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{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8200 }	Medical Text: Admission Date: [2200-4-8] Discharge Date: [2200-4-14] Date of Birth: [2158-11-18] Sex: F Service: [Location (un) ] CHIEF COMPLAINT: 1. Melanotic stools. HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 19730] is a 41 year-old female with past medical history significant for type I diabetes, end stage renal disease on hemodialysis, hypertension, hyperprolactinemia, history of a GI bleed who presents to the Emergency Department with shortness of breath, abdominal pain and nausea. The patient states that she has had epigastric pain for the past three or four days and that her mother had noted dark / bloody stools which subsequently lead her to bring her daughter to the Emergency Department. The patient states she has been taking two Motrin a day for the past month for chronic leg pain. The patient has a history of upper GI bleed several years ago. She denies any hematemesis, vomiting. She states she has not eaten since the night before admission. In the Emergency Department the patient's blood pressure was 79/44. Her O2 saturation was 100% on room air with a heart rate of 60%, access was obtained in view of a femoral triple lumen catheter. Her blood pressure increased without bolus of fluid or transfusion. Her blood pressure on arrival to the MICU was 100/70 and G tube was placed. Bright red blood was retained which did not clear after 750 cc of flushing with normal saline. The patient continued to remained hemodynamically stable. Her laboratory values were significant for hypokalemia with peaked T waves seen on her EKG. The patient was given sliding scale insulin IV to enhance sodium bicarb along with 2 grams of calcium gluconate. The renal fellow on call was notified and emergent hemodialysis was arranged upon arriving in the medical ICU. REVIEW OF SYSTEMS: Negative for fevers or chills. She has decreased po intake lately secondary to nausea, pain. She does not complain of any shortness of breath or cough. She denies any chest pain. No history of syncope. The patient is completely anuric. She has a left lower extremity foot ulcer which has been improving over the past four weeks. PAST MEDICAL HISTORY: 1. Type I diabetes since the age of 23 years old. She has had several episodes of DKA. 2. End stage renal disease on hemodialysis Tuesday, Thursday and Saturday secondary to diabetes. 3. Diabetes. 4. Hyperprolactinemia. 5. History of upper GI bleed 6. Foot ulcer for which she has had for one month. ALLERGIES: Azithromycin leads to gastric upset. MEDICATIONS AT HOME: 1. Lorazepam 2 milligrams po given at hemodialysis. 2. Protonix 40 milligrams po q day. 3. Nortriptyline 75 milligrams q HS. 4. Metoprolol 50 milligrams po bid. 5. Reglan 10 milligrams po q AC / q HS. 6. Norvasc. 7. PhosLo. 8. Nephrocaps one po q day. 9. Atlantis 10 units subcutaneous q HS. 10. Humalog sliding scale. SOCIAL HISTORY: She lives with her mother. She is a nonsmoker. She occasionally uses alcohol. She has VNA for foot ulcer care. PHYSICAL EXAMINATION: Temperature 95 F orally in the Emergency Department. Heart rate 60. Blood pressure 100/60. O2 saturation is 100% on two liters. General she appears slightly anxious female sitting upright. HEENT - pale conjunctivae. Mucous membranes are moist. Her lungs are clear to auscultation bilaterally. She had decreased breath sounds at the right base. She has no wheezing and no crackles heard on auscultation. Her heart was regular rate and rhythm with an S3 heard. There are no murmurs appreciated. Abdomen has decreased bowel sounds, soft and nontender on examination. Rectal - there is evidence of gross hematochezia. Extremities were slightly cool. She has a left lower extremity plantar ulcer 1 cm in diameter with hepatorrheic edges without warmth or erythema. Pulses were not palpable. Neurologically she was alert and oriented times three. There is no facial droop. Her tongue was midline. She was moving all four extremities. LABORATORY DATA: White count 9.2, hematocrit 24.7, platelet count 320,000. Sodium 134, potassium 7.4, chloride 96, bicarb 21, BUN 149, creatinine 7, glucose 312. Anion gap 13, INR 1.5, PTT 28.2, PT 14.5. CK 44, Troponin less than 0.3. EKG revealed that she was in sinus rhythm with beats of 64 beats per minute. She had left axis deviation with evidence of left ventricular hypertrophy. She had poor R wave progression, precordium with peaked T waves. She had QRS interval of 144 compared with 88 from previous EKG. She had T wave depressions on lateral leads. She had an HG done in[2200-2-5] which revealed a mild reversal of septal defect. HOSPITAL COURSE: 1. Upper Gastrointestinal Bleed - The patient was started on IV proton inhibitor and transfused a total of 40 units of packed red blood cells during this admission. An EGD was performed which revealed blood in the entire stomach. There was erythema and congestion in the pre-pyloric region compatible with gastritis. Her EGD was otherwise normal to the third part of the duodenum. The cause of her GI bleed was thought to be end stage induced gastritis. Her hematocrit remained stable throughout the rest of her hospital course. She was discharged on proton pump inhibitor to be dosed twice a day and to follow up with her gastroenterologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 19731]. 2. Diabetes - The patient was started on an insulin drip for mild DKA after hospital day three her anion gap had closed and the patient was started on her outpatient dose of Lantus with fair control of her blood sugars. 3. Renal failure - The patient had emergency hemodialysis for hyperkalemia with EKG changes which subsequently resolved after one course of hemodialysis. During this admission the patient continued to have multiple courses of hemodialysis every other day which she tolerated well. The patient was given Vancomycin at dialysis for a question of SBP given return of .................... fluid from a new peritoneal dialysis catheter placed two weeks ago. Her peritoneal fluid was sampled on the day prior to discharge which fit criteria for SBP. Her abdominal exam was nontender throughout her hospital stay. She will resume the use of her peritoneal dialysis catheter in the near future as dictated by her nephrologist. During this admission her PhosLo does was increased from two tablets with meals to four tablets with meals due to persistent hyperphosphatemia. She was discharged from the hospital to continue her usual regimen of hemodialysis three times a week. 4. Cardiovascular - During this admission the patient's Troponin levels were found to be elevated with no CK leak. Despite these findings and significant anemia, the patient remained chest pain free throughout her hospital course. Given her known history of mild reversible septal defect on a recent Persantine MIBI the patient should be evaluated for a cardiac catheterization in the near future. Her Troponin leak is most likely from a combination of anemia and ..................... She was not started on aspirin secondary to her ANSAID induced GI bleed and was continued on her beta-blocker and on an Ace inhibitor. She was set to follow up with Dr. [Last Name (STitle) ] of the cardiology division for evaluation of a possible cardiac catheterization. 5. Dizziness - The patient developed persistent dizziness two days prior to being discharged. After being restarted on Florinef her symptoms of dizziness resolved completely. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Discharged to home. DISCHARGE MEDICATIONS: 1. Florinef 0.2 milligrams po q day. 2. Lantus 10 units subcutaneous q HS. 3. Neurontin 100 milligrams po tid. 4. PhosLo four caps po with meals. 5. Nephrocaps one po q day. 6. Nortriptyline 75 milligrams po q HS. 7. Protonix 40 milligrams po bid. 8. Lopressor 50 milligrams po bid. 9. Ativan 1 to 2 milligrams po q six to eight hours prn anxiety. 10. Lisinopril 10 milligrams po q day. DISCHARGE INSTRUCTIONS: Return to the Emergency Department if you develop chest pain, shortness of breath, or persistent dark or bloody stools. Follow up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 19512] of [Company 191] within one week to review the results of this admission. Please follow up with Gastroenterologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 19731] on [2200-5-30] at 10:40 A.M. Follow up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] on [2200-5-6] at 3 P.M. at [Last Name (NamePattern1) 19732] for further cardiac work up. DISCHARGE DIAGNOSIS: 1. ANSAID induced gastritis. 2. Positive cardiac pharmacologic stress test. 3. End stage renal disease on hemodialysis. 4. Type I diabetes. 5. Hypertension. 6. Hyperprolactinemia. 7. Left lower extremity foot ulcer. [Name6 (MD) 7853] [Last Name (NamePattern4) 7854], M.D. [MD Number(1) 7855] Dictated By:[Last Name (NamePattern1) 7690] MEDQUIST36 D: [2200-4-18] 20:44 T: [2200-4-21] 09:47 JOB#: [Job Number 19733] cc: [Doctor First Name 475] [Initials (NamePattern4) ] [Last Name (NamePattern4) 474], M.D. Division of Cardiology [First Name11 (Name Pattern1) 20] [Last Name (NamePattern4) 19734], M.D. Division of Gastroenterology and Hepatology [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [Company 191] West ICD9 Codes: 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8201 }	Medical Text: Admission Date: [2135-1-11] Discharge Date: [2135-1-18] Date of Birth: [2081-3-23] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5018] Chief Complaint: Slurred speech and right sided facial weakness Major Surgical or Invasive Procedure: None. History of Present Illness: Patient is a 53 yo RH man with poorly controlled HTN who was found by his daughter at 5:30Pm today confused with slurred speech and right sided weakness. He was taken to an OSH where a head CT revealed a moderate sized left basal ganglia bleed. He was transferred to [Hospital1 18] for further evaluation. He denies headache, dizziness, blurry vision or diplopia, numbness or tingling. ROS negative for fever, URI sxs, N/V/D, dysuria. Denies cp, sob. Past Medical History: HTN, NIDDM, GERD, PVD s/p right BKA, left great toe amputation Social History: Lives at home with his sister, Smokes 1 ppd, denies ETOH or other drugs Family History: Noncontributory Physical Exam: Vitals: 98 209/123 on entry to ED now 175/109 20 RA Gen: NAD Neuro: awake, oriented to "End of [2134-12-13] and [Hospital3 ]"; fluent; severe dysarthria, naming intact to pen and thumb with more difficulty with low frequency objects; repetition intact to 7 word sentence but dysarthric, good attention with months year forward and backward to [Month (only) ]; memory [4-14] at 30 seconds and [2-13] at 5minutes pupils equal and reactive b/l; EOMI with no nystagmus b/l; no field cut face with right facial droop at rest and with activation; facial sensation intact; tongue midline and moves in all directions with good coordination; palate elevates symmetrically Power [6-16] in LE b/l and right pronator drift. Has more weakness distally at interossei on right reflexes 2+ in UE b/l and 1+ in LE b/l at knees (difficult to examine right knee); no ankle jerks b/l; toes moot b/l; sensory exam: intact to LT, temperature, and joint position in UE and LE b/l No ataxia or dysmetria on FNF in UE b/l Gait: deferred Pertinent Results: Head CT (OSH): left basal ganglia bleed with surrounding edema in 4 sections with minimal mass effect on left frontal [Doctor Last Name 534] of lateral ventricle Head CT [1-11] and [1-12] are stable ESR 73 Lipid panel pending HgBA1C pending ECHO pending Carotid ultrasound pending Brief Hospital Course: Patient admitted to the ICU for blood pressure managment and monitoring. NEURO: Remained stable in ICU with exam notable for R facial droop, mild RUE distal weakness and dysarthria. Repeat head CT's were stable. He is due for an MRI/MRA to evaluate for any underlying etiology (vascular malformation, tumor) for his hemorrhage. Most likely pt's hemorrhage is secondary to hypertension. CV: Pt's blood pressure difficult initially to control. He required nicardipine and nipride drips initially, then was transitioned to IV lopressor and hydralazine. On ICU day 3 he was transferred to PO antihypertensives after he passed his swallowing evaluation. RENAL: Pt had creatinine of 2, unclear if this is new or chronic in the setting of long standing diabetes. Pt was transferred to the floor on HD 3 in stable condition. On the floor his blood pressure medications were titrated in order to achieve optimal blood pressure control. The patient continued to do well and is now discharged in stable condition to [Hospital1 ] Rehabilitation Center. Medications on Admission: glipizide, norvasc, lasix, lopressor, lipitor, protonix Discharge Medications: 1. Atorvastatin Calcium 10 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. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Hydralazine HCl 10 mg Tablet Sig: Two (2) Tablet PO Q6 HOURS PRN SBP>160 (). 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 7. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: 1. Intracerebral Hemorrhage 2. hypertension Discharge Condition: good Discharge Instructions: Please take medications as prescribed. Return to ER if symptoms worsen. Keep all follow-up appointments. Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] in 3 months, call [Telephone/Fax (1) 56548] to schedule a convenient time. [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2135-1-18] ICD9 Codes: 431, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8202 }	Medical Text: Admission Date: [2166-9-2] Discharge Date: [2166-9-26] Date of Birth: [2098-12-15] Sex: M Service: MEDICINE Allergies: Ivp Dye, Iodine Containing / Sulfa (Sulfonamides) / Bactrim Attending:[First Name3 (LF) 2297] Chief Complaint: weakness, rash (?bactrim allergy), acute respiratory failure. Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 67yo M with CAD s/p CABG, DM, PVD, [Hospital 16627] transferred from OSH with ARDS. . He initially presented to OSH w/ 3 days history of increasing weakness and unable to situp and ambulate w/ his walker. He had some dizziness and some neck pain but no photophobia. He also had bitemporal headache an anorexia. H ealso had a couple episode of vomiting but no diarrhea. He also had a non-productive cough. He noted a fascicular and papular rash on his bilateral hands, including his palms and trunk and extremities. . Of note, he has chronic yeast infection in his groin. IN the ED, he was hypotensive to the 80s w/ HR 62 but afebrile (on b-blocker). He was very ill appearing and dry looking. . About 1 wk prior, he was started on bactrim by Dr. [Last Name (STitle) ] for ulcer on both feet. He took a few days of bactrim but developed severe diarrhea as a result of It. He stopped it. He was advised by Dr. [Last Name (STitle) ] to resume bactrim b/c of concern of persistent infection. Upon resuming bactrim, he developed a generalized rash started initially over his face and spreading to his abd, his upper and lower ext. The rash was not painful and no itchy. It then began to itch subsequently. . Brief OSH course [Date range (1) 16628]: He was admitted on [8-29] w/ profound weakness and worsening renal fx w/ BUN 78 creat 2.5. Baseline BUN 30-40s. notable labs initially WBC 12K, Hct 32.7 Plt 203. 26% band, 2 % eos Na 142 K 4.0 Bun 78 and creat 2.5. Gluc 159. AST 79, ALT 55, Alk phos 84. INR 1.1. EKG initially RBBB w/ non specific ST T wave changes w/ NSR at 62. CXR showed some bilateral patchy infiltrate. AN LP was attempted in the ED for concern of disseminated zoster. . He was sats 98 % on Ra and BP 98/43 and afebrile. He had an extensive exfoliate rash on his upper and lower ext. Of note, he was on bactrim for heel ulcer. He required hypotensive and required IVF. . He was started on diflucan and acyclovir and CTX. Bld cx was drawn and these have remained negative. One of the exfoliateive lesion was unroofed and sent for culture. Derm [First Name9 (NamePattern2) 16629] [Last Name (un) ] and di not believed that it was virla or herpetic and recommended stopping acyclovir. (of note, he had been given lasix as outpt meds.). He was noted to be in increasing respiratory distress 1-2 days and was given additional dosage of lasix. (total 3 dosages of 40 IV lasix given on [8-31]). He was also seen by ID who recommended stopping diflucan, acyclovir, CTA. Prednisone was also started for presumed exfoliate dermatitis. Renal was also consulted and felt that the rash is likely from bactrim and sulfa related allergy. and recommended IVF hydration. Despite attempted diuresis, he developed bilateral infiltrate (diffuse) and increasing hypoxic respiratory failure. He was emergently intubated after midnite [8-31]. He was sating low 90s w/ FiO2 100 and PEEP of 7.5. Central line was inserted and CVP was 16 w/ BNP 1020. Frothy pinkish secretions were obtained from his ETT tubes. Cultures were sent. Pt was started on ceftaz 1 q8 and cipro 400 IV and 1 dose of 1gm vanco given empirically. He was also started on hydrocort 100 q8 on [9-1] AM. . Of note pt was recently admitted to the vascular [Doctor First Name ] service for L>R ulcer and was planned to have f/u surgery pending cardiac evaluation. Past Medical History: 1. CAD- s/p CABG x 3 in [2158] at [Hospital1 112], last cath [6-28] with 80% stenosis in SVG to OM1 s/p stent placement 2. Aortic stenosis- moderate by [4-29] TTE 3. CKD- by report, baseline Cr 1.2, h/o ARF with IV contrast 4. DM- HgA1C 6.4 in [4-29]; c/b nephropathy, neuropathy, retinopathy 5. PVD- b/l ischemic heel ulcers, s/p R foot partial amputation 6. Hypertension 7. Hypercholesterolemia 8. Peripheral neuropathy 9. bilateral carotid stenosis, s/p R CEA [2161] 10. OSA- on home BiPAP 11. history of junctional tachycardia Social History: He is married. He is a retired quality assurance engineer. nonsmoker and uses alcohol occasionally Family History: (+) FHx CAD: Mother died at age 65 of an "enlarged heart". Physical Exam: PHYSICAL EXAM on ADMISSION: Vitals- p 109 BP 106/44 O2 90% RR 14 AC TV 450 FI O2 100% RR 14 PEEP 5 PIP 34 General- NAD, intubated, sedated, generalized exfoliate dermatitis HEENT- PERRL, OP clear w/ dry MMM Neck- Supple, flat JVD Pulm- diffuse crackles and rhonchi CV- RRR, S1 and S2, no m/r/g Abd- soft, NT, ND +BS Extrem- cool to touch, poor distal pulses Neuro- sedated Brief Hospital Course: Pt admitted to [Hospital Unit Name 153] on [2166-9-3] hemodynamically stable, but with ARDS for further management. Pt was extubated on [9-15], but did poorly on CPAP with trials of high flow ventilation. He elected to be DNR/DNI on [9-16] after extubation, and on [9-24] goals of care where changed to comfort measures only. Pt expired on [9-25] from hypercarbic respiratory failure. . . # respiratory failure: the etiology of pt's ARDS unclear, but is presumably [12-26] bactrim allergy which was being used to treat ?foot cellulitis. . Pt did have bandemia at OSH on arrival, but numerous cultures on presentation to [Hospital1 18] and at OSH negative including blood, sputum, BAL, urine, and foot wounds (left and right) were negative. On presentation to OSH pt noted to have rash of B LE and it was thought that he had a bactrim allergy which he was started on for foot ulcers. . Pt intubated at OSH on ~[9-1]. His respiratory mechanics gradually improved with gentle diuresis with lasix gtt + diamox, and pt was extubated [9-15], and transitioned to his home BiPaP with PS 14/8. After extubation, pt continued to have copious secretions which improved slowly. He also remained grossly volume overloaded, and was tolerating only gentle diuresis (~500-1000cc fluid removal daily), given his severe aortic stenosis and preload dependence. Pt gradually improved, tolerating trial of high flow face mask ventilation, with O2 sats 95-100% on 8-15LPM. His secretions were improving on [9-22], and less copious. . Blood and sputum cultures, though initially negative [Hospital1 18] (pt previously on vanco/zosyn from OSH for unclear indication, abx d/c'd [9-14]), subseqeuntly were positive for MRSA in blood and sputum on [9-17]. Pt was begun on vanco/zosysn, and switched to linezolid/meropenem for ?improved lung penetration. however pt continued to progress off of cpap, and on [9-24] decision was made to change goals of care to CMO. Pt expired on [9-25]. . . # sepsis - on [9-19] pt was noted to be hypothermic. central line and left a-line were removed earlier that day. source remained unclear, though ddx included [Name (NI) 16630] versus aline/LIJ central line. Blood Cx subsequently +mrsa. SBPS remained elevated, and pt was already being treated with a second course of vanco/zosyn, which was continued. lactate level was unremarkable. By [9-22], pt was afebrile for 48hrs, and without hypotension. his UOP, however remained, low, and given his failure to improve from a respiratory standpoint, pt elected to change goals of care to CMO on [9-24] and expired on [9-25]. . . # CV: pt with h/o CAD s/p CABG [2158], last Cath [6-28]. This admission pt with cardiac enzymes x 3 w/ + trop but negative CKs and these trended down. Thought to be due to demand ischemia with hypotension. Pt's plavix was d/c'd as pt is >1.5 yrs s/p cath and has had had guaic pos stools. Aspirin dose decreased to 81 mg po qdaily, and held pending restarting oral feeding. On [9-24] pt complained of CP, however no new EKG changes were noted, cardiac enzymes unremarkable compared to prior bump, and CP resolved within <5 min. On [9-24] goals of care were changed to CMO. . b) pump-last ECHO showed decreased EF from [4-29] w/ 1+ MR and AS, now with EF 30-40% and mod-severe AS-attempting diuresis with diamox and lasix although on this hospitlization, diureses was complicated by pt's preload dependence. He continued to remain volume overloaded on [9-22], and diuresis was also complicated by ?sepsis physiology. On [9-24], decision was made to change goals of care to CMO. . c) rhythmn: had episode of aflutter on admission, digoxin loaded but not continued. On [9-20] pt developed intermittent aflutter with variable block. This was felt to be [12-26] to his pulmonary processes, rather than ischemia. Plan was to treat underlying pulmonary process (pna and pulmonary edema) with linezolid, meropenem and diuresis, however on [9-24] decision was made to change goals of care to CMO. . . # DM2 with complications - pt initially treated with insulin gtt which was weaned and transitioned to sliding scale coverage with good fsbs. . # Foot ulcers- vascular sugery was consulted regarding pt's foot ulcer. The wound did not probe to bone. One wound was swabbed which did not grow anything, and the wound do not appear to be infected. B/L foot xrays could not r/o osteomyelitis. Pt was afebrile without white count initially off abx. Spoke with pt's vascular surgeon, who feels that if wound does not probe to bone, osteo is unlikely. as this is the case, will continue wound care, but will not workup further for osteomyelitis. . Regarding bilateral lower extremity rash, this was largely resolved on [9-20]. Do not feel that this represents cellulitis, as it lacks erythema, no wbc, or fever (off abx, or tyelenol). Plan was for f/u with vascular surgeon as outpatient ([First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [-1/1000]), however pt expired on [9-25]. . . #ARF- patients creatinine on admission was elevated to approx 2 and had returned to wnl despite continuing to diuresing with lasix to remove fluid exacerbating respiratory failure. On [9-22] it had started trending upward again with diuresis. . . #Anemia-chronic anemia. Iron studies demonstrate ACD [12-26] likely [12-26] DM, CHF. Pt breifly had guaic positive stool upon presentation, though hct stable after 1 U PRBC. Pt started On [Hospital1 ] PPI for ?GIB, however subsequent stool guaic were negative. Nevertheless plavix was d/c'd. . #hypernatremia- pt initially hypernatremic, felt likely [12-26] to hypovolemia and free water deficit. Pt was treated with free water boluses in TF and d5w once OGT was removed, with subsequent resolution on [9-19]. . # FEN: s/p extubation pt, evaluation of pt's swallow was attempted, however he was requiring long periods of CPAP which made this difficult. If pt does not tolerate face mask for significant periods of time, plan was to place NGT and use CPAP on top, despite poor seal. s&s consulted placed, however they were unable to see pt until after he can tolerate being off of CPAP for significant periods of time, pt was treated with TPN. . . # DISPOSITION - on [9-24] decision was made to change goals of care to CMO after discussion with pt, and family. on [9-25] pt expired due to hypercarbic respiratory failure. Medications on Admission: OUTPATIENT MEDS (per d/c summary [4-29]): Hydrochlorothiazide 25 mg PO qd Acetazolamide 250 mg PO qd Lisinopril 10 mg PO qd Aspirin EC 325 mg PO qd Metoprolol 12.5 mg PO BID Citalopram Hydrobromide 20 mg PO qd Nifedipine CR 30 mg PO qd Clopidogrel Bisulfate 75 mg PO qd Papain-Urea Ointment 1 Appl TP qd Potassium Chloride 20 mEq PO bid Ezetimibe 10 mg PO qpm Simvastatin 40 mg PO qpm Furosemide 80 mg PO bid . MEDICATIONS ( on addmission to OSH): lopressor 25 [Hospital1 ] plavix 75 daily fosamax 75 q sunday potassium 20 [Hospital1 ] lisinopril 20 daily diamox 50 daily ECASA 325 daily celexa 20 daily lasix 680 [Hospital1 ] HCTZ 25 daily vytorin 10/41 daily fish oil 1700 [Hospital1 ] lantus 18 u qhs humalog SSI colace Discharge Disposition: Expired Discharge Diagnosis: pt expired on [9-25]. Discharge Condition: expired. ICD9 Codes: 0389, 5849, 5859, 2760, 3572
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8203 }	Medical Text: Admission Date: [2191-7-1] Discharge Date: [2191-7-6] Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2356] Chief Complaint: diarrhea Major Surgical or Invasive Procedure: PICC line placement flexible sigmoidoscopy History of Present Illness: Ms. [Known lastname ] is a [Age over 90 ] YOF with a history of Crohns, DM type II, and CAD who presented to the ED with diarrhea, abd pain and nausea, vomiting. Pt reports 1 week of watery, non-bloody, non-melena diarrhea about 5-6 episodes/day. Pt reports associated N/V, 1 episode of non-bloody emesis. Pt has assoc [5-29] abd pain below the umbilicus, that was non-radiating. No alleviating or aggravating factors. Pt reports decreased po intake (food and fluids). No fevers or chills, CP, or SOB. . In the ED, initial VS: 97.8 80 144/83 20 100% 2L. Physical exam was significant for pt well looking, guiaic positive. Labs showed Cr 4.9 (baseline 1.9 in [2184]), Na 132, K 5.2 and bicarb 8, BUN 96. Lactate was 0.9 and phos 8.9. CBC was normal except for Hct 33.6 and serum osms 310. Serum aspirin and acetaminophen levels negative. UA showed Lg LE, tr bld, many bacteria, 30 prot, < 1 epi, neg nit. Bld cx negative x 2. The pt received 1L NS. She was seen by renal who requested that the pt admitted to medicine for bicarb drip, and eval of renal failure. The recommended starting a Bicarb drip in the ED (with 1L 1/2NS + 1amp bicarb @ 125ml/hr) as well as VBG. However, bicarb drip not started in ED as pt only had a 22 G peripheral IV. She was admitted to MICU for better access to start bicarb gtt. . On the floor, the patient was comfortable. She stated that she did not have any recent changes in her urination, changes in medications, increased NSAID use, suprapubic pain, flank pain or dysuria. She states she was diagnosed with Crohns 10 years ago and gets flares a few times a year with the current flare being no worse than usual. She is not followed by anyone for this. Her last Creatinine was probably drawn in [2190-8-20] by her PCP. [Name10 (NameIs) ] stated she was not particularly thirsty. Past Medical History: 1. CAD s/p IMI in [2157]. Prior cath, no intervention. 2. Hypertension 3. Hypercholesterolemia 4. Diabetes mellitus type 2 5. Chronic diarrhea (?Crohn's disease vs malabsorp vs colitis) 6. History of TIA 7. Peptic ulcer disease. Prior history of GI bleed (>5 years ago) Past surgical history: 1. Status post bowel resection in [2173] following colonoscopy complicated by perforation. Social History: Ms. [Known lastname ] lives alone in an assisted-living facility. She is an ex-smoker, with a 10 pack-year smoking history, quit in [2157]. No EtOH use. Family History: NC Physical Exam: Admission Exam T 95.4, HR 101, BP 122/95, O2 sat 99% on RA General: well appearing elderly lady, Alert, oriented x 3, no acute distress, mild tremor but no asterixis HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD LUNGS: CTAB CV: Regular rate and rhythm, systolic murmur radiating to the axilla Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: foley with pale yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII grossly intact, moving all extremitites, nml sensation Discharge Exam VS: 98.1 129-196/60-82 59-70 18 97% GENERAL: well-appearing in NAD. Oriented x3. Mood, affect appropriate CARDIAC: RRR, no mrg LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Right ankle pain resolved SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Admission Labs: [2191-7-1] 06:30PM BLOOD WBC-9.5 RBC-3.76* Hgb-11.5* Hct-33.6* MCV-89 MCH-30.5 MCHC-34.2 RDW-15.1 Plt Ct-255# [2191-7-1] 06:30PM BLOOD Neuts-75.2* Lymphs-16.6* Monos-6.1 Eos-1.8 Baso-0.3 [2191-7-1] 06:30PM BLOOD Glucose-127* UreaN-96* Creat-4.9# Na-132 K-5.2* Cl-105 HCO3-8* AnGap-24* [2191-7-1] 06:30PM BLOOD Calcium-8.9 Phos-8.9# Mg-2.1 [2191-7-1] 06:30PM BLOOD Osmolal-310 [2191-7-1] 06:30PM BLOOD ASA-NEG Acetmnp-NEG [2191-7-2] 06:33PM BLOOD freeCa-1.09 [2191-7-1] 09:55PM BLOOD Lactate-0.9 [2191-7-1] 09:55PM BLOOD Type-[Last Name (un) ] pO2-74* pCO2-29* pH-7.09* calTCO2-9* Base XS--20 . [2191-7-2] 02:30AM BLOOD Type-[Last Name (un) ] pH-7.19* [2191-7-2] 06:01AM BLOOD Type-[Last Name (un) ] pH-7.29* [2191-7-2] 12:57PM BLOOD Type-ART Temp-36.1 pH-7.38 Comment-GREEN TOP [2191-7-2] 06:33PM BLOOD Type-[Last Name (un) ] pH-7.41 Comment-GREEN TOP . [2191-7-2] 02:25AM BLOOD Glucose-194* UreaN-87* Creat-3.9* Na-135 K-4.2 Cl-110* HCO3-10* AnGap-19 [2191-7-2] 05:45AM BLOOD Glucose-176* UreaN-84* Creat-3.7* Na-135 K-3.5 Cl-109* HCO3-14* AnGap-16 [2191-7-2] 12:43PM BLOOD Glucose-151* UreaN-76* Creat-3.5* Na-141 K-3.0* Cl-106 HCO3-20* AnGap-18 [2191-7-2] 06:07PM BLOOD Glucose-144* UreaN-71* Creat-3.3* Na-140 K-3.3 Cl-105 HCO3-22 AnGap-16 . Discharge Labs: [2191-7-6] 03:44AM BLOOD WBC-8.7 RBC-3.76* Hgb-11.3* Hct-33.6* MCV-89 MCH-30.1 MCHC-33.7 RDW-15.2 Plt Ct-200 [2191-7-6] 03:44AM BLOOD Glucose-106* UreaN-47* Creat-2.3* Na-141 K-3.9 Cl-110* HCO3-21* AnGap-14 [2191-7-3] 11:47AM BLOOD calTIBC-215* VitB12-177* Folate-12.2 Hapto-238* Ferritn-66 TRF-165* . Flexible Sigmoidoscopy [2191-7-6]: Brief Hospital Course: [Age over 90 ] yo F with Chrohns, admitted in renal failure after worsening diarrhea. Initially sent to the MICU then called out to the floor. ACUTE: # Metabolic acidosis and acute on chronic renal failure secondary to diarrheaa: The patient was admitted to the MICU where she recieved 2L of D5W each with 3 amps of NaHCO3. Lytes were check q4 hours and bicarb and pH steadily improved. Calcium gluconate was given to replete ionized Ca. PICC line was placed for better access. FeNa 0.6%, and Cr improved with IVF. When her acidemia had corrected, she was called out to the floor. On the floor, her creatinine and lytes continued to improve with encouraged PO intake. She continued to have frequent diarrhea, but her creatinine improved to baseline with PO intake only. . # Anemia - Initially admitted with a Hct of 33.6. Decreased to 21.7 within 2 days. And then bumped to 32.0 with 2 units of PRBCs, and remained stable. Discharged with Hct of 33.6. By report, guaiac positive brown stools in the MICU but guaiac negative on the floor. Remained hemodynamically stable. No etiology of the bleeding. # Crohn's disease/diarrhea: Pt continued having diarrhea which was guaic + without gross blood. Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) 679] was consulted and recommended a flexible sigmoidoscopy and stool studies for evaluation. C diff toxin was negative. Flex sig revealed normal colon. Biopsies sent and pending. . # Bactiuria: Pt was given levoflox x1 in the in ED. Given she was asymptomatic, further abx were held in the MICU. UCx showed no growth. . # Gout: Left medial ankle became swollen and red in the MICU. Per the patient, she typically uses colchicine at home. She was given one dose of colcichine with significant worsening of her diarrhea, so further doses were held. Tylenol given for pain control and her gout resolved without further intervention. TRANSITIONAL: # Stool culture - sent on [2191-7-5] and still pending on discharge # Blood culture - sent on [2191-7-1] and pending # Colon biopsies - taken by flex sig on [2191-7-6] and pending Medications on Admission: (per PCP [Name Initial (PRE) 626] [2-/2191]) ASA 81mg daily amlodipine 10mg daily glyburide-metformin 5-500mg [Hospital1 ] Coreg CR 80mg daily simvastatin 80mg daily losartan-HCTZ 100-25mg daily hydroxizine 50 qHS and 25mg [Hospital1 ] PRN Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. glyburide-metformin 5-500 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Coreg CR 80 mg Cap, ER Multiphase 24 hr Sig: One (1) Cap, ER Multiphase 24 hr PO once a day. 5. losartan-hydrochlorothiazide 100-25 mg Tablet Sig: One (1) Tablet PO once a day. 6. hydroxyzine HCl 50 mg Tablet Sig: One (1) Tablet PO at bedtime: and 25mg [Hospital1 ] PRN allergies. 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 8. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One (1) gram Injection once a week for 4 weeks: subcutaneous injection. starting after daily injection x3. 9. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One (1) gram Injection once a day for 3 days: subcutaneous injection. 10. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One (1) gram Injection once a month: subcutaneous injection. after completion of weekly injection x4. 11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital 4316] Rehabilitation & [Hospital ] Care Center - [Location (un) ] Discharge Diagnosis: Acute on chronic kidney injury Diarrhea The Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [Known lastname ], you were admitted to the hospital for your severe diarrhea. You were given IV fluids to improve your kidney function. You also underwent a flexible sigmoidoscopy which showed no evidence of Chrohns, biopsies were taken. Medication Changes: # Start albuterol inhalers up to four times daily as needed for wheezing # Start Vitamin B12 subcutaneous injection daily for 3 days, then weekly for 4 weeks, then monthly # Start iron daily Followup Instructions: Department: ADULT MEDICINE When: WEDNESDAY [2191-7-13] at 1:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8471], MD [Telephone/Fax (1) 1144] Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: Nephrology When: THURSDAY [2191-7-21] at 10:30 AM Building: [Location (un) 2355] ([Location (un) ], MA) [Location (un) 551] With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2088], MD Phone: [Telephone/Fax (1) 721] Department: Gastroenterology When: [2191-8-1] 1:30pm Building: [Last Name (NamePattern1) ]. [Hospital Unit Name ] With: Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) 679] Phone: [Telephone/Fax (1) 682] [First Name4 (NamePattern1) 1730] [Last Name (NamePattern1) ] MD [MD Number(1) 2362] ICD9 Codes: 5849, 2762, 2767, 412, 2720, 5859, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8204 }	Medical Text: Admission Date: [2109-11-15] Discharge Date: [2109-11-23] Date of Birth: [2109-11-15] Sex: M Service: NEONATAL HISTORY: This is a full term baby boy transferred from the Well Baby Nursery at 48 hours of age to the Neonatal Intensive Care Unit for further evaluation and management of tachypnea and increased work of breathing. The baby is a 3315 gram baby boy [Name2 (NI) ] to a 30 year old Gravida 4, P 2 to 3 mother with prenatal screens of maternal blood type of A positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, Group B Streptococcus negative. There is a benign prepartum course notable only for Zoloft secondary to depression. There was an uncomplicated vaginal delivery with no perinatal risk factors for sepsis, short second stage, presence of meconium stained amniotic fluid. Rupture of membranes were minutes before delivery with no maternal fever, no intrapartum antibiotic prophylaxis. Resuscitation required only blow-by oxygen and routine care in the delivery room with Apgars of 8 at one minute and 10 at five minutes. The baby boy was transferred to the Well Baby Nursery, where he was eating well with no concerns until the night prior to transfer to the Neonatal Intensive Care Unit when he was evaluated for tachypnea, felt to be mildly symptomatic and attributed to retained fetal lung fluid; however, in the morning he was noted to still be tachypneic with mild intermittent retractions, therefore transferred to the NICU for further evaluation. On initial physical examination, his oxygen saturation was 91% in room air with respiratory rates ranging from 40s to 70s. Overall, he was well appearing, non-dysmorphic. Anterior fontanel was soft, open and flat. The palate was intact. Breath sounds were clear with intermittent tachypnea and subcostal retractions. Cardiovascular examination was reportedly without murmur initially. The abdomen was benign without any hepatosplenomegaly, no masses, with normal male genitals with bilateral descended testes. He had a normal back. His extremities and skin were warm and well perfused. He had normal tone, strength, and responsivity. INITIAL ASSESSMENT: This is a 48 hour old male with mild but persistent respiratory symptoms, still most likely to be transitional physiology, but concerning because of delayed onset of respiratory distress on day of life number two. Therefore, he was admitted to the Neonatal Intensive Care Unit for evaluation for infection. SUMMARY OF HOSPITAL COURSE BY SYSTEM: 1. RESPIRATORY: The infant initially required nasal cannula at a flow of 100 cc per minute of 100% special inspired oxygen. Over the next two days, he was gradually weaned off of nasal cannula to room air. By day of life number five, he was saturating in the high 90s in room air, and by the time of discharge, he was no longer tachypneic, saturating in the high 90s in room air, with clear breath sounds and no retractions. His initial chest x-ray on admission showed minimally hazy lung fields, right greater than left, possibly consistent with a transient tachypnea of the newborn, but not able to rule out pneumonia. The cardiac was normal. No further imaging studies were done. At the time of discharge, he had no respiratory issues. 2. CARDIOVASCULAR: He remained stable throughout his admission from a cardiovascular standpoint with normal heart rates and blood pressures; however, on day of life three, a soft murmur was noted. A cardiac evaluation was initiated. As mentioned previously, the chest x-ray showed a normal cardiac silhouette. Four extremity blood pressures were normal. By the time of discharge, pre and post room air saturations were well over 95% with no differential saturation. An EKG was performed on day of life six and repeated on day of life seven, which when reviewed by Cardiology, seemed to be indicative of mild right sided predominant voltages within normal limits for age. Cardiology examined and evaluated this baby, and concluded that he had no significant cardiac disease. His soft systolic murmur persisted throughout his admission. He has no active cardiac issues at this time. His initial blood sugar was 65. Because he was not in significant respiratory distress on admission, he was continued on ad lib exclusive breast feeding. Throughout his admission, he breast fed extremely well, typically every one to two hours. He was gaining weight very well. At the time of discharge, his weight was 3475 grams, up from his birth weight of 3315 grams. 3. INFECTIOUS DISEASE: For initial sepsis evaluation, a CBC was sent with a white blood cell count of 14.4, 70% polys, 2% bands, 1% metamyelocytes, 23% lymphocytes, for an ITT ratio of 4%. Hematocrit was 43, platelets 422. Blood cultures were sent which remained no growth to date. Because of the mild chest x-ray abnormalities, he was started on Ampicillin and gentamicin on admission and completed a seven day course on [11-23]. A gentamicin level after three doses were within the normal range. A lumbar puncture was performed on day of life three, one day after initiation of antibiotics. It showed 22 white blood cells, 56,000 red blood cells which cleared during the tap, protein of 193, glucose 61, negative Gram stain, and negative cerebrospinal fluid cultures. He will have completed a seven day course of Ampicillin, gentamicin for presumed pneumonia on [11-23]. 4. SENSORY: A hearing screen was performed with automated auditory brain stem responses with normal results in both ears; however, because of the seven day course of gentamicin, repeat testing in 3 months is recommended. 5. ROUTINE HEALTH CARE MAINTENANCE: Newborn screen was sent on [11-17] with the results pending. Hepatitis B vaccine was administered on [11-17]. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) 2048] [Last Name (NamePattern1) 53585] at the South [Location (un) 538] Health Center. I believe Dr.[Name (NI) 53586] phone number is [Telephone/Fax (1) 53587]. CARE/RECOMMENDATIONS: 1. Continue ad lib breast feeding. 2. Medications at discharge only included multivitamin because of the exclusive breast feeding. 3. State Newborn Screen is still pending. 4. Hepatitis B number one has been given. 5. Follow-up Auditory Brain Stem Response testing should be done in 3 months as above DISCHARGE DIAGNOSES: 1. Respiratory distress. 2. Presumed pneumonia. 3. Benign cardiac murmur. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By: [Name6 (MD) ] [Name8 (MD) 2601], M.D. MEDQUIST36 D: [2109-11-22] 16:50 T: [2109-11-22] 18:48 JOB#: [Job Number 53588] ICD9 Codes: 486, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8205 }	Medical Text: Admission Date: [2184-10-16] Discharge Date: [2184-10-20] Date of Birth: [2108-7-7] Sex: F Service: MED Allergies: Sulfa (Sulfonamides) / Norvasc Attending:[First Name3 (LF) 1377] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Esophogastroduodonoscopy X2 History of Present Illness: 75 yo f with a med hx of polycystic kidney and liver disease, HTN admitted from OSH for BRBPR found to have large antral ulcer on EGD. Pt was in USOH until 1am on [9-13] when she felt mild epigastric discomfort and nausea and dizziness w/o vomiting after dinner which resolved with maalox. At 1am pt woke with need to defacate and noticed BRBPR but was otherwise asymptomatic with 2 more bloody bm's so waited until 6 am to present to ED. Pt reported only one recent use of suspected ibuprofen use for HA but no chronic use of NSAIDS. SHe denied EtOH or smoking hx. She reported a hx of chronic anemia for which she sees a hematologist but has not had guaic neg stool and denied colonoscopy in past. She has never had BRBPR in past but has chronic black stools from iron pills. In OSH ed pt vitals were T 98.0 HR 94 BP 119/49 O2 sat 100% and had an hct 19 an hg 6.6, so she was transfused 3u PRBC's in ED with 3l ns and started on an 40mg protonix q12 and vitals remained stable. Past Medical History: 1. Polycystic disease of liver and kidney disease [2140] w/drainage of cysts and subsequent infx requiring long term abx therapy. Head MRI in [2179] neg for aneurysm. 2. hysterectomy-?oophorectomy 3. Anemia 4. Hypertension Social History: Widowed, lives in [Location 8447]. No alcohol or tob. [Doctor First Name ]: [Telephone/Fax (1) 27818] Family History: Mother died at 67 with [Name (NI) 18048], Father died at 91 of pancreatic CA, aunts with hx CVA. 1 duaghter with [Name (NI) 18048]. Physical Exam: Gen: NAD, A&O X 4, Heent: EOMI, PERRL, MMM, OP clear Neck: No JVD, LAD Heart: RRR, No murmurs or gallops. PMI non-displaced. Lungs: Scattered rhonchi. No rales or wheezes. Abd: Distended R>L. Nontender. +BS Ext: trace pedal edema. Neuro: Non-focal. Pertinent Results: [2184-10-19] 06:30PM BLOOD Hct-31.9* [2184-10-19] 06:15AM BLOOD WBC-2.4* RBC-3.40* Hgb-10.2* Hct-29.9* MCV-88 MCH-30.1 MCHC-34.2 RDW-16.6* Plt Ct-81* [2184-10-19] 06:15AM BLOOD Plt Ct-81* [2184-10-18] 06:40AM BLOOD Plt Ct-84* [2184-10-16] 08:10PM BLOOD PT-13.4 PTT-25.3 INR(PT)-1.1 [2184-10-19] 06:30PM BLOOD Glucose-128* UreaN-46* Creat-2.0* Na-141 K-4.6 Cl-111* HCO3-20* AnGap-15 [2184-10-16] 08:10PM BLOOD ALT-10 AST-22 AlkPhos-90 TotBili-0.5 [2184-10-19] 06:15AM BLOOD Cholest-125 [2184-10-18] 06:40AM BLOOD Albumin-2.9* Calcium-7.4* Phos-3.0 Mg-2.0 [2184-10-19] 06:15AM BLOOD Triglyc-96 HDL-36 CHOL/HD-3.5 LDLcalc-70 H.pylori negative. Brief Hospital Course: 1. Antral ulcer- EGD was performed which revealed a large antral ulcer with epi and malignancy was suspected but it was not bx'ed. CEA=3.50 and Abd CT obtained for CA workup. She received 2 more units prbc's post EGD despite hemodynamic stability and hgb 9.4 hct 27.8, and she was started on a protonix gtt. Pt was then transferred to the floor on her 3rd hospital day, with stable hematocrits. She had a repeat EGD whice showed a healing ulcer, gastritis and possible varicies. She was continued on protonix 40IV [Hospital1 ] for ulcer. Currently on [Hospital1 ] po. Pt typed and crossed and started on maintenance IVF with [Hospital1 ] hct checks which was normal. H.pylori serologies negative. Dr.[First Name (STitle) 1158] Tray is the pt's outpt doctor, and he assumed care of the patient while in house. The record of her OSH abd CT read were significant for hepatic and renal cysts, normal spleen, scattered para-aortic adenopathy, small amount of ascities and emphysematous changes in bilateral lung bases. 2. Renal: Pt with [First Name (STitle) 18048] with liver involvement. Her baseline creatinine is 1.4, and she came in at 1.6 which elevated to 1.9. She improved with some fluids, so her ARF was likely secondary to prerenal azotemia. No hematuria. Renal was consulted and suggested optimal BP control, of crucial importance in the care of [Name (NI) 18048] pt's. We added clonidine and held ACE/[Last Name (un) ] becuase of her pre-renal azotemia. She will f/u with renal as an outpt. 3. Cardiovascular: Pt was continued on metoprolol for hx of SVT (details not known). Metoprolol was switched to the non-cardiac selective beta blocker nadolol 40mg po QD for potential decompression of portal system (pt found to have varicies on EGD). No arrhythmias while in house. For hypertension, the pt was continued on HCTZ. Renal suggested clonidine and not ACE-I/[Last Name (un) ] in lieu of slight renal failure. She was placed on clonidine TTS once a week. 4. Pulmonary-CXR with atelectasis. Sats remained stable. She was recommended ambulation and treated with incentive spirometry. 5. Pancytopenia: Pt with wbc 2.2 and plts 80-100's. A reasonable explanation for her anemia was GI blood loss, however, a component of possible marrow failure is suggested by the two other low level blood lines. She has had a negative BM in the past (specifics unknown). She may have a myelodisplastic syndrome vs non-malignanct aplastic anemia. Her normal MCV does not rule out MDS. She should have an outpt BM biopsy for this. She will be referred to H/O clinic for this ([2184-11-16] at 1445 on [Hospital Ward Name 23] [Location (un) ] with Dr.[First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2539], ([Telephone/Fax (1) 27819]. The patient also has an oncologist she has been seeing for over one year whom she may also f/u with. 5. FEN-Pt was placed on IVF while NPO. Her diet was advanced from NPO to clears to full liquids, finally to solids by the last hospital day. The pt did have a non-gap acidosis attributed to diarrhea (blood being a cathartic). This [Female First Name (un) ] resolved by time of discharge. Medications on Admission: Protonix 40 IV BID MSO4 prn Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 2. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). Disp:4 Patch Weekly(s) Refills:2 3. Nadolol 40 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Gastric Bleed Discharge Condition: Good Discharge Instructions: If you have these symptoms, call your doctor or go to the ER: -blood in stool -black stools -dizziness -fainting -dark vision -blood in vomit Followup Instructions: 1. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 9052], MD Where: [Hospital6 29] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2184-11-16] 2:45 2. Dr.[First Name (STitle) 679]: Please call for an appointment. ([Telephone/Fax (1) 16940] 3. Kidney Clinic: Dr.[Last Name (STitle) ], Tuesday, [12-14] at 1pm [Location (un) 436] of [Hospital 23] Clinic. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(1) 1379] Completed by:[2184-10-20] ICD9 Codes: 2765, 2762, 5849, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8206 }	Medical Text: Admission Date: [2160-11-27] Discharge Date: [2160-12-3] Date of Birth: [2082-3-31] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2186] Chief Complaint: tachypnea at nursing home Major Surgical or Invasive Procedure: None History of Present Illness: HPI: (pt non-verbal non-responsive at baseline) 78 yo m NH resident w/ h/o DM, HTN, CVA, who had an attack of hypoglycemia on [2160-11-26] which resolved with [Location (un) 2452] juice administration. Next morning he was tachypneic and required NRB. hence transferred to [Hospital1 ] ED. In the ED was hypotensive to 80s, which resolved with 2L NS. thought to be sepsis and started on vanc, levo and flagyl. per family, h/o cough w/ yellowish sputum production without fever, chills. was admitted to MICU. . In MICU, abx changed to vanc and zosyn. also received 4 L NS for hypotension. Patient had afib with RVR and heart rate was stabilized with IV diltiazem and lopressor. Pt was stabilized and transferred to floor . On floor, he triggered for HR in 150s. also was found to have vomit in mouth and chest with satts in low 90s on 8L. was transferred to MICU for presumed aspiration. . Continued on vanc and zosyn. lopressor ineffective in controlling HR. hence continued on dilt 30 qid. pt stable and hence transferred back to floor. Past Medical History: DM2 (HgbA1c 6.0% [6-/2160]) HTN Tobacco abuse CRI (followed by Dr. [Last Name (STitle) ], b/l Cre 1.5) gout cataracts glaucoma s/p left inguinal hernia repair h/o TB (while in [Country 651] in his 30's, denies ever being treated) Social History: Retired machinist, moved to the United States 13 years ago from [Country 651]. He lives in a nursing home. His daughter lives nearby. Long-time smoker. He denies any alcohol or illicit drug use. Family History: noncontributory Physical Exam: VS: T 97.1 HR 94(91-104) BP 152/73 (151-173/61-84) RR 24 O2 sat 98% Face mask 35% O2. Gen: elderly male, lying in bed, non-verbal, non responsive to deep stimuli, tachphyneic HEENT: PERRL, no JVD, no LAD, MMM Neck: supple Heart: irregularly irregular, no M/R/G Pulm: CTABL ant Abd: soft, NT, ND, + BS, Gtube in place Ext: no peripheral edema, distal pulses 2+ Neuro: awake, unable to assess motor or sensory function Pertinent Results: Urine [11-27]: STAPHYLOCOCCUS, COAGULASE NEGATIVE \| GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S . bcx [11-27]: coag negative staph in [11-27] bottles sputum cx [11-27]: moderate growth of MRSA . Diagnostics: ECG: atrial fibrillation with a rate of 143 TWF in III, V6, AVF . CXR [11-27]:Bilateral consolidations due to pneumonia or aspiration . CXR [11-28]: Worsening left perihilar and right lower lobe opacities highly suspect for aspiration versus multifocal pneumonia. . CXR [11-30]:: No interval change. Diffuse airspace opacities consistent with known multifocal pneumonia. . Sputum [2160-11-30]: GRAM STAIN (Final [2160-11-30]): <10 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [2160-12-2]): MODERATE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). SPARSE GROWTH. . MRSA screen [2160-12-1]: MRSA SCREEN (Final [2160-12-1]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS . Blood culture [2160-11-27]: AEROBIC BOTTLE (Final [2160-11-30]): REPORTED BY PHONE TO [Doctor First Name ] [Doctor Last Name 10280] @ 2035 ON [11-28] - CC6D. STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. ANAEROBIC BOTTLE (Final [2160-12-3]): NO GROWTH. Brief Hospital Course: A/P: 78 yo male with h/o HTN, DM, CVA, afib w/ RVR p/w hypoglycemia, hypotension. was treated for aspiration pneumonia and suspected sepsis. was in MICU twice and was finally transferred to floor for further care. . #Tachypnea/hypoxia: Patient had a known multifocal PNA, with MRSA in his sputum. had witnessed aspration of his vomit. CXR showed bilat consolidation. pt was afebrile and wbc count was wnl. was hypotensive on presentation and hence considered to be in sepsis. was started on vanc, zosyn and flagyl initially. on transfer to the MICU, the flagyl was discontinued. on discharge the antibiotics were converted to PO abx. hence vanc and zosyn were d/c'd and linezolid and ciproflox were started. the patient will be treated for total 14 days. hence will be on linezolid and ciproflox for 7 more days from discharge. the O2 satts improved after starting the abx. as mentioned above, pt was afebrile with nl wbc count.aspiration precautions were followed . #Afib with RVR: identified during this admission. HR ranged from 90 to 170. pt used to convert to sinus rhythm by himself sometimes and then would [Last Name (un) 7162] go back into afib. was started on dilt 30 qid and was uptitrated to 60 qid. the HR was well controlled at this dose with patient in sinus rhythm. will require anticoagulation with coumadin. coumadin was held during this admission as INR was supratherapeutic. will need to restart once INR becomes therapeutic. . #Hypertension: Admitted with hypotension, which was thought to be from sepsis. received 2 L NS in ED and BP returned to [Location 213]. was hypertensive later in the course. was treated with dilt 60 qid. . #s/p CVA: Patient was anticoagulated. was supratherapeutic on coumadin. hence it was held. will need to restart once INR becomes therapeutic. . #FEN: Continue tube feeds. NPO as aspiration risk. will need to check electrolytes daily and replete accordingly as his potassium, magnesium and phosphate were low during this admission. . #Prophylaxis: no need of heparin SQ as INR was supratherapeutic, bowel regimen, famotidine . #Code: DNR/DNI. . #Communication: With patient and family. daughter [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 26144]) . Medications on Admission: Hydrochlorothiazide 50 mg PO DAILY Insulin sliding scale Docusate Sodium (Liquid) 100 mg PO BID Famotidine 20 mg PO BID Piperacillin-Tazobactam Na 4.5 gm IV Q8H Vancomycin HCl 1000 mg IV Q 12H Diltiazem 30 mg PO QID Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): hld for HR <60, SBP <90. 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 6. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Discharge Disposition: Extended Care Facility: [Hospital1 2670] - [Location (un) ] Discharge Diagnosis: Aspiration pneumonia Atrial fibrillation . DM2 HTN Tobacco abuse CRI gout cataracts glaucoma s/p left inguinal hernia repair h/o TB (while in [Country 651] in his 30's, denies ever being treated) Discharge Condition: Stable Discharge Instructions: You were diagnosed with pneumonia and hence will be treated with antibiotics for total 14 days. . If you have chest pain, shortness of breath, palpitations, dizziness, fever, chills, cough, pain in stomach, nausea or vomitting please call your doctor or go to the emergency room Followup Instructions: Please make a follow up appointment with your Primary care provider Dr [Last Name (STitle) ] ([Telephone/Fax (1) 26145]) within 2 weeks of discharge . Please check Serum potassium, magnesium and phosphate regularly as these have been low during this hospitalization. Please replete these electrolytes accordingly. . We have held the coumadin as patient's INR was supratherapeutic. Please restart it when the INR becomes therapeutic. . Please follow aspiration precautions. Completed by:[2160-12-3] ICD9 Codes: 0389, 5070, 5859, 4280, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8207 }	Medical Text: Admission Date: [2161-11-22] Discharge Date: [2161-11-27] Date of Birth: [2109-6-15] Sex: F Service: MEDICINE Allergies: Ciprofloxacin Attending:[First Name3 (LF) 613] Chief Complaint: Transfer from [Hospital3 15174] for treatment of altered mental status. Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a 52 year old woman with past medical history significant for chronic pain on narcotics and benzodiazepines, malabsorption syndrome due to complications of gastric bypass surgery, and severe osteoporosis. Three days prior to her admission to the outside hospital, the patient presented to her PCP's office for evaluation of ~20 pound weight loss that had occurred over the past 6-8 weeks. The patient was found to have a urinary tract infection, and she was prescribed Ciprofloxacin. The patient took two doses of the antibiotic. The following day, the patient's husband noted that his wife seemed very nervous and agitated. He called the PCP, [Name10 (NameIs) 1023] advised the patient to discontinue the Ciprofloxacin. That evening, the patient's husband noted that the patient was laughing inappropriately while she watched TV. She thought the TV was "talking to her." The patient's husband called 911, but by the time the EMTs arrived at their home, the patient was able to answer questions correctly, and she refused to go to the hospital. The following morning, the patient was noted to be more agitated, paranoid, and delusional, so her huaband called 911 again. This time, the patient was taken to [Hospital3 15174]. On presentation to the outside hospital, the patient was noted to have a low grade temperature (100.2). Her neurologic exam was reported as "non-focal," and a non-contrast head CT was negative for bleed. The patient's tox screen was negative for ETOH. Her other laboratory data was unremarkable. The patient was admitted to the hospital for treatment of narcotic withdrawal. During her 36 hour hospitalization, the patient was given two doses of Buprenex. Subsequently, the patient became lethargic, confused, combative, and agitated. She was transferred to the ICU for further management. She was given a few doses of Haldol and Ativan for her agitation. Lumbar puncture was unsuccessful. Given her persistent agitation and concern for narcotic withdrawal, the patient was transferred to [Hospital1 18] MICU for further management. Past Medical History: Motor vehicle accident, complicated by R ankle injury and rib fractures, [2151] Chronic pain syndrome since motor vehicle accident s/p R leg BKA due to R ankle injury in above MVA, [2154] Malabsorption syndrome, s/p gastric bypass surgery for morbid obesity, ~22 years ago Asthma. Patient has been hospitalized for asthma exacerbations, but she has never been intubated. Relapsing-remitting multiple sclerosis, questionable diagnosis ~8 years ago. Patient given diagnosis based on problems with motor coordination. Depression. Hospitalized in [2141] at [Hospital3 3765] for psychiatric illness. Migraine Social History: The patient lives at home with her husband. She has three children. Her husband states that she does not abuse tobacco, alcohol, or illicit drugs. The patient is currently on SSI. Family History: Mother with alcoholism. Physical Exam: GEN: Agitated, diaphoretic, cachectic appearing female lying in bed. Patient appears tremulous. VS: T: 98.8 HR: 122 BP: 140/69 RR: 18 O2sat: 98% RA HEENT: NC/AT. PERRL. EOMI. Pupils dilated ~3 mm. Edentulous. MM dry. OP clear. NECK: Supple. No nuchal rigidity. Palpable thyroid. CVS: Tachycardic. S1, S2. No murmurs, rubs, or gallops. LUNGS: CTAB. No rales, wheezes, or crackles. ABD: Scaphoid, non-tender, non-distended, +BS. EXT: Right stump without c/c/e. Left leg without c/c/e. Extremities warm, well-perfused. SKIN: No rashes or lesions. NEURO: Patient thinks the year is "[2162]," knows she is in a hospital, and thinks "[Last Name (un) 2450]" is the president. +Tremor. Strength [5-13] in all extremities. Finger-to-nose intact. Reflexes 2+ throughout. Pertinent Results: [2161-11-22] 07:36PM WBC-10.0 RBC-3.68* HGB-8.5* HCT-27.6* MCV-75* MCH-23.1* MCHC-30.8* RDW-22.6* Labs on admission: [2161-11-22] 07:36PM NEUTS-85.8* LYMPHS-10.0* MONOS-3.8 EOS-0.3 BASOS-0.1 [2161-11-22] 07:36PM PLT COUNT-878* [2161-11-22] 07:36PM GLUCOSE-97 UREA N-7 CREAT-0.3* SODIUM-139 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13 [2161-11-22] 07:36PM ALT(SGPT)-10 AST(SGOT)-17 ALK PHOS-89 TOT BILI-0.2 [2161-11-22] 07:36PM ALBUMIN-3.1* CALCIUM-8.3* PHOSPHATE-3.0 MAGNESIUM-1.8 [2161-11-22] 07:36PM PT-13.1 PTT-26.9 INR(PT)-1.1 [2161-11-22] 07:36PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.014 [2161-11-22] 07:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2161-11-22] 10:12PM CEREBROSPINAL FLUID (CSF) PROTEIN-28 GLUCOSE-76 [2161-11-22] 10:12PM CEREBROSPINAL FLUID (CSF) WBC-7 RBC-370* POLYS-20 LYMPHS-76 MONOS-4 [2161-11-22] 10:12PM CEREBROSPINAL FLUID (CSF) WBC-10 RBC-2500* [2161-11-23] 02:53AM BLOOD calTIBC-384 Ferritn-7.5* TRF-295 [2161-11-22] 07:36PM BLOOD VitB12-GREATER TH Folate-GREATER TH [2161-11-22] 07:36PM BLOOD TSH-0.62 [2161-11-22] 07:36PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG EKG: (OSH) Sinus tachycardia, 96 bpm. Nl int, nl axis. No ST/TW changes. CXR: No infiltrates or consolidations. Labs on discharge: [2161-11-26] 05:59AM BLOOD WBC-9.6 RBC-3.82* Hgb-8.6* Hct-29.0* MCV-76* MCH-22.6* MCHC-29.8* RDW-22.5* Plt Ct-657* [2161-11-26] 05:59AM BLOOD Plt Ct-657* [2161-11-26] 05:59AM BLOOD Glucose-108* UreaN-12 Creat-0.3* Na-142 K-4.8 Cl-108 HCO3-32* AnGap-7* [2161-11-26] 05:59AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.0 [2161-11-25] 07:51AM BLOOD tTG-IgA-DONE [2161-11-25] 07:51AM BLOOD ENDOMYSIAL ANTIBODIES-PND Brief Hospital Course: 1. MICU COURSE ([Date range (1) 12258]): Pt had an LP and the results of the CSF analysis were unremarkable. Her mental status improved in ICU and she became much more alert and was oriented by the morning of the second hospital day. While in the ICU, the chronic pain service was consulted. Their recommendations are noted below. 2. Altered mental status: As above, the pt. underwent a lumbar puncture, the results of which were not suggestive of CNS infection as the cause of her encephalopathy. A TSH, B12 and electrolytes were sent which were all within normal limits. An RPR was sent and was nonreactive. Upon further discussion with the pt. when she became more alert, it was discovered that after taking the first two doses of ciprofloxacin the week prior to admission, the pt. became extremely nauseous and had episodes of emesis and diarrhea. This led the pt. to stop taking her narcotics which she is on chronically for pain. Thus, it was believed that the pt's. altered mental status was secondary to narcotics withdrawal. It should be noted, however, that ciprofloxacin has been associated with acute psychosis, seizures, and acute delirium. 3. Chronic pain: The pt. reported that she had been on large doses of oxycontin, valium and neurontin for pain in her right shoulder, back and legs prior to admission. In the context of her heavy narcotics use, a chronic pain service consult was obtained while the pt. was in the intensive care unit. They recommended stopping oxycontin and decreasing the dose of valium. In addition, they recommended continuing neurontin and adding methadone. The pt. initially tolerated this regimen well. However, on the fourth hospital day, the pt. continued to complain of leg spasms. Baclofen was introduced with some success in relieving her spasms. The pain service also recommended that the pt. be started on celecoxib for musculoskeletal pain but this was held over the concern of possible upper gastrointestinal bleeding in the setting of iron deficiency anemia of yet uncertain etiology. 4. Iron deficiency anemia: The pt. was found to have profound iron deficiency anemia on admission. Further discussion with the pt. and her PCP revealed that the pt. has known iron deficiency and has received supplementation in the past. A gastroenterology consult was called. They had recommended performing both colonoscopy to examine for occult malignancy (especially in the face of recent unintentional weight loss and cachexia) and an EGD to evaluate the anatomy of her upper GI tract in light of her prior gastric bypass. The pt. did not desire to undergo these procedures during this inpatient hospitalization, but agreed to follow-up for these studies on an outpatient basis. The importance of following-up regarding this issue was explicitly stressed to the pt. prior to discharge. She was discharged on 325mg of ferrous sulfate once per day. 5. Weight loss/cachexia/?malabsorption: In light of the pt's. ~20 pounds over the 6 to 8 weeks prior to admission, a nutrition consult was obtained. They had recommended TPN in addition to encouraging the pt. to increase her p.o. intake. The pt. did received three days of TPN through a PICC line in addition to a regular diet. There was, again, concern over occult malignancy which further prompted the desire to perform a colonoscopy. A breast exam was also performed as a part of a malignancy work-up and was unremarkable. The pt. stated that she has had a "negative" mammography within the last year. The gastroenterology service also raised the possibility of celiac disease and tTG-IgA and endomysial antibodies were sent and were pending at the time of discharge. There is also the possibility that her weight loss is secondary to her profound depression with vegetative symptoms. 6. Depression: The pt. admitted to severe depression in the months prior to admission. As such, the psychiatry service was consulted. They recommended re-starting fluoxetine which was done at a dose of 20mg per day. 7. Osteoporosis: The pt. was started on calcium and vitamin D supplementation. 8. Migraine Headaches: The pt. complained of headache suggestive of typical (not classical) migraine. Her pain was not relieved with acetaminophen. A trial of subcutaneous sumatriptan, however, did provide relief. She was discharged with a prescription for subcutaneous sumatriptan with instructions to stop taking the medication if she experienced flushing, dizziness, fatigue (suggestive of serotonin syndrome due to concomitant use of fluoxetine). Medications on Admission: [Doctor First Name ] 180 mg PO daily Premarin 1.25 mg PO daily Maxair prn Oxycontin 160 mg PO 8x/daily Neurontin 600 mg PO daily Percocet 325-650 mg PO q4-6hours prn pain Valium 20 mg qid prn pain Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 2. Methadone HCl 5 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). Disp:60 Tablet(s) Refills:0 3. Diazepam 10 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:0 4. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). Disp:120 Capsule(s) Refills:2 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet, Chewable(s) Refills:2 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 8. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 9. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. Sumatriptan Succinate 6 mg/0.5 mL Kit Sig: One (1) Subcutaneous Q1H PRN as needed for headache not controlled by tylenol: [Month (only) 116] repaat after one hour if headache not controlled by first dose. Do NOT take more than 12mg in a 24 hour time period. Disp:60 syringes Refills:2 12. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: -acute delirium, likely secondary to narcotics withdrawal vs. reaction to ciprofloxacin, resolved. -iron deficiency anemia -depression -chronic pain -osteoporosis -migraine headache Discharge Condition: The pt. was alert and completely oriented. She was tolerating a p.o. diet and eating well. She was ambulating with the assistance of a walker. Discharge Instructions: Please take all of your medications as perscribed. Please notice that you have had many medication changes. Please be sure to attend all of your follow-up appointments. If you experience any concerning symptoms, including dizziness, flushing or confusion, please call your primary care doctor or come to the emergency department for evaluation. Followup Instructions: Please call your primary care doctor, Dr. [First Name4 (NamePattern1) 487] [Last Name (NamePattern1) 59655] at [Telephone/Fax (1) 26677], to schedule a follow-up appointment regarding this hospitalization within one week. It is strongly recommmended that you undergo a colonoscopy and esophagogastroduodenoscopy to investigate the cause of your anemia and weight loss. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] ICD9 Codes: 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8208 }	Medical Text: Admission Date: [2188-5-27] Discharge Date: [2188-6-4] Date of Birth: [2112-8-21] Sex: F Service: ADDENDUM: CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Acute renal failure. 2. Urinary tract infection. 3. Dependence on ventilator. 4. Diabetes mellitus. 5. Pseudomonal colonization of airways. DR [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] 11.685 Dictated By:[Last Name (NamePattern4) 20726] MEDQUIST36 D: [2188-6-3] 13:52 T: [2188-6-3] 21:24 JOB#: [Job Number 20727] ICD9 Codes: 5845, 5990, 2762, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8209 }	Medical Text: Admission Date: [2149-1-3] Discharge Date: [2149-1-8] Date of Birth: [2095-9-22] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1711] Chief Complaint: chest pain Major Surgical or Invasive Procedure: intubation History of Present Illness: 53 yo male with history of CHF EF 40%, HTN, HLD, PAF, tobacco abuse, COPD, PE, severe PVD with SFA and B/L iliac stents and medication noncomplicance. He also underwent DCCV on [2148-1-3] orning and started on amiodarone (despite prior LFT elevations with amiodarone). He presented with chest pain [2147-4-5] of sudden onset while at the store doing some shopping; he also developed shortness of breath at that time. The patient states that the pain is pleuritic in nature. Otherwise the patient does not have any leg swelling. Pain not worse with exertion. Otherwise no abdominal pain, fevers, chills, cough, sputum. Pain not worse with exertion. Otherwise no abdominal pain, fevers, chills, cough, sputum. . He was recently admitted [Date range (1) 66521] for Afib with RVR and chest pain. He ruled in for NSTEMI felt to be demand from hypertensive urgency (SBP 200/100's) and RVR. Consideration was given to AVJ ablation and pacemaker placement as well but he remained in sinus rhythm after DCCV and amiodarone initiation. Also treated with a course of levofloxacin for pneumonia, and treated for a CHF exacerbation. He was also started on dabigatran. There was also some question if he was having intermittent short runs of VT vs Afib with aberrancy.Furthermore, this morning he had undergone Successful electrical cardioversion of atrial fibrillation to sinus rhythm. . ED Course (labs, imaging, interventions, consults): - Initial Vitals/Trigger: Pain-7 98.5 73 182/103 20 93% RA - EKG: sr 69, lad/no ST/TW changes. [x] cxr - unremarkable. [x] asa [x] [Hospital Unit Name ] attending: give lasix 120 mg iv, admit Admission Vitals: Pulse: 63, RR: 21, BP: 166/87, O2Sat: 94 2L PIV: 18 g x1. CTA not done due to elevated creatinine. . On arrival to the floor, patient complained of mild chest pain, which was unchanged from his initial presentation, and was relieved with morphine. He had no other active complaints. His blood pressures continued to go up to about 200/100, therefore he was started on a nitro drip. . At about 7 am, he desatted to 70s, was given atrovent nebs, and became unresponsive. A code blue was called. BP 220s/110s. ABG 7.02/109/113. Lactate 5.5. IV lasix/NTG started, and pt emergently intubated. During the code, he was also noted to have some bleeding out of his left ear, and his pupils were noted to be unequal He was intubated and transferred to the ICU. In the CCU, initial vitals were 174/93, 113, 22, 99% on [10-8] 70% FiO2. He became responsive, and was orientated x3. Pupils were equal. Continues to complain of left-sided mild chest pain, no worse than prior. He was started on fenatyl/ midazolam. His blood pressures started dropping, nitroglycerin drip was stopped. However, BP plateaued at 85 systolic, and are currently stable at around 110 systolic. . REVIEW OF SYSTEMS: + -fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: Atrial fibrillation with RVR s/p multiple DCCV, most recently on [12-11] now on dabigatran and amio; has hx of poor rate control partly due to noncompliance with meds -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: PE ([2138]); unknown cause CHF PVD s/p Aortoiliac bifurcation stents SFA [2147-7-28] and CIA [2147-2-10] Small Infarenal AAA Scoliosis Tobacco abuse (1 1/2 packs daily)- Interested in quitting smoking Heroin abuse Social History: -Tobacco history: 1.5 ppd for >30 years -ETOH: Used to drink 10 beers per day. Now does not take any. -Illicit drugs: Snorts every other day. Otherwise, no illicits. He is married, working as a night crew clerk. Family History: Father: Leukemia Mother: emphysema, CHF Mother died from CHF. Physical Exam: On admission: Gen: Intubated, calm, NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. Otoscopic examination: tympanic membranes both clear. NECK: Supple, No LAD. Normal carotid upstroke without bruits CV: Irreg/Irreg. Normal S1,S2. No murmurs. LUNGS: CTAB. No wheezes, rales, or rhonchi. Reduced air entry bilaterally. ABD: NABS. Soft, NT, ND. EXT: WWP, NO CCE. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Grossly non-focal. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . At discharge: Vitals: 97.9/97.9 HR:57-60 BP:160-168/88-101 RR:18 02 sat:97% RA 53 yo M in no acute distress, sitting in chair HEENT: mucous membs moist, no lymphadenopathy, JVP non elevated CHEST: CTABL no wheezes, no rales, no rhonchi CV: S1 S2 Normal in quality and intensity RRR, 2/6 systolic murmur at right upper sternal border. ABD: soft, non-tender, non-distended, BS normoactive. EXT: wwp, no edema. DPs, PTs 2+. NEURO: 5/5 strength in U/L extremities. gait WNL. SKIN: no rash PSYCH: a/o, pleasant, conversant Pertinent Results: [2149-1-3] 09:03PM BLOOD WBC-12.4* RBC-4.29* Hgb-12.1* Hct-36.5* MCV-85 MCH-28.2 MCHC-33.2 RDW-15.3 Plt Ct-263 [2149-1-4] 10:59AM BLOOD WBC-19.8# RBC-4.09 Hgb-11.4* Hct-34.8* MCV-85 MCH-27.9 MCHC-32.8 RDW-15.4 Plt Ct-256 [2149-1-5] 05:03AM BLOOD WBC-8.5# RBC-4.02* Hgb-11.3* Hct-33.6* MCV-84 MCH-28.1 MCHC-33.6 RDW-15.2 Plt Ct-181 [2149-1-6] 06:34AM BLOOD WBC-8.4 RBC-4.10* Hgb-11.6* Hct-35.0* MCV-86 MCH-28.4 MCHC-33.2 RDW-15.4 Plt Ct-194 [2149-1-7] 06:20AM BLOOD WBC-8.0 RBC-4.19* Hgb-11.8* Hct-35.3* MCV-84 MCH-28.1 MCHC-33.3 RDW-15.4 Plt Ct-208 [2149-1-3] 09:03PM BLOOD Neuts-68.5 Lymphs-23.5 Monos-3.3 Eos-3.8 Baso-1.0 [2149-1-7] 06:20AM BLOOD Neuts-62.5 Lymphs-25.4 Monos-4.9 Eos-5.9* Baso-1.3 [2149-1-3] 09:03PM BLOOD PT-15.8* PTT-87.1* INR(PT)-1.5* [2149-1-3] 09:03PM BLOOD Plt Ct-263 [2149-1-3] 10:30PM BLOOD PT-15.9* PTT-90.5 INR(PT)-1.5* [2149-1-4] 10:59AM BLOOD PT-13.6* PTT-65.5* INR(PT)-1.3* [2149-1-4] 10:59AM BLOOD Plt Ct-256 [2149-1-5] 05:03AM BLOOD Plt Ct-181 [2149-1-6] 06:34AM BLOOD PT-14.6* PTT-77.3* INR(PT)-1.4* [2149-1-6] 06:34AM BLOOD Plt Ct-194 [2149-1-7] 06:20AM BLOOD Plt Ct-208 [2149-1-3] 09:03PM BLOOD Glucose-114* UreaN-26* Creat-1.3* Na-141 K-4.3 Cl-106 HCO3-24 AnGap-15 [2149-1-4] 10:59AM BLOOD Glucose-124* UreaN-26* Creat-1.9* Na-143 K-3.8 Cl-105 HCO3-26 AnGap-16 [2149-1-4] 07:51PM BLOOD UreaN-27* Creat-1.8* Na-145 K-3.2* Cl-103 [2149-1-5] 05:03AM BLOOD Glucose-98 UreaN-23* Creat-1.5* Na-145 K-3.1* Cl-104 HCO3-28 AnGap-16 [2149-1-5] 04:49PM BLOOD Glucose-101* UreaN-26* Creat-1.4* Na-144 K-3.7 Cl-104 HCO3-28 AnGap-16 [2149-1-6] 06:34AM BLOOD Glucose-116* UreaN-24* Creat-1.3* Na-145 K-3.5 Cl-106 HCO3-28 AnGap-15 [2149-1-6] 02:45PM BLOOD UreaN-26* Creat-1.5* Na-146* K-3.5 Cl-104 HCO3-28 AnGap-18 [2149-1-7] 06:20AM BLOOD Glucose-110* UreaN-25* Creat-1.2 Na-140 K-3.3 Cl-101 HCO3-27 AnGap-15 [2149-1-4] 03:40AM BLOOD CK(CPK)-51 [2149-1-4] 10:59AM BLOOD CK(CPK)-57 [2149-1-3] 09:03PM BLOOD proBNP-1870* [2149-1-3] 09:03PM BLOOD cTropnT-<0.01 [2149-1-4] 03:40AM BLOOD CK-MB-2 cTropnT-<0.01 [2149-1-4] 10:59AM BLOOD CK-MB-3 cTropnT-0.02* [2149-1-4] 10:59AM BLOOD Calcium-8.8 Phos-5.7# Mg-2.2 [2149-1-4] 07:51PM BLOOD Mg-2.0 [2149-1-5] 05:03AM BLOOD Calcium-8.8 Phos-3.3# Mg-2.1 [2149-1-6] 06:34AM BLOOD Mg-2.2 [2149-1-6] 02:45PM BLOOD Mg-2.3 [2149-1-7] 06:20AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.1 [2149-1-4] 07:35AM BLOOD Type-ART pO2-113 pCO2-109* pH-7.02* calTCO2-30 Base XS--6 Intubat-NOT INTUBA [2149-1-4] 11:51AM BLOOD Type-ART pO2-149* pCO2-44 pH-7.40 calTCO2-28 Base XS-2 [2149-1-3] 09:06PM BLOOD K-4.4 [2149-1-4] 07:35AM BLOOD Glucose-268* Lactate-5.5* Na-146* K-4.0 Cl-101 [2149-1-4] 11:51AM BLOOD Lactate-1.0 [2149-1-4] 07:35AM BLOOD Hgb-13.8* calcHCT-41 O2 Sat-94 COHgb-2 MetHgb-0 [2149-1-4] 07:35AM BLOOD freeCa-1.36* . Discharge labs: [2149-1-8] 06:20a 140 104 21 102 AGap=14 3.6 26 1.1 Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes Mg: 2.3 6.9>12.1/35.8<212 [2149-1-3] CXR Slight vascular prominence with peribronchial cuffing, but otherwise unremarkable. . [2149-1-4] Echocardiogram The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is mild to moderate regional left ventricular systolic dysfunction with basal to mid inferior and inferolateral hypokinesis. The other segments are very mildly hypokinetic. Right ventricular chamber size is normal. with borderline normal free wall function. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2148-12-2], the right ventricle is probably mildly hypokinetic on the current study. Overall LV systolic dysfunction has worsened. . [2149-1-4] Echocardiogram AP radiograph of the chest was reviewed in comparison to [1-3], [2148]. The ET tube tip is 5 cm above the carina. The NG tube tip is in the stomach. There is interval development of moderate interstitial pulmonary edema. Note is made that the left costophrenic angle was excluded from the field of view but small bilateral pleural effusions cannot be excluded. Findings discussed with Dr. [First Name (STitle) 17385] over the phone by Dr. [Last Name (STitle) ] at 10:20 a.m. on [2149-1-4]. Brief Hospital Course: 53 yo male with history of CHF EF 40%, HTN, HLD, PAF, tobacco abuse, COPD, PE, severe PVD with SFA and B/L iliac stents and medication noncomplicance, and cardioversion this morning, who presented with chest pain [2147-4-5] of sudden onset while at the store doing some shopping, s/p code blue in hosptial for hypoxia and unresponsiveness. . # Hypoxia/flash pulmonary edema: S/p pulmonary edema and respiratory arrest [2149-1-4] with hypoxemia and unresponsiveness, intubated and then extubated 7 hours later. We diuresed him with furosemide, then transitioned him to his home lasix dose. He rapidly became euvolemic, had good oxygen saturation and respiration, and was stable prior to dishcarge. . # HTN: Workup for secondary causes negative. Pt has strong family history. Medication compliance an issue in the past, pt states he has no cost issues now and takes his medicines regularly. Has BP cuff at home. Goal BP 120-140. High this am before meds. We continued carvedilol, lisinopril and amlodipine. . #Atrial fibrillation - He was in sinus rhythm during this hospitalization. then started on amiodarone. At the time of discharge he had cardioverted, in sinus with some bradycardia to the high 40s. Planned amiodarone schedule: 200mg [Hospital1 ] ([2148-1-3]), then 200mg daily maintenance starting [1-9]. He will also continue carvedilol and pradaxa. . #Acute on Chronic Systolic CHF ?????? EF was mildly depressed from previous TTE, however recently s/p cardioversion for afib. We continued carvedilol, lisinopril and lasix. He was euvolemic at the time of discharge. . #[Last Name (un) ] ?????? baseline 1-1.2. Elevation to 1.9 likely in the setting of flash pulmonary edema/respiratory arrest with poor forward flow. We continued gentle diuresis until he was euvolemic. His [Last Name (un) ] had resolved and his creatinine was trending down at the time of discharge. Medications on Admission: 1. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 2 days: [2066-12-25]. Disp:6 Capsule(s) Refills:0 2. carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 3. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 8. diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). Disp:30 Capsule, Extended Release(s) Refills:2 11. amiodarone 100 mg Tablet Sig: Four (4) Tablet PO twice a day: Take 400mg twice daily [12-26], 300mg twice daily [Date range (1) 66523], 200mg twice daily [Date range (1) 33500], then 200mg daily starting [1-9]. Disp:120 Tablet(s) Refills:0 Discharge Medications: 1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Imdur 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 11. diazepam 5 mg Tablet Sig: One (1) Tablet PO PRN as needed for anxiety. Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: Acute on Chronic systolic congestive heart failure with respiratory arrest Atrial fibrillation s/p cardioversion Hypertension, poorly controlled Leukocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had high blood pressure after your cardioversion and developed flash pulmonary edema or congestive heart failure. You had to have a breathing tube inserted to help your breathe and you were given diuretics to get rid of the extra fluid. You will continue to take your lasix 80 mg daily at home. Your weight at discharge is 191 lbs. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 2 lbs in 1 day or 5 pounds in 3 days. You will have a home tele monitoring system set up at home that will check your weight, blood pressure, heart rate and oxygen level at home once a day. If you feel like your blood pressure is high at other times of the day, you can check it and if the blood pressure is higher than 150 (the top number) call the heartline or call your PCP (Dr. [Last Name (STitle) 66517]. When you are working nights, you should continue to take your medicines every 12 hours if possible and make sure that you take your twice a day medicines within a 24 hour period. We made the following changes to your medicines: -DECREASE the Amiodarone to 200mg daily -DECREASE your Carvedilol to 25 mg every 12 hours (was 37.5 mg) -ADD Imdur 30mg daily (long acting nitrate to help contol your blood pressure) Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [2149-1-21] at 2:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: FRIDAY [2149-1-31] at 12:30 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: FRIDAY [2149-1-31] at 2:00 PM With: [Name6 (MD) 251] [Last Name (NamePattern4) 677], 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 Completed by:[2149-1-8] ICD9 Codes: 5849, 4589, 4280, 496, 4439, 4019, 2724, 311, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8210 }	Medical Text: Admission Date: [2201-6-18] Discharge Date: [2201-6-24] Date of Birth: [2158-11-18] Sex: F Service: Neurology/MICU/Medicine HISTORY OF PRESENT ILLNESS: The patient is a 43 year old woman with a longstanding history of type I diabetes mellitus end stage renal disease on peritoenal dialysis, atrial fibrillation with prior right atrial thrombus, hypothyroidism and chronic hypotension who presented on [2201-6-18] with complaints of headache, and right sided weakness. Family members noted that she was not acting her usual herself. She was initially evaluated by Neurology service. MRI confirmed an ischemic stroke in the left inferior division of the Lt MCA artery. She was admitted to neurology but was then soon transferred to the Medical Intensive Care Unit secondary to the acute development of hypoxia. PAST MEDICAL HISTORY: Type I diabetes mellitus, complicated by triopathy. End stage renal disease, on peritoneal dialysis q. night and hemodialysis q. two weeks complicated by hypotension. Atrial fibrillation, with history of right atrial thrombus on coumadin. Barrett's esophagus. Chronic hypotension. Hypothyroidism. Osteoporosis. ALLERGIES: The patient has allergies to Tetracycline, Erythromycin, Morphine, Dilaudid and Ace inhibitors. HOME MEDICATIONS: Midodrine. Reglan. Levoxyl. Nephro-caps. Renogel. Phos-Lo. Amiodarone. Neurontin. Protonic. Vitamin D. Coumadin, currently 4 mg p.o. q. day. Epogen. Humilog insulin sliding scale, Lantis insulin. Compazine. Senokot. Colace. Lactulose. Lomotil. PHYSICAL EXAMINATION: Physical examination at the time of admission to [Hospital1 69] revealed the following: Vital signs revealed temperature of 97.2; blood pressure 142/80; heart rate 676 and regular; respirations 18; and oxygen saturation 98% on two liters of oxygen. General: The patient was awake and alert, coherent with fluent speech. HEAD, EYES, EARS, NOSE AND THROAT: Anicteric. No oral lesions. Moist mucosa. Heart: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. Lungs: clear to auscultation bilaterally. Abdomen: Soft, distended with diastole, nontender. Normal bowel sounds. Extremities: No clubbing or cyanosis, trace ankle edema. Neurologic: Mental status awake, alert, oriented, coherent, fluent speech. Cranial nerves: Right facial droop. Motor: 3/5 strength throughout on the right, compared to [5-4] on the left. LABORATORY DATA: CBC revealed a white blood cell count of 8.9; hemoglobin of 10.2; hematocrit of 33.4. PT 15.1, INR of 1.6; PTT 26.6. Sodium of 141; potassium of 4.8; chloride of 99; bicarbonate 22; BUN 63; creatinine 8.7; glucose 204. Initial blood gas was 7.32, 46, 135. Lactate was 1.7. CT of the head showed no acute intracranial hemorrhage; probable subacute to chronic left temporal lobe infarct. MR of the head showed an acute left frontoparietal infarct. Electrocardiogram showed normal sinus rhythm with a left axis. HOSPITAL COURSE: 1.) Acute Stroke presenting with Rt facial droop and mild Rt hemiparesis. Initial magnetic resonance scan showed an acute stroke in the medial temporal lobe, left insula and left posterior parietal lobe. The likely source of the stroke was embolus from atrial fibrillation and sub- therapeutic INR. A cardiac echo was done showing a right atrial thrombus. Carotid ultrasound did not show significant carotid disease. A bubble study was not able to be performed, secondary to a lack of venous access. Heparin was started and coumadin was loaded. When the INR came above two, the heparin was discontinued while the Coumadin was continued, closely following the INR. Goal INR [2-2]. In terms of the patient's right hemiparesis, the patient slowly regained some strength on her right side throughout her hospital course. At the time of discharge, she had 5/5 strength in her right lower extremity and 4/5 strength on her right upper extremity, the patient having most difficulty with hand grip on the right side. Also during her course, the patient had episodes of incoherent speech and dysarthriawhich improved by the time of discharge. Speech and swallow evaluation showed aspiratino of thin liquids and she was maintained on puree diet and thickened liquids. By discharge she was switched to ground foods and liquids at nectar consistency (thickened). The patient was loaded with Dilantin for seizure prophylaxis to be maintained for 4-6 weeks duration . She also is receiving physical therapy daily with much improvement and she will be discharged to a rehabilitation center. 2.) Hypoxia: The patient was initially admitted to the Intensive Care Unit because of hypoxia. This resolved without specific intervention. X- ray did show a possible new right lower lobe infiltrate but, given the lack of fever and no increased white count, it was most likely not an infectious process and no antibiotics were started. It was presumed that this was from aspiration and represented a chemical pneumonitis. 3.) End stage renal disease: The renal team was following the patient throughout her visit and she was getting her peritoneal dialysis five times a day. She was dialyzed less aggressively than at home to avoid hypotension and to keep systolic blood pressure at goal of 140 due to the acute stroke. Patient has a history of too aggressively dialyzing herself at home with peritoneal dialysis to the point of frequent hypotension. She was also maintained on midodrine for blood pressure support. 4.) Atrial fibrillation: The patient was in sinus rhythm throughout most of her hospital stay. Amiodarone and Coumadin were continued. Goal INR [2-2]. 5.) Mental status: The patient's mental status waxed and waned during her stay in the unit and the first couple of days. Once transferred to the floor, it was noted that she was receiving many doses of Haldol. When that was discontinued, along with her Zyprexa, her mental status improved. She did exhibit much reversal in sleep cycle and it was emphasized to the family that she needed to be kept active and awake during the day so she could sleep at night. 6.) Hypothyroidism: During her hospital stay, her TSH was noted to be 14. However, her dose of Levothyroxine was only recently increased and it was decided to keep her at her current dose and have TSH rechecked in another months time. CONDITION AT DISCHARGE: Good. DISCHARGE DIAGNOSES: Left frontal parietal stroke. Subtherapeutic INR. MEDICATIONS AT DISCHARGE: Phenytoin 150 mg p.o. three times a day. Metoclopromide 5 mg p.o. q.i.d. Calcitriol 0.25 mcg p.o. q. day. Warfarin 3 mg p.o. q h.s. - INR to be monitored - Goal [2-2]. Levothyroxine 88 mcg p.o. q. day. Aluminum hydroxide 30 mls p.o. three times a day with meals. Midodrine 5 mg p.o. three times a day. Atorvastatin 10 mg p.o. q. day. Epoetin 1,200 units subcutaneous two times per week on Tuesdays and Fridays. Docusate sodium 100 mg p.o. twice a day. Pantoprazole 40 mg p.o. q. day. Gabapentin 100 mg p.o. three times a day. Amiodarone 200 mg p.o. q. day. Nephro-caps, one capsule p.o. q. day. Lantus Insulin QD SSI - Regular DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-AEH Dictated By:[Last Name (NamePattern4) 19744] MEDQUIST36 D: [2201-6-24] 06:16 T: [2201-6-24] 05:31 JOB#: [Job Number 19745] cc:[2201] ICD9 Codes: 5070, 3572
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8211 }	Medical Text: Admission Date: [2109-4-16] Discharge Date: [2109-4-18] Date of Birth: [2054-8-17] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 443] Chief Complaint: Chest pain, LAD occlusion Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Mr. [Known firstname ] [Known lastname 89610] is a 54 year old male with a history of HTN, HLD, OSA who presented to an OSH on [4-15] with intermittant chest pain, dyspnea, new LE edema, and back pain ongoing for 3 days. His symptoms occured with both rest and activity. He had seen his PCP earlier in the day for these symptoms and was told that he likely had a heart attack based on EKG. Troponin peaked at 0.138. ECHO at OSH was notable for new CHF with EF of 25-30%. He also had a new cough and CXR that showed pneumonia vs. atelectasis in the LLL. He was afebrile and started on ceftriaxone and also given lasix. His cough subsequently resolved. He was transferred to [Hospital1 18] for cardiac catheterization and further management. . Cardiac catheterization showed 100% occlusion of the LAD that after multiple wire passes was eventually opened with [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 with good distal flow. He also had a 70% RCA lesion that was not intervened upon. He received a total of 410 cc of contrast and had an angioseal placed in the right groin. On arrival to the CCU he was chest pain free. . On review of systems, he notes recent cough, now resolved. He had a single episode of syncope a couple of years ago of unclear etiology. He has chronic back pain and left shoulder pain. He denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for the presence of chest pain, dyspnea on exertion, orthopnea, and new ankle edema. These symptoms have all improved since receiving lasix. He has one prior episode of syncope two years ago, but none since. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: 100% LAD occlusion with [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] 2 [2109-4-16] 3. OTHER PAST MEDICAL HISTORY: Hypertension Dyslipidemia Sleep apnea (on CPAP) CHF (Acute systolic heart failure, EF 25%) Diverticulosis Colon polyps BPH GERD Depression Erectile dysfunction Back pain s/p tonsillectomy and adenoidectomy s/p nasal septoplasty s/p maxillofacial surgery Social History: Lives at home with wife and son. Watches his 3 grandchildren on mondays during the week. Works as warehouse auditor for Shaws. No tobacco use, no history of tobacco use, ETOH- drinks 6 drinks/ week, denies illicit drug use. Family History: Father passed away age 52 from colon CA. Mom passed away age 74 from dementia. Brother alive, had MI in his 50's. Brother alive, had MI age 54. Sister passed away in her 60's from breast CA. Physical Exam: On Admission: VS: T=97.3 BP=147/102 HR=99 RR=17 O2 sat=96% RA GENERAL: WDWN middle-aged caucasian male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. [Name (NI) 44264] ptosis. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple without lymphadenopathy. Unable to assess JVP. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. Right groin dressing c/d/i. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 1+ Left: Carotid 2+ DP 1+ . On Discharge: Pertinent Results: Discharge labs: [2109-4-18] 07:20AM BLOOD WBC-7.4 RBC-5.38 Hgb-16.3 Hct-45.7 MCV-85 MCH-30.3 MCHC-35.7* RDW-13.9 Plt Ct-234 [2109-4-18] 07:20AM BLOOD Glucose-98 UreaN-21* Creat-1.2 Na-138 K-4.3 Cl-103 HCO3-28 AnGap-11 [2109-4-17] 04:37AM BLOOD Triglyc-149 HDL-32 CHOL/HD-6.7 LDLcalc-151* Cardiac Enzymes: [2109-4-17] 04:37AM BLOOD CK-MB-7 [2109-4-17] 04:37AM BLOOD CK(CPK)-109 Cardiac Cath FINAL DIAGNOSIS: 1. Total occlusion of the proximal LAD: see comments 2. [Name (NI) 9927] PTCA/stenting of the prox/mid LAD with a Promus OTW 2.5x18 mm [Name (NI) ] (proximally) and a Promus OTW 2.5x18 mm [Name (NI) ] (distally) deployed at 12 and 13 atm respectively. (see PTCA comments) 3. R 6Fr femoral artery Angioseal closure device deployed without complications (see PTCA comments) 4. ASA indefinitely; plavix (clopidogrel) 75 mg daily for at least 12 months for [Name (NI) ] Brief Hospital Course: Mr. [Known lastname 89610] is a 54 year old male with a history of HTN, HLD, OSA who presented to an OSH with chest pain, dyspnea, cough new LE edema, found to have acute CHF with an EF 25-30% and CAD now s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ] 2 to the LAD. . # CORONARIES: Patient has no prior history of CAD, but old EKG had changes concerning for MI in the past with no intervention at that time. EKG is consistent with LAD lesion, however, the overall pattern is very similar to an EKG from last [Month (only) 1096] that also had Q waves. Had 100% LAD occlusion and 70% mid RCA lesion on cath with elevated troponins. Now s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (Prefixes) ] 2 to the LAD. No evidence of diabetes on OSH labs. Pt was started on aspirin, plavix, and metoprolol. Lisinopril restarted in the am . # PUMP: New acute CHF with EF 25-30% per OSH discharge summary. New cough, dyspnea, and lower extremity edema prior to presentation are all consistent with acute CHF. PAtient received additional 20mg IV lasix. He will be getting a TTE as outpatient . # RHYTHM: No evidence of arrhythmias . # Cough and Dyspnea: Resolved. Question of pneumonia vs. atelectasis on OSH CXR for which he received ceftriaxone. Patient afebrile and no other signs or symptoms of infection and WBC count never elevated. Suspect cough and dyspnea were related to acute CHF and not infectious process. Antibiotics were not restarted during the hospitalization. . # Hypertension: Not on medical therapy at home. Metoprolol and lisinopril started in the am after cath, . # Hyperlipidemia: Not on medical therapy at home. Started on Atorvastatin 80mg daily # OSA: Uses nasal CPAP at home. Consulted respiratory for CPAP in hospital. Pt continued to use CPAP in the hospital and will continue it in the outpatient setting. . # GERD: Started Ranitidine 150mg PO BID . Medications on Admission: Cialis PRN Advil PRN back pain Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for CAD: LAD [Last Name (Prefixes) ]. Disp:30 Tablet(s) Refills:11 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes as needed for chest pain: do not take more than 3 tablets total. Call 911 if the chest pain is not gone. . Disp:25 tablets Refills:0 5. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:45 Tablet Extended Release 24 hr(s) Refills:2 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Non ST Elevation myocardial Infarction Hypertension Dyslipidemia Obstructive sleep apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. . VS: 98.1, 76, 18, 118/61, 94% RA, weight 204 lb Discharge Instructions: You had a heart attack and required a cardiac catheterization. Two drug eluting stents were placed in your left anterior coronary artery to clear the blockage. You also have a blockage in your right coronary artery. The heart attack caused your heart function to be weak. We think this is temporary and your heart fucntion will improve in the next 1-2 months. We started you on some medicines to help your heart pump better and you should avoid salt in your diet, eat less than 2000mg per day, until your heart function improves. Weigh yourself every morning before breakfast, call Dr. [Last Name (STitle) ] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. WEight at discharge was 204 pounds . Medication changes: 1. Do not take Cialis if you have taken nitroglycerin within 24 hours. Please talk to Dr. [Last Name (STitle) ] about this medicine and refrain from sexual activity until you see him in 3 weeks. 2. Stop taking ibuprofen for your back pain, take tylenol instead. 3. Start taking aspirin and plavix (clopidogrel) every day to keep the stents open. This is critically important to prevent another heart attack. Do not miss [First Name (Titles) 691] [Last Name (Titles) 4319] or stop taking Plavix unless Dr. [Last Name (STitle) ] tells you it is OK. 4. Start taking atorvastatin to lower your cholesterol 5. STart taking metoprolol to lower your heart rate and improve your heart function 6. Start taking lisinopril to lower your blood pressure and improve your heart function 7. Start taking ranitidine as needed to protect your stomach from the aspirin and plavix 8. Use nitroglycerin as needed for chest pain. Call Dr. [Last Name (STitle) ] if you have any chest pain. Followup Instructions: Name: [Doctor Last Name ], [Name8 (MD) ] MD Location: [Location (un) 4499] INTERNAL MEDICINE Address: [Location (un) 89209], [Location (un) 4499],[Numeric Identifier 4501] Phone: [0-0-] Appointment: Tuesday [4-23] at 2:30PM Name: [Last Name (LF) 7526], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] BLDG Address: 131 ORNAC, [Apartment Address(1) 88875], [Location (un) ],[Numeric Identifier 17125] Phone: [Telephone/Fax (1) 88876] Appointment: Thursday [5-2] at 1:30PM ICD9 Codes: 4280, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8212 }	Medical Text: Admission Date: [2122-3-25] Discharge Date: [2122-4-16] Date of Birth: [2057-1-21] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[First Name3 (LF) 552] Chief Complaint: admitted for AAA repair c/b Mysthenia crisis Major Surgical or Invasive Procedure: -AAA repair and right femoral endarterectomy [2122-3-25] -Intubation for respiratory failure ([Date range (3) 81216], [Date range (2) 81217]) -Plasmapheresis x5 ([Date range (2) 81218]) -Right IJ pheresis catheter placement ([2122-3-31]) -Right PICC placement ([2122-4-10]) History of Present Illness: 65 yo female with h/o of myasthenia [Last Name (un) 2902], lung cancer s/p chemoradiation, HTN, hypercholesterolemia, atrial fibrillation, and admitted on [3-25] for vascular repair of AAA. Pt was on the vascular service and she was extubated on POD#1 w/o any events. On [3-28] pt developed hyponatremia from 138->123, and weakness, and medicine was consulted. The medical consult though the hyponatremia was [2-9] SIADH. Over the subsequent days, she was noted to have generalized weakness and fatigueability. Neurology was consulted on [3-30] and per their note, she complained of limb weakness, facial weakness marked by difficulty maintaining her eyes open. VC was 0.95L with NIF of -40 on this date. Neurology recommended monitoring of NIF and VC, increasing mestinon to 120mg TID. Pt developed worsening weakness despite mestinon and plasmaphereis was initiated. VC and NIF noted to decrease to 0.90 and -25 respectively. On [4-1] pt had worsening weakness respiratory distress with a RR 18 w/ sat 99% on 2L, NIF -30 and VC 900cc. She had a weak cough and grade 2-3/5 power in distal and proximal LE. ABG 7.48/52, and CXR w/ cardiomegaly, RML fullness but no effisons. . In the MICU: Patient had NIFs less than 25 and was intubated on [4-1] and started on SoluMedrol 80mg QD. Extubated on [4-2], but was reintubated on [4-3]. Patient underwent a total of 5 days of plasmapheresis. Pt was extubated on [4-9], pt tolerated BiPAP [10-17] that evening. NIF post-intubation was -22, but the next day did well since and this morning had NIF of -50. . Other events: - [3-31] the RIJ triple lumen was changed over a wire - [4-5] completed 3d course of Ctx for UTI - [4-6] vasc changed pheresis line - [4-8] vascular [Doctor First Name ] was concerned about seeding hardware and started Ancef - plan to cont until groin wound heels Past Medical History: 1. Myasthenia [Last Name (un) 2902]: - [2121]: diagnosed; closely followed by primary neurologist in [Location (un) 38] - mild crisis in the past marked by visual changes (diplopia) and generalized weakness - has been on mestinon 60mg TID for her maintenance - at baseline, uses wheelchair for any extended travel and walks around the home with a walker most of the time - not really able to perform activities of daily living without substantial support by her husband who is also her primary caretaker 2. Stroke, [2121] - felt to be [2-9] hypertension - residual weakness in BLLE 3. History of lung CA, s/p chemoradiation 4. Atrial fibrillation 5. Hypertension 6. Hypercholesterolemia 7. OSA 8. GERD 9. Chronic low back pain 10. Spine surgery, [2120] 11. Bilateral knee arthroscopy 12. Degenerative arthritis 13. Cholecystectomy Social History: Lives with husband. She is a former heavy smoker up to a pack and a half of cigarettes per day and continues to actively smoke, although she says now only a few cigarettes per day. Family History: Denies any known neurological familial history. Physical Exam: VITALS: BP 177/81, HR 90, 97% on 2 liters GEN: Weak appearing. Lying in bed in no distress. Able to speak though appears to tire. HEENT: Pupils 4mm-->2mm bilaterally. No icterus or pallor. CV: Regular. No murmurs. PULM: Clear though effort poor. ABD: Soft. Non-tender. EXT: Warm. Lower extremity varicosities. NEURO: Pupils as above. EOMI intact. Mild ptosis bilaterally though will open eyes fully on command. Slightly weak shoulder shrug. Gag weak (per neuro note). Tongue midline. Upper extremities [4-12] bilaterally proximally and distally. Lower extremties [3-12] at the hip and [4-12] at ankle. Sensation grossly intact. Pertinent Results: HCT: 36.1 --> 30.9 WBC: 8.4 --> 7.3 PLT: 139 --> 181 . INR: 1.1 . Na: 138 --> 123 --> 134 HCO3: 29 --> 39 --> 35 Cr: 0.8 --> 0.7 . ABG: 7.48/44/135 . UOSM: 164 UNa: 39 . CXR ([2122-3-26]): 1. Globoid cardiomegaly without overt CHF or significant pleural effusion. 2. Basilar atelectasis without focal consolidation. 3. Gaseous distention of the stomach, new since [3-25]. . CT chest [4-7]: 1. No thymoma. 2. Moderate-to-severe emphysema. 3. Bilateral pleural effusions and adjacent atelectasis in the dorsal lung bases. No focal parenchymal opacities to suggest pneumonia. . CXR [4-10]: In comparison with the study of [4-9], the endotracheal tube is not definitely seen and may have been removed or substantially pulled back. The IJ catheter and NG tube are essentially unchanged. The cardiac silhouette is less prominent than on the previous study and there has been decreased pulmonary congestion and pleural effusion. No evidence of acute focal pneumonia at this time. . EKG: in Afib rate 77, II, III, AVF w/ <1mm ST depressions, TWI in precordial leads Brief Hospital Course: 65F with history of MG, admitted for AAA repair, who developed [Month/Day (2) 15099] crisis post-op requiring intubation x 2. HOSPTIAL COURSE BY PROBLEMS: #. Respiratory failure [2-9] myasthenia flare: Likely related to post-operative state. Patient intubated on [4-1] for worsening respiratory distress in post-operative period after elective AAA repair. Extubation was done on [4-2] requiring reintubation the following day for muscle weakness. Received plasmapheresis treatment for 5 days started on [4-8]. Pt was extubated on [2122-4-9] and had some increased work of breathing and post-extubation NIF of -22; however, did well since and the morning of [4-12] had a NIF of -50. Called out to floor on [4-12] with stable respiratory status. Pt had nightly CPAP, and NIFs and VC was followed initially q8 on the floor. Pt's NIF stayed stable near -50, and VC near 1.3L. She denied any further SOB or respiratory distress. Pt was transitioned from Solu-Medrol to prednisone 60mg. The pt will be on prednisone for a long-term basis. She may be transitioned to 50mg QD after 1mo, but will have a slow taper. Pt was started on Bactrim 3x/wk for PCP [Name9 (PRE) 6187], and Ca/Vit D. Pt should be continued on CPAP at nighttime, and NIFs and VC should be checked daily at least for the 1st week. Pt should also receive nebs as needed, and suction as needed. #. Myasthenia [Name (NI) ] - Pt had muscle weakness and severe fatigability that is now resolving. In the ICU pt did have mild ptosis bilaterally though will open eyes fully on command, a slightly weak shoulder shrug, weak gag. Her upper extremities [4-12] bilaterally proximally and distally. Lower extremties [3-12] at the hip and [4-12] at ankle. Sensation was grossly intact. While in MICU, patient had 5 runs of plasmapheresis which she tolerated well, and continued on the mestinon. Her strength continued to improve daily and was extubated without complications. Evaluated by CT surgery with CT scan which did not show thymoma. CT surgery will plan to eval for thymectomy at later date. On the floor, her illopsoas was still [4-12] b/l, but at time of discharge her motor exam was [5-12] b/l UE and LE w/ no ptosis or diplopia. Pt was on TF while her PO intake was small. She had a video swallow and passed. Her dobhoff was removed. Currently she now on a regular diet, and nutrition recommended at least for the next few days to have smaller but more frequent meals to avoid fatiguing, and to continue ensure TID until caloric intake is adqeuete. Pt is to be continued. Pt should be contiued on pyridostigmine 60mg TID, and was also started on Cellcept by neurology to decrease frequency of attacks. These should be kept unchanged unless neurology outpt recommends otherwise. Care should also be taken to be mindful of adding medications that can interact with her [First Name9 (NamePattern2) 15099] [Last Name (un) 2902], like aminoglycosides. #. Atrial fibrillation: Pt has a history of afib, Verapamil and metoprolol held due to acute MG flare, as a medication known to cause worsening of MG. Pt was continued on digoxin and was therapeutic when the level was checked. Pt remained rate controlled for the most part, but did have short periods of RVR that did not require intervention. Prior to discharge, in discussion with neurology, her metoprolol was restarted, initially at 12.5mg [Hospital1 ], and discharged at 25mg [Hospital1 ]. This can be converted to toprol XL 50 if pt tolerates 25 [Hospital1 ]. Although neurology was weary, in her case the metoprol does not appear to be affecting her [First Name9 (NamePattern2) 15099] [Last Name (un) 2902]. Her verapamil was not restarted at time of discharge (to avoid 2 nodal agents). She was not on anticoagulation when she arived but w/ signficant CHADS score, it was thought that she would benefit from anticoagulation. We spoke with her outpatient neurologist who said that it was held in the setting of hemorrhagic stroke [2-9] htn, but he and vascualar surgery was agreeable to restarting coumadin on discharge. Pt was restarted on her home dose of Coumadin 5mg QD except 2.5 on M,Th. Her INR level should be checked to ensure she is therapeutic at 2-3, with first check on Monday. . #. Hypertension: BPs are high off of her home medications and with verapamil/metop held. So she was started on captopril 100 tid and IV hydral PRN as needed while in the ICU. Did receive dose of IV metoprolol 5mg for afib with RVR on [4-11] once for Afib w/ RVR. Pt tolerated without difficulty. Once out of the ICU pt was transitioned ot lisinopril, now on 40mg, and PO hydralizine. Her BP was still systolics 170-190s, and hydrochlorthiazide was also started. Now metoprol may slightly help also. Her BP is much better controlled now, averaging 140s-150s. # Electrolyte abnormalities: Pt had metabolic alkalosis that is resolved, and intially hyponatremia that was thought to be SIADH while in the ICU that also resolved. Pt had hyperkalemia to 5.2 on day of discharge, it was repeated prior to leaving and was 4.7 This may be due to her lisinopril and her BMP and Cr should be monitered for the next two to three days to ensure her electolytes remain stable. #. AAA repair: Pt had successful repair. Vascular surgery was following. Pt had a new occurance of wound hematoma on [4-7] during MICU stay during treatment for plasmapheresis, fibrinogen normal, no intervention at this time. She was placed on ancef by vascular surgery due to drainage from the wound. The pt's wound stopped drainined 2 days prior to dishcarge, but per vascualar surgery pt is to continue Keflex for 1 wk after discharge, follow up with [Hospital ] [Hospital ] clinic at 1wk, and be given 1 refill of Keflex if needed. #. New DVT- The day prior to discharge pt started complaining of RLE pain. Pt had no focal neurological deficits, and neurology was not . On day of discharge pt's RLE appeared swollen and asymetric. Pt was on Heparin 5000mg TID while patient. LENI was ordered of the RLE and was positive for DVT at R common femoral vein. Pt was given first dose of lovenox 70 sc Q12, to be bridged while coumadin is subtherapeutic. Please check INR and d/c lovenox when coumadin therapeutic. #. R-sided hematoma- s/p AAA repair and endarectomy. Vascular surgery was agreeable to starting anticoagulation on discharge. Pt's hematocrit has been stable, but now that pt is being restarted on lovenox, pt's hematoma at R inguinal area should be visually inspected daily, and hematocrits should be checked daily for the next week to ensure hematoma is not enlarging. Medications on Admission: 1. Aspirin 81 mg QD 2. Verapamil 240 mg QD 3. Digoxin 250mcg QD 4. Metoprolol Succinate 25mg QD 5. Pyridostigmine Bromide 60 mg TID 6. Celexa 30mg Qd 7. Elavil 25mg QD 8. Modafinil 200 mg QD 9. Pantoprazole 40mg QD 10. Folic acid 1mg 11. Ambien 5 mg QD 12. Ascorbic Acid 500 mg QD 13. Calcium Carbonate-Vitamin D3 500 mg (1,250 mg)-200 QD 14. Colace 100mg [Hospital1 ] 15. Ferrous Sulfate 325 mg QD 16. MVI QD 17. Omega-3 Fatty Acids 1,000 mg Capsule 18. Senna 8.6 mg prn Discharge Medications: 1. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: One (1) PO Q8H (every 8 hours). 6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Disp:28 Capsule(s) Refills:1 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR) as needed for PCP prophylaxis while on cellcept. Disp:12 Tablet(s) Refills:4 8. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. Modafinil 200 mg Tablet Sig: One (1) Tablet PO once a day. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for osteoporosis PPX while on steroids. 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for osteoporosis PPx while on steroids. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 17. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 18. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 19. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAYS (MO,TH). Disp:8 Tablet(s) Refills:2 20. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS ([Doctor First Name ],TU,WE,FR,SA). Disp:35 Tablet(s) Refills:2 21. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 22. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 23. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 24. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/Wheezing. 25. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 26. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) as needed for myasthenia [Last Name (un) 2902]. Disp:90 Tablet(s) Refills:3 27. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for myasthenia [Last Name (un) 2902] maintenence therapy. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: Radius [Hospital1 392] Discharge Diagnosis: Primary diagnosis: Myasthenia [Last Name (un) 2902] Respiratory failure secondary to myasthenia flare s/p AAA endovascular repair and right femoral endarterectomy Secondary diagnosis: Atrial fibrillation Emphysema HTN Hyponatremia Discharge Condition: good Discharge Instructions: You were admitted to the hospital for surgery to repair an abdominal aortic aneurysm (AAA). After your operation you had a flare of myasthenia [Last Name (un) 2902] that led to generalized weakness and respiratory failure. You were treated with pyridostigmine, but eventually had to be intubated to support your breathing. Your myasthenia flare was also treated with corticosteriods and plasmapheresis. Your breathing improved and you were extubated and demonstrated significant recovery of your strength and breathing. During your hospitalization you were treated with antibiotics for a urinary tract infection and to prevent infection of your surgical wounds. . The following changes were made to your medications: 1. Start prednisone 60 mg by mouth daily. Continue for a month on this dose, until tapering to 50 mg daily under the direction of your neurologist. 2. Start cellcept (MMF) 500 mg twice daily. 3. Continue to take the pyridostigmine 60 mg three times daily. 4. Start taking metoprolol 25 mg twice daily. 5. Start taking coumadin 5 mg daily, except Monday and Thursday take 2.5 mg. 6. Stop taking verapamil or other calcium channel blockers because of myasthenia flare. 7. Start taking ipratropium bromide MDI inhale 6 puffs four times daily. 8. Start taking albuterol 0.083% nebulizer inhaled every 6 hours. 9. Start taking cephalexin 500 mg by mouth four times daily. 10. Start taking lisinopril 40 mg by mouth daily. 11. Start taking hydrochlorothiazide 50 mg by mouth daily. 12. Start taking hydralazine 25 mg by mouth every 6 hours. 13. Start taking vitamin D 800 U by mouth every day. 14. Start taking calcium carbonate 500 mg by mouth four times a day. 15. Start taking Bactrim DS 1 tab by mouth every monday/wednesday/friday. 16. Start lansoprazole 30 mg tab by mouth every day. . Please return to the ED if you have a significant difficulty breathing, worsening weakness, chest pain, abdominal pain, bleeding, fever, chills, or for any other symptoms concerning to you. Followup Instructions: Please come to your appointment next week with your [Hospital1 18] vascular surgeon as follows: Please follow-up with your PCPProvider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2122-4-23] 3:00P . Please come to your appointment in [2-10] weeks with your PCP (Dr. [Last Name (STitle) 28436] Phone: [Telephone/Fax (1) 17503], Date/Time: [2122-4-28] 1:30P. . Please come to your apptointment next month with your [Hospital1 18] neurologist as follows: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2122-5-28] 11:30A. You should call in a month on [5-16] to discuss prednisone taper regimen. . Completed by:[2122-4-16] ICD9 Codes: 5990, 5849, 4280, 2720, 4019, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8213 }	Medical Text: Admission Date: [2190-6-22] Discharge Date: [2190-7-1] Date of Birth: [2136-9-11] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Benadryl / Morphine / Percocet / Carboplatin / Red Dye Attending:[First Name3 (LF) 4679] Chief Complaint: Admission to [Hospital1 18] for left-side hemothorax Major Surgical or Invasive Procedure: [6-23] Left video-assisted thoracoscopy, evacuation of hemothorax; placement of left-sided chest tube, placement of left-sided pleurex catheter [6-23] Placement of A-line [6-24] Placement of CVL R IJ History of Present Illness: HISTORY OF PRESENT ILLNESS: 53 yo F w/extensive metastatic invasive ductal right breast ca (liver, bone, lung, brain, pleura) s/p right partial mastectomy with lymph node dissection in [2179] and multiple chemo cycles most recently complicated by pathologic fracture of left femur s/p IM nail c/b infection, PE on lovenox, s/p thoracentesis x2 in [3-15] and [5-15] for pleural effusion (cytology with +malignant adenoca) on the left just having completed 3 cycles of c3d15 treatment with abraxane not on home O2 who developed shortness of breath at rest and weakness four days prior to admission. The patient was doing okay at home, walking around the house, starting PT, when Friday she developed a rather sudden onset of shortness of breath at rest, being unable to complete a full sentence. The dyspnea was accompanied concurrently with "rib" pain around her chest that felt like a pressure and tightness preventing her from fully breathing; this pain was similar to that which she developed with her pleural effusions though at those times the pain was of gradual onset. She also felt extremely weak. Of note, she has been on lovenox for her history of PE, diagnosed in [Month (only) 958]. She saw her oncologist on Monday; CXR revealed "Complete opacification of the left hemithorax with right mediastinal shift...mostly consistent with interval accumulation of large amount of pleural effusion" and her Hct was low at 23.5. She received one unit of pRBC and underwent CT scan of the chest today [6-22], which was concerning for large new hemothorax, multiple areas of pleural loculations concerning for metastatic deposits with internal areas of necrosis, and unchanged extensive metastases of the spine. She was referred to thoracic surgery for drainage of her hemothorax. Past Medical History: PAST MEDICAL/PAST SURGICAL HISTORY: Invasive ductal right breast cancer, metastatic to liver, bone, lung, pleura, brain -s/p right partial mastectomy with lymph node dissection in [2179] (stage 2 at diagnosis) -received 3 cycles of CMF and XRT to right breast post-op -Received additional 5 cycles of CMF then tamoxifen for 5 years. -Found to have rib metastases in [2184]; treated with Lupron and Arimidex from [2184-7-6] to [2186-7-7] -progressed on numerous chemotherapy regimens including Taxotere, gemcitabine, Navelbine, Doxil, carboplatin, and, most recently, Velban; received three cycles of Velban from [2189-12-24], to [2190-2-17] -Recent course complicated by hypercalcemia treated with zoledronate -Now s/p three cycles of c3d15 treatment with abraxane (starting fourth cycle week of [6-22]) -IM nail L femur for pathologic fracture [3-15] complicated by left thigh wound infected hematoma; s/p I and D of hematoma, deep culture of hematoma, debridement down to and inclusive of vastus lateralis muscle surface and placement of vacuum sponge in [4-15]; treated by ID initially with ctx and vancomycin now on standing levaquin - found to have PE in [3-15], s/p IVC filter placement, maintained on lovenox - s/p thoracentesis for SOB; found to have metastatic pleural effusion in [3-15] and [5-15] (noted to have trapped lung in [5-15]) - ORIF of traumatic ankle fracture in [2187] - Port placement in [2188] - L posterior rib biopsy [3-23] path fx Social History: No IVDU, no smoking, social EtOH; patient is married, lives w/husband and son, daughter lives w/[State 8449], just had new baby; pt worked as bookeeper, likes to do outdoor activities (camping, hiking, kayaking Family History: Per chart review: Two paternal aunts had breast cancer. One sister developed breast cancer and died in her 50s and the other sister developed breast cancer in her late 50s, outcome is unknown. The patient has six sisters without breast cancer. Physical Exam: Upon discharge: T: 96.4 HR: 102 SR BP: 130/84 Sats: 96 4L General: fragile appearing 53 year-old sitting in chair no apparent distess Card: RRR Resp: decreased breath sounds with faint crackles on left GI: benign Extr: warm no edema Skin: left hip non-healing ulcer Pertinent Results: Imaging: CT [6-22] Significant interval increase in pleural effusion causing complete collapse of the left lung and right mediastinal shift. Areas of high density consistent with hemorrhage within the pleural effusion. Potential presence of large bulk metastatic deposits on the pleura. Extensive metastatic disease of the spine, not significantly changed since the prior study. Patient is known to have pulmonary embolism seen on the prior chest CT that cannot be assessed on the current study due to lack of contrast enhancement. CXR [6-21] Complete opacification of the left hemithorax with right mediastinal shift [2-8] pleural effusion. The opacity projecting over the right upper lobe is unchanged and it most likely represents the extensive metastatic disease within the entire skeleton. CXR [7-1] A left subclavian Mediport remains in place with tip terminating in the right atrium. A left-sided pleural chest drain courses posteriorly and then superiorly and terminates in the upper lung region, which is unchanged. Small bilateral pleural effusions are likely not changed. No new pneumothorax is seen. Extensive bilateral areas of consolidation and pulmonary metastases which is greater on the left appear similar to that seen one day prior. An IVC filter is again noted. Extensive heterogeneous bony mineralization is noted, consistent with history of bony metastases, as well as multiple anterior compression deformities in the mid-to-lower thoracic spine with exaggerated kyphosis. CT Chest [6-24] Severe reexpansion pulm edema of left lung, new ground glass opacities on pleural surface, R lung small right pleural effusion [2190-7-1] WBC-8.5 RBC-4.39 Hgb-12.9 Hct-39.9 Plt Ct-306 [2190-6-30] WBC-9.2 RBC-4.11* Hgb-11.9* Hct-36.5 Plt Ct-252 [2190-6-21] WBC-7.7 RBC-2.64* Hgb-7.5* Hct-23.4* Plt Ct-401 [2190-7-1] Glucose-104 UreaN-12 Creat-0.6 Na-142 K-3.5 Cl-105 HCO3-29 [2190-6-30] Glucose-93 UreaN-13 Creat-0.5 Na-138 K-3.7 Cl-101 HCO3-28 [2190-6-23] Glucose-103 UreaN-9 Creat-0.4 Na-133 K-4.1 Cl-97 HCO3-28 [2190-7-1] Calcium-11.5* Phos-3.1 Mg-2.0 Brief Hospital Course: OPERATIONS DURING ADMISSION [6-23] Left video-assisted thoracoscopy, evacuation of hemothorax, placement of left-side chest tube, placement of pleurex catheter. BRIEF HOSPITAL COURSE BY PROBLEM: 1. LEFT-SIDE HEMOTHORAX The patient presented to [Hospital1 18] on [6-23] with left-side hemothorax, left-side loculated pleural effusions, and a low Hct as discussed in HPI. She was given 1 u pRBC (had 1 unit as outpatient), and her Hct jumped to 27 from 23. She did remain and appear short of breath at rest even on nasal cannula. She was taken to the OR on [6-23] for the above-mentioned procedure, which she tolerated well. 2. RE-EXPANSION PULMONARY EDEMA Unfortunately, while still in the O.R. after being extubated she was noted to be extremely short of breath, tachypneic, and with decreased breath-sounds on the left. She was thus re-intubated intra-operatively and sent to the ICU. CXR was concerning for re-expansion pulmonary edema and non-expanded left lower lobe. She had a high pressor requirement and was brought to the ICU on Neo at 2.0. That evening she required multiple fluid boluses (crystalloid and colloid) given her hypotension. Unfortunately, her CXR the following morning showed severe re-expansion pulmonary edema on the left worse since prior exam. She concurrently had a decreased Hct; that day she received 2 u PRBC, 2 FFP. She remained with a pressor requirement. She underwent Chest CT (results listed above) concerning for re-expansion pulmonary edema, and also underwent bronchoscopy that did reveal inflated lungs bilaterally. She underwent placement of a R CVL (IJ) on [6-24]. She was also started on tube feeds. 3. FLUID OVERLOAD Given her pressor requirements and need for crystal and colloid the patient became fluid overloaded and, with a high CVP, was started on gentle diuresis. She was started on a lasix gtt on [6-25] with much improvement in her overall fluid status, though she still remained with a pressor requirement. By [6-27] she had diuresed and was off her vasopressors. She was placed on CPAP from CMV, which she tolerated well, initially at PS/Peep [8-14] and then weaned down to 5/5. She was successfully extubated on [6-28]. Wean to nasal cannula 2-4 Liters oxygen saturations 985-98% with aggressive pulmonary toilet and nebs. The left chest tube was placed to water-seal once drainage decreased. It was removed on [6-30]. The pleureX catheter was capped. On [2187-7-1] her chest film showed no re-accumalation of fluid. No drainage from the pleureX catheter. Skin: Left hip with small ongoing non-healing wound. Wet-Dry packing [Hospital1 ]. Site clean. Kyphotic spine with abrasion. Mepilex intact. Dispositon: She was discharged to home on [7-1] on home oxygen (as previous) with her husband. She continued on her home pain regime with good control. She will follow-up with Dr. [First Name (STitle) ] and [First Name8 (NamePattern2) 14163] [Last Name (NamePattern1) 11710] NP for pleueX catheter drainage in 2 weeks. Medications on Admission: MEDICATIONS:dilaudid 4 q3 PRN, gabapentin 100 TID, lovenox 60 mg q12h (last taken [6-21]), fentanyl 100 mcg TP q72h, levaquin 500 PO q24h, ondansetron 4 mg q8 Discharge Medications: 1. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO three times a day. 4. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Chronic left pleural effusion Discharge Condition: stable Discharge Instructions: [Name6 (MD) ] IP NP [First Name8 (NamePattern2) 14163] [Last Name (NamePattern1) 11710] with questions or concerns regarding Pleurex catheter. [Telephone/Fax (1) 10651] Followup Instructions: Follow-up with [First Name8 (NamePattern2) 14163] [Last Name (NamePattern1) 11710] NP regarding Pleurex Catheter [Telephone/Fax (1) 10651] Follow-up with Dr. [First Name4 (NamePattern1) ] [2192-7-14]:00am on the [Hospital Ward Name 516] Sharpiro Clinical Center [Location (un) 24]. Report to the 4th Radiology Department for a Chest X-Ray 45 minutes before your appointment Completed by:[2190-7-1] ICD9 Codes: 5180, 5185
