-246*
.
[**11-24**] MRI (full read): FINDINGS: There are multiple new areas
of T2 signal abnormality, involving the cortex and underlying
white matter of the occipital lobes and cerebellar hemispheres.
These areas exhibit diffusion signal hyperintensity, consistent
with recent infarction. However, there are also small foci of
diffusion signal abnormality in both parietal and frontal lobes,
primarily near the cortical surface. These areas are difficult
to distinguish from regions of chronic infarction and gliosis
also identified as hyperintense foci on T2 and FLAIR images.
There is ventricular enlargement, but not substantially changed
since previous exam.
The right occipital lobe enhancing metastasis is unchanged in
size and less well seen on today's study than previously. Other
small areas of enhancement are appreciated, some of which are in
locations of infarction. Overall, the post-gadolinium images are
blurry due to motion artifact.
Gradient echo images demonstrate previously identified areas of
susceptibility artifact.
MRA of the circle of [**Location (un) 431**] demonstrates flow in both
intracranial internal carotid arteries and in the anterior and
middle cerebral arterial branches proximally.
There is attenuation of flow in the left vertebral artery. Flow
signal is observed in the right vertebral artery, basilar artery
and proximal portions of the posterior cerebral and superior
cerebellar arteries.
IMPRESSION:
1. Multifocal recent infarction is identified within the
cerebrum and cerebellum.
2. MRA of the circle of [**Location (un) 431**] is limited but demonstrates flow
in the major branches of this circulation, though flow is
attenuated in the left vertebral artery.
Brief Hospital Course:
A/P: 83 yo male, h/o metastatic breast and lung cancer,
presenting with weakness, delta MS, new findings on head CT,
elevated troponin.
.
1. Neuro: upon admission, pt had a head MRI performed which
showed new multifocal cerebral and cerebellar infarcts which
were believed to be responsible for the mental status changes
and R sided weakness. The cause of the new multifocal infarcts
was believed to be hypercoagulability [**2-3**] malignancy. Pt was
initially started on heparin IV, but a decision was made to
discontinue this given the pt's high fall risk and he was
instead placed on aggrenox. He was continued on decadron and a
decision was made to stop XRT. His mental status subsequently
improved, as did his weakness. He was continued on decadron 4mg
PO q6hrs.
.
2. Metastatic breast/lung cancer: previously undergoing XRT,
which was stopped given the mental status changes. A decision
in conjunction with primary oncologist and family not to pursue
further agressive treatment was made.
.
3. Elevated troponin: no changes in CK-MB, no significant EKG
changes, no symptoms suggestive of cardiac ischemia. Likely due
to decreased renal clearance given slightly elevated creatinine.
.
4. DM: pt maintained on ISS. Had poor control of sugars while
on steroids.
.
5. FEN - diabetic diet, Cr improved with some hydration.
Medications on Admission:
Meds on Admission:
Atenolol 50 mg daily
Zantac
Vicodin PRN
Decadron (?4mg [**Hospital1 **] as per son, unclear on dose)
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain: hold for
oversedation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
6. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12
HR Sig: One (1) Cap PO BID (2 times a day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3894**] Hospice VNA
Discharge Diagnosis:
Metastatic lung cancer
Breast cancer
Stroke, ischemic
Insulin dependent diabetes
Discharge Condition:
fair
Discharge Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] as needed. Take your
medications as prescribed.
Followup Instructions:
Schedule follow-up with your PCP as needed
Completed by:[**2112-12-7**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8191
} | Medical Text: Admission Date: [**2192-5-16**] Discharge Date: [**2192-5-23**]
Date of Birth: [**2113-12-14**] Sex: F
Service: MEDICINE
Allergies:
Prednisone / Azithromycin / Trilisate / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
cardioversion
History of Present Illness:
78 yo F w/ PMH Afib on coumadin who presents with a "racing
heart". Patient states that she exeprienced palpitatins one day
ago, however was unsure if she was in a. fib. She had an appt
with PCP for neck pain when ECG done showed a. fib with RVR so
she was sent to ED. She denies any chest pain, sob,
palpitations. denies doe. Denies recent fevers or chills,
caugh/n/v.
.
In the ED, 96.9 HR 130 BP 122/76 and 98%RA. she received 325 mg
aspirin and lopressor 5 mg IV X 3 with slowing of her heart rate
to 110s.
.
On transfer to the floor pt c/o neck pain which she states has
been bothering her for several months. She has tried tylenol
with minimal relief. Some relief with local heat and bengay.
Denies any recent trauma.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle, syncope or presyncope.
Past Medical History:
1. Parkinson's disease
2. Congestive heart failure with an ejection fraction of 50-55%
on TEE in [**1-29**]
3. Atrial fibrillation
4. Hypertension
5. Constipation
6. Dizziness
7. Colonic polyps
8. Irritable bowel syndrome
9. Gastritis
10. Hyponatremia
11. Back pain
12. Hearing loss
13. Insomnia
14. Basal cell carcinoma
15. Left bundle-branch block
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Pt cares for her
husband at
home, has [**Name (NI) **] on Wheels, cleaning woman every other week;
husband has aide 4x/week.
Family History:
Her parents died when they were in their 60s, her mother of
renal disease, her father of heart disease.
Physical Exam:
Vitals: T 97.6 HR 65 BP 158/78 RR: 20 100% 2L
Gen: awake, alert, sitting in chair breathing comfortably
HEENT: Clear OP, MMM
NECK: Supple, No LAD, JVP 8-10
CV: RR, NL rate. NL S1, S2. soft sys murmur LLSB
LUNGS: crackles bilaterally [**1-24**] way up.
ABD: Soft, NT, ND. NL BS. No HSM
EXT: trace edema. 2+ DP pulses BL
Pertinent Results:
REPORTS:
.
CHEST (PORTABLE AP) [**2192-5-16**] 1:11 PM
IMPRESSION:
1. Unchanged cardiomegaly, without evidence of pulmonary edema.
2. Probable small bilateral pleural effusions with bilateral
basilar atelectasis.
.
CHEST (PORTABLE AP) [**2192-5-19**] 9:34 AM
Cardiac silhouette is enlarged, and there has been development
of congestive heart failure with perihilar and basilar edema.
Bilateral moderate pleural effusions have increased in size with
adjacent atelectasis.
.
TTE: [**2192-5-21**]:
Conclusions:
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). The right
atrium is markedly dilated. The estimated right atrial pressure
is 11-15mmHg. Left ventricular wall thicknesses and cavity size
are normal. There is mild regional left ventricular systolic
dysfunction with severe hypokinesis of the inferior and
inferoseptal walls. The remaining segments contract well.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] The
right ventricular cavity is mildly dilated. Right ventricular
systolic function is normal. [Intrinsic function may be
depressed given the severity of tricuspid regurgitation.] The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
severe pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is a small
pericardial effusion without hemodynamic evidence of
compromise/tamponade physiology.
.
Compared with the prior study (images reviewed) of [**2192-1-4**], the
inferior/inferoseptal wall motion abnormality is new, overall
LVEF is more depressed, and the severity of mitral regurgitation
has increased. The severity of pulmonary artery systolic
hypertension is also markedly increased.
.
.
ADMISSION LABS:
[**2192-5-16**] 12:55PM GLUCOSE-102 UREA N-34* CREAT-1.3* SODIUM-138
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-29 ANION GAP-18
[**2192-5-16**] 12:55PM estGFR-Using this
[**2192-5-16**] 12:55PM CK(CPK)-61
[**2192-5-16**] 12:55PM cTropnT-<0.01
[**2192-5-16**] 12:55PM CK-MB-NotDone
[**2192-5-16**] 12:55PM WBC-7.7 RBC-3.60* HGB-11.5* HCT-34.4* MCV-96
MCH-32.0 MCHC-33.5 RDW-15.0
[**2192-5-16**] 12:55PM NEUTS-66.8 LYMPHS-26.2 MONOS-4.7 EOS-0.6
BASOS-1.7
[**2192-5-16**] 12:55PM MACROCYT-1+
[**2192-5-16**] 12:55PM PLT COUNT-454*
[**2192-5-16**] 12:55PM PT-25.5* PTT-33.4 INR(PT)-2.6*
[**2192-5-23**] 06:20AM BLOOD WBC-8.1 RBC-3.43* Hgb-11.1* Hct-32.5*
MCV-95 MCH-32.5* MCHC-34.3 RDW-15.2 Plt Ct-395
[**2192-5-21**] 06:06AM BLOOD Neuts-62.7 Lymphs-27.8 Monos-7.1 Eos-2.0
Baso-0.4
[**2192-5-23**] 06:20AM BLOOD Plt Ct-395
[**2192-5-23**] 06:20AM BLOOD PT-23.1* PTT-150 INR(PT)-2.3*
[**2192-5-22**] 01:00PM BLOOD PT-18.8* PTT-24.9 INR(PT)-1.8*
[**2192-5-21**] 06:06AM BLOOD PT-24.2* PTT-30.4 INR(PT)-2.4*
[**2192-5-23**] 06:20AM BLOOD Glucose-89 UreaN-26* Creat-0.9 Na-141
K-3.7 Cl-97 HCO3-34* AnGap-14
[**2192-5-20**] 05:09AM BLOOD CK(CPK)-94
[**2192-5-19**] 04:35PM BLOOD ALT-9 AST-35 LD(LDH)-193 CK(CPK)-136
AlkPhos-109 Amylase-83 TotBili-0.8
[**2192-5-20**] 05:09AM BLOOD CK-MB-3 cTropnT-<0.01
[**2192-5-19**] 04:35PM BLOOD CK-MB-3 cTropnT-<0.01
[**2192-5-19**] 11:05AM BLOOD CK-MB-3 cTropnT-<0.01
[**2192-5-20**] 05:09AM BLOOD calTIBC-339 VitB12-912* Folate-19.0
Ferritn-33 TRF-261
[**2192-5-19**] 11:28AM BLOOD Type-ART pO2-91 pCO2-58* pH-7.28*
calTCO2-28 Base XS-0
[**2192-5-19**] 11:28AM BLOOD Lactate-2.2*
Brief Hospital Course:
78 yo F with CHF (EF 50%) and a history of Afib who presented
with palpitations due to recurrent Afib.
.
#. Rhythm:
The patient presented in Afib w/RVR. There were no signs of
infection or any complaint of chest pain suggesting ischemia as
etiology for afib recurrance. Had rates 120's-130's on
admission, with stable blood pressure. Initially rate control
was attempted by increasing metoprolol to 75mg [**Hospital1 **], however pt
still had HR's in 110's. Pt was then DC cardioverted, and
remained in NSR. She did not need a TEE prior to cardioversion,
as PCP records were [**Name9 (PRE) 97121**] and INR had largely been therapeutic
in past month. Metoprolol dose was then decreased to home dose
as pt had rate in 70's.
--pt's INR became supratherapeutic, so coumadin was held for
several days, and then re-started once INR was in acceptable
range.
--started sotalol for rhythm control, however pt had prolonging
QTc. Sotalol dose was then decreased from 80mg [**Hospital1 **] to 40mg [**Hospital1 **].
QTc was monitored while on sotalol.
.
#. Pump - EF 40%
-- given renal insufficiency on admission and dry mucous
membranes, lasix and lisinopril were held, however lasix and
lisinopril were later restarted
-- approximately 24 hours after cardioversion, pt c/o SOB and
had hypoxic respiratory failure, which was thought secondary to
post-cardioversion CHF. She required a 100% NRB, nitro gtt, and
was transferred to the CCU for BiPAP. She underwent aggressive
diuresis along with BiPAP, and SOB and O2 requirement greatly
improved. Pt now satting well on 2L NC and returned to the floor
once breathing was stable. She ruled out for MI during this
episode.