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8214 }	Medical Text: Admission Date: [2114-7-21] Discharge Date: [2114-8-24] Date of Birth: [2053-11-28] Sex: F Service: MEDICINE Allergies: Penicillins / Metoprolol Attending:[First Name3 (LF) 2745] Chief Complaint: Pt found down after 10 hours; transfer from OSH for abnormal LFTs, unable to wean from ventilator. Major Surgical or Invasive Procedure: Left IJ central line placed on [7-22] Right chest tube pulled out on [7-26] Lumbar puncture [7-26] Left IJ central line retreived on [7-27] Left PICC line palced on [7-27] Tracheostomy placed on [7-27] Left PICC line retreived on [7-30] after positive blood cultures Thoracosentesis [8-2] draining 500 CC History of Present Illness: 60 y/o F with PMHx of borderline DM and Crohns disease who was admitted to OSH on [7-10] after being found non-responsive at home for 8-10 hours. She was hypothermic, bradycardic and hypotensive. BS was 1467 on admission with elevated anion gap consistent with DKA. She was also noted to have elevated serum CK, increased amylase and lipase and WBC of 30k. CT head was negative. In the ED she was intubated for airway protection and given Vanc/Levo. She was given one dose of hydrocortisone and started on a levophed gtt. Her presumptive diagnosis was DKA [12-23] acute pancreatitis. She was transferred to the ICU where she was warmed, her bradycardia resolved and she was weaned from levophed. Brief course: 60 yo WF w PMHx of T2DM, Crohn's disease, initially presented on [7-10] at OSH after being found down at home w BS of 1400. Pt was intubated in ER for airway protection, and req'd pressors for hypotension. Etiology of MS was thought to be DKA [12-23] acute pancreatitis. Started empirically on vanco/levoflox. OSH course complicated by iatrogenic PTX s/p chest tube, ARF likely [12-23] rhabdo (CK peak 11,000) requring HD, and failed extubation req re-intubation. Pt also noted to have incr AlkPhos & GGT, nl TBili, [Month/Day (2) 5283] u/s unrevealing. Was briefly on TPN. Bronch performed on 8/30Transferred to [Hospital1 18] ICU on [7-21] for further management. Was on vanco& fluco on transfer. For workup of her altered mental status, she has had normal MRI, LP, and unrevaling EEG. Pt continued to spike fevers despite normalization of her pancreatic enzymes. She underwent trachestomy on [7-27]. Central line removed [7-27], replaced by PICC. Cefepime & cipro added empirically for persistent fevers.Line Cx +Coag neg staph, lines removed on [7-31]. Thoracentesis performed on [8-2] was unrevealing. Started on meropenem on [8-3] for ESBL enterobacter from sputum Cx. Pt was started on Vanc and Meropenem for hospital acquired Pneumonia. Based on sputum cx, Vanc was discontinued after an 8 day course and meropenem was continued. Hospital course continued to be signif for persistent fevers (o/n 102F) and episodes of tachycardia and hypertension thought [12-23] anxiety. Pt was seen by ID on [8-7] and underwent C/A/P CT to look of source of infection and it showed increasing/stable upper lobe opacities and decreasing pleural effusions as well as diffuse LAD. Surgery was consulted to biopsy one of the lymph nodes and they did not feel as though it was worth the risk and thought that LAD was likely [12-23] infection. On [8-9], pt noted to have increasing WBC again and ID recommended starting pt on po vanc on [8-10] to cover for Cdiff. No diarrhea noted, Cdiff stool pending. Pt also followed by psych due to agitation/delirium. They noted increased cogwheel rigidity, which they thought [12-23] haldol and [Month (only) ] dose. CPK was not elevated. Pt is very interactive and less frustrated after having a passy muir valve placed. Past Medical History: Borderline DM (presented with DKA) Crohns Disease Social History: Pt takes care of mentally challenged family and has not been taking care of herself. Family History: non-contributory Physical Exam: Vitals: T 96.7 BP 110/58 HR 66 Sats 94% on Vent AC/40%/12/500/PEEP 5 GEN: Comfortable, intubated, sedated, does not respond to commands HEENT: pinpoint pupils bilaterally, minimal response to light, sclera anicteric, no epistaxis or rhinorrhea, NECK: RIJ with erythema around base, right subclavian temp dialysis line with mild erythema at site, no purulent drainage COR: RRR, no M/G/R PULM: coarse BS bilaterally, [Month (only) ] BS at bases ABD: Soft, NT, ND, Active BS, no [Month (only) 5283] tenderness EXT: No C/C/E +DP/PT NEURO: minimal response to sternal rub SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2114-7-21] 05:17PM LACTATE-0.7 [2114-7-21] 05:17PM TYPE-ART PO2-66* PCO2-48* PH-7.40 TOTAL CO2-31* BASE XS-3 INTUBATED-INTUBATED [2114-7-21] 05:30PM PT-14.9* PTT-27.9 INR(PT)-1.3* [2114-7-21] 05:30PM PLT COUNT-125* [2114-7-21] 05:30PM NEUTS-88.0* LYMPHS-8.3* MONOS-2.4 EOS-0.8 BASOS-0.5 [2114-7-21] 05:30PM WBC-17.2* RBC-3.12* HGB-9.7* HCT-28.4* MCV-91 MCH-31.2 MCHC-34.3 RDW-15.5 [2114-7-21] 05:30PM TRIGLYCER-148 [2114-7-21] 05:30PM ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-4.4 MAGNESIUM-2.3 [2114-7-21] 05:30PM proBNP-4265* [2114-7-21] 05:30PM LIPASE-57 [2114-7-21] 05:30PM ALT(SGPT)-23 AST(SGOT)-12 LD(LDH)-188 ALK PHOS-752* AMYLASE-44 TOT BILI-0.5 [2114-7-21] 05:30PM estGFR-Using this [2114-7-21] 05:30PM GLUCOSE-204* UREA N-44* CREAT-2.9* SODIUM-145 POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-29 ANION GAP-12 [2114-7-21] 08:46PM URINE MUCOUS-RARE [2114-7-21] 08:46PM URINE RBC-8* WBC-24* BACTERIA-FEW YEAST-OCC EPI-0 TRANS EPI-<1 RENAL EPI-<1 [2114-7-21] 08:46PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2114-7-21] 08:46PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.008 Brief Hospital Course: AP: 60 yo WF w T2DM, Crohn's disease, presents w/ altered mental status likely [12-23] to DKA from acute pancreatitis, w/ complicated hospital course including line assoc pneumothorax s/p Ct placement/removal, ventilator associate pneumonia, funguria, ARF [12-23] rhabdo requiring intermittent HD, w persistent delirium, fevers and leukocytosis, all of which are resolved. 1. Fevers/leukocytosis - Over the weekend of [9-21], pt noted to have rise in wbc and low grade temp. All cx neg at that point. Repeat Chest CT stable. Per ID,even though no diarrhea, pt started on po vanc empirically for possible Cdiff and wbc improved. C diff X2 neg. Per ID, po vanc discontinued after a 7 day course. The patient did not have any further leukocytosis for 4 days prior to discharge and was without low grade fevers for over 5 days prior to discharge. 2. Altered MS - Per notes, pt improved significantly from admission when she was essentially unresponsive. Head CT, MRI, LP, EEG all unrevealing. MS change likely multi-factorial including delirium [12-23] recent DKA, infection, ICU course and also ? anoxic event. Pt then had issues w delirium and was followed by psych. Pt was initially on haldol but she developed cogwheel rigidity, so was switched to zyprexa. Zyprexa was weaned to off on [8-17]. Overall, the patient has had dramatic improvement in her mental status, although she has some residual deficits. She underwent some cognitive testing by OT that revealed some deficits. She currently needs some help with daily activities. Pt will need outpt Neuropscyh eval to further evaluate. 3. Hypoxia - Resolved. Pt had both effusions and vent assoc pna. Pt is sp treatment with both Vanc and Meropenem. Passy muir valve was decannulated on [2114-8-21]. The patient has done well since removal of her trach. She also has some left lower lobe collapse which was evaluated by pulmonary and they recommended conservative management. Over time, this should reexpand. The patient is breathing in the mid 90s on RA with ambulation. 4. Hx of ARF - resolved and likely [12-23] rhabdo as CPK 11K on admission. 5. Hx of fungal UTI - s/p tx w fluconazole, last UCX NGTD 6. Acute pancreatitis - Per records from here, on admission at OSH, pt's lipase was in [2105] range. Etiology of this attack remains unclear, pt has had [Name (NI) 5283] US at OSH per records which was neg and CT A/P here which also did not show any abn. Pt was initially seen by GI here for eval and they recommended MRCP for further eval once ARF resolved. Anti-mitochondrial Ab negative. MRCP ordered and revealed evidence of pancreas divisum or a dominant dorsal duct an nondistended pancreatic duct. Pt will need to fu w Dr. [Last Name (STitle) 174] as outpt. Dr. [Last Name (STitle) 174] did mention that there is an association between new onset diabetes and pancreatic adeno within 2 year frame. MRCP does not show any mass, which is re-assuring but if repeat CT shows persistent LAD (see below), concern will be higher. 7. Hx of Crohn's - no reports of abd pain or diarrhea here. cont to monitor. GI consult appreciated, since asymptomatic and was not on anything as outpt for this, no meds right now, Dr. [Last Name (STitle) 174] will follow as outpt. 8. Hx of atrial fibrillation - in setting of acute illness. Pt had TTE and CTA of chest which were neg for structural hrt dz and neg for PE respectively. TSH wnl. Cont to monitor. was on tele but has been in NSR but with frequent ectopy. Cont tele for now 9. DM - Per sister she was told she had diet controlled about 5 years ago. Had BS in 1400 on admission likely stress response from acute pancreatitis. Patient now on metformin 850 mg po bid with lispro sliding scale. 10. Diffuse lymphadenopathy - pt's recent cT C/A/P on [7-24] and [8-7] have shown diffuse LaD. On [8-9], Gen [Doctor First Name ] was consulted for biopsy but they declined stating that she is high risk for OR as she was recovering from VAP and that LAD was likely [12-23] infection. Dr. [Last Name (STitle) 174] will determine whether he wants to perform repeat CT scan in f/u appointment. Radiologists here thought that the LAD was not concrening for malignancy and did not recommend reimaging. . FEN -Patient repeatedly evaluated by nutrition, currently tolerating po comfortably but not achieving large caloric intake. Would continue calorie counts and if patient does not improve her intake, consider supplemental tube feeds. . Code status - Full . Comm: with sister, [Name (NI) 3508] [Name (NI) 2808] [Name (NI) 79268] [Telephone/Fax (1) 79269]/ lives in CT. She only has one sister. Medications on Admission: Medications on transfer: chlorhexidine mouthwash Senna prn Pantoprazole 40mg daily Fluconazole 200mg IV daily Heparin 5000u sc TID Fentanyl gtt Propofol gtt Multivitamin IV Levofloxacin 250mg IV q48hrs Regular Insulin SS Nystatin powder Duoneb q4hrs Epoeitin 40000units Bisacodyl Magnesium Tylenol Ativan prn Vancomycin Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: see sliding scale attached units Injection ASDIR (AS DIRECTED): SEE attached lispro sliding scale. 2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 4. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Diltiazem HCl 180 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: HOLD FOR SBP<100, HR<55. Discharge Disposition: Extended Care Facility: Eagle [Hospital ] Rehab Discharge Diagnosis: Altered Mental Status Diabetic Ketoacidosis Acute Pancreatitis Vent Associated Pneumonia Rhabdomyolysis Acute Renal Failure Cognitive Deficits s/p acute illness Abdominal Lymphadenopathy Discharge Condition: Vital Signs Stable Discharge Instructions: Return to emergency room if having severe abdominal pain, confusion, high fevers, high blood sugars that do not improve at [Hospital1 1501] with aggressive insulin treatment. Followup Instructions: 1. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 174], GI, [Hospital1 18] [Telephone/Fax (1) 68666]. Patient to call and arrange appointment. 2. PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 22149], [First Name3 (LF) ], Ph: [Telephone/Fax (1) 79270]. Patient to arrange f/u 3. Outpatient Neuropsych testing at [Hospital1 18]. Patient to call and schedule appointment at [Telephone/Fax (1) 1669]. 4. Patient to arrange f/u with physician located near her that casemanagment is helping locate for her. Patient should arrange close f/u. ICD9 Codes: 5845, 5119
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8215 }	Medical Text: Admission Date: [2116-3-24] Discharge Date: [2116-3-29] Date of Birth: [2049-9-23] Sex: M Service: CT SURGERY HISTORY OF PRESENT ILLNESS: This is a 66 year old male with new onset of increased shortness of breath on exertion that started in [2115-9-30]. The patient has felt increasing fatigue for the past year. The patient had a positive exercise treadmill test. The patient underwent a catheterization on [2116-2-12]. The patient had no chest pain, positive throat tightness. Catheterization showed a 100% right coronary artery, 100% circumflex and 70% left anterior descending occlusion, ejection fraction 50%, left ventricular end diastolic pressure 12, and the patient was referred for coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Noninsulin dependent diabetes mellitus. 2. Hypertension. 3. Hemochromatosis. 4. Hypercholesterolemia. PAST SURGICAL HISTORY: 1. Bilateral cataract surgery. 2. Status post appendectomy. SOCIAL HISTORY: Rare ethanol. The patient quit smoking approximately one year ago. FAMILY HISTORY: Mother is alive at age [Age over 90 ]. Father died at age 65 with cerebrovascular accident and myocardial infarction. ALLERGIES: Codeine causes nausea and vomiting. MEDICATIONS ON ADMISSION: 1. Lisinopril 40 mg p.o. once daily. 2. Aspirin 325 mg p.o. once daily. 3. Glipizide 5 mg p.o. once daily. 4. Norvasc 10 mg p.o. once daily. 5. Atenolol. 6. Nitroglycerin sublingual p.r.n. PHYSICAL EXAMINATION: Blood pressure is 157/73, heart rate 51, oxygen saturation 98%. Heart revealed regular rate and rhythm, S1 and S2, no murmurs with muffled heart sounds. The lungs were clear to auscultation bilaterally. Chest showed well healed sternotomy site on left anterior chest. The abdomen was soft, nontender, nondistented with positive bowel sounds. No hepatosplenomegaly. No costovertebral angle tenderness. Examination of extremities revealed no cyanosis, clubbing or edema, warm and well perfused, no varicosities were noted. The patient had 2+ dorsalis pedis pulses bilaterally and 1+ posterior tibial bilaterally. Examination of the neck revealed no jugular venous distention or bruits were appreciated. Neurologic examination was grossly nonfocal. Cranial nerves II through [Doctor First Name 81] are intact. Excellent strength in all extremities and good sensation. Extraocular movements are intact. The pupils are equal, round, and reactive to light and accommodation. The patient's buccal mucosa was moist. Eyes were nonicteric. REVIEW OF SYSTEMS: No pulmonary, liver, gallbladder or renal disease. The patient has hypertension and noninsulin dependent diabetes mellitus. No bleeding disorders or melena. HOSPITAL COURSE: The patient was admitted to Cardiac Surgery service. The patient underwent a coronary artery bypass graft times three, left internal mammary artery to left anterior descending, saphenous vein graft to DRCA, saphenous vein graft to obtuse marginal, for unstable angina. Postoperatively, the patient was transferred to the CSRU. The patient's mean arterial pressure was 72/11, PAD and [Doctor First Name 1052] were not applicable since the patient had no Swan-Ganz. The patient was A paced with a rate of 88 beats per minute and was on Neo-Synephrine 0.2 mcg/kg/minute. On postoperative day number one, the patient had no major events, was off Nitroglycerin drip and remained afebrile with sinus rhythm and was saturating well. The patient was net 2.2 liters positive. White blood cell count was 10.2, hematocrit 32.4, creatinine 0.7 and the patient was transferred to the floor. On postoperative day number two, the patient remained afebrile with stable vital signs, taking good p.o. and making good urine. The patient's chest tubes were removed and wires were removed. Physical therapy was asked to see the patient. On postoperative day number three, the patient continued to remain afebrile with stable vital signs. The patient was taking good p.o. and making good urine. White blood cell count was 8.5. Creatinine was 0.9. Hematocrit was 32.2. The patient was physical therapy level four. On postoperative day number four, the patient remained afebrile with stable vital signs, taking good p.o. and making good urine. The white blood cell count was 7.8, creatinine 0.8. The only issue was the patient began to complain of musculoskeletal pain on the left side below the scapula. The patient was treated with Toradol which improved the patient's pain. On postoperative day number five, the patient remained afebrile with stable vital signs and taking good p.o. and making good urine. The patient was discharged home after passing level five with physical therapy. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with services. MEDICATIONS ON DISCHARGE: 1. Lopressor 25 mg p.o. twice a day. 2. Lasix 20 mg p.o. twice a day for ten days. 3. Colace 100 mg p.o. twice a day. 4. Aspirin 325 mg p.o. once daily. 5. Percocet one to two tablets q4hours p.r.n. pain. 6. Glipizide 5 mg p.o. once daily. 7. Lipitor 10 mg p.o. once daily. 8. Motrin 400 mg p.o. q8hours p.r.n. pain. 9. Potassium Chloride 20 mEq p.o. twice a day for ten days. FOLLOW-UP PLANS: Please follow-up with Dr. [Last Name (STitle) 70] in six weeks. Please follow-up with primary care physician in one to two weeks. Please follow-up with cardiologist in one to two weeks. DISCHARGE DIAGNOSES: 1. Unstable angina, status post coronary artery bypass graft times three. 2. Noninsulin dependent diabetes mellitus. 3. Hypertension. 4. Hemochromatosis. 5. Hypercholesterolemia. 6. Status post bilateral cataract surgery. 7. Status post appendectomy. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 3118] MEDQUIST36 D: [2116-3-29] 08:18 T: [2116-3-29] 08:44 JOB#: [Job Number 53011] ICD9 Codes: 4111
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8216 }	Medical Text: Admission Date: [2144-10-17] Discharge Date: [2144-10-23] Date of Birth: [2096-10-14] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[First Name3 (LF) 1990] Chief Complaint: Fever Major Surgical or Invasive Procedure: none History of Present Illness: HPI: MR. [Known lastname 6164] is a 48 yo M with HIV/AIDS (CD4 311 [2144-10-2] VL <48), Hep C, who presented to the ED with fevers for the past 2 days. He reports having headache, sore throat, nasal congestion, cough and body aches since the start of the fevers. Of note he admits to injecting crystal meth in his left arm on the day prior to symptom onset, reports cleaning the area prior and using a clean needle. He denies any history of endocarditis. He presented to [Hospital1 2025] yesterday, where he had a treadmill stress test which patient reports was normal, went 12minutes on the treadmill. Otherwise he denies getting any other treatment. He presented to our ED overnight when the fevers persisted and he continued to feel poorly. Otherwise he denies nausea, vomiting, diarrhea, dysuria, hematuria, pain at the site where he injected drugs, abdominal pain. . Of note he had recent LP in [Hospital ] clinic due to concern for possible neurosyphillis however his CSF VDRL was negative. . In the ED T100.8 HR 75 BP 105/63 RR 20 100% RA. He spiked fever up to 104 with no localizing symptoms other than neck stiffness so he had an LP which was unremarkable. Cultures were sent and he was started on Vancomycin and Ceftriaxone. He was also given 1gm tylenol and motrin 400mg for his fevers. He dropped his pressure to 75/32 in the ED so he was given 3L IVF, a central line was placed, and he was started on levophed. He was evaluated by the ID service in the ED who agreed with the management and also recommended droplet precautions and nasal swab for influenza. Past Medical History: 1)HIV/AIDS-nadir CD4 count around 50, CMV retinitis in his right eye, Toxo IgG neg, CMV IgG pos, only known [Last Name (un) 10291] was [2-11] and was wild type (off therapy). 2)HCV, as above, [Last Name (un) ] 1b, baseline VL around 4 million, Sono [2-12] with fatty infiltration ([9-16] HCV viral load not detectable) 3)Chronic Sinusits 4)Depression, was followed by Dr. [Last Name (STitle) 75205] at [Hospital1 2025] 5)Hypogonadism 6)Hx of MRSA infections 7)Onychomycosis 8)Cataract and mild glaucoma in his right eye 9) +RPR s/p LP on [2144-9-24] to eval for neuro syphillis which was negative Social History: Lives with partner [Name (NI) ], endorses injecting crystal meth on the day prior to symptom onset, last injection prior probably about 2 months ago, remote intranasal cocaine, no tob or etoh. Family History: non-contributory Physical Exam: DISCHARGE PHYSICAL VSS Gen: NAD, pleasant SKIN: Maculopapular, fading erythematous rash on trunk, arms, back, groin, thighs and buttocks, coalescing into plaques, scattered urticaria with minimal desquamation HEENT: NC/AT, PERRL, EOMI, small erythematous patch on hard palate, no ulcerations Neck: supple CV: RRR s1 s2 Lungs: CTAB Abd: soft, NT, ND BS+ no rebound or guarding Ext: no edema, warm, 2+ distal pulses NEURO: a/o x3, no focal deficits PSYCH: psychomotor agiation Pertinent Results: [2144-10-17] 12:50AM BLOOD WBC-4.2 RBC-3.34* Hgb-11.0* Hct-32.0* MCV-96 MCH-33.0* MCHC-34.5 RDW-17.7* Plt Ct-79* [2144-10-17] 12:50AM BLOOD Neuts-56.6 Lymphs-36.3 Monos-6.4 Eos-0.2 Baso-0.4 [2144-10-17] 12:50AM BLOOD PT-14.6* PTT-42.5* INR(PT)-1.3* [2144-10-17] 05:05PM BLOOD Fibrino-309 [2144-10-17] 05:05PM BLOOD FDP-0-10 [2144-10-17] 12:50AM BLOOD Glucose-100 UreaN-21* Creat-1.2 Na-138 K-3.9 Cl-106 HCO3-23 AnGap-13 [2144-10-17] 12:50AM BLOOD ALT-72* AST-79* AlkPhos-65 TotBili-0.9 [2144-10-17] 10:58AM BLOOD Calcium-7.0* Phos-1.5* Mg-1.7 [2144-10-18] 03:00PM BLOOD Cortsol-12.2 [2144-10-18] 03:35PM BLOOD Cortsol-32.1* [2144-10-17] 10:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2144-10-17] 02:19AM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-1* Polys-0 Lymphs-79 Monos-0 Macroph-21 [2144-10-17] 02:19AM CEREBROSPINAL FLUID (CSF) TotProt-37 Glucose-58 . Cultures: Blood cultures: No growth Urine cultures: No growth RPR negative Lyme serology: positive by EIA. negative by Western Blot CSF culture: No growth, no organisms seen on gram stain . Head CT [2144-10-17]: 1. No acute intracranial process including no hemorrhage, mass or edema. MRI is more sensitive for evaluation of acute ischemia or meningeal abnormalities. 2. Stable mild parenchymal volume loss in the frontal and parietal lobes. . Chest X-ray [2144-10-17]: No acute cardiopulmonary process identified . Echocardiogram [2144-10-19]: The left atrium is mildly dilated. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is high (>4.0L/min/m2). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2144-8-13], moderate pulmonary hypertension is now identified. No vegetations identified. . MICROBIOLOGY: Stool: negative for C. diff, camphylobacter, salmonella, e.coli, Blood: NGTD Urine: CX negative, urine legionella negative Line tip cx: negative Brief Hospital Course: 48 yo M with PMH of HIV last CD4 311 in [9-16] admitted with 2 days of fever, recevied IV abx including vacnomycin and ceftriazone in the ED and developed hypotension requiring MICU admission and pressors. His vancomycin was changed to daptomycin after he developed a maculopapular rash which was suspected to be a drug rash by dermatology consult Infectious disease was consulted. He was pan-cultured to look for course of infection but all cultures returned negative. He has a possible history of vancomycin allergy and a known red man syndrome with rapid vancomycin infusion. He was weaned off pressors in the MICU and transferred to the floor after being afebrile for 24 hours. He remained on the floor for observation and was stable during this time. He was discharged in stable condition with close infecious diease follwo up with Dr. [First Name (STitle) ]. . MICU COURSE: Mr. [Known lastname 6164] was admitted to the MICU on pressors due to hypotension with concern for sepsis. He was started initially on Vancomycin to cover gram positives associated with IV drug use and Zosyn for 24 hours which was then stopped. He was briefly treated with Clindamycin which was stopped on [2144-10-19]. The ID service was consulted. He had a prior history of red man syndrome associated with Vancomycin. His Vancomycin was changed to Daptomycin due to a maculopapular rash which the patient developed on the day after admission. Dermatology was consulted and recommended supportive care with hydoxyzine, triamcinolone cream and sarna lotion. He was still requiring Levophed for blood pressure support and underwent [Initials (NamePattern4) ] [Last Name (NamePattern4) 104] stim test on 11/90/08 to which he responded appropriately. A TTE was negative for valve vegetations. He was able to be weaned from Levophed on [2144-10-20]. He had received several liters of IV fluids. Blood pressures were in the 90s/50s but he experienced no end-organ ischemia and was beleived to have low blood pressure at baseline. He was started on Azithromycin for atypicals on [2144-10-19]. He continued to have persistent fevers for the first 3 days of his admission. Interferon and Ribaviron were held per primary ID physician [Last Name (NamePattern4) ]. [First Name (STitle) ] and will be restarted at her discretion. A social work consult was obtained for substance abuse. . All blood, sputum and urine cultures were negative, CXR was clear, LP was without evidence of meningitis. He was continued on his antiretroviral medications. He was transferred to the floor on [2144-10-21]. . FLOOR COURSE: On transfer to the floor, antibiotics were discontinued as cultures were all negative. It was felt that patient may have had a viral URI that was the cause of his initial fever. Per the ED notes, hypotension developed only after the administration of vancomycin and ceftriaxone. Unclear whether or not this represented an anaphylactiod reaction particularly given the subsequent development of drug rash and resolution of hypotension after vancomycin was discontinued. Patient should not received vancomyin in the future given possibility of true allergy. Patient was discharged home in stable condition. He has plans to obtain substance abuse counseling at [Hospital 882] Hospital. Medications on Admission: CLONAZEPAM 1 mg Tablet qHS Aranesp injections qmonth TRUVADA - 200 mg-300 mg Tablet - 1 Tablet(s) by mouth once a day FOLIC ACID - 1 mg Tablet - 3 Tablet(s) by mouth once a day KALETRA - 50 mg-200 mg Tablet - 2 Tablet(s)by mouth twice a day MUPIROCIN - 2 % Ointment - use as directed twice a day PEGINTERFERON ALFA-2A q week RIBAVIRIN - 200 mg Capsule 3 capsules in the am and 2 pm TESTOSTERONE [ANDROGEL] - 1.25 gram per Actuation (1%) Gel in Metered-dose Pump - 4 pumps once a day VARDENAFIL [LEVITRA] - 5 mg Tablet - 1/2-1 Tablet(s) by mouth every three days as needed Trazodone 2 tabs qhs Discharge Medications: 1. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:1 bottle Refills:0 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) for 14 days. Disp:1 tube Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Fever Hypotension Drug Rash . . Secondary: HIV H/o CMV retinitis in R eye Hepatitis C genotype 1b Chronic Sinusits Depression Hypogonadism Hx of MRSA infections s/p partial R lobectomy Cataract and mild glaucoma in his right eye Discharge Condition: Good, vital signs stable Discharge Instructions: You were admitted with fever and low blood pressure. This low blood pressure was severe and required medication to treat it while you were in the intensive care unit. Your fever was treated with several antibiotics and cultures were taken to determine the source of your fever. All of the cultures that were taken have been negative suggesting a non-infectious cause of the fever. You also had a rash which was likely related to one of the antibiotics you received while you were here. You will be given a prescription for the topical steroid cream to treat it at home. . Additionally, you were not give your hepatitis C medication (Interferon and Ribaviron) because of your fever, low blood pressure and rash. Dr. [First Name (STitle) ] will follow you out-patient and will decide when to restart those medications. . No other medication changes were made. You should resume all your other home medications as directed. . You saw social work and as you had previously arranged, you spoke about going to the [Hospital1 882] out-patient addicition program. You should follow up with them directly. . Finally, you had lab tests in [Month (only) 359] that showed that your thyroid wasn't making enough thyroid hormone. You should talk with Dr. [First Name (STitle) ] about this and see endocrinology. If you have fever higher than 100.5, chills, shortness of breath, chest pain, severe abdominal pain, dizziness or any other concerning symptom, please seek medical care immediately. . It was a pleasure meeting you and participating in your care. Followup Instructions: Provider: [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern4) 2335], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2144-10-27] 2:00 . Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 1387] Date/Time:[2144-11-24] 4:00 . Please follow up with endocrinology about your thyroid tests. ICD9 Codes: 4589, 2875, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8217 }	Medical Text: Admission Date: [2132-9-30] Discharge Date: [2132-10-6] Service: ORTHOPAEDICS Allergies: Bactrim Attending:[First Name3 (LF) 11261] Chief Complaint: Ms. [Known lastname 11257] presents for definitive treatment to her right hip. Major Surgical or Invasive Procedure: Right hip revision Past Medical History: -CAD with CABG4 in [2117] -Hypertension -Diabetes -Hypothyroidism -Osteoarthritis -Status post choleycystectomy -Status post hysterectomy for unclear reasons -Status post right hip arthroplasty in [2119] Social History: Does not use tabacco or ETOH. She currently lives with her daughter. Family History: Patient reports both her parents died of pneumonia in middle age. She is otherwise unable to give much family history. Physical Exam: On discharge: Afebrile, All vital signs stable General: Alert and oriented, No acute distress Extremities: right lower Weight bearing: partial weight bearing Incision: intact, no swelling/erythema/drainage Dressing: clean/dry/intact Sensation intact to light touch Neurovascular intact distally Capillary refill brisk 2+ pulses Pertinent Results: [2132-9-30] 11:02AM BLOOD WBC-14.6# RBC-4.23 Hgb-10.8* Hct-33.2* MCV-78* MCH-25.5* MCHC-32.5 RDW-16.1* Plt Ct-221 [2132-10-2] 05:00AM BLOOD WBC-11.2* RBC-3.43* Hgb-8.6* Hct-26.8* MCV-78* MCH-25.0* MCHC-32.0 RDW-17.4* Plt Ct-180 [2132-10-5] 04:50AM BLOOD WBC-8.1 RBC-3.66* Hgb-9.6* Hct-28.7* MCV-79* MCH-26.1* MCHC-33.3 RDW-17.0* Plt Ct-239 [2132-9-30] 11:02AM BLOOD Neuts-70.1* Lymphs-23.3 Monos-4.2 Eos-2.0 Baso-0.4 [2132-9-30] 11:02AM BLOOD Glucose-126* UreaN-47* Creat-1.8* Na-141 K-4.6 Cl-105 HCO3-27 AnGap-14 [2132-10-3] 09:00AM BLOOD Glucose-142* UreaN-44* Creat-1.9* Na-141 K-4.2 Cl-107 HCO3-26 AnGap-12 [2132-10-5] 04:50AM BLOOD Glucose-125* UreaN-52* Creat-1.9* Na-142 K-3.4 Cl-107 HCO3-28 AnGap-10 [2132-9-30] 11:02AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.1 [2132-10-3] 09:00AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.1 [2132-10-5] 04:50AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9 [2132-9-30] 08:45AM BLOOD Type-ART pO2-146* pCO2-46* pH-7.42 calTCO2-31* Base XS-5 Intubat-INTUBATED [2132-9-30] 08:45AM BLOOD Glucose-112* Lactate-1.3 Na-142 K-4.0 Cl-101 Brief Hospital Course: Mrs.[Known lastname 11257] was admitted to [Hospital1 18] on [2132-9-30] for an elective right total hip replacement. Pre-operatively, she was consented, prepped, and brought to the operating room. Intra-operatively, she was closely monitored and remained hemodynamically stable. She tolerated the procedure well without any complication. Post-operatively, she was transferred to the PACU/SICU and floor for further recovery. On the floor,she was consulted by geriatric services due to some confusion/agitation whose recommendations were appreciated and followed. On [10-3] hct was 24.5 and received 2 units prbc, chest xray normal no consolodation, u/a normal. [Last Name (un) ] recommendations appreciated as well. [10-4] hct 28.7 bun 52/1.9 geriatric services aware. she remained hemodynamically stable. Her pain was controlled. Sh progressed with physical therapy to improve her strength and mobility. Sh was discharged today in stable condition. Medications on Admission: clopidograel 75mg', Levothyroxine 88mcg', ASA 325mg', Furosemide 40mg', Gliburide 10mg'', Allergies: Bactrim Discharge Disposition: Extended Care Facility: Baypointe - [Hospital1 1474] Discharge Diagnosis: OA right hip Discharge Condition: Stable Discharge Instructions: If you experience any shortness of breath, new redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation. You may not bear weight on your right leg. Please use your crutches for ambulation. You may resume all of the medications you took prior to your hospital admission. Take all medication as prescribed by your doctor. You have been prescribed a narcotic pain medication. Please do not drive or operate any machinery while taking this medication. * Continue your warfarin as prescribed to help prevent blood clots. You need to have weekly blood draws while taking this medication. We may change your medication dose depending upon your INR level. Followup Instructions: Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 7145] ORTHOPEDIC PRIVATE PRACTICE Phone:[Telephone/Fax (1) 11262] Date/Time:[2132-11-5] 2:30 Completed by:[2132-10-6] ICD9 Codes: 5849, 4241, 2449, 5859, 496
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8218 }	Medical Text: Admission Date: [2118-9-28] Discharge Date: [2118-10-1] Date of Birth: [2052-6-1] Sex: F Service: MEDICINE Allergies: Morphine / Imdur / Haldol Attending:[First Name3 (LF) 2234] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 66 F c CAD/CHF, diabetes, hypertension, [First Name3 (LF) 20440] [First Name3 (LF) 20441], schizoaffective disorder, who presents with shortness of breath. The pt recalls that she started to have trouble breathing this morning. it came on gradually and worsened slowly. It was initally associated with non-radiating chest pain over her left chest and sternum, which was pressure like, pleuritic and positional as well as intermittent and resolved completed already when "the paramedics started working on me". On further questioning the patient reports shortness of breath already overnight as well as 3-pillow orthopnea. She also recalls a more pronounced LLE over the last three days. She denies any dietary indiscretion, however reports sometimes eating salt, "but not too much". She reports taking her medications diligently. . ROS: She reports intermittent fevers, ongoing for several months as well as night sweats. She also has had about a 20lb weight loss over the last months since her hospitalization. Also positive for constipation for three months, mild "abdominal cramping". Denies cough, diarrhea, blood in the stool or urine, dysuria. No recent sedentary episodes but at baseline not very mobile. . ED course: Pt arrived to the ED on BIPAP. VS 64 172/86 24 100%, settings unknown. Pt had received Lasix iv by the paramedics. Nitro gtt was started for BP control. The patient then was titrated down to 100% facemask and continued to do well. CXR was done and showed mild pulmonary edema. BNP was elevated at 5000. Past Medical History: CAD: NSTEMI [2-17] s/p PCI w/ DES to proximal and distal LCX. CHF (diastolic dysfunction w/ EF >55%, 1+ AR and 2+MR) H/o rheumatic heart disease w/ mild AR [Month/Year (2) ] [Month/Year (2) 20441] DM 2, diet controlled HTN Schizoaffectie disorder Hypercholesteronemia ? COPD Restricitve pattern on Spirometry in [2113] History of pulmonary embolus in [2080], while taking oral contraceptives, s/p IVC "interruption procedure") H/o thyroiditis H/o seizure disorder from infancy to age of 17 . PSH: - Status post C5 to C7 anterior decompression fusion. - Status post cholecystectomy. - Status post repair of carpal tunnel syndrome. Social History: She lives alone, her daughter, [Name (NI) ], who lives nearby and visits her frequently and helps her managing her medications. Currently uses walker for walking. Has home nurse [First Name (Titles) ] [Last Name (Titles) ] her regularly for daily acitivity as well; Tobacco abuse: 30 pyrs, quit in [2118-4-14], social drinker; no illicit drugs Family History: CAD in mother at age 68. No history of coagulation problems in her family. Physical Exam: Aspirin 81 mg PO DAILY Amlodipine 10mg DAILY Atorvastatin 20 mg PO DAILY Folic Acid 1 mg PO DAILY Hexavitamin PO DAILY Cymbalta 20mg DAILY Metoprolol Tartrate 175 mg PO BID HCTZ 25mg DAILY Protonix 40mg [Hospital1 ] Ipratropium Bromide 2puff QID Hydroxychloroquine 200 mg Tablet PO Sulfasalazine 500 mg PO BID Quetiapine 50mg DAILY Mirtazapine 15mg DAILY Florinef 0.1mg DAILY Imdur 30mg DAILY FeS 325mg DAILY Vitamin D, Calcium Pertinent Results: Admit labs: [2118-9-28] 05:50PM WBC-9.0# RBC-3.18* Hgb-10.7* Hct-31.7* MCV-100* MCH-33.6* MCHC-33.7 RDW-15.1 Plt Ct-257 Neuts-84.2* Lymphs-10.4* Monos-3.7 Eos-1.3 Baso-0.3 PT-11.8 PTT-27.2 INR(PT)-1.0 Glucose-120* UreaN-17 Creat-1.3* Na-142 K-4.0 Cl-105 HCO3-26 AnGap-15 Calcium-9.1 Phos-4.4 Mg-2.0 . [2118-9-28] 05:50PM BLOOD CK-MB-4 cTropnT-0.01 proBNP-5022* CK(CPK)-145* [2118-9-29] 12:23AM BLOOD CK-MB-3 cTropnT-<0.01 CK(CPK)-169* [2118-9-29] 04:07AM BLOOD CK-MB-4 cTropnT-<0.01 CK(CPK)-121 . [2118-9-29] 04:07AM BLOOD VitB12-568 Folate-GREATER TH [2118-9-29] 04:07AM BLOOD TSH-2.1 . PAST STUDIES: Stress Mibi [5-24]: No anginal type symptoms or ischemic EKG changes. No reversible myocardial perfusion defect is identified. . [Month/Year (2) ]: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers (however images suboptimal; cannot exclude). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. . Spirometry in [2113]: mild restricitve pattern . CT chest [9-26]: Interval increase in size of the dominant right upper lobe pulmonary nodule. The interval growth and CT morphology are highly suspicious for malignancy. Although slightly below the size threshold for reliability of PET imaging, PET-CT may still be potentially helpful if it produces a positive result. Other options include short-term followup CT in 3 months or VATS biopsy/resection. 2) Two other subpleural right upper and lower nodules are stable. Tiny lingular and left lower lobe nodules were previously obscured by atelectasis on the study of [2118-5-12]. 3) Stable, ectatic thoracic aorta. . CURRENT STUDIES: . [9-28] EKG: SR, HR 67, NA, NI, no ST/TW changes . [2118-9-28] CHEST XR (PORTABLE AP): There is vascular pedicles engorgement. The pulmonary vessels are indistinct with mild cephalization. These findings are consistent with hydrostatic edema. There is a tortuous aorta. The cardiac silhouette is enlarged. No definite blunting of the costophrenic angles is seen to suggest large effusion. There is no pneumothorax. Incidental note is made of cervical fusion plate. Since the prior exam, the nasogastric tube has been removed. IMPRESSION: Mild cardiogenic hydrostatic edema. Repeat radiography following appropriate diuresis recommended to assess for underlying infection. Brief Hospital Course: 66 year old Female with CAD/CHF, diabetes, hypertension, [Month/Day/Year 20440] [Month/Day/Year 20441], schizoaffective disorder, and lung nodule who presents with shortness of breath, most likely due to CHF with component of mild COPD exacerbation. The following issues were addressed on this admission. . 1. Hypoxia: likely due to CHF with component of mild COPD exacerbation. MICU team's suspicion for PE was low given the clinical context, no recent sedentary episodes, and no clinical concern for DVT. However they did consider that she might be at increased risk for coagulation as her recent CT findings were suspicious for malignancy. Clinically and based on absence of leukocytosis, they did not suspect infection. Patient given lasix by EMS and started on nitro drip in emergency room. Over the first night of admission in the ICU the patient was weaned from BIPAP to 3L nasal cannula. She continued to diurese from the lasix administered by EMT. Repeat CXR in the morning showed minimal change in pulmonary edema. Nitro drip was weaned over first night of admission, transitioned to oral nitrates. The patient was placed on daily lasix, 40mg daily, and continued to diurese. She was transferred to the floor on the evening of [9-29]. By [9-30] she was satting in the high 90's on room air. By [10-1] she was satting mid 90's with ambulation on room air. Felt secondary to heart failure and possibly underlying COPD. See below. . 2. Heart Failure, diastolic: no clear precipitating factor for exacerbation, however most likely dietary indiscretion and possibly hypertension. EKG unremarkable and cardiac enzymes were negative times 3. TSH was checked given history of thyroiditis and was normal. Florinef was held, as it could contribute to CHF symptoms and there was no clear indication in past notes for its continued use. Patient diuresed over course of admission about [4-17] pounds. Daily lasix of 40mg institutued. Patient reports she had been on 120mg lasix in the past for "fluid in her lungs". Patient maintained on metoprolol throughout. Dose changed from 175mg [Hospital1 ] to 200mg [Hospital1 ] for compliance reasons. Would consider addition of ACE inhibition as outpatient. Recent [Hospital1 113] with preserved ejection fraction. Could consider repeat stress testing although given severe debilitation and [Hospital1 20440] [Hospital1 20441], would need chemical stress. Imdur dosing increased from 30mg to 60mg daily. . 3. Coronary Artery Disease: History of PCI in [2115]. Ruled out for MI here. Aspirin, beta blocker and statin maintained. Consider ace as outpatient. Beta blocker titrated as above. Imdur dose titrated as above. . 4. Hypertension: BP elevated on admission, unclear if causitive of heart failure or in response to heart failure, extremis. The patient was placed on nitro drip in ER and weaned off the nitro drip overnight of admission with the sequential addition of Amlodipine at 10mg, Metoprolol (increased from 175mg [Hospital1 ] to to 200mg [Hospital1 ]), and shortacting Isosorbide Dinitrate. HCTX was discontinued on hospital day 2 as it was thought the patient would benefit from greater diuresis from low dose Lasix as outpatient rather then HCTZ. Short acting isordil changed to imdur on [9-30]. Discharged on imdur 60, metoprolol 200bid, amlodipine 10mg daily. Consider adding ace inhibition as outpatient as indications include chf, cad and ckd. . 5. COPD exacerbation: mild, no clear precipitating factor, no evidence of infection. Patient reportedly was not on inhaled steroids. Patient was provided with Fluticasone INH [Hospital1 ], Albuterol INH prn, and Ipratropium standing. Discharged on flovent and albuterol. . 6 Pulmonary nodule: Recent outpatient CT demonstrated suspicious pulmonary nodule in RUL. Findings discussed with patient and patient informed to have follow up PET scan as outpatient. Patient needs outpatient PET/CT for follow-up. I have emailed Dr. [Last Name (STitle) 9006] about this finding and with summary of hospitalization. . 7. Chronic Kidney Disease: Creatinine stable and at baseline between 1.3 and 1.5. Will need creatinine check this week given addition of lasix. Likely due to HTN and Diabetes. . 8. Anxiety/Depression: The patient was continued on Duloxetine and Quetiapine . 9 Diabetes mellitus: The patient has managed her diabetes with diet. She was started on a RISS while in the hospital. FS generally less than 150 while here. . 10. [Last Name (STitle) ] [Last Name (STitle) 20441]: The patient was continued on outpatient hydroxychloroquine and sulfazalazine. . 11. Hypercholesterolemia: Patient was continued on outpatient Atorvastatin Patient to follow up with Dr. [Last Name (STitle) 9006] this week. Spoke with patient's sister on day of discharge and gave patient explicit instructions regarding medication changes and need for follow up. Medications on Admission: Aspirin 81 mg PO DAILY Amlodipine 10mg DAILY Atorvastatin 20 mg PO DAILY Folic Acid 1 mg PO DAILY Hexavitamin PO DAILY Cymbalta 20mg DAILY Metoprolol Tartrate 175 mg PO BID HCTZ 25mg DAILY Protonix 40mg [Hospital1 ] Ipratropium Bromide 2puff QID Hydroxychloroquine 200 mg Tablet PO Sulfasalazine 500 mg PO BID Quetiapine 50mg DAILY Mirtazapine 15mg DAILY Florinef 0.1mg DAILY Imdur 30mg DAILY FeS 325mg DAILY Vitamin D, Calcium Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Amlodipine 10 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 4. Atorvastatin 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Duloxetine 20 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 7. Folic Acid 1 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 8. Hexavitamin Tablet [Hospital1 ]: One (1) Cap PO DAILY (Daily). 9. Metoprolol Tartrate 100 mg Tablet [Hospital1 ]: Two (2) Tablet PO twice a day. Disp:120 Tablet(s) Refills:0 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Fluticasone 110 mcg/Actuation Aerosol [Hospital1 ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 inhaler Refills:2 12. Atrovent HFA 17 mcg/Actuation Aerosol [Hospital1 ]: Two (2) puffs Inhalation four times a day. 13. Hydroxychloroquine 200 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 14. Sulfasalazine 500 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 15. Seroquel 50 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 16. Mirtazapine 15 mg Tablet [Hospital1 ]: One (1) Tablet PO at bedtime. 17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr [Hospital1 ]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 18. Furosemide 20 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 19. Ferrous Sulfate 325 (65) mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 20. CALCIUM 500+D 500 (1,250)-400 mg-unit Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO twice a day. 21. Outpatient Lab Work CBC, Chem-10 to be collected once the week of [10-3]. Results to Dr. [First Name8 (NamePattern2) ] [Last Name (STitle) 9006], [Telephone/Fax (1) 1247] Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: 1. Heart Failure, diastolic 2. Pulmonary Nodule 3. Hypertension 4. COPD Secondary: 1. Chronic kidney disease, stage II 2. Coronary Artery Disease 3. Type II Diabetes mellitus, controlled 4. Depressoni 5. [Hospital ] [Hospital ] Discharge Condition: Stable, ambulating with walker which is baseline. Taking good PO, no longer short of breath, oxgyen saturation on room air with ambulation is 93% Discharge Instructions: Follow up with Dr. [Last Name (STitle) 9006] this week. . Take all your medications as prescribed. I have made the following changes: 1)I have started you on lasix, which is a "water pill" for the fluid in your lungs. You will need to have your creatinine checked this week on this medication along with your potassium since it can affect your kidney function. (I have given you a prescription for this) 2)I have stopped your hydrochlorothiazide. Do not take this until you are seen by Dr. [Last Name (STitle) 9006]. 3)I have increased the dose of your Imdur from 30mg to 60mg daily. I have given you a prescription for this. 4)I have discontinued your florinef. Do not take this until you are seen by Dr. [Last Name (STitle) 9006]. 5)I have increased your metoprolol dose to 200mg twice a day from 175mg twice a day. 6)I have added flovent inhaler. You should take this because of your history of smoking and "COPD". .. If you have return of your shortness of breath or develop any chest pain, nausea, vomiting, fevers, chills or any other new concerning symptoms, contact your doctor or go to the emergency room. . On the CT scan of your chest done on the 13th, you were noted to have a "pulmonary nodule" as we discussed. This needs further studies to determine if it is a cancer. Make sure to follow up with Dr. [Last Name (STitle) 9006]. You will likely need a "PET" scan as an outpatient. Followup Instructions: Follow up with Dr. [Last Name (STitle) 9006] this week. Please call on Monday to make an appointment for this week. I will contact her to let her know you should be seen this week. her number if [Telephone/Fax (1) 8693]. You also have the following appointments scheduled in the future: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 250] Date/Time:[2118-10-19] 2:10 Provider: [Name Initial (NameIs) 11595] (RHEUM LMOB) [Doctor Last Name 11596] Phone:[Telephone/Fax (1) 2226] Date/Time:[2118-10-19] 3:30 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 20442], MD Phone:[Telephone/Fax (1) 1387] Date/Time:[2118-10-18] 5:00 ICD9 Codes: 4280, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8219 }	Medical Text: Admission Date: [2162-3-2] Discharge Date: [2162-3-10] Date of Birth: [2090-9-18] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: [2162-3-2] Cardiac Catheterization [2162-3-3] Aortic Valve Replacement (29mm CE pericardial valve), Ascending Aorta Replacement (28mm gelweave graft), Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to OM) History of Present Illness: 71 y/o male who has been followed by cardiologist for years for asymptomatic aortic stenosis. [Month/Day/Year ] stress test to determine his functional capacity, d/t cardiologist concerned if his Parkinson's could be masking symptoms of aortic stenosis. No EKG changes, but after 46 seconds his BP dropped from 110/70 to 98/70 and the test was stopped. Echo did reveal severe aortic stenosis with a bicuspid valve. In terms of symptoms he does feel fatigued with dyspnea on exertion occuring after [1-12] block. Referred for cardiac cath to further evaluate. Past Medical History: Aortic Stenosis, Parkinson's Disease, non-Hodgkin's Lymphoma s/p chemo and stem cell transplant (in remission), Anxiety, Gastroesophageal Reflux Disease, Benign Prostatic Hypertrophy s/p TURP Social History: Married, does not work. Denies ETOH or Tobacco use. Family History: Non-contributory Physical Exam: VS: 92 16 104/71 6'2" 180# Gen: NAD Skin: Unremarkable HEENT: EOMI, PEERL, NC/AT Neck: Supple, FROM, -JVD, -Bruits Chest: CTAB -w/r/r Heart: RRR 2/6 SEM Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, -varicosities Neuro: A&O x 3, MAE Discharge Neuro Alert, oriented x3, MAE r=l strength no tremors Pulm CTA decreased at bases bilat Cardiac RRR no M/R/G Abd Soft, nt, nd +BS Sternal inc midline healing no drainage/erythema steris sternum stable Leg inc Left EVH steris no erythema/drainage Ext warm +1 edema, pulses palpable Pertinent Results: [2162-3-2] CNIS: On the right, peak velocities are 65, 60, and 53 cm/sec in the ICA, CCA, and ECA respectively. This is consistent with no stenosis. On the left, peak velocities are 50, 71, and 40 cm/sec in the ICA, CCA, and ECA respectively. This is consistent with no stenosis. [2162-3-2] Cardiac Cath: 1. Selective coronary angiography of this right dominant system demonstrated a two vessel CAD. The LMCA was patent. The LAD had a 70% proximal and a 90% mid vessel stenoses. The LCx was patent but there was an 80% stenosis in the OM1. The RCA had mild nonflow limiting disease. 2. Resting hemodynamics revealed normal right and left sided filling pressures with an RVEDP of 8 mm Hg and a mean PCWP of 10 mm Hg. The cardiac index was preserved at 2.33 l/min/m2. 3. Left ventriculography was deferred. 4. There was a severe aortic stenosis with a peak to peak gradient of 45.89 mm Hg and a calculated [Location (un) 109] of 0.62 cm2. 5. Peripheral angiography demonstrated no right iliac disease. 6. Short run of SVT during the case that terminated spontaneously. [2162-3-3] Echo: PRE-BYPASS: 1. The left atrium is normal in size. No spontaneous echo contrast 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. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic root is mildly dilated at the sinus level. The sino-tubular junction is preserved. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are complex (>4mm) atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed and extremely calcified. There is severe aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trace to Mild (1+)mitral regurgitation is seen. POST-BYPASS: Pt is being atrially paced and is on an infusion of phenylephrine 1. AV bioprosthesis well seated in good position. No significant perivalvular gradient. Trace central valvular AI is noted, no perivalvular leak seen. Aortic graft noted in ascending aorta. 2. No wall motion abn noted, maintained LV and RV function 3. Aortic contours unchanged 4. Remaining exam unchanged [2162-3-4] UE U/S: Grayscale and Doppler images of the left IJ, subclavian, axillary, brachial, basilic, and cephalic veins were performed. Normal flow, augmentation, compressibility, and waveforms are demonstrated. Intraluminal thrombus is not identified. [2162-3-2] 07:40AM BLOOD WBC-5.4# RBC-4.23* Hgb-12.8* Hct-35.8* MCV-85 MCH-30.2 MCHC-35.6* RDW-15.0 Plt Ct-133* [2162-3-3] 03:34PM BLOOD WBC-6.4 RBC-2.24* Hgb-6.8* Hct-19.9* MCV-89 MCH-30.2 MCHC-34.0 RDW-14.8 Plt Ct-172# [2162-3-7] 05:45AM BLOOD WBC-6.2 RBC-4.08* Hgb-12.0* Hct-35.6* MCV-87 MCH-29.5 MCHC-33.8 RDW-15.0 Plt Ct-133* [2162-3-2] 07:40AM BLOOD PT-12.7 INR(PT)-1.1 [2162-3-5] 03:08AM BLOOD PT-12.8 PTT-32.0 INR(PT)-1.1 [2162-3-2] 07:40AM BLOOD Glucose-104 UreaN-27* Creat-1.2 Na-139 K-4.0 Cl-105 HCO3-23 AnGap-15 [2162-3-7] 05:45AM BLOOD Glucose-90 UreaN-28* Creat-1.2 Na-136 K-4.0 Cl-101 HCO3-28 AnGap-11 Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname 35501] [Last Name (Titles) 1834] a cardiac cath on [2162-3-2]. Cardiac cath revealed severe aortic stenosis along with 2 vessel coronary artery disease and a dilated ascending aorta. He was then referred for surgical evaluation. [Date Range ] all pre-operative testing and was brought to the operating room on [2162-3-3]. He [Date Range 1834] an Aortic Valve Replacement, Asc. Aorta Replacement, and Coronary Artery Bypass Graft x 2. Please see operative report for surgical details. He did have significant amount of post-op bleeding that required multiple blood products. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation awoke neurologically intact and extubated. On post-op day one there appeared to be left arm edema with bluish discoloration and left-sided neck bulge. All left arm peripheral IV's and arterial line were removed, vascular surgery was consulted and an upper extremity ultrasound was performed. Ultrasound was negative for DVT. His chest tubes and epicardial pacing wires were removed per protocol. Diuretics and beta-blockers were initiated and he was gently diuresed towards his pre-op weight. On post-op day two he was transferred to the telemetry floor. He continued to improve post-operatively and worked with PT for strength and mobility. Left arm swelling and neck bulge has resolved. Clinically he appeared to be doing well but needed additional PT and was discharged to rehab facility on post-op day seven. Medications on Admission: Primidone 150mg qhs, Mirapex 0.5mg TID, Diazepam 4mg [Hospital1 ], Zyprexa 5mg qhs, Omeprazole 20mg prn Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Nursing Home - [Location (un) ] Discharge Diagnosis: Aortic Stenosis, Asc. Aortic Aneurysm, Coronary Artery Disease s/p Aortic Valve Replacement, Asc. Aorta Replacement, Coronary Artery Bypass Graft x 2 PMH: Parkinson's Disease, non-Hodgkin's Lymphoma s/p chemo and stem cell transplant (in remission), Anxiety, Gastroesophageal Reflux Disease, Benign Prostatic Hypertrophy s/p TURP Discharge Condition: Good Discharge Instructions: [Month (only) 116] shower, 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 [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in 4 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) ] after discharge from rehab [Telephone/Fax (1) 10548] Dr. [Last Name (STitle) 22741] after discharge from rehab [Telephone/Fax (1) 35502] Please call to schedule all appointments Completed by:[2162-3-10] ICD9 Codes: 4241
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8220 }	Medical Text: Admission Date: [2174-1-28] Discharge Date: [2174-2-7] Date of Birth: [2101-7-2] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1] Chief Complaint: Lower GI bleed Major Surgical or Invasive Procedure: extended R colectomy History of Present Illness: 72 yo F presenting with 4 days of bloody diarrhea and diffuse abdominal pain. The symptoms started 3 days ago after a trip to [Location (un) 5622]. She and other family members stopped at a fast-food restaurant on the way home and all members reported diarrhea and abdominal pain later that evening. The patient had two episodes of vomiting that evening, then later diarrhea, which quickly became bloody. The diarrhea is described as explosive. She estimates ~5 bouts of diarrhea for the last few days. The blood turned the bowl a reddish color. She has not moved her bowels since early this AM. She also complains of sharp pain, diffusely, that has grown progressively worse since onset. The pain does not radiate. It is worse in the lower abdomen. She denies any prior history of bloody diarrhea. She denies any fevers or chills. She has not had any more vomiting since the first evening. She also has not eaten or drank much since onset of symptoms. Of note, she has had a significantly decreased appetite over the last year and reports a 25 pound weight loss during this time. She attributes this to the Alzheimer's medication she started a while back, which causes her to have no appetite. She had a normal colonoscopy in [2168]. She does not have any prior history to suggest cardiovascular disease. Past Medical History: Aortic stenosis, Hypertension, Hypercholesterolemia, Hypothyroidism, Anxiety, Insomnia, Arthritis, s/p Hysterectomy(hospital course complicated by gram negative sepsis), s/p Vaginal Suspension Social History: Married with three adult children. She is the primary caretaker for her husband, who recently is recovering from a severe illness. She recently has been under a lot of stress at home. Family History: Negative for premature coronary artery disease Physical Exam: Day of discharge VS. 98.4 98.4 73 132/74 18 94 RA Gen: NAD Card: RRR No M/R/G Lungs: CTAB ABD: +BS soft, non-distended, appropriately tender Wound C/D/I Pertinent Results: [2174-1-28] 04:40PM PT-13.1 INR(PT)-1.1 [2174-1-28] 04:40PM PLT SMR-LOW PLT COUNT-133* [2174-1-28] 04:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2174-1-28] 04:40PM NEUTS-65 BANDS-20* LYMPHS-3* MONOS-6 EOS-0 BASOS-0 ATYPS-6* METAS-0 MYELOS-0 [2174-1-28] 04:40PM WBC-7.6 RBC-4.21 HGB-13.1 HCT-38.7 MCV-92 MCH-31.2 MCHC-34.0 RDW-14.6 [2174-1-28] 04:40PM LACTATE-2.0 [2174-1-28] 04:40PM COMMENTS-GREEN TOP [2174-1-28] 04:40PM TOT PROT-6.7 [2174-1-28] 04:40PM cTropnT-<0.01 [2174-1-28] 04:40PM ALT(SGPT)-23 AST(SGOT)-35 TOT BILI-0.6 [2174-1-28] 04:40PM estGFR-Using this [2174-1-28] 04:40PM GLUCOSE-143* UREA N-52* CREAT-2.4# SODIUM-138 POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15 [2174-1-28] 05:22PM VoidSpec-UNLABELED [2174-1-28] 07:28PM URINE GRANULAR-[2-24] HYALINE-[2-24]* [2174-1-28] 07:28PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2174-1-28] 07:28PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2174-1-28] 07:28PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.017 [2174-1-28] 07:28PM URINE GR HOLD-HOLD [2174-1-28] 07:28PM URINE HOURS-RANDOM [2174-1-28] 08:14PM LACTATE-1.6 Brief Hospital Course: The pt presented to [Hospital1 18] from her PCP's office secondary to bloody stool and abd pain. She was admitted to the TICU for assessment. She was made NPO except meds and was started IVF and a foley was placed. . A CT scan of her abdomen and pelvis on [1-28] indicated: Bowel wall thickening and surrounding stranding/fluid involving the cecum, ascending and proximal transverse colon, compatible with colitis. Pneumatosis within the cecum was worrisome for an ischemic etiology. There was no evidence of free intraperitoneal air or portal venous gas detected. Stool samples were sent to rule out C.dif and all were negative. She was transferred to [Hospital Ward Name 1950] 5 for continued assessment. . The patient was clinically well with only mild abdominal pain and no fever or leukocytosis. However on [2-1] she has had increasing abdominal pain and tenderness with right-sided peritonitis, and a repeat CT scan showed persistent pneumatosis of the ascending and proximal transverse colon as well as significant stranding within the mesentery. The patient was placed on telemetry secondary to ischemic bowel and plans for surgery were discussed with the patient and her husband. She was pre-op'd and underwent an extended R colectomy on [2174-2-2]. . She returned to [Location ] 5 from the PACU and was made NPO except meds. She had a foley, IV hydration and a PCA. With the return of bowel function and flatus the patient was started on sips and advanced as tolerated. On the day of discharge, the patient was tolerating a regular diet, had continued passage of flatus, her pain was well controlled on an oral pain regimen. Medications on Admission: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day AMOXICILLIN - 500 mg Tablet - 3 Tablet(s) by mouth 1 hour prior to dental work ATORVASTATIN [LIPITOR] - 40 mg Tablet - [12-24] Tablet(s) by mouth once a day DONEPEZIL - 10 mg Tablet - 1 Tablet(s) by mouth with food daily FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays nostril once a day KETOCONAZOLE - 2 % Cream - apply to effected area twice a day LEVOTHYROXINE [LEVOXYL] - 100 mcg Tablet - 1 Tablet(s) by mouth once a day MEMANTINE [NAMENDA TITRATION PAK] - 5 mg (28)-10 mg (21) Tablets, Dose Pack - 1 Tablets(s) by mouth as directed on the package Titration Pack MEMANTINE [NAMENDA] - 10 mg Tablet - 1 (One) Tablet(s) by mouth twice a day - No Substitution QUETIAPINE [SEROQUEL] - 25 mg Tablet - 1 Tablet(s) by mouth twice a day SERTRALINE - 100 mg Tablet - 1 Tablet(s) by mouth in the morning VITAMINC C - (Prescribed by Other Provider) - Dosage uncertain ZOSTER VACCINE LIVE (PF) [ZOSTAVAX] - 19,400 unit Recon Soln - IM deltoid x 1 ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day MULTIVITAMINS - (OTC) - Tablet, Chewable - 1 Tablet(s) by mouth daily OMEGA-3 FATTY ACIDS-VITAMIN E [OMEGA-3 FISH OIL] - 1,000 mg-5 unit Capsule - 1 Capsule(s) by mouth once a day Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain for 2 weeks: Please do not exceed more than 4000 mg in 24 hrs. . 8. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid (). 10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:25 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary: ischemic R bowel . Secondary: Hypertension, Hypothyroidism, Alzheimer's dementia PSH: Aortic valve replacement (Bovine), Hysterectomy [2134]'s c/b bladder injury, Bladder suspension. Discharge Condition: Stable. Tolerating a regular diet. Pain well controlled with oral medications. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at your follow up appointment with Dr. [Last Name (STitle) 1924] . -Steri-strips will be applied and they will fall off on their own. Please remove any remaining strips 7-10 days after application. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: 1. Please call Dr.[Name (NI) 12822] [Telephone/Fax (1) 7508] office to make a follow up appointment in [12-24] weeks to have your staples removed. 2. Please call your PCP, [Name10 (NameIs) 10531],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 9347], to make a follow up appointment in 1 week or as needed. . Scheduled appointments: 1. Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 95298], MD Phone:[Telephone/Fax (1) 1682] Date/Time:[2174-2-14] 3:00 2. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 11771], M.D. Phone:[Telephone/Fax (1) 26488] Date/Time:[2174-6-14] 3:00 3. Provider: [Name10 (NameIs) ] Phone:[Telephone/Fax (1) 62] Date/Time:[2174-9-15] 3:00 Completed by:[2174-2-7] ICD9 Codes: 5849, 2449, 4241, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8221 }	Medical Text: Admission Date: [2201-4-21] Discharge Date: [2201-4-25] Date of Birth: [2120-10-14] Sex: M Service: MEDICINE Allergies: Alprazolam / Hydrochlorothiazide / Sulfonamides / Iodine / Clindamycin / Amoxicillin / Doxycycline / Cefaclor / Erythromycin Base / Amiodarone / Levofloxacin Attending:[First Name3 (LF) 458] Chief Complaint: polymorphic VT Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: This is an 80 yo M hx nonischemic cardiomyopathy and cardiac arrest w/AICD placement [2194], DM2 and Hypertension, recently admitted for polymorphic VT in the setting of prolonged QT. At that time he presented with dyspnea, conerning for infection, was initially started on levofloxacin. He subsequently developed polymorphic VT storm with ICD cluster shocks requiring generator change, performed [4-15]. He was discharged on [4-20] after PM was adjusted to HR 90, started on mixilotine after initially being started on lidocaine drip, as well as started on verapamil and changed from metoprolol to toprol. Unfortunately the patient was unable to fill the rx for mexilitine as it was not avaiable to pharmacy, had planned to pick up this AM, was able to fill his other meds. Pt left hospital yesterday, felt well. This AM he woke up at 4am, developed some mild substernal chest discomfort, [5-7], non-radiating, no associated sx's. He called EMS and while being transferred to ambulance, had recurrence of his ICD shocks. Initially evaluated at OSH, where K was 3.5, repleted, transferred to [Hospital1 18] for further care. He was seen on arrival to CCU, feels well. He continue to have mild substernal chest discomfort, [4-6], which he believes is heartburn, he has had this discomfort for years, it is never exertional. . ROS: chest pain as per HPI, no further cough or dyspnea, no orthopnea or PND, no recent fever, chills, lower extremity edema, no diarrhea or dysuria. No known prior hx of MI. Past Medical History: 1. As child, question big heart according to the father. 2. Hypertension. 3. Noninsulin dependent diabetes mellitus . 3. Hiatal hernia. 4. History of left bundle branch block. 5. Status post cardiac arrest [2194] with ICD placement at that time. 6. Status post right epididymectomy in [2163] and right inguinal hernia surgery in [2163]. 8. [2194-3-31] echocardiogram with mild left atrial dilatation, mild dilated left ventricular cavity, moderate to severe left ventricular systolic dysfunction, delayed relaxation for c/w left ventricular infiltrate, transaortic regurgitation. 9. CAD: On [2194-3-31], catheterization showed no significant coronary artery disease with hypokinesis of the anterior basal, anterolateral, apical, inferior posterior basal walls with ejection fraction of 25% to 30% and elevated LVEDP at 22. 10. VT/torsades in [2194] in setting of prolonged QTc (approx 70 shocks at that time) Social History: Married. Tobb 36yrs ago. 1 dtr. no etoh. R and D engineer, now retired. Can walk 1 block. Family History: no early CAD Physical Exam: VS: T 98.8 BP 129/65, HR 95, RR 14, O2 sat 95% on RA Gen: [Last Name (un) 664] obese, elderly male, in NAD HEENT: MMM, JVP difficult to assess [2-28] body habitus Cards: RRR nl S1S2 no MGR, PMI displaced laterally Resp: slight ronchi at bases, no wheezes, good air entry. Abd: BS+ NTND soft, no HSM Ext: 2+ DP, PT b/l, no edema Neuro: moving all 4 extremities Skin: no rash Pertinent Results: [2201-4-20] 02:58AM BLOOD WBC-6.8 RBC-4.09* Hgb-12.4* Hct-35.7* MCV-87 MCH-30.3 MCHC-34.8 RDW-13.4 Plt Ct-187 [2201-4-25] 07:31AM BLOOD WBC-10.3 RBC-4.81 Hgb-14.3 Hct-42.0 MCV-87 MCH-29.7 MCHC-34.0 RDW-13.8 Plt Ct-314 [2201-4-20] 02:58AM BLOOD PT-15.1* PTT-34.0 INR(PT)-1.3* [2201-4-22] 03:11AM BLOOD PT-14.7* PTT-25.1 INR(PT)-1.3* [2201-4-20] 02:58AM BLOOD Glucose-167* UreaN-31* Creat-1.0 Na-137 K-4.1 Cl-102 HCO3-30 AnGap-9 [2201-4-25] 07:31AM BLOOD Glucose-136* UreaN-32* Creat-1.4* Na-135 K-5.2* Cl-98 HCO3-29 AnGap-13 [2201-4-20] 02:58AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.2 [2201-4-25] 07:31AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.6 [2201-4-21] 12:40PM BLOOD TSH-2.7 [2201-4-21] 12:40PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2201-4-21] 12:40PM BLOOD CK(CPK)-50 . Cardiac Cath [4-22] 1. Coronary angiography of this left dominant system revealed no significant coronary artery disease. The LMCA was short and had no angiographically-apparent coronary disease. The LAD was normal. The LCX was a large dominant vessel without obstructive coronary disease. The RCA was a small vessel and also was normal. 2. Resting hemodynamics revealed normal systemic arterial pressure with an SBP of 123 mm Hg. The LVEDP was elevated at 20 mm Hg suggestive of moderate diastolic dysfunction. There was no aortic stenosis on left-heart pullback. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Moderate diastolic left ventricular dysfunction. 3. No aortic stenosis. Brief Hospital Course: Assessment: 80 yo M hx non-ischemic cardiomyopathy, HTN, recent VT/torsades storm who returns with recurrence of torsades. . # VT/torsades: This appears to be related to prolonged QT. No evidence of active ischemia and cath did not show evidence of ischemic lesion. QT continues to be prolonged, initially was attributed to treatment with levaquin, although should have been out of system. Other potential reasons for recurrence include hypokalemia and missing mexilletine. K may have been somewhat low in the setting of stress and catecholamine driven intracellular shift. He was initially on lidocaine drip and then transitioned to several antiarrhythmic regimens. Final discharge regimen was mexillitine 200mg q8h, verapamil 240mg SR (previously 120), and inderall LA 160mg . # Pump: nonischemic cardiomyopathy, EF 30-40%, appeared euvolemic. Continued spironolactone, changed beta-blocker from metoprolol to propranolol and started lisinopril 2.5mg daily Medications on Admission: Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS Spironolactone 50mg daily Toprol 150mg daily Artificial Tears 1-2 DROP BOTH EYES PRN Magnesium Oxide 400mg daily Aspirin 325 mg PO DAILY Pantoprazole 40mg daily Metformin Mexilitine 200mg q8hrs Verapamil SR 120mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 7. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 8. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). Disp:30 Tablet Sustained Release(s) Refills:2 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 10. Inderal LA 160 mg Capsule,Sustained Action 24 hr Sig: One (1) Capsule,Sustained Action 24 hr PO once a day. Disp:30 Capsule,Sustained Action 24 hr(s) Refills:2 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Outpatient Lab Work Monday [2201-4-27]: sodium, potassium, chloride, bicarb, BUN, creatinine, glucose, calcium, magnesium, phosphate. . Please [Month/Day/Year ] to his primary care provider, [Name10 (NameIs) ],[First Name7 (NamePattern1) 488] [Initial (NamePattern1) ] [Last Name (NamePattern4) ]: [Telephone/Fax (1) 8719], Phone: [Telephone/Fax (1) 8725] Discharge Disposition: Home Discharge Diagnosis: Long QT syndrome Ventricular Tachycardia / Torsades de points chronic systolic heart failure diabetes mellitus type II Discharge Condition: Good, no further ventricular arrhythmias. Discharge Instructions: You were admitted for an arrhythmia which caused your defibrillator to fire. This was most likely due to not having one of your antiarrhythmic drugs available. When put on this medication, mexilitine, your rhythm improved. We also changed some of your medications including verapamil, propranolol, and magnesium to help prevent arrhythmias. You had a cardiac catheterization procedure which showed no disease in the heart arteries which would contribute to your arrhythmias. . For your heart function, we started a low dose of lisinopril which helps prevent progression of heart failure. . For your heart failure: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1L . We initially increased your spironolactone to 75mg (three 25mg tablets) daily, but your potassium increased and your kidney function worsened slightly on the day of your discharge, so we are asking you to decrease the spironolactone back down to 50mg (two 25mg tablets) daily. . Because of this, you are also being given a prescription to get lab work done on Monday [2201-4-27]. It is very important for you to get this done to make sure that your electrolytes are at appropriate levels. You can have this done at your primary care physicians office or any local lab. Your results should be faxed to your primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) ], if you do not get them drawn at his office. . Please take all your medications as prescribed. If you are unable to take your medications, please call your primary care physician or your cardiologist. Please seek medical attention if you experience recurrent firing of your defibrillator, chest pain, shortness of breath, or any other new or concerning symptoms. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 285] Date/Time:[2201-4-28] 12:20 . Please also follow-up in Dr. [Last Name (STitle) 34490] device clinic. You can discuss this in your appointment with him on [2201-4-28]. . Please follow-up with your primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) ] for lab work on Monday as described above. Please also make an appointment with him for sometime in the next 7 days. His number is [Telephone/Fax (1) 8725]. . Please follow-up with [First Name8 (NamePattern2) 122] [Last Name (NamePattern1) ], cardiology, in the next month. His number is Phone: [Telephone/Fax (1) 8725]. ICD9 Codes: 4271, 4254, 4280, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8222 }	Medical Text: Admission Date: [2132-6-3] Discharge Date: [2132-6-5] Date of Birth: [2073-12-9] Sex: F Service: CCU CHIEF COMPLAINT: Chest pain. HISTORY OF THE PRESENT ILLNESS: This is a 58-year-old female with multiple cardiac risk factors but no prior cardiac history who presented to an outside hospital the day prior to presentation to [Hospital6 256] complaining of intermittent chest pain radiating to both arms. The patient describes the onset of pain in her arms which does spread across her back and ended up in her chest. The EKG was not impressive for ischemia, but troponins were elevated. Spiral CT scan was negative for dissection. No relief of chest pain with nitroglycerin. Aspirin, heparin, Aggrastat, and Dilaudid were started. The symptoms returned intermittently throughout the night. Repeat enzymes on the morning of transfer to [Hospital6 256] were CK 42, troponin 0.38. The patient was transferred to [Hospital6 256] for catheterization. Urgent catheterization showed 90% middle RCA stenosis and 70% proximal LAD stenosis. The right coronary artery was stented and normal flow was noted to the LAD. The procedure was complicated by nausea, vomiting, and lethargy, presumably from narcotic administration prior to the procedure. The patient was given Narcan and flumazenil. The patient went into atrial fibrillation with a rapid ventricular response at 150 beats per minute. After the procedure, Lopressor IV initially controlled the rate and then broke the arrhythmia. The patient was transferred to the CCU for close observation. No further nausea, vomiting, lethargy, or atrial fibrillation in the unit. No complaints at the time of examination in the unit. PAST MEDICAL HISTORY: 1. Fibromyalgia. 2. Chronic lymphocytosis, questionable. 3. Status post nephrectomy for nephrolithiasis, right kidney. 4. Status post appendectomy and cholecystectomy. 5. History of colon cancer, status post partial colectomy. 6. Hypercholesterolemia. 7. Hypertension. 8. History of tobacco use. 9. Family history of coronary artery disease in the patient's mother. ADMISSION MEDICATIONS: 1. Norvasc 5 mg p.o. q.d. 2. Lisinopril 10 mg p.o. q.d. 3. Lasix 80 mg p.o. q.a.m., 40 mg p.o. q.p.m. 4. Celexa 5 mg p.o. q.a.m. 5. Tagamet. 6. Colace. 7. Amitriptyline 50 q.h.s. MEDICATIONS AT TRANSFER: 1. Aspirin. 2. Plavix. 3. Aggrastat drip. 4. Nitroglycerin drip. ALLERGIES: Augmentin causes nausea and vomiting. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.1, pulse 69, respirations 18, blood pressure 125/49, oxygen saturation 94% on 3 liters nasal cannula. Neurologic: No focal neurological deficits. The patient was alert and oriented times three. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. No jugular venous distention. No peripheral edema. Abdomen: Soft, nontender, nondistended. Pulmonary: Lungs clear to auscultation. Groin catheterization site is covered, clean, dry, and intact, no hematoma, no bruit. LABORATORY/RADIOLOGIC DATA: Potassium 3.0, creatinine 0.7. Hematocrit 30.6. Blood gas 7.30, 52, 68. HOSPITAL COURSE: The patient's remaining hospital course was uneventful. She had no recurrent chest pain or shortness of breath or other ischemic symptoms in-house. She was able to ambulate with PT without a problem and without onset of symptoms. Her Lasix was initially held around the time of catheterization. It was restarted on the day after the catheterization. She was started on a beta blocker, statin, and ACE inhibitor and Plavix. Her aspirin and ACE inhibitor were continued. Her beta blocker and ACE inhibitor were increased as tolerated. The nitroglycerin drip was weaned off overnight on the night of the catheterization. Aggrastat was continued after the catheterization until the morning after when it was discontinued. DISCHARGE STATUS: The patient is stable for discharge home. FOLLOW-UP: The patient is to follow-up with the [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) ]. She will need to return for cardiac catheterization in three to four weeks for possible intervention on her left anterior descending artery lesion. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Plavix 75 mg p.o. q.d. 3. Atorvostatin 10 mg p.o. q.d. 4. Lisinopril 10 mg p.o. q.d. 5. Metoprolol 25 mg p.o. b.i.d. 6. Lasix 80 mg p.o. q.a.m., 40 mg p.o. q.p.m. 7. Celexa 5 mg p.o. q.a.m. 8. Amitriptyline 50 mg p.o. q.h.s. DISCHARGE DIAGNOSIS: Non ST elevation MI, status post right coronary artery stent. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Last Name (NamePattern1) 2582] MEDQUIST36 D: [2132-6-5] 12:44 T: [2132-6-8] 15:08 JOB#: [Job Number ] ICD9 Codes: 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8223 }	Medical Text: Admission Date: [2197-5-10] Discharge Date: [2197-5-13] Date of Birth: [2137-1-4] Sex: F Service: NEUROSURGE HISTORY OF PRESENT ILLNESS: The patient is a 60 year old woman diagnosed with breast cancer in [2191], with metastasis to the right hip, left spine, left proximal humerus and left ankle, and also the brain. On [2197-5-1], the patient had a tonoclonic seizure on the right side for which she was placed on antiseizure medication. A CT scan at an outside hospital revealed white matter edema involving the proximal parietal lobe with metastatic tumor. She underwent chemotherapy at that time. CT of the chest and abdomen at that time were negative for metastatic disease. PAST MEDICAL HISTORY: 1. Rheumatic fever as a child. 2. Hypertension. 3. Positive for H. pylori in the past. PAST SURGICAL HISTORY: 1. Tonsillectomy and adenoidectomy. 2. Breast biopsy. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: On physical examination, the patient is alert, oriented times three. The pupils are 3.0 millimeters and regular reactive to light. The face is symmetric. Motor strength is [4-29] in all extremities. The chest is clear to auscultation. Cardiac is regular rate and rhythm. Extremities are warm with no edema, positive pulses. Neurologically, no drift, extraocular movements are full. The pupils are equal, round, and reactive to light and accommodation. IPs are [4-29] bilaterally. HOSPITAL COURSE: The patient on [2197-5-10], underwent left parietal craniotomy for resection of tumor without complications. Postoperatively, the patient was monitored in the Surgical Intensive Care Unit and was transferred to the regular floor on postoperative day one. Vital signs remained stable. The patient was afebrile. The patient's condition remained stable. She was afebrile and neurologically intact. The patient was discharged to home on [2197-5-13], with follow-up in the Brain [Hospital 341] Clinic in one to two weeks and follow-up for staple removal in one week. MEDICATIONS ON DISCHARGE: 1. Dilantin 100 mg p.o. q8hours. 2. Hydrochlorothiazide 12.5 mg p.o. q.d. 3. Decadron taper to 2 mg p.o. b.i.d. 4. Zantac 150 mg p.o. b.i.d. 5. Percocet one to two tablets p.o. q4hours p.r.n. 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: [2197-8-16] 12:58 T: [2197-8-20] 11:37 JOB#: [Job Number 35002] ICD9 Codes: 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8224 }	Medical Text: Admission Date: [2190-6-16] Discharge Date: [2190-6-23] Date of Birth: [2122-11-2] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is a 66-year-old patient, who has a known history of coronary artery disease and has undergone multiple PTCA stents and PCIs in the last year, who underwent placement of a stent in his proximal left anterior descending artery on [2190-6-9]. On [2190-6-14], the patient was at home and began experiencing angina and called his cardiologist. On [2190-6-16], was referred to the Emergency Room. The patient presented to the Emergency Room on [2190-6-16] and was admitted for workup. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Status post circumflex and left anterior descending artery stenting. 3. Hypercholesterolemia. 4. Hypertension. 5. History of Bell's palsy. 6. Status post hernia repair. 7. Positive tobacco use greater than 30 pack year history. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Mavik 4 mg po q day. 2. Cardura 4 mg po q day. 3. Lipitor 40 mg po q day. 4. Aspirin 325 mg po q day. 5. Atenolol 50 mg po q day. 6. Folate. 7. Multivitamins. HOSPITAL COURSE: The patient was admitted to the Emergency Room. Vital signs in the Emergency Room: Temperature 97.5, pulse 69. Regular, rate, and rhythm. Blood pressure 93/51, respiratory rate 17, oxygen saturation 97%. Patient was awake, alert, and oriented times three in no apparent distress. Pain level upon arrival was [1-1]. Lungs were clear. Heart was regular. Abdomen was soft, positive bowel sounds. Extremities were without edema. Cardiology was consulted. The patient was taken to the Catheterization Laboratory. In the Cardiac Catheterization Laboratory, the patient was found to have elevated filling pressures with a pulmonary capillary wedge pressure of 19. The left main coronary artery showed severe 90% eccentric narrowing of entire length. The stent to the left anterior descending artery was patent. The stent to the left circumflex was patent, and the right coronary artery showed chronic total occlusion which was unchanged. An intra-aortic balloon pump was inserted and Cardiac Surgery was consulted. The patient had an echocardiogram which showed mild aortic stenosis with a valve area of 1.3. An ejection fraction of 40-45%, an aortic valve peak gradient of 38 mm Hg and a mean gradient of 24 mm Hg. Patient was taken to the operating room from the Catheterization Laboratory due to the severe nature of his left main disease with Dr. [Last Name (STitle) 70]. The patient underwent a coronary artery bypass graft x3 with LIMA to left anterior descending artery, saphenous vein graft to PDA, and OM sequential, as well as an aortic valve replacement with a 21 mm bovine [Last Name (un) 3843]-[Doctor Last Name ] pericardial valve on [2190-6-16] with Dr. [Last Name (STitle) 70]. Please see operative note for further details. The patient was transferred from the operating room to the Intensive Care Unit in stable condition. Upon admission to the Intensive Care Unit, patient was mildly hypoxic with a respiratory acidosis and the patient remained intubated overnight. On postoperative day #1, the patient was weaned and extubated from mechanical ventilation. Preoperatively, the patient had been noted to have a large hematoma in his right groin from his cardiac catheterization one week later, and had been reported to have an audible bruit. A vascular ultrasound was obtained which showed no evidence of pseudoaneurysm or A-V fistula in his right groin. A Vascular consult was attained. The Vascular team decided that no treatment was necessary of the hematoma, however, patient did report to Dr. [Last Name (STitle) ], the Vascular surgeon that he did have symptoms of claudication. Dr. [Last Name (STitle) ] suggested that the patient see him in the office for followup for his claudication. On postoperative day #1, patient spiked a fever to 101. The patient was pancultured. The results of the cultures subsequently had been negative, and patient's temperature defervesced and had no further temperature spikes. Patient's balloon pump was weaned and removed on postoperative day #1 without complication. On the evening of postoperative day #1, it was noted that the patient had progressively decreasing urine output with significant oliguria. Patient's Foley catheter was flushed without difficulty. Patient had little response to Lasix in volume. Patient was noted to have distended bladder. Foley catheter was replaced with over a liter of urine output noted. On postoperative day #2, the patient was noted to be progressively hypoxic, and thought to be due to the volume challenge the patient had received when he was thought to be oliguric. The patient was given aggressive diuretic therapy with good improvement in his oxygenation as well as aggressive pulmonary toilet. Patient continued to need low dosed Neo-Synephrine to maintain adequate blood pressure. On postoperative day #2, patient had episode of rapid atrial fibrillation, started on IV amiodarone. Rate was controlled with IV amiodarone and Lopressor. Patient began working with Physical Therapy and ambulating. On postoperative day #3, the patient continued to have episodes of atrial fibrillation. Rate was controlled with Lopressor. Patient's oxygenation improved dramatically, and was able to be weaned down to nasal cannula. Patient's chest tubes were removed without incident. Patient, on postoperative day #3, was noted to have some serosanguinous drainage coming from the distal portion of his sternum. The area was clean and Dermabond was applied. The patient was noted to have elevated white blood cell count of 27,000. Patient was empirically started on levofloxacin/Vancomycin. On postoperative day #4, the drainage from the lower portion of the sternum had significantly decreased. Patient's white blood cell count continued to be elevated, however, patient remained afebrile. Patient continued on the antibiotics. On postoperative day #5, the patient was transferred from the Intensive Care Unit to the floor. Patient's white blood cell count had dropped to 16.8. Patient was started on Coumadin and Heparin to anticoagulate for his continued episodes of atrial fibrillation. On postoperative day #6, the Heparin drip was discontinued. Coumadin dosing continued. His sterile drainage had stopped and on postoperative day #7, patient was cleared for discharge to rehabilitation. CONDITION ON DISCHARGE: Temperature max 97.1, pulse 67, sinus rhythm, although the patient has had multiple episodes of atrial fibrillation, blood pressure 110/60, respiratory rate 16, on room air oxygen saturation of 97%. Weight on [6-23] is 98.2 kg. The patient weighed 97 kg preoperatively. LABORATORY DATA: White blood cell count 17.1, hematocrit 27.5, platelet count 268. Sodium 135, potassium 5.5, chloride 97, bicarb 31, BUN 28, creatinine 1.2, glucose 114, PT 16.9, INR 1.9. Neurologically the patient is awake, alert, and oriented times three. Neurologically nonfocal. Heart is regular, rate, and rhythm, positive rub, no murmur. Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Abdomen has positive bowel sounds, is soft, nontender, nondistended. Patient is tolerating a regular diet. Extremities have [12-24]+ pitting edema. Both extremities are warm and well perfused. Right groin has an old hematoma which is decreasing in size. Right lower extremity vein harvest site Steri-Strips are intact. There is no erythema or drainage. Sternal incision: The upper portion, Steri-Strips are intact, lower portion has Dermabond. There is no erythema or drainage. The sternum is intact. DISCHARGE MEDICATIONS: 1. Lasix 40 mg po bid x10 days. 2. Potassium chloride 10 mEq po bid x10 days. 3. Colace 100 mg po bid. 4. Zantac 150 mg po bid. 5. Enteric coated aspirin 81 mg po q day. 6. Dulcolax suppositories prn. 7. Amiodarone 400 mg po bid x7 days, then amiodarone 400 mg po q day. 8. Albuterol MDI two puffs q4h prn. 9. Atorvastatin 40 mg po q day. 10. Ambien 5 mg po q hs prn. 11. Atenolol 50 mg po q day. 12. Coumadin 3 mg po on [6-23] and INR is to be checked on [6-24], and Coumadin dose to be adjusted for a goal INR of 2.0. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Unstable angina. 3. Status post coronary artery bypass graft x3. 4. Status post aortic valve replacement. 5. Hypertension. 6. Hypercholesterolemia. 7. Postoperative atrial fibrillation. 8. Claudication. 9. Postoperative sternal drainage now resolved. DISCHARGE STATUS: The patient is to be discharged to rehab in stable condition. FOLLOW-UP INSTRUCTIONS: The patient is to followup with Dr. [Last Name (STitle) 70] in [4-27] weeks. The patient is to followup with his primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ] upon discharge from rehabilitation. The patient is to followup with Dr. [Last Name (STitle) ] in [4-27] weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 16172] MEDQUIST36 D: [2190-6-23] 10:08 T: [2190-6-23] 10:08 JOB#: [Job Number 101627] ICD9 Codes: 4111, 9971, 4241, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8225 }	Medical Text: Admission Date: [2151-12-15] Discharge Date: [2151-12-17] Date of Birth: [2131-9-1] Sex: F Service: MEDICINE Allergies: Haldol / Morphine / Percocet / Dilaudid / Demerol Attending:[First Name3 (LF) 2297] Chief Complaint: Status asthmaticus, vocal cord dysfunction Major Surgical or Invasive Procedure: None History of Present Illness: 20F h/o asthma and vocal cord dysfunction admitted in status asthmaticus in the setting of 3 days URI symptoms. She was most recently discharged [2151-11-24] after a similar asthma exacerbation. Three days prior to presentation, she completed the prednisone taper from that previous admission. On that same day, she developed increased symptoms including cough, chest tightness, and wheezing. On ROS, she denies fevers, chills, sweats, chest pain although does feel tightness. Frequent coughing with scant sputum production. At home has been taking advair, combivent inhaler, [Doctor First Name 130], and singulair. Today she took duonebs x3 due to worsening of symptoms and presented to PCP for visit given her shortness of breath. In the office was minimally wheezy but congested and reported ambulatory stridor; peak flow was 240. She was sent to the ED for evaluation, but decided to go to her dorm first where she became more short of breath and notified campus police who called EMS. In the ED initial vitals: 99.2, 128, 138/87, 21, 99% on RA. Exam wheezy, tachycardic, tachypnic. Given ativan, nebs, solumedrol with no significant improvement so started on heliox which led to subjective improvement but once removed she developed coughing fits and subjective shortness of breath. Admitted to the ICU for ongoing care. Past Medical History: Depression Anxiety Paradoxical vocal cord motion (diagnosed per ENT fiberoptic exam [10/2150]; repeat exam by MEEI physician [2151] told she did not have vocal cord problems) Asthma - Patient had been treated for asthma since [2148], with home medications including prednisone, albuterol,ipratropium, montelukast, and fluticasone. Additionally, pt had been hospitalized with "asthma flares" requiring intubation (3x, last [10-24]) - PFTs have been normal multiple times. Social History: She is a nursing student at [University/College ]. She lives in a dorm. She denies tobacco, alcohol, and other illicit drugs. Family History: # Brother: Seasonal allergies # Father died of MI in his 40s Physical Exam: T 97.6 HR 116 BP 131/47 RR 19 SaO2 100% General: Speaking in full sentences, no acc muscle use, appears in mild respiratory distress HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink Neck: supple, trachea midline, no thyromegaly or masses, no LAD, no stridor Cardiac: RRR, s1s2 normal, no m/r/g, no JVD Pulmonary: +Tachypnea, +intermittent dry cough, scattered exp wheezes, poor air movement, no stridor Abdomen: +BS, soft, nontender, nondistended, no HSM Extremities: warm, 2+ DP pulses, no edema Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves all extremities Pertinent Results: Admission Labs: WBC-10.2 RBC-4.84 Hgb-13.5 Hct-39.1 MCV-81* MCH-28.0 MCHC-34.6 RDW-14.3 Plt Ct-315 Neuts-66.0 Lymphs-28.9 Monos-3.7 Eos-0.9 Baso-0.5 Glucose-104 UreaN-14 Creat-1.0 Na-140 K-3.7 Cl-102 HCO3-20* Glucose-143* Lactate-4.2* Na-143 K-3.7 Cl-100 freeCa-1.12 [2151-12-15] CXR: IMPRESSION: No acute intrathoracic process. Brief Hospital Course: 20F h/o asthma and vocal cord dysfunction admitted with respiratory distress, likely secondary to status asthmaticus and vocal cord dysfunction. # Status asthmaticus - The patient presented in status asthmaticus in the setting of a URI, finishing a recent prednisone taper, and recent colder weather. The patient was continued on oral steroids, 60mg po daily. Heliox was discontinued upon patient arrival to the ICU. She was initially on continuous albuterol nebulizer treatments, and her lung exam rapidly improved, though she continued to have intermittent coughing fits. The morning after admission, she was breathing comfortably on RA with normal oxygen saturation and a clear lung exam. She was transitioned to prn xopenex nebulizer treatments and continued on her home regimen. She was given a 5 day course of oral azithromycin as well given the initial severity of her symptoms. She was discharged to home to complete a prednisone taper and to continue her home regimen. She will have close follow-up with her primary care physician. # Vocal cord dysfunction - given initial concerns for stridor, rapid resolution of her symptoms, and known past history, VCD was thought to be a contributing factor for this flare. This diagnosis was discussed with [Known firstname ], and we discussed techniques for managing her VCD. She was given low dose lorazepam with good effect. She was discharged to home with a limited amount of ativan to be used as needed. # Depression - Her home Lamictal was continued. No active issues during this admission. # Anemia ?????? Hct 34 with a slightly low MCV. Stable from previous admission. Medications on Admission: ALBUTEROL Nebulization Q4H prn shortness of breath or wheezing CROMOLYN - 800 mcg Aerosol - 3 puffs INH 20 min before exercise [Doctor First Name ]-D 24 HOUR - 240 mg-180 mg SR 24 hr - 1 tab PO qam ADVAIR DISKUS - 250 mcg-50 mcg - 1 INH [Hospital1 ] COMBIVENT inh Q4H prn LAMICTAL 100 mg PO QHS SINGULAIR 10 mg PO daily PANTOPRAZOLE 40 mg PO daily MULTIVITAMIN daily Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:90 Capsule(s) Refills:0 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 4 days. Disp:8 Tablet(s) Refills:0 8. Prednisone 10 mg Tablet Sig: as prescribed Tablet PO once a day for 2 weeks: Please take 40 mg for 3 days, then 30 mg for 3 days, then 20 mg for 3 days, then 10 mg for 3 days, then 5 mg for 3 days then stop. Disp:32 Tablet(s) Refills:0 9. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: [2-17] Inhalation every 4-6 hours as needed for 3 days. Disp:1 inhaler Refills:0 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for Stridor for 5 doses. Disp:5 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Asthma exacerbation Secondary Diagnoses: 1. Vocal chord dysfunction 2. Anxiety 3. Depression Discharge Condition: Stable, satting well on room air, breathing comfortably Discharge Instructions: You were admitted to the hospital for shortness of breath and an asthma exacerbation. You were treated with steroids and frequent nebulizer treatments and your symptoms improved. Please take the prednisone taper as prescribed below as well as the antibiotic azithromycin for the next 3 days. You have also been given a few lorazepam pills to use if you are having upper vocal chord dysfunction with upper airway stridor. Please follow-up with your physicians as below. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 30764], MD Phone:[Telephone/Fax (1) 9316] Date/Time:[2151-12-29] 4:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN, CS Phone:[Telephone/Fax (1) 250] Date/Time:[2152-1-7] 11:20 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2152-2-7] 11:40 ICD9 Codes: 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8226 }	Medical Text: Admission Date: [2159-3-16] Discharge Date: [2159-3-26] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7651] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: [Known lastname 80294] is an 84 y/o M with history of recent CHF exacerbation following hospitalizatin for sepsis who presents to the hospital with increasing LE edema and dyspnea. This morning, he developed acute shortness of breath, and was brought to the hospital by ambulance. He denied any other symptoms such as fever, cough, or chest pain. In the ED, Initially, he was satting 97% on RA but tachypneic to 30s. BPs 118/83 initially, now 111/74. He was started on nitro gtt, and received hydralazine 5mg IV as well. He also received a dose of vancomycin and zosyn for possible infectious precipitant. He is anticoagulated for a history of DVT, and his present INR is 4.4. He also received 60mg PO K for a potassium of 3.4. CXR showed volume overload. He then received 80mg IV lasix putting out only 500cc (home 80), put on bipap. He was trialed off bipap and looked okay by numbers but was still felt to be tenuous and was placed back on bipap for transfer. . Cardiac review of systems is notable for + orthopnea, longstanding. On review of symptoms, he denies any prior history of stroke, TIA, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: compiled from prior discharge summary: Multiple Myeloma - treated at DF currently, on dexamethasone DVT x 2, on coumadin Valvular heart disease (MODERATE MR) Hyperlipidemia BPH Constipation Hypertension Plantar fasciitis Severe leg pain appendectomy and tonsillectomy as a child a kidney stone removed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 986] in [2146] cholecystectomy by Dr. [Last Name (STitle) ] in [2153-9-17] Cardiac Risk Factors: Dyslipidemia, Hypertension Cardiac History: No h/o CABG or revascularization Percutaneous coronary intervention: none Pacemaker/ICD: None Social History: He does not smoke nor drink. Smoked < 1 year when young. He is married, has a son and a daughter. [Name (NI) ] used to run a sportswear factory. Family History: His father died at 90 of cancer in the brain and his mother at 52 of breast cancer. Physical Exam: Initially, he was satting 97% on RA but tachypneic to 30s. BPs 118/83 initially, now 111/74 GEN:The patient is in no distress and appears comfortable SKIN:No rashes or skin changes noted HEENT:No JVD, neck supple, No lymphadenopathy in cervical, posterior, or supraclavicular chains noted. CHEST:Lungs are clear without wheeze, rales, or rhonchi. CARDIAC: Regular rhythm; no murmurs, rubs, or gallops. ABDOMEN: No apparent scars. Non-distended, and soft without tenderness EXTREMITIES:no peripheral edema, warm without cyanosis NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE [5-22], and BLE [5-22] both proximally and distally. No pronator drift. Reflexes were symmetric. [Last Name (un) ] going toes. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ At discharge, pt satting mid 90s on room air, walking with assist with only faint bibasilar rales Pertinent Results: Admission Labs [2159-3-16] WBC-6.0 RBC-3.36* Hgb-11.5* Hct-33.7* MCV-100* MCH-34.3* MCHC-34.2 RDW-15.1 Plt Ct-265# PT-41.1* PTT-33.5 INR(PT)-4.4* Glucose-117* UreaN-21* Creat-1.3* Na-140 K-3.4 Cl-99 HCO3-33* AnGap-11 ALT-12 AST-21 CK(CPK)-75 AlkPhos-50 CK-MB-NotDone proBNP-5767* cTropnT-0.05* CK-MB-NotDone cTropnT-0.06* Phos-2.8 Mg-2.0 Other Labs [2159-3-20] Lactate-1.1 [2159-3-21] Cortsol-19.0 [2159-3-19] Glucose-124* UreaN-17 Creat-1.6* Na-143 K-3.7 Cl-92* HCO3-46* AnGap-9 [2159-3-21] Glucose-108* UreaN-28* Creat-1.8* Na-141 K-3.2* Cl-92* HCO3-45* AnGap-7* [2159-3-24] Glucose-108* UreaN-36* Creat-1.4* Na-138 K-2.5* Cl-88* HCO3-43* AnGap-10 [2159-3-25] Glucose-109* UreaN-37* Creat-1.5* Na-135 K-3.2* Cl-89* HCO3-38* AnGap-11 [2159-3-26] Glucose-104 UreaN-38* Creat-1.7* Na-137 K-2.7* Cl-87* HCO3-41* AnGap-12 [2159-3-17] PT-43.2* PTT-35.3* INR(PT)-4.8* [2159-3-18] PT-44.2* PTT-35.6* INR(PT)-4.9* [2159-3-24] PT-26.3* PTT-28.1 INR(PT)-2.6* [2159-3-25] PT-34.6* PTT-31.1 INR(PT)-3.6* [2159-3-26] WBC-8.2 RBC-3.63* Hgb-12.5* Hct-35.3* MCV-97 MCH-34.5* MCHC-35.4* RDW-14.2 Plt Ct-292 Urine Studies [2159-3-21] 11:25PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.011 [2159-3-21] 11:25PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [2159-3-21] 11:25PM URINE RBC-[6-27]* WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 Micro Data Blood cx x 4 NGTD urine cx 10-100K yeast Imaging CXR [2159-3-16] FINDINGS: AP semi-upright portable chest radiograph is obtained. There is persistent cardiomegaly with central pulmonary vascular congestion and relative indistinctness of the hilum. Bilateral pleural effusions are again noted with fissural fluid noted on the right. Mediastinal contour is grossly stable and difficult to accurately assess on this portable AP chest radiograph. No pneumothorax is seen. Bibasilar atelectasis is also stable. Osseous structures are unchanged. IMPRESSION: Mild CHF with bilateral pleural effusions. TTE [2159-3-17] The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated with depressed free wall contractility. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. Moderate to severe (3+) mitral regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. If clinically indicated, a transesophageal echocardiographic examination is recommended to assess mitral valve morphology, exclude a vegetation, and better evaluate severity of mitral regurgitation. IMPRESSION: Dilated left ventricle with normal global systolic function. Dilated and at least mildly hypokinetic right ventricle. Mild aortic regurgitation. Moderate to severe mitral regurgitation. Severe pulmonary hypertension. Compared with the prior study (images reviewed) of [2159-2-15], LV is more dilated. Mitral regurgitation severity has increased, and pulmonary pressure is more severe. Findings discussed with Dr. [First Name (STitle) 4135] at 1410 hours on the day of the study. [2159-3-23] CXR FINDINGS: In comparison with the study of [3-21], there may be some continued improvement in the mild pulmonary edema. Enlargement of the cardiac silhouette persists. Progressive decrease in the pleural effusions, especially on the right. Mild bibasilar atelectasis persists. ECG [2159-3-18] The rhythm appears to be atrial fibrillation with a moderate ventricular response and occasional ventricular ectopy. Right bundle-branch block. Compared to the previous tracing of [2159-3-16] atrial fibrillation has appeared. Clinical correlation is suggested. ECG [2159-3-17] Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Compared to the previous tracing of [2159-3-16] no diagnostic interim change. Brief Hospital Course: Assessment and Plan 84 y/o gentleman with history of diastolic CHF and hypertension who presents with acute CHF exacerbation initially requiring non-invasive ventilation as well as new 3+MR now improved satting mid 90s after aggressive diuresis. . # ACUTE ON CHRONIC DIASTOLIC CONGESTIVE HEART FAILURE - Pt was admitted with acute on chronic diastolic heart failure decompensation with [Date Range 113] on admission showing worsening moderate to severe MR [Name13 (STitle) 104756] with [2159-1-18]. He had no evidence of new ischemia by ECG or biomarkers. Diuresis with lasix IV boluses was initially limited by low BPs with SBPs in 70s-80s but BP improved throughout hospital course as he was diuresed with lasix gtt. He tolerated approximately 3L negative per day and his renal function improved with diuresis. Lasix gtt was transitioned to torsemide 80mg PO BID and metolazone with goal 1L negative per 24 hr period. He bumped his creatinine on day of discharge from 1.7 to 2.3, so regimen was downtitrated to torsemide 60mg PO BID with no metolazone. He was also restarted on lisinopril 5mg PO daily for heart fialure and low dose beat blocker metoprolol 12.5 PO BID. He will continue on this for outpatient regimen. His dry weight at time of discharge was 94 kg on floor standing scale. He had been 92kg on CCU scale on day prior to discharge. His admission weight was 106kg. His SBP was 80s-90s at discharge which is likely his baseline. He was mentating well and was asymptomatic with SBP 80s-90s. . # MR: New 3+ MR [First Name (Titles) ] [Last Name (Titles) 113] concerning for ischemic MR vs volume overload. Continued diuresis as above and attempted to optimize medical management as patient does not want surgery or any invasive procedures. . # H/O DVT ON ANTICOAGULATION: Coumadin initially held due to supratherapeutic INR but then restarted at home doses. INR again supratherpaeutic on [2159-3-26] so will likely need adjustment of home regimen as outpatient. Goal INR [2-20]. . # MYELOMA: Have been holding dexamethasone secondary to fluid overload . # CHRONIC KIDNEY DISEASE: Creatinine trended up through admission likely from heart failure and decreased renal perfusion as well as diuresis. Creatinine bump on [2159-3-26] likely related to starting low dose ACE as well as reaching limit of diuresis. Started on low dose aceI as above. Will need follow up of renal function as well as electrolytes after discharge and has repeat labs this week. . # HEMATURIA: Likely from elevated INR. He tolerated removing foley and was voiding without difficulty at discharge. He should follow up with urology and primary care as an outpatient. . # BPH/Bladder spasms- Patient started on pyrimidine 100mg PO TID for 3 days which improved spasms. Continued finasteride. . # FEN : Pt with hypokalemia while being diuresed. He required daily to [Hospital1 ] potassium repletion and potassium levels will need to be closely followed on discharge. He was also discharged on standing low dose potassium repletion. . # CODE DNR/DNI , confirmed with patient and daughter Medications on Admission: 1. Finasteride 5 mg dailu 2. Gabapentin 100 mg TID 4. STOPPED Tamsulosin 0.4 mg qHS 5. Calcitrate-Vitamin D 315-200 mg-unit [Hospital1 ] 6. Docusate Sodium 100 mg [Hospital1 ] 7. Folic Acid 0.5 mg Daily 8. Citalopram 40mg PO daily 9. Warfarin 4mg daily 11. Furosemide 80 mg daily 12. Acetic Acid - 2 % Solution - half cc in ears twice a day 13. STOPPED- Dexamethasone - 40mg qMonday 14. Famotidine - 20 mg [Hospital1 ] 15. Tylenol 16. ASA b325mg PO daily 17. CHLORHEXIDINE GLUCONATE - 2 % Liquid - mouth wash twice a day 19. MULTIVITAMINS WITH MINERALS 20. SENNA - 8.6 mg Tablet - 2 Tablet [Hospital1 ] Discharge Medications: 1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 3. Calcium 500 + D 500 (1,250)-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day. 6. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for constipation. 9. Gabapentin 100 mg Capsule Sig: Three (3) Capsule PO once a day. 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day. Disp:60 Capsule, Sustained Release(s) Refills:2 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 13. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 14. Outpatient Lab Work Please check INR, Chem-7 and Hct on thursday [2159-3-29] and call results to Dr. [Last Name (STitle) 713] at [Telephone/Fax (1) 719] Discharge Disposition: Home With Service Facility: [Location (un) 701] VNA Discharge Diagnosis: Acute on Chronic Diastolic Congestive Heart failure Hematuria Chronic Kidney Disease Stage 3 Multiple myeloma Discharge Condition: stable Discharge Instructions: You were admitted with congestive heart failure that was making your legs swell and causing shortness of breath. We changed some of your medicines to help your heart work better. You also had some blood in your urine that was from the foley catheter placement. This should resolve on it's own. Please call Dr. [Last Name (STitle) 713] if you have trouble urinating and talk to her about seeing a urologist. Your coumadin level was 3.4 on [3-27] so your coumadin was held. Please check it again on Thursday [2159-3-29]. Do not start taking your coumadin again until Dr. [Last Name (STitle) 713] or Dr. [Name (NI) 11723] tells you to. . Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to [2150] mg sodium diet Fluid Restriction: about [6-24] cups of fluid per day. , Medication changes: 1. Your Lisinopril was restarted at a very low dose 2. Metoprolol 12.5 mg twice daily: to help you heart pump better 3. Torsemide 80 mg twice daily: to replace the Furosemide to get rid of fluid. 4. Potassium: to take every day to replace the potassium lost from the torsemide 5.Stop taking your Furosemide 6. Please do not take your warfarin until after you get your INR checked on [2159-3-29]. . Please call Dr.[Name (NI) 3733] if you have any trouble breathing, swelling in your legs, dizziness, feeling very thirsty, palpitations or chest pain. . I have talked to Dr. [Last Name (STitle) 713] and Dr.[Name (NI) 3733], they agree to defer a pulmonology work-up for now. These appts have been cancelled. Followup Instructions: Cardiology: Provider: [First Name4 (NamePattern1) ] [Name Initial (NameIs) ], MD Phone: [Telephone/Fax (1) 62] Date/time: Friday [3-30] at 1:40pm. [Hospital Ward Name 23] Clinical Center [Location (un) 436]. . Heart Failure Clinic: Tuesday [4-17] at 2:30pm with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP [Hospital Ward Name 23] [Location (un) 436]. . Primary Care: Dr. [First Name8 (NamePattern2) 712] [Name (STitle) 713] Phone: [Telephone/Fax (1) 719] Date/time: [2159-4-12] 09:00am, [Hospital Unit Name ], [Location (un) 448]. ICD9 Codes: 5849, 2761, 4280, 5859, 4589, 4240