.
#. CAD:
no documented history of CAD, though inferior HK on echo
--she was contined on BB, asa
--she was not previously on statin LDL 102 [**2192-1-23**], previously
114. Simvastatin was started during the admission.
#. HTN:
The lasix, metoprolol, and lisinopril were held on admission,
then restarted to her home doses.
.
#. [**Doctor First Name 48**]:
Pt had elevated BUN and creatinine up to 1.3 on admission, came
down to 1.0.
ACEI and Lasix were held on admission, now both have been
re-started
.
#. Nausea + Abdominal distension:
pt complained of this during her episode of SOB. Now resolved.
KUB negative for obstruction. Likely due to constipation. LFTs
WNL.
.
#. Parkinson's Disease - continued Sinemet
.
# Neck pain:
Pt has had chronic neck pain for several months, thought [**2-24**]
arthritis. Has tried ultram and physical therapy in the past
without relief. Pain consult was called, however would need
C-spine MRI prior to any injections, so will continue
conservative management for now and hold off on inpatient
consult. We re-scheduled her outpatient pain appointment (had
appt scheduled for [**5-22**] prior to admission).
.
#. FEN - low-sodium/cardiac diet, replete lytes prn
.
#. Access: PIV
#. PPx: therapeutic INR, bowel regimen, PPI
#. Code: Full
Medications on Admission:
Coumadin 5 mg PO daily
Lasix 20 mg PO daily
Lisinopril 10 mg daily
Toprol XL 50 mg qhs
Sinemet 25-100MG-- 1.5 tablets TID
Coenzyme Q10 400 mg TID
Fosamax 70 mg q weekly
Calcium Citrate With D [**Hospital1 **]
Discharge Medications:
1. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
4. Coenzyme Q10 10 mg Capsule Sig: One (1) Capsule PO tid ().
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
12. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
Primary diagnoses:
Afib w/RVR
hypoxic respiratory failure
pulmonary edema s/p cardioversion
Secondary diagnoses:
Parkinson's disease
CHF
HTN
Discharge Condition:
Stable. In sinus rhythm.
Discharge Instructions:
Please seek medical attention immediately if you experiences
chest pain, shortness of breath, palpitations, nausea, vomiting,
sweating, or any other concerning symptoms.
Please take all medications as prescribed. You have been
started on sotalol.
Followup Instructions:
You have the following appointments scheduled:
Provider: [**Name10 (NameIs) 19245**] [**Last Name (NamePattern4) 19246**], MD Date/Time:[**2192-5-22**] 10:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2192-6-13**] 11:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2192-6-20**] 1:40
[**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic appointment [**2192-6-7**] at 2:30pm ([**Telephone/Fax (1) 19088**]
ICD9 Codes: 4280, 4240, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8192
} | Medical Text: Admission Date: [**2128-1-11**] Discharge Date: [**2128-1-21**]
Date of Birth: [**2057-1-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2128-1-11**] - Cardiac Catheterization
[**2128-1-15**] CABGx4 (LIMA->LAD, SVG->OM, DIAG, PDA)
History of Present Illness:
70 year old gentleman with history of HTN, hyperlipidemia and
chronic hepatitis C who was woke from sleep with severe chest
pain. He presented to the emergency department at [**Hospital 882**]
Hospital where an EKG revealed ST changes. He was treated with
aspirin, lopressor and heparin. He was subsequently transferred
to the [**Hospital1 18**] for further care.
Past Medical History:
HTN
Dyslipidemia
Hepatitis C
H/O TB
Diabetes mellitus type II
Atrial Fibrillation
STEMI
Social History:
Former Korean war vet. Used to smoke 2 ppd for 20 years, quit 30
years ago. Drank 6 beers per day for 20 years quitting in [**2119**].
No drug use. Lives with wife in [**Name (NI) 1268**].
Family History:
Father died of MI in his 60's. Two brothers died in 60's of CAD.
Sister with lung cancer.
Physical Exam:
GEN: WDWN in NAD
NECK: No JVD
CHEST: Clear
HEART: RRR, nl s1-s2, no murmur
ABD: Soft, NT, ND, NABS
EXT: No edema, warm, pulses intact
Pertinent Results:
[**2128-1-11**] 07:00AM PT-16.0* PTT-112.4* INR(PT)-1.8
[**2128-1-11**] 07:00AM PLT SMR-NORMAL PLT COUNT-267
[**2128-1-11**] 07:00AM WBC-16.7*# RBC-4.69 HGB-15.0 HCT-41.9 MCV-89
MCH-32.0 MCHC-35.8* RDW-13.1
[**2128-1-11**] 07:00AM ALT(SGPT)-19 AST(SGOT)-29 CK(CPK)-180* ALK
PHOS-76 TOT BILI-0.5
[**2128-1-11**] 07:00AM GLUCOSE-146* UREA N-19 CREAT-1.0 SODIUM-138
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-22 ANION GAP-23*
[**2128-1-11**] 12:25PM WBC-10.9 RBC-4.21* HGB-13.7* HCT-36.6* MCV-87
MCH-32.6* MCHC-37.4* RDW-13.0
[**2128-1-11**] 08:40PM PT-13.8* PTT-36.3* INR(PT)-1.3
[**2128-1-18**] 09:00AM BLOOD WBC-11.7* RBC-2.91* Hgb-9.2* Hct-25.9*
MCV-89 MCH-31.6 MCHC-35.4* RDW-14.4 Plt Ct-165
[**2128-1-18**] 09:00AM BLOOD Plt Ct-165
[**2128-1-18**] 09:00AM BLOOD Glucose-137* UreaN-28* Creat-0.9 Na-133
K-4.8 Cl-99 HCO3-24 AnGap-15
[**2128-1-20**] CXR
Continued cardiomegaly and small bilateral pleural effusion and
bibasilar patchy atelectasis.
[**2128-1-11**] Cardiac Catheterization
1. Coronary angiography revealed a right dominant system. The
LMCA
showed a 40% tapering distal stenosis, which did not
angiographically
appear to be flow-limiting. The LAD showed a 60% proximal and
90%
midsegment stenosis. The LCX showed a 90% proximal stenosis
followed by
a 100% distal segment stenosis. The RCA showed mild diffuse
calcified
disease in the proximal and mid segments with a 100% stenosis in
the
posterolateral branch just distal to the right posterior
descending
artery, with left to right collaterals filling the distal right
posterolateral branch artery. The right acute marginal artery
showed a
100% stenosis.
2. Left ventriculography did not adequately visualize the
ventricular
lumen due to insufficient contrast volume. The LVEF was
approximately
50% with posterobasal akinesis and [**2-9**]+ mitral regurgitation.
3. Limited left-sided hemodynamics demonstrated severely
elevated left
ventricular end-diastolic pressures of 25 mmHg, suggestive of
severe
diastolic dysfunction.
[**2128-1-15**] EKG
Sinus rhythm. Left axis deviation. There are Q waves in the
inferior leads
consistent with prior infarction. Low voltage. Compared to the
previous tracing voltage has decreased.
[**2128-1-12**] ECHO
1.The left atrium is mildly dilated.
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed. Resting regional wall
motion abnormalities include inferolateral and basal lateral
with apical hypokinesis.
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are structurally normal. No mitral
regurgitation present.
6.There is an anterior space which most likely represents a fat
pad, though a loculated anterior pericardial effusion cannot be
excluded.
Brief Hospital Course:
Mr. [**Known lastname **] [**Known lastname 1269**] was admitted to the [**Hospital1 18**] on [**2128-1-11**] for further
management of his chest pain and EKG changes. Heparin and
aspirin were continued without chest pain. A cardiac
catheterization was performed which revealed severe three vessel
disease, [**2-9**]+ mitral regurgitation and an ejection fraction of
50%. Integrilin was started. Given the severity of his disease,
the cardiac surgery service was consulted for surgical
revascularization. Mr. [**Known lastname **] [**Known lastname 1269**] was worked-up in the usual
preoperative manner. As he elevated blood sugars, the [**Last Name (un) 387**]
diabetes service was consulted for assistance with his
management. An echocardiogram was performed which revealed an
ejection fraction of 40%, no mitral regurgitation, normal aortic
valve and diffuse left ventricular hypokinesis. Integrilin was
discontinued in preparation for cardiac surgery. On [**2128-1-15**], Mr.
[**Known lastname **] [**Known lastname 1269**] was taken to the operating room where he underwent
coronary artery bypass grafting to four vessels. Postoperatively
he was taken to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Mr. [**Known lastname **] [**Known lastname 1269**] awoke
neurologically intact and was extubated. Aspirin and beta
blockade were resumed. He developed atrial fibrillation which
converted to normal sinus rhythm with beta blockade and
amiodarone. Later on postoperative day two, he was transferred
to the cardiac surgical 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. His drains and pacing wires
were removed without issue. Mr. [**Known lastname **] [**Known lastname 1269**] continued to make
steady progress and was discharged home on postoperative six. He
will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary
care physician as an outpatient.
Medications on Admission:
Zestril 5 mg once daily
HCTZ 25 mg once daily
Lipitor 10mg once daily
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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. 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. 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
9. 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*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
HTN
hyperlipidemia
Hepatitis C
TB s/p RUL resection
Discharge Condition:
Good.
Discharge Instructions:
Shower, wash incision with soap and water and pat dry. No
lotions, creams or powders to incisions.
Call with fever, redness or drainage from incision, or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds or driving.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 1270**] in 2 weeks
return to [**Hospital Ward Name 121**] 2 in [**3-13**] weeks for staple removal and wound check
Completed by:[**2128-1-21**]
ICD9 Codes: 4240, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8193
} | Medical Text: Admission Date: [**2139-8-5**] Discharge Date: [**2139-8-11**]
Date of Birth: [**2062-9-30**] Sex: M
Service: [**Location (un) **] SERVICE.
ANTICIPATED DISCHARGE: [**2139-8-12**].
HISTORY OF THE PRESENT ILLNESS: This is a 76-year-old male
nursing home resident with a history of cerebrovascular
accident, which resulted in dementia and aphasia, history of
aspiration pneumonia plus dysphagia, status post G-tube
placement and history of hypernatremia. The patient
presented with fevers. The patient had a cyst on his back
for over one week and had been treated with Duricef for one
week and started on Levofloxacin the day prior to admission
for failure to respond to Duricef. On the morning of
admission, he developed a fever to 104.2. Vital signs at the
nursing home were significant for an oxygen saturation of 88%
on room air, which increased to 93% on two liters nasal
cannula. The patient is demented and aphasic at baseline and
he is unable to communicate.
PAST MEDICAL HISTORY:
1. History of cerebrovascular accident leading to dementia,
plus aphasia.
2. History of dysphasia plus aspiration pneumonia status
post G-tube placement.
3. Hypernatremia.
4. Depression.
5. Hypertension.
6. Atypical psychosis.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is a resident at [**Hospital3 2558**].
PHYSICAL EXAMINATION: Examination on admission revealed the
following: Vital signs: Temperature 103, heart rate 96,
blood pressure 123/66, respiratory rate 20, saturating 92% on
two liters. GENERAL: The patient was aphasic in no acute
distress. HEENT: Pupils equal, round, and reactive to
light. Mucous membranes were dry. LUNGS: Lungs were clear
to auscultation, but limited examination secondary to patient
unable to comply. CARDIOVASCULAR: Regular rate and rhythm,
no murmurs, rubs, or gallops. NECK: Abdomen was soft,
nontender, mildly distended. G tube in place. LOWER
EXTREMITIES: No clubbing, cyanosis or edema. Back revealed
a 10-cm raised, erythematous, warm, fluctuant area on the
upper mid back.
LABORATORY DATA: Pertinent labs on admission: White count
22.7, hematocrit 44.7, platelet count 293,000, differential
and the white count were 79 neutrophils, 2 bands, 13 lymphs,
5 monos. Chem 7: Sodium 157, potassium 3.5, chloride 118,
bicarbonate 27, BUN 37, creatinine 1.3, glucose 119. Serum
osmolality 334, urine osmolality 429. Chest x-ray: Showed
an infiltrate involving the entire left lower lobe.
HOSPITAL COURSE: (by systems)
#1. INFECTIOUS DISEASE: The patient was taken to the
operating room on the day of admission for incision and
drainage of his back abscess. Cultures subsequently grew out
proteus and two out two blood cultures in the emergency
department grew out proteus. The chest x-ray on admission
also showed a left lower lobe pneumonia, possibly an
aspiration pneumonia given the patient's history. He was
started on Unasyn, but changed to Vancomycin, Levofloxacin,
and Flagyl. Sensitivities from the Proteus came back as
intermediate to Levofloxacin and he was changed to
Ceftriaxone. The Vancomycin was also discontinued, but the
Flagyl was continued for empiric anaerobic coverage. The
patient defervesced and the white count came down.
On hospital day #7, he was switched to PO cefpodoxime and PO
Flagyl. He will be continued for a total antibiotic course
of 14 days.
#2. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
hypernatremic on admission with a sodium of 157. He was
initially felt to be volume depleted, as well as having a
free-water deficit. He was initially repleted with normal
saline and then ?????? normal saline as well as free-water boluses
via the G tube feeds. He remained hyponatremic and the IV
fluids were switched to D5 water and the sodium subsequently
corrected to 143. He is being discharged on free-water
boluses via the G-tube at 250 cc q.6.
#3. PULMONARY: The patient had a left lower lobe pneumonia
on admission. They had difficulty extubating him after going
to the operating room for incision and drainage and he
remained in the SICU for two days. He was extubated late
postoperative day #1 and subsequently maintained his
saturations in the 90s on minimal oxygen. He received chest
PT and nasopharyngeal suctioning.
#4. GASTROINTESTINAL: Abdomen was distended on admission,
but he tolerated G tube feeds that were titrated up to 75 cc
an hour with no residuals. He subsequently had bowel
movements and his abdomen became less distended. He is being
discharged on a bowel regimen.
#5. CARDIOVASCULAR: The patient's blood pressure remained
well controlled on his outpatient Norvasc.
#5. SKIN: The patient had an incision and drainage of his
back abscess on the day of admission. The Department of
General Surgery followed him throughout the stay. He
required no further debridement, but careful wound care with
wet-to-dry dressing changes twice a day and turning of the
patient every two hours to prevent pressure on his back.
#6. PSYCHIATRIC: The patient was continued on his
outpatient medications.
#7. CODE STATUS: The patient is full code.
CONDITION ON DISCHARGE: Stable at the time of this discharge
summary.
MEDICATIONS ON DISCHARGE:
1. Cefpodoxime 200 mg per G-tube q.12h. through [**2139-8-20**].
2. Flagyl per G tube q.8h. through [**2139-8-18**].
3. Lactulose 30 cc per G tube q.d.
4. Colace 100 mg PO G tube b.i.d.
5. Multivitamin liquid 5 cc per G tube q.d.
6. Hyoscyamine 0.125 mg PO G tube t.i.d.
7. Trazodone 25 mg per G tube q.d.
8. Sertraline 100 mg per G tube q.d.
9. Norvasc 10 mg per G tube q.d.
10. Seroquel 25 mg per G tube q.a.m.
11. Heparin 5000 units subcutaneously b.i.d.
12. Pantoprazole 40 mg per G tube q.d.
DIAGNOSIS ON DISCHARGE:
1. Status post incision and drainage of back abscess,
cultures positive for Proteus.
2. Proteus bacteremia.
3. Left lower lobe pneumonia.
4. Hypernatremia.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-924
Dictated By:[**Name8 (MD) 27241**]
MEDQUIST36
D: [**2139-8-11**] 14:50
T: [**2139-8-11**] 15:02
JOB#: [**Job Number 27242**]
ICD9 Codes: 7907, 2760, 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8194
} | Medical Text: Admission Date: [**2157-9-26**] Discharge Date: [**2157-10-2**]
Date of Birth: [**2079-12-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
Mitral valve repair (28mm CG Future Annuloplasty Ring),
Tricuspid valve repair (28mm Contour 3D) [**9-27**]
History of Present Illness:
Ms. [**Known lastname 18329**] is a 77 year old female with history of valvular
disease, now admitted for atrial fibrillation and heart failure.
She has been having increasing dyspnea with activity and has
been followed with serial echocardiograms. The most recent study
showed moderate to severe mitral regurgitation, moderate aortic
regurgitation and tricuspid regurgitation. A cardiac
catheterization on [**7-20**] revealed no significant coronary artery
disease but aortic and mitral regurgitation. She now presents
for a heparin bridge from coumadin for surgery.
Past Medical History:
Mitral regurgitation
Tricuspid regurgitation
Aortic regurgitation
Hypertension
heart failure d/t valvular disease
Atrial fibrillation
Chronic constipation
IBS
GERD
Polyuria
Osteopenia
Arthritis
Vertigo
Allergic rhinitis
Heriditary homocystemia
Pericarditis [**2132**]
Palendromic rheumatism
Renal infarction
Shingles Rt eye affecting 5th cranial nerve - lost sensation in
cornea and underwent corneal transplant x2
Glaucoma right eye
s/p Hernia repair
s/p Total Hysterectomy [**2136**]
s/p Tonsillectomy
s/p Corneal transplant [**2148**] and [**2150**]
s/p arthoscopy right knee [**2148**]
s/p right total knee replacement [**2149**]
s/p gall bladder removal [**2149**]
s/p cataract removal [**2149**]
Social History:
Family History: mother deceased 73 heart disease and TB, sibling
deceased 78 heart disease
Race:Caucasian
Last Dental Exam: ~ 4 months
Lives with: Husband
Contact: [**Name (NI) 18330**] [**Known lastname 18329**] (spouse) Phone # [**Telephone/Fax (1) 18331**]
Occupation: Retired used to work in insurance company
Cigarettes: Smoked no [] yes [X] quit 42 years ago
~ 54 pack year history
Other Tobacco use:
ETOH: 1 glass a month
Family History:
Ms. [**Known lastname 18332**] mother died at age 73 of heart disease and
tuberculosis. A sibling was noted to have died at age 78 of
heart disease.
Physical Exam:
Admission Physical Exam
Pulse: 87 Resp: 16 Sat 100% RA
B/P 126/70
General: Pleasant, interactive no acute distress
Skin: Dry [x] intact [x] old healed ulcer right ankle, right
knee
surgical scar
HEENT: PERRLA [x] EOMI [x] right eye sclera reddened no drainage
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [**1-30**] holosystolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] trace
bilateral lower extremities mid calf down
Varicosities: multiple bilateral lower extremities
Neuro: Alert and oriented x3 nonfocal
Pulses:
Femoral Right: +1 Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit no bruit
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 539**] [**Hospital1 18**] [**Numeric Identifier 18333**]
(Complete) Done [**2157-9-27**] at 9:41:08 AM PRELIMINARY
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: [**2079-12-15**]
Age (years): 77 F Hgt (in): 64
BP (mm Hg): 123/60 Wgt (lb): 119
HR (bpm): 96 BSA (m2): 1.57 m2
Indication: Aortic valve disease. Atrial fibrillation.
Hypertension. Left ventricular function. Mitral valve disease.
Shortness of breath. Valvular heart disease.
ICD-9 Codes: 428.0, 427.31, 786.05, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2157-9-27**] at 09:41 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 #: 2011AW-:1 Machine: us3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *6.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: 2.4 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - LVOT diam: 1.8 cm
Findings
LEFT ATRIUM: Mild spontaneous echo contrast in the body of the
LA. Mild spontaneous echo contrast in the LAA. Depressed LAA
emptying velocity (<0.2m/s) No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D
or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Complex
(>4mm) atheroma in the aortic arch. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Moderate (2+) MR.
TRICUSPID VALVE: Mild to moderate [[**12-26**]+] 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 rhythm appears
to be atrial fibrillation. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS: Mild spontaneous echo contrast is seen in the body
of the left atrium. Mild spontaneous echo contrast is present in
the left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). No thrombus is seen in the left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. 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. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. Moderate
(2+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. A central jet of moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion.
POST-BYPASS: The patient is AV paced, on no inotropes.
Biventricular function is unchanged. There is a mitral
annuloplasty ring in good position. No mitral regurgitation is
seen. No paravalvular leak is seen. There is no mitral stenosis
with a mean gradient of 2mmHg at a cardiac output of 3.7 L/min.
There is a tricuspid annuloplasty ring in good position. There
is no tricuspid regurgitation. No paravalvular leak is seen.
There is a mean gradient of 1 mmHg across the tricuspid valve
with cardiac output at 3.7 L/min.. Aortic regurgitation is mild
to moderate ([**12-26**]+). The aorta is intact post-decannulation.
Final Report
PA AND LATERAL CHEST
HISTORY: 77-year-old woman following mitral valve and tricuspid
valve repair.
Assess right pleural effusion.
IMPRESSION: PA and lateral chest compared to [**9-26**] through
6.
Small bilateral pleural effusions, right greater than left have
both decreased
since [**9-29**] and pulmonary vascular engorgement in the upper lobes
and previous
mild pulmonary edema in the lower has decreased as well. Severe
cardiomegaly
is stable. No pneumothorax.
CT CHEST W/CONTRAST Clip # [**Clip Number (Radiology) 18334**]
Reason: eval for right effusion/ apical thickening/ neoplasm
Contrast: VISAPAQUE Amt: 75CC
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman s/p mv repair/ tv repair with preoperative
apical thickening on the right, chronicity undetermined
REASON FOR THIS EXAMINATION:
eval for right effusion/ apical thickening/ neoplasm
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: Status post mitral valve repair and tricuspid repair
with
preoperative thickening on the right.
CT CHEST: MDCT imaging was performed from the thoracic inlet to
the upper
abdomen after the uneventful intravenous administration of
Visipaque. Axial 5 and 1.25-mm images were displayed. Sagittal
and coronal reformats were performed.
COMPARISON: CTA chest [**2152-10-17**], chest radiograph [**9-30**], [**2156**].
FINDINGS: The right apical thickening is present. Nodular
opacities in the
lingula (2:31) measuring 8 mm and in the right middle lobe
(2:35) are likely secondary to infectious or inflammatory foci.
Atelectasis is present. Small pleural effusions are present
without evidence for nodularity or loculation.
The patient is recently status post cardiac surgery with a small
amount of air in the anterior mediastinum. A minimal left
anterior pneumothorax is present (3:36). A small amount of air
is located subdiaphragmatically (2:56) which is likely due to
the presence of a small posterior diaphragmatic defect better
evaluated on the CT abdomen examination from [**2152-10-17**].
A region of thrombus at inferior wall of the the aortic arch
measuring 11 x 3 mm is only slightly increased in size since the
prior examination. Prosthetic mitral, and tricuspid valves are
present. The heart is top normal in size.
Pleural plaques are present along the diaphragm and along the
right pleura.
Sternal wires are intact. The lobes of the thyroid appear
normal. The main
pulmonary artery is enlarged up to 4 cm. No pathologically
enlarged lymph
nodes are present in the axilla, hilum, or mediastinum.
Although not tailored for subdiaphragmatic evaluation, limited
views of the upper abdomen demonstrate a small fat-containing
defect in the right posterior diaphragm. Again minimal air is
located along the left anterior
subdiaphragmatic contour.