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8227 }	Medical Text: Admission Date: [2154-8-25] Discharge Date: [2154-9-12] Date of Birth: [2115-1-28] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old gentleman with a negative past medical history who began having low back pain three days prior to admission which eventually radiated up to having a stiff neck with positive nausea and vomiting three days prior to admission. He went to [Hospital6 3872] in [Location (un) 47] where he was afebrile. A CT of the head showed no blood and no mass. An lumbar puncture was done at that time which showed in tube #1 36,750 red blood cells and tube #4 24,000 red blood cells. Examination of cerebrospinal fluid after spinning revealed yellow color, xanthochromia. The patient was transferred to [Hospital1 69] for further management. PHYSICAL EXAMINATION ON ADMISSION: On physical examination, he was afebrile at 99.2, blood pressure 113/54, saturations 100%, heart rate 38, respiratory rate 16. The neck was supple. Cardiac revealed S1 and S2, a regular rate and rhythm. Lungs were clear to auscultation bilaterally. Abdomen was soft, positive bowel sounds, nontender, and nondistended. Mental status was awake and alert, oriented times three, spoke slowly. Cranial nerves revealed extraocular movements were intact. Pupil 1.5 mm to 1 mm, equal and reactive. Face was symmetric. Tongue was midline. Motor strength was [4-13] in all muscle groups. Tone was slightly increased in the right leg. Sensory was intact to pinprick. Reflexes were hyperreflexic at knees and ankles, decreased plantar flexion bilaterally. Finger-to-nose was intact. LABORATORY DATA ON ADMISSION: Laboratories on admission revealed a white blood cell count of 9.6, hematocrit 42.1, platelet count 150. Sodium 141, potassium of 4.1, chloride 102, bicarbonate 27, BUN 10, creatinine 0.1, glucose 161. HOSPITAL COURSE: On [2154-8-26], the patient went for an arteriogram which showed the presence of a ruptured anterior communicating artery aneurysm. The patient had coiling of that aneurysm without intraoperative procedure complications. Postoperatively, the patient was monitored in the Surgical Intensive Care Unit. On neurologic examination he had full strength bilaterally. He had no headache, was sleepy but easily arousable. Post procedure, on [2154-8-26], the patient had a central line placed, anti-hypertensive medications were discontinued, and the patient's blood pressure was allowed to climb to the 150 to 170 range, and intravenous fluid at 150 cc an hour. The patient was also started on albumin q.12h. and on subcutaneous heparin. On [2154-8-28], the patient started having difficulty with dropping his oxygen saturations. Chest x-ray at the time showed evidence of bilateral infiltrates. On [2154-8-30], the patient showed early signs of acute respiratory distress syndrome thought most likely due to albumin since his saturations dropped after each dose. Albumin was held. The patient had lower extremity Dopplers on [8-30] which were negative for the presence of deep venous thrombosis. The patient had a repeat head CT on [2154-8-31], which was negative for bleeding, negative for hydrocephalus. Neurologically, the patient was awake, and alert, oriented times three with no pronator drift and had antigravity strength in both lower extremities. He also had no complaints of headache. On [2154-9-2], chest x-ray continued to show evidence of early acute respiratory distress syndrome. On [2154-9-4], the patient underwent arteriogram to visualize aneurysm coiling. Angiogram showed no evidence of aneurysm. Angiogram showed evidence of right internal carotid artery pseudoaneurysm. The patient had a stent placed. There were no complications during the procedure. The patient remained neurologically stable. The patient was neurologically stable. The patient was transferred to the regular floor. On [2154-9-9], the patient was seen by Physical Therapy and Occupational Therapy and found to be safe for discharge to home. MEDICATIONS ON DISCHARGE: 1. Plavix 75 mg p.o. q.d. 2. Aspirin 81 mg p.o. q.d. CONDITION AT DISCHARGE: The patient was stable at the time of discharge and neurologically intact. DISCHARGE FOLLOWUP: Was to follow up with Dr. [Last Name (STitle) 1132] in three weeks' time. [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 1133] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2154-9-12] 10:34 T: [2154-9-15] 07:53 JOB#: [Job Number 36265] ICD9 Codes: 5185, 4019, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8228 }	Medical Text: Admission Date: [2122-5-25] Discharge Date: [2122-5-31] Date of Birth: [2061-3-1] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 165] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [2122-5-26] Off pump coronary artery bypass grafting times four (Left internal mammary artery to left anterior descending artery, Saphenous vein graft to Ramus, Saphenous vein graft to Obtuse Marginal, Saphenous vein graft to Right coronary artery) History of Present Illness: Mr. [Known lastname 20825] is a 61 year old male experiencing left sided chest discomfort which radiates toward left shoulder for about two months, occuring with activity and rest, lasting about 2 minutes. He was referred to cardiac surgery after a cardiac catheterization revealed severe coronary artery disease. Past Medical History: Coronary artery disease, multiple PCI Unstable angina Aortic Aneurysm Carotid stenosis (left occlusion, 99% right stenosis) Hypertension Pericarditis Dyslipidemia (intolerant to lipitor) Pancreatitis Colon polyps Diverticulosis Peripheral artery disease Permanent pacemaker (syncopal episode) - guidant pacr s/p Pancreatectomy s/p Splenectomy Surgical repair of Abdominal Aortic aneurysm Social History: Mr. [Known lastname 20825] works in production at ice cream factory. He lives with his spouse. [Name (NI) ] has a 50 pack year history, and his last cigarette was on [5-22]. He imbibes 5 drinks each day on saturday and sunday. Family History: His mother had carotid disease and died at age 66. Physical Exam: Pulse: 50 AV paced Resp: 14 O2 sat: 96 % B/P Right: 145/83 Left: 122/70 Height: 5'8" Weight: 172 # General: Skin: Dry [x] intact [x] multiple areas of red discoloration circular non raised have been occuring for last year HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 100% AV paced 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, nonfocal alert and oriented x3 Pulses: Femoral Right: +2 Left: cath site DP Right: +1 Left: +1 PT [Name (NI) 167]: +1 Left: +1 Radial Right: +2 Left: +2 Pertinent Results: [2122-5-25] Carotid U/S: 1. Occluded left ICA. 2. 70 to 79% right ICA stenosis. [2122-5-26] Echo: PRE-BYPASS: 1.The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). 3. Right ventricular chamber size and free wall motion are normal. 4. There are complex (mobile) atheroma in the aortic arch. There are complex (mobile) atheroma in the descending aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. There is no pericardial effusion. POST Off Pump CABG: Pt is on Phenylephrine and intermittently paced. 1. Biventricular function is unchanged. 2. Aorta is intact. Visualized Mobile atheromas appear to be still present. 3. Other fingings are unchanged Dr. [First Name (STitle) ] notified in person of the results. [2122-5-31] CXR: There is new pleural effusion seen on the lateral view, most likely right, corresponding to the clinical findings. The cardiomediastinal silhouette is stable. The pacemaker leads are in the right atrium and right ventricle. The patient is after median sternotomy and CABG. There is no pneumothorax. [2122-5-25] 03:59PM BLOOD WBC-10.4 RBC-4.66 Hgb-15.1# Hct-44.2 MCV-95 MCH-32.5* MCHC-34.3 RDW-13.6 Plt Ct-305 [2122-5-31] 10:25AM BLOOD WBC-13.3* RBC-2.94* Hgb-9.4* Hct-28.6* MCV-98 MCH-32.1* MCHC-32.9 RDW-14.0 Plt Ct-330 [2122-5-25] 03:59PM BLOOD PT-14.2* PTT-31.9 INR(PT)-1.2* [2122-5-29] 06:45AM BLOOD PT-12.6 INR(PT)-1.1 [2122-5-25] 03:59PM BLOOD Glucose-100 UreaN-20 Creat-0.9 Na-140 K-4.6 Cl-102 HCO3-28 AnGap-15 [2122-5-31] 10:25AM BLOOD Glucose-160* UreaN-17 Creat-0.8 Na-135 K-4.4 Cl-102 HCO3-24 AnGap-13 [2122-5-28] 07:25PM BLOOD ALT-18 AST-50* LD(LDH)-439* AlkPhos-71 Amylase-23 TotBili-0.4 Brief Hospital Course: Mr. [Known lastname 20825] was admitted on [2122-5-25] from [Hospital6 1109] to cardiac surgery for a pre-operative work-up. On [2122-5-26] he underwent an off pump coronary artery bypass grafting times four. Please see the operative note for details. He was transferred in critical but stable condition to the cardiac surgery intensive care unit. By post-op day one the patient was extubated, alert and oriented, neurologically intact and hemodynamically stable on no inotropic or vasopressor support. He was found suitable for transfer to telemetry at this time. He continued to make good progress. Chest tubes and pacing wires were discontinued without complication. The patient's permanent pacemaker was interrogated by the electrophysiology service. Beta blocker was started and the patient was gently diuresed toward his preoperative weight. He did have a brief burst of post-operative atrial fibrillation and was started on amiodarone. The remainder of his post-op course remained uneventful and he was discharged to home in good condition with VNA services on post-op day five. Medications on Admission: lopressor 100 mg daily Norvasc 10 mg daily ASA 325 mg daily Mmultivitamin Omeprazole 20 mg daily simvastatin 20 mg daily started [5-22] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 6 days: then 400mg daily for 7 days then 200mg daily ongoing. Disp:75 Tablet(s) Refills:1 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:75 Tablet(s) Refills:1 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): check leiver function test in one month. Disp:30 Tablet(s) Refills:2 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass x 4 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) ] for Dr. [Last Name (STitle) ](cardiac surgery) at [Hospital1 ] in 3 weeks ([Telephone/Fax (1) 6256]), please call for appointment. Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 37063] (PCP) in [12-26] weeks ([Telephone/Fax (1) 37064]), please call for appointment. Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 32255] (cardiologist) in 4 weeks ([Telephone/Fax (1) 6256]), please call for appointment. See Dr. [First Name (STitle) 1557] (MW Vascular) in 1 month. Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3071]) [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2122-6-2] ICD9 Codes: 4111, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8229 }	Medical Text: Admission Date: [2199-3-8] Discharge Date: [2199-3-11] Date of Birth: [2153-12-17] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Flagyl Attending:[First Name3 (LF) 106] Chief Complaint: transfer from [Hospital ] Hospital with shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 45 yo female w/ hx of of SVT (? avnrt vs avrt) who presented to OSH six days post-partum with shortness of breath. Patient states that she noticed being short of breath with exertion for several days prior to her delivery six days ago. She then had an uncomplicated vaginal delivery on [2199-3-2]. No hypertension, pre-eclampsia during her pregnancy. Placenta was normal. Patient noticed increasing shortness of breath in the days following delivery, which became acutely worse 2-3 days ago. She noticed decreased exercise tolerance and soon was short of breath just walking across the room. Also noted orthopnea and could not sleep lying flat. She denies chest pain, cough, hemoptysis. No fevers or chills. No syncope. Had some rhinorrhea a few weeks ago, which had completely resolved. . At OSH patient was noted to be hemodynamically stable. She had a CTA which was negative for PE but did demonstrate bilateral pleural effusions and evidence of pulmonary edema. She had an echo performed - EF 15%, mild LV enlargement, global hypokinesis, MR 2+, TR 2+. Patient was given lasix 20 mg IV x 2, digoxin 0.5 mg IV x 1, nitro paste, and was started on a heparin gtt. She was transferred to [Hospital1 18] for further evaluation. . On arrival here, she was feeling relatively well. Denied shortness of breath at rest. No chest pain. Past Medical History: paroxysmal SVT - has had episdoes of SVT for 20+ years, usually last a few minutes, had one prolonged episode which persisted overnight. She was treated with digoxin and metoprolol in the past. During her pregnancy she was treated with labetolol, although had discontinued at some point in the last nine months. Patient reports that she can always feel when her tachycardia starts and stops, sometimes has dizziness associated with it. Has never had syncope/loss of consciousness. Social History: Lives in [Hospital1 ] with her husband. Stopped working [2-22] pregnancy, but she was working on an assembly line prior to delivery. No Etoh. Former smoker - smoked 1/2PPD for 20+ years, wuit 8 yrs ago. Family History: father - MI in 50s, then developed a cardiomyopathy that resulted in a hreat transplant in late 60s mother - breast ca daughter - post-partum cardiomyopathy folloing her first pregnancy Physical Exam: Gen: NAD, comfortable, speaking in full sentences HEENT: perrla, op - clear, mmm Neck: neck veins flat, no lad Lungs: decreased breath sounds at right base, bilateral crackles ni the lower thirds of her lungs Card: reg, + S3, [2-26] sys murmur @ apex Abd: + bs, mildly distended, mildy tender to palp over supra-pubic area Ext: DP 2+ bilat, no edema Neuro: alert and oriented x3, sensation and motor function grossly intact, CN II-XII intact. Pertinent Results: Labs: [2199-3-8] 10:54PM BLOOD WBC-15.6* RBC-4.10* Hgb-13.0 Hct-36.7 MCV-90 MCH-31.7 MCHC-35.4* RDW-14.1 Plt Ct-430 [2199-3-8] 10:54PM BLOOD Neuts-76.5* Lymphs-15.8* Monos-7.1 Eos-0.5 Baso-0.2 [2199-3-8] 10:54PM BLOOD Glucose-109* UreaN-16 Creat-0.6 Na-141 K-3.4 Cl-103 HCO3-25 AnGap-16 [2199-3-8] 10:54PM BLOOD ALT-48* AST-33 CK(CPK)-80 AlkPhos-137* TotBili-0.3 [2199-3-8] 10:54PM BLOOD cTropnT-<0.01 [2199-3-8] 10:54PM BLOOD Calcium-9.2 Phos-4.1 Mg-2.2 Iron-27* [2199-3-9] 06:19AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.4 Cholest-343* [2199-3-8] 10:54PM BLOOD calTIBC-484* Ferritn-35 TRF-372* [2199-3-9] 06:19AM BLOOD Triglyc-151* HDL-119 CHOL/HD-2.9 LDLcalc-194* [2199-3-8] 10:54PM BLOOD TSH-1.8 [2199-3-9] 06:19AM BLOOD HCV Ab-NEGATIVE . EKG: 84 bpm, Sinus rhythm. T wave inversion in leads VI-V2 with ST-T wave flattening in leads I and aVL. The right precordial T wave inversion may be a normal variant. . CHEST (PORTABLE AP) [2199-3-9] 1:19 PM The cardiomediastinal silhouette is within normal limits. There is no CHF or effusion. There is some prominence of interstitial markings in the right cardiophrenic angle, without frank consolidation. Compared with earlier the same day, there has been considerable improvement at right base and in the small amount of right costophrenic sulcus blunting. Rapid improvement suggests that this represent residua from earlier CHF. Correlation with clinical symptoms is requested for full assessment. . CHEST (PORTABLE AP) [2199-3-9] 12:19 AM The heart is not enlarged. The aortic contour and superior mediastinum are within normal limits. There is no upper zone redistribution to suggest CHF. There is some patchy increased density at the right base which could represent a pneumonic infiltrate. No frank consolidation is identified. Thereis possible minimal blunting of the right costophrenic angle. Otherwise, no effusions are seen. IMPRESSION: Patchy opacity in the right lower lobe medially, which could represent an infectious infiltrate. Possible minimal blunting of the right costophrenic angle. No chf or gross effusion. . TTE [2199-3-9]: LVEF 25%. The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: 45 yo female w/ HX of paroxysmal SVT who presents with worsening shortness of breath since her delivery on [2199-3-2]. Seen at OSH and found to have significantly depressed EF and global hypokinesis. . 1. CHF: Patient presenting with shortness of breath and depressed EF 6 days post-partum. Given time of onset, most likely has developed post-partum cardiomyopathy. Viral cardiomyopathy is another possible cause of her presentation given recent URI symptoms. HCV AB was negative and the patient reports a negative HIV test recently done during prenatal course. Her triglycerides were also not highly elevated. The patient has a history of paroxysmal SVT, however given the short duration of these symptoms, their symptomatic nature, it is unlikely that she would have had a persistent extended episode of tachycardia resulting in cardiomyopathy. She has a normal TSH making hypothyroidism unlikely and a normal ferritin and iron level making hemochromatosis unlikely. Ischemia is another cause for her symptoms although it is unlikely given normal cardiac enzymes and few risk factors for heart disease in this patient. Digoxin and nitropaste which were started at the OSH were discontinued. Echo showed hypokinesis but no akinesis and heparin was discontinued. She was treated with aspirin, lisinopril, low dose beta blocker, Statin, and Lasix. . 2. Hx of paroxysmal SVT: She presented to [Hospital1 18] in sinus rhythm and was monitored on telemetry. . 3. Leukocytosis: Although she had leukocytosis, she was afebrile and without localizing signs or symptoms of infection. Urine and blood cultures were negative. Leukocytosis was most likely [2-22] recent delivery. . 4. Post-partum: Vaginal bleeding has been mild/moderate. She was started on an ACEi for cardiomyopathy and was advised not to breast feed given the potential adverse side effects of this medication in infants. The patient reports that she understands the adverse reactions and will not breast feed. . 5. Code: full. Medications on Admission: prenatal vitamins Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). Disp:60 Tablet, Chewable(s) Refills:2 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:30 Tablet(s) Refills:0 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Outpatient Lab Work Check chem 10 in 1 week. Have results sent to Dr.[Name (NI) 12389] office, ([Telephone/Fax (1) 7437] Discharge Disposition: Home Discharge Diagnosis: Post partum cardiomyopathy Discharge Condition: Good, ambulatory, respiratory status stable Discharge Instructions: Please take all medications as directed. . You will be taking some medications that are important for your heart but are not compatible with breast feeding. Please do not breast feed. . If you develop shortness of breath, chest pain, palpitations, or any other symptoms that concerns you, call your doctor or go to the emergency room. Followup Instructions: Make a follow up appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6073] for [1-22] weeks from now. You can call his office at ([Telephone/Fax (1) 7437] . Make an appointmet to get a transthoracic echo in 1 month. The phone number is ([Telephone/Fax (1) 19380]. . Have your lab work checked in 1 week. ICD9 Codes: 4280, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8230 }	Medical Text: Admission Date: [2164-7-28] Discharge Date: [2164-10-18] Date of Birth: [2164-7-28] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: [Known lastname ] [Known lastname ] is an 892-gram, 26 and [5-21]-week, twin II, admitted to the Neonatal Intensive Care Unit secondary to respiratory distress and prematurity. He was born to a 37-year-old gravida 3, para 1 (now 3) white female. Prenatal screens revealed blood type AB negative, antibody negative, rapid plasma reagin nonreactive, Rubella immune, hepatitis B surface antigen negative, and group B strep status unknown. This was an in [Last Name (un) 5153] fertilization pregnancy with triplets spontaneously reduced to twins at 13 weeks gestation. Cervical incompetence treated with cerclage. There was a spontaneous rupture of membranes on [Month (only) ] (12 days prior to delivery). The cerclage removed. The mother received a course of betamethasone, and antibiotics were given, on the day of delivery with evidence of chorioamnionitis. Therefore, a cesarean section was performed. This twin was breech with significant bruising. He received blow-by oxygen and was suctioned, and the infant was subsequently intubated in the delivery room. The infant was brought to the Neonatal Intensive Care Unit with bagging. Apgar scores were 6 at one minute of age and 7 at five minutes of age. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed a premature male with significant bruising on the lower body and in respiratory distress. His temperature was 97.4 degrees Fahrenheit, his heart rate was 164, his respiratory rate was 38, his blood pressure was 51/33, with a mean arterial pressure of 43, and his oxygen saturation was 92%. The infant's weight was 892 grams (50th percentile), length was 36 cm (50th percentile), and head circumference was 25 cm (50th percentile). The anterior fontanel was soft, flat, nondysmorphic. Orally intubated. Coarse breath sounds bilaterally. Positive retractions. No murmurs. The abdomen was soft. A 3-vessel cord. No hepatosplenomegaly. Normal male genitalia. The testes were descended into scrotum. No hip clicks. No sacral dimple. Normal tone for age. The infant with significant bruising on legs, toes, buttocks, and penis. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. RESPIRATORY ISSUES: [Known lastname ] was intubated in the delivery room. He received a total of two doses of Survanta. He was switched from conventional ventilation to high-frequency oscillatory ventilation on day of life two for increasing respiratory distress and presentation of a patent ductus arteriosus. He was weaned from high-frequency oscillatory ventilation to conventional ventilation on day of life five and then to continuous positive airway pressure on day of life seven. He was weaned from continuous positive airway pressure to room air on day of life 37. He has not required any supplemental oxygen since that time. He was started on caffeine on day of life four for apnea of prematurity. The caffeine was discontinued on day of life 53. His last bradycardic spell was on [10-10]. Because of a history of reflux disease, and apnea, and an abnormal pneumogram in his sibling; [Known lastname ] had a pneumogram with a PH probe on [10-15] which was normal. 2. CARDIOVASCULAR ISSUES: [Known lastname ] received two normal saline boluses shortly after admission to the Newborn Intensive Care Unit. The infant was then started on dopamine with a maximum infusion of 12.5 mcg/kg per minute. The dopamine was discontinued on day of life one. An echocardiogram on day of life two showed a large patent ductus arteriosus with left-to-right shunting. The infant received one course of indomethacin. A follow-up echocardiogram on day of life five showed no patent ductus arteriosus. His blood pressure was stable for the remainder of his hospital course. 3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: Umbilical artery and umbilical venous catheters were placed upon admission to the Newborn Intensive Care Unit. Fluids were initiated at 100 cc/kg per day and increased to a maximum of 160 cc/kg per day on day of life five. Enteral feeds were started on day of life eight and progressed to full volume feeds by day of life 16. Caloric density maximum of 32-calorie breast milk with ProMod. No feeding intolerance during this hospitalization. His electrolytes remained stable. The infant's last electrolytes on [8-30] revealed sodium was 136, a hemolyzed potassium was 6, chloride was 100, and his bicarbonate was 23. On [9-3], he had a calcium of 10.8, his phosphorous was 7.2, and his alkaline phosphatase was 264. He was to be discharged to home feeding well by mouth, breast milk 24-calories with 4 calories per ounce of Enfamil powder. The infant's discharge weight was 2720 grams, his length was 46 cm, and his head circumference was 33 cm. 3. GASTROINTESTINAL ISSUES: Phototherapy was started on day of life one for a bilirubin of 4.5. His peak bilirubin was 5.1 on day of life three. Phototherapy was discontinued on day of life 12 with a rebound bilirubin of 2.2 on day of life 13. 4. HEMATOLOGIC ISSUES: [Known lastname 43967] blood type was B positive and Coombs negative. He received a transfusion of a total of 2 units of packed red blood cells during his hospitalization. His last transfusion was on day of life 21. His last hematocrit level on [9-13] (which was day of life 47) was 28.3 with a reticulocyte count of 4%. 5. INFECTIOUS DISEASE ISSUES: [Known lastname ] was placed on ampicillin and gentamicin upon admission to the Neonatal Intensive Care Unit. He received a 7-day course based on likely chorioamnionitis in the mother and severity of illness. A sepsis evaluation for increased apnea of prematurity on day of life 10 revealed a shifted complete blood count with a white blood cell count of 37, a hematocrit of 33, and a platelet count of 358. Differential with 38% polys, 10% bands, 6% myelocytes, and 7% promyelocytes. The blood culture was negative. The lumbar puncture was negative at that time, but he did receive a 7-day course of vancomycin and cefotaxime (which was completed on day of life 17). He has had no further Infectious Disease issues during his hospitalization. 6. NEUROLOGIC ISSUES: Head ultrasounds were performed on [7-31], [8-9], [8-14], [8-20], [8-27], and [10-4]; which have shown a small plexus on the left and very mild enlargement of the lateral ventricles. The last study on [10-4] which was showing resolution of that mild ventriculomegaly. 7. SENSORY ISSUES: A hearing screen was performed with automated auditory brain stem responses. The infant passed in both ears. 8. OPHTHALMOLOGIC ISSUES: The eyes were examined, most recently, on [10-8] which revealed retinopathy of prematurity, stage I, zone 2, 6 o'clock hours in the right eye and stage I, zone 2, 5 o'clock hours in the left eye. A follow-up examination by Dr. [Last Name (STitle) 6955] at [Hospital3 1810] has been arranged for two weeks following the last examination on [10-8]. 9. PSYCHOSOCIAL ISSUES: A [Hospital1 188] social worker has been involved with the family. The contact social worker can be reached at telephone number [Telephone/Fax (1) ]. CONDITION AT DISCHARGE: The infant was well and growing on full-volume feedings, resolution of apnea of prematurity, stable temperature in open crib. DISCHARGE DISPOSITION: Discharge status was to home with parents. NAME OF PRIMARY PEDIATRICIAN: The primary pediatrician is Dr. [Last Name (STitle) 34141] at [Hospital ] Pediatrics (telephone number [Telephone/Fax (1) 46615]). CARE RECOMMENDATIONS: 1. Feeds on discharge: Breast milk enriched to 24 calories with Enfamil powder at 4 calories per ounce. 2. Medications: Iron supplements of 0.4 cc every day and a multivitamin 1 cc once per day. 3. Car seat positioning screening: [Known lastname ] passed. 4. State newborn screen: The last state newborn screen was sent on [9-11], and no abnormal results have been reported. 5. Immunizations received: [Known lastname ] received his 2-month immunizations on [9-29]. He received his hepatitis B vaccine, his DTaP, his polysaccharide vaccine, and inactivated poliovirus vaccine. 6. [Known lastname ] did receive a circumcision on [10-4]; which has healed nicely. IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial virus prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: (1) Born at less than 32 weeks gestation. (2) Born between 32 and 35 weeks gestation with plans for day care during respiratory syncytial virus season, with a smoker in the household, or with preschool siblings; and/or (3) With chronic lung disease. Influenza immunization should be considered annually in the Fall for preterm infants with chronic lung disease once they reach six months of age. Before this age, the family and other care givers should be considered for immunization against influenza to protect the infant. DISCHARGE DIAGNOSES: 1. Prematurity at 26 and 4/7 weeks gestation. 2. Respiratory distress syndrome. 3. Presumed sepsis. 4. Hyperbilirubinemia. 5. Apnea of prematurity. 6. Retinopathy of prematurity. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], M.D. [MD Number(1) 48739] Dictated By:[Name8 (MD) 35942] MEDQUIST36 D: [2164-10-18] 12:33 T: [2164-10-18] 12:35 JOB#: [Job Number 48740] ICD9 Codes: 769, 7742, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8231 }	Medical Text: Admission Date: [2156-12-3] Discharge Date: [2156-12-11] Date of Birth: [2082-6-21] Sex: F Service: CT SURGERY HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 36913] is a 74-year-old blind female who was transferred from [Hospital3 1443] Hospital status post cardiac catheterization. Her history goes that she was in excellent health until one month prior to admission, when she noted a new onset of dyspnea on exertion accompanied by chest heaviness. The night of [2156-12-1], she experienced rest dyspnea and spent most of the night sleeping in a chair. She saw her primary care doctor, who admitted her to [Hospital3 1443] Hospital, where she ruled out for a myocardial infarction. Her initial electrocardiogram revealed a chronic left bundle branch block. An adenosine Thallium was done [2156-12-3], which revealed an ejection fraction of 71% and an anteroapical ischemia. An echocardiogram and carotid ultrasound for carotid bruits were performed prior to transfer, and were ultimately negative for significant hemodynamic disease. The patient denied any history of claudication, no paroxysmal nocturnal dyspnea, no orthopnea, no lightheadedness, no pedal edema. Her coronary artery disease risk factors included hypertension, a questionable history of diabetes mellitus, no evidence of hypercholesterolemia, has never smoked in the past, but does have a strong positive family history for coronary disease. PAST MEDICAL HISTORY: Legally blind since birth, osteoporosis, hypertension. PAST SURGICAL HISTORY: None. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Aspirin 325 mg by mouth once daily, Lopressor 25 mg by mouth twice a day, Bumex 1 mg by mouth once daily, Colace 100 mg by mouth twice a day. REVIEW OF SYSTEMS: There is no evidence of cerebrovascular accident, transient ischemic attack or melena. SOCIAL HISTORY: She lives with a friend and has a seeing eye dog. PHYSICAL EXAMINATION: Height 5'2", weight 123 pounds, pulse 96 and regular, blood pressure 156/68. The neck showed no evidence of jugular venous distention. Carotids were 1+. Bilateral bruit was auscultated. The lungs were clear. The heart was S1, S2, systolic murmur at the left sternal border was present. The abdomen was nontender, nondistended, no hepatosplenomegaly, positive bowel sounds. The extremities were warm and well perfused. She had palpable pulses from the femoral to the dorsalis pedis and posterior tibial bilaterally. LABORATORY DATA: BUN and creatinine 15 and .7, CBC not available. Electrocardiogram on admission shows left bundle branch block, sinus rhythm. Chest x-ray initially showed ground-glass appearance. A Pulmonary consult revealed no evidence of pulmonary disease. Chest x-ray changes are due to congestive heart failure, and the patient was started on Bumex. ASSESSMENT: She is a 74-year-old woman with new onset dyspnea on exertion and a positive adenosine Thallium, and was therefore referred for cardiac catheterization. HOSPITAL COURSE: On [2156-12-3], Ms. [Known lastname 36913] [Last Name (Titles) 1834] a cardiac catheterization showing a 90% distal left anterior descending lesion involving part of the left circumflex and left main. Additionally, there was a 50% proximal right coronary artery occlusion and a 50% mid-right coronary artery occlusion. Given the severe 90% distal left main disease involving the proximal left anterior descending and proximal left circumflex, as well as the previously-mentioned right coronary artery lesions, 50% proximally and mid, a coronary artery bypass graft consult with Dr. [Last Name (STitle) ] was acquired. The patient was admitted to the C-Med service initially. She remained hemodynamically stable status post catheterization. She was preopped on [2156-12-5], when Dr. [Last Name (STitle) ] reviewed the patient's case. Her laboratories at that time were noted for a CBC of 10,000 white count, 36 hematocrit, 297,000 platelet count. PT and PTT were 11 and 23 respectively, and INR was 1.0. Her BUN and creatinine were 23 and .6. Chest x-ray done preoperatively showed no acute cardiopulmonary process. On [2156-12-6], the patient went to the operating room with Dr. [Last Name (STitle) ], where she [Last Name (STitle) 1834] a coronary artery bypass graft x 4, including grafts from left internal mammary artery to the left anterior descending, a saphenous vein graft to the oblique marginal I, saphenous vein graft to the oblique marginal II, and a saphenous vein graft to the right posterior descending artery. The patient tolerated the procedure well, and was transferred to the Cardiac Intensive Care Unit, where she was extubated on the night of surgery. She was transfused one unit postoperatively. She was stable and on an insulin drip at this time, and Nipride was additionally weaned due to some postoperative hypertension. Once the patient was started on oral antihypertensives, Lopressor, and diuresis was begun with lasix, her pressures normalized. The Nipride drip was quickly weaned. Her postoperative hematocrit was 29 on postoperative day number one, and BUN and creatinine were 23 and .6 respectively. She was ultimately transported to the floor on postoperative day number one, where she did well, remained hemodynamically stable. Over the ensuing 48 hours, she worked aggressively with Physical Therapy and reached a Level III ambulation status by postoperative day number three. Intermittently her heart rate would get into the 130s to 150s by monitor, however, there was no active capture of this rhythm by electrocardiogram, as as soon as the patient was evaluated by house officer at the bedside, the rhythm disturbance would seem to spontaneously disappear. Her Lopressor was ultimately titrated to 50 mg by mouth twice a day on postoperative day number three, however, she did end up going into atrial fibrillation with a rapid ventricular response. This was diagnosed by electrocardiogram and clinically by evaluating the telemetry strips on the Cardiac floor monitor. The patient ultimately had to be treated with 20 mg intravenous Lopressor given over an hour. Since this did not work, a Diltiazem drip was started at 10 mg/hour. After approximately four to six hours of Diltiazem drip, the patient broke into sinus. Her pressures were dropping into the 110 to 106 range. As a consequence of this, the Diltiazem drip was discontinued. Once she was in a sinus rhythm, her pressures remained in the systolic ranges of 110 to 120. She remained stable mentating wise. Her discharge laboratories were noted for a hematocrit of 30, a BUN and creatinine of 20 and .6, and a magnesium of 3 and a calcium of 1.06, and a phosphate of 2.8. Her weight was down to 57.3 kg. Otherwise she was stable. By postoperative day number four, the patient was still ambulating at a Level III, working with Physical Therapy, and receiving pulmonary toilet as well. Her temperature was 99.5. Her heart rate was 90 and sinus rhythm. Blood pressure was 106 to 125 systolic over 50s diastolic. Her room air saturation was 94%, 18 respiratory rate and unlabored. The sternum was stable, with staples intact, no evidence of drainage, no evidence of erythema. Her wires were present, however, they were discontinued on postoperative day number three. Her lungs were clear to auscultation except for bibasilar crackles. Ultimately her Lopressor was increased to 100 mg by mouth twice a day. Amiodarone was begun on postoperative day number three. She was encouraged to ambulate as much as possible. Physical Therapy consultation was obtained. Her electrolytes were repleted. By postoperative day number four, the patient was afebrile, stable, in sinus rhythm, and deemed appropriate for discharge to home, where she lives with a friend who is a close assistant and will be able to help her in her recovery. CONDITION ON DISCHARGE: To home with Visiting Nurse assistance. DISCHARGE STATUS: Afebrile, normal sinus rhythm. DISCHARGE DIAGNOSIS: 1. Significant distal left main disease and proximal and mid-right coronary artery lesions status post coronary artery bypass graft x 4 DISCHARGE MEDICATIONS: Lopressor 100 mg by mouth twice a day, lasix 20 mg by mouth once daily for seven days, K-Dur 20 mEq by mouth once daily for seven days, aspirin 325 mg by mouth once daily, Zantac 150 mg by mouth twice a day, amiodarone 400 mg by mouth three times a day for one week then 400 mg by mouth twice a day for one week, then 400 mg by mouth once daily for 14 days and then discontinue, percocet 5/325 one to two tablets by mouth every four to six hours as needed, Colace 100 mg by mouth twice a day. DISCHARGE INSTRUCTIONS: The patient is not to do any heavy lifting greater than ten pounds for one month. She will have follow up in the Wound Care Clinic in one week, when she will have her staples removed. She is to see her primary care provider or cardiologist in three weeks from the time of discharge, and will follow up with Dr. [Last Name (STitle) ] in the [Last Name (NamePattern1) 21589] office in approximately 30 days from the time of discharge. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern4) 3204] MEDQUIST36 D: [2156-12-10] 23:31 T: [2156-12-11] 00:00 JOB#: [Job Number 36914] ICD9 Codes: 4280, 9971, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8232 }	Medical Text: Admission Date: [2177-3-15] Discharge Date: [2177-3-20] Date of Birth: [2122-5-26] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 465] Chief Complaint: back pain Major Surgical or Invasive Procedure: Transesophageal echocardiogram History of Present Illness: M with Crohn's disease recently admitted from [Hospital1 18] from [2177-2-20] to [2177-3-2] with a Crohn's flare c/b cdiff discharged on prednisone, po vanc and po flagyl with good effect who presents with acute bilateral [9-24] lower back pain on the morning of presentation. His back pain radiated to his stomach anteriorly. No radiation to lower extremities or focal weakness. He has had back pain since his last admission which has gradually worsened. He has had difficulty controlling his bowel movements but felt that this was improving. No change in urinary habits. Did not report nausea or emesis. His Crohn's flare had improved such that he was sleeping through the night with 5-6 bowel movements per day. He presented to [Hospital ] Hospital where he was found to be febrile to 106.2. He then became hypotensive to 83/53- his BP on presentation was 180/70 and tachy to 122. He had one episode of non-bloody, non-bilious emesis. He He was given vanc/tylenol/hydrocortisone 100 mg IV/imipenum/fentanyl 75 and NS. Of note he had a root canal performed on [1-31] for which he was given abx. He also has a dental abcess. Upon arrival to the [Name (NI) ] pt was hypotensive to 77/59. Central line placed and started on dopamine in addition to levophed. Had one large BM in ED. Given po vancomycin, and decadron 10 mg IV. . **** In the MICU, patient was maintained initially on pressors, volume resuscitated, given stress dose steroids, treated with flagyl/zosyn/vanc, as well as oral vanc. He was found to have MSSA bacteremia. CT abdomen showed possible stranding around pancreatic head. An MRI of the spine without gadolinium was inconclusive and so on day of call-out to floor an MRI with gad was still pending to evaluate for T10 osteomyelitis. Past Medical History: 1. Ileocolonic colitis 2. Hypertension 3. Hemachromatosis 4. Hypercholesterolemia 5. S/p arthroscopic knee surgery 6. Recent history of clostridium difficile infection Social History: The patient is married and has three adult children, one of whom has juvenile onset diabetes. Tobacco - former use, 1.5pk/day, stopped 9 years ago ETOH - Denies alcohol or illicit drug use Family History: His mother is deceased. She had hypertension and myocardial infarction. His father died at the age of 61 due to colon cancer. The patient has two male siblings, one of whom has hepatitis C requiring a transplant and the other is alive and well. Physical Exam: VS T 98.8 P 81 BP 146/95 RR 17 O2Sat 95% on RA GENERAL: Pleasant obese male HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, decreased bowel sounds, peri-umbilical tenderness with moderate palpation. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -cerebellar: No nystagmus, dysarthria, intention or action tremor, dysdiadochokinesia noted. -DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: [2177-3-15] 05:20PM PT-13.1 PTT-22.0 INR(PT)-1.1 [2177-3-15] 05:20PM PLT SMR-NORMAL PLT COUNT-169 [2177-3-15*] 05:20PM WBC-13.7 RBC-3.99* HGB-11.7* HCT-34.7* MCV-87 MCH-29.4 MCHC-33.7 RDW-15.7* [2177-3-15] 05:20PM NEUTS-93.2* BANDS-0 LYMPHS-3.9* MONOS-2.5 EOS-0.2 BASOS-0.3 [2177-3-15] 05:20PM ALBUMIN-2.9* CALCIUM-7.7* PHOSPHATE-1.3* MAGNESIUM-1.2* [2177-3-15] 05:20PM CK-MB-2 [2177-3-15] 05:20PM cTropnT-0.05* [2177-3-15] 05:20PM ALT(SGPT)-40 AST(SGOT)-25 LD(LDH)-279* CK(CPK)-152 ALK PHOS-87 AMYLASE-192* TOT BILI-0.6 [2177-3-15] 05:20PM LIPASE-234* [2177-3-15] 05:20PM GLUCOSE-113* UREA N-25* CREAT-1.9* SODIUM-137 POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-19* ANION GAP-15 [2177-3-15] 05:28PM TYPE-ART PO2-94 PCO2-38 PH-7.38 TOTAL CO2-23 BASE XS--1 . CT Chest, Abdomen, Pelvis: IMPRESSION: 1. No evidence of pulmonary embolism. 2. No evidence of aortic dissection or injury. 3. Fluid filled colon likely related to colitis. No other bowel pathology identified. 4. Non-specific stranding in the porta hepatis region; this may relate to pancreatitis. 5. Loss of height in the T10 vertebral body, chronicity indeterminate. If clinical concern exists in this area, a dedicated CT or MR of the thoracic spine may be of value. . MR WITHOUT CONTRAST T AND L SPINE: IMPRESSION: 1. Increased signal intensity in the T9-10 disc with increased signal intensity of the adjacent superior endplate of T10 vertebral body, which could be due to infection, given the clinical history of fever and bacteremia. This needs clinical correlation as well as repeat MRI of the thoracic spine with IV contrast. If the patient's EGFR is about 30, IV gadolinium contrast can be administered, provided the risks of possible nephrogenic systemic fibrosis are understood by the patient as well as the treating clinical team. There is also a horseshoe-shaped soft tissue mass under anterior longitudinal ligament at this level, raising the possibility of paraspinal extension of infection anteriorly. No evidence of epidural space or cord involvement on the present study. 2. Multilevel degenerative changes in the cervical spine, most prominent at C4-5 and C5-6 with right neural foraminal narrowing. 3. Moderate left central disc protrusion at L5-S1, impinging left S1 nerve root. . MR W/ AND W/O CONTRAST T-SPINE: INDICATION: Evaluate T9-10 level for a possibility of discitis and paraspinal abscess. TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through the thoracic spine. FINDINGS: As noted on the prior examination of [2177-3-16], there is increased T2 signal within the T9-10 disc as well as increased T2 signal within the superior endplate of T10. As before, there is slight reduction in the height of the T10 vertebral body. Unlike on the prior study, today's exam demonstrates that the increased T2 signal within T9-10 disc level is not any different than the T2 signal within the T10-11, T11-12 and T12-L1 disc spaces. There is no evidence of enhancement or a paraspinal soft tissue mass. These findings could be due to a subacute compression fracture of the T10 vertebral body with marrow edema. There is no retropulsion of bone fragments. There is no spinal canal stenosis or abnormal spinal cord signal. There are no areas of abnormal enhancement. However, mild osteomyelitis and discitis could give a similar appearance, even with the lack of enhancement. Since the T10-11 disc spaces do not appear brighter than any of the discs inferior to that level, the findings are slightly more consistent with degenerative change with a compression fracture of the T10 vertebral body. IMPRESSION: No evidence of enhancement or a paraspinal soft tissue mass. On today's exam, the T9-10 disc T2 hyperintensity is the same as the disc spaces inferior to it. This constellation of findings suggests that the signal abnormalities relate to a subacute T10 compression fracture rather than osteomyelitis and discitis. A followup exam could be obtained if clinically warranted as the possibility of a discitis and osteomyelitis remains. . TRANSTHORACIC ECHO: Left Atrium - Long Axis Dimension: 4.2 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 5.8 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 5.4 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.4 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 5.7 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 4.0 cm Left Ventricle - Fractional Shortening: 0.30 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 60% (nl >=55%) Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm) Aorta - Ascending: 3.4 cm (nl <= 3.4 cm) Aorta - Arch: 3.0 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 0.86 Mitral Valve - E Wave Deceleration Time: 227 msec TR Gradient (+ RA = PASP): 18 to 27 mm Hg (nl <= 25 mm Hg) Pericardium - Effusion Size: 1.2 cm INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous hypertrophy of the interatrial septum. LEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity size. Overall normal LVEF (>55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. No vegetation seen (cannot definitively exclude). . TRANSESOPHAGEAL ECHOCARDIOGRAM: INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast in the body of the LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or vegetations on aortic valve. MITRAL VALVE: Normal mitral valve leaflets. No mass or vegetation on mitral valve. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or vegetation on tricuspid valve. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No vegetation/mass on pulmonic valve. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The patient was monitored by a nurse [First Name (Titles) ] [Last Name (Titles) 9833] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). The posterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related complications. 0.2 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion. The patient appears to be in sinus rhythm. Conclusions: No spontaneous echo contrast is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. 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. IMPRESSION: No valvular vegetation seen. . ULTRASOUND OF THE RIGHT UPPER EXTREMITY: INDICATION: Right arm swelling. IMPRESSION: Occlusive thrombus within the cephalic vein extending from several centimeters proximal to the antecubital fossa to the distal forearm. No thrombus identified in the other major veins of the right arm. Findings were discussed with Dr. [Last Name (STitle) 29932] at the time of dictation CULTURE DATA: [2177-3-15] 5:25 pm BLOOD CULTURE FINAL REPORT [2177-3-19]* AEROBIC BOTTLE (Final [2177-3-18]): REPORTED BY PHONE TO [Doctor Last Name ] [Doctor Last Name ] [2177-3-16] 10:30AM. STAPH AUREUS COAG +. FINAL SENSITIVITIES. Please contact the Microbiology Laboratory ([6-/2476]) immediately if sensitivity to clindamycin is required on this patient's isolate days after initiation of therapy. Testing of repeat isolates may be warranted Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R ANAEROBIC BOTTLE (Final [2177-3-18]): STAPH AUREUS COAG +. SENSITIVITIES PERFORMED FROM ANAEROBIC BOTTLE. . BLOOD CULTURE X 2 ([2177-3-16]): NO GROWTH TO DATE . BLOOD CULTURE X 2 ([2177-3-17]): NO GROWTH TO DATE DISCHARGE LABS: Na 141 K 3.1 (before repletion) Cl 106 Bicarb 27 BUN 18 Cr 1.1 Mg 1.8 . WBC 8.6 HGB 12.7 HCT 37 Plt 131 . Brief Hospital Course: 1. Hypotension: The patient was found to be hypotensive on presentation and required aggressive fluid infusion and pressors while monitored in the ICU. Blood cultures were positive for Staph aureus, which was found to be sensitive to oxacillin. On initial presentation the patient was noted to have a warm, tender erythematous area of skin just below his right antecubital fossa. This was investigated with ultrasound and found to be an occlusive thrombus of the cephalic vein. The patient reported to have had a peripheral IV at this location during his previous hospitalization in [2177-2-13]. The thrombophlebitis was thought to be the most likely nidus of infection leading to the staph bacteremia. However, other sources were sought: a panarex of the jaw revealed no areas suspicious for infection and TTE and TEE revealed no vegetations either as a cause or a result of the bacteremia. An MR was done of the spine (workup detailed below). The patient quickly stabalized his blood pressure and was transferred to the floor. After his initial presentation, he remained afebrile, his repeat blood cultures were negative, and his WBC trended downward. He was discharged on a 4 week course of nafcillin to be followed by a home-infusion team. The visiting nurse was given instructions on weekly lab reports to be faxed to the patient's infectious disease doctor, [First Name8 (NamePattern2) ] [Name8 (MD) 3394], MD at the [Hospital1 ] infectious disease group, and the patient was scheduled for an [Hospital ] clinic visit in 4 weeks time. . 2. Back pain: The patient described his back pain as [9-24] on the day leading up to admission and he continued to experience pain after his transfer out of the ICU. At no time during his stay did he have a change in his neurologic exam, and he had no bowel/bladder incontinence or saddle parasthesias. An MR without contrast was scheduled initially, which found increased signal intensity in the T9-10 disc and T10 vertebral superior endplate which were somewhat suspicious for infection, given the patient's presentation. This was followed up with an MRI with gadolinium contrast, which again found T9-10 disc enhancement, but found an equal amount of enhancement in the T11-12 an T12-L1 disc spaces. In addition to the finding of T10 vertebral endplate enhancement, the imaging was most consistent with at subacute compression fracture of the T10 vertebra, likely secondary to degenerative changes. However, the study could not entirely rule out the possibility of infection. The orthospine team was consulted and they offered the patient the option of doing a needle biopsy to rule out the chance of infection completely. However the patient declined, and the ID, ortho-spine, and primary teams were in agreement that the patient could be followed clinically and if he showed worsening signs of infection or back pain, the issue could be readdressed. In addition, he was scheduled for a repeat MRI in 4 weeks time, to be done before his 4 week ID appointment. Given the subacute fracture, the ortho-spine team strongly recommended that the patient wear a TLSO brace for support. This was repeatedly reinforced to the patient, but the patient declined the brace. If he continues to have back pain, the recommendation for a brace should be readdressed and an [Hospital ] clinic visit scheduled by his primary care physician. [Name10 (NameIs) 227] the strong indication of the imaging findings that the patient has had a compression fracture, the patient is likely at risk for repeated compression fractures. Chronic high dose steroid use is likely a contributing factor. The patient was started on vitamin D 800 u per day and calcium 500 mg TID on discharge. The patient continued to have intermittent back pain which was particularly exacerbated by certain positions, such as lying flat. He was discharged on percocet and a limited amount of oral dilaudid for control of the back pain, with instructions to call his physician if his pain was escalating. 3. Renal failure: While in the ICU the patient had an increase in his creatinine to a peak of 2.4. This was thought secondary to sepsis and resolved with fluids. On discharge his creatinine was at his baseline range of 1.1. . 4. Hypertension: The patient's outpatient hypertensive medications were held on admission due to hypotension. On the general [Hospital1 ], it was difficult to control his blood pressure. He was discharged on atenolol 50 mg once a day (equal to his previous dose) and lisinopril 40 mg (up from previous dose of 20 mg). He was instructed to follow his blood pressure closely over the next week with his primary care physician. . 4. Diarrhea: The patient tested negative for clostridium difficile on this admission and had no diarrhea. He was continued on a 4 week course after discharge of oral vancomycin with input from infectious disease service. The decision to continue oral vancomycin was made in part because he is scheduled for long course of nafcillin, potentially reexposing him to c.diff infection. . 5. IBD: Ulcerative colitis: The patient was maintained on 60 mg prednisone daily as he had taken prior to admission. On the day before discharge, he was tapered to 50 mg daily as he had previously discussed with his gastroenterologist. Further tapering decisions to made with gastroenterologist. 6. Thrombocytopenia: The patient had steadily decreasing platelets during his stay, reaching a low of 89 (admission 169). Prior to his platelets dropping below 100, his subcutaneous heparin and his central line heparin flushes were discontinued. Heparin antibodies were negative. On the day after the central line was replaced and the labs were drawn off the PICC, his platelets rebounded to 131. The thrombocytopenia was thus thought either secondary to sepsis, with appropriate rebound, or secondary to blood collection technique. The patient did NOT meet diagnostic criteria for HIT on this admission. . 7. Pre-diabetes: The patient had elevated blood sugars during his stay, and steroid use is likely a contributing factor. He was discharged with a glucometer and instructions on use and this will hopefully facilitate further management with his primary care physician. . 8. Prophylaxis: Given his chronic steroid use, the patient was dosed with protonix. 9. Follow-up: Followup with Infectious Disease as described above, with infusion therapy team and weekly labs, with MRI in 4 weeks, and with primary care physician. Medications on Admission: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) 3. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bismuth Subsalicylate Thirty (30) ML PO Q1H (every hour) as needed 7. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO as directed: Take 1 qid for 17 more days. After that, take 1 tid X 1 week, then 1 [Hospital1 ] X 1 week, then 1 daily x 1 week, then 1 qod X 1 week, then 1 q3d X 1 week, then stop. Allergies: Discharge Medications: 1. Nafcillin 2 g Recon Soln Sig: Two (2) g Intravenous every four (4) hours for 4 weeks. Disp:qs grams Refills:0 2. IV care PICC line care per protocol 3. IV Pump Pump for nafcillin home therapy 4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 4 weeks. Disp:112 Capsule(s) Refills:0 5. 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 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:90 Tablet, Chewable(s) Refills:2 8. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day: Daily dose 50 mg per day. Further adjustments to dose to be determined by gastroenterologist. Disp:150 Tablet(s) Refills:2 9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for 7 days: Take 1-3 tablets as needed if pain not controlled by percocet and call your doctor if you are requiring this medication. . Disp:30 Tablet(s) Refills:0 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: Do not take more than 4 grams of acetaminophen in one day. . Disp:30 Tablet(s) Refills:2 12. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) ] home therapies Discharge Diagnosis: Primary: MSSA septicemia HTN Hyperglycemia secondary prednisone Thrombocytopenia likely secondary to sepsis (HIT negative) Acute Renal Failure, now at baseline creatinine 1.1 Anemia . Secondary: Hypertension previous Clostridium difficile Ulcerative colitis Hemochromatosis Discharge Condition: Good Discharge Instructions: You were admitted with bacteremia and there was concern that you might have a spine infection. We do not believe that you have an infection of your spine, but it is important that you be vigilant for symptoms. If you develop fevers, increasing severe back pain, incontinence of urine or stool, or numbness/tingling in your legs or groin, you should call your physician [Name Initial (PRE) 2227]. You should also call the [Hospital ] clinic at ([Telephone/Fax (1) 10]. Your infectious disease doctor is Dr. [First Name8 (NamePattern2) ] [Name (STitle) 3394]. . The infusion company will give you instructions on how to deliver the nafcillin through your infusion pump. In addition, they will monitor some laboratory levels for you, including your CBC with differential, BUN, Creatinine and Liver function tests. These results should then be faxed to Dr. [Last Name (STitle) 3394] at [Telephone/Fax (1) 1419]. The visiting nurse drawing the labs will have this information, but if you have your labs drawn at another location, such as your primary care doctor's office, please make sure the results are faxed to this number. . You have been given a prescription for a glucometer. This is for better measurement of your blood sugar on a daily basis. We recommend checking your blood sugars before meals and if you are feeling sick for any reason. If you notice blood sugars greater than 200, please call your primary care doctor. . You have been instructed to follow a diabetic diet in order to keep your blood sugar well controlled. . You are planning to have your blood pressure closely monitored by your primary care physician after discharge. You are being discharged on two blood pressure medications: Atenolol 50 mg once a day Lisinopril 40 mg once a day. . Take your other medications as prescribed in the medications section. . You have been prescribed oral vancomycin for prevention of clostridium difficile infection, which causes diarrhea. Your infectious disease physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 3394], [First Name3 (LF) ] determine how long you need to take this medication at your appointment with her. . You have an appointment scheduled with Dr. [Last Name (STitle) 3394] in the [Hospital ] clinic in the [Hospital1 ] [Hospital Unit Name ] on [2177-4-15] at 9:30 AM. . You have an appointment to get an MRI scan on [2177-4-10] at 3:15 PM. You should get this MRI prior to your ID appointment. . Your prednisone for your ulcerative colitis has been reduced to 50 mg per day. You should discuss further changes with Dr. [First Name (STitle) 2643]. . It was strongly recommended to you that you use a back brace to stabalize your thoracic spine for the next few weeks. At this time, you declined this intervention. Please discuss this decision with your primary care physician, [Name10 (NameIs) ] if you reconsider this decision, please obtain a TLSO back brace as soon as possible. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2837], MD Phone:[Telephone/Fax (1) 1983] Date/Time:[2177-3-26] 1:30 Provider: [Name10 (NameIs) 706] MRI Phone:[Telephone/Fax (1) 327] Date/Time:[2177-4-10] 3:15 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472] Completed by:[2177-3-21] ICD9 Codes: 2875, 5849, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8233 }	Medical Text: Admission Date: [2199-3-27] Discharge Date: [2199-4-4] Date of Birth: [2144-10-21] Sex: F 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: [2199-3-29] Coronary artery bypass graft times three (LIMA to LAD, SVG to DIAG, and SVG to PDA) History of Present Illness: Ms. [Known lastname ] is a 54 year old woman who presented to [Hospital 5279] Hospital with chest pain, diarrhea, and weakness. During a work-up for these complaints she was found to have escheria coli in her urine and blood. She was subsequently placed on Rocephin. Her blood cultures had been negative on Rocephin since [3-22]. She was also found to have three vessel coronary artery disease and therefore was transferred to [Hospital1 771] for surgical work-up. Past Medical History: coronary artery disease diabetes mellitis hypertension gallstones Social History: Ms. [Known lastname ] quit smoking 20 years ago, but smoked 1.5 packs per day for about 20 years. She is a teacher and a call center operator. She lives with her grandson. [Name (NI) ] son passed away 15 years ago. Family History: non-contributory Physical Exam: At the time of admission, Ms. [Known lastname ] was noted to be obese. Her skin exam was unremarkable. Her neck was noted to be thickened. Her lungs were clear to ausculation bilaterally. Her heart was of regular rate and rhythm. Her abdomen was soft, non-tender, non-distended. Her extremities were well perfused and no edema was noted. No varicosities were noted. She was neurologically grossly intact. Pertinent Results: [2199-3-27] 01:00PM %HbA1c-6.3* [2199-3-27] 01:00PM ALT(SGPT)-25 AST(SGOT)-17 LD(LDH)-157 ALK PHOS-153* TOT BILI-0.2 [2199-3-27] 01:00PM GLUCOSE-116* UREA N-23* CREAT-1.2* SODIUM-142 POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-31 ANION GAP-14 [2199-3-27] 08:23PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2199-3-29] ECHO PREBYPASS A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is mild regional left ventricular systolic dysfunction with hypokinesis of the inferior,inferoseptal and inferolateral base and mid inferior wall. Overall left ventricular systolic function is mildly depressed (LVEF=40-45%). The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (area 1.7 by Continuity equation and 2.0cm2 by planimetry). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POSTBYPASS RV systolic function appears normal. Previously described wall motion abnormalities persist. LVEF remains mildly depressed. The PFO shunt remains left to right. The remaining study is unchanged from prebypass. [2199-4-1] CXR There is interval removal of all the lines and tubes including endotracheal tube, Swan-Ganz catheter, NG tube, and the mediastinal tubes. The left lower lobe infiltrate has slightly worsened. Small left pleural effusion is unchanged. The right lung is clear. The sternotomy wires are in a standard position. Brief Hospital Course: Ms. [Known lastname ] was admitted on [2199-3-27] and given IV hydration for an elevated creatinine after cardiac catheterization. She was also given rocephin for outside hospital urine and blood cultures with escherichia coli. Her cultures were negative since [3-22]. On [2199-3-29] she was taken to the operating room and underwent a coronary artery bypass grafting times three (LIMA to LAD, SVG to DIAG, and SVG to PDA). This procedure was performed by [Name6 (MD) ] [Name8 (MD) ], MD. She tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. She was extubated within hours of arriving in the unit. Her chest tubes were removed on POD#1 and was transferred from the ICU to the step down unit. Low dose betablocker, a statin and lasix were resumed. Her temporary pacing wires were removed on POD#3. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with postoperative strength and mobility. Sternal drainage was noted on exam on post operative day 4, so her incision was painted with betadine two times daily. She continued to progress well. On post-operative day 6 her sternal drainage abated and she was discharged to rebilitation. Medications on Admission: aspirin 81 mg, combivent, mucinex, fish oil, duonebs, lisinopril 5, lopressor 25 mg [Hospital1 ], rocephin 1 gm daily, niaspan 50, zocor 10 mg, nitroglycerin 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) for 1 months. 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Niacin 250 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 2 weeks. 6. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO bid (). 7. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Inhalation [Hospital1 ] (). 8. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [7-17] Puffs Inhalation Q6H (every 6 hours). 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO QAM for 5 days. 10. 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. 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Doctor Last Name ]Healthcare Discharge Diagnosis: coronary artery disease s/p coronary artery bypass x 3 (LIMA-LAD, SVG-Dx, SVG-PDA) [2199-3-29] 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 Wear your surgical bra 24 hrs a day for 6 weeks. You may remove your bra for one hour per day. Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr [Last Name (STitle) 39975] (cardiology) in [3-12] weeks. please call for appointment Dr [Last Name (STitle) ] (PCP)in [3-12] weeks ([Telephone/Fax (1) 81266] please call for appointment Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3071]) Completed by:[2199-4-4] ICD9 Codes: 2767, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8234 }	Medical Text: Admission Date: [2140-7-10] Discharge Date: [2140-7-15] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Iodine / B12/E,B6-Fa(<1mg)/Mn/Dietary 1 Attending:[First Name3 (LF) 11495] Chief Complaint: acute shortness of breath Major Surgical or Invasive Procedure: cardiac catheterization [7-10] with stent and IABP placement, central line placement History of Present Illness: 83 y/o Jehovah's witness with PMH significant for Colon CA, DMII, CAD (MI in past, refused angioplasty), living at Sunrise Senior Living Center, was found to be acutely SOB. EMS found pt in severe respiratory distress. No chest pain. RR 32 BP: 130/palp. Able to answer questions but responded with one word answers b/c so SOB. Put on non-rebreather, sent to [Hospital3 1280] Hospital. On arrival, BP 152/92 HR 120-130 Afib-Asystole with agonal respirations. Intubated and responded to atropine, with a HR of 77 with pulse (afib) BP 167/145 then went into SVT to 185. She was given IV lasix, IV nitro gtt, ASA, Lopressor 5mg IV, and a heparin drip. Sent to ICU and found to have ST elevation in aVR with depressions in V2-V4 and II, III, and aVF, concerning for right posterior MI. Initially, the pt was in rate-controlled Atrial fibrillation, but developed CHF-- a dobutamine gtt was started and she was transferred to [Hospital1 18] for cardiac catheterization. She was given solumedrol, benadryl, and pepcid for allergy ppx, in cath lab, stented left circumflex artery (occl) with BP drop to 60 systolic upon stenting (good flow)--- changed to dopamine gtt. Stented right coronary artery, and started intra-aortic balloon pump. She was subsequently transferred to the coronary care unit on IV dopamine at 10 mcg/kg/min. No GP IIa/IIIb inhibitors started. Of note, she is a Jehovah's witness (with form for no transfusions to be given in the chart). Her HCP is [Name (NI) ] [Name (NI) 10076] ([Telephone/Fax (1) 107105]. Her labs at [Hospital1 ] were CK 99, Trop I 2.01 (M 0-0.34), BNP 407. Past Medical History: 1. Colon ca- recently had abd surgery, found recurrence, but pt refused additional sx or chemo 2. DM type II 3. CAD (s/p prior MI, with refusal of angioplasty) 4. Brain tumor- s/p resection (distant past) 5. Alzheimer's demetia 6. Anxiety 7. Hypothyroidism 8. Seizure d/o 9. Depression 10. Hypercholesterolemia Social History: Unknown smoking history, alcohol. Jehovah's witness. Lives at [Hospital3 ]. No known family members. HCP are both members of her [Name (NI) 16042] witness community. Family History: Non contributory. Physical Exam: VS: T: 96.5 BP: 105/53 P: 89 RR: 25 on vent Vent: AC TV 500/R 25/FiO2 1.0/PEEP 10 ABG: 7.26/43/70 when she first arrived, most recent this PM ABG: 7.32/39/147 General: Sedated and intubated, elderly female HEENT: PERRL, MMM, with blood in the ET tube Neck: JVD to jawline Lungs: With coarse rhonchi throughout. CV: Difficult to assess with IABP in place. Abd: Large pannus. Ventral hernia. Pos BS, no masses. Peripheral ext: Cool, mottled skin. Poor peripheral pulses bilaterally. No edema peripheral ext. 0 pulses, but dopplerable. Neuro: Moving all 4 extremities. Opened eyes but did not follow commands. Neg [Doctor Last Name 937] sign and Babinski's sign. . Pertinent Results: Cardiac Catheterization [2140-7-10]: Elevated L and R filling pressures. PCWP 33. Nl LMA. LAD occluded proximally with distal collaterals from RCA (right-dominant). CO: 6.06, CI 3.21 PCW: (M/A/V) 33/36/43 RA: (M/A/V) 19/20/26 AO: (S/D/M) 99/53/61 PA: (S/D/M) 61/33/45 RV: (S/D/E) [2096-11-4] LMCA: nl LAD: proximally occluded, filling via left and RCA collaterals showing severe diffuse ds LCX: occluded after OM1 RCA: 80% mid lesion; 50% origin posterolateral branch COMMENTS: 1. Selective coronary angiography showed a right dimonant system with severe three vessel disease. The LMCA was angiographically without significant disease. The LAD was proximally occluded and was filled by left-to-left and right-to-left collaterals. The mid and distal LAD was severely diffusely diseased. The proximal LCX was without flow limiting stenoses and filled a moderate sized OM1. The mid LCX was occluded prior to a large OM2. The RCA was a large dominant vessel with a mid 80% stenosis and a 50% stenosis at the origin of the PL branch. There was a considerable amount of right to left collaterals to the LAD. 2. Limited hemodynamics showed severe pulmonary hypertension (PA mean 47 mmHg). The left and right sided filling presures were severely elevated (RA mean 20 mmhg, RVEDP 19 mmHg, PCW mean 37 mmHg). The cardiac output was normal with low systemic resistance (CO 6.2 l/min, CI 3.3 l/min/m2). 3. Successful PTCA and stenting of the RCA with a 2.5 x 18 mm Cypher DES. Final angiography revealed no residual stenosis, no apparent dissection, and normal epicardial flow (see PTCA comments). 4. Successful PTCA and stenting of the RCA with a 3.0 x 13 mm Cypher DES. FInal angiography revealed no residual stenosis, no apparent dissection, and normal epicardial flow (see PTCA comments). 5. Successful insertion and timing of a 30 cc intraaortic balloon pump. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe elevation of left and right sided pressures 3. Moderately severe pulmonary hypertension. 4. Acute inferolateral myocardial infarction with cardiogenic shock managed by PTCA and placement of drug-eluting stents in the mid LCX and mid RCA. 5. Successful insertion of an intraaortic balloon pump. . Arrived in cath lab with SBP 100 on 15mcg dobutamine. LCX occlusion crossed and dilated and stented Cypher with no residual, nl flow. 60% prox M1 ds with moderate distal LCX ds, after LCX PCI, SBP decr to 60. IABP inserted via LFA and dobutamine changed to dopamine with return of SBP to 100. RCA lesion dilated, Cypher stent with no residual, normal flow. . Echocardiogram [2140-7-11] Conclusions: The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small with near cavit obliteration during systole. Overall left ventricular ejection fraction is normal to hyperdynamic (EF 65-75%, Inotropes?) with basal to mid infero-lateral wall hypokinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . [7-14], [7-15], and [2140-7-10]: All blood cultures were negative. [7-14] and [2140-7-10]: All urine cultures were negative. [2140-7-14] 8:12 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. FINAL REPORT [2140-7-18] GRAM STAIN (Final [2140-7-15]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2140-7-18]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. RARE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R . CXR [2140-7-11] IMPRESSION: AP chest compared to [7-10] at 1:03 p.m.: Moderately severe pulmonary edema has improved dramatically. The ascending Swan-Ganz line tip projects over the main pulmonary artery, tip of the intraaortic balloon pump projects over the left main bronchus approximately 7 cm from the apex to the aortic knob. The heart is normal size. Small left pleural effusion persist. No pneumothorax. Nasogastric tube coiled in the stomach. . CXR [2140-7-13] IMPRESSION: AP chest compared to 9:09 a.m. on [7-12]. Severe pulmonary edema has worsened, accompanied by increasing moderate-sized bilateral pleural effusions. Heart size top normal. ET tube in standard placement. Nasogastric tube looped in the stomach. A Swan-Ganz catheter has been removed. No pneumothorax. . REPEAT CXR [2140-7-13] IMPRESSION: AP chest compared to 8:05 a.m. Severe infiltrative pulmonary abnormality, worse in the right lung than the left has improved slightly, perhaps function of increased positive pressure ventilation or interval diuresis. Small-to-moderate bilateral pleural effusions persist. The heart is normal size. There is no pneumothorax. ET tube in standard placement. Nasogastric tube passes below the diaphragm and out of view. . CXR [2140-7-15] INDICATION: Right subclavian placement. PORTABLE AP CHEST AT 8:12 A.M: Comparison is made to [2140-7-13]. The endotracheal tube is in satisfactory position in the mid trachea, but the cuff is hyperinflated, expanding the trachea. Right subclavian central venous line tip is in the upper SVC. NG tube tip not visualized, off inferior cassette edge. Cardiac size remains stable at the upper limits of normal. There is improvement in multiple bilateral asymmetrical areas of hazy opacity, likely from resolving pulmonary edema. Small bilateral effusions and residual lower lobe atelectasis remain. Endotracheal tube cuff findings were called to Dr. [Last Name (STitle) 10919] at 4:25 p.m. on [2140-7-15]. . CT ABD/PEL [2140-7-13] CT ABDOMEN WITHOUT ORAL, WITHOUT INTRAVENOUS CONTRAST: A nasogastric tube descends below the diaphragm, and is coiled within the stomach. There are mild coronary artery calcifications. Large bilateral pleural effusions are seen, resulting in compressive atelectasis, and there are mild ground glass opacities within the lungs. Imaging of the abdomen is limited by the lack of intravenous contrast. Allowing for this, the liver attenuates normally without focal nodules or masses. A single 3mm calcification seen within the liver dome, consistent with prior granulomatous infection. The patient is status post cholecystectomy and surgical clips are seen within the right upper quadrant. The pancreas, spleen, bilateral adrenal glands, and intra-abdominal loops of large and small bowel are unremarkable. The kidneys appear slightly atrophic, but are symmetric. There are moderate calcifications involving the abdominal aorta without aneurysmal dilatation. There is no free fluid identified within the abdomen to indicate a retroperitoneal hematoma. CT PELVIS WITHOUT ORAL, WITHOUT IV CONTRAST: CT imaging was continued into the mid thigh. The muscles attenuate normally, and fat planes are preserved. There is no evidence of retroperitoneal hematoma or bleeding into the thigh. A right femoral vein catheter extends to the level of the superior ischia. Suture material is seen within the distal sigmoid. A large amount of subcutaneous edema extends along the abdomen and pelvis. Foley catheter is seen within a collapsed bladder. IMPRESSION: No evidence of retroperitoneal hematoma. Findings consistent with fluid overload including bilateral pleural effusions, ground glass opacities within the lungs, and subcutaneous edema. These findings were discussed with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] form the Medicine service at 2pm on [2140-7-13]. . CT HEAD [2140-7-14] CT OF THE HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage or mass effect. There is no shift of the normally midline structures. The ventricles and sulci are symmetrical and appropriate in size for the patient's age. No major vascular territorial infarction is appreciated on this non-contrast CT exam. Bone windows show evidence of prior craniotomy defect and burr holes seen in the right frontal cortex. Partial opacification of the mastoid air cells is seen bilaterally, which probably relates to intubation. Probable cerumen is seen in the right external auditory canal. IMPRESSION: No intracranial hemorrhage or mass effect. . CARDIAC ENZYMES: [2140-7-10] 12pm CK 3680, MB 412, TnT 21.34 (PEAK) [2140-7-10] 8pm CK 2545, MB 234, TnT 19.70 TRENDING DOWN [2140-7-11] CK 1571, MB 93, Tn not done . LABS: [2140-7-10] Na 141, K 4.1, Cl 110, HCO3 20, BUN 22, Cr 1.1, Glucose 239 [2140-7-15] Na 136, K 3.7, Cl 110, HCO3 18, BUN 30, Cr 0.9, Glucose 201 [2140-7-10] 12:56PM ALT(SGPT)-46* AST(SGOT)-307* CK(CPK)-3680* ALK PHOS-67 TOT BILI-0.3 [2140-7-10]: ABG 7.32/40/147 LACTATE-2.1* . [2140-7-10] WBC 33.7 HCT 36.3 PLT 306 [2140-7-11] WBC 31.1 HCT 32.4 PLT 265 [2140-7-12] WBC 22.1 HCT 19.8 PLT 240 [2140-7-13] AM WBC 17.8 HCT 14.7 PLT 165 [2140-7-13] PM WBC 19.7 HCT 16.0 PLT 209 [2140-7-14] WBC 13.4 HCT 14.8 PLT 198 [2140-7-15] WBC 11.3 HCT 14.0 PLT 182 . HEMOLYSIS LABS [2140-7-11] LDH 785, [2140-7-13] LDH 570 [2140-7-11] RETIC CT 2% [2140-7-11] HAPTOGLOBIN 84, [2140-7-13] HAPTOGLOBIN 132 . IRON STUDIES revealed low serum Fe, low TIBC, high ferritin . TSH 1.3 WNL Brief Hospital Course: Impression: 84 y/o Jehovah's witness with h/o colon CA, brain CA, DM II, CAD with MI in past, refused angioplasty, and Alzheimer's ds presents with STEMI s/p cath with Cypher stents to LCX, RCA complicated by cardiogenic shock with IABP placement with hypotension on pressors, worsening pulm status, now intubated. Her hospital course was complicated by profound anemia, septic shock, cardiovascular and respiratory failure. The patient died on [2140-7-15]. 1. CARDIAC: The patient underwent catheterization on [2140-7-10] showing a right dominant system with severe three vessel disease. The LMCA was angiographically without significant disease. The LAD was proximally occluded and was filled by left-to-left and right-to-left collaterals. The mid and distal LAD was severely diffusely diseased. The proximal LCX was without flow limiting stenoses and filled a moderate sized OM1. The mid LCX was occluded prior to a large OM2. The RCA was a large dominant vessel with a mid 80% stenosis and a 50% stenosis at the origin of the PL branch. There was a considerable amount of right to left collaterals to the LAD. She demonstrated severe pulmonary hypertension (PA mean 47 mmHg). The left and right sided filling presures were severely elevated (RA mean 20 mmhg, RVEDP 19 mmHg, PCW mean 37 mmHg). The cardiac output was normal with low systemic resistance (CO 6.2 l/min, CI 3.3 l/min/m2). Her final cath diagnoses were: 1. Three vessel coronary artery disease. 2. Severe left and right sided diastolic dysfunction 3. Severe pulmonary hypertension. She was placed on IABP post cath, which was weaned 1 day post cath. As she was hypotensive post procedure, she was started on pressors. It was not clear the etiology of her hypotension her first night post cath, as her CI was fine, but she was persistently 70s-90s/50s-60s with cool, clammy extremities and peripheral vasodilation. Cardiogenic shock was considered. She was started on dopamine gtt and maxed out on dosage with persistent MAP in 40s-50s, then given dobutamine, which was weaned. As it was then felt she was not likely in cardiogenic shock, she was begun on levophed with good response in her mean arterial pressure (MAP >60). At this time, however, she spiked a temperature to 102, was pan cultured, and started on empiric broad-spectrum antibiotic therapy. Her shock was most likely secondary to sepsis. A MAP of >60 was kept during her stay in the unit, supported by pressors and fluid boluses. As she is a Jehovah's witness, she would not accept transfusions of pRBCs, so epoetin and ferrous sulfate were begun as adjunctive therapy. She was also started on aspirin, plavix, a statin, and integrillin gtt for her coronary disease. Despite aggressive measures, the patient acutely decompensated on [2140-7-15] in the setting of profound anemia, cardiovascular and respiratory failure, and sepsis. . 2. Septic shock: Though the pt had a cardiac index of 3.3 in the cath lab, post-cath the pt seemed peripherally vasodilated. Initially, the pt was afebrile, and it was thought her low systemic vascular resistance was secondary to medications for intubation, however, during the night post-cath, she spiked a temp to 102, and was pan-cultured with blood cx X2 sent, ua and urine cx sent, with endotracheal cx sent. [All blood cultures during her stay ([7-10], [7-14], and [7-15]) were negative. All urine cultures sent during her stay ([7-10] and [7-14]) were negative. An endotracheal culture from [7-10] grew coag positive S. aureus. A sputum cx from [2140-7-10] grew sparse oropharyngeal flora.] A CXR during the night of her admission to the CCU demonstrated extensive bilateral perihilar infiltrates involving virtually all segments of the lungs. She was started empirically on IV Vancomycin and IV Zosyn for broad coverage (started [2140-7-11]) and these meds were continued throughout her stay. She was begun on pressors to maintain a MAP of >60. Despite aggressive measures with IVF boluses, pressors, and IV antibiotics, the pt expired [2140-7-15], as stated above. . 3. Profound anemia secondary to gastrointestinal bleeding with bloody secretions in ET tube after IABP removal. No evidence of retroperitoneal bleed on Abdominal/Pelvic CT scans. It was unclear the precise etiology of the pt's source of bleed. She developed guiaic positive stool during her stay, and heparin gtt was held. Initially, on arrival to CCU, the pt had bloody secretions in the ET tube, which persisted for several days, then resolved. Her health care proxy was notified of her profound anemia, and because she is a Jehovah's witness, no tranfusions were given to the patient to correct her anemia. Instead, fluid boluses with pressors were given to maintain her MAP. IV ferrous sulfate, and epoetin was given to the pt. Blood draws were minimized and only necessary labs were obtained. The pt's Hct dropped from 36 on [7-10] to 20.5 on [7-11]. A CT scan of abd/pel did not reveal a retroperitoneal bleed post-cath. Her IABP removal was not complicated by bleeding in excess of normal to explain her acute drop in Hct. On [7-13] her Hct was 14.7, and had held steady in the 14-16 range for three days. She developed bloody stools four days post-admission, and GI was consulted. A nasogastric lavage was performed and was negative. Her hemolytic workup was negative. Her stool was guiaic positive and maroon in color. It was felt she had a lower GI bleed, however she was not stable enough to undergo colonoscopy. Her heparin gtt was discontinued. Her MAP was supported as stated above. On the day of her death, her Hct was 14.0. Her health care proxy was informed of all events and procedures during her stay, and was given updates as to her Hct and measures being taken to support her MAP. . 4. RESPIRATORY: The pt's CXR was read as "extensive bilateral perihilar infiltrates involving virtually all segments of the lungs." Post-cath, she was intubated and sedated on mechanical ventilation. She was unable to be weaned from the vent secondary to hypoxia. Her CXR improved somewhat during her stay, with [2140-7-12] CXR showing mild-to-moderate residual pulmonary edema, largely basal, unchanged since [7-11], having improved dramatically since [7-10], with leftward mediastinal shift reflecting left lower lobe atelectasis, accompanied by persistent small left pleural effusion. CXR on [2140-7-15] demonstrated multiple bilateral asymmetrical areas of hazy opacity, likely from resolving pulmonary edema. Her small bilateral effusions and residual lower lobe atelectasis remained. She remained on broad spectrum IV antibiotics throughout her admission. . 6. DM TYPE II: Her blood sugars were well controlled with sliding scale insulin, and fingersticks were checked qid. . # Decreased mental status: A head CT was performed to rule out intracranial bleed as a cause of her depressed mental status and inability to be weaned from the vent (a central cause for respiratory depression/hypoxia was considered) and in the setting of possible systemic hypoperfusion given her septic picture, and was negative for intracranial bleed or mass effect or any acute abnormality. The pt remained minimally responsive and sedated and intubated throughout her stay. . 7. seizure d/o No seizures occurred during her admission. Her Dilantin level at [Hospital1 ] was 10.6. We restarted dilantin on admission. . 8. Alzheimer's ds: Her Aricept was held in light of her critical status. . 9. Depression: Her Zoloft was held in light of pt's unstable status. She remained intubated and sedated throughout her stay, only minimally responsive on sedation. . 10. CODE: FULL CODE, although her health care proxy requested at admssion that he wanted to be notified if there was futility/no benefit to further aggressive measures. The health care proxy was communicated with nearly every day by housestaff physicians, RNs in the CCU and the attending physician as to the pt's prognosis, status, and measures being taken in her care. He was involved in all decision making. . Medications on Admission: 1. Lipitor 20mg po qd 2. Zestril 2.5mg po qd 3. Imdur 60mg po qd 4. Dilantin 100mg po tid 5. Zoloft 75mg po qd 6. Risperadol 0.5mg po qd 7. Aricept 10mg po qd 8. Synthroid 0.025mg po qd 9. Lasix 80mg po qd 10. KCl 10-20mg po qd 11. Atenolol 50mg po qd 12. MVI 13. Ca suppl 14. Vit C 15. ASA 81mg po qd 16. Vit E Discharge Disposition: Expired Discharge Diagnosis: 1. Sepsis 2. Profound anemia, with lower gastrointestinal bleed, with inability to give transfusions (patient is a Jehovah's witness) 3. ST-segment elevation myocardial infarction status post stent placement to left circumflex artery and right coronary artery 4. Cardiac catheterization complicated by hypotension treated with pressors and IV fluids, cardiogenic shock status post intra-aortic balloon pump placement 5. pulmonary edema and respiratory failure on mechanical ventilation 6. altered mental status 7. history of colon cancer 8. history of brain cancer 9. Alzheimer's disease 10. Type II Diabetes Mellitus 11. history of depression Discharge Condition: Pt expired on [2140-7-15] in setting of sepsis on broad-spectrum IV antibiotics, hypotension on pressors and IV fluids. Pt had profound anemia despite IV ferrous sulfate, fluid boluses, and epoeitin as pt was a Jehovah's witness with lower GI bleeding and without evidence of retroperitoneal bleed after cardiac cath. Hemolysis labs negative. With STEMI s/p cardiac catheterization with stents placed and IABP placement and removal. Completed by:[2140-8-3] ICD9 Codes: 0389, 4280, 4168
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8235 }	Medical Text: Admission Date: [2132-3-11] Discharge Date: Date of Birth: [2060-3-22] Sex: F Service: CCU/[Hospital Unit Name 196] HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 22807] is a 71-year-old woman who was referred from her primary care physician's office for left shoulder pain and new T wave inversions in V2-V6. She has a history of recent anterolateral myocardial infarction from two weeks ago where she presented with left shoulder pain. She described the pain as severe as [12-29], wrenching, and associated with shortness of breath and diaphoresis. Her CKs peaked to 250. Catheterization revealed 99% mid circumflex and 90% mid left anterior descending artery stenoses, both of which were stented with good flow. The ejection fraction was 53%. Since discharge, she has had some residual pain and over the last week has had increasing cough with associated pleuritic pain and chills, but no fever. She also complained of malaise, fatigue, coryza, and URI symptomatology. As well, she has had gastrointestinal upset for which she saw Dr. [Last Name (STitle) 5361] three days prior to admission. On the day of admission, she developed left shoulder pain which was described as sharp and shooting occurring twice at rest. The pain was relieved by Nitroglycerin. She saw her covering primary care physician who performed an electrocardiogram and referred her to [Hospital6 649] for concerns of new T wave inversions in V2-V6. Of note, her symptoms were associated with shortness of breath and chills. She denied nausea, vomiting, and diaphoresis. She also denied orthopnea, paroxysmal nocturnal dyspnea, and edema. PAST MEDICAL HISTORY: The past medical history revealed hypertension, hypercholesterolemia, and coronary artery disease as described above. She had an anterolateral myocardial infarction in [2132-2-21] with catheterization showing 99% mid circumflex and 90% mid left anterior descending artery stenosis stented x2. She has also had a history of Persantine Thallium which was positive with ST depressions in V5-V6. Other past medical history revealed gastroesophageal reflux disease, uterine cyst, and status post cholecystectomy. MEDICATIONS: Atenolol 100 mg p.o. q.d., ECASA 325 mg p.o. q.d., Plavix 75 mg p.o. q.d., Zestril 2.5 mg p.o. q.d., Lipitor 40 mg p.o. q.h.s., Prevacid 30 mg b.i.d., Carafate 1 mg p.o. q.i.d. p.r.n. ALLERGIES: The patient has allergies to sulfa which gives her an itch and Pravachol which gives her hives. FAMILY HISTORY: The family history is notable for myocardial infarction in her parents and myocardial infarction in her brother who died at age 69. SOCIAL HISTORY: The patient was formerly [Street Address(1) 22808] financial operator. Her husband expired on [1-14]. She lives with her son who is supportive. She denies alcohol and smoking. PHYSICAL EXAMINATION: Temperature was not recorded, heart rate 60, blood pressure 118/71, respiratory rate 16, O2 saturation 99% on 2 liters. In general, she appeared obese and mildly anxious but pleasant. On head and neck examination, she had a right eyelid xanthoma. The fundi were clear with no plaques. The oropharynx was clear. She had no enlarged thyroid and there were no carotid bruits. The chest was clear. She had a regular rate and rhythm with normal S1 and S2 and no gallops or murmurs. JVP was 2 cm ASA at the clavicle. The abdomen was obese, soft, and nontender. Guaiac was negative as per Dr. [Last Name (STitle) 22809]. She had trace edema. There was no bruit in her femoral pulses and she had good pulses palpable distally. LABORATORY DATA: White blood cell count was 9.3, hematocrit 40, platelets 318,000, neutrophils 66.7, lymphocytes 27.3, INR 1.1. SMA-7 was normal including BUN 13 and creatinine 0.7. CK was 80 and troponin was 0.3. Chest x-ray showed an enlarged heart. The aorta was unfolded and calcified. There was slight prominence of the pulmonary vascularity. The lungs were clear. There were no focal opacities nor pleural effusion. The impression was of mild congestive heart failure. Electrocardiogram showed left axis at approximately 15 degrees with atrial abnormality. She had T wave inversions in V2-V6 and ST depression of 1 mm in I and aVL. HOSPITAL COURSE: In summary, Mrs. [Known lastname 22807] is a 71-year-old woman with coronary artery disease status post left anterior descending artery and left circumflex stents two weeks prior to admission with a history of hypertension and hypercholesterolemia who presented with recurrence of left shoulder pain similar to her anginal equivalent but not as intense. Her symptoms were relieved by Nitroglycerin. Her examination was unremarkable. The electrocardiogram was concerning for T wave inversions in V2-V6 as well as ST depression in I and aVL. Because of a concern for possible re-stenosis in her stents, she was initiated on a GP23A inhibitor, Aggrastat, to prevent platelet aggregation and re-stenosis as a bridge to catheterization for another look. Aspirin and Heparin were also initiated for her unstable angina. Atenolol was converted to Lopressor 100 mg b.i.d. for tighter hourly control. Zestril was increased to 5 mg p.o. q.d. for increased afterload reduction. The CKs were cycled and she ruled out. A repeat catheterization was performed for the recurrence of her left shoulder pain post stent placement. It revealed widely patent stents in the left anterior descending artery and left circumflex. The left main had a 20% proximal stenosis. The left anterior descending artery had a widely patent mid vessel stent with mid luminal irregularities throughout the vessel. The left circumflex had mild luminal irregularities with a widely patent stent. The right coronary artery was mildly calcified throughout with a 40% mid vessel narrowing with a small chronic appearing ulcer which had been present and unchanged from the prior study. In summary, it was felt she had coronary arteries without significant residual narrowing and the previously placed stents were widely patent. In the hospital, Mrs. [Known lastname 22807] was shoulder pain free but on hospital day #1, she noted some bruising of her left hip. On examination, she had a hematoma which was 10 cm x 8 cm in size. Despite this, Heparin and Aggrastat were continued pre-catheterization. Once her catheterization was performed and was not revealing for further stenosis, the Heparin and Aggrastat were discontinued. On hospital day #2, Mrs. [Known lastname 22807] did very well and the hematoma was noted to be re-absorbing. Her examination at the time of discharge revealed mild ecchymoses at the site of entry from her catheterization in the left groin but no bruit was audible. Her pulses were palpable in the dorsalis pedis and posterior tibialis regions. Her extremities were warm. DISCHARGE DIAGNOSIS: Unstable angina as manifested by left shoulder pain, status post catheterization revealing for coronary arteries without significant residual narrowing and previously placed stents widely patent. DISCHARGE MEDICATIONS: Lipitor 40 mg p.o. q.h.s., Zestril 5 mg p.o. q.d., Atenolol 100 mg p.o. q.d., Plavix 75 mg p.o. q.d. for the remainder of her initial treatment of one month, ECASA 325 mg p.o. q.d., Prevacid 30 mg p.o. b.i.d., Carafate 1 mg p.o. q.i.d. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [Last Name (STitle) 5361]. DISPOSITION: To home. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 8227] Dictated By:[Last Name (NamePattern1) 19923] MEDQUIST36 D: [2132-3-13] 11:09 T: [2132-3-13] 20:18 JOB#: [Job Number ] ICD9 Codes: 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8236 }	Medical Text: Admission Date: [2168-7-7] Discharge Date: [2168-7-11] Date of Birth: [2120-9-9] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Methadone Attending:[First Name3 (LF) 1835] Chief Complaint: left sided neglect, right sided weakness, dysarthria Major Surgical or Invasive Procedure: [2168-7-7] L frontal craniotomy & tumor resection History of Present Illness: Patient is a 47 year old woman with a history of metastatic melanoma with mets to the abdomen, brain, right tibia initially found via a shoulder lesion which was excised. She underwent craniotomies for resection of Brain lesions with Dr [Last Name (STitle) ] in [2164] and [2165], as well as cyberknife 3 times in [2164] and [2165] following her resections and then again in [2166]. She was seen by Dr [Last Name (STitle) 724] in clinic on [6-23] after an MRI on [6-22] showed worsening of her left frontal and left cerebellar lesions in the interval from her last MRI which was done in [2166-12-24]. She reported 3 days of progressive left sided weakness prior to that visit. Plan following that visit was for her to be discussed in brain [Hospital 341] Clinic on [6-27] with neuro-onc, rad-onc, and neurosurgery. On [6-24] she developed what was described by OSH reports as expressive aphasia and left facial droop which were not noted in Dr [Last Name (STitle) 73943] note from [6-23]. She was subsequently transferred to [Hospital1 18] for further management given these findings. Of note at the OSH she was found to have a hematocrit of 15 a hemoglobin of 4.3, a WBC of 31.9, and a platelet count of 920. She was given Decadron 10mg IV x 1, as well as 2 units of RBCs and transferred here. On arrival she was evaluated by the ED who found that she also had a guaiac positive rectal exam. Past Medical History: PAST ONCOLOGIC HISTORY: (from OMR) - [1-26] 0.47-mm thick, [Doctor Last Name 10834] level II melanoma resected from right shoulder lesion during her second pregnancy, then observed - [2162] developed a forehead nodule and a biopsy in [2163-8-24] revealing melanoma. PET/CT scan revealed uptake in the right frontal bone, a 2 cm soft tissue mass near the ascending colon and in the right tibia - Cyberknife radiosurgery to the skull lesion on [2163-10-11], followed by high-dose IL-2 therapy that was started on [2163-11-14]. A follow up PET/CT at week 11 revealed interval increase in size of the right tibial lesion, but no FDG avidity in the right frontal bone or ascending colon soft tissue mass. - XRT to the right tibia over 5 fractions completed on [2164-3-15]. Follow up tibial MRI showed increased enhancement while PET scan was stable in that area. - right tibial metastasis resected by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4223], M.D. on [2164-12-26]. She took Chinese herbal medication until [2165-3-5]. She then received ipilimumab treatment from [2165-3-6] to [2165-5-22] in a phase II protocol. - [9-/2164], she developed forgetfulness and frontal headaches. Outpatient head MRI on [2164-10-18] showed a large right frontal heterogeneously enhancing mass suggestive of a metastasis. - resection by [Name8 (MD) ], M.D. on [2164-10-18], and the pathology was metastatic melanoma. - Cyberknife radiosurgery to the resection cavity from [2164-11-6] to [2164-11-8] to 2,400 cGy (800 cGy x 3 fractions). She later had more Cyberknife radiosurgery procedure to a left parietal brain metastasis on [2165-9-27] to 2,000 cGy at 78% isodose line. She then had a left parietal craniotomy for resection of hemorrhagic tumor by Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] on [2165-12-23], followed by more Cyberknife radisurgery to a left cerebellar to 2200 cGy at 79% isodose line on [2165-12-25], and another Cyberknife radiosurgery to a left medial frontal metastasis on [2166-4-15] to 2,200 cGy at 75% isodose line. - One month F/U brain MRI was stable. PET scan on [2166-5-19] revealed increased FDG avidity in the right tibia and in the posterior stomach felt c/w recurrent disease. - She began compassionate-use ipilimumab on [2166-6-25] with worsening right LE pain noted. She received radiation, 10 fractions over two weeks, to the RLE, completed on [2166-11-19]. - underwent resection of the right proximal tibia and reconstruction with an oncologic hinged proximal tibia replacement prosthesis on [2167-2-4] by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4223]. - status post EGD with biopsy on [2167-7-16] showing melanoma, and - received PD-1 antibody treatment from [2168-1-27] to [2168-4-20]. - Left occipital craniotomy resection of brain mass [2168-7-7] Social History: No tobacco, alcohol or drug use. Lives with her husband who is her HCP. Brother is very involved in care as well. On Hospice Family History: Mother had pancreatic cancer and diabetes at 63. Her grandmother's brother died of melanoma and her great grandmother died of colon cancer. Physical Exam: Gen: cachetic, tired, comfortable, NAD. HEENT: Pupils: PERRL EOMs left gaze neglect but crosses midline with prompting 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, flat affect. Orientation: Oriented to person, place, and date. Language: some dysarthria, pt says her speech feels garbled, she has good comprehension and repetition. Naming intact. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4mm to 3mm bilaterally. Visual fields are difficult to assess given patient cooperation III, IV, VI: Extraocular movements intact bilaterally without nystagmus when prompted, has a left gaze neglect. V, VII: Left facial droop 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 deviates to left without fasciculations. Motor: decreased bulk and tone bilaterally. No abnormal movements or tremors. LUE 4+, RUE grip 5-, [Hospital1 ] and tri [3-28], LLE 4+ throughout, RLE IP 4, Q/H/Gas/AT/[Last Name (un) 938] [3-28], No pronator drift. Left sided exam likely secondary to neglect as patient verbalizes knowledge she is moving right when asked to move left. With much prompting and discussion moves left side well Sensation: Decreased on left upper and lower extremities likely secondary to neglect. On right side is Intact to light touch Toes downgoing bilaterally Coordination: normal on finger-nose-finger with right upper extremity, does not complete on left side Discharge exam: Gen; pleasant and cooperative neuro: AOX3 PERRL, EOM intact, face symmetric, motor [5-28] except for LLE secondary to known osteosarcoma, sensory intact to light tough, no clonus skin: incision intact, clean and dry with absorbable monocryl sutures in place. Pertinent Results: MRI Brain [6-22] 1. Marked interval increase in size of the left frontal contrast-enhancing lesion, with an even larger interval increase in surrounding vasogenic edema in the bilateral frontal lobes, which now causes subfalcine herniation with 9-mm rightward shift of midline structures, as well as further effacement of the frontal [Doctor Last Name 534] of the left lateral ventricle. 2. Minimal increase in size and comparatively larger interval increase in surrounding vasogenic edema seen at the left cerebellar enhancing lesion. 3. Stable contrast enhancement adjacent to the right frontal lobe resection cavity. 4. No new lesions detected. MRI Brain [2168-7-7] No significant changes are identified since the most recent examination, unchanged left frontal heterogeneous enhancing lesion, similar pattern of enhancement surrounding the right frontal surgical cavity with ex vacuo dilatation of the ventricular frontal [Doctor Last Name 534]. Fiducial markers are in place. Stable left cerebellar enhancing lesion. No new lesions are identified since the most recent exam. CT Head [2168-7-7] Expected post craniotomy appearance. MRI Brain [2168-7-8] 1. Small amount of residual circumferential nodular enhancement around the left frontal surgical bed. Continued attention to this area should be paid on followup exams. 2. Expected postoperative findings of pneumocephalus, a small amount of blood products, and cytotoxic edema is present. 3. Stable appearance of prior resections in the left parietal and right frontal lobes. A stable pattern of enhancement is present adjacent to the right frontal lobe resection. 4. Tiny regions of nodular dural thickening with mild enhancement. Attention to these lesions should be paid in followup exams. Brief Hospital Course: 47 y/o F with L frontal metastatic lesion with L neglect, R arm weakness and dysarthria presents for elective tumor resection. She was taken to the OR on [7-7] with no complications. She was transferred to the ICU post surgery. On [7-9], the patient was started on iron for a hematocrit of 24. Her dose of Dexamethasone was weaned, and her Foley was discontinued. (Concern for tongue deviation on [7-9] exam??) The following day, her hematocrit decreased to 23 and she was transfused 2 units of pRBCs. He post transfusion hematocrit was 31%. She was evaluated by PT and was deemed stable for discharge with outpatient physical therapy. Medications on Admission: citalopram, dexamethasone, keppra, lidocaine patch, ativan, ritalin, omeprazole, oxycodone Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain/temp/ha max 4g/24hrs 2. Citalopram 20 mg PO DAILY 3. Dexamethasone 2 mg po bid Duration: 30 Days RX dexamethasone 2 mg twice a day Disp #60 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID RX Colace 100 mg twice a day Disp #60 Capsule Refills:0 5. Ferrous Sulfate 325 mg PO DAILY 6. Fluconazole 200 mg PO Q24H Duration: 4 Days RX Diflucan 200 mg daily Disp #4 Tablet Refills:0 7. Lorazepam 0.5 mg PO Q8H:PRN nausea, anxiety 8. MethylPHENIDATE (Ritalin) 5 mg PO QAM 9. Omeprazole 40 mg PO BID RX omeprazole 40 mg twice a day Disp #60 Capsule Refills:0 10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX oxycodone 5 mg every four (4) hours Disp #60 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Hospice Discharge Diagnosis: L frontal metastatic lesion pterygium post operative anemia constipation oral candidiasis 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. ?????? 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. ?????? 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. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????You will need an appointment in 2 weeks at the Brain [Hospital 341] Clinic and please call. Their phone number is [Telephone/Fax (1) 1844]. 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) ]. - Please follow up with Ophthomolgy in [7-1] weeks for your Pterygium for evaluation and treatment. Completed by:[2168-7-11*] ICD9 Codes: 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8237 }	Medical Text: Admission Date: [2195-2-18] Discharge Date: [2195-2-25] Date of Birth: [2129-12-24] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) / Erythromycin Base / Ampicillin Attending:[First Name3 (LF) 1505] Chief Complaint: Chest Tightness Major Surgical or Invasive Procedure: [2195-2-19] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to OM, SVG to Ramus, SVG to Diag) History of Present Illness: 65 y/o female with chest tightness during walking and exercise over the last month. Along with associated dyspnea. She had a +ETT and then underwent a cardiac cath at OSH. Cath revealed severe three vessel disease along with LM disease and she was transferred to [Hospital1 18] for surgical intervention. Past Medical History: Diabetes Mellitus, Hyperlipidemia, Chronic Gastritis, s/p L TK replcament, s/p Tubal ligation, s/p Appendectomy, s/p T&A, s/p Herniated disc repair x 2, s/p right Carpal tunnel surgery, s/p Right Trigger finger release Social History: Tob: Quit 2 yrs ago after 3ppd x 30 yrs ETOH: Occ. on holidays Retired from customer service Lives with spouse Family History: Father pacemaker Physical Exam: VS: 82 20 140/80 Gen: NAD, WD female Skin: Unremarkable with right groin cath site ecchymotic, -hematoma HEENT: EOMI, PERRLA Neck: Supple, FROM, -JVD, -Carotid Bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft NT/ND +BS Ext: Warm, well-perfused -edema, -varicosities, 2+ pulses throughout Neuro: MAE, Non-focal, A&O x 3 Discharge Neuro a/ox3 nonfocal Pulm CTA Cardiac RRR Sternal inc no drainage/erythema, sternum stable Abd soft, NT, ND +BS Ext warm Edema +1 Left leg EVH CDI Pertinent Results: [2195-2-25] 06:40AM BLOOD WBC-6.8 RBC-3.47* Hgb-10.7* Hct-31.4* MCV-90 MCH-30.9 MCHC-34.2 RDW-14.7 Plt Ct-232# [2195-2-18] 07:36PM BLOOD WBC-7.3 RBC-4.17* Hgb-13.1 Hct-37.1 MCV-89 MCH-31.5 MCHC-35.4* RDW-14.8 Plt Ct-154 [2195-2-25] 06:40AM BLOOD Plt Ct-232# [2195-2-25] 02:07AM BLOOD PT-12.3 PTT-30.0 INR(PT)-1.1 [2195-2-18] 07:36PM BLOOD Plt Ct-154 [2195-2-18] 07:36PM BLOOD PT-12.0 PTT-31.4 INR(PT)-1.0 [2195-2-25] 06:40AM BLOOD Glucose-92 UreaN-19 Creat-0.5 Na-140 K-4.3 Cl-103 HCO3-29 AnGap-12 [2195-2-18] 07:36PM BLOOD Glucose-89 UreaN-16 Creat-0.6 Na-139 K-4.0 Cl-102 HCO3-28 AnGap-13 [2195-2-18] 07:36PM BLOOD ALT-25 AST-24 LD(LDH)-188 AlkPhos-114 Amylase-93 TotBili-0.7 [2195-2-22] 04:06AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.4 [2195-2-18] 07:36PM BLOOD Albumin-4.5 Calcium-9.6 Phos-3.7 Mg-2.1 [2195-2-18] 07:36PM BLOOD %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE CXR [2-24] Comparison is made to prior radiograph dated [2195-2-21] and [2195-2-19]. PA AND LATERAL CHEST RADIOGRAPH. Since prior radiograph, there has been interval removal of right-sided central venous line. There are small bilateral pleural effusions, however, no parenchymal consolidation is identified. No pneumothorax. Heart size is again identified to be enlarged in this patient status post median sternotomy and CABG. Stabilization plate from prior left-sided humeral fracture in incompletely visualized. IMPRESSION: Bilateral pleural effusions, left greater than right side. No evidence of focal pulmonary consolidation.. TEE [2-19] MEASUREMENTS: Left Ventricle - Inferolateral Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.9 cm Left Ventricle - Fractional Shortening: 0.15 (nl >= 0.29) Left Ventricle - Ejection Fraction: 55% (nl >=55%) Aorta - Valve Level: 2.7 cm (nl <= 3.6 cm) Aorta - Ascending: 3.0 cm (nl <= 3.4 cm) Aorta - Arch: 2.4 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: 2.0 cm (nl <= 2.5 cm) INTERPRETATION: Findings: RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild symmetric LVH. 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. Focal calcifications in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: No MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Resting tachycardia for the patient. See Conclusions for post-bypass data Conclusions: PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular cavity size is normal. There is borderline mild left ventricular hypertrophy. .Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma 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. Trivial mitral regurgitation is seen. POST-BYPASS: Pt is in sinus tachycardia on an epineprhine infusion. 1. Bi ventricular systolic function is preserved 2. Aorta is intact post decannulation 3. Other findings are unchanged Brief Hospital Course: Ms. [Known lastname ] was transferred from OSH and immediately underwent routine pre-operative testing for surgery. On [2-19] she was brought to the operating room where she underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. She tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. Later on op day she was weaned from sedation, awoke neurologically intact and was extubated. On post-op day one she was transfused with one unit of PRBC's and started on beta blockers and diuretics. She was gently diuresed towards her pre-op weight. Chest tubes were removed on post-op day two and epicardial pacing wires on post-op day three. On post-op day three she was transferred to the telemetry floor where she received the remainder of her care while in the hospital. Physical followed patient during entire post-op course for strength and mobility. She continued to make steady process without any post-op complications and was discharged home with VNA services on post-op day six. Medications on Admission: Atenolol 25mg qd, Neurontin 100mg TID, [Doctor First Name ] 30mg [Hospital1 ], Avandia 8mg qd, Zocor 40mg qd, Mobic 7.5mg qd, Ultracet t tabs q6h prn, Zantac 300mg qd, Aspirin 81mg qd, MVI, Mineral Oil prn, Oscal, Osteo bioflex, Glucosamine 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: Two (2) Tablet PO once 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:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:0 6. Fexofenadine 60 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 7. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 10 days. Disp:40 Capsule, Sustained Release(s) Refills:0 10. 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 11. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 3597] HH Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: Diabetes Mellitus, Hyperlipidemia, Chronic Gastritis, s/p L TK replcament, s/p Tubal ligation, s/p Appendectomy, s/p T&A, s/p Herniated disc repair x 2, s/p right Carpal tunnel surgery, s/p Right Trigger finger release Discharge Condition: Good Discharge Instructions: [Month (only) 116] shower, 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 Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Dr. [Last Name (STitle) 5017] in [2-28] weeks Dr. [Last Name (STitle) ] in [1-27] weeks [Telephone/Fax (1) 70836] please call for appointments Completed by:[2195-2-25] ICD9 Codes: 4111, 2875, 2859, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8238 }	Medical Text: Admission Date: [2208-8-19] Discharge Date: [2208-8-25] Date of Birth: [2147-10-12] Sex: F Service: CARDIOTHORACIC Allergies: Morphine Attending:[First Name3 (LF) 5790] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: [2208-8-19] Redo right thoracotomy, removal of portion of posterior splinting mesh and tracheoplasty with mesh, flexible bronchoscopy with bronchoalveolar lavage History of Present Illness: Ms [Known lastname ] is a 60F with TBM. She is s/p tracheobronchoplasty [2200] but had recurrence of sx. A tracheal stent was placed [2208-5-25] with noted improvement in dyspnea and cough. It was removed [2208-6-16] and pt has now returned to her baseline easy DOE, cough but denies fever, sweats, chest pain or other related sx. She saw Dr [Last Name (STitle) 5543] for a cardiac pre op eval, had a f/u bronch and is now planning on moving forward with redo tracheobronchoplasty. Past Medical History: PMH: Fibromyalgia, Hepatitis C, RUL bronchiectasis, Chronic bronchitis, Hx of chemical pneumonitis . PSH: s/p Tracheoplasty, s/p bronchiectasis surgery, Csxn x2, s/p breast augmentation (implants), s/p tonsils and adenoids, "eye operation as child". Social History: Quit smoking >20 yrs ago, smoked <1 ppd for about 10 years, denies EtOH, no illicit drugs. Family History: Non-contributory Physical Exam: BP: 148/93. Heart Rate: 98. Weight: 152. BMI: 29.7. Temperature: 98.5. O2 Saturation%: 98. Gen:NAD Neck:no [Doctor First Name ] Chest: Clear ausc Cor:RRR no murmur Abd:deferred Extrem: no CCE Pertinent Results: [2208-8-19] 09:38AM HGB-11.5* calcHCT-35 [2208-8-19] 09:38AM GLUCOSE-95 LACTATE-1.2 NA+-138 K+-3.5 CL--106 [2208-8-19] 02:28PM GLUCOSE-117* UREA N-13 CREAT-0.6 SODIUM-141 POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-27 ANION GAP-10 [2208-8-22] CXR : In comparison with the study of [8-21], the right IJ catheter has been removed. No change in the appearance of the heart and lungs. Elevation of the right hemidiaphragm anteriorly is again seen. Large hiatal hernia is present. [2208-8-24] Ba swallow :Preliminary Report dysphagia 1. Large hiatal hernia. Small caliber of the stomach passing through the Preliminary Reportdiaphragmatic hiatus delays passage of a 13 mm barium tablet. 2. No direct correlation of the above findings with the patient's symptoms of Preliminary Reportdysphagia [2208-8-25] Bedside swallow : Based on results of pt's recent barium swallow with impaired esophageal motility and hiatal hernia impacting speed of passage of PO and pt's correlated symptom of sensation that food will not go down is likely [3-17] globus sensation from her esophageal deficits. Pt was educated on strategies such as keeping foods moist, alternating bites and sips, eating slowly and smaller meals in attempt to alleviate discomfort. Brief Hospital Course: Ms. [Known lastname ] was admitted to the hospital and taken to the Operating Room where she underwent a redo right thoracotomy, removal of portion of posterior splinting mesh and tracheoplasty with mesh and flexible bronchoscopy with bronchoalveolar lavage. She tolerated the procedure well and was extubated in the OR. She returned to the SICU in stable condition with an epidural catheter for pain control. The pain service followed her closely and made adjustments in her epidural infusion to improve her pain control so as to make pulmonary toilet more effective. She maintained stable hemodynamics but did have a hematocrit drop from 33 intraop to 25 early post op. Serial hematocrits were followed along with chest xrays and there was no evidence of active bleeding. Following removal of her chest tube, her epidural catheter was also removed and she had adequate pain relief with Oxycodone, Tylenol, Ibuprofen and Tramadol. She was able to use her incentive spirometer effectively and cough and deep breath comfortably. She used a CPAP mask at night and had RA saturations of 95% during the day. She was tolerating a regular diet in moderation but her liquid intake was poor which ultimately reflected in a creatinine bump from 0.6 to 1.2 within 24 hours. She was then rehydrated with 2 liters of fluid and her creatinine decreased to 0.9 but her hematocrit was also 22.8. She remained hemodynamically stable with a blood pressure of 110/70 . She complained of dysphagia to soft foods and some liquids and subsequently underwent a barium swallow which showed a large hiatal hernia but no other pathology. The speech and swallow therapist evaluated her at the bedside and found no mechanical problem or evidence of aspiration. She was given some hints on how to keep food moist to allow for easier passage. Her pain medication was adjusted as she had inadequate pain control with Oxycodone 5 mg q 4 hours along with Tramadol, Ibuprofen and Tylenol. She was better controlled with 10 mg every 4 hours although not pain free. She did have a large ecchymotic area around her chest tube site which extended to the right hip and upper thigh but the areas were soft. Her Ibuprofen was reduced to 400 mg TID and she may ultimately stop it. She will use local heat or cool packs for comfort. Her hematocrit remained stable at 25. She was discharged to home on [2208-8-25] and will follow up in the Thoracic Clinic in 2 weeks. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Amphetamine Salt Combo NF (amphetamine-dextroamphetamine) 40 mg Oral daily 2. Losartan Potassium 25 mg PO DAILY 3. Benzonatate 200 mg PO TID 4. HydrOXYzine 50 mg PO HS 5. guaiFENesin NF 1,200 mg Oral [Hospital1 ] 6. Acetylcysteine 20% NF 5 mls Other TID use 30 minutes after albuteral 7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 8. Omeprazole 20 mg PO DAILY 9. Sodium Chloride 3% Inhalation Soln 1 neb NEB TID:PRN SOB, cough Supplied by Respiratory 10. albuterol sulfate NF 90 mcg/actuation Inhalation q 6 hrs SOB 11. Escitalopram Oxalate 20 mg PO DAILY Discharge Medications: 1. Escitalopram Oxalate 20 mg PO DAILY 2. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #80 Tablet Refills:1 3. Acetaminophen 650 mg PO Q6H pain 4. Adderall XR NF* (amphetamine-dextroamphetamine) 40 mg ORAL DAILY Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 5. Docusate Sodium 100 mg PO BID 6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX oxycodone 5 mg [2-15] tablet(s) by mouth every four (4) hours Disp #100 Tablet Refills:0 7. albuterol sulfate NF* 90 mcg/actuation Inhalation q 6 hrs SOB 8. Amphetamine Salt Combo NF (amphetamine-dextroamphetamine) 40 mg Oral daily 9. Sodium Chloride 3% Inhalation Soln 1 neb NEB TID:PRN SOB, cough Supplied by Respiratory 10. Ferrous Sulfate 325 mg PO DAILY 11. guaiFENesin NF 1,200 mg Oral [Hospital1 ] 12. Omeprazole 20 mg PO DAILY 13. Senna 1 TAB PO BID:PRN constipation 14. Losartan Potassium 25 mg PO DAILY 15. Ibuprofen 400 mg PO Q8H RX ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours Disp #100 Tablet Refills:1 Discharge Disposition: Home Discharge Diagnosis: Recurrent tracheomalacia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for surgery to correct your tracheomalacia and you've recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. You should also use your CPAP mask at night. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * If your chest tube site starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * You will continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol 650 mg every 6 hours in between your narcotic. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk 4-5 times a day and gradually increase your activity as you can tolerate. Call Dr.[Name (NI) 2347] office [Telephone/Fax (1) 2348] if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: Department: WEST [Hospital 2002] CLINIC When: TUESDAY [2208-9-6] at 9:00 AM With: [Name6 (MD) 1532] [Last Name (NamePattern4) 8786], MD [Telephone/Fax (1) 3020] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Please report 30 minutes prior to your appointment to the Radiology Departmment on the [Location (un) 470] of the [Location (un) 40900] for a chest xray. Completed by:[2208-8-25] ICD9 Codes: 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8239 }	Medical Text: Admission Date: [2133-5-9] Discharge Date: [2133-5-22] Date of Birth: [2060-4-11] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Unresponsive. Major Surgical or Invasive Procedure: Intubation History of Present Illness: The patient is a 73 year old woman with past medical history of hypertension, hypercholesterolemia, COPD, recent car accident 3 weeks ago with rib fractures and patellar fracture, dementia, who was transferred from [Hospital3 3583] after being unheard of from since Wednesday and subsequently being found down. Per her daughter, she was last seen on Wednesday. When she wasn't heard from in several days, her daughter went to check on her tonight. Daughter found her lying on floor, in between couch and stable, soiled with urine and stool. She was not speaking and did not seem to understand what daughter was saying. Taken to [Hospital3 ] and arrived at 21:45. Documentation limited but received several milligrams of Ativan, Dilantin 600 mg IV, and Labetalol for SBP of 242/122. Labs there remarkable for WBC 16.9, INRX 1.1, normal renal function, CK of 1566. Head CT with large left MCA infarction. Transferred to [Hospital1 18] for further evaluation. Past Medical History: 1. Hypertension 2. Hypercholesterolemia 3. Glaucoma 4. Dementia 5. COPD 6. Recent car accident with rib fracture and patellar fracture Social History: Widowed. Lived alone and independent in ADLs per her daughter. [Name (NI) ] term memory problems. Positive tobacco use. No alcohol, drug use. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 96842] [Telephone/Fax (1) 96843]. Family History: No family history of neurological disease. Physical Exam: Gen: Intubated, recently received bolus of sedation. HEENT: Mucosa dry. Neck: In hard cervical collar. Lungs: CTA anterolaterally. No R/R/W. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Eyes closed. Does not open spontaneously. No verbal output. Not following commands. Cranial Nerves: I: Not tested II: Pupils are post surgical and fixed. Unable to appreciate fundi. III, IV, VI: No doll's due to collar. V, VII: Weak corneals bilaterally. VIII: Unable to assess. IX, X: +Gag. [Doctor First Name 81]: Unable to assess. XII: Tongue midline without fasciculations. Motor: Legs are extended, plantar flexed. Moves left leg, bending and withdrawing it. Right leg moves side to side on bed. Triple flexion response in right lower extremity. Slow extension response in right upper extremity. Sensation: Withdraws to noxious x4 Reflexes: Reflexes are brisk with several beats of clonus at her ankles. Toes are both upgoing. Coordination: Unable to assess. Gait: Unable to assess. Pertinent Results: [2133-5-9] 03:15AM BLOOD WBC-15.2* RBC-5.72* Hgb-14.8 Hct-46.2 MCV-81* MCH-25.8* MCHC-31.9 RDW-16.4* Plt Ct-265 [2133-5-9] 03:15AM BLOOD Neuts-85.4* Lymphs-6.7* Monos-7.5 Eos-0 Baso-0.4 [2133-5-9] 02:15AM BLOOD PT-14.4* PTT-26.7 INR(PT)-1.3* [2133-5-9] 02:15AM BLOOD Glucose-170* UreaN-20 Creat-0.7 Na-142 K-5.8* Cl-110* HCO3-18* AnGap-20 [2133-5-9] 02:15AM BLOOD CK(CPK)-5119* [2133-5-9] 07:21AM BLOOD ALT-37 AST-136* LD(LDH)-329* CK(CPK)-5067* AlkPhos-79 Amylase-343* TotBili-0.6 [2133-5-11] 10:23AM BLOOD CK(CPK)-1350* [2133-5-9] 02:15AM BLOOD CK-MB-52* MB Indx-1.0 cTropnT-<0.01 [2133-5-9] 02:15AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.7 [2133-5-9] 07:21AM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [2133-5-9] 07:21AM BLOOD Triglyc-111 HDL-60 CHOL/HD-3.3 LDLcalc-114 [2133-5-9] 01:39PM BLOOD Phenyto-5.5* BRAIN MRI: The diffusion images demonstrate an acute infarct involving the left middle cerebral artery with mild mass effect on the left lateral ventricle. There are mild-to-moderate periventricular changes of small vessel disease seen. There is no midline shift or hydrocephalus. There is mild-to-moderate brain atrophy seen. There is evidence of increased signal seen in the pons indicative of small vessel disease. No definite slow diffusion seen in the pons to indicate pontine infarct. Note is made of absence of flow void in the left cavernous carotid artery, which could be due to occlusion in the neck. IMPRESSION: Acute left MCA infarct with mild mass effect on the left lateral ventricle. Absent flow void in the left carotid artery. MRA OF THE HEAD: The head MRA demonstrates absence of flow signal in the left internal carotid artery. The left MCA is faintly visualized on the source images, most likely secondary to collaterals from the anterior communicating and left posterior communicating artery. The right internal carotid, right middle cerebral, and both anterior cerebral arteries demonstrate normal flow signal. In the posterior circulation, distal left vertebral artery appears to be ending in posterior inferior cerebellar artery. The right distal vertebral, basilar, and both posterior cerebral arteries demonstrate normal flow signal. IMPRESSION: Non-visualization of the left internal carotid artery, likely secondary to occlusion in the neck. Faint flow signal indicating diminished flow is seen within the left middle cerebral artery. TTE: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure. Right ventricular chamber size and free wall motion are normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Moderate to severe [3+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderate to severe tricuspid regurgitation. Pulmonary artery systolic hypertension. EEG: This is an abnormal routine EEG due to the presence of sharp and sharp and slow wave discharges seen over the right frontal region and due to a slow and disorganized background rhythm with multifocal polymorphic slowing in the delta frequency range. Additionally, there is an increased voltage gradient over the left fronto-temporal region. The first abnormality suggests a cortical dysfunction in the right frontal region. The second abnormality represents a mild encephalopathy. There was no clear seizure activity recorded, however, and post-ictal events cannot be excluded. Brief Hospital Course: 1. Stroke: The pt was found to have aphasia and a right hemiparesis at an outside hospital. She was intubated and transferred here for further management. A head CT was obtained which showed a large left MCA distribution stroke. An MRI was then performed which showed the left MCA stroke as well as an occluded [Doctor First Name 3098] in the neck. This was felt to be an acute event which led to her stroke. As for the reason for the embolus, the patient had a TTE which showed LVH, but no thrombus or valvular lesions. She was monitored on telemetry and shown to have intermittent AF which was not previously known. This is likely the reason for her embolus. Carotid arteries were not evaluated with Doppler given the known [Doctor First Name 3098] occlusion and the fact that her source was almost certainly her heart. Given the large size of her stroke, she was not placed on coumadin/heparin. She was started on ASA 300 mg daily instead. She was also started on Lipitor. After several days, she was also started on heparin sq when this was deemed safe. She remained intubated and not attempting to answer questions while in the ICU. She had no spontaneous movement on the right and minimal movement to painful stimuli. This did not change while she was in the ICU. She opened her eyes spontaneously and would look ot her left, but it is unclear if this was in reaction to anything specific. She did not follow any commands, even on her right side which did move spontaneously at times. Multiple family meetings were held in which it was determined that the pt would not want a PEG and/or tracheostomy. This was clear from the beginning. She was kept intubated for 10 days and then extubated. She did well from a respiratory standpoint, but we had a high suspicion that she may aspirate given her inability to handle her own secretions. This was known by the family when she was extubated. As she was breathing well with minimal care required, she was transferred to the floor for further care. There she remained stable. Prior to transfer, another family meeting was held to reaffirm the pt's status as comfort measures only. 2. UTI:The patient had a UTI on admission that was treated well with 5 days of levofloxacin. 3. Cellulitis: The patient had a questionable cellulitis on her right ankle which was treated for 3 days with cefazolin. It improved significantly and this medication was stopped. It is unclear whether this was definitely cellutlitis or only a local skin irritation. Her legs seemed to cause her pain when it was touched. Given that she was found down, we did X-rays of her pelvis and hips to confirm no fracture. These films were normal. The pain seemed to resolve with the skin lesion. Medications on Admission: 1. Levoxyl 2. Diovan 3. Atenolol 4. Evista 5. Aricept 6. Advair 7. Albuterol 8. KCLe Daughter is unsure of exact meds and will bring them in am. Discharge Medications: 1. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR Transdermal ONCE (Once) for 1 doses. 2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q4H (every 4 hours) as needed for pain or fever. 3. Lorazepam 2 mg/mL Syringe Sig: [12-4] ml Injection Q4HPRN () as needed for agitation. 4. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1-2H () as needed for pain or discomfort. Discharge Disposition: Extended Care Facility: [Location (un) 582] at Silver [Doctor Last Name ] Discharge Diagnosis: -left MCA territory stroke Discharge Condition: Comfort Measures Only Discharge Instructions: Please continue medications as prescribed, titrating for pt comfort. Followup Instructions: N/A [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 4019, 496, 5990, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8240 }	Medical Text: Admission Date: [2207-6-16] Discharge Date: [2207-6-20] Date of Birth: [2141-3-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4975] Chief Complaint: found unresponsive Major Surgical or Invasive Procedure: s/p catheterization on [6-19] History of Present Illness: Mr. [Known lastname 29079] is a 66 year old male with a history of CAD s/p multiple interventions, HTN, DM2, hypercholesterolemia who was transferred from the MICU due to concern of NSTEMI (elevated cardiac enzymes). He was found to be difficult to arouse by his wife on [6-16] and was transferred to [Hospital3 3583]. He was electively intubated at [Hospital1 46] due to altered mental status and transferred to [Hospital1 18]. He was accepted into the ICU and extubated on [6-17]. He was noted to have rising cardiac enzymes and was transferred to the Cardiology service. He reports that he has not felt the same since after his last cath in [Month (only) 116]. He states that he has felt weak and that he gets some chest discomfort when he exerts himself. He reports that the discomfort only lasts a few minutes and that it resolves with rest. The day he was found to be unresponsive he does not recall much of the day. He denied havig any chest pain, shortness of breath, lightheadedness or palpitations. He only notes that he had 3 beers that day. As per his wife, she left him sleeping in the morining and found him still sleeping when she got home at 3PM. She notes he was making some gurgling sounds and was difficult to arouse. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: - CAD NSTEMI (95) s/p PTCA of proximal RCA PTCA (98) s/p stent proximal LAD STEMI (03) LAD with severe ISR s/p PTCA/cutting balloon PCI (09) s/p Cypher stent to LAD, Taxus stent to RCA. PCI (10) - HTN - HL - DM - GERD - Depression Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension Social History: Lives w/ wife at home alone. Currently under great financial stress, as lost much of prior wealth. The patient quit smoking in [2181]. He drinks approximately four to five beers per month. He is a small business owner. - Tobacco: quit in [2181], 50+pk years. - Alcohol: [12-13] night. - Illicits: denied by wife. Family History: Father died at the age of 58 [1-13] CAD, diabetes. Mother died of old age. No Hx of strokes, ICH. Physical Exam: VS - 98.8 66 114/44 992L Gen: elderly male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with unremarkable JVP. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: MSE: AAOx3 CN: II-XII grossly intact, right eye prosthesis Strength: [4-15] bilaterally for both upper and lower extremitities Reflexes: 2+ Biceps/Triceps and Patellar bilaterally, Babinski down going. Pulses: Right: Carotid 2+ DP 2+ PT 2+ \ Physical Exam unchanged upon discharge Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: Cardiac Cath [6-19]: Cornary angiography showed a R dominant system. R radial approach was used. Selective angiography of left system: LMCA: Normnal LAD: 50-60% ostial LAD, 70% origin diagonal branch, patent stents LCX: patnent stent in LCX, 60% stenoses of continuation of AV circumflex. RCA: 70% diffuse distal RCA and 60% at the bifurcation. ECHO [6-17]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the distal left ventricular segments. The remaining segments contract normally (LVEF = 40-45 %). The right ventricular size and systolic function are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion MRI Head [6-18]: 1. Multiple foci of restricted diffusion: In the bilateral basal ganglia, the subcortical left frontal white matter and the left subependymal region, compatible with focal infarcts. The distribution is most suggestive of a hypoxic or hypotensive event. Alternatively, this could represent a thromboembolic etiology. 2. Minimal irregularity of the right vertebral artery, with minimal luminal narrowing. This may be artifactual, or may be related to atherosclerotic disease. Overall, the intracranial and neck vasculature is patent, with no significant stenosis or occlusion. 3. Chronic small vessel ischemic change. EEG [6-17]: IMPRESSION: Abnormal portable EEG due to the mildly slow background rhythm. This indicates a widespread encephalopathy. Medications are likely the most common explanation of such tracings. Metabolic disturbances and infection can produce similar tracings. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no epileptiform features. Brief Hospital Course: 66 yo man w/ CAD (NSTEMI in 95, PTCA and stent to prox LAD [2194], STEMI in [2199], LAD/PCA stenting in [2205], DES to LCX in [2206]), HTN, HL, DM, GERD, Depression who was found unresponsive by his wife in the afternoon of [6-16] and found to have nSTEMI, ARF, transaminitis, aspiration pneumonia vs. pneumonitis and metabolic/resp. acidosis who came to the MICU intubated at OSH. # NSTEMI: New TwI in lateral leads and elevated Trop, likely LAD territory and restenosis of prior LAD. Pt was started on a heparin gtt, goal PTT of 60-90. Continued on ASA, Plavix, atenolol, statin, isosorbide. Pt was then transferred to CCU for further management of NSTEMI. Since pt with known OSA, and perhaps EtOH intake earlier in evening caused increased myocardial demand -> NSTEMI -> Hypotension -> multiorgan involvement (see below). Repeat ECHO revealed mild symmetric left ventricular hypertrophy with normal cavity size, mild left ventricular systolic dysfunction with focal hypokinesis of the distal left ventricular segments, LVEF = 40-45 %, normal right ventricular size and systolic function. Cardiac Cath did not show disease that needed intervention. # AMS: Etiology unclear. U and Stox negative, but pt with h/o EtOH use. Non focal neuro exam, unlikely stroke, though could not r/o TIA, so ordered MRI/MRA head and neck. Also could not rule out potential post-ictal somnolence, so ordered 20min EEG recording to investigate potential epileptiform activity. Also did infectious work-up, but cx (BCx, UA, Sputum Cx) pending at time of transfer. # ARF: Potentially related to hypoperfusion, and ratio of BUN/Cr suppportive of hypoperfusion. UA positive for blood, ketones, and protein, but no WBC. Urine electrolytes with FEurea<35%, which supports prerenal etiology. Gave fluid challenge. # CAD: See above, NSTEMI. # Aspiration pneumonitis vs. PNA: Pt initially intubated, but once in MICU, weaned off ventilator and extubated since not intubated for respiratory status. Because of aspiration risk, started Zosyn, though antibx can be discontinued if CXR improves significantly. # HTN. Currently normotensive. Continued home meds with holding parameters. # Hyperlipidemia: Pt with known CAD, so continued statin. Also checked fasting lipids, which revealed LDL 49 and HDL 52. Incidentally, these numbers also support a higher-than-admitted use of EtOH. # Metabolic acidosis, metabolic alkalosis, and respiratory acidosis: Metab. acidosis likely due to renal failure, lactate is normal (which goes agains a hypoperfusion theory). Trended electrolytes. # Transaminitis. Likely [1-13] a hypoperfusion episode, could be due to myocardial injury/muscle leak. Trended LFTs. # DM: HbA1C = 6.5, continued on half of home-dose humulin and started on ISS. Medications on Admission: ATENOLOL - 25 mg Tablet qpm CITALOPRAM - 20 mg Tablet morning CLOPIDOGREL 75 mg morning CYANOCOBALAMIN - 1,000 mcg/mL Solution - 1 QAM ESOMEPRAZOLE 40 mg Capsule GLIPIZIDE - 5 mg Tablet Extended Rel qam IRBESARTAN 150 mg qam ISOSORBIDE MONONITRATE SR 60 mg [Hospital1 ] LORAZEPAM - 0.5 mg prn NITROGLYCERIN 0.4 mg prn PIOGLITAZONE 45 mg qam ROSUVASTATIN 20 mg qpm SITAGLIPTIN-METFORMIN [JANUMET] - 50 mg-1000 mg twice a day ASPIRIN 325 mg am HCTZ - dose unknown Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily (). 5. Isosorbide Mononitrate 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO PRN as needed for anxiety. 12. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual PRN as needed for pain. 13. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day. 14. Janumet 50-1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: s/p Unresponsiveness Secondary Diagnosis: Type 2 Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because you had elevated cardiac enzymes in your blood concerning for a small heart attack. You had a catheterization to see if you had any blockages. There were no significant blockages in your artery. Medications changed upon discharge: START Ranitidine 150 mg twice a day STOP ESOMEPRAZOLE Followup Instructions: Please make a follow up appointment with your primary care physician [Name Initial (PRE) 176] 2 weeks of discharge. Please make a follow up appointment with your cardiologist within 4 weeks of discharge. ICD9 Codes: 5849, 5070, 4019, 2724, 311, 412
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8241 }	Medical Text: Admission Date: [2167-12-12] Discharge Date: [2167-12-21] Date of Birth: [2131-8-10] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins Attending:[First Name3 (LF) 6743] Chief Complaint: transfer from outside hospital for management of DIC Major Surgical or Invasive Procedure: transfusion of packed red blood cells History of Present Illness: 36yo G6P6 transferred from an outside hospital for management of hemorrhage and DIC after a vaginal delivery. She was admitted to the OSH one day prior to transfer and underwent a normal vaginal delivery, complicated by a postpartum hemorrhage. She was taken to the OR twice on PPD#1, the first time for exploratory laparotomy during which a large amout of hemoperitoneum was evacuated, a cervical laceration was repaired, and the uterus was packed; the second time, she underwent TAH, evacuation of retroperitoneal hematoma, and cystoscopy with ureteral stent placment. Postoperatively she went into DIC and was transfused a total of 13 units PRBCs, 3 units FFP, 2 units cryoprecipitate. Cardiac echo obtained at OSH due to tachycardia and hypotension showed EF>80%. Past Medical History: MedHx: morbid obesity SurgHx: none prior to this hospitalization ObHx: G6P6, SVDx6, no comps GynHx: reg menses, no abnl Paps or STDs Social History: +smoking, quit 2 months ago. No EtOH, drug use. Family History: no clotting disorders, no pregnancy disorders Physical Exam: VS: T 98.4, HR 130, BP 149/61, RR 20, SaO2 100% Vent: CPAP + PS, FiO2 0.4, RR 14, PS 5, PEEP 5 Genl: NAD, intubated, awake HEENT: NCAT, some scleral erythema, tearing CV: RRR, nl S1, S2, no rubs, gallops, II/VI systolic murmur Chest: CTA bilaterally, no wheezes or crackles Abd: morbidly obese, soft, vertical midline incision with dressing C/D/I Ext: 3+ edema, PP+ Skin: no ecchymoses/petechiae Neuro: alert, answering questions appropriately Pertinent Results: [2167-12-12] 01:51PM BLOOD WBC-9.0 RBC-2.89* Hgb-8.4* Hct-23.6* MCV-82 MCH-29.2 MCHC-35.6* RDW-15.5 Plt Ct-56* [2167-12-12] 01:51PM BLOOD PT-12.8 PTT-27.5 INR(PT)-1.1 [2167-12-12] 01:51PM BLOOD Fibrino-472* [2167-12-12] 01:51PM BLOOD FacVIII-160* Fact IX-142 Fact [Doctor First Name 81]-77 [2167-12-12] 01:51PM BLOOD Glucose-117* UreaN-11 Creat-0.7 Na-139 K-3.6 Cl-107 HCO3-23 AnGap-13 [2167-12-12] 01:51PM BLOOD Calcium-7.6* Phos-3.4 Mg-1.3* [2167-12-18] 10:29AM BLOOD WBC-5.6 RBC-3.42* Hgb-10.2* Hct-29.6* MCV-87 MCH-29.8 MCHC-34.3 RDW-14.6 Plt Ct-165 [2167-12-18] 10:29AM BLOOD Neuts-75.9* Lymphs-19.2 Monos-3.1 Eos-1.4 Baso-0.3 [2167-12-18] 10:29AM BLOOD Plt Ct-165 [2167-12-17] 04:45AM BLOOD Glucose-111* UreaN-7 Creat-0.7 Na-140 K-3.7 Cl-103 HCO3-27 AnGap-14 [2167-12-17] 04:45AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.5* CXR [2167-12-12]: The lung volumes are low. There is no evidence of pneumothorax. There is mild perihilar haziness, which may be secondary to fluid overload. The lungs are otherwise clear. KUB [2167-12-13]: Abdomen, a single supine view of the abdomen shows no visible stent. There is abundant gas in small and large bowels, compatible with postoperative ileus. CXR [2167-12-14]: Low lung volumes without significant change from prior study. Renal U/S [2167-12-15]: No evidence of hydronephrosis. RLE Doppler [2167-12-17]: No evidence of hydronephrosis. Brief Hospital Course: The pt was admitted to the intensive care unit on POD#0/0 from her two laparotomies. She was called out to the floor on HD#3. 1. Pulm: The pt arrived intubated and sedated. She was extubated on HD#2 and placed on O2 via nasal cannula. Oxygen was weaned by HD#3 and her saturation remained good on room air. 2. Heme: The pt received an additional 4u pRBCs after her arrival. Her Hct stabilized at 25. She was never symptomatically anemic. Her coagulopathy had resolved by the time she was admitted to [Hospital1 18], and her coagulation studies remained normal. Her platelet count nadired at 51,000 on HD#2 and then started to rise; it reached a normal level of 161,000 by her date of discharge. 3. ID: The pt received 2 doses of prophylactic Levaquin at the outside hospital ; this was D/C'd on transfer. Erythema was noted around the pt's incision on HD#2, and she was started on IV cefazolin for a presumed wound infection. She continued to have occasional low-grade temperatures, though never any high spikes, and the redness around her incision spread slightly over her pannus. On HD#7, her staples were removed and her wound opened, with drainage of a seroma and debridement of old tissue performed at the bedside. Antibiotics were D/C'd on HD#13. She had [Hospital1 ] wet-to-dry packing changes for the remainder of her hospital stay, and was discharged home with VNA to help her pack the wound. 4. GU: The pt's ureteral stent fell out spontaneously on HD#3. Her Foley was noted to be draining pink urine; there was no evidence of infection. Renal U/S and GU consultation were obtained, and there was no evidence of damage to kidneys or ureters; the Foley catheter was therefore D/C'd on HD#5. Her urine output remained stable for the rest of her stay. 5. DVT: The pt complained of calf tenderness on her right side on HD#6. Doppler U/S of the lower extremity was negative for DVT. Her symptoms resolved spontaneously on HD#7. Medications on Admission: Meds on transfer: Nexium Levofloxacin (last at 9am) Morphine prn . Meds on admission at OSH: none noted Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:40 Tablet(s) Refills:0 2. Motrin 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 12017],NH Discharge Diagnosis: s/p postpartum hemorrhage s/p total abdominal hysterectomy s/p DIC wound separation Discharge Condition: good, stable Discharge Instructions: Take all medications as prescribed. Do not drive for 2 weeks or while taking narcotics. No heavy lifting or heavy exercise for 6 weeks. Nothing in vagina for 6 weeks. Call if you have fever of 100.4 or higher, pus from your incision, redness or swelling spreading around your incision, or any other symptoms that worry you. Followup Instructions: Call Dr.[Name (NI) 27357] office at [Telephone/Fax (1) 5777] for an appointment in a week and a half for a wound check. Call your general obstetrician for a follow-up appointment. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 6753] Completed by:[2167-12-28] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8242 }	Medical Text: Admission Date: [2157-6-9] Discharge Date: [2157-6-23] Service: OBSTETRICS/GYNECOLOGY Allergies: Vicodin / Codeine Attending:[First Name3 (LF) 6743] Chief Complaint: Urinary retention, pelvic mass Major Surgical or Invasive Procedure: Exploratory laparotomy, total abdominal hysterectomy, left salpingoophorectomy, excision of mass History of Present Illness: The patient is an 86 year old who was transfered from [Hospital ] hospital where she was admitted with urinary retention and a pelvic mass. The patient first noted bladder spasms and suprapubic pain about 6 weeks ago noticing that they were worse when standing. She presented to an OSH ED where she was found to have urinary retention. She had multiple subsequent ED visits at several hospitals in the [Location (un) 47] area where she had multiple catherizations. She had an indwelling catheter placed at one of those visits and has had it in for about 4 weeks. She had a CT scan done at [Hospital ] hospital on [2157-5-11] which described findings consistent with a multifibroid uterus. This report is not available here today. She had a cystography in the ED at [Hospital 47] hospital which according to her records was normal. She had a cystoscopy attempt which failed due to patient intolerance. She then had an MRI done on [2157-6-7] showing a 10 x 11.5 x 13cm midline heterogenous mass with fluid components and irregularly shaped peripheral nodules occupying much of the lower third of the pelvis. This mass was thought to possibly originate from the right ovary. The MRI also noted a normal- sized uterus with a 2mm endometrium but no fibroids. She had another cystoscopy today [2157-6-8] where multiple trigonal polyps were noted, biopsied and fulgurated. In addition. a bladder diverticulum was noted. Of note, the patient has been noted to have continued retention despite indwelling foley catheter. She reports suprapubic discomfort, discomfort from the catheter and bladder spasms at this time. Denies vaginal bleeding fever, chills, nausea, vomiting, loss of appetite. She does endorse some abdominal bloating but denies early satiety. Denies HA, CP, SOB, palpitations. Past Medical History: OB: G4P4 - uncomplicated vaginal deliveries Gyn: - Postmenopausal PMH: - HTN - HLD - CAD (4 vessel CABG) - Vertigo PSH: - L Oophorectomy for benign ovarian mass - Ventral hernia repair - 4 vessel CABG Social History: lives with husband, has two daughters, active at home, participates in social clubs. She is primary caregiver for her husband, who is blind. Daughters are closely involved and supportive. Phone [Telephone/Fax (1) 88614]. Quit tobacco > 50 years ago. No EtOH. Family History: NC Physical Exam: On admission: VS 99.4 132/56 76 18 95%RA Gen: Appears comfortable, NAD CV: RRR Lungs: CTAB Abd: Softly distended, dull, non-tympanic, (+) fluid wave. Nontender mobile mass palpated that occupies most of her pelvis extending 2cm below the umbilicus. Pelvic: No bleeding. The rest of the exam was deferred per patient request as she is not in a private room. Ext: No edema, NT GU: Foley [Last Name (un) ] in place draining [Location (un) 2452] urine c/w pyridium ingestion. On discharge: VS Tmax 99.8 Tc 97.6 HR 70 BP 164/74 RR 18 O2sat 98% RA NAD Some bruising on UEs b/l. PICC site c/d/i Abdomen soft, minimally tender, no rebound or guarding, + BS Incision with steri-strips, clean/dry/intact LE NT/minimal edema Pertinent Results: Heme: [2157-6-9] 06:42PM BLOOD WBC-5.8 RBC-3.73* Hgb-11.7* Hct-35.8* MCV-96 MCH-31.4 MCHC-32.7 RDW-14.1 Plt Ct-214 [2157-6-11] 07:03AM BLOOD WBC-4.4 RBC-3.41* Hgb-10.8* Hct-32.8* MCV-97 MCH-31.6 MCHC-32.8 RDW-13.8 Plt Ct-162 [2157-6-12] 06:53AM BLOOD WBC-3.7* RBC-3.32* Hgb-10.8* Hct-32.4* MCV-98 MCH-32.4* MCHC-33.2 RDW-14.3 Plt Ct-166 [2157-6-13] 06:50AM BLOOD WBC-4.9 RBC-3.33* Hgb-11.0* Hct-32.6* MCV-98 MCH-33.1* MCHC-33.7 RDW-14.0 Plt Ct-168 [2157-6-14] 08:29PM BLOOD WBC-12.0# RBC-3.59 Hgb-11.0* Hct-33.0* MCV-92 MCH-30.8 MCHC-33.5 RDW-15.7* Plt Ct-150 [2157-6-15] 04:13AM BLOOD WBC-11.4* RBC-3.28* Hgb-10.3* Hct-30.3* MCV-93 MCH-31.5 MCHC-34.0 RDW-16.0* Plt Ct-164 [2157-6-15] 05:34PM BLOOD WBC-10.4 RBC-3.15* Hgb-9.7* Hct-29.0* MCV-92 MCH-31.0 MCHC-33.6 RDW-16.1* Plt Ct-137* [2157-6-16] 09:24AM BLOOD WBC-8.8 RBC-3.49# Hgb-10.8# Hct-30.9# MCV-89 MCH-30.9 MCHC-34.9 RDW-17.6 Plt Ct-130* [2157-6-16] 11:51PM BLOOD WBC-8.8 RBC-3.43* Hgb-10.4* Hct-30.4* MCV-89 MCH-30.2 MCHC-34.1 RDW-17.6* Plt Ct-149* [2157-6-17] 09:21PM BLOOD WBC-7.7 RBC-3.20* Hgb-9.8* Hct-28.4* MCV-89 MCH-30.7 MCHC-34.6 RDW-17.4* Plt Ct-136* [2157-6-18] 05:19PM BLOOD WBC-6.2 RBC-3.26* Hgb-10.2* Hct-29.9* MCV-92 MCH-31.3 MCHC-34.1 RDW-17.1* Plt Ct-183 [2157-6-21] 05:37AM BLOOD WBC-6.1 RBC-3.24* Hgb-9.8* Hct-29.7* MCV-92 MCH-30.3 MCHC-33.1 RDW-16.3* Plt Ct-190 [2157-6-23] 05:43AM BLOOD WBC-4.6 RBC-3.23* Hgb-9.7* Hct-29.0* MCV-90 MCH-30.0 MCHC-33.5 RDW-16.0* Plt Ct-190 Coags: [2157-6-9] 06:42PM BLOOD PT-13.3 PTT-24.1 INR(PT)-1.1 [2157-6-14] 07:00AM BLOOD PT-12.7 PTT-33.1 INR(PT)-1.1 [2157-6-15] 01:28AM BLOOD PT-13.5* PTT-27.5 INR(PT)-1.2* [2157-6-15] 07:30PM BLOOD PT-13.3 PTT-29.7 INR(PT)-1.1 [2157-6-16] 11:51PM BLOOD PT-13.8* PTT-24.5 INR(PT)-1.2* [2157-6-18] 05:19PM BLOOD PT-13.3 PTT-24.0 INR(PT)-1.1 Chemistry: [2157-6-9] 06:42PM BLOOD Glucose-131* UreaN-19 Creat-1.2* Na-141 K-4.1 Cl-105 HCO3-25 AnGap-15 [2157-6-13] 06:50AM BLOOD Glucose-96 UreaN-17 Creat-1.1 Na-143 K-4.3 Cl-112* HCO3-21* AnGap-14 [2157-6-15] 04:13AM BLOOD Glucose-170* UreaN-16 Creat-1.4* Na-137 K-4.8 Cl-108 HCO3-18* AnGap-16 [2157-6-16] 02:31AM BLOOD Glucose-133* UreaN-25* Creat-1.5* Na-140 K-4.5 Cl-109* HCO3-23 AnGap-13 [2157-6-16] 11:51PM BLOOD Glucose-132* UreaN-23* Creat-1.3* Na-143 K-4.6 Cl-111* HCO3-20* AnGap-17 [2157-6-17] 03:44PM BLOOD Glucose-103* UreaN-26* Creat-0.9 Na-141 K-4.2 Cl-109* HCO3-26 AnGap-10 [2157-6-20] 05:24AM BLOOD Glucose-122* UreaN-22* Creat-0.7 Na-143 K-3.4 Cl-105 HCO3-31 AnGap-10 [2157-6-22] 04:08AM BLOOD Glucose-111* UreaN-24* Creat-0.8 Na-140 K-4.2 Cl-105 HCO3-28 AnGap-11 [2157-6-23] 05:43AM BLOOD Glucose-99 UreaN-27* Creat-1.0 Na-138 K-4.0 Cl-104 HCO3-30 AnGap-8 [2157-6-11] 07:03AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8 [2157-6-13] 06:50AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.1 [2157-6-14] 08:29PM BLOOD Calcium-8.6 Phos-4.2 Mg-1.5* [2157-6-16] 02:31AM BLOOD Calcium-7.5* Phos-3.4# Mg-2.1 [2157-6-18] 04:52AM BLOOD Calcium-8.6 Phos-2.0* Mg-2.0 [2157-6-20] 05:24AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.0 [2157-6-23] 05:43AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1 Urine: [2157-6-9] 07:20PM URINE Blood-TR Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2157-6-16] 01:17PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2157-6-22] 01:31PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG Cultures: [2157-6-9] 6:42 pm BLOOD CULTURE #1. FINAL REPORT [2157-6-15] Blood Culture, Routine (Final [2157-6-15]): NO GROWTH. [2157-6-9] 7:20 pm URINE Site: CATHETER FINAL REPORT [2157-6-10] URINE CULTURE (Final [2157-6-10]): NO GROWTH. [2157-6-14] 8:29 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2157-6-17] MRSA SCREEN (Final [2157-6-17]): No MRSA isolated. [2157-6-15] 10:14 am SPUTUM Source: Endotracheal. FINAL REPORT [2157-6-17] GRAM STAIN (Final [2157-6-15]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2157-6-17]): MODERATE GROWTH Commensal Respiratory Flora. [2157-6-16] 1:17 pm URINE Source: Catheter. FINAL REPORT [2157-6-17] URINE CULTURE (Final [2157-6-17]): NO GROWTH. [2157-6-16] 1:17 pm URINE Source: Catheter. FINAL REPORT [2157-6-17] Legionella Urinary Antigen (Final [2157-6-17]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. Imaging: CXR [6-13]: PA AND LATERAL CHEST RADIOGRAPHS: Anterior mediastinal wires are intact. The cardiac and mediastinal contours are normal. The aorta is tortuous with calcification at the knob. The lungs are clear. No pneumothorax or pleural effusion is noted. No evidence of metastatic disease is seen. IMPRESSION: No acute cardiopulmonary process. CXR [6-15]: CHEST RADIOGRAPH PORTABLE AP VIEW: Endotracheal tube tip terminates approximately 6.8 cm above the carina and advancing 3 cm is recommended. There are low lung volumes with no pneumothorax. The left costophrenic angle is mild blunted, likely positional. Cardiomediastinal and hilar silhouettes are stable. IMPRESSION: No acute cardiopulmonary abnormality. PICC placement [6-17]: IMPRESSION: Uncomplicated ultrasound and fluoroscopically-guided 5 French double-lumen PICC line placement via the left basilic venous approach. Final internal length is 49 cm, with the tip positioned in SVC. The line is ready to use. CXR [6-20]: PA and lateral upright chest radiographs were reviewed in comparison to [2157-6-15] and [2157-6-13]. Heart size is normal, unchanged. The left central venous line tip is at the junction of brachiocephalic vein and SVC. There is interval increase in bilateral pleural effusions, moderate. There is no pneumothorax. The upper lungs are essentially clear. Bibasilar atelectasis has developed in the interim. EKG: [6-10]: Sinus bradycardia. P-R interval prolongation. Left axis deviation. Modest lateral T wave changes which are non-specific. No previous tracing available for comparison. [6-13]: Sinus bradycardia with A-V conduction delay. Left anterior fascicular block. Modest low amplitude lateral lead T wave changes are non-specific. Since the previous tracing of [2157-6-10] probably no significant change. Pathology: Surgical specimen [6-14]: 1. Frozen section uterine tumor: Carcinosarcoma, see synoptic report. 2. Uterus: Carcinosarcoma. 3. Vaginal margin/cervix: Carcinosarcoma, see note. Note: The location of the tumor (vaginal or parametrial) is unclear due to tissue distortion. Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 7108] reviewed and concurs. 4. Left tube and ovary: No malignancy identified. 5. Omentum biopsy: No malignancy identified. Endometrium: Hysterectomy, with or without Other Organs or Tissues Synopsis Staging according to American Joint Committee on Cancer Staging Manual -- 7th Edition, [2155] MACROSCOPIC Specimen Type: Hysterectomy, left salpingo-oophorectomy, omentectomy, vaginal margin/cervix. Tumor Size: Greatest dimension: 5 cm (aggregate measurement from "uterine tumor" specimen). MICROSCOPIC Histologic Type: Carcinosarcoma, see comment. Histologic Grade: See comment. Washings/cytology: Not applicable. EXTENT OF INVASION Primary Tumor: pT3b (IIIA): Vaginal involvement (direct extension or metastasis) or parametrial involvement. Myometrial Invasion: Invasion present: 25%. Depth of invasion: 2 mm. Myometrial thickness: 8 mm. Cervix: Negative. Ovaries Right: Not applicable. Left: Negative. Fallopian tube Right: Not applicable. Left: Negative. Serosa: Negative. Omentum: Negative. Regional Lymph Nodes: pNX: Cannot be assessed. Distant metastasis: pMX: Cannot be assessed. Lymph-Vascular invasion: Absent. Additional findings: Adenomyosis. Comments: Histologic sections from the specimen labeled "uterine tumor" show a carcinosarcoma. The carcinomatous portion shows an intermediate grade (grade 2) adenocarcinoma with an endometrioid histology. The sarcomatous component is low grade with no heterologous elements seen. The vast majority of tumor burden seen in this case is in the "uterine tumor" specimen. There is a 2 mm focus of tumor present in the myometrium. Tumor is also seen at the vaginal margin/cervix. Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 7108] has reviewed slides B, F, and U. Brief Hospital Course: Mrs [Known lastname ] was admitted to the GYN/ONC service for evaluation. She was found to not be in acute renal failure. The catheter was continued as she still was having urinary retention. She was seen by Dr. [Last Name (STitle) 2028] who agreed that surgical evaluation was necessary for evaluation of the tumor, however, not necessary in an urgent manner given that the patient was otherwise so stable. She was able to be added on to the OR for [6-14]. In the meantime, the pyridium was stopped. The urine culture from the outside hospital was negative so the Bactrim was stopped. An initial urine culture at [Hospital1 ] was also negative. The patient was started on oxybutinin 5mg [Hospital1 ] for bladder spasms which were intermittent. The tamusolin was discontinued. Her catheter had to be replaced on [6-11]. She was seen by medicine pre-operatively and they recommended changing atenolol to metoprolol 12.5mg [Hospital1 ]. They felt that although the patient had a history of CABG she did not need to have an echo prior to surgery given her excellent functional status at baseline. The patient went to the OR on [6-14]. The full operative note is available in the medical record, and was notable for finding that the pelvic mass was in fact an enlarged tumor-filled uterus. The patient had a cystoscopy intraop, demonstrating normal bladder mucosa and bilateral ureteral jets seen; proctoscopy to 25 cm also revealed normal findings. She received 3 units PRBCs intraop. An OGT had been placed. The patient was taken intubated to the ICU post-op. She was initially on pressors and these were able to be weaned. Her heparin was held given high risk of postoperative bleeding. She had some abnormal sputum and was started on vancomycin and cefipime. The culture returned with 3+ GPCs, and this was switched to vancomycin, zosyn, and levofloxacin. Her Hct post-op drifted down to 23 and she was transfused 2 units PRBCs, with return to 30. A PICC was placed by IR for access. She was started on TPN. Prior to her call-out to the floor, the vanc and zosyn were stopped and the levofloxacin was continued. On the floor, her diet was very slowly advanced. She was taking regular by POD #7. Her Hct was carefully watched, and her heparin was eventually restarted by [6-19]. She was continued on IV dilaudid and changed to PO meds with good relief. She did have a cough and was started on robitussin and tessalon pearls. A CXR was overall stable with no evidence of consolidation. Her BPs began to creep up and she was restarted on the metoprolol and norvasc on [6-20]. Norvasc was increased to 10mg daily on the day of discharge. The foley was removed on [6-21]. The patient passed her trial of void but was noted to be incontinent. She was able to notice when her bladder was full but felt that she was not mobile enough to get to the bathroom when having an urge. A bedside commode was placed. The incontinence improved by discharge but was still present at night. A UA was negative and a culture was pending on discharge. The TPN was stopped on [6-22]. The PICC line was pulled prior to discharge. She was discharged to rehab on POD#9. Medications on Admission: - Atenolol - Norvasc - Zocor - Flomax - Bactrim Discharge Medications: 1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 2 days. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection [Hospital1 ] (2 times a day). 5. zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. benzonatate 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for cough. 7. guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours) as needed for cough. 8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for BP <100/60 or HR <60. 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 15644] Long Term Care - [Location (un) 47] Discharge Diagnosis: Pelvic mass, uterine cancer Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Discharge Instructions: Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * No strenuous activity, nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. For your bladder issues, please try to go to the bathroom frquently and regularly. This makes sure your bladder stays empty and helps you become continent of urine again. Followup Instructions: You will need to follow-up with Dr. [Last Name (STitle) 2028] in the next several weeks. Please call his office for an appointment, [Telephone/Fax (1) 5777] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 6753] Completed by:[2157-6-23] ICD9 Codes: 2762, 4589, 2851, 2724, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8243 }	Medical Text: Admission Date: [2173-7-10] Discharge Date: [2173-7-23] Date of Birth: [2107-7-24] Sex: M Service: MEDICINE Allergies: IV Dye, Iodine Containing Contrast Media Attending:[Doctor First Name 3298] Chief Complaint: back pain x 3 days Major Surgical or Invasive Procedure: 1. Renal angiography. 2. Intravascular ultrasound. 3. Left renal artery stenting 4. Temporary HD cath placement 5. Double-lumen tunnelled cath placement History of Present Illness: Mr. [Known lastname 25067] is a 65 y/o gentleman with a known large thoracoabdominal aortic dissection discovered after presenting to the [Hospital6 1708] with an episode of back pain in 12/[2172]. Of note, that hospitalization was complicated by acute renal failure, but he was treated conservatively with blood pressure controlling agents and hydration, and his renal function returned to [Location 213]. He has had intermittent back pain on one side or the other since then, but his pain has never been this severe. The pain started getting worse 3-4 days ago. It seems to be located on both sides of his abdomen and both flanks. It is not alleviated or exacerbated by anything. He also reports decreased appetite over the past [4-6] days, and decreased fluid intake as well. The abdominal pain is not worsened by eating or drinking. He had some nausea and a large episode of nonbilious emesis yesterday. He also says that he has not made much urine over the past 4-5 days. He does report some R sided sciatica but denies any claudication or symptoms of rest pain. He also denies F/C, N/V, CP or SOB. Presentation also notable for patient having noted less urine output. ROS: Positive per HPI, otherwise unremarkable. Past Medical History: 1. Aortic Dissection 2. HTN 3. Hyperlipidemia 4. Anxiety 5. OA 6. Obesity Social History: Etoh: drinks occasionally; last had about [1-3] pint liquor 3d prior to admission. Tob: smokes 1 ppd intermittently. Drugs: No RDA Family History: No aneurysms or end stage renal disease. Physical Exam: ADMISSION EXAM: Vital Signs: Temp: 96.6 RR: 18 Pulse: 98 BP: 126/91 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, Guarding or rebound, No hepatosplenomegally, No hernia, No AAA, abnormal: Slight hepatomegaly. b/l flank pain. no palpable masses or tenderness over the aorta. Rectal: Not Examined. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. . DISCHARGE EXAM: Vitals: 98.1, 97.6, 120-169/88-101, 55-61, 18-20, 98-99% on RA. I-1.1L, O-3.9L, o/n 750cc General: AOX3. no acute distress, lying comfortable in bed. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: ADMISSION LABS: CBC with DIFF: [2173-7-10] 08:30PM BLOOD WBC-8.2 RBC-4.70 Hgb-14.0 Hct-39.8* MCV-85 MCH-29.7 MCHC-35.1* RDW-13.8 Plt Ct-182 Neuts-69.7 Lymphs-20.2 Monos-4.3 Eos-4.5* Baso-1.2 . COAG: [2173-7-10] 08:30PM BLOOD PT-12.0 PTT-25.6 INR(PT)-1.0 . CHEM: [2173-7-10] 08:30PM BLOOD Glucose-91 UreaN-36* Creat-5.3* Na-142 K-3.7 Cl-99 HCO3-26 AnGap-21* Calcium-9.3 Phos-4.6* Mg-2.3 . LIVER FUNCTION ENZYMES: [2173-7-11] 03:02AM BLOOD ALT-23 AST-56* AlkPhos-71 Amylase-85 TotBili-0.3 [2173-7-11] 03:02AM BLOOD Lipase-41 . OTHER: [2173-7-10] 08:30PM BLOOD cTropnT-<0.01 [2173-7-13] 11:12AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2173-7-13] 11:12AM BLOOD HCV Ab-NEGATIVE . DISCHARGE LABS: CBC: [2173-7-22] 07:48AM BLOOD WBC-4.9 RBC-3.60* Hgb-10.3* Hct-29.8* MCV-83 MCH-28.7 MCHC-34.6 RDW-13.9 Plt Ct-358 . CHEM: [2173-7-22] 07:48AM BLOOD Glucose-86 UreaN-45* Creat-8.8# Na-138 K-4.9 Cl-98 HCO3-30 AnGap-15 Calcium-8.9 Phos-4.9 Mg-2.0 . IMAGING: EKG ([2173-7-10]): Sinus rhythm. The tracing is marred by baseline artifact. Right bundle-branch block. Left anterior fascicular block. Consider prior inferolateral myocardial infarction. No previous tracing available for comparison. Clinical correlation is suggested. . DUPLEX US ([2173-7-10]): IMPRESSION: 1. Intact bilateral renal perfusion. 2. Bilateral simple renal cysts. . Renal US ([2173-7-10]) RENAL ULTRASOUND: The right kidney measures 12.6 cm, and the left kidney measures 10.6 cm. There is a 3.4 x 3.3 x 3.3 cm simple cyst in the right interpole, and a 5.1 x 4.6 x 4.0 cm simple cyst in the left upper pole. No renal stones, [Name (NI) 79068] evidence masse, or hydronephrosis. Color flow images show perfusion to the main, lobar, and interlobar arteries and veins. Doppler waveforms are normal in the bilateral renal arteries, with resistive indices of 0.6-0.7 on the right and 0.65 on the left. There is no free fluid. IMPRESSION: 1. Intact bilateral renal perfusion. 2. Bilateral simple renal cysts. . ECHO ([2173-7-11]) IMPRESSION: Aneurysm of the aortic arch and descending thoracic aorta with dissection involving the distal arch and extending into the descending thoracic aorta. . Portable CXR ([2173-7-12]) IMPRESSION: 1. Dilated, tortuous arch and descending thoracic aorta, which may relate to known aortic dissection. This can be evaluated with a dedicated chest CTA if this has not been performed previously (reference images on our system do not include the chest). 2. Left sided central venous catheter in appropriate position. 3. Bilateral low lung volumes and left lower lobe platelike atelectasis. Right central venous line terminates in the proximal SVC. Brief Hospital Course: HISTORY: This is a 65M with h/o of known type B aortic dissection from the brachiocephalic to the internal iliac, HTN, who ran out of bp medication and found to be hypertensive. Also had a 90% left renal artery stenosis and obtained a stent placement. He developed ARF and was started on HD. Double lumen tunnelled cath was placed prior to d/c for out-patient HD (M/W/F). He was d/ced home in stable condition. . ACTIVE PROBLEMS: #ACUTE RENAL FAILURE: Most likely due to ischemic ATN due to severe Left renal artery stenosis. However, it is unclear why pt would have ARF with intact right renal perfusion. Pt is s/p left renal artery stent placement. He will continue plavix and ASA to prevent stent thrombosis. Duration of therapy will be determined by vascular as out-patient. Pt was dialyzed x5 as an in-patient. He had a RIJ tunnelled cath placed on [2173-7-22]. He will have outpatient HD M/W/F. He will followup with PCP and renal for return of renal function. . #AORTIC DISSECTION: stable on imaging. He will need to have strict BP control with SBP < 140. . INACTIVE PROBLEMS: #HYPERTENSION: SBP goal of 140. Pt had been noncompliant with antihypertensive for several months prior to admission, but admission BP was only mildly elevated at 126/91. BP meds adjusted to labetalol 400mg TID, amlodipine 10mg daily and clonidine 0.3mg TID prior to d/c. . #DELIRIUM: Currently alert and oriented, HD-stable. Delirium in TICU, etiology unknown, ?ETOH withdrawal. Was given 2.5mg Zprexa, haldol 5mg x2, 4-pt restraint, 10IV haldol. No resolution with haldol, but lorazepam 5mg was helpful. Pt was briefly placed on CIWA protocol with minimal valium requirements. TRANSFER OF CARE: 1. Continue to follow Type B aortic dissection on imaging 2. Continue to monitor return of renal function 3. Close followup of management hypertension. Consider outpatient adjustment of anti-hypertensive regimen. 4. Pt is NOT immunized for Hepatitis B (HbsAb negative), please followup with PCP for immunization 5. Bilateral simple renal cyst noted on US. Medications on Admission: 1. Clonidine patch 0.1 top qweek 2. Norvasc 10mg po daily 3. Labetalol 400mg po TID--> had not taken in 2mos 4. Simvastatin 10mg po daily 5. ASA 81 mg po daily 6. MVI po daily Discharge Medications: 1. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. multivitamin Capsule Sig: One (1) Capsule PO once a day. 7. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:270 Capsule(s) Refills:2 8. clonidine 0.3 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 9. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Daignosis 1. Acute renal failure 2. Aortic dissection 3. Hypertension . Secondary Diagnosis: 1. Dyslipidemia 2. Anxiety 3. Osteoarthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 25067], It was a pleasure taking care of you when you were admitted for acute renal failure due to a 90% blockage in your left renal artery. The vascular surgeon placed a stent in this artery. You also have a known chronic aortic dissection which is stable. You were found to have acute renal failure. You were dialyzed four times. The kidney doctors [Name5 (PTitle) ] [Name5 (PTitle) ] [Name5 (PTitle) ] need dialysis as an out-patient. . It is very important to maintain appropriate blood pressure control at home. You may do normal activity but should not lift, push or pull more than 60-70lbs given your aortic dissection. Please keep follow up appointment with the vascular surgeon for your renal stent and make an appointment with your cardiologist to f/u on your chronic dissection. . The antihypertensive regimen you will go home with are: 1. labetolol 400mg: you will take this three times a day. 2. amlodipine 10mg: you will take this once a day 3. clonidine 0.3mg: you will take this medication three times a day. . Other new medications you will go home with are: 1. Plavix (clopidogrel) 75mg: you will take it once a day until you see the vascular surgeons. This medication will prevent clotting at your stent. 2. Calcium Acetate [2163] mg: you will take this three times a day with meals 3. Colace 100mg: you will take this medication twice a day to help soften your stool. Stop the medication if your stool becomes too loose. . Medications that you will continue with are: 1. Simvastatin 10mg: you will take one pill daily for lowering of your cholesterol 2. Aspirin 81mg: you will take one pill daily. 3. Thiamine and folate containing Multivitamin: take one MVI daily. Followup Instructions: Scheduled Appointments: Provider DIALYSIS,SCHEDULE HEMODIALYSIS UNIT Date/Time:[2173-7-23] 7:30 Location: [Hospital1 641] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 19604] Phone: [Telephone/Fax (1) 3530] When: Thursday [7-29] at 12PM Department: VASCULAR SURGERY When: WEDNESDAY [2173-8-25] at 10:30 AM With: VASCULAR LMOB (NHB) [Telephone/Fax (1) 1237] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: VASCULAR SURGERY When: WEDNESDAY [2173-8-25] at 11:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD [Telephone/Fax (1) 2625] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage ICD9 Codes: 5845, 2724, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8244 }	Medical Text: Admission Date: [2200-5-2] Discharge Date: Dictation date [2200-5-10] Date of Birth: [2158-11-18] Sex: F Service: [Hospital 14843] Medical Service CHIEF COMPLAINT: Status post fall, near syncope. HISTORY OF PRESENT ILLNESS: Ms [Known lastname 19730] is a 41 year old woman well as diabetes mellitus Type 1 with a recent admission between [4-22] and [2200-4-30] for atrial flutter as well as multiple medical problems who presented on [2200-5-2] with 1-2 of watery diarrhea, two to three bowel movements per day and having attempted to make the journey to her bathroom, was unable to hold her bowels and produced diarrhea on the floor which she later slipped on injuring her and her parents called the Emergency Medical Services. The initial hip films in the Emergency Room being negative for fracture, the patient was admitted for pain control. The patient's initial glucose in the Emergency Room was 338, no insulin was given at that time and the patient missed her evening dose of lantus the day prior to admission. Her fingerstick at 5:30 AM the day of admission was greater than 600 and she was given regular insulin 10 units intravenously as well as NPH 5 units subcutaneously in a 500 cc normal saline bolus. The patient denied fevers, chills, abdominal pain, bloody stools, nausea or vomiting. The patient had had hemodialysis the day of admission and 7 kg were taken off with post hemodialysis dry weight of 67 kg with an estimated post hemodialysis weight of 67 kg and a dry weight of 60 kg. PAST MEDICAL HISTORY: Diabetes mellitus Type 1 since the age of 23 with a history of diabetic ketoacidosis, end stage renal disease on hemodialysis for one year, anxiety, depression, hypertension, upper gastrointestinal bleed with a recent Medicine Intensive Care Unit admission [2200-4-14] which demonstrated gastritis on an esophagogastroduodenoscopy, hyperprolactinemia, foot ulcer, history of Barrett's esophagus and atrial flutter. ALLERGIES TO MEDICATIONS: Erythromycin. ACE-I-worsens hyperkalemia MEDICATIONS ON ADMISSION: Florinef 0.2 mg p.o. q. day, Atlantis 10 units subcutaneously q.h.s., Humalog sliding scale, Neurontin 100 mg p.o. t.i.d., PhosLo 4 mg p.o. t.i.d., Nephrocaps one p.o. q. day, Nortriptyline 75 mg p.o. q.h.s., Protonix 40 mg p.o. b.i.d., Lopressor 100 mg p.o. b.i.d., Ativan 1 to 2 mg p.o. q. 6-8 hours prn Reglan 20 mg p.o. q. day. SOCIAL HISTORY: Lives with her parents, does not use tobacco, occasionally uses alcohol. PHYSICAL EXAMINATION: Physical examination at the time of admission revealed temperature 98.8, blood pressure 215/86 at the time of admission, decreasing to 110/52, pulse 82, respirations 15, 94% on room air. In general, alert in no apparent distress. Dry mucous membranes. Pupils are equal, round, and reactive to light. Extraocular movements intact. No lymphadenopathy, crackles were noted at the right base. There was a regular rate and rhythm with a normal S1 and S2 as well as a II/VI systolic murmur. The abdomen is soft, nontender with no hepatosplenomegaly, no guarding and no rebound. Extremities showed no edema. There was tenderness over the right lateral hip and buttock. Pain with internal rotation of right hip and pressure against lateral aspect of pelvis. The back showed no spinous tenderness. The neurological examination showed the patient alert and oriented times three. Cranial nerves II through XII were intact. It was difficult to assess the lower extremity strength due to the patient's pain. LABORATORY DATA: Radiologic data - A bilateral film of the pelvis and hips was performed on [2200-5-2] with no fracture seen, however, it was noted that due to the patient's demineralization an insufficiency fracture might be difficult to detect and further imaging was suggested. An magnetic resonance imaging of the hip on [2200-5-4] was read as follows: Impression - "Insufficiency fractures of the sacral ala, injection of the ilium and right superior pubic ramus." Chest x-ray was performed on [2200-5-3] and demonstrated the following impression: "Probable pneumonia in the left lower lobe. Follow up views suggested." A repeat chest x-ray performed on [2200-5-5] was read as follows: "Mild improvement in the left lower lobe infiltrate, otherwise no significant change from prior." Rib films were performed on [2200-5-7] with the following impression: "No fractures or bone lesions in the available views of the ribs, Perma-Cath in the right atrium and bibasilar atelectasis increased since the prior study of [5-5]. No pneumothorax." Laboratory data - Complete blood count at the time of admission revealed a white count of 12.2, hematocrit of 37.5 with 83.5% neutrophils, 9.5% lymphocytes, 5.1% monocytes, 1.1% eosinophils, 0.8% basophils. Platelet count at the time of admission was 337. PT was 13.5 with an INR of 1.3, PTT 24.1. Chem-7 at the time of admission was as follows: Sodium 139, potassium 5.2, chloride 100, bicarbonate 22, BUN 53, creatinine 5.2, glucose 338, creatinine kinase was repeatedly cycled during this admission, on [5-2], [5-5], [5-6] and all values were noted to be below 15. ALT on [5-6] was 34 and AST was 30, alkaline phosphatase was 235, total bilirubin was 0.2. A troponin on [5-6] was 1.0 with a repeat that evening of 0.6. Calcium at the time of admission was 8.5, phosphate 7.3, magnesium 1.5. Acetones were absent on [5-4] at 5 AM, noted to be large at 12:45 AM on [5-5] and negative on [5-5] at 6 AM as well as negative on [5-6] at 9 PM. They had been negative on [5-2], 2 AM as well. Cortisol levels were drawn on [5-6] at approximately 9 AM and were after Cosyntropin stimulation, 30 minutes post stimulation the value was 27, 60 minutes post stimulation the value was 35 for Cortisol with a baseline of 14. Calcium on [5-6] was 1.07 and then on repeat 1.12. Blood cultures from [5-6] are pending at the time of this discharge. Blood cultures from [5-3] demonstrated no growth. The mycolytic blood culture from [5-7] is likewise pending. Perineal fluid from [2200-5-6] demonstrated no PMNs, no microorganisms, we saw no growth out of the fluid. Electrocardiogram from [5-2] was read as follows: Sinus rhythm, left ventricular hypertrophy, nondiagnostic ST-T abnormalities, not changed from prior. Electrocardiogram from [5-2], at 2255 was read as atrial fibrillation with rapid ventricular response, left axis deviation and possible left anterior vesicular block. QRS changes in V3 and V4 probably due to left ventricular hypertrophy with consistent anterior infarction, left ventricular hypertrophy nondiagnostic ST-T abnormalities. On [5-4], at 12:26 the electrocardiogram was read as follows, sinus rhythm, long QTC interval with possible left ventricular hypertrophy, tall T waves and at 22:47 it was noted that the P wave after a change was somewhat of pure antral consistent with ectopic atrial tachycardia, possibly high junctional tachycardia. These changes were felt to be nonspecific. Electrocardiogram on [5-6] was read as sinus rhythm, minor nonspecific ST-T segment sagging, since prior electrocardiogram ST-T abnormalities are nearly resolved. An electrocardiogram was performed on [2200-5-5] with the following results, ejection fraction of 55 to 60%. Conclusion was "Left atrium normal, left ventricular wall thickness normal, left ventricular cavity size normal, overall left ventricular systolic function normal, mild septal hypokinesis, right ventricular chamber size and free wall normal aortic valve leaflets mildly thickened, mitral valve leaflets are structurally normal and trivial mitral regurgitation, estimated pulmonary artery systolic pressure is normal, no pericardial effusion. There is a 2 by 1 cm mass in the right atrium, at the site of the Porta-Cath which may present thrombus or vegetation." HOSPITAL COURSE: The patient was admitted status post fall complaining of right hip pain as stated above. Endocrine: The patient had a history of diabetes mellitus Type 1 since the age of 23 and she has a history of diabetic ketoacidosis as well. The patient admits to a prior dose of Lantus prior to admission and fingersticks in the AM at the time of admission were noted to be quite elevated and the patient did administer intravenous insulin. The patient's hyperglycemia rapidly resolved on the day of admission. She was maintained on frequent fingersticks blood glucoses as well as a Humalog sliding scale as well as Lantis 10 units subcutaneously q.h.s. On [2200-5-4] at 11:30 PM, the medical team was called to see the patient for hypotension and initial tachycardia and the patient's fingerstick blood glucose was noted to be critically high. The chem-7 was sent and acetones were large. The patient was begun on an insulin drip over night which was discontinued by the morning hours with a repeat chem-7 demonstrating no acetone, noting that increased anion gap also resolved, although the patient at baseline presumably secondary to her renal failure has had widened anion gap. [Last Name (un) ] was consulted on [2200-5-5] and raised concern that the patient might indeed be septic contributing to the etiology of diabetic ketoacidosis versus a cardiac etiology for this problem. The patient was admitted to the Intensive Care Unit on [2200-5-5] for further management of diabetic ketoacidosis and hypotension in the setting of end stage renal disease on hemodialysis. An insulin drip was restarted until the anion gap was noted to be closing and the patient was ultimately transferred back to the floor on [2200-5-7] with resolved diabetic ketoacidosis. There was initially some concern in the Intensive Care Unit for the possibility of hypoadrenalism but Cosyntropin stimulation test did not support this. The patient had been transiently taken off of while insulin drip was applied. This was restarted at the time of transfer out of the Medicine Intensive Care Unit at 10 units subcutaneously q.h.s. and the sliding scale for Humalog was resumed. The Lentis was increased to 12 units subcutaneously q.h.s. on [2200-5-8] for better control of consistently elevated fingersticks. On [2200-5-9] the patient's sliding scale was changed in accordance with [Last Name (un) ] recommendations, again for better diabetic control. Cardiovascular: The patient had a history of atrial flutter as well as supraventricular tachycardia which had been treated with Adenosine in the past. The patient was noted on [2200-5-3], in the evening to have a tachycardia which was felt possibly to represent atrioventricular nodal reentrant tachycardia and was given Adenosine 6 mg and 12 mg and ultimately the patient returned to [Location 213] sinus rhythm. She was continued on beta blocker, although these were transiently stopped due to hypotension. The patient was maintained on Telemetry and was transferred to the Telemetry Floor after this episode of tachycardia. On the morning of [2200-5-5], noting the events of the prior night, that the patient had been diabetic ketoacidosis with persistent hypotension and the hypotension had not responded adequately and with a sustained response of foot ulcer, the patient was transferred to the Medical Intensive Care Unit. She was noted to have nonspecific ST-T changes as well as shortened PR consistent with ectopic atrial focus at the time of hypotension prior to admission to the Intensive Care Unit. The patient was noted to be cyanotic and hypotensive at 11:30 PM on [2200-5-6] in the Intensive Care Unit and received chest compressions for what was felt possibly to be pulseless electrical activity for 30 seconds. The patient was noted to have had Q wave inversions and QRS widening in the context of possibly becoming more hypoxic after receiving analgesia in the form of narcotic analgesics. Transesophageal echocardiogram was performed as described above and demonstrated clot adherent to the patient's hemodialysis catheter within the right atrium. Cardiology Service was consulted for management of tachycardia. The Cardiology Service recommended beginning the patient on Amiodarone 400 mg p.o. q. day for one month and then switched over to 200 mg p.o. q. day. Additionally note that the patient had had a nuclear stress in [2200-1-31] which showed a mild reversible septal defect and ejection fraction of 61% as well as an anterior fixed defect which had not been demonstrated on the first of these, suggesting interval myocardial infarction. The patient had no further arrhythmias for the course of her admission and maintained excellent blood pressures well above 100 whereas the patient had been, at the time of admission, with blood pressures in the 80 to 90 range. Note as well, the patient was transiently started on Dopamine for blood pressure support although this was rapidly discontinued in the Intensive Care Unit. Orthopedics: The patient was noted to have insufficiency fractures as noted in the radiology report above. Orthopedics was consulted and suggested no acute intervention surgically, instead suggesting physical therapy and rehabilitation as tolerated. The patient was seen by physical therapy which was continued for the course of this admission.Pain control was an issue. Due to transient apnea on dilaudid drip in ICU we were cautious around narcotic use. She was givien tylenol and ultram initially with inadequate results. Codeine was added and titrated up to help get better pain control. Renal: The patient continues on hemodialysis and received hemodialysis multiple times during the course of this admission. The patient's hemodialysis catheter was noted to have clot in the right atrium although this was not felt to be a significant posing risk to her at the current time, especially since the patient would be placed on anticoagulation. The patient also had a peritoneal dialysis catheter in place which was not used during the course of this admission. She continues to be followed by the Renal Service. Infectious diseases: The patient was noted to be febrile on [2200-5-4], spiking a temperature to 102.7. Blood cultures failed to reveal organism. It was suspected that the patient might have the pneumonia and the patient was covered with Levofloxacin 250 mg p.o. q. 4-8 hours which was maintained for the remainder of the patient's admission. Although suspicion initially suggested the possibility of infected hemodialysis or peritoneal dialysis catheter, blood cultures failed to grow organisms and these catheters were left in place. Infectious Disease Service was consulted in the Intensive Care Unit and suggested Vancomycin as well as Levofloxacin with suggestion to discontinue the Vancomycin if cultures were negative as well as suggestion to draw fungal cultures. As noted above, these cultures had not grown organisms at the time of this discharge summary. Pain control: The patient was initially maintained on Morphine for analgesia. Narcotic analgesia was continued in the Intensive Care Unit, however, the patient was noted to have an apneic episode felt to possibly be related to oversedation with narcotic analgesia and the patient upon transfer to the floor was soon thereafter started on Codeine as well as Ultram for pain control on which she is continued at the current moment.[Name (NI) 19736] Pt briefly had chest compressions in ICU for brief episode of unresponsiveness and now has chest wall pain over sternam that is reproduced with palpation. x-ray neg for rib fractures however ?sternal fracture or contusion. Continue narcotics as needed for pain. Atrila clot at timp of permacath. Discussed with renal team and IR. The plan is to anticoagualte for 2 weeks with heparin and coumadin when INR therapeutic, repeat the TTE in 2 weeks, if clot has decreased in size her line may be removed at that time and/or anticoagulation d/c'd/ Code status: Full. DISCHARGE PLAN: The patient will be discharged to a rehabilitation facility. She will be maintained on Coumadin 3 mg p.o. q. day with her INR being checked q. day with a goal INR of approximately 2 for a small clot on the patient's hemodialysis line. The patient will follow up for PTT one week status post discharge and the patient should be discharged for an outpatient transesophageal echocardiogram approximately two weeks from the time of discharge to reassess the clot in the patient's right atrium. She will be maintained on Lantus insulin at h.s. as well as Humalog sliding scale for control of her diabetes mellitus with fingersticks q.i.d. as well as diabetic diet. She will participate in physical therapy at rehabilitation. The patient will be continued on Amiodarone 400 mg p.o. q. day for one month at which time Amiodarone should be altered to 200 mg p.o. q. day. She needs f/u with her cardilogist re: possible cardiac cath as she had some st segment changes when in her atrial tachycardia. DISCHARGE DIAGNOSIS: 1. Supraventricular tachycardia 2. Status post diabetic ketoacidosis 3. New insufficiency fractures of the pelvis as described above. 4, Brittle Type 1 DM 5. Atrial clot on tip of HD catheter 6. ESRD on HD Please see past medical history for additional diagnoses. MEDICATIONS ON DISCHARGE: Coumadin 3 mg p.o. q. day Nortriptyline 75 mg p.o. q.h.s. Lorazepam 1 to 2 mg p.o. q. 8 hours prn Nephrocaps 1 p.o. q. day Gabapentin 100 mg p.o. t.i.d. Calcium acetate 4 tablets p.o. t.i.d. with meals Fludrocortisone acetate .02 mg p.o. q. day Metoclopramide 5 mg p.o. q.i.d. a.c. h.s. Colace 100 mg p.o. b.i.d. Humalog insulin sliding scale (please see current sheet) Senna 2 p.o. q.h.s. Amiodarone 400 mg p.o. q. day times one month Pantoprazole 40 mg p.o. b.i.d. Tramadol 50 to 100 mg p.o. b.i.d. prn Codeine 15 mg p.o. q. 4 hours prn pain, hold sedation Lantus Insulin 12 units subcutaneously q. h.s. Levofloxacin 250 mg p.o. q. 48 hours time six additional days CONDITION ON DISCHARGE: Stable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3022], M.D. [MD Number(1) 3023] Dictated By:[Name8 (MD) 2058] MEDQUIST36 D: [2200-5-9] 19:02 T: [2200-5-9] 20:28 JOB#: [Job Number 19737] ICD9 Codes: 4271
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8245 }	Medical Text: Admission Date: [2114-8-26] Discharge Date: [2114-8-30] Date of Birth: [2043-2-28] Sex: M Service: MEDICINE Allergies: Demerol / Actos Attending:[Last Name (NamePattern1) 1167] Chief Complaint: SOB x 1 day, Cough x 1 week Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a retired security officer with a cadiac history significant for chronic systolic CHF with an EF 10% with ICD, CAD significant for single vessel LCx disease, Vfib arrest in [2102] with ICD, PAF, HTN, Dyslipidemia, DM2 (last Hgb AIC 10.3) and COPD (not on home O2) who presented one day of dyspnea. Of note the patient has been hospitalized four times this year for CHF exacerbation. His last hospitalization was in [Month (only) ], and he was in rehab for six weeks thereafter. Per the patient, he typically begins to feel short of breath for a days when he has a CHF exacerbation. Unlike prior exacerbations, he notes that he felt acutely short of breath while taking a shower prior to presentation to the [Hospital1 18] ED. This dyspnea has also been accompanied by a productive cough for the past week, without any antecedent illnesss, fever, chills, sick contacts, or recent travel. He also says that feels fluid overload, and similar to his previous CHF exacerbations. He reports no recent changes in his medication or dietary indegression. He also reports no recent palpitations, syncope, lightheadedness, dizziness, chest pain, PND, orthopnea, calf or buttock claudication or ICD discharges. He was able to lay supine the other day, but is unable to do so today. At home, he is able to walk three blocks in 30 minutes while resting frequently. He feels fatigued during these episodes, but not short of breath. He also reports no dyspnea at rest. His blood sugars at home have been in the 200's and his BP has been 150-170's by automated cuff. ROS: Negative for dysuria, BRBPR, melena, nausea, emesis, or diarrhea. . In the ED, initial vitals were 113-118 HR (up to 150), 107/63 97% 3-5L RR 25 Afebrile. He had Afib with RVR and was given 3 doses of dilt and IV digoxin for a low dilt level. Labs and a CXR were taken. A lactate was 7.1. Upon arrival to the CCU his vitals were: 98.5, 97, 128/76, 17, 91% 4L He was chest pain free and had a productive cough with clear sputum. Past Medical History: PAST MEDICAL HISTORY: 1) CHF- TTE 20-25%, dry weight 198 lbs. 2) CAD-Most recent cath in [2-22] showed single vessel LCx disease 3) Ventricular Fibrillation- s/p VF arrest [2102], AICD placed at that time 4) Paroxysmal atrial fibrillation- started on amiodarone [2-22], also on BB, anticoagulated with Coumadin 4) [Name (NI) 3672] pt uses inhalers, steroids during [1-22] admission, PFTs showing both mod. restrictive and marked obstructive component 5) DM Type 2- Lantus + Humalog ISS, Hgb A1C 10.3 in [2-/2112] at [Last Name (un) ] 6) Hypertension 7) Barrett's esophagus with high grade dysplasia. Post cryotherapy x 3, BARRx [2-23] 8) Hypercholesterolemia 9) s/p GI bleed- UGIB from a gastric ulcer [12/2102] 10) s/p Appendectomy [2063] 11) s/p Bone tumor excision from shoulder [2057] 12) ? portal vein thrombosis Pacemaker/ICD placed: [Company 1543] [Last Name (un) 24119] VR 7232Cx [12/2102] Social History: Pt is retired from the [Location (un) 86] police force and security service at [Location (un) 745] [Hospital 3678] hospital. He lives independently at [Doctor Last Name 406] Estates senior center, a retirement community. Closest family is his cousin [First Name5 (NamePattern1) ] [Name (NI) 23636]) who lives down the street from him. He was adopted, never married, and has no children. He smoked for 45 yrs, [11-18] ppd, quit 8 yrs ago. He denies any alcohol intake or other drug use. Family History: Adopted. He does not know his family history. Physical Exam: Vitals: 98.5, 97, 128/76, 17, 91% 4L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 15 cm. CARDIAC: No carotid bruits. Normal carotid upstroke and volume. Regular Normal S1 and S2 with paradoxical split. No S3. No S4 while in Sinus rythm. PMI laterally displaced, dime size, palpable when rotated on Left side. No thrills over LSB. No R ventricular heave. LUNGS: Scar below left clavicle. Resp were unlabored, no accessory muscle use. Decreased breath sounds at bases, R > L with L basilar crackles. Diffuse wheezes posteriorly, with bronchial breath sounds anteriorly. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: No cyanosis. Extremities warm, hands and feet cold. 2+ ankle edema. 1+ Thigh edema. SKIN: Stasis dermatitis over the tibial area. PULSES: PT, DP dopplerable. Pertinent Results: Admission Labs: [2114-8-26] 05:25PM BLOOD WBC-7.8 RBC-4.28* Hgb-11.5* Hct-36.6* MCV-86# MCH-26.9# MCHC-31.4 RDW-18.7 Plt Ct-293 [2114-8-26] 05:25PM BLOOD Neuts-79.9* Lymphs-16.0* Monos-3.6 Eos-0.2 Baso-0.3 [2114-8-26] 05:25PM BLOOD WBC-7.8 RBC-4.28* Hgb-11.5* Hct-36.6* MCV-86# MCH-26.9# MCHC-31.4 RDW-18.7 Plt Ct-293 [2114-8-26] 05:25PM BLOOD WBC-7.8 RBC-4.28* Hgb-11.5* Hct-36.6* MCV-86# MCH-26.9# MCHC-31.4 RDW-18.7 Plt Ct-293 [2114-8-26] 05:25PM BLOOD Glucose-323* UreaN-26* Creat-0.9 Na-133 K-4.7 Cl-93* HCO3-22 AnGap-23* [2114-8-26] 05:25PM BLOOD ALT-52* AST-44* AlkPhos-135* TotBili-1.6* [2114-8-26] 05:25PM BLOOD proBNP-[Numeric Identifier 25164]* [2114-8-27] 03:46AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.7 Cholest-144 [2114-8-27] 03:46AM BLOOD %HbA1c-8.8* eAG-206* [2114-8-27] 03:46AM BLOOD Triglyc-77 HDL-20 CHOL/HD-7.2 LDLcalc-109 LDLmeas-107 [2114-8-27] 03:46AM BLOOD TSH-4.2 [2114-8-26] 05:25PM BLOOD Digoxin-0.2* [2114-8-26] 05:36PM BLOOD Lactate-7.2* K-4.7 Admission Studies: ECG: Sinus rhythm. Left atrial abnormality. Left bundle-branch block. Diminished limb lead voltage compared to the previous tracing of [2114-3-24] and, compared with tracing of [2114-8-26], sinus rhythm has appeared. CXR [8-26] IMPRESSION: Cardiomegaly, with central vascular congestion and likely bilateral small effusions, compatible with congestive failure. CXR [8-29] Comparison is made with prior study performed a day earlier. Small-to-moderate left and moderate right pleural effusions are unchanged. Bibasilar opacities, right greater than left, are likely atelectases. There is mild-to-moderate cardiomegaly. ICD leads are unchanged. There is no evident pneumothorax or new lung abnormalities. Brief Hospital Course: 71 y/o male with cadiac history significant for chronic systolic CHF with an EF 15% with ICD, CAD significant for single vessel LCx disease, Vfib arrest in [2102] with ICD, PAF, HTN, Dyslipidemia, DM2 (last Hgb AIC 10.3) and COPD (not on home O2) who presented one day of dyspnea, cough, and elevated lactate, in the absence of leukocytosis or fever. His working diagnosis this admission was CHF decompensation in the setting of a COPD exacerbation. # Systolic CHF Decompensation: Aggressively diuresed this admission with Lasix and transitioned to PO torsemide for discharge. Discharged home in hemodynamically stable and clinically euvolemic condition on Torsemide, Spironolactone, Lisinopril, and Metoprolol as detailed below. . # AF RVR: In the ED he had a rapid ventricular rate to the 150's. He was given IV dig for a low dig level. Upon arrival to the floor his ECG demonstrated SR in the 90's, but thereafter he continued to convert his rhythm between sinuse and Afib while remaining hemodynamically stable. He was maintained at a therapeutic INR on warfarin, his amiodarone was continued for the duration of the admission and he was sent home on Amiodarone, Digoxin, Metoprolol, and Warfarin as detailed below. . # COPD Exacerbation: Wheezing on presentation thought to be due to CHF decompensation as well as COPD flare. Symptomatically improved with ipratropium nebs and a 5 day prednisone/azithromycin course, which he started as an inpatient and completed as an outpatient. Albuterol nebs were held given his predisposition for AF RVR. . # Transaminitis / Congestive Hep: His exam was reassuring. LFTs continued to rise while he was in the hospital. Of note, patient had transaminitis during last admission for CHF exacerbation that was attributed to ischemia due to poor forward flow and resolved with treatment of CHF decompensation. His statin was held, and he will need to have his LFT's checked in clinic. . # CAD: Medical management of CAD was unchanged this admission. # Blood sugars were well controlled on an insulin sliding scale and the patient was discharged home on glargine and lispro as detailed below. Medications on Admission: Active Medication list as of [2114-8-30]: confirmed with [Company 4916] pharmacy, pt has not picked up any prescriptions since [2114-4-17] except for Warfarin picked up in [Month (only) ]. AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth once a day except for Sat and Sun DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth DAILY, tues, thurs, sat only INSULIN GLARGINE [LANTUS] 18u daily: not filled since [2112] INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - Dosage uncertain, not filled since [2112] LISINOPRIL [PRINIVIL] - 5 mg Tablet - one-half Tablet(s) by mouth daily METOPROLOL Tartrate - 12.5 mg PO daily. Torsemide 5 mg daily PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily POTASSIUM CHLORIDE - 20 mEq Tab Sust.Rel. Particle/Crystal - 2 Tab(s) by mouth daily SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth daily WARFARIN - 5 mg Tablet - 1 Tablet(s) daily Atrovent 2 puffs QID PRN Ibuprofen 200 [Hospital1 ] as needed ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). [Hospital1 ]:60 Tablet(s) Refills:2 2. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). [Hospital1 ]:30 Tablet Sustained Release 24 hr(s) Refills:2 3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:30 Tablet(s) Refills:2 4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:30 Tablet(s) Refills:2 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). [Hospital1 ]:30 Capsule, Delayed Release(E.C.)(s) Refills:2 6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [Hospital1 ]:30 Tablet, Delayed Release (E.C.)(s) Refills:2 7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [Hospital1 ]:30 Tablet(s) Refills:2 8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: Take 5 minutes apart for maximum of 2 doses, call Dr. [First Name (STitle) 437] if you have any chest pain. [First Name (STitle) ]:25 Tablet, Sublingual(s) Refills:0 9. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. [First Name (STitle) ]:30 Tablet(s) Refills:2 10. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 1 days. [First Name (STitle) ]:3 Tablet(s) Refills:0 11. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. [First Name (STitle) ]:1 Tablet(s) Refills:0 12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [First Name (STitle) ]:30 Tablet(s) Refills:2 13. insulin glargine 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous once a day. [First Name (STitle) ]:3 bottles Refills:2 14. insulin safety needles ([First Name (STitle) ]) 29 x [11-18] Needle Sig: One (1) syringe Miscellaneous once a day: please substitute another syringe if pt asks. 1cc. [Month/Day (2) ]:1 box Refills:2 15. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [Month/Day (2) ]:30 Tablet(s) Refills:2 16. Outpatient Lab Work Please check INR, Chem 7 and CBC on Monday [9-3] and call results to Dr. [First Name (STitle) ],[First Name3 (LF) 25160] L. [Telephone/Fax (1) 25161] and Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] at [Telephone/Fax (1) 62]. Can alternatively get blood drawn at his appt on Monday with Dr. [First Name (STitle) 437]. 17. lancets Misc Sig: One (1) lancet Miscellaneous three times a day: One touch freestyle light lancets. [First Name (STitle) ]:1 box Refills:2 18. Humalog 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous three times a day: before [Last Name (LF) 16429], [First Name3 (LF) ] sliding scale you were given by [Hospital ] clinic. [Hospital ]:1 bottle Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Acute on Chronic Systolic Congestive Heart Failure exacerbation Chronic Obstructive Pulmonary Disease exacerbation Secondary Diagnosis: Diabetes Mellitus 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 were admitted to [Hospital3 ] Hospital for a Congestive Heart Failure exacerbation and a emphysema exacerbation. You were diuresed with lasix, and given steroids, and antibiotics for your COPD. When you go home you will continue to take two water pills, Torsemide and spironolactone at home to keep the fluid off. You will need to weigh yourself every day in the morning before breakfast and write it down on the log sheet. Call Dr. [First Name (STitle) ] or [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 62] if you notice that your weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. It is very important that you take your medications daily and check a fingerstick each day before dinner. Write down the fingerstick numbers to take to Dr. [Last Name (STitle) ] . Please try to avoid salt in your diet, this could lead to fluid buildup and coming back to the hospital. The following medication changes have been made: 1. INCREASE Toresmide to 40 mg daily 2. INCREASE Glargine to 60 units daily 4. INCREASE Digoxin to 0.125mg daily 5. change Metoprolol Tartrate to Metoprolol Succinate and increase the dose to 50 mg daily 6. Stop taking Pantoprazole, start Omeprazole instead 7. START Spironolactone to help keep your fluid off 8. START Nitroglycerin to take if you have chest pain 9. START Vitamin B 12 to treat your anemia 10. Take Azithromycine and Prednisone for one more day to treat your emphysema. 11. Increase the Lisinopril to 5mg daily. 12. STOP taking Ibuprofen, take tylenol instead 13. continue Humalog using the sliding scale that [Hospital ] clinic gave you. Please check your fingersticks before each meal. Followup Instructions: Department: Cardiac Surgery When: [9-25] at 1pm With: Dr. [Last Name (STitle) 914] [Name (STitle) ] parking: [Hospital ] Medical Building Garage. Phone: [Telephone/Fax (1) 170] . Department: CARDIAC SERVICES When: MONDAY [2114-9-3] at 2:00 PM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: MONDAY [2114-9-3] at 3:00 PM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital1 18] PODIATRY [Location (un) ] When: TUESDAY [2114-9-11] at 3:20 PM [2114-9-21] 10:00a [Doctor Last Name ] [Doctor First Name ],EAST PROCEDURES [First Name8 (NamePattern2) ] [Hospital Ward Name ] BUILDING ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX), [Location (un) ] ENDOSCOPY SUITES [2114-9-21] 10:00a GI [Apartment Address(1) ] (ST-3) GI ROOMS ICD9 Codes: 4280, 4019, 2720, 4168, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8246 }	Medical Text: Admission Date: [2140-3-19] Discharge Date: [2140-3-21] Date of Birth: [2140-3-19] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: This male infant, birth weight of 2495 grams, 34 and [5-31] week gestation was born to a 22 year-old mother [Name (NI) ] P1 now 3. Estimated date of confinement was [2140-4-27] by an eight week ultrasound. These were spontaneous twins. Prenatal screens were significant for a blood type B positive, antibody negative, rubella immune, RPR nonreactive, hepatitis surface antigen negative, GBS unknown. Prior OB history was notable for a 23 week loss in [2136], spontaneous vaginal delivery at term in [2137]. This pregnancy had a cerclage placed at 21 weeks. The patient was admitted with contractions and the cerclage was removed and the mother was allowed to deliver. The mother was initially treated with intravenous Penicillin due to unknown GBS status, however, she developed a fever to 100.4, which prompted treatment with Ampicillin and Gentamycin. Rupture of membrane for twin number one was six hours prior to delivery. Twin number two was rupture of membranes two minutes prior to delivery and was born spontaneous vaginal delivery nine minutes after twin one. The infant emerged with spontaneous cry, dried, bulb suction, blow by O2 briefly, Apgars were 8 and 9. The patient was admitted to the Neonatal Intensive Care Unit. Initial O2 saturation on room air was 99% and had no respiratory distress. PHYSICAL EXAMINATION ON ADMISSION: Weight was 2495 grams, which is the 75th percentile. The length was 47 cm at 75% percentile and the head circumference was 34 cm, which is greater then the 90th percentile, however, on discharge examination this patient was noted to have significant molding on initial examination and on discharge examination the head circumference was 33 cm, which was closer to the 75th to 90th percentile. The rest of the physical examination, the patient was resting comfortably on a radiant warmer with a significant molding on the head. The anterior fontanel was open and flat. The sutures were approximated. The clavicles were intact. The chest was clear to auscultation bilaterally. There was a regular rate and rhythm on the cardiovascular examination with no murmur noted and 2+ femoral pulses. The abdomen was soft, nontender with normoactive bowel sounds and no hepatosplenomegaly. There was a normal phallus with the testes descended bilaterally. There was a patent anus. The extremities were pink and well profused with a capillary refill of less then 3 seconds and there was a PIV in the left arm. HOSPITAL COURSE: 1. Respiratory: The patient needed brief blow by O2 in the delivery room and remained on room air subsequent to that and never developed any respiratory distress, apnea or bradycardia. 2. Cardiovascular: There was no evidence of a murmur during the hospital stay and the patient never suffered any bradycardia or apneic episodes. 3. Fluid, electrolytes and nutrition: The patient initially started off on D10W at 80 cc per kilo per day, but then was allowed to begin breast feeding and was supplemented with Enfamil 20. At discharge, the patient was breast feeding every feed and being supplemented in addition to the breast feeding and was taking approximately 80 cc per kilo per day of Enfamil 20. 4. Gastrointestinal: The patient had mild hyperbilirubinemia. He never required phototherapy while in the hospital and had a total bilirubin of 5.0 with a direct of 4.6. 5. Hematology: No issues. 6. Infectious disease: A blood culture was obtained and was no growth at 48 hours. The patient was started on Ampicillin and Gentamycin for 48 hours, but was discontinued after 48 hours when all cultures were negative. The CBC on admission had a white count of 8.2, hematocrit 56.2 and a platelet count of 246. There were 29 polys, 0 bands and 59 lymphocytes. 7. Neurology: The patient had a normal neurologic examination. 8. Sensory: Audiology- the patient did have a hearing screen, which was performed with an automated auditory brain stem response. The result was the baby did pass the hearing screen bilaterally. The patient also had a car seat test, which he did pass. CONDITION ON DISCHARGE: The patient was discharged in good condition. DISCHARGE DISPOSITION: To home. The name of the primary pediatrician is [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 38263]. Phone number [Telephone/Fax (1) ]. The fax number is [Telephone/Fax (1) 38261]. CARE AND RECOMMENDATIONS: 1. Breast feed ad lib with supplementation of Enfamil 20 and continue to follow weight and urine output. 2. Medications -none. 3. State newborn screen was sent and the status is pending. 4. Immunizations received, the patient did receive hepatitis B immunization and also Synagis immunization prior to discharge. 5. Immunizations recommended: A: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 958] for infants who meet any of the following three criteria: 1. Born at less then 32 weeks. 2. Born between 32 and 35 weeks with plans for daycare during respiratory syncytial virus season, with a smoker in the household or with preschool siblings. 3. Or with chronic lung disease. B: Influenza immunizations should be considered annually in the fall for preterm infants with chronic lung disease once they have reached six months of age. Before this age the family and other care givers should be considered for immunizations against influenza to protect the infant. 6. Follow up appointments: This patient was scheduled to see his primary pediatrician on Thursday [3-24] at 1:00 p.m. This was confirmed by myself and when I called the office. DISCHARGE DIAGNOSES: 1. Preterm 34 week appropriate for gestational male infant. 2. Rule out sepsis resolved. 3. Status post circumcision. [First Name8 (NamePattern2) 36400] [Name8 (MD) ], M.D. [MD Number(1) 37201] Dictated By:[Last Name (NamePattern1) 37851] MEDQUIST36 D: [2140-3-21] 13:49 T: [2140-3-21] 13:55 JOB#: [Job Number ] ICD9 Codes: V290, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8247 }	Medical Text: Admission Date: [2148-12-10] Discharge Date: [2148-12-26] Date of Birth: [2113-7-5] Sex: M Service: Neurosurgery and Trauma SICU HISTORY OF PRESENT ILLNESS: Patient is a 35-year-old male with a history of substance abuse with subarachnoid intercerebral hemorrhage. By report on [12-9], he was initially found down on the grounds of [University/College 25203]and was intoxicated. Later that day he had a witnessed fall with loss of consciousness. He was taken to [Hospital6 ], where he was described as being combative and agitated, however, his initial [Location (un) 2611] coma score was 15. He eventually required intubation for airway protection due to his extreme combativeness and agitation. A head CT subsequently revealed bilateral left greater than right subarachnoid hemorrhage and intracerebral hemorrhage. There was no documented hypotension or hypoxia at [Hospital6 ]. He was therefore transferred to [Hospital1 346] for further care. PAST MEDICAL HISTORY: 1. Polysubstance abuse. 2. Prior head trauma. MEDICATIONS: None. ALLERGIES: No known drug allergies. PHYSICAL EXAM ON ADMISSION: Is reported as temperature of 99.8, blood pressure 150/palp, pulse 105, O2 saturation 100% intubated and ventilated. In general, he was intubated and sedated. His HEENT examination showed no hemotympanum. His cardiac examination showed a regular rate and rhythm without murmurs, rubs, or gallops. His lungs were clear to auscultation bilaterally. His abdomen was soft, nontender, nondistended. His extremities showed no deformities. On neurologic examination, his pupils are 2 mm and trace reactive bilaterally. His eyes were opened spontaneously. He moved all four extremities to stimulation. He has spontaneous bilateral lower extremity movements, antigravity, but less spontaneous movements in bilateral upper extremities. HOSPITAL COURSE BY SYSTEMS: 1. Neurologic: Initial head CT showed a large hemorrhage contusion temporal lobe with edema and subarachnoid hemorrhage. There is a small hemorrhagic contusion in the anterior right frontal lobe. There was also a nondisplaced right occipital fracture. C spine CT was negative for fracture. Head CTA showed no evidence of aneurysm. Therefore, the likely etiology of his intracranial hemorrhages were traumatic. An interventricular catheter was not placed. The patient was therefore followed clinically and with serial head CT scans. His head CT scans were followed and were stable until [12-22]. On [12-22], a head CT showed worsening global edema with new hypoattenuation areas in the left frontal, bilateral temporal-parietal areas suspicious for infarct. MRI showed increased flare signal and DWI in the right insula, right frontal-temporal region, left internal capsule, and left temporal regions suspicious for infarct. This may have been related to vasospasm induced by the subarachnoid hemorrhage. Despite the neuroimaging findings, the patient's neurologic examination slowly improved over the course of his admission. With regards to his neurologic management, he was initially loaded with Dilantin, and this was stopped after one week. His pCO2 was adjusted with a goal of maintaining between 35 and 40. He had a goal of being euvolemic, but at times was fluid positive. His blood pressure was initially tightly controlled to be less than 130 with continuous hemodynamic monitoring and this parameters was gradually liberated over the course of admission. He initially needed significant sedation with both propofol and Ativan, and the propofol was eventually discontinued. His neurologic examination was followed closely throughout his admission and slowly improved, although he still continues to have significant deficits. At discharge, his neurologic examination was significant for being awake and alert, unable to make eye contact and visually track. He had no speech output. He was not able to follow commands. He was able to lift his arm up in the air and move his fingers individually. He was able to flex at the right elbow and shrug his shoulder, but did not have antigravity on the right. He withdrew both legs spontaneously lifted them off the bed. He was seen by the neuro-rehabilitation service, who found this to be consistent with global aphasia and mild right hemiparesis mostly in the arm. They expected that the blood and edema in the left temporal-parietal area resolved. That he had a significant chance of recovering language and right arm function. They expected that he would be ambulatory after recovery. They expect that he would obtain significant benefit from OT, PT, and Speech Therapy at rehab. 2. Cardiovascular: There were no significant issues. His blood pressures were controlled as above as needed. At discharge, he was on Lopressor prn. 3. Respiratory: He was initially intubated and ventilated. He had significant problems with secretions due to either sinusitis or pneumonia. Chest x-ray on [12-20] revealed a right lung base infiltrate consistent with pneumonia. He was treated with both Vancomycin and ceftriaxone. The infiltrate had resolved on x-ray by [12-25]. The patient had two trials of extubation, but failed due to significant respiratory secretions. He therefore underwent tracheostomy placement on [12-24], and was successfully weaned off the ventilator. At discharge, he was receiving albuterol and acetylcysteine nebulizers as needed. He was stable from a respiratory standpoint on a trache mask. 4. Fluids, electrolytes, and nutrition: The patient as above had a goal of being euvolemic, but was at times fluid positive. His electrolytes were repleted as needed. His sugars were followed closely and controlled with an insulin-sliding scale. 5. GI: Patient initially had nasogastric tube feedings and on [12-24], a PEG was placed. His goal feedings are Impact with fiber at 40 cc/hour at this time. Reglan was given to promote GI motility. 6. Infectious disease: The patient was persistently febrile for most of his admission. Cultures were obtained. Blood culture on [12-10] from his arterial line showed alpha Strep. Sputum from [12-10] grew hemophilus influenzae, MRSA and beta Strep. He was treated with Vancomycin from [12-12] to [12-25]. He was also treated with ceftriaxone from [12-16] to [7-26]. He had been afebrile for the day prior to discharge. 7. Orthopedics: He did sustain a right sided transverse process fractures of L3, L4, and L5. 8. Prophylaxis: He is on subcutaneous Heparin for DVT prophylaxis. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: [Hospital ] [Hospital ] Hospital. DISCHARGE DIAGNOSES: 1. Bilateral left greater than right intracerebral hemorrhage and subarachnoid hemorrhage. 2. Right lumbar three, four, and five transverse process fractures. 3. Status post trache. 4. Status post PEG. 5. Pneumonia. 6. Alcohol abuse. MEDICATIONS: 1. Heparin 5,000 units subQ b.i.d. 2. Reglan q.8. 3. Regular insulin-sliding scale. 4. Medications prn including Tylenol, Mucomyst nebulizers, albuterol nebulizers, magnesium supplementation, potassium supplementation, calcium supplementation, and Lacrilube ointment. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Name8 (MD) 33494] MEDQUIST36 D: [2148-12-26] 10:49 T: [2148-12-26] 12:01 JOB#: [Job Number 33495] ICD9 Codes: 486
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8248 }	Medical Text: Admission Date: [2109-12-23] Discharge Date: [2109-12-27] Date of Birth: [2033-9-7] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4616] Chief Complaint: Malaise and fever Major Surgical or Invasive Procedure: central line placement History of Present Illness: This is a 76 yo F w/h/o pancreatic cancer s/p whipple and s/p external beam XRT concurrent with xeloda, currently being treated with Gemcitabine weekly w/last chemo [2109-12-18]. At home, pt had persistant malaise, light-headedness, and LE myalgias which normally last ~2 days after chemotherapy but this time persisted. She also noted 2 days of fever to max of 101.5, along with rhinorrhea, sore throat, and epistaxis which had been bothering her for ~1 week. She normally checks her BP at home, but for the past few days her automated BP cuff had been saying "unreadable" when she tried to measure it. Pt's baseline BP is reportedly in 120s, but in the past after chemo it would dip to the 100s. With chemo, pt reports decreased apetite, and her daughter notes that she has lost 2 lbs in the past week. Also of note, pt has had chronic diarrhea for ~6 months, but after starting Lomotil, Immodium, and Viokase 8 (pancreatic enzyme replacment) her #of BMs has decreased from 4 to 2 per day. On the morning of admission, the fever and light-headedness prompted the pt's family to call her oncology NP, who told them to call EMS. On EMS arrival BP was 100/50. . On ROS Pt denies SOB, chest pain, cough, headache, sinus pressure, neck stiffness, visual changes, nausea, vommiting, worsening diarrhea, melena, hematochezia, dysuria, and hematuria. . In the [Hospital1 18] ED SBP was initially in the low 100s, and temp=100.6. 2L IVF where given, and despite the administraton of fluid SBP fell to the 80s. Right IJ placed (MAP 58 CVP 10) and pt was started on norepinephrine gtt and Vanco/Ceftaz were administered. Pt was never tachycardic or hypoxic. Lactate 1.0, HCT 25. Guiac (-) brown stool. CXR was clear, and U/A clear. Past Medical History: -pancreatic cancer diagnosed at [Hospital6 1597] [4-16], s/p Whipple [2109-5-10]. S/p Cyber Knife and external beam XRT concurrent with xeloda. Currently getting Gemcitabine weekly w/last chemo [2109-12-18]. -CBD obstruction with stent - s/p PE on coumadin - h/o uterine sarcoma: stage Ib, grade III endometrial carcinoma: s/p TAH-BSO [9-13], - Aortic stenosis - Hypertension - Type 2 diabetes - Glaucoma - herpes in L eye Social History: No smoking, No alcohol, no drug use. Lives alone in home in [Location (un) 583], but son or daughter stays with her at night. Independent when well. Children have been staying with her because they are concerned about her. Dtr. is HCP. Family History: daughter with endometrial carcinoma, sister with liver cancer, father with lung cancer, no fam h/o blood clots Physical Exam: VS: Temp: 97.3 BP: 102/42 HR:71 RR:16 O2sat 98 RA CVP 11 GEN: pleasant, comfortable, NAD HEENT: R PERRL, L Pupil Surgical, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no blowing [2-13] creshendo/decreshendo M heard throughout precorium but best at RUSB ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No clonus. RECTAL (in ED): Guiac (-) brown stool Pertinent Results: CBC: [2109-12-23] WBC-4.4 RBC-2.66* Hgb-9.2* Hct-24.5* MCV-92 MCH-34.5* MCHC-37.6* RDW-13.5 Plt Ct-93* [2109-12-23] WBC-3.9* RBC-1.94# Hgb-6.6# Hct-18.7* MCV-97 MCH-34.0* MCHC-35.1* RDW-14.0 Plt Ct-75* [2109-12-27] WBC-3.7* RBC-2.63* Hgb-8.7* Hct-24.5* MCV-93 MCH-33.2* MCHC-35.6* RDW-13.9 Plt Ct-88* . COAGS: [2109-12-23] PT-36.1* PTT-51.4* INR(PT)-3.8* [2109-12-27] PT-18.9* PTT-30.4 INR(PT)-1.7* . CHEM: [2109-12-23] Glucose-154* UreaN-37* Creat-1.6* Na-131* K-3.9 Cl-97 HCO3-18* AnGap-20 [2109-12-27] Glucose-153* UreaN-14 Creat-0.9 Na-133 K-3.8 Cl-105 HCO3-22 AnGap-10 . ANEMIA LABS: [2109-12-26] Iron-36 calTIBC-139* Folate-9.2 Ferritn-GREATER TH TRF-107* . URINE: [2109-12-23] Color-Straw Appear-Clear Sp [Last Name (un) ]-1.006 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM RBC-0 WBC-[5-20]* Bacteri-MOD Yeast-MOD Epi-[2-12] . [12-23] BCx: negative [12-23] UCx: YEAST. 10,000-100,000 ORGANISMS/ML.. [12-24] UCx: YEAST. ~6OOO/ML. [12-26] Stool: FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. . [2109-12-23] CXR AP UPRIGHT CHEST: The tip of a new right internal jugular central venous catheter terminates in the distal SVC. The cardiac, mediastinal and hilar contours appear stable. The lungs are clear. The pulmonary vasculature is normal. There is no pleural effusion or pneumothorax. The visualized osseous structures appear unremarkable. IMPRESSION: 1. Standard position of the right IJ central venous catheter, terminating in the distal SVC. 2. No acute cardiopulmonary process. . [12-23] EKG Sinus rhythm. Compared to the previous tracing of [2109-7-3] R wave progression is improved. Brief Hospital Course: A/P: 76 yo F w/ h/o pancreatic cancer, currently receiving chemotherapy who presented with fever and hypotension requiring pressors: pt initially admitted to ICU for r/o sepsis. Pt with mildly positive UA and no other clear source of infection, . . # Hypotension: on presentation had hypotension that was not responisve to fluids. She was started on levophed in the ED and after 12 hours in ICU levofed was successfully weaned and BP was stable. Hypotension was most likely [1-11] decreased PO intake in the setting of chronic diarrhea and outpatient antihypertensive medications. Sepsis was considered since pt continued to have hypotension despite CVP of 12. Before D/C from the ICU BP was stable for 24 hours and pt was afebrile. Pt had initially been started on cipro and flagyl for weakly positive UA and empiric coverage for possible intra-abdominal process. These antibiotics were stopped shortly thereafter due to lack of data c/w infectious etiology (see below). Remained afebrile and BP stable off of antibiotics. On the Onc floor, her BPs were stable off of her antihypertensive regimen. We were able to restart her atenolol but ACE was held on discharge, to be restarted as tolerated as an outpatient. . # Pancreatic Cancer: Chemo side effects likely contributed to diarrhea. Onc plans were held and deferred to outpatient oncology team. . # Diarrhea: Pt was continued on home viokase for pancreatic enzyme replacement. She also takes immodium and lomotil for chronic diarrhea. A Ciff assay was negative. . # Pancytopenia: All cell lines were depressed -- likely pancytopenia [1-11] chemotherapy. No signs of bleeding aside from epistaxis in the setting of supratherapeutic INR. Pt was transfused a total of 2 units pRBCs with appropriate HCT response. Also received 1 unit platelets (see below). . # Fever: Fever resolved by the time of call out from the ICU. Pt was afebrile on floor. Culture data did not reveal a clear source. Likely that fever on presentation was due to a viral URI, given history of rhinorrhea and sore throat. Because Cx data was negative cipro and flagyl were discontinued on the day that she was called out from the MICU. Abx not resumed on floor. . # Hx of PE: treated with coumadin at home. INR was supratherapeutic throughout time in the ICU. On the day of call-out she was having epistaxis. Likely that quinolone administration was prolonging the INR. Given FFP before transfer to the floor. Had some persistent bleeding on floor. Was transfused 1 unit of platelets (nadir value was 40 with bleeding), with resolution of epistaxis. Resumed coumadin regimen prior to d/c, but was still not therapeutic prior to discharge. Therefore, given enoxaparin daily injections with plan for outpt INR checks. . # Myalgias: most likley [1-11] chemo. Gave tylenol PRN. . # DM: On glyburide at home, which was held and HISS was given. Restarted on discharge. . # Code: Full Medications on Admission: Atenolol 50 mg PO DAILY Enalapril 10 mg PO DAILY Warfarin 2.5 mg TTSS and 3 mg MWF Glyburide 2.5 mg PO BID Ativan 0.5-1 mg QDay PRN Compazine 10 mg TID PRN Lomotil 2.5 mg PO BID Viokase 8 1-2 tabs QIDAC Vit B12 Immodium Discharge Medications: 1. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK ([Doctor First Name ],TU,TH,SA). 2. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK (MO,WE,FR). 3. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as needed for Anxiety. 7. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig: 1-2 Tablets PO QIDAC (). 8. GlyBURIDE 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO as directed as needed for diarrhea. 10. Enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous once a day: until otherwise instructed by MD. [Last Name (Titles) ]:5 syringes Refills:0 Discharge Disposition: Home With Service Facility: [Hospital ] Home Health Care Discharge Diagnosis: Primary: Hypotension . Secondary: # pancreatic cancer diagnosed at [Hospital6 1597] [4-16], s/p Whipple [2109-5-10]. S/p Cyber Knife and external beam XRT concurrent with xeloda. Currently getting Gemcitabine weekly w/last chemo [2109-12-18]. # CBD obstruction with stent # s/p PE on coumadin # h/o uterine sarcoma: stage Ib, grade III endometrial carcinoma: s/p TAH-BSO [9-13], # Aortic stenosis # Hypertension # Type 2 diabetes # Glaucoma # herpes in L eye Discharge Condition: stable, normotensive, ambulating independently Discharge Instructions: You were admitted to the hospital with fevers and low blood pressure. You were briefly in our ICU because you needed medicine to suppport your blood pressure. However, you were quickly able to come off that medicine. We checked for any signs of infection but there were none. . We are restarting one of your blood pressure medicines, atenolol. However, given your recent low blood pressures, you should not take you enalapril until instructed by your PCP or oncologist. . You will be going home with physical therapy and a visiting nurse to check your blood counts as well as the level of couadin in your blood. In the meantime, you will need to take an injection of Lovenox once per day to make sure your blood is thin enough. . Please make sure to take all your medicines as prescribed. Please keep all your followup appointments. If you experience any fevers/chills, lightheadedness, or other symptoms which concern you, please call your doctor or go to the ED. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2110-1-8] 1:00 Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2110-1-8] 1:00 Provider: [Name10 (NameIs) ] FELT, RN Phone:[Telephone/Fax (1) 22] Date/Time:[2110-1-8] 2:00 . Please see your PCP: [Name10 (NameIs) ],[First Name3 (LF) 251] R [Telephone/Fax (1) 57021], in the next 2 weeks. ICD9 Codes: 5849, 2761, 2762, 4019, 4241