BONE WINDOWS: No suspicious bone lesions are present.
IMPRESSION:
1. Apical thickening, but without discrete mass identified.
Nodularity in
the lingula, and right middle lobe which is likely infectious in
etiology, but a 3-month followup chest CT should be performed to
assess for resolution.
2. Extensive subcutaneous and mediastinal air related to recent
surgery.
Trace amount of left anterior subdiaphragmatic air may relate to
prior chest tube or air tracking through a previously noted
small diaphragmatic defect.
3. Small trace basilar left pneumothorax.
4. Minimal increased size of thrombus at the aortic arch.
5. Enlarged pulmonary artery suggestive of pulmonary
hypertension, which is little changed since [**2151**].
[**2157-9-26**] 12:40PM BLOOD WBC-4.7 RBC-3.33* Hgb-11.3* Hct-33.4*
MCV-100* MCH-33.9* MCHC-33.7 RDW-14.5 Plt Ct-167
[**2157-9-27**] 11:09AM BLOOD WBC-4.0 RBC-2.37*# Hgb-7.8*# Hct-24.5*#
MCV-103* MCH-33.0* MCHC-31.9 RDW-14.7 Plt Ct-105*
[**2157-9-27**] 12:29PM BLOOD WBC-4.7 RBC-3.06*# Hgb-10.2*# Hct-31.3*#
MCV-102* MCH-33.3* MCHC-32.6 RDW-14.6 Plt Ct-123*
[**2157-9-27**] 05:30PM BLOOD Hct-29.0*
[**2157-9-27**] 10:08PM BLOOD Hgb-9.5* Hct-26.6*
[**2157-9-28**] 03:05AM BLOOD WBC-7.5# RBC-3.02* Hgb-10.3* Hct-28.3*
MCV-94# MCH-34.2* MCHC-36.5*# RDW-16.5* Plt Ct-79*
[**2157-9-29**] 05:30AM BLOOD WBC-8.8 RBC-3.35* Hgb-11.0* Hct-32.6*
MCV-97 MCH-32.9* MCHC-33.8 RDW-16.0* Plt Ct-83*
[**2157-9-30**] 05:45AM BLOOD WBC-7.6 RBC-3.14* Hgb-10.3* Hct-31.4*
MCV-100* MCH-32.8* MCHC-32.8 RDW-15.6* Plt Ct-87*
[**2157-10-1**] 06:20AM BLOOD WBC-5.9 RBC-3.27* Hgb-10.4* Hct-32.1*
MCV-98 MCH-31.8 MCHC-32.4 RDW-15.1 Plt Ct-102*
[**2157-9-26**] 12:40PM BLOOD PT-15.6* PTT-28.3 INR(PT)-1.4*
[**2157-9-26**] 12:40PM BLOOD Plt Ct-167
[**2157-9-27**] 11:09AM BLOOD PT-20.0* PTT-46.9* INR(PT)-1.8*
[**2157-9-27**] 11:09AM BLOOD Plt Ct-105*
[**2157-9-27**] 12:29PM BLOOD PT-16.9* PTT-46.0* INR(PT)-1.5*
[**2157-9-27**] 12:29PM BLOOD Plt Ct-123*
[**2157-9-28**] 03:05AM BLOOD PT-16.2* PTT-33.5 INR(PT)-1.4*
[**2157-9-28**] 03:05AM BLOOD Plt Smr-VERY LOW Plt Ct-79*
[**2157-9-29**] 05:30AM BLOOD Plt Ct-83*
[**2157-9-29**] 08:45AM BLOOD PT-17.6* INR(PT)-1.6*
[**2157-9-30**] 05:45AM BLOOD PT-19.1* INR(PT)-1.7*
[**2157-9-30**] 05:45AM BLOOD Plt Ct-87*
[**2157-10-1**] 06:20AM BLOOD PT-20.0* PTT-34.0 INR(PT)-1.8*
[**2157-10-1**] 06:20AM BLOOD Plt Ct-102*
[**2157-10-2**] 06:40AM BLOOD PT-21.8* INR(PT)-2.0*
[**2157-9-26**] 12:40PM BLOOD Glucose-88 UreaN-22* Creat-1.1 Na-143
K-3.7 Cl-102 HCO3-30 AnGap-15
[**2157-9-27**] 12:29PM BLOOD UreaN-15 Creat-0.8 Na-142 K-3.9 Cl-109*
HCO3-23 AnGap-14
[**2157-9-28**] 03:05AM BLOOD Glucose-117* UreaN-17 Creat-1.0 Na-141
K-4.1 Cl-107 HCO3-23 AnGap-15
[**2157-9-29**] 05:30AM BLOOD Glucose-80 UreaN-24* Creat-1.1 Na-140
K-4.3 Cl-104 HCO3-26 AnGap-14
[**2157-9-30**] 05:45AM BLOOD Glucose-106* UreaN-30* Creat-1.1 Na-142
K-3.4 Cl-103 HCO3-31 AnGap-11
[**2157-10-1**] 06:20AM BLOOD Glucose-103* UreaN-32* Creat-1.1 Na-145
K-3.8 Cl-104 HCO3-34* AnGap-11
[**2157-10-2**] 06:40AM BLOOD UreaN-28* Creat-1.1 Na-144 K-3.8 Cl-101
[**2157-9-26**] 12:40PM BLOOD ALT-20 AST-36 LD(LDH)-198 AlkPhos-68
Amylase-105* TotBili-0.6
[**2157-10-2**] 06:40AM BLOOD Mg-2.1
Brief Hospital Course:
On [**9-26**] Ms. [**Known lastname 18329**] was admitted for a heparin bridge from
coumadin before undergoing surgery. On [**9-27**] she underwent a
mitral valve repair (28mm CG Future Annuloplasty Ring),
tricuspid valve repair (28mm Contour 3D) performed by Dr.
[**Last Name (STitle) **]. Please see the operative note for details. She
tolerated the procedure well and was transferred in critical but
stable condition to the surgical intensive care unit for
recovery and invasive monitoring. She extubated later that same
day. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. By the following day
her chest tubes were removed and she was ready for transfer to
the step down floor. On POD2, pacing wires were removed and
coumadin was resumed for chronic atrial fibrillation. Narcotics
were held due to lethargy. Physical therapy was consulted for
strength and mobility and cleared her for home with PT when
medically ready. Chest CT was performed to evaluate right
pleural thickening found on preop chest xray. By the time of
discharge on POD 5 the patient was ambulating freely, the wound
was healing and pain was controlled with acetaminophen. The
patient was discharged to home with VNA and PT services in good
condition with appropriate follow up instructions.
Medications on Admission:
Prednisolone AC 1% 1 gtt daily - right eye
Travatan 0.04% 1 drop daily - right eye
Combigan 0.2/5% twice a day - right eye
Fluticasone 50 mcg nares daily
Coumadin 2.5 mg daily - last dose ? [**9-20**]
Torsemide 20 mg daily
Dicyclomine 10 mg twice a day
Omeprazole 20 mg daily
Norvasc 5 mg daily
Diovan 320 mg daily
Atenolol 50 mg daily
Clonazepam 0.125 mg twice a day
Plaquenil 200 mg daily
Folic Acid 3 mg at 8am then 2 mg at 6pm
Vitamin B 6 100mg daily
Vitamin B 12 500 mg daily
Aspirin 81 mg daily
Centrum daily
Vitamin D 1000 mg daily
Vitamin C 1000 mg daily
Tums 1500 mg daily
Discharge Medications:
1. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily): Right eye.
2. travoprost 0.004 % Drops Sig: 1 Drop Ophthalmic Daily ():
Right eye.
3. Combigan 0.2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): Right eye.
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools. Continue while on narcotic
pain medication.
Disp:*30 Capsule(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*3*
9. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
10. folic acid 1 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
11. folic acid 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
12. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a
day.
16. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Three (3) Tablet, Chewable PO DAILY (Daily).
17. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please have PT/INR checked Tues [**10-4**].
18. Outpatient Lab Work
Please have PT/INR checked Tues [**10-4**] and results to Dr.
[**First Name4 (NamePattern1) 2174**] [**Last Name (NamePattern1) 2912**] Phone: [**Telephone/Fax (1) 8543**] Fax: [**Telephone/Fax (1) 13359**]
19. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
20. pyridoxine 100 mg Tablet Sig: One (1) Tablet PO once a day.
21. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
22. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 10 days.
Disp:*10 Tablet, ER Particles/Crystals(s)* Refills:*0*
23. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
Please start after finishing course of furosemide for 10 days.
24. clonazepam 0.125 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO twice a day: per home regimen.
25. Do not restart atenolol. You may resume dicyclomine after
completing potassium course
26. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
mitral regurgitation, aortic regurgitation, tricuspid
regurgitation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
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**
Recommended Follow-up:
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**11-2**] at 1:15pm in the [**Hospital **]
medical office building [**Hospital Unit Name **]
Cardiologist: [**First Name4 (NamePattern1) 2174**] [**Last Name (NamePattern1) 2912**] [**11-8**] at 2:30pm
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 13358**],[**First Name3 (LF) 2747**] A. [**Telephone/Fax (2) 8543**]in 4-5 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 ?????? atrial fibrillation
Goal INR:[**1-27**]
First draw:Tues [**2157-10-4**]
Results to:Dr. [**First Name4 (NamePattern1) 2174**] [**Last Name (NamePattern1) 2912**] Phone: [**Telephone/Fax (1) 8543**]
Fax: [**Telephone/Fax (1) 13359**]
Completed by:[**2157-10-2**]
ICD9 Codes: 4168, 2875, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8195
} | Medical Text: Admission Date: [**2157-2-15**] Discharge Date: [**2157-2-17**]
Date of Birth: [**2083-8-18**] Sex: F
Service: MEDICINE
Allergies:
Allopurinol / Ethambutol / Colchicine / Efavirenz
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
HPI: 73-yo-woman w/ CAD, CHF, ESRD presents w/ dyspnea x 12
hours. She was feeling well until 1 day prior to admission
during dinner, when she developed acute onset dyspnea assoc w/
substernal chest pain. The pain was "achy," moderate severity,
non-radiating. There were no assoc palpitations, cough, nausea,
vomiting, or diaphoresis. ROS reveals no fever, weight loss,
increasing edema, orthopnea, PND, or dietary indiscretion. She
has been taking all her meds as prescribed. Her last HD session
was the day prior to presentation to the ED.
.
In the [**Hospital1 18**] ED, she was initially hypertensive w/ BP 210/110,
HR 80, O2 sat 100% on BiPAP. She was treated w/ nitro gtt,
hydralazine 5mg IV, and enalapril 1.25mg IV x 1, and BP improved
to 190/82. Chest pain resolved early during her ED stay. She
was dialyzed urgently and admitted to the MICU where she had no
further CP or SOB. She was called out to the floor after 1 day.
Past Medical History:
1. 3-V CAD; s/p NSTEMI [**6-/2154**], Had Taxus stent placed [**2154-6-7**] in
mid-LCx.
2. CHF: Echo [**12-6**] with EF=20%, 1+ AR, [**1-4**]+MR
3. H/o malignant hypertension.
4. Status post intubation for flash pulmonary edema on [**2154-6-3**], complicated by laryngeal edema.
5. History of human immunodeficiency virus, CD4 count 302 on
[**2156-12-8**]; viral load less than <50 on [**12-8**], on [**Month/Year (2) 2775**] therapy.
6. End-stage renal disease on hemodialysis secondary to HIV
nephropathy.
7. DM II, diet controlled
8. Spinal tuberculosis.
9. Hypercholesterolemia.
10. Hepatitis C viral infection.
11. Gout - has been on prednisone tapers in the past for flares.
12. H/o anemia
13.s/p unknown back surgery, possibly for spinal TB
Social History:
Pt lives alone and gets around with a walker. She cooks for
herself. Her daughter comes over daily to help her take her
meds. She denies tobacco, EtOH, IVDA, herbals/vitamins. She
has 6 kids.