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8249 }	Medical Text: Admission Date: [2193-9-6] Discharge Date: [2193-9-13] Date of Birth: [2149-9-12] Sex: F Service: MEDICINE Allergies: Penicillins / Iodine / Platinum Complexes / Aspirin / Shellfish Derived Attending:[First Name3 (LF) 14689] Chief Complaint: Enlarging Flank Mass, Sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 43-year old female with stage IV ovarian ca on home hospice care and recently identified left flank mass presenting with rapidly increasing size of mass with concurrent increasing L hip pain. 1.5 wks ago, patient reports that her nurse identified a small mass on her L flank. Pt was seen on [8-29] by her oncologist, who recommended imagine. On CT, mass was identified as tumor, fluid collection with connection to colon. At that point, after discussion with radiology, it was decided not to tap the mass. She was started on cipro for treatment of presumed adbominal infection. Patient reports that the mass responded to the abx, decreasing in size. However, on Thursday AM of this week, the patient reports that the mass began to rapidly enlarge and became increasingly painful. In addition patient reports increasing fatigue and weakness, along with decreased PO intake and urinary output. Denies fevers, chills, N/V, change in ostomy output. . She is admitted tonight for management of this mass. . In the ED, initial vital signs were: T98.8 93 81/52 16 100 . Patient was given 1.5L of NS. No central line was placed as per patient's wishes, 2 PIVs placed. . On the floor, patient's vitals were 90/50 90 17 100% RA. She complained of pain over L flank and hip and was given 4mg IV morphine and started on a bolus of 500cc NS . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. 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, or changes in bowel habits. Denies dysuria. Past Medical History: Clear cell ovarian Cancer ([2189]) TAH-BSO, appendectomy, omentectomy ([7-12]) sigmoid resection w end colostomy for perforated diverticulitis Anemia - requiring regular RBC transfusions L Hip Pain - requiring regular steroid injection Diabetes Hypothyroidism HTN Social History: Patient lives alone; is on home hospice. Her father is her HCP. Does not smoke or drink. Family History: Mother with NHL, tongue CA, died of "strep throat." Father has a pacemaker. Physical Exam: On admission - VITALS: T99.2, BP 92/58, HR 93, RR 19, SaO2 99%RA GENERAL: Thin, chronically ill-appearing woman, laying in bed in pain HEENT: EOMI, PERRL, no LAD CHEST: Clear to auscultation bilaterally CARDIAC: RRR, nl S1/S2, no mrg ABDOMEN: +BS, ostomy bag in place with dark hue around site and minimal substance in bag, mild tenderness at ostomy site FLANK: L flank with 15cm ovoid ulceration with surrounding ecchymosis and partially overlaid eschar, tender to touch EXTREMITIES: No edema bilaterally SKIN: Cool, gradeII sacral decub w mild surrounding erythema NEURO: AOx3, CNII-XII grossly intact On discharge: Tm/Tc: 99.2/98.4 BP 98/60 (92-112/50-67) P 92 (88-104) R 16 Sat 100%RA I/O: 24h: 2128 (960 PO, 1168 IV)/650 GENERAL: Thin, chronically ill appearing woman, lying in bed in NAD HEENT: NCAT, EOMI, PERRL, mild [Month/Year (2) 11395] on tongue. CHEST: Clear to auscultation bilaterally, no w/r/r audible on anterior exam CARDIAC: RRR, nl S1/S2, no m/r/g ABDOMEN: +BS, ostomy bag in place, diffuse tenderness to light touch on left abdomen, slightly tender on right, voluntary guarding present; dressing in place over left flank wound BACK: pressure ulcer on gluteal cleft, eroded skin (stage 3 likely) with surrounding erythema and serosanguinous drainage EXTREMITIES: Left leg with increased swelling, 2+ pitting edema. Upper thigh and groin on left side with increased swelling and erythema, 20 cm area from right hip to groin. Right leg with no c/c/e. NEURO: AOx3, CNII-XII grossly intact Pertinent Results: ==== Labs ==== [2193-9-6] 06:45PM PT-15.7* PTT-30.6 INR(PT)-1.4* [2193-9-6] 06:45PM PLT COUNT-439 [2193-9-6] 06:45PM NEUTS-92* BANDS-0 LYMPHS-3* MONOS-5 EOS-0 BASOS-0 [2193-9-6] 06:45PM WBC-31.2# RBC-2.76 HGB-7.5* HCT-22.8* MCV-83 MCH-27.1 MCHC-32.8 RDW-16.4* [2193-9-6] 06:45PM estGFR-Using this [2193-9-6] 06:45PM GLUCOSE-181* UREA N-104* CREAT-4.0# SODIUM-132 POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-15* ANION GAP-26* [2193-9-6] 08:31PM LACTATE-1.7 [2193-9-6] 10:00PM URINE AMORPH-NONE [2193-9-6] 10:00PM URINE RBC-0-2 WBC-[3-8] BACTERIA-FEW YEAST-NONE EPI-0-2 RENAL EPI-0-2 [2193-9-6] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR [2193-9-6] 10:00PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.016 [2193-9-13] 09:10AM BLOOD WBC-14.5* RBC-2.85* Hgb-7.8* Hct-24.3* MCV-85 MCH-27.4 MCHC-32.1 RDW-16.8* Plt Ct-205 [2193-9-13] 09:10AM BLOOD PT-21.5* PTT-30.9 INR(PT)-2.0* [2193-9-13] 09:10AM BLOOD Glucose-122* UreaN-45* Creat-1.3* Na-137 K-3.9 Cl-104 HCO3-22 AnGap-15 [2193-9-13] 09:10AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.6 ========= Radiology ========= [2193-9-7] Abdomen/Pelvis CT with PO contrast: IMPRESSION: 1. Interval severely worsening and spread of subcutaneous air along the left posterolateral pelvic wall, compatible with aggressive tissue necrosis. 2. Hyperdense material is seen within the necrotic tissue, compatible with extraluminal oral contrast from enterocolonic fistulization to the necrotic tissues. Small amount of free air is noted along the left lateral pelvic cavity. Recommend consideration for surgical consult for extensive surgical debridement. 3. Grossly unchanged large amorphous mid pelvis mass with fluid. No percutaneously drainable fluid collection. 4. Unchanged bilateral hydronephrosis and hydroureter. 5. Cholelithiasis without acute cholecystitis. 6. Unchanged hypodensity in segment V of the liver, in completely evaluated ====== Micro ====== [2193-9-6] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [2193-9-6] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT Brief Hospital Course: 43y/o lady with stage IV ovarian cancer, presenting with enlarging left flank mass previously identified as being composed of tumor, fluid collection, air, c/w progression of tumor vs expansion of infection. . #Flank Mass: enlarged since it was originally identified on [2193-8-29] (less than 2 weeks ago). There was concern for expanding intraabdominal infection, so Vanco/Cefepime/Flagyl were started. The patient declines any major intervention, but in case there was a percutaneously accessible fluid collection that could be drained and offer pain relief, a CT was obtained. It appears that the mass is composed of necrotic tissue and that no such collection is visualized. There has been progression of disease, and possible enterocolonic fistulalization to the necrotic tissues. Blood cultures remained negative, so patient was transitioned from cefepime and flagyl IV to cipro and flagyl po for planned 14 day course. Doxycycline was added to added [9-12] for some concern of LLE cellulitus near this mass. Given her MRSA status, we felt she deserved MRSA coverage. We plan to continue this for 10 days. . #Acute renal failure, likely prerenal vs. obstructive: admitted with Cr 4.0 (baseline 1.1), in setting of poor appetite x1wk, and rapidly expanding infection, consistent with obstruction vs hypoperfusion [2-5] to poor PO intake vs shock. Her low-normal Na/Cl/HCO3 support poor PO intake. CT scan also revealed some hydronephrosis. She received aggressive volume rescucitation with normal saline and her creatinine improved to 1.3 on the day of discharge. . #Stage IV Ovarian Cancer: very poor prognosis. She has multiple abdominal masses, and was in [Hospital 68721] hospice care. She is known to palliative care, is DNR/DNI, does not wish to have central line. Her Oncologist (Dr. [Last Name (STitle) 68722] was aware of her admission and reinforced that her goals of care are centered on patient comfort. . #Anemia: chronic anemia requiring regular transfusions, HCT of 22 on admission. She was transfused 2U PRBCs on admission. . # Pain: Patient was transitioned from IV pain medications to fentanyl patch 25 mcg, with dilaudid 2-4 mg po Q3H prn with instructions for patient to chew medication for quicker onset. Patient was advised to use dilaudid 20 minutes prior to dressing changes. Palliative care followed the patient, and felt other options could include a morphine cream as well as fentanyl lollipops. . # [Last Name (STitle) ]: Patient was noted to have [Last Name (LF) 11395], [First Name3 (LF) ] she was started on nystatin and fluconazole. We plan to continue fluconazole for 12 more days, to complete a 14 day course. Medications on Admission: CIPROFLOXACIN 250mg [Hospital1 ] ([8-29]-today) Ducodyl Fentanyl Patch 12mcg/hour q72h GABAPENTIN - 300 mg Capsule TID METOCLOPRAMIDE - 10 mg Tablet - QID prn for nausea NYSTATIN 5mL swish and swallow ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth 1 hour before treatment then as needed for every 8 hours 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection Q8H (every 8 hours). 4. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritus. 6. Oral Wound Care Products Gel in Packet Sig: One (1) ML Mucous membrane TID (3 times a day) as needed for oral mucositis. 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-5] Sprays Nasal QID (4 times a day) as needed for nasal congestion. 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for [Month/Day (2) 11395]. 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. 10. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) for 12 days. 11. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nasal congestion. 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain: Please have patient chew pill instead of directly swallow; please also time dose before dressing changes and moving patient. 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 14. Haloperidol 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for nausea. 15. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 10 days. 17. Reglan 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 18. Reglan 5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours. Discharge Disposition: Extended Care Facility: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 68723] [Hospital ] [Hospital ] Hospice Home Discharge Diagnosis: Abdominal pain, likely due to left flank mass Acute renal failure, prerenal Nausea and vomiting Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [Known lastname 45419], It was a pleasure taking care of you at the [Hospital1 18]. You came for further evaluation of abdominal pain and mass, and decreased kidney function. Further tests showed that the mass in your abdomen is related to your ovarian cancer, and surgery would not be a good option at this time. Your decrease in kidney function was most likely due to dehydration, and has recovered with intravenous fluids. It is important that you continue to take your medications and follow up with your outpatient oncologist. Followup Instructions: Department: PAIN MANAGEMENT CENTER When: MONDAY [2193-9-23] at 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], MD [Telephone/Fax (1) 1652] Building: One [Location (un) ] Place ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Parking on Site [Name6 (MD) ] [Name8 (MD) 10341] MD [MD Number(2) 14690] ICD9 Codes: 0389, 5849, 2762, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8250 }	Medical Text: Admission Date: [2123-6-21] Discharge Date: [2123-7-13] Date of Birth: [2060-9-24] Sex: M Service: NEUROSURGERY Allergies: Dilantin Attending:[First Name3 (LF) 1835] Chief Complaint: Transfer from OSH with L parietal brain mass Major Surgical or Invasive Procedure: External Ventricular drain- Right External Ventricular drain- Left tracheostomy Peg Tube PICC line Subclavian Central line History of Present Illness: Pt is a 62m who was at work when he developed nausea today. This was accompanied by 1 episode of vomiting. His co-workers called his wife when he began acting different and wasn't his usual self. He was taken to OSH where CT head showed L parietal brain mass. Currently he denies headache, visual changes, motor weakness or speech difficulty. Past Medical History: HTN, High cholesterol Social History: Lives with wife at home, non smoker Family History: NC Physical Exam: BP: 136/80 HR: 96 R 12 O2Sats 99 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRLA EOMs full Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [3-20] 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,4 to 3 mm bilaterally.visual fields show L inferior quadrant visual field cut III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-22] throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Handedness Right Pertinent Results: HEAD CT [2123-6-21] OSH L parietal lesion with significant vasogenic edema, no midline shift MRI head [2123-6-22] incomplete study d/t movement, L parietal mass with vasogenic edema seen [6-23] CT TORSO: IMPRESSION: 1. Small bilateral pleural effusions. 2. No acute process of the chest, abdomen or pelvis. 3. Small hypoattenuating liver and renal lesions are too small to characterize, likely simple cysts. 4. Significantly distended urinary bladder. [6-23] CXR: Left lung is clear. Mild volume loss and heterogeneous opacification at the right lung base could be due to hypoventilation alone or alternatively recent aspiration. The stomach is mildly-to-moderately distended with gas. Upper lungs are clear. Ascending thoracic aorta is tortuous or minimally dilated. [6-24] EEG: [6-24]: Head CT: IMPRESSION: 1. Post ventriculostomy catheter placement with new small amount of subarachnoid hemorrhage in the right frontal lobe. 2. Left parietal vasogenic edema has increased and there is slightly increased midline shift to the right by about 5 mm, new from the CT from [2123-6-21]. 3. Ventricles are normal in size, but slightly more prominent than on [2123-6-21] predominantly involving the temporal horns. NOTE ADDED AT ATTENDING REVIEW: I agree with the above interpretation and note that the involvement of the corpus callosum and the fast diffusion seen in the nonenhancing core of the lesion on the MR study argue that a primary malignant neoplasm, such as a glioblastoma, is more likely than abscess or metastatic disease. [6-24] Head CT: 1. Rapidly progressive ventricular enlargement, particularly right greater than left occipital horns, since nine hours ago. Interval increased cerebral edema nad rightward midline shift, now by 7 mm. Increased effacement of right ambient cistern, suggesting uncal herniation. 2. Stable position of a right frontal approach intraventricular shunt catheter. 3. Stable right frontal subarachnoid hemorrhage with new intraventricular component in the right occipital [Doctor Last Name 534]. Alternatively, new right intraventricular density could represent pus, in the setting of ventriculitis. 4. Substantial edema about a left parietal lesion, better seen on preceding MRI. [6-24] CXR:NG tube tip is in the stomach. ET tube tip is 6 cm above the carina. Left subclavian catheter tip is in the upper SVC. There is no pneumothorax. Bilateral pleural effusions are small. MR [Name13 (STitle) ] W& W/O CONTRAST [2123-6-25] 1. Again areas of edema are demonstrated in the cerebellum with associated subependymal enhancement along the fourth ventricle, likely related with the previously demonstrated intraventricular abscess. 2. The signal intensity throughout the cervical spinal cord is normal with no evidence of focal or diffuse lesions. 3. Mild-to-moderate multilevel degenerative changes throughout the cervical spine, more significant at C5/C6 and C6/C7 levels MRI OF THE THORACIC SPINE 1. Mild degenerative changes in the thoracic spine as described above involving the T7, T8, and T8/T9 levels. No focal or diffuse lesions are noted throughout the thoracic spinal cord or areas with abnormal enhancement. 2. Areas of edema are noted along the right musculature with no evidence of fluid collections. 3. Bilateral pleural effusions, slightly right greater than left. MRI OF THE LUMBAR SPINE 1. Mild thickening of the nerve roots at the level of L5/S1, concerning for arachnoiditis. 2. Mild disc degenerative changes identified at L4/L5 with bilateral joint effusions, disc degenerative changes are also present at L5-S1 with no evidence of spinal canal stenosis. [6-26] ECHO: no vegetations, EF > 50%, no ASD [6-27] CT head AM: worsening left edema, and rightward shift enlarged temporal horns bialt [6-27] CT head 6PM: enlarging left ventricular system. Interval progression of rightward shift of the normally midline structures by 18 mm (previously 9 mm). [6-28] MRI Brain with and without contrast: IMPRESSION: Interval evolution of the previously noted left parietal lesion, with increase in the nonenhancing necrotic central portion. Areas of slow diffusion and abnormal enhancement noted in the lateral, the third, and the fourth ventricles related to the presence of purulent material; obliteration of cerebral aqueduct. Small foci of slow diffusion in the left parietal lesion and splenium and right centrum semiovale- ? infarcts/purulent material. Assessment for infarction is limited given the confounding effects of possible purulent material based on the clinical details. There are extensive areas of increased signal intensity in the cerebellar hemisphere, vermis, and in the brainstem. There is mild meningeal enhancement noted along the surface of the brain, predominantly on the left side. Subependymal enhancement is noted in the lateral, third and 4th ventricles. Extensive FLAIR hyperintense signal in the cerebral parenchyma and in the brainstem structures as described above related to surrounding edema and parenchymal changes along with some degree of CSF seepage. However, the etiology of these changes is not clear. Correlate clinically A small enhancing focus in the left temporal lobe, attention on close followup. Mucosal thickening in the ethmoid and the mastoid air cells bilaterally and diffusely. [6-28] AM CT head: IMPRESSION: 1. Decompression of the left lateral ventricle after new external ventricular drain has been placed. 2. Decrease in rightward shift of the normal midline structures from 18 mm to 8 mm. 3. Stable extensive vasogenic edema in the left parieto-occipital lobe with stable appearance of small hyperdense abscess. 4. No evidence of new hemorrhage. [6-28] CXR: There is bibasilar atelectasis. Lungs are otherwise clear. Small bilateral pleural effusions are unchanged. Hilar and cardiomediastinal contours are normal. There is no pneumothorax. The endotracheal tube and left subclavian central venous catheter are in unchanged and appropriate position. A feeding tube passes through the expected course of the esophagus and enters the left upper quadrant of the abdomen. [6-30] EEG:nonconvulsive status [7-1] CXR: Unchanged bibasilar atelectasis and trace left effusion. [7-2] Bilateral lower extemity ultrasound venous studies: No evidence of deep venous thrombosis in bilateral lower extremities. [7-3] CXR: Tracheostomy tube whose distal tip is 4 cm above the carina. There is a left-sided PICC line whose distal tip is in the mid SVC. Heart size is within normal limits. Tortuosity of the thoracic aorta. There is a small amount of free air underneath the right hemidiaphragm which after discussion with the clinical team is related to recent PEG tube placement. [7-4] MRI Head: 1. Overall improvement with decrease in size of left parietal ring-enhancing lesion, amount of intraventricular fluid and complete resolution of FLAIR signal abnormality involving brainstem and cerebellum. 2. Mild decrease in ventricular size with stable position of bifrontal ventriculostomy catheters. 3. Unchanged partial opacification of the bilateral mastoid air cells. CT Head [7-6] 1. Unchanged position of the external ventricular drain. The ventricles are unchanged in size when compared to the exam performed approximately 24 hours. 2. No evidence of hemorrhage. 3.. Stable appearance of vasogenic edema surrounding the known abscess in the left temporal lobe [7-7] CT Head: 1. Status post removal of the left external ventricular drain, with a small amount of air layering in the left lateral ventricle. 2. Unchanged ventricular size. 3. No evidence of hemorrhage. [7-7] Mandible Xray: There are no signs for acute fractures or dislocations. Mineralization is within normal limits. There is subtlelucency surrounding the left second molar within the mandible which corresponds to the abnormality seen on the prior CT study. The paranasal sinuses are within normal limits. The nasal bone is unremarkable. Portion of the cervical spine is within normal limits aside from some spurring at the articulation of C1 and C2. [7-9]: Bilateral lower extremity dopplers: No evidence of deep venous thrombosis in bilateral lower extremities Brief Hospital Course: 62 y/o M n/v at work and change in personality presented to OSH where head CT revealed large L parietal mass. He was transferred to [Hospital1 18] for further neurosurgical evaluation. On examination, patient was nonfocal. He was admitted to neurosurgery and awaiting MRI of head for further evaluation and keppra was added. On [6-22], patient was unable to tolerate MRI scanner and imaging was incomplete. Neuro and rad onc were consulted. Infectious workup was also initiated, labs were sent. On [6-23] Mr. [Known lastname ] was found in distress in his room having projectile vomited and was complaning of severe pain. His Temperature was noted to be 102 rectaly and he was slightly more lethargic. He was transfered to the ICU for close monitoring, nausea control and more frequent neuro checks. Upon arrival in the ICU he was further worked up for possible causes of his hematemsis, fevers, and lab abnormalities. The decision was made to perform a lumbar puncture which showed an openign pressure of 28 and was yellow and cloudy in appearance. The fluid also was viscous and only 2-3ml were able to be removed. The fluid was sent and found to have protein in the 800's a glucose of 1, and 99% polys. As such ID was consulted for cocnerns for intracranial bacterial infection. The decision was made to place an external ventricular drain on [6-24] for intrathecal administration of antibiotics. Later in the evening his condition worsened and he was intubated and EVD was placed at the bedside. On the morning of [6-24] his exam continued to worsen and there was question of seizure activity so an EEG was placed. He was started on additional antiseizure agents. His ICP was noted to be increasing so he recieved 23% saline x 1 dosage. This worked temporarily but then the ICP increased again. Due to the location of shift and risk of herniation he was given decadron, mannitol and started on 3% saline gtt. After his physical exam remained stable throughout he was restarted on propofol, and subsequent ICP's were well controlled as well as his blood pressure. He was started on intrathecal antibiotics per ID's recommendations. On [6-25]: patient remained stable, somewhat improved as compared to [6-24]. ICPs stable and less than 10. His Decadron was decreased to 6mg Q6 hours. A repeat CT showed persistant hydrocephalus, but less mass effect on the brain stem. EVD was lowered to 10 to allow for more drainage. An Echo cardiogram was performed which ruled out endocarditis and showed EF of > 50%. On [6-26], patient's exam showed new disconjugate gaze, but was otherwise unchanged. His ICP were stable overnight ranging from [5-25] and his EVD had an output of 106cc and 29cc. He continues to recieve IT antibiotics. CSF culture is pending. EEG remains in place. EVD was lowered to 5cm in an attempt to reduce occipital and temporal [Doctor Last Name 534] ventriculomegaly. Overnight he developed transient ICPs to the low to mid 20s and became transiently bradycardic to the 40s. Blood pressure remained stable. ICPs normalized after increasing hypertonic saline gtt to 15cc/hour. Repeat Head CT on [6-27] demonstrated increase rightward shift and continued bilateral enlarged temporal horns. The EVD was raised to 15cm above the tragus in an effort to not overdrain the lateral ventricles and improve the rightward shift. He received the morning doses of IT Gent and Vanco. CSF Cultures returned demonstrating speciation to STREPTOCOCCUS ANGINOSUS with pansensitivites. Both IV and IT antibiotics were narrowed and he continued on only IV Flagyl and IV PCN with only IT Vancomycin [Hospital1 ]. His exam remained unchanged. Repeat Head CT at 6pm demonstrasted * On [6-28], The external ventricular drain on right stopped working at 0300am and was discontinued. The left external ventricular drain patent and open at 5 H2Ocm above the tragus. At approximately 3 pm the EVD stopped draining and TPA was administered and clamped x 30 mins. The drain was opened and the was again draining CSF with a good waveform. The continuous EEG was consitent with 3-4 seizures in the morning and Keppra was restarted at 1000mg [Hospital1 ] with a loading dose of 1400mg. A non contrast Head Ct was performed which was consistent with decompression of the left lateral ventricle after new external ventricular drain has been placed. decrease in rightward shift of the normal midline structures from 18 mm to 8 mm.Stable extensive vasogenic edema in the left parieto-occipital lobe with stable appearance of small hyperdense abscess.No evidence of new hemorrhage. The 3% sodium chloride gtt was discontinued. The serum sodium was 142. Per infectious disease, as the patient was experiencing seizures penicillin was discontinued and ceftriaxone 2 gm q 12 hours. On exam, the patient was intubated. He was spontaneously opening his eyes. There was no tracking noted and sluggish pupillary response bilaterally. There was no movement in the 4 extremities to noxious. The patient did not follow commands. a MRI was performed which was consistent with edema within the pons and brainstem but no clear stroke and showed a small increase in the size of the left parietal brain abscess. On [6-29] the patient's neurological exam remained the same. Eye opening was spontaneous and he had positive corneals and positive blink to threat. Discussion was held with ID and due to the lack of a sizeable abscess to drain, there is no role for surgical intervention aside from current EVD. He continued to received IT vancomycin [Hospital1 ] in addition to IV Ceftriaxone. On [6-30] his neurologic exam was stable however he was noted to be febrile o/n and was cultured except CSF. His EEG was reviewed and it was found that he had been in non-convulsive status on [6-29]. In the setting of fevers ID recommended addition of IV Vancomycin and requested CSF be sent the evening of [6-30]. On [7-1], patient continued to be febrile with an increase in his WBC, CSF gram stain showed no growth to date, sputum and blood cultures are still pending. On exam, there was no EO or movement in all extermities to noxious stimuli. IT vanco was adminitistered at 10am. His NA level was 128, standing salt tabs were added and labs were ordered to follow up the level. On [7-2], the patient began to follow commands. He developed a rash believed to be due to Dilantin. Dilantin was subseqently discontinued, and he was started on Lacosamide per the Epilepsy team. The EEG leads were temporarily removed. LENIs studies were performed and were negative. The patient was able to tolerate trach mask. On [7-3], MRI Head showed decrease in size of abcess and resolving ventriculitis. EEG showed no seizures. The Infectious Diseases team recommended a likely time period of 2 more weeks of IV antibiotics. He continued to follow commands. On [7-4], the patient was noted to have a normal sleep/active pattern on EEG and continued to follow commands. He worked with Physical Therapy and was able to sit up at the side of the bed and dangle his feet. EEG was discontinued due to lack of seizures for the previous 48 hours. On [7-5] his intrathecal abx were discontinued and he went for a baseline CT head prior to having his EVD clamped. His EVD was clamped at noon. On [7-6] a repeat CT head showed no change in ventricular size and it was decided to continue his clamping for 24 more hours and if his exam was unchanged to take it out on [7-7]. His serum Na dropped to 128 and he was started on NaCl tabs. On [7-7] his neuro exam remained stable. He was AOx2, MAE and following commands. His left EVD was discontinued without complication as well as the right EVD staples. Post removal CT revealed no hemorrhage. His trach was capped with a passe muir valve which he tolerated well. Na was improved to 129 but still low so we also started on florinef. On [7-8] he was neurologically stable. Na was up to 131. PT/OT and social work continued to work on his discharge plan. He was transferred to step-down. OMFS plan to take him to OR [7-9] for extraction of lower left 2nd molar. On [7-9], patient alert, EO to voice, nods his head appropriately and follows commands. His sodium level has improved from 128 to 133 with the addition of salt tabs and florinef per renal. They also recommended urine lytes and osm be sent for further evaluation. He was taken to the OR for tooth extraction. He toelrated the tooth extraction well under MAC and went to the PACU post-operatively. On [7-10] he was seen again by renal and they recommended continuign his florinef at the same dose and signed off. He remained stable on [7-11] and on [7-12] was evalauted by speech and swallow and transfer orders were written for him to go to the floor from step down. Speech and swallow recommended a video swallow to be completed. On [7-13], video swallow was cancelled. Patient remained stable on examination and was discharged to rehab in stable condition. Medications on Admission: Simvastatin, Lisinopril Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain or fever 2. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry eyes 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 4. CeftriaXONE 2 gm IV Q 12H 5. Dexamethasone 1 MG IV QD Duration: 1 Days 6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 7. DiphenhydrAMINE 25 mg IV Q6H:PRN itching 8. Docusate Sodium (Liquid) 200 mg PO BID 9. Fludrocortisone Acetate 0.1 mg PO DAILY 10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 11. Heparin 5000 UNIT SC TID 12. HydrALAzine 10 mg IV Q6H:PRN SBP > 160 13. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 14. LeVETiracetam Oral Solution 1500 mg PO BID 15. Lacosamide 200 mg PO BID 16. MetRONIDAZOLE (FLagyl) 500 mg IV Q6H per ID recs 17. Ondansetron 4 mg IV Q4H:PRN nausea 18. Pantoprazole 40 mg IV Q24H 19. Promethazine 12.5 mg IV Q6H:PRN n/emesis 20. Sarna Lotion 1 Appl TP TID:PRN pruritis 21. Senna 2 TAB PO BID 22. Simvastatin 20 mg PO DAILY 23. Sodium Chloride 2 gm PO TID 24. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 25. Outpatient Lab Work CBC w/ diff, LFTs, ESR, CRP Please have this information faxed to the [Hospital ] clinic at [Telephone/Fax (1) 1419] Discharge Disposition: Extended Care Facility: [Hospital ] Hospital for Continuing Medical Care - [Location (un) 1121] ([Hospital3 1122] Center) Discharge Diagnosis: L parietal Mass intracranial abscess Meningitis Coma Elevated ICP Cerebral Edema Respiratory failure Electrolyte imbalance Protien/Calorie malnutrition Hydrocephalus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ?????? 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. ?????? Your wound was closed with staples 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. These staples can be removed on [7-14]. ?????? 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. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [Telephone/Fax (1) 87]. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Staples can be removed on [7-14]. This can be done at your rehab facility. If there are any questions please call [Telephone/Fax (1) 1669]. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ], to be seen 4 weeks after your antibiotic have been discontinued. ??????You will need an MRI of the brain with and without gadolinium contrast. ?????? You should follow up in the infectious disease clinic in 4 weeks with an MRI of the head. This appointment can be scheduled by calling [Telephone/Fax (1) 457]. Completed by:[2123-7-13] ICD9 Codes: 2761, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8251 }	Medical Text: Admission Date: [2139-4-20] Discharge Date: [2139-5-1] Date of Birth: [2098-11-20] Sex: M Service: CARDIOTHORACIC Allergies: Amoxicillin Attending:[First Name3 (LF) 1283] Chief Complaint: Nausea, Vomiting and Fever: Fd. to have Endocarditis at OSH Major Surgical or Invasive Procedure: [2139-4-27] Mitral Valve Replacement (33mm [Company 1543] mosaic tissue valve) [2139-4-30] PICC Line History of Present Illness: 40 y/o male with PMH of "heart mumur" who p/w 6d fever, chills, n/v and profuse watery diarrhea. Was in usual state of health until last Tueday when he developed acute onset of rigors. Had fevers of 102.5 and also developed n/v with profuse watery diarrhea. Symptoms persisted through the week and eventually went to OSH ER on [4-19]. Past Medical History: Nephrolithiasis, h/o "heart murmur" Social History: Denies tobacco or drug use. Social ETOH. Civil Engineer. Family History: GF died at age 64 from MI. M uncle died from CHF age 52. Physical Exam: NAD, resting comfortably RRR, systolic murmur CTAB + BS, soft, umbilical hernia extrems with + peripheral pulses, no edema 101/65 ST 116 T 100.4 RR 17 97% O2 sat 2L NC 6'4" 175# Pertinent Results: [2139-4-21] Echo: Small (0.6 cm) mobile vegetation on the posterior mitral valve leaflet. Mild bileaflet mitral valve prolapse. At least moderate mitral regurgitation (may be underestimated given acoustic shadowing, eccentricity, and tachycardia). Mild left ventricular cavity dilation with preserved biventricular systolic function. Small circumferential pericardial effusion. Resting tachycardia. [2139-4-27] Echo: PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are myxomatous. There is partial mitral leaflet flail. A bioprosthetic mitral valve prosthesis is present. Severe (4+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is a trivial/physiologic pericardial effusion. POST CPB: Preserved biventricular systolic function. Bioprosthesis in th emitral position. Well seated and mechanically stable. Good leaflet excursion and minimal gradient aross the mitral valve. No other change. No LVOT gradient. [2139-4-29] CXR: 1. Slightly more rounded configuration of the LV/apex might possibly reflect an increasing amount of pericardial fluid, but is more likely positional. 2. Retrocardiac left lower lobe opacity which is more prominent than on the prior study. Small left-sided pleural effusion. 3. Stable small amount of pneumomediastinum. [2139-4-20] 08:35PM BLOOD WBC-16.6* RBC-4.45* Hgb-13.5* Hct-38.1* MCV-86 MCH-30.2 MCHC-35.4* RDW-14.2 Plt Ct-118* [2139-4-25] 06:30AM BLOOD WBC-16.0* RBC-4.37* Hgb-12.9* Hct-37.8* MCV-87 MCH-29.5 MCHC-34.1 RDW-14.0 Plt Ct-457* [2139-4-30] 05:55AM BLOOD WBC-13.1* RBC-2.79* Hgb-8.1* Hct-23.7* MCV-85 MCH-29.1 MCHC-34.3 RDW-14.8 Plt Ct-381 [2139-4-20] 08:35PM BLOOD PT-14.0* PTT-23.9 INR(PT)-1.2* [2139-4-28] 03:37AM BLOOD PT-14.2* PTT-27.3 INR(PT)-1.3* [2139-4-20] 08:35PM BLOOD Glucose-127* UreaN-9 Creat-0.7 Na-136 K-3.1* Cl-99 HCO3-28 AnGap-12 [2139-4-30] 05:55AM BLOOD Glucose-115* UreaN-17 Creat-0.8 Na-132* K-4.3 Cl-97 HCO3-28 AnGap-11 Brief Hospital Course: Mr. [Known firstname ] [Known lastname 73031] is a 40 year old gentleman who was transferred to [Hospital1 69] on [2139-4-20] with a history of a heart murmur and recent shortness of breath and fevers up to 102 degrees. An echocardiogram at the outside hospital revealed severe mitral regurgitation and a possible vegetation on the mitral valve. A repeat TEE was obtained at [Hospital1 18] which revealed 3+ mitral regurgitation and the possibility of a flail leaflet that might have been previously misinterpreted as a vegetation. He was seen in consultation by the cardiology and infectious disease services. He was placed on antibiotics per the infectious disease service. By [2139-4-26] one out of four blood culture bottles from the outside hospital had grown out gram positive rods. On [2139-4-27] he was taken to the operating room and underwent a mitral valve replacement with a 33mm [Company 1543] Mosaic porcine valve for severe mitral regurgitation and possible endoocarditis. This procedure was performed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Mr. [Known lastname 73031] [Last Name (Titles) 8337] the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. In the surgical intensive care unit Mr. [First Name (Titles) 73032] [Last Name (Titles) 27836] well. He was extubated on post-operative day one. He was weaned from his pressors. His blood cultures from the outside hospital grew H. parainfluenzae. By post-operative day two he was ready for transfer to the surgical step down floor. Mr. [Known lastname 73033] course on the surgical step down floor was uncomplicated. He was seen in consultation by physical therapy and he was diuresed. A PICC line was placed for long-term antibiotics per the recommendations of the infectious disease service. By post-operative day #4 he was ready for discharge in good condition with 4 weeks of ceftriaxone IV. Pt. to make all follow-up appts. as per discharge instructions. Medications on Admission: None at home. At transfer: Vancomycin, Ciprofloxacin, Heparin SC, Protonix, Colace Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 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:1 3. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed. Disp:40 Tablet(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:1 7. Ceftriaxone 2 g Recon Soln Sig: One (1) Intravenous Q24H (every 24 hours) for 4 weeks: til [5-25] then re eval by ID . Disp:28 Refills:0 8. PICC line PICC line care per NEHT protocol 9. Outpatient Lab Work Outpatient Lab Work Labs: CBC w/ diff, Bun/Cr, LFT, qwednesday Results to [Hospital ] clinic attn: [Doctor First Name ]/[Doctor First Name ] Fax #[Telephone/Fax (1) 457] 10. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: LSR Discharge Diagnosis: Mitral Valve Endocarditis and Regurgitation s/p Mitral Valve Replacement PMH: Nephrolithiasis, h/o "heart murmur" Discharge Condition: Good Discharge Instructions: [Month (only) 116] shower, 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 Continue IV Antibiotics x 4 weeks [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in 4 weeks Dr. [Last Name (STitle) 20764] in [12-23] weeks Cardiologist in [1-24] weeks Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Phone:[Telephone/Fax (1) 457] Date/Time:[2139-5-25] 8:45 Completed by:[2139-5-7] ICD9 Codes: 7907, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8252 }	Medical Text: Admission Date: [2107-9-15] Discharge Date: [2107-9-20] Date of Birth: [2061-1-7] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors Attending:[First Name3 (LF) 1267] Chief Complaint: Abnormal Stress Test Major Surgical or Invasive Procedure: s/p Coronary Artery Bypass Graft x 3 (LIMA->LAD, SVG->OM, SVG->diag) History of Present Illness: Pleasant 46 y/o male who was under evaluation for possible renal transplant and during cardiac clearance pt had an abnormal ETT. He was then referred for cardiac catheterization which revealed 3 vessel disease. Pt. was then referred for cardiac surgery. Past Medical History: End-Stage Renal Disease on Hemodialysis Renal Artery Stenosis s/p Right Renal Artery Stenting [12-19] Renal Osteodystrophy Cardiomyopathy Hypertension Hypercholesterolemia h/o Cellulitis left hip/LE Social History: Lives with significant other. Unemployed originally from [Country ]. Family History: Brother died of an MI at age 37 Physical Exam: VS: 189/91 90 20 36.5 66in 76kg General: WD/WN male in NAD Neuro: A&O x 3, non-focal HEENT: EOMI Neck: FROM, NC/AT Heart: RRR, -c/r/m/g Lungs: CTAB. -w/r/r Abd: Soft, NT/ND Ext: warm, -c/c/e Pertinent Results: CXR [2107-9-19]: Improving Pneumothoraces with residual tiny [Hospital1 ]-apical pneumothoraces. Slight improvement in bibasilar atelectasis and persistant pleural effusion. [2107-9-15] 11:10AM BLOOD WBC-9.2 RBC-2.90* Hgb-9.6* Hct-27.8* MCV-96 MCH-33.1* MCHC-34.4 RDW-14.4 Plt Ct-98* [2107-9-16] 02:02AM BLOOD WBC-7.8 RBC-3.11* Hgb-10.2* Hct-29.2* MCV-94 MCH-32.9* MCHC-35.0 RDW-16.2* Plt Ct-107* [2107-9-19] 08:25AM BLOOD WBC-1.2# RBC-2.86 Hgb-9.3* Hct-27.5* MCV-96 MCH-32.5* MCHC-33.8 RDW-14.7 Plt Ct-135* [2107-9-19] 04:58PM BLOOD WBC-5.5# [2107-9-15] 11:10AM BLOOD PT-18.7* PTT-44.6* INR(PT)-2.5 [2107-9-16] 02:02AM BLOOD PT-14.0* PTT-35.4* INR(PT)-1.3 [2107-9-15] 11:33AM BLOOD UreaN-42* Creat-6.4# Cl-107 HCO3-25 [2107-9-19] 08:25AM BLOOD Glucose-140 UreaN-69* Creat-9.9* Na-134 K-3.8 Cl-95* HCO3-26 AnGap-17 [2107-9-19] 08:25AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.7 Mg-2.5 Brief Hospital Course: Pt. was a same day admit and on [2107-9-15] pt was brought directly to the OR and underwent a Coronary Artery Bypass Graft x 3. Please see op note for surgical details. Pt. tolerated the procedure well and had total bypass time of 64 minutes and cross-clamp time of 55 minutes. He was transferred to the CSRU in stable condition on a Neo-Synephrine gtt. That evening pt was weaned from sedation and mechanical ventilation and was extubated. Pt. was alert, awake and moving all extremities. By POD #1 Neo was weaned off, but was receiving a Nitro gtt (which was later weaned off on this day). He had hemodialysis and was then transferred to telemetry floor. Renal was consulted for further management of pt's ESRD. B-blockers were initiated. On POD #3 chest tubes were removed. On POD #4 pt was again dialyzed and had his epicardial pacing wires removed. Pt. was stable and improving well. Continued PT and improved with ambulation. On POD #5 pt was doing well, hemodynamically stable and cleared level 5. He was thus discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: 1. [Date Range ] 81mg qd 2. IC Renal 1 tablet qd 3. Toprol 100mg qd 4. Diovan 160mg qd 5. Lipitor 20mg qd 6. TUMS 5 tablets 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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 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:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:90 Tablet, Chewable(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Myocardial Infarction s/p Coronary Artery Bypass Graft x 3 End-Stage Renal Disease on Hemodialysis Renal Artery Stenosis Hypertension Hypercholesterolemia Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You should not lift more than 10 lbs for 3 months. You should not drive for 4 weeks. You should shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for sternal drainage, temp>101.5 Followup Instructions: Make an appointment with Dr. [Last Name (STitle) ] for 4 weeks. Make an appointment with your caridologist to 2-3 weeks. Please follow-up with your PCP next week. Completed by:[2107-10-5] ICD9 Codes: 4280, 4254, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8253 }	Medical Text: Admission Date: [2176-3-18] Discharge Date: [2176-3-29] Date of Birth: [2121-3-25] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor First Name 16571] Chief Complaint: Shortness of Breath/Abdominal Distension Major Surgical or Invasive Procedure: Therapeutic paracentesis History of Present Illness: Mrs. [Known lastname 81308] is a 55 year old female, who was diagnosed with breast cancer at [Hospital1 2025] about 2 years ago, however due to her religious beliefs as [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Scientist, she decided against persuing treatment. Patient had noticed a lump and nipple retraction in her left breast two years before presenting to [Hospital1 2025] at the urging of her husband for evaluation. According to [Hospital1 2025] records patient had a core biopsy of a 8 X 9 cm firm mass occupying the entire L breast. The core biopsy showed an invasive mammary carcinoma (lobular, E-Cadherin negative) that was ER +, PR+ and Her2neu-. Dr. [Last Name (STitle) 52918], the treating physician at [Name9 (PRE) 2025] discussed staging w/the patient including CT/bone scan imaging, lymph node biopsy and surgery. Mrs. [Known lastname 81308] did not follow up on these recommendations. . [Name (NI) 1094] husband, who is not [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Scientist, has been concerned but supportive of her beliefs. In the meantime patient chose to persue a CS approach by working with a CS practioner instead of paying attention to the progression of her illness. Patient had felt well until 9 months ago when she started becoming increasingly fatigued and limited in function, first unable to leave home and since [Month (only) 404] only able to ambulate from bed to comode. Husband noticed patient's abdominal girth increasing over last year with an acceleration over the last couple of weeks. Over the last few days Mrs. [Known lastname 81308] has had worsening abdominal distension and shortness of breath and has noted that her abdomen has increased in size markedly over that time. She has been laying only on one side, and has had increasing difficulty transfering from the bed to her commode. Her PO intake has been poor with significant wasting of her extremities and decreased appetite since [Month (only) 404]. . On [3-18] when her respiratory status became labored and he could no longer transfer her to the commode, she agreed to go to the hospital. The patient's sister had researched palliative care providers and was interested in coming to [Last Name (LF) 50345], [First Name3 (LF) ] transfer was made here. According to a palliative care note, Mrs. [Known lastname 81308] did not elaborate on her thoughts reagrding her illness or disease progression which her sister explained as part of CS belief system that thinking of any negative outcomes as that impacts the healing process. Note, according to family it is a contradiction to her religious practice to note the earthly changes in her body and seek medical help therefore she is uncomfortable answering questions regarding the history of her symptoms. According to patient she would prefer that medical team speak to the husband and allow him to filter information to her as he deems appropriate. Initially the husband and patient's sister said that they would like to hear all the oncological options possible and persue if necessary a more agressive approach and then afterwards consider a palliative approach. Both husband, sister, and pt confirmed that talking about her illness is uncomfortable and potentially damaging to pt's ability to practice her [Doctor First Name ] Science. They emphasized talking to pt about how she is currently feeling rather than the historical nature of her illness. A priority to the family is gettting a sense of prognosis because if it is believed that patient has only a short time to live they would like her daughter, who is living in [Country 14635] to come home as soon as possible. . In the emergency room, her initial vital signs were temperature of 97.8, blood pressure of 125/92, heart rate of 126, respiratory rate of 18, and oxygen saturation 84% on room air, requiring a non-rebreather. Discussion took place in the ED regarding goals, and patient expressed desire to be made more comfortable and although she did not want to be intubated, she was willing to undergo a paracentesis. She was admitted to the [Hospital Unit Name 153] for further management. . In the [Hospital Unit Name 153], she promptly underwent a 12.5L paracentesis with good effect on her dyspnea. Cytology was sent off. She was afebrile, tachycardic to the 120s, RR 24 and sating 92 on 40% face mask. . Review of systems was negative for fevers, chest pain, abdominal pain, nausea/vomiting, diarrhea/constipation. . Past Medical History: -Breast Cancer: ER/PR pos, Her2Neu neg, diagnosed at [Hospital1 2025]. Lobular carcinoma. Nodal status at time unknown (pt never had any imaging or further surgical interventions, treatments, or biopsies s/p core biopsy). Social History: Observant [Doctor First Name ] Scientist, married, lives in [Location (un) 3844]. Pt has a 22 year old daughter, [Name (NI) 636], living in [Country 14635], who has not seen her mother in 4 years. [Doctor Last Name 636] is also [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Scientist, she knows her mother is in the hospital and is communicating with her father for information. [Name (NI) 1094] sister (lives in [Location ]) and brother are aware of her diagnosis. Mrs. [Name (NI) 81309] sister has also been involved in patient's care. Mrs. [Known lastname 81308] worked at home (in bed) as a computer programmer for the [Doctor First Name ] Science Church in [Location (un) 7073] up until recently. Family History: Pt's parents both died from cancer. Her mother was [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Scientist and rejected treatment due to her religious beliefs. She died in her 70s. It's unclear when she was diagnosed. Her father died of Lymphoma. There is no other known breast or ovarian cancer in the family. Physical Exam: On admission: HR 125, BP 119/85, RR20, SAT 97% on ventimask, desating to 84% shortly thereafter General: Disheveled female appearing older than stated age, tachypneic, catchetic extremities HEENT: Atraumatic. Poor dentition, dry mucous membranes, clear oropharnyx. Neck: Supple, JVP difficult to assess secondary to tachypnea Lungs: Ascites tracking in soft tissue up left lung field in dependent area, to 3 cm below scapula. Lungs with slightly bronchial breath sounds bilaterally. No rales or rhonchi. Cardiac: Regular, tachycardic, no m/g/r appreciated Abdomen: Massively distended, with dullness and fluid wave appreciable. No tenderness, +BS Extr: Thin, no c/c/e Neuro: Awake, alert, appearing slightly uncomfortable. PEERL. Speech fluent, but limited by dyspnea. Pertinent Results: [2176-3-18] CXR: 1. Complete opacification of the left hemithorax, could represent large effusion, atelectasis, or pneumonia. 2. Near complete opacification of the imaged upper abdomen with few bowel loops interposed lateral to expected hepatic contour. [2176-3-18] 10:05PM BLOOD WBC-9.2 RBC-4.68 Hgb-11.9* Hct-37.2 MCV-79* MCH-25.5* MCHC-32.1 RDW-17.3* Plt Ct-316 [2176-3-18] 10:05PM BLOOD Neuts-74.7* Lymphs-20.3 Monos-3.5 Eos-1.3 Baso-0.3 [2176-3-18] 10:05PM BLOOD ALT-20 AST-49* CK(CPK)-173* AlkPhos-93 TotBili-0.4 [2176-3-18] 10:05PM BLOOD Lipase-46 [2176-3-18] 10:05PM BLOOD cTropnT-0.03* Brief Hospital Course: Patient is a 55 year old female who was diagnosed with breast cancer 2 years ago but declined medical care due to reglious beliefs, and then presented with massive ascites and shortness of breath. The following issues were addressed during her hospitalization: . #. Shortness of breath: Patient's chief complaint on arrival was her shortness of breath and she agreed to therapeutic paracentesis on several occasions to relieve her dyspnea and improve her mobility. Over 40 liters of fluid was drained on four seperate occasions with good effect on her dyspena. We attributed her dyspnea to the elevation of her diaphragm and splinting in the context of massive ascites and this was supported by improvement in her dyspnea with each tap. Her oxygen saturation was in her high 90s after the first initial paracentesis and throughout her stay. Patient was repleted with albumin on several occasions and her blood pressure remained in the systolic range of low 90s, high 80s and diastolic range between 50-60. She tolerated taps well without electolyte shifts and by the end of her hospitalization patient was able to lie on her back without dyspnea. A pulmonary embolism was initally also part of the differential for her dyspnea given her concurrent diagnosis of cancer but it was felt that a CTA was not possible given pt's inability to lie flat during most of her stay. We also didn't know whether or not she has metastatic lesions to her brain for which anticoagulation might be contraindicated. Patient was afebrile throughout her hospitalization without cough or leukocytosis to suggest pneumonia or spontaneous bacterial peritonitis. Given symptomatic improvement in SOB further diagnostic studies were not obtained. By the end of her hospitalization patient was able to lie on her back without dyspnea. . #. Breast cancer: Patient's diagnosis of lobular breast cancer was obtained at [Hospital1 2025] over two years ago. Mrs. [Known lastname 81308] has rejected treatment until this hospitalization. Mrs. [Known lastname 81308] deferred much of the decision making to her husband during the hospitalization but this preference was reaccessed each day by the team. There was an initial family meeting between Dr. [Last Name (STitle) 19], Mr. [Known lastname 81308], and patient's sister and brother that clarified this relationship and patient's evolving religious orientation to illness. Patient agreed to treatment with Letrozole 2.5 mg daily in setting of ER+ disease. Given the slower rate of reaccumulation after the last tap, we felt that Letrizole was having an effect. Endocrine was consulted about an abnormally low FSH and LH especially in a presumed post-menopausal woman (pt said her last period was several years ago). Other pituitary hormones were normal except for a low T4 which was explained as sick euthyroid. These alterations were explained as hypothalamic supression in the setting of illness and cachexia and patient was presumed to be post-menopausal by age and history of several years of amenorhea. . Pt had a transudative ascites by initial SAAG calculation. Cytology showed "rare, atypical cells" and a subsequent tap showed no malignant cells. Her CEA was 24, her CA27.29 was pending at the time of discharge. This will be followed by her primary oncologist at subsequent appointments. . At the time of discharge Mrs. [Known lastname 81308] had significantly more strength and mobility as compared to the time of admission. She was afebrile, with stable blood pressure and able to ambulate with the help of physical therapy. Medications on Admission: None Discharge Medications: 1. Letrozole 2.5 mg Tablet Sig: One (1) Tablet PO daily () as needed for metastatic breast cancer. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [1-5] Drops Ophthalmic PRN (as needed). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Metastatic Breast Cancer Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital because you were having shortness of breath. We drained over 40 liters of fluid out of your abdomen on several occasions in order for you to feel less short of breath and have better mobility. . You also decided that you would like treatment for your breast cancer so we started you on a medication called Letrozole 2.5 mg daily. It works by blocking estrogen production, the hormone that your tumor needs to grow. . We discharged you from the hospital because we felt that the level of care that you need could be given at a rehabilitation facility close to your home. You are going to a facility where they can monitor your breathing and blood pressure. They will also monitor your diet and offer you physical therapy to get you stronger before you return to home. . While you were here you also were noted to have a urinary tract infection which we treated with antibiotics. Your urinary burning went away. . Please follow-up with Dr. [Last Name (STitle) 19], the oncologist that treated you in the hospital (we have given you his card). If your abdomen becomes very large again, interfers with your breathing, and you would like more fluid taken off, you should call Dr. [Last Name (STitle) 19] and he will arrange a "tap" at the [Hospital1 ]. . If you become more short of breath, have chest pain, abdominal pain, fevers, nausea, vomiting, diarrhea, or any new concerns, please call your doctor or come back to the emergency room. Followup Instructions: Please call Dr. [Last Name (STitle) 19] at([Telephone/Fax (1) 5328] to schedule an appointment whenever you think is necessary. ICD9 Codes: 5119, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8254 }	Medical Text: Admission Date: [2129-5-12] Discharge Date: [2129-5-17] Date of Birth: [2072-5-1] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 348] Chief Complaint: Abdominal pain, Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: History of Present Illness: 57 yo female with ESRD on HD (MWF), HTN, HCV cirrhosis, Hypothyroidism, Anxiety, chronic back pain on methadone, called in to [Company 191] complaining of lower right abdominal pain, and referred to the ED. Of note, she was recently admitted to the hospitalist service for hypotension. During that admission she was thought to be over medicated, taking nitroglycerin daily instead of PRN, over beta-blocked. The patient was found to also be very hypothyroid, with TSH > assay. Adrenal insufficiency was ruled out. She was determined to have a dry weight of 74kg. Today, she reported to the [Company 191] nurse that her pain started on Sunday and radiates to the right side of the umbilicus. She feels this pain was similar to ovarian and renal cysts she had in the past. The pain limits ambulation and po intake. She reports nausea and vomiting X1 today. Denies diarrhea, melena, hematochezia, urinary symptoms. Last HD yesterday, and per her report her BP dropped to 70/p, HD had to be stopped early. . In the ED, initial vs were: 97.8 87 74/55 18 98% RA. Triggered for hypotension on arrival, denies taking any antihypertensives, took methadone at 7am. On exam, she was found to be somnolent, right sided CVA tenderness. Her labs were significant for lipase of 118, AP 199, ALT 47, AST 52, Tbili wnl, no leukocytosis, mild thrombocytopenia, INR 1.4, AG of 16, lactate of 2.5 initially and corrected to 1.5 with fluids. CXR showed mild bibasilar atelectasis. CT of the abd showed no acute abd pathology, fibroid uterus, 4-cm R adnexal complex cyst (old), atrophic right kidney, right hemicolectomy, new splenomegaly. Received a total of 1.2L NS with only mild improvement in BP to 89 systolic. She then had a R IJ placed, with improvement in BP to 104/69 without pressors. She also received vanc/zosyn for ? infection, although unclear source. On transfer to the floor, 77 104/69 12 98% on 2L. . On the floor, the patient continues to complain of right lower abdominal pain that radiates to her right flank and right leg. She reports mental slowing and "not feeling well." Past Medical History: -HTN -ESRD on hemodialysis -HCV cirrhosis -spinal stenosis with back pain -seizure disorder -depression -hypothyroidism -substance abuse -Lumbar laminectomy -status post failed renal transplant -cholecystectomy -thyroidectomy Social History: Retired special education teacher. Widowed, lives at home with sister, who is primary caregiver. [Name (NI) ] one son, who is healthy. # Tobacco: 3 packs per week since teenager # Alcohol: Denies # Drugs: Past IVDU, but not in several years Family History: Father: ESRD and hypertension Mother: lung cancer Physical Exam: General: Alert, with mildly slow to answer questions, oriented, no acute distress HEENT: Sclera anicteric, mm mildly dry, oropharynx clear Neck: RIJ in place, supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: [2-20] murmur radiates to the graft on the left, no rubs, gallops Abdomen: mild TTP of RLQ, RUQ, distended, soft, +BS GU: no foley Ext: RLE first two missing large portion of the toenail, granulation tissue present, no purulence. Pertinent Results: [2129-5-12] 07:31PM LACTATE-1.5 [2129-5-12] 06:48PM LACTATE-1.7 [2129-5-12] 03:33PM LACTATE-2.5* [2129-5-12] 03:33PM HGB-11.7* calcHCT-35 [2129-5-12] 03:20PM GLUCOSE-151* UREA N-37* CREAT-6.5* SODIUM-140 POTASSIUM-5.1 CHLORIDE-97 TOTAL CO2-27 ANION GAP-21* [2129-5-12] 03:20PM estGFR-Using this [2129-5-12] 03:20PM ALT(SGPT)-47* AST(SGOT)-52* ALK PHOS-199* TOT BILI-0.3 [2129-5-12] 03:20PM LIPASE-118* [2129-5-12] 03:20PM ALBUMIN-4.3 CALCIUM-7.9* PHOSPHATE-5.3* MAGNESIUM-1.8 [2129-5-12] 03:20PM WBC-5.9# RBC-3.76* HGB-11.4* HCT-34.2* MCV-91 MCH-30.3 MCHC-33.3 RDW-18.1* [2129-5-12] 03:20PM NEUTS-61.2 LYMPHS-29.2 MONOS-6.0 EOS-2.8 BASOS-0.7 [2129-5-12] 03:20PM PLT COUNT-119* [2129-5-12] 03:20PM PT-16.3* PTT-27.1 INR(PT)-1.4* , Imaging: CT Abdomen: INDICATION: 57-year-old female with right abdominal and flank pain x few days. COMPARISON: CT from [2129-4-20] and MR from [2129-4-22]. TECHNIQUE: Helical MDCT images were acquired from the lung bases through the greater trochanters without and with intravenous contrast, per the CT urogram protocol. The patient is scheduled for dialysis within the next 24 hours, per discussion with the referring physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2093]. 5-mm axial, coronal, and sagittal multiplanar reformats were generated. FINDINGS: Mild atelectasis is noted at the lung bases. There are no pleural effusions. The heart is normal in size, without pericardial effusion. Note is made of a moderate sliding hiatal hernia. ABDOMEN: The liver is mildly heterogeneous with a slightly irregular contour, consistent with known cirrhosis. Note is made of a recanalized umbilical vein and mild gastrohepatic varices. The gallbladder is surgically absent. The pancreas is normal. There is no intra- or extra-hepatic biliary ductal dilatation. The spleen is enlarged at 19 cm, previously 15 cm. Accessory splenule is noted posterior to the main splenic body. The adrenals are normal. The kidneys are atrophic, but enhance symmetrically. Multiple bilateral renal cysts are present. There are no renal stones, masses, or hydronephrosis. Stomach is distended with retained oral contents. Note is made of a diverticulum arising from the second portion of the duodenum. The small bowel demonstrates a slightly unusual configuration, likely post-surgical. PELVIS: Slightly atrophic transplant kidney measuring 6 cm in length is noted in the right iliac fossa, without significant contrast enhancement. Changes of right hemicolectomy are present, with intact anastomotic suture line in the right abdomen. There is a moderate amount of retained fecal material throughout the transverse and sigmoid colon. Multiple calcified fibroids are again noted in the uterus. There is a 4 x 4 cm right adnexal cystic lesion with single internal septation, which previously measured 4.3 x 3.5 cm. The bladder is partially collapsed. Small bilateral fat-containing inguinal hernias are present, left greater than right. Scattered calcifications are noted in the abdominal aorta and iliac arteries, with patent branch vessel origins. Scattered retroperitoneal and mesenteric lymph nodes measure up to 6 mm in short axis. There is no free intraperitoneal fluid or air. Mild degenerative changes are noted in the thoracolumbar spine, with grade 1 anterolisthesis at L4-L5. Moderate diffuse disc bulges are noted at L3-L4 through L5-S1, with impingement of the thecal sac outline; please note that CT cannot visualize intrathecal detail. Moderate facet hypertrophy and ligamentum flavum thickening are also present. IMPRESSION: 1. Fibroid uterus, with 4-cm right adnexal hypodense structure that should be evaluated by non-emergent pelvic ultrasound. 2. Acutely increased splenomegaly, may reflect infection or lymphoproliferative process. Please correlate clinically. 3. Cirrhosis 4. Atrophic native and transplant kidneys 5. Moderate hiatal hernia. The study and the report were reviewed by the staff radiologist. . US: The transabdominal ultrasound did not allow visualization of the uterus or the ovaries; therefore, we proceeded to a transvaginal examination. The uterus is enlarged and contains multiple fibroids. Overall, the uterus measures approximately 7.6 x 5.5 x 6 cm. Multiple, partially calcified fibroids distort the endometrial cavity. The largest fibroid lies posteriorly in the uterine body and measures approximately 4.5 x 4.3 x 3.9 cm. The endometrium is distorted by the multiple fibroids and difficult to visualize throughout its length, this measures approximately 3 mm in thickness. There is a large predominantly cystic mass in the right ovary. This measures 4 x 5 x 3 cm and contains multiple internal septations, several of which demonstrate internal blood flow. The left ovary measures 2.6 x 2 x 2 cm and contains multiple small cysts as well as a small calcified lesion measuring 0.7 x 0.6 x 0.6 cm. No free fluid seen in the pelvis. . IMPRESSION: 1. Bulky fibroid uterus as described. 2. The large cystic mass in the right ovary has some complex features, with multiple internal septations, some of which demonstrate vascularity and concerning for neoplasm. Recommend referral to OB/GYN for further assessment. 3. Multiple small cysts seen in the left ovary are also atypical in a postmenopausal woman and this should also be evaluated by OB/GYN. Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] was informed of the findings by telephone at 2pm [2129-5-13]. . MRI FINDINGS: Arising from the right ovary is a multiseptated lobular well-circumscribed T2 hyperintense lesion measuring 4.2 x 3.7 x 5.0 cm. Multiple internal septations are seen some with slight thickening. No nodular components are present. No surrounding inflammatory changes. The left ovary measures 2.8 x 1.5 cm and contains many physiologic follicles The uterus is anteverted with multiple T1 and T2 hypoattenuating masses demonstrating significant enhancement. The largest is in the posterior myometrium and measures 4.0 x 4.4 x 4.4 cm. It demonstrates progressive enhancement. An avidly enhancing exophytic anterior fibroid is also present measuring 2.2 x 2.4 cm. Additional smaller myometrial and subserosal fibroids are seen. There is trace fluid in the endometrial canal. Adjacent to the right external iliac vessels, a 1.0 x 0.8 cm ovoid soft tissue density is seen, perhaps a lymph node. No significant free fluid is present within the pelvis. No significant pelvic sidewall or inguinal adenopathy. Subcentimeter inguinal lymph nodes are present. Fat-containing left inguinal hernia without bowel content. The rectosigmoid contains a large amount of stool. No pericolonic stranding. Presacral fat is preserved. Within the right iliac fossa is an atrophic, abnormally appearing right renal transplant measuring 5.6 x 2.6 cm with diffuse irregular enhancement. No surrounding inflammatory changes. Visualized bone marrow signal is preserved. Multilevel lower lumbar degenerative disease. Post-surgical changes in the anterior hypogastrium are seen. No abnormal fluid collections. IMPRESSION: 1. Well-circumscribed multiseptated right adnexal lesion is present containing fluid content. Septations appear smooth throughout though some of the septations are mildly thickened. Though enhancement cannot be assessed without contrast, no definite nodular components or adjacent inflammatory changes are present. It appears stable in size since [Month (only) 404] [2129] but is new since the examination of [2125]. This lesion has features suggesting mucinous cystadenoma of the ovary. If no surgical intervention is planned, consider follow up imaging with MR or US to assess for continued stability. 2. Multiple uterine fibroids as previously described. Most demonstrate avid enhancement. 3. Left ovary with multiple physiologic follicles. No free fluid. 4. Atrophic, deformed right iliac fossa renal transplant. Discharge labs [2129-5-17] 05:34AM BLOOD WBC-4.0 RBC-3.52* Hgb-10.7* Hct-31.9* MCV-91 MCH-30.4 MCHC-33.6 RDW-17.4* Plt Ct-106* [2129-5-17] 05:34AM BLOOD Glucose-95 UreaN-42* Creat-6.1# Na-138 K-5.0 Cl-91 HCO3-35* AnGap-17 [2129-5-13] 03:03AM BLOOD ALT-43* AST-44* CK(CPK)-79 AlkPhos-175* TotBili-0.3 [2129-5-17] 05:34AM BLOOD Calcium-7.9* Phos-4.9# Mg-2.0 [2129-5-12] 03:20PM BLOOD TSH-5.6 [2129-5-14] 11:42AM BLOOD Cortsol-32.1* Brief Hospital Course: Ms. [Known lastname 3671] is a 57 year old female with HCV cirrhosis, ESRD s/p failed renal transplant, htn, CAD, hypothyroidism, and chronic back pain requiring methadone who presented to the ED with right lower quadrant pain in the context of a right adnexal complex mass. She became hypotensive in the ED and required fluid rescusitation in MICU overnight with an unclear cause of her hypotension. # Hypotension: The differential diganosis for her hypotension was broad, but it was felt that she had been taking her anti-hypertensives incorrectly and her hypotension corrected with volume. Additional causes of hypotension including adrenal insufficieny, hypothyroidism, and sepsis were all entertained. Upon arrival to the floor she was continued on HD for her ESRD, and her anti-hypertension medications were held. She will need to have her anti-hypertensive medications restarted as an outpatient. . # R ovarian mass: She presented with focal RLQ abdominal pain that was concerning for malignancy, but after consultation with Gyn/Onc, it was felt that the mass was not cancer and should be followed with serial imaging. # Chronic Pain: She has been on methadone for chronic pain. She was started on dilaudid PRN for addtional right lower quadrant pain. . # ESRD: Due to her hypocalcemia when she presented, there was concern that it may have caused her hypotension. Cinacalcet was discontinued, and she was started on vitamin D and calcium. . #Cirrhosis and splenomegaly: Secondary to HCV. Her LT's were mildly elevated during this admission, but otherwise stable. She has tender splenomegaly and portal or mesenteric vein thrombosis could be considered. . # CAD: Her last Cath showed that she did not have significant Coronary artery disease. Nevertheless, due to her hypotension, she was ruled out during this admission. She was continued on asa 81 mg and simvastatin 20 mg PO daily. . # Hypothyroidism: She was continued on her home levothyroxine 188mcg. . # Coagulopathy: She had a mildly elevated INR which was thought to be secondary to underlying poor synthetic liver function . # Thrombocytopenia: Her thrombocytopenia was thought to be secondary to her cirrhosis and was stable during this admission. . # Anemia of CKD: She receives erythropoietin as an outpatient. Her anemia was stable during this admission. . # Seizure Disorder: She was continued on her levetiracetam . # Depression/Anxiety: She was continued on her clonazepam and fluoxetine. . Discharge: Home with services Transition of care: The patient will need help with her medication regiment, she will also need to have her medications, including her hypertensive medication regiment adjusted. Medications on Admission: levetiracetam 250 mg PO BID fluticasone-salmeterol 250-50 mcg/dose Disk [Hospital1 ] levothyroxine 100 mcg + 88mcg once a day gabapentin 300 mg PO QHD clonazepam 0.5 mg PO BID methadone 10 mg/mL Concentrate 44 mg PO DAILY fluoxetine 60 mg PO DAILY calcium acetate 667 mg PO TID with meals aspirin 81 mg PO once a day. simvastatin 20 mg PO once a day. Sensipar 30 mg PO once a day. omeprazole 20 mg PO once a day. folic acid 1 mg PO once a day. trazodone 50 mg PO at bedtime. Discharge Medications: 1. levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 5. methadone 10 mg/mL Concentrate Sig: Forty Four (44) mg PO DAILY (Daily). 6. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. levothyroxine 100 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. levothyroxine 88 mcg Capsule Sig: One (1) Capsule PO once a day. 16. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 17. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 18. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Hypotension Right ovarian mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname 3671], It was a pleasure taking care of you at [Hospital1 18]. You were admitted to the hospital for treatment of low blood pressure and a right ovarian mass. You were in the medical intensive care unit for one night, where you were given intravenous fluids. Your blood pressure improved. On the regular medical floor, the gynecologists evaluated your right ovarian mass. After doing an ultrasound and MRI, we determined that the right ovarian mass is unlikely to be cancer. We will follow it with an ultrasound in [Month (only) ]. Please make the following changes to your home medications: - Take Dilaudid 2-4 mg up to four times per day as needed for pain for the next few days - STOP Sensipar - START calcium carbonate 500 mg twice daily - START vitamin D 1000 units daily Followup Instructions: Department: [Hospital3 249] When: THURSDAY [2129-5-26] at 3:20 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GASTROENTEROLOGY When: THURSDAY [2129-6-2] at 4:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4465], MD [Telephone/Fax (1) 463] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RADIOLOGY When: THURSDAY [2129-6-16] at 10:00 AM [Telephone/Fax (1) 327] Building: [Hospital6 29] [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: GYN SPECIALTY When: THURSDAY [2129-6-23] at 12:00 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 5777] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2129-6-16] ICD9 Codes: 5856, 2762, 5715, 2449, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8255 }	Medical Text: Admission Date: [2163-2-1] Discharge Date: [2163-2-24] Date of Birth: [2087-4-9] Sex: F Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This is a 75 year old female patient with a history of a right coronary angioplasty in [2155], who was referred for outpatient cardiac catheterization due to recurrence of anginal symptoms and a recent positive stress test. PAST MEDICAL HISTORY: Significant for: 1. Hypertension. 2. Hypercholesterolemia. 3. Significant smoking history, however, quit twenty years ago. 4. Insulin dependent diabetes mellitus. 5. Chronic anemia. 6. Gastroesophageal reflux disease. 7. Chronic renal insufficiency. 8. Status post hernia repair as a child. ALLERGIES: The patient states no known drug allergies. MEDICATIONS ON ADMISSION: 1. Humalog sliding scale insulin before meals. 2. Lantus insulin 25 units subcutaneous q.h.s. 3. Imdur 120 mg p.o. q.a.m. 4. Isordil 10 mg p.o. 2:00 p.m. daily. 5. Aspirin 81 mg p.o. q.d. 6. Lipitor 10 mg p.o. q.d. 7. Captopril 25 mg p.o. t.i.d. 8. Toprol 50 mg p.o. q.a.m. and 25 mg Toprol at 6:00 p.m. and 25 mg Toprol q.h.s. 9. Prevacid 30 mg p.o. q.d. 10. Vitamin E. 11. Senokot. LABORATORY DATA: On admission to the hospital include a white blood cell count 5.3, hematocrit 32.8, platelets 187,000. Sodium 141, potassium 4.0, chloride 107, CO2 27, blood urea nitrogen 21, creatinine 1.2. INR 1.17. PHYSICAL EXAMINATION: Upon admission to the hospital was unremarkable. Her room air oxygen saturation was 98%. Vital signs were stable. HOSPITAL COURSE: The patient was taken to the cardiac catheterization laboratory which reveals an 80% left main occlusion as well as three vessel coronary artery disease, left ventricular ejection fraction of 25%. Cardiothoracic surgery consultation was obtained at that time. The patient was taken to the operating room on [2163-2-2], with Dr. [Last Name (STitle) 70], and underwent coronary artery bypass graft times four with saphenous vein sequential graft to the left anterior descending and diagonal and saphenous vein sequential graft to the OM and distal right coronary artery. Postoperatively, the patient was transported from the operating room to the cardiac surgery recovery unit on intravenous Dobutamine, Neo-Synephrine, insulin and Caripoide, study drug. On postoperative day one, the patient was hemodynamically stable and was weaning off her vasoactive drips. The patient was transferred to the telemetry floor out of the Intensive Care Unit late in the day on postoperative day one. On postoperative day two, the patient remained hemodynamically stable. She was begun with diuretics and ace inhibitors and was beginning with postoperative physical therapy. On postoperative day three, the patient was noted having increased lethargy with intermittent periods of agitation. An echocardiogram was performed later that day to rule out cardiac tamponade and this was ruled out by echocardiogram. Her ejection fraction was estimated to be 35 to 40% which was essentially the same as her preoperative left ventricular ejection fraction and she had a small pericardial effusion with no evidence of tamponade by echocardiography. Neurology consultation was obtained also on [2163-2-5], which is postoperative day three due to her significant decline in mental status that was fairly acute in origin. Their thought at the time was that her mental status change was probably multifactorial and possibly related to medication effect. General surgery consultation was obtained at that time because the patient in addition to having mental status changes had been transferred to the Intensive Care Unit and was noted to have right lower quadrant abdominal pain for approximately one to two hours. A general surgery consultation was obtained for this reason. Later that day, the patient was intubated due to worsening respiratory distress and placed on a mechanical ventilator. CAT scan of the abdomen and pelvis revealed a distended gallbladder and hence the patient was taken late that night to the operating room for an exploratory laparotomy. Necrotic gallbladder with bilious fluid in the abdomen was found at that time as well as scarring of the anterior duodenal surface. A cholecystectomy was performed and the patient was transported postoperatively from the operating room to the Intensive Care Unit. She was on Neo-Synephrine, insulin, Propofol and Dobutamine drips postoperatively. The patient remained sedated over the next 48 hours, however, was noted to have decrease in urine output and an increasing creatinine and a renal medicine consultation was obtained at that time. It was their recommendation to dose medications for low creatinine clearance since her creatinine at that time had increased from a baseline of 1.2 to 2.0 and she was essentially oliguric. They also recommended to avoid diuretics and to avoid any nephrotoxic agents to try to maintain good blood flow to her periphery by maximizing hemodynamics. The patient had been started on Amiodarone intravenous drip due to postoperative atrial fibrillation on postoperative day seven from her coronary artery bypass graft and postoperative day two from her cholecystectomy, exploratory laparotomy. She had begun to improve hemodynamically. Her cardiac index had remained around 2.0 and remained on Amiodarone, Dobutamine, Neo-Synephrine, insulin and Propofol drips. She was also at that time on broad spectrum antibiotics due to her operative findings. The following day, [2163-2-7], the patient was noted to have decreasing metabolic acidosis. Her creatinine had stabilized at about 2.1 and her urine output was beginning to increase. Her antibiotics were continued at that time. The patient remained on full ventilator support throughout this course of her initial postoperative period due to fluid overload and need for continued sedation while she was stabilizing hemodynamically. On [2163-2-8], the patient remained on full ventilatory support. She had become very tachypneic every time any vent weaning was attempted. Pulmonary medicine consultation was obtained at that time. It was their recommendation to limit the fluid intake, to consider ultrafiltration due to her fluid overload and her marginal urine output and to attempt pressure support wean. The patient was initiated on low rate tube feedings enterally, however, she did not tolerate that due to high gastric residuals so she was placed on hyperalimentation at that time. Over the next 48 to 72 hours, the patient began to wake up and became more interactive, was tolerating her hyperalimentation, remained on Dobutamine which had been weaned down slowly and was on Fentanyl intravenous drip for sedation, remained on Amiodarone as well as triple antibiotic coverage for her bilious peritonitis. On [2163-2-10], the patient's spiked a fever to 102. Her intravenous central lines were changed. She was continued on antibiotics and continued on hyperalimentation. On [2163-2-11], postoperative day eleven from her cardiac surgery and postoperative day five from her abdominal surgery, the patient remains afebrile at this point in time and remains on full ventilator support. She was weaned off her Dobutamine, intravenous Hydralazine was initiated, and she began diuresing. Tube feeding was also reinstituted at this time. Late in the day on [2163-2-11], the patient had rapid atrial fibrillation and required electric cardioversion. She also received an extra bolus of intravenous Amiodarone and was converted successfully to normal sinus rhythm. By [2163-2-13], the patient was postoperative day seven from her abdominal surgery and had been weaned off all vasoactive drips. She had begun to be more awake and responsive and continued to diurese well. On [2163-2-16], because the patient still required full ventilatory support, it was determined to be in her best interest to undergo tracheostomy for continued support with a ventilator. This was done percutaneously by Dr. [First Name4 (NamePattern1) 951] [Last Name (NamePattern1) 952] in the Intensive Care Unit. The patient tolerated the procedure well. Around this time, the patient also underwent a dermatology consultation for a rash of unknown etiology and it was believed after skin biopsy was taken that this was a contact dermatitis of some sort. No treatment was initiated for it. Over the next few days, the patient began to become more awake and alert. She had been increasingly able to tolerate her tube feedings. Her hyperalimentation was discontinued and she was increased on her tube feeds to goal which is 60 cc/hour through a nasogastric feeding tube. The patient was begun on pressure support ventilation and beginning to tolerate intermittent periods of pressure support rather than full ventilatory support on the ventilator. The patient continued to progress well and remained stable hemodynamically. There were no new results on her cultures over the next few days. She was continued on her triple antibiotics for her surgical events, and her diuresis was continued and she was tolerating that well. Over the next few days, [Initials (NamePattern4) ] [Last Name (NamePattern4) ] consultation was obtained due to the patient's ongoing need for insulin and variable blood sugar due to tube feedings being increased. They made recommendations regarding her insulin and they have been following the patient over the next few days as well. On [2163-2-21], due to the patient become more awake and alert and more interactive, a bedside swallow evaluation was obtained as well as a video swallow which was obtained the following day. It was determined from the speech therapy evaluation that she can tolerate pudding, thick liquids and pureed solids but no thin liquids yet and she is to observed closely with aspiration precautions. The patient over the next two days has significantly been decreased from her ventilator and tolerating that quite well. She was noted [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Name8 (MD) 964] MEDQUIST36 D: [2163-2-23] 17:51 T: [2163-2-23] 1821 JOB ID#: [Numeric Identifier 29841] ICD9 Codes: 5845, 5185, 2762, 5119, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8256 }	Medical Text: Admission Date: [2145-7-22] Discharge Date: [2145-7-29] Date of Birth: [2077-8-22] Sex: M Service: MEDICINE Allergies: Penicillins / Avandia Attending:[First Name3 (LF) 1145] Chief Complaint: 6lb weight gain Major Surgical or Invasive Procedure: Swan Ganz Catherization History of Present Illness: 67yo Arabic-apeaking man with h/o severe biventricular failure, dilated ischemic CM, EF<=20%, s/p BiV ICD, severe pulm HTN, who was transferred to CCU today from OSH for CHF management. Pt was recently discharged from [Hospital Unit Name 196] ([Date range (1) 32502]), where he was treated for decompensated, [Last Name (un) 11840]. R sided, heart failure. He was discharged to home on [7-17] and has been doing well until a couple of days ago, when he noticed 6lb weight gain, mild dyspnea and profound weakness. Yesterday, he was having difficulty urinating, called clinic, was instructed to increase his aldactone to 25mg po qd. However, he was unable to urinate the entire day, and finally presented to [Hospital 7188] Hospital, RI at 4am this morning. Pt denies palpitations, CP, N/V, abd pain, fever, chills, dysuria, orthopnea, PND, LE swelling. He c/o some lightheadedness. No reports of ICD firing. Compliant with all medications and dietary modifications. At the OSH, got CTA chest/abd that showed no dissection/AAA, mod. ascites abd/pelvis, increased density within omental and mesenteric fat. He was afebrile, HR 70, initial BP 70/45, 96% 2L NC; got 300cc NS bolus, then NS @ 100cc/hr. At [Hospital1 18], c/o "wheezing" in chest, mild dyspnea, profound fatigue. Past Medical History: 1. CAD, s/p MI [2119]; exercise mibi ([2145-7-7])- reversible ant/apical perf. defect, fixed inf/lat defects 2. CHF: dilated ischemic cardiomyopathy w/VT (h/o ablation [2137]), s/p [Hospital1 ]-V ICD placement ([2137]); TTE- EF<=20%, severe global hypokinesis, 3+MR, 2+TR, severe pulm HTN 3. s/p BiV pacemaker 4. HTN 5. Type II diabetes mellitus 6. Gout 7. Ascites [2-24] R heart failure 8. Hypothyroidism s/p thyroidectomy 9. Chronic renal insufficiency, baseline Cr 2.0 10. Anemia of chronic disease 11. Guaiac+ stools, negative EGD and colonoscopy 11. h/o +PPD, treated with INH/PZA/RIF in [Country 1684] Social History: originally from [Country 1684], moved to US in [2125], prior distant tobacco hx, denies EtOH use Family History: F- MI @59yo, B- MI in 40s Physical Exam: Vit: 78 92/55 18 100% 2L NC Gen: appears fatigued HEENT: WNL Neck: JVD to ear CV: PMI displaced, RRR, nl s1 and s2, [3-28] TR and 2-3/6 MR Pulm: CTAB, no w/c/r Abd: distended, + ascites, + fluid wave, + palpable liver edge Ext: trace - 1+ edema, 1+ DP and PT pulses Pertinent Results: Admission Labs: [2145-7-22] 02:38PM BLOOD WBC-12.8* RBC-3.42* Hgb-9.7* Hct-29.3* MCV-86 MCH-28.3 MCHC-33.1 RDW-17.5* Plt Ct-182 [2145-7-22] 02:38PM BLOOD Glucose-40* UreaN-84* Creat-2.5* Na-127* K-3.9 Cl-90* HCO3-25 AnGap-16 [2145-7-22] 02:38PM BLOOD ALT-21 AST-24 LD(LDH)-140 CK(CPK)-51 AlkPhos-91 TotBili-0.6 . [2145-7-25] 04:20PM BLOOD Digoxin-1.0 [2145-7-29] 07:30AM BLOOD Glucose-144* UreaN-72* Creat-1.8* Na-127* K-4.7 Cl-91* HCO3-25 AnGap-16 . Urine Cytology - NEGATIVE FOR MALIGNANT CELLS. . [2145-7-22] - CXR: The heart is enlarged. There are no focal infiltrates. The defibrillator with RA, RV, and coronary sinus leads is again noted. There is pulmonary vascular engorgement. The post-CABG changes are evident. IMPRESSION: Congestive failure. . [2145-7-22] - LIMITED ABDOMEN ULTRASOUND: The liver is normal in echotexture and without intrahepatic biliary ductal dilatation. A large pocket of ascites fluid is identified within the right lower quadrant and a smaller amount is identified within the left upper quadrant. There is a left pleural effusion. IMPRESSION: Intraabdominal ascites. . EKG: A-V sequential pacing. Compared to the previous tracing of [2145-7-7] no significant diagnostic change. Brief Hospital Course: # CHF - Patient was admitted with CHF exacerbation felt to be secondary to confusion regarding medication regimen. A PA catheter was placed and showed CVP=22, RA=25, RV=70/26, PA=70/32, PCWP=32. He was diuresed with improvement in pulmonary edema and was started on lasix, hydralazine, isosorbide dinitrate, and digoxin. His lisinopril and aldactone were discontinued due to increasing potassium and history of hyperkalemia. . # CAD - He was continued on ASA, atorvastatin, digoxin and started on hydralazine and isosorbide dinitrate for afterload reduction in place of his lisinopril. He was hemodynamically stable on this regimen. . # h/o VT, h/o AFib, [Hospital1 ]-V ICD in place - Patient was continued on amiodarone and did not have any episodes of VT or Afib during this admission. . # Hematuria - Patient was noted to have gross blood on admission with report of traumatic foley insertion at the OSH and a hx of non-cancerous bladder lesions treated in [Country 1684] 3 years ago. U/A and culture ruled out UTI. Continuous bladder irrigation was performed until urine cleared. He was seen by urology who recommended urine cytology which was negative for malignant cells, and follow up as outpatient for further workup including cystoscopy and CT urogram (cr 1.9), MR-urogram or U/S. . # DM - Patient was hypoglycemic to 49 on admission. Oral hypoglycemics were held. He was seen by [Last Name (un) ] and started on lantus with an insulin sliding scale. He will have VNA services for further diabetes teaching and will call [Hospital ] clinic at [Telephone/Fax (1) 2384] for diabetes follow up appt as oupatient. . # ARF/CRF - Patient was admitted in prerenal ARF with inital Cr of 2.3, with diuresis and afterload reduction his Cr had improved to 1.8 (baseline) at discharge. . # Anemia of chronic disease - Patient had a slight decrease in hct and given his cardiac risk factors, the patient received one unit of blood during this admission without complications. He was continued on Procrit and iron supplements. Medications on Admission: Digoxin 62.5mcg qd ASA 325mg qd Atorvastatin 10mg qd Hydralazine 10mg q6h Furosemide 120mg [Hospital1 ] Amiodarone 100mg qd Lisinopril 2.5mg qd Spironolactone 25mg qd Glyburide 10mg qam, 5mg qpm Avandia 4mg qd Lantus (per home regimen) Procrit 4,000U MWF Levothyroxine 250mg qd Allopurinol 100mg qd Pantoprazole EC 40mg q12h Flomax SR 0.4mg qd MVI qd Folic acid 1mg qd Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Epoetin Alfa 4,000 unit/mL Solution Sig: [Numeric Identifier 890] ([Numeric Identifier 890]) units Injection once a week. 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Levothyroxine Sodium 125 mcg Tablet Sig: Two (2) Tablet PO once a day. 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:30 Capsule(s) Refills:2 12. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:2 14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 15. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 16. Lantus 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. Disp:1 Refills:2 Discharge Disposition: Home With Service Facility: VNA of [Location (un) 7188] [Doctor Last Name ] Discharge Diagnosis: Congestion Heart Failure exacerbation Hyperglycemia Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1 L Please note the changes in your medications. Followup Instructions: Please follow up with your PCP within one week.[First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3330], M.D. Where: OFF CAMPUS Phone:[Telephone/Fax (1) 3331] Date/Time:[2145-8-2] 11:30 Please follow up with [Doctor Last Name ] on [8-18], call the office for specific time at ([Telephone/Fax (1) 9530]. Please follow up with Urology ([Telephone/Fax (1) 32503] for an appt and scheduling of studies. Please call [Hospital ] clinic at [Telephone/Fax (1) 2384] for diabetes follow up appt as soon as possible. Completed by:[2146-2-13] ICD9 Codes: 4280, 5849, 2761, 4168, 2859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8257 }	Medical Text: Admission Date: [2168-5-28] Discharge Date: [2168-6-2] Date of Birth: [2117-8-31] Sex: M Service: MEDICINE Allergies: Fish derived Attending:[First Name3 (LF) 12174] Chief Complaint: hematemasis Major Surgical or Invasive Procedure: 1. EGD [2168-5-28] History of Present Illness: 50 yo M with history of PSC cirrhosis, varices, encephalopathy in addition to portal hypertension, on the transplant list who presents with 1 day of hematemsis and abd pain. Of note, patient was admitted [Date range (1) 62162] for similar presentation. He had an EGD on [5-4] which showed varices but no stigmata of bleeding. His nadolol was stopped for bradycardia. He underwent PMIBI for CP which was negative. He represents now after noticing black stools yesterday. He had dinner last night around 6pm and then at midnight had three episodes of emesis after eating at Chilis last night. The first episode he had small specs of fresh blood but then more blood to clots with subseqent episodes. He originally presented to OSH ED where VSS. Labs notable for WBC to 14.5, hct 38.5, plt 162, no bands. Na 130, K 6.0, lipase 347. He had hypoglycemia to 69 and given amp of d50, treated with morphine 4mg x2, zofran 4mg iv, and 10 U regular insulin. . In the ED, 95.4 80 100/70 18 2L NC. Tender abd. Not encephalopathic. Had 2 20G IVs placed and started on protonix bolus and drip, octreotide bolus and drip. He was type and crossed for two units. Blood cx and lactate obtained. Liver wanted CTX. Abdominal u/s with Doppler, r/o portal vein thrombosis. No emesis in ED. Admit for EGD. Prior to transfer 97.1 87 120/77 18 95% on RA. . Upon arriving to ICU, patient reported ongoing abd pain but no more emesis. He endorsed that his abd pain was different as usually it is associated with abd distention which he denied currently. Located mostly in the right upper quadrant. Endorsed urinary retention on admission. Denied fever, chills, or confusion. Reports lower edema extremity swelling improved. Reports compliance with medications. . ROS: Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation. No recent change in bladder habits. No dysuria. Denied arthralgias or myalgias. . Past Medical History: # Primary sclerosing cholangitis # History of UGIB in [10-12] # Hepatic encephalopathy # HCV: by history, had positive HCV with HCV VL in [2157], but on follow up cleared HCV spontaneously # Horseshoe kidney # Heart murmur # Distant history of polysubstance abuse # History of dysphagia with normal barium swallow on [2167-11-24] # Typical Angina Social History: Last drink 20 years ago. Quit smoking 14 years ago. Not employeed. Lives alone. Family History: No pertinent family history, including PSC, liver disease, or other gastrointestinal disease. Grandfather with diabetes. Physical Exam: ADMISSION: VS: Temp: 97.1 BP: 105/79 HR:87 RR:23 O2sat 95% 2L GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, icteric sclera, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: Decreased BS at b/l bases, otherwise CV: RR, S1 and S2 wnl, no m/r/g ABD: mild distension, tender diffusely worse in RUQ, no rebound or guarding, +b/s, soft, no masses or hepatosplenomegaly EXT: no c/c, 2+edema to midshins SKIN: no rashes/no splinters, slight jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis. DISCHARGE: VS: 98 97.1 109/68 99-118/68-82 60-71 18 98%RA 24H [Telephone/Fax (1) 82265]+, BMx2 GEN: pleasant, comfortable, NAD, appears slightly fatigued, A&Ox3 HEENT: EOMI, icteric sclera, MMM NECK: supple, no JVD RESP: no use access mm, CTAB without wheezes or crackles CV: RRR, S1 and S2 wnl, no appreciated murmurs ABD: +BS, moderate distension, tympanic to percussion, mildly tender to palpation RLQ, no rebound or guarding, soft, no masses or hepatosplenomegaly. No shifting dullness appreciated. EXT: warm, dry, 1+ pitting edema to just below the knee, mildly increased SKIN: no rashes, slight jaundice NEURO: AOx3. Cn II-XII grossing intact. Moving all extremities. Pertinent Results: ADMISSION LABS: [2168-5-28] 09:04PM SODIUM-132* POTASSIUM-4.7 CHLORIDE-103 [2168-5-28] 09:04PM HCT-33.3* [2168-5-28] 02:52PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.021 [2168-5-28] 02:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.5 LEUK-NEG [2168-5-28] 01:58PM GLUCOSE-122* UREA N-40* CREAT-1.3* SODIUM-130* POTASSIUM-7.1* CHLORIDE-98 TOTAL CO2-26 ANION GAP-13 [2168-5-28] 01:58PM ALT(SGPT)-107* AST(SGOT)-170* LD(LDH)-212 ALK PHOS-340* TOT BILI-5.1* [2168-5-28] 01:58PM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-2.1 [2168-5-28] 01:58PM VoidSpec-UNABLE TO [2168-5-28] 01:58PM HCT-39.2* [2168-5-28] 01:58PM PT-16.9* PTT-32.6 INR(PT)-1.5* [2168-5-28] 12:38PM LACTATE-1.7 [2168-5-28] 09:25AM GLUCOSE-112* UREA N-36* CREAT-1.1 SODIUM-130* POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-25 ANION GAP-14 [2168-5-28] 09:25AM estGFR-Using this [2168-5-28] 09:25AM WBC-17.3# RBC-4.49 HGB-14.3 HCT-41.7 MCV-93 MCH-31.8 MCHC-34.2 RDW-17.3* [2168-5-28] 09:25AM NEUTS-85* BANDS-0 LYMPHS-4* MONOS-10 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2168-5-28] 09:25AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-1+ TARGET-2+ SCHISTOCY-OCCASIONAL [2168-5-28] 09:25AM PLT SMR-NORMAL PLT COUNT-196 DISCHARGE LABS: [2168-6-2]: Na 131 K 4.5 Cl 100 HCO3 25 BUN 20 Cr 1.1 Gluc 104 Ca 8.2 Mg 2.2 P 2.8 ALT 86 AST 130 AP 260 Tbili 3.4 PT 18.4 PTT 34.9 INR 1.6 WBC 8.9 Hgb 11.5 Hgb 34.1 plt 153 Micro: BLOOD CX [2168-5-28]: PENDING URINE CX [2168-5-28]: NO GROWTH . CXR: [5-28] IMPRESSION: 1. Streaky bibasilar opacities, likely atelectasis, although early pneumonic infiltrates cannot be entirely excluded. 2. Prominence of the right superior mediastinum, to which attention should be paid with followup PA and lateral chest radiographs. [5-28] EGD: prelim: gastropathy with blood in the fundus, no major active bleeding, banded varices LIVER U/S [5-28]: IMPRESSION: 1. Patent hepatic vasculature. No evidence of portal vein thrombosis. 2. No acute process of the liver or gallbladder. 3. Liver cirrhosis, splenomegaly and mild-to-moderate amount of ascites. CXR [2168-5-29]: IMPRESSION: Streaky bibasilar atelectasis. Brief Hospital Course: Mr. [Known lastname 26438] is a 50 yo M with history of PSC cirrhosis, varices, encephalopathy in addition to portal hypertension, on the transplant list who presents with 1 day of hematemsis and abdominal pain. He was admitted to the ICU and had an EGD suggestive of portal hypertensive gastropathy with varices banded prophylactically. He was treated with 5 days of ceftriaxone for SBP ppx. He was transferred to the medicine floors and remained stable without further episodes of bleeding. He had a leukocytosis thought to be inflammatory response without fever or s/s of infection that downtrended. He was improved and discharged home. # Hematemesis: Patient s/p EGD in ICU. Showed portal hypertensive gastropathy as likely source of bleeding. He had esophageal varices that were not overtly bleeding but were banded prophylactically. Remained HD stable with active t+s. He was initially treated with octreotide and protonix gtt. Ceftriaxone was given for SBP prophylaxis. He was transferred to the medicine floors and had no further episodes of bleeding. He was transitioned to po protonix and carafate. Also restarted on Nadolol 10mg daily. He should have repeat EGD in [4-6] weeks with GI as an outpatient. # Abdominal pain: Seems to be chronic in nature per liver. Liver u/s showed patent vasculature. Lipase was normal. Pt had some mild discomfort on the floors, thought to be related to banding. Pt noted to have possible colopathy [2-3] cirrhosis vs. colitis on previous imaging. Pt was symptomatically improved and will follow-up with GI on discharge for further management. # Leukocytosis: Likely inflammatory response to GIB bleeding. WBC trended downward. Urine culture showed no growth. Blood cultures were negative. He remained afebrile during this admission and WBC was within normal limits on discharge. # ESLD: [2-3] PSC, MELD 17. Patient having GIB on admission, but not variceal (see above). He did not appear decompensated otherwise. His diuretics were initially held, and restarted on the floors. Restarted lasix 120mg daily (per recent dose change), and spironolactone at lowered dose 150mg daily. He was also restarted on Nadolol at a lowered dose. He was continued on home rifaximin, lactulose, and ursodiol. # Hyponatremia: Sodium lower than baseline, likely [2-3] hypervolemia and volume overload. Improved with fluid restriction and increased diuresis. Na was 131 on discharge. # Hyperkalemia: Slightly elevated on admission may be [2-3] spironolactone. Held spironolactone initially. Spironolactone was restarted slowly on the medicine floors with no more hyperkalemia. Discharged home on a lowered dose. TRANSITIONAL CARE: 1. CODE: FULL 2. CONTACT: [Name (NI) ] [Name (NI) 26438] sister Phone: [Telephone/Fax (1) 82266] 3. FOLLOW-UP: - GI, REPEAT EGD IN [4-6] WEEKS - LIVER - PCP 4. MEDICAL MANAGEMENT: - STARTED Pantoprazole 40mg by mouth twice daily, Sucralfate 1gm by mouth four times daily - DECREASE the amount of Spironolactone from 200mg daily to 150mg by mouth daily - RESTARTED Nadolol at 10mg by mouth daily 5. OUTSTANDING TASKS: none Medications on Admission: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Do not exceed [2157] mg daily as this can damage the liver. . 4. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. furosemide 40mg mg Tablet Sig: 3 Tablet PO DAILY (Daily). 6. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO TID (3 times a day). 7. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 8. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. ursodiol 250 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual once a day as needed for chest pain for 1 doses: Use for chest pain. If chest pain persists after 3 doses, call 911 or report to the nearest emergency room. . 12. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. tramadol 50 mg Tablet Sig: One 1.5 Tablet PO every 6-8 hours as needed for pain: Do not drive or operate machinery while using this medication. [Month (only) 116] cause confusion or somnolence. 14. clotrimazole 10 mg Troche Sig: One (1) Mucous membrane four times a day. Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: Do not exceed [2157] mg daily as this can damage the liver. . 4. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO TID (3 times a day). 5. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 7. hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO three times a day. 8. ursodiol 250 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once may repeat x1 as needed for chest pain: Use for chest pain. If chest pain persists after 3 doses, call 911 or report to the nearest emergency room. . 10. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. tramadol 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours) as needed for abd pain: Do not drive or operate machinery while using this medication. [Month (only) 116] cause confusion or somnolence. . 12. clotrimazole 10 mg Troche Sig: One (1) Mucous membrane four times a day. 13. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 15. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 16. furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 17. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Discharge Disposition: Home With Service Facility: VNAs of [Location (un) 511] Discharge Diagnosis: Primary Diagnoses: 1. Upper GI bleed 2. Portal hypertensive gastropathy 3. Abdominal pain 4. Hyperkalemia Secondary Diagnoses: 1. End-stage liver disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 26438], It was a pleasure taking care of you during this admission. You were admitted with vomiting up blood. You had an endoscopy showing some blood probably from portal hypertension associated with you liver disease. You had several varices that were not bleeding but were banded to prevent bleeding. You will need to have a repeated endoscopy with the GI doctors [Last Name (NamePattern4) ] [4-6] weeks when you leave here. We made a few medication changes, see below. You had some chest pain, which is due to the banding, and should improve over time. The following medications were changed during this admission: - DEACREASE the amount of Spironolactone from 200mg daily to 150mg by mouth daily You will need to have your labs checked and this dose may be adjusted by your doctors based on the labs and your swelling. - START Pantoprazole 40mg by mouth twice daily - START Sucralfate 1gm by mouth four times daily - RESTART Nadolol at a lower dose that you have taken prior at 10mg by mouth daily Please continue the other medications you were on prior to this admission. Followup Instructions: Please follow-up with the following appointments: Department: TRANSPLANT When: WEDNESDAY [2168-6-8] at 2:20 PM With: TRANSPLANT [Hospital 1389] CLINIC [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Name: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 82267],MD Specialty: Primary Care Address: [Street Address(2) 82262], E. [Hospital1 ],[Numeric Identifier 82263] Phone: [Telephone/Fax (1) 82264] When: Wednesday, [6-15] at 12:30pm Department: ENDO SUITES When: THURSDAY [2168-6-16] at 12:30 PM You will have to be accompanied by someone as they will need to take you home after receiving sedating medications. Department: DIGESTIVE DISEASE CENTER When: THURSDAY [2168-6-16] at 12:30 PM With: [Name6 (MD) 1382] [Name8 (MD) 1383], MD [Telephone/Fax (1) 463] Building: [First Name8 (NamePattern2) ] [Hospital Ward Name 1950] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3202] Campus: EAST Best Parking: Main Garage Completed by:[2168-6-3**] ICD9 Codes: 5789, 2761, 5715, 2767
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8258 }	Medical Text: Admission Date: [2155-12-6] Discharge Date: [2155-12-6] Date of Birth: [2091-6-10] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5018] Chief Complaint: Headache Major Surgical or Invasive Procedure: None History of Present Illness: HPI: The pt is a 64 year-old man with a history of DM, HTN and chronic back pain who presents with headache and unresponsiveness, found to have a large cerebellar hemorrhage. Per his family, overnight last night he began to complain of a worsening headache, and became less responsive this morning, at which time EMS was called. On arrival EMS reported that he was awake, but only oriented to self, with possible decreased movement on the right compared to the left. En route to the hospital he developed agonal respirations, and by the time he arrived in the ED he was completely unresponsive, though was still breathing on his own. On arrival he was noted to have 2mm minimally reactive pupils, and no gag reflex. He was intubated for airway protection. He had a head CT which showed a large cerebellar hemorrhage with intraventricular extension. He was seen by Neurosurgery, who felt this was non-operative, at which point Neurology was consulted. He was also noted to be hypertensive to 213/103, for which he was started on a nicardipine drip. Patient intubated, unable to answer ROS. Past Medical History: -HTN -DM -Gout Social History: Lives in [Location 745] with his wife, son and daughter in law. Family History: Unknown Physical Exam: Vitals: P: 92 R: 13 BP: 152/67 SaO2: 100% intubated General: Intubated 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: RRR, nl. S1S2, no M/R/G noted Abdomen: obese, soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: occasional areas of scarring over distal lower extremities Neurologic: -Mental Status: Intubated, off propofol for ~2 hours, not responsive to verbal or painful stimuli. -Cranial Nerves: Pupils 2mm, sluggish, minimally reactive. Negative corneals, negative oculocephalics. Negative gag. -Motor/Sensory: Flaccid tone throughout, though with occasional fine amplitude rhythmic shaking of his shoulders, that is suppressible. No response to painful stimuli in upper extremities, triple flexion in bilateral lower extremities. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 3 3 3 3 1 Plantar response was extensor bilaterally. Pertinent Results: Admission Labs: 144 \| 114 \| 15 ---------------< 151 3.3 \| 17 \| 0.6 Ca: 6.6 Mg: 1.3 PO4: 2.4 ALT: 16 AST: 30 AlkP: 68 TBil: 0.6 Trop: <0.01 PT: 13.6 PTT: 23.3 INR: 1.2 17.1 8.1 >--------< 135 49.1 U/A: negative Imaging: NON-CONTRAST HEAD CT: There is a large intraparenchymal hematoma within the posterior fossa, measuring 4.0 x 7.3 cm axially. There is extension into the ventricular system, including the fourth, third, and lateral ventricles. There is extensive mass effect, with herniation of the tonsils inferiorly through the foramen magnum, and upward transtentorial herniation with effacement of the basal cisterns. The brainstem is compressed anteriorly. There is additional subarachnoid hemorrhage seen within the basal cisterns. There is no further intraparenchymal hematoma supratentorially. There is no subdural or epidural hematoma. The bones are unremarkable, and the visualized paranasal sinuses are clear. IMPRESSION: Large posterior fossa intraparenchymal hematoma measuring up to 4 x 7.3 cm, actually, with extension into the ventricles. Additional subarachnoid hemorrhage is seen in the basal cisterns. There is extensive mass effect, with upward transtentorial herniation causing effacement of the basal cisterns, compression of the brainstem anteriorly, and downward tonsillar herniation through the foramen magnum.Dilated temporal horns indicate developing hydrocephalus. CXR: FINDINGS: An endotracheal tube is in position with tip approximately 8 cm above the carina. Lung volumes are low. There is likely some atelectasis at the bases and in the right middle lobe; however, no definite opacity to suggest pneumonia is seen, though the right infrahilar region is not well evaluted. No pleural effusion or pneumothorax is identified. An NGT is in place with tip out of view of the radiograph, below the diaphragm. IMPRESSION: Status post endotracheal tube placement with tip approximately 8 cm above the carina. Brief Hospital Course: Mr. [Known firstname ] [Known lastname 30485] is a 64 year-old man with a history of HTN, DM, gout and chronic back pain presenting with severe headache followed by unresponsiveness, found to have a large cerebellar hemorrhage with intraventricular extension. On discovery of the hemorrhage, he was initially evaluated by Neurosurgery, however given the extent of the hemorrhage, he was determined not to be a surgical candidate. He was initially intubated for airway protection, and placed on a nicardipine drip for blood pressure control, and admitted to the NeuroICU. After the rest of his family arrived, further discussion was held with the family regarding his overall poor prognosis given the extent of the hemorrhage and low likelihood of meaningful recovery. The family stated that their father would not desire to be on extended life support and the decision was made to make him CMO. The priest was called to administer last rites, afterwhich the patient was extubated, and died shortly thereafter. Medications on Admission: Unknown - thought to include lisinopril and prednisone Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] ICD9 Codes: 431, 4019, 2749