Family History:
She has a son with DM and CAD
Physical Exam:
PE: T 98.8 rectal, BP 143/67, HR 77, RR 14, O2 sat 100% RA
Gen: chronically ill appearing elderly woman, lying at 45
degrees in bed, pleasant and conversational, breathing
comfortably.
[**Month/Year (2) 4459**]: anicteric, EOMI, PERRL, OP clear w/ [**Month/Year (2) 5674**], EJ fills to
the mandible at 45 degrees.
CV: reg s1/s2, + 2/6 systolic murmur at apex, no s3/s4/r
Pulm: CTA anteriorly, no crackles or wheezes.
Abd: obese, +BS, soft, NT, ND
Ext: warm, 2+ DP b/l, no edema
Neuro: a/o x 3, CN 2-12 intact (vision impaired), strength 4/5
throughout, sensation to fine touch intact throughout.
Pertinent Results:
[**2157-2-15**] 11:08PM CK(CPK)-80
[**2157-2-15**] 11:08PM CK-MB-NotDone cTropnT-0.43*
[**2157-2-15**] 04:17PM K+-5.5*
[**2157-2-15**] 04:00PM GLUCOSE-235* UREA N-53* CREAT-6.3*#
SODIUM-139 POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-30 ANION GAP-18
[**2157-2-15**] 04:00PM ALT(SGPT)-29 AST(SGOT)-39 LD(LDH)-259*
CK(CPK)-75 ALK PHOS-159* AMYLASE-272* TOT BILI-0.3
[**2157-2-15**] 04:00PM LIPASE-129*
[**2157-2-15**] 04:00PM CK-MB-NotDone proBNP-9881*
[**2157-2-15**] 04:00PM CALCIUM-10.5* PHOSPHATE-6.7*# MAGNESIUM-2.5
[**2157-2-15**] 04:00PM WBC-6.6 RBC-3.52*# HGB-13.9# HCT-43.4#
MCV-123* MCH-39.6* MCHC-32.1 RDW-17.6*
[**2157-2-15**] 04:00PM NEUTS-70.2* LYMPHS-23.9 MONOS-3.5 EOS-1.8
BASOS-0.6
[**2157-2-15**] 04:00PM PT-11.8 PTT-27.2 INR(PT)-1.0
[**2157-2-15**] 04:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
.
EKG: NSR @ 93 bpm, LAD, LVH, pseudonormalization of T waves in
V1-V6 since prior tracing [**5-7**].
.
pCXR [**2157-2-15**]:
Since most recent comparison film, there appears to be increased
interstitial alveolar opacities likely representing [**Month/Day/Year 9140**]
pulmonary edema with unchanged appearance to cardiomegaly, and
linear calcifications within the ascending and descending
thoracic aorta. No focal parenchymal consolidation, pleural
effusions, or pneumothorax is identified
.
pCXR [**2157-2-16**]:
A small atelectasis is seen in the left lower lobe retrocardiac
area. There has been almost complete resolution of the
pulmonary edema. There is no pneumothorax or pleural effusion.
Mild cardiomegaly is unchanged. The aorta is unfolded with
extensive atheromatous plaques in the ascending, descending, and
the arch
Brief Hospital Course:
73-yo-woman w/ CAD, CHF, ESRD on HD, HIV, HCV, HTN, and anemia
presents w/ dyspnea, thought [**2-4**] pulmonary edema in setting of
hypertensive emergency.
.
# Dyspnea: The patient's shortness of breath was felt most
likely secondary to pulmonary edema as evidenced by initial exam
and CXR in setting of severe hypertension. Pt with CHF and
renal failure, making her prone to this. There is no evidence
of PNA, PE, or obstructive disease. The precipitant is unknown,
but the patient does have a history of flash pulmonary edema.
She denies medication non-compliance or excessive sodium
consumption. Her shortness of breath resolved after
hemodialysis and better BP control, and she maintained her O2
saturation on room air. Cardiac enzymes revealed flat CKs and
elevated troponins (in setting of ESRD) which did not rise.
She continued hemodialysis and will continue to be followed by
the [**Hospital6 **] in [**Location (un) **].
.
# Chest pain: The patient is known to have 3vd, w/ stent in LCX.
Her pain was in the setting of hypertensive emergency and
resolved with control of her blood pressure, including nitro
drip. There were no specific EKG changes on presentation to
indicate active ischemia. Her cardiac enzymes were notable for
an elevated troponin (in setting of ESRD), with flat CKs. She
was monitored on telemetry withoug event. Her chest pain did
not recur. She was placed back on her home medications: ASA,
metoprolol, ACEI, lipitor, and zetia. She should follow up with
her cardiologist.
.
# ESRD: Her renal failure is secondary to HIV nephropathy. She
was urgently dialyzed on the day of admission and then placed
back on her usual dialysis schedule(M,W,F). She was followed by
the renal service who recommended to switch lisinopril to
captopril [**Hospital1 **] (this was done). She was continued on Renagel and
Sensipar. The patient will continue to be followed by the
[**Hospital6 **] in [**Location (un) **], with dialysis M,W,F.
.
# Hypertensive Emergency: The patient's blood pressure was
initially controlled with volume removal by HD, IV enalapril, IV
hydralazine, and nitroglycerin drip. Her BP normalized and she
was placed back on her home regimen and monitored. Her
pressures remained appropriate. As per renal, her ACEI was
changed to Captopril 50mg [**Hospital1 **]. She will continue on Toprol XL
and Captopril [**Hospital1 **] as an outpatient. Her HD will resume at
[**Hospital6 **] tomorrow.
.
# Elevated amylase/lipase: This is chronic and likely a chemical
pancreatitis from her [**Hospital6 2775**] therapy. There were no signs of
clinical pancreatitis. The patient will follow with her ID
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 724**].
.
# HIV: The patient's viral load is suppressed with [**Last Name (STitle) 2775**]. She
was continued on lamivudine, nevirapine, and zidovudine. She
has follow up scheduled with her Infectious disease specialist
this month.
.
# DM type 2: This is controlled with diet as an outpt. Her
fingerstick blood glucose was check four times daily. She was
covered with an insulin sliding scale. She did not require much
insulin and will resume diet control as an outpatient.
.
# FEN: [**Doctor First Name **], low sodium, cardiac diet. Her electrolytes were
repleted prn.
.
# Proph: She was given heparin SC, but developed a hematoma in
her abdomen from these injections. Therefore her heparin
injections were stopped. She was ambulatory on the floor. She
was given a bowel regimen.
.
* FULL CODE
Medications on Admission:
* ASA 325 mg daily
* plavix 75 mg daily
* lisinopril 20mg daily
* Toprol xl 100 mg daily
* lipitor 80 mg daily
* zetia 10 mg daily
* lamivudine 100 mg daily
* nevirapine 200 mg [**Hospital1 **]
* zidovudine 100 mg tid
* renagel 1600 mg tid
* sensipar 30 mg daily
Discharge Medications:
1. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Captopril 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Zidovudine 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
1. Hypertensive emergency
2. Pulmonary edema
3. Congestive Heart failure
4. End Stage Renal Disease
Discharge Condition:
Stable, symptoms resolved.
Discharge Instructions:
You were admitted with shortness of breath and chest pain,
thought due to severe high blood pressure and fluid building up
in the lungs. You were treated with hemodialysis and blood
pressure medications.
.
You should take all medications as prescribed. Please note that
your lisinopril was changed to captopril, which is to be taken
twice a day. All your other medications are unchanged.
.
Call your doctor or return to the hospital if you have shortness
of breath, chest pain, dizziness, or any other symptom that
concerns you.
Followup Instructions:
* Please follow up with your primary physician [**Last Name (NamePattern4) **] [**1-4**] weeks.
* Please continue Dialysis at [**Hospital6 **] in
[**Location (un) **] on M,W,F as before.
* Please keep your appointments with your infectious disease
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 724**], and your Cardiologist, Dr. [**Last Name (STitle) 8499**], as
below:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2157-2-22**]
1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2157-4-5**] 9:00
Completed by:[**2157-2-18**]
ICD9 Codes: 4280, 5856, 5180, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8196
} | Medical Text: Admission Date: [**2142-7-30**] Discharge Date: [**2142-9-4**]
Service: MED
Allergies:
Penicillins / Sulfa (Sulfonamides) / Aspirin / Heparin Agents
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Transfer from [**Hospital3 628**] for infectious disease and
neurosurgical evaluation of epidural abscess with MRSA
Major Surgical or Invasive Procedure:
Multiple VAC Dressing Changes in the Operating [**Apartment Address(1) 41332**]/204: "Incision and drainage of postoperative
wound which was treated elsewhere."
[**2142-8-16**]:"Incision and drainage of the
osteomyelitis, incision and drainage of the postoperative
wound, and exchange nailing using Synthes, subtrochanteric
nail."
[**2142-8-30**]: Closure of Wound with irrigation and drainage
History of Present Illness:
This is an 87 y.o. female s/p Right Hip ORIF in [**2142-2-4**]
who presented to [**Hospital3 628**] on [**2142-7-11**] after her daughter
tripped on her and she fell, sustaining a Left Hip Fracture.
She underwent a Left Hip ORIF on [**2142-7-13**]. (She was
anticoagulated with coumadin given a heparin allergy). Her
hospital course was complicated by a temp spike to 101 on [**7-14**]
with 2/4 bottles + for MRSA. (per her family she had been
febrile for several weeks prior). A TEE on [**7-17**] was (-) for SBE
and a PICC line was placed for 6 weeks of vancomycin.
Surveillance cx on [**7-18**] grew [**4-8**] MRSA and the PICC line was
d/c'd. On [**7-24**] surveillance cultures were (-) and another PICC
line was placed. On the same day the patient complained of back
pain and a CT T-L Spine demonstrated multiple compression
fractures and an MRI on [**7-27**] demonstrated L2-3 diskitis and a
small epidural abscess (w/o evidence of cord compression). She
was transferred to [**Hospital1 18**] on [**2142-7-30**] for neurosurgical and
infectious disease evaluation.
Past Medical History:
1) Hypertension
2) GERD
3) CVA [**2140**] (residual short-term memory loss and diminished
vision b/l)
4) Right Hip Fracture s/p ORIF by Dr. [**Last Name (STitle) 28272**] in [**2-7**]
5) Hypothyroidism
6) Asthma
Social History:
No Tob/EtOH. Independent prior to 1st hip fracture. Close with
daughters [**Name (NI) **] (Healthcare proxy) and [**Name (NI) **].
Family History:
non-contributory
Physical Exam:
T:99.3, BP:140/70, HR:102, RR:22, O2:99% 2L
Gen: NAD. A/O x 3
HEENT: Small ulcer on hard palate. No LAD, supple neck
CV: II/VI SM at RUSB
Pulm: CTA B/L.
ABD: S/NT/ND
Ext:Swollen left LE with TTP. Trace PT.
Erythematous Papules in diaper area, under breasts, eythema at
Right PICC line site.
Neuro: CN II-XII GI. MAEW. Sensation GI
Pertinent Results:
WBC:12.3
Hct:31.5
Plt:636
Na:132
K:3.4
Cl:91
HCO3:31.6
BUN:9
Cr:0.7
Gluc:91
Ca:8.2
CXR: PICC line well positioned w/o CHF/infiltrates
MRI: L2-3 diskitis, possible small epidural abscess, no cord
compression
Brief Hospital Course:
The patient had a long and complicated hospital course as
follows by issue:
1) ID:(ID Service--[**Doctor First Name **] [**Doctor Last Name **]--following) (also see ortho
below)
She spiked a temp to 101 on [**7-14**] and blood cx drew [**2-7**] MRSA and
vancomycin was started.
[**7-16**] - repeat cx no growth
[**7-17**]- no growth, picc line placed. TTE negative
[**7-18**] spiked temp and cultures at that time grew [**4-8**] mrsa
[**7-19**] continued to be febrile -- picc line d/c'd (picc tip cx
grew staph coag negative NOT MRSA), gent added for synergy
(duration 4 days)
abdominal CT negative for abscess
[**7-20**] TEE negative for evidence of endocarditis
[**Date range (1) 9435**] surveillence cultures negative
[**7-22**] LOST IV ACCESS therefore no IV abx for 2 days
[**2058-7-22**] -- spiked temp, surviellence cx negative
[**7-25**] PICC placed, then cx from [**7-24**] [**1-7**] MRSA
[**7-26**] pt c/o back pain, plain films negative, rifampin added, ESR
66
[**7-27**] underwent MRI L2-L3 diskitis, small epidural abcess, no
cord compression
When initially evaluated by ID the following recommendations
were made:
-Dose of vanco (begun on [**7-14**]) was changed to [**Hospital1 **] with trough
checks q72 hours
-Rifampin (begun on [**7-28**]) was continued with LFT checks qweek.
[**8-1**] and [**8-5**]: left knee was tapped with no growth
[**8-3**]: Repeat MRI with L2-3 epidural abscess without cord
compression
[**2142-8-5**]: Vanco changed to q8 hours
[**2142-8-6**]: Ortho hardware removal with Deep tissue (from hip)
Culture + for Enterobacter resistant to all organisms save
meropenem, bactrim and cefepime. Given possibility of inducible
resistance,
Meropenem begun after desensitization in the MICU (given h/o
cefepime allergy)
[**2142-8-7**]: Spiked to 102.4 on [**8-14**]. CXR with ? LLL infiltrate
[**2142-8-16**]: Left hip hardware exchange performed with I+D.
[**2142-8-20**]: Given persistent low-grade fevers and +yeast in tissue
cx and urine, started Fluconazole on [**8-20**].
D/C Antibiotic Plan as follows:
-Vanco/Rifampin until [**2142-9-17**] for treatment of epidural abscess
and left hip, then po doxycycline 100 po BID indefinitely (given
sensitivity of MRSA and Enterobacter to doxycycline)
-Meropenem for enterobacter soft issue infectionuntil [**2142-9-27**]
-Fluconazole until [**2142-9-2**]
-LFTs, CBC and Chem-7 followed at rehab
-F/U with [**Doctor First Name **] [**Doctor Last Name 9404**] in [**Hospital **] clinic in [**10-8**]
2) EPIDURAL ABCESS
Dr [**Last Name (STitle) 1338**] (neurology) consulted. He advised medical
management, neurologically intact.
[**8-2**]: incontinence of stool, ? decreased rectal tone
therefore repeated MRI ---> stable epidural abcess, no cord
compression
3) ORTHO: Intertrochanteric fx of Left Hip s/p orif
ortho following (Dr. [**First Name (STitle) 1022**].
[**8-1**]: knee tap negative for septic joint
[**8-5**]: Ct guided aspiration of left hip -- cx ngtd
[**8-6**]: ortho took to or and removed hardware, took cx from hip
tissue and placed new hardware as joint unstable
++ Enterobacter
[**8-10**]: increased pain in left knee, lenis negative (except
could not visualize popliteal), ortho retapped knee, cx NTD.
[**8-12**] LENI (repeated given LLE edema) (-).
[**8-16**] to OR to replace hardware. Gross drainage of pus.
***POST-OP with SBP in 80s w/o tachycardia, bolused with
1L NS with normalization of pressure. O2 sat remained>92% on
RA.
Urine output was minimal but slowly picked up (to
~20-25cc/hour) with boluses and lasix (thought to be ATN)
>>to OR [**8-20**] for sterile VAC DSG change
>>to OR [**8-24**] for sterile VAC DSG Change
>>to OR [**8-27**] for sterile VAC DSG Change
>> Wound Closed with 2 JP drains placed on [**8-30**] with plans
for aggressive rehab with PWB on LLE.
>>JP drain #2 pulled after no output x 24 hours.
>>Per ortho recs, the remaining JP drain should be pulled
(one suture in place) after no output for 24 hours. Patient
will follow-up with Dr. [**First Name (STitle) 1022**] in 3 weeks.
4. HEPARIN ALLERGY
-consulted allergy --> NO HEPARIN PRODUCTS.
5. SVT/ A TACH -- occasional burst of SVT in 160s w/o sx,
evaluated by EP on [**8-4**] and recommended metoprolol. underwent
CTA (given not adequately anticoagulated -- use of coumadin and
possible surgery) but NEGATIVE for PE.
6. ATN (by muddy brown cast on [**8-8**]) and oliguria s/p surgeries
on [**8-6**] and [**8-16**] in the setting of transient hypotension.
-- at dischargee resolved with CrCL >80.
7. ?CAD
See SVT above.
EF by ECHO on [**7-8**] was 75%.
8. Anticoag: Given heparin allergy, she was placed on coumadin
with INR goal of 1.5-2.0.
9. Code Status/Goals of Care: Discussed with daughter [**Name (NI) **] (HCP)
on [**8-13**]. [**Telephone/Fax (1) 41333**]. Changed to DNR/DNI status on [**8-19**]. She
would, however, want pressors and all other aggressive measures
short of defibrillation and intubation. She provided us with
the health care proxy form indicating that her daughter [**Name (NI) **] will
make all decisions for her should she not be able to make
decisions for herself. She values her function and would want
all measures that would allow a reasonable chance of retaining
her physical and mental function. She found comfort in prayer.
Medications on Admission:
(Medications on transfer from [**Location (un) 620**] to [**Hospital1 18**])
Vanco 1.5 qd, Rifampin 300 [**Hospital1 **], Lumigan eye gtts, advair,
lexapro, protonix, norvasc 2.5, fosamax qweek, coumadin 3,
tylenol, oxycodone [**5-14**] prn
Discharge Medications:
1. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
twice a day: START on [**2142-9-17**].
2. Outpatient Lab Work
LFTs, CBC, Chem-7 qweek
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Bimatoprost 0.03 % Drops Sig: One (1) drop Ophthalmic qd ().
7. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 2 weeks: LAST DOSE ON [**2142-9-17**]
Please follow LFTs qweek.
8. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QWED
(every Wednesday).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
15. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO
QD (once a day).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
17. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
19. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days: LAST DOSE on [**2142-9-2**].
20. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
21. Multivitamin Capsule Sig: One (1) Cap PO QD (once a
day).
22. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
23. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO BID (2 times a day).
24. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
25. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
26. Warfarin Sodium 2 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime): Titrate to INR 1.5-2.0 for DVT Prophylaxis given
heparin allergy.
27. Morphine Sulfate 1-3 mg IV Q4H:PRN
hold for sedation, or RR <12
28. Meropenem 1 g Recon Soln Sig: One (1) gram Intravenous
three times a day for 2 weeks: Last dose on [**2142-9-17**].
29. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram
Intravenous once a day for 2 weeks: LAST DOSE ON [**2142-9-17**]
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Congestive Heart Failure
Right Hip Fracture s/p ORIF
Left Hip Fracture s/p ORIF and hardware exchanges
Hypertension
Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
Please notify your [**Location (un) 2449**] or doctors of chest [**Name5 (PTitle) **], shortness of
breath, palpitations, swelling, weakness, numbness, fevers,
chills, dysuria, constipation, diarrhea, rashes or any other
symptoms of concern. You will take meropenem until [**2142-9-17**] and
then begin taking doxycycline. Please follow-up (see below)
with Dr. [**First Name (STitle) **] [**Name (STitle) 9404**].
Notify your doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**] of weight gain (>3 pounds). Limit
fluid intake to less than 1.5 L per day and salt intake to less
than 2g/day.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9406**], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2142-10-8**] 11:30
Please call [**First Name8 (NamePattern2) **] [**Name8 (MD) 1022**], MD (orthopedics) to be seen in 2 weeks
Phone: [**Telephone/Fax (1) 5499**]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 7907, 5845, 2851, 2761, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8197
} | Medical Text: Admission Date: [**2188-1-24**] Discharge Date: [**2188-2-12**]
Date of Birth: [**2156-12-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Bactrim
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
malaise, decreased PO intake
Major Surgical or Invasive Procedure:
[**2-6**] MVR ([**First Name8 (NamePattern2) 7163**] [**Male First Name (un) 923**] Tissue), AVR ([**Street Address(2) 11688**]. [**Male First Name (un) 923**] Tissue)
History of Present Illness:
Mr. [**Known lastname **] is a 31yo male with HIV, not on HAART, with last CD4
27, HIV nephropathy on HD, HBV, HCV who presented with several
weeks of malaise and diarrhea, found to have MSSE endocarditis.
He initially presented to the hospital on [**1-24**] with chief
complaints of 3 weeks of GI upset, watery diarrhea [**2-20**]
times/day, nausea, vomiting X1 followed by shaking chills and
mild non-productive cough for several days. Vitals in the ED
were T 95, HR 64, BP 117/55, RR 18, 99%RA. CXR was concerning
for RLL pneumonia and he was started on Vancomycin IV 1gm X1 and
Levaquin 250 PO X1.
Past Medical History:
PAST MEDICAL HISTORY:
- HIV dx [**2172**], reports from sexual contact but hx of IVDU;
[**Year (4 digits) **] HAART [**2186-10-18**] with renally adjusted 3TC and
ZDV, and ritonavir boosted atazanavir; Currently not on HAART
due to intolerance. [**8-/2187**] CD4 34
- HCV+ but has no detectable circulating virus
- HBV+ but HBc equivocal [**10/2186**]
- ESRD [**1-19**] HIV Nephropathy on HD (was on PD until a few weeks
ago)
- Genital and anal wart s/p surgical removal
- History of R thigh abscess
- Chronic LBP; seen in pain clinic;told secondary to
osteoarthritis/
nerve impingement
- Asthma
- Migraine
- s/p L knee arthroscopy for lateral meniscus tear ('[**75**])
- s/p tonsillectomy (as child)
Social History:
- Patient is originally from the Bronx, [**State 531**]. He is single
and
lives with his mother.
- He currently works as an HIV case manager although has been
noted
to have history of poor HAART compliance himself. Currently
not on
HARRT
- Tobacco: 1/2-2/3ppd x 20yrs, denies EtoH; IVDU as teenager,
denies
recent use.
- Not currently sexually active
Family History:
- Father: Hypertension/Diabetes [**State **]
- No family hx of liver problems
Physical Exam:
PE: 95.7 102/50 101 16 100%RA O2 Sats
Gen: thin, emaciated, fatigued
HEENT: Clear OP, MM dry, no thrush, oral lesions
NECK: Supple, No LAD, No JVD
CHEST: RIJ tunneled HD line, site slightly erythematous and
tender with large area of skin discoloration
CV: RR, NL rate. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: end expiratory wheezes heard throughout, no crackles
ABD: Soft, mildly tender to palpation throughout especially at
site of old PD catheter
EXT: No edema. 2+ DP pulses BL, hypersensitive to light tough in
calves Bilterally and over tibial bone
SKIN: No lesions, rashes, sores
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 4+/5 strength throughout. [**12-19**]+ reflexes,
equal BL.
Pertinent Results:
CHEST (PA & LAT) [**2188-2-12**] 10:09 AM
CHEST (PA & LAT)
Reason: f/o pneumomediastinum
[**Hospital 93**] MEDICAL CONDITION:
31 year old man with s/p avr mvr
REASON FOR THIS EXAMINATION:
f/o pneumomediastinum
PROCEDURE: Chest PA and lateral on [**2188-2-12**].