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8259 }	Medical Text: Admission Date: [2175-9-27] Discharge Date: [2175-9-28] Date of Birth: [2101-11-11] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 158] Chief Complaint: rectal bleeding following prostate biopsy Major Surgical or Invasive Procedure: 1. prostate biopsy 2. exam under anesthesia 3. ligation of post-prostate biopsy bleeding History of Present Illness: The patient is a 73-year-old man who underwent a prostate biopsy in [Hospital 159] clinic complicated by immediate significant bright red blood bleeding. Attempts were made to stop the bleeding with a dilating Foley balloon and Surgicel packing without success. He was admitted for surgical management of bleeding. Past Medical History: hyperlipidemia, coronary artery disease, prostate cancer, gout Social History: Retired as a waiter in a Chinese restaurant. Patient is an accomplished poet who has published works in Chinese. Daughter is nurse. Tobacco none ETOH: None Drugs: None Family History: non-contributory Physical Exam: VS T 98.5 HR 68 BP 91/52 RR 18 SpO2 98%RA\ Gen: NAD, AOx3 Cv: RRR Pulm: CTAB Abd: soft, non-tender Rectal: no gross blood Ext: warm Pertinent Results: [2175-9-27] 05:16PM BLOOD WBC-13.0# RBC-3.64 Hgb-11.8* Hct-33.7* MCV-93 MCH-32.5* MCHC-35.1* RDW-13.0 Plt Ct-138* [2175-9-27] 08:54PM BLOOD WBC-11.9* RBC-3.61* Hgb-11.8* Hct-33.7* MCV-93 MCH-32.7* MCHC-35.0 RDW-12.9 Plt Ct-143* [2175-9-28] 01:45AM BLOOD Hct-29.6* [2175-9-28] 05:30AM BLOOD WBC-10.1 RBC-3.07* Hgb-10.1* Hct-28.6* MCV-93 MCH-32.9* MCHC-35.3* RDW-13.4 Plt Ct-144* Brief Hospital Course: The patient was admitted to the surgery service for management of rectal bleeding following prostate biopsy. He underwent a rectal exam under anesthesia followed by ligation of the bleeding biopsy site. He tolerated the procedure well and recovered briefly in the PACU before being transferred to the floor. Please see the operative report for further details. His hospital course was relatively uneventful. N: His pain was managed initially with IV pain medicines and then transitioned to po medicines with issue Cv: stable, no issues Pulm: Excellent oxygen saturations on room air GI: overnight the patient passed clotted blood per rectum several times. This resolved on POD #1 and no bright red blood was observed. Serial hematocrit values were obtained and shown to be stable in the AM compared to the post-operative value. He was started on a clear liquid diet and was advanced to a regular diet without issues. GU: voided without difficulty HEME: stable as described above. No transfusions required. ID: afebrile without issues DISPO: The patient was no longer bleeding and felt to be stable. He was tolerating a regular diet, voiding, and ambulating appropriately. He was discharged home with follow-up instructions. Medications on Admission: allopurinol, finasteride, metoprolol, simvastatin Discharge Medications: 1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 5. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:45 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: rectal bleeding 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. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Followup Instructions: Please call the surgery clinic at [Telephone/Fax (1) 160] to schedule follow-up with Dr. [Last Name (STitle) ] in [1-15] weeks or as necessary. Please also follow-up with your primary care physician. Provider [First Name8 (NamePattern2) 161] [Name9 (PRE) 162] [Name8 (MD) 163], MD Phone:[Telephone/Fax (1) 164] Date/Time:[2175-10-11] 1:00 Completed by:[2175-9-28] ICD9 Codes: 2875, 4589, 2851, 2724, 2749, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8260 }	Medical Text: Admission Date: [2145-8-11] Discharge Date: [2145-8-15] Date of Birth: [2079-10-15] Sex: M Service: SURGERY Allergies: Reglan Attending:[First Name3 (LF) 148] Chief Complaint: Abdominal pain, nausea and vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Patient reported to a referring hospital presenting with one day of nausea, vomiting and abdominal pain described as "the worst pain of his life." The pain was located in the epigastric region with no radiation. Past Medical History: 1. Duodenal mass 2. Whipple - s/p pancreaticoduodenectomy w/open cholecystectomy ([8-12]) (Benign) 3. CAD s/p stent 4. DM type 2 5. HTN 6. Arthritis 7. Hypercholesterolemia 8. Afferent loop syndrome 9. Pancreatitis 10. Pancreatic duct anastomotic stricture 11. Revision of pancreatico-jejunostomy anastomosis ([10-12]). Social History: 1ppd, quit >23 years ago. Alcohol history is significant only for occasional use. He has no known environmental exposures. Family History: non contributory Physical Exam: On discharge the patient looked well and his vital signs were stable and within normal limits. The patient was not in any acute distress and ambulating well. His pulmonary exam was clear to ausculation bilaterally, cardiovascular exam - regular rate and rhythmn, his abdomen was soft, nontender and non distended with no organomegaly, and he had bowel sounds present. Pertinent Results: [2145-8-11] 01:02PM LACTATE-1.7 [2145-8-11] 10:29AM CK-MB-NotDone cTropnT-<0.01 [2145-8-11] 06:09AM GLUCOSE-191* UREA N-19 CREAT-1.3* SODIUM-141 POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-21* ANION GAP-14 [2145-8-11] 06:09AM ALT(SGPT)-314* AST(SGOT)-275* LD(LDH)-240 ALK PHOS-76 AMYLASE-372* TOT BILI-2.6* DIR BILI-2.4* INDIR BIL-0.2 [2145-8-11] 06:09AM LIPASE-921* [2145-8-11] 06:09AM CALCIUM-7.5* PHOSPHATE-2.1* MAGNESIUM-1.4* [2145-8-11] 06:09AM WBC-12.8* RBC-3.42* HGB-11.1* HCT-31.2* MCV-91 MCH-32.4* MCHC-35.6* RDW-14.0 [2145-8-11] 06:09AM PLT COUNT-205 [2145-8-11] 06:09AM PT-13.4* PTT-28.7 INR(PT)-1.2* . CT abdomen/pelvis 1. Enhancement of the bile ducts consistent with acute cholangitis. 2. Pancreatic duct dilation and peripancreatic stranding could suggest pancreatitis.Correlation with biochemistry recommeded 3. Mildly dilated intra-hepatic ducts with decreased pneumobilia. 4. Increased peribronchial and interstitial opacities in the lung bases. Brief Hospital Course: The patient was admitted as a direct admit to the floor. He complained of epigastric abdominal pain, nausea and was vomiting. On the floor his blood pressure was low at 80's systolic after 1 liter of normal saline and he was thus transferred to the intensive care unit. He underwent an emergent CT scan of the abdomen and pelvis that showed 1. Enhancement of the bile ducts consistent with acute cholangitis. 2. Pancreatic duct dilation and peripancreatic stranding could suggest pancreatitis. 3. Mildly dilated intra-hepatic ducts with decreased pneumobilia. 4. Increased peribronchial and interstitial opacities in the lung bases. . Neuro: His pain was well-controlled with IV and oral dilaudid. . Cardiovascular He was fluid resuscitated in the intensive care unit with good response and transferred to the floor in hemodyanically stable condition. . Pulmonary No issues . FEN/GI: . Renal: . Heme The patient's hematocrit remained stable throughout his hospitalization. . Infectious disease He was started empirically on vancomycin and zosyn. His blood cultures grew out klebsiella that was pan-sensitive (except for penicillin). He was discharged on oral augmentin for a 10-day course. He was discharged in stable condition on hospital day #5 with plans for ERCP 2 days later. Medications on Admission: Metformin lisinopril lipitor tricor Discharge Medications: 1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day for 10 days. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. cholangitis 2. Pancreatitis 3. Klebsiella bacteremia Discharge Condition: Good to home with plans for follow-up Discharge Instructions: Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience a return of abdominal pain, nausea or vomiting * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Continue on antibiotics for 10 days. * Continue to amubulate several times per day. Followup Instructions: 1. You are scheduled for an Endoscopic Retrograde Cholangiopancreatography (ERCP) on Tuesday, [2145-8-17]. Please report to the hospital for this as directed. The phone number for Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] is ([Telephone/Fax (1) 2306] and the phone number for ERCP is ([Telephone/Fax (1) 2360]. Please call for details regarding this procedure. Dr. [Last Name (STitle) ] will follow-up the results of this study. ICD9 Codes: 7907, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8261 }	Medical Text: Admission Date: [2173-10-16] Discharge Date: [2173-10-18] Date of Birth: [2173-10-16] Sex: F Service: NB NICU was asked to evaluate this infant born at term with mild respiratory distress after delivery. PRENATAL HISTORY: Mother is a 41-year-old G2, P0 now 1 mother with an [Name (NI) 37516] of [2173-10-29]. PRENATAL SCREENS: Blood type A+, antibody negative, HBSAG negative, RPR nonreactive, rubella immune, GBS unknown. [Hospital ] MEDICAL HISTORY: Notable for hypothyroidism treated with Levoxyl. Benign antepartum course. Labor and delivery was notable for induction secondary to fetal heart rate decels noted in the obstetrician's office. Continued fetal heart rate deceleration and failure to progress prompted delivery by cesarean section. Maternal maximum temperature prior to delivery was 99, but increased to 100 degrees after delivery. AROM occurred 8 hours prior to delivery. There was no intrapartum antibiotic prophylaxis administered. The infant required only routine care and blow-by oxygen in the delivery room. Apgars were 8 and 9 at 1 and 5 minutes. The infant was noted to have persisted grunting in the delivery room and therefore the NICU was consulted and the infant was transferred to the NICU for further evaluation and management. PHYSICAL EXAMINATION: Physical exam showed a birth weight of 3360 grams which is 75th percentile, length of 41 cm which is 75th to 90th percentile, head circumference not measured. Physical exam on discharge from the NICU shows active and alert infant. Anterior fontanelle open and flat with some molding. Respiratory: Breath sounds clear and equal with mild subcostal retractions. Cardiac: Normal rate and rhythm, no murmur, normal pulses, pink and well perfused. Abdomen: Soft and benign, no masses. Patent anus. GU: Normal female external genitalia. Normal back, extremities and hips. Neuro: Appropriate tone strength for gestational age. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The infant came to the NICU with grunting, flaring and retracting. Had a chest x-ray that was consistent with transient tachypnea of the newborn. The infant was placed on CPAP and remained on CPAP for approximately 12 hours prior to transitioning to room air. The infant has been on room air since [2173-10-17] at 9 a.m (>24 hours). The infant has had no issues with apnea or desaturation episodes. Cardiovascular: The infant has maintained cardiovascular stability while in the NICU. There is a murmur present. Fluid, electrolytes and nutrition: The infant was started on IV fluids due to the increased respiratory effort on the newborn day. The infant started enteral feedings on [2173-10-17]. The infant is presently weaned off IV fluid and ad lib p.o. feeding of breast milk or E20 with iron. No electrolytes have been done on this infant. Most recent weight is 3280 grams. GI: Bilirubin screening has not been done on this infant thus far, but is recommended for day 3 of life or prior to discharge from the newborn nursery. Hematology: Crit at birth was 52 with a platelet count of 230, no further crits or platelets have been measured. No blood typing has been done on this infant. Infectious disease: A CBC and blood culture were screened on admission to the NICU due to the respiratory distress. The CBC was benign with no left shift. Ampicillin and Gentamycin were initiated and the infant will receive 48 hours of ampicillin and gentamycin pending blood culture 48 hour results. Blood culture has been negative to date. Neurology: The infant has maintained a normal neurologic exam. Sensory: Audiology: A hearing screen will need to be performed prior to discharge from the newborn nursery. It has not been done thus far in the NICU. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Transfer to the newborn nursery. NAME OF PRIMARY PEDIATRICIAN: At the time of delivery, the parents had not decided on a pediatrician. While in the hospital she will be cared for by the [Location (un) 13248] Newborn Service physicians. They will need to choose a pediatrician prior to discharge from the hospital. CARE RECOMMENDATIONS: Ad lib p.o. feeding by breast or supplement with Enfamil 20 cal per ounce. MEDICATIONS: None. IRON AND VITAMIN D SUPPLEMENTATION: 1. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. 2. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 IU which may be provided as multivitamin preparation daily until 12 months corrected age. State newborn screen will need to be sent on day of life 3, it has not been sent thus far. IMMUNIZATIONS RECEIVED: None IMMUNIZATIONS RECOMMENDED: 1. Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 4 criteria. a. Born less than 32 weeks gestation. b. Born between 32 and 35 weeks with 2 of following: Either daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school- aged siblings; c. Chronic lung disease; d. Hemodynamically significant congenital heart defect. 2. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. 3. This infant has not received a rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks, but fewer than 12 weeks of age. Follow-up appointment is recommended with the pediatrician after discharge. DISCHARGE DIAGNOSES: Transient tachypnea of the newborn resolved. Sepsis ruled out. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 54936] Dictated By:[Name8 (MD) 62299] MEDQUIST36 D: [2173-10-17] 22:14:53 T: [2173-10-18] 01:54:21 Job#: [Job Number 75056] ICD9 Codes: V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8262 }	Medical Text: Admission Date: [2156-7-28] Discharge Date: [2156-7-30] Service: MEDICINE Allergies: Oxycodone / Percocet / Percodan / simvastatin / aspirin Attending:[Last Name (un) 2888] Chief Complaint: Hypertension Major Surgical or Invasive Procedure: None History of Present Illness: [Age over 90 ]F w/ CHF s/p CORE VALVE for AS, saw Dr [Last Name (STitle) ] (cards) in [Location (un) ] building today when was noted be hypertensive (SBP in 230s). Was also reporting weakness so was sent to ED for evaluation. On arrival, pt c/o feeling generalized weakness x "weeks", "tired", reports feeling unsteady gait. No CP, no SOB. SBP in 210s-220s in both arms on manuak recheck. pt not reporting any CP, anuria, visual changes. Pt unable to recall whether she took her medications for BP. Says list is long and is mostly managed by husband. . Admit weight 45kg Vitals in ED: 98.0, HR 47, BP 235/74, 20 99% RA Nicardipine 1mc/kg/min . EKG: compared to prior, prominent peaked t waves in V [12-2], with ?ST elevations in V1-3 and depression in I and AVL. HR in the 40s, sinus. Based on EKG, absolute HR, and headache/weakness, pt was treated for HTN emergency and started on nicardapine drip. . CXR wet read: hyperinflation, no ptx, no pulm edema, no acute process. . - Pertinent recent medical hx includes core valve on [2156-2-19] [multiple ER visits for GI discomfort, was noted to have murmer, echo revealed severe AS. She admits to frequent episodes of dizziness, sometimes at rest. She is only able to tolerate [1-2] steps without stopping due to shortness of breath. She reports extreme worsening fatigue, and inability to do any ADLs without frequently stopping due to shortness of breath and fatigue. She is unable to bend forward to reach something low due to dizziness and lightheadedness. ] . Pt has been in paroxysmal afib since after procedure, EP evaluated the patient and recommended rate control with beta blocker, without amiodarone. Additionally, it was decided by Dr. [Last Name (STitle) ] not to anti-coagulate the patient taking into consideration her age and that she is already on Plavix and Aspirin. . [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]: [Date range (1) 92298] - SOB, found to have pAFib HR 90-130s -> continued full dose ASA, inc metoprolol 50mg [Hospital1 ] HR 50s on discharge, EGD showed moderate erosive antral gastritis, cont Protonix . [Date range (1) 92299]/12 - 110lbs. admitted with palpitations, some confusion about her medications at home, he mainly complains of weakness and dizziness, no active chest pain -> Nuclear stress test showed (1) No arrhythmias. (2) No chest pain. (3) Normal conduction. (4) ST-segment normal. - 28. 5 mg of persantine infused. Non diagnostic/baseline EKG changes. . [Date range (1) 92300] - Complaint of fatigue, dizziness, lightheadedness, and urinary frequency. Attributed to hypoNa and UTI, responded well to IVF and Rocephin(CTX), evaluated by Cards without concern. . [Date range (1) 92301] - Nausea, anorexia, and 10pound weight loss, tx 2U RBC, . On arrival to the floor, patient 180s-190s/80s-90s, HR 50-60, 98% on RA . REVIEW OF SYSTEMS No chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: - Severe Aortic stenosis s/p Transcatheter aortic valve replacement with a CoreValve [2156-2-19] - myasthenia [Last Name (un) 2902] - left carotid bruit - hypertension - hyperlipidemia - COPD - Seasonal allergies - hypothyroid - irritable bowel syndrome (current loose stools, abd pain) - GERD - chronic anemia (r/o IgA kappa MGUS) - polypectomy - herniated cervical disk - L4-L5 back pain (epidural injections - pain clinic) - overactive bladder - double scoliosis (pain clinic) - partial vulvectomy - exlap, oopherectomy, lysis of adhesions Social History: - independent ADLs - gardens, cooks - Split level home, lives with husband (age [Age over 90 ]) and disabled son (age 56). No assistance currently. Son with many medical issues, patient and husband manage his care. -Tobacco history: never -ETOH: none -Illicit drugs: none Family History: Father deceased (age 85), CAD. Mother deceased (age 85), colon Ca. Two brothers living with CAD, sister deceased, cause unknown Physical Exam: VS: 98.9, 182/88, 62, 17, 97% RA GENERAL: NAD, poor historian. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to angle of mandible, bounding of pulses carotid appreciated CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [2156-7-28] 01:32PM PT-10.8 PTT-32.7 INR(PT)-1.0 [2156-7-28] 01:32PM PLT COUNT-237 [2156-7-28] 01:32PM NEUTS-69.2 LYMPHS-22.0 MONOS-5.0 EOS-2.0 BASOS-1.7 [2156-7-28] 01:32PM WBC-7.1 RBC-4.04# HGB-12.7# HCT-38.1# MCV-94 MCH-31.4 MCHC-33.3 RDW-13.9 [2156-7-28] 01:32PM cTropnT-<0.01 [2156-7-28] 01:32PM estGFR-Using this [2156-7-28] 01:32PM GLUCOSE-95 UREA N-22 CREAT-1.3* SODIUM-137 POTASSIUM-7.5* CHLORIDE-103 TOTAL CO2-27 ANION GAP-15 [2156-7-28] 02:34PM K+-5.0 [2156-7-28] 02:34PM COMMENTS-GREEN TOP [2156-7-28] 02:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2156-7-28] 02:55PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 [2156-7-28] 02:55PM URINE UHOLD-HOLD [2156-7-28] 02:55PM URINE HOURS-RANDOM Brief Hospital Course: [Age over 90 ] yo female with CoreValve [2156-2-19], since then several admissions to [Hospital1 ] for weakness, one for pAfib, now presents for HTN emergency, SBP 200s with headahces. . # HTN EMERGENCY - Patient was placed on a nicardipine dip in the ED and then admitted to the CCU. There was no evidence of aortic dissection, papillary muscle rupture, head bleed, renal failure, ACS, or pulmonary edema. The patient's blood pressure was maintained in range of SBPs 160s-170s, as that is what she usually runs, even on multiple antihypertensives. She came in on lisinopril and metoprolol, and, in house, she was transitioned from the nicardipine drip to lisinopril, amlodipine, and carvedilol. Her CCU course was unremarkable, and she was transferred to the regular cardiology floor for optimization of anti-hypertensives prior to discharge. . # CORONARIES: Last cath [11/2155] showed LAD w/ 30% stenosis in the mid vessel and an eccentric 70% stenosis in a diagonal branch. The LCx had a 60% stenosis proximal vessel. Her cardiac enzymes did not increase during her hospital stay, and she did not report chest pain. She was discharged on carvedilol, lisinopril, aspirin, atorvastatin, and Plavix. . # PUMP: Last Echo [6-/2156] showed an EF > 55%. During her hospital stay, she had no signs or symptoms or cardiac failure. . # CKD (baseline Cr 1.1-1.4): Patient came it with a creatinine within her baseline range (1.2), and stayed within her baseline range during the admission. . Transitional Issues: Patient will follow up with cardiologist Dr. [Last Name (STitle) ] and PCP [Last Name (NamePattern4) ]. [First Name (STitle) 6164]. CODE: Full EMERGENCY CONTACT: [Name (NI) 4906] [Name (NI) 26079] [Telephone/Fax (1) 92302] Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Metoprolol Tartrate 50 mg PO BID hold for sbp < 100, hr < 55 2. Atorvastatin 80 mg PO DAILY 3. Lisinopril 40 mg PO DAILY hold for sbp < 100, hr < 55 4. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 5. Aspirin 81 mg PO DAILY 6. Ferrous Sulfate 325 mg PO DAILY 7. Magnesium Oxide 280 mg PO ONCE Duration: 1 Doses 8. Pantoprazole 40 mg PO Q24H 9. Clopidogrel 75 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY hold for sbp < 130, hr < 55 RX amlodipine 10 mg one tablet(s) by mouth daily Disp #30 Tablet Refills:2 2. bimatoprost NF* 0.03 % OU QHS Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 3. Carvedilol 6.25 mg PO BID hold for sbp < 130, hr < 55 start [7-29] at PM RX carvedilol 6.25 mg one tablet(s) by mouth twice a day Disp #60 Tablet Refills:2 4. Timolol Maleate 0.5% 1 DROP BOTH EYES [Hospital1 ] 5. Atorvastatin 80 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. Lisinopril 40 mg PO DAILY hold for sbp < 100, hr < 55 8. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 9. Aspirin EC 81 mg PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Hypertensive Urgency S/P CoreValve Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Discharge Instructions: Mrs. [Known lastname 92297], you were seen at [Hospital1 18] and treated for elevated blood pressure. We changed around your blood pressure medications which we think will better control your blood pressure. Please check your blood pressure twice daily and record the readings to share with all of your doctors. Call Dr [First Name (STitle) 6164] or Dr. [Last Name (STitle) ] if your top number of your blood pressure is higher than 180 as your medicine may need to be adjusted. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [2156-8-4] at 11:20 AM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Last Name (LF) ],[First Name3 (LF) 1730] O. Location: [Hospital3 ] INTERNAL MEDICINE ASSOCIATES Address: [Street Address(2) 4472], [Apartment Address(1) 4473], [Hospital1 ],[Numeric Identifier 9331] Phone: [Telephone/Fax (1) 4475] Appointment: Tuesday [2156-8-10*] 3:45pm ICD9 Codes: 4280, 496, 2724, 2449, 5859
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8263 }	Medical Text: Admission Date: [2130-10-6] Discharge Date: [2130-10-9] Date of Birth: [2078-4-17] Sex: M Service: CCU DISCHARGE DIAGNOSIS: Acute myocardial infarction. HISTORY OF PRESENT ILLNESS: The patient is a 52 year old smoker who presented with intermittent anginal pain for one week and rest pain for the 12 hours prior to admission. The patient was in his usual state of health until one week prior to admission, when he began experiencing left chest, arm and jaw pain while working. The pain lasted two to three minutes, was five out of ten, and was alleviated by rest. There was no associated shortness of breath, nausea, vomiting or diaphoresis. The patient had two or three of these episodes per day for the week leading up to his admission. At home on the evening prior to admission, the patient had sudden onset, seven out of ten, chest pressure with radiation to the jaw and the left arm. Again, there was no shortness of breath, nausea, vomiting or diaphoresis. The pain persisted overnight and the patient presented to an outside hospital on the day of admission. On presentation to the outside hospital, the patient's blood pressure was 88/58, pulse 54. His electrocardiogram showed sinus bradycardia at 55 beats per minute with normal axis and T wave inversions in II and AVF. The patient received aspirin and was bolused with normal saline. His CK and troponin were sent. CK was found to be elevated at 940 and his troponin was slightly elevated at 0.42. The patient was started on heparin and transferred to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] for a cardiac catheterization. Catheterization showed a normal left main with minor disease in the left anterior descending artery and a normal left circumflex. The right coronary artery had a 60% proximal lesion and 100% mid-right coronary artery lesion. The patient had stents to both of those lesions, with normal residual flow. Post procedure electrocardiogram showed normal sinus rhythm at 90 beats per minute with a normal axis, Q waves inferiorly in II, III and AVF with some elevation of ST segments in II, III and AVF. Hemodynamics were remarkable for a wedge pressure of 15 and a right atrial pressure of 8. PAST MEDICAL HISTORY: 1. Rheumatic fever, no history of murmur. 2. Status post cholecystectomy. ALLERGIES: Tetanus vaccine. MEDICATIONS ON ADMISSION: Multivitamins, aspirin, Plavix and Integrilin. SOCIAL HISTORY: The patient is a tobacco smoker, one to one and one-half packs times 30 years. He does not use alcohol or intravenous drugs. FAMILY HISTORY: Family history is negative for coronary artery disease. PHYSICAL EXAMINATION: On presentation to the Coronary Care Unit, the patient had a blood pressure of 99/60, pulse 86, respiratory rate 18 and oxygen saturation 95% on two liters nasal cannula. General: Awake, alert and oriented times three, in no acute distress. Neck: No obvious jugular venous distention. Chest: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmurs. Abdomen: Soft, nontender, nondistended, positive bowel sounds, benign. Extremities: Right groin without hematoma, no ooze at site of venous sheath, no lower extremity edema bilaterally, palpable dorsalis pedis and posterior tibialis pulses bilaterally. LABORATORY DATA: Admission hematocrit was 34.2, platelet count 226,000, white blood cell count 14 with a normal differential, electrolytes within normal limits, BUN 14, creatinine 0.8. Electrocardiogram as per history of present illness. Cardiac catheterization as per history of present illness. HOSPITAL COURSE: The patient is a 52 year old male smoker with a non-ST elevation myocardial infarction, status post stents times two to his right coronary artery, presenting to the Coronary Care Unit with mild residual chest pain. 1. Cardiovascular: Coronary artery disease. The patient's chest pain resolved overnight on a nitroglycerin drip. The patient's CKs were followed, eventually at around 1,000 with an MB of 63 and MB index of 6.2 and a troponin greater than 50 before trending downward. The patient was started on aspirin and Plavix and Lipitor. A lipid panel was sent and was pending at the time of discharge. The patient remained chest pain free throughout the course of his stay. 2. Pump: The patient was given fluids the first night due to his blood pressure, to maintain his preload. He was started on a beta blocker and ACE inhibitor as his blood pressure tolerated. He had an echocardiogram prior to discharge which, on preliminary read, showed a preserved left ventricular ejection fraction of approximately 50%. 3. Rhythm: The patient was monitored on telemetry and had no arrhythmic events during the course of his hospital stay. DISPOSITION: The patient was discharged home in good condition on [2130-10-9] to follow-up with Dr. [First Name (STitle) ] in cardiology as well as his primary care physician at an outside facility. DISCHARGE DIAGNOSIS: Coronary artery disease. DISCHARGE MEDICATIONS: Aspirin 325 mg p.o.q.d. Plavix 75 mg p.o.q.d. Atenolol 25 mg p.o.q.d. Lisinopril 5 mg p.o.q.d. Lipitor 10 mg p.o.q.d. DR.[First Name (STitle) ],[Known firstname ] 11-691 Dictated By:[Name8 (MD) 8330] MEDQUIST36 D: [2130-10-10] 15:25 T: [2130-10-16] 10:19 JOB#: [Job Number 44718] ICD9 Codes: 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8264 }	Medical Text: Admission Date: [2162-3-6] Discharge Date: [2162-3-13] Date of Birth: [2094-12-7] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: inability to speak or move right side Major Surgical or Invasive Procedure: MRI/MRA PEG ECHO History of Present Illness: Mr. [Known lastname 39615] is a 67-year-old right-handed man with a history of CAD, hyperlipidemia, PAF not anticoagulated, and lung cancer in remission who presents with acute onset aphemia and right hemiplegia. He was last seen normal at 10 pm last night by his daughter; his wife had already gone to bed. When his wife awoke the next morning, she found him at about 6 am lying face down on the floor, unable to speak or move his right side. His daughter came over, and thought he seemed sleepy, but noted he did look up at her when she was there. EMS was called and brought him immediately to [Hospital1 18] ED. NIH Stroke Scale score was 16: 1a. Level of Consciousness: 1 1b. LOC Question: 2 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 2 5a. Motor arm, left: 0 5b. Motor arm, right: 4 6a. Motor leg, left: 0 6b. Motor leg, right: 4 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 3 10. Dysarthria: UN 11. Extinction and Neglect: 0 Formal ROS is not possible. His daughter reports that last night he was sitting on the edge of his bed apparently uncomfortable, but did not complain of anything and otherwise was normal. Past Medical History: - CAD s/p MI and angioplasty [2145] - Paroxysmal atrial fibrillation (per last cardiology note, "he has had atrial fibrillation when he gets acutely sick with COPD flares with pneumonias. However, he has been in sinus rhythm in the recent past.") - RUL SCLC s/p chemo and radiation [2155], in remission - COPD - Hyperlipidemia - "Probable DM" Social History: Former heavy smoker, [2-9] ppd for 20-30 years, but quitin [2155] years ago with lung cancer diagnosis. Family History: His mother died from a heart disease at the age of 75. His father died from a throat cancer at the age of 52. Physical Exam: Vitals: T: 97.9 P: 88 reg R: 20 BP: 136/95 SaO2: 100%RA General: Awake, cooperative, NAD. Labored breathing, with significant upper airway sounds. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Hard collar in place. Pulmonary: Loud upper airway sounds. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: obese. 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: -Mental Status: Awake and alert. No speech production. Follows one-step commands, both appendicular and midline. Nods yes/no to orientation questions appropriately. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2.5 to 2mm and brisk. VFF to threat. Funduscopic exam limited by miosis. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: Partial right facial droop. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk. Flaccid in right UE and LE. No pronator drift on left. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 5 5 5 5 5 5 5- 5 5- 5 5 R 0 0 0 0 0 0 0 0 0 0 0 Withdraws right LE to pain, no movement of R UE. -Sensory: Grossly, he nods that he can feel light touch throughout. -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 0 0 0 1 1 Plantar response was flexor bilaterally. -Coordination: Not tested on right. On left, no intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF. -Gait: Unable due to right hemiplegia. Pertinent Results: [2162-3-12] 06:01AM BLOOD WBC-8.9 RBC-4.50* Hgb-14.4 Hct-41.5 MCV-92 MCH-32.0 MCHC-34.7 RDW-13.2 Plt Ct-281 [2162-3-11] 06:00AM BLOOD WBC-9.9 RBC-4.51* Hgb-14.7 Hct-41.7 MCV-92 MCH-32.6* MCHC-35.3* RDW-13.3 Plt Ct-279 [2162-3-10] 08:35AM BLOOD WBC-11.5* RBC-4.90 Hgb-15.2 Hct-45.5 MCV-93 MCH-31.0 MCHC-33.3 RDW-13.6 Plt Ct-267 [2162-3-9] 06:15AM BLOOD WBC-9.4 RBC-4.21* Hgb-14.1 Hct-38.6* MCV-92 MCH-33.4* MCHC-36.5* RDW-12.9 Plt Ct-247 [2162-3-8] 06:45AM BLOOD WBC-9.1 RBC-4.18* Hgb-13.6* Hct-38.2* MCV-91 MCH-32.5* MCHC-35.6* RDW-13.1 Plt Ct-263 [2162-3-7] 02:27AM BLOOD WBC-9.7 RBC-4.18* Hgb-13.7* Hct-37.9* MCV-91 MCH-32.7* MCHC-36.1* RDW-13.1 Plt Ct-263 [2162-3-6] 07:30AM BLOOD Neuts-79.6* Lymphs-13.4* Monos-5.7 Eos-0.8 Baso-0.4 [2162-3-12] 06:01AM BLOOD PT-15.9* PTT-27.1 INR(PT)-1.4* [2162-3-11] 06:00AM BLOOD PT-16.1* PTT-26.3 INR(PT)-1.4* [2162-3-7] 02:27AM BLOOD PT-16.6* PTT-28.4 INR(PT)-1.5* [2162-3-6] 07:30AM BLOOD PT-16.0* PTT-28.1 INR(PT)-1.4* [2162-3-12] 06:01AM BLOOD Glucose-138* UreaN-33* Creat-0.7 Na-142 K-4.0 Cl-107 HCO3-26 AnGap-13 [2162-3-11] 06:00AM BLOOD Glucose-132* UreaN-33* Creat-0.8 Na-140 K-4.2 Cl-103 HCO3-27 AnGap-14 [2162-3-10] 08:35AM BLOOD Glucose-173* UreaN-27* Creat-0.8 Na-137 K-4.5 Cl-101 HCO3-28 AnGap-13 [2162-3-9] 06:15AM BLOOD Glucose-204* UreaN-22* Creat-0.8 Na-137 K-4.2 Cl-100 HCO3-27 AnGap-14 [2162-3-7] 02:27AM BLOOD Glucose-165* UreaN-15 Creat-0.8 Na-136 K-4.0 Cl-103 HCO3-24 AnGap-13 [2162-3-6] 07:30AM BLOOD Glucose-246* UreaN-15 Creat-0.7 Na-135 K-3.8 Cl-97 HCO3-26 AnGap-16 [2162-3-6] 07:30AM BLOOD ALT-33 AST-40 CK(CPK)-234* AlkPhos-120* TotBili-0.5 [2162-3-7] 02:27AM BLOOD CK-MB-3 cTropnT-<0.01 [2162-3-12] 06:01AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.3 [2162-3-6] 07:30AM BLOOD Albumin-4.4 Calcium-9.3 Phos-2.8 Mg-2.0 [2162-3-8] 06:45AM BLOOD Triglyc-147 HDL-40 CHOL/HD-3.7 LDLcalc-80 [2162-3-6] 07:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CT HEAD: 1. Dense left middle cerebral artery with loss of definition of insular region indicative of an evolving infarct. 2. Perfusion defect in the left middle cerebral artery territory with increased transit time and decreased blood volume suggestive of an evolving infarct. 3. CT angiography of the neck demonstrates complete occlusion of the left internal carotid artery in the neck with calcification at the bifurcation. 60-70% stenosis of the right internal carotid artery is seen at the bifurcation. 4. CTA of the head demonstrates filling defect in the left middle cerebral artery M1 segment with diminished flow in the distal left MCA territory. MRI: Acute left sided basal ganglia and anterior MCA territory infarcts. No hemorrhage. Clot in the middle cerebral artery region. ECHO: Suboptimal image quality. Preserved left ventricular systolic function. No intracardiac shunt with saline contrast injected at rest (unable to cooperate with maneuvers). Brief Hospital Course: Pt was initially admitted to the neuro-ICU for observation following his acute infarct. An MRI showed an acute infarct in left MCA territory. This was likely cardio-embolic as he was noted to be in A-fib upon admission. He was started on aspirin but anticoagulation was not initiallly started because of the size of the lesion and risk for hemorrhagic conversion. His exam slowly improved and he became more alert. Despite being more alert he failed multiple swallow evaluations and had a g-tube placed on [3-12]. He was started on coumadin after the g-tube was placed. He should stay on aspirin 81mg until his coumadin becomes therapeutic (INR [2-9]). Medications on Admission: ASA 325 mg po daily Metoprolol 50 mg po bid Simvastatin 10 mg po qhs NTG SR 2.5 mg po bid Atrovent 17 mcg 2 puffs qid Albuterol 90 mcg 2 puffs q6h prn Flovent 220 mcg 2 puffs [Hospital1 ] ProAir Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for temp > 100.4 or pain. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO Q12H (every 12 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for temp > 100.4 or pain. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO Q12H (every 12 hours) as needed. 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [Hospital1 ] (2 times a day). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Left MCA Infarct AFIB Discharge Condition: Right hemiparesis, global aphasia Discharge Instructions: You were admitted for right sided weakness and difficulty speaking. This was caused by a stroke which was likley due to a blood clot from your heart. You will need to take coumadin to prevent blood clots in the future. Followup Instructions: Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2162-4-12] 9:45 Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2162-4-22] 9:10 Provider: [First Name11 (Name Pattern1) 1569] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2162-4-22] 9:30 Dr. [Last Name (STitle) ] - Call [Telephone/Fax (1) 44] for appointment info [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 496, 2724, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8265 }	Medical Text: Admission Date: [2144-11-4] Discharge Date: [2144-11-18] Date of Birth: [2095-7-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 783] Chief Complaint: leg swelling, alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: 49 M with hx of vicodin abus now on methadone, alcohol abuse, HTN, who was transferred from OSH for cellulitis and ? of necrotizing fascitis. Pt was in USOH with the excpetion of pain in his left ankle/leg for last 3-4 months. Pt states he fractured this several months ago, thinks he had a cast. Also with leg pain and swelling. Denies fevers, chills. Last night he noticed shaking, "like the DTs". He missed his methadone doses last two days, once because he over slept and another time b/c he had been drinking. Denies AH/VH, no extra sensations. Deneis CP/SOB/N/V/cough. His last drink was on [11-3] in the evening. . In the ED, 98.7, 95, 168/104, 18, 94 % RA. Exam was concerning for LE stasis and erythema. He recieved ativan, clindamycin in the ED. Per Ed resident, pt got CTX at OSH. . Admitted to medicine for alcohol intoxication, cellulitis and subsequently transferred to MICU for closely obeservation and medical care given EtOH withdrawal. . MICU Course: Monitored o/n with q1hr CIWA requring less Valium; approx every 4 hours. HDS stable. Seen and evaluated by Ortho/VSURG. No nec fasc. Continued Unasyn. Past Medical History: 1. HTN 2. Hypercholesterolemia 3. h/o vicodin abuse now on methadone 4. alcohol abuse 5. h/o left ankle fx 2.5 yrs ago, managed by Dr. [Last Name (STitle) 13648] at [Hospital3 ], patient refused surgery Social History: Married. Lives with his wife and 3 kids in [Location (un) 7661]. Running his own furniture making business. + tob: 1 ppd x 30yrs + Etoh: 7 tequila shots qd, last drink yesterday afternoon, no h/o DTs + h/o vicodin abuse (was a pharmacy tech at the time), on methadone since about '[37] Family History: NC Physical Exam: genrl: pleasant, in nad, eating dinner heent: perrla, EOMI, sclera anicteric and not injected, op wnl neck: thick, no LAD, no jvd cv: tachy w/ rr, no m/r/g pulm: diffuse expiratory wheeze, no ronchi/rhales abd: nabs, soft, moderate distention, nt extr: B/L ACE wraps. Per exam this AM:diffuse erythema of bilateral LE w/ overlying skin breakdown and ulceration, significant swelling of left ankle. pulses dop b/l neuro: a, o x 3, cn 2-12 WNL except ? slight right facial droop, strength 5/5 UE/LE, intact to soft grossly intact thru/o Pertinent Results: [2144-11-4] 01:50AM WBC-9.1 RBC-3.92* HGB-13.1* HCT-39.4* MCV-101* MCH-33.4* MCHC-33.2 RDW-14.9 [2144-11-4] 01:50AM NEUTS-70.1* LYMPHS-21.7 MONOS-5.3 EOS-1.6 BASOS-1.2 [2144-11-4] 01:50AM ALT(SGPT)-29 AST(SGOT)-57* ALK PHOS-154* AMYLASE-60 TOT BILI-0.6 [2144-11-4] 01:50AM LIPASE-35 [2144-11-4] 01:50AM UREA N-10 CREAT-0.8 SODIUM-140 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-19. . LE US ([2144-11-4]): No deep venous thrombosis in right or left common femoral, superficial femoral, or popliteal veins . CXR ([2144-11-4]): Low lung volumes. Ill-defined opacity at left base likely relates to superimposition of soft tissue versus focal consolidation. Recommend dedicated PA and lateral chest radiograph for further evaluation . Brief Hospital Course: A/P: 49yo M with HTN, alcohol abuse c/b w/d, h/o vicodin abuse on methadone, admitted with cellulitis. . 1. Alcohol withdrawal: Patient stated he had been drinking tequila over the past several months in an effort to relieve his LE pain. He was initially admitted to the MICU for alcohol withdrawal requiring high doses of benzodiazepines. On the floor, he was maintained on a CIWA scale with prn Valium. He had no signs or symptoms of DTs. His CIWA scale was discontinued on [11-9] as he had not required Valium for over 40 hours. He was continued on MVI, thiamine, and folate. He was seen by Social Work to address his alcohol abuse. He declined alcohol abuse rehab programs. . 2. LE edema/Cellulitis: He has severe LE vascular insufficiency and cellulitis. He was treated with Unasyn for his cellulitis. He was followed by Vascular Surgery. His dressing changes were monitored by Wound Care. He was given Unaboots and maintained on Unasyn, for a 6 week course as discussed below. His WBC count was normal on discharge. He was discharged with a plan for Vascular Surgery follow up in 2 weeks. . 3. L Ankle deformity: History of fracture of left ankle, was set but not surgically corrected as he did not follow up. He presented this admission with destructive changes and overlying cellulitis. He underwent x-rays, CT, bone scan, and MRI in an effort to determine whether he had osteomyelitis, all of which were inconclusive. It was therefore decided to treat him with IV antibiotics for a total of 6 weeks, a sufficient course to treat osteomyelitis. Ortho/Foot and Ankle service followed him and determined he would need ankle fusion at some point, but as an outpatient once his cellulitis has resolved. He was discharged with the plan for Ortho follow up in [2-13] weeks. He was non-weight-bearing on his LLE. . 4. Acute renal failure: His creatinine trended up to 1.7 during his hospitalization. He had good urine output, and was afebrile and without urinary symptoms. The most likely etiology was thought to be med effect from HCTZ, as he was on a high dose for LE edema and was noncompliant as an outpatient for the last year. His FEUrea was calculated to be 24.6%, suggesting a prerenal ARF. His HCTZ was initially decreased to an antihypertensive dose (25mg qd), and then discontinued. His creatinine subsequently improved to 1.2 on discharge. He was discharged to follow up with his PCP. . 5. H/o vicodin abuse: He worked as a pharmacist for several years and thus had access to vicodin. He is in a methadone program as an outpatient. He was maintained on his outpatient regimen after his dose was verified with the treatment program. . 6. HTN: He was prescribed atenolol and HCTZ (at LE edema doses) as an outpatient, but reported decreased compliance over the past year. He was maintained on metoprolol and HCTZ (at an antihypertensive dose) during his hospitalization with good control of his BP. His HCTZ was discontinued secondary to ARF. He was discharged on metoprolol. . 7. Hypoxia: He had an oxygen requirement and some episodes of desaturation overnight. His CXRs were negative for pneumonia. He had a V/Q scan that was normal. His O2 requirement improved with deep breathing and incentive spirometry. Possible etiologies include restrictive pulmonary disease secondary to body habitus, OSA/obesity-hypoventilation, and/or underlying COPD secondary to smoking. On discharge, he had good O2 saturation on room air. He was discharged to new PCP follow up, to consider PFTs and further investigation of his underlying pulmonary status. . 8. Code: FULL. . Medications on Admission: methadone 130 mg po qd HCTZ 100 mg po bid (off x 1 year due to noncompliance) atenolol 100 mg po qam, 50 mg po qpm (off x 1 year due to noncompliance) Discharge Medications: 1. Methadone 40 mg Tablet, Soluble Sig: Three (3) Tablet, Soluble PO once a day. 2. Methadone 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 month supply Refills:0 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 7. Ampicillin-Sulbactam [2-11] g Recon Soln Sig: Three (3) g Injection Q8H (every 8 hours) for 4 weeks. Disp:4 wks supply Refills:0 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Last Name (LF) 486], [First Name3 (LF) 487] Discharge Diagnosis: cellulitis severe venous stasis left ankle deformity Discharge Condition: good, last dose of methadone given on [11-18] Discharge Instructions: If you experience worsening leg pain, drainage, swelling, fevers >101, or other concerning symptoms, please call your doctor or return to the ER. Followup Instructions: 1) Please call the [Hospital 191] clinic ([Telephone/Fax (1) 1921], to arrange a follow up appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 15264] within the next 4 weeks. 2) Vascular Surgery: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [2150-12-22]:45, [Hospital Unit Name 3269] [Location (un) 442], ([Telephone/Fax (1) 10880]. 3) Orthopedic Surgery: [Doctor Last Name ] Brown, [Last Name (un) 469] 2, [2149-12-18]:30am, ([Telephone/Fax (1) 5238]. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] Completed by:[2145-2-23] ICD9 Codes: 5849, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8266 }	Medical Text: Admission Date: [2175-6-29] Discharge Date: [2175-7-4] Date of Birth: [2112-4-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: DKA Major Surgical or Invasive Procedure: None History of Present Illness: 62 yo M with DMI on an insulin pump admitted with hyperglycemia and in diabetic ketoacidosis. Patient was admitted to [Hospital1 2025] in [2175-5-5] with trauma (fall from ladder) resulting in intracranial hemorrhage, SAH, C3 and C4 fractures and L2/L3 fractures. Wife does not know if EtOH was involved in the fall. He was discharged to [Hospital3 ] and while he was there, he was maintained on RISS without the pump. He had episodes of orthostatic hypotension at the time which required re-admission to [Hospital1 2025] for work-up. He was discharged on [2175-6-23] home with Lantus 20 U QHS and Lispro insulin sliding scale. Since then, the patient's wife reports hyperglycemia at home with FS ranging from 200s to 600s. She does not know his pump settings but stated that his carbohydrate ratio was 10:1. He also had increased increased nocturia (increased from some baseline difficulty with urinary retention due to traumatic foley placement at rehab), anorexia, and 20 lb weight loss. No polyphagia or polydipsia. Denied any chest pain, fevers, cough, shortness of breath, abdominal pain, diarrhea. No illicit ingestions. His wife states that even after the brain injury, his mental status was stable (AOx3, requiring some help with ADLs, but enough concentration to possibly operate his pump.) on discharge from rehab. However, the day of presentation, she noted he was more confused and not responding appropriately to questions. His primary endocrinologist is Dr.[Name (NI) 4849] at the [Last Name (un) ]. He presented to the [Last Name (un) ] today out of concern for these symptoms, and was sent to the ED by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 32886] for treatment of DKA. . In the ED, initial vs were: T 97.3 125 92/51 20 92% on RA. Patient appeared pale in triage, confused, and smelled of ketones. FS was 703. Lab sig for Na of 126, K of 6.9, Cre of 1.3, and anion gap of 35. VBG 7.08/35/48/11. U/A with ketones and glucose. EKG without any ischemic changes or peaked T-waves. He received Zofran 4 mg IV x2, Morphine 2 mg IV x1 for a headache, 4 L of normal saline, and insulin gtt at 5 U/hr. Prior to transfer, his VS were 97.6 92 108/72 16 98% on RA. FS was 432. No chemistries ordered prior to transfer. . On the floor, the patient appeared AOx1 to name only, and unable to concentrate on answering questions, saying only 'insulin'. He continued to be fluid resuscitated with ~1400 ccs of NS, 1 L of 20 meQ KCL and NS, and 6 U/hr insulin gtt. His FS decreased from 351 to 279 and anion gap closed from 20 to 15. His gtt was decreased to 2 U/hr and fluids changed to D5 1/2 NS until patient would be alert enough to eat. . Review of systems: (per wife) (+) 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: Type I Diabetes Mellitus - complicated by neuropathy, retinopathy - on insulin pump since [2154] - s/p laser treatment Hypertension Hypercholesterolemia Depression Peripheral Vascular Disease- s/p L fem [Doctor Last Name ] in [2154] due to heel infection. iliac stent. Carpal Tunnel Syndrome PTSD GERD . Past Surgical History: s/p appendectomy Bilateral Shoulder surgery Social History: lives with wife [Name (NI) ]. disabled plumber. smoker (50 ppy hx) quit 2 months ago. no illicits. Possible EtOH dependence (wife is not able to quantify how much patient drinks but is concerned he drinks more than she knows) Family History: father died of lung cancer. No cardiac dz. Physical Exam: Vitals: 98.1 109 147/63 84 19 98% on RA General: AOx3 (could not name hospital name); comfortable, in NAD HEENT: Sclera anicteric, MMdry, oropharynx clear Neck: supple, JVP flat, no LAD Lungs: Mild wheezing left lower lobe, no rales/rhonchi, good air entry CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds minimal, no rebound tenderness or guarding, no organomegaly skin: poor skin turgor Ext: cold LEs (L>R), 1+ pulses, no edema Neurologic exam: cn intact, no gross motor deficits, decreased sensation to LT in LE b/l, gait not assessed Pertinent Results: [2175-6-29] 06:00PM BLOOD WBC-10.3 RBC-4.45* Hgb-13.7* Hct-45.1 MCV-102* MCH-30.9 MCHC-30.5* RDW-13.9 Plt Ct-380 [2175-6-29] 06:00PM BLOOD Neuts-91.1* Lymphs-6.7* Monos-1.5* Eos-0.1 Baso-0.5 [2175-6-29] 06:00PM BLOOD Plt Ct-380 [2175-7-2] 02:00AM BLOOD PT-12.0 PTT-26.4 INR(PT)-1.0 [2175-6-29] 06:00PM BLOOD Glucose-730* UreaN-36* Creat-1.3* Na-126* K-6.2* Cl-81* HCO3-10* AnGap-41* [2175-7-2] 02:00AM BLOOD Glucose-177* UreaN-4* Creat-0.6 Na-137 K-4.2 Cl-102 HCO3-25 AnGap-14 [2175-6-30] 01:12AM BLOOD CK(CPK)-344* [2175-6-30] 07:20AM BLOOD Lipase-53 [2175-6-30] 01:12AM BLOOD CK-MB-34* MB Indx-9.9* cTropnT-0.88* [2175-6-30] 05:28AM BLOOD CK-MB-39* MB Indx-10.7* cTropnT-1.19* [2175-6-30] 12:30PM BLOOD CK-MB-37* MB Indx-11.6* cTropnT-1.42* [2175-6-30] 08:26PM BLOOD CK-MB-22* MB Indx-9.9* cTropnT-1.10* [2175-6-29] 11:27PM BLOOD Calcium-8.1* Phos-3.7 Mg-1.8 [2175-6-30] 07:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2175-6-29] 08:16PM BLOOD pO2-48* pCO2-35 pH-7.08* calTCO2-11* Base XS--20 Comment-GREEN TOP [2175-6-29] 08:16PM BLOOD Glucose-GREATER TH Lactate-3.4* Na-134* K-5.4* Cl-99* [2175-6-29] 11:33PM BLOOD Glucose-303* Lactate-1.8 [2175-6-29] 11:33PM BLOOD freeCa-1.17 ....................... [2175-6-29] ECG: Sinus tachycardia. Right axis deviation. Right bundle-branch block. Non-specific ST-T wave abnormalities. Cannot rule out anterolateral ischemia. Suggest clinical correlation and repeat tracing. No previous tracing available for comparison. . [2175-6-29] CXR: 1. No consolidation or acute abnormality. 2. Vague nodular opacity projecting over the right mid lung. Nonemergent chest CT can be obtained for further evaluation. . [2175-6-30] CT Head W/Out Contrast: 1. No acute intracranial abnormality. 2. Hypodensity in the left frontal lobe, likely due to encephalomalacia. Brief Hospital Course: 63 yo M with IDDMI presenting with hyperglycemia, anorexia, and weight loss, admitted to the MICU with diabetic ketoacidosis. . MICU [Location (un) ] Course: The patient was in DKA on admission with altered mental statu, polyuria, and weight loss. Labs notable for FS in the 700s, metabolic acidosis, ketones in urine. Likely in setting of decreased insulin administration compared to his usual pump settings. No evidence of infection (U/A negative, no consolidation on CXR). He was made NPO, aggressively resuscitated with IVF, and placed on an insulin drip with frequent finget sticks. He was successfully transitioned to subcutaneous insulin and his diet was advanced. His symptoms resolved. [Last Name (un) ] was consulted. He was also found to have an NSTEMI. He was placed on full dose ASA, a statin, beta-blocker, and ACE-I. A TTE showed mild regional left ventricular systolic dysfunction with lateral hypokinesis. Cardiology was consulted and recommended outpatient follow-up. Altered Mental Status: Patient with delirium likely in setting of DKA. However, given known ICH, he had a CT scan of the head to rule out further intracranial processes which was negative. With lowering of his blood sugar, his mental status returned to baseline. Abnormal CXR: The pt needs a f/u Ct in 6 months to ensure stability of pulmonary nodules. Medications on Admission: ASA 325 mg PO daily Captopril 25 mg PO BID Finasteride 5 mg PO daily Lantus 20 U SQ QHS Lispro RISS TID Metformin 1000 mg PO BID Nicotine Patch 21 mg/24 hr TD daily Crestor 20 mg PO daily Effexor XR 150 mg PO daily Trazodone 50 mg PO daily Reglan 5 mg PO TID before meals Discharge Disposition: Home With Service Facility: [Hospital1 6136] Home Care Discharge Diagnosis: Primary: Diabetic keto-acidosis, Non-ST Elevation MI Secondary: DM Type 1, HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (cane). Discharge Instructions: You were admitted to the [Hospital1 18] on [6-29] for symptoms of diabetic keto-acidosis (confusion, dizziness). You were also found to have had a non-ST elevation myocardial infarction (heart attack) when you presented to the emergency department on [6-29]. For your diabetic keto-acidosis, we gave you regular IV insulin and IV fluids to bring your blood sugars down. For your heart attack, we continued you on your home medications (aspirin, statin, and captopril) and we started you on a new medication- metoprolol. We also obtained an ECHO of your heart to see how it was pumping on [6-30]- the study showed some irregularity in the heart's ability to contract in one particular area. We re-started you on your insulin pump and you have follow-up apts. scheduled at [Hospital ] Medical Center on [2175-7-20] and [2175-8-4]. We are also suggesting that you follow-up with a cardiologist as an out-patient regarding your recent heart attack. Physical therapy will be necessary for you to have at home. However it is important that you do not over exert yourself for the next month. And you are now able to urinate w/out the need of a catheter. Please stop taking the following medications: Finasteride Metformin Lantus Lispro Please start taking the following medications: Metoprolol 25mg three times daily [Last Name (un) ] recommends the following settings for your insulin pump: Basal: 12am-9am 1.1 U/hr, Basal: 9am-12am 1.4 U/hr Ins:Carb - B 1:10, L 1:8, D 1:10 [Last Name (un) ] F - 1:30 correct to 120 You will be following up with Dr.[Doctor Last Name 4849] on [7-20] and you will meet with the pump nurse on [8-4]. You should ask to sign up for a pump class when you are there. You should follow with your PCP within one week. Please talk to your PCP about obtaining [Name Initial (PRE) ] stress test to evaluate your heart function. Your cardiology appt is next month. Followup Instructions: Name: [Last Name (LF) 12203],[First Name3 (LF) ] P. Location: [Hospital1 ] PRIMARY CARE Address: [Street Address(2) ]., 1ST FL, [Location (un) 10068],[Numeric Identifier 10069] Phone: [Telephone/Fax (1) 31010] Appointment: Tuesday [2175-7-18] 11:15am [2175-7-20] at 12:30 pm: apt. w/ Dr.[Name (NI) ] ([Last Name (un) ] Diabetes Center) ph: ([Telephone/Fax (1) 17484] [2175-8-4] at 2:30 pm: apt. w/ insulin pump educator ([Last Name (un) ] Diabetes Center) ph: ([Telephone/Fax (1) 17484] Department: CARDIAC SERVICES When: MONDAY [2175-8-14] at 3:20 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1523], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2175-7-5] ICD9 Codes: 3572, 4019, 2720, 311, 4439
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8267 }	Medical Text: Admission Date: [2109-4-23] Discharge Date: [2109-5-10] Date of Birth: [2109-4-23] Sex: M Service: Neonatology HISTORY OF PRESENT ILLNESS: This is a [2094] gram, 34 [12-12] week male born to a 29 year old gravida I, para 0 to I mother with prenatal screens of O negative, status post RhoGAM at 28 weeks, antibody negative/hepatitis B surface antigen negative, RPR nonreactive/rubella immune/Group B unknown mother. Pregnancy is complicated by preterm contractions at 33 weeks at which point she received a course of beta Methasone. Pregnancy was also complicated by intrauterine growth restriction of unknown etiology. There was no gestational hypertension. Cesarean section was performed for breech presentation and growth restriction under spinal anesthesia. There was clear amniotic fluid. Infant emerged vigorous. He was given blow-by O2 and Apgars were 7 and 9. PHYSICAL EXAMINATION: On admission weight [2094] grams, OFC 31.5 cm, length 43.5 cm. His anterior fontanelle was soft and flat. He had nondysmorphic facies. Palate was intact. He had mild nasal flaring. He had mild intercostal retractions. Fair breath sounds bilaterally without crackles. He had mild grunting. His heart was regular rate and rhythm without a murmur. He had 2+ femoral pulses. Abdomen was soft, nondistended without hepatosplenomegaly or masses. Patent anus. Three vessel cord. Normal male genitalia. Testes descended bilaterally. Central nervous system: He had active response to stimulus. Extremities were all intact. His hips were stable. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: The patient was initially placed on CPAP up to 36 percent FIO2. On day of life number five he was weaned off CPAP to room air which he has been stable since. 2. Cardiovascular: Patient has been cardiovascularly stable without a murmur. His blood pressures have been within normal range. The patient had apnea and bradycardia of prematurity the last event was on [2109-5-2]. He has not been started on caffeine. 3. Gastrointestinal-fluid, electrolytes and nutrition: The patient was initially n.p.o. on 80 cc per kilogram per day of D10W. Enteral feedings were initiated on day of life number two and he advanced slowly to 150 cc per kilogram per day of breast milk 24. He is currently PO ad lib: BF + bottles of expressed breast milk enhanced to 24 calories. His discharge weight is 2125 gms. 4. Gastrointestinal - Serial bilirubins were followed. Patient was initiated on phototherapy on day of life number three for a bilirubin of 12/0.4. His peak bilirubin was 12.7/0.3 on day of life number five. Phototherapy was discontinued on day of life number five and rebound bilirubin was 9.3/0.3. 5. Heme: Patient's initial hematocrit was 61. He was stable and required no transfusions. 6. Infectious disease: Patient's initial white blood count was 7.6 with 19 segs, 0 percent bands. Blood culture was drawn. Ampicillin and Gentamicin were initiated and were continued for 48 hours until blood cultures were negative. 7. Condition at discharge: stable 8. Discharge home 9. Care recommendations: a. Feeds: Breastfeeding ad lib, breastmilk 24 (4 cal/oz) Enfamil powder. b. Car seat screen passed c. State newborn screen sent, [4-26] and [5-7], result pending d. Hep B vaccine given [2109-5-8] e. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following criteria: born btw 32 and 35 wks with 2 of 3 of the following: dycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age children. f. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for household contacts and out-of-home caregivers. Parents live in [Location (un) ]. Their pediatrician will be Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 56146] at [Location (un) 55] Pediatrics. (P) [Telephone/Fax (1) 56147]. An appointment is scheduled for today ([2109-5-10]). DIAGNOSES: 1. Prematurity at 34 1/7 weeks. 2. Respiratory distress. 3. Hyperbilirubinemia. 4. Sepsis evaluation negative. 5. Feeding immaturity. MEDICATIONS: 1. Vidalyn (multivitamin) 1 cc P.O. q day. 2. Ferrous sulfate 0.2 ml P.O. q day. DR.[First Name (STitle) ],[First Name3 (LF) 36400] 50-595 Dictated By:[Last Name (NamePattern1) 55432] MEDQUIST36 D: [2109-5-6] 15:27:53 T: [2109-5-6] 21:11:15 Job#: [Job Number 56148] ICD9 Codes: 769, V053, 7742
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8268 }	Medical Text: Admission Date: [2117-11-8] Discharge Date: [2117-11-17] Date of Birth: [2040-8-9] Sex: M Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old man with known history of atrial fibrillation, congestive heart failure and valvular disease. He recently underwent cardiac catheterization for shortness of breath and to evaluate his known mitral regurgitation. The cardiac catheterization revealed two vessel coronary artery disease, severe mitral regurgitation, mild systolic and diastolic ventricular dysfunction and severe pulmonary hypertension. Specifically there was a 70% stenosis of the left circumflex, 30% stenosis of the right coronary artery and 70% stenosis of the posterior descending coronary artery . The estimated ejection fraction was 42%. The patient presented to the service for mitral valve repair after the planned procedure was postponed approximately two weeks ago secondary to cellulitis of the right calf, which was treated with antibiotics for ten days prior to admission. On the day of admission the patient denied any chest pain. He does complain of mild exertional shortness of breath with activities such as climbing stairs. He denies any claudication, orthopnea, paroxysmal nocturnal dyspnea, lightheadedness. He does have chronic lower extremity edema. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Congestive heart failure with ejection fraction of 42% by the cardiac catheterization and more then 55% by surface echocardiogram. 3. Hypothyroid, which is a new diagnosis. 4. Coronary artery disease. 5. Hypercholesterolemia. PAST SURGICAL HISTORY: 1. Hernia repair. 2. Detached retina surgery on the right eye. ALLERGIES: No known drug allergies. MEDICATION ON ADMISSION: Coumadin originally on 2.5 mg stopped ten days prior to admission. Lasix 20 mg po b.i.d., Captopril 50 mg po t.i.d., Digoxin 0.125 mg po q day, Unithyroid 50 micrograms po q day, Procardia 240 mg po q day. PHYSICAL EXAMINATION: The patient was alert and oriented and in no acute distress. Blood pressure 113/58. Pulse 82. Temperature 97.0. General, in no acute distress. HEENT examination within normal limits. Chest examination clear to auscultation bilaterally. Cardiac examination irregular heart rate with 3 out of 6 systolic ejection murmur, which radiates to the neck bilaterally. Abdomen soft, nontender, nondistended. No hepatosplenomegaly. Extremities warm and well perfuse without any evidence of edema, however, there are bilateral lower extremity venostasis changes. LABORATORY STUDIES: Hematocrit 31.9, PT 14.1, PTT 37.2, INR 1.4. BUN 16, creatinine 0.9, glucose 168, potassium 4.0, sodium 141. HOSPITAL COURSE: The patient was admitted to the Cardiac Surgery Service for surgical intervention. On [2117-11-8] the patient underwent mitral valve repair with a 30 mm [Doctor Last Name 405] ring, tricuspid valve anuloplasty, with 32 mm ring, coronary artery bypass graft times two/ligation of the left atrial appendage. Please see the full operative note for details. The procedure was without complications. The patient was transferred to the Intensive Care Unit in stable condition. The patient remained intubated. He was making adequate urine. His white blood cell count was noted to be 18 on postoperative day one. The chest x-ray was taken to confirm the position of the pulmonary artery catheter as well as the nasogastric tube. The patient was maintained on aspirin. Aggressive pulmonary toilet was initiated. Chest tubes were in place. The patient's hematocrit remained stable. His white blood cell count was still elevated on postoperative day two at 17.9. Physical therapy was consulted who followed the patient throughout the hospitalization. Electrophysiology/Cardiology Service was consulted regarding partial heart block. The patient was consequently extubated on postop day two. He remained afebrile with stable blood pressure and 98% on 4 liters nasal cannula. The patient continued to be in atrial fibrillation with occasional atrial flutter. He also had runs of nonsustained ventricular tachycardia, which was not new to him. The patient was transferred to the floor on postoperative day three. He was continued on Coumadin and intravenous heparin to achieve adequate coagulation. Electrophysiology Service was following the patient regarding a possible placement of a pacer device. Echocardiogram was obtained on [2117-11-15], which showed a left ventricular ejection fraction of 50 to 55%. Also some septal hypokinesis was noted, but no other wall motion abnormalities. The decision was made that given no evidence of myocardial scar and no significant left ventricular dysfunction (normal EF), the history of nonsustained ventricular tachycardia in isolation does not confer high risk for sudden cardiac death. Consequently the electrophisilogy recommendation was not to place the device at that time. The patient continued to do well. He was in atrial fibrillation/flutter during his hospitalization. He also had runs of ventricular tachycardia that was nonsustained as mentioned previously. He was discharged to the rehabilitation center on [2117-11-17]. On discharge the patient's INR was 1.9. Consequently his intravenous heparin was stopped and he was continued on po Coumadin only. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To rehabilitation center. DISCHARGE DIAGNOSES: 1. Coronary artery disease and mitral valve disease status post coronary artery bypass graft times two and mitral valve repair with a 30 mm [Doctor Last Name 405] ring. 2. Congestive heart failure. 3. Hypercholesterolemia. 4. History of nonsustained ventricular tachycardia. 5. Atrial fibrillation. 6. Hypothyroid. DISCHARGE MEDICATIONS: 1. Coumadin dose to be adjusted at the rehabilitation center based on coagulation laboratories obtained daily. 2. Lasix 20 mg po b.i.d. 3. Captopril 50 mg po t.i.d. 4. Procardia XT 240 mg po q day. 5. Digoxin 0.125 mg po q.d. 6. Unithyroid 50 micrograms po q day. 7. Colace 100 mg po b.i.d. prn constipation. 8. Protonix 40 mg po q day. DISCHARGE INSTRUCTIONS: 1. The patient is to follow up with his surgeon Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537] in approximately four weeks. 2. The patient is to follow up with his cardiologist in approximately three to four weeks. 3. The patient is to follow up with his primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in approximately one to two weeks. 4. The patient is to have coagulation laboratories drawn (PT, PTT, INR) daily until a stable Coumadin regimen is obtained. The anticoagulation will be followed at the rehabilitation center where the patient is being transferred and then by the primary care physician. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern1) 1741] MEDQUIST36 D: [2117-11-17] 12:21 T: [2117-11-17] 14:51 JOB#: [Job Number 10785] ICD9 Codes: 4240, 4280, 2720, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8269 }	Medical Text: Admission Date: [2135-10-23] Discharge Date: [2135-10-25] Date of Birth: [2095-3-22] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5868] Chief Complaint: Seizure Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 40 yo R-handed man with hx of IVDU, HepC, GTC in the past in the setting of withdrawal, who is brought to the ED by [Location (un) ] Police for question of seizures. The patient was taken off the street [10-21] for shoplifting and was found to carry needles. He denied any IVDU and said he had IDDM (also gave a false name and DOB). He was doing fine [10-21]. On [10-22] early pm, he reportedly was seen "shaking". No information is available regarding this event. He was not lethargic following the event. At 10pm he had another episode; his arms and legs were shaking (twitching and moving, and looked rigid when he was doing it), lasting about 3 minutes. Reportedly he was not lethargic, but non-cooperative. He was brought to the ED where he had a similar episode at 1.40 (few minutes). Another episode occured at 2.50 when I was examining him: he put his R- hand behind is head, would not respond to vocal stimuli, turned his head to the L. He then started making rhythmic movements in his arms and legs, before going into a GTC sz that lasted about 30s, incontinent for urine. He received 2mg ativan at that point. He continued shaking in his arms and legs and received further ativan inj. while he was being loaded on dilantin. Before the seizure, the patient denied any IVDU and denied any medical problems. [Name (NI) ] felt cold and tired and was yawning a lot. Review of systems: denies any fever, visual changes, hearing changes, headache, neckpain, nausea, vomiting, dysphagia, weakness, tingling, numbness, bowel-bladder dysfunction, chest pain, shortness of breath, abdominal pain, dysuria, hematuria, or bright red blood per rectum. Past Medical History: -hepC -explorative abdominal surgery for knife wound -GTC x2 in the setting of heroin withdrawal (mid 90's); been on dilantin Social History: Occupation: no work; says he lives in [Location 86]. Smoking: 1 ppd, unkown how long EthOH. Denied IV drug use at admission. Recently incarcerated. Family History: Married: no children. Father with MI. Physical Exam: T 99.3 BP 120/80 HR 68 Pox 98% RA Gen NAD HEENT: no lesions, MMM CHEST: lungs clear bilaterally, heart sounds normal with no m/r/g Abd: soft nt nd +bs ext: no c/c/e Neuro: a/o x3. speech fluent without errors. EOMI without nystagmus, PERRLA, VFFC. No facial weakness or asymmetry. Facial sensation intact. Tongue midline, uvula midline. Motor exam with full strength in all major muscle groups. Coordination intact - normal in UE and LE. Senastion intact throughout without extinction. Gati: normal. Pertinent Results: 2211/22/05 06:10AM BLOOD WBC-11.9* RBC-4.61 Hgb-13.5* Hct-38.1* MCV-83 MCH-29.2 MCHC-35.3* RDW-14.0 Plt Ct-230 [2135-10-23] 09:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-26 GLUCOSE-96 [2135-10-23] 09:30AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* POLYS-71 LYMPHS-7 MONOS-[2135-10-23] 06:45AM PHENYTOIN-19.4 [2135-10-23] 05:15AM LACTATE-2.0 [2135-10-23] 06:45AM HBsAg-NEGATIVE HBs Ab-NEGATIVE [2135-10-23] 05:00AM GLUCOSE-132* UREA N-14 CREAT-0.6 SODIUM-139 POTASSIUM-3.0* CHLORIDE-106 TOTAL CO2-20* ANION GAP-16 [2135-10-22] 11:55PM LIPASE-31 [2135-10-22] 11:55PM VIT B12-716 [2135-10-22] 11:55PM TSH-0.22* [2135-10-22] 11:55PM HBsAg-NEGATIVE HBs Ab-NEGATIVE [2135-10-22] 11:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2135-10-22] 11:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [2135-10-22] 11:55PM WBC-16.4# RBC-4.87 HGB-15.0 HCT-39.7 MCV-81# MCH-30.7 MCHC-37.7 RDW-13.8 [2135-10-22] 11:55PM PLT COUNT-287 [2135-10-22] 11:55PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2135-10-22] 11:55PM URINE RBC-[5-13]* WBC-[5-13]* BACTERIA-MOD YEAST-NONE EPI-1 [2135-10-23] 9:30 am CSF;SPINAL FLUID Site: LUMBAR PUNCTURE TUBE #3. GRAM STAIN (Final [2135-10-23]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. URINE CULTURE (Final [2135-10-24]): NO GROWTH. Head CT:IMPRESSION: No evidence for acute intracranial abnormality including hemorrhage or mass effect. Right maxillary sinus mucus retention cyst. MRI with gadolinium brain [2135-10-25]: No mass lesion noted. There is T2 flair hypodensity in the posterior frontal lobe bilaterally that is likely secondary to chronic white matter changes. There is no obvious evidence of intracranial abscess. The ventricles appear to be normal in size. (Neurology Resident Read). CXR Chest: A single upright AP view of the chest shows an endotracheal tube with the tip at the level of T3 and a NG tube with its tip below the diaphragm. The lungs are clear. There is no evidence of pneumothorax. The cardiomediastinal silhouette and the costophrenic sulci appear normal. EEG: This is an abnormal EEG due to the presence of overlying beta activity with suppressive periods during times when Propafol medication was being administered. With the alleviation of Propafol, what was seen was a pattern similar to a spindle coma with beta being the primary rhythm observed. There was no evidence of statusepilepticus. There is no evidence of any focal or sharp activity seenthroughout this recording suggesting ongoing seizures. Repeat EEG with the alleviation of medication in the future to better assess the presence of background activity should be performed if clinically required. Brief Hospital Course: Mr [Known lastname 8976] is a 40 year old with history of seizures in the setting of alcohol withdrawal, known IVDU (Heroin), Hepatitis C, was interrogated by police for shoplifting, on the same day developed episode of shaking in all four limbs. Patient proceeded to have several such episodes upon arrival at the [Hospital1 18]. He had reported seizures of left side with generalization to entiure body with loss of consciousness. He received 10mg of lorazepam and was loaded with pheyntoin in the ED. The patient was intubated for airway protection as we was poorly responsive after at least 3 seizure events. He was transferred to the Neuro ICU for monitoring. He was not noted to have any focal deficits however was inattentive and somewhat uncooperative. He was found to have a UTI and received antibiotics. He was administered methadone for heroin withdrawal. NEURO: patient stabilized and was extubated on [2135-10-23]. Dilantin level was 19.4. THe patient received methadone 20mg [Hospital1 ] for opiate withdrawal. His dilantin was discontinued on [2135-10-24]. A LP was performed which revealed CSF: WBC 3 RBC 1 Protein 26 and Glucose 96. CSF gram stain was negative and there were no organisms visualized. Head CT was negative for intracranial mass. Given the pt.'s use of IV drugs and his seizures, an MRI was performed with gadolinium: no abscesses or mass lesions are seen and there are no enhancing structures. An EEG was performed while pt was intubated and revealed predominant beta rhythm. Status epilepticus was not observed. CV: The pt. received IV hydrazaline in the ICU for high blood pressures but was ablt to be weaned and the pt. did not require anti-hypertensives to maintain normal BPs. RESP: no acute issues. Pt. is stable on room air. ID: urinalysis was consistent with borderline UTI (6-10 WBCs, nitrite negative) and the patient was started on oral Bactrim DS. Urine culture is negative however pt will complete a three day course. Pt. was negative for HBsAg. HIV test was sent but the results are pending at time of discharge. There has been no growth x2days in three sets of blood cultures. His WBC count has fallen to 11.9 from >16 while on Bactrim. Heme: no active issues Dispo: pt. is currently incarcerated and will return to police custody at discharge. Discharge Condition: Stable Discharge Diagnoses: 1. Generalized tonic-clonic seizures 2. Opiate withdrawal 3. UTI Medications on Admission: None reported Discharge Medications: Bactrim DS 1tab [Hospital1 ] x 1 day post-discharge Discharge Disposition: Home Discharge Diagnosis: Generalized tonic-clonic Seizure Opiate addiction/withdrawal UTI Discharge Condition: Stable Discharge Instructions: Please take bactrim for one more day Addiction counseling Please take methadone 20mg [Hospital1 ] Refrain from use of IV heroin (or other drugs of abuse) Methadone not given at Sherrif office - spoke with Medical Staff @[Telephone/Fax (1) 8977] BE AWARE THAT PATIENT [Month (only) ] HAVE WITHDRAWAL SEIZURES. Followup Instructions: No neurology follow-up required Pt. will follow-up with medical team at prison facility. ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8270 }	Medical Text: Admission Date: [2148-2-19] Discharge Date: [2148-2-22] Date of Birth: [2115-10-6] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 905] Chief Complaint: Alcohol intoxication Major Surgical or Invasive Procedure: None History of Present Illness: Mr [Known lastname 7208] is a 32 yo male with hx of ETOH abuse, tachycardia, brought in by EMS for AMS. He was found with multiple bottles of hard liquor around him and reportedly said that he wanted to drink himself to death. He was drinking about one liter of vodka per day for the past five weeks. He has a history of heavy drinking. He claims he had been sober for 3-4 years, although he was seen in [Month (only) ] in the ED for EtOH related trauma. No clear h/o DT, but reports on seizure. He was then brought to the [Hospital1 18] ED for further workup. . In the ED, initial VS were 97.2 131 151/87 16 98% RA. He was somnolent, and had no evidence of trauma. PERRLA. Lungs were clear. Abd was benign. He had no stigmata of chronic liver disease. He was AOx1 and moving all extremities. There was no seizure activity or focal deficits. He was given a banana bag, 2L IVF, and 20mg IV valium. He was noted to have a serum etoh level of 574 and and osmolal gap of 16 when corrected for EtOH. He had an elevated lipase of 130, an ALT of 184, and an AST of 255. The rest of his serum and urine tox is negative. He had a lactate of 4.2 and a normal gas. Before transfer to the floor, vitals: HR 122, BP 137/80 RR15 99% RA . Upon arrival to the ICU, he was awake and alert, though somewhat sluggish. He reports shakiness, anxiety, nausea, HA, and "hallucinations" which he cannot characterize. He denied f/c, CP, SOB, abd pain, focal neurologic defects. He reports that he has had seizures from withdrawal before when he tried to detox on his own. He denies ingestion of other substances such as ethylene glycol, methanol, isopropanol. He denied SI/HI. Past Medical History: Lonstanding alcohol abuse Tachycardia - treated with atenolol for the past 10 years. Social History: Reports about 1L of hard alcohol daily. 1 PPD smoker. Denies other illicit drugs. Family History: EtOH abuse Physical Exam: vitals: 98.6 128 136/82 21 98%RA gen: dissheveled, diaphoretic, shaky, appears intoxicated heent: ncat, nontraumatic, pupils large and equal, sluggish pulm: bibasilar rales which clear with deep inspiration. o/w ctab cv: tachy, 2/6 sem at base abd: s/nt/nd/nabs, no hsm extr: no c/c/e neuro: strength 5/5 and sensation to light touch intact throughout. CN 2-12 intact. Pertinent Results: [2148-2-22] 06:45AM BLOOD WBC-2.9* RBC-4.47* Hgb-14.7 Hct-41.0 MCV-92 MCH-32.9* MCHC-35.8* RDW-14.5 Plt Ct-51* [2148-2-19] 02:55PM BLOOD WBC-6.1 RBC-4.86 Hgb-15.9 Hct-43.0 MCV-89 MCH-32.8* MCHC-37.1* RDW-14.3 Plt Ct-66# [2148-2-19] 02:55PM BLOOD Neuts-80.5 Lymphs-15.1* Monos-3.8 Eos-0.1 Baso-0.5 [2148-2-20] 03:07AM BLOOD PT-13.5* PTT-25.3 INR(PT)-1.2* [2148-2-22] 06:45AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-141 K-3.4 Cl-102 HCO3-30 AnGap-12 [2148-2-19] 02:55PM BLOOD Glucose-129* UreaN-9 Creat-0.7 Na-139 K-3.4 Cl-91* HCO3-32 AnGap-19 [2148-2-20] 03:07AM BLOOD ALT-133* AST-192* AlkPhos-72 Amylase-47 TotBili-0.8 [2148-2-22] 06:45AM BLOOD ALT-95* AST-107* [2148-2-19] 02:55PM BLOOD ALT-184* AST-255* AlkPhos-92 TotBili-0.9 [2148-2-20] 03:07AM BLOOD Calcium-8.1* Phos-2.1* Mg-1.6 Iron-123 Cholest-229* [2148-2-20] 03:07AM BLOOD calTIBC-231* Ferritn-798* TRF-178* [2148-2-20] 03:07AM BLOOD Triglyc-66 HDL-41 CHOL/HD-5.6 LDLcalc-175* [2148-2-19] 02:55PM BLOOD Osmolal-430* [2148-2-20] 03:07AM BLOOD TSH-2.5 [2148-2-20] 03:07AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2148-2-19] 02:55PM BLOOD ASA-NEG Ethanol-574* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2148-2-19] 02:55PM BLOOD LtGrnHD-HOLD [2148-2-20] 03:07AM BLOOD HCV Ab-NEGATIVE [2148-2-19] 04:10PM BLOOD Type-ART pO2-90 pCO2-45 pH-7.44 calTCO2-32* Base XS-5 Intubat-NOT INTUBA Comment-ROOM AIR [2148-2-19] 03:04PM BLOOD Lactate-4.2* [2148-2-20] 01:30PM BLOOD Lactate-2.3* . LIVER ULTRASOUND: Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. No liver lesions identified. No splenomegaly. . CHEST X-RAY: No acute cardiopulmonary process. Brief Hospital Course: 32 yo male with history of EtOH abuse and comorbid psychiatric problems presents with acute intoxication and withdrawal. . MICU COURSE: He was seen by psychiatry and social work. He was placed on a standing taper as CIWA scales had been unreliable given baseline tachycardia. His osmolality gap went from 145 to 60. Lipids WNL. No acidosis. No evidence of withdrawal. Heart rate improved from 130s to 70s. . EtOH WITHDRAWAL: Patient admitted with elevated blood alcohol level, so likely was not in withdrawal. CIWA scales consistantly < 10. He was started on a benzodiazepine taper per psychiatry recommendations. Osm gap resolved. He was given thiamine, folate, and MVI. His atenolol was held. . TACHYCARDIA: Currently normal rate. Patient had tachycardia to the 120s on admission. This trended down to 60-80s in the ICU with IVF. His tacycardia was atributed to agitaion vs. withdawel, but he has a history of tachycardia, unclear etiology. TSH wnl. As he was not tachycardic on discharge, he probably does not need this medication except prn anxiety. . LFT abnormalities: likely related to EtOH ingestion with AST > ALT (although not the classic 2:1). Liver ultrasound showed fatty liver. Hepatitis serologies negative. - Patient should have these rechecked as an outpatient. . LEUKOPENIA and THROMBOCYTOPENIA: There were thought to be most likely [1-29] direct EtOH toxicity. He has been trending up as an inpatient. No splenomegaly on ultrasound - further outpatient w/u if not resolved . DEPRESSION and ANXIETY: Per report, he had reported SI to EMS. Since admission, he denyied SI/HI. He has history of depression and anxiety. He was seen by psych and felt to be not suicidal, not a danger to self or others, and not in need of inpatient admission. He was continued on citalopram. . ELEVATED LIPASE: Asymptomatic, possibly subclinical pancreatitis from etoh. Improving. - continue to trend . CODE: FULL . CONTACT: [Name (NI) 21206] [Name (NI) ] [Name (NI) 7208], [Telephone/Fax (1) 80478](c) [Telephone/Fax (1) 80479] (h) Medications on Admission: atenolol 25 klonipin 4 citalopram 20 Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Seroquel 100 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Disp:30 Tablet(s) Refills:0 4. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: ALCOHOL WITHDRAWAL TACHYCARDIA LIVER FUNCTION TEST abnormalities LEUKOPENIA and THROMBOCYTOPENIA DEPRESSION ANXIETY ELEVATED LIPASE Discharge Condition: Stable. CIWA 4 Discharge Instructions: You were admitted with alcohol intoxication. You were monitored in the ICU for signs of withdrawal. Although you did not have signs of withdrawal, you blood tests did show signs of damage from chronic alcohol use. You should follow up with your PCP for follow up testing and to consider further evaluation. You should avoid alcohol use entirely as this is particularly dangerous for you. We encourage you in seeking assistance to help stay sober. If you have fevers, sweats, shaking, agitation, confusion, or feling of alcohol withdrawal, please seek medical attention. Followup Instructions: Mon [2-26], with Dr. [Last Name (STitle) 62417], 9:10 AM in [Location (un) 2274] ([Telephone/Fax (1) 50515]. Please bring this paperwork with you. [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2148-2-27] ICD9 Codes: 2875, 311
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8271 }	Medical Text: Admission Date: [2104-9-29] Discharge Date: [2104-10-15] Date of Birth: [2027-7-16] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2104-10-2] Mitral Valve Replacement utilizing a [Street Address(2) 11599]. [Male First Name (un) 923] mechanical valve and Two vessel coronary artery bypass grafting with left internal mammary artery to left anterior descending, and vein graft to obtuse marginal History of Present Illness: This is a 77 year old female who presented to outside hospital with congestive heart failure. Her major complaints at that time were shortness of breath and increasing fatigue. Cardiac catheterization on [9-25] revealed severe three vessel coronary disease, 3+ mitral regurgitation and an LVEF of 55%. Angiography showed a non-dominant RCA with a 70% stenosis; 50% ostial left main lesion; 95% stenosis in the LAD with diffuse disease of the circumflex system. Based on the above results, she was transferred to [Hospital1 18] for cardiac surgical intervention. Of note, prior ECHO from [2104-8-14] was notable for severe MR with an estimated LVEF of 40-45%. Past Medical History: Congestive Heart Failure Mitral Regurgitation Coronary Artery Disease End-Stage Renal Disease Atiral Fibrillation Hypertension Diabetes mellitus Hyperlipidemia Anxiety Spinal stenosis s/p right nephrectomy s/p colostomy with reversal s/p chole s/p Totoal Abdominal Hysterectomy and Bilateral salpingo-oophorectomy Prior left leg vein stripping Social History: Occasional ETOH. No tobacco history. Family History: Non-contributory Physical Exam: VS: 100.0 105/52 80 20 99%2L 63.8kg General: Pleasant elderly male in NAD HEENT: PERRL, EOMI Lungs: CTAB Heart: SEM [1-20] Abd: Soft, NT/ND +BS Ext: Cool feet w/ DP 1+ Bilat, -edema, +varicosities Neuro: CN2-12 intact grossly Pertinent Results: [2104-9-29] 09:50PM BLOOD WBC-10.3 RBC-3.13* Hgb-10.7* Hct-31.4* MCV-100* MCH-34.1* MCHC-34.0 RDW-15.1 Plt Ct-208 [2104-10-4] 03:14AM BLOOD WBC-22.2* RBC-3.14* Hgb-10.1* Hct-28.8* MCV-92 MCH-32.0 MCHC-34.9 RDW-18.1* Plt Ct-130* [2104-10-14] 06:40AM BLOOD WBC-12.4* RBC-3.16* Hgb-10.8* Hct-32.9* MCV-104* MCH-34.1* MCHC-32.8 RDW-22.4* Plt Ct-113* [2104-9-29] 09:50PM BLOOD PT-13.4* INR(PT)-1.2 [2104-10-13] 09:57AM BLOOD PT-18.5* PTT-150 IS HIG INR(PT)-2.4 [2104-9-29] 09:50PM BLOOD Glucose-135* UreaN-27* Creat-5.9* Na-137 K-4.6 Cl-93* HCO3-30 AnGap-19 [2104-10-12] 08:00AM BLOOD Glucose-152* UreaN-31* Creat-4.1* Na-136 K-4.8 Cl-97 HCO3-26 AnGap-18 [2104-10-11] 07:52AM BLOOD Albumin-2.7* Calcium-8.4 Phos-4.9* Mg-2.0 UricAcd-7.5* [2104-10-1] 12:12PM URINE Blood-LG Nitrite-POS Protein-30 Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-MOD Brief Hospital Course: As noted in the HPI, pt was transferred to [Hospital1 18] and admitted for surgical intervention. Prior to surgery pt needed to have complete work-up which included labs, Echo, Chest CT, LE vein mapping. She also required a Renal (for HD) and Dental consult. Following work-up and consults, pt consented to surgery and was brought to the operating room on HD#4 where she underwent a Mitral valve replacement (27mm St. [Male First Name (un) 923] mechanical valve) and two vessel coronary artery bypass. Pt. tolerated the procedure well with bypass time of 113 minutes and cross-clamp time of 94 minutes. Please see op note for surgical details. Pt. was transferred to CSRU in stable condition on the following gtts: Epinephrine, Neosynephrine, and Nitroglycerin. Pt. remained intubated for several days and on POD #2 was weaned from mechanical ventilation and sedation and extubated. Pt. remained in the CSRU for an extended period of time (until POD #7) d/t requiring Neo or Epi for hemodyamic support. She was started on a Heparin gtt and remained on that for awhile until Coumadin was initiated and her INR was at a therapeutic level (>2.5). She also had complete heart block (asystolic underneath temp. pacer) while in the CSRU and had a permanent pacemaker placed on POD#5. Epicardial pacing wires removed on this day. Chest tubes were removed per protocol. Renal saw pt again post-operatively and followed pt for entire hospital stay. She was dialyzed mutlpile times while in the unit (and also while on the floor). She had an elevated WBC during post-op period (>20'000's) and had blood cultures and RIJ cordis tip sent for cultures (all negative). She also had 2 units of red cells transfused on POD #6 d/t low Hct (26). Pt. was evaluated by Physical Therapy and worked with pt during entire post-operative period. Once pt. was transferred to telemetry floor, POD #7, she slowly improved and increased ambulation. She had some pedal edema on exam at time of discharge otherwise exam was unremarkable. Labs were stable (Hct increased to 36.5 and WBC was down to 11.9) and she remained on the floor until POD #12 when she was discharged to a rehab facility Medications on Admission: 1. Lisinopril 2.5mg qd 2. Nephrocaps 1mg qd Zocor 10mg qhs 4. Nortriptyline 25mg qhs 5. Epogen [2098] IV qd 6. ASA 81mg qd 7. Hydroxyline 25mg qhs 8. Humalin sliding scale 9. Atenolol 25mg bis 10. Heparin gtt Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Warfarin 1 mg Tablet Sig: 2.5 Tablets PO ONCE (once): check INR [2104-10-16] and PRN. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as needed). Discharge Disposition: Extended Care Facility: [Hospital 62289] hospital of [Doctor Last Name ] Discharge Diagnosis: Mitral Regurgitation s/p Mitral Valve Replacement([Street Address(2) 11599]. [Male First Name (un) 923] mechanical valve) Coronary Artery Disease s/p Two vessel coronary artery bypass grafting(LIMA to LAD, vein graft to OM) Congestive Heart Failure End-Stage Renal Disease Atiral Fibrillation Hypertension Diabetes mellitus Hyperlipidemia Anxiety Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. Avoid creams, lotions and ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks. Followup Instructions: Dr. [Last Name (STitle) ] in [3-18] weeks Dr. [Last Name (STitle) ] in [1-17] weeks Completed by:[2104-10-14] ICD9 Codes: 5856, 2859, 2724, 4439
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8272 }	Medical Text: Admission Date: [2105-3-5] Discharge Date: [2105-3-15] Date of Birth: [2034-9-26] 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: Coronary Artery Bypass Graft (LIMA to LAD, SVG to OM, SVG to PDA)times three on [2105-3-11] History of Present Illness: 70 year old gentleman with known coronary artery disease who had an MI and stent placement in [2091]. He has felt well until roughly 6 months ago where he developed frequent episodes of chest pain which were not related to physical exertion. He underwent a cardiac catheterization at [Hospital6 5016] which revealed severe proximal left anterior descending artery stenosis. Given the findings, he was referred to the [Hospital1 18] for surgical management. Past Medical History: CAD MI [2091] PTCA/Stent to LAD in [2091] HTN Hyperlipidemia GERD Social History: Retired shipping clerk. Current smoker of [3-25] cigs/day. Previous 2ppd smoker. Occassional ETOH with meals. Lives with wife and sons. Family History: None noted Physical Exam: 61 120/59 GEN: WDWN in NAD SKIN: Warm, dry, no clubbing or cyanosis. HEENT: PERRL, Anicteric sclera, OP Benign NECK: Supple, no JVD, FROM. LUNGS: Left CTA, Right with scattered wheezes. HEART: RRR, No M/R/G ABD: Soft, ND/NT/NABS EXT:warm, well perfused, no bruits, mild varicosities bilaterally NEURO: No focal deficits. Pertinent Results: [2105-3-6] 01:00AM BLOOD WBC-5.7 RBC-4.16* Hgb-12.7* Hct-36.9* MCV-89 MCH-30.6 MCHC-34.5 RDW-13.2 Plt Ct-145* [2105-3-6] 01:00AM BLOOD Plt Ct-145* [2105-3-6] 01:00AM BLOOD Glucose-97 UreaN-18 Creat-0.8 Na-139 K-3.8 Cl-107 HCO3-26 AnGap-10 [2105-3-6] 01:00AM BLOOD ALT-17 AST-22 AlkPhos-55 Amylase-55 TotBili-0.3 [2105-3-6] 01:00AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0 [2105-3-6] - CXR Heart size is normal. Mediastinal position, contour and width are unremarkable. Lungs are essentially clear within the limitation of this portable suboptimal radiograph. The left costophrenic angle was not included in the field of view. No obvious pneumothorax or pleural effusion is seen. [2105-3-11] ECHO Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Normal LV systolic fxn. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. Mild to moderate ([1-23]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Preserved biventricular systolic fxn. No MR. AI as pre-bypass. Aorta intact. [2105-3-9] Vein Mapping Dilated right greater saphenous vein with varicosities. Left greater saphenous vein is patent with appropriate diameters for bypass. Both lesser saphenous veins are thick walled and the left is small. Brief Hospital Course: Mr. [Known lastname 41614] was admitted to the [Hospital1 18] on [2105-3-5] for surgical management of his coronary artery disease. He was worked-up in the usual preoperative manner and found to be suitable for surgery. Benadryl and sarna lotion were started for pruritis of his back which was present upon admission. Plavix was allowed to washout while low dose nitroglycerin was continued. On [2105-3-11], Mr. [Known lastname 41614] was taken to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. He later awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. His chest tubes were removed. On postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. His epicardial wires were removed. By post-operative day four he was ready for discharge to home. Medications on Admission: ASA 81', lisinopril/HCTZ 10/12.5 daily, lopressor 25", Plavix LD [3-4], vytorin 10/40, zantac 150" Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:65 Tablet(s) Refills:0 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 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 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 9. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day: smoking cessation. Disp:60 Tablet Sustained Release(s) Refills:2 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 11. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Amedisys [Location (un) ] Discharge Diagnosis: CAD MI in [2091] HTN Hyperlipidemia GERD 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) 5017] in 2 weeks. [Telephone/Fax (1) 5424] Please follow-up with Dr. [Last Name (STitle) ] in [2-25] weeks. Please call all providers for appointments. Completed by:[2105-3-15] ICD9 Codes: 4111, 4019, 2724, 412, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8273 }	Medical Text: Admission Date: [2199-5-21] Discharge Date: [2199-6-26] Date of Birth: [2172-2-15] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1556] Chief Complaint: s/p multiple gunshot wounds to chest and back Major Surgical or Invasive Procedure: [2199-5-21] Exploratory Laparotomy; Right tube thoracostomy; Distal pancreatectomy; splenectomy; small bowel resection; gastostomy tube; enteroenterostomy; repair left renal laceration; repair transverse colon laceration History of Present Illness: 27-year-old male who sustained a number of gunshot wounds and presented to an area hospital where he was intubated and bilateral chest tubes were placed. He was transferred to [Hospital1 346] for definitive management. On arrival, he was hypotensive with a systolic blood pressure in the 70s and tachycardic. He was taken directly to the operating room for exploration of his injuries. Past Medical History: Unknown Social History: Has girlfriend who is expecting Family History: Noncontributory Physical Exam: Upon admission to trauma bay: Intubated/sedated/paralyzed Chest: decreased BS on right; bullet wound on right; supraxyphoid wound Back: wound at right scapula tip; wound lower thoracic spine Cor: tachy Abd: distended GU: + hematuria Extr: right arm deformity; bullet wound visible RUE Pertinent Results: [2199-5-21] 07:46PM GLUCOSE-166* UREA N-14 CREAT-1.0 SODIUM-136 POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-20* ANION GAP-14 [2199-5-21] 07:46PM CALCIUM-7.9* PHOSPHATE-4.2 MAGNESIUM-2.0 [2199-5-21] 07:46PM WBC-10.5 RBC-3.80* HGB-11.4* HCT-31.5* MCV-83 MCH-30.1 MCHC-36.2* RDW-17.6* [2199-5-21] 07:46PM PLT COUNT-170 [2199-5-21] 07:46PM PT-12.9 PTT-27.0 INR(PT)-1.1 [2199-5-21] 08:58AM ALT(SGPT)-127* AST(SGOT)-149* ALK PHOS-26* AMYLASE-73 TOT BILI-1.9* HUMERUS (AP & LAT) RIGHT [2199-6-18] 1:38 PM HUMERUS (AP & LAT) RIGHT; ELBOW (AP, LAT & OBLIQUE) RIGH Reason: ? interval change [Hospital 93] MEDICAL CONDITION: 27 year old man with R arm fx s/o ORIF REASON FOR THIS EXAMINATION: ? interval change HISTORY: Status post ORIF, question interval change. RIGHT HUMERUS, TWO VIEWS. RIGHT ELBOW, THREE VIEWS. RIGHT FOREARM, 2 VWS . RIGHT HUMERUS: There is a comminuted fracture of the distal humerus, transfixed by two plates and multiple screws. There is marked comminution. Fracture lines remain visible. No definite hardware loosening is identified. There is callus formation/heterotopic bone formation to some degree between the fractured fragments, but more pronounced in the soft tissues surrounding the humeral fracture. Innumerable small pieces of shrapnel are also present. RIGHT ELBOW: The lateral view is obliqued, limiting assessment for joint effusion. However, there is a probable joint effusion. There is a fracture or osteotomy of the proximal ulna, which is secured by a screw, in overall anatomic alignment. The fracture/osteotomy site remains visible with minimal articular irregularity. I suspect slight widening of the radiocapitellar and ulnar trochlear articulations, but this appearance may be accentuated by the atypical positioning. No hardware loosening is identified. RIGHT FOREARM: Allowing for the proximal humeral fracture/osteotomy site, the right forearm is otherwise within normal limits. PORTABLE ABDOMEN [2199-6-17] 3:41 PM PORTABLE ABDOMEN Reason: ? ileus/obstruction [Hospital 93] MEDICAL CONDITION: 27M s/p multiple gsw to [Last Name (un) 103] s/p PEG recent emesis REASON FOR THIS EXAMINATION: ? ileus/obstruction INDICATION: Multiple gunshot wounds to the abdomen, status post PEG tube, recent emesis. COMPARISON: CT of the abdomen and pelvis from [2199-6-11]. FINDINGS: No dilated loops of small or large bowel are identified. Contrast is seen throughout the colon. One left sided abdominal drain is visible. An IVC filter is seen in place. IMPRESSION: No evidence of small or large bowel obstruction. CHEST (PORTABLE AP) [2199-6-12] 12:51 PM CHEST (PORTABLE AP) Reason: ? aspiration, pt with emesis trach cuff deflated at time [Hospital 93] MEDICAL CONDITION: 27M s/p trach REASON FOR THIS EXAMINATION: ? aspiration, pt with emesis trach cuff deflated at time PORTABLE CHEST AT 1 P.M. ON [6-12] INDICATION: Vomiting while tracheostomy cuff deflated. Evaluate for aspiration. FINDINGS: Compared with [2199-5-31], the left lung now appears almost completely reexpanded and clear. A pigtail drainage catheter is seen in the left upper quadrant of the abdomen. The right pleural effusion has decreased somewhat, but there is still residual fluid present at the lung base as well as what appears to be fluid loculated in the fissure overlying the right mid lung field. The visualized portions of the right lung appear clear. Position of the tracheostomy tube is unremarkable. IMPRESSION: No large volume aspiration detected. Sinus rhythm, rate 70. The tracing is within normal limits. No previous tracing available for comparison. Read by: [Last Name (LF) ],[First Name3 (LF) 1730] Intervals Axes Rate PR QRS QT/QTc P QRS T 70 162 74 [Telephone/Fax (2) 66740] 33 31 \ VIDEO OROPHARYNGEAL SWALLOW [2199-6-7] 2:52 PM VIDEO OROPHARYNGEAL SWALLOW Reason: ? aspiration [Hospital 93] MEDICAL CONDITION: 27 year old man s/p GSW REASON FOR THIS EXAMINATION: ? aspiration INDICATION: 27-year-old with gunshot wound. Question aspiration. VIDEO-OROPHARYNGEAL FLUOROSCOPIC EXAMINATION. FINDINGS: A video swallow examination was performed under fluoroscopic guidance in collaboration with speech pathology. Barium of varying consistencies including barium mixed with solids, and a barium tablet was administered. There was no evidence of residual, penetration, or aspiration. IMPRESSION: 1. No evidence of penetration or aspiration. US EXTREMITY NONVASCULAR RIGHT [2199-6-6] 10:36 AM US EXTREMITY NONVASCULAR RIGHT Reason: assess for RUE collection [Hospital 93] MEDICAL CONDITION: 27 year old man s/p gsw to R humerus, s/p ORIF now with erythema at elbow, fever, wbc REASON FOR THIS EXAMINATION: assess for RUE collection ULTRASOUND SCAN OF RIGHT ARM CLINICAL DETAILS: Right upper limb edema post-reduction internal fixation. Evaluation collection FINDINGS: Focused ultrasound over the area of swelling in the lateral right elbow region shows an ovoid heterogenous collection measuring up to 3.2 cm sagittal x 3.2 cm transverse. It is mainly anechoic (cystic) with some lattice-like internal echogenicity. The appearance on ultrasound are most suggestive of a localized postoperative hematoma. Infection cannot be excluded by imaging. CONCLUSION: 1. Small (3.2cm) collection in the right lateral elbow subcutaneous tissues. CT GUIDANCE DRAINAGE [2199-6-4] 9:55 AM CT GUIDANCE DRAINAGE; CT GUIDANCE DRAINAGE Reason: CT quided Drainage of peripancreatic fluid collection. [Hospital 93] MEDICAL CONDITION: 27 year old man with multiple gun shot wound traumas, s/p partial pancreatectomy currently with fluid collection seen on CT. REASON FOR THIS EXAMINATION: CT quided Drainage of peripancreatic fluid collection. CONTRAINDICATIONS for IV CONTRAST: None. CT GUIDANCE DRAINAGE HISTORY: 27-year-old man with multiple gunshot wound traumas, S/P partial pancreatectomy with multiple intra-abdominal fluid collections. Needs drainage of peripancreatic and upper left quadrant fluid collections. Comparison is made with prior study dated [2199-6-3]. ABDOMEN CT WITHOUT CONTRAST: Images obtained throughout the bases of the lungs show bilateral lower lobe consolidations and small bilateral pleural effusions. Left hepatic laceration is unchanged. Adrenal glands, gallbladder, and right kidney are unremarkable. Stable upper pole contusion in the left kidney. Again seen is a fluid collection in the splenic fossa that shows interval increase in size now measuring 5.4 x 13 cm. Again visualized is another fluid collection in the pancreatic tail resection site measuring approximately 70 x 39 mm. Stable collection/hematoma posterior to the left kidney. Gastrostomy tube is seen in the stomach. A surgical drain is seen along the anterior left abdomen. PROCEDURE: The risks and benefits of the procedure were explained to the patient. The patient was prepped and draped in the usual sterile fashion. The patient received conscious sedation during the procedure and local lidocaine 1%. A preprocedure timeout was performed to verify the patient identity. CT fluoroscopy was used to identify the sites over the left lateral upper and mid abdomen for insertion of the needles. After localization of the first collection located in the upper left quadrant and standard technique for cleansing, and local anesthesia infiltrated in the soft tissues, an 18-gauge spinal needle was inserted into the fluid collection under continuous fluoroscopic guidance. With parallel technique, a 10-French pig tail catheter was inserted into the fluid collection and approximately 30 cc of pus were aspirated. Using CT fluoroscopy, the second fluid collection located at the site of the pancreatic tail resection was localized. After cleansing and local anesthesia infiltrated, an 18- gauge spinal needle was inserted into the fluid collection under continuous fluoroscopic guidance. Using parallel technique, a 10-French pigtail catheter was inserted into the fluid collection and approximately 20 cc of pus were aspirated with no complications. IMPRESSION: Satisfactory CT-guided insertion of catheters into two fluid collections in the left upper quadrant and left mid abdomen with no complications. Brief Hospital Course: He was admitted to the Trauma service and taken immediately to the operating room for an exploratory laparotomy and the following: 1. Right chest thoracostomy tube placement. 2. Exploratory laparotomy. 3. Distal pancreatectomy. 4. Splenectomy. 5. Resection of small intestine (25-cm). 6. Enteroenterostomy. 7. Gastrostomy tube placement. 8. Suture repair of left renal laceration. 9. Suture repair of transverse colon laceration. Orthopedic surgery was consulted for his right humerus fracture; he underwent closed reduction for this initially and was later taken to the operating room for an ORIF. He has remained NWB through his RUE since the surgery. He will need to follow up with Orthopedics in 2 weeks. Thoracic surgery was consulted because of the injuries to his chest from the gunshot wound; recommendations to continue with chest tubes to suction. His chest tubes were later discontinued. He was fitted for a TLSO brace which will need to be worn while out of bed. Vascular Surgery was consulted for IVC filter placement; this was placed on [2199-6-3]. Infectious Disease was consulted because of persistent fevers; he was already being treated for a pneumonia. He also underwent repeat radiologic scanning of his abdomen, a fluid collection was identified (see Pertinent results CT abdomen); CT guided drainage catheters were placed x2 on [2199-6-4]. The output from these drains were monitored closely; he was started on Octreotide on [6-18]; the output began to decrease. The Octreotide should be continued for another 7 days then discontinued His first drain was pulled on [6-22] and the second was pulled on [6-26].The Octreotide should be continued for another 7 days then discontinued. He was also treated for a UTI with Ciprofloxacin; this has been discontinued. Orthopedic Spine Surgery was consulted as well because of his spinal injuries. He was fitted for a TLSO brace. Psychiatry was consulted because of increased episodes of anxiety and depression; he was started on an SSRI; dose increased from Zoloft 25 QD to 50 QD after 5 days. It was recommended that prn Ativan be used for his anxiety. His Zoloft dose should be increased as tolerated per recommendations of Psychiatry. A Speech and Swallow evaluation was also performed. He was changed to a Passy Muir valve and passed his swallow study. He was already receiving tube feedings via his PEG tube; he was given an oral diet in addition to this. His appetite has remained poor; calorie counts were initiated. His tube feedings which were being cycled over 12 hours at night were increased to 16 hours. Physical and Occupational therapy have also worked very closely with him and have recommended spinal cord injury rehab. Medications on Admission: None Discharge Medications: 1. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a day). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold for HR <60 and SBP < 100. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 10. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 17. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 19. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 20. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for UTI for 7 days. 21. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). Continue for 7 days. 23. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [Hospital6 ] - Rehab and SCI Discharge Diagnosis: s/p Multiple Gunshot Wounds to Chest and Back Liver Laceration Left Kidney Laceration Transverse Colon Laceration Bullet Deformity Right Humerus Discharge Condition: Stable Discharge Instructions: Follow up with Orthopedics in 2 weeks. Follow up in Trauma Clinic in 2 weeks. Followup Instructions: Call [Telephone/Fax (1) 1228] for an appointment in [Hospital ] Clinic in 2 weeks. Call [Telephone/Fax (1) 6439] for an appointment in Trauma Clinic in 2 weeks. Completed by:[2199-6-26] ICD9 Codes: 2851
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8274 }	Medical Text: Admission Date: [2114-7-25] Discharge Date: [2114-8-1] Date of Birth: [2051-1-3] 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: [2114-7-28] - CABGx3 (Left internal mammary artery->Left anterior descending artery, Saphenous vein graft(SVG)->Obtuse marginal artery, SVG->Posterior descending artery). History of Present Illness: Mr [Known lastname 12130] is a 63-year-old male with angina, positive stress test. Catheterization showed severe left main disease and right coronary stenosis. He is known to have peripheral vascular disease and has had bilateral carotid endarterectomies and has occlusion of both internal carotid arteries. He understands the necessity for the operation and the high-risk involved. Past Medical History: s/p frontal-parietal CVA [2107] Neurogenic Claudication s/p Bilateral CEA's in [2091] and [2092] s/p Aorto-bifem bypass [2101] Hypertension Hyperlipidemia s/p Right toe amputation Social History: Unemployed currently. Quit smoking [2113-8-5], but had a 90 pack year history prior. Has 2 alcoholic beverages per night. Family History: Both parents with CAD s/p MI. Physical Exam: Vitals- T 98.4 , HR 55 , BP 150/96 , RR 18 , O2sat Gen- NAD, alert Head and neck- AT, NC, soft, supple, no masses Heart- RRR, diastolic murmur Lungs- CTAB Abd- s, nt, nd Ext- warm, well-perfused, no edema 1+ palp pulses fem/[Doctor Last Name ]/dp/pt bilaterally Pertinent Results: [2114-7-25] 09:45PM WBC-6.0 RBC-4.61 HGB-13.7* HCT-40.3 MCV-88 MCH-29.6 MCHC-33.9 RDW-13.9 [2114-7-25] 09:45PM ALT(SGPT)-23 AST(SGOT)-19 CK(CPK)-68 ALK PHOS-54 AMYLASE-60 TOT BILI-0.3 [2114-7-25] 09:45PM GLUCOSE-112* UREA N-12 CREAT-1.0 SODIUM-141 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-32 ANION GAP-10 [2114-7-26] Carotid Duplex Ultrasound Right ICA occlusion. Left ICA, CCA, and ECA occlusion. Right vertebral occlusion. [2114-7-28] ECHO Pre-CPB: The left atrium is normal in size. No mass/thrombus is seen in the left atrium or left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. No left ventricular aneurysm is seen. Regional left ventricular wall motion is normal. No masses or thrombi are seen in the left ventricle. 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 ascending aorta. The aortic arch is mildly dilated. There are complex (>4mm) atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are moderately thickened. No mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Patient is AV-Paced, on no infusion. Normal biventricular systolic fxn. Aorta intact. No AI, no MR. [2114-7-26] Vein Mapping Patent bilateral greater and lesser saphenous veins with diameters as noted. Brief Hospital Course: Mr. [Known lastname 12130] was admitted to the [Hospital1 18] on [2114-7-25] via transfer from [Hospital6 5016] for surgical management of his severe coronary artery disease. He was worked-up in the usual preoperative manner. A carotid duplex ultrasound showed occlusion of both his internal carotid arteries and a right vertebral artery occlusion. The vascular surgery service was consulted who found indication for surgical intervention at this time. The neurology service was consulted for assistance in his care given his severe cerebral vascular disease. An opthalmology consult was obtained who diagnosed him with occular ischemic syndrome and recommended a higher perfusion pressure during bypass. On [2114-7-28], Mr. [Known lastname 12130] was taken to th eoperating room where he underwent coronary artery bypass grafting to three vessels. Postoperatively he was taken to the cardiac surgical intensive care unit. Within 24 hours, Mr. [Known lastname 12130] had awoke neurologically intact and was extubated. He required neosynephrine for blood pressure support until postoperative day two. He was then transferred to the step down unit for further recovery. Beta blockade, aspirin and a statin were resumed. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. By post-operative day four he was ready for discharge to home on his home dose of coumadin for his CVA history. Medications on Admission: Wellbutrin, Zetia, Lipitor, Norvasc, Aspirin and coumadin Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 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. 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:0 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:0 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:50 Tablet(s) Refills:0 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 12. Outpatient Lab Work INR to be checked on Friday [2114-8-3] and sent to the office of Dr. [Last Name (STitle) ]. Fax ([Telephone/Fax (1) 79204]. Plan confirmed with [Location (un) 7049]. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: s/p CABG x3 (LIMA-LAD, SVG-OMI, SVG-PDA) CVA [2107] Hyperlipidemia HTN 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. 6) No driving for 1 month. 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) 4783] in 2 weeks. Please follow-up with Dr. [Last Name (STitle) ] in [1-7] weeks. [Telephone/Fax (1) 41901] INR to be checked on Friday [2114-8-3] and sent to the office of Dr. [Last Name (STitle) ]. Fax ([Telephone/Fax (1) 79204]. Plan confirmed with [Location (un) 7049]. Completed by:[2114-8-1] ICD9 Codes: 4439, 4019, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8275 }	Medical Text: Admission Date: [2128-2-6] Discharge Date: [2128-2-10] Date of Birth: [2073-9-28] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2181] Chief Complaint: acute overdose Tylenol/Benadryl/EtOH Major Surgical or Invasive Procedure: extubation History of Present Illness: 54 yo F with h/o depression was transferred from [Hospital ] hosp after she was found unresponsive in a car with empty bottles of tylenol, benadryl, vodka. Estimated ingestion was around ~50 tabs of 500 mg tylenol tabs, 25-50 tabs of 25 mg of bendaryl. Initial tylenol level was 385, ETOH was 235 at OSH. Pt was intubated for airway protection and charcoal given via NGT. Toxicology was consulted and she was started on NAC. A suicide note was also found in the car (which is in her chart). Past Medical History: - Major Depression s/p 4 prior hospitalizations in psych [Hospital1 ] in [Hospital1 1559] [3-12] suicidal ideation. - Breast Cancer s/p lumpectomy in [2120], axillary node dissection, XRT, Tamoxifen (completed 5 yr course recently) Social History: She has a supportive family. She reports many recent stressors dating back from [2120] when she was dx with breast ca. Her mother died around that time and her husband had a complicated course of endocarditis. She also reports recently realizing that her brother and his friend sexually assaulted her when she was 8 years old. This has caused significant stress and yesterday she drove by his house prior to her suicide attempt. She drinks 1 glass to 1 bottle of wine per day. She denies tob and other drugs. Has not been working since [2122] although had good jobs previously. Family History: NC Physical Exam: Admission Physical: Vitals: 98.9, 130/97, 18, 100/AC 0.5/500/16/5 HEENT: intubated, MMM, anicteric sclera Heart: S1/S2, RRR, no murmurs Lungs: CTAB Abd: soft/NT/ND Ext: no edema Neuro: PERLA, EOMI, no focal deficits Pertinent Results: WBC: 9.6 - 14.2 - 9.0 HCT 43.8 Plt: 249 . Coags: [2128-2-7] 04:05AM BLOOD PT-13.3* PTT-28.0 INR(PT)-1.2* [2128-2-7] 11:33AM BLOOD PT-12.4 PTT-23.7 INR(PT)-1.1 [2128-2-7] 03:31PM BLOOD PT-12.0 PTT-25.8 INR(PT)-1.0 . Chemistries: [2128-2-6] Glucose-150* UreaN-9 Creat-0.5 Na-141 K-3.5 Cl-105 HCO3-19* . Trends: ALT 74, 64, 61, 60, to 44 AST 46, 34, 30, 27, 20 AlkPhos and TBili remained normal . Tox screen: [2128-2-6] 09:30PM BLOOD ASA-NEG Ethanol-119* Acetmnp-235.7* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2128-2-7] 04:05AM BLOOD Acetmnp-60.1* [2128-2-8] 11:30AM BLOOD Acetmnp-NEG . Radiology: CXR [2-6]: Subsegmental atelectatic features . Micro: Blood and urine cx NGTD Brief Hospital Course: 54 yo woman with hx of depression, anxiety, sexual abuse who presents with suicide attempt with tylenol, benadryl, and alcohol. Hospital Course by problem: . # Acetaminophen toxicity: She was appropriately loaded with NAC then was treated with a NAC drip in the intensive care unit. She received approx 10h IV NAC. After she was safely extubated and transferred to the floor, she was switched to an oral regimen of NAC. She received a total of 72h of NAC. Her acetaminophen level trended down to negative and her LFTs improved, as above. She was considered medically cleared by the primary team prior to transfer to psychiatry. . # ETOH intoxication: ETOH levels trended down. We treated the patient with a CIWA scale with diazepam prn. She did not exhibit signs/symptoms of withdrawal. . # Psych: The patient was afraid and upset with her decision to overdose on the above mentioned medications. However, given the seriousness of the suicide attempt, it was recommended by the primary team as well as psychiatry for the patient to transition to an inpatient psychiatric service after medical clearance. She was monitored by a 1:1 sitter post-extubation. We used ativan as needed for agitation then restarted her lexapro and seroquel once her liver enzymes normalized. She was also seen by the social workers to assist with her coping. . # ID: She had a temperature of 101 on the morning of [2-7]. We sent urine and blood cultures which did not show growth. She also had a CXR on [2-6] which showed atelectasis as above. It was thought that her low-grade temperature was secondary to possible aspiration pneumonia while she was sedate after her overdose. Given that her respiratory function remained normal and her WBC normalized, we did not start antibiotics. She also has occasional bacteria in her urine with WBC. She did not have any dysuria so we did not treat with antibiotics. . # Code: full . # Contact: HCP is her daughter, [Name (NI) 1453] [Name (NI) 70503] ([Telephone/Fax (1) 70504]). Her psychiatrist is [Doctor First Name ] Botsaris in [Location (un) ] [Telephone/Fax (1) 70505] Medications on Admission: Lexapro 30mg daily seroquel 200mg qhs Discharge Medications: 1. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for agitation/insomnia. 2. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Extended Care Facility: [Hospital3 1280] Discharge Diagnosis: Primary: - major depression - s/p suicide attempt with benadryl, tylenol overdose - respiratory depression requiring intubation Secondary: - breast cancer s/p lumpectomy, radiation, and chemo Discharge Condition: hemodynamically stable, afebrile ambulating Discharge Instructions: You were admitted to the hospital after overdosing on tylenol, benadryl, and alcohol. You were intubated at an outside hospital, transferred here and extubated. We also treated you with medication to protect your liver. You tolerated this well. . This was very serious and could have resulted in your death. You were seen by the psychiatrists who recommended an inpatient psychiatric hospitalization. Please notify your psychiatrist or return to the emergency department if you have thoughts of harming yourself again. . Please take your medications as instructed. Followup Instructions: Please followup with your psychiatrist following your discharge from the psychiatric hospitalization. Also follow up with your PCP after your discharge: [Last Name (LF) 70506],[First Name3 (LF) ] [Telephone/Fax (1) 47884] Completed by:[2128-2-10] ICD9 Codes: 5070