COMPARISON: [**2188-2-10**].
HISTORY: Followup pneumomediastinum.
FINDINGS: The air-fluid level seen in the right upper quadrant
has decreased on today's examination. There is persistent
pneumoperitoneum persistent in both right and left upper
quadrants of the abdomen. Pulmonary and mediastinal vascular
engorgement has improved, although the heart remains enlarged.
There is small bilateral right more than left pleural effusion.
Pneumopericardium and pneumomediastinum are no longer visualized
on today's examination. The moderately severe bibasilar
atelectasis are unchanged. No pneumothorax.
IMPRESSION:
1. Pneumopericardium and pneumomediastinum are no longer
visualized.
2. Persistent pneumoperitoneum with a decrease in the air-fluid
level seen in the right upper quadrant of the abdomen underneath
the right hemidiaphragm.
3. Small bilateral right more than left pleural effusion.
4. Small pulmonary and mediastinal vascular engorgement.
5. Persistent severe bibasilar atelectasis.
Cardiology Report ECG Study Date of [**2188-2-7**] 7:00:04 PM
Sinus rhythm. Borderline left ventricular hypertrophy. Prolonged
Q-T interval. Intraventricular conduction delay. Compared to the
previous
tracing diffuse ST-T wave changes are slightly more prominent.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 154 100 456/485 55 53 15
[**2188-2-12**] 06:55AM BLOOD WBC-8.7 RBC-2.31* Hgb-6.9* Hct-23.2*
MCV-101* MCH-30.0 MCHC-29.8* RDW-24.9* Plt Ct-203
[**2188-1-24**] 12:02AM BLOOD WBC-4.2 RBC-2.68*# Hgb-7.7*# Hct-24.2*#
MCV-91# MCH-28.9 MCHC-31.9 RDW-17.4* Plt Ct-72*
[**2188-2-12**] 06:55AM BLOOD Neuts-80.4* Lymphs-13.5* Monos-4.7
Eos-1.1 Baso-0.3
[**2188-2-12**] 06:55AM BLOOD Plt Ct-203
[**2188-2-11**] 03:15PM BLOOD PT-15.7* PTT-28.8 INR(PT)-1.4*
[**2188-1-24**] 12:02AM BLOOD Plt Ct-72*
[**2188-2-7**] 05:02PM BLOOD Fibrino-208
[**2188-1-26**] 05:45AM BLOOD ESR-68*
[**2188-1-24**] 10:05PM BLOOD WBC-5.3 Lymph-17* Abs [**Last Name (un) **]-901 CD3%-56
Abs CD3-501* CD4%-3 Abs CD4-27* CD8%-47 Abs CD8-427
CD4/CD8-0.06*
[**2188-1-24**] 10:05PM BLOOD Ret Aut-1.6
[**2188-2-12**] 06:55AM BLOOD Glucose-87 UreaN-47* Creat-7.6* Na-133
K-4.6 Cl-96 HCO3-25 AnGap-17
[**2188-2-10**] 10:30AM BLOOD ALT-9 AST-31 LD(LDH)-351* AlkPhos-452*
Amylase-44 TotBili-0.6
[**2188-2-10**] 10:30AM BLOOD Lipase-22
[**2188-1-24**] 01:45AM BLOOD GGT-293*
[**2188-2-11**] 06:20AM BLOOD Calcium-7.9* Phos-5.9*# Mg-2.8*
[**2188-1-24**] 01:45AM BLOOD calTIBC-176 Hapto-351* Ferritn-[**2104**]*
TRF-135*
[**2188-1-24**] 10:05PM BLOOD PTH-168*
[**2188-1-26**] 05:45AM BLOOD CRP-107.0*
[**2188-2-12**] 06:55AM BLOOD Vanco-16.4
Brief Hospital Course:
Once admitted to the medical floor he underwent an
echocardiogram which showed mitral and aortic valve vegetations,
suggestive of endocarditis. He was started Vancomycin with plan
for TEE and cardiac surgery evaluation. found to have MSSE
bacteremia (cxs on [**1-24**]), believed source is HD cath. TEE which
again showed MV involvement w/ severe MR, and AV involvement w/
severe AI. HD line was resited. He also underwent a CT scan of
abdomen, which showed splenic infarction vs. septic emboli, also
pulmonary nodules suggesting possible septic emboli. He became
hypoxic as well as had episode of hemoptysis and tachycardia and
was transferred to the MICU. EKG showed sinus tach with inverted
t waves in lateral leads.
CXR at the time demonstrated primarily R sided consolidation vs
volume overload. Emergent repeat TTE at time of event showed no
change in MR. The likely explanation for the hemmoptysis was
felt to be acute pulmonary HTN combined with pulmonary edema and
bacteremia leading alveolar hemorrhage. Pt was stabilized on NRB
face mask, nitorprusside drip, hydralazine, and metoprolol
following transfer to the MICU. Pt had no subsequent respiratory
distress and was transferred to the medical floor while awaiting
MVR/AVR, hydralazine and metoprolol were continued on the
medical floor. Pt received HD while in-house with continued EPO
as dosed by the HD protocol for chronic anemia in the setting of
ESRD/HIV. Pt's HD frequency was adjusted/increased given acute
volume overload in the setting of valvular insufficiency-related
heart failure. He continued on methadone.
He continued with preoperative workup including dental
clearance, CT head and TEE. He was electively intubated and then
extubated after TEE. His blood cultures remained negative and he
was taken to the operating room on [**2-7**] where he underwent an
AVR/MVR. He was transferred to the ICU in critical but stable
condition. He was extubated the morning of POD #1. He was
transferred to the floor later on POD #1. He did well
postoperatively. His AV fistula failed, and he was taken for a
fistulogram which showed Severe stenosis of the draining vein of
the brachiocephalic AV fistula within 2 cm of the arterial
anastomosis. It was angioplastied and he underwent dialysis on
[**2-12**] with PRBC transfusion. He was ready for discharge to rehab
that same day. He will require 4 total weeks of vanco from the
day of surgery (until [**3-7**]).
Medications on Admission:
MEDs per last d/c summary; however, Pt unable to confirm
.
Methadone 40 mg TID
Lisinopril 40 mg daily
Cinacalcet 60 mg daily
Calcium Acetate 667 mg [**Hospital1 **]
Albuterol
Clonidine 0.1 mg [**Hospital1 **]
Nifedipine 90 mg Tablet Sustained Release daily
Trimethoprim-Sulfamethoxazole 160-800 mg 3X/WEEK (TU,TH,SA)
after HD
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) g
Intravenous HD PROTOCOL (HD Protochol) for 4 weeks: with HD; 4
weeks from surgery ([**3-7**]).
Dose for level < 20.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Methadone 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
11. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Epogen with HD
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
MV and AV endocarditis now s/p AVR/MVR
HIV, HCV+, HBV+, ESRD [**1-19**] HIV Nephropathy on HD, Genital and
anal wart s/p surgical removal, R thigh abscess, Chronic LBP,
Asthma, Migraine
Discharge Condition:
good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week,
Shower, no baths, no lotions,creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 1-2 weeks.
Dr. [**First Name (STitle) **] 4 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2188-2-12**]
ICD9 Codes: 5856, 486, 4240, 4241, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8198
} | Medical Text: Admission Date: [**2193-2-2**] Discharge Date: [**2193-2-7**]
Date of Birth: [**2143-5-24**] Sex: M
Service: Medicine, [**Hospital1 139**] Firm
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 49-year-old
male with a history of Crohn's disease, status post multiple
surgeries and ileostomy at 19 years of age, on chronic total
parenteral nutrition, with steroid-induced osteomyelitis with
a history of frequent peripherally inserted central catheter
line infections. The patient has also had a recent diagnosis
of C4-C5 epidural abscess and osteomyelitis with
coagulase-negative Staphylococcus aureus, status post 10
weeks of intravenous oxacillin treatment. He was recently
switched to doxycycline two weeks ago by mouth.
The patient was in his usual state of health until the
morning of [**2-1**] when he had a temperature of 100.6 which
was a high temperature for the patient. His home care nurse
was concerned given his history of multiple line infections,
but Mr. [**Known lastname **] was asymptomatic at that time with no
complaints. Later on the same day, the patient developed
rigors and another temperature spike during total parenteral
nutrition infusion. He was subsequently brought to the [**Hospital1 1444**] Emergency Department for
evaluation.
REVIEW OF SYSTEMS: On review of systems, the patient denied
nausea, vomiting, hematemesis or any change in his ostomy
output. He had no headache, no cough, no shortness of
breath, and no chest pain. He had fevers and chills, but no
dysuria.
On arrival in the Emergency Department, the patient was found
to have a systolic blood pressure in the 60s. He was also
noted to be anemic with a hematocrit of 22 (down from his
usual of 25), and an increase in his serum creatinine to 2.9
(up from a baseline of 1.4 to 2.1 in [**2192-11-20**]). The
patient was started on intravenous fluid resuscitation and
dopamine for hypotension. He was given a dose of ceftazidime
and vancomycin. The patient also received 100 mg of
hydrocortisone given his chronic steroid use for his Crohn's
disease. He was transferred the Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Crohn's disease, status post multiple abdominal surgeries
with ileostomy since the age of 19. The patient is followed
by Dr. [**Last Name (STitle) 79**] at the [**Hospital6 1708**]. He is
currently on prednisone.
2. Short bowel syndrome, on chronic total parenteral
nutrition.
3. Osteoporosis, steroid-induced.
4. A recent history of C4-C5 epidural abscess and
osteomyelitis secondary to line infection. The patient is
status post surgical decompression by Dr. [**Last Name (STitle) 1327**], treated
with 10 weeks of intravenous oxacillin and recently changed
to p.o. doxycycline two weeks prior to admission. Cultures
from this infection grew coagulase-negative Staphylococcus
aureus.
5. The patient has history of multiple polymicrobial line
sepsis from his indwelling peripherally inserted central
catheter lines.
6. The patient has a history of chronic renal insufficiency
with a baseline creatinine of 1.9.
MEDICATIONS ON ADMISSION: Medications on admission included
prednisone 3 mg p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on arrival to the Medical Intensive Care Unit revealed a
blood pressure of 95/60, heart rate of 80, respiratory rate
of 18, and a temperature of 100.1. General examination
revealed a cachectic male who was diaphoretic.
Cardiovascular examination revealed a regular rate and rhythm
with normal first heart sound and second heart sound. A [**1-23**]
holosystolic murmur at the left sternal border with no third
heart sound or fourth heart sound. No rubs. The patient's
jugular venous pulsation was measured to be 6 cm. Lung
examination revealed bibasilar crackles; otherwise, clear to
auscultation. The abdominal examination revealed a healed
old multiple surgical scars. The patient had an ileostomy
bag. He had normal bowel sounds, and his abdomen was
nontender and nondistended. Extremity examination revealed
warm extremities with no edema and palpable pedal pulses.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory
studies on admission revealed a hematocrit of 22, white blood
cell count of 7, and a platelet count of 109. Serum
chemistry revealed a sodium of 140, potassium of 3.1,
chloride of 108, bicarbonate of 20, blood urea nitrogen
of 56, and creatinine of 2.4, and a serum glucose of 53.
RADIOLOGY/IMAGING: Chest x-ray on admission revealed
bibasilar atelectasis with no focal consolidation.
HOSPITAL COURSE: The patient was transferred to the Medical
Intensive Care Unit after stabilization in the Emergency
Department.
In the Medical Intensive Care Unit, his peripherally inserted
central catheter line was removed for a suspicion of line
sepsis. A right internal jugular central line was placed.