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8276 }	Medical Text: Admission Date: [2146-2-12] Discharge Date: [2146-2-15] Date of Birth: [2078-3-29] Sex: M Service: NEUROLOGY HISTORY OF PRESENT ILLNESS: The patient is a 67 year old right handed man with a history of a-fib (who is on Coumadin), seizure disorder with no seizures for about 28 years on Dilantin, hypertension and mitral valve regurgitation who was in his usual state of health until about 6:00-6:30 p.m. when he was shopping with his wife and suddenly complained of arm heaviness, became confused and his speech was incoherent. There was no witnessed seizure. The patient was taken to [Hospital 8641] Hospital where head CT was negative and without hemorrhage. His INR was 1.4. The patient was not given IV tPA fearing risk of hemorrhage and he was transferred to [Hospital1 18] via Med-Flight for further eval and management. On arrival the patient was extremely aphasic and could not give any history. PAST MEDICAL HISTORY: Atrial fibrillation. Epilepsy. Hypertension. Mitral valve regurgitation. ALLERGIES: NKDA. MEDICATIONS: Coumadin, Dilantin, lisinopril. SOCIAL HISTORY: The patient quit smoking 40 years ago and drinks socially. FAMILY HISTORY: Hypertension, CAD. PHYSICAL EXAMINATION: General medical exam unremarkable. Neurologic exam the patient was awake, alert, did not follow verbal commands, could not name or repeat, is fluent but incoherent speech, somewhat frustrated, said "I cannot speak" on one occasion. Pupils equal, round, reactive to light. Followed in all directions. No response to visual threat on the right. Subtle flattened right nasolabial fold. No tongue bites. Moved all extremities well. No drift. Deep tendon reflexes symmetrical bilaterally. Right toe mute, left toe downgoing. No bruits in his neck. Stool guaiac negative. LABORATORY DATA: White count 8.6, hematocrit 39.7, platelet count 245. INR 1.1 on [2-14]. Fibrinogen 514. UA negative. Sodium 137, glucose 102, BUN 24, creatinine 1.2, potassium 4.1, chloride 103, bicarb 25. ALT 21, AST 23, alka phos 214, total bilirubin 0.5. The patient ruled out for MI by enzymes. Lipase 62, amylase 109. Uric acid 5.1. Total cholesterol 170, triglycerides 71, HDL 67, LDL 89. Phenytoin level on [2-14] was 9.5. Urine culture contaminated. MRI of the head showed acute left temporoparietal middle cerebral artery partial territorial infarct, no mass or hydrocephalus. MRA showed no evidence of vascular occlusion. Hypoplastic A1 segment of the right anterior cerebral artery is incidentally noted. Also incidentally noted is a linear area of low signal within the petrous and precavernous portions of the left internal carotid artery which could be artifact or due to a thrombus. Repeat head CT on [2146-2-13] showed stable left MCA territory infarction with some petechial hemorrhages. Carotid Doppler showed no significant stenosis in right or left carotid arteries. HOSPITAL COURSE: The patient was taken immediately for MRI and it was determined that he was a candidate for a DEDAS study and he was given either placebo or Desmoteplase. The next morning he improved slightly and was able to follow a few axial commands and state his name. Repeat head CT on the first full day of admission showed some petechial hemorrhages. Heparin drip was started a low dose. However, the following day it was decided to stop the heparin drip and start the patient on Coumadin and Lovenox. The patient continued to somewhat improve and was able to follow more commands, answer more questions and speak more on the day of discharge. The patient was also found to have right hemianopsia which did not improve. He was not weak in any of his extremities and was felt safe to go home per physical therapy and occupational therapy. The patient will be discharged on [2146-2-15]. He will be discharged with outpatient occupational therapy and outpatient speech therapy. He will follow up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] on [3-8] at 3:30 p.m. DISCHARGE DIAGNOSIS: 1- s/p left MCA stroke 2- Aphasia DISCHARGE MEDICATIONS: 1. Simvastatin 10 mg p.o. q.d. 2. Coumadin 5 mg p.o. q.d. 3. Phenytoin 200 mg q.a.m., 300 mg q.p.m. 4. Lovenox 80 mg b.i.d. for six days or until INR is therapeutic. A baby ASA will be added to coumadin once Lovenox is discontinued. [Name6 (MD) 4267] [Last Name (NamePattern4) 4268], M.D. [MD Number(1) 4269] Dictated By:[Last Name (NamePattern1) 10034] MEDQUIST36 D: [2146-2-14] 16:31 T: [2146-2-14] 17:30 JOB#: [Job Number 52402] ICD9 Codes: 4240, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8277 }	Medical Text: Admission Date: [2173-11-21] Discharge Date: [2173-12-15] Date of Birth: [2103-8-12] Sex: F Service: MEDICINE Allergies: Lisinopril / Atorvastatin Attending:[First Name3 (LF) 783] Chief Complaint: MS changes and seizure Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 70 year old woman with a history of hypertension, diabetes, dementia, CRI (1.8) who was recently discharged from the neurology service with a large temporo-parietal bleed in the setting of Lovenox now presenting from nursing home with mental status changes and possible seizure activity. Believed that ICH was secondary to amyloid angiopathy and that surgical intervention would be in vain. Pt transferred to [Hospital ] rehab on seizure prohphlaxis, but apparently was seizure free during initial hospitalization. Pt transitioned from rehab to nursing home yesterday. Pt unable to provide history and there is no documentation of event, however, per EMS report they witnessed tonic-clonic activity. . Review of Systems: unobtainable Past Medical History: -left temporo-parietal bleed -amyloid angiopathy -CKD (1.8) -diabetes "labile" -hypertension -CHF (unknown EF) -h/o hyperkalemia -depression -asthma/copd -peripheral neuropathy -dementia -s/p trach Social History: -resident of [Hospital6 25759] Home -no recent history of smoking or alcohol use Family History: -unobtainable Physical Exam: Physical Exam: Vitals: 98.9, 68, 160/71, 77, 98% RA General: Comfortable, NAD, does not respond to voice, shaking or sternal rub HEENT: pinpoint pupils, OP wnl Neck: supple, Lungs: CTAB anteriorly CV: regular rate and rhythm, s1/s2, no M/R/G Abdomen: soft, non-tender, non-distended, NA-bowel sounds present, GTube in place Ext: warm/dry, no edema Neurologic Examination: Patient does not respond to voice, shaking or sternal rub. Has pinpoint pupils. Patient not able to cooperate with neuro exam. Pertinent Results: [2173-11-21] 08:59AM BLOOD WBC-12.5* RBC-3.06* Hgb-9.8* Hct-30.5* MCV-99* MCH-32.1* MCHC-32.3 RDW-13.4 Plt Ct-230 [2173-11-22] 04:15PM BLOOD WBC-7.4 RBC-3.10* Hgb-10.3* Hct-31.2* MCV-101* MCH-33.2* MCHC-33.0 RDW-13.3 Plt Ct-201 [2173-11-23] 04:44AM BLOOD WBC-6.2 RBC-2.73* Hgb-9.0* Hct-27.8* MCV-102* MCH-32.8* MCHC-32.2 RDW-13.5 Plt Ct-179 [2173-11-21] 08:59AM BLOOD Neuts-87.3* Lymphs-8.3* Monos-4.0 Eos-0.2 Baso-0.2 [2173-11-21] 08:59AM BLOOD PT-12.8 PTT-28.7 INR(PT)-1.1 [2173-11-21] 08:59AM BLOOD Glucose-333* UreaN-73* Creat-2.6# Na-142 K-5.1 Cl-94 HCO3-42* AnGap-11 [2173-11-22] 04:15PM BLOOD Glucose-86 UreaN-55* Creat-1.9* Na-147* K-4.8 Cl-100 HCO3-41* AnGap-11 [2173-11-23] 04:44AM BLOOD Glucose-331* UreaN-50* Creat-1.9* Na-146* K-4.6 Cl-96 HCO3-43* AnGap-12 [2173-11-21] 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2173-11-23] 11:51AM BLOOD Type-ART pO2-86 pCO2-82* pH-7.38 calHCO3-50* Base XS-18 [2173-11-23] 11:51AM BLOOD Lactate-2.5* [2173-11-21] 08:00AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2173-11-23] 08:35AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD [2173-11-21] 08:00AM URINE RBC-0 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2 [2173-11-23] 08:35AM URINE RBC-0-2 WBC-[4-3] Bacteri-MOD Yeast-NONE Epi-0 [2173-11-21] 08:00AM URINE CastHy-0-2 [2173-11-21] 05:48PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . CXR [11-21]: 1. No pneumonia. 2. Mild volume overload. . head CT [11-21]: IMPRESSION: 2.8 x 2.2 cm rounded focus at the site of prior intraparenchymal hemorrhage. There is surrounding decreased attenuation, consistent with edema or malacia. While this could represent resorbing hematoma, this appearance is concerning for a mass lesion and further evaluation could be obtained . CXR [11-22]: Opacity in the right middle lobe, not present on the previous study. Findings represent aspiration and/or pneumonia . ECHO [11-22]: Conclusions: 1. The left atrium is mildly dilated. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 3. The mitral valve leaflets are mildly thickened. Mild to moderate ([1-31]+) mitral regurgitation is seen. 4. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension . CXR [11-28]: IMPRESSION: 1. Slight improvement in patchy right infrahilar opacity, which may be due to improving asymmetrical edema, focal atelectasis or pneumonia. 2. Mild congestive heart failure. . CXR [12-8]: IMPRESSION: 1. Persistent mild congestive heart failure. 2. Right infrahilar opacity is stable and may represent asymmetric edema or may be due to aspiration. . EKG [12-10]: Normal sinus rhythm, rate 70. Left-sided early repolarization. Compared to the previous tracing of [2173-12-8] probably no significant change. . CXR [12-13] IMPRESSION: No evidence of congestive heart failure or pneumonia. Brief Hospital Course: 70 year old female w/ h/o HTN, diabetes, dementia, CRI, and recent temporo-parietal bleed presented with MS changes likely secondary to seizure, c/b acute renal failure. . # Neuro/Resp: Patient was admitted with seizures likely d/t temporo-parietal ICH with possible mass on CT. Was seen by neurology in the ER and loaded on dilantin and started on keppra. Tox-Met workup performed and was negative (negative serum and urine tox screen, neg. UA). It was felt that the patient would benefit from additional imaging of mass to differentiate resolvind hematoma from other mass, but this was not able to be performed because patient was unable to tolerate MRI at any point d/t continued agitations [Hospital 49997] hospital stay. Patient was on and off agitated throughout her hospital course, and a variety of antipsychotics including olanzapine, risperidone, seroquel, and eventually haldol were used. The patient required level II restraints for the majority of her hospitalization, renewed daily. Psychiatry was consulted, followed the patient, and made recommendations. A FM was used for a couple of days to maintain O2 saturations, but this was stopped for fear of decreasing resp drive and an increasing PCO2 (ABG showed pH 7.38/86/80, due to metabolic acidosis with significant chronic renal compensation). Patient was transferred to MICU on [2173-11-25] for bradycardia, hypotension, and hypoxia. Cause unclear although there was some concern for seizure. (Patient had initially had evidence of PNA on CXR and this was treated with 14 days of abx, but the opacity cleared after two days and it was unclear if she actually had PNA). Episode resolved on its own without intervention. Loaded with dilantin. Thought to be d/t cenrally mediated process. CT of head unchanged with no new bleed or mass effect. Cardiology consulted and found no evidence of structural heart disease or conduction delay. A breast mass was found on exam in MICU, raising concern for etiology of head mass. Plan was to work this up further once patient more stable. No pressors required while in MICU. Transferred to floor. Patient remained agitated a frequently desaturated to 70's when agitated, but would bump to 100% with nebs. Etiology thought to be combination of asthma/COPD, CHF, agitation, and decreased respiratory drive. On [2173-12-11], pt was noted to be more somnolent with ABG 7.16/110/39/51 and was transferred to unit for trial of BIPAP. Etiology hypercarbic respiratory failure secondary to sedation and infection (UTI and +blood cultures 1/4) and COPD. While in the MICU the patient was essentially made comfort care d/t poor prognosis and no improvement with BIPAP (pt DNR/DNI). She was transferred to the floor where sshe continued to decline. Family meeting had and it was decided that her chances of returning to a meaningful life or even back to near baseline was minimal, and care was focused on comfort. Antibiotics, FS, insulin, and diuretics were stopped on [2173-12-14] and the patient passed on [2173-12-15], likely d/t respiratory arrest. Permission to perform autopsy was obtained from health care proxy with specific interest in identifying the intracranial mass. . # ARF: Pt with CKD and baseline Cr 1.8 who presented with acute worsening (cr 2.6). Thought to be pre-renal process, possibly secondary to over diuresis. Initially UA did not show any evidence of UTI, but pt eventually developed klebsiella UTI, for which she was treated. During second MICU stay there was some concern for urosepsis, and antibiotic coverage was broadened to cover this possibility. For part of her hospitalization the Cr returned to baseline with gentle IVF's, but eventually this again worsened and while in the MICU the second time she became anuric. . # CHF: Patient had an unknown EF but was on chronic lasix. Lasix was administered on as needed basis, taking into account her renal failure and pulmonary edema potentially contributing to respiratory distress. . # DM: Pt initially hypoglycemia (11) in ED after getting 10 units RI for BG ~325 and not receiving tube feeds. Throughout hospitalization patient alternated between hypoglycemia and hyperglycemia. [Last Name (un) ] followed the patient closely but it was very difficult to control her sugars, especially in setting of receiving intermittent TF's d/t pulling out PEG and high residuals. . #Hypernatremia: Patient fluctuated between normal and hypernatremic, likely because she was unable to take free water d/t agitation and delerium. Free water flushes via PEG were administered, but high residuals made this difficult. . # HTN: Outpatient lopressor continued with moderate control . # Dementia: Acute on chronic. Multifactorial. Did not improve during hospitalization. . # DNR/DNI Medications on Admission: Lasix 40 mg NG qd z 2 days then 20 mg NG qd Risperidal 0.5 mg NG qAm and 0.75 mg qhs Insulin: Lantus 10 units qAM and NPH qPM RISS Lopressor 37.5 mg NG TID Heparin 500 units SC q 12 hrs Prevacid 30 mg qd Zantact 150 mg [Hospital1 ] MVI Colace NG 100 mg [Hospital1 ] Duonevs q 4 hrs PRN Lactulose 30 cc NG q12 hours PRn NaCL 2 gm [Hospital1 ] with 300 cc H2O H20 300 cc NG [Hospital1 ] Celexa 10 mg NG qd . Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Hypercarbic hypoventilation PNA Urosepsis COPD/Asthma Acute renal failure Dementia Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] ICD9 Codes: 5849, 4280, 5070, 5990, 2930, 5845
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8278 }	Medical Text: Admission Date: [2127-3-24] Discharge Date: [2127-3-31] Date of Birth: [2063-7-21] Sex: F Service: CARDIOTHORACIC Allergies: Iodine Attending:[First Name3 (LF) 1505] Chief Complaint: positive stress test Major Surgical or Invasive Procedure: CABG X 3, PFO closure, MV repair (26 mm ring) on [2127-3-24] History of Present Illness: 63 y/o w/known CAD, monitored by regular stress tests, most recently positive, referred for cardiac catheterization. This revealed 3vCAD, & MR. She was referred for suregery. Past Medical History: CAD s/p LAD stenting hyperlipidemia DM Hodgkin's disease hypothyroidism GERD Barrett's esophagus s/p hemmorhoidectomy Social History: divorced, lives alone works as a software trainer no ETOH or tobacco Family History: non-contributory Physical Exam: unremarkable pre-operatively Pertinent Results: [2127-3-31] 06:40AM BLOOD WBC-12.9* RBC-2.79* Hgb-8.2* Hct-25.0* MCV-90 MCH-29.6 MCHC-32.9 RDW-16.8* Plt Ct-463* [2127-3-31] 06:40AM BLOOD Plt Ct-463* [2127-3-30] 05:55AM BLOOD PT-12.4 PTT-23.8 INR(PT)-1.1 [2127-3-30] 05:55AM BLOOD Glucose-141* UreaN-18 Creat-0.9 Na-140 K-4.9 Cl-104 HCO3-30 AnGap-11 PATIENT/TEST INFORMATION: Indication: Left ventricular function. Right ventricular function. Height: (in) 64 Weight (lb): 210 BSA (m2): 2.00 m2 BP (mm Hg): 110/46 HR (bpm): 80 Status: Inpatient Date/Time: [2127-3-28] at 10:00 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: Definity Tape Number: 2007W000-0:00 Test Location: West SICU/CTIC/VICU Technical Quality: Suboptimal REFERRING DOCTOR: DR. [First Name (STitle) ] R. [Doctor Last Name ] MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.5 cm (nl <= 4.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.2 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.2 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.6 cm Left Ventricle - Fractional Shortening: 0.38 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm) Aorta - Ascending: 3.2 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec) Mitral Valve - Peak Velocity: 1.4 m/sec Mitral Valve - Mean Gradient: 6 mm Hg Mitral Valve - Pressure Half Time: 115 ms Mitral Valve - E Wave: 1.4 m/sec Mitral Valve - A Wave: 1.2 m/sec Mitral Valve - E/A Ratio: 1.17 Mitral Valve - E Wave Deceleration Time: 407 msec TR Gradient (+ RA = PASP): 23 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: This study was compared to the prior study of [2127-3-13]. LEFT ATRIUM: Normal LA size. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: ?# aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Mitral valve annuloplasty ring. Mild mitral annular calcification. No MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - bandages, defibrillator pads or electrodes. Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. A mitral valve annuloplasty ring is present. There is turbulent transmitral flow, but no frank mitral stenosis. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Normally-functioning mitral annuloplasty band. Mild aortic regurgitation. Compared with the prior study (images reviewed) of [2127-3-13], mitral annuloplasty band is now present. The other findings are similar. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171], MD on [2127-3-28] 14:38. [Location (un) ] PHYSICIAN: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. Brief Hospital Course: Admitted to the pre-op holding area on [2127-3-24], taken to the OR, underwent CABG X 3, PFO closure, MV repair. In the initial post-op period she required pressors and inotropes, she had a metabolic acidosis for which she received NaHCO3. She was weaned from mechanical vantilation, and extubated on POD # 1. On POD # 2, she was placed on IV ceftriaxone for positive gm stain of her sputum and elev. WBC. Her pressors and inotropes were weaned off over the next few days. Ms. [Known lastname 28673] did have some junctional rhythm while in the CSRU, and her beta blockers were initially held for this. She returned to [Location 213] sinus rhythm, her beta blocker was started, and well tolerated. She was transrferred to the telemetry floor on post-op day # 4. She has remained hemodynamically stable, and has progressed well with physical therapy. She is ready to be discharged home on post-op day # 7. Medications on Admission: metformin omeprazole levoxyl toprol XL lipitor insulin folic acid ASA niaspan Discharge Medications: 1. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s)* Refills:2 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 3. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:14 Tablet(s) Refills:0 6. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. Disp:14 Packet(s) Refills:0 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 8. 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 9. Insulin Lispro (Human) 100 unit/mL Solution Sig: as pre-op Units Subcutaneous twice a day: 22 U Q am, and 28 U Q pm as pre-op. Disp:1 vial Refills:2 10. 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 11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO at bedtime. Disp:30 Tablet Sustained Release(s) Refills:2 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: Caritas Home Care Discharge Diagnosis: MR PFO CAD DM hyperlipidemia GERD Barrett's esophagus Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no lifting > 10# for 10 weeks Followup Instructions: with Dr. [Last Name (STitle) ] in [1-4] weeks with Dr. [Last Name (STitle) 7047] in [1-4] weeks with Dr. [Last Name (STitle) ] in [3-6] weeks Completed by:[2127-3-31] ICD9 Codes: 4280, 2762, 4240, 2449, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8279 }	Medical Text: Admission Date: [2116-5-4] Discharge Date: [2116-5-8] Date of Birth: [2048-11-30] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Aortic Valve Replacement(21mm St. [Male First Name (un) 923] tissue) History of Present Illness: Ms. [Known lastname 9381] is a 67 year old caucasian female with prior excellent functional status who experienced a near syncopal episode and mild chest pressure while reaching over to feed chickens 2 weeks ago. Local workup included an echocardiogram revealing aortic stenosis with peak velocity 4.3m/sec, peak gradient 70mmhg, mean gradient 46 mmHg, EF 50%. Patient reports new shortness of breath in the last 4 months after swimming long distance or going up a flight of stairs. Past Medical History: Hyperlipidemia TAH secondary to fibroids rt breast biopsy (neg) stress incontinence Social History: Retired flight attendant, travels frequently with husband who is a veterinarian. Lives on a farm with cows, pigs, chickens, and cats. Family History: Denies a family history of early cardiac disease Physical Exam: Pulse: 82 B/P: Right 141/100 Left 121/84 Resp: 16 O2 Sat: 100% Temp: 97.7 Height: Weight: General: well developed female in NAD at rest. Skin: tan, turgor good. HEENT: normocephalic, anicteric, EOMI's, eyeglasses, good dentition, oropharynx moist. Neck: supple, trachea midline, no JVD, bruit vs referred murmer Chest: CTA, no whz, no deformities/scarring Heart: murmer RSB radiating throughout Abdomen: soft,NT, ND (+) bowel sounds Extremities: no edema, left shin varicosity r/t trauma Neuro: calm, gait steady, +5/5 strength x 4. Pulses: palp peripheral pulses. Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT Intra-op TEE [2116-5-4] Conclusions No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([11-18]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([11-18]+) mitral regurgitation is seen. There is no pericardial effusion. The patient has moderate aortic regurgitation. If they remain asymptomatic, a follow-up echocardiogram is suggested in [11-18] years. Post-Bypass: s/p AVR 21mm bio-prosthetic valve. The patient is on Norepi 0.15 mcg/kg/min, epi 0.04 mcg/kg/min, The CO is 9.5 L/min, There is now a well seated bioprosthetic valve in the aortic position.There are no peri/paravalvular leaks seen.The mean gradient across the valve is 27 mmhg with the max gradient is 44mmhg. All the other valves are similar to prebypass. The aorta is intact post decannulation. LV and RV function is preserved . [2116-5-8] 05:15AM BLOOD WBC-5.8 RBC-2.52* Hgb-8.1* Hct-24.2* MCV-96 MCH-32.2* MCHC-33.5 RDW-14.2 Plt Ct-164 [2116-5-7] 05:23AM BLOOD WBC-6.3 RBC-2.56* Hgb-8.3* Hct-24.3* MCV-95 MCH-32.4* MCHC-34.1 RDW-13.9 Plt Ct-133* [2116-5-8] 05:15AM BLOOD Glucose-111* UreaN-7 Creat-0.5 Na-135 K-4.2 Cl-101 HCO3-28 AnGap-10 [2116-5-7] 05:23AM BLOOD Glucose-108* UreaN-7 Creat-0.5 Na-131* K-3.9 Cl-98 HCO3-27 AnGap-10 Brief Hospital Course: The patient was brought to the Operating Room on [2116-5-4] where the patient underwent Aortic Valve Replacement with Dr. [Last Name (STitle) ]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was hemodynamically stable, weaned from inotropic and vasopressor support. She developed some neck fasciculations and neurology was consulted. Movement resolved. Thepatient continued to progress. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Estradiol Transdermal Patch NF (estradiol) 0.025 mg Transdermal weekly 2. Aspirin 81 mg PO DAILY 3. Loratadine NF 10 mg Oral daily prn allergies Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Furosemide 40 mg PO DAILY Duration: 7 Days RX furosemide 40 mg 1 Tablet(s) by mouth daily Disp #7 Tablet Refills:0 3. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days RX Klor-Con 20 mEq 1 packet by mouth daily Disp #7 Tablet Refills:0 4. Ibuprofen 400 mg PO Q6H:PRN pain, headaches take with food 5. Metoprolol Tartrate 25 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. [Last Name (NamePattern4) 9641] metoprolol tartrate 25 mg 1 Tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 6. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX tramadol 50 mg 1 Tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 7. Estradiol Transdermal Patch NF (estradiol) 0.025 mg Transdermal weekly 8. Loratadine NF 10 mg Oral daily prn allergies Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA, [Hospital1 1559] Discharge Diagnosis: Severe aortic stenosis, Hypertension (pt reports white coat syndrome only) Dyslipidemia(not on meds) Right knee pain/arthritis Mild Stress incontinence, needle bx right breast(negative) Uterine fibroids, s/p TAH/BSO '[01] 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 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [Telephone/Fax (1) 170] Date/Time:[2116-5-14] 11:00 in the [Hospital ] Medical Building [Last Name (NamePattern1) 10357] Surgeon Dr. [Last Name (STitle) ] [Telephone/Fax (1) 170] Date/Time:[2116-6-10] 2:15 in the [Hospital ] Medical Building [Last Name (NamePattern1) ] Cardiologist Dr. [Last Name (STitle) ] (office will call patient) Please call to schedule the following: Primary Care Dr. [First Name (STitle) 1313] [Telephone/Fax (1) 7318] in [2-20] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2116-5-8] ICD9 Codes: 4241, 2762, 2851, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8280 }	Medical Text: Admission Date: [2200-5-28] Discharge Date: [2200-5-29] Date of Birth: [2181-3-30] Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 3984] Chief Complaint: Respiratory failure, unresponsive Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: Pt, initally listed as an EU critical is a 21F w/ AMS [1-9] EtOH with no signs of trauma. In the ED, it was felt she was unable to protect her airway [1-9] vomiting, and so intubated. She came to the [Hospital Ward Name 332] MICU on propofol for sedation. She was found by her friend down, [Name2 (NI) 112323]. Talking to [Initials (NamePattern4) 228] [Last Name (NamePattern4) ], [First Name3 (LF) 4051], patient was identified as [Known firstname ] [Known lastname ]. Pt and friend were in a limo with 12 other friends when she got to [Name (NI) 86] Red [Name (NI) 112324] game after drinking heavily (amount unknown) and then vomiting several times (red wine vomit). She then walked out of the limo at Gate B, at around 6:30PM, at wich point she just "dropped to the ground". She as not seen seizing. EMS was called and she was taken to [Hospital1 18] Emergency Department. ED Course (labs, imaging, interventions, consults): Diagnosis: ams, alcohol intoxication, intubated - Initial Vitals/Trigger: unresponsive -Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative -UA Negative - pH 7.34 pCO2-46 pO2-141 HCO3 26 - Post intubation pH-7.37 pCO2-37 pO2-374 HCO3-22 - Lactate 2.5 -> 1.9 - PT: 11.1 PTT: 29.1 INR: 1.0 - WBC 6.5 HGB 13.3 HCT 38.5 PLT 280 - HEAD CT - negative - EKG: Sinus tachycardia. On arrival to the MICU, patient's VS: HR 72, BP 95/52, RR 17, 100% on CMV with TV 500cc, RR 12, PEEP 5, 100% FiO2. Past Medical History: depression (unconfirmed) Social History: Student at [Hospital1 40198] CC. EtOH use, unable to obtain further substance use Hx. Family History: unknown Physical Exam: Admission exam: General: Intubated, mildly responsive, especially to a paging beeper. HEENT: Sclera anicteric, Neck: supple, JVP not elevated, no LAD CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: moving all extremities spontaneously. Discharge exam: General: Awake, alert, oriented, conversng appropriately. Extubated. HEENT: Sclera anicteric, Neck: supple, JVP not elevated, no LAD CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: moving all extremities spontaneously. Pertinent Results: [2200-5-28] 09:01PM TYPE-ART RATES-16/ TIDAL VOL-400 PEEP-5 O2-100 PO2-374* PCO2-37 PH-7.37 TOTAL CO2-22 BASE XS--3 AADO2-312 REQ O2-57 -ASSIST/CON INTUBATED-INTUBATED [2200-5-28] 09:01PM LACTATE-1.9 [2200-5-28] 09:01PM O2 SAT-99 [2200-5-28] 08:45PM URINE HOURS-RANDOM [2200-5-28] 08:45PM URINE UCG-NEGATIVE [2200-5-28] 08:45PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.002 [2200-5-28] 08:45PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.002 [2200-5-28] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2200-5-28] 08:20PM TYPE-ART PO2-141* PCO2-46* PH-7.34* TOTAL CO2-26 BASE XS--1 COMMENTS-GREEN-TOP [2200-5-28] 08:20PM GLUCOSE-96 LACTATE-2.5* NA+-147* K+-3.3 CL--106 [2200-5-28] 08:20PM freeCa-1.17 [2200-5-28] 08:15PM UREA N-8 CREAT-0.9 [2200-5-28] 08:15PM estGFR-Using this [2200-5-28] 08:15PM LIPASE-21 [2200-5-28] 08:15PM ASA-NEG ETHANOL-295* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2200-5-28] 08:15PM WBC-6.5 RBC-4.13* HGB-13.3 HCT-38.5 MCV-93 MCH-32.1* MCHC-34.5 RDW-12.3 [2200-5-28] 08:15PM PLT COUNT-280 [2200-5-28] 08:15PM PT-11.1 PTT-29.1 INR(PT)-1.0 [2200-5-28] 08:15PM FIBRINOGE-315 CT head: No acute intracranial process. CXR ET and NG tubes positioned appropriately. Diffuse mild ground-glass opacity within the lungs, possibly indicative of pulmonary edema. Brief Hospital Course: 21 year old woman with unknown past medical history, found down by friend. Was not protecting airway in the [Last Name (LF) ], [First Name3 (LF) ] was intubated. #Unresponsiveness/EtOH intoxication - Pt did not have any evidence of infectious process, CT head was unremarkable. She did not have any other toxidromes and serum tox was only + for EtOH. Pt was weaned off of propofol in ICU and extubated without complication. She was monitored overnight and her mental status improved. She tolerated a normal diet, had negative orthostatics and was able to ambulate normally at time of discharge. Issues and dangers of acute alcohol intoxication were discussed with the patient prior to discharge. At time of discharge, a friend drove her home. Medications on Admission: none Discharge Medications: 1. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours as needed for headache. 2. ibuprofen 200 mg Tablet Sig: 2-3 Tablets PO Q8H (every 8 hours) as needed for headache. Discharge Disposition: Home Discharge Diagnosis: Primary: ethanol intoxication Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ], It has been a pleasure taking care of you here at [Hospital1 771]. You were admitted to the hospital because you were very sedated. You were found to have a high alcohol level. A breathing tube was used briefly to protect your airway because you were so sleepy. When you were more awake, the breathing tube was removed. We encourage you to abstain from alcohol in the future and to stay well-hydrated at home. We made the following changes to your medications: - You may take acetamnophen (Tylenol) 1g (2 extra-strength) three times a day as needed for headache. You can use ibuprofen (advil or Motrin) 400-600mg (2-3 tablets) every 8 hours in between as needed. Please continue all other medications as previosuly prescribed. Followup Instructions: Please follow up with your primary care doctor or student health clinic in the next 1-2 weeks. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] ICD9 Codes: 2760
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8281 }	Medical Text: Admission Date: [2183-11-18] Discharge Date: [2183-12-11] Date of Birth: [2136-12-24] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 46-year-old woman with history of insulin dependent diabetes mellitus, coronary artery disease, status post CABG, gastroparesis with chronic nausea, admitted initially to medicine service with hyperglycemia and more pronounced nausea and vomiting. She had multiple previous admissions for similar symptoms believed to be secondary to gastroparesis. She was awaiting for gastric implant procedure which was unfortunately not accepted by her insurance company. Her nausea became much more pronounced several days prior to admission with several episodes of vomiting leading to decreased po intake and increased blood sugar levels. She, however, did not have any signs of diabetic ketoacidosis, was not lethargic, had no focal neurological symptomatology. PAST MEDICAL HISTORY: 1) Coronary artery disease, status post CABG, complicated by osteomyelitis. Status post sternotomy. Status post MI in [2179], status post exercise mibi on [8-9] revealing ejection fraction of 29%. 2) Insulin dependent diabetes mellitus, triopathy and gastroparesis. 3) History of diabetes for 16 years. 4) Obesity. 5) Sarcoid, status post tracheostomy. 6) History of urinary incontinence. 7) OSA. 8) Hypertension. 9) Status post appendectomy in [2178], status post cholecystectomy in [2178]. 10) History of MRSA and VRE. 11) History of vasculitis. MEDICATIONS: On admission insulin, sliding scale, regular insulin in the morning, sliding scale for Humalog before supper and at bedtime, NPH 54 units subcu a.m., 24 units q p.m., Colace 100 mg po q d, Vitamin E 400 units po q d, Lasix 40 mg po q d, Amitriptyline 10 mg po q h.s., Lipitor 10 mg po q d, Cozaar 25 mg po q d, Flexeril 10 mg po q h.s., Darvon 65 mg po q h.s., Tylenol 650 mg q h.s., Potassium 20 mEq po q d, Mavik 7.5 mg po q d, Ativan 2 mg po q h.s., Lopressor 25 mg po bid, Multivitamin one tablet po bid, Cogentin 1 mg po bid, Phenergan 25 mg po qid, Ultram 150 mg po qid, Reglan 20 mg po bid, 10 mg po bid, Uro-Mag 160 mg po qid, Aspirin 325 mg po q d, Albuterol and Serevent and Flovent inhalers prn, Celexa 20 mg po q d. ALLERGIES: Paper tape and Vancomycin. SOCIAL HISTORY: Patient lives at home with her partner. Denies alcohol, quit tobacco about 16 years ago. PHYSICAL EXAMINATION: On admission the patient is without acute distress. Temperature 99.2, blood pressure 120/80, heart rate 68, respiratory rate 18, 98% on room air. The patient is without acute distress. HEENT: Pupils are equal, round, and reactive to light and accommodation, neck supple with no jugulovenous distension, cardiac exam reveals S1 and S2, regular rate and rhythm, no murmur. Lungs clear to auscultation and percussion. Abdomen is slightly distended but there is no tenderness, no rebound, positive bowel sounds. J tube in place. Extremities revealed no edema and there is no peripheral pulsation. HOSPITAL COURSE: This is a 46-year-old woman with insulin dependent diabetes mellitus, coronary artery disease, severe gastroparesis. She was admitted to medical service with hyperglycemia and nausea. 1. Endocrine: Patient has history of type I diabetes, insulin dependent, uncomplicated insulin sliding scale. The patient was started on insulin IV drip after admission but was not believed to be in DKA. Due to prolonged episode of nausea, she remained on insulin drip for nearly two weeks with minimal po intake and only IV fluids. She continued to be nauseous despite different anti-emetics including Zofran, Reglan, Droperidol. She had been intermittently started on J tube feeding about second hospital week but unfortunately she did not tolerate J tube feeding very well. Her insulin sliding scale was changed after her insulin IV drip to Glargine and Humalog sliding scale but patient later requested change back to her previous sliding scale which consists of regular insulin at breakfast, Humalog sliding scale before supper and bedtime, and additional NPH dose in the morning and in the evening. Her blood sugars remained stable on this combination. 2. GI: The patient has history of severe gastroparesis and chronic nausea. She had multiple previous hospitalizations for increased amount of nausea and vomiting believed to be due to gastroparesis. She had been previously treated with different anti-emetics with complication including tardive dyskinesia after Reglan. The most helpful anti-emetics are Zofran and Droperidol. Due to severe persistent nausea during this hospital course, the patient was initially kept npo with only IV fluids, slowly advanced to J tube feeding and later to po intake. This was very slow and difficult process complicated by two time placement of J/G tube. The second EGD placement of J/G tube was done on [12-7] and this was without complications. The patient started to receive her J tube feedings through J tube and po medication through G tube and she tolerated this well. She was also slowly tapered off her medications for nausea, Reglan was discontinued given the presence of tardive dyskinesia. She continued on Zofran and Droperidol on prn basis. In the last [6-16] hospital days the patient had no nausea and was taking po without any significant complications. GI service was consulted regarding gastric stimulator placement given her history of gastroparesis. This was previously addressed but not approved by her insurance company. Drs. [Last Name (STitle) 10689] and [Name5 (PTitle) 17185] submitted application for this procedure back to the insurance company and will await results of this after patient is discharged. It was felt that this procedure will be necessary given the multiple hospitalizations for her severe nausea and vomiting, requiring insulin IV drip. 3. IV access: The patient has longstanding history of difficulties with IV access. Initially she had right femoral line placed in, later unfortunately developed line sepsis and multiple attempts were made for better central IV access. She had attempt to insert Porta-cath in the OR which was unsuccessful. Her IV access was maintained by femoral line later with PICC line which was not done with IR guidance. She was discharged without central line since there will be no need for long-term IV access after the discharge. 4. ID: Initially patient was treated with enterococcal urinary tract infection with Ampicillin. Later during the hospital course she developed line sepsis with hypotension and fever. Because of hypotension she was transferred to medical Intensive Care Unit on [2183-11-30] and stayed there until [12-2]. She received Dopamine and her blood pressure stabilized within 24 hours. She was started on broad spectrum antibiotics, was treated with Ceftriaxone, Oxacillin, later based on cultures the antibiotics were switched to Levofloxacin and she finished 10 day course. There were no recurrent agents in blood culture or line culture or urine culture making a persistent course for infection or significant blood stream infection which was the reason for switching to Levofloxacin. The patient remained afebrile throughout hospital course after transfer from the medical ICU. 5. DVT: The patient developed left arm swelling on [2183-12-7] with pain in the same region. She had ultrasound of the upper extremity which unfortunately revealed an optimal study without a possibility to visualize her left axillary vein and therefore the possibility of DVT could not be excluded. Since at this moment the patient did not have any IV access (and given the difficulty of obtaining IV access), it was felt that clinical suspicion for DVT is very likely and patient should be started on chronic anticoagulation. She was started on Lovenox on [2183-12-8]. 6. Fluids, Electrolytes & Nutrition: The patient had persistent hypomagnesemia and hypokalemia during the hospital course. Those were believed to be secondary to IV insulin and those were repleted during hospitalization. 7. Neurology: The patient has history of tardive dyskinesia which is most likely produced by Reglan. The patient continued Cogentin chronically with mild improvement of her facial involuntary movements. It was decided that Reglan would be discontinued during this hospitalization which was done and patient tolerated that well. LABORATORY DATA: White blood count on admission 17.3, hemoglobin 14.2, hematocrit 42.6, platelet count 164,000, white blood count on discharge 7.1, hematocrit 31.4, hemoglobin 10.8, platelet count 213,000. BUN 10, creatinine 1.1, sodium 136, potassium 4.8, chloride 95, CO2 30, calcium 8.6, phosphorus 4.1, magnesium 1.4, ALT 41, AST 39, alkaline phosphatase 216, total bilirubin 0.5, albumin 3.0. Blood cultures revealed no growth. Wound cultures from her femoral line revealed mixed bacterial types including gram positive cocci in pairs, chains and clusters, butting yeast, gram negative rods. Abdominal x-ray revealed normal position of the J/G tube. Chest x-ray revealed no evidence of pneumonia or CHF. DISCHARGE DIAGNOSIS: 1. Gastroparesis, chronic nausea. 2. Insulin dependent diabetes mellitus. 3. Enterococcal UTI, line sepsis. 4. Status post J/G tube replacement. 5. Hypertension. 6. Coronary artery disease. DISCHARGE MEDICATIONS: NPH 54 units subcu q a.m., 24 units subcu q p.m., Regular insulin sliding scale before breakfast, Humalog sliding scale before supper, Humalog sliding scale at bedtime, Albuterol, Serevent, Flovent prn, Amitriptyline, Phenergan 2.5 mg qid, Zofran 4 mg po tid prn, Cogentin 1 mg po bid, Prevacid suspension 30 cc qid, Celexa 10 mg po q d, Aspirin 325 mg po q d, Colace 100 mg po bid prn, Lipitor 10 mg po q d, KCL 40 mEq po q d, Lovenox 100 units subcu [Hospital1 ]. Patient will be discharged home in stable condition. She will follow-up with [Last Name (un) ] Diabetes Center as well as the GI service. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 17186], M.D. [MD Number(1) 16896] Dictated By:[Last Name (NamePattern1) 6063] MEDQUIST36 D: [2183-12-9] 16:29 T: [2183-12-9] 15:49 JOB#: [Job Number 17187] ICD9 Codes: 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8282 }	Medical Text: Unit No: [Numeric Identifier 103376] Admission Date: [2142-12-26] Discharge Date: [2143-1-4] Date of Birth: [2085-5-20] Sex: Service: HISTORY OF PRESENT ILLNESS: This patient who is known to Dr. [First Name (STitle) ] [Last Name (Prefixes) ] and Dr. [First Name4 (NamePattern1) 7422] [Doctor Last Name 61313] of the adult congenital group at [Hospital3 1810] was seen for follow up in [2141-12-25]. She has had increasing shortness of breath and angina. She had a prior history of heart surgery in [2097] for tetralogy of Fallot. Her work up started again in [2141-12-25] with an echocardiogram which showed pulmonic stenosis and left ventricular hypertrophy. She had cardiac catheterization in [2142-8-26] which showed no coronary disease per patient. Prior surgeries include a congenital heart repair in [2097], appendectomy in [2103], back surgery in [2109], cholecystectomy in [2115], hysterectomy in [2127] and ovarian cancer with oophorectomy, status post chemotherapy and radiation therapy. She also has a history of shortness of breath, palpitations, obesity, gastroesophageal reflux disease, pulmonic stenosis and a deep venous thrombosis in her right arm. MEDICATIONS PRIOR TO ADMISSION: Os-Cal daily, multivitamin daily, Tylenol, ibuprofen and Prilosec PRN for headaches and pain. She is allergic to penicillin which causes a rash, morphine which causes vomiting and Coumadin which causes a rash. She was seen originally on [2142-12-17] in the office with examination as follows. Five foot 3, 250 pounds. Heart rate was 71 in sinus rhythm, saturations 96 percent on room air. Blood pressure 108/84 in the right, 154/67 on the left. She was sitting up in the chair with no apparent distress. She had no rashes on her skin. Her pupils were equally round and reactive to light and accommodation. Her neck was supple with no carotid bruits. Her lungs were clear bilaterally. Heart was regular rate and rhythm with S1, S2 tones and a grade II/VI holosystolic ejection murmur. Abdomen is soft, obese, nontender, nondistended with positive bowel sounds. Her extremities were warm and well perfused without edema. No varicosities were noted. She was alert and oriented times three, appropriate and grossly neurologically intact. Femoral pulses were not palpated but she had 1 plus bilateral dorsalis pedis, posterior tibial and radial pulses. She had no carotid bruits present. Preoperative electrocardiogram showed first degree AV block with a right bundle branch block. PREOPERATIVE LABORATORY DATA: White count 8.2, hematocrit 44.1, PT 12.6, PTT 24.2, INR 1.0. Sodium 142, potassium 4.1, chloride 101, bicarb 31, BUN 15, creatinine 0.8, with a blood sugar of 71. ALT 42, AST 29, alkaline phosphatase 99, amylase 54, total bilirubin 0.6. The preoperative chest x- ray did not identify any acute cardiopulmonary process. She was also evaluated preoperatively on [12-19] by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of neurology for evaluation of spells of visual loss and facial numbness. She stated that she had for approximately one year been having these stereotypical episodes of numbness of her face and visual loss. She also has a known history of migraines. Dr. [Last Name (STitle) ] evaluated her on [12-19] and recommended MRI of the brain with MRA angiography to rule out any intracranial stenosis and also rule out ischemic stroke. She also discussed with the patient better management of her migraine headaches and headache prevention in regards to her sleep and was started on Topamax 25 mg P.O. at bedtime, increasing it 50 mg P.O. at bedtime thereafter for headache prophylaxis with the plan to follow up in two months with Dr. [Last Name (STitle) ] after she undergoes cardiac surgery. HO[Last Name (STitle) ] COURSE: The patient was admitted to the hospital on [2142-12-26] to undergo her procedure with Dr. [Last Name (Prefixes) ] and Dr. [First Name4 (NamePattern1) 7422] [Doctor Last Name 61313] and on [2142-12-26] she underwent right ventricular outflow tract reconstruction with a pericardial patch and a pulmonic valve replacement with a mitral bioprosthesis 27 mm in the pulmonic position. Patient was transferred to the cardiothoracic Intensive Care Unit in stable condition. On postoperative day one the patient was on epinephrine drip at 0.05 mcg per kilograms per minute and insulin drip at 15 units per hour and nitroglycerin drip which was weaned to off. She started Lasix diuresis and remained intubated on CPAP pending blood gases for weaning to extubated. Postoperative laboratories as follows: White count 9.7, hematocrit 27, sodium 144, potassium 4.5, chloride 108, bicarb 28, BUN 16, creatinine 1.0, blood sugar of 95. PT 13, PTT 30, INR 1.2. The patient remained intubated. Right course remained in the groin. Later that day the patient was extubated and was doing well. Patient remained on pressors at its low rate. Patient was also seen postoperatively that evening and the following morning by the [Location (un) 86] Area Cardiology Group, Dr. [Last Name (STitle) 56666], and also initial evaluation by rehabilitation services. Recommendations were recognized and appreciated by the cardiology service. Patient was placed on deep venous thrombosis prophylaxis and was aggressively diuresed. Several hours after extubation patient had to be reintubated and appeared to have partial airway obstruction. Her saturations dropped to 94 percent and given the amount of edema and difficulty it was elected to fiberoptically intubate the patient again by anesthesia. This was difficult secondary to edema and partial obstruction but endotracheal tube was placed successfully and patient tolerated the procedure without any complications. She remained under sedation at that time. She remained on postoperative day two also on an epinephrine drip of 0.05 and an insulin drip of 11 units. Patient also continued with Lasix diuresis and aspirin and perioperative Vancomycin. She remained sedated with a Swan-Ganz and an arterial line in place, was hemodynamically stable with blood pressure 152/71, in sinus rhythm at 87. Her creatinine dropped slightly to 26.8. Patient was also given steroids to help with the edema. She was also screened by the clinical nutrition team. The patient was also placed on Natrecor and was off epinephrine on [12-29] and had significant diuresis. Patient continued to be evaluated for extubation and on postoperative day three remained on propofol and epinephrine at low dose. White count rose slightly to 18.1 and the creatinine remained stable at 1.1. The remained comfortable on the propofol. Patient had supraventricular tachycardia on postoperative day four. Epinephrine was stopped. She remained on Natrecor drip at 0.02 and Neo-Synephrine drip at 0.018 and continued with 4 mg dexamethasone q.i.d. for airway edema. Patient also received a dose of Diamox and on postoperative day five the patient continued with diuresis. Neo-Synephrine was restarted. Natrecor was held. The patient received two doses of Diamox again. The white count dropped slightly to 17.6. Patient continued overall to do well, had good pain control and was hemodynamically stable with blood pressure 106/49 and sinus rhythm at 68. On postoperative day six the patient was transferred from the cardiothoracic recovery unit out to [Hospital Ward Name 121] 2, was encouraged to start her activity with the nurses and physical therapist. Electrolytes were repleted. Lasix was changed to 20 B.I.D. A follow up chest x-ray was ordered. Heart sounds were distant. She had decreased breath sounds at the bases. Her neurologic examination was nonfocal. The sternum was stable. The incision was clean, dry and intact. Extremities were warm with trace edema. Central venous line was out. Pacing wires were removed. Chest tubes were removed. Physical therapy evaluation was done on the floor. Patient continued to be seen every day by the Adult Congenital Service from [Hospital1 ]. On postoperative day seven patient had a left arm intravenous line infiltration in the antecubital space with some erythema and swelling and tenderness to touch. She was neurologically stable. She had decreased breath sounds at the left base. Her examination was otherwise unremarkable. She continued to work with physical therapy in cough and deep breathing and to increase her ambulation. She was started on Keflex 500 mg P.O. q.i.d. The left arm was elevated. Warm packs were applied t.i.d. Left arm ultrasound was ordered to rule out a thrombus as the patient had a prior history of a right upper extremity deep venous thrombosis. Potassium was repleted with two doses of 40 mEq. The patient continued to work with physical therapy despite the slight swelling in the arm and continued to progress well on the floor. Vascular ultrasound was performed on [2143-1-2]. Her left jugular subclavian, brachial, axillary and cephalic veins were patent. A clot was seen in her basilic vein. Please refer to the official report dated [2143-1-12]. Patient was slowly improving on postoperative day seven, needed to increase her ambulation. She remained slightly tachypneic but stated this was her baseline. Lasix was increased to 40 P.O. B.I.D. Her left arm continued to be elevated as much as possible. Atenolol was decreased to 25 P.O. once a day for heart rate sinus rhythm at 67. Her blood pressure was 97/52. On evaluation the patient continued to progress. Patient continued to improve. She was doing very well, moving independently for significant distances and was signed off by physical therapy on [2143-1-4] and the patient was discharged to home with [Hospital6 407] services from [Location (un) 6159] on [2143-1-4]. DISCHARGE DIAGNOSES: 1. Status post repair of tetralogy of Fallot as a child. 2. Status post pulmonary valve replacement and RVOT reconstruction with pericardial patch. 3. Status post ovarian cancer. 4. Palpitations. 5. Shortness of breath. 6. Gastroesophageal reflux disease. 7. Status post remote right arm deep venous thrombosis and current left arm deep venous thrombosis. [Last Name (STitle) 2708]was instructed to follow up with [Last Name (STitle) 56666], her cardiologist at [Hospital1 ] on Wednesday, [1-9]. Phone number is [Telephone/Fax (1) 41241]. She was also instructed to make an appointment with Dr. [First Name (STitle) 103377] for approximately one to two weeks post discharge and to follow up with Dr. [Last Name (Prefixes) ] in the office for a postoperative surgical visit in four weeks. DISCHARGE MEDICATIONS: 1. Colace 100 mg P.O. B.I.D. 2. Aspirin, enteric coated 81 mg P.O. once daily. 3. Percocet 5/325 1 to 2 tablets P.O. PRN q 4 to 6 hours for pain. 4. Lasix 20 mg P.O. twice a day. 5. Potassium chloride 20 mEq P.O. twice a day. 6. Atenolol 25 mg P.O. once daily. 7. Topiramate 25 mg P.O. once a day in the evening at bedtime. 8. Keflex 500 mg P.O. q 6 hours times seven days. 9. Multivitamin 1 P.O. daily. Again the patient was instructed to make her follow up appointments with the physicians and is discharged to home in stable condition on [2143-1-4]. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2143-3-14] 15:26:52 T: [2143-3-14] 16:55:42 Job#: [Job Number 101977] ICD9 Codes: 5185, 4241, 4280
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8283 }	Medical Text: Admission Date: [2167-1-8] Discharge Date: [2167-5-15] Date of Birth: [2112-3-27] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 495] Chief Complaint: Admitted for cord blood allogenic transplant. Major Surgical or Invasive Procedure: Double-cord stem cell transplant Hickman line placement Colonscopy EGD Enteroscopy History of Present Illness: Mr. [Known lastname ] is a 54-year-old gentleman with a history of recurrent myeloma w/ hx of autologous stem cell rescue in [Month (only) ], [2166], who now presents for a matched unrelated cord blood allogeneic transplant. The patient was originally diagnosed with multiple myeloma in [2164-1-4] when he presented for evaluation of bilateral pleuritic rib pain. Work up demonstrated a pathologic rib fracture, HCT of 29, and IgA level of 5540 with positive monoclonal spike. The patient was treated with two cycles of DVD (Doxil, vincristine, Decadron) in 2/[2164]. Status post 2 cycles of Velcade and Decadron in [6-/2164], status post one month of thalidomide, status post 3 cycles of Cytoxan and status post 3 cycles of D-Pace (Decadron, Cisplatin, Doxorubicin, Cytoxan, and Etoposide). Status post another cycle of high-dose Cytoxan for stem cell mobilization in [1-/2165], status post high-dose melphalan with stem cell rescue in [2-/2165], status post 3 vaccinations with the dendritic cell vaccine study on protocol 04-098 in 5/[2165]. The patient is status post 3 cycles Revlimid and Decadron alone (Took 25mg po daily x 21 days of Revlimid with these cycles). The patient is status post XRT to left humerus. Pt is s/p 8 cycles of Velcade, Decadron, and Revlimid (Velcade was held for part of cycle 7 and cycle 8). S/P 2 more cycles of Revlimid at 25mg po daily and Decadron alone [11-10]. The patient has had multiple relapses as discussed above but stable disease since [Month (only) 216]. After discussion with Dr. [Last Name (STitle) ], the decision was made to go forward with a cord blood allogenic transplant as he does not have an HLA suitable donor from the unrelated donor pool. He has been admitted to have a cord blood transplant with 2-/46 cord matches. On review of system the patient denies any changes in vision, headache, URI symptoms, cough, fever, shortness of breath, chest pain, abdominal pain, constipation, peripheral numbness or tingling, hematochezia, melena, hematuria, or dysuria. He does note some diarrhea the day before yesterday which he attributes to eating some pork, but this responded to Immodium and has since resolved over the past day or so. The patient also describes some xerosis but denies any other complaints. Past Medical History: 1) Multiple Myeloma: history as above. 2) DM- insulin requiring, diagnosed in [2159]; no end organ involvement 3) HTN- diagnosed in [2159] 4) OSA -diagnosed in [2162] and prescribed a CPAP device but does not use this routinely 5) history of hydrocoele ([2161]) 6) history of Zoster (distant) without PHN. Social History: Unmarried, lives in [Location 669] w/ sister and her family. Was a clothing factory worker. Originally from the [Country ] republic; then moved to [Male First Name (un) 1056] in [2132] then immediately moved to [State 531]. No tob, ETOH, or illicit drug use. Family History: No history of cancer. His father died of an MI. His mother died of a stroke. He has two sisters. [Name (NI) ] has been married for 25 years. Physical Exam: V: T 97.3 BP 144/64 HR 87 RR 22 O2 sat 100% RA Wt Gen: NAD, AOX3 HEENT: MMM dry, slight white denuded lesion in posterior oropharynx, no other mucositis lesions seen Heart: RRR, quiet heart sounds, no m/r/g Lungs: lungs relatively clear with only occasional ronchi bilaterally Abd: soft, NT, mildly distended, no masses, BS+ Extrem: WWP, 1+ pitting pedal edema to mid shin, RUE 3+ pitting edema, LUE only trace edema Neuro: AOx3, CN2-12, [6-8] stregnth in all 4 extremities Pertinent Results: ADMISSION LABS: ================ 9.9 6.5 >-------< 213 30.8 MCV 99 Neuts 93.2 Bands 0 Lymphs 5.6 Monos 1.1 Eos 0.1 Basos 0 PT 12.0 PTT 23.2 INR 1.0 133 96 21 -----\|-----\|-----< 196 4.3 26 0.9 ALT 11 AST 7 LDH 165 Alk Phos 67 Tot Bili 0.3 Alb 3.4 Ca 9.0 Phos 2.7 Mg 2.3 Uric Acid 3.7 PERTINENT LABS DURING HOSPITALIZATION: ====================================== [2167-1-16] Free Hemoglobin: 6.3 [2167-3-19] BLOOD PEP-HYPOGAMMAG [2167-3-19] U-PEP-ONLY ALBUM IFE-NO MONOCLO [2167-3-20] [Doctor Last Name 17012] Body Prep-POSITIVE MICROBIOLOGY: ============= [2167-1-12] BCx x 3: negative [2167-1-15] Stem Cell Cx x 2: negative [2167-1-18] C. difficile: negative [2167-1-18] BCx x 1: negative [2167-1-18] 4:20 am BLOOD CULTURE Source: Line-central 1 OF 2. FINAL REPORT [2167-1-28] Blood Culture, Routine (Final [2167-1-28]): CAPNOCYTOPHAGA SPECIES. Anaerobic Bottle Gram Stain (Final [2167-1-20]): REPORTED BY PHONE TO [Doctor Last Name ] [Doctor Last Name ] @ 2047 ON [1-21] - 7F. GRAM NEGATIVE ROD(S). [2167-1-18] 4:29 am BLOOD CULTURE Source: Line-hickman 2 OF 2. FINAL REPORT [2167-1-24] Blood Culture, Routine (Final [2167-1-24]): NO GROWTH. [2167-1-19] CMV VL: negative [2167-1-19] C. difficile: negative [2167-1-20] C. difficile: negative [2167-1-21] Urine Cx: negative [2167-1-27] CMV VL: negative [2167-1-31] C. difficile: negative [2167-1-31] Urine Cx: negative [2167-1-31] BCx x 2: negative [2167-2-2] Femoral Catheter Tip Cx: negative [2167-2-3] CMV VL: <600 copies [2167-2-3] 10:03 am STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT [2167-2-5] MICROSPORIDIA STAIN (Final [2167-2-4]): NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final [2167-2-4]): NO CYCLOSPORA SEEN. FECAL CULTURE (Final [2167-2-5]): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2167-2-5]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [2167-2-4]): NO WORM FOUND. . NO OVA AND PARASITES SEEN. . This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O YERSINIA (Final [2167-2-5]): NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [2167-2-5]): NO E.COLI 0157:H7 FOUND. Cryptosporidium/Giardia (DFA) (Final [2167-2-4]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2167-2-3]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). [2167-2-3] BCx x 2: negative [2167-2-6] Stool O&P: negative [2167-2-7] Urine Cx: negative [2167-2-11] CMV VL: <600 copies [2167-2-16] CMV VL: 1,130 copies [2167-2-19] CMV VL: <600 copies [2167-2-20] 2:08 pm STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT [2167-2-23] MICROSPORIDIA STAIN (Final [2167-2-23]): NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final [2167-2-23]): NO CYCLOSPORA SEEN. OVA + PARASITES (Final [2167-2-23]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. Cryptosporidium/Giardia (DFA) (Final [2167-2-23]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. O&P MACROSCOPIC EXAM - WORM (Final [2167-2-23]): NO WORM SEEN. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2167-2-22]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). [2167-2-20] 6:00 pm SWAB Site: TOE Source: Right 4th toe wound. FINAL REPORT [2167-2-26] GRAM STAIN (Final [2167-2-20]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2167-2-23]): NO GROWTH. ANAEROBIC CULTURE (Final [2167-2-26]): NO GROWTH. [2167-2-21] 3:33 pm STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT [2167-2-23] OVA + PARASITES (Final [2167-2-23]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2167-2-22]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). [2167-2-22] 5:47 pm STOOL CONSISTENCY: WATERY Source: Stool. FINAL REPORT [2167-2-23] OVA + PARASITES (Final [2167-2-23]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2167-2-23]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). [2167-2-26] CMV VL: negative [2167-3-2] CMV VL: negative [2167-3-2] Stool Viral Culture: negative [2167-3-3] Glucan: negative [2167-3-3] Galactomannan: negative Time Taken Not Noted Log-In Date/Time: [2167-3-5] 8:29 pm ASPIRATE DUODENAL ASPIRATE. R/O ISOSPORA ,,STRONGYLOIDES. R/O EBV/ CMV. GRAM STAIN (Final [2167-3-5]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. MICROSPORIDIA STAIN (Final [2167-3-9]): NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final [2167-3-9]): NO CYCLOSPORA SEEN. FLUID CULTURE (Final [2167-3-9]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). Susceptibility will be performed on P. aeruginosa and S. aureus if sparse growth or greater. ENTEROCOCCUS SP.. MODERATE GROWTH. VIRIDANS STREPTOCOCCI. SPARSE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S PENICILLIN------------ 2 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [2167-3-9]): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [2167-3-7]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Final [2167-3-19]): NO FUNGUS ISOLATED. OVA + PARASITES (Final [2167-3-9]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. . NO STRONGYLOIDES SEEN. . NO ISOSPORA SEEN. Cryptosporidium/Giardia (DFA) (Final [2167-3-9]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. VIRAL CULTURE (Preliminary): No Virus isolated so far. [2167-3-6] Mycolytic BCx: pending [2167-3-7] CMV VL: negative [2167-3-10] C. difficile: negative [2167-3-11] C. difficile: negative [2167-3-12] CMV VL: negative [2167-3-12] EBV PCR: negative [2167-3-12] HHV-6 PCR: negative [2167-3-15] BCx x 2: negative [2167-3-16] C. difficile: negative [2167-3-17] CMV VL: negative [2167-3-21] 4:27 pm SWAB ANTRIUM R/O CMV,EBV,HPV. VIRAL CULTURE (Preliminary): No Virus isolated so far. [2167-3-23] CMV VL: negative [2167-3-27] H. pylori: positive [2167-3-28] CMV VL: negative [2167-4-4] CMV VL: negative [2167-4-11] CMV VL: negative [2167-4-16] CMV VL: negative [2167-4-21] CMV VL: negative [2167-4-25] CMV VL: 862 copies/ml . STUDIES: ======== CT ABDOMEN W/O CONTRAST [2167-4-23] 10:06 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: please evaluate for interval change in size of bleeding with Field of view: 42 [Hospital 93] MEDICAL CONDITION: 55 year old man with multiple myeloma day + 98 from cord blood transplant now with evidence of intraperitoneal hemorrhage s/p hepatic biopsy. REASON FOR THIS EXAMINATION: please evaluate for interval change in size of bleeding with CT Abd/Pelvis without contrast CONTRAINDICATIONS for IV CONTRAST: Acute Renal Failure CLINICAL INDICATION: Intraperitoneal hemorrhage. TECHNIQUE: 0.625 mm helically-acquired images are obtained from the lung bases to the pubic symphysis without intravenous contrast. Multiplanar reformations are provided for interpretation. FINDINGS: Direct comparison is made to prior examination dated [2167-4-23] at 3:25 a.m. Areas of interstitial septal thickening are identified at the lung bases. This is a nonspecific finding. Differential considerations do include a component of congestive failure. This has not significantly changed since the recent prior exam. A mild-to-moderate-sized pericardial effusion is again seen. Again there is evidence of hemoperitoneum. Overall, the size is somewhat increased. The sentinel clot noted about the inferomedial aspect of the liver has increased in size, measuring 7.9 x 3.7 cm on the current examination. The liver does appear somewhat hyperattenuating. This may be related to the patient's known hemosiderosis. The adrenal glands, pancreas, gallbladder, kidneys appear normal. The spleen is also, hyperattenuating, again possibly reflecting the deposition of iron. Diverticulosis noted throughout the descending and sigmoid colon. Bowel is otherwise grossly unremarkable. Pelvic structures are grossly unremarkable. Again multiple compression fractures seen within the lumbar spine as well as permeative lytic areas within the bone, consistent with the patient's known multiple myeloma. IMPRESSION: 1. Possible mild congestive failure noted at the lung bases. 2. Increasing hemoperitoneum. Sentinel clot increased in size since the prior examination. 3. Findings consistent with the patient's known multiple myeloma. 4. Findings consistent with the patient's known hemosiderosis. . CT ABDOMEN AND PELVIS ON [2167-4-23] CLINICAL HISTORY: Multiple myeloma and prior stem cell transplantation, recently performed transjugular liver biopsy, now with acute onset of abdominal pain and question of intraperitoneal hemorrhage. TECHNIQUE: Non-contrast helical acquisition of CT images performed from the lung bases through the ischial tuberosities. Comparison was made to prior CT of [2167-3-15]. FINDINGS: Respiratory motion artifact limits evaluation of the parenchyma. There are scattered areas of ground glass opacity, with more focal area seen in the right middle lobe, as well as the posterior segment of the right upper lobe. These are compatible with atelectasis or possibly pneumonitis. Emphysematous changes are seen near the apices. The heart is centrally located within the thorax, partially due to elevated left hemidiaphragm. No pleural effusion. There is a tiny pericardial effusion. Ventricular septum is hyperdense indicating underlying anemia. Mild atherosclerotic calcifications. There is a catheter extending to distal SVC. ABDOMEN: Non-contrast evaluation of the abdomen reveals a slightly hyperdense liver and spleen compatible with hemosiderosis. There has been interval development of a moderate amount of hyperdense fluid, most notably in the region of the gallbladder fossa, with density measurements approximately 55 Hounsfield units. Fluid tracks along the right paracolic gutter as well as extending to a perisplenic location, none of which was present on prior examination. Small amount of fluid which tracks into the lower pelvis, all slightly hyperdense and compatible with blood, resulting from hemorrhage due to recent transjugular biopsy. There is a small amount of pericholecystic fluid. Non-contrast evaluation of the pancreas, adrenal glands, and kidneys is unremarkable. There are vascular calcifications seen throughout a nondilated aortoiliac system. No abnormal mass or lymphadenopathy. Nondistended bladder. There is extensive bony mineralization, with ill-defined permeative pattern seen throughout the osseous spine, unchanged from prior study. There are multiple compression fractures including superior endplate of all lumbar vertebral bodies and inferior endplate of L3. These appear stable. Evaluation for myelomatous involvement would be more thorough by MRI if there is clinical concern for progression. IMPRESSION: 1. Moderate amount of intraperitoneal fluid, particularly in a perisplenic location with slightly increased density, not seen on prior study and is suggestive of intraperitoneal hemorrhage from recent transjugular liver biopsy. 2. Scattered atelectasis within the lungs, particularly right middle and right upper lung as described, question developing pneumonia. 3. Multiple compression fractures, marked demineralization, grossly unchanged. . Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 93049],[Known firstname 11136] [2112-3-27] 55 Male [Numeric Identifier 93050] [Numeric Identifier 93051] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/mtd SPECIMEN SUBMITTED: LIVER BX...Rush...(1 jar). Procedure date Tissue received Report Date Diagnosed by [2167-4-22] [2167-4-22] [2167-4-24] DR. [Last Name (STitle) ] [Last Name (NamePattern4) 7001]/cma?????? Previous biopsies: [Numeric Identifier 93052] BONE MARROW BX. [Numeric Identifier 93053] GI BIOPSIES (2 JARS). [Numeric Identifier 93054] Peripheral blood for immunophenotyping. [Numeric Identifier 93055] DUODENUM AND RANDOM COLON BIOPSIES (2 JARS). (and more) DIAGNOSIS: Liver, transjugular needle biopsy: 1. Mild portal, predominantly mononuclear inflammation with lymphocytic bile duct infiltration, associated bile duct damage and focal endothelialitis, see note. 2. Marked iron deposition in Kupffer cells and mild to moderate iron within hepatocytes on special stain; focal associated hepatocyte necrosis seen. 3. Scattered apoptotic hepatocytes with minimal lobular inflammation; no significant steatosis present. 4. GMS stain is negative for fungi, with a satisfactory control. 5. CMV immunostain is negative for viral inclusions, with a satisfactory control. 6. Trichrome stain demonstrates minimal portal fibrosis. Note: The biliary features are consistent with acute graft vs. host disease. A component of injury related to hemachromatosis is also identified. Drs. [Last Name (STitle) ] [Last Name (NamePattern4) ] and [Initials (NamePattern4) ] [Last Name (NamePattern4) ] were notified of the preliminary diagnosis by Dr. [Last Name (STitle) ] [Last Name (NamePattern4) ] on [2167-4-23]. Clinical: "55 year old male, day 97 status post cord transplant for multiple myeloma with recurrent diarrhea and now rapidly rising LFTs. Concern for graft versus host disease versus fungal/viral infection. Patient has history of CMV viremia in [2167-2-3]". Gross: The specimen is received in a formalin container labeled with the patient's name, "[Known firstname ] [Known lastname ]", the [Hospital 228] medical record number and additionally labeled "transjugular liver biopsy". It consists of two liver core biopsies, one measuring 0.1 cm in diameter x 1.6 cm in length and a second that measures 0.1 cm in diameter x 0.8 cm in length. In addition, there are multiple additional small tan fragments of tissue that measure 0.2 x 0.1 x 0.1 cm in aggregate. The specimen is entirely submitted in cassette A. . [2167-4-21] MRI ABDOMEN W/O & W/CONTRAST Reason: Please evaluate for evidence of infection vs GVHD Contrast: MAGNEVIST [Hospital 93] MEDICAL CONDITION: 55 year old man with MM day +96 s/p cord transplant now with rising LFTs, bilirubin 3.7. Concern for GVHD vs infection. Has hx of CMV viremia REASON FOR THIS EXAMINATION: Please evaluate for evidence of infection vs GVHD CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Multiple myeloma, status post transplant with rising LFTs and bilirubin. Evaluate for graft versus host disease or infection. COMPARISON: CT abdomen and pelvis [2167-3-15]. TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen were obtained on a 1.5 Tesla magnet utilizing a breath-hold independent technique including dynamic sequential images obtained prior to, during, and after the uneventful intravenous administration of 0.1 mmol/kg of gadolinium-DTPA (17 cc). MRI OF THE ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: Study is limited due to the patient's inability to hold his breath. Diffuse dropout in signal on the T1 in-phase images compared to the out-of-phase images within the liver and spleen are compatible with hemosiderosis. The liver otherwise demonstrates no focal lesions or evidence of abscess formation. No intra- or extra-hepatic biliary duct dilatation is seen. No periportal edema is identified. The hepatic arteries, hepatic veins, and portal veins are widely patent. The gallbladder is non-distended but does demonstrate gallbladder wall edema; the gallbladder wall measures up to 4 mm thick. No intra- or extra-hepatic biliary duct dilatation is seen. Spleen demonstrates no focal lesions and is normal in size. The adrenal glands, kidneys, pancreas are within normal limits. Stomach and visualized bowel loops appear decompressed, without evidence of surrounding inflammatory fat stranding or mural hyperenhancement. Bowel wall thickening is difficult to assess given the lack of distention of the bowel loops. No free fluid is demonstrated. The abdominal aorta is normal in caliber. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are present. Multiple compression fractures are again demonstrated within the lumbar spine, unchanged from the prior CT from [2167-2-3]. IMPRESSION: 1. No definite evidence for intra-abdominal abscess or graft versus host disease. 2. Hemosiderosis involving the liver and spleen. 3. Nonspecific gallbladder wall edema, possibly related to hypoalbuminemia. 4. Multiple compression fractures, unchanged. . Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 93049],[Known firstname 11136] [2112-3-27] 55 Male [Numeric Identifier 93052] [Numeric Identifier 93051] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) 21496], [Doctor Last Name 15785],[Doctor First Name ]/lo?????? SPECIMEN SUBMITTED: BONE MARROW BX. Procedure date Tissue received Report Date Diagnosed by [2167-3-31] [2167-4-1] [2167-4-3] DR. [Last Name (STitle) ] [Last Name (NamePattern4) 21496]/cma?????? Previous biopsies: [Numeric Identifier 93053] GI BIOPSIES (2 JARS). [Numeric Identifier 93054] Peripheral blood for immunophenotyping. [Numeric Identifier 93055] DUODENUM AND RANDOM COLON BIOPSIES (2 JARS). [-8/4366] BONE MARROW (1) (and more) **********This report contains an addendum******* SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY. DIAGNOSIS: Markedly hypocellular bone marrow (~10% cellular, however, see core limited, see description) with marked megakaryocytic hypoplasia. MICROSCOPIC DESCRIPTION Peripheral Blood Smear: The smear is adequate for evaluation. Erythrocytes show anisopoikilocytosis with occasional burr cells, dacrocytes, microcytes, rare target cells, and scattered schistocytes (2/HPF). Occasional polychromatophils are present. Rare coarse basophilic stippling is seen. Two nucleated red cells per [Pager number ] white cells are seen. The white blood cell count appears decreased. Platelet count appears decreased; rare large forms are seen. Differential count shows 81% neutrophils/bands, 5% monocytes, 11% lymphocytes, 3% eosinophils. Neutrophils include rare hyposegmented forms. Aspirate Smear: The aspirate material is adequate for evaluation. The M:E ratio is 0.4:1. Erythroid precursors appear relatively increased (although. notably, the distribution of erythroid and myeloid precursors is variable with focal areas with myeloid predominance noted) and show occasional megaloblastoid forms as well as occasional forms with asymmetric nuclear budding. Myeloid precursors appear relatively decreased in number; maturation appears left-shifted and occasional giant myelocytes and metamyelocytes are noted. Megakaryocytes are markedly decreased in number with only a rare form seen. Differential (300 cells) shows <1% Blasts, 1% Promyelocytes, 8% Myelocytes, 5% Metamyelocytes, 16% Bands/Neutrophils, 2% Plasma cells, 2% Lymphocytes, 66% Erythroid. Plasma cells include rare large atypical nucleolated forms. Numerous hemosiderin-laden macrophages, including few with ingested cellular debris are noted. Clot Section and Biopsy Slides: The biopsy material is suboptimal for evaluation and consists of a fragmented core measuring up to 0.7 cm in length and is comprised of periosteum, hypocellular subcortical bone, and a small amount of detached marrow. In the evaluable marrow, the cellularity is approximately 10%. Hemosiderin-laden macrophages are present. The M:E ratio estimate is normal. Erythroid precursors are proportionately normal in number and exhibit complete maturation. Myeloid elements are proportionately normal in number and exhibit full spectrum maturation. Megakaryocytes are markedly decreased. Special Stains: Iron stain is adequate for evaluation. Storage iron is markedly increased. Sideroblasts are present. Ringed sideroblasts are absent. ADDITIONAL STUDIES: Cytogenetics studies: See separate report. ADDENDUM CD138 staining, as well as Kappa and Lambda, show no evidence of a plasma cell dyscrasia. CD42 stain for megakaryocytes shows no staining. The diagnosis, as above, remains unchanged. Addendum added by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) 3157]/cma?????? Date: [2167-4-15] [2167-4-10] CAPSULE ENDOSCOPY: Clinical: 55 year old male with relapsed multiple myeloma, D+ 75, status post cord blood transplant. Gross: The specimen is received in one B+ container, labeled with the patient's name "[Known lastname ], [Known firstname ]", the medical record number and additionally labeled "M08-114". It consists of a 0.6 x 0.2 cm in diameter bone core biopsy. Entirely submitted in A, following decalcification. . Reason for referral: This patient was referred by Dr. [First Name4 (NamePattern1) 1790] [Last Name (NamePattern1) 1789] and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] for evaluation of GI bleeding. Procedure data: Gastric passage time: 0h 2m. Small bowel passage time: 3h 54m. Procedure info & findings: 1. Several sites of ctive bleeding in the stomach, duodenum, and proximal small bowel. There are no well visualized bleeding lesions. DDx includes erosions, ulcers, or angioectasias. 2. Small erosions in the duodenum 3. Mild erosions in the proximal small bowel 4. Nonbleeding redspots in the proximal and mid small bowel 5. Old blood in the colon Summary & recommendations: Summary: 1. Several sites of ctive bleeding in the stomach, duodenum, and proximal small bowel. There are no well visualized bleeding lesions. DDx includes erosions, ulcers, or angioectasias. 2. Small erosions in the duodenum 3. Mild erosions in the proximal small bowel 4. Nonbleeding redspots in the proximal and mid small bowel 5. Old blood in the colon Recommendations: 1. Follow up with referring physician 2. Follow HGB/HCT 3. Repeat EGD or enteroscopy Brief Hospital Course: HYPOXIC RESPIRATORY FAILURE: Pt was transferred to the ICU in the setting of hypoxia s/p cord blood transplant. This was considered multifactorial, with likely contributions from diffuse alveolar hemorrhage, VAP, GVHD with obliterative bronchiolitis. Sputum cultures grew group B beta-hemolytic streptococcus and pt was started on cefepime, which was later broadened to include ciprofloxacin and vancomycin given pt's persistent fevers. PE workup was completed and found negative. For pt's likely DAH, platelets and PRBC were transfused to goals. # Thrombocytopenia: Pt's persistent thrombocytopenia was considered likely [3-7] to DIC v anti-platelet Ab v HLA-antibody v cyclosporine-induced TTP. Cyclosporine was discontinued and plasmapheresis was held given ineffectiveness in setting of cyclosporine-related TTP. DIC labs presented a possible mixed picture, with decreasing fibrinogen but negative FDP negative and normal INR. Blood bank was consulted and anti-platelet Ab as well as HLA-Ab workup was submitted. # PCP [Name Initial (PRE) ]: Pt was initially started on dapsone but given his relatively low G6PD levels, was switched to atovaquone for PCP [Name Initial (PRE) ]. MULTIPLE MYELOMA: The patient received Cytoxan and total body irradiation prior to his cord transplant per protocol. He tolerated these well other than the development of mucositis and fatigue. He suffered a prolonged course awaiting engraftment. Delays possibly caused by acute illness post transplant given his multifocal pneumonia and his renal failure requiring hemodialysis for a period of time as well as his CMV viremia up to 1100 copies which became undetectable after initiation of treatment with ganciclovir. His counts began to increase slowly but peaked at an ANC of 210 after ganciclovir initiation and the thought was to switch to foscarnet (cr stable for days at 1.2-1.3) in order to avoid the marrow suppression of ganciclovir. His ANC increased while on foscarnet to peak in [2159]'s. However, he developed ARF, and his foscarnet was switched to valganciclovir. With this antiviral switch, it was noted that his ANC started to decrease slowly. ID was consulted, and he was switched to acyclovir for CMV ppx, and his counts continued to slowly decline. The patient underwent BM biospy on [3-/2088] with results demonstrating a markedly hypocellular bone marrow (~10% cellular) with marked megakaryocytic hypoplasia. His chimerism demonstrated engraftment with 195/200 XX chromosome, representing cells from donor. The patient continued to require frequent transfusions of PRBC and platelets. The patient was immunosuppressed with tacrolimus; he developed tacrolimus toxicity with a level up to 24 and likely the cause of renal failure in [2167-1-3]. He was started on steroids while the tacrolimus was held. Eventually when renal function improved, he was restarted on tacrolimus for a goal level of [6-10]. Given concern for its contribution to diarrhea and possible microangiopathic angiopathy his tacrolimus was changed to cyclosporin and his dose adjusted for a goal trough of 200. He was also started on cellcept and dose titrated to 750mg [Hospital1 ] and was continued on predisone at 30mg daily. His steroid dose was then uptitrated due to his persistent diarrhea and elevated LFTs related to GVHD. He was started on etancept on [4-25] for steroid refractory GVHD. During his ICU stay, pt's MM was considered stable and in remission, and pt was continued on mycophenolate mofetil and methylprednisolone. GVHD: Throughout his hospitalization the patient had recurrent episodes of diarrhea and intermittednt BRBPR. Infectious workup remained completely negative. The patient's diarrhea did not improve with anti-CMV treatment. His diarrhea initially improved with steroids, but then worsened while on high dose steroids, so it was felt that the diarrhea was not associated with GVHD. GI was consulted, and he had an EGD/colonoscopy twice while hospitalized that showed gastritis and duodenitis. Small bowel enteroscopy demonstrated segmental continuous erythema, friability and congestion of the mucosa with contact bleeding in the second part of the duodenum. Cold forceps biopsies were performed for histology and viral cultures at the duodenum CMV and EBV stains were negative, and no findings were shown on pathology that were consistent with GVHD. No evidence of amyloidosis. Diarrhea may be exacerbated by his essential medications including CellCept. He was started on rifaximin per GI for possible bacterial overgrowth however this was discontinued out of concern for its contribution to marrow suppression. The patient underwent capsule endoscopy which demonstrated several sites of ctive bleeding in the stomach, duodenum, and proximal small bowel. There are no well visualized bleeding lesions. Conservative management with maintaining adequate platelet levels was recommended. As the patient was being transitioned from tacrolimus to cyclosporin and his steroids were tapered to prednisone from solu-medrol, he developed a bump in his LFTs and recurrent diarrhea with approx. 1L daily production. His cellcept and cyclosporin were increased and he was started on Entocort with subsequent improvement in diarrhea and liver function. Abd US was unremarkable. The patient was made NPO except medications and had improvement of his diarrhea with bowel rest and was continued on TPN. Unfortunately, the patient the developed a rapid elevation in his liver function tests from his baseline of 0.8 to 5.0. Given his progressive worsening of liver function and elevation of transaminases despite increase in immunosuppression, he underwent liver biopsy on [4-22]. Pathology was consistent with GVHD. Following the procedure the patient dropped his HCT and was found to have a intraperitoneal hemorrhage related to his liver biopsy site. He was transferred to the ICU for closer hemodynamic monitoring. Surgery and IR were consulted. The patient was monitored and HCT remained stable. He was transferred back to the floor for further managment. He was started on entarcept on [4-25] for steroid refractory GVH and in the setting of needing to lower cyclosporin dose with concurrent ganciclovir to avoid further renal toxicity. Cyclosporine as well as ganciclovir was later discontinued given the development of significant persistent thrombocytopenia. LFTs ultimately stabilized and pt was continued on ursodiol, mycophenylate mofetil, and methylprednisolone. (Of note, he is H. pylori positive and should pursue treatment as an outpatient.) CMV VIREMIA: As stated above, the patient was found to have CMV viremia without evidence of CMV colitis. ID was consulted. The patient was started on ganciclovir, and this was switched to foscarnet with hopes of improving cell counts. While on foscarnet, the patient's ANC improved, however, his renal function started to decline. He was then switched to valganciclovir. While on this medication, his counts slowly trended down; thus, ID recommended that he switch to acyclovir for CMV prophylaxis. He continued on acyclovir prophylaxsis with multiple negative viral loads. He then was found to have a VL on [4-25] of 862 and was restarted on ganciclovir. Ganciclovir was later discontinued given concern for toxicity to platelets. MULTIFOCAL PNEUMONIA/FEBRILE NEUTROPENIA: In the beginning of his hospital course, he developed a multifocal pneumonia and respiratory distress and was intubated in the ICU. He was extubated on [1-30] and has done well since then. Repeat Chest CT imaging revealed much improvement in his pneumonia. He was placed on cefepime, vancomycin, and caspofungin for empiric coverage while neutropenic. The patient also developed Capnocytophaga (gram negative rod) on a blood culture drawn early in his course ([1-19]). All repeat blood cultures have been negative. The patient was continued on cefepime for this for 7 days after ANC > 500. His vancomycin was stopped after engraftment. The patient was continued on caspofungin prophylaxsis. He spiked low grade temps to 99 and repeat CT chest on [4-13] demonstrated ronchovascular thickening of LLL. He was started on empiric levaquin after CXR on [4-23] demonstrated question of RLL infiltrate. ACUTE RENAL FAILURE: The patient had acute renal failure with creatinine elevation from 1.0 to 2.6 on day 0. This renal failure was thought to be secondary to elevated tacrolimus levels which had reached 24. The patient was evaluated by renal and found to have acute tubular necrosis. His tacrolimus was held until he reached the goal level of between [6-13] and stopped altogether when steroid therapy was initiated. He was initially started on CVVH for volume overload, pulmonary edema and deterioration of respiratory status. He was transitioned to hemodialysis and began making some urine output. Eventually his creatinine had come down close to his baseline and he was not requiring hemodialysis. He autodiuresed. In [2167-3-6], his creatinine slowly started to increase from 1.2 to 2.0. Renal was consulted again, who felt that etiology of the ARF was due to medications, including tacrolimus and foscarnet. His Cr improved and remained stable at 1.6-1.8 after discontinuation of tacrolimus and foscarnet. During pt's ICU admission for hypoxia, pt became uremic and anuric, and was started on HD. HEMOLYSIS: The patient was found to have [2-4]+ schistocytes on peripheral smear with [Doctor Last Name 17012] prep positive. His medications were reviewed for possible oxidative stressors. No evidence of angiopathy on review of path from GI biopsies. Chimerism study demonstrated no evidence of persistent chimerism as cause for hemolysis. Concern was raised for TTP and cyclosporine was discontinued. DIABETES: He received HISS and insulin in his TPN. HYPERTENSION: Pt was started on labetalol and nifedipine while in the hospital, and these medications were titrated to control his blood pressure. After pt was started on HD, BP was controlled with PRN hydralazine. The patient expired on [2167-5-15] of respiratory failure. He had a trial of CRRT which he was unable to tolerate secondary to hypotension. He went into PEA arrest, and was already DNR. Medications on Admission: 1.Metformin 500 QD 2.Famvir 250 [Hospital1 ] 3.Metoprolol 25 [Hospital1 **] Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Multiple Myeloma Graft Versus Host Disease End Stage Renal Disease Thrombocytopenia Discharge Condition: expired Discharge Instructions: expired Followup Instructions: Expired ICD9 Codes: 5849, 7907, 2851, 4019, 2768, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8284 }	Medical Text: Admission Date: [2121-7-15] Discharge Date: [2121-7-15] Date of Birth: [2080-9-11] Sex: M Service: NEUROSURGERY Allergies: Iodine / Bactrim / naproxen / Shellfish Attending:[First Name3 (LF) 14802] Chief Complaint: Headaches Major Surgical or Invasive Procedure: [2121-7-14] Diagnostic cerebral angiogram History of Present Illness: 40 M had sudden onset severe headache in context of receiving treatment for anaphylaxis to shrimp at another hospital (23:30 on [7-13]). He was subsequently discharged. He returned home and had a second sudden onset severe headache during intercourse at 15:30 on [7-14] and a second time at 18:00 on [7-14]. Presented to OSH where CT head was interpreted as normal and LP (19:30) demonstrated 60,000 RBC and 115 WBC. Patient referred for further workup. Pt has no feves, chills, or persistent neck pain. Had some neck pain during headache episodes. Headache resolved at present time. Pt has some paresthesias in riht hand which are new since this episode. He has classical migranies, and also seizure d/o, neither of which have presented with headaches or neurologic symptoms similar to those he has experienced over the past 2 days. He has not taken his antiepileptics in two days. Past Medical History: Classical migraines Seizure d/o EtOH abuse Polysubstance abuse (used crack cocaine on [7-12]) Tobacco use Social History: Previous IVDU, current crack cocaine and alcohol use. 5 cigarettes daily. Family History: No brain aneurysms Physical Exam: T:97.2 BP:103/42 HR:69 R:18 O2Sats:96 Gen: comfortable, NAD. Awake and alert, cooperative with exam, normal affect Orientation: Oriented to person, place, and date Speech fluent with good comprehension and repetition Naming intact Pupils equally round and reactive to light Visual fields are full to confrontation Extraocular movements intact bilaterally Facial strength and sensation intact and symmetric Hearing intact to voice Palatal elevation symmetrical Sternocleidomastoid and trapezius normal bilaterally Tongue midline without fasciculations Normal bulk and tone bilaterally No abnormal movements, tremors Strength full power [6-7] throughout No pronator drift Intact to light touch. Toes downgoing bilaterally Coordination normal on finger-nose-finger No meningismus Pertinent Results: [7-15] CT HEAD: There is no acute intracranial hemorrhage, vascular territorial infarction, edema, or mass effect seen. There is no hydrocephalus or midline shift. There is slight asymmetry of the lateral ventricles, which is likely a normal variant. No fractures identified. Visualized orbits, paranasal sinuses, and mastoid air cells are unremarkable. [7-15] CTA HEAD: Bilateral intracranial internal carotid arteries, vertebral arteries, basilar artery and their major branches are patent with no evidence of stenosis, occlusion, dissection or aneurysm formation. Left vertebral artery is dominant. There is an effective PICA termination of the right vertebral artery. Left posterior communicating artery is hypoplastic. [7-15] Cerebral angiogram: cerebral vasculitis Brief Hospital Course: Mr. [Known lastname ] was admitted to the Neuro-ICU for work up to rule out to aneurysm or vascular abnormality. He underwent a diagnostic cerebral angiogram that was negative for aneurysm but demonstrated diffuse cerebral vasculitis. Post-Procedure he remained flat x2 hours for hemostasis. Pulses remained bounding and intact and the groin was without hematoma. There was a mild ooze from groin that did not extend the boundaries of the dressing. Stroke neurology was consulted and felt that it was cocaine induced vasculitis. The patient remained neurologically intact throughout his hospital stay and his headache improved. Neurology felt that since his headache improved there was no need to start a new [Doctor Last Name 360] for headache control. They recommend follow up in 3 months in outpatient clinic or sooner if his headaches increase in frequency. The patient was counselled on stopping all cocaine use. At the time of discharge the patient was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. Medications on Admission: Topamax 75 mg po bid Ativan 1 mg PO prn aura Fioricet Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Topiramate (Topamax) 75 mg PO BID 3. Nicotine Patch 14 mg TD DAILY RX Nicoderm CQ 14 mg/24 hour Daily Disp #1 Box Refills:1 4. Lorazepam 1 mg PO Q12H:PRN Seizure activity RX Ativan 1 mg Every 12 hours as needed Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Cerebral Vasculitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. 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 for 24 hours. What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? 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) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Follow up with Neurology in 3 months or sooner if your headaches become more frequent. Call ([Telephone/Fax (1) 2528] to schedule an appointment. Completed by:[2121-7-15*] ICD9 Codes: 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8285 }	Medical Text: Admission Date: [2101-3-7] Discharge Date: [2101-3-14] Date of Birth: [2026-8-8] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Right [Doctor First Name ] ganglia hemorrhage Left sided weakness Unwitnessed fall Slurred speech Major Surgical or Invasive Procedure: None. History of Present Illness: 74 year-old man with no known history presented to OSH after unwitnessed fall with slurred speech and left-sided paresis, now transferred to [Hospital1 18]. Per chart, patient was found down covered in bleach after an unwitnessed fall. He reported being on ground for at least 30 minutes. He was taken to [Hospital ] Hospital and on arrival was alert, with slurred speech, left facial, droopy left arm, not following commands, and with abrasions on his left shoulder, elbow and knee. Per report, head CT showed a 5.6x3.1 cm bleed in right basal ganglia and insular cortex. He was given 1gm of fosphenytoin and 10mg labetalol. His mental status then "worsened" and he was intubated with etomidate and succinylcholine. He was also given pancuronium and 2mg ativan, and started on a nipride gtt for blood pressure control. He was then transferred to [Hospital1 18] for further management. On arrival here, blood pressure was in 180s/140s and nipride drip was initially increased, then changed to labetalol. ROS: Apparently did complain of headache today, though time and characteristics unknown. Past Medical History: 1. Arthritis, bilateral knee surgery vs replacement based on scars 2. Colon polyps 3. Rheumatoid arthritis 4. Prostate cancer Social History: Married. Lives with wife. [Name (NI) ] tobacco, alcohol, drug history. Family History: No family history of neurologic disease. Physical Exam: PE: T 101 BP 180s/140s init then 111/86 HR 93-100 AC 600x14, FiO2 1.0, PEEP 5, O2 sat 100% ABG: 7.48/33/258/25 General: Appears stated age, intubated, sedated and paralyzed though starting to arouse HEENT: NC/AT Sclera anicteric Neck: Supple Lungs: Coarse, upper airway sounds throughout CV: nl S1, S2, no murmur. 2+ carotids without bruit Abd: Soft, nontender, normoactive bowel sounds Extr: No edema. Scar along knee bilaterally Neurologic Examination: Mental Status: Sedated/paralyzed, starting to arouse. Does not open eyes to voice/stimulation, does not follow commands. Does arouse some to stimulation. Cranial Nerves: Pupils equally round and reactive to light, 3 to 2 mm bilaterally, brisk. Eyes remain midline with horizontal head movement. Shakes head and moves all 4 extremities to nasal tickle, but poor grimace so unable to assess facial symmetry. Motor: Rare spontaneous movement all 4 extremities. Tone decreased on left compared to right. Fasiculations absent in upper and lower extremities. No tremor. Sensation: Extensor posture to pain on left arm, minimal response to pain in other 3 limbs. Reflexes: Increased in left arm, normal in right arm, absent in bilateral legs. Toes were mute bilaterally. Unable to assess coordination and gait given menatl status. Pertinent Results: [2101-3-7] 06:18AM GLUCOSE-147* UREA N-13 CREAT-0.6 SODIUM-141 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 [2101-3-7] 06:18AM CK(CPK)-195* [2101-3-7] 06:18AM CK-MB-5 cTropnT-<0.01 [2101-3-7] 06:18AM CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-1.8 [2101-3-7] 06:18AM WBC-8.8 RBC-4.90 HGB-13.6* HCT-41.2 MCV-84 MCH-27.7 MCHC-33.0 RDW-14.3 [2101-3-7] 06:18AM PLT COUNT-522* [2101-3-7] 06:18AM PT-13.6 PTT-28.8 INR(PT)-1.2 [2101-3-7] 01:21AM TYPE-ART PO2-258* PCO2-33* PH-7.48* TOTAL CO2-25 BASE XS-2 [2101-3-7] 01:21AM HGB-14.5 calcHCT-44 O2 SAT-99 CARBOXYHB-LESS THAN MET HGB-LESS THAN [2101-3-7] 01:21AM freeCa-1.18 [2101-3-7] 01:10AM CK(CPK)-263* [2101-3-7] 01:10AM CALCIUM-9.1 PHOSPHATE-2.8 MAGNESIUM-1.8 [2101-3-7] 01:10AM PHENYTOIN-15.7 [2101-3-7] 01:10AM PT-13.6 PTT-28.8 INR(PT)-1.2 [2101-3-7] 01:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ----- CT OF THE BRAIN WITHOUT IV CONTRAST: There is a large right intraparenchymal hemorrhage located in the right basal ganglia and extending superiorly to the centrum semiovale and inferiorly to the right anterior temporal lobe. In its farther dimension, this hemorrhage measures 5.5 x 3.0 cm. There is adjacent hypodensity consistent with edema extending throughout the adjacent portions of the right frontal, parietal, temporal, and possibly minimally within the occipital lobes. There is mass effect upon the adjacent right lateral ventricle, which is compressed. There is no definite shift of normally midline structures. Inferiorly, there is a suggestion of possible early displacement of the right uncus, which appears to contact the cerebral peduncle, however the basilar cisterns remain patent. There is no definite loss of grey/white matter differentiation within the right hemisphere to suggest an acute minor or major vascular territorial infarct. There are several punctate calcifications within the left temporal lobe anteriorly, as well as within the sella, findings that are of uncertain significance but could possibly relate to vascular calcifications. The temporal lobe calcifications could also possibly relate to prior neurocystosarcosis. There is mild fluid opacification of a portion of the left mastoid air cells and of the ethmoid sinuses bilaterally. The maxillary, sphenoid, and frontal sinuses are normally pneumatized. No fractures are identified. IMPRESSION: Large right intraparenchymal hemorrhage originating in the right basal ganglia, likely consistent with a hypertensive hemorrhage, with extension to the right frontal, parietal, and temporal lobes, and with adjacent edema. Mass effect involves compression of the lateral ventricle and possible early displacement of the right uncus, although there is no definite herniation at the time of this examination. By report, a prior head CT is available from the outside hospital for comparison. When these images become available, an addendum will be dictated indicating any interval change. ADDENDUM: CT images have been made available from the outside hospital. Comparison with the non-contrast head CT dated [2101-3-6] at 10:37p is made. This demonstrates similar size of the right intraparenchymal hemorrhage, and similar degree of mass effect upon the right lateral ventricle. NOTE ADDED AT ATTENDING REVIEW: The small hyperdense foci in the middle fossa, and in the sella turscica are typical of retained myelographic contrast material, usually Pantopaque. These are too dense to be calcifications. I agree with the remainder of the interpretation. ----- VIDEO SWALLOW EVALUATION OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION EVALUATION: An oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with Radiology. Thin liquid, Nectar-thick liquid, pureed consistency barium, and one barium pill were administered. Results follow: ORAL PHASE: Oral phase was severely impaired for bolus control and bolus formation, with premature spillover of thin and nectar liquids to the valleculae appreciated. Solids were defered during this exam due to the pt's significantly prolonged mastication this morning during his bedside examination. At bedside, pt had large, unchewed pieces remaining in his mouth after multiple swallows. Oral transit was also severely impaired, with the pt holding food in his mouth for extended periods of time before initiating transport of the bolus. AP tongue movement was wfl with minimal oral residue remaining for all consistencies. PHARYNGEAL PHASE: Pharyngeal phase was wfl for swallow initiation, velar elevation, and laryngeal elevation. Pharyngeal transit was timely, with adequate bolus propulsion. No residue in the pyriform sinuses appreciated. Pharyngoesophageal sphinctor relaxation wfl as 13mm barium tablet passed freely to the stomach. Mild residue was appreciated in the valleculae on all consistencies. Incomplete epiglottic deflection also appreciated, which is contributing to the overall moderately impaired laryngeal valve closure. Mild backflow from the esophagus secondary to the NG tube in place also noted. ASPIRATION/PENETRATION: Mild aspiration was appreciated on the initial tsp of thin liquids due to premature spillover of the bolus. Delayed spontaneous cough was mildly effective at clearing aspirate material. Cued cough was also mildly effective at clearing some of the remaining aspirate material. Mild-moderate penetration to the level of the vocal cords was appreciated on both cup and straw sips of thin liquid. Penetration was the result of incomplete epiglottic deflection and laryngeal valve closure. Spontanous cough was not present, and cued coughs were inconsistently effective at clearing the penetration. Some of the remaining material in the vestibule was cleared with subsequent swallows. Penetration to the level of the cords was also appreciated on straw sips of thin liquid using a chin tuck. The chin tuck was ineffective at preventing or reducing the penetration, as material still reached the level of the cords. TREATMENT TECHNIQUES: Repeat swallows proved to be effective at clearing pharyngeal residue in the valleculae. Pt required minimal cuing to engage in repeat swallows, often initiating them himself. Swallow-cough-swallow was also attempted during the study. Pt presented with a strong cough which was inconsistely effective at clearing aspirated/penetrated material in the laryngeal vestibule. The chin tuck was also attempted with straw sips of thin liquid. It did not prevent or reduce the amount of penetration appreciated. Pt did demonstrate good awareness and understanding of the technique however, asking on the next sip if he should tuck his chin. Due to pt's current fatigue and cognitive issues, combination strategies were not attempted, however it is anticipated that the pt would be able to safely advance to thin liquids usnig a combination of swallow- cough-swallow and chin tuck when less fatigued and with therapy in rehab. SUMMARY: Pt presents with servere oral deficits and mild to moderate pharyngeal deficits. Poor bolus control and formation are contributing to the spillover to the valleculae. Pt has significantly prolonged mastication for solids as seen today at the bedside, where pieces of unchewed cracker remained in the oral cavity. Oral transit is also severely impaired as the pt holds the food and liquid in his mouth before initiating the swallow. The pharyngeal stage is notable for incomplete laryngeal valve closure and epiglottic deflection, which are contibuting to the penetration appreciated with thin liquids. Pt has decreased sensation and spontanous coughs are present inconsistently, and are delayed when present. At this time due to decreased sensation, the pt presents with an inconsistent spontaneous cough. Cued coughs are inconsistent at clearing the aspirated/penetrated material appreciated with thin liquids. Nectar thick liquids are recommended at this time, however it is believed that when pt's fatigue decreases and he can recieve follow up speech therapy in rehab, he will be able to participate in trials of thin liquids using a combination of a chin tuck and swallow-cough-swallow technique. He should also likely have a repeat video swallow study in the next 2-3 weeks as appropriate prior to upgrading po diet consistency. Purees are also the current recommendation due to pt's severe oral deficits and increased mastication time. RECOMMENDATIONS: 1. Advance to a diet of nectar thick liquids and purees. Pills whole with nectar liquids. 2. Swallow [2-17] x's for each bite or sip. 3. Pt should receive follow up speech therapy in rehab for dysphagia. These recommendations were shared with the patient, the nurse and the medical team. ----- Brief Hospital Course: 1. Right basal ganglia hemorrhage. The patient is a 74M with no known h/o HTN, h/o osteoarthritis, prostate cancer s/p prostatectomy, who presented to the OSH with left face droop, left hemiparesis and slurred speech. He was transferred from OSH after being diagnosed with right basal ganglia bleed by CT. CT of the head here revealed moderated size (40-60 cc basal ganglia bleed). Etiology is most likely to be hypertensive given the location, but the patient has not history of hypertension and his BP have been only mildly elevated. He will need to have a MRI of brain in 6 weeks to evaluate for any underling pathology. The patient was intubated for airway protection before arrival to [Hospital1 18] and was initially admitted to the ICU. He was extubated in the first 24 hours and was transferred to the regular hospital floor on HD #1. The patient was loaded with dilantin which was tapered prior to discharge. The patient was monitored on the floor and his systolic blood pressure was between 120-140. He did not require any anti-hypertensive medications. He ruled out for MI with negative EKG and three negative sets of enzymes. The patient failed speech and swallowing study on several occasions and was started on tube feeding via NG. The patient was seen by PT and OT who felt that he is a candidate for a rehab. The patient has improved slightly neurologically over his hospital stay. At the time of discharge, the patient was awake, alert, speaking fluently with mild dysarthria. He has a mild left hemiparesis. 2. Fever. The patient spiked fever to 100.9 on [3-11]. He had no localizing signs or symptoms of infection except for erythema around his IV site. Peripheral IV in question was removed and catheter tip sent for culture which was negative at the time of discharge. His WBC was normal and UA negative. Urine culture and blood culture results negative. CXR showed LLL atelectasis but no other changes. 3. Thrush. This was treated with fluconazole started [3-10]. Medications on Admission: Celebrex Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Insulin Lispro (Human) 100 unit/mL Solution Sig: variable units Subcutaneous ASDIR (AS DIRECTED): per regular insulin sliding scale. 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 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. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days: for thrush. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Dilantin 100 mg Capsule Sig: One (1) Capsule PO twice a day for five days, then discontinue. Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: 1. Intracranial hemorrhage, right basal ganglia 2. Thrush Discharge Condition: Mild left hemiparesis; requiring assistance with transfer to chair, ambulation. Discharge Instructions: Please take all medications as prescribed. Please follow up as listed below. Please return to the hospital if you develop new or worsening weakness, numbness, fever, shortness of breath, difficulty speaking or other concerning symptoms. Followup Instructions: Will need to have MRI in 6 weeks. He will need to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in the [Hospital 4038] Clinic after discharge from Rehab. Please call [Telephone/Fax (1) 44] to schedule a follow up appointment. [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8286 }	Medical Text: Admission Date: [2110-3-11] Discharge Date: [2110-5-27] Date of Birth: [2110-3-11] Sex: M Service: Neonatology IDENTIFICATION: [Known firstname ] [Known lastname ] [Known lastname 1022] is a 77 day old former 27 [4-8] wk twin with chronic lung disease, feeding immaturity, retinopathy of prematurity, and an inguinal hernia, who is being transferred from the [Hospital1 18] NICU to [Hospital ] Hospital Special Care Nursery. HISTORY: Baby boy [Known lastname 1022], twin #2, was delivered on [2110-3-11] at 27 and 3/7 weeks gestation and was admitted to the newborn intensive care nursery for management of prematurity and respiratory distress. His birth weight was 1220 grams. Mother is 29-year-old gravida 2, para 1 (now 3) Korean woman with an estimated date of delivery of [2110-6-7]. Prenatal screens included BT O+/Ab-, HBsAg-, RPR NR, RI, and GBS unknown. The pregnancy was complicated by twin-to-twin transfusion syndrome diagnosed at 16 weeks gestation. The mother was referred to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] who followed the pregnancy with serial ultrasounds. She received betamethasone on [2110-2-27]. She was transferred to [Hospital1 188] from [Hospital ] Hospital on [2110-3-10] because of worsening oligohydramnios with an estimated fetal weight of 705 grams in this twin with polyhydramnios with an estimated fetal weight of 1184 in twin #2. The decision was made to deliver by cesarean section on [2110-3-11] due to reversed diastolic flow with this twin. Twin #2 was also noted to have a small pericardial effusion at that time. This twin emerged with some tone and respiratory effort, cyanotic. The infant received CPAP briefly but then was intubated because of poor air movements. The infant was transferred to the newborn intensive care unit quickly after short visit with parents. PHYSICAL EXAMINATION: Weight 1220, 75th percentile; length 35 cm, 25th to 50th percentile; head circumference 26.5 cm, 50th to 75th percentile. Skin with multiple areas of bruising on trunk and extremities, mottled with poor perfusion. Anterior fontanel soft and flat. Sutures open. Palate intact. Breath sounds coarse and equal. S1 and S2 normal in intensity. No murmurs. No gallop. Pulses easily palpable, somewhat thready. Capillary refill slow. Abdomen soft. Liver edge 3 to 4 cm. GU normal and appropriate for gestational age male. Testes not palpable. Tones overall slightly reduced. Hips stable. Sacrum without abnormality. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Baby [Name (NI) ] [Known lastname 1022] #2 was initially begun on conventional mechanical ventilation with maximal settings of approximately 25/6 x 30, with FiO2 50-60%. He received 3 doses of surfactant, with gradual ventilator weaning over first week of life. On day of life 9, [2110-3-20], patient experienced an acute decompensation resulting in severe desaturation and bradycardia, requiring resuscitation with chest compressions, epinephrine, and bicarbonate. He also received normal saline, PRBC, FFP, and cryoprecipitate, and was started on dopamine. After a gradual initial recovery, he quickly improved thereafter, returning shortly to previous status. ECHO revealed a large PDA, but otherwise etiology for the decompensation was not clear; it was attributed to acidosis with impaired cardiac function, perhaps further compromised by mild hyperkalemia. Ventilator support did increase after the decompensation. The next day he was taken for PDA ligation, and upon return was electively placed on high-frequency ventilation due to high settings required on SIMV prior to surgery. He transitioned again to SIMV after 48 hours. He failed a trial of CPAP on [4-3], day of life 23, but then successful was extubated to CPAP on [4-11], day of life 31. He remained on CPAP for approximately 2 weeks, and then transitioned on [4-27] to high-flow nasal cannula of 400cc with FiO2 approx 30-40%. This was gradually weaned then switched to low-flow cannula. However, oxygen requirement and a moderate baseline level of work of breathing persisted, and on [5-9], he was begun on maintenance diuretic therapy with diuril. Dosing was gradually advanced in corcordance with KCl supplementation, but was held at 30 mg/kg/day due to mild electrolyte abnormalities treated with increased KCl. At the time of transfer, he continues on diuril 30 mg/kg/day and KCl [3-7] meq/kg/day, with electrolytes on [5-25] of 136/4.8/98/28; further increase in diuril dosing may be possible. Overall work of breathing has improved, and he is currently on nasan cannula oxygen 13-25 cc. Overall course is consistent with moderate bronchopulmonary dysplasia. With regards to other respiratory treatments, he was treated with vitamin A per protocol, and caffeine for apnea of prematurity. The caffeine was discontinued on [5-11], and he has had no spells for over 1 week by the time of transfer. CARDIOVASCULAR: Upon admission, [Known firstname ] [Known firstname ] was hemodynamically stable without need for blood pressure support, although mild to moderate hypertension was noted (see below). He received 2 courses of indomethacin for a PDA with unsuccessful closure. Following the acute decompensation described above [3-20], he was briefly on dopamine, but this was discontinued by [3-21]. He was taken for PDA ligation on [3-21] which was overall uncomplicated, and he has been hemodynamically stable since that time. His initial echocardiogram revealed a tiny pericardial effusion, but resolved on subsequent studies. FLUIDS, ELECTROLYTES AND NUTRITION: His birth weight was 1220 grams, and weight at discharge is 2775 gm. The infant was initially maintained on IVF and parenteral nutrition, initially via UVC and subsequently via PICC line. No notable electrolyte or blood chemistry abnormalities were noted. Enteral feedings were delayed due to clinical course, initiated finally on [3-25] with breast milk. After a prolonged advancement including several episodes of feeding intolerance prompting sepsis evaluations and periods of bowel rest, he achieved full volume enteral feedings by [4-20]. He is currently on 140 cc per kg per day of breast milk 30 calories per ounce with ProMod. Electrolytes and supplementations were as described above. His most recently nutrition labs on [5-25] revealed calcium 10.3, phosphorous 6.0, and alkaline phosphatase 210. PO feedings were introduced as tolerated, and by the time of transfer, infant is taking most of his feedings PO but still with some difficulties with discoordination and desaturations with feeding. Recent weight gain has been appropriate. GASTROINTESTINAL: His peak bilirubin was on day of life 12 at 7.0 and 0.1, and resolved with phototherapy. The infant has been noted to have a large left inguinal hernia, easily reduced. Surgery has been consulted and recommend herniorrhaphy at the time of discharge. Attending surgeon is [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 64492], office number is [Telephone/Fax (1) 64494]. HEMATOLOGY: Hematocrit on admission was 39, blood type is O positive, Coombs' negative. The infant was thought to be the recipient of an in-utero twin-twin transfusion, based on weight discrepancy and exam, although hematocrit was similar for both twins. he received multiple blood transfusions over his course (7 total), most over first several weeks and last on [2110-4-22]. In addition, infant was found to have a moderate coagulopathy after birth with elevated PT and PTT, and received several transfusions of FFP and cryoprecipitate over first week of life. Last coagulation studies on [3-21] were within normal limits. He also was found to have mild thrombocytopenia at approximately 1 week of age, but this resolved without transfusion. The infant's most recent hematocrit was on [5-25] at 28.2 with a reticulocyte count of 4.8%. He is currently receiving ferrous sulfate supplementation at 0.25 ml PO once daily. RENAL: Infant was noted shortly after admission to have mild to moderate hypertension. Renal ultrasound on [3-12] revealed mildly echogenic kidneys with mild right pelviectasis. Repeat study on [3-13] including Doppler flows revealed high resistance flow in the renal arteries, but this was thought to be consistent with the infant's prematurity and overall severity of illness. Final renal ultrasound on [3-20] was normal. Infant continued with normal renal function throughout, with normal urine output and creatinine that increased mildly to maximum of 1.2 on day of life [9-10] and then normalized. Hypertension also resolved within first week of life. INFECTIOUS DISEASE: Initial CBC and blood cultures were obtained, and infant was begun on ampicillin and gentamicin. WBC was 5.2 with an ANC of 728; this was repeated on day of life 2, and was normal with WBC of 6.4 and ANC of 4500. Blood cultures remained negative at 48 hours and the infant's antibiotics were discontinued. On [3-20], during the acute decompensation described above, blood cx were sent and infant was begun on vancomycin and gentamicin. Blood cx subsequently returned Staph coag negative; repeat blood cx (after one dose of abx) was negative, and infant completed 7 days of vancomycin therapy. Lumbar puncture was negative. On [4-4], infant was noted to be lethargic. Blood cx were sent, and infant was begun on vancomycin and gent. Blood cx and several subsequent blood cx over the next several days grew Staph aureus (3 positive total), and one subsequent blood cx grew Staph epi. Several daily cultures were then negative. Over the first few days following the first positive culture, a soft erythematous nodule was noted over the lower sternum, and the left lower leg and left knee were noted to be swollen and firm but not tender or erythemaotous. Ultrasound of both areas did not suggest presence of free fluid, abscess, or joint effusion. The chest nodule and left leg improved clinically on antibiotics, and given the persistent positive cultures, in consultation with the ID and orthopedic services, it was decided to treat the infant for presumed osteomyelitis. The infant 28 days of oxacillin and 7 days of gentamicin from the 1st negative culture, or almost 5 weeks total of antibiotics. CRP was initially elevated at approximately 80, and rapidly normalized to 1-2 range. X-rays of the left leg before and after antibiotic course were unremarkable. Antibiotic course was completed [2110-5-6]. NEUROLOGIC: Multiple head ultrasounds have been normal, most recent being on [2110-4-10]. Overall exam has been appropriate for gestational age, with mildly increased tone diffusely. SENSORY: Hearing screen has not yet been performed but should be done prior to discharge. OPHTHALMOLOGY: [Known firstname ] [Known lastname ] has been noted to develop retinopathy of prematurity. He has been followed by Dr.[First Name9 (NamePattern2) ] [Name (STitle) ], and ROP was first noted on [4-14] 1 Zone 2 ROP in the right eye. This was followed weekly, progressing to stage 2 zone II bilaterally, but over past 2 weeks has been stable to slightly improved. Last exam on [5-26] revealed right eye with St 1 Z II ROP in 5 clock hours, and left eye with St 2 Z II ROP in 2 clock hours. Weekly follow-up is recommended for now. Dr.[Doctor Last Name 60295] telephone No.: [Telephone/Fax (1) 50314]. PSYCHOSOCIAL: Social work has been involved with the family and can be reached at [Telephone/Fax (1) 8717]. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To [Hospital ] Hospital. NAME OF PRIMARY PEDIATRICIAN: Not yet identified. CARE RECOMMENDATIONS: 1. Feeds at discharge: Continue ad lib feeding of 140 cc per kg per day of breast milk 30 calorie with ProMod, weaning caloric density as appropriate for weight, PO as tolerated. 2. Medications: Continue diuril 40 mg b.i.d (30 mg/kg/day), potassium chloride of 3 mEq b.i.d., ferrous sulfate 0.25 ml once daily, vitamin E 5 IU once daily. 3. Car seat position screening has not been performed. 4. State newborn screens have been sent per protocol and have been within normal limits. 5. Immunizations received: The infant received hepatitis B vaccine on [2110-4-17], and Pediarix, HIB, and PCV on [5-23]. 6. Left inguinal hernia repair should be coordinated before discharge. DISCHARGE DIAGNOSES: 1. Premature infant born at 27 and [4-8] wks. 2. Recipient, twin-twin transfusion syndromde. 3. Respiratory distress syndrome. 4. Bronchopulmonary dysplasia. 5. Patent ductus arteriosis. 6. Staph coag negative bacteremia. 7. Staph aureus bacteremia. 8. Presumed osteomyelitis of left leg. 9. Anemia of prematurity. 10. Apnea of prematurity. 11. Hyperbilirubinemia. 12. Retinopathy of prematurity. 13. Feeding immaturity. 14. Left inguinal hernia. [First Name8 (NamePattern2) ] [Name8 (MD) ], MD [MD Number(2) 56682] Dictated By:[Last Name (NamePattern1) 58682] MEDQUIST36 D: [2110-5-26] 22:40:06 T: [2110-5-26] 23:50:48 Job#: [Job Number 65498] ICD9 Codes: 7742, 769, 2767, 2762, 4019, V053
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8287 }	Medical Text: Admission Date: [2122-6-9] Discharge Date: [2122-6-29] Date of Birth: [2040-7-16] Sex: F Service: MEDICINE Allergies: Digoxin / Heparin Agents Attending:[Last Name (NamePattern1) 495] Chief Complaint: acute renal failure Major Surgical or Invasive Procedure: femoral hemodialysis line placement central venous catheterization History of Present Illness: 81 yo Greek speaking only woman with CHF, EF 50% with cirrhosis, portal HTN, CRI, BL 1.5 admitted to [Hospital3 ]1 week ago ([6-2])with RUQ abdominal pain. RUQ US and HIDA scan per OSH showed acute cholecystitis for which unasyn was started. Cr gradually increased from 1.6 on admit despite hydration. Per notes, renal was consulted and gave fluid challenge, urine lytes with UNa of 6. Was thought to be in hepatorenal syndrome and started on octreotide and midodrine with minimal response. per notes, also started on IV steroids and dopamine at times for ? hypotension, though none documented. Urine output 100 cc for past 24 hours with gradual increase in LE edema Was afebrile throughout with no localizing sx. other than continued RUQ abdominal pain. On d/c, labs significant for Na 131, HCO3 16, BUN 62, Cr 4.0. CBC, INR 1.4. On day of transfer had emesis X1 and O2 transiently decreased with new o2 requirement of 4L. ABG 7.20/33/127 on 4L. Family concerned with care at [Location (un) ] and requested transfer to [Hospital1 18]. . In ambulance, apparently pt. with desats and increased lethargy. In ED, afebrile satting well. CKs flat, head CT done, and negative. Past Medical History: - CHF with EF 50%, severe tricuspid regurg, R pulmonary HTN on ECHO in [2120]. - Atrial fibrillation, not on coumadin since subdural bleed s/p fall 4 years ago - Anemia - h/o pancreatitis - dyslipidemia - Hypothyroidism - Hepatic cirrhosis NOS with portal HTN - pancytopenia - Dementia Physical Exam: Vitals - T afebrile, BP 109/55, HR 73, RR 26, O2 94%/3L General - awake, alert, oriented to person and somewhat to place ("[Location (un) 86]") HEENT - PERRL, EOMI, MMM Neck - unable to assess JVP given RIJ which is C/D/I, no tenderness or erythema. no carotid bruits CVS - irregularly irregular, no MRGs Lungs - decreased BS R base. + crackles bilaterally, no wheezes Abd - soft, mildly distended. no dullness to percussion. TTP in RUQ, + rebound. otherwise, no TTP. Ext - no palmar erythema, 2+ pitting edema throughout, including abdomen, back Skin no stigmata of liver dz Neuro: + asterixis. CN III-XII grossly intact Pertinent Results: [2122-6-9] 10:39PM URINE HOURS-RANDOM UREA N-145 CREAT-79 SODIUM-58 [2122-6-9] 10:39PM URINE OSMOLAL-312 [2122-6-9] 06:57PM GLUCOSE-150* UREA N-78* CREAT-4.9* SODIUM-135 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-15* ANION GAP-24* [2122-6-9] 06:57PM CALCIUM-8.6 PHOSPHATE-5.6* MAGNESIUM-2.6 [2122-6-9] 06:57PM OSMOLAL-301 [2122-6-9] 05:15PM URINE HOURS-RANDOM UREA N-104 CREAT-49 SODIUM-87 [2122-6-9] 05:15PM URINE OSMOLAL-304 [2122-6-9] 05:15PM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.025 [2122-6-9] 05:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN->300 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-MOD [2122-6-9] 05:15PM URINE RBC-[10-27]* WBC-21-50* BACTERIA-MANY YEAST-MANY EPI-0 [2122-6-9] 05:15PM URINE EOS-NEGATIVE [2122-6-9] 08:50AM GLUCOSE-106* UREA N-73* CREAT-4.7* SODIUM-135 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-15* ANION GAP-24* [2122-6-9] 08:50AM CK(CPK)-19* [2122-6-9] 08:50AM cTropnT-0.08* [2122-6-9] 08:50AM WBC-6.9 RBC-3.63* HGB-10.9* HCT-33.9* MCV-94 MCH-30.0 MCHC-32.1 RDW-19.2* [2122-6-9] 08:50AM NEUTS-90.5* LYMPHS-4.2* MONOS-5.0 EOS-0.2 BASOS-0.2 [2122-6-9] 08:50AM PLT COUNT-104* [2122-6-9] 06:55AM AMMONIA-85* [2122-6-9] 03:45AM PT-15.9* PTT-33.2 INR(PT)-1.4* [2122-6-9] 02:58AM TYPE-[Last Name (un) ] PO2-75* PCO2-34* PH-7.26* TOTAL CO2-16* BASE XS--10 [2122-6-9] 02:58AM GLUCOSE-110* LACTATE-2.0 NA+-133* K+-3.7 CL--104 [2122-6-9] 02:58AM O2 SAT-92 CARBOXYHB-2 MET HGB-0 [2122-6-9] 02:58AM freeCa-1.12 [2122-6-9] 02:50AM GLUCOSE-118* UREA N-70* CREAT-4.5* SODIUM-135 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-12* ANION GAP-27* [2122-6-9] 02:50AM estGFR-Using this [2122-6-9] 02:50AM ALT(SGPT)-4 AST(SGOT)-16 LD(LDH)-228 CK(CPK)-22* ALK PHOS-66 AMYLASE-156* TOT BILI-0.8 DIR BILI-0.4* INDIR BIL-0.4 [2122-6-9] 02:50AM LIPASE-76* [2122-6-9] 02:50AM CK-MB-NotDone [2122-6-9] 02:50AM PHOSPHATE-5.4* MAGNESIUM-2.6 [2122-6-9] 02:50AM WBC-7.6# RBC-3.46* HGB-10.6* HCT-31.7* MCV-92 MCH-30.6 MCHC-33.4 RDW-19.4* [2122-6-9] 02:50AM NEUTS-91.8* LYMPHS-2.9* MONOS-5.1 EOS-0.2 BASOS-0 [2122-6-9] 02:50AM PLT COUNT-95* [2122-6-9] 02:50AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.025 [2122-6-9] 02:50AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2122-6-9] 02:50AM URINE RBC-[5-17]* WBC-[2-9] BACTERIA-MOD YEAST-MOD EPI-[2-9] [6-9] head ct with contrast: IMPRESSION: No acute intracranial pathology. Atrophy with dilatation of lateral ventricles including temporal horns. [Month (only) 116] be seen with communicating hydrocephalus in appropriate setting. If old exams are available, comparison would be helpful. [6-10] abd us: IMPRESSION: 1. Nondistended gallbladder with multiple shadowing stones within its lumen. A small amount of fluid adjacent to it. No prior studies are available for comparison. Findings are equivocal for acute cholecystitis, please correlate clinically. 2. Patent portal veins and hepatic veins with biphasic flow suggestive of hepatic congestion and right heart failure. 3. Borderline splenomegaly. 4. Bilateral small pleural effusions. 5. Small amount of ascites. [2122-6-11] CTA abd/pelvis IMPRESSION: 1. Nondistended gallbladder with multiple shadowing stones within its lumen. A small amount of fluid adjacent to it. No prior studies are available for comparison. Findings are equivocal for acute cholecystitis, please correlate clinically. 2. Patent portal veins and hepatic veins with biphasic flow suggestive of hepatic congestion and right heart failure. 3. Borderline splenomegaly. 4. Bilateral small pleural effusions. 5. Small amount of ascites. Brief Hospital Course: 81 yo with cirrhosis, renal failure, biventricular heart failure presented with abdominal pain and renal failure, now intubated on pressors, received trial of CRRT with no improvement with worsenign volume overload, respiratory failure. . # Fever: Increased secretions but no clear infiltrate on CXR. Also with positive U/A. Femoral HD line another potensial source. Spiked to 100.9F 3d ago. Leukocytosis but lactate normal. Pt initially received vanco/zosyn for broad coverage (dose vanco by level, goal 15-20). vanco d/c'd as no e/o G+ infection. Pt then was found to have Burkholderia Cepacia in sputum, ceftaz sensitive, but apparently this bug develops ESBL rather fast, so will tx with bactim per ID recs. started today (day 1=[6-28]) will continue for 14d course. During [6-28] and [6-29] the patient began to have increasing pressor requirements due to morbidity of her other conditions. After multiple discussions with the family, the patient was first made DNR and then changed to CMO and expired shortly afterwards. Blood cultures never turned positive. . # Hypotension: Likely biventricular failure based on elevated PCWP and dilated RV, worsened in the setting of acute infection and possibly volume overload. Echo with normal EF, mild hypertrophy suggesting some diastolic dysfunction; trial of Swan with fluid challenges showed no change in CI/CO which was 2.8/41. Initiall on steroids but had appropriate [Last Name (un) 104] stim so tapered off. Pressor requirement increased yesterday but now decreasing. Patient was maintained on levophed gtt for the last 7 days of the hospital course. As her the heart failure became more severe and while the patient was off cvvhd, the pressor rquirements increased. Renal recommended no CVVHD continuation since there is no chance of recovery to HD. Patien experied on [2122-6-29] after being made CMO. . # Respiratory failure: Pt initally Hypercarbic with low tidal volumes, resp rate; likely from fatigue in context of metabolic acidosis and pulmonary effusions from renal failure although could also be a central cause. Later in the hospital course, due to the patient's heart failure, she developed pulmonary edema, increasing distress, now on AC. currently overbreathing the vent , likely due to central causes, putting self into respiratory alkalosis. AC ventillation was maintained until the patietn was made CMO and was terminally extubated. . # Heme: Thrombocytopenia - patient [12-9]'d her platelets while receiving CVVHD with heparin. Pt was HIT positive, confirmed by SRA, in setting of heparin flushes for HD line. No evidence of arterial thrombosis. Plt now slowly recovering. Also with coagulopathy due to combination of underlying liver disease and argatroban. DIC/hemolysis labs negative. plt count recovering. Pt was transfused platelets with procedures. Platelet counts continued to recover, but the patient was made CMO due to no chance of recovery from other insults. . # Neuro: Presented with AMS likely toxic-metabolic [1-9] hepatic and renal status. CT head negative. Non-reactive pupils (?surgical) concerning for intracran pathology in the setting of high bleeding risk given thrombocytopenia and coagulopathy; however, repeat head CT without evidence of bleed. Lactulose titrated to [1-10] BMs per day for hepatic encephalopathy. Sedation was weaned, but the patient continued only to be responsive to painful stimuli. Since no chance of neurologic recovery was possible, and in addtion to the morbidity of other conditions (i.e. irreversible biventricular heart failure), the patient was made CMO and expired shortly afterwards. . # Acute on chronic renal failure: Most likely ATN rather than hepatorenal, possibly due to CHF vs. sepsis. Nearly anuric, no real recovery of renal function as of yet. Renal and hepatology believe more likely ATN; failed lasix + thiazide + albumin challenge and, per OSH, also failed fluid challenge. Briefly on octreotide, midodrine which were then d/c'd. Received dopamine/hydorocort at OSH suggesting hypotension which would support ATN. Urine eos negative. Temporary femoral dialysis line d/c'd. Pt. had trial of CVVHD with no improvement in pressor requirements, so decision was made to not restart. The patient progressively became more fluid overloaded as cvvhd was pulle of and decision was made not to restart due to futility of this treatment. Patient expired shortly after decision to make the patient CMO was made. . # Cirrhosis: Childs B. Possible [1-9] right heart failure; less likely NASH. No biopsies. Unclear how much it has been worked up in the past. Hepatology consulted. U/S with little ascites. Elevated LFTs from hepatic congestion. Hep serologies neg for B, C; HAV Ab positive. Not a significant contributor to this [Hospital 228] hospital course. . # RUQ pain: Most likely from capsule distension due to right heart failure as improves with fluid off-loading. Treated with unasyn at OSH for acute cholecystitis, then zosyn/levo for ?intra-abdominal process given rising lactate but unknown source (d/c'd [6-16]). U/S here for cholecystitis nondiagnostic. Surgery consulted, who did not believe this represents cholangitis or cholecystitis. Also no e/o mesenteric ischemia on CT scan, although non-contrast study. Minimal ascites makes SBP less likely. . # Code: Patient remainded full code for the majority of her stay. Together with social work, ethics, multiple attnedings, the patietn was made DNR. Due to overall complexity of the medical problmes, it was explained to the patient's family that Mrs. [Known lastname 39694] was unlikely to ever recover and leave the ICU. As she developed increasing pressor requirements and was unable to maintain her blood pressures, the decision was made to make her CMO. She expired shortly afterwards. Daughter, [Name (NI) 803] same as above Daughter [Name (NI) 3908] ([Telephone/Fax (1) 39695] transferring MD: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 732]: [Telephone/Fax (1) 39696], ICU: [Telephone/Fax (1) 39697] Dr. [Last Name (STitle) 39698]: ([Telephone/Fax (1) 39699] or 3270 Medications on Admission: lasix 80bid levothyroxine 150 qdaily prozac 10mg qdaily detrol LA 4mg qdaily lipitor 20 mg qdaily protonix 40 qdaily aldactone 37.5bid dextromethorphan LA one po bid FeS04 qdaily ranitidine 150bid resource instant powder: 1 scoop tid with food Discharge Disposition: Expired Discharge Diagnosis: Biventricular heart failure Renal failure due to acute tubular necrosis Hepatic cirrhosis due to right heart failure Heparin-Induced Thrombocytopenia Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a Completed by:[2122-6-30] ICD9 Codes: 4280, 5715, 5845, 5990, 2449
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8288 }	Medical Text: Admission Date: [2166-12-6] Discharge Date: [2166-12-10] Date of Birth: [2106-4-18] Sex: F PRINCIPAL DIAGNOSIS: Hypercarbic respiratory arrest. CHIEF COMPLAINT: Hypoxia, unresponsiveness. woman with Marfan's disease and severe restrictive lung disease at baseline who was transferred to the [Hospital1 346] Emergency Room from [Hospital 100] Rehab after being found unresponsive and in respiratory distress. At [Hospital 100] Rehab she was found to have an oxygen saturation of 63% on room air which improved to 97% on non rebreather. Her blood pressure was 70/30. She was brought to the [Hospital3 ] Dopamine for hypotension and was placed on bi-pap 10/5. Her blood gas upon admission to the Emergency Room, PH 7.06, PCO2 165, PO2 51. She was not able to communicate although she was able to respond to voice and to touch. She was given Ampicillin, Gentamycin and Flagyl for treatment of possible sepsis of unclear etiology. Her blood pressure improved to 100, to 110 with Dopamine and she was transferred to the medical Intensive Care Unit. PAST MEDICAL HISTORY: Marfan's syndrome, atrial valve replacement, mitral valve replacement, CVA with right sided weakness, kyphoscoliosis with restrictive lung disease, nocturnal apnea, receives bi-pap 10/5 at night, status post pacemaker placement, pubic ramus fracture within past month with residual pain, history of seizure disorder, congestive heart failure with ejection fraction of 35%. SOCIAL HISTORY: She is a non smoker, widowed, a resident of [Hospital 100] Rehab since [3-23]. FAMILY HISTORY: Significant for son and daughter, both with [Name (NI) 1564] disease. The son is [Name (NI) ], [Telephone/Fax (1) 97112], daughter is [Name (NI) 698], [Telephone/Fax (1) 97113]. MEDICATIONS: On admission, Coumadin 5 mg po q d, Propranolol 10 mg tid, Trazodone 25 mg q h.s., Calcium Carbonate with Vitamin D 500 mg [Hospital1 ], Digoxin 0.125 mg q d, Nasalide 2 puffs [Hospital1 ], Ultram 50 mg po q 6 hours, Oxycodone 2.5 mg po q 6 hours prn, Dilantin 200 mg q d, 200 mg/100 mg q o d, Zoloft 125 mg q d, Lasix 80 mg q d, Prevacid 15 mg [Hospital1 ], Vasotec 5 mg q d, Ativan 1 mg q 6 hours prn, Aldactone 25 mg q d, Senokot prn, Tylenol prn, Ocean nasal spray, two sprays qid. ALLERGIES: Amiodarone, Lidocaine, Quinidine, Procainamide, Disopyramide. PHYSICAL EXAMINATION: On admission temperature 100.6, heart rate 72, blood pressure 100-110/70 on Dopamine, respiratory rate 28, oxygen saturation 97% on 100% non rebreather. General, obtunded, not following commands, not conversing, responsive to pain. HEENT: Right pupil opaque with cataracts, left pupil reactive. Neck, JVP 7 cm. Chest, absent breath sounds on the right except slight breath sounds in the right apex, very distant breath sounds on the left. Heart, regular rate and rhythm, normal S1 and S2, valvular heart sounds. Abdomen soft, positive bowel sounds with 10-15 cm mass in right lower quadrant. Extremities, cool, cyanotic. LABORATORY DATA: On admission, WBC 6.7, hemoglobin and hematocrit 11/35.1, platelet count 286,000, MCV 95. Differential, 76% neutrophils, 14% lymphocytes, 8% monocytes, sodium 135, potassium 4.6, chloride 89, CO2 38, BUN 44, creatinine 1.0, glucose 106, PT 15.6, PTT 36.5, INR 1.7. Urinalysis, moderate blood, positive nitrites, trace ketones, [6-1] RBC, [2-24] WBC, no bacteria, less than 1 epithelial cell. Chest x-ray, cardiomegaly, complete opacification of right lower lung, question air bronchogram in the left lower lung. Arterial blood gas upon admission, 7.06/165/51. Abdominal ultrasound revealed that the large mass in the right lower quadrant was the patient's liver and gallbladder. The patient receives all of her care at [Hospital3 2576] [Hospital3 ] and per discussion with [Hospital3 2576], at baseline she has opacification in the right lower lung consistent with her current chest x-ray. HOSPITAL COURSE: It was felt that the patient's initial sedation and hypoxia at [Hospital 100] Rehab were probably due to a combination of over sedation from Benzodiazepine and Opiate medications as well as from dehydration exacerbated by the diuretics that she was taking. Then when she received supplemental oxygen she likely became hypercarbic owing to loss of respiratory drive because at baseline she is likely a CO2 retainer. Per her son, her baseline oxygen saturation is only 89-90% on room air and 94-96% on two liters. As a result of excessive supplemental O2, she lost her respiratory drive. When she was admitted to the medical Intensive Care Unit she was initially placed on bi-pap 10/5 and the FIO2 was weaned down to maintain an oxygen saturation greater than 90%. Her mental status gradually improved and she was changed to nasal cannula O2 and able to maintain oxygen saturation of 99% on one liter of O2. At night she continued to require bi-pap 10/5 in order to maintain her respirations. A house officer was called at night because her oxygen saturation was in the 80's although she was not complaining of any dyspnea. Her arterial blood gas at that time was 7.37/62/50. She was given increasing amounts of supplemental O2 and subsequently became increasingly hypercarbic and unresponsive. She was thus transferred to the medical Intensive Care Unit and was placed on non invasive mask ventilation because she appeared to be in significant respiratory distress and to be fatiguing. Her mental status gradually cleared over the course of 24 hours and she required progressively less supplemental O2 such that within 24 hours she was satting at 99% on 35% O2 by face mask. It was felt that her desaturation into the 80's at night is part of her normal baseline. Given her large abdominal contents and her complaints of dyspnea when lying flat, it was felt that she breathes poorly when she is lying down because her abdominal content press heavily against her diaphragm. Therefore, she should be kept lying down at at least a 45 degree angle even when she is sleeping at night. 2. Infectious Disease: Owing to her abnormal baseline chest x-ray, it is impossible to ascertain whether or not she has a pneumonia present. However, given her lack of fever as well as lack of elevated white blood cell count and lack of cough, it was unlikely that she had a pneumonia present. She had initially been started on Vancomycin, Levofloxacin and Flagyl in the Intensive Care Unit. Subsequently Vancomycin and Flagyl were discontinued and she was placed on Levofloxacin to finish a 7 day course for possible sinusitis because she complains of chronic baseline nasal discharge. 3. Cardiovascular: She was hypotensive to the 70's initially when she presented to the hospital. Her blood pressure improved with Dopamine and also with fluids. She was able to be weaned off Dopamine quickly and maintained her blood pressure at about 100 which per her son is her baseline. During her second episode of hypercarbia and hypoxia which was on the floor, her blood pressure dropped into the 70's. The hypotension was likely due to a combination of vasodilation from hypocarbia as well as volume depletion. 4. Hematologic: She is status post valve replacement and goal INR should be 2.5 to 3.5. Her INR was 1.7 upon admission and she was started on Coumadin 7.5 mg q d (at home she takes 5 mg po q d). On hospital day #2 her INR was 4.3, hospital day #3 it was 6.5. Consequently Coumadin was held for the time being. 5. Renal: She appeared to be dehydrated initially, based upon her hypotension as well as elevated BUN to creatinine ratio. She does take diuretics at baseline, presumably for her congestive heart failure. Given her hypotension, her diuretics were held during this hospitalization. 6. Gastrointestinal: She had a large right sided abdominal mass found on physical exam. On ultrasound this is found to represent both her liver and gallbladder. These findings are consistent with likely tympanic congestion from right sided heart failure secondary to valvular disease and Marfan's disease as well as to downward displacement because the right heart impinges marginally in the right thorax. 7. Psychiatric: The patient's mental status cleared promptly after her hypercarbia had resolved. Her depressed mental status was therefore felt to be due entirely to hypercarbia. She did seem anxious during most of the hospitalization per her son. She was very anxious at baseline. 8. Neurologic: She was receiving Opiates and Benzodiazepines status post two recent falls. Given concern regarding over sedation, these were both held during her hospitalization. The patient herself requested only Tylenol for relief of her pain which she described as "pain all over". If she is to receive Benzodiazepines or Opiates in the future, they must be dosed conservatively to avoid over sedation. CODE STATUS: The patient's son and daughter acknowledge that her baseline health is compromised but they feel that she does have a reasonable quality of life. Therefore, they would like for her to receive aggressive medical care if she is admitted with easily reversible conditions, however, she is a DNR/DNI. DISPOSITION: The patient received all of her care at [Hospital6 1129] with the exception of this admission. When discharged she will return home to [Hospital 100] Rehab. Addendum of discharge summary will follow. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Name8 (MD) 4123] MEDQUIST36 D: [2166-12-9] 14:34 T: [2166-12-9] 15:20 JOB#: [Job Number 97114] ICD9 Codes: 4280, 2765, 5849, 5990
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8289 }	Medical Text: Admission Date: [2167-5-26] Discharge Date: [2167-6-2] Date of Birth: [2098-8-18] Sex: M Service: MEDICINE Allergies: Benzodiazepines / Augmentin Attending:[First Name3 (LF) 30] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Left-sided nephrostomy tube placement [2167-5-28] PICC line placement History of Present Illness: 68yo man with end-stage multiple sclerosis with [Month/Day/Year ] suprapubic foley comes in from [Hospital3 2558] with two days of fevers and one day of abdominal pain and nausea. Yesterday he had a fever to 102. WBC of 14.6 with 89% PMN's. Txfd to [Hospital1 18] for further evaluation. . In the ED, initial vs were: T 98 P 91 BP 122/63 R 20 O2 sat 95%RA. UA positive large leuks, mod bact, 87 WBCs. CT abdomen consistent with [Last Name (un) 3696] Syndrome and possible pyelo, ? staghorn calculus. Surgery was consulted, who recommended admission to medicine. Patient was febrile to 102 and was given Tylenol and Vanc/Zosyn for broad coverage of pyelonephritis. Given 2L fluids. There were problems with venous access - anatomy made an IJ difficult (pt contracted), and two attempts at a R subclavian were c/b air in the syringe, then arterial puncture. Pressure held x15 minutes, no PTX on CXR. A right femoral line was placed. Troponin 0.08 and pt had ? new Q waves inferiorly in III/AVF with TWI in V2/V3, and rectal Aspirin given. Transferred to the floor . On the floor, the patient has [4-21] low pelvic abdominal pain. [Month/Year (2) 8304] trouble clearing secretions. Past Medical History: 1. MS, endstage secondary progressive type. 1. Decubitus ulcer (healing). 2. History of lung aspiration and lung abscess. 3. Hypertension. 4. Gastroesophageal reflux. 5. Status post gastrostomy tube. 6. Status post suprapubic catheter. Social History: Lives in Nursing Home at [Hospital3 2558], divorced, two children. Retired Biochemist. Denies etoh/tobacco/drugs. Family History: Non-contributory. Physical Exam: ADMISSION EXAM: Vitals: T: 99 BP: 115/68 P: 79 R:21 O2: 97 General: Alert, oriented. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP difficult to assess Lungs: Anterior/lateral auscultation has poor inspiratory effort with coarse breath sounds and some rhonchi bilaterally. CV: Distant heart sounds. Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Distended firm abdomen. Tympanic to percussion. G-tube in place as well as suprapubic catheter in place. NT to palpation. No organomegaly appreciated. GU: clear urine Ext: Atrophic lower extremities. Warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Neuro: Quadraplegic. AOX3. Movement of right shoulder and can move eyes. DISCHARGE EXAM: Generally unchanged from admission. Abdomen distended but soft, and non-tender with normoactive bowel sounds. Discharge VS: 98.5, 114/70, 78, 26, 93% RA. Pertinent Results: Admission Labs [2167-5-26] 08:12PM URINE HOURS-RANDOM [2167-5-26] 08:12PM URINE GR HOLD-HOLD [2167-5-26] 08:12PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.033 [2167-5-26] 08:12PM URINE BLOOD-SM NITRITE-POS PROTEIN-100 GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-LG [2167-5-26] 08:12PM URINE RBC-9* WBC-87* BACTERIA-MOD YEAST-NONE EPI-<1 [2167-5-26] 08:12PM URINE HYALINE-1* [2167-5-26] 08:12PM URINE MUCOUS-RARE [2167-5-26] 03:55PM PT-12.3 PTT-25.5 INR(PT)-1.0 [2167-5-26] 03:28PM LACTATE-1.9 [2167-5-26] 03:15PM GLUCOSE-309* UREA N-24* CREAT-0.8 SODIUM-126* POTASSIUM-4.2 CHLORIDE-89* TOTAL CO2-27 ANION GAP-14 [2167-5-26] 03:15PM estGFR-Using this [2167-5-26] 03:15PM ALT(SGPT)-44* AST(SGOT)-19 CK(CPK)-33* ALK PHOS-157* TOT BILI-0.8 [2167-5-26] 03:15PM LIPASE-17 [2167-5-26] 03:15PM cTropnT-0.08* [2167-5-26] 03:15PM CK-MB-2 [2167-5-26] 03:15PM CALCIUM-8.5 PHOSPHATE-2.4* MAGNESIUM-2.3 [2167-5-26] 03:15PM WBC-13.5* RBC-4.47* HGB-13.2* HCT-38.3* MCV-86 MCH-29.6 MCHC-34.6 RDW-16.5* [2167-5-26] 03:15PM NEUTS-87.9* LYMPHS-7.6* MONOS-3.8 EOS-0.4 BASOS-0.4 [2167-5-26] 03:15PM PLT COUNT-134* OTHER PERTINENT LABS: [2167-5-31] 04:00AM BLOOD ALT-58* AST-48* LD(LDH)-148 AlkPhos-256* TotBili-0.7 [2167-6-1] 05:33AM BLOOD ALT-46* AST-27 LD(LDH)-135 AlkPhos-265* TotBili-0.6 [2167-5-26] 03:15PM BLOOD cTropnT-0.08* [2167-5-27] 12:38AM BLOOD cTropnT-0.11* [2167-5-27] 07:56AM BLOOD CK-MB-2 cTropnT-0.14* [2167-5-27] 03:11PM BLOOD CK-MB-3 cTropnT-0.09* [2167-5-30] 03:50AM BLOOD CK-MB-2 cTropnT-0.04* [2167-6-1] 05:33AM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.7 Mg-1.8 [2167-5-27] 12:38AM BLOOD Osmolal-281 [2167-6-1] 05:33AM BLOOD Vanco-17.4 DISCHARGE LABS: [2167-6-2] 04:37AM BLOOD WBC-9.4 RBC-3.46* Hgb-10.0* Hct-30.3* MCV-88 MCH-29.1 MCHC-33.1 RDW-16.3* Plt Ct-211 [2167-6-2] 04:37AM BLOOD Glucose-160* UreaN-12 Creat-0.4* Na-141 K-4.4 Cl-102 HCO3-33* AnGap-10 [2167-6-2] 04:37AM BLOOD ALT-37 AST-17 AlkPhos-228* TotBili-0.5 [2167-6-2] 04:37AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8 MICROBIOLOGY: Urine culture [2167-5-26]: PROTEUS MIRABILIS \| PROVIDENCIA STUARTII \| \| MORGANELLA MORGANII \| \| \| ENTEROCOCCUS SP. \| \| \| \| ENTER \| \| \| \| \| AMIKACIN-------------- 4 S 4 S AMPICILLIN------------ =>32 R <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S 32 R CEFTAZIDIME----------- <=1 S <=1 S =>64 R CEFTRIAXONE----------- <=1 S <=1 S =>64 R CIPROFLOXACIN--------- 2 I =>4 R 1 S GENTAMICIN------------ =>16 R S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S NITROFURANTOIN-------- 256 R 256 R <=16 S <=16 S TETRACYCLINE---------- =>16 R =>16 R TOBRAMYCIN------------ =>16 R I <=1 S TRIMETHOPRIM/SULFA---- =>16 R <=1 S <=1 S VANCOMYCIN------------ 1 S 1 S . Blood culture [2167-5-27]: negative Blood culture [2167-5-27]: GPCs in pairs and chains Urine culture [2167-5-29]: negative IMAGING: CXR [2167-5-26]: 1. Bibasilar opacities could reflect aspiration or atelectasis. 2. Right costophrenic angle blunting could reflect pleural thickening given chronicity of appearance. CT Abd/Pelvis [2167-5-26]: 1. Large staghorn calculus in the left renal pelvis, new from [2161] CT. Possible mild pyelitis though no overt signs of pyelonephritis. Suprapubic catheter in place with apparent bladder wall thickening, correlate for infection. 2. Mild dilation of the redundant sigmoid colon without distal obstruction -likely [Last Name (un) ] syndrome. Mild fecal rectal impaction. 3. Stable hepatic hemangioma. 4. Bibasilar opacities in the lungs, likely [Last Name (un) ] atelectasis or aspiration. CXR [2167-5-31]: Interval changes suggest interval development of CHF with interstitial edema. CXR [2167-5-31]: A right subclavian PICC line is present, tip over distal SVC near SVC/RA junction. No pneumothorax is detected. Otherwise, I doubt significant interval change. UNILAT UP EXT VEINS US RIGHT [2167-5-31]: No evidence of DVT in the right upper extremity. TTE [2167-6-1]: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 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 structurally normal. There is no mitral valve prolapse or regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a very small pericardial effusion. The effusion appears circumferential. IMPRESSION: Suboptimal image quality. Preserved regional and global biventricular systolic function. Very small circumferential pericardial effusion. Brief Hospital Course: #) Sepsis Secondary to Pyelonephritis/Bacteremia: Patient with endstage MS [First Name (Titles) ] [Last Name (Titles) ] suprapubic cath presented with fevers, tachycardia, and leukocytosis with dirty UA. CT abdomen was concerning for struvite stone in left kidney. He was initially admitted to MICU w/sepsis requiring fluid boluses and pressors, and was empirically started on vancomycin/zosyn for broad coverage. Stablizied and was off pressors since [5-28]. Urology consulted with no recommendations for change in suprapubic catheter exchange (recently replaced 2 weeks prior to presentation per report), though did recommend percutaneous nephrostomy tube placement. Patient had IR placement of left nephrostomy tube on [2167-5-27], and had adequate urostomy drainage and improvement in hemodynamics/leukocytosis/fevers by post intervention day 2. Patient likely has colonization of resistant bacteria from his [Date Range ] suprapubic Foley, though acute infection occurring now in setting of left kidney staghorn calculus. Urine culture positive for Proteus mirabilis, providencia stuartii, morganella morganii, and vanc-sensitive enterococcus. Per Urology, would have high suspicion that Proteus was responsible for much of acute infection, as this bacteria is known to cause calculi. Patient was continued on vanc/zosyn but was switched to vanc/ertapenem on [2167-6-2], and per Urology recs patient should continue on this regimen through Urology follow-up appt on [2167-6-17]. Will likely need surgical management of left staghorn calculi at that time. Left nephrostomy tube should remain in place and open to drainage until Urologyg follow-up. Of note, blood cultures from [2167-5-27] positive for GPCs in pairs and chains, though speciation still pending at time of discharge. TTE was suboptimal but did not show evidence of vegetations. Patient already on >2 week course of broad spectrum abx. #) Hypoxia: Patient not on O2 at baseline, though was requiring 5L NC suppplemental O2 on arrival to floor following ICU stay. CXR [5-31] showed e/o effusions and interstitial edema, as well as probable atalectasis. Suspected volume overload following ICU course with IVF and pressor administration in setting of sepsis. Echo showed preseved systolic function with EF >55. [Month (only) 116] also be component of aspiration, and per speech and swallow evaluation patient should only have ice chips with supervision, otherwise strict NPO. Patient diuresed with 20mg IV furosemide on [6-1], and was net negative 2.1L with improvement in O2 sat to 93% on RA. O2 sats should be monitored on discharge, and patient should continue on albuterol/ipratropium nebs Q6H prn cough/wheeze/SOB. Will require suctioning of secretions, and should be NPO with all meds given via G-tube. #) Apnea/Transient desaturation: Likely secondary to patient's neuromuscular disease/MS and inability to clear secretions. Patient failed multiple trials of CPAP while in the ICU, though was able to tolerate CPAP on floor. Will need outpatient sleep study once discharged. #) AFib with RVR: Patient with new onset AFib with RVR to 140s in the setting of transient apnea and desaturations. Patient was started on metoprolol tartrate 12.5 TID. His episodes spontaneously resolved after 5-10 minutes, and he coverted back to NSR. For CHADS2 score 0-1, was started on aspirin 81 mg. Echo showed moderate LA enlargement. #) Abdominal pain/distention with 1 week's worth of constipation: Imaging consistent with [Last Name (un) 3696] syndrome, which can be a complication of multiple sclerosis as well as [Last Name (un) ] oxybutynin use. DC'd anticholinergics and started aggressive bowel regimen with good results. No evidence of perforation on imaging. Patient was not restarted on oxybutynin on discharge. #) Positive troponin on admission: Likely strain as CK-MB was flat. There are EKG changes relative to previous EKG from [2160], but clinical picture more consistent with strain than ACS. Echo showed preserved systolic function. #) Multiple sclerosis: Held oxybutynin per above but continued baclofen. Will need suctioning of oral secretions. LABS/STUDIES PENDING AT TIME OF DISCHARGE: Blood culture [2167-5-27]: speciation of GPCs ISSUES REQUIRING FOLLOW-UP: -Patient with new onset Afib this admission and was started on metoprolol for rate control and ASA 81mg daily. Will need outpatiet follow-up -Patient should continue on aggresive bowel regimen and discuss with PCP whether he should restart oxybutynin -Patient's FSBS were elevated this admission in setting of acute infection, and should be monitored in outpatient setting -Patient may benefit from outpatient sleep study given concern for sleep apnea, may also benefit from CPAP at night if patient will tolerate Medications on Admission: - oxybutynin ER 10mg daily - simvastatin 80mg daily - metoclopramide 5mg QID - omeprazole 20mg daily - provigil 200mg daily - bisacodyl 10mg suppository QHS - baclofen 10mg Q12am/12pm, 15mg Q6am/6pm - natural balance tear drops 2 drops OU Q8hrs - levothyroxine 50mcg daily - acetaminophen 650 mg/20.3 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours) as needed for pain - Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation - albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for cough, wheezing, or shortness of breath - ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for cough, wheezing, or shortness of breath. - multivitamin Liquid Sig: Fifteen (15) mL PO once a day. - Guiatuss 100 mg/5 mL Liquid Sig: Ten (10) mL PO every six (6) hours as needed for cough. - Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO once a day as needed for constipation. - magnesium citrate Solution Sig: 0.5 bottle PO Monday, Wednesday, Friday. - Enulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO every six (6) hours: given on Tuesday, Thursday, Saturday, Sunday. Discharge Medications: 1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times a day. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Provigil 200 mg Tablet Sig: One (1) Tablet PO once a day. 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime). 6. baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): given at 12 AM and 12 PM. 7. baclofen 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): given at 6 AM and 6 PM. 8. Natural Balance 0.4 % Drops Sig: Two (2) drop Ophthalmic every eight (8) hours. 9. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen 650 mg/20.3 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours) as needed for pain. 11. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal once a day as needed for constipation. 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for cough, wheezing, or shortness of breath. 13. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for cough, wheezing, or shortness of breath. 14. multivitamin Liquid Sig: Fifteen (15) mL PO once a day. 15. Guiatuss 100 mg/5 mL Liquid Sig: Ten (10) mL PO every six (6) hours as needed for cough. 16. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO once a day as needed for constipation. 17. magnesium citrate Solution Sig: 0.5 bottle PO Monday, Wednesday, Friday. 18. Enulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO every six (6) hours: given on Tuesday, Thursday, Saturday, Sunday. 19. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 21. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous daily () for 6 days. 22. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 6 days. 23. PICC Line Orders Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary: Sepsis secondary to pyelonephritis and bacteremia Secondary: Multiple sclerosis, Pulmonary edema, Atrial fibrillation, [Last Name (un) ]??????s Syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Mr. [Known lastname 9319], It was a pleasure taking care of you during your stay at [Hospital1 18]. You were initially admitted to the ICU with fevers and abdominal pain. We found you had a urinary tract infection/kidney infection, due to a large stone in your left kidney. You were seen by the Urologists, who recommended you have a tube placed to help drain urine from the left kidney while the stone is causing an obstruction. We started you on antibiotics, and gave you IV fluids and medications to help raise your blood pressure. You improved with these treatments and were stable for transfer to the medicine floor. The urologists recommend you continue on IV antibiotics for another 2 week course. They will see you in the clinic after the infection has resolved, to discuss what the next steps are to treat the kidney stone. The tube in your kidney will remain in place until that appointment. While you were here, you heart also went in and out of an abnormal rhythm called atrial fibrillation. We started you on an aspirin, and also a medication to control your heart rate. We made the following changes to your medications: 1. STARTED aspirin 81mg daily 2. STARTED metoprolol 12.5mg TID 3. STARTED vancomycin 1gm IV Q12H (through [2167-6-17]) 4. STARTED ertapenem 1gm daily (through [2167-6-17]) 5. STOPPED oxybutynin (please discuss whether you should restart this medication with your PCP) We did not make any other changes to your medications. Please continue to take them as you have been doing. Followup Instructions: Department: SURGICAL SPECIALTIES When: WEDNESDAY [2167-6-17] at 9:00 AM With: UROLOGY UNIT [Telephone/Fax (1) 164] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage ICD9 Codes: 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8290 }	Medical Text: Admission Date: [2166-1-20] Discharge Date: [2166-1-26] Date of Birth: [2089-10-8] Sex: F Service: C-MEDICINE ADMISSION DIAGNOSES: 1. Aortic stenosis. 2. Coronary artery disease. DISCHARGE DIAGNOSES: 1. Aortic stenosis. 2. Coronary artery disease. 3. Status post coronary artery bypass graft times one and aortic valve replacement with #21 bovine valve. HISTORY OF PRESENT ILLNESS: The patient is a 78 year old woman who initially had aortic stenosis diagnosed and a planned aortic valve replacement in [Month (only) 404]. She was, however, admitted to the hospital with diabetic ketoacidosis and electrocardiogram revealed changes. Cardiac workup ultimately led to catheterization which showed significant coronary artery disease, and the patient's planned aortic valve replacement was changed to an aortic valve replacement and coronary artery bypass graft. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus. 2. Aortic stenosis. 3. Coronary artery disease. 4. Hypertension. 5. Uterine polyps. MEDICATIONS ON ADMISSION: 1. Metoprolol. 2. Lisinopril. 3. Aspirin. 4. Plavix. 5. Glucophage. 6. Lipitor. 7. Lasix p.r.n. 8. NPH insulin 20 units q.a.m. and 5 units q.p.m. PHYSICAL EXAMINATION: In general, the patient is an elderly white woman in no acute distress . Vital signs are stable, afebrile. Head, eyes, ears, nose and throat is atraumatic and normocephalic. The extraocular movements are intact. The pupils are equal, round, and reactive to light and accommodation. Anicteric. Neck - no masses and no lymphadenopathy. The chest is clear to auscultation bilaterally. Cardiovascular is regular rate and rhythm with a grade II to III systolic ejection murmur. The abdomen is soft, nontender, nondistended, obese, no masses or organomegaly. The extremities are warm, noncyanotic times four. Neurologically, the patient is alert and oriented times three, no gross motor or sensory deficits. LABORATORY DATA: Complete blood count revealed white blood cell count 9.3, hemoglobin 10.6, hematocrit 31.1, platelet count 152,000. Prothrombin time 13.6, INR 1.2, partial thromboplastin time 28.4. HOSPITAL COURSE: The patient was admitted for coronary artery bypass graft times one and aortic valve replacement. The patient tolerated the procedure well and was taken to the Intensive Care Unit in the immediate postoperative period for closer monitoring. On postoperative day zero, the patient was maintained on an insulin drip and otherwise seemed to be very stable. She was mildly confused after awakened from a nap. She was otherwise doing well with a heart rate in the 80s and systolic blood pressure of 100 to 120s without Neo-Synephrine or Nitroglycerin drips. On postoperative day number one, the patient still had some intermittent confusion but was doing very well hemodynamically without pressors or Nitroglycerin. The PA and A lines were discontinued. Insulin drip was changed to a sliding scale. The patient was working with physical therapy postoperative day number one and noted to do OK with transfers but having some pain issues across the incision. The patient was subsequently transferred to the floor on postoperative day number three and had decrease in her confusion. She did have one episode of rapid atrial fibrillation into the 150s which converted back to normal sinus rhythm with 10 mg of intravenous Lopressor and Amiodarone. The patient's blood sugar continued to be high although they were slightly improved. [Last Name (un) ] was consulted for help in management of her blood sugar. The patient continued to work with [Last Name (un) ] for maintenance of her blood sugar and physical therapy. The patient was set to be discharged on postoperative day number five, however, blood sugar reached the 400 level. [Last Name (un) ] was consulted and managed the sugar over the telephone. The patient did receive one unit of packed red blood cells in the morning of postoperative day number five. The patient's blood sugar did normalize and the patient was discharged to home on postoperative day number six with VNA services to help monitor her blood sugar as well as continue physical therapy. The patient was discharged tolerating regular diet on p.o. pain medications and good understanding that her blood sugar needs to remain well controlled. MEDICATIONS ON DISCHARGE: 1. Lopressor 25 mg p.o. twice a day. 2. Lasix 20 mg p.o. twice a day times seven days. 3. Potassium Chloride 20 meq p.o. twice a day times seven days. 4. Colace 100 mg p.o. twice a day. 5. Aspirin 325 mg p.o. once daily. 6. Percocet 5/325 one to two q4hours p.r.n. 7. Oxazepam 15 to 30 mg p.o. q.h.s. p.r.n. 8. Metformin 500 mg p.o. twice a day. 9. Lipitor 10 mg p.o. once daily. 10. Pultaridine 4 mg p.o. once daily. 11. Latanoprost 0.005% drops twice a day. 12. Amiodarone 400 mg p.o. twice a day. 13. NPH insulin 30 units q.a.m. and 12 units q.h.s. 14. Humalog sliding scale as directed. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with VNA. DIET: Cardiac and diabetic. DI[Last Name (STitle) 408]E INSTRUCTIONS: The patient is to follow-up with her cardiologist in one to two weeks. Continuation of diuresis will be addressed at that time. The patient should follow-up with Dr. [Last Name (Prefixes) ] in four weeks. The patient should also follow-up with Dr. [First Name (STitle) ] of [Last Name (un) ] for treatment of her diabetes mellitus. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 5745] MEDQUIST36 D: [2166-1-26] 13:16 T: [2166-1-27] 20:03 JOB#: [Job Number 47411] ICD9 Codes: 4241, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8291 }	Medical Text: Admission Date: [2112-1-30] Discharge Date: [2112-2-8] Date of Birth: [2053-10-2] Sex: F Service: MEDICINE Allergies: Lisinopril / Felodipine / Benadryl / Iodine / Latex / Levofloxacin Hemihydrate / Augmentin / Sulfa (Sulfonamides) / Clindamycin Attending:[First Name3 (LF) 2297] Chief Complaint: Shortness of breath. Reason for MICU admission: severe septic shock and multiple organ failure. Major Surgical or Invasive Procedure: Intubation and mechanical ventilation. History of Present Illness: 58F with metastatic colon cancer, recent admission for N/V/abd pain with subsequent establishment of hospice, presenting to ED with confusion x few days day and shortness of breath. She had sudden onset of shortness of breath today, no chest pain; persistent but unchanged abdominal pain. No recent diarrhea, constipation, N/V. Husband notes patient taking increasing doses of oxycontin (120 mg in 24 hour period - twice what is prescribed - unclear if intentional). No HA, fever, cough. In the ED, initial vs were: T97.7 rectal, P70, BP66/43 -> 93/53, R13-20 O2 sats 80s on RA, 100% on 3L. Confused, sleepy. Very icteric on exam. Bilateral coarse breath sounds. Guaiac positive. 2+ edema. Patient was given ceftriaxone and vancomycin; calcium gluconate, 1 gram, D50 and insulin, kayexalate 60 g, and levophed gtt started for hypotension. BPs dipping into 70s even after 3L so levophed gtt started (running through port). BP in upper 90s. Lab abnls included lactate 10, severe metabolic acidosis (bicarb 8, pH 7.24), WBCs 18.8 with 17% bands, elevated coags with low plts, ARF, hyperkalemia to 7.4, transaminitis with hyperbilirubinemia. QRS 106 on ECG, no peaked T waves. Difficulty laying flat (dyspneic but not de-satting). On the floor, patient arrives altered, confused. Denies pain or discomfort. Past Medical History: Metastatic colon cancer (brain/liver) -[2109-5-14], colonoscopy due to anemia w/ fungating, friable and infiltration mass (mets), at ascending colon w/ partial obs: adenocarcinoma. Referred to Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1120] for surgery. -[2109-5-23], CCT, ACT: multiple bilateral pulmonary nodules, 7 mm. Scattering smaller ones concern for mets; metastatic foci within the liver also. 4.5 x 5 cm left hepatic lobe mets, 4.5 x 2.9 cm & 4 cm x 3 cm right hepatic lobe mets -[6-10] right palliative hemicolectomy -[2109-7-17] FOLFOX started -[2109-8-28] Avastin added -[2110-1-1] Oxaloplatin held due to neuropathy HTN baseline Cr 0.9-1.2 celiac disease OA - spine, right wrist peripheral neuropathy from chemotherapy recurrent vaginal abscesses Asthma Uterine fibroids Iron deficiency anemia s/p transfusion during hospitalization in [11-12] VIN lactose intolerance hyponatremia hypoalbuminemia with LE edema Pul HTN anterior wall abdominal hernia postmenopausal bleeding s/p negative endometrial bx's Social History: Never smoked, never drank. Lived in [State 4565] 3 years ago. Lives in [Location 1468] with husband. [Name (NI) ] is a grad student at [Hospital1 3278]. She was something of an activist. Family History: Mother and father with CAD and CVA, sister with DM2. Physical Exam: On admission: General: Somnolent though arousable, speech mostly confused when awakened. HEENT: Sclera mildly icteric, MM slightly dry Neck: supple, JVD difficult to appreciate, no LAD appreciated. Lungs: Bilaterally wheezy and rhonchorous, diminished at R base. CV: Regular rate and rhythm, normal S1 + S2, distant beneath breath sounds. R port in place. Abdomen: Distended, bowel sounds present though ?hypoactive, appears diffused tender throughout, ?slightly firm. no apparently rebound tenderness or guarding. No clear ascites. Ext: cool extrems on pressors, no clubbing, cyanosis. 2+ LE edema, equal bilat. Neuro: lethargic/somnolent, arousable, confused speech at times. Unable to perform further neuro exam. Pertinent Results: 137 102 73 AGap=34 ------------- 73 7.4 8 4.1 ∆ K: Not Hemolyzed Ck: 541 MB: 9 Trop-T: 0.10 Ca: 7.5 Mg: 3.6 P: 9.1 ∆ ALT: 448 AP: 1043 Tbili: 5.7 Alb: 2.5 AST: 1390 LDH: 9775 Lip: 36 10.2 18.8 ----146 ∆ 34.7 Diff: N:75 Band:17 L:1 M:5 E:0 Bas:0 Metas: 1 Myelos: 1 Nrbc: 2 PT: 25.0 PTT: 39.0 INR: 2.4 Micro: Blood cultures x 2 pending. Images: CXR: increased R sided pleural effusion. concerning for opacity in R lower lung fields. Diffuse pulmonary nodules consistent with known metastatic disease. EKG: NSR at 75. poor baseline. LAD. slightly wide QRS (~100), QTc 470, no peaked T waves. Poor RWP. Low voltage in precordial and limb leads. Compared to prior, voltage lower, RWP worse. ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size is normal. with mild global free wall hypokinesis. 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 pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion CT Torso: 1. Limited study without contrast with significant progression of innumerable pulmonary and hepatic metastases with massive enlargement of the liver causing volume loss in the right lower lobe secondary to elevation of right hemidiaphragm. 2. Moderate abdominal and pelvic ascites with anasarca. No significant pleural effusion noted. Chest Xray: There is an endotracheal tube, right-sided central venous catheter, and feeding tube which are unchanged in position. The distal tip of the right- sided catheter is again in the right atrium and could be pulled back a few centimeters for more optimal placement. Diffuse opacities throughout both lungs consistent with patient's extensive pulmonary metastases. Superimposed consolidation cannot be entirely excluded. There is a right-sided pleural effusion. Brief Hospital Course: 58F with widely metastatic colon cancer, presenting with septic shock and severe metabolic acidosis, ARF, hyperkalemia. # Hypotension/Septic shock/MODS. Patient presented with septic shock, Leukocytosis/Bandemia and severe metabolic acidosis and multiple organ dysfunction including pulmonary, cardiac, heme, hepatic, renal failure. While source of infection was identified patient was covered broadly with Cefepime, Cipro, Flagyl, and Vancomycin. Blood Cultures were negative throughout hospitalization. Sputum culture only with MSSA. Urine Cultures negative. UA positive covered with Cefepime. Levophed started and titrated to maintain MAP of >60. During hospitalization pt continued to reguire pressor support. Despite identification of a MSSA pneumonia broad coverage was continued while discussion regarding patients Code status was determined. Patient was made CMO, antibiotics/pressors were stopped. Patient expired. # Metabolic/lactic acidosis. With severe systemic hypoperfusion and hypotension in the setting of sepsis. Pt started on levophed which was required throughout hospitalization to maintain adequate perfusion. Lactate trended down during hospitalization and acidosis stabilized with stabilization of blood pressure and antibiotic treatment. # ARF/hyperkalemia. Secondary to ATN int the setting of hypotension/sepsis. No known offending meds. During hospitalization did not respond to fluids. Hyperkalemia without ECG changes. Bicarb gtt started and DC'd with resolution of metabolic acidosis. Dialysis was not initiated given the patients very poor prognosis after long discussion with the family. Throughout the hospitalization no meaningful return in kidney function was attained. # Coagulopathy/thrombocytopenia. Patient with increased INR and decreased platelets during admission. Likely DIC given severity of infection however Fibrinogen stable. During Admission platelets improved/remained stable. INR continued to increase during hospitalization. Patient had no active signs of bleeding. # Transaminitis. Likely shock liver. Liver enzymes were followed during hospitalization and trended down after blood pressure was controlled. # Hypoxia and respiratory distress. Evidence of pneumonia on right. Also with wheezes. Respiratory distress reportedly acute onset; would be at high risk for PE given malignancy, however given patient's clinical status this was deferred. Patient was intubated and vent settings were weaned throughout the hospitalization to Pressure Support [11-8], until patient was extubated when made CMO. # ECG changes. Lower voltage, poor RWP compared to prior. No clear elevation in JVD, not tachycardic, and sources other than tamponade more likely playing a role in hypotension. TTE was negative for pericardial effusion. On [2-6] EKG was performed for hyperkalemia which should 1mm ST Elevation in V1-V2 and ST Depression laterally. Enzymes were checked and were minimally elevated. Repeat ECG with resolution in the height of ST elevation in V1-V2. Given pt comorbidities these abnormalities were not further evaluated. Medications on Admission: Reglan 5 mg three times a day as needed for nausea Oxycodone SR 30 mg Q12H Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Metastatic colon cancer with lethal multiple organ failure. Discharge Condition: Expired. Discharge Instructions: None. Followup Instructions: None. ICD9 Codes: 0389, 5845, 2762, 2767, 4168, 5859, 2875
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8292 }	Medical Text: Admission Date: [2154-5-2] Discharge Date: [2154-5-8] Date of Birth: [2154-5-2] Sex: M Service: NEONATOLOGY HISTORY OF THE PRESENT ILLNESS: Baby boy, [Known lastname ] [Known lastname ], is a 3,620 gram former 37 [12-4] week male infant born to a 37-year-old G4, P3 now 4 mother with serologies as follows; A positive, antibody negative, RPR nonreactive, rubella immune, GBS unknown. He was delivered via elective repeat cesarean section. No maternal fever. Ruptured membranes at the time of delivery. Placenta accreta noted at delivery. There was maternal blood loss/transfusion, per report. The birth weight was 3,625 grams (LGA), Apgar scores seven and eight. The NICU Team was called for persistent grunting post delivery. PHYSICAL EXAMINATION ON ADMISSION: Initial physical examination was remarkable for a male infant in room air, pale, pink, and slightly mottled with grunting, flaring, and retracting. He was admitted to the NICU for further evaluation and management of respiratory distress. Upon arrival in the NICU, his initial D stick was 90. He was pale, pink, active, with slightly decreased but symmetrical tone. The anterior fontanelle was open and flat, no molding. The lungs were well aerated bilaterally despite grunting. The heart revealed a regular rate and rhythm without murmurs. The abdomen was soft without hepatosplenomegaly. Male genitalia. The hips were stable. HOSPITAL COURSE: He was given 10 cc per kilogram normal saline [Month/Day (4) 1868] for poor perfusion and pallor. 1. RESPIRATORY: The baby's initial chest x-ray showed low volume and hazy lung fields consistent with surfactant deficiency. He was intubated and given a total of three doses of surfactant with excellent response. He was transitioned to CPAP and subsequently to nasal cannula by day of life number four. He subsequently weaned to room air on [5-11]. He has had no apnea and bradycardia. 2. CARDIOVASCULAR: After the initial normal saline [Last Name (LF) 1868], [Known lastname ] had been hemodynamically stable. He has no heart murmur on examination. BP was 78/44 54. 3. FLUIDS, ELECTROLYTES, AND NUTRITION: Given his respiratory distress, he was initially made n.p.o., subsequently enteral feeds were started on day of life number four and since then he has been taking p.o. ad lib, breast feeding with bottle supplements, off IV fluids. Discharge weight is 3410gm. 4. GI: [Known lastname 15000] bilirubin level peaked on day of life number six at 12 and 0.3. No phototherapy was initiated. 5. INFECTIOUS DISEASE: The baby's initial WBC was 10.1 with 34 polys and 2 bands. He was started on ampicillin and gentamicin for 48 hours, sepsis rule out. Blood cultures remained negative at this time. 6. HEMATOLOGY: The baby's initial hematocrit was 35.9%. He was subsequently noted to be pale and mottled appearing. A repeat hematocrit on day of life number one was 22.3%. He was transfused with 20 cc per kilogram of packed red blood cells with a post transfusion crit on day of life number two of 37. A repeat hematocrit on [5-9] was 49.5%. 7. GENITOURINARY: The baby was circumcised on [5-12]. 8. SENSORY: Hearing screening was performed with automated auditory brainstem responses and passed in both ears. CONDITION ON DISCHARGE: The baby has been stable on room air for 2 days. He has been hemodynamically stable and he is doing well with ad lib breastfeeding. DISCHARGE DISPOSITION: The patient is to be discharged to home. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) 12208] [Last Name (NamePattern1) 48039], telephone number [Telephone/Fax (1) 8506], fax number [Telephone/Fax (1) 48040]. CARE AND RECOMMENDATIONS: 1. Feeding at discharge: P.O. ad lib breast feeding. 2. Medications: none at present. If mother continues to exclusively breastfeed, supplementation with Vit D will be indicated with Tri-vi-[Male First Name (un) ] or Polyfisol. 3. State newborn screen status: Sent. 4. Immunizations received: Hepatitis B vaccine given. 5. Follow-up with pediatrician and VNA set up in the next 2 days. DISCHARGE DIAGNOSIS: 1. Respiratory distress syndrome, status post surfactant therapy. 2. Anemia from fetal maternal hemorrhage. DR.[First Name (STitle) 1877],[First Name3 (LF) ] 50-466 Dictated By:[Name8 (MD) 47634] MEDQUIST36 D: [2154-5-8] 02:45 T: [2154-5-8] 15:24 JOB#: [Job Number 48041] ICD9 Codes: 769, V290
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8293 }	Medical Text: Admission Date: [2154-12-12] Discharge Date: [2154-12-15] Date of Birth: [2101-12-30] Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins Attending:[First Name3 (LF) 2745] Chief Complaint: transfer for management of possible sepsis and hypercarbic respiratory failure Major Surgical or Invasive Procedure: Intubation PICC Line Placement History of Present Illness: 52 year old female with HTN, T2DM, COPD, and sleep apnea who was transferred from an OSH for further management and evaluation of hypotension and respiratory failure. She presented on [1-13] with fever to 104 and WBC 19,000 and was found to have b/l LE cellulitis. She was initially treated with vancomycin. She was treated with Zyvoxx. She was noted to be lethargic the night of admission and ABG revealed 7.17/70/70. She was placed on BiPAP and transferred to the ICU. She also became hypotensive and was started on dopamine. Her respiratory status did not improve on BiPAP and she was intubated. . Of note, pt was admitted from [2154-7-27] to [2154-8-1] for community acquired pneumonia, sepsis, respiratory Failure, laryngeal edema secondary to endotracheal intubation, asymptomatic sinus bradycardia NOS, and mild aortic valve stenosis (area 1.2-1.9cm2). She was initially transferred to [Hospital1 18] for evaluation of laryngeal edema after she was unable to be extubated. She was seen by pulmonary, they treated her with steroids, and then successfully extubated her without complications. Her course was complicated by asymptomatic bradycardia; cardiology did not feel that this required further evaluation, but recommended echocardiography to rule out structural heart disease. This showed mild aortic stenosis, but was otherwise normal. . Admitted again to [Hospital3 ] for chest pain in [10-5]. P-MIBI was negative at the time. . ROS: Cannot obtain. Past Medical History: COPD Mild aortic valve stenosis (area 1.2-1.9cm2) Hypertension Morbid Obesity Obstructive sleep apnea Schizophrenia Recurrent lower extremetiy cellulitis and lymphedema Diabetes mellitus type II Hyperlipidemia. s/p CCY Social History: Disabled. Nonsmoker. Nondrinker. Widowed with three children. She lives with a family member. Family History: Noncontributory Physical Exam: On Presentation: Vitals: Per Metavision GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2154-12-12] 11:11PM WBC-11.0# RBC-4.12* HGB-10.9* HCT-33.4* MCV-81* MCH-26.5* MCHC-32.6 RDW-14.2 [2154-12-12] 11:11PM NEUTS-77.8* LYMPHS-15.1* MONOS-6.0 EOS-0.7 BASOS-0.4 [2154-12-12] 11:11PM PLT COUNT-255 [2154-12-12] 11:11PM GLUCOSE-215* UREA N-27* CREAT-1.1 SODIUM-139 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13 [2154-12-12] 11:54PM LACTATE-0.7 [2154-12-12] 11:54PM TYPE-ART PO2-58* PCO2-60* PH-7.32* TOTAL CO2-32* BASE XS-2 pCXR [2154-12-12]: Tip of the endotracheal tube is at the upper margin of the clavicles, at least 32 mm from the carina. Right subclavian catheter can be traced as far as the upper SVC, but the tip is indistinct. Nasogastric tube passes into the stomach and out of view. Mild-to-moderate cardiomegaly is stable. Pulmonary vascular congestion and mild edema are new. No appreciable pleural effusion and no evidence of pneumothorax. Brief Hospital Course: 52 year old female with HTN, T2DM, COPD, and sleep apnea who was transferred from an OSH for further management and evaluation of hypotension and respiratory failure. . # Hypotension/Sepsis - Pt presented to the OSH with fever to 104 and lethargy/weakness x 2 days. She became hypotensive during her admission. Most likely source is pt's B/L LE cellulitis, R > L. U/S negative for DVT. At the OSH, the patient was initially started on vancomycin and then switched to Linezolid. U/A was not grossly positive and cultures were NGTD. XRAY did not reveal any infiltrate. No report of diarrhea or abdominal pain. LFTs were elevated at the OSH. Briefly required dopamine here at [Hospital1 18], but quickly weaned off after aggressive volume resuscitation. Patient was treated with vanc and cipro that was then changed to linezolid on discharge to complete a 10 day course. . # Elevated liver enzymes: Likely secondary from transient hypoperfusion of liver in setting of hypotension. The transaminitis had almost completely resolved by day of discharge. . # Respiratory failure - Initially hypercarbic respiratory failure given lethargy on floor and markedly increased pCO2. Per reports, failed BiPAP and was subsequently intubated. Unclear what precipitated respiratory failure. Patient was extubated to BiPAP morning of [12-13]; one episode of hypoxia resolved spontaneously while patient was on BiPAP. The patient was changed to BIPAP. She suffers from OSA, obesity hypoventilation and COPD. The patient was counselled on the importance of weight loss and BIPAP use to prevent further respiratory complications. . # COPD - Given inhalers via ET tube. Discharged on outpatient regimen. . # HTN - Given hypotension, had held home BP meds. Restrted meds as bp improved. . # Obesity: family expressed interested in Lap Banding; given current acute illness, this should be deferred to outpatient providers, but her numerous medical problems are related to obesity and this is a worthwhile consideration if other weight loss methods are failing. -outpatient f/u regarding lap banding # Hyperlipidemia - Continue statin. # T2DM - Home regimen. Medications on Admission: Home Medications: Atorvastatin 20 mg PO daily Valsartan 320 mg PO daily Aspirin 81 mg PO daily Furosemide 20 mg PO BID Montelukast 10 mg PO daily Lyrica 100 mg PO TID Fluphenazine HCl 5 mg PO QHS Docusate Sodium 100 mg PO BID Budesonide 0.5 mg/2 mL two IH [Hospital1 ] Albuterol Nebs PRN Ipratropium Bromide Nebs PRN Insulin Norvasc 2.5 mg PO daily Advair CPAP/supplemental oxygen Please use a pressure of 12 in-line humidification and a ramp of 30. . Medications on transfer: Amlodipine 2.5 mg PO daily ISS Linezolid 600 mg IV Q12H Dopamine 5 mcg/kg/min Albuterol Nebs Atropine Nebs Lovenox 40 mg PO daily Heparin SQ [Hospital1 ] Fluphenazine 5 mg PO QHS Tylenol PRN Lorazepam 2 mg IV Q2H PRN Zofran PRN Oxycodone PRN . Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day: Can be uptitrated by PCP to patient's prior home dose of 320 mg po qd. Disp:30 Tablet(s) Refills:0 4. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Fluphenazine HCl 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: Two (2) doses Inhalation twice a day: Take per prior home dose. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing: If having acute SOB, may use these nebs much more frequently. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 12. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 13. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 14. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT RESTART THIS EMDICATION UNTIL YOU F/U WITH YOUR PCP. 15. BIPAP NIGHTLY AND PRN Sig: One (1) treatment at bedtime. Disp:1 unit Refills:0 16. Home Oxygen 2 liters per nasal cannula Sig: One (1) treatment once a day: Use per prior home regimen. Disp:1 tank Refills:10 17. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 18. Pulmonary Rehab Sig: One (1) Pulmonary rehab once a day: This is prescription to enroll the patient in a [Hospital 79271] rehab program. Disp:1 prescription Refills:20 19. Lantus 100 unit/mL Solution Sig: One (1) unit Subcutaneous at bedtime: CONTINUE PRIOR HOME INSULIN REGIMEN WITH GLARGINE AND LISPRO/HUMALOG SLIDING SCALE. Discharge Disposition: Home With Service Facility: [Location (un) 6138] Home Care Services Discharge Diagnosis: Hypercarbic Respiratory Failure Hypotension on dopamine COPD Obstructive Sleep Apnea Obesity Hypoventilation Morbid Obesity Aortic Stenosis Lower Extremity Cellulitis and lymphedema Schizophrenia Discharge Condition: Vital Signs Stable Discharged on 2 liter home oxygen (per prior outpatient use) Discharge Instructions: Return to the emergency department if you are having difficulty breathing, are wheezy, have fevers, chills, worsening lower extremity cellulitis. You would greatly benefit from pulmonary rehab and weight loss. Please attend pulmonary rehab programs. Prescription given for pulmonary rehab given. USE BIPAP AT NIGHT!! Followup Instructions: Patient to schedule f/u this week with PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Telephone/Fax (1) 62464]. ICD9 Codes: 0389, 4241
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8294 }	Medical Text: Admission Date: [2171-1-1] Discharge Date: [2171-1-9] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1055] Chief Complaint: Hematochezia Major Surgical or Invasive Procedure: Colonoscopy x 2 ([2171-1-2] and [2171-1-4]) EGD ([2171-1-2]) Angiogram History of Present Illness: 85 y/o female with PMH significant for HTN, hypercholesterolemia, MCA CVA in [1-/2170], and two past GI bleeds (most recent was hematochezia during hospitalization for CVA) admitted from nursing home after passing approximately half a cup of blood from her rectum. Pt reports no concerning GI symptoms prior to this since [0-]/[2170]. During this previous bleed, the pt required transfusion of [10-12] units of PRBC. Colonosocpy at this time was notable for diverticulosis but no acute bleeding. A tagged red cell scan showed the source of bleeding to be the hepatic flexure of her colon. Pt was followed up in [Hospital ] clinic on [2170-4-10] at which time it was felt that she was doing well and a repeat colonoscopy was not indicated. In further ROS, pt reports that she had been doing well otherwise. No fevers or chills. No lightheadedness or dizziness. No CP, SOB, or cough. Pt denied a change in appetite. In the [Hospital1 18] [Name (NI) ], pt's NG lavage was negative and she had a watery, guaiac negative stool. At that time, the pt was admitted to the medicine service for further care. A GI consult was obtained on admission. It was felt that given the pt's presentation and history, she most probably had a lower GI bleed due to diverticulosis. Pt was started on IV protonix [Hospital1 ]. Her Hct on admission was 35.9. On the night of admission, pt had another episode of BRBPR associated with lightheadedness. At that time, she was transfused 1 unit of PRBC and the pt was transferred to the MICU. A surgical consult was obtained and they followed the pt. A tagged red blood cell scan was also obtained which showed no active areas of bleeding. On the morning of [1-2], an EGD was done which showed a Schatzki's ring at the GE junction but no bleeding. A colonoscopy was significant for dark red blood in the rectum, sigmoid colon, and descending colon. Multiple non-bleeding diverticula were seen in the sigmoid colon. Another tagged red blood cell scan was then obtained which showed bleeding at the hepatic flexure felt to be coming from the right colic or middle colic artery. However, subsequent angio was negative so no embolization was preformed. Over the last one and a half days, pt's Hct has been fairly stable ranging between 28.2 and 30.9. She has had no further episodes of BRBPR. Since admission, pt has been transfused a total of 6 units of PRBC. Colonoscopy today ([1-4]) was normal. Past Medical History: 1. H/O GI bleeds in [2168] and as above 2. HTN 3. Hypercholesterolemia 4. S/P MCA CVA on [2171-1-28]- Since this time, pt has suffered from residual aphasia and left hemiparesis. 5. Depression 6. S/P cholecystectomy 7. H/O nocturia 8. Recurrent UTIs Social History: Pt lives in the [Hospital3 9475] Home in [Location (un) 3146]. She is able to bathe and dress herself. She ambulates using a walker. Pt does receive assistance with eating. Her daughter lives in the area and is involved. No tobacco, ETOH, or drugs. Family History: No family history of CAD, CVA, or bleeding disorders. Physical Exam: Vitals:97.8, 88, 117/49, 18, 100% on RA Gen:NAD. Lying in stretcher HEENT:MMM. OP clear. Right pupil reactive, left surgical. Neck:Supple, no LAD Pulm:CTAB CV:RRR with II/VI cres,desc murmur best heard at apex. Abd:Soft, NT/ND. NABS Ext:Trace LE edema bilaterally. Neuro:A&O, but trouble with word finding and expression. Able to answer questions appropriately. Pertinent Results: [2171-1-1] 11:00AM BLOOD WBC-5.6 RBC-3.85* Hgb-12.5 Hct-35.9* MCV-93 MCH-32.5* MCHC-34.9 RDW-12.7 Plt Ct-297 [2171-1-2] 05:13AM BLOOD WBC-6.0 RBC-2.70* Hgb-8.6* Hct-27.2* MCV-101# MCH-31.9 MCHC-31.6 RDW-14.1 Plt Ct-222 [2171-1-8] 06:20AM BLOOD WBC-7.4 RBC-3.48 Hgb-11.2* Hct-32.4* MCV-93 MCH-32.2* MCHC-34.6 RDW-14.9 Plt Ct-163 --- [2171-1-1] 11:00AM BLOOD PT-12.4 INR(PT)-1.0 --- [2171-1-1] 11:00AM BLOOD Glucose-98 UreaN-43* Creat-1.1 Na-140 K-4.1 Cl-104 HCO3-25 AnGap-15 [2171-1-8] 10:35AM BLOOD Glucose-102 UreaN-8 Creat-0.7 Na-143 K-4.0 Cl-107 HCO3-31* AnGap-9 --- [2171-1-1] 11:00AM BLOOD ALT-8 AST-14 AlkPhos-58 Amylase-127* TotBili-0.4 [2171-1-1] 11:00AM BLOOD Lipase-54 --- [2171-1-2] 05:13AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.5* [2171-1-8] 10:35AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9 --- [2171-1-1] 12:05PM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.008 [2171-1-1] 12:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG --- Urine culture on admit neg. Blood culture [1-7] neg x2 --- Femoral vascular U/S [2171-1-4]:No evidence of pseudoaneurysm or AV fistula in the right inguinal region. ---- Colonoscopy [2171-1-4]:Diverticulosis of the ascending colon, transverse colon, descending colon and sigmoid colon. Polyp in the rectum. Recommendations: High fiber diet Continue hospital care, serial Hct. If pt rebleeds would perform angiogram. ---- EGD([2171-1-2]):Findings: Esophagus: Lumen: A Schatzki's ring was found in the gastroesophageal junction. Stomach: Normal stomach. Duodenum: Normal duodenum. Recommendations: Consider dilation if patient experiences dysphagia --- Tagged RBC scan [2171-1-2]:Active gastrointestinal bleeding localized to the hepatic flexure Brief Hospital Course: 1.GI: The pt seen by GI in ED. She had a h/o lower GIB attributed to diverticulosis. This seemed to be the case on admission. Had not had bleeding since episode at [Hospital1 1501] when we evaluated her. The plan was to check q6h Hcts and to keep her NPO other than Golytely bowel prep overnight for colonoscopy in the morning. She was asymptomatic. Also started [Hospital1 ] protonix. However, she began to have moderately brisk BRBPR, associated with the bowel prep. She received a unit of PRBCs and was lightheaded, so she had a tagged RBC scan which did not show source of bleeding. She was transferred to MICU for monitoring, but remained stable. In the unit, she had an EGD which did not show bleeding, and a colonoscopy which showed blood in sigmoid and descending colon along with diverticuli. A repeat tagged RBC scan showed source at hepatic flexure(same as previous bleed in [Month (only) 404]), but a follow-up angio did not reveal a source, so no embolization was performed. Repeat colonoscopy two days later showed multipls diverticuli throughout colon, but no active bleeding. At this point, pt transferred to floor where her Hct was checked twice daily. It remained stable in the low 30s, and she had no further bleeding on the floor. She was transferred back to her nursing home after 6 days without bleeding and a stable Hct. She was afebrile. Per surgery team, most surgeons have a cut-off for rate of bleeding before performing colectomy for this problem. This is usually a cut-off of [6-7] units over 24 hours. This pt required a total of 6 units over her 4 day MICU stay. Her BP was always stable. In addition, pt found to have Schatzki's Ring in esophagus. Keep in mind if pt begisn to experience dysphagia. GI follow-up as below. Surgery follow-up as below. 2. HTN: Her BP was elevated with SBP 170 when she came out of the unit. It remained this way for a day as we were holding her BP meds in case she bled again. When this proved to not be the case, her ACE-I was restarted and corrected her BP. It was not quite back into a normal range, with SBPs of 140, and her Lasix should be restarted at some point to hopefully bring her pressure back to normal if needed. Also, if she has symptomatic LE edema, the Lasix may be useful to restart. Her statin was continued throughout. 3.Psych:We continued her celexa and xanax initially. When she went to the unit, her xanax was stopped and not restarted when she came back to floor. She had 2 nights of delirium after coming from unit. At this time, her prn pain med was decreased and her xanax qhs was restarted. She did not have any additional delirium while here and returned to her normal mental status. Her doxepin was also continued as family stated that this helped her anxiety/confusion in the past. She was sent out on the doses of these meds that she came in on. 5.h/o UTIs: Initial UA and Ucx were negative. 6.Renal: Creatinine at 1.1 on admit. Most recent value is from [Month (only) 404], but is 0.6. We hydrated her gently and rechecked in the morning. It had normalized to her baseline and stayed there the remainder of her stay. 7.Left abdominal pain/Neuro:Pt was complaining of this on day of discharge. On review of records, this pain has been present for some time and is believed to be part of a central pain syndrome. She has been seeing neurologists for this and has been trying different medication regimens. We will send her on low dose oxycodone, and have her follow-up as an outpt with her neurologist. Consider a pain consult at nursing home. She was discharged after stable Hct and no bleeding x6 days. Her mental status had returned to [Location 213] after 2 nights of delirium. She was seen by PT and will need PT at nursing home to correct deconditioning. In addition, she will make appointments to follow-up with her PCP, [Name10 (NameIs) ], GI, and neuro to make sure she has all options available in the future and that she stays connected within the system should she require treatment in the future. In addition, a small poylp was seen on colonoscopy, and can be followed by GI as an outpatient. She was sent on 2 months of iron to replace iron stores lost by GI bleeding, as well as B12 and folate. Medications on Admission: 1. Lisinopril 20 mg QAM 2. Protonix 40 mg QAM 3. Celexa 20 mg QAM 4. Xanax 0.25 QHS and PRN 5. Lipitor 10 mg QHS 6. Lasix 40 mg QAM 7. Colace 100 mg [Hospital1 ] 8. Doxepin 10 mg QHS Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 9. Oxycodone HCl 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 10. Doxepin HCl 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 12. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation/anxiety. 13. Iron 325 (65) mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day for 2 months. 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 15. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 9475] Care Center - [Location (un) 3146] Discharge Diagnosis: Lower GI bleed ---- HTN Hypercholesterolemia Anxiety Delirium s/p right sided stroke, with dysphasia Discharge Condition: Pt was at her baseline. She had not had any bleedeing for 6 days and had a stable hematocrit. She was pain free and eating normally for her. She was deconditioned, and will require PT to recover her mobility. Discharge Instructions: Please call your doctor or return to the ED if you experience chest pain, shortness of breath, nausea, or vomiting. Also return or call right away if you have any more bleeding from your rectum or if you see blood in your stool. Followup Instructions: Please follow-up with your primary care doctor, Dr [Last Name (STitle) ], in [2-2] weeks for hospital follow-up. Also please see your doctor as needed, or as the doctors/nurses at the nursing home think you should. Please call your neurologist, Dr [First Name (STitle) ], at [Telephone/Fax (1) 1690], to schedule an appointment for stroke follow-up and pain control follow-up in [4-5] weeks. Please call the general surgery clinic at [Telephone/Fax (1) 21370] for a follow-up appointment in about 1 month(request Dr [Last Name (STitle) ] if available, but other surgeons are also acceptable)to discuss any possible surgery you may be able to have in the future for your bleeding. Finally, Please call ([Telephone/Fax (1) 2306] to schedule a follow-up in the [Hospital ] clinic here in [4-5] weeks to discuss need for repeat colonoscopy. ICD9 Codes: 5789, 2851, 2720, 4019
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8295 }	Medical Text: Admission Date: [2131-9-11] Discharge Date: [2131-9-19] Date of Birth: [2052-1-28] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 134] Chief Complaint: Chest Pain<h3>[Known lastname 103687],[Known firstname 103688] J. [Numeric Identifier 103689] . Major Surgical or Invasive Procedure: Cardiac cath with drug eluting stent placed in the proximal LAD History of Present Illness: Pt was eating dinner this evening, then developed SSCP, no radiation, lasted about 1hr. + diaphoresis, no palpitations, no n/v, no dizziness, no lightheadedness. Thinking it was indigestion, pt took 2 tylenol, alka-seltzer and peptobismol. When this produced no relief, famiy took pt to OSH, chest pain improved on the way to OSH. At OSH, given ASA, NTG w/improvement of sx. EKG changes persisted (STE's in V2-V4) and pt was xferred to [Hospital1 18] for cath. Pt was given a bolus of integrillin, bivalirudin, but no heparin, given h/o HIT. He was given a total of 180cc's of optiray dye. Social History: lives with wife at daughter in law's house. Pt has smoked 2ppd x 65yrs. now smokes 1ppd. No EtOH Family History: brother died of CAD in his 80's Physical Exam: PE: Vitals: T96.8 HR 72 BP 127/67 RR 14 O2sat 97% on 4L NC . Gen: elderly male, in bed, NAD HEENT: OP clear, no lesions, PERRLA, EOMI, flat JVP. no carotid bruits Pulm: barrel chested. diffuse wheezes throughout. no rales/rhonchi CV: distant heart sounds. S1, S2 RRR. no M,R,G Abd: +BS. soft, NT, ND, no HSM Groin: arterial and venous sheaths in R groin. slight ooze. no bruits Ext: warm, dry, no lesions. + onychomycosis Neuro: A&Ox3. hard of hearing. Pertinent Results: Cath results: . HD: PAP 52/22/36 PCWP 28 CI: 2.39 PA sat 60% Art Sat 91% . R dominant system LMCA: no obstructive dz LAD: TO proximally LCx: Minimal Dz RCA: Minimal Dz, RCA large dominant vessel giving collaterals to LAD . Cypher stent was placed in LAd and patient experienced crushing SSCP during deployment which resolved shortly thereafter-->given nitro, SSCP resolved-->TIMI 3 flow. . Brief Hospital Course: a/p: 79 yo male, HTN, ESRD on HD, COPD, extensive smokeing hx presented w/SSCP, c/w STEMI, taken to cath at [Hospital1 18] where totally occluded prox LAD lesion was stented with DES, now chest pain free, recovering in the CCU/step down unit. . 1. CAD: As above pt is s/p STEMI, s/p cardiac cath with stenting of his LAD. Following his cardiac catheterization, the pt??????s cardiac enzymes trended down. He was briefly placed on a nitro drip for ? of cardiac chest pain vs. indigestion, but was quickly weaned off the drip and remained chest pain free for the remainder of his hospitalization. He was placed on aspirin, plavix, lopressor, and a statin post-stenting and continued on these medications throughout his hospitalization. The pt was also placede on coumadin for anti-coagulation. . 2. Pump: Post MI the pt??????s echo showed overall left ventricular systolic function depression with akinesis of the antero-septum, anterior wall and apex. The remaining segements of his LV appeared hypokinetic (basal lateral wall moves best). No masses or thrombi were seen in the left ventricle. The pt was placed on lisinopril for afterload reduction as well as being continued on his HD. . 3. Rhythm: Pt was monitored on telemetry throughout his hospitalization. Post MI the pt remained largely in NSR with occasional PVCs. However, post-MI he was noted to have LAFB and RBBB. It was unclear whether this was his baseline or the result of his MI. The pt did have an episode of Afib with RVR. The pt was loaded with amiodarone. Initially he was planned to receive amio 800 mg qd X1 week with a taper in the usual fashion (400 qd X 1 wk, then 200 qd X1 week). However, given that this was an isolated episode and that the pt is no longer experiencing Afib with RVR the pt??????s amiodarone will be decreased to 200 mg, to be worked up further by his out-pt cardiologist. 4. h/o HTN: As above, the pt??????s blood pressure was well-controlled on lopressor 100 mg [Hospital1 ]. . 5. COPD: The pt was initially wheezing on exam. The pt was started on his out-pt alb/atrovent nebs. Serially CXRs were followed and demonstrated stable b/l pleural effusions. Following the administration of his nebs he has been asymptomatic. . 6. ESRD on HD: The pt received dialysis on Tu/Th/Sat. His meds were renally dosed. 7. Physical limitations: The pt has had continued difficulty with transfers out of bed unless assisted. PT has recommended [Hospital 31940] rehab. The pt has also had continued musculoskeletal ??????related right shoulder pain. The pt should receive continued PT for this issue as well. . 8. Cold L hand: The pt has been noted to have a transiently cold and numb left hand. Angiography has revealed diminished flow in his AV graft. Transplant team saw pt and feel that pt??????s hand is viable and is stable.Per their recs, his sx are likely [1-3] to fluid shifts related to HD??????this is a typical manifestation of A-V grafts. However, pt needs out-pt follow-up in one week for further evaluation. 9. ? facial droop??????The pt??????s nursing staff was initially concerned that the pt had a left facial droop. However, full neurologic exam and head CT were normal. .. 9. FEN??????the pt was placed on a cardiac healthy/low NA diet during hosp 10. ppx??????The pt was on ppi, bowel regimen, and coumadin during hospi. 11. Code: full code. This status was discussed with patient and family. 12. Dispo: The pt is to be d/c??????d to [Doctor First Name 391] Bay for [Hospital 64052] rehabilitation. Physical therapy saw the pt and recommended continued PT given his poor transfer/ambulatory status. Medications on Admission: 1. Flomax 0.4mg daily 2. Trazodone 50mg qhs 3. Atenolol 50mg daily 4. Norvasc 10mg daily 5. Avodart 0.5mg qd 6. Clonidine 0.2mg [Hospital1 ] 7. Xalatan 1 gtt qhs 8. Hydralazine 100mg daily 9. Protonix 40mg daily 10. Tylenol prn 11. Nicotine patch 14 mg daily for two weeks, then 7mg daily x 2wks, then d/c 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). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed. 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: On [2131-9-19] pt was on day 4 of a seven day course. 15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. 17. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 18. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [Doctor First Name 391] Bay - [Hospital1 392] Discharge Diagnosis: STEMI Discharge Condition: Stable Discharge Instructions: Pt or ECF should contact pt's primary care physician or [Name9 (PRE) ] if pt: --experinces chest pain or shortness of breath --gains more than 5 lbs in one week --experiences persistent numbess in his left hand --has any change in mental status above his baseline Followup Instructions: Pt should follow up with: Appointments: --With his PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 1692] [Last Name (NamePattern1) 28436] ([Telephone/Fax (1) 103690] on [2131-9-28] at 3:15 pm. Duringt this visit he will be seeing both Dr. [Last Name (STitle) 28436] as well as attending the coumadin clinic. --Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4469] ([Telephone/Fax (1) 24747], Cardiology [2131-9-24] at 10:45 in [Hospital1 ]. --Transplant Center at [Hospital1 18] ([Telephone/Fax (1) 3618] will contact pt with appointment for the next week. If they do not call within three days of discharge, please contact them at the above number for an appointment. ICD9 Codes: 4280, 5856, 496, 5990, 3051
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8296 }	Medical Text: Admission Date: [2169-12-12] Discharge Date: [2169-12-22] Date of Birth: Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 55 year old male with a history of coronary artery disease with a myocardial infarction at age 20, also history of diabetes mellitus, and cerebrovascular accident, who was transferred emergently to [Hospital1 69] catheterization laboratory from outside hospital. The patient was diaphoretic the p.m. of admission, reportedly took his medicines and went to bed. He was then found unresponsive in bed by his family and EMS was called. He had a prolonged code in the field by EMS and was given initially 2 mg of Atropine and 6 mg of Epinephrine and was transferred to the outside hospital Emergency Department. At the outside hospital Emergency Department, he was found to be in ventricular fibrillation and given Epinephrine and followed by defibrillation times three, followed by Lidocaine and followed by one more defibrillation attempt, which resulted in sinus tachycardia with a rate of 140 and systolic blood pressure of 110/50, and fingerstick of 36. He then became hypotensive at 53/35 and developed PEA and was given Epinephrine times two. He was then started on Levophed and Dopamine and transferred to [Hospital1 188]. At the time of transfer, cardiac catheterization revealed ulceration of the left main artery along with a stump occlusion of the left anterior descending and diagonal arteries. A DS stent was placed in the left main and a Hepacoat stent was placed in the diagonal. The left anterior descending was noted to be totally occluded and could not be crossed. He was then transferred to the CCU in critical condition on multiple pressors, not responsive, with dilated pupils. HOSPITAL COURSE: As noted above, the patient was transferred to the CCU in critical condition on multiple pressors including Levophed and Dopamine. He was unresponsive with noted dilated pupils. Neurology was consulted and recommended apnea test, which was done and, subsequently the day after admission, the patient was declared clinically brain dead. There was much difficulty in maintaining his blood pressure. On [2169-12-22], discussion was held with his family concerning the severe nature of his condition. It was decided to withdraw care and he was pronounced dead at 11:05 p.m. on [2169-12-22]. The family was present. Autopsy was and organ donation were declined. [First Name4 (NamePattern1) 610] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3812] Dictated By:[Last Name (NamePattern1) 14268] MEDQUIST36 D: [2170-3-31] 16:41 T: [2170-4-1] 08:27 JOB#: [Job Number 52374] ICD9 Codes: 2767, 2762
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8297 }	Medical Text: Admission Date: [2146-2-4] Discharge Date: [2146-2-16] Date of Birth: [2084-5-25] Sex: M Service: NEUROSURGERY Allergies: IV Dye, Iodine Containing Attending:[First Name3 (LF) 2724] Chief Complaint: Bilateral lower extremity numbness, abdominal wound drainage Major Surgical or Invasive Procedure: [2146-2-4]: Bedside incision and drainage of abdominal wound [2146-2-10]: T1-6 posterior laminectomy/fusion with vertebrectomy/reconstruction T4 History of Present Illness: Mr. [Known lastname 95891] is a 61 year old man s/p left hepatic lobectomy with Dr. [Last Name (STitle) ] on [2146-1-3] for a large L HCC. Prior to this on [2145-12-17] Dr. [Last Name (STitle) ] performed VATS left upper lobe and left lower lobe nodules: one node positive for metastatic disease with clear margins and the other was negative. He had an uneventful post-op course from both surgeries. He has seen oncology for possible sorafenib treatment. However he complained of new back pain to his pcp, [Name10 (NameIs) ] [Last Name (STitle) 1407]. At that time he had no neurologic symptoms. An MRI obtained [2-1] showed a new pathologic fx of T4 and an epidural lesion at that level compressing the cord. Plans were to stabilize the spine and radiate the lesion.However yesterday he developed b/l LE weakness and numbness. He has been brought in to the hospital for more immediate management.He has had some drainage from his incision and this was opened at the bedside. Past Medical History: PMH: hyperuricemia (no gout) dyspepsia hyperlipidemia diverticulosis osteoarthritis lumbar disc displacement basal cell CA face PSH: L knee arthroscopy [2116] L VATS wedge resection x 2 [11/2145] [2146-1-3] Left hepatic lobectomy, cholecystectomy, intraoperative ultrasound. Social History: Scottish. Educational administrator teacher/coach in HS. Married with 2 adult kids. No IVDU. Drinks 15/week, never smoker. No tattoos. Family History: Father: Coronary artery disease (died at age 47). Mother: Breast cancer Physical Exam: EXAM: PE: AFVSS A&Ox4 Hent: anicteric, mmm CV: RRR Resp: clear Abd: middle of incision opened, fascia intact, 5 cc's of turbid fluid evacuated Back: no mid-line spinal ttp Ext: no edema, able to lift legs against gravity, able to stand with assistance, sensation intact to b/l LE but feels a heavy, leaden feeling to mid thigh. 2+ pulses Physical Exam at Discharge: Pertinent Results: LABORATORIES: IMAGING: Abdominal Wall U/S: [2146-2-4]: Localized peri-incisional collection compatible with subcutaneous peri-incisional infection. CT A/P: [2146-2-4]: 1. Fluid collection along the hepatic resection margin with thin wall and without adjacent inflammatory. This most likely represents a post-operative seroma. 2. Midline open wound just inferior to the xiphoid with small amount of fluid. This may have been opened since the ultrasound from earlier in the day and may be nfected. 3. Marked interval increase in bilateral pulmonary metastases in the visualized lung bases, up to 1.2 cm. MRI T/L Spine: [2146-2-4]: Pathologic fracture T4 w associated cord compression; Extension of T4 epidural tumor to posterior vertebral body. CT C/A/P: [2146-2-6]: 1. Interval development of multiple bilateral pulmonary metastases involving all lobes. Enlarged metastatic left gastric lymph node. Interval progression of the lytic T4 lesion with increased epidural extension and anterior vertebral body compression fracture. 2. Slight decrease in the perihepatic fluid collection, which now contains some air consistent with the recent aspiration. 3. Thrombus in the anterior right portal vein and its segment V branch, bland thrombus is favored but this is uncertain. MICROBIOLOGY: Abdominal wound swab [2146-2-4]: MSSA BCx: [2146-2-4]: No growth - FINAL Urine Cx: [2146-2-5]: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| AMPICILLIN------------ <=2 S LEVOFLOXACIN---------- 0.5 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S Peritoneal Fluid: [2146-2-5]: No growth - FINAL Urine Cx: [2146-2-8]: No growth - FINAL Brief Hospital Course: 1. Metastatic Hepatocellular Carcinoma: Patient is s/p L VATS wedge resection x 2 [11/2145], L hepatic lobectomy [2146-1-1]. Onset of radicular pain prompted MRI spine prior to this admission which showed a T4 epidural metastasis. CT of the chest, abdoment and pelvis [2-6] was performed to further stage possible recurrent HCC. He was found to have diffuse pulmonary metastases bilaterally in addition to previously seen spinal metastasis. Medical oncology, who sees patient as an outpatient, was consulted to discuss chemotherapeutic options with patient. They would like to start serafinib four to six weeks following neurosurgical intervention and will follow patient accordingly. - Spinal Metastasis: Patient admitted [2146-2-4] with complaint of worsening B/L lower extremity weakness in setting of T4 epidural mestatic lesion seen on MRI [1-31]. Neurosurgery was consulted on admission. Patient was placed on bed rest and given high dose IV steroids. Repeat MRI of thoracic and lumbar spine was performed [2-4] which showed pathologic fracture of T4 vertebral body and persistence of T4 epidural lesion. Patient was taken to the operating room on [2-10] for T1-6 posterior decompression and fusion with T4 vertebrectomy/reconstruction. He tolerated this well, was extubated and transferred to ICU overnight for close monitoring. His neuro exam remained stable. JP drain that was placed intra-op was recorded and was removed on [2-13] without difficulty. His foley was removed on [2-12] and he was able to void on his on without trouble. He was mobilized with PT and they recommended a rehab facility. He will be discharged to rehab facility in stable condition on [2146-2-16]. - Pain Control: Patient on oxycontin/oxycodone as an outpatient and these were continued in hospital. [2-7] patient noted increased pain and patient's medications were titrated with good effect pre and post-op. He is currently on oxycontin 30mg TID as well as oxycodone 15-20mg q1 per palliative care rec's and his pain is well controlled. 2. Fever: Patient was found to be febrile on day of admission. Cultures were drawn from all possible sources of infection and patient was started on vancomycin, unasyn [2-5]. Blood cultures [2-4] were shown to be negative. - Wound Infection: At time of admission, patient was complaining of drainage from medial aspect of abdominal incision related to hepatic resection [1-7]. Limited abdominal wall U/S [2-4] showed small fluid collection at medial aspect of incision. This was incised and drained at the bedside and contents was sent for culture. Cultures revealed MSSA and patient was treated with vancomycin x 4 days and nafcillin x 1 day. Wound packing was changed [Hospital1 ] and monitored for any further signs of infection. - UTI: UA on admission was positive and subsequent urine culture drawn [2-5] showed enterococcus > 100k colonies. Patient completed unasyn x 4 days and one additional day of ampicillin. Repeat UA and urine culture [2-8] was negative and antibiotics were discontinued. - Fluid Collection: CT abdomen [2-4] without contrast showed a perihepatic fluid collection. This was aspirated by IR [2-5] and fluid was sent for culture. Cultures were negative and fluid analysis showed this to be a seroma/biloma. No further management was indicated. 3. Disposition: Given the patient's prognsosis, palliative care was consulted. Patient participated in Reiki sessions and will follow with palliative care for future services. Medications on Admission: ALLOPURINOL - (Prescribed by Other Provider) - 300 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime OXYCODONE - 5 mg Tablet - [1-30] Tablet(s) by mouth prn: every [5-4] as needed for pain oxycontin - 20'' Medications - OTC BISACODYL - (Prescribed by Other Provider) - 5 mg Tablet, Delayed Release (E.C.) - 1 PR by mouth once a day as needed for constipation DIPHENHYDRAMINE HCL [SLEEP AID (DIPHENHYDRAMINE)] - (Prescribed by Other Provider) - Dosage uncertain DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day as needed for constipation SENNA - (Prescribed by Other Provider) - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: 1. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release PO every eight (8) hours. Disp:90 tablets Refills:0 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 7. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 8. oxycodone 5 mg Tablet Sig: 3-4 Tablets PO Q1H (every hour) as needed for pain. 9. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days. 10. dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours) for 1 days. Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital 8] Rehab Center Discharge Diagnosis: Metastatic Hepatocellular Carcinoma 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: ?????? Do not smoke. ?????? Keep your wound clean/shower daily including incision but do not immerse in water for 6 weeks from your date of surgery. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting for 2 weeks then increase as tolerated. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have your incision checked daily for signs of infection. ?????? Take your pain medication as instructed. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. Followup Instructions: Follow Up Instructions/Appointments ??????Please return to the office for removal of your staples/suture or have this done at rehab or by visiting nurse [First Name8 (NamePattern2) ] [2-24]. ??????Please call ([Telephone/Fax (1) 2726] to schedule an appointment with Dr. [Name (NI) 548]_to be seen in 6 weeks. ??????You will need AP and lateral x-rays of the thoracic spine prior to your appointment. Dr. [Last Name (STitle) ] on [2-23] @ 940am. [Hospital1 18], [Last Name (NamePattern1) ], [Location (un) 436] [Telephone/Fax (1) 673] Completed by:[2146-2-16] ICD9 Codes: 5990, 2724
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8298 }	Medical Text: Admission Date: [2154-10-16] Discharge Date: [2154-10-25] Date of Birth: [2075-7-30] Sex: M Service: CSU CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 57347] is a 79 year old gentleman with a history of coronary artery disease who presented to an outside hospital's Emergency Department on [10-13], with chest pain and shortness of breath. He reports a prior episode similar to the admitting chest pain but in the past this has spontaneously stopped at the outside hospital. The patient ruled in for myocardial infarction with a stress test that showed partially reversible inferior defect and a normal ejection fraction. He was transferred to [Hospital6 256] for cardiac catheterization which was done shortly after arrival. Catheterization showed 70 percent left main, 90 percent left anterior descending coronary artery, 70 percent obtuse marginal 1, 100 percent right coronary artery. The patient was then seen by Cardiothoracic Surgery and ultimately accepted for coronary artery bypass grafting. PAST MEDICAL HISTORY: Significant for peripheral vascular disease, status post right femoral artery stent, benign prostatic hypertrophy, urethral strictures, hypertension, hypercholesterolemia, glaucoma and a left carotid endarterectomy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Atenolol 50 mg b.i.d., lisinopril 50 mg once daily, aspirin 81 mg once daily, Lasix 20 mg once daily, Norvasc 10 mg once daily, Terazosin 2 mg every bedtime, Mevacor 40 mg once daily as well as eye drops for his glaucoma. SOCIAL HISTORY: The patient lives in [Location 8072] with his wife, works [Name2 (NI) 57348], doing senior citizen work. Tobacco use is remote, but ethyl alcohol three to four drinks per night. FAMILY HISTORY: He has an uncle who died of an myocardial infarction at age 70. REVIEW OF SYSTEMS: Non-contributory. PHYSICAL EXAMINATION: Height 5 feet 5 inches, weight 160 pounds. Vital signs: Heart rate 53, sinus bradycardiac, blood pressure 142/59, respiratory rate 16, oxygen saturation 96 percent on room air. General: Lying flat in bed, in no acute distress. Neurologic: Alert and oriented times three, appropriately anxious, nonfocal examination. Respiratory: Clear to auscultation anteriorly. Cardiovascular: Regular rate and rhythm, S1 and S2, no murmurs, rubs or gallops. Abdomen: Soft, nontender, nondistended with normoactive bowel sounds. Extremities: Warm and well perfused with no edema and no varicosities. Pulses: Radial 2 plus bilaterally, dorsalis pedis and posterior tibial 1 plus bilaterally. LABORATORY DATA: White count 7, hematocrit 35, platelets 248, sodium 135, potassium 3.4, chloride 100, carbon dioxide 25, BUN 24, creatinine 1.3, glucose 221. Liver function tests were within normal limits. Urinalysis showed positive Escherichia coli urinary tract infection and he was treated appropriately with ciprofloxacin. Carotid ultrasound showed no significant hemodynamic lesions on either the right or the left. Additionally, the patient had an anal artery angiogram which showed bilateral renal artery stenosis with 50 percent right lesion and 80 percent left lesion as well as a chest computerized tomography scan that showed significant aortic calcifications in the upper abdominal aorta, the renal arteries and celiac axis as well as calcified lower lobe nodules consistent with calcified granulomas and a lower lobe left bronchiectasis suggestive of congestive heart failure. HOSPITAL COURSE: Ultimately the patient was brought to the Operating Room on [10-18] where he underwent coronary artery bypass grafting, please see the operative report for full details. In summary, the patient had an off-pump coronary artery bypass graft with left internal mammary artery to the left anterior descending coronary artery and a saphenous vein graft to the diagonal. Additionally, the patient returned to the Catheter Laboratory where he underwent percutaneous angioplasty with stenting of his left circumflex coronary artery and obtuse marginal. The patient was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer he was in a sinus rhythm at 62 beats/minute with a mean arterial pressure of 74. He had Propofol at 20 mcg/kg/min and Neo-Synephrine at 0.3 mcg/kg/min, and epinephrine at 0.03 mcg/kg/min. The patient did well in the immediate postoperative period, however, the patient remained sedated during postoperative day Number 1 until all sheaths were removed from his angioplasties. Following removal of the sheaths, the patient's sedation was discontinued. He was weaned from the ventilator and successfully extubated. On postoperative day Number 2, the patient remained hemodynamically stable. He was weaned from all cardioactive intravenous medications. His chest tubes and PA catheter were removed, and on postoperative day Number 3, his temporary wires were removed and he was transferred to the floor for continuing postoperative and cardiac rehabilitation. Over the next several days the patient had an uneventful postoperative course. His activity level was increased with the assistance of the nursing staff and the Physical Therapy Department. Ultimately on postoperative day Number 7 it was decided the patient was stable and ready to be transferred to rehabilitation for continuing postoperative care. At the time of this dictation, the patient's physical examination is as follows: Temperature 98.5, heart rate 79 sinus rhythm, blood pressure 156/60, respiratory rate 20, oxygen saturation 94 percent on room air. Weight preoperatively 72.7 kg, at discharge 74.8 kg. Laboratory data with sodium of 138, potassium 3.6, chloride 98, carbon dioxide 30, BUN 28, creatinine 1.4, glucose 110, hematocrit 29. Physical examination, alert and oriented times three, moves all extremities, follows commands, nonfocal examination. Pulmonary, clear to auscultation bilaterally. Cardiac, regular rate and rhythm, S1 and S2, no murmur. Sternum is stable. Incision with Steri-Strips, open to air, clean and dry. No erythema. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused with no edema. Left leg incision from saphenous vein graft harvest site clean and dry with large ecchymotic area throughout the thigh. CONDITION ON DISCHARGE: The patient's condition at the time of discharge is good. DISCHARGE DIAGNOSIS: Coronary artery disease, status post coronary artery bypass grafting times two with left internal mammary artery to the left anterior descending coronary artery and saphenous vein graft to the diagonal as well as percutaneous angioplasty with stenting of the circumflex coronary artery and obtuse marginal 1. Hypertension. Peripheral vascular disease. Benign prostatic hypertrophy. Carotid endarterectomy. Urethral strictures. Glaucoma. DISCHARGE DISPOSITION/FOLLOW UP: The patient is to be discharged to rehabilitation. He is to follow up with Dr. [Last Name (STitle) 5310] in two to three weeks after discharge from rehabilitation, follow up with Dr. [Last Name (STitle) 57349], his urologist within one week of discharge and follow up with Dr. [Last Name (STitle) ] in one month. DISCHARGE MEDICATIONS: 1. Lasix 40 mg once daily times two weeks. 2. Potassium chloride 20 mEq once daily times two weeks. 3. Colace 100 mg b.i.d. 4. Aspirin 81 mg once daily 5. Oxycodone 5/325 one tablet q. 4-6 hours prn. 6. Plavix 75 mg once daily times three months. 7. Pantoprazole 40 mg once daily until discharged home. 8. Albuterol metered dose inhaler 1 to 2 puffs q. 6 hours prn. 9. Atenolol 50 mg b.i.d. 10. Dorzolamide timolol one drop b.i.d. 11. Latanoprost drops one drop every bedtime. 12. Lisinopril 10 mg once daily. 13. Mevacor 40 mg once daily. 14. Terazosin 2 mg once daily. 15. Norvasc 5 mg once daily. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2154-10-25] 09:24:15 T: [2154-10-25] 10:07:57 Job#: [Job Number 57350] ICD9 Codes: 5990, 4019, 2720
{ "dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered", "dataset_name": "ehrcomplete-icdfiltered", "id": 8299 }	Medical Text: Admission Date: [2156-10-4] Discharge Date: [2156-10-11] Date of Birth: [2104-4-28] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2279] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation, extubation History of Present Illness: Ms. [Name14 (STitle) 106357] is a 56 year-old woman with a history of bronchiectasis, likely COPD, ?sarcoidosis, and mild mental retardation who presented to the ED with acute on chronic abdominal pain and dyspnea and was intubated in the setting of hypoxia and respiratory distress. . The patient is intubated and history was obtained from ED staff, hospital records, and her case manager, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 805]. She lives in a group home and per report has had two admissions this year for shortness of breath, last in [2156-8-5], attributed to either pneumonia or COPD exacerbation. She has also had multiple PCP/outpatient office visits and ED visits for shortness of breath, generally attributed to bronchitis or reactive airway disease. She has also had acute on chronic abdominal pain and underwent EGD recently that demonstrated gastritis. . She was in her USOH until this afternoon when she began having worsening abdominal pain after being picked up in a car by her case manager. During this episode, she had tachypnea/dyspnea, and her case manager activated EMS. Her recent history is notable for the absence of fevers, chronic nonproductive cough, and no increase in her baseline nebulizer requirement. . In the ED, initial vs were: 99.9 127 158/80 18 100%NRB -> 88%ra. She was agitated, removing her NRB, tachypneic to the 40s, and not moving air on exam. She became hypertensive to SBP 180-200 and had worsening hypoxia to the low 80s on room air. She was then intubated for hypoxic respiratory failure and tachypnea, and was given methylpred 125, bronchodilators, and levofloxacin, after which she was noted to be moving air more effectively. She also was given 3L NS. . On arrival to the [Hospital Unit Name 153], she is intubated and sedated on propofol. She is accompanied by her case manager. Of note, ROS is negative for change in bowel or bladder movement, blood in stool, diarrhea, or nausea, though patient has chronically reduced appetite with 50 lb weight loss over past year. Past Medical History: 1. Question sarcoid. She had a CT scan of her chest in [Month (only) ] of [2152] that showed hilar lymphadenopathy that was stable on a repeat CT in [2153-6-5]. She does not have any parenchymal lung disease on these scans and no further workup was pursued at the time. 2. ? allergic bronchopulmonary aspergillosis (ABPA) 3. Type 2 diabetes. 4. Hypertension. 5. Schizophrenia. 6. Hepatitis C. 7. Mild mental retardation. 8. Anxiety. Social History: She lives in a group home. She is on disability. She smoked a significant amount of cigarettes but quit last month. She has never been exposed to anybody with tuberculosis, and there are no pets in her home. Family History: Her sister has schizophrenia. Physical Exam: ADMISSION: Vitals: 98 115/70 16 100% cmv fio2 50% peep 5 TV 400 General: sedated HEENT: ETT in place, 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, obese, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge: VS: Stable, with RR 16-18, SaO2 99/RA No other pertinent findings on exam Pertinent Results: Admission Labs: [2156-10-4] 03:20PM BLOOD WBC-4.2 RBC-4.88 Hgb-14.1 Hct-43.3 MCV-89 MCH-28.8 MCHC-32.4 RDW-14.4 Plt Ct-245 [2156-10-4] 03:20PM BLOOD Neuts-52.8 Lymphs-27.0 Monos-4.7 Eos-14.5* Baso-0.9 [2156-10-4] 03:20PM BLOOD PT-12.2 PTT-22.7 INR(PT)-1.0 [2156-10-4] 04:42PM BLOOD Glucose-156* UreaN-5* Creat-0.5 Na-138 K-4.1 Cl-106 HCO3-24 AnGap-12 [2156-10-4] 04:42PM BLOOD ALT-23 AST-28 AlkPhos-50 TotBili-0.4 [2156-10-4] 04:42PM BLOOD cTropnT-<0.01 [2156-10-5] 02:50AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.7 [2156-10-4] 04:42PM BLOOD ASA-NEG Acetmnp-9* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ABGs: #1) [2156-10-4] 04:50PM BLOOD Type-ART Temp-37.9 Tidal V-380 FiO2-50 pO2-148* pCO2-46* pH-7.34* calTCO2-26 Base XS--1 -ASSIST/CON Intubat-INTUBATED #2) [2156-10-4] 09:04PM BLOOD Type-ART Rates-16/ Tidal V-380 PEEP-5 FiO2-50 pO2-161* pCO2-54* pH-7.30* calTCO2-28 Base XS-0 -ASSIST/CON Intubat-INTUBATED #3) [2156-10-4] 11:35PM BLOOD Type-ART Tidal V-400 PEEP-5 FiO2-50 pO2-131* pCO2-41 pH-7.39 calTCO2-26 Base XS-0 -ASSIST/CON Intubat-INTUBATED #4) [2156-10-6] 02:19AM BLOOD Type-ART Temp-35.8 PEEP-5 pO2-84* pCO2-43 pH-7.46* calTCO2-32* Base XS-5 Intubat-INTUBATED Comment-CPAP/PS [2156-10-4] 9:11 pm SPUTUM Source: Endotracheal. FINAL REPORT [2156-10-6] GRAM STAIN (Final [2156-10-4]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2156-10-6]): MODERATE GROWTH Commensal Respiratory Flora. Brief Hospital Course: Ms. [Name14 (STitle) 106357] is a 56 year-old woman with a history of bronchiectasis, likely COPD, ?sarcoidosis, and mild mental retardation who presented to the ED with acute on chronic abdominal pain and dyspnea and was intubated in the setting of hypoxia and respiratory distress. Respiratory failure: Pt was intubated in the setting of hypoxia, tachypnea, and hypertension in ED. Found to have poor air movement on exam. No significant pulmonary edema on cxr although circumstances raised question if pt had flash edema. Initial ABG showed mild acidosis with mild CO2 retention. She was started on IV steroids as well as broad spectrum Abx vanc/cefepime/azithro for emperic PNA coverage. Albuterol/ipratropium inhalers continued. When CXR showed no obvious infiltrate taken off Vanco/Cefepime and unasyn added for possibility of aspiration event. Question of fluid overload was raised so pt given IV lasix with good diuresis response. Pt with continued wheezing on auscultation, so albuterol inhaler changed from Q6hr to Q2hr. Vent was then weaned to PS from CMV. Vanco was briefly restarted as sputum GS showed GPC but then stopped again once culture grew commensal organisms. Unasyn was also stopped at this point. BNP was WNL and ECHO was done which showed grossly normal heart. On morning of [10-7] pt was successfully extubated. Pts respiratory status remained stable as she was monitored overnight in the ICU before transfer to the floor. She continued to be stable on the floor and discharged with a steroid taper. Her underlying lung disease requires further outpatient workup but at the present time the most likely cause for her acute deterioration was a COPD flare. Abdominal pain/Gastritis: Initial symptoms prompted by acute on chronic abdominal pain, unclear etiology with known gastritis and hepatitis C, and no acute etiology on abdominal CT in [3-17]. Improved without treatment. Schizophrenia: no change in outpatient management. Medications on Admission: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - 1 neb(s) inh every 4-6 hours as needed for wheezing or shortness of breath Dx: COPD, unable to use MDI with spacer ALBUTEROL SULFATE [PROVENTIL HFA] - 90 mcg HFA Aerosol Inhaler - [2-7] puff inh four times a day BENZTROPINE - (Prescribed by Other Provider) - 1 mg Tablet - 1 (One) Tablet(s) by mouth at bedtime BUDESONIDE-FORMOTEROL [SYMBICORT] - 160 mcg-4.5 mcg/Actuation HFA Aerosol Inhaler - 2 spray(s) inh twice a day FLUPHENAZINE HCL - (Prescribed by Other Provider: [Name Initial (NameIs) ]) - 10 mg Tablet - 3 Tablet(s) by mouth once a day FREESTYLE GLUCOMETER - - starter kit with lancets and strips LAMOTRIGINE - (Prescribed by Other Provider: [Name Initial (NameIs) ]) - 100 mg Tablet - 1 Tablet(s) by mouth twice daily LISINOPRIL - 2.5 mg Tablet - 1 (One) Tablet(s) by mouth once a day LORAZEPAM - (Prescribed by Other Provider: [Name Initial (NameIs) 84236]) - 2 mg Tablet - 1 Tablet(s) by mouth at bedtime METFORMIN [GLUCOPHAGE] - 500 mg Tablet - 2 (Two) Tablet(s) by mouth once a day with biggest meal of the day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily PREDNISONE - 20 mg Tablet - 3 Tablet(s) by mouth daily taper: 3 tabs daily x 4 days, then 2 tabs daily x 4 days, then 1 tab daily x 4 days, then [2-7] tab daily x 4 days RISPERIDONE - (Prescribed by Other Provider: [Name Initial (NameIs) ]) - 4 mg Tablet - 1 Tablet(s) by mouth at bedtime SOLIFENACIN [VESICARE] - (Prescribed by Other Provider) - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day bedtime SPACER - - with face mask use with symbicort MDI ACETAMINOPHEN - 325 mg Tablet - 2 (Two) Tablet(s) by mouth every six (6) hours as needed for for temp > 101 and for pain ASPIRIN [ECOTRIN] - 325 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day FERROUS SULFATE [IRON (FERROUS SULFATE)] - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by mouth once a day GUAIFENESIN [GUIATUSS] - 100 mg/5 mL Syrup - one tablespoonful by mouth every 6 hours as needed for cough Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath/wheezing. 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 3. Benztropine 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 5. Fluphenazine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Lorazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Risperidone 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 12. Vesicare 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 15. Prednisone 10 mg Tablet Sig: taper as directed Tablet PO once a day: 3 tabs (30mg) daily for 3 days, 2 tabs (20mg) daily for 3 days, 1 tab (10mg) daily for 3 days, 0.5 tab (5mg) for 3 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: COPD Flare Secondary Diagnosis: Sarcoidosis Discharge Condition: stable, sating well on room air Discharge Instructions: You were admitted with shortness of breath likely related to a COPD flare. MEDICATION CHANGES: Prednisone (taper over a short period of time, follow instructions on prescription) Followup Instructions: Department: BE WELL CENTER When: WEDNESDAY [2156-10-13] at 10:00 AM With: [First Name11 (Name Pattern1) 8826] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 8021], RD [Telephone/Fax (1) 3681] Building: SC [Hospital Ward Name 23] Clinical Ctr [Hospital 1422] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital Ward Name 706] When: FRIDAY [2156-10-22] at 10:50 AM With: [Year (4 digits) 706] [Telephone/Fax (1) 327] Building: [Hospital6 29] [Location (un) 861] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PULMONARY FUNCTION LAB When: MONDAY [2156-11-8] at 1:40 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 2285] Completed by:[2156-10-11] ICD9 Codes: 2762, 2875

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