After removal of his peripherally inserted central catheter
line, the patient was able to be weaned off dopamine in one
to two hours after his arrival to the Medical Intensive Care
Unit. The patient was continued on ceftazidime and
vancomycin intravenously as well as stress-dose steroids.
During his stay in the Medical Intensive Care Unit, the
patient continued to spike temperatures of up to 102.2.
However, he remained hemodynamically stable throughout his
entire course.
He was transferred out to the Medicine Service on [**2193-2-3**] after stabilization. At the time of transfer, the
patient was only on vancomycin intravenously. The patient
remained afebrile during his entire course on the Medicine
Service with his temperature maximum being 100.4 on [**2193-2-5**]. All of his blood cultures obtained since his admission
remained negative. The tip of his peripherally inserted
central catheter line that was removed was cultured and was
found to grow methicillin-resistant Staphylococcus aureus,
for which the patient was kept on intravenous vancomycin.
The patient continued to defervesce, and his stress-dose
steroids were discontinued. His blood pressure remained
stable after discontinuation of his steroids. The patient
was maintained on 3 mg of prednisone q.d. which was his
baseline.
A transthoracic echocardiogram was obtained for evaluation of
possible endocarditis. On echocardiogram, on [**2193-2-4**],
the patient was found to have no echocardiographic evidence
of endocarditis. His left ventricular ejection fraction was
normal at greater than 55%. The patient was found to have
moderate-to-severe 3+ mitral regurgitation, and 2+ tricuspid
regurgitation was also seen. His left atrium was mildly
dilated. There was mild pulmonary systolic hypertension.
There was no pericardial effusion.
The patient's acute renal failure resolved during his stay on
the Medicine Service. He was thought to have acute tubular
necrosis secondary to transient hypotension when he presented
to the Emergency Department. After hydration and blood
pressure resuscitation, the patient's acute renal failure
resolved.
After being afebrile for over 48 hours, the patient received
a peripherally inserted central catheter line placement on
[**2193-2-7**] and was discharged to home on intravenous
vancomycin. The patient has a follow-up appointment with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22874**] in the Infectious Disease Clinic on [**2193-2-25**]. The patient was to be discharged on intravenous
vancomycin (finishing a 2-week course) and then restarted on
dicloxacillin by mouth until he sees Dr. [**Last Name (STitle) 22874**].
DISCHARGE DIAGNOSES: Peripherally inserted central catheter
line sepsis.
MEDICATIONS ON DISCHARGE:
1. Wellbutrin 150 mg p.o. q.12h.
2. Niferex 150 mg p.o. b.i.d.
3. Prednisone 3 mg p.o. q.d.
4. Tums 1250 mg p.o. q.d.
5. Fentanyl patch 50 mcg transdermally every three days.
6. Vancomycin 1 g intravenous q.24h. (times nine more
days).
7. Ativan 0.5 mg to 1 mg p.o. q.6h. p.r.n.
8. Imodium 4 mg p.o. q.4-6h. p.r.n.
9. Tylenol p.o. q.4-6h. p.r.n.
10. Dicloxacillin 500 mg p.o. q.i.d. (to start after
finishing nine days of intravenous vancomycin).
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 14609**]
Dictated By:[**Name8 (MD) 9921**]
MEDQUIST36
D: [**2193-3-11**] 19:01
T: [**2193-3-12**] 10:28
JOB#: [**Job Number **]
ICD9 Codes: 0389, 5849, 2859, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 8199
} | Medical Text: Admission Date: [**2180-8-14**] Discharge Date: [**2180-8-18**]
Date of Birth: [**2150-5-11**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
EtOH withdrawal
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
30 M with long history of EtOH abuse with history of withdrawal
seizures, schizophrenia, admit to MICU with EtOH withdrawal.
Patient was admitted to [**Hospital1 **] for detox on [**8-11**]. Etoh level
on admission was >400. On [**8-13**] noted to have tachycardia and
increased BP (baseline 90s-100s now into 140s+). Today patient
sent from [**Hospital1 **] for agitation and confusion/disorientation.
In ED, vitals were: AF, BP 142/100, HR 101, 98% on RA. Remained
hypertensive and tachy during course. Given 4 mg IV ativan and
40 mg IV valium; also banana bag. Placed in 4 points and 1:1
sitter. Serum and urine tox negative. Currently denies auditory
hallucinations, reports seeing brother walk by him (+VH). Denies
chest pain, abdominal pain, shortness of breath. Denies recent
cold symptoms or cough. Does not answer other ROS questions.
Denies recent drug use. Thinks last EtOH use was vodka yesterday
at 3pm after a 2pm appointment that he cannot further specify
about.
Past Medical History:
1) EtOH abuse including seizures from withdrawal (reports 3
hospitalizations in last year in [**State 531**]). Detox most recently
in [**2180-3-4**] in [**State 531**].
2) Reported h/o MI due to cocaine abuse per OMR
3) Cocaine abuse
4) Schizophrenia
5) Depression (h/o suicide attempt at age 15)
6) ADHD
Social History:
Pt. born in [**Country 13622**] Republic and moved to United States at the
age of 1. Raised in Bronx, NY and moved 2 months ago to [**Location (un) 86**]
where he mother currently lives.
Denies tobacco use.
+EtOH abuse [began 7 years ago, reports drinking 1 pint
vodka/day, last drink [**2180-8-11**]]
Polysubstance abuse/recreational drug use (including cocaine and
remote use of marijuana, heroin, LSD, crystal meth)
Pt. worked as a bar manager from [**2176**]-[**2177**], but has been
unemployed for the past year and a half.
Patient has seen numerous therapists since the age of twelve. He
reports being abused and raped when he was younger. Currently,
he has a therapist in [**Location (un) 86**] who has referred him to a
psychiatrist. He has not started treatment yet.
Family History:
He has noticed no history of MI, cancer, or depression in his
first degree relatives. There is a history of high cholesterol,
hypertension, and alcohol use in his father's side of his
family.
Physical Exam:
Vitals: T: 98.1, BP 147/94, HR 100, R24, 100% RA
General/mental status: Thin male, alert and conversant. Speech
quiet but understandable. Thought process often very tangential
but at times showing awareness of current situation ("I'm at
detox, I've seen so many doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**]..."). + VH +
paranoia.
Neck: supple, no adenopathy.
Chest: CTA bilat.
Heart: RRR, tachy, no m/r/g appreciated.
Abdomen: soft, NT, ND, relaxes abdomen poorly but liver edge
palpable.
Extrem: warm, no edema
Neuro: alert, refuses to answer orientation questions. MAE,
grossly intact.
Pertinent Results:
[**2180-8-14**] 08:45AM BLOOD WBC-5.5# RBC-4.44* Hgb-14.0 Hct-38.2*
MCV-86 MCH-31.5 MCHC-36.7* RDW-15.8* Plt Ct-150
[**2180-8-14**] 08:45AM BLOOD Glucose-149* UreaN-7 Creat-0.8 Na-135
K-3.3 Cl-95* HCO3-26 AnGap-17
[**2180-8-14**] 08:45AM BLOOD ALT-218* AST-280* CK(CPK)-375*
AlkPhos-107 Amylase-62 TotBili-0.6
CK 375 -> 2549 -> 4031 -> 4280 -> 6277 -> 6220
[**2180-8-14**] 08:45AM BLOOD CK-MB-4 cTropnT-<0.01
[**2180-8-14**] 08:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
[**2180-8-14**] 08:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2180-8-14**] 12:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
CXR ([**8-14**]):
IMPRESSIONS: No consolidation, but increased opacity at the lung
apices may reflect aspiration. Correlation with dedicated PA and
lateral CXR is
recommended.
Brief Hospital Course:
# EtOH withdrawal:
Last known drink [**8-11**]. Presented with agitation, visual
hallucinations, tachycardia, hypertension, consistent with
delirium tremens. Also had mild transaminitis that trended down,
negative hepatitis serologies. Pt was initially admitted to the
MICU [**8-14**] and started on a CIWA protocol with diazepam 15 mg IV
Q15-30 min for CIWA >10. He was also started on MVI, thiamine,
and folate. Initially, he required a 1:1 sitter, restraints, and
haldol for agitation, but this was stopped after 1 day. He
received over 200 mg IV diazepam during the first day. He was
transferred to the floor on [**8-16**] after a substantial decrease
in his benzo requirement. He was continued on PO diazepam prn,
but his CIWA was 6 or less on the floor for 2 days. Social work
was consulted and recommended inpatient detoxification.
# Schizophrenia/Depression/ADHD:
He was continued on his outpatient risperidone. By the time of
transfer to the wards, he denied hallucinations, suicidal or
homicidal ideations. At discharge, he was interacting
appropriately and felt optimistic. He will follow up with
outpatient psychiatry.
- Note to PCP/Psychiatry re: medications. He was previously on
Strattera 60mg daily for ADHD, but hasn't taken this in a couple
of months. He was discharged with trazodone for insomnia, which
he tolerated well during admission. He was not given any ativan
on discharge due to low CIWA and risk for abuse. Please assess
the need for these medications at his follow-up appointment.
# Elevated CK
No muscular symptoms or recent trauma. Thought to be in the
setting of delirium tremens. He was given aggressive fluids to
prevent renal damage, and his BUN and Cr remained normal
throughout. His CK had peaked and come down slightly on the day
of discharge.
Medications on Admission:
Risperdal 2 mg HS
Ativan 1 mg Q4-6H prn
Thiamine 100 mg daily
Folate 1 mg daily
MVI 1 mg daily
Discharge Medications:
1. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Trazodone 100 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Delirium tremens
Alcohol abuse/dependence
Schizophrenia
Polysubstance abuse
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
You were admitted to [**Hospital1 18**] due to signs of alcohol withdrawal.
You had hallucinations, tremors, elevated heart rate and blood
pressure, which is part of a syndrome called delirium tremens.
We gave you diazepam and observed you in the ICU. Now that your
vitals signs are normal and your mental status has improved, we
will discharge you with close follow-up for your alcohol abuse.
As we discussed in length during your admission, continuing to
drink alcohol will cause progressive damage to many parts of
your body, including your liver. We strongly recommend that you
seek treatment, either as an inpatient, or through intensive
outpatient therapy. We have provided you with information about
BEST, a program that can provide you with these resources.
Please contact [**Name (NI) **] at BEST as soon as possible to set up a
treatment plan: ([**Telephone/Fax (1) 79589**].
Also, please contact your therapist, [**Name (NI) 803**] [**Name (NI) 79590**], at
[**Hospital **] [**Hospital **] Health Center on Monday morning to set up an
appointment. Phone: ([**Telephone/Fax (1) 79591**].
Please take all of your medications as prescribed and go to all
follow-up appointments. We will continue your trazodone that you
received here to use if needed at nighttime for insomnia.
If you experience any tremors, palpitations, chest pain,
agitation, dizziness, headache, hear or see things others do
not, experience any thoughts of harm to yourself or others, or
have any other concerning symptoms, please seek medical
attention or come to the emergency room immediately.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2180-8-24**]
2:00
Psychiatry: [**Hospital1 **] St. Health Center, [**2180-8-30**], 2:30pm, Dr.
[**First Name (STitle) **]
Provider: [**Name10 (NameIs) **] FERN, RNC Date/Time:[**2180-9-21**] 9:20
Please call your therapist [**First Name5 (NamePattern1) 803**] [**Last Name (NamePattern1) 79590**] at [**Hospital1 **],
([**Telephone/Fax (1) 79591**], and [**Doctor First Name **] at BEST, ([**Telephone/Fax (1) 79589**], as
instructed above.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2180-8-18**]
ICD9 Codes: 412, 311, 4019 |
